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Eczema

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ICD-10	L20-L30
ICD-9	692
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OMIM	{{{OMIM}}}
DiseasesDB	{{{DiseasesDB}}}
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Typical, mild dermatitis

Eczema is a form of dermatitis, a skin irritation characterized by red, flaky skin, sometimes with cracks or tiny blisters. It is extremely itchy, but scratching damages the fragile skin and exacerbates the problem so it is important for people with eczema to try to leave the area alone.

Types

ICD-10 codes are provided where available.

Allergenic

There are several causes of dermatitis, but the most common ones are related to allergies.

• (L20) Atopic eczema, the most common, is caused by general systemic allergic reactions, as opposed to direct contact with an allergen or an irritant. It is very common in people with related allergic conditions, including asthma or chronic hay fever.

• (L23) Allergic contact dermatitis, as the name implies, is the result of direct contact with a contact allergen. One of the most common causes of this form are buttons and rivets in jeans, which contain the metal salt, nickel. Allergic contact dermatitis is considered a delayed-response immune reaction, because elicitation of an allergic reaction typically takes 48 to 72 hours to occur, while IgE and mast cell facilitated responses which appear within 20 minutes.

• (L24) Irritant contact dermatitis is similar, but is caused by a reaction to some chemical substance, often unrinsed detergents left on clothing or various household chemicals being handled. Often, the inflammation occurs mainly on the hands and feet, as the hands come in contact with most of the chemicals that a person may encounter, and the environment for shoe-clad feet is warm and moist, perfect for fungal infections to begin.

Non-allergenic

Several other forms appear unrelated to the main allergic causes.

• (L21.0) Infantile seborrhoeic eczema, also known as Cradle Cap, forms on the head and quickly spreads. It looks like normal dermatitis, but apparently doesn't itch and eventually goes away on its own.

• (L21) Adult seborrhoeic dermatitis typically affects those between 20 and 40 years old. It affects the scalp, face, and upper body.

• (I83.1) Varicose eczema occurs later in life, the result of poor circulation in the legs.

• (L30.0) Finally discoid eczema suddenly appears as small disk shaped spots of severe dermatitis, but disappear on their own.

• Stress and anxiety can make otherwise minor outbreaks spread in some people. Deep unresolved or suppressed emotions are believed by some to be expressed externally in the form of physical skin conditions such as dermatitis (this being borne out by increased irritation at times of emotional upset such as anger or stress).

• Low humidity is also thought to exacerbate dermatitis.

Diagnosis

Eczema diagnosis is generally based on the appearance of inflamed, itchy skin in eczema sensitive areas such as face, chest and other skin crease areas. However, given to the many possible reasons of eczema flare ups, a doctor is likely to ascertain a number of other things before making a judgment:

• An insight to family history
• Dietary habits
• Lifestyle habits
• Allergic tendencies
• Any prescribed drug intake
• Any chemical or material exposure at home or workplace

To determine whether your eczema flare is resulting from an allergen, a doctor may suggest a blood test called radioallergosorbent test (RAST). In the test, blood is mixed with an allergen; antibodies developing in the blood are the sign of an allergy.

The diagnosis may also involve a skin lesion biopsy; removal of a small piece of skin for examination in a laboratory.

Blood test and biopsy are not regular procedure for eczema diagnosis. However, doctors at times do follow it in order to draw a conclusive judgment.

Treatment

Moisturizing

Dermatitis severely dries out the skin,and keeping the affected area moistened can promote healing and retain natural moisture. This is the most important self-care treatment that one can use in atopic eczema.

The use of anything that may dry out the skin should be discontinued and this includes both normal soaps and bubble baths that remove the natural oils from the skin.

The moistening agents are called 'emollients'. The rule to use is: match the thicker ointments to the driest, flakiest skin. Light emollients like Aqueous Cream may dry the skin if it is very flaky and whilst it is the moisturiser traditionally prescribed by doctors in the UK, it is in fact only licensed for use as a soap substitute on washing

Emollient bath oils should be added to bath water and then suitable agents applied after patting-dry the skin. Generally twice daily applications of emollients work best and whilst creams are easy to apply, they are quickly absorbed into the skin and so need frequent re-application. Ointments, with their lesser water content, stay on the skin for longer and so need fewer applications but they must be applied sparingly if to avoid a sticky mess.

Typical emollients in the U.K. are: Oilatum or Balneum bath oils, Aqueous cream for washing with, Diprobase or Doublebase pump-action creams also used for washing and may be later applied directly to the skin. The preferred moisturiser of dermatologists is a mix of liquid and white-soft paraffins. Sebexol, Epaderm ointment and Eucerin lotion or cream may be helpful with itching. Moisturizing gloves can be worn while sleeping.

Some report improvement of symptoms after treatment of the skin with porridge oats, either directly or with an extract. Others report improvement of symptoms after treatment of the skin with the rich natural oils contained Repcillin, a skin balm containing crocodile oil.

Eczema and detergents

The first and primary recommendation is that people suffering from eczema shouldn't use detergents of any kind unless absolutely necessary. The current medical school of thought is that people wash too much and that eczema sufferers should use cleansers only when water is not sufficient to remove dirt from skin.

Another point of view is that detergents are so ubiquitous in modern environments and so persistent in tissues and surfaces, safe soaps are necessary to remove them in order to eliminate the eczema in a percentage of cases. Although most recommendations use the terms "detergents" and "soaps" interchangeably, and tell eczema sufferers to avoid both, detergents and soaps are not the same and are not equally problematic to eczema sufferers. Detergents increase the permeability of skin membranes in a way that soaps and water alone do not. Sodium lauryl sulfate, the most common household detergent, has been shown to amplify the allergenicity of other substances ("increase antigen penetration"). (For example, Corazza M, Virgili A, Allergic contact dermatitis from ophthalmic products: can pre-treatment with sodium lauryl sulfate increase patch test sensitivity? Contact Dermatitis. 2005 May;52(5):239-41.)

The use of detergents in recent decades has increased dramatically, while the use of soaps began to decline when detergents were invented, and leveled off to a constant around the '60s. Complicating this picture is the recent development of mild plant-based detergents for the natural products sector.

Unfortunately there is no one agreed upon best kind of cleanser for eczema sufferers. Different clinical tests, sponsored by different personal product companies, unsurprisingly tout various brands as the most skin friendly based on specific properties of various products and different underlying assumptions as to what really determines skin friendliness. The terms "hypoallergenic" and "doctor tested" are not regulated (according to Consumer Reports), and no research has been done showing that products labeled "hypoallergenic" are in fact less problematic than any others.

Dermatological recommendations in choosing a soap generally include:

• Avoid harsh detergents or drying soaps.
• Choose a soap that has an oil or fat base; a "superfatted" soap is best.
• Use an unscented soap.
• Patch test your soap choice, by using it only on a chosen area until you are sure of its results.
• Use a non-soap based cleanser.

How to use soap when one must

• Bathe in warm water — not hot.
• Use soap sparingly.
• Avoid using washcloths, sponges, or loofahs.
• Use soap only on areas where it is necessary.
• Soap up only at the very end of your bath.
• Use a fragrance free barrier type moisturizer such as vaseline or aquaphor before drying off.
• Never use any kind of lotion, soap, or fragrance unless your doctor tells you to or it's allergen free
• Never rub your skin dry, elsewise your skin's oil/moisture will be on the towel and not your body.

Itch Relief

Antihistamine medication may reduce the itch during a flare up of ezcema, and the reduced scratching in turn reduces damage & irritation to the skin (the Itch cycle).

Capsaicin applied to the skin acts as a counter irritant (see Gate control theory of nerve signal transmission). Other agents that act on nerve transmissions, like menthol, also have been found to mitigate the body's itch signals, providing some relief. Whilst research has suggested Naloxone hydrochloride and dibucaine suppress the itch cycle in atopic-dermatitis model mice.

Repcillin which contains crocodile oil relieves the symptomatic itch associated with eczema and psoriasis.

Corticosteroids

Dermatitis is often treated by doctors with prescribed Glucocorticoid (a corticosteroid steroid) ointments or creams. For mild-moderate eczema a weak steroid may be used (e.g. Hydrocortisone or Desonide), whilst more severe cases require a higher-potency steroid (e.g. Clobetasol propionate). They are highly effective in most cases, but must be used sparingly to avoid possible side effects, the most significant of which is that their prolonged use can cause the skin to thin and become fragile (atrophy). High strength steroids used over large areas may be significantly absorbed into the body causing bone demineralisation (osteoporosis). Finally by their immunosuppression action they can, if used alone, exacerbate some skin infections (fungal or viral).

Hence a steroid of an appropriate strength to promptly settle an episode of eczema should be sparingly applied. Once the desired response has been achieved, it should be discontinued and not used for long-term prevention.

Immunomodulators

Topical immunomodulators like pimecrolimus (Elidel® and Douglan®) and tacrolimus (Protopic®) were developed after corticosteroid treatments, effectively suppressing the immune system in the affected area, and appear to yield better results in some populations. The US Food and Drug Administration has issued a public health advisory about the possible risk of lymph node or skin cancer from use of these products, but many professional medical organizations disagree with the FDA's findings:

• The postulation is that the immune system may help remove some pre-cancerous abnormal cells which is prevented by these drugs. However, any chronic inflammatory condition such as eczema, by the very nature of increased metabolism and cell replication, has a tiny associated risk of cancer (see Bowen's disease).
• Current practice by UK dermatologists [1] is not to consider this a significant real concern and they are increasingly recommending the use of these new drugs. The dramatic improvement on the condition can significantly improve the quality of life of sufferers (and families kept awake by the distress of affected children). The major debate, in the UK, has been about the cost of such newer treatments and, given only finite NHS resources, when they are most appropriate to use.[2]

Antibiotics

The disruption to the skin's normal barrier protection through dry and cracked skin allows easy entry for bacteria and fungi. Scratching by the patient both introduces infection and spreads it from one area to another. Any skin infection further irritates the skin and a rapid detoriation in the condition may ensue; the appropriate antibiotic should be given.

Psychological Effects

Eczema often comes and goes in cycles and this means that sufferers at some times of the year are able to feel normal and at other times distance themselves from social contact. Sufferers with visible marks can act normal, but when it's mentioned they become withdrawn and self-conscious at their problems. Also, when told to stop scratching the sufferer can sometimes feel annoyance at the person who said it. Since it's a disease, which is made worse by scratching the sufferer feels bad in themselves and sometimes experiences feelings that everyone is looking at them. Although scratching does give pain it can feel like a release and this leads to problems with constant scratching. Sufferers may also be able to not scratch for example at school or at work and scratch the moment they get home. In summary sufferers of eczema, especially children, may suffer psychological distress in addition to the physical discomfort of their condition. This may both be through their own embarrassment about the condition and from any teasing or social rejection by their peers.

Light Therapy

See also light therapy.

Light therapy using ultraviolet light can help. PUVA, UVB, and Narrow Band UVB are all used. Current research seems to show that Narrow Band UVB is the most effective, in addition to having lowest risk of skin cancer.

When light therapy alone is found to be ineffective, it is combined with a drug called Psoralen. This treatment is termed as photo-chemotherapy.

Traditional remedies

Other historical sources - notably traditional Chinese medicine and Western herbalism - suggest a wide variety of treatments, each of which may vary from individual to individual as to efficacy or harm. Toxicity may be present in some.

• Ledeboureilla seseloides
• Potentilla chinensis
• Aebia clematidis
• Clematis armandii
• Rehmannia glutinosa
• Paeonia lactiflora
• Lophatherum gracile
• Dictamnus dasycarpus
• Tribulus terrestris
• Glycyrrhiza uralensis
• Glycyrrhiza glabra
• Schizonepeta tenuifolia
• Schizonepeta tennuifolia
• Azadirachta indica
• evening primrose oil
• tea tree oil
• burdock
• rooibos
• calamine
• oatmeal
• crocodile oil
• Repcillin

Some alternative (and even conventional) medicine sources state that oatmeal in solution applied topically has a healing effect. This has been noticed through occupational sources, where a person's skin is often exposed to oatmeal at work, e.g., through baking or milling. Often such people retain exceptionally soft and healthy skin into old age.

The symptoms of Biotin deficiency include Seborrheic dermatitis, a skin disorder which is similar to eczema[3]. Current research has found that taking biotin alleviates the symptoms of eczema [4].

Patients should inform their doctor/allergist/dermatologist if they are pursuing one of these treatment routes.

Future Treatments

Other than direct treatments of the symptoms, no "cure" for dermatitis is presently known; even cortisone treatments and immunomodulation may often have only minor effects on what may be a complex problem. As the condition is often related to family history of allergies (and thus heredity), it is probable that gene therapy or genetic engineering might help.

The March 2006 issue of the journal Nature Genetics, reports on research at the University of Dundee identifying a gene that the researchers believe to be the cause of inherited eczema and some related disorders. The gene produces the protein filaggrin, the lack of which causes dry skin.

See also

• List of skin diseases
• Dermatology
• SCORAD
• Glucocorticoid for table of comparative strengths of some commonly used steroids

External links

• MedlinePlus: Dermatitis
• DermNet: Dermatitis (eczema)
• National Eczema Society (UK)
• Mayo Clinic: Dermatitis and Eczema - Overview, Treatment, Causes, Prevention, Self-Care
• Neurodermatitis, atopic Eczema and Eczema Discussion Board
• What Soap Should Dermatoligists Recommend for Eczema?--Medscape Article
• Soap and Eczema
• National Eczema Association
• Detergent-reactive Eczema: Detergents vs. Soaps

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