Atopic dermatitis; Dermatitis - atopic; Skin disorders - eczema
Signs and Symptoms
The most common signs of eczema are:
- Dry, extremely itchy skin
- Blisters with oozing and crusting
- Red skin around the blisters
- Raw areas on the skin from scratching, which can cause bleeding
- Dry, leathery areas that are either darker or lighter than their normal skin tone (called lichenification)
- Scaling, or thickened skin
Eczema in children under 2 years old generally starts on the cheeks, elbows, or knees. In adults, it tends to be found on the inside surfaces of the knees and elbows.
Researchers do not know for sure what causes eczema. It may be a combination of hereditary (genetic) and environmental factors. In some people, allergies may trigger eczema. Exposure to certain irritants and allergens can make symptoms worse, as can dry skin, exposure to water, temperature changes, and stress.
- Young age. Infants and young children are most affected (about 65% of cases occur before age 1, and about 90% occur before age 5).
- Exposing skin to harsh conditions
- Living in a climate with low humidity
- Personal or family history of allergies to plants, chemicals, or food
- Not getting enough of certain vitamins and minerals (for example, zinc)
- Living in an urban, rather than rural, area
- Adolescent obesity
Stress can make eczema worse. Other irritants that can make eczema worse include:
- Wool or synthetic fibers
- Certain soaps and detergents, as well as perfumes and some cosmetics
- Dust or sand
- Cigarette smoke
- Traffic-related air pollution
Your doctor will look at your skin and ask questions about your personal and family medical history before making a diagnosis. Your doctor may ask about stress in your life, your diet, drugs you are taking, soaps and detergents you use, and chemicals or materials you may be exposed to at work. Your doctor may perform a skin lesion biopsy (removal of a small piece of skin), but it is not always needed to make the diagnosis.
Reducing stress, nervousness, anxiety, and depression may help prevent flares of eczema. Mind-body techniques, including cognitive behavioral therapy and autogenic training, have been shown to help. Both techniques can also be combined with learning about eczema.
Avoiding eggs, fish, peanuts, and soy may help some people reduce flares. Ask your doctor to help you determine if avoiding these foods might reduce the frequency and severity of flares.
Some studies show that children who are exclusively breastfed for at least 4 months are less likely to get eczema. This is particularly true when the nursing mother has avoided cow's milk in her own diet.
Some studies also suggest that babies whose mothers took probiotics ("friendly bacteria") during pregnancy and while breastfeeding were less likely to have eczema at up to 2 years of age. One study found that children who were given probiotics for the first 2 years of life were less likely to develop eczema than those who did not take probiotics. Other studies found no association. More research is needed.
Preliminary studies suggest that using skin creams containing omega fatty acids can reduce the severity of eczema or prevent eczema entirely.
Other preliminary studies suggest that children who have a pet dog are significantly less likely to have eczema during the first 3 years of life than children who do not have a pet dog.
The goals when treating eczema are to heal the skin, reduce symptoms, prevent skin damage, and prevent flares. Developing skin care routines, identifying what triggers flares, and avoiding triggers are a large part of any treatment plan.
- Avoid anything that makes symptoms worse, such as allergens (things you are allergic to) and things that irritate skin. Common allergens include pollen, dust mites, and pet dander. Common skin irritants include wool, synthetic fibers, soaps and detergents, perfumes, cosmetics, lanolin, certain chemicals, such as chlorine and solvents (including mineral oil), cigarette smoke, dust, and sand.
- DO NOT scratch or rub affected areas.
- Protect skin from rough clothing and irritants.
- Reduce stress with relaxation techniques.
- Keep your environment cool, with stable humidity.
Dry skin often makes the condition worse. Remember to:
- Avoid hot baths or showers; lukewarm water is best.
- Wash or bathe as quickly as possible to lessen water contact.
- Use a mild soap or a nonsoap cleanser, or less soap than usual.
- Moisturize. Apply lotion or cream within a few minutes of getting out of the shower or bath to seal the moisture in your skin.
- Wet compresses. The wet cloth macerates vesicles, and when removed, debrides the area, preventing serum and crust from accumulating. Wet compresses should be removed after 30 minutes and replaced with a freshly soaked cloth. Otherwise, irritation may occur.
Parents can help their children by:
- Distracting them so they do not scratch dry skin.
- Keeping fingernails short to reduce chances of infection from scratching.
- Understanding that visible skin problems can cause social and emotional stress.
- Offering support and encouragement.
- Mild anti-itch lotions (Caladryl or Calamine), or topical corticosteroids (hydrocortisone), may soothe mild, dry, scaly patches.
- Area where skin is thickened may be treated with ointments or creams that contain tar compounds (such as Psoriasin), corticosteroids, and ingredients that lubricate or soften the skin.
- Oral corticosteroids may be prescribed to reduce inflammation in severe cases. Examples include prednisone (Deltasone) and methylprednisolone (Medrol).
- Rarely, in severe cases where adults have not shown improvement with oral corticosteroids, physicians may prescribe medications that suppress the immune system.
- Your doctor may prescribe antihistamines at night, such as diphenhydramine (Benadryl), to prevent scratching. These medications may cause drowsiness. Topical (on the skin) antihistamine preparations are also available.
- Topical immunomodulators (TCIs) are newer drugs that are applied to the skin to reduce inflammation. They are steroid free. The most commonly prescribed TCIs are tacrolimus (Protopic) and pimecrolimus (Elidel). Doctors recommend these drugs only after other therapies have not worked.
- Oral antibiotics may be helpful if signs of secondary infection, such as pustules, purulent material, and crusts are present.
Surgery and Other Procedures
Phototherapy and Photochemotherapy
Treatment with ultraviolet light may help mild-to-moderate cases of eczema in children over age 12 and adults. Phototherapy or light therapy may be combined with a type of drug called psoralen. It is then called photochemotherapy.
Nutrition and Dietary Supplements
People who have eczema often have food allergies, so eating a healthy diet may help reduce inflammation and allergic reactions.
Check with your doctor before giving a supplement to a child.
Avoid exposure to environmental or food allergens. Common foods that cause allergic reactions are dairy, soy, citrus, peanuts, wheat (sometimes all gluten-containing grains), fish, eggs, corn, and tomatoes. There is much controversy regarding the most effective way to test for food allergies or sensitivities.
Eat fewer refined foods and sugar. These foods contribute to inflammation in the body.
Eat more fresh vegetables, whole grains, and essential fatty acids (cold-water fish, nuts, and seeds).
- Fish oil. In one study people taking fish oil equal to 1.8 g of EPA (one of the omega-3 fatty acids found in fish oil) experienced significant reduction in symptoms of eczema after 12 weeks. Researchers think that may be because fish oil helps reduce leukotriene B4, an inflammatory substance that plays a role in eczema. Talk to your doctor before taking fish oil if you are taking blood-thinning medications, and before taking a high dose. If you are taking high-dose fish oil, use a brand that removes most of the vitamin A. Too much vitamin A over time can be toxic.
- Probiotics (bifidobacteria and lactobacillus) may boost the immune system and control allergies, especially in children. More research is needed to determine whether probiotics will help reduce eczema symptoms. People with weakened immune systems should use caution when taking probiotics. Talk to your doctor.
- Evening primrose oil (EPO). In some studies, EPO helps reduce the itching of eczema. However, other studies show no benefit. People who take anticoagulants (blood thinners) should talk to their doctor before taking EPO, and you should always ask your doctor before taking a high dose of EPO. People with a history of any type of seizure disorder should also talk to their doctor before taking EPO. Pregnant and breastfeeding women should avoid EPO.
- Borage oil, like EPO, contains the essential fatty acid gamma-linolenic acid (GLA), which acts as an anti-inflammatory. Evidence is mixed, with some studies showing that GLA helps reduce eczema symptoms and others showing no effect. Borage, like EPO can interact with blood thinners and other medications. Borage oil may be unsafe for pregnant and breastfeeding women. Speak with your doctor.
- Vitamin C can act as an antihistamine. In one study, it helped reduce symptoms of eczema. More studies are needed. Rose hips or palmitate are citrus-free and hypoallergenic. Vitamin C can interact with some medications, including certain medications used to treat cancer, as well as hormone medications. Speak with your physician.
- Bromelain, an enzyme derived from pineapple, helps reduce inflammation. Bromelain may increase the risk of bleeding, particularly in people who take blood-thinning medications, such as warfarin (Coumadin) and aspirin, among others. Bromelain may also interfere with certain antibiotics.
- Flavonoids, antioxidants found in dark berries and some plants, have anti-inflammatory properties, strengthen connective tissue, and may help reduce allergic reactions.
- Vitamin D. Preliminary studies suggest that low vitamin D status during pregnancy may be a risk factor for developing eczema in the first year of life. Other studies suggest that low levels of vitamin D is associated with eczema among children and adolescents. Most prenatal vitamins contain vitamin D. DO NOT take extra vitamin D unless instructed to do so by your physician.
Herbs are one way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider before starting any treatment, and ask your doctor before taking any herbs. You may use herbs as dried extracts (capsules, powders, or teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, make teas with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups per day. You may use tinctures alone or in combination as noted.
- Topical creams and salves containing one or more of the following herbs may help relieve itching and burning, and promote healing. The best evidence is for chamomile (Matricaria recutita) creams. Chickweed (Stellaria media), marigold (Calendula officinalis), and licorice (Glycyrrhiza glabra) may also help. Speak with your doctor or pharmacist before using these treatments.
- Witch hazel (Hamamelis virginiana) cream can relieve itching. Liquid witch hazel can help with "weeping" or oozing eczema.
- St. John's wort (Hypericum perforatum), used as a topical cream, has shown promise in one study. People with eczema who used St. John's wort on one arm and a placebo cream on the other saw more improvement on the arm treated with St. John's wort.
- Traditional Chinese medicine (TCM), which uses a variety of herbs often combined with acupuncture, seems to be effective for treating eczema in children and adults. In one retrospective study, children with eczema who drank Erka Shizheng Herbal Tea, applied an herbal cream, took herbals baths, and had acupuncture experienced an improvement in their symptoms. In another study, adults who received individual treatment with TCM based on their eczema symptoms also experienced improvement. More studies are needed before doctors can recommend this treatment or can speak to its safety or effectiveness.
- Other herbs that have been used to treat eczema include sarsaparilla (Smilax sp.) and marshmallow (Althea officinalis).
Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of eczema based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account a person's constitution, includes your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual. Any remedy that causes aggravation of symptoms should be discontinued right away.
- Calendula. Applied to the skin, particularly if the affected area is inflamed; this remedy soothes, but does not cure, the skin condition.
- Sulphur. For redness, burning, itching, and hot skin that tends to worsen with washing and scratching.
- Urtica urens. For large, red rashes (particularly those related to allergies) that itch and burn intensely.
- Rhus toxicodendron. Used as a remedy for inflamed skin resulting from direct contact with an irritating substance; some homeopaths use it to treat eczema.
Massage and Physical Therapy
One clinical study looking at essential oils for treating children with eczema found that massage with and without essential oils helped improve dry, scaly skin lesions. Children with this scaly, itchy skin problem seem to have less redness, scaling, and other symptoms if they had massage between flares. DO NOT use massage when skin is actively inflamed. The essential oils most often chosen by the mothers in the study included sweet marjoram, frankincense, German chamomile, myrrh, thyme, benzoin, spike lavender, and Litsea cubeba.
In one clinical study, participating in regular group sporting activities for 3 weeks improved eczema symptoms. Exercise may improve symptoms because of the positive impact it has on emotions. Sports should be avoided during the worst stages of an outbreak.
Climatotherapy uses sunlight and water (such as the ocean) as therapy. The Dead Sea in Israel is known for its healing properties, and many people with eczema go there to sit in the sun and swim in the water. Scientific studies support the benefits. One clinical study looked at the experience of more than 1,500 people with eczema and found that 95% of skin was cleared in people who had stayed at the Dead Sea longer than 4 weeks.
Flares of eczema are associated with anxiety and stress. Several clinical studies show that relaxation techniques can reduce the number of flares and relieve symptoms of eczema. Biofeedback seems to be particularly useful.
Starting an infant on solid foods slowly and gradually may help prevent the food sensitivities that may contribute to eczema.
People who are allergic to ragweed, chrysanthemums, asters, echinacea, or feverfew should avoid chamomile because it is in the same plant family.
Avoid the use of burdock and sulfur during pregnancy.
Warnings and Precautions
Traditional Chinese Medicine (TCM) for eczema have been gaining popularity in both the United States and the United Kingdom, but you should be cautious. Some Chinese herbal creams have high amounts of steroid medications. In rare instances, the use of oral Chinese herbs (like a tea) for eczema has led to kidney damage. If you want to try TCM for your eczema, find a respected TCM practitioner and make sure your doctor knows about all herbs you are using, either orally or on your skin.
Prognosis and Complications
Although eczema can lead to complications, such as bacterial infections of the skin and permanent scar formation, in many cases is can be easily controlled by avoiding triggers and treating your dry, scaly patches. See your doctor if your eczema does not respond to treatment or if signs of infection (such as fever, redness, or pain) occur. Often children with eczema go into remission after a period of time. The remission may last the rest of their lives, although skin may remain sensitive and dry.
Preliminary studies suggest that eczema during infancy may lead to allergies and asthma later in childhood. Some studies also show a correlation between adult eczema and increased risk of heart disease.
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