Atopic Eczema - An Overview

Atopic eczema is an inflammation of the skin which tends to flare-up from time to time. It usually starts in early childhood. There is no 'cure', but treatment can usually control or ease symptoms. Emollients (moisturisers) and steroid creams or ointments are the common treatments. About 2 in 3 children with eczema 'grow out of it' by their mid teens.

What is atopic eczema?

Eczema is sometimes called dermatitis which means 'inflammation of the skin'. There are different types of eczema. The most common type is atopic eczema. In this type of eczema there is a typical pattern of skin inflammation which causes the symptoms.

The word 'atopic' describes people with certain 'allergic' tendencies. However, atopic eczema is not just a simple allergic condition. People with atopic eczema have an increased chance of developing other 'atopic' conditions such as asthma and hay fever.

What are the symptoms of atopic eczema?

• The skin usually feels dry.
• Some areas of the skin become red and inflamed. The most common areas affected are next to skin creases such as the front of the elbows and wrists, backs of knees, and around the neck. However, any areas of skin may be affected. The face is a commonly affected in babies.
• Inflamed skin is itchy. If you scratch a lot it may cause patches of skin to become thickened.
• Sometimes the inflamed areas of skin become blistered and weepy.
• Sometimes inflamed areas of skin become infected.

As a rule, inflamed areas of skin tend to 'flare-up' from time to time, and then tend to settle down. The severity and duration of 'flare-ups' varies from person to person, and from time to time in the same person.

• In mild cases, a flare up may cause just one or two small, mild patches of inflammation. Often these are behind the knees, or in front of elbows or wrists. Flare-ups may occur only 'now and then'.
• In severe cases the flare-ups can last several weeks or more, and cover many areas of skin. This can cause great distress.
• Many people with atopic eczema are somewhere in between these extremes.

Who has atopic eczema?

Most cases first develop in children under the age of five years. It is unusual to first develop atopic eczema after the age of 20. About 1 in 6 schoolchildren have some degree of atopic eczema. However, in about 2 in 3 cases, by the mid teenage years, the flare-ups of eczema have either gone completely, or are much less of a problem. However, there is no way of predicting which children will still be affected as adults. About 3 in 100 adults have atopic eczema.

What causes atopic eczema?

The cause is not known. Some cells of the immune system release chemicals under the skin surface which causes the inflammation. But it is not known why this occurs. Genetic (hereditary) factors play a part. Atopic eczema occurs in about 8 in 10 children where both parents have the condition, and in about 6 in 10 children where one parent has the condition. The precise genetic cause is not clear (which genes are responsible, what effects they have on the skin, etc).

Atopic eczema has become more common in recent years. There are various theories for this. Factors which may play a role include: changes in climate, pollution, allergies to house dust mite or pollens, diet, infections, or other 'early-life factors'. However, there is no proven single cause. There may be a combination of factors in someone who is 'genetically prone to eczema' which causes the immune system to react and cause inflammation in the skin.

What is the usual treatment for atopic eczema?

The usual treatment consists of three parts:

1. Avoid irritants to the skin and other 'triggers' wherever possible.
2. Emollients (Moisturisers) - use every day to help prevent inflammation developing.
3. Topical steroids (steroid creams and ointments) - use when inflammation flares-up.

Treatment part 1 - avoid irritants and 'triggers' where possible

Many people with eczema have flare-ups of from time to time for no apparent reason. However, some flare-ups may be caused (triggered) or made worse by irritants to the skin, or other factors. It is commonly advised to:

• Avoid soaps, bubble baths, etc, when you wash. They can dry out the skin and make it more prone to irritation. Instead, use a soap substitute plus a bath/shower emollient (see below).
• Wear cotton clothes next to the skin rather than irritating fabrics such as wool. However, it is probably the smoothness of the material rather than the type of the material which helps. Some smooth man-made fabrics are probably just as good as cotton.
• Avoid getting too hot or too cold as extremes of temerature can irritate the skin.
• After you wash clothes with detergent, rinse them well. Some 'biological' detergents are said by some people to be irritating. But there is little proof that commonly used detergents which are used in the normal way make eczema worse.

House dust mite may be a trigger in some cases
House dust mite is a tiny insect that occurs in every home. You cannot see it without a microscope. It mainly lives in bedrooms and mattresses as part of the dust. Many people with eczema are allergic to house dust mite. If you are allergic, you have to greatly reduce the numbers of house dust mite for any chance that symptoms may improve.

However, it is impossible to clear house dust mite completely from a home, and it is hard work to greatly reduce their number to a level which may be of benefit. It involves regular cleaning and vacuuming with particular attention to your bedroom, mattress, and bedclothes.

Therefore, if your eczema is mild to moderate, and can be managed by the usual treatments of emollients and short courses of topical steroids, it is usually not worthwhile doing anything about house dust mite. However, if you have moderate or severe eczema which is difficult to control with the usual treatments, you may wish to consider reducing the number of house dust mites from your home. Another leaflet gives more details on how to reduce house dust mites.

Food sensitivity may be a trigger in some cases
Less than 1 in 10 children with atopic eczema have a food sensitivity (allergy) which can make symptoms worse. In general, it is young children with severe eczema who may have a food sensitivity as a trigger factor. The most common foods which trigger eczema symptoms in some people include: cow's milk, eggs, soya, wheat, fish, and nuts.

If you suspect a food is making your child's symptoms worse, then see a doctor. You may be asked to keep a diary over 4-6 weeks. The diary aims to record any symptoms and all foods and drink taken. It may help to identify one or more suspect foods. In some cases, if a 'trigger food' is identified, a diet without this food may be advised if the eczema is severe and difficult to control by other means. But this should only be done under the supervision of a dietician and only helps in a small proportion of cases.

Other triggers
Other possible factors which may trigger symptoms, or make symptoms worse, include: stress and 'habit scratching', pollens, moulds, dander from pets, pregnancy, and hormone changes before a period in women. However, some of these may not be avoidable.

Another leaflet in this series called 'Eczema - Triggers and Irritants' gives more details.

Treatment part 2 - emollients (moisturisers)

People with eczema have a tendency for their skin to become dry. Dry skin tends to 'flare-up' and become inflamed into patches of eczema. Emollients are lotions, creams, ointments and bath/shower additives which prevent the skin from becoming dry. They 'oil' the skin, keep it supple and moist and help to protect the skin from irritants. This helps to prevent itch and reduces the frequency of eczema flare-ups.

The regular use of emollients is the most important part of the day-to-day treatment for eczema. Your doctor, nurse or pharmacist can advise on the various types and brands available, and the ones which may be best suit you.

You should apply emollients as often as you need. This may be twice a day, or several times a day if your skin becomes very dry. Some points about emollients include:

• As a rule, thicker, greasy ointments work better and for longer than thinner creams, but they are messier to use. Some people dont mind using thick ointments, but some people prefer creams (but apply them more often.)
• Apply liberally to all areas of skin. You cannot overdose or overuse emollients. They are not active drugs and do not get absorbed through the skin.
• Use emollients every day. A common mistake is to stop using emollients when the skin appears good. Patches of inflammation, which may have been prevented, may then quickly flare-up again.
• If you are also using a steroid cream or ointment, wait 30-60 minutes after you have applied the steroid before applying emollients. This avoids 'diluting' the steroid which may make it less effective.

Many people with eczema use a range of different emollients. For example, a typical routine for an 'average' person with eczema might be:

• When you have a bath or shower, add an emollient oil to the bathwater or as you shower. This will give your skin a general background 'oiling'.
• Use a thick emollient ointment as a soap substitute for cleaning. You can also rub this into particularly dry areas of skin.
• After a bath or shower it is best to dry by patting with a towel rather than by rubbing.
• Then apply a less thick emollient cream or ointment to any remaining dry areas of skin.
• Between baths or showers, use an emollient cream, ointment or lotion as often as necessary.
• Use an emollient ointment at bedtime.

Note: moisturisers used for eczema tend to be 'bland' and non-perfumed. Occasionally, some people become sensitised to an ingredient in a moisturiser. This can make the skin worse rather than better. If you suspect this, see your doctor for advice. There are many different types of moisturisers with various ingredients. A switch to a different type will usually sort this uncommon problem.

Warning: Bath additive emollients will coat the bath and make it greasy and slippery. It is best to use a mat and/or grab rails to reduce the risk of slipping. Warn anybody else who may use the bath that it will be slippery.

Another leaflet in this series called 'Emollients (Moisturisers) for Eczema' gives more details.

Treatment part 3 - topical steroids (steroid creams and ointments)

Topical steroids work by reducing inflammation in the skin. (Steroid drugs that reduce inflammation are sometimes called corticosteroids. They are very different to the anabolic steroids which are used by some body-builders and athletes.)

Topical steroids are grouped into four categories depending on their strength - mild, moderately potent, potent, and very potent. There are various brands and types in each category. For example, hydrocortisone cream 1% is a commonly used steroid cream and is classed as a mild topical steroid. The greater the strength (potency), the more effect it has on reducing inflammation, but the greater the risk of side-effects with continued use.

Creams are usually best to treat moist or weeping areas of skin. Ointments are usually best to treat areas of skin which are dry or thickened. Lotions may be useful to treat hairy areas such as the scalp.

As a rule, a course of topical steroid is used when one or more patches of eczema flare up. You should use topical steroids until the flare-up has completely gone, and then stop it. In many cases, a course of treatment for 7-14 days is enough to clear a flare-up of eczema. In some cases, a longer course is needed. Many people with eczema require a course of topical steroids every 'now and then' to clear a flare-up. The frequency of flare-ups, and the number of times a course of topical steroids is needed varies greatly from case to case.

It is common practice to use the lowest strength topical steroid which clears the flare-up. If there is no improvement after 3-7 days then a stronger topical steroid is usually then prescribed. For severe flare-ups a stronger topical steroid may be prescribed from the outset.

Sometimes two or more preparations of different strengths are used at the same time. For example, a mild steroid for the face, and a stronger steroid for patches of eczema on the thicker skin of the arms or legs.

Short bursts of high strength steroid as an alternative
For adults with eczema a short course (usually three days) of a strong topical steroid is often used to treat a mild to moderate flare-up of eczema. A strong topical steroid often works quicker than a mild one. (This is in contrast to the traditional method of using the lowest strength wherever possible. However, studies have shown that using a high strength for a short period can be more convenient and is thought to be safe.)

How do I apply topical steroids?
Topical steroids are usually applied once a day (sometimes twice a day - your doctor will advise). Rub a small amount thinly and evenly just onto areas of skin which are inflamed. (This is different to emollients which should be applied liberally all over.)

To work out how much you should use each dose: squeeze out some cream or ointment from the tube onto the end of an adult finger - from the tip of the finger to the first crease. This is called a 'fingertip unit'. One fingertip unit is enough to treat an area of skin twice the size of the flat of an adult's hand with the fingers together. Gently rub the cream or ointment into the skin until it has disappeared. Then wash your hands (unless your hands are the treated area).

Note: dont forget to use emollients as well when you are using a course of topical steroids. (Wait 30-60 minutes after you apply the steroid before applying emollients or vice versa.)

What about side-effects of topical steroids?
Short courses of topical steroids (less than four weeks) are usually safe and usually cause no problems. Problems may develop if topical steroids are used for long periods, or if short courses are repeated often. The concern is mainly if strong steroids are used long-term. Side-effects from mild topical steroids are uncommon.

• Thinning of the skin is the most common possible problem. If skin thinning occurs it often reverses when the topical steroid is stopped.
• With long-term use of topical steroid the skin may develop permanent striae (like 'stretch' marks), bruising, discolouration, or thin spidery blood vessels (telangiectasia).
• Topical steroids may trigger or worsen other skin disorders such as acne, rosacea and perioral dermatitis.
• Some topical steroid gets through the skin and into the bloodstream. The amount is usually small and usually causes no problems unless strong topical steroids are used regularly on large areas of the skin. The main concern is with children who need frequent courses of strong topical steroids. The steroid can have an effect on growth. Therefore, children who need repeated courses of strong topical steroids should have their growth monitored.

Another leaflet in this series called 'Topical Steroids for Eczema' gives more details.

What if treatment does not work?

See your doctor if a flare-up of eczema is getting worse or not clearing despite the usual treatments with emollients and topical steroids. Things which may be considered include:

• Should the strength of the topical steroid be increased?
• Are emollients being used often enough to keep the skin supple and moist?
• Has the inflamed skin become infected and needs an antibiotic?
• Allergy. Occasionally, some people become sensitised ('allergic') to an ingredient in a cream (such as a preservative which is included with the steroid or emollient). This can make the skin inflammation worse rather than better.

You may be referred to a skin specialist if a flare-up does not improve with the usual treatments.

Other treatments

• Tacrolimus ointment and pimecrolimus cream are new treatments introduced in 2002. They work by suppressing some cells involved in causing inflammation. (They are 'topical immunomodulators'.) They are not steroids. They seem to work well to reduce the skin inflammation of eczema. At present they are licensed for use in people aged two years and over who have eczema which is not controlled very well with usual treatments. The long-term safety of these new products is still being evaluated.
• Antibiotics are sometimes prescribed if eczema patches become infected.
• Eczema with blisters may need special soaks to dry up the weepy blisters.
• Hospital treatment is sometimes needed for severe cases. Treatments which are sometimes used include: 'wet wraps', tar and/or steroid occlusion bandages, light therapy, and immunosuppressive medication.
• Tar shampoos are useful to lift scale from affected scalps.

'Alternative' remedies are sometimes tried by some people. There is little proof that any alternative treatment helps. But, turning to these remedies is understandable if conventional treatments fail to control severe eczema. Beware of extravagant claims of success which cost large amounts of money.

Further help and information

National Eczema Society
Hill House, Highgate Hill, London, N19 5NA
Tel (Helpline): 0870 241 3604   Web: www.eczema.org

© EMIS and PIP 2004   Updated: September 2004   Review Date: October 2005   CHIQ Accredited   PRODIGY Validated