Eczema

• Eczema, medically known as atopic dermatitis, is a chronic inflammatory skin condition that causes the skin to become dry, itchy, red, and inflamed. It represents a group of conditions that make skin irritated and inflamed, with atopic dermatitis being the most common form.
• The condition occurs when the skin's protective barrier function is compromised, allowing moisture to escape and permitting irritants, allergens, and bacteria to enter. This leads to inflammation and the characteristic symptoms associated with eczema.
• Eczema affects people of all ages but most commonly begins in childhood. Approximately 10-20% of children and 1-3% of adults worldwide experience this condition. While many children outgrow eczema by adolescence, some continue to experience symptoms throughout adulthood.
• The condition tends to run in families and is often associated with other atopic conditions such as asthma, hay fever, and food allergies. This connection suggests a genetic component involving the immune system's response to environmental triggers.

2. Symptoms of Eczema

Eczema symptoms can vary significantly between individuals and may change over time. The presentation also differs based on age and the severity of the condition.

Common symptoms include:

• Intense itching that often worsens at night, making sleep difficult. This itching can be so severe that it significantly impacts quality of life and daily activities.
• Dry, sensitive skin that feels rough to the touch. The skin may appear scaly or leathery in texture, particularly in areas that have been affected for extended periods.
• Red or brownish-gray patches that typically appear on hands, feet, ankles, wrists, neck, upper chest, eyelids, inside the bend of elbows and knees, and in infants, the face and scalp.
• Small, raised bumps that may leak fluid and crust over when scratched. This weeping or oozing is particularly common during flare-ups and can lead to secondary infections.
• Thickened, cracked, or scaly skin that develops from chronic scratching and rubbing. This condition, known as lichenification, creates a leather-like appearance.
• Raw, sensitive, swollen skin from scratching. Repeated scratching can damage the skin barrier further and lead to a cycle of itching and scratching that worsens the condition.

Age-specific presentations:

• In infants, eczema typically appears on the face, scalp, and outer surfaces of the arms and legs. The rash may be particularly weepy and crusty.
• In children, eczema often affects the creases of elbows and knees, as well as the neck, wrists, and ankles. The skin may become lighter or darker in affected areas.
• In adults, eczema commonly appears on the hands, neck, face, and around the eyes. The skin tends to be very dry and scaly, with more pronounced lichenification.
• 3. Medical and Blood Tests for Identifying Eczema
• Eczema diagnosis is primarily clinical, meaning doctors typically diagnose it based on physical examination and medical history rather than specific laboratory tests. However, certain tests can help confirm the diagnosis, rule out other conditions, or identify triggers.

3. Diagnostic approach:

• Physical examination remains the cornerstone of eczema diagnosis. Dermatologists assess the appearance, distribution, and pattern of skin lesions, along with evaluating the patient's personal and family history of atopic conditions.
• There is no single definitive blood test for eczema. However, several tests can provide supporting evidence and help guide treatment decisions.

Blood tests that may be ordered:

• Total serum IgE (Immunoglobulin E) levels are often elevated in people with atopic dermatitis. Normal IgE levels vary by age: in adults, normal values are typically below 100-150 IU/mL. However, elevated IgE is not specific to eczema and can occur in other allergic conditions, asthma, and parasitic infections. Conversely, some people with eczema have normal IgE levels.
• Complete blood count with differential may show elevated eosinophils (a type of white blood cell associated with allergic reactions). Normal eosinophil count is 0-500 cells per microliter of blood. Elevated levels suggest an allergic or inflammatory process.
• Specific IgE testing (RAST test or ImmunoCAP) can identify allergies to specific foods, environmental allergens, or other triggers. These tests measure antibodies to particular substances and help identify potential triggers that may worsen eczema.

Other diagnostic procedures:

• Patch testing helps identify contact allergens that may trigger or worsen eczema. Small amounts of potential allergens are applied to the skin under patches, which are removed after 48 hours. The skin is then examined for reactions.
• Skin biopsy is rarely needed but may be performed in atypical cases to rule out other skin conditions such as psoriasis, cutaneous T-cell lymphoma, or fungal infections. The biopsy shows characteristic changes including spongiosis (fluid between skin cells) and inflammatory cell infiltration.
• Skin swab cultures may be taken if secondary bacterial infection is suspected. Staphylococcus aureus commonly colonizes eczematous skin and can cause infections requiring antibiotic treatment.

Important considerations:

The absence of abnormal test results does not rule out eczema, as diagnosis relies primarily on clinical presentation and history. Tests serve to support the clinical diagnosis and identify contributing factors rather than definitively confirm or exclude eczema.

4. How Eczema Can Be Treated

Eczema treatment focuses on repairing the skin barrier, reducing inflammation, controlling itching, and preventing flare-ups. A comprehensive approach combining multiple strategies typically yields the best results.

Moisturization and skin care:

• Regular application of emollients and moisturizers forms the foundation of eczema management. These products should be applied at least twice daily, and ideally immediately after bathing to lock in moisture. Thicker ointments and creams are generally more effective than lotions for severe dryness.
• Bathing practices significantly impact eczema management. Lukewarm baths lasting 5-10 minutes help hydrate the skin. Adding colloidal oatmeal or bath oils can provide additional relief. Pat skin dry gently rather than rubbing, and apply moisturizer within three minutes of bathing.

Topical medications:

• Topical corticosteroids reduce inflammation and remain the first-line treatment for active eczema. These come in various strengths, from mild (hydrocortisone) to very potent formulations. The appropriate strength depends on the severity of eczema and the body area being treated. Face and skin folds require milder preparations.
• Topical calcineurin inhibitors such as tacrolimus and pimecrolimus offer an alternative to steroids, particularly for sensitive areas like the face and eyelids. These medications reduce inflammation without the side effects associated with prolonged steroid use.
• PDE4 inhibitors like crisaborole provide another non-steroidal option for mild to moderate eczema, working by reducing inflammation through a different mechanism.

Systemic treatments:

• For moderate to severe eczema not adequately controlled with topical therapy, systemic treatments may be necessary. These affect the entire body rather than just the skin surface.
• Biologic medications such as dupilumab target specific parts of the immune system involved in eczema. These injectable medications have shown remarkable effectiveness for severe cases with a relatively favorable safety profile.
• Oral immunosuppressants including cyclosporine, methotrexate, azathioprine, and mycophenolate mofetil may be prescribed for severe, refractory eczema. These require careful monitoring due to potential side effects.
• JAK inhibitors, both topical and oral formulations, represent a newer class of medications that block specific pathways involved in inflammation.

Phototherapy:

• Ultraviolet light therapy, particularly narrowband UVB, can effectively treat moderate to severe eczema. This treatment involves exposing the skin to controlled amounts of ultraviolet light under medical supervision, typically two to three times weekly.

Management of complications:

• Secondary bacterial infections require prompt treatment with topical or oral antibiotics. Staphylococcus aureus commonly infects eczematous skin, causing increased redness, warmth, oozing, and crusting.
• Antihistamines may help reduce itching, particularly at night. Sedating antihistamines can improve sleep quality when itching is severe.

5. Home Remedies and Natural Remedies for Eczema

Natural and home remedies can complement medical treatments and help manage eczema symptoms. While these approaches may provide relief, they should not replace prescribed medical treatments for moderate to severe eczema.

Natural moisturizers and oils:

• Coconut oil possesses natural antibacterial and anti-inflammatory properties. Virgin, cold-pressed coconut oil can be applied directly to damp skin to seal in moisture and reduce bacterial colonization.
• Sunflower seed oil helps maintain the skin barrier and reduces inflammation. Applied topically, it can improve skin hydration and reduce the severity of eczema symptoms.

Soothing compresses and baths:

• Colloidal oatmeal baths provide immediate relief from itching and inflammation. Finely ground oatmeal disperses in bathwater, creating a milky solution that soothes irritated skin. Soak for 10-15 minutes in lukewarm water, then apply moisturizer.
• Wet wrap therapy involves applying moisturizer and wrapping damp gauze or clothing over affected areas. This technique enhances moisture penetration and provides a barrier against scratching. It is particularly effective for severe flare-ups and can be done under medical guidance.

Dietary supplements:

• Probiotics may help modulate the immune system and reduce eczema severity, particularly when started during pregnancy or early infancy. Strains like Lactobacillus rhamnosus have shown promise in studies.
• Omega-3 fatty acids found in fish oil supplements possess anti-inflammatory properties that may benefit people with eczema. However, evidence for effectiveness remains mixed, and consultation with a healthcare provider is recommended.
• Vitamin D supplementation may help, as deficiency has been associated with increased eczema severity. Maintaining adequate vitamin D levels through supplementation or safe sun exposure may support skin health.

Herbal remedies:

• Chamomile applied topically in cream form or used in compresses may reduce inflammation. However, people allergic to ragweed should avoid chamomile as it can cause allergic reactions.
• Calendula cream has been traditionally used for skin inflammation and wound healing. Some studies suggest it may help reduce eczema symptoms.
• Aloe vera gel provides cooling relief and may help reduce inflammation. Use pure aloe vera gel from the plant or products with high aloe content.

Stress management:

• Stress commonly triggers or worsens eczema flare-ups. Incorporating stress-reduction techniques such as meditation, yoga, deep breathing exercises, and adequate sleep can help manage symptoms.

Important considerations:

• Always perform a patch test before applying any new substance to large areas of skin. Apply a small amount to a discrete area and wait 24 hours to check for adverse reactions.
• Natural remedies can still cause allergic reactions or irritation. Discontinue use if symptoms worsen.
• Consult healthcare providers before starting supplements, especially if taking other medications or if treating children.

6. Diet Recommendations for Eczema

Diet plays a complex role in eczema management. While food is not the primary cause of eczema, certain foods can trigger or worsen symptoms in susceptible individuals, particularly children.

General dietary principles:

• An anti-inflammatory diet rich in whole foods, vegetables, fruits, and omega-3 fatty acids may help reduce eczema severity. This approach emphasizes nutrient-dense foods that support immune function and skin health.
• Identifying and eliminating personal food triggers is crucial, as these vary considerably between individuals. Working with an allergist or dietitian can help identify specific problematic foods through elimination diets or allergy testing.

Foods that may help manage eczema:

• Fatty fish including salmon, mackerel, herring, and sardines provide omega-3 fatty acids that possess anti-inflammatory properties. Consuming these two to three times weekly may benefit skin health.
• Foods rich in quercetin, a natural antihistamine and anti-inflammatory compound, may help reduce eczema symptoms. These include apples, berries, cherries, broccoli, spinach, and kale.
• Probiotic-rich foods such as yogurt with live cultures, kefir, sauerkraut, kimchi, and other fermented foods support gut health, which may influence skin conditions through the gut-skin axis.
• Foods high in vitamin E, including nuts, seeds, avocados, and leafy greens, provide antioxidant protection that may benefit skin health.
• Adequate hydration through water and herbal teas helps maintain skin moisture from within. Aim for eight glasses of water daily.

Foods to avoid or limit:

• Common food allergens may trigger eczema flares in sensitive individuals. The most frequent culprits include cow's milk, eggs, soy, wheat, peanuts, tree nuts, fish, and shellfish. However, these should only be eliminated if testing or supervised elimination diets confirm sensitivity.
• Processed and refined foods high in sugar and unhealthy fats may promote inflammation. Limiting consumption of packaged snacks, fast food, and sugary beverages may help some individuals.
• Foods high in histamine or that trigger histamine release can worsen itching in some people. These include aged cheeses, fermented foods, processed meats, alcohol, and certain fruits like strawberries and citrus.
• Artificial food additives, preservatives, and food colorings may trigger reactions in sensitive individuals. Reading labels and choosing whole foods over processed options reduces exposure.
• Nightshade vegetables including tomatoes, eggplant, peppers, and white potatoes contain compounds that may worsen inflammation in some people, though this is not universal.
• Trans fats and excessive omega-6 fatty acids found in many processed foods and vegetable oils may promote inflammation. Reducing intake of fried foods and processed snacks helps balance fatty acid ratios.

Important dietary considerations:

• Restrictive diets should only be implemented under medical supervision, particularly in children, to ensure adequate nutrition for growth and development. Unnecessary food restrictions can lead to nutritional deficiencies and eating disorders.
• Elimination diets should be conducted systematically, removing suspected foods for 4-6 weeks before reintroducing them one at a time to identify true triggers.
• Food allergies differ from food sensitivities. True food allergies involve immune responses and can be life-threatening, while sensitivities may cause less severe but bothersome symptoms.
• Keeping a food and symptom diary helps identify patterns between diet and eczema flares. Record meals, snacks, and any changes in skin condition over several weeks.

7. Medications Available to Treat Eczema

A wide range of medications is available for eczema treatment, from over-the-counter options to prescription therapies. Treatment selection depends on severity, age, location of affected skin, and response to previous treatments.

Topical corticosteroids:

• These remain the cornerstone of eczema treatment, available in seven potency classes from mild to very potent. Hydrocortisone in 0.5% to 1% strength is available over the counter for mild eczema. Prescription-strength options include triamcinolone, betamethasone, clobetasol, and others, prescribed based on severity and location.
• Application typically occurs once or twice daily during flare-ups, with gradual tapering as symptoms improve. Prolonged use requires medical supervision due to potential side effects including skin thinning, stretch marks, and systemic absorption.

Topical calcineurin inhibitors:

• Tacrolimus ointment and pimecrolimus cream offer steroid-free alternatives for treating eczema, particularly on sensitive areas like the face, eyelids, and skin folds. These medications work by suppressing immune system activity in the skin.
• These are typically used twice daily and may cause temporary burning or stinging upon application. They are approved for patients aged two years and older.

Topical PDE4 inhibitors:

• Crisaborole ointment provides a non-steroidal option for mild to moderate atopic dermatitis in patients as young as three months. Applied twice daily, it works by inhibiting an enzyme involved in inflammation.

Topical JAK inhibitors:

• Ruxolitinib cream represents a newer class of medications that block Janus kinase enzymes involved in inflammation. Approved for mild to moderate atopic dermatitis, it offers another non-steroidal treatment option.

Systemic immunosuppressants:

• Cyclosporine effectively treats severe eczema by suppressing immune system activity. It requires careful monitoring for side effects including high blood pressure, kidney function changes, and increased infection risk.
• Methotrexate, traditionally used for psoriasis and rheumatoid arthritis, can help severe eczema cases. Weekly dosing requires regular blood test monitoring.
• Azathioprine and mycophenolate mofetil offer alternative systemic immunosuppression options for severe, refractory cases.

Biologic medications:

• Dupilumab, administered by injection every two weeks, specifically targets interleukin-4 and interleukin-13, key proteins involved in eczema inflammation. This medication has demonstrated excellent efficacy for moderate to severe atopic dermatitis with a favorable safety profile. It is approved for patients aged six months and older.
• Tralokinumab, another biologic targeting interleukin-13, offers an alternative for adults with moderate to severe eczema.

Oral JAK inhibitors:

• Upadacitinib and abrocitinib represent oral medications that block JAK enzymes involved in inflammation. These medications have shown significant efficacy for moderate to severe atopic dermatitis but require monitoring for potential side effects.

Antihistamines:

• Both sedating antihistamines like hydroxyzine and diphenhydramine and non-sedating options like cetirizine and loratadine may help reduce itching. Sedating antihistamines taken at bedtime can improve sleep quality when nighttime itching is problematic.

Antibiotics:

• Topical antibiotics such as mupirocin treat localized bacterial infections. Oral antibiotics including cephalexin, dicloxacillin, or doxycycline are prescribed for more widespread infections or when topical treatment is insufficient.

Barrier repair moisturizers:

• Prescription moisturizers containing ceramides and other skin-identical ingredients help restore the skin barrier. Examples include products with specific ceramide formulations designed to mimic natural skin lipids.

Important medication considerations:

• All medications carry potential benefits and risks. Discuss thoroughly with healthcare providers to understand expected outcomes, proper application techniques, duration of treatment, and possible side effects.
• Combination therapy often proves more effective than single treatments. A comprehensive approach addressing multiple aspects of eczema typically yields the best results.
• Regular follow-up with dermatologists ensures optimal treatment adjustment as the condition evolves over time.
• This comprehensive information about eczema provides educational content for better understanding and managing this common skin condition. Always consult qualified healthcare professionals for personalized medical advice, diagnosis, and treatment plans tailored to individual circumstances. While home remedies and dietary modifications can support conventional treatment, they should complement rather than replace medical care for moderate to severe eczema.