Also known as atopic dermatitis, eczema is characterized by the presence of a chronic, itchy rash that predominantly occurs in childhood, but can also develop among adults.
Genetics play a role, as patients with eczema have a family or personal history of allergies, asthma, or hay fever. Disruption of the skin’s barrier can be due to a genetic predisposition to deficiencies in the structure of the skin’s outer layer, increased destruction of the skin’s outer layer, and decreased lipid or oil production of the skin. It is also worsened by environmental factors such as extreme cold or heat, low humidity, irritants, allergens, and hot showers.
Increased inflammation of the skin often results in symptoms such as itching and burning. Often, patients with eczema have changes in the skin’s flora, including increased colonization of Staphylococcus aureus (S. aureus) and fungus, which increases inflammation. Both factors also contribute to the disruption of the skin’s barrier.
Early signs of eczema include pink-red, scaly inflamed bumps. Chronic signs of eczema include thickened, scaly lesions and bumps. Infants usually have lesions on the face while children often have lesions on their arm folds and posterior knees. While adults also present with lesions on the arms and posterior knees, they can also have lesions on their hands and face. Patients of all ages may exhibit lesions with honey crust, which could be a sign of S. aureus, Streptococcus pyogenes (S. pyogenes), or herpes simples virus infection, and signs of dryness on the skin, especially on the legs. Patients with darker skin types may exhibit light colored patches on their skin, as the inflammation temporarily decreases pigment on the skin, or darker scaly plaques.
Risk factors of eczema include a family or personal history of asthma, allergies, eczema, and hay fever. Patients who have increased exposure to allergens and irritants along with increased breakdown of the skin barrier by genetic factors or trauma can be more prone to eczema. Hot showers can worsen eczema, as hot water can be an irritant during prolonged exposure. Poor sleep patterns have been associated with eczema. Exposure to extreme cold, low humidity, and dehydration caused by consumption of diuretics such as alcohol and caffeine can worsen eczema. Patients who are on statins to treat high cholesterol often have decreased amounts of cholesterol in the skin layer, which can exacerbate eczema.
Eczema is diagnosed by the presence of itchy, scaly plaques, some with honey crust, on age-specific areas of the body. Most patients, especially adults, also have xerosis or cracking of the skin, especially on the legs. Patients often have a personal or family history of allergies, asthma, and hay fever.
Topical steroids are considered first-line treatment for children and adults to reduce itching and inflammation and can be safely used in the short-term. Prolonged topical steroid used continuously over months, especially on areas with thinner skin such as the armpits, inner thighs, and face, can cause stretch marks, thin blood vessels, and acne eruptions.
Topical calcineurin inhibitors, including pimecrolimus and tacrolimus, and phosphodiesterase inhibitors, such as crisaborole (or EucrisaⓇ) ointment, can also be safely used in adults and children over two years of age. They are not associated with the formation of stretch marks and can be used on thinner skin and can be used as a maintenance treatment. The use of topical calcineurin inhibitors can be associated with burning and stinging.
Topical Janus kinases (JAK) inhibitors such as ruxolitinib (or OpzeluraⓇ) cream are a newer class of medications that have been shown to decrease itching and inflammation on adults and children. They do not cause stretch marks and can be safely used over the long-term on all areas of the body.
Patients experiencing infected lesions would benefit from topical and oral antibiotics or antivirals in conjunction with topical steroids. Antiseptic treatments such as bleach baths performed twice weekly and hypochlorite body wash, such as ClnⓇ, can also be a useful additive treatment to help treat infected areas. Sedating oral antihistamines can be helpful for patients who are suffering from impaired sleep as a result of itching. Oral steroids such as prednisone can be used for short-term control, but are generally not recommended long-term use due to the risk of rebound, increased severity of symptoms, and side effect profile.
There are several treatment options for atopic dermatitis that are not available at New Bloom Dermatology. These treatments include phototherapy, which has anti-inflammatory properties, and biologics such as dupilumab (or DupixentⓇ), which is an injected medication that targets a specific arm of the immune system for atopic dermatitis patients who are not responsive to topical medications. Other oral medications include methotrexate, azathioprine, cyclosporine, and mycophenolate mofetil. These medications require regular surveillance by a board-certified dermatologist.
Patients are encouraged to avoid long, hot showers or baths and take lukewarm showers for up to 10 minutes. Non-fragranced body washes are preferred over soaps, as soaps can be irritating to the skin barrier. Moisturizers such as Vanicream, Cerave, Cetaphil Eczema Restoraderm, and La Roche Posay Lipikar are recommended to be used after showering. Patients with extremely dry skin can use a strategy called “soak and smear”, which is the application of moisturizers immediately after showering, without drying the body. Patients are encouraged to increase their rest to seven hours and over and decrease caffeine and alcohol intake.
Untreated eczema lesions are prone to be picked or scratched over, leaving the patient vulnerable to bacterial and viral infections. Furthermore, failure to treat could lead to extensive disease that may be resistant to treatment in the future. Patients with eczema have been shown to be prone to depression and suicidality.
Patients with eczema have been shown to be genetically susceptible to allergies, asthma, and hay fever.
Patients with eczema are recommended to immediately see a board-certified dermatologist for a complete medical history and evaluation. At the visit, appropriate treatment options will be discussed, including risks and benefits of each treatment.
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