Eczema’ is a term which comes from the Greek word ‘to boil’ and is used to describe red, dry, itchy skin which can sometimes become weeping, blistered, crusted, scaling and thickened. The words eczema and dermatitis mean the same thing, and thus atopic eczema is the same as atopic dermatitis.
Atopic eczema is the most common type. It is an extremely common inflammatory condition of the skin. It may start any age but is most common in children, affecting 1 in every 5 children in the UK at some stage. The term ‘atopic’ is used to describe a group of conditions which include asthma, eczema and hay-fever. These conditions are linked by an increased activity of the allergy component of the immune system.
How can atopic eczema be treated?
‘Topical’ means ‘applied to the skin surface’. Most eczema treatments are topical, although for more severe eczema some people need to take ‘oral’ medication (by mouth) as well.
‘Complete emollient therapy’ is the mainstay of treatment for all patients with eczema as the most important part of their treatment – this means regular application of a moisturiser, washing with a moisturiser instead of soap (known as a soap substitute), and use of a moisturising bath oil.
Moisturisers (emollients): These should be applied several times every day to help the outer layer of your skin function better as a barrier to your environment. The drier your skin, the more frequently you should apply a moisturiser. Many different ones are available, varying in their degree of greasiness, and it is important that you choose one you like to use. The best one to use is the greasiest one you are prepared to apply. Moisturisers containing an antiseptic may be useful if repeated infections are a problem.
Aqueous cream was originally developed as a soap substitute. It is often used as a moisturiser but can irritate the skin and make eczema worse. For this reason it is recommended that aqueous cream is not used as a moisturiser.
Topical steroid creams or ointments: These will usually settle the redness and itching of eczema when it is active. They come in different strengths (mild, moderately-strong, strong and very strong). Your doctor will advise you on which type needs to be used where, and for how long. In general, ointments are preferred to creams. Use a fingertip unit (squeeze steroid from the tube to cover the length of your index fingertip) to cover an area the size of the front and back of your hand.Use of a topical steroid once daily is usually adequate, however, they should not be applied more than twice daily.
Used appropriately topical steroids are very effective and safe to use. However used inappropriately, (too strong or for too long), topical steroids may cause side effects, including thinning of the skin, Doctors vary in their preference for how to stop topical steroids: some may suggest they are stopped abruptly, others may prefer to gradually decrease the potency of the steroid preparation, and yet others will advise a “maintenance regimen” of using them intermittently for a few weeks after a flare of eczema has settled.
Weaker topical steroids are usually prescribed for use on the face, breasts, genitals, eyelids and armpits. Stronger steroids can be used at other sites especially thicker areas such as hands and feet.
Antibiotics and antiseptics: If your eczema becomes wet, weepy and crusted, it may be infected and a course of antibiotics may be needed. Antiseptics, when applied to the skin alone or as part of a moisturising preparation, can be helpful in stopping the growth of bugs. Incorrect use of antiseptics can, however, irritate the skin and make eczema worse.
Topical immunosuppressants (calcineurin inhibitors): Calcineurin inhibitors, tacrolimus ointment and pimecrolimus cream, may be used when eczema is not responding to topical steroids or in skin sites which are more susceptible to the side effects of steroids such as the face, eyelids and armpits and groin. These treatments are usually prescribed initially by a dermatologist. Their commonest side effect is stinging on application, and this usually disappears after a few applications. They are associated with an increased risk of skin infections and, should not be applied to infected (weeping, crusted) skin. Theoretically they may increase the risk of skin cancer, and should not be applied to sun-exposed sites in the long term, nor used at the same time as ultraviolet light treatment. There is however no evidence that this occurs in practice. There has also been some suggestion there may be an increased risk of lymphoma but there is no evidence to support this from the studies carried out on their use in the short to medium term.
A maintenance regimen using intermittent calcineurin inhibitors (see below) is licensed for use in patients who have frequent flares of eczema.
Antihistamines: Your doctor may recommend antihistamine tablets, which in some patients can be helpful. Those antihistamines that make people sleepy (such as chlorphenamine and hydroxyzine) are most useful, and are generally given at night. They have no effect on the inflammation of eczema and are helpful largely as a result of their sedating effects, reducing sleep disruption.
Bandaging (dressings): Cotton bandages or cotton vests/legging worn on top of creams can help keep creams in the skin and stop scratching. Sometimes these may be applied as‘Wet wraps’ which can be useful for short periods. For some patients the use of medicated paste bandages may be helpful, as they are soothing and provide a physical barrier to scratching. If the skin is infected, appropriate treatment is necessary if dressings are being considered. Your doctor or nurse will advise you regarding the suitability of dressings, and can also advise on the use of special silk garments which can be helpful for some people.
Avoidance of Allergens: Allergy and atopic dermatitis: Atopic people often have allergies, but some allergens are more important for eczema than others.
Air borne allergens: from cats, dogs, pollen, grass or the house dust mite more frequently cause flares in asthma and hay-fever but in some patients may exacerbate eczema and if this is suspected avoidance measures should be undertaken.
Food allergies: In some patients food allergens may aggravate eczema. This is seen more frequently in infants and young children and may be suspected if the eczema is difficult to control or if the child is intensely itchy even without a severe rash. The avoidance of certain foods, after appropriate investigation, may help to control their eczema. A healthy, well-balanced diet is important, especially for children. Foods should not be excluded without advice from your doctor or a dietician.
Latex (rubber) allergy: is more common in people who are atopic. The symptoms may be minor, consisting only of itching of the skin after contact with rubber products, or they may be more severe, requiring hospital treatment.
Contact allergy: to creams and ointments used to treat atopic eczema can occur. Let your doctor know if your treatments seem to be making your skin worse.
Ultraviolet light: Some people with chronic eczema benefit from ultraviolet light treatment, which is usually given in a specialist hospital department and supervised by a dermatologist.This is rarely used for children.
Stronger treatments: People with severe or widespread atopic eczema not responding to topical treatment may need oral treatments (taken by mouth) Theses work by dampening down the immune system and are given under the close supervision of a health care professional. Options include:
Oral steroids: (prednisolone) are sometimes used for a short time if the eczema has flared badly: they work well but should not be used long term because of the risk of side effects.