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.
I have lightish olive skin and notice that I get darker area persisting even when my eczema has cleared. Why is this?
It sounds as though you have had a change in the pigment in your
skin. Episodes of inflammation in the skin from eczema and other
causes can lead to pigment changes, leaving the skin lighter or
darker. We call this process post-inflammatory hypo- (if lighter) or
hyper- (if darker) pigmentation. The darker your skin is to start
with, the more likely it is to get darker still. Except in a few cases,
the effect is not permanent, although it can last for several monthsor longer depending on how bad your eczema is. Please don’t try
treating these areas with any lightening creams you might see
advertised as these can be irritant to the skin, make your eczema
flare up and make the problem worse!
skin. Episodes of inflammation in the skin from eczema and other
causes can lead to pigment changes, leaving the skin lighter or
darker. We call this process post-inflammatory hypo- (if lighter) or
hyper- (if darker) pigmentation. The darker your skin is to start
with, the more likely it is to get darker still. Except in a few cases,
the effect is not permanent, although it can last for several monthsor longer depending on how bad your eczema is. Please don’t try
treating these areas with any lightening creams you might see
advertised as these can be irritant to the skin, make your eczema
flare up and make the problem worse!
My daughter has had eczema for 3 years. She recently developed a new rash, which our doctor said was molluscum. What is this?
Molluscum, also called molluscum contagiosum, is a type of tiny
wart in the skin that looks rather like small, translucent blisters.
These are caused by an infection with a poxvirus. Some people
refer to them as water warts, although they are in fact solid. They
are dome shaped and often have a small depression or punctum
on the top. Molluscum is common in children and young adults,
and is more frequently seen in patients with eczema, perhaps
because the process of scratching causes the virus to spread. As
with warts, the blisters eventually clear on their own, which is just
as well because treatment can be painful – for example, using liquid
nitrogen spray to freeze them off. They are not serious and can be
safely left alone.
wart in the skin that looks rather like small, translucent blisters.
These are caused by an infection with a poxvirus. Some people
refer to them as water warts, although they are in fact solid. They
are dome shaped and often have a small depression or punctum
on the top. Molluscum is common in children and young adults,
and is more frequently seen in patients with eczema, perhaps
because the process of scratching causes the virus to spread. As
with warts, the blisters eventually clear on their own, which is just
as well because treatment can be painful – for example, using liquid
nitrogen spray to freeze them off. They are not serious and can be
safely left alone.
Are warts more common with children with eczema?
Viral warts are very common in all children, especially on the hands
and feet. They are often noticed more readily in children with
eczema because such children are already being seen by doctors
about their eczema and are having their skin examined more
frequently. Warts are not necessarily more common in children –
or adults – with eczema, but there is some evidence that theybecome more numerous once they have been caught. A wart is
actually an virus infection in the skin so scratching will help to
spread it around the skin. In addition, it is thought that skin affected
by eczema is not as efficient as ‘normal’ skin at getting rid of viral
infections so this may also cause them to spread more easily. Warts
are ‘self-limiting’, which means that they will eventually disappear
with no treatment even in the presence of eczema. This can be as
soon as a couple of months or stretch up to a few years for some
people, and having eczema does not mean that they will last any
longer.
and feet. They are often noticed more readily in children with
eczema because such children are already being seen by doctors
about their eczema and are having their skin examined more
frequently. Warts are not necessarily more common in children –
or adults – with eczema, but there is some evidence that theybecome more numerous once they have been caught. A wart is
actually an virus infection in the skin so scratching will help to
spread it around the skin. In addition, it is thought that skin affected
by eczema is not as efficient as ‘normal’ skin at getting rid of viral
infections so this may also cause them to spread more easily. Warts
are ‘self-limiting’, which means that they will eventually disappear
with no treatment even in the presence of eczema. This can be as
soon as a couple of months or stretch up to a few years for some
people, and having eczema does not mean that they will last any
longer.
Eczema herpeticum, warts and molluscum
I was diagnosed with eczema herpeticum, which cleared
up quickly after treatment with aciclovir. Is there more
information on this condition?
Eczema herpeticum is a term used for a severe, widespread skin
infection with the herpes virus that occasionally occurs in people
with eczema. Herpes infections are usually localised, causing a few
blisters or a cold sore on the lip. Eczema herpeticum shows much
more widespread blistering of the skin and also ‘punched-out’ sores
which look like little holes in the skin. Typically, the condition
involves the face, but it can occur anywhere on the body. Multiple
punched-out, crusted lesions around a patch of eczema should
make you suspicious. It is sometimes, but not always, associated
with a high temperature, and if this was the case with you, you
probably felt very unwell. In rare cases, it can be a very severe
infection, especially if it is not recognised and treated – and it may
require hospital admission. Although it is said to have caused death
on one or two occasions, we believe that this is rare because most
individuals or their carers will seek medical help before such a risk
arises. As you have found out, treatment involves a simple course
of tablets taken by mouth.
Eczema herpeticum is thought to occur because some people
with eczema do not fight off viruses affecting the skin very quickly
and the scratching and skin damage helps to spread the virus. It is
possible to suffer from it more that once, but it seems that the first
bout of infection is often the worst, with much less chance of it
becoming serious during recurrences.
up quickly after treatment with aciclovir. Is there more
information on this condition?
Eczema herpeticum is a term used for a severe, widespread skin
infection with the herpes virus that occasionally occurs in people
with eczema. Herpes infections are usually localised, causing a few
blisters or a cold sore on the lip. Eczema herpeticum shows much
more widespread blistering of the skin and also ‘punched-out’ sores
which look like little holes in the skin. Typically, the condition
involves the face, but it can occur anywhere on the body. Multiple
punched-out, crusted lesions around a patch of eczema should
make you suspicious. It is sometimes, but not always, associated
with a high temperature, and if this was the case with you, you
probably felt very unwell. In rare cases, it can be a very severe
infection, especially if it is not recognised and treated – and it may
require hospital admission. Although it is said to have caused death
on one or two occasions, we believe that this is rare because most
individuals or their carers will seek medical help before such a risk
arises. As you have found out, treatment involves a simple course
of tablets taken by mouth.
Eczema herpeticum is thought to occur because some people
with eczema do not fight off viruses affecting the skin very quickly
and the scratching and skin damage helps to spread the virus. It is
possible to suffer from it more that once, but it seems that the first
bout of infection is often the worst, with much less chance of it
becoming serious during recurrences.
Complications
Bacterial infection
My son’s eczema became much worse and wasn’t
improving with the creams. The GP said it was infected
and gave him a course of antibiotics. What caused this
infection, and can it be dangerous?
We all have micro-organisms on our skin called Staphylococcus
aureus. In eczematous skin, the barrier function is not working
effectively, and micro-organisms that come into contact with the
skin are more likely to initiate an inflammatory response. It is
thought that there are more Staphylococcus organisms on
eczematous skin, and this can lead to clinical infection.
A bacterial infection on the skin generally has a localised effect,
seen as redness, weeping, crusting and odour. If extensive areas
are affected, this can lead to symptoms of general malaise and fever
arising from a toxic reaction to the chemicals released as part of
the process of fighting the infection in the skin. There is evidence
that a toxin produced by Staphylococcus aureus can cause a flare
of eczema elsewhere on the skin so it is often treated with
antibiotics by mouth to try to prevent this. If you or your son
recognises that there is an infection present and seeks treatment
from your GP, you should find that it settles quickly with no danger
to your son.
My daughter’s eczema is raw and weepy. Does this mean
that it is infected?
Not necessarily. An acute eczema does present as inflamed weeping
skin, which can be made worse by scratching and can then become
infected. The more chronic, or long term, an area of eczema
becomes, the more likely it is to be dry and thickened. If your
daughter had chronic eczema that suddenly became wet and weepy,
it would be quite likely that an infection had triggered this change.
Signs of clinical infection are pain, swelling, odour and pus. As
previously mentioned, eczematous skin may harbour the bacterium
Staphylococcus aureus; if the skin appears to be infected, a swab
can be taken to identify the bacteria responsible and the antibiotics
that will work.When I saw the specialist recently, she took swabs from
my nose and skin. Later, she wrote to say I had an
infection and gave me some nose cream. Why treat the
nose for a skin infection?
Bacteria that can cause infection on the skin can sometimes be
harboured in the nose. If we see people who have been troubled
with recurrent flares and infections of the skin, we will often carry
out a nose swab to see whether they are a carrier of Staphylococcus
aureus. As in your case, a positive swab can be treated effectively
with a nasal ointment called mupirocin (Bactroban). This will
reduce the bacterial count and prevent further infective flares. It
seems that bacteria living inside the nose often survive despite
courses of antibiotics given by mouth so this extra treatment is
necessary to help to prevent a recurrence. In difficult cases, we
often ask for similar swabs to be taken from other people living
with you in case they are harbouring the bacteria. Like you, they
will not have any signs of infection in the nose – we call this
‘carriage’ as the bacteria are just being carried inside the nose
without causing local infection.I have quite widespread eczema that has been good
recently, but I have developed what looks like a shaving
rash on my legs! Can I still apply my creams?
It sounds as though you are doing your best to treat your eczema
and keep your skin in good condition with moisturisers. In eczema
management, we use very greasy moisturisers as these help to
manage the dryness of the skin, but they can cause the small hair
follicles on the skin’s surface to become blocked. Once the follicles
are blocked, folliculitis (an inflammation of the hair follicle) can
develop, which tends to look like a shaving rash. This can
commonly be seen after using paste bandages or when the weather
has been hot and sticky. You can still use creams to treat the
eczema, but it would be helpful to follow the guidance below to
avoid further bouts of folliculitis:
• Use a lighter, cream-based moisturiser (see Table 2 in
Chapter 4).
• Smooth the moisturiser on to the skin in a wiping action,
following the same direction that the hairs grow (i.e. like
stroking a cat). There is no need to massage or rub cream
into the skin as this just pushes the cream up into the hair
follicle.
• If a topical steroid is being used, it should be in a cream
rather than an ointment base.
• It might be useful to leave bandaging off until the problem
has settled.
If the areas of folliculitis become more widespread, inflamed
and painful, they may have become infected. Seek advice from your
doctor if this happens as oral antibiotics are sometimes needed.
My son’s eczema became much worse and wasn’t
improving with the creams. The GP said it was infected
and gave him a course of antibiotics. What caused this
infection, and can it be dangerous?
We all have micro-organisms on our skin called Staphylococcus
aureus. In eczematous skin, the barrier function is not working
effectively, and micro-organisms that come into contact with the
skin are more likely to initiate an inflammatory response. It is
thought that there are more Staphylococcus organisms on
eczematous skin, and this can lead to clinical infection.
A bacterial infection on the skin generally has a localised effect,
seen as redness, weeping, crusting and odour. If extensive areas
are affected, this can lead to symptoms of general malaise and fever
arising from a toxic reaction to the chemicals released as part of
the process of fighting the infection in the skin. There is evidence
that a toxin produced by Staphylococcus aureus can cause a flare
of eczema elsewhere on the skin so it is often treated with
antibiotics by mouth to try to prevent this. If you or your son
recognises that there is an infection present and seeks treatment
from your GP, you should find that it settles quickly with no danger
to your son.
My daughter’s eczema is raw and weepy. Does this mean
that it is infected?
Not necessarily. An acute eczema does present as inflamed weeping
skin, which can be made worse by scratching and can then become
infected. The more chronic, or long term, an area of eczema
becomes, the more likely it is to be dry and thickened. If your
daughter had chronic eczema that suddenly became wet and weepy,
it would be quite likely that an infection had triggered this change.
Signs of clinical infection are pain, swelling, odour and pus. As
previously mentioned, eczematous skin may harbour the bacterium
Staphylococcus aureus; if the skin appears to be infected, a swab
can be taken to identify the bacteria responsible and the antibiotics
that will work.When I saw the specialist recently, she took swabs from
my nose and skin. Later, she wrote to say I had an
infection and gave me some nose cream. Why treat the
nose for a skin infection?
Bacteria that can cause infection on the skin can sometimes be
harboured in the nose. If we see people who have been troubled
with recurrent flares and infections of the skin, we will often carry
out a nose swab to see whether they are a carrier of Staphylococcus
aureus. As in your case, a positive swab can be treated effectively
with a nasal ointment called mupirocin (Bactroban). This will
reduce the bacterial count and prevent further infective flares. It
seems that bacteria living inside the nose often survive despite
courses of antibiotics given by mouth so this extra treatment is
necessary to help to prevent a recurrence. In difficult cases, we
often ask for similar swabs to be taken from other people living
with you in case they are harbouring the bacteria. Like you, they
will not have any signs of infection in the nose – we call this
‘carriage’ as the bacteria are just being carried inside the nose
without causing local infection.I have quite widespread eczema that has been good
recently, but I have developed what looks like a shaving
rash on my legs! Can I still apply my creams?
It sounds as though you are doing your best to treat your eczema
and keep your skin in good condition with moisturisers. In eczema
management, we use very greasy moisturisers as these help to
manage the dryness of the skin, but they can cause the small hair
follicles on the skin’s surface to become blocked. Once the follicles
are blocked, folliculitis (an inflammation of the hair follicle) can
develop, which tends to look like a shaving rash. This can
commonly be seen after using paste bandages or when the weather
has been hot and sticky. You can still use creams to treat the
eczema, but it would be helpful to follow the guidance below to
avoid further bouts of folliculitis:
• Use a lighter, cream-based moisturiser (see Table 2 in
Chapter 4).
• Smooth the moisturiser on to the skin in a wiping action,
following the same direction that the hairs grow (i.e. like
stroking a cat). There is no need to massage or rub cream
into the skin as this just pushes the cream up into the hair
follicle.
• If a topical steroid is being used, it should be in a cream
rather than an ointment base.
• It might be useful to leave bandaging off until the problem
has settled.
If the areas of folliculitis become more widespread, inflamed
and painful, they may have become infected. Seek advice from your
doctor if this happens as oral antibiotics are sometimes needed.
Complications and what can make eczema worse
Introduction
Eczema is a condition that has a tendency to flare up and settle. It
will often seem manageable and tolerable, but there may well be
times when the skin becomes more red and inflamed, with weeping
areas and general background dryness. The chapters on treatment
will help to give guidance on managing such flares, so this chapter
will concentrate on some factors that may tend to make eczema
worse or that may trigger a flare. Eczema can vary in severity from
one individual to the next: some readers will find that they have
eczema affecting their whole body, whereas others may have it
only on specific areas such as the hands, legs or scalp. A ‘flare’
describes a worsening of the eczema. An acute eczema flare can
cause you to feel generally unwell, which may in some cases require
hospitalisation, but the majority of cases can be self-managed at
home.There are some triggers that can make existing eczema worse
even though they do not cause it to start in normal skin. The reason
for this is that our skin acts as a barrier, but when it is inflamed
and dry, it stops working so well. Imagine your skin as a brick wall
with faulty cement between the bricks: gaps then appear, and items
can pass through the wall. This allows water to leak out of the body
and the skin to be rather oversensitive and susceptible to things it
comes into contact with. This might be items such as woolly
clothes, perfumes or cosmetics, or microscopic factors that act as
triggers, for example bacterial or viral infections.
Eczema is a condition that has a tendency to flare up and settle. It
will often seem manageable and tolerable, but there may well be
times when the skin becomes more red and inflamed, with weeping
areas and general background dryness. The chapters on treatment
will help to give guidance on managing such flares, so this chapter
will concentrate on some factors that may tend to make eczema
worse or that may trigger a flare. Eczema can vary in severity from
one individual to the next: some readers will find that they have
eczema affecting their whole body, whereas others may have it
only on specific areas such as the hands, legs or scalp. A ‘flare’
describes a worsening of the eczema. An acute eczema flare can
cause you to feel generally unwell, which may in some cases require
hospitalisation, but the majority of cases can be self-managed at
home.There are some triggers that can make existing eczema worse
even though they do not cause it to start in normal skin. The reason
for this is that our skin acts as a barrier, but when it is inflamed
and dry, it stops working so well. Imagine your skin as a brick wall
with faulty cement between the bricks: gaps then appear, and items
can pass through the wall. This allows water to leak out of the body
and the skin to be rather oversensitive and susceptible to things it
comes into contact with. This might be items such as woolly
clothes, perfumes or cosmetics, or microscopic factors that act as
triggers, for example bacterial or viral infections.
Miscellaneous
I work in a sawmill and get eczema on my hands. This is
put down to wear and tear, but recently I got eczema on
my face, which I think is also worse at work. Could it be
something in the air?
You could have a combination of a physical contact irritant eczema
from the wear and tear, and an allergic form from natural resins in
the wood or agents used to treat the wood. If the ventilation is poor
and the atmosphere you work in is heavy with dust, you could well
get an allergic reaction on your face. Talk to your GP about a
referral for patch-testing.
My parents have always recommended massaging mustard
oil into the arms and legs of our children to help with
strong bone growth. I have a 3-year-old daughter with
eczema and am worried that this might make it worse.
What should I do?
We have come across the practice of using mustard oil on the skin
in families from Africa and the Indian subcontinent. There isn’t anyscientific evidence that this practice helps with bone growth, but
many people are strong believers in it. It is important to try to
respect cultural practices as they may be helpful, or at least not
harmful, to eczema. For example, many West Indian and Indian
parents use olive oil or aloe vera cream as a moisturiser, and these
seem to be beneficial. Some Nigerian families use hibiscus flower
water on the skin; although we are not sure that this helps, it
certainly does not seem to make things worse.
Mustard oil, however, is very irritant to the broken skin of eczema
and will nearly always make it worse. Because of this, we strongly
advise you not to use it. A balanced diet with plenty of calcium and
exercise will ensure good bone growth. You will have to explain
to your parents politely, but firmly, that mustard oil would make
their grand-daughter’s eczema worse and that she is growing into
a healthy girl without it.All my children have suffered with bad cradle cap and
nappy rash. Why is this, and why did they all get better
after a few months?
It sounds as though all your children had seborrhoeic eczema. In
a mild form, this is almost universal in babies. It is probably caused
by a transfer of hormones (androgens) from mother to baby just
before birth. These hormones act to stimulate the grease glands
(sebaceous glands) of the skin, making them overactive. They are
usually inactive in children until puberty. This hormonal stimulation
causes the greasy scaling so typical of this type of eczema. The
scalp and nappy area are commonly affected – hence the usual
presentation with cradle cap and nappy rash.
As babies do not make these hormones themselves, and because
the transferred hormones are soon broken down and inactivated,
the problem of seborrhoeic eczema resolves completely on its own
in a few months.I suffer with eczema on my hands, which I think is made
worse by work, although I work in an office and don’t
handle any chemicals. Could there be another
explanation?
Your work environment might be a problem as the low-humidity
from air-conditioning can dry out anybody’s skin, and this will be
a bigger problem for you. It will show up as redness and scaling.
Repeated friction from handling papers or other materials can also
be a problem, leading to a physical eczema that will differ in looking
less red, but dry and thickened.
I have just come back from holiday with the most awful
eczema. My doctor says it is photo-dermatitis and might
be due to a new sunscreen. Will I ever be able to go on
holiday again?
Yes, you will. A type of allergic contact eczema whose cause
involves natural or artificial ultraviolet light is quite rare but may
be on the increase. Sunscreens are the most commonly reported
culprits (photo-allergens), but they are always used in the sun!
Other common photo-allergens are fragrances, topical non-steroidal
anti-inflammatory drugs and some antibacterial creams. You might
need to be referred to hospital for a special form of patch-testing
that uses ultraviolet light to mimic the conditions in which you
reacted – this is called photo-patch-testing. This should allow the
dermatologist to tell you what sunscreens you can safely use.
I first started having eczema around my fingernails, which
might have been due to the false nails I wore. I then got it
in my hair – have I transferred it to my scalp from my
fingers when I wash my hair?
Eczema is not a contagious disease so you will not have transferred
it to your scalp. As you have developed eczema around your
fingernails from an allergy to the acrylics in false nails, you do have
a risk of developing eczema elsewhere. Once you have an allergy
to something, any part of your skin can react in the same way, soif you washed your hair with the false nails on, this might have
been enough contact to start the eczema. There may, however, have
been a different trigger for your scalp eczema, such as a different
shampoo or hair treatment.
One of the residents in the nursing home where I work
had scabies. I caught it and had treatment, but my doctor
says I now have eczema. Does scabies cause eczema?
It is very common to have a rash that looks just like eczema after
scabies (an infestation with little mites that burrow into the skin)
as you will have developed an allergy to the dead mites and their
waste matter. Standard eczema treatments should settle it down
over a few weeks, but it will leave your skin in a vulnerable state
for the next few months so soaps and other products that might
not have bothered you before could cause a problem. Take good
care of your skin and it should all settle down and not trouble you
again.
I think something in my garden makes my eczema worse.
Any clues you could give me would be welcome as I don’t
want to give up gardening.
There are many things in the garden that can cause skin problems,
some of which are quite dramatic, with acute blistering rashes from
a combination of plant juices and the sun. It sounds as though you
already have eczema that gets worse when you garden, and this
could be due to several factors. The very act of using your hands
outdoors, with rubbing, hard work and the extra washing required,
can cause problems in terms of physical irritants. Some plants are
associated with eczema; these include chrysanthemums, which
tend to give a thickened, dry eczema on exposed parts, and tulip
bulbs, which classically give rise to a fingertip eczema. The pollen
in the air near chrysanthemums can cause the reaction so you don’t
even have to be in direct contact.
put down to wear and tear, but recently I got eczema on
my face, which I think is also worse at work. Could it be
something in the air?
You could have a combination of a physical contact irritant eczema
from the wear and tear, and an allergic form from natural resins in
the wood or agents used to treat the wood. If the ventilation is poor
and the atmosphere you work in is heavy with dust, you could well
get an allergic reaction on your face. Talk to your GP about a
referral for patch-testing.
My parents have always recommended massaging mustard
oil into the arms and legs of our children to help with
strong bone growth. I have a 3-year-old daughter with
eczema and am worried that this might make it worse.
What should I do?
We have come across the practice of using mustard oil on the skin
in families from Africa and the Indian subcontinent. There isn’t anyscientific evidence that this practice helps with bone growth, but
many people are strong believers in it. It is important to try to
respect cultural practices as they may be helpful, or at least not
harmful, to eczema. For example, many West Indian and Indian
parents use olive oil or aloe vera cream as a moisturiser, and these
seem to be beneficial. Some Nigerian families use hibiscus flower
water on the skin; although we are not sure that this helps, it
certainly does not seem to make things worse.
Mustard oil, however, is very irritant to the broken skin of eczema
and will nearly always make it worse. Because of this, we strongly
advise you not to use it. A balanced diet with plenty of calcium and
exercise will ensure good bone growth. You will have to explain
to your parents politely, but firmly, that mustard oil would make
their grand-daughter’s eczema worse and that she is growing into
a healthy girl without it.All my children have suffered with bad cradle cap and
nappy rash. Why is this, and why did they all get better
after a few months?
It sounds as though all your children had seborrhoeic eczema. In
a mild form, this is almost universal in babies. It is probably caused
by a transfer of hormones (androgens) from mother to baby just
before birth. These hormones act to stimulate the grease glands
(sebaceous glands) of the skin, making them overactive. They are
usually inactive in children until puberty. This hormonal stimulation
causes the greasy scaling so typical of this type of eczema. The
scalp and nappy area are commonly affected – hence the usual
presentation with cradle cap and nappy rash.
As babies do not make these hormones themselves, and because
the transferred hormones are soon broken down and inactivated,
the problem of seborrhoeic eczema resolves completely on its own
in a few months.I suffer with eczema on my hands, which I think is made
worse by work, although I work in an office and don’t
handle any chemicals. Could there be another
explanation?
Your work environment might be a problem as the low-humidity
from air-conditioning can dry out anybody’s skin, and this will be
a bigger problem for you. It will show up as redness and scaling.
Repeated friction from handling papers or other materials can also
be a problem, leading to a physical eczema that will differ in looking
less red, but dry and thickened.
I have just come back from holiday with the most awful
eczema. My doctor says it is photo-dermatitis and might
be due to a new sunscreen. Will I ever be able to go on
holiday again?
Yes, you will. A type of allergic contact eczema whose cause
involves natural or artificial ultraviolet light is quite rare but may
be on the increase. Sunscreens are the most commonly reported
culprits (photo-allergens), but they are always used in the sun!
Other common photo-allergens are fragrances, topical non-steroidal
anti-inflammatory drugs and some antibacterial creams. You might
need to be referred to hospital for a special form of patch-testing
that uses ultraviolet light to mimic the conditions in which you
reacted – this is called photo-patch-testing. This should allow the
dermatologist to tell you what sunscreens you can safely use.
I first started having eczema around my fingernails, which
might have been due to the false nails I wore. I then got it
in my hair – have I transferred it to my scalp from my
fingers when I wash my hair?
Eczema is not a contagious disease so you will not have transferred
it to your scalp. As you have developed eczema around your
fingernails from an allergy to the acrylics in false nails, you do have
a risk of developing eczema elsewhere. Once you have an allergy
to something, any part of your skin can react in the same way, soif you washed your hair with the false nails on, this might have
been enough contact to start the eczema. There may, however, have
been a different trigger for your scalp eczema, such as a different
shampoo or hair treatment.
One of the residents in the nursing home where I work
had scabies. I caught it and had treatment, but my doctor
says I now have eczema. Does scabies cause eczema?
It is very common to have a rash that looks just like eczema after
scabies (an infestation with little mites that burrow into the skin)
as you will have developed an allergy to the dead mites and their
waste matter. Standard eczema treatments should settle it down
over a few weeks, but it will leave your skin in a vulnerable state
for the next few months so soaps and other products that might
not have bothered you before could cause a problem. Take good
care of your skin and it should all settle down and not trouble you
again.
I think something in my garden makes my eczema worse.
Any clues you could give me would be welcome as I don’t
want to give up gardening.
There are many things in the garden that can cause skin problems,
some of which are quite dramatic, with acute blistering rashes from
a combination of plant juices and the sun. It sounds as though you
already have eczema that gets worse when you garden, and this
could be due to several factors. The very act of using your hands
outdoors, with rubbing, hard work and the extra washing required,
can cause problems in terms of physical irritants. Some plants are
associated with eczema; these include chrysanthemums, which
tend to give a thickened, dry eczema on exposed parts, and tulip
bulbs, which classically give rise to a fingertip eczema. The pollen
in the air near chrysanthemums can cause the reaction so you don’t
even have to be in direct contact.
Food and oral medication
Is it worth having tests for food intolerance? I have
recently read about this testing and about claims that
most people get better after testing, although nothing has
been published. Is it worth doing?
These tests are being developed but, at the time of writing, have
not been fully evaluated or validated. This process is very important
if the tests are to be used to change treatments or dietary habits.
Tests need to be accurate and repeatable – this means that they
should give the same result no matter how many times you are
tested before having any treatment so that changes in the results
can be believed.
Could I sometimes be allergic to dairy products and
sometimes not? I notice that my skin sometimes seems to
get worse when I drink milk?
One possible explanation may be that the lining of the gut can
become inflamed when eczema is severe, and larger proteins than
normal can get through. These larger proteins may trigger an
immune response and cause further exacerbations, but once the
eczema has settled, the gut returns to normal and the larger proteins
are kept out. My asthma flared up recently, and my doctor told me to
stop taking aspirin or Nurofen. Could these also have
been causing my eczema?
Some people with atopic diseases such as eczema, asthma and hay
fever are sensitive to the effects of ‘salicylates’. These are naturally
occurring substances very similar to aspirin, which was derived
originally from willow bark. Nurofen and other ‘non-steroidal anti-
inflammatory drugs’ have a similar action to aspirin and can share
some of its potential reactions. This appears to be much more of
a problem with asthma than eczema. Salicylates tend to give an
urticaria (hives) rather than eczema, but they could be a factor for
you.
recently read about this testing and about claims that
most people get better after testing, although nothing has
been published. Is it worth doing?
These tests are being developed but, at the time of writing, have
not been fully evaluated or validated. This process is very important
if the tests are to be used to change treatments or dietary habits.
Tests need to be accurate and repeatable – this means that they
should give the same result no matter how many times you are
tested before having any treatment so that changes in the results
can be believed.
Could I sometimes be allergic to dairy products and
sometimes not? I notice that my skin sometimes seems to
get worse when I drink milk?
One possible explanation may be that the lining of the gut can
become inflamed when eczema is severe, and larger proteins than
normal can get through. These larger proteins may trigger an
immune response and cause further exacerbations, but once the
eczema has settled, the gut returns to normal and the larger proteins
are kept out. My asthma flared up recently, and my doctor told me to
stop taking aspirin or Nurofen. Could these also have
been causing my eczema?
Some people with atopic diseases such as eczema, asthma and hay
fever are sensitive to the effects of ‘salicylates’. These are naturally
occurring substances very similar to aspirin, which was derived
originally from willow bark. Nurofen and other ‘non-steroidal anti-
inflammatory drugs’ have a similar action to aspirin and can share
some of its potential reactions. This appears to be much more of
a problem with asthma than eczema. Salicylates tend to give an
urticaria (hives) rather than eczema, but they could be a factor for
you.
Allergy problems
My eczema doesn’t seem to behave as it should! I keep
getting flares around my eyes and eyelids, and my GP
can’t explain why. I always use the same creams, which
sometimes work and sometimes don’t. Should I see a
consultant?
This is a common presentation of any allergic contact eczema.
Unusual patterns like this should always suggest the need for allergy
testing. The skin around the eyes and on the eyelids is very
sensitive, and one common cause of allergy is actually nail varnish.
We are sure you are not applying nail varnish anywhere near your
eyes, but you might be surprised how often you touch this area,
and if you are wearing nail varnish this can cause a reaction. It
could also be a reaction to any make-up you might use inter-
mittently around the eyes, and you could also have developed an
allergy to one of your treatments.
I recently had to go to hospital for patch-testing and
found out I was allergic to nickel. I try to make sure I
don’t come into contact with it, but I still seem to get
eczema. Is nickel eczema just from contact with it?
You have probably been given a list of metals that contain nickel,
but it also occurs in many foods, which could be a reason for your
eczema continuing. You could also have several different triggers
for your eczema, not just nickel.
Cheap jewellery is not the only source of direct contact with
nickel as it is unfortunately present in many common items made
of, or containing, metal:
• clothes fastenings such as jeans studs, hooks and zips;
• other personal objects – cigarette lighters, wristwatches,
key rings, keys, parts of spectacle frames and pens;
• household items such as drawer and cupboard handles,
kitchen utensils, toasters, etc.• silver coins.
The list could almost be endless so only a few examples are given
here. The nickel content of some foods comes from natural sources
or from the way in which they are prepared. This is usually only a
problem if you have a severe reaction to nickel, which often shows
up as a blistering eczema (pompholyx) on the hands. Avoid canned
foods, and use aluminium or stainless steel utensils when cooking.
A dietitian could give you a list of foods to avoid, which will include
asparagus, oysters, herrings (other fish are OK), mushrooms,
onions, tomatoes and rhubarb.
getting flares around my eyes and eyelids, and my GP
can’t explain why. I always use the same creams, which
sometimes work and sometimes don’t. Should I see a
consultant?
This is a common presentation of any allergic contact eczema.
Unusual patterns like this should always suggest the need for allergy
testing. The skin around the eyes and on the eyelids is very
sensitive, and one common cause of allergy is actually nail varnish.
We are sure you are not applying nail varnish anywhere near your
eyes, but you might be surprised how often you touch this area,
and if you are wearing nail varnish this can cause a reaction. It
could also be a reaction to any make-up you might use inter-
mittently around the eyes, and you could also have developed an
allergy to one of your treatments.
I recently had to go to hospital for patch-testing and
found out I was allergic to nickel. I try to make sure I
don’t come into contact with it, but I still seem to get
eczema. Is nickel eczema just from contact with it?
You have probably been given a list of metals that contain nickel,
but it also occurs in many foods, which could be a reason for your
eczema continuing. You could also have several different triggers
for your eczema, not just nickel.
Cheap jewellery is not the only source of direct contact with
nickel as it is unfortunately present in many common items made
of, or containing, metal:
• clothes fastenings such as jeans studs, hooks and zips;
• other personal objects – cigarette lighters, wristwatches,
key rings, keys, parts of spectacle frames and pens;
• household items such as drawer and cupboard handles,
kitchen utensils, toasters, etc.• silver coins.
The list could almost be endless so only a few examples are given
here. The nickel content of some foods comes from natural sources
or from the way in which they are prepared. This is usually only a
problem if you have a severe reaction to nickel, which often shows
up as a blistering eczema (pompholyx) on the hands. Avoid canned
foods, and use aluminium or stainless steel utensils when cooking.
A dietitian could give you a list of foods to avoid, which will include
asparagus, oysters, herrings (other fish are OK), mushrooms,
onions, tomatoes and rhubarb.
I sent a piece of my hair away for testing and it came back with a whole list of foods that I am allergic to. My GP doesn’t believe the result and say
There is a great problem with the sort of testing you have had done.
Often, there is very little science behind the test and the results,
and we feel that the people doing the tests have a financial interest
in the test being positive. Immunologists work much more with
properly researched and what we call ‘evidence-based’ tests so can
give more accurate results. If you tried to avoid the ‘whole list of
Often, there is very little science behind the test and the results,
and we feel that the people doing the tests have a financial interest
in the test being positive. Immunologists work much more with
properly researched and what we call ‘evidence-based’ tests so can
give more accurate results. If you tried to avoid the ‘whole list of
Are there any tests?
I have heard a lot about different allergy tests and am
confused. My local supermarket offers tests of this kind,
and a friend has also suggested an ELISA test. Can you
give me any more information about these types of test
and allergy tests in general?
‘Allergy tests’ mean different things to different people, and you
will hear a lot of conflicting information about their use. Broadly
speaking, there are two types of allergy test applicable to skin
disease:
• patch tests;
• skin-prick tests (this type of testing can also be carried out
on blood samples with an ELISA test, but both of these
techniques are testing the same thing).
Patch tests look for evidence of contact eczema (also called
dermatitis), such as is seen in allergy to nickel, chromate, rubber,
dyes, glues or perfumes. This is a delayed allergy that sometimes
develops after repeated exposure to a substance. Contact eczemais uncommon in children, perhaps because they have not had
enough exposure to these allergens, so patch tests are not needed
(or indeed helpful) in uncomplicated atopic eczema in childhood.
Patch tests are complicated to do and interpret (they are carried
out only by specialist dermatologists) but are useful in investigating
certain types of eczema – such as isolated hand eczema, especially
in people with certain jobs, for example hairdressers, builders and
nurses.
Skin-prick tests (or ELISA tests) look for an immediate type of
allergy (type 1 allergy). There are hundreds of allergens that can
be used in these tests, but the common ones are pollens (grass and
tree), dog fur, cat fur, house dust mite, egg, milk, fish and nuts.
They can be useful in detecting relevant allergens in asthma, food
intolerance and hay fever. They do not, however, provide much, if
any, useful information in atopic eczema, and most experts in
childhood eczema now realise this. The majority of children with
eczema have multiple positive results to the skin-prick test, and
these are difficult to interpret in any useful way. Children’s skin
seems hyperreactive to many substances. Although some doctors
still do these tests, we believe that it is unjustified to inflict 15
pin-pricks or a blood test on a young child with atopic eczema if
it is not going to provide any practical information in helping to
manage the eczema. These tests do not help in deciding whether
a certain food might make eczema worse and, if they are wrongly
interpreted, can cause problems if nutritional foods are
unnecessarily excluded.
confused. My local supermarket offers tests of this kind,
and a friend has also suggested an ELISA test. Can you
give me any more information about these types of test
and allergy tests in general?
‘Allergy tests’ mean different things to different people, and you
will hear a lot of conflicting information about their use. Broadly
speaking, there are two types of allergy test applicable to skin
disease:
• patch tests;
• skin-prick tests (this type of testing can also be carried out
on blood samples with an ELISA test, but both of these
techniques are testing the same thing).
Patch tests look for evidence of contact eczema (also called
dermatitis), such as is seen in allergy to nickel, chromate, rubber,
dyes, glues or perfumes. This is a delayed allergy that sometimes
develops after repeated exposure to a substance. Contact eczemais uncommon in children, perhaps because they have not had
enough exposure to these allergens, so patch tests are not needed
(or indeed helpful) in uncomplicated atopic eczema in childhood.
Patch tests are complicated to do and interpret (they are carried
out only by specialist dermatologists) but are useful in investigating
certain types of eczema – such as isolated hand eczema, especially
in people with certain jobs, for example hairdressers, builders and
nurses.
Skin-prick tests (or ELISA tests) look for an immediate type of
allergy (type 1 allergy). There are hundreds of allergens that can
be used in these tests, but the common ones are pollens (grass and
tree), dog fur, cat fur, house dust mite, egg, milk, fish and nuts.
They can be useful in detecting relevant allergens in asthma, food
intolerance and hay fever. They do not, however, provide much, if
any, useful information in atopic eczema, and most experts in
childhood eczema now realise this. The majority of children with
eczema have multiple positive results to the skin-prick test, and
these are difficult to interpret in any useful way. Children’s skin
seems hyperreactive to many substances. Although some doctors
still do these tests, we believe that it is unjustified to inflict 15
pin-pricks or a blood test on a young child with atopic eczema if
it is not going to provide any practical information in helping to
manage the eczema. These tests do not help in deciding whether
a certain food might make eczema worse and, if they are wrongly
interpreted, can cause problems if nutritional foods are
unnecessarily excluded.
Is diet important?
During a recent bout of sickness and diarrhoea, my
daughter’s eczema almost disappeared. She ate hardly
anything during this time. Could this mean that her
eczema is related to the food she eats?
Unfortunately, this is not the likeliest explanation for the
improvement in your daughter’s eczema. Diet has not been shown
to be a major factor in causing eczema, despite many people’s view
to the contrary. You have to remember that eczema fluctuates in
severity all the time, often for reasons that we cannot explain. It
is always tempting to look at ‘what happened the day before’ as
the cause of a flare or an improvement, and doctors are no different
from you in wanting a simple explanation.
Any infections (including tummy upsets) can improve eczema
or cause a flare, presumably owing to the effect that they can have
on the body’s immune system or the fact that having a hightemperature may make the skin more itchy. It is equally likely that
your daughter’s sickness had no effect on her eczema but that it
was simply improving spontaneously at that time.
Could something in my son’s diet be causing his eczema?
Although you don’t say how old your son is, the answer is probably
that his diet is not having an effect. Diet may be important in the
initial triggering of eczema in infants with an inherited susceptibility,
but it seems to have little to do with keeping eczema going or
triggering it in older children. It is true that many parents, and
indeed some doctors, think that diet is very important in eczema,
but evidence from research studies over the past few years does
not support this view. Life would be a lot easier if diet did have a
major impact, but we have to believe the evidence from these well-
conducted studies. We have used special diets in the past, but they
are normally disappointing in terms of improving the eczema and
are difficult to stick to, especially for children of school age.
Our advice to you is that if there is a clear history of your son’s
eczema always worsening after eating a certain food, it is worth a
3-month trial of excluding that food – after taking advice from a
dietitian. If there is no improvement in his eczema after 3 months,
that food should be gradually reintroduced. It cannot be
overemphasised that all attempts at dietary manipulation should
be made under the control of a dietitian to ensure that there is
adequate calorie, protein, calcium and vitamin replacement. We
have seen children with malnutrition and even rickets from
unsupervised severe exclusion diets, and unfortunately they both
still had bad eczema.
Will altering my diet during breast-feeding stop my baby
from developing eczema? What else can I do to avoid
triggering the condition?
Eczema is an inherited condition, but it is also influenced by
environmental factors. We do not understand why it develops at a
certain age in any one individual. There are important trigger
factors, but little is known about them. It has been suggested thatthe early diet of a child, particularly an exposure to dairy products,
might be important in triggering eczema.
There is scant evidence to support the idea that if you changed
to a diet free from milk and eggs during breast-feeding, it might
provide some protection against your baby developing eczema,
especially if both you and the baby’s father have a history of the
condition. This view is still controversial, and we would not
recommend such a diet routinely. It would certainly need to be
done under the guidance of a dietitian.
Is breast-feeding better than bottle-feeding for helping to
prevent my baby getting eczema?
This is a bit controversial now! The old answer was that the
evidence seemed to suggest it was of benefit, although some
research studies failed to show any advantage. Recently, however,
a big study in New Zealand showed that breast-feeding was linked
to a greater chance of a baby getting eczema than bottle-feeding.
More research is needed before a definite answer can be given to
this simple question as it relates to eczema. Breast-feeding does,
however, have many other advantages, so we wouldn’t yet go
against the motto ‘breast is best’.
I want to continue breast-feeding my baby, but the eczema
on my nipples is making this very difficult. Have you any
advice that could help?
Breast-feeding with eczema on the nipple or areolar tissue round
it can be troublesome from time to time because this area can easily
become infected with thrush, making it cracked and sore. Ask your
doctor to examine your baby’s mouth as well as your breasts as
thrush may be present there too. There are topical creams that can
be prescribed to resolve the infection.
During treatment, breast-feeding from the affected side should
be temporarily stopped and expressing carried out instead, either
manually or with the aid of an electric or hand pump. Your baby
will be able to feed sufficiently from one breast only as the extra
demand will increase the milk supply. Any expressed milk may begiven to your baby or frozen for future use. As the skin heals, breast-
feeding can be resumed, but care must be taken that your baby is
well positioned and correctly attached on the breast at each feed
to minimise any trauma or friction to the nipple. Further assistance
with breast-feeding can be obtained from your local breast-feeding
counsellor.
My baby has developed eczema. Could it be something to
do with what I ate during pregnancy?
It sounds as though you are feeling guilty, as if your baby’s eczema
is your fault. There is no good evidence that what you eat during
pregnancy has any effect on the subsequent development of eczema
in a baby. Relax – it is not your ‘fault’.
daughter’s eczema almost disappeared. She ate hardly
anything during this time. Could this mean that her
eczema is related to the food she eats?
Unfortunately, this is not the likeliest explanation for the
improvement in your daughter’s eczema. Diet has not been shown
to be a major factor in causing eczema, despite many people’s view
to the contrary. You have to remember that eczema fluctuates in
severity all the time, often for reasons that we cannot explain. It
is always tempting to look at ‘what happened the day before’ as
the cause of a flare or an improvement, and doctors are no different
from you in wanting a simple explanation.
Any infections (including tummy upsets) can improve eczema
or cause a flare, presumably owing to the effect that they can have
on the body’s immune system or the fact that having a hightemperature may make the skin more itchy. It is equally likely that
your daughter’s sickness had no effect on her eczema but that it
was simply improving spontaneously at that time.
Could something in my son’s diet be causing his eczema?
Although you don’t say how old your son is, the answer is probably
that his diet is not having an effect. Diet may be important in the
initial triggering of eczema in infants with an inherited susceptibility,
but it seems to have little to do with keeping eczema going or
triggering it in older children. It is true that many parents, and
indeed some doctors, think that diet is very important in eczema,
but evidence from research studies over the past few years does
not support this view. Life would be a lot easier if diet did have a
major impact, but we have to believe the evidence from these well-
conducted studies. We have used special diets in the past, but they
are normally disappointing in terms of improving the eczema and
are difficult to stick to, especially for children of school age.
Our advice to you is that if there is a clear history of your son’s
eczema always worsening after eating a certain food, it is worth a
3-month trial of excluding that food – after taking advice from a
dietitian. If there is no improvement in his eczema after 3 months,
that food should be gradually reintroduced. It cannot be
overemphasised that all attempts at dietary manipulation should
be made under the control of a dietitian to ensure that there is
adequate calorie, protein, calcium and vitamin replacement. We
have seen children with malnutrition and even rickets from
unsupervised severe exclusion diets, and unfortunately they both
still had bad eczema.
Will altering my diet during breast-feeding stop my baby
from developing eczema? What else can I do to avoid
triggering the condition?
Eczema is an inherited condition, but it is also influenced by
environmental factors. We do not understand why it develops at a
certain age in any one individual. There are important trigger
factors, but little is known about them. It has been suggested thatthe early diet of a child, particularly an exposure to dairy products,
might be important in triggering eczema.
There is scant evidence to support the idea that if you changed
to a diet free from milk and eggs during breast-feeding, it might
provide some protection against your baby developing eczema,
especially if both you and the baby’s father have a history of the
condition. This view is still controversial, and we would not
recommend such a diet routinely. It would certainly need to be
done under the guidance of a dietitian.
Is breast-feeding better than bottle-feeding for helping to
prevent my baby getting eczema?
This is a bit controversial now! The old answer was that the
evidence seemed to suggest it was of benefit, although some
research studies failed to show any advantage. Recently, however,
a big study in New Zealand showed that breast-feeding was linked
to a greater chance of a baby getting eczema than bottle-feeding.
More research is needed before a definite answer can be given to
this simple question as it relates to eczema. Breast-feeding does,
however, have many other advantages, so we wouldn’t yet go
against the motto ‘breast is best’.
I want to continue breast-feeding my baby, but the eczema
on my nipples is making this very difficult. Have you any
advice that could help?
Breast-feeding with eczema on the nipple or areolar tissue round
it can be troublesome from time to time because this area can easily
become infected with thrush, making it cracked and sore. Ask your
doctor to examine your baby’s mouth as well as your breasts as
thrush may be present there too. There are topical creams that can
be prescribed to resolve the infection.
During treatment, breast-feeding from the affected side should
be temporarily stopped and expressing carried out instead, either
manually or with the aid of an electric or hand pump. Your baby
will be able to feed sufficiently from one breast only as the extra
demand will increase the milk supply. Any expressed milk may begiven to your baby or frozen for future use. As the skin heals, breast-
feeding can be resumed, but care must be taken that your baby is
well positioned and correctly attached on the breast at each feed
to minimise any trauma or friction to the nipple. Further assistance
with breast-feeding can be obtained from your local breast-feeding
counsellor.
My baby has developed eczema. Could it be something to
do with what I ate during pregnancy?
It sounds as though you are feeling guilty, as if your baby’s eczema
is your fault. There is no good evidence that what you eat during
pregnancy has any effect on the subsequent development of eczema
in a baby. Relax – it is not your ‘fault’.
Are house dust mites involved?
What are house dust mites?
House dust mites are very small insects that are invisible to the
naked eye. They are found in all of our homes, and they particularlylike living in soft furnishings such as sofas, mattresses, carpets and
duvets, where they are found in large numbers. Modern standards
of living, with central heating, seem to encourage their growth, and
in practice they are difficult to eradicate completely.
House dust mites do seem to be important in making asthma
worse. Although their role in atopic eczema is less well established,
they are worth taking seriously in some cases.
How do I know if my son is allergic to house dust mites?
It is easy to find evidence of allergy to house dust mites by
subjecting your son to skin-prick testing, but the result may not be
very useful. Many people with eczema have a positive reaction to
house dust mites – and to many other allergens that do not seem
to make their eczema worse. Many children without eczema also
have positive reactions to house dust mites. If you suspect that
house dust mites may be important in your son’s eczema, it may
be best to try some avoidance measures (see Chapter 4) rather
than having the test done. The test itself involves putting on to the
skin drops of liquid that either contains mite extract in saline (salt
water) or is just saline on its own. The skin is then pricked with a
needle through each drop, and the skin’s reaction is tested. A strong
reaction to mite extract compared with saline indicates a positive
result.
I had a blood test at the hospital and have been told I am
allergic to house dust mites. Is this a good test?
This is probably a RAST test, which detects antibodies in your
blood that react to different things. The test is good at detecting
an allergy, but the link between having the allergy and actually
getting problems on your skin is sometimes less clear. It is certainly
worth you trying all the avoidance measures (see Chapter 4). A
RAST test is not able to detect general allergies as it is quite specific,
so each test needs to focus on one possible cause or related groups
of substances, for example dairy products, nuts or cats.People keep telling me that the eczema on my hands is
just a sign of stress. Is this true?
Stress is mentioned as a cause or trigger of many different diseases,
not just ones that affect the skin. It is easy to generalise but difficult
to be sure in any individual case. The best test may be to keep a
diary of when your hands flare up and see whether this is related
to times when you feel under stress. Some interesting work has
been done looking at people’s reaction to stress as a risk factor for
developing eczema on the hands. It does seem that if you are
someone who is more affected by stress and doesn’t deal with it
well, you do have a greater chance of developing hand eczema.
This is interesting as it relates to some of the ideas in homeopathy,
acupuncture and other complementary medical philosophies that
take account of the type of person you are when choosing a
treatment. To generalise a bit, the younger you are when you
develop hand eczema and if patch tests are negative for allergy,
the more likely you are to be affected by stress.
House dust mites are very small insects that are invisible to the
naked eye. They are found in all of our homes, and they particularlylike living in soft furnishings such as sofas, mattresses, carpets and
duvets, where they are found in large numbers. Modern standards
of living, with central heating, seem to encourage their growth, and
in practice they are difficult to eradicate completely.
House dust mites do seem to be important in making asthma
worse. Although their role in atopic eczema is less well established,
they are worth taking seriously in some cases.
How do I know if my son is allergic to house dust mites?
It is easy to find evidence of allergy to house dust mites by
subjecting your son to skin-prick testing, but the result may not be
very useful. Many people with eczema have a positive reaction to
house dust mites – and to many other allergens that do not seem
to make their eczema worse. Many children without eczema also
have positive reactions to house dust mites. If you suspect that
house dust mites may be important in your son’s eczema, it may
be best to try some avoidance measures (see Chapter 4) rather
than having the test done. The test itself involves putting on to the
skin drops of liquid that either contains mite extract in saline (salt
water) or is just saline on its own. The skin is then pricked with a
needle through each drop, and the skin’s reaction is tested. A strong
reaction to mite extract compared with saline indicates a positive
result.
I had a blood test at the hospital and have been told I am
allergic to house dust mites. Is this a good test?
This is probably a RAST test, which detects antibodies in your
blood that react to different things. The test is good at detecting
an allergy, but the link between having the allergy and actually
getting problems on your skin is sometimes less clear. It is certainly
worth you trying all the avoidance measures (see Chapter 4). A
RAST test is not able to detect general allergies as it is quite specific,
so each test needs to focus on one possible cause or related groups
of substances, for example dairy products, nuts or cats.People keep telling me that the eczema on my hands is
just a sign of stress. Is this true?
Stress is mentioned as a cause or trigger of many different diseases,
not just ones that affect the skin. It is easy to generalise but difficult
to be sure in any individual case. The best test may be to keep a
diary of when your hands flare up and see whether this is related
to times when you feel under stress. Some interesting work has
been done looking at people’s reaction to stress as a risk factor for
developing eczema on the hands. It does seem that if you are
someone who is more affected by stress and doesn’t deal with it
well, you do have a greater chance of developing hand eczema.
This is interesting as it relates to some of the ideas in homeopathy,
acupuncture and other complementary medical philosophies that
take account of the type of person you are when choosing a
treatment. To generalise a bit, the younger you are when you
develop hand eczema and if patch tests are negative for allergy,
the more likely you are to be affected by stress.
What type of dog can I have that will not irritate my son’s eczema?
Dogs, and indeed any animals with furry or hairy coats (e.g. horses,
cats), shed their hair and skin into the environment. These small
particles are made up of proteins that are ‘foreign’ to humans. They
can irritate the skin without an allergic reaction taking place,
especially if the skin is already damaged with eczema. They may
also cause a genuine allergic response. Although breeds of dogs
with shorter coats may spread their proteins around the house in
lesser amounts, these will still be present in a significant quantity.
All dogs therefore have the potential to make eczema worse, so it
is probably best not to get a dog or other pet with a furry or hairy
coat.
cats), shed their hair and skin into the environment. These small
particles are made up of proteins that are ‘foreign’ to humans. They
can irritate the skin without an allergic reaction taking place,
especially if the skin is already damaged with eczema. They may
also cause a genuine allergic response. Although breeds of dogs
with shorter coats may spread their proteins around the house in
lesser amounts, these will still be present in a significant quantity.
All dogs therefore have the potential to make eczema worse, so it
is probably best not to get a dog or other pet with a furry or hairy
coat.
What is the hygiene hypothesis?
In the late 1980s, it was noticed that large families seemed to have
much less in the way of atopic disease. This was mainly found when
studying asthma, for which the link is much more established than
it is for atopic eczema. (The link does not apply to other types of
eczema.) It is thought that allergic diseases might be more likely to develop
if the immune system of an infant or young child is understimulated
from a lack of contact with infection, dirt, dust etc. The immune
system is designed to allow us to develop protection against
infections, so if a child is not exposed to any, the immune system
finds something else to react to! No single, specific infection has
been linked to atopic eczema, so this is not an argument against
immunisation, but it is worth avoiding unnecessary courses of
antibiotics in early life and trying to be relaxed about children
playing together and sharing germs and dirt. Perhaps the old saying
about ‘eating a peck of dirt’ has some validity. Some further support
for the hypothesis has come from developing countries, where
improvements in hygiene, and perhaps a better availability of
treatment for worms and other gut parasites, seem to be linked to
an increase in atopic disease.
much less in the way of atopic disease. This was mainly found when
studying asthma, for which the link is much more established than
it is for atopic eczema. (The link does not apply to other types of
eczema.) It is thought that allergic diseases might be more likely to develop
if the immune system of an infant or young child is understimulated
from a lack of contact with infection, dirt, dust etc. The immune
system is designed to allow us to develop protection against
infections, so if a child is not exposed to any, the immune system
finds something else to react to! No single, specific infection has
been linked to atopic eczema, so this is not an argument against
immunisation, but it is worth avoiding unnecessary courses of
antibiotics in early life and trying to be relaxed about children
playing together and sharing germs and dirt. Perhaps the old saying
about ‘eating a peck of dirt’ has some validity. Some further support
for the hypothesis has come from developing countries, where
improvements in hygiene, and perhaps a better availability of
treatment for worms and other gut parasites, seem to be linked to
an increase in atopic disease.
But isn’t eczema caused by an allergy to something?
It depends what you mean by ‘allergy’. The strictly scientific
definition of allergy refers to ‘when a substance causes an
abnormally excessive response to arise from the body’s immune
or defence system’. This may be measured by determining the levels
of antibody in the white blood cells (lymphocytes). The allergic
reaction should be reproducible by ‘re-challenging’ with the same
substance – the same reaction will be produced each time the
substance is used.
Many people, however, use the word ‘allergy’ in a different way.
They may use it to imply that a certain disorder is caused by a
specific substance and that this disorder will disappear if the
offending agent is avoided. Unfortunately, this is not the case withatopic eczema. It is perhaps best imagined as a built-in reaction
that can be modified (but not caused) by the environment. Many
things in the environment can make eczema worse (e.g. woollen
clothes, dog hair), but this may be because they act purely as an
irritant rather than as a true allergen.
My GP says that my hand eczema is caused by things I
come in contact with. What does this really mean?
Contact is the most common cause of hand eczema in adults. Your
GP’s comment can be looked at in a couple of ways. First, some
substances are potentially irritant to the skin such that anyone
would eventually develop a rash that looked like eczema if they
were exposed to high enough concentrations for long enough. An
example here is strong detergent. Your problem could be that you
have a much lower threshold to a wide range of possible irritants,
so you react to lower concentrations and a shorter contact time.
This will especially be the case if you have a little bit of eczema or
just dry skin at the time of the contact. The same contact on an
area of normal skin would not cause you a problem.
The other possibility is that you are allergic to a particular
substance (or several if you are unlucky). This substance would
be unlikely to cause any reaction in someone without an allergy to
it no matter how long they were in contact with it, and it would be
able to cause eczema on any part of your skin after the initial
‘sensitising’ reaction had taken place. Your first contact that caused
a problem would lead to eczema after a few days or so, but
subsequent contacts would cause the eczema to start within a
matter of hours. An example of this is an allergy to something in a
perfume such as ‘balsam of Peru’.
definition of allergy refers to ‘when a substance causes an
abnormally excessive response to arise from the body’s immune
or defence system’. This may be measured by determining the levels
of antibody in the white blood cells (lymphocytes). The allergic
reaction should be reproducible by ‘re-challenging’ with the same
substance – the same reaction will be produced each time the
substance is used.
Many people, however, use the word ‘allergy’ in a different way.
They may use it to imply that a certain disorder is caused by a
specific substance and that this disorder will disappear if the
offending agent is avoided. Unfortunately, this is not the case withatopic eczema. It is perhaps best imagined as a built-in reaction
that can be modified (but not caused) by the environment. Many
things in the environment can make eczema worse (e.g. woollen
clothes, dog hair), but this may be because they act purely as an
irritant rather than as a true allergen.
My GP says that my hand eczema is caused by things I
come in contact with. What does this really mean?
Contact is the most common cause of hand eczema in adults. Your
GP’s comment can be looked at in a couple of ways. First, some
substances are potentially irritant to the skin such that anyone
would eventually develop a rash that looked like eczema if they
were exposed to high enough concentrations for long enough. An
example here is strong detergent. Your problem could be that you
have a much lower threshold to a wide range of possible irritants,
so you react to lower concentrations and a shorter contact time.
This will especially be the case if you have a little bit of eczema or
just dry skin at the time of the contact. The same contact on an
area of normal skin would not cause you a problem.
The other possibility is that you are allergic to a particular
substance (or several if you are unlucky). This substance would
be unlikely to cause any reaction in someone without an allergy to
it no matter how long they were in contact with it, and it would be
able to cause eczema on any part of your skin after the initial
‘sensitising’ reaction had taken place. Your first contact that caused
a problem would lead to eczema after a few days or so, but
subsequent contacts would cause the eczema to start within a
matter of hours. An example of this is an allergy to something in a
perfume such as ‘balsam of Peru’.
Inheritance and allergy
I want to find out exactly what is causing my son’s
eczema. How can I get him tested?
You have asked one of the most difficult questions to answer
because we do not have a complete understanding of the cause or
causes of the various types of eczema. Your son is likely to have
atopic eczema as this is the most common childhood form, so it is
unlikely to be due to a single allergy, for which avoidance of the
‘allergen’ (the cause or trigger of the allergy) would result in a cure.
This approach might apply in contact allergic eczema, which is
much more common in adult life, but even then there is usually
more than one trigger.
We do know that there is a strong inherited or genetic component
to atopic eczema. If you son has inherited a certain gene, or
combination of genes, this predisposes him to being ‘atopic’, buthe would still need some other trigger to cause him to have eczema.
To date, several genes have been identified that show a link with
atopic disease, but it seems likely that there are other, as yet
unidentified, genes that are important, and we hope that these will
be discovered over the next few years. We still do not understand
the function of these genes as we do not know whether they can
all lead to asthma, eczema or hay fever – the three atopic diseases
– or whether individual genes are linked to just one of the diseases.
It is more likely that various different gene combinations can lead
to atopic eczema as this would help to explain why different triggers
are important in different patients and why eczema has more that
one ‘cause’.
In other words, if your son has a susceptibility to developing
eczema by having a particular group of genes, the eczema may be
triggered by several different factors. Despite much research, the
evidence for any one trigger is very limited, and trials excluding or
limiting exposure to different environmental factors (e.g. pets,
woollen clothing, dust, car pollution) have been very disappointing
in terms of improving eczema. There is therefore no simple way
to get your son tested, and it is more likely that simple detective
work, looking at when it gets worse, may give you more of a clue.
(For more about testing, though, see the section ‘Are there any
tests?’ later in this chapter.)
eczema. How can I get him tested?
You have asked one of the most difficult questions to answer
because we do not have a complete understanding of the cause or
causes of the various types of eczema. Your son is likely to have
atopic eczema as this is the most common childhood form, so it is
unlikely to be due to a single allergy, for which avoidance of the
‘allergen’ (the cause or trigger of the allergy) would result in a cure.
This approach might apply in contact allergic eczema, which is
much more common in adult life, but even then there is usually
more than one trigger.
We do know that there is a strong inherited or genetic component
to atopic eczema. If you son has inherited a certain gene, or
combination of genes, this predisposes him to being ‘atopic’, buthe would still need some other trigger to cause him to have eczema.
To date, several genes have been identified that show a link with
atopic disease, but it seems likely that there are other, as yet
unidentified, genes that are important, and we hope that these will
be discovered over the next few years. We still do not understand
the function of these genes as we do not know whether they can
all lead to asthma, eczema or hay fever – the three atopic diseases
– or whether individual genes are linked to just one of the diseases.
It is more likely that various different gene combinations can lead
to atopic eczema as this would help to explain why different triggers
are important in different patients and why eczema has more that
one ‘cause’.
In other words, if your son has a susceptibility to developing
eczema by having a particular group of genes, the eczema may be
triggered by several different factors. Despite much research, the
evidence for any one trigger is very limited, and trials excluding or
limiting exposure to different environmental factors (e.g. pets,
woollen clothing, dust, car pollution) have been very disappointing
in terms of improving eczema. There is therefore no simple way
to get your son tested, and it is more likely that simple detective
work, looking at when it gets worse, may give you more of a clue.
(For more about testing, though, see the section ‘Are there any
tests?’ later in this chapter.)
What causes eczema?
Introduction
It must be very frustrating to ask your doctor why you have eczema
only to get a vague answer suggesting several possible causes. The
truth is that we don’t yet have a simple answer to this simple
question – and we may never have. In this chapter we will try to
explain what our current understanding is and, just as importantly,
try to dispel some of the myths that abound. It may be easier to
establish what does not cause eczema, but we fully understand
that myths and untruths will arise if we do not fully understand the
causes of eczema. It is important to do clear up misconceptions of
the cause as they can lead to wholly inappropriate treatment and
poorly controlled disease. If there were a simple answer to ‘What
causes eczema?’, you would not be reading this book! As with much of this book, we have many more answers related
to studies on atopic eczema and contact eczema than on some of
the other types, but the general messages are appropriate for all
the different types.
Are there any common things that make eczema worse?
This depends to some extent on what type of eczema you are talking
about. Much more research has been carried out in people with
atopic eczema, so most of the answers to the more general questions
relate more to atopic eczema than to the other forms. It is safe to
say that if you have large areas of contact eczema, your skin is likely
to be irritated by the same sorts of thing that have come up in studies
of atopic individuals. Apart from the use of soaps and other things
that can directly irritate the skin, the most common reasons are
sweating (usually from exercise), fabrics (especially if the contact
was at work) and hot weather. Fabrics encountered at work seem
to relate not just to a direct irritant effect, but also to a physical
friction effect if they have to be handled constantly as part of a job.
It must be very frustrating to ask your doctor why you have eczema
only to get a vague answer suggesting several possible causes. The
truth is that we don’t yet have a simple answer to this simple
question – and we may never have. In this chapter we will try to
explain what our current understanding is and, just as importantly,
try to dispel some of the myths that abound. It may be easier to
establish what does not cause eczema, but we fully understand
that myths and untruths will arise if we do not fully understand the
causes of eczema. It is important to do clear up misconceptions of
the cause as they can lead to wholly inappropriate treatment and
poorly controlled disease. If there were a simple answer to ‘What
causes eczema?’, you would not be reading this book! As with much of this book, we have many more answers related
to studies on atopic eczema and contact eczema than on some of
the other types, but the general messages are appropriate for all
the different types.
Are there any common things that make eczema worse?
This depends to some extent on what type of eczema you are talking
about. Much more research has been carried out in people with
atopic eczema, so most of the answers to the more general questions
relate more to atopic eczema than to the other forms. It is safe to
say that if you have large areas of contact eczema, your skin is likely
to be irritated by the same sorts of thing that have come up in studies
of atopic individuals. Apart from the use of soaps and other things
that can directly irritate the skin, the most common reasons are
sweating (usually from exercise), fabrics (especially if the contact
was at work) and hot weather. Fabrics encountered at work seem
to relate not just to a direct irritant effect, but also to a physical
friction effect if they have to be handled constantly as part of a job.
My husband is 51 and has redness and itching on his eyelids, spreading to his cheeks. Is this eczema?
It is very difficult to tell you what this is without more information.
At his age, it could be a condition called rosacea, which can cause
a red, sometimes bumpy, rash over the cheeks that can be
associated with irritation of the eyelids – called blepharitis. Rosacea
can also cause flushing and a burning feeling in the face after
alcohol, spicy foods or a sudden change of temperature. He should
see his GP as the steroid creams used to treat eczema can
sometimes cause rosacea if used for too long a time.
These days I only have mild eczema, but I recently
developed blister eczema in the middle of the sole of one
foot. It doesn’t seem to respond to my usual creams and
seems to be getting bigger. Is it just more stubborn than
my normal eczema?
You may not have ‘blister eczema’, which we call pompholyx, as it
is just affecting one foot. Eczema tends to affect both sides of the
body, so you should be suspicious that an outbreak like this is
caused by something else. The first thing to come to mind is a fungal
infection, which can be quite inflamed and can cause little blisters.
You should see your GP and get some skin scrapings taken to look
for fungus.
Many people treat fungal infections (also known as tinea) with
steroids in the mistaken belief that the rash is eczema. The steroids
will damp down the inflammation in the skin and mask the
infection, allowing it to spread in the skin. They then get a much
larger patch of slightly itchy skin, often with a thin red line all the
way round the edge where the fungus is growing – this is called
‘tinea incognito’ as the typical features of a fungal infection are
hidden.
At his age, it could be a condition called rosacea, which can cause
a red, sometimes bumpy, rash over the cheeks that can be
associated with irritation of the eyelids – called blepharitis. Rosacea
can also cause flushing and a burning feeling in the face after
alcohol, spicy foods or a sudden change of temperature. He should
see his GP as the steroid creams used to treat eczema can
sometimes cause rosacea if used for too long a time.
These days I only have mild eczema, but I recently
developed blister eczema in the middle of the sole of one
foot. It doesn’t seem to respond to my usual creams and
seems to be getting bigger. Is it just more stubborn than
my normal eczema?
You may not have ‘blister eczema’, which we call pompholyx, as it
is just affecting one foot. Eczema tends to affect both sides of the
body, so you should be suspicious that an outbreak like this is
caused by something else. The first thing to come to mind is a fungal
infection, which can be quite inflamed and can cause little blisters.
You should see your GP and get some skin scrapings taken to look
for fungus.
Many people treat fungal infections (also known as tinea) with
steroids in the mistaken belief that the rash is eczema. The steroids
will damp down the inflammation in the skin and mask the
infection, allowing it to spread in the skin. They then get a much
larger patch of slightly itchy skin, often with a thin red line all the
way round the edge where the fungus is growing – this is called
‘tinea incognito’ as the typical features of a fungal infection are
hidden.
Are there any other diseases that are less common if you have eczema?
High blood pressure (hypertension) seems to be rare in adults with
atopic eczema, whether it is active or not. This has been found in
studies, but no definite reason has yet been established.
When I saw a dermatologist about my eczema, he said I
also had keratosis pilaris and gave me a cream for that – I
thought it was all part of my eczema, but have I got two
diseases?
Keratosis pilaris is a common condition in which the hair follicles
in the skin become filled with plugs of keratin. It usually begins in
childhood and tends to improve as you get older. The outer aspects
of the upper arms and thighs feel rough because of the plugging of
the follicles and can look red. Many people have a very mild form
of it, but it does seem to be more common in people with atopic
eczema. You do have another disease but one that is associated
with having eczema. Creams that help to soften and ‘dissolve’ the
keratin plugs are known as ‘keratolytics’, and this may be what the
doctor has given you. They will only ever have a temporary effect
on the skin, so you need to keep using them.
atopic eczema, whether it is active or not. This has been found in
studies, but no definite reason has yet been established.
When I saw a dermatologist about my eczema, he said I
also had keratosis pilaris and gave me a cream for that – I
thought it was all part of my eczema, but have I got two
diseases?
Keratosis pilaris is a common condition in which the hair follicles
in the skin become filled with plugs of keratin. It usually begins in
childhood and tends to improve as you get older. The outer aspects
of the upper arms and thighs feel rough because of the plugging of
the follicles and can look red. Many people have a very mild form
of it, but it does seem to be more common in people with atopic
eczema. You do have another disease but one that is associated
with having eczema. Creams that help to soften and ‘dissolve’ the
keratin plugs are known as ‘keratolytics’, and this may be what the
doctor has given you. They will only ever have a temporary effect
on the skin, so you need to keep using them.
What if it isn’t eczema?
For several years, I have been getting recurrent crops of
dry yellow blisters that come up on my hands on the palm
side. They seem to start deep in the skin and end up on
the surface as a brown scale. Is this a form of eczema?
This sounds as though it is a condition called palmar pustulosis,
which can also affect the soles of the feet, when it is called palmo-
plantar pustulosis. The yellow blisters you describe contain pus
that is sterile, so not caused by an infection. Pus is just a collection
of white cells, which are involved in inflammation as well as fighting
infection. As they come up to the surface, the pustules dry up so
that only a dry discoloured patch of skin is left. This condition is
thought to have features of both eczema and another skin problem
called psoriasis and can be quite difficult to treat.What is the difference between eczema and psoriasis?
They are both capable of producing widespread chronic rashes,
ut psoriasis is a disease in which the turnover of the skin is greatly
peeded up – from the normal of 28 days down to 3 or 4. It therefore
roduces much more scale than eczema and the rash is much more
demarcated’, so you can see when it stops and normal skin takes
ver. It can be confused with eczema on certain parts of the body
uch as the face, hands and feet, and with certain types of eczema
uch as discoid eczema, in which there also tends to be scaling and
iscrete patches. Psoriasis involves parts of the immune system in
he skin that are different from the ones involved in eczema, so it
s rare to have both diseases together.
dry yellow blisters that come up on my hands on the palm
side. They seem to start deep in the skin and end up on
the surface as a brown scale. Is this a form of eczema?
This sounds as though it is a condition called palmar pustulosis,
which can also affect the soles of the feet, when it is called palmo-
plantar pustulosis. The yellow blisters you describe contain pus
that is sterile, so not caused by an infection. Pus is just a collection
of white cells, which are involved in inflammation as well as fighting
infection. As they come up to the surface, the pustules dry up so
that only a dry discoloured patch of skin is left. This condition is
thought to have features of both eczema and another skin problem
called psoriasis and can be quite difficult to treat.What is the difference between eczema and psoriasis?
They are both capable of producing widespread chronic rashes,
ut psoriasis is a disease in which the turnover of the skin is greatly
peeded up – from the normal of 28 days down to 3 or 4. It therefore
roduces much more scale than eczema and the rash is much more
demarcated’, so you can see when it stops and normal skin takes
ver. It can be confused with eczema on certain parts of the body
uch as the face, hands and feet, and with certain types of eczema
uch as discoid eczema, in which there also tends to be scaling and
iscrete patches. Psoriasis involves parts of the immune system in
he skin that are different from the ones involved in eczema, so it
s rare to have both diseases together.
Facts and figures 3
Do people with eczema have a higher chance of developing
asthma?
Atopic eczema, asthma and hay fever tend to go together as ‘atopic’
diseases. Asthma is a common disease in its own right as it affects
up to 10% of people at some time in their life. A child with eczema
has an increased risk of suffering from asthma as well – perhapsup to a 50% chance. Eczema tends to start earlier in life, and
research is being done to see whether any form of treatment for
the eczema will make later asthma less likely.
I moved to England from Jamaica 16 years ago. Two of my
children have eczema, and I have other friends who also
have affected children. Is eczema more common in the UK
than in the West Indies?
Yes, it seems that eczema is much more common in the UK. One
recent study showed that eczema is almost twice as common
among schoolchildren in London than in Kingston, Jamaica. When
just the black children were studied, the difference was even more
marked – eczema was up to four times more common in London.
This difference also seems to apply to Indian and Bangladeshi
populations living in the UK.
asthma?
Atopic eczema, asthma and hay fever tend to go together as ‘atopic’
diseases. Asthma is a common disease in its own right as it affects
up to 10% of people at some time in their life. A child with eczema
has an increased risk of suffering from asthma as well – perhapsup to a 50% chance. Eczema tends to start earlier in life, and
research is being done to see whether any form of treatment for
the eczema will make later asthma less likely.
I moved to England from Jamaica 16 years ago. Two of my
children have eczema, and I have other friends who also
have affected children. Is eczema more common in the UK
than in the West Indies?
Yes, it seems that eczema is much more common in the UK. One
recent study showed that eczema is almost twice as common
among schoolchildren in London than in Kingston, Jamaica. When
just the black children were studied, the difference was even more
marked – eczema was up to four times more common in London.
This difference also seems to apply to Indian and Bangladeshi
populations living in the UK.
Facts and figures 2
Do boys get eczema more than girls?
Yes, atopic eczema is a little more common in boys than girls.
When does eczema start?
It depends what sort of eczema you are talking about. The most
common form, atopic eczema, starts in childhood, and the earlier
it starts, the more likely the child is to grow out of it. For example,
if it starts before the age of 1, there is a more than 90% chance of
growing out of it before adult life. Contact eczema, often affecting
the hands, tends to come on in adult life, especially if there is a
history of atopic eczema. About 5–10% of children with atopic
eczema will develop hand eczema in adult life even if they have
grown out of their original eczema. This is especially true if they
take up certain careers (e.g. as a hairdresser, mechanic or nurse)
that lead to repeated irritation and damage to the hands.
Yes, atopic eczema is a little more common in boys than girls.
When does eczema start?
It depends what sort of eczema you are talking about. The most
common form, atopic eczema, starts in childhood, and the earlier
it starts, the more likely the child is to grow out of it. For example,
if it starts before the age of 1, there is a more than 90% chance of
growing out of it before adult life. Contact eczema, often affecting
the hands, tends to come on in adult life, especially if there is a
history of atopic eczema. About 5–10% of children with atopic
eczema will develop hand eczema in adult life even if they have
grown out of their original eczema. This is especially true if they
take up certain careers (e.g. as a hairdresser, mechanic or nurse)
that lead to repeated irritation and damage to the hands.
Facts and figures How many people are affected by eczema?
It is very difficult to answer this precisely as there are so many
different types of eczema. Skin disease in general can make up
around 15% of the workload of a GP, and a third of this is down to
eczema. We know most about children with atopic eczema, and
different studies suggest that as many as 15% of those living in
developed countries will suffer from eczema at some time. This
percentage has been gradually increasing over the past 30 years.
different types of eczema. Skin disease in general can make up
around 15% of the workload of a GP, and a third of this is down to
eczema. We know most about children with atopic eczema, and
different studies suggest that as many as 15% of those living in
developed countries will suffer from eczema at some time. This
percentage has been gradually increasing over the past 30 years.
Why does skin itch with eczema?
Surprisingly, this is a very difficult question to answer as the current
scientific understanding of itch is really very poor. We do know
that certain small nerve fibres in the skin transmit ‘itch’ signals to
the spinal cord and then to the brain. These same fibres can also
transmit pain signals. There are certain centres in the brain that
receive these signals and then interpret them either as an itch
sensation or sometimes as pain. Two different types of nerve fibre
are involved, one being faster than the other. This explains why
itching can be made up of an early localised pricking sensation
followed by a diffuse itching or burning sensation.
Why people with eczema itch isn’t really known, but it may be
that the dry, inflamed skin of eczema fires off these nerve fibres,
causing the itch. There is, however, also some evidence that these
nerve fibres and the chemical signals (neurotransmitters) that they
contain may be abnormal in eczema. This could mean that the
abnormal itching sensation is the first problem, with the other skin
changes being ‘secondary’ – i.e. being the result of the damage
caused by scratching. A lot more research needs to be done into
the mechanisms of itch before we have a clearer picture.
scientific understanding of itch is really very poor. We do know
that certain small nerve fibres in the skin transmit ‘itch’ signals to
the spinal cord and then to the brain. These same fibres can also
transmit pain signals. There are certain centres in the brain that
receive these signals and then interpret them either as an itch
sensation or sometimes as pain. Two different types of nerve fibre
are involved, one being faster than the other. This explains why
itching can be made up of an early localised pricking sensation
followed by a diffuse itching or burning sensation.
Why people with eczema itch isn’t really known, but it may be
that the dry, inflamed skin of eczema fires off these nerve fibres,
causing the itch. There is, however, also some evidence that these
nerve fibres and the chemical signals (neurotransmitters) that they
contain may be abnormal in eczema. This could mean that the
abnormal itching sensation is the first problem, with the other skin
changes being ‘secondary’ – i.e. being the result of the damage
caused by scratching. A lot more research needs to be done into
the mechanisms of itch before we have a clearer picture.
My family are from India and I have noticed that my eczema looks different from eczema in my friends with white skin. Why is this?
I am afraid that we cannot explain why there are different patterns
of eczema in different racial groups, but you are right to have
spotted the difference. Eczema often affects the flexures (the
creases in front of the elbows and behind the knees), but in Asian
and particularly in African/Caribbean people, eczema sometimes
shows a reverse pattern, affecting the extensor surfaces (behind
the elbows and the front of the knees). There can be otherdifferences in the way in which pigmented skin reacts giving rise
to unusual presentations of eczema:
• Thickening of the skin (lichenification) seems to happen
much more readily.
• Lumps or papules are more common, giving a raised,
bumpy appearance to the skin.
• There may be a marked increase or decrease in
pigmentation of the skin after the eczema has settled down.
This can be very distressing as it can be quite disfiguring.
of eczema in different racial groups, but you are right to have
spotted the difference. Eczema often affects the flexures (the
creases in front of the elbows and behind the knees), but in Asian
and particularly in African/Caribbean people, eczema sometimes
shows a reverse pattern, affecting the extensor surfaces (behind
the elbows and the front of the knees). There can be otherdifferences in the way in which pigmented skin reacts giving rise
to unusual presentations of eczema:
• Thickening of the skin (lichenification) seems to happen
much more readily.
• Lumps or papules are more common, giving a raised,
bumpy appearance to the skin.
• There may be a marked increase or decrease in
pigmentation of the skin after the eczema has settled down.
This can be very distressing as it can be quite disfiguring.
How does our doctor know that my child’s rash is eczema?
As there are no specific tests for most types of eczema, your doctor
will have reached a diagnosis on what we call ‘clinical grounds’.
This means taking a careful history of the problem and any family
history of eczema, asthma or hay fever. Examination of the skin
will add to the clues in the history, allowing a diagnosis to be made.
Some people with atopic eczema may have abnormal blood tests,
such as high levels of an antibody called immunoglobulin E (IgE).
Antibodies are chemicals made by the body as a defence against
infection but are also involved in allergic reactions. Specific
allergens (the causes or triggers of allergy) can lead to high levels
of linked IgE, which can be measured by a blood test called an
ELISA test. (This is discussed in Chapter 2 under allergy testing.)
These tests do not, however, diagnose atopic eczema as you can
have abnormal tests and never develop eczema, or have normal
IgE levels and very definite eczema.
will have reached a diagnosis on what we call ‘clinical grounds’.
This means taking a careful history of the problem and any family
history of eczema, asthma or hay fever. Examination of the skin
will add to the clues in the history, allowing a diagnosis to be made.
Some people with atopic eczema may have abnormal blood tests,
such as high levels of an antibody called immunoglobulin E (IgE).
Antibodies are chemicals made by the body as a defence against
infection but are also involved in allergic reactions. Specific
allergens (the causes or triggers of allergy) can lead to high levels
of linked IgE, which can be measured by a blood test called an
ELISA test. (This is discussed in Chapter 2 under allergy testing.)
These tests do not, however, diagnose atopic eczema as you can
have abnormal tests and never develop eczema, or have normal
IgE levels and very definite eczema.
Why is skin with eczema so susceptible to irritants?
As fluid accumulates in the epidermis, the ‘bricks’ separate and the
‘cement’ becomes disrupted, leaving big cracks in the ‘barrier’.
Irritants that would normally be kept on the surface are allowed
through to the more sensitive dermis. Some irritants, such as soaps,
act to dissolve the lipid-based cement, leading to a further
breakdown of the skin’s barrier function.
‘cement’ becomes disrupted, leaving big cracks in the ‘barrier’.
Irritants that would normally be kept on the surface are allowed
through to the more sensitive dermis. Some irritants, such as soaps,
act to dissolve the lipid-based cement, leading to a further
breakdown of the skin’s barrier function.
Why does my skin weep fluid and feel wet?
If you think of the epidermis changing to look like a sponge, you
can imagine the fluid leaking out and making the outer layer stretch
up into blisters. Once these break, you will be left with a wet
weeping area as the skin has lost its barrier function.
can imagine the fluid leaking out and making the outer layer stretch
up into blisters. Once these break, you will be left with a wet
weeping area as the skin has lost its barrier function.
Is the skin just a simple barrier?
No, it is much more than that, and this accounts for the many
physical and psychological effects that it can have, especially if
you are badly affected by eczema. It is the last line of defence
against the outside world, protecting our bodies from external
attack and keeping the right conditions inside (homeostasis)
through its prevention of loss of fluid and regulation of temperature.
It also allows for a display of individuality through decoration,
jewellery and hair-styling.
Skin, therefore:
• acts as a barrier to physical agents including ultraviolet
radiation;
• protects against mechanical injury;
• defends against microbes;
• is involved in homeostasis – preventing the loss of water
and electrolytes;
• regulates temperature and insulates;
• is involved in sensory functions;
• is integral to fine touch and grip;
• is the site of vitamin D synthesis;
• acts as a calorie store in the subcutaneous fat;
• has cosmetic, psychosocial and display functions.
physical and psychological effects that it can have, especially if
you are badly affected by eczema. It is the last line of defence
against the outside world, protecting our bodies from external
attack and keeping the right conditions inside (homeostasis)
through its prevention of loss of fluid and regulation of temperature.
It also allows for a display of individuality through decoration,
jewellery and hair-styling.
Skin, therefore:
• acts as a barrier to physical agents including ultraviolet
radiation;
• protects against mechanical injury;
• defends against microbes;
• is involved in homeostasis – preventing the loss of water
and electrolytes;
• regulates temperature and insulates;
• is involved in sensory functions;
• is integral to fine touch and grip;
• is the site of vitamin D synthesis;
• acts as a calorie store in the subcutaneous fat;
• has cosmetic, psychosocial and display functions.
What happens in the skin of people with eczema?
To explain what happens in eczema, you need to understand the
structure of the skin as seen down a microscope. The skin consists
of three layers:
• The outer layer is called the epidermis. This contains a
‘brick wall’ of skin cells (keratinocytes) that are held
together by a cement (the mortar) mostly made up of fats
or lipids. The many different layers start with live cells that
constantly reproduce, creating new cells that move up to
the surface, die and are shed. This whole process takes
about 28 days. The lipid cement makes the brick wall into a
very effective barrier against the environment. It prevents
the skin losing too much water and prevents noxious
(poisonous) substances getting in.
• The middle layer is called the dermis. This consists of
tough structural fibres called collagen and elastin, which
provide strength and elasticity to the skin. It also contains
blood vessels that supply nutrients and oxygen to both the
dermis and the epidermis.
• The deepest layer of the skin is called the subcutis and is
predominantly made up of an insulating layer of fat.
In eczema, it is the dermis and epidermis that are affected. The
epidermis shows the most marked changes. The inflammation leads
to leaky blood vessels, so fluid collects between the keratinocytes,
causing them to separate. The brick wall takes on a sponge-like
appearance. As the eczema becomes chronic, the constant rubbing
and scratching causes the epidermis to regenerate more quickly,
so it becomes thickened.
Finally, eczema causes changes in the upper part of the dermis.
This region becomes flooded with white blood cells, which are part
of the body’s immune system or defences. They leak out of vessels
and even pass up into the epidermis. Current evidence suggeststhat it is these cells that drive the whole process of inflammation
in the skin.
structure of the skin as seen down a microscope. The skin consists
of three layers:
• The outer layer is called the epidermis. This contains a
‘brick wall’ of skin cells (keratinocytes) that are held
together by a cement (the mortar) mostly made up of fats
or lipids. The many different layers start with live cells that
constantly reproduce, creating new cells that move up to
the surface, die and are shed. This whole process takes
about 28 days. The lipid cement makes the brick wall into a
very effective barrier against the environment. It prevents
the skin losing too much water and prevents noxious
(poisonous) substances getting in.
• The middle layer is called the dermis. This consists of
tough structural fibres called collagen and elastin, which
provide strength and elasticity to the skin. It also contains
blood vessels that supply nutrients and oxygen to both the
dermis and the epidermis.
• The deepest layer of the skin is called the subcutis and is
predominantly made up of an insulating layer of fat.
In eczema, it is the dermis and epidermis that are affected. The
epidermis shows the most marked changes. The inflammation leads
to leaky blood vessels, so fluid collects between the keratinocytes,
causing them to separate. The brick wall takes on a sponge-like
appearance. As the eczema becomes chronic, the constant rubbing
and scratching causes the epidermis to regenerate more quickly,
so it becomes thickened.
Finally, eczema causes changes in the upper part of the dermis.
This region becomes flooded with white blood cells, which are part
of the body’s immune system or defences. They leak out of vessels
and even pass up into the epidermis. Current evidence suggeststhat it is these cells that drive the whole process of inflammation
in the skin.
Does it look the same in the acute and chronic stages?
Acute eczema will occur quite quickly – hours or a few days –
sometimes in previously normal skin. Little blisters may appear
and then break to give a weeping surface. The underlying skin will
be red, perhaps swollen and often a little bumpy. Most acute eczema
is very itchy, but when the skin surface has broken down, this may
be replaced by soreness. As days go by, crusting and then scaling
may occur alongside the weeping or gradually replace it.
‘Chronic eczema’ is eczema that has been present for a long
time – usually at least weeks. The ongoing inflammation, rubbing
and scratching all contribute to an increased thickness of the skin,
which may develop a leathery appearance and show much more
prominent skin surface markings. In dark skin, there may be
changes in the pigmentation – both an increase and a decrease are
possible. This thickened skin is liable to split, producing painful
fissures, especially over the joints.I get very confused by all the different types of eczema
that can affect the skin. You say that the final process in
the skin is the same for all of them. Why can’t we just call
it eczema and get on with treating it?
Despite the fact that, at microscopic level, the skin looks very
similar in the different types of eczema, this is the end stage as the
skin can only behave in so many different ways when disordered.
The main reason for trying to label the different patterns accurately
is that the cause, severity and outcome vary enormously between
the different eczemas. Whereas some of the treatments are similar
for the different types, there are many that are more specific, so
accurate diagnosis is essential. Treating eczema is also not just
about creams: it must involve prevention, and this is much more
possible in some types than in others.
sometimes in previously normal skin. Little blisters may appear
and then break to give a weeping surface. The underlying skin will
be red, perhaps swollen and often a little bumpy. Most acute eczema
is very itchy, but when the skin surface has broken down, this may
be replaced by soreness. As days go by, crusting and then scaling
may occur alongside the weeping or gradually replace it.
‘Chronic eczema’ is eczema that has been present for a long
time – usually at least weeks. The ongoing inflammation, rubbing
and scratching all contribute to an increased thickness of the skin,
which may develop a leathery appearance and show much more
prominent skin surface markings. In dark skin, there may be
changes in the pigmentation – both an increase and a decrease are
possible. This thickened skin is liable to split, producing painful
fissures, especially over the joints.I get very confused by all the different types of eczema
that can affect the skin. You say that the final process in
the skin is the same for all of them. Why can’t we just call
it eczema and get on with treating it?
Despite the fact that, at microscopic level, the skin looks very
similar in the different types of eczema, this is the end stage as the
skin can only behave in so many different ways when disordered.
The main reason for trying to label the different patterns accurately
is that the cause, severity and outcome vary enormously between
the different eczemas. Whereas some of the treatments are similar
for the different types, there are many that are more specific, so
accurate diagnosis is essential. Treating eczema is also not just
about creams: it must involve prevention, and this is much more
possible in some types than in others.
Are some types of eczema more common at different ages?
The age of onset can be helpful in deciding what type(s) of eczema
a person has. Eczema in an infant is most commonly atopic
(although this may appear discoid in places and can be aggravated
by irritants) or seborrhoeic. In the child and teenager, atopic eczema
is most common, but there will be some instances of contact allergy,
for example to nickel. In adults of working age, irritant, contact
allergic, seborrhoeic, discoid and atopic eczema are all common
and can occur at many body sites; pompholyx and venous eczema
are recognisable by their locations. The elderly are prone to
asteatotic eczema, especially on the shins, in addition to the types
experienced by younger adults.
a person has. Eczema in an infant is most commonly atopic
(although this may appear discoid in places and can be aggravated
by irritants) or seborrhoeic. In the child and teenager, atopic eczema
is most common, but there will be some instances of contact allergy,
for example to nickel. In adults of working age, irritant, contact
allergic, seborrhoeic, discoid and atopic eczema are all common
and can occur at many body sites; pompholyx and venous eczema
are recognisable by their locations. The elderly are prone to
asteatotic eczema, especially on the shins, in addition to the types
experienced by younger adults.
My doctor says that my varicose veins have caused eczema. Is he right?
Yes, it sounds as though you have venous eczema, also called
varicose, stasis or gravitational eczema. It is linked to poor blood
flow in the veins in the lower legs, sometimes after clots in the deep
veins. The eczema is chronic, and the legs can become stained a
browny colour from blood pigments getting into the skin. You will
have to be very careful not to scratch the skin as it will be very
fragile and prone to ulceration. If this does happen, you will need
dressings and bandages; these can sometimes, however, lead toextra problems of allergic contact eczema, so be careful and look
after your skin.
I have suffered from eczema since I was a child. In my
adult years it has changed, and my GP has told me it was
something called ‘pomphlics’. What is this?
‘Pompholyx’ is a word used to describe a pattern of eczema
affecting the hands and feet that typically shows blistering and is
very itchy. There are recurring outbreaks of tense, thick-walled
vesicles or larger blisters on the palms, along the fingers and
sometimes on the soles of the feet. Each outbreak can last a few
weeks and recur at irregular intervals. It is more common in hot
weather and can occur in three types:
• in association with atopic eczema;
• linked to allergic contact eczema – people allergic to nickel
may also develop it in response to low levels of nickel in
food;
• in isolation (the cause here being unknown).
varicose, stasis or gravitational eczema. It is linked to poor blood
flow in the veins in the lower legs, sometimes after clots in the deep
veins. The eczema is chronic, and the legs can become stained a
browny colour from blood pigments getting into the skin. You will
have to be very careful not to scratch the skin as it will be very
fragile and prone to ulceration. If this does happen, you will need
dressings and bandages; these can sometimes, however, lead toextra problems of allergic contact eczema, so be careful and look
after your skin.
I have suffered from eczema since I was a child. In my
adult years it has changed, and my GP has told me it was
something called ‘pomphlics’. What is this?
‘Pompholyx’ is a word used to describe a pattern of eczema
affecting the hands and feet that typically shows blistering and is
very itchy. There are recurring outbreaks of tense, thick-walled
vesicles or larger blisters on the palms, along the fingers and
sometimes on the soles of the feet. Each outbreak can last a few
weeks and recur at irregular intervals. It is more common in hot
weather and can occur in three types:
• in association with atopic eczema;
• linked to allergic contact eczema – people allergic to nickel
may also develop it in response to low levels of nickel in
food;
• in isolation (the cause here being unknown).
My gran has very itchy legs with not much to see other
than dry skin with a sort of criss-cross pattern. She used
to get eczema as a child but says it didn’t look like this.
She probably has asteatotic eczema, which occurs in older people
who may have had eczema in the past or have, at least, a tendency
to have dry skin. It is made worse by low humidity in centrally
heated rooms and the removal of the natural oils from washing
with soap. Diuretics can increase the problem from dehydration
and hypothyroidism should be excluded. As with your gran, i
presents on the legs, which itch and show a background of dry skin
with a superficial network of fine red lines giving a ‘crazy paving
appearance. These fines lines are actually small cracks or fissure
in the skin. Treatment with water tablets (diuretics), for blood
pressure or heart problems, can make it worse, as can having a
thyroid gland that is not working very well.
than dry skin with a sort of criss-cross pattern. She used
to get eczema as a child but says it didn’t look like this.
She probably has asteatotic eczema, which occurs in older people
who may have had eczema in the past or have, at least, a tendency
to have dry skin. It is made worse by low humidity in centrally
heated rooms and the removal of the natural oils from washing
with soap. Diuretics can increase the problem from dehydration
and hypothyroidism should be excluded. As with your gran, i
presents on the legs, which itch and show a background of dry skin
with a superficial network of fine red lines giving a ‘crazy paving
appearance. These fines lines are actually small cracks or fissure
in the skin. Treatment with water tablets (diuretics), for blood
pressure or heart problems, can make it worse, as can having a
thyroid gland that is not working very well.
I get eczema under my watch strap but nowhere else. Is it some sort of allergy?
If the watch strap is metal, you could be allergic to nickel and have
allergic contact eczema. This is different from irritant contact
eczema in several ways as it is a type of immune problem called a
delayed hypersensitivity reaction. The key points about it are:
• previous contact is necessary to induce the response;
• the response is specific to one substance;
• all areas of skin will react once sensitisation has taken
place;
• sensitisation persists indefinitely, and desensitisation is
unlikely to be possible.Various patterns are seen, depending on the original site of
contact. Your case is typical of nickel allergy, which can also be
seen under jewellery and metal fastenings in clothing, such as the
studs in jeans. Other patterns include fingertip eczema from garlic,
and eczema on the face and neck from perfume. An allergic cause
should be suspected if the pattern of eczema is unusual – eyelids,
around leg ulcers, hands or feet – if there is a known exposure to
some of the common allergens, or if the type of work is ‘high risk’,
for example hairdressing, nursing, gardening or floristry.
allergic contact eczema. This is different from irritant contact
eczema in several ways as it is a type of immune problem called a
delayed hypersensitivity reaction. The key points about it are:
• previous contact is necessary to induce the response;
• the response is specific to one substance;
• all areas of skin will react once sensitisation has taken
place;
• sensitisation persists indefinitely, and desensitisation is
unlikely to be possible.Various patterns are seen, depending on the original site of
contact. Your case is typical of nickel allergy, which can also be
seen under jewellery and metal fastenings in clothing, such as the
studs in jeans. Other patterns include fingertip eczema from garlic,
and eczema on the face and neck from perfume. An allergic cause
should be suspected if the pattern of eczema is unusual – eyelids,
around leg ulcers, hands or feet – if there is a known exposure to
some of the common allergens, or if the type of work is ‘high risk’,
for example hairdressing, nursing, gardening or floristry.
My son has what looks like eczema but just round his mouth. What might have caused it?
This could be another form of irritant eczema. If it looks red and
dry with cracks or fissures, it is probably ‘lip-licking’ eczema. It
might also be linked to irritation from, or even allergy to, toothpaste.
dry with cracks or fissures, it is probably ‘lip-licking’ eczema. It
might also be linked to irritation from, or even allergy to, toothpaste.
Is hand eczema different from other eczemas?
As far as the basic underlying process in the skin goes, it is the
same as other types of eczema. It can be caused by a variety of
different types of eczema, so the common thing is the site – on the
hands. A background of atopic eczema, wet work and contact
seems to be the most important factor, and it affects women more
than men. Environmental triggers from wet work and contact seem
to be more important than any genetic factors. It can be a very long-
lasting form of eczema, especially if it starts at a young age and is
not caused by any specific allergies. It has been estimated to affect
more than 1% of the adult population in the UK.
same as other types of eczema. It can be caused by a variety of
different types of eczema, so the common thing is the site – on the
hands. A background of atopic eczema, wet work and contact
seems to be the most important factor, and it affects women more
than men. Environmental triggers from wet work and contact seem
to be more important than any genetic factors. It can be a very long-
lasting form of eczema, especially if it starts at a young age and is
not caused by any specific allergies. It has been estimated to affect
more than 1% of the adult population in the UK.
My baby has bad nappy rash despite regular changing and the use of a barrier cream. Could she have a form of eczema?
There are actually three types of eczema that can affect the nappy
area. The most common is irritant eczema (nappy rash), which can
affect nearly all babies to some extent. This simply reflects the fact
that urine and faeces are irritant to the skin if left in contact with
it for prolonged periods. This type of nappy rash usually spares the
skin right in the groins. The skin fold between the leg and the
tummy therefore looks normal but is surrounded on either side by
red, inflamed skin.
As you are already doing all the right things to prevent nappy
rash, your baby may have one of the other types of eczema (atopicor seborrhoeic). Both of these tend to involve rather than spare
the skin fold at the top of the leg. Atopic eczema only rarely affects
the nappy area and is normally very itchy. You may see eczema in
the skin folds elsewhere on the body (e.g. in front of the elbows
or behind the knees). In contrast, seborrhoeic eczema tends not
to be itchy and tends to be associated with greasy yellow scales
on the scalp (cradle cap).
I am 45 and have never had any problems with my skin. I
now have itchy, round, scaly patches on my arms and legs
that my GP says are eczema. Is this right?
Yes, these could be, although your GP may also have considered
other causes such as fungal infection and psoriasis. This pattern
is called discoid eczema. The precise cause of this has yet to be
identified, but chronic stress and local infection may play a part.
As you have found, the rash typically presents on the limbs in
people in their forties and fifties, and it is more common in men.
Unlike atopic eczema, it favours the extensor surfaces and appears
as round ‘plaques’ rather than being more spread out. These plaques
are usually 5 cm or less in diameter. Looking closely at them, you
should see some tiny little blisters and crusting where the fluid
from the blisters has dried. The underlying skin will probably be
thickened. Discoid eczema can be very stubborn and difficult to
treat, so it may persist for many months.I had eczema as a child, but it cleared up until recently
when I got it again on my hands. Why is this?
It sounds as though you have a form of eczema caused by contact
with irritant chemicals. Not surprisingly, this is called ‘irritant
contact eczema’, and it is the most common form caused by contact
(perhaps 80% of cases), the other cause being allergic. Strong
irritants will cause an obvious and acute reaction on anybody’s
skin, but weaker irritants need months or years of exposure to
cause the same problems. As you have found, the eczema usually
affects the hands and forearms as the most common parts of the
body exposed to detergents, industrial oils, solvents, etc. Manypeople with dry or fair skin are likely to develop irritant problems,
but your history of atopic eczema doubles the risk.
area. The most common is irritant eczema (nappy rash), which can
affect nearly all babies to some extent. This simply reflects the fact
that urine and faeces are irritant to the skin if left in contact with
it for prolonged periods. This type of nappy rash usually spares the
skin right in the groins. The skin fold between the leg and the
tummy therefore looks normal but is surrounded on either side by
red, inflamed skin.
As you are already doing all the right things to prevent nappy
rash, your baby may have one of the other types of eczema (atopicor seborrhoeic). Both of these tend to involve rather than spare
the skin fold at the top of the leg. Atopic eczema only rarely affects
the nappy area and is normally very itchy. You may see eczema in
the skin folds elsewhere on the body (e.g. in front of the elbows
or behind the knees). In contrast, seborrhoeic eczema tends not
to be itchy and tends to be associated with greasy yellow scales
on the scalp (cradle cap).
I am 45 and have never had any problems with my skin. I
now have itchy, round, scaly patches on my arms and legs
that my GP says are eczema. Is this right?
Yes, these could be, although your GP may also have considered
other causes such as fungal infection and psoriasis. This pattern
is called discoid eczema. The precise cause of this has yet to be
identified, but chronic stress and local infection may play a part.
As you have found, the rash typically presents on the limbs in
people in their forties and fifties, and it is more common in men.
Unlike atopic eczema, it favours the extensor surfaces and appears
as round ‘plaques’ rather than being more spread out. These plaques
are usually 5 cm or less in diameter. Looking closely at them, you
should see some tiny little blisters and crusting where the fluid
from the blisters has dried. The underlying skin will probably be
thickened. Discoid eczema can be very stubborn and difficult to
treat, so it may persist for many months.I had eczema as a child, but it cleared up until recently
when I got it again on my hands. Why is this?
It sounds as though you have a form of eczema caused by contact
with irritant chemicals. Not surprisingly, this is called ‘irritant
contact eczema’, and it is the most common form caused by contact
(perhaps 80% of cases), the other cause being allergic. Strong
irritants will cause an obvious and acute reaction on anybody’s
skin, but weaker irritants need months or years of exposure to
cause the same problems. As you have found, the eczema usually
affects the hands and forearms as the most common parts of the
body exposed to detergents, industrial oils, solvents, etc. Manypeople with dry or fair skin are likely to develop irritant problems,
but your history of atopic eczema doubles the risk.
Will I ever grow out of my atopic eczema? I am now in my thirties!
Unfortunately, most adults who have atopic eczema that has
persisted from childhood tend to find that it continues into old age.
It is therefore very important that you work hard on finding a
treatment regime that allows you to maThe health visitor says that my baby has cradle cap and
that this is a type of eczema. Is this true?
Yes, this is a type of eczema called seborrhoeic eczema. It may
affect infants but is rare during later childhood. It is probably most
common in men. It has several different patterns but most
commonly affects the face and scalp in infants as well as the napkin
area. Unlike atopic eczema, it does not feel itchy, so your baby
won’t scratch very much. There are three main patterns:
• A red, scaly rash on the scalp and ears, around the nose
and in the creases down to the lips and eyebrows. It is
often associated with eczema in the ear canals and on the
eyelids. This is the ‘cradle cap’ your health visitor is
referring to.
• On the trunk in the centre of the chest and upper back.
There is a dry, scaly rash sometimes accompanied by a
more extensive outbreak of little bumps and spots around
the hair follicles.
• An intertriginous form affecting the armpits, belly button
and groins, which can also present under spectacles or
hearing aids.nage it as easily as possible.
persisted from childhood tend to find that it continues into old age.
It is therefore very important that you work hard on finding a
treatment regime that allows you to maThe health visitor says that my baby has cradle cap and
that this is a type of eczema. Is this true?
Yes, this is a type of eczema called seborrhoeic eczema. It may
affect infants but is rare during later childhood. It is probably most
common in men. It has several different patterns but most
commonly affects the face and scalp in infants as well as the napkin
area. Unlike atopic eczema, it does not feel itchy, so your baby
won’t scratch very much. There are three main patterns:
• A red, scaly rash on the scalp and ears, around the nose
and in the creases down to the lips and eyebrows. It is
often associated with eczema in the ear canals and on the
eyelids. This is the ‘cradle cap’ your health visitor is
referring to.
• On the trunk in the centre of the chest and upper back.
There is a dry, scaly rash sometimes accompanied by a
more extensive outbreak of little bumps and spots around
the hair follicles.
• An intertriginous form affecting the armpits, belly button
and groins, which can also present under spectacles or
hearing aids.nage it as easily as possible.
What is atopic eczema?
This comes from the word ‘atopy’, which refers to a group of
conditions in which the immune system reacts to allergens in the
environment by producing raised levels of immunoglobulin type
E (IgE), which in turn leads to the changes in the skin. Seventy-
five per cent of cases present before the age of 6 months, rising to
90% before the age of 5 years. It is thought to affect 3% of infants
and persists for several years. Of the children affected, 60–70% will
have gone into remission (no longer suffer from eczema) by their
early teenage years, although they remain vulnerable to recurrences
and may always have problems with dry skin. The pattern of rash
on the skin varies with age:
• In infancy, it often starts on the face with vesicles and
weeping. Distribution elsewhere is non-specific, but it does
tend to spare the napkin area.
• As the child ages, the distribution becomes more flexural
around knees, elbows, wrists and ankles. The skin becomes
increasingly thickened, dry and excoriated – often looking
‘leathery’ (lichenification).
This pattern continues into adulthood, with increasing
lichenification and an increasing tendency to affect the trunk,
face and hands.
conditions in which the immune system reacts to allergens in the
environment by producing raised levels of immunoglobulin type
E (IgE), which in turn leads to the changes in the skin. Seventy-
five per cent of cases present before the age of 6 months, rising to
90% before the age of 5 years. It is thought to affect 3% of infants
and persists for several years. Of the children affected, 60–70% will
have gone into remission (no longer suffer from eczema) by their
early teenage years, although they remain vulnerable to recurrences
and may always have problems with dry skin. The pattern of rash
on the skin varies with age:
• In infancy, it often starts on the face with vesicles and
weeping. Distribution elsewhere is non-specific, but it does
tend to spare the napkin area.
• As the child ages, the distribution becomes more flexural
around knees, elbows, wrists and ankles. The skin becomes
increasingly thickened, dry and excoriated – often looking
‘leathery’ (lichenification).
This pattern continues into adulthood, with increasing
lichenification and an increasing tendency to affect the trunk,
face and hands.
Is eczema the same as dermatitis?
Yes, and no!
‘Dermatitis’ is a more generalised word, simply meaning
inflammation of the skin. All eczema is dermatitis, but many other
conditions that can be called dermatitis fall within the grouping of
dermatitis. Most of the different types of eczema can, and often
are, interchangeably termed dermatitis – the term is more
commonly used in the USA. Previously more than now, an
eczematous process caused by an irritant or allergic problem in
the workplace was called contact dermatitis, and issues concerning
compensation might at least have been implied.
For some types of eczema, it is more commonplace to use
‘dermatitis’. Cases include napkin (diaper) dermatitis, photo-
dermatitis and neuro-dermatitis. For others, for example asteatotic
eczema, ‘eczema’ has been the preferred term. For some of the rest
– such as seborrhoeic and discoid – eczema and dermatitis are used
interchangeably. The situation is therefore still very confusing, and
it is always worth asking your doctor if he or she means something
different from your understanding of the words.
‘Dermatitis’ is a more generalised word, simply meaning
inflammation of the skin. All eczema is dermatitis, but many other
conditions that can be called dermatitis fall within the grouping of
dermatitis. Most of the different types of eczema can, and often
are, interchangeably termed dermatitis – the term is more
commonly used in the USA. Previously more than now, an
eczematous process caused by an irritant or allergic problem in
the workplace was called contact dermatitis, and issues concerning
compensation might at least have been implied.
For some types of eczema, it is more commonplace to use
‘dermatitis’. Cases include napkin (diaper) dermatitis, photo-
dermatitis and neuro-dermatitis. For others, for example asteatotic
eczema, ‘eczema’ has been the preferred term. For some of the rest
– such as seborrhoeic and discoid – eczema and dermatitis are used
interchangeably. The situation is therefore still very confusing, and
it is always worth asking your doctor if he or she means something
different from your understanding of the words.
Is there a simple way of classifying eczema?
Unfortunately, no.
There are many different causes and triggers for eczema – some
from the outside world, for example irritants, allergy and bacterial
infection, and others from within the body. The ones from within
are called ‘intrinsic’ and include ‘atopy’ – having a genetic tendency
to eczema, asthma and hay fever – raised pressure in the leg veins,
and reactions to stressful circumstances. These causes and trigger
factors are not mutually exclusive, so several may be important at
the same time in the same person; it is, however, usually possible
to give a general label to the main underlying cause.
As well as trying to provide an appropriate label, it is often useful
to classify eczema in terms of how long it has been there and how
quickly it appeared. Calling it ‘acute’ suggests a rapid onset and a
short but maybe severe course; ‘chronic’ means continuing for a
long time. This time course may give some extra clues to the trigger
or triggers involved.
Most classifications are imperfect but do serve to show the
different factors involved in producing similar changes in the skin.
Eczema can be classified as follows:
1. Mainly caused by external triggers.
• Irritant – various chemicals, including detergents in soap.
• Physical factors – friction and chronic rubbing, sunlight and
artificial ultraviolet light.
• Allergic – the immune system reacting to something coming
into contact with the skin or taken by mouth.
2. Internal and other causes.
• Atopic – often associated with hay fever, asthma and food
allergies.
• Seborrhoeic – related to yeasts on the skin, which has a
specific pattern.
• Discoid – a descriptive term for rounded patches of eczema
with no obvious cause.
• Venous/varicose/gravitational/stasis – a number of different
terms for eczema on the lower legs owing to problems with
the blood flow and pressure in the superficial veins, which
can be varicose.
• Asteatotic – usually in elderly people and caused by
excessive washing and dry, low-humidity environments.
The skin takes on an appearance like crazy paving.
• Pompholyx – lots of very itchy blisters on the hands and
feet.
• Neuro-dermatitis – often called lichen simplex, this is
linked to chronic rubbing or scratching.
There are many different causes and triggers for eczema – some
from the outside world, for example irritants, allergy and bacterial
infection, and others from within the body. The ones from within
are called ‘intrinsic’ and include ‘atopy’ – having a genetic tendency
to eczema, asthma and hay fever – raised pressure in the leg veins,
and reactions to stressful circumstances. These causes and trigger
factors are not mutually exclusive, so several may be important at
the same time in the same person; it is, however, usually possible
to give a general label to the main underlying cause.
As well as trying to provide an appropriate label, it is often useful
to classify eczema in terms of how long it has been there and how
quickly it appeared. Calling it ‘acute’ suggests a rapid onset and a
short but maybe severe course; ‘chronic’ means continuing for a
long time. This time course may give some extra clues to the trigger
or triggers involved.
Most classifications are imperfect but do serve to show the
different factors involved in producing similar changes in the skin.
Eczema can be classified as follows:
1. Mainly caused by external triggers.
• Irritant – various chemicals, including detergents in soap.
• Physical factors – friction and chronic rubbing, sunlight and
artificial ultraviolet light.
• Allergic – the immune system reacting to something coming
into contact with the skin or taken by mouth.
2. Internal and other causes.
• Atopic – often associated with hay fever, asthma and food
allergies.
• Seborrhoeic – related to yeasts on the skin, which has a
specific pattern.
• Discoid – a descriptive term for rounded patches of eczema
with no obvious cause.
• Venous/varicose/gravitational/stasis – a number of different
terms for eczema on the lower legs owing to problems with
the blood flow and pressure in the superficial veins, which
can be varicose.
• Asteatotic – usually in elderly people and caused by
excessive washing and dry, low-humidity environments.
The skin takes on an appearance like crazy paving.
• Pompholyx – lots of very itchy blisters on the hands and
feet.
• Neuro-dermatitis – often called lichen simplex, this is
linked to chronic rubbing or scratching.
What is eczema?
Introduction
The term ‘eczema’ is used for a group of conditions that show a
similar pattern of changes in the skin, giving rise to specific changes
on the surface. The word itself comes from the Greek and means
‘to boil or flow out’ – anyone who has had acute eczema will
understand how appropriate this is.
In acute (short-term) eczema, intense inflammation leads to the
formation of little blisters (vesicles) in the skin, which soon burst
or are scratched open, leading to weeping and the ‘flowing out’ of
fluid. Even if there are no vesicles, a section of skin affected by
eczema looked at under a microscope shows fluid between the
skin cells, tending to push them apart. This produces an appearance
reminiscent of a sponge – hence the term ‘spongiosis’ that is used
by doctors. All the different conditions called eczema would be
expected to show this spongiosis, together with some degree of
inflammation around superficial blood vessels, which are dilated,
producing the hot, red feeling and appearance.
The term ‘eczema’ is used for a group of conditions that show a
similar pattern of changes in the skin, giving rise to specific changes
on the surface. The word itself comes from the Greek and means
‘to boil or flow out’ – anyone who has had acute eczema will
understand how appropriate this is.
In acute (short-term) eczema, intense inflammation leads to the
formation of little blisters (vesicles) in the skin, which soon burst
or are scratched open, leading to weeping and the ‘flowing out’ of
fluid. Even if there are no vesicles, a section of skin affected by
eczema looked at under a microscope shows fluid between the
skin cells, tending to push them apart. This produces an appearance
reminiscent of a sponge – hence the term ‘spongiosis’ that is used
by doctors. All the different conditions called eczema would be
expected to show this spongiosis, together with some degree of
inflammation around superficial blood vessels, which are dilated,
producing the hot, red feeling and appearance.
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