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Eczema - causes, symptoms, treatment

 
Eczema (atopic dermatitis) is a common form of dermatitis (skin inflammation) that causes the skin to become itchy, red, swollen and painful.  Symptoms can vary from a mild rash that disappears quite quickly to a more severe condition that’s present for a long time.   The main goal of treatment is to eliminate itching which, in left untreated, can provoke or worsen the other symptoms.  In New Zealand eczema affects 15–20% of children and 1–2% of adults.

General information

Eczema generally occurs in babies and children, although it can occur at any time of life.  Approximately one in seven children will get the condition at some time - the first signs usually begin at nine to twelve months of age, although sometimes it can start as early as four months. 

Eczema usually starts on the face followed by the hands and feet.  Older children tend to be affected in the elbow and knee creases, neck, wrists, ankles and feet.  The hands and feet tend to be the most commonly affected areas in adults. Eczema is not a contagious condition.

If eczema appears in the first year of life there is a 50% chance it will not be a problem by the age of five.  Even if it continues into school age only one in twenty will still have trouble in adult life.  However, there are no hard and fast rules and each case is different.

Causes

A child who has eczema makes extra amounts of a certain type of antibody (IgE).  This tendency is genetically inherited but, even so, some children who have the genetic disposition towards eczema may never suffer from the condition. 

Fifty per cent of children who make extra amounts of this antibody are more prone to suffer from asthma and hayfever.  Also, children who have eczema often have an allergic reaction against environmental particles.  These particles include pollen, dust, animal hair and skin cells, fungus spores and mites.
 

Certain substances or conditions called trigger factors can cause eczema to flare. These trigger factors can be: 

  • Irritants such as wool, skin infections, dry skin, low humidity, heat, sweating or emotional stress.
  • Allergens such as dust mites, pollen, moulds or foods.
Consultation with your doctor may be helpful in identifying the triggers.
 
An infant with eczema is more likely to be allergic to food than other children are. There is at least a 40 to 50 per cent chance that food allergies may be triggers if your child has moderate to severe eczema. The foods responsible for 90 per cent of these reactions are egg, peanut, milk, soy, wheat, fish, nuts and shellfish. Salicylates and some preservatives can also trigger eczema.

Signs and symptoms

The classic symptoms of eczema are:  

  • Itching.  This is the worst aspect because it can be upsetting for the child.  It also makes the child scratch causing further rawness of the skin and possible infections to develop.
  • Redness caused by extra blood flowing through the blood vessels in the skin in the affected area.
  • A grainy appearance to the skin, caused by tiny fluid filled blisters just under the skin called “vesicles.”
  • Weeping when the blisters burst, either by themselves or because of scratching, and the fluid oozes on to the surface of the skin.
  • Crusts or scabs that form when the fluid dries.
  • Children with eczema often have dry, scaly skin.  This may be the result of the disease or it may also be the natural skin type of the family.  Dry skin can be a predisposing factor to developing eczema.
  • Pale patches of skin may appear because eczema can disturb the production of pigment which controls skin colour. The effect does fade and disappear.
  • Lichenification - a leathery, thicker skin area in response to scratching.  

Treatment

The main goal of treatment is to eliminate the itching which provokes or worsens the other symptoms and causes the most discomfort.  In some very mild cases eczema can be managed by:  

  • Avoiding likely sources of irritation (triggers)
  • Using emollients such as special bath oils and moisturisers.
It is necessary to work with the child's doctor in order to develop a treatment plan that works best for each child.  Treatment may need to be reassessed, especially if the condition worsens or fails to respond to treatment.  In some cases the doctor will refer the child to a skin specialist (dermatologist).
 
Steroids, such as hydrocortisone, reduce the inflammation in response to an allergic reaction.  There are different strengths of steroid creams and ointments available on prescription.  Care needs to be taken, especially if applying a very strong steroid as it can cause the skin to become thin.  These creams should not be put on liberally but instead only the thinnest smear should be applied to the rash.  The best time to do this is after a bath, as the skin is more absorbent. 

Discuss with a doctor or pharmacist the correct use and application of the steroid cream or ointment prescribed.  Establish when it is appropriate to use and when to stop using it.  It is not advisable to use a steroid on the face unless prescribed by a doctor. Occasionally, steroid medication may need to be given orally.

Talk with your doctor if the child's skin shows signs of damage.  A weaker steroid or non-steroid cream can often reverse the damage if caught in time.

Pimecrolimus cream (Elidel) is a topical, steroid-free, anti-inflammatory medication used to treat eczema, amongst other inflammatory skin conditions. It is available on prescription and can be applied to affected skin on the face, head and around the eyes where steroid creams are not recommended.

Tar preparations such as coal tar have anti-itching and anti-eczema properties.  They are available in various bath oils, shampoos and gels.  Talk to the doctor about the use of these preparations.
 
Special diets that exclude certain foods (elimination diets) have been effective in treating eczema in some children. However, not all children respond to diet therapy.  Talk to your doctor or a dietitian about this.

Antihistamines may help the itching.  The drowsiness they cause can also be useful at night to conquer sleeplessness caused by the irritation. 

In some cases, medications to suppress the immune system may be needed to treat the condition.
 
In severe cases, phototherapy or ultaviolet (UV) treatment may be suggested.  This involves controlled exposure to UV-A and/or UV-B for a few minutes, two to three times each week.  A treatment course may continue for several months.

Other effects of eczema

Skin that is broken and damaged is more likely to be infected by bacteria or yeasts.  One common type of bacterium (staphylococcus aureus) produces yellow crusts or pus filled spots.
Should bacterial infection occur, this can be treated with a course of antibiotics.  Antibiotics can be taken orally in the form of syrup, capsules or tablets.  Once infection has broken out, it may be useful to add antiseptic solutions to a child's bath.  If the child is prone to infections, talk to your doctor about using an antiseptic solution as a preventative measure.

Poor temperature control can occur as a result of eczema.  Too much heat is lost through inflamed skin so the body tries to compensate by “turning up the heating”.  The result is that the child can feel too cold and then when moving into a warmer atmosphere quickly get too hot.  Sweating is another way of losing heat when we get too hot.  Eczema also prevents the sweat glands from working properly.

Preventative measures

 The following may help alleviate the symptoms and prevent future outbreaks of eczema:  

  • Use pure cotton or cotton mixtures instead of wool or synthetics
  • Do not use soap.  Instead add bath oils to bath water and use emulsifying ointment or a water dispersible cream instead of soap
  • Avoid enzyme detergents and fabric softeners when washing clothes as these can irritate the skin
  • Avoid acid fruits and vegetables like tomatoes and citrus fruits.  They can cause a reaction on the hands and around the mouth.  Salty foods can also cause a similar reaction
  • Direct use of antiseptics and solvents should also be avoided
  • Environmental factors, such as heat, sunlight and cold can irritate the condition.  If this is the case, protect the child from them or avoid them as much as possible
  • Moisturise the skin.  Washing with water alone rapidly results in drying, but adding oil to water will moisturise dry, eczema-prone skin effectively.  Discuss with the doctor or a pharmacist what is available. It may take some time and experimentation to find the best product for the child
  • Bandages can be used to stop scratching at night.  Cotton mittens can be especially helpful
  • Fingernails should be kept short to decrease the damage caused by scratching.

Further information and support

Allergy New Zealand can assist with further information, support and resources. Their contact details are:

Allergy New Zealand
Freephone: 0800 34 0800
Website: www.allergy.org.nz  

References

Allergy New Zealand (2010) Eczema. Allergy New Zealand, Auckland. www.allergy.org.nz/Allergy+help/A-Z+Allergies/Eczema.html
Anderson, K. N., Anderson, L. E. & Glanze, W. D. (Eds.) (2006) Mosby’s Medical, Nursing and Allied Health Dictionary. (6th ed.) St. Louis: The C.V. Mosby Company
DermNet NZ (2013) Atopic eczema. New Zealand Dermatological Society Inc.  http://dermnetnz.org/dermatitis/atopic.html

Last Reviewed – 24 May 2013
 
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