Atopic eczema

Definition

Eczema is a chronic skin disorder that involves scaly and itchy rashes. Atopic eczema is the most common type.

See also:

• Contact dermatitis
• Dyshidrotic eczema
• Nummular eczema
• Seborrheic dermatitis

Alternative Names

Infantile eczema; Atopic dermatitis; Dermatitis - atopic; Eczema - atopic

Causes, incidence, and risk factors

Atopic eczema is due to a hypersensitivity reaction (similar to an allergy) in the skin, which leads to long-term inflammation of the skin.

Eczema is most common in infants. Many people outgrow it by early adulthood. The condition tends to run in families.

People with eczema often have asthma or hay fever, too. There is often a family history of allergic conditions such as asthma, hay fever, or eczema.

The following can make eczema symptoms worse:

• Allergies to pollen, mold, dust mites, or animals
• Colds or the flu
• Contact with rough materials
• Dry skin
• Exposure to environmental irritants
• Exposure to water
• Feeling too hot or too cold
• Fragrances or dyes added to skin lotions or soaps
• Stress

Symptoms

Typical skin changes may include:

• Blisters with oozing and crusting
• Ear discharge or bleeding
• Raw areas of the skin from scratching
• Skin coloring changes -- more or less coloring than the normal skin tone (See: Skin abnormally dark or light)
• Skin redness or inflammation around the blisters
• Thickened or leather-like areas, called lichenification, which can occur after long-term irritation and scratching

Both the type of rash and where the rash appears can depend on the age of the patient:

• In children younger than age 2, skin lesions begin on the face, scalp, hands, and feet. It is often a crusting, bubbling, or oozing rash.
• In older children and adults, the rash is more commonly seen on the inside of the knees and elbows, as well as the neck, hands, and feet.
• During a severe outbreak, rashes may occur anywhere on the body.

Itching, which is sometimes intense, almost always occurs. Itching may start even before the rash appears.

Signs and tests

Diagnosis is primarily based on:

• Appearance of the skin
• Personal and family history

The health care provider should examine the lesions to rule out other possible causes. A skin lesion biopsy may be performed, but is not always needed to make the diagnosis.

Allergy skin testing may be helpful for people with:

• Difficult-to-treat eczema
• Other allergy symptoms

Treatment

SKIN CARE AT HOME

Taking care of your skin at home may reduce the need for medications.

Avoid scratching the rash or skin if you can:

• Relieve the itch by using a cold compress and taking antihistamines to reduce severe itching.
• Keep your child's fingernails cut short. Consider light gloves if nighttime scratching is a problem.

Keep the skin moist (called lubricating or moisturizing the skin). Use ointments (such as petroleum jelly), creams, or lotions 2 - 3 times a day. Moisturizers should be free of alcohol, scents, dyes, fragrances, or other chemicals. A humidifier in the home will also help.

Avoid anything that makes your symptoms worse. This may include:

• Foods such as eggs in a very young child (always discuss with your doctor first)
• Irritants such as wool and lanolin
• Strong soaps or detergents, as well as chemicals and solvents
• Sudden changes in body temperature and stress, which may cuase sweating and worsen the condition
• Triggers that cause allergy symptoms

When washing or bathing:

• Keep water contact as brief as possible and use less soap than usual. Short, cooler baths are better then long, hot baths.
• Do not scrub or dry the skin too hard or for too long.
• After bathing, it is important to apply lubricating creams, lotions, or ointment on the skin while it is damp. This will help trap moisture in the skin.

MEDICATIONS

Antihistamines taken by mouth may help with itching or if you have allergies. Often you can buy them without a prescription.

• Some antihistamines can cause sleepiness, but they may help with scratching while sleeping.
• Newer antihistamines cause little or no sleepiness. Some are available over the counter. These medications include fexofenadine (Allegra), loratadine (Claritin, Alavert), and cetirizine (Zyrtec).

Most causes of atopic eczema are treated with medications that are placed directly on the skin or scalp (called topical medicines):

• At first, you will probably be prescribed a mild cortisone (or steroid) cream or ointment. If this doesn't work, you may need a stronger steroid medicine. You may need different strengths of steroids for different areas of skin.
• Medicines called topical immunomodulators (TIMs) may be prescribed for anyone over 2 years old. TIMs include tacrolimus (protopic) and pimecrolimus (Elidel). Ask your doctor about concerns over a possible cancer risk with the use of these medicines.
• Creams or ointments that contain coal tar or anthralin may be used for thickened areas.
• Barrier repair creams containing ceramides

Other medicines that may be used include:

• Oral or injected corticosteroids when the eczema is severe
• Antibiotic creams or pills if the skin is infected
• Allergy shots (immunotherapy)
• Oral immunosuppressants, such as cyclosporine, methotrexate, or mycophenolate mofetil

Support Groups

Expectations (prognosis)

Eczema is a chronic condition, but you can control it with treatment, by avoiding irritants, and by keeping the skin well-moisturized.

In children, it often clears beginning around age 5 - 6, but flareups will often occur. In adults, it is generally a long-term or recurring condition.

People with eczema tend to have dry skin that flares up more in the winter, when the air is cold and dry.

Complications

• Infections of the skin caused by bacteria, fungi, or viruses
• Permanent scars

Calling your health care provider

Call for an appointment with your health care provider if:

• Eczema does not respond to moisturizers or avoiding allergens
• Symptoms worsen or treatment is ineffective
• You have signs of infection (such as fever, redness, pain)

Prevention

Studies have shown that children who are breast-fed until age 4 months are less likely to get eczema.

If the child is not breast-fed, using a formula that contains processed cow milk protein (called partially hydrolyzed formula) may decrease the chances of developing eczema.

Eczema tends to run in families.

Keeping the skin well-moisturized and avoiding irritants is important.

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References

Excema and hand dermatitis. In: Habif TP, ed. Clinical Dermatology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2009:chap 3.

Atopic dermatitis. In: Habif TP, ed. Clinical Dermatology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2009:chap 5.

Greer FR, Sicherer SH, Burks, W and the Committee on Nutrition and Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: The role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008;121:183-191.

Lewis-Jones S, Mugglestone MA; Guideline Development Group. Management of atopic eczema in children aged up to 12 years: summary of NICE guidance. BMJ. 2007;335:1263-1264.

Ascroft DM, Chen LC, Garside R, Stein K, Williams HC. Topical pimecrolimus for eczema. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005500.

Bath-Hextall FJ, Delamere FM, Williams HC. Dietary exclusions for established atopic eczema. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD005203.