Eczema, also called atopic dermatitis (AD), is a noncontagious inflammation of the skin that is characteristically very dry and itchy. The condition is frequently related to some form of allergy, which may include foods or inhalants.
Atopic dermatitis is sometimes described as "the itch that rashes"—the scratching of the irritated areas may very well initiate the rash in some patients. The skin of those affected by AD is abnormally dry because of excessive loss of moisture. Chronic or severe cases of it can cause the affected areas to form thick plaques (patches of slightly raised skin), develop serous (watery) exudates, or become infected.
The areas of the body that are affected by AD tend to vary with age. Children under five years old most commonly have AD, but it can occur at any age. It can be mild and intermittent, or severe and chronic. Infants frequently experience it on the face and other areas of the head. They frequently rub their heads with their hands or on the crib bedding. The stomach and limbs may also become involved. Older children commonly have the worst spots on flexor surfaces, namely the inner wrists and elbows, backs of knees, and tops of ankles. The hands and feet are other common sites. The knees, elbows, hands, and feet may continue to be a problem into adulthood.
Causes & symptoms
Genetic predisposition plays a large role in who will get AD or other allergies . The condition is not contagious. A child who has one parent with some form of allergic, or atopic, disease has somewhere between a 25–60% chance of also experiencing allergies, whether AD or some other form. There is approximately a 50–80% chance that a child of two parents with allergies will also develop some form of atopy. The genetic predisposition of the individual, combined with such factors such as early exposure to strong antigens, will determine whether and to what extent that person will develop allergies. Aside from a predisposition to eczema, increased use of soapy detergents and baby wipes is probably responsible for higher incidence of childhood eczema as well.
The hallmark sign of AD is a red, itchy rash. The age of the patient determines what regions are most likely affected, as described above, but exceptions do occur.
No laboratory test can reliably diagnose AD, although some patients will be reactive to tests designed to diagnose allergy. These would include skin tests by intradermal injection, scratch, or patch tests. There is also a blood test available that measures levels of antibodies to suspected allergens. Diagnosis is generally made by the appearance and location of the rash. A personal or family history of allergy of any type, including food allergy, asthma , or hay fever also supports the diagnosis of AD.
Other types of dermatitis that may be described as eczematous include contact dermatitis , nummular dermatitis, and stasis dermatitis. The stasis type is related to poor circulation, which may also be a factor in nummular dermatitis. These forms generally occur in older adults, whereas AD is primarily a disease of children. Contact dermatitis can occur at any age. It results from skin contact with either an irritant or an allergen. The area affected is limited to the area in contact with the offending substance.
The basis of treatment for AD is keeping the skin moist and clean, as well as avoiding irritants and known allergens as much as possible. Further measures become necessary if the case is particularly severe, or if the skin becomes infected.
Conventional wisdom has been that minimal bathing of the patient with AD is ideal. The rationale was that bathing would break down the natural oil barrier of the skin and cause further drying. It actually appears now that frequent long, tepid soaks are beneficial to hydrate the very dry skin that this condition produces. Adding a muslin bag filled with milled oats or the commercially available preparation Aveeno bath to the water can be soothing. The bath water should cover as much of the skin as possible. Wet towels may be draped around the shoulders, upper trunk, and arms if they are above the water level. The face should be dabbed frequently during bathing to keep it moist. The use of soap should be minimized, and limited to very mild agents such as Cetaphil. The bath must be followed within two or three minutes by a gentle patting dry, and a thick application of a water barrier ointment, such as Aquaphor, Unibase, or Vaseline. Lotions are not generally recommended as they almost universally contain alcohol, which is drying and may burn when applied. Soaking in plain water can be painful during severe episodes of AD. Adding one-half cup of table salt to one-half tub of water creates a normal saline solution, similar to what is naturally present in the tissues, and may relieve the burning. Commercial Domeboro powder may also be helpful.
One alternative to bathing is to use soaking wraps. For this method, cotton towels or other cloths are soaked in tepid water, with table salt or Domeboro powder added for comfort if desired. The patient's bed is covered with something waterproof, and the bare skin is covered as thoroughly as possible with the wet wrappings. The body should then be covered by a waterproof covering to slow evaporation. Vinyl sheeting and plastic wrap are two alternatives. The wraps should be left in place for as long as possible, but at least for 30 minutes, before the water barrier and any topical medications are applied.
Environmental improvement affords some relief for many patients. Pet dander and cigarette smoke are potential aggravating factors. Keeping these out of the home is probably for the best, but at minimum, they should not be allowed in the room of the allergic person. Clothing and bedding should be 100% soft cotton, and laundered in detergent with no perfumes. These items should also be washed before the initial use in order to rid them of potentially irritating residues. Clothes should fit loosely to prevent irritation from rubbing. Washing bedding in hot water will help to kill dust mites. Running laundry through a double rinse cycle will help to remove any vestiges of detergent. Avoiding the use of fabric softener or dryer sheets helps, as these are frequently scented and may be irritating. Drying clothes or bedding outdoors should be avoided, because pollen and other potential allergens are likely to cling to them. Mattresses and pillowcase can be covered by special casings that are impervious to the microscopic dust mites that infest them. Under normal circumstances, these mites cause no problem, but they can be a major irritant for the individual with asthma or AD.
Temperature extremes can make AD worse, so heating and cooling should be employed as appropriate, along with adding humidity if needed. Patients tend to have abnormal regulation of body temperature, and sometimes feel warmer or colder than other people in similar circumstances. Sweating will frequently aggravate AD. Room temperature should be adjusted for comfort. Central air conditioning is the best option for cooling the home. Evaporative cooling brings a large amount of potential irritants into the house, as do open windows. Air conditioning rather than open windows should also be used to cool the car. Electrostatic filters and vent covers are available to remove irritants from the air in the house. These should be frequently changed or cleaned as recommended by the manufacturer.
In the patient's room, dust-collecting items such as curtains, carpeting, and stuffed animals are best minimized. Vacuuming and dusting should be done regularly when the affected person is not in the room. A HEPA filter unit, and a vacuum with a built-in HEPA filter remove a high percent of dust and pollen from the environment.
Some simple mechanical measures will reduce the amount of skin damage done by scratching. It is important to keep fingernails short. Using a nail file will produce a smoother nail edge than scissors or clippers. It is particularly difficult to keep children from scratching irritated and itchy skin, but using pajamas and clothing with maximum skin coverage will help to protect the bare skin from fingernails. Mittens or socks may be used to cover the hands at night to reduce the effects of scratching. Infant gowns with hand coverings are useful for the very young patient.
In addition to the skin care and environmental measures to relieve eczema, there are some complementary therapies that may prove helpful.
Any type of therapy that relieves stress can also help to manage AD. Acupuncturists also claim to be able to treat blood and energy deficiencies, and to counteract the effects of detrimental elements, including heat, dampness, and wind.
Autogenic training is similar to methods of meditation and self-hypnosis. Instructors help the patient to achieve and maintain a relaxed state of positive concentration. This is eventually done independently. Even ten minutes of practice per day can produce beneficial results for mind and body. Research has shown AD to be one of the conditions that is improved by this technique.
Massage is another therapy that can be effective in reducing stress. The oils that are used in the treatment can also make a difference in AD. Some patients get relief from the topical use of evening primrose oil (EPO) diluted in carrier oil. Aromatherapists may use small amounts of essential oils from lavender , bergamot, and geranium. These are promoted to decrease both itching and inflammation. Improper dilutions, however, can worsen the condition.
Some herbal therapies can be useful for skin conditions. Among the herbs most often recommended are:
- Calendula (Calendula officinalis ) ointment, for anti-inflammatory and antiseptic properties.
- Chickweed (Stellaria media ) ointment, to soothe itching.
- Evening primrose oil (Oenograceae ) topically to relieve itching, and internally to supplement fatty acids.
- German chamomile (Chamomilla recutita ) ointment, for anti-inflammatory properties.
- Nettle (Urtica dioica ) ointment, to relieve itching.
- Peppermint (Menta piperita ) lotion, for antibacterial and antiseptic properties.
- Chinese herbal medicine. In traditional Chinese medicine , there are formulas used to treat eczema that nourish the blood, moisten the skin, stop itching, and encourage healing. Some formulas are used topically and others taken internally.
There is individual variation in the effectiveness of the topical treatments. Some experimentation may help to find the combination that most benefits an individual. When the condition is chronic, severe, or infected, guidance from a health care professional should be sought before attempting self-treatment.
Hypnotherapy has the potential to improve AD through using the power of suggestion to reduce itching. Since mechanical damage to the skin done by scratching may irritate, or actually cause, the rash, any measure that reduces scratching can prove helpful.
There are several nutrients that can prove helpful for treating AD. Oral doses of EPO, which contains gammalinolenic acid, have been shown to significantly reduce itching. The amount used in studies was approximately six grams of EPO per day. Fish oil has also been shown to improve AD, at an approximate dose of 1.8 g per day. Vitamin C can affect both skin healing and boost the immune system. Doses of 50–75 mg per kilogram of body weight have been proven to relieve symptoms of AD. Additional copper may be required in supplemental form when high doses of vitamin C are taken. Vitamin E is reportedly useful, but there are no documented studies of its benefits.
The areas of the foot that receive attention from a reflexologist when a patient has AD include the ones relating to the affected areas of the body, as well as those for the solar plexus, adrenal glands, pituitary gland, liver, kidneys, gastrointestinal tract, and reproductive glands.
Allopathic treatment involves use of oral antihistamines to decrease itching, topical water barriers as mentioned above, mild topical corticosteroids when indicated, and topical antibiotics if needed. The water barrier should be applied generously; the corticosteroids and antibiotics used sparingly, and only on areas where indicated. The person applying the topical medications can wear gloves to minimize exposure to the steroids and antibiotics. Oral antibiotics may also be used when widespread infection is present. On rare occasions, oral corticosteroids are prescribed to reduce severe itching and inflammation, but this course is best avoided due to its potential side effects. In 2001, the U.S. Food and Drug Administration (FDA) approved a new nonsteroid prescription cream for patients age two and older called Elidel.
There is no cure for AD, although most patients will experience improvement with age. Perhaps half of children will have no further trouble past the age of five years. However, as many as 75% of those who have AD in childhood will go on to have other allergic manifestations such as asthma, food allergies, and hay fever . Diligent daily care of the skin and avoidance of known triggers will control most cases of AD to a large extent.
One of the best things a mother can do to help keep her child from getting AD is to breastfeed. It is best for the baby to have breast milk exclusively for at least six months, particularly when there is a family history of AD or other types of allergy. There also appears to be an advantage to the breastfeeding mother avoiding foods known to be commonly allergenic, particularly if there is a family history. This would include wheat, eggs, products made from cow's milk, peanuts, and fish. If breastfeeding is not possible, a hypoallergenic formula should be used if there is family history of allergy. Consult a health care provider for help with determining the best type.
The patient already diagnosed with AD can minimize flare-ups by avoiding known triggers and following the skin care program outlined above. It is important to continue to follow guidelines for a daily emollient routine (moistening skin twice daily) even when skin is under control to prevent flare-ups. Eczematous skin is also more susceptible to infections . Patients should try to stay away from people with chicken pox, cold sores, and other contagious skin infections.
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Teresa G. Odle
—eczematous (eks-em-ă-tŭs) adj.
ec·ze·ma / ˈegzəmə; ˈeksə-; igˈzēmə/ • n. a medical condition in which patches of skin become rough and inflamed, with blisters that cause itching and bleeding, sometimes resulting from a reaction to irritation (eczematous dermatitis) but more typically having no obvious external cause. DERIVATIVES: ec·zem·a·tous / igˈzemətəs; ikˈsem-; igˈzē-/ adj.