Introduction
The treatment of eczema should reflect the needs of the individual
and their eczema. The extent of the eczema and the areas affected
will influence the choice of treatment. Although there are a variety
of different treatment approaches, first-line therapy usually involves
a topical skin-care regime in which creams or ointments are applied
directly to the skin. This usually involves the regular use of
moisturisers with the addition of topical steroids as an active
treatment when needed.
Skin-care regimes such as these are the mainstay of eczema
management, but they can be messy, fiddly and time-consuming,
leading to a potential underuse or misuse of treatment and
difficulties of ‘sticking’ to the regime. With a chronic condition such
as eczema, the results of treatment are not always instant or clearly
visible, hence it can be difficult to maintain motivation and
concordance with therapy. It is the skill of the doctor or nurse to
enthuse, inform and educate those with eczema so that they can
make informed treatment decisions in partnership with health-care
professionals. This is why we use the term ‘concordance’ instead
of the more old-fashioned term ‘compliance’ as it reflects some
agreement on the type of treatment regime chosen. In addition, it
is important to be aware of other sources of information, such as
the National Eczema Society.
Overall, the key thing to consider with the management of
eczema is to be realistic about treatment expectations. Eczema is
a chronic condition, and therefore the aim of treatment is improved
management and maintenance. Clearance may be attained in the
short term, but a cure is not possible. When deciding on the mode
of treatment, one must consider the fine balance between clearance
and the potential of side-effects of the treatment. To better illustrate
this point, think of a couple of different scenarios: for a child a
realistic expectation might be to control the eczema at a level that
does not interfere with social, psychological or physical
development, whereas with adults the goal may be to maintain
eczema at a level that does not interfere with a desirable quality
of life. This can be much more realistic and achievable than always
aiming for completely clear skin.
No matter how well eczema is controlled, there will always be
the occasion when a flare is experienced. The nature of eczema is
to fluctuate: a flare is not an indication that treatment has failed
but just an indication to step up a gear to tackle a more severe
presentation. It is therefore helpful to think of first-line eczema
treatment as having two phases. The first is a maintenance phase
consisting of a weaker treatment regime that will continue as long
as the eczema has the potential to cause problems; the second is
a stronger set of creams to use in the short term when the condition
flares. A recent study of attitudes to eczema treatment interviewed
200 patients across Europe, with the following findings:
• 75% of patients/carers said that being able to control the
eczema effectively would be the single most important
improvement to their quality of life;
• 55% admitted to worrying about the next flare (36%
sometimes worried, 19% always worried);
• patients with moderate eczema spent an average of 97 days
each year in a flare, whereas for those with severe eczema
the figure was 146 days;
• 66% of patients/carers used topical steroids only as a last
resort; 58% restricted their use of topical steroids to certain
body areas owing to concern about side-effects, and 39%
used them less frequently than their doctor recommended,
for the same reason;
• 67% of patients/carers said that their preferred treatment
option was to apply a non-steroid treatment as early as
possible to prevent a flare.
Wednesday, April 1, 2009
Is there anything else we can do to stop the eczema getting worse?
Apart from following the advice in the chapter on treatment, there
are some general measures that can be of benefit. As with other
bits of general advice in this book, the measures may apply much
more to people with an atopic type of eczema:
• Avoid any pets with furry or hairy coats, such as rabbits,
hamsters, cats, dogs and horses. We don’t advise getting rid
of existing pets, but you might want to consider not
replacing them when they die.
• Clothes and bedding should be of cotton or even silk as
these are less irritant than wool and synthetic materials.
• Keep fingernails cut short, and consider wearing cotton
gloves or mittens at night.
• Try to use a non-biological washing powder and rinse
clothes thoroughly after washing to remove traces of soap
powder. It might be useful to use an extra rinse cycle on the
washing machine.
• Pollen can sometimes make eczema worse. Adult eczema
sufferers can ask a relative or friend to cut the grass; if your
child is affected, cut the grass in the evening after he or she
has gone to bed.
• Wear cotton gloves when doing housework such as
vacuuming, polishing or dusting, keep the room well
ventilated, and if your child has eczema, ask him or her to
stay out of the room you are cleaning.
• Keep cool; sweat can irritate the skin, leading to intensely
itchy, dry, eczematous skin.
• Avoid handling or preparing irritant foods such as citrus
fruits, onions, chillies, raw vegetables (especially tomatoes)
and salty food.
• Cigarette smoke can be an irritant to eczema so encourage
smokers to keep their habit outside the home.I have been recently advised that my daughter’s eczema is
aggravated by teething, smoke and cat or dog hair. She is
18 months old. Could you please advise on such claims –
she hasn’t had any tests?
It depends a bit on who is giving you this advice and whether it is
general or specific. Teething has been reported as causing flares
of eczema on the face in young children, but this could be related
to the increased dribbling causing irritation around the mouth
rather than to any direct effect of teething. Smoke is irritant to the
skin so this is good advice – try to make sure that your daughter
is not exposed to any smoke.
Cat and dog hair can be a problem, and this is usually a direct
allergic effect so could show up on a blood test. It is very unfair to
make young children have blood tests as you may already have a
feeling that the family pet is causing a problem. It is interesting
that it is not cat hair itself that causes the problem but something
in the cat’s saliva, which coats the hairs after all the washing that
cats do. With dogs, the allergen is in the hair itself. Try to keep the
pet out of your daughter’s bedroom, and keep a play mat handy to
put down on carpets that may have pet hair on them.
are some general measures that can be of benefit. As with other
bits of general advice in this book, the measures may apply much
more to people with an atopic type of eczema:
• Avoid any pets with furry or hairy coats, such as rabbits,
hamsters, cats, dogs and horses. We don’t advise getting rid
of existing pets, but you might want to consider not
replacing them when they die.
• Clothes and bedding should be of cotton or even silk as
these are less irritant than wool and synthetic materials.
• Keep fingernails cut short, and consider wearing cotton
gloves or mittens at night.
• Try to use a non-biological washing powder and rinse
clothes thoroughly after washing to remove traces of soap
powder. It might be useful to use an extra rinse cycle on the
washing machine.
• Pollen can sometimes make eczema worse. Adult eczema
sufferers can ask a relative or friend to cut the grass; if your
child is affected, cut the grass in the evening after he or she
has gone to bed.
• Wear cotton gloves when doing housework such as
vacuuming, polishing or dusting, keep the room well
ventilated, and if your child has eczema, ask him or her to
stay out of the room you are cleaning.
• Keep cool; sweat can irritate the skin, leading to intensely
itchy, dry, eczematous skin.
• Avoid handling or preparing irritant foods such as citrus
fruits, onions, chillies, raw vegetables (especially tomatoes)
and salty food.
• Cigarette smoke can be an irritant to eczema so encourage
smokers to keep their habit outside the home.I have been recently advised that my daughter’s eczema is
aggravated by teething, smoke and cat or dog hair. She is
18 months old. Could you please advise on such claims –
she hasn’t had any tests?
It depends a bit on who is giving you this advice and whether it is
general or specific. Teething has been reported as causing flares
of eczema on the face in young children, but this could be related
to the increased dribbling causing irritation around the mouth
rather than to any direct effect of teething. Smoke is irritant to the
skin so this is good advice – try to make sure that your daughter
is not exposed to any smoke.
Cat and dog hair can be a problem, and this is usually a direct
allergic effect so could show up on a blood test. It is very unfair to
make young children have blood tests as you may already have a
feeling that the family pet is causing a problem. It is interesting
that it is not cat hair itself that causes the problem but something
in the cat’s saliva, which coats the hairs after all the washing that
cats do. With dogs, the allergen is in the hair itself. Try to keep the
pet out of your daughter’s bedroom, and keep a play mat handy to
put down on carpets that may have pet hair on them.
Should I remove foods containing colourings and additives from my daughter’s diet?
Unless there is a very strong link with her eczema, i.e. every time
these foods are consumed the eczema becomes worse, we do not
think that this is necessary. Colourings and additives may be
important with some children with another disorder called urticaria
or hives, but the link with eczema is very tenuous. In practice, they
are extremely difficult to avoid as they seem to be added to so many
foods favoured by children. It may be helpful to discuss this further
with a dietitian before embarking on such an exclusion diet.
these foods are consumed the eczema becomes worse, we do not
think that this is necessary. Colourings and additives may be
important with some children with another disorder called urticaria
or hives, but the link with eczema is very tenuous. In practice, they
are extremely difficult to avoid as they seem to be added to so many
foods favoured by children. It may be helpful to discuss this further
with a dietitian before embarking on such an exclusion diet.
Would you ever use a diet?
Yes, we would occasionally consider a dairy-free diet in a child less
than 1 year old if other conventional treatments were not working
well. In addition, if there were a clear-cut history of a certain food
making the eczema worse every time it was consumed, we would
consider a 3-month exclusion trial.
To ensure that adequate nutrition is provided, a dietitian should
supervise any dietary approach. A dietitian can also give invaluable
advice on which foods to use and where to obtain them. Do not
try to follow diets listed in magazines or shown on the television
as there is the potential to develop a regime that does not
completely exclude all the relevant food, and there is also a risk
of undernourishing the child.
At the end of the 3-month exclusion, the food thought to be at
fault should be reintroduced. If the eczema does not come back,
it may be that it was only a temporary problem or that the food
was not making the eczema worse. If the eczema returns, theexclusion diet should be restarted as the final ‘proof’ needs to
come from demonstrating that the exclusion works a second time.
Even in this case, the problem rarely persists for more than a year
or so.
We wish that diet were more important in eczema as it would
provide an easy and safe approach to therapy. Our general
experience has, however, shown that diets are extremely hard work
and are often disappointing in terms of any impact they have on
eczema.
I have eczema and am very allergic to peanuts. Are these
two conditions related?
No, they are probably not directly related. Nuts, especially peanuts,
are well known for causing a severe allergic reaction, called
anaphylaxis, characterised by swelling of the lips and face, vomiting,
difficulty breathing, a widespread nettle rash and even collapse.
The incidence of this appears to be increasing, and the allergy is
lifelong, unlike many other childhood food intolerances.
There is a growing feeling that children, especially those with
an ‘atopic tendency’, should avoid eating peanuts, and to a lesser
extent other nuts, until late childhood. This may prevent nut allergy
developing but has nothing to do with the causes of eczema. You
should make sure that you carry a card or wear a bracelet to let
anyone know that you have this problem in case you are so badly
affected that you cannot speak.
than 1 year old if other conventional treatments were not working
well. In addition, if there were a clear-cut history of a certain food
making the eczema worse every time it was consumed, we would
consider a 3-month exclusion trial.
To ensure that adequate nutrition is provided, a dietitian should
supervise any dietary approach. A dietitian can also give invaluable
advice on which foods to use and where to obtain them. Do not
try to follow diets listed in magazines or shown on the television
as there is the potential to develop a regime that does not
completely exclude all the relevant food, and there is also a risk
of undernourishing the child.
At the end of the 3-month exclusion, the food thought to be at
fault should be reintroduced. If the eczema does not come back,
it may be that it was only a temporary problem or that the food
was not making the eczema worse. If the eczema returns, theexclusion diet should be restarted as the final ‘proof’ needs to
come from demonstrating that the exclusion works a second time.
Even in this case, the problem rarely persists for more than a year
or so.
We wish that diet were more important in eczema as it would
provide an easy and safe approach to therapy. Our general
experience has, however, shown that diets are extremely hard work
and are often disappointing in terms of any impact they have on
eczema.
I have eczema and am very allergic to peanuts. Are these
two conditions related?
No, they are probably not directly related. Nuts, especially peanuts,
are well known for causing a severe allergic reaction, called
anaphylaxis, characterised by swelling of the lips and face, vomiting,
difficulty breathing, a widespread nettle rash and even collapse.
The incidence of this appears to be increasing, and the allergy is
lifelong, unlike many other childhood food intolerances.
There is a growing feeling that children, especially those with
an ‘atopic tendency’, should avoid eating peanuts, and to a lesser
extent other nuts, until late childhood. This may prevent nut allergy
developing but has nothing to do with the causes of eczema. You
should make sure that you carry a card or wear a bracelet to let
anyone know that you have this problem in case you are so badly
affected that you cannot speak.
Can you give me some advice about diet and eczema?
A number of research studies have examined the role of diet in
atopic eczema so this answer really only applies if you have this
type. These studies have looked at exclusion of diary products,
chicken, wheat, flavourings and additives. Some studies seem to
indicate a link, but many of the newer studies do not show any
relationship. You have to remember that all studies of eczema are
difficult, for three reasons:
• First, eczema fluctuates in severity, regardless of any
treatment given.
• Second, eczema spontaneously resolves in most children as
they get older.
• Finally, it is difficult to accurately quantify or score the
severity of eczema.
Studies have to take all these factors into account and ideallyuse a placebo group who receive no active treatment. The placebo
group is important because one must know how many people
would improve even though they are not getting any of the specific
treatments being assessed in the trial.
This all seems rather confusing, but the most recent studies
have been well conducted and have used placebo groups. They
have looked mainly at dairy-free diets and very severe exclusion
diets, such as elemental diets in which only a few types of food
are allowed. The results have shown that dietary changes do not
usually cause an improvement in eczema after the age of 1 year.
There was a possible benefit from a dairy-free diet in children
under 1 year old, but the effect was so small that, statistically, this
might have occurred by chance. All studies have revealed that it
is difficult for families to stick to special diets, especially when
children go to school, parties, etc. We do not routinely advise
dietary manipulation as a way of treating eczema. If you are
convinced that one food or a group of related foods is important
in making your eczema worse, you should only try and change
your diet with the help of a dietitian.
atopic eczema so this answer really only applies if you have this
type. These studies have looked at exclusion of diary products,
chicken, wheat, flavourings and additives. Some studies seem to
indicate a link, but many of the newer studies do not show any
relationship. You have to remember that all studies of eczema are
difficult, for three reasons:
• First, eczema fluctuates in severity, regardless of any
treatment given.
• Second, eczema spontaneously resolves in most children as
they get older.
• Finally, it is difficult to accurately quantify or score the
severity of eczema.
Studies have to take all these factors into account and ideallyuse a placebo group who receive no active treatment. The placebo
group is important because one must know how many people
would improve even though they are not getting any of the specific
treatments being assessed in the trial.
This all seems rather confusing, but the most recent studies
have been well conducted and have used placebo groups. They
have looked mainly at dairy-free diets and very severe exclusion
diets, such as elemental diets in which only a few types of food
are allowed. The results have shown that dietary changes do not
usually cause an improvement in eczema after the age of 1 year.
There was a possible benefit from a dairy-free diet in children
under 1 year old, but the effect was so small that, statistically, this
might have occurred by chance. All studies have revealed that it
is difficult for families to stick to special diets, especially when
children go to school, parties, etc. We do not routinely advise
dietary manipulation as a way of treating eczema. If you are
convinced that one food or a group of related foods is important
in making your eczema worse, you should only try and change
your diet with the help of a dietitian.
What can make eczema worse?
My symptoms of eczema seems to be much worse now as
soon as I get home from work. As soon as I get in, I start
scratching for no reason, and it gets worse over the
evening and in my sleep. Why is this happening?
The pattern of scratching and irritation you describe could arise
for a number of reasons. First, consider your home environment:
for example, do you keep your home very warm? The use of central
heating can create a dry atmosphere; this plus the heat can act as
a trigger to irritation in eczema so it is best to keep your home cool
if possible. This might not be tolerated quite as well by others you
share the house with, but it will be helpful in reducing your
irritation. Also consider whether other factors at home – for
example, animal dander or cigarette smoke – could be causing the
exacerbation. Your home differs from the environment at work as
it comprises more carpeting, curtains and soft furnishings, all of
which are a potential haven for house dust mites. Measures to
reduce house dust mites (as described in Chapter 4) might help
your eczema so might be worth trying for a couple of months to
see whether they have an effect.
Just being relaxed at home could be part of the problem too as
you are probably busy and distracted at work – so although you
might get the itchy sensation, you might not have the opportunity
to scratch. Once at home, you might feel more ‘free’ to scratch, and
there are fewer distractions to blur the itch sensation. This can
progress to the point at which you might have developed a habit
of scratching as soon as you get home. Once an itch–scratch cycle
is established, it can become habitual. If you feel that this could
be a possibility, you may find the advice at the end of Chapter 4
helpful.Since I have developed eczema, I have been told not to
use soap, but I don’t really feel clean unless I have used
soap. Can you suggest one that I can use?
Soaps have an alkaline base and as such have a drying, irritant
effect on the skin. When we use a soap to cleanse the skin, it
removes not only the dirt, but also the protective grease produced
by the skin to maintain the barrier function. We only have to look
at the hands of people who do a lot of washing-up and cleaning to
see how irritant soap can be so it should be avoided by anyone
with eczema. By soap, we mean anything that creates lather or
bubbles so bubble bath and shower gel should also be avoided. A
soap substitute, such as aqueous cream or emulsifying ointment,
should be used instead; this will still have an effective cleansing
effect on your skin. There are also some more expensive soap-free
lotions that you might find easier to use – they even come in
containers like shower gel. If you are set on using soap, try to limit
it to specific areas such as your armpits and choose a pH-neutral
variety that is non-perfumed and has added moisturising creams.
soon as I get home from work. As soon as I get in, I start
scratching for no reason, and it gets worse over the
evening and in my sleep. Why is this happening?
The pattern of scratching and irritation you describe could arise
for a number of reasons. First, consider your home environment:
for example, do you keep your home very warm? The use of central
heating can create a dry atmosphere; this plus the heat can act as
a trigger to irritation in eczema so it is best to keep your home cool
if possible. This might not be tolerated quite as well by others you
share the house with, but it will be helpful in reducing your
irritation. Also consider whether other factors at home – for
example, animal dander or cigarette smoke – could be causing the
exacerbation. Your home differs from the environment at work as
it comprises more carpeting, curtains and soft furnishings, all of
which are a potential haven for house dust mites. Measures to
reduce house dust mites (as described in Chapter 4) might help
your eczema so might be worth trying for a couple of months to
see whether they have an effect.
Just being relaxed at home could be part of the problem too as
you are probably busy and distracted at work – so although you
might get the itchy sensation, you might not have the opportunity
to scratch. Once at home, you might feel more ‘free’ to scratch, and
there are fewer distractions to blur the itch sensation. This can
progress to the point at which you might have developed a habit
of scratching as soon as you get home. Once an itch–scratch cycle
is established, it can become habitual. If you feel that this could
be a possibility, you may find the advice at the end of Chapter 4
helpful.Since I have developed eczema, I have been told not to
use soap, but I don’t really feel clean unless I have used
soap. Can you suggest one that I can use?
Soaps have an alkaline base and as such have a drying, irritant
effect on the skin. When we use a soap to cleanse the skin, it
removes not only the dirt, but also the protective grease produced
by the skin to maintain the barrier function. We only have to look
at the hands of people who do a lot of washing-up and cleaning to
see how irritant soap can be so it should be avoided by anyone
with eczema. By soap, we mean anything that creates lather or
bubbles so bubble bath and shower gel should also be avoided. A
soap substitute, such as aqueous cream or emulsifying ointment,
should be used instead; this will still have an effective cleansing
effect on your skin. There are also some more expensive soap-free
lotions that you might find easier to use – they even come in
containers like shower gel. If you are set on using soap, try to limit
it to specific areas such as your armpits and choose a pH-neutral
variety that is non-perfumed and has added moisturising creams.
It can be serious
My daughter had to be admitted urgently to hospital
because her eczema was bad and she became very floppy
and ill. I thought eczema was ‘just a skin disease’.
It sounds as though your daughter’s eczema has been very severe.
As you say, many people see eczema simply as ‘just a skin disease’,
but the skin is the body’s largest organ, and it is responsible for
maintaining temperature control and fluid balance. If a considerable
area of skin becomes inflamed and weepy, as seen in eczema flares,
this role becomes more and more difficult to maintain, leading to
water and heat loss from the body. The water loss can occur
through wet, weepy areas of skin or simply via the process of
evaporation from the hot, inflamed skin.
When the skin becomes hot and red all over, this is known as
erythroderma, and urgent treatment is necessary. This is particularly
important in children, who can very quickly become ill from
dehydration as they have a larger area of skin in relation to their
body size so the potential for losing too much water is greater.
Although the skin is not damaged or scarred in the long term from
severe problems like this, the effects of losing heat and water can
be as bad as if your daughter had suffered widespread burns. This
problem is not confined to children: although it is rare, anyone with
a tendency to widespread eczema (usually atopic in type) could
suffer this type of complication.
because her eczema was bad and she became very floppy
and ill. I thought eczema was ‘just a skin disease’.
It sounds as though your daughter’s eczema has been very severe.
As you say, many people see eczema simply as ‘just a skin disease’,
but the skin is the body’s largest organ, and it is responsible for
maintaining temperature control and fluid balance. If a considerable
area of skin becomes inflamed and weepy, as seen in eczema flares,
this role becomes more and more difficult to maintain, leading to
water and heat loss from the body. The water loss can occur
through wet, weepy areas of skin or simply via the process of
evaporation from the hot, inflamed skin.
When the skin becomes hot and red all over, this is known as
erythroderma, and urgent treatment is necessary. This is particularly
important in children, who can very quickly become ill from
dehydration as they have a larger area of skin in relation to their
body size so the potential for losing too much water is greater.
Although the skin is not damaged or scarred in the long term from
severe problems like this, the effects of losing heat and water can
be as bad as if your daughter had suffered widespread burns. This
problem is not confined to children: although it is rare, anyone with
a tendency to widespread eczema (usually atopic in type) could
suffer this type of complication.
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