An Overview of Eczema (Atopic Dermatitis)

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Eczema, also known as atopic dermatitis, is an inflammatory skin condition that causes a scaly, inflamed, itchy rash. It can affect people of all ages, although it occurs more frequently in children (generally before the age of five) than adults.

Although the exact cause of eczema is unknown, it is believed to be the result of both genetic and environmental factors. Since there are no tests available to diagnose eczema, the disease will be confirmed based on a physical exam and whether the symptoms meet specific diagnostic criteria.

Treatments options include moisturizers, over-the-counter topical steroids, and prescription medications and therapies designed to alleviate skin inflammation.

Symptoms

Itching (pruritus) is often the first symptom of eczema which typically precedes the outbreak of a rash. The itching tends to get worse at night and can sometimes interfere with sleep.

Not all eczema rashes look the same and can vary by their location and eczema type (such as discoid eczema and dyshidrotic eczema). Still, there are classic signs and symptoms that characterize the disease, including.

  • Dry, scaly patches of skin
  • Areas of swelling and redness
  • Oozing bumps that crust over (particularly where the skin is scratched)
  • Skin discoloration, either lighter or darker, after the rash has healed
  • Areas of thick, leathery skin (most especially in adults)

Scratching only makes eczema worse. In some cases, scratching can cause breaks in the skin through which bacteria and other microbes can pass, causing infection.

Location by Age

The location and appearance of an eczema rash can differ by age group and help distinguish the disease in infants, children, and adults.

  • In infants, the rash typically appears on the cheeks and trunk as well as extensor surfaces (such as the front of a knee or back of the elbow or forearm).
  • In children, flares will less on the face and more on flexor areas (such as behind the knees or in the crook of the elbow).
  • In adolescents and adults, eczema tends to develop on the neck, face, and hands. Adults are also likely to experience lichenification in which affected areas of skin will begin to thicken and turn leathery.

A tell-tale sign of eczema in both adults and kids is the absence of rash in either the armpits or groin.

Stages of Eczema

Eczema has three distinct stages—acute, subacute, and chronic—each of which has different symptoms and treatment approaches.

Unlike other conditions, the stages don't necessarily confer to the disease severity or move in a linear fashion. It is not uncommon for eczema to move back and forth between stages or to suddenly go into low disease activity (remission).

  • Acute eczema is the sudden and severe onset of symptoms characterized by the development of weeping and crusting blisters.
  • Subacute eczema generally bridges the acute and chronic stages and manifests with dry, red, and scaly skin.
  • Chronic eczema is characterized by episodes lasting three months or more with frequent acute flares. n which the skin will change and develop signs of long-term injury.

Dryness and itching are two hallmarks of eczema that occurs with all stages.

Causes

As of yet, the exact cause of atopic dermatitis isn't completely clear. It's believed to be caused by a combination of genetic and environmental factors that work in tandem to cause the inflammatory skin disease.

Genetics

Genetics is believed to play a central role in the development of eczema given that the disease tends to run in families.

In recent years, scientists have proposed that various gene mutations interfere with the production of a protein called filaggrin that provides skin cells structure and helps them retain moisture. The loss of filaggrin undermines the barrier function of the skin, allowing allergens and irritants to enter cells and trigger inflammation.

Environment

Scientists believe that environmental triggers may help instigate eczema in those genetically predisposed to the disease. Some have suggested that babies raised in a "too clean" environment may have impaired immunity and be less able to ward off allergens and irritants that cause inflammation at the cellular level.

Environmental triggers may also instigate acute flares. The triggers can vary from one person to the next and may include:

  • Very dry skin
  • Stress and anxiety
  • Extreme dry, cold temperatures
  • Extremely hot, humid weather
  • Food allergens
  • Dust mites, pollen, molds, and pet dander
  • Highly fragrance soap and skincare products
  • Rough fabrics, such as wool
  • Exposure to metal, especially nickel
  • Cigarette smoke
  • Beauty products containing isothiazolinones, cocamidopropyl betaine, and paraphenylenediamine

Diagnosis

There are no tests or imaging studies able to diagnose eczema. Uncomplicated cases are most often diagnosed with a combination of a physical exam and a review of one's medical history.

This is especially true in babies and children in whom eczema is common. Diagnosing eczema in adults can be more complicated since the disease is less likely to develop in adulthood and is easily mistaken for other skin conditions.

A dermatologist can determine whether the features of the disease meet the diagnostic criteria in established guidelines (such as the Hanifin and Rajka Diagnostic Criteria for Atopic Dermatitis).

Other tests (including patch testing, a KOH test, and skin biopsy) may be ordered to differentiate eczema from other possible causes.

Differential Diagnoses

To ensure the correct diagnosis and the correct treatment plan, the doctor will often perform a differential diagnosis if the cause is anything the certain.

A differential diagnosis is used to differentiate eczema from other related conditions or those that simply look like eczema. Examples include:

Treatment

Eczema is a chronic condition with no known cure. When an eczema flare occurs, the appropriate treatment will vary based on the severity of the rash.

Over-the-Counter Treatments

Mild eczema can often be effectively controlled with a combination of over-the-counter (OTC) treatments, regular moisturizing, and other home remedies. Among them:

  • Skin barrier creams contain lipids and ceramides which help restore moisture and improve the barrier function of the skin.
  • 1% hydrocortisone cream is typically applied before moisturizing to help reduce inflammation.
  • Wet wrap therapy involves wrapping the skin in moist fabric strips for a couple of hours to help hydrate and cool dry, inflamed skin.
  • Bleach baths are sometimes used to reduce inflammation and reduce the risk of bacterial skin infections.

Speak with your doctor before using any home remedy to ensure that it doesn't undermine standard treatments or worsen symptoms.

Prescription Medications and Procedures

Prescription medications are needed in cases where eczema does not clear up with over-the-counter hydrocortisone. These are not typically used on a continuous basis but rather when you have an acute flare. Among the options:

  • Prescription topical steroids like prednisolone, or betamethasone may be more effective than OTC versions but must be used as directed to avoid side effects, like irreversible skin thinning.
  • Topical calcineurin inhibitors such as Protopic (tacrolimus) and Elidel (pimecrolimus) are used in second-line treatment when topical steroids fail.
  • Dupixent (dupilumab) is an injectable medication that is used to treat moderate to severe eczema in adults when topical drugs fail to provide relief.
  • Oral steroids or immunosuppressants are occasionally prescribed to control an eczema flare but are typically reserved for the most severe, recurrent cases.
  • Antibiotics or antifungals may be necessary if your rash has become infected.
  • Phototherapy involves the use of ultraviolet B (UVB) light to reduce inflammation, although it works better for some than others.

Prevention

With conscientious care of your skin, you can greatly reduce your chance of an eczema flare-up by following some key strategies:

  • Use moisturizers liberally. Apply daily, ideally immediately after showering or bathing, and reapply when needed
  • Avoid oversoaking the skin. Limit baths to no more than 10 to 15 minutes as the oversaturation of skin can worsen dryness.
  • Avoid harsh soaps, detergents or solvents. Opt for products that are non-fragrances and dye-free.
  • Wear loose-fitting, light clothing. Avoid scratchy fabrics, tight belts and collars, and fabrics that don't breathe.
  • Know your triggers. Keep a diary to track which substance or events trigger a flare.
  • Manage your stress. Combining stress management with good sleep hygiene and regular exercise may go a long way toward preventing flares.

A Word From Verywell

Gentle skin care and the consistent application of moisturizers are the best steps to minimizing flares and reducing itchiness and irritation. If home treatment isn't enough, over-the-counter and prescription medications can help.

Although eczema can be difficult to manage for some people, a stepped approach to treatment—moving from topical to oral/injectable to combination therapies—can usually identify the best solution for you as an individual.

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