Eczema

Atopic, Contact, Discoid, Varicose

Eczema is a skin condition, which can result in dry, red and flaky skin. The skin may feel hot and very itchy and scratching can lead to the skin becoming damaged and infected. Eczema is not contagious. Eczema is also known as dermatitis, a term used to describe inflammation of the skin.

Atopic

Atopic eczema is the most common type of eczema and is linked with hay fever and asthma. The tendency to develop atopic eczema is inherited but is strongly influenced by environmental factors.

Atopic means an extra sensitivity to substances (allergens). The most common allergens are house dust mites, feathers, pollen, cat or dog fur and sometimes foodstuffs e.g. cows milk, eggs or nuts.

Atopic eczema may start in babies from 3 months, often on the face, then to the outside limbs and the body. In older children it can occur on almost any part of the skin but most commonly involves the creases of the limbs, especially in front of the elbows and behind the knees and the wrists, ankle and neck.

Atopic eczema affects approximately 15-20% of young children in the UK. Atopic eczema clears up in approximately 70% of children by the time they reach their teens and in many it largely clears up by 4-5 years of age. If it persists into adult life, it usually affects the body creases, the face and hands. The incidence of atopic eczema has increased in recent years.

Contact

Contact eczema is often referred to as dermatitis. It is an acute (short- term flare-up) or chronic (long term) skin reaction where there is sensitivity to materials or substances that come in contact with your skin. It may involve allergic or non-allergic reactions.

Irritant contact dermatitis is a skin reaction caused by the direct effect of an irritant substance on the skin. Contact dermatitis typically causes inflammation on areas of skin which have come into contact with the substance. No prior exposure to the substance is necessary. An irritant dermatitis is most likely to occur on the hands. If you have atopic eczema (the most common type of eczema, which is linked with hay fever and asthma) you may be more prone to irritant dermatitis. These irritants are commonly found in various occupations e.g. cleaning, hairdressing, horticulture and building work.

Allergic contact dermatitis is a skin reaction that occurs when your immune system reacts against a specific substance (called an allergen). Your immune system becomes sensitised to the allergen over time. Previous exposure to the substance is needed to produce an allergy. Therefore you can suddenly react to a substance you may have come in contact with many times before. A small amount of the allergen can then cause a skin reaction. Once your skin has become sensitised it can persist for life and there is no cure. Common substances include: nickel (jewellery, bra straps, belt buckles etc.), perfumes, rubber, some plants, some ingredients in cosmetics, skin medications, hairdressing chemicals etc.

Discoid

Discoid eczema can occur in adults at any age, but more often in later life. It can affect any part of the body, but usually affects the lower leg and feet and sometimes the arms. It shows as distinct round-shaped patches of eczema.


Varicose

Varicose eczema affects the lower legs; it is associated with varicose veins and is caused by poor circulation. The skin becomes dry and inflamed. It can affect middle aged to elderly people.

Atopic

Atopic eczema is a condition where inherited factors are important . These inherited factors make you more sensitive to allergens in the environment and increase the risk of developing eczema, asthma or hay fever.

Atopic eczema has become more common in recent years, the cause of this is uncertain.

There are also a number of factors may trigger an eczema flare-up, these include specific allergies to foods, overheating, secondary infection, wool next to the skin, cat and dog fur, soaps, detergents, house dust mites and pollen.


Contact

Substances penetrate the skin and the outer layer of the skin (epidermis) becomes damaged. This damage can be due to an irritant effect, which can cause a reaction in anyone or an allergic reaction, which will only cause a reaction in some people. It is unclear why some people become allergic to some substances, while most people do not.

Common irritants include detergents and cleaning products, solvents, oils and chemicals.

Common substances that cause allergies include: nickel, jewellery, wristwatches, belt buckles, cement, leather, tights, rubber, creams and ointments, cosmetics and perfumes, hair dyes, some plants and preservatives.

Discoid

The cause of discoid eczema is unknown. A minor skin injury such as an insect bite or a burn may set it off. It is not associated with an allergy and it does not run in families.

Varicose

Varicose eczema is caused by poor circulation in the legs. It is often preceded by the presence of varicose veins. These occur when the blood does not flow properly from the surface veins to the deep veins and pressure builds up in the surface veins, which results in blood pooling and venous insufficiency.

It is not understood why some people with varicose veins go on to develop varicose eczema and others do not.

Atopic

In the acute form (flare- ups):

The skin will be extremely itchy, red, hot, dry and scaly
The skin may also be wet and weeping and swollen
There may be infection with bacteria (usually staphylococcus)
The most common areas affected are the skin creases such as the front of the elbows and wrists, backs of knees. However, any areas of skin may be affected. The common area for babies to be affected is the face.
In the chronic form (persistent):

The skin will be dry and thickened and may be scaly or cracked.
Your skin is vulnerable to further damage and infection when you have atopic ezcema, it is more likely to be sensitive to and react more easily to certain substances. These trigger factors will make you particularly vulnerable to a flare ups.

Itchiness and heat cause a strong urge to scratch, which further damages the skin. The scratching can disrupt sleep and may be so severe as to make the area bleed. Scratching can make an itch worse and an itch-scratch cycle may develop with regular scratching. In children this can lead to sleepless nights and difficulty concentrating at school.

Contact

Irritant dermatitis may appear as a slight redness, with mild inflammation to a severe inflammation with redness, itching and skin blistering or cracking and bleeding at the site of contact with the irritant. If the condition becomes chronic (long-term), the skin will be dry, inflamed, scaly and thickened.

Allergic contact dermatitis may initially appear as an itchy red rash at the site of contact with the skin. There may be some swelling and blistering. The skin may become thicker and dry and scaly if the allergen persists. The reaction is generally confined to the site of contact with the allergen, although occasionally it may extend outside the contact area or it may spread all over your body. The rash usually clears if the allergen is no longer in contact with the skin, but recurs with any slight contact with it again.

Discoid

One or many round-shaped patches of red skin appear, with well-defined edges. These patches may become very itchy and can have blisters, or they may be hardly noticeable.

It is common for discoid eczema to be infected with bacteria.


Varicose

The first sign is mild itchiness of the skin, just above the ankle, which then becomes speckled, scaly, inflamed and itchy and lesions may develop. If left untreated the skin all around the lower leg can become affected, it can also lead to the formation of ulcers.

Atopic

Your doctor can usually diagnose atopic eczema by skin examination. You will be asked if there is a family history of eczema, asthma and hay fever. Sometimes a blood allergy test will be suggested to help identify any eczema triggers, this however will not usually alter your treatment unless the trigger is easily avoided.

Contact

Your GP will normally refer you to a skin specialist (dermatologist) for patch testing to find out what is causing your allergic contact dermatitis. The test patches are left in place for two days then removed and any reaction is noted. A further examination is carried out after a further two days to detect any further reactions.

Your GP may refer you to a dermatologist for a full assessment and investigation as to the cause of irritant dermatitis, although this is sometimes clear. If the reaction is due to substances you are working with, they can be avoided as far as possible.

Discoid

Your doctor will usually come to the diagnosis by looking at the areas affected. If in doubt, or you need further tests, you may be referred to a skin specialist (dermatologist)

Varicose

Your doctor will usually come to the diagnosis by looking at the areas affected. If in doubt, or you need further tests, you may be referred to a dermatologist (skin specialist).

Atopic

There is no simple cure for atopic eczema but you can do a lot to prevent and treat it. The three main goals of treatment of atopic eczema are healing the skin and keeping it healthy, preventing flare-ups, and treating symptoms as they occur.

Treatment is based on the use of, emollients (moisturisers) including soap substitutes, bath oils and general moisturizers, and topical corticosteroids (steroids) for flare-ups.

There may also be a need for antimicrobial treatment (to treat skin infection), and antihistamine tablets (to help sleep disturbance caused by itching).

In more severe cases which are difficult to treat there may be a need for, oral corticosteroids, other immunosuppressant medicines such as ciclosporin and azathioprine, and phototherapy and photochemotherapy. (light treatment, or light treatment plus medication).

The way you use and apply the treatments is a key factor in how successful control. Failure of treatment can often be due to incorrect use. There are many preparations of each type of treatment. It may take time to find the best one(s). Do not try several new treatments at once - for example, a mixture of creams, new diet and herbal medicine, because if things improve, you will not know which treatment has worked.

Emollients (moisturisers) reduce water loss from the outer layer of your skin by covering it with a protective film. This keeps the water in the skin where it is needed and also helps to keep infections and other harsh substances out. Emollient creams and ointments are essential in the prevention and treatment of eczema. Emollients are very safe and you cannot overuse them. They are not active drugs and do not get absorbed through the skin into the body. See general section on emollients for more information.

Topical corticosteroid (steroid) preparations, including creams or ointments can quickly bring the eczema under control and is the main treatment even in small children. It is not a cure but is effective in reducing the inflammation associated with a flare up of eczema.

For most people with mild to moderate eczema, treatment with a mild steroid (hydrocortisone 1% cream or ointment) for one to two weeks is enough to treat a flare up. You may need to step up to a stronger steroid if there is no response, but in general, you should use the lowest strength that works. Your doctor or pharmacist can explain the differences between the preparations available.

Topical steroids must only be used to treat eczema when the eczema has flared. Start treatment at the first sign of a flare up. You should already be using emollients regularly. Used correctly, topical steroids are safe and effective whereas untreated eczema can have serious consequences. You could be sensitive to one of the ingredients in the cream or ointment, apart from the steroid. If you notice that the eczema gets worse, it is important that you talk to your pharmacist or doctor to discuss alternatives. See general section on topical steroids for more information.

Anti-infective agents You can help to prevent eczema becoming infected by, keeping hands clean and nails clean and short, and avoiding scratching.

If there is any suspicion that the eczema has become infected (redness, weeping or blisters) see your doctor because the infection can spread quickly and the use of steroid creams can mask or further spread the infection. Your GP will give you a course of oral antibiotics and/or an antibiotic cream or ointment.

The oral antibiotic is usually a penicillin such as flucloxacillin (or erythromycin if the patient is allergic to penicillin). Antibiotic creams or ointments used are fusidic acid or mupiricin or a combined steroid and antibiotic cream or ointment Rarely, the infection may have been caused by the cold sore virus (herpes simplex). This is treated with an anti-viral medicine such as aciclovir and hospital admission may be necessary if severe.

Antihistamines Sedative antihistamines, such as alimemazine (previously known as trimeprazine) and hydroxyzine may sometimes help to reduce the itch of eczema at night and give a good night’s sleep. They are only suitable for short periods of treatment (e.g. to break a pattern of sleepless nights). They can make you feel drowsy the next day so may not be suitable if you drive or, if you are treating a child going to school. Give the dose about one hour before bedtime so that it has time to take effect. A bath about an hour before bed followed by plenty of moisturisers can help cool the skin and may be more effective than the antihistamine. Give the antihistamine after bathing not before.

Antihistamine creams are not effective in eczema treatment and should be avoided as sometimes the ingredients in them can make the eczema worse.

Topical immunomodulators Tacrolimus ointment and pimecrolimus cream have recently been introduced. They are not recommended for the treatment of mild atopic eczema or as first-line treatments for atopic eczema of any severity.


Topical tacrolimus is recommended, within its licensed indications, as an option for the second-line treatment of moderate to severe atopic eczema in adults and children aged 2 years and older that has not been controlled by topical corticosteroids where there is a serious risk of important adverse effects from further topical corticosteroid use, particularly irreversible skin atrophy.


Pimecrolimus is recommended, within its licensed indications, as an option for the second-line treatment of moderate atopic eczema on the face and neck in children aged 2 to 16 years that has not been controlled by topical corticosteroids, where there is a serious risk of important adverse effects from further topical corticosteroid use, particularly irreversible skin atrophy.


Over-the-counter medicines for eczema A range of shampoos, emollient products and some topical steroid preparations can be bought from pharmacies. Some of them are cheaper to buy this way, than on a prescription. Ask your pharmacist for advice on the different products and how to use them. After asking you a few questions to find out about you, your condition and any medicines you may take or use (including any treatments applied directly to the skin), they may decide it would be better for you to see your GP to review your condition and its treatment.

Tell your pharmacist if you, or the person who needs the treatment, is allergic to peanuts because some products contain peanut (arachis) oil. If your eczema does not improve after one week of using an over-the-counter preparation, particularly a moderately potent corticosteroid e.g. clobetasone butyrate, you should see your GP.

Hospital treatments People with severe eczema or eczema resistant to treatment may require referral to a skin specialist (dermatologist). Treatments used may include: 'wet wraps', tar and/or steroid occlusion bandages, light therapy, and medicines which suppress the immune system such as ciclosporin.

Complementary treatments Evening primrose oil supplements, borage oil, homeopathy (graphites, nat.mur) and Chinese herbal medicine (Chinese gentian, Chinese wormwood, peony root, rehmannia) have all been used to treat atopic eczema. There is little evidence to prove how these alternative medicines work or how safe or effective many of them are. Certain herbs and preparations contain ingredients that can be harmful if not used with care or if not obtained from reputable sources.

Before using any complementary medicine for eczema, you should talk to your GP or pharmacist (chemist). You can also phone NHS Direct on 0845 4647.

Contact

The three main goals of controlling and treating contact eczema are, the identification and avoidance of the cause, and healing the skin and keeping it healthy.

Whether your eczema is due to an irritant, such as detergent, or due to an allergen, such as nickel, care and treatment of your skin is the same. Treatment is based on the use of, emollients (moisturisers) including soap substitutes, bath oils, and topical corticosteroids (steroids) for flare-ups.

There may also be a need for antimicrobial treatment (to treat skin infection), and antihistamine tablets (to help sleep disturbance caused by itching).

In more severe cases which are difficult to treat there may be a need for, other immunosuppressant medicines such as ciclosporin and azathioprine, and phototherapy and photochemotherapy. (light treatment, or light treatment plus medication).

The way you use and apply the treatments is a key factor in how successful you will be in keeping the eczema under control. Failure of treatment can often be due to incorrect use. There are many preparations of each type of treatment. It is often a matter of practicality and personal preference that determines which preparation is best. It may take time to find the best one(s).

Emollients (moisturisers)

Emollients reduce water loss from the outer layer of your skin by covering it with a protective film. This keeps the water in the skin where it is needed and also helps to keep infections and other harsh substances out. Emollient creams and ointments are essential in the prevention and treatment of eczema. Emollients are very safe and you cannot overuse them. They are not active drugs and do not get absorbed through the skin into the body.

Topical corticosteroid (steroid) preparations

A topical corticosteroid cream or ointment can quickly bring the eczema under control. It is not a cure but is effective in reducn

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