Eczema, also called dermatitis is not one specific skin condition. There are many types of eczematous skin conditions. The word “eczema” refers to a family of skin conditions associated with irritated, itchy skin.
The most common form of eczema is atopic dermatitis (AD), a chronic, intensely itchy skin condition that is very common in children but may occur at any age. Scratching leads to redness, scaling, crusting, swelling and weeping of the skin. Scratching can also lead to infection as people with AD tend to have more bacteria on their skin. Atopic dermatitis can be localized or wide-spread.
Atopic dermatitis affects 15-20% of children but only 1-2% of adults. In 1/3 of children AD disappears after 2 years of age, and in another 1/3 after 5 years of age. In the rest, the symptoms and signs of AD continue into adulthood, usually as hand dermatitis. The number of people with atopic dermatitis in the United States is increasing.
AD is not contagious. It tends to run in families. People who have AD usually have family members with dry skin, asthma, seasonal allergies, hay fever, atopic dermatitis, and sometimes penicillin or aspirin allergies.
All together the combination of asthma, atopic dermatitis and hay fever is called atopy.
What causes eczema/atopic dermatitis?
In atopic dermatitis there a combination of several factors.
There is an overactive immune system response to environmental factors.
Environmental factors that tend to aggravate AD
Skin irritants, such as soaps, detergents and fragrances
Weather – AD commonly flares in the winter due to low humidity both outside and indoors
Heat and high humidity
Outdoor pollution
Food allergens play a big role in flaring children’s eczema
Most common food allergens in children are egg whites, cow’s milk, peanuts, soy, shellfish and flour.
There also is an inherited skin abnormality that causes a dysfunction of the skin barrier that protects us from the environment (skin barrier defect).
Decreased barrier function and allows more irritants to penetrate the skin and more water to escape it, leading to dry skin, inflammation and skin damage, characteristic of AD.
What does eczema/atopic dermatitis look like?
What atopic dermatitis looks like depends on many factors, such as age, ethnic group, course and duration of the disease, aggravating factors and possible overlying infection of the skin.
In infants the AD starts of the cheeks, then may become widely distributed. Skin is dry, red and scaly. The diaper area is usually not involved due to the moisture there.
In children AD affects the outer (extensor) surfaces of the wrists, elbows, ankles and knees. As the child grows the location changes to involve the flexor areas, like the inside of the elbow and behind the knee. Because kids are excellent scratchers, the skin becomes dry and thickened.
Adults may continue to have generalized AD, but more commonly they have localized eczema of the hands, eyelids, flexures, nipples or all the areas together.
What other medical conditions are associated with atopic dermatitis?
Asthma
Hay fever (allergic rhinitis)
Dry skin
Ichthyosis vulgaris – an inherited dry skin condition that makes the skin look like fish scales
Keratosis pilaris –
A very common condition
Occurs on the backs of arms, as well as on legs, buttocks, and occasionally on the face and abdomen
Small, hard, red bumps in hair follicles, often mistaken for acne
Pityriasis alba – slightly scaly patches, usually lighter than normal skin color, on the face and arms in children
More visible in the summer, as these patches don’t tan
Dark circles and skin folds under the eyes (allergic shiners)
Eye abnormalities
How is eczema diagnosed?
Atopic dermatitis is diagnosed clinically by using the criteria outlined by Hanifin and Rajka1.
Complications of eczema
Slowed growth in children
Sleep disturbances
Stress
Social alienation
Skin infections with bacteria (impetigo), viruses (herpes, warts, or molluscum contagiosum) and fungi (ringworm)
Erythroderma – severe skin condition with generalized redness and itching of the skin. Erythroderma can be life-threatening.
Treatment of eczema
Personal care
Use lukewarm, not hot water for bathing
Use a mild, soap-free cleanser
Don’t use washcloths, buffpuffs or any other object to scrub the skin
Wear soft, cotton clothing that was washed in a fragrance-free, dye-free mild detergent without chlorine bleach.
Avoid wool clothing as it tends to irritate skin
Moisturize often with a fragrance-free cream or ointment made for sensitive skin. Avoid lotions as they tend to dry the skin. Applying a moisturizer immediately after bathing helps retain moisture in the skin.
Avoid foods that may cause irritation of the skin, like citrus and tomatoes
Reduce exposure to dust and smoke
Medical treatments
Topical treatments
Topical creams or ointments should be applied shortly after bathing to increase their effectiveness
Corticosteroid creams or ointments
Must be used sparingly if at all on the face, and particularly around the eye area.
Tacrolimus ointment
Pimecrolimus cream
Tar preparation
Antihistamines – to reduce itching
Control of infection with antibiotics, anti-viral or anti-fungal medications
For severe atopic dermatitis, unresponsive to topical and emollient treatment:
Phototherapy
Systemic medications, such as cyclosporine, azathioprine, systemic steroids
Biologic therapies are being tested for atopic dermatitis
References:
Rothe MJ, Grant-Kels JM. Diagnostic criteria for atopic dermatitis. Lancet 1996;348 (9030):769-770
Macias ES et al. Superantigens in dermatology. JAAD 2011;64(3):455-472
Ou HT et al. Understanding and improving treatment adherence in pediatric patients. Semin Cutan Med Surg 2010;29(2):137-40
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