What is Eczema?
“Skin inflammation,” “dermatitis,” and “eczema” are typically used to describe the same thing—itchy and chronic skin inflammation. The term, eczema, used by itself, refers to the condition known as atopic dermatitis, which is a genetic (hereditary) tendency to develop eczema, usually beginning in childhood. In fact up to 20% of children worldwide have it (11% in the USA), and it appears to be increasing for unknown reasons. Almost three quarters of those with it have a family history of allergies such as eczema, asthma, or allergic rhinitis (allergic runny nose).
People with it don’t “catch” eczema. The fault is in their stars—or in their case, their genes.
The beauty of skin is only skin deep
Skin is the first barrier against bad things in the environment. It not only provides the first defense against irritants and infections, but it also is important in preventing loss of water. In eczema, this barrier is a bit faulty; there is an increase in water loss, the skin gets dry and flaky, and the amount of water loss through the skin can be used to indicate the severity of the eczema. This faultiness in the skin barrier—that is, eczema itself—is a genetic problem, since it is been seen to be almost always shared by identical twins but not much by fraternal twins.
Besides offering a physical barrier, the skin also provides anti-microbial properties. One of these properties is its microbiome, or, the usual collection of bacteria on one’s skin. Show me a human being, and I’ll show you over 35 trillion micro-organisms. They’re everywhere, and our skin is no exception.
There are certainly bad bacteria, but the good ones we have evolved with together are our friends, presenting as an exclusive club of sorts that won’t let others play with them. Like the bad guys. But when this barrier is faulty, as in eczema, the microbiome can change and, to use a cliché, there goes the neighborhood. No doubt this contributes to the extreme itching that comes with eczema.
People with eczema are more likely, therefore, to suffer bacterial and viral skin infections. Since one particular bacterium, Staphylococcus aureus, is on everyone with eczema, there can often be the tell-tale signs of impetigo (infected red sores), one of the hallmarks of a Staph infection.
What’s the deal? What happens in eczema?
Severe itching and dry skin are the main things. There can be papules (bumps) or blisters and crusting in acute eczema. In the chronic (long-standing or adult) versions, the lesions are dry, scaly, or thickened from the scarring of persistent scratching (called lichenification). There are episodes of eczema flares that can be brought on by hypersensitivities to certain foods, irritants, change in humidity, or even stress.
How is it diagnosed?
Itching is mandatory, plus three of the following:
- Dermatitis at areas of flexure
- Dermatitis in skin creases
- Family history of asthma or hay fever
- Dry skin within the past year
- Symptoms before age 2
It is noteworthy that in severe cases, it can occur on any skin surface, not just the above areas of flexure or skin creases. Other associated features include the aforementioned impetigo, extra, darkened folds under the eyes, white patterns on the skin, or absence of the outer eyebrows.
With what can it be confused?
- Allergic or contact dermatitis, such as poison ivy.
- Seborrhea, which well may co-exist with eczema, further confusing things. But seborrhea is greasy, not dry, and doesn’t itch.
- Psoriasis. Although infants and young children can get psoriasis, it is usually in the diaper area with scaling of the skin.
- Scabies (mites). This can look like eczema, but lesions on the palms and soles, generally not seen in eczema, favor a diagnosis of scabies.
Does eczema ever go away?
Most (19 out of 20) people with eczema will see it fade away by late childhood. The remaining 5% will continue with the most persistent sufferers being those who developed it the earliest (age of onset). These chronic sufferers have to treat their condition.
How is eczema treated?
Since severe itching (pruritus) is the major worry for patients, the goal of treatment is to reduce this symptom with anti-inflammatories. This is in combination with moisturizing the skin, since the condition increases the loss of moisture. It all comes down to coaxing the skin to become, once again, an effective barrier to the outside world.
Treatment, therefore, is centered on:
- Anti-inflammatories (topical diclofenac: Votaren;
- Skin moisturizers
- Anti-pruritic medication (anti-itching preparations, such as diphenhydramine: Benadryl Cream; )
- Possibly anti-depressants
- Tincture of time. You won’t find this in any drugstore, but waiting out childhood will see eczema resolve in 95% of people by the time they become adults.
What to not do
Someone has eczema, and that’s a drag. O.K. Understood. Short of invoking a time paradox by going back in time with a time machine and shooting one’s grandfather, the treatments above are matched in importance by the things one should not do:
- Avoid heat and low humidity (sorry, Arizona).
- Don’t ignore infections (jump on them soon with antibiotics, especially those that treat Staph such as Amoxicillin).
- Don’t scratch (easy to recommend, hard to do). Use of sedating antihistamines (diphenhydramine, hydroxyzine, cyproheptadine) can help control pruritus, but getting a good night’s sleep with these may be a bigger benefit. If these fail, topical doxepin (an antidepressant) may be helpful (although many are allergic to it—two steps forward and three back).
- Address sources of stress and anxiety. Depression is often a cause of these, so there may be value in antidepressants, such as fluoxetine.
- Don’t enjoy your favorite foods known to provoke flare-ups, because you won’t enjoy them for very long. The satisfaction of being well-fed won’t last if you begin scratching for days after.
- Don’t be a hoarder. A dirty house bestrewn with dust (and its mites), animal dander, molds, and pollens can be an eczema incubator.
Eczema is a genetically inherited condition which thwarts the skin’s main functions of being an effective barrier against environmental irritants and opportunistic bacteria, resulting in not only loss of moisture, but hypersensitivity to irritating triggers around us, superficial infections, and damage from excessive scratching.
The heaviest burden to otherwise healthy individuals is the utter devastation to the activities of their daily living that occurs with such severe itching.
Treatment is based on reducing the amount of triggers around, calming the hypersensitivity with topical medications, and restoring the moisture to the skin. These, and the passage of time.
Resources
- https://www.uptodate.com/contents/atopic-dermatitis-eczema-pathogenesis-clinical-manifestations-and-diagnosis?source=search_result&search=eczema&selectedTitle=2~150
- Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol 2014; 71:116.
- Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol 2014; 71:116.
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