How Should I Treat Eczema?

What is eczema?

Eczema (or ‘dermatitis’) is a non-contagious, inflammatory dry skin condition that affects around one quarter of babies and one fifth of children and 10% of adults. The process usually starts with dry or sensitive skin, and then sometimes patches of itchy eczema then develop. The distribution is often different in different age-groups with babies affected over cheeks and trunk, school-aged children having insides of knees and elbows, and adults scratching face and hands.

We need to treat eczema with great care. Eczema has a huge impact upon quality of life, through affecting sleep quality, children’s ability to engage in sport and social events. If they do not feel comfortable, they may start to lack confidence, avoid activities and feel different to their friends and family members. Eczema can have a big impact upon children’s mental health and happiness.

Why does eczema develop?

If you have eczema, your skin may not produce as much fats and oils as other people’s and will be less able to retain water. The protective barrier is therefore not as good as it should be, and so moisturisers may help provide some relief from dry cracked skin. We now know that one of the major causes of eczema is the dryness of skin, which is made more likely from a broken ‘waterproofing gene’ called filaggrin. If there is less waterproofing filaggrin, the skin dries, looses its protective barrier function, and is more likely to become inflamed, itchy, infected and sensitised to environmental allergens.

How can I tell if it is eczema?

The visual definition of eczema includes poorly outlined patches of dry, itchy skin, with signs of textural change on the surface. In pale skin colours, it often appears pink or even red, however there may be no redness on pigmented skin. In fact, eczema may appear as lighter patches on people with darker skin, or hyper-pigmented darker areas of thickened skin for others. The textural change may appear to be;

  • Roughened
  • Scaly
  • Scratched
  • Open weeping patches (which suggest bacterial skin infection)
  • Popular raised bumps which stay for days or even weeks
  • Diffuse sandpaper-type rash (especially in Afro Caribbean pigmented skin)

The SkinDeep project shows lots of pictures of common skin conditions such as eczema. These pictures have been checked and categorised by dermatologists, and so it represents a library of useful pictures that you can compare to your own skin and the skin of your family members.

The Itch

The urge to scratch is a key diagnostic feature of eczema, and it comes from the inflammation. This is routinely treated with anti-inflammatory creams and ointments, which include the steroid group as well as calcineurin-inhibitor group. Although there is widespread concern, appropriately prescribed and reviewed topical steroid creams are extremely safe. Mild steroid cream (such as Hydrocortisone) do not give rise to side effects, and therefore 1% Hydrocortisone cream is available over the counter. Even moderate topical steroids cannot produce side effects when used daily for 2-4 weeks in appropriate manner, and should be considered the routine treatment to

To review medical guidance on topical steroids and find how strong your prescribed cream is, please refer to the British National Formulary here; Topical corticosteroids | Treatment summary | BNF content published by NICE

Additional eczema treatment may become necessary with higher strengths of creams, phototherapy or oral treatments if there is a lack of response to therapy, however other trigger causes also need to be assessed.

Infection makes eczema flare

Eczematous skin can be infected over individual patches, or flare at the time of a general intercurrent viral illness.

Eczema typically flares at the time of viral coughs and colds, as well as setting off other symptoms such as reflux, stomach ache and loose stool.

However, there can also be direct infection of eczema when staphylococcal skin commensal organisms become very active. These may require antiseptic treatment or antibiotic creams, oral antibiotics or in some cases intravenous antibiotics. Similarly, early onset or severe eczema may be vulnerable to viral infection of the skin as well. If a ‘cold sore’ herpes virus infects the skin of someone with eczema, there can be a marked deterioration with ‘punched out’ round ulcers in the skin which require medical review (and called Eczema Herpeticum).

Further triggers may include allergens, and physical irritants, which are addressed in this blog here.

Myths relating to eczema

Brands of washing powder do not make eczema worse. The link with washing powder came from factory workers making the washing powder with their hands (no gloves!) who developed contact dermatitis from immersion in concentrated alkaline soap all day! There is no medical evidence that changing washing powder improves eczema.

Although milk allergy can be IgE or non-IgE driven, eczema is unlikely to be driven by trace amounts of milk ingestion. If you are considering whether cow’s milk may be causing eczema, it is important to see a doctor because cow’s milk avoidance can result in reduced growth and it is important to assess objectively whether cow’s milk may have a safety implication for your child.

How can I best treat eczema?

Here is an overview on helping your child’s eczema. The essential steps include;

  • Keep the skin consistency in good condition – which may involve daily moisturising with clean hands, and some dry skin types may need regular cream
  • Using an anti-inflammatory cream for patches of itchy eczema. It is safe and normal to buy Hydrocortisone 1% cream over the counter, and this should be considered as first treatment for mild patches of eczema.
  • Consider antiseptic creams or bath wash lotions such as Dermol 500
  • Join Eczema.org to review wide range of advice

Unfortunately, a recent high quality trial in the BMJ showed no benefit for using bath oil treatments for eczema.

There had been hope that eczema could be prevented by moisturising a newborn baby’s skin from birth, however a recent excellent multi-centre trial showed that daily moisturising did not protect babies against the development of eczema.

Eczema is a moving field with lots of active research, so new studies and findings will help us support healthier skin over the years!

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