What is Eczema?
Eczema (atopic dermatitis) is a skin condition characterized by chronic inflammation and itching (pruritus), most frequently involving the hands and face. Patients often develop redness, dryness, thickening, and oozing and crusting of the skin. The disease most often affects children but may also be seen in adults. Individuals often have a coexisting diagnosis of asthma and allergic rhinitis. The predilection for allergy and conditions such as eczema, asthma, and allergic rhinitis is referred to as atopy.
Risk factors for the disease include a family history of atopy and certain genetic mutations that result in low skin barrier function.
What Causes Eczema?
Eczema is caused by multiple factors such as genetic mutations, skin barrier dysfunction, and abnormalities in immune function. It is still unclear whether skin inflammation is initiated by abnormalities in the skin barrier or whether it is due to an abnormal immune response.
Major risk factors include family history of atopy - this refers to the presence of eczema, asthma, and allergic rhinitis. About 70% of patients have family members affected with atopy. Genetic mutations such as loss-of-function of the filaggrin gene is also implicated in the pathogenesis of the disease. Individuals exposed to early day care and pets early in life may have a lower risk of developing eczema.
How Common is Eczema?
Eczema is an extremely common skin disorder that is frequently evaluated in the primary care clinic. Severe or advanced cases may require referral to a dermatologist, especially if first-line treatment was unsuccessful.
Worldwide, the prevalence of atopic dermatitis in children is about 5%-20% in the United States, approximately 11% of children are affected by the disease. The annual prevalence in adults is estimated to be 10%-15%. The incidence of atopic dermatitis is rising and is greater in urban areas and developed countries. The condition is slightly more common in females compared to males. Up to 50% of individuals who acquire the disease during childhood continue to have symptoms into adulthood. Approximately 60% of cases occur in the first year of life and about 85% of cases happen by age 5.
Signs and Symptoms
Patients typically develop symptoms before age 5. The most common features include:
- Dry skin
- Severe itching
- Skin hyper-reactivity to environmental stimuli
- Redness - erythema
- Papulation – bump formation
- Oozing & crusting
Environmental stimuli that may provoke inflammation include exposure to certain foods, inhaled allergens, skin irritants, and bacterial infection. Patients with chronic skin lesions often overlying abrasions from scratching (excoriations). They also frequently develop thickening of the skin (lichenification). There are variants of the disease characterized by predominantly eyelid symptoms and occasionally lip eczema (atopic cheilitis). This latter condition results in lip peeling and fissuring.
Mild disease often results in intermittent flares of inflammation that are self-limited and resolve. Moderate to severe disease may be characterized by rash that rarely clears without medical therapy. Patients may have symptoms lasting months to years.
Atopic dermatitis is a clinical diagnosis based on symptoms, history, and physical examination. Major features of diagnosis include one or more of the following:
- Itchy skin (pruritus)
- Inflammation involving the skin creases
- Inflammation involving flexural surfaces
- Inflammation involving the cheeks or dorsal extremities
- History of asthma or allergic rhinitis
- Dry skin within the past year
In rare cases, your dermatologist may obtain immunoglobulin E levels or skin biopsy.
Eczema Medication and Treatment
The treatment of eczema involves eliminating triggers, restoring the skin barrier function, skin hydration, and medical treatment of dermatitis. Mild disease is usually treated with topical corticosteroids and emollients. Low potency corticosteroid cream or ointment may include Desonate (desonide 0.05%) or Cortizone (hydrocortisone 2.5%) applied once or twice daily for up to 1 month.
Low potency corticosteroids are also generally indicated when there is involvement of the face or skin folds. Atopic dermatitis involving the face or skin folds that is refractory to topical corticosteroids may benefit from topical calcineurin inhibitors such as Protopic (tacrolimus) or Elidel (pimecrolimus).
Moderate eczema is usually treated with medium to high potency corticosteroids such as Synalar (fluocinolone 0.025%), Aristocort (triamcinolone 0.1%), and betamethasone dipropionate 0.05%. Severe atopic dermatitis may warrant the use of phototherapy or rarely systemic immunosuppressants in adolescents.
Skin hydration is also an important treatment consideration as the skin tends to get significantly dry with eczema. Dry skin also impedes skin healing. Lotions can actually worsen dry skin as they have a low oil content – therefore, water can evaporate easier. Thick creams such as Eucerin or Cetaphil, or ointments such as Vaseline or Aquaphor are better at hydrating skin. Some patients complain that they result in greasiness of the skin.
- Weidinger S, Novak N. Atopic dermatitis. Lancet 2016; 387:1109. - https://www.ncbi.nlm.nih.gov/pubmed/26377142
- Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol 2014; 71:116. - https://www.ncbi.nlm.nih.gov/pubmed/24813302
The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.