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Eczema Skin Treatment

Eczema (Atopic dermatitis, or AD for short) is a common chronic skin disease which usually starts in childhood. Atopic is a term used to describe allergic conditions such as asthma and hay fever. Both dermatitis and eczema mean inflammation of the skin.
People with eczema tend to have dry, itchy and easily irritated skin. They may have times when their skin is clear and other times when they have a rash.

Atopic dermatitis usually begins and ends during childhood, but some people continue to have the disease into adulthood. If you ever had atopic dermatitis, you may have trouble with one or more of these:

  • Dry, sensitive skin
  • Hand dermatitis
  • Skin infections

More than half of people with eczema also suffer from asthma and/or hayfever (allergic rhinitis). One out of three children with moderate to severe eczema may have food allergy.

The main symptom of eczema is itchy skin. The itching can interfere with daily activities and make it hard to sleep. Scratching the rash can irritate the skin, making it itch even more, which, in turn, increases the tendency to scratch. This itch-scratch cycle can leave the skin open to infections.

Our cold Wisconsin winters can make eczema worse as cold air is dry and heating further removes moisture from the skin.
Comprehensive eczema skin treatment begins with an accurate diagnosis, including identification of triggers and the development of an effective skin care regimen.

Causes of eczema

Eczema is now thought to be due to a “leaky” skin barrier. This allows water to leak out, making the skin dry. In addition, allergens, irritants and bacteria can more easily penetrate the leaky skin further contributing to eczema. Leaky skin can be caused by genes inherited from parents or by factors in the environment:

  • Faults in the Filaggrin gene cause moderate to severe eczema in up to a third of people of North European and Eastern Asian descent.
  • Exposure to soaps, detergents, house dust mite, pollens, animal dander and some bacteria, which contain proteins called “proteases” can all flare eczema.  Proteases break the links between skin cells and make the skin barrier leaky.  

Symptoms

In infants and children the rash usually occurs on the scalp, knees, elbows and cheeks.

In adults the rash can occur on the creases of wrists, elbows, knees, ankles, face and neck.

The rash is usually itchy, red and scaly. Scratch marks often occur due to the itchy nature of the rash. If one has this rash for a long period of time the affected skin can become thicker.

The dry skin can worsen the itching and rash. An “itch-scratch cycle” can occur with rubbing or scratching the skin causing more irritation, and thus, additional itching. 

It is important to remember that the symptoms of eczema vary from person-to-person and mild cases may be mistaken for simply chapped skin. In more severe cases, the skin can have open sores that may weep. The specialists at the Allergy & Asthma Center have the medical knowledge to assess and treat your eczema. You’ll receive a treatment plan to help you control your symptoms and keep eczema at bay.

Triggers

Irritants: Irritants such as chemicals, soaps, detergents, fragrances, certain fabrics, and smoke can further irritate the skin in patients with eczema.  

The following steps can be taken to reduce irritant exposures:

  • Wear comfortable clothing.
  • Wash all new clothes prior to wearing.
  • Keep fingernails short and smooth to help prevent additional skin damage from scratching.
  • Use broad-spectrum ultraviolet (UV) protective sunscreen (UV-A and UV-B with an SPF of 15 or higher).
  • Bathe immediately after swimming to reduce and remove exposure to various chemicals found in swimming pools and beaches. Always apply your moisturizer immediately afterwards to minimize further drying out of the skin.

Inhaled Allergens: House dust mites are small, microscopic (you cannot see them with the naked eye) organisms. They are typically found indoors (mattresses, pillows, carpet), typically in areas of high humidity. These have been associated with eczema. Additional inhaled allergens such as animal hair and dander, pollens and molds can lead to intermittent, chronic and seasonally exacerbations of eczema.

Foods: Common allergic foods have been associated with eczema. If you consistently notice worsening of your rash after ingesting certain foods, notify your allergist / immunologist for further evaluation. Of particular note, eliminating a variety of foods from the diet that you are not allergic to is rarely helpful in patients with eczema, so any evaluation of a possible food allergy should first be done with careful consultation with an allergist / immunologist.

Stress: Emotions and stress, including anger and frustration, can cause additional itching, thus potentially worsening the “itch-scratch cycle.”

Treatment

Topical Therapies: Topical means applying directly to your skin. There are many topical therapies:

Ointments: These tend to have more oil than water and  usually are more thick and greasy. These are the most common types of moisturizers used to treat eczema.

Creams: These are a mix of oil and water, and usually looks white and smooth. They are less greasy than ointments.

Lotions: These are thinner than ointments and creams.

Solutions: These are a more liquid form and feel like water.

Topical moisturizers

Dry skin tends to worsen the itching and rash. In addition, the drier the skin, the more disrupted and “leaky” the barrier. Various environmental issues, such as exposure to low humidity and wind can further dry the skin. Therefore, moisturizing (hydrating, or adding water) your skin is an important component to eczema care. After soaking your skin in a bath or shower, pat dry the skin gently (pat the excess droplets of water). Then, immediately apply a moisturizer on the slightly wet skin to “lock” in the water and thus, improve dryness.

It is important to know that moisturizers are NOT steroids. In fact, aggressive moisturizer use has been shown to reduce (not eliminate) the need for topical anti-inflammatory medications. It is also important to tell the difference between steroids or other anti-inflammatory medications and moisturizers. Your allergist / immunologist can help you differentiate between them.

Topical steroids

Topical steroids are anti-inflammatory medications that are used on the rash areas (the red and inflamed areas of the skin) of the skin. The steroids used for eczema are different from other types of steroids, such as testosterone and estrogen. When used properly as advised by your physician, topical steroids are safe and very effective. One topical steroid may be stronger (more potent) than another, and thus, may improve the rash more effectively than a weaker topical steroid. However, the stronger steroid also has the potential for more severe side effects including thinning of the skin. Therefore potent steroids should not be used on certain areas, such as the underarms, groin area, and face. Usually, topical steroids found over-the-counter are less strong than prescription steroids. Bring all topical medications (they come in various forms, including creams, lotions, and ointments) to your allergist / immunologist, so the physician can differentiate between the various steroids and other topical medications.

Steroid pills or steroid injections (shots) are much stronger than topical steroids and can therefore cause more side-effects (including weight gain and bone problems). In general, they should be avoided, particularly in children.  

Other topical anti-inflammatory medications

Other topical anti-inflammatory medications called topical immunomodulators are becoming more widely available and used to treat eczema. They are usually second-line agents which are used if steroids are unsuccessful. As they are not steroids, these medicines can be used on eyelid and other facial areas, as they do not normally thin the skin. As with any other medications, they have other potential side effects, so one must discuss them with an allergist / immunologist prior to use.

Wet-wrap therapy

Wet wrap therapy is usually used for people with moderate to severe and difficult to manage eczema. With this therapy, the skin is soaked in warm water for about 15-20 minutes and then, is patted dry. Topical medications (typically, steroids) are then placed on the “rash” areas of the skin. Then, a wet (not dripping) dressing (either gauze or clothing) is applied on top of the rash areas. This is followed by a dry wrap material, such as elastic bandage, pajamas, or sock, placed over the wet dressing. For patient comfort, a warm blanket may also be used. Wraps are used typically for 2-6 hours. The use of wet wrap therapy is individualized and should be performed under the close guidance of your allergist / immunologist.

Antihistamines

Oral, or pill, antihistamines do not reduce the itch associated with eczema, as it is not triggered by histamine. Sedative antihistamines are sometimes used to help encourage much needed sleep at night. However, there are potential side effects, including increased sleepiness, or sedation during the day, increased dryness, and difficulty urinating. Topical antihistamines should be avoided, as they may worsen your rash.  

Therapies for associated infections

If your allergist / immunologist diagnoses an associated infection with the rash, an antibiotic may be prescribed. Your skin may be infected if there is oozing, crusting, your clothes start to stick to your skin, or you have the development of cold sores or fever blisters.

Bathing strategies including dilute bleach baths

Very dilute bleach baths (typically, one quarter to one half cup of bleach mixed with 40 gallons of water bath) once weekly may help improve the rash and may decrease the need for antibiotics, particularly in people who tend to develop recurrent skin infections with their eczema.

Stress-relieving therapies

Stress reduction techniques, such as biofeedback and other techniques may be used to improve mood and decrease anxiety associated with eczema.

Vitamins

There has been a recent increase in studies associating vitamin D deficiency with eczema. If you have been diagnosed with vitamin D deficiency (low Vitamin D level) by your physician, Vitamin D supplements may be prescribed.

Biologic medicines

Biologic medications are newer anti-inflammatory medications that have been approved for other allergic diseases, such as asthma, as well as for other skin conditions, such as psoriasis. Dupilumab is a newer biologic therapy that has been approved for the treatment of severe eczema.  Your allergist / immunologist can discuss biological medications with you.

Allergy shots (allergy injections)

Allergy shots (giving injections of small doses of what you are allergic to, such as dust mites, under the skin in the arms) are currently approved for the treatment of asthma and allergic rhinitis (hay fever). Allergy shots can help some patients with eczema. Allergy shots are not the same as steroid shots, or steroid injections. Your allergist / immunologist can discuss whether allergy shots are appropriate for your eczema.   

In summary, eczema is usually manageable, regardless of your age. There are many treatments currently available and future therapies are on the way. With careful evaluation and follow up with your allergist / immunologist, you can have a very high quality of life and enjoy all your activities.

Patients at the Allergy & Asthma Center can expect to receive an individualized treatment plan for their eczema. 
If you have itchy, dry or red skin that doesn’t seem to go away, call and make an appointment for an evaluation at the Allergy & Asthma Center today.

References

Lio P, Lee M, LeBovidge J, Timmons K, Schneider L.  Clinical Management of Atopic Dermatitis: Practical Highlights and Updates from the Atopic Dermatitis Practice Parameter 2012. J Allergy Clin Immunol Pract. 2014; 2: 361-9.

Nicol N, Boguniewicz M, Strand M, Klinnert M. Wet Wrap Therapy in Children with Moderate to Severe Atopic Dermatitis in a Multidisciplinary Treatment Program.  J Allergy Clin Immunol Pract. 2014; 2: 400-6.

Boguniewicz M and Leung D.  The ABC’s of managing patients with severe atopic dermatitis.  J Allergy Clin Immunol 2013; 132: 511-512e1-e5.

Eczema: Topical Corticosteroids Myths and Facts, National Eczema Association 2013.
Therapeutic Principles in Dermatology.  ACP-MKSAP 17; 2016: 4.

www.AAAAI.org