Eczema (Atopic Dermatitis)

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What is exzema?

Eczema is a general term encompassing various inflamed skin conditions. One of the most common forms of eczema is atopic dermatitis (or “atopic eczema”).

Eczema is an inherited tendency of the skin to be easily irritated and become dried out. The skin looses its ability to hold water especially in the winter time which is the typical eczema season in the Tri-Cities. Eczema usually runs in families with some relatives having a similar tendency for dry skin. The tendency for eczema generally presents soon after birth and continues throughout childhood and teenage years. The eczema improves with age in most patients. There is some variation in the severity depending on the climate that the patient lives in. Desert climate tends to worsen eczema in the winter months. Asthma and hay fever are often present in the patient or in the patient’s family and this association is commonly called the allergic triad.

The most common locations for eczema are the face, elbows and knees in infants, and later this changes to behind the knees, front of the arms and sides of the neck later in life. The rash consists of dry, scaly, red and itchy skin. In any stage of development the person with atopic dermatitis has a tendency to “break out” to harsh soaps such as Dial, Zest, Coast, Lifebouy, Irish Spring and Lever 2000. Other skin irritants such as dishwashing soap, gasoline, perfumes, deodorants, repeated friction, fragrances, chlorine and organic solvents that come in contact with the skin can worsen the eczema.

There is a saying in dermatology to the effect that “If it doesn’t itch, it’s not eczema.” Itching usually is the complaint that prompts the sufferer to seek treatment. There is no cure for eczema, but there are some very good treatments that can make this condition much better. Education is a key to treating this disease. If a patient or parent knows what to do, a great deal of progress can be made in relieving the symptoms associated with this condition.

What’s the treatment?

If you remember one thing about treating eczema, remember to put on the topical treatments when the skin is wet. Eczema is a dry skin condition, and the skin does not hold on to water like normal skin. In a desert climate everything is dry, including your skin. If water is applied to the skin it will evaporate unless a barrier is placed over it to prevent evaporation. This is what moisturizers do; they prevent evaporation from the skin. Since moisturizers do no contain a lot of water they are much more effective when applied to skin that is already wet. It does not matter which moisturizer a patients uses as long as the moisturizer is fragrance free and does not contain extra additives like aloe vera, vitamin E, or alpha hydroxy acids. What matters is applying the lotion to wet skin right after a bath or shower.

1. Use cool water to shower, hot water will make the skin more itchy.
2. Shake water off instead of rubbing yourself dry with a towel.
3. Apply the moisturizer to skin.

By doing this, water is trapped in the skin and the dry skin disappears. Old dogma used to call for avoiding baths and showers. The reason this got started is that no one told the patients to put on a moisturizer after bathing. The water evaporated after the bath and the skin became dry. If this was repeated over and over the skin began to chap; just like licking your lips repeatedly. In reality having wet skin is an opportunity to treat the eczema and make it better by putting a moisturizer on to trap the water in the skin. Remember this when you see dry skin.

What to avoid

Avoid harsh soaps and chemicals and products with fragrances and perfumes. Examples include Dial, Zest, Lifebouy, Irish Spring, Coast and Lever 2000. Avoid products with lots of extra additives like aloe vera, vitamin E, and alpa hydroxy acids. Avoid bubble baths for children.

Avoid chlorinated pools and hot tubs, especially public pools which by law must have high levels of chlorine or bromine. These are usually tolerated in the summer, but not in the winter. Be sure and rinse with unchlorinated water after swimming.

Hot environments such as a hot bath, sauna and exercise will make the skin itchy because the blood  flow to the skin is increased to the skin. The skin becomes flushed, turns red and itchs when the body is warm.

What helps?

Conversely, the opposite effect occurs with cooling; cool baths, cotton clothing, air conditioning and a low stress environment will make the skin less itchy.

Topical steroid creams

The purpose of topical steroid is to relieve itching and reduce redness in the skin. These medicines reduce the itching, redness, and discomfort of eczema. Topical steroid creams are most effective when applied to moist skin because the penetration of the medication is improved. There are many strengths of topical steroids and interestingly the percent listed on the label has nothing to do with the potency. It is the chemical structure that determines the strength, and there is a well established rating system to compare these. Some topical steroids are safe on the face and are safe for children, while other stronger steroids must be used more cautiously. Potent topical steroids should not be applied to the face, underneath the arms or in the groin area without explicit instructions from the doctor. Topical steroids are very safe if used correctly, but these medicines can cause thinning of the skin, stretch marks and bruising if used incorrectly.

Topical corticosteroids

Topical corticosteroids are used for short periods of time to relieve the eczema, and then moisturizers can be substituted for long-term routine care of the skin. A simple way to remember how to use topical steroids is to remember “They get the red out.” Once the redness has faded, then a moisturizer will do as much for the skin as a topical steroid.

Antihistamines

Antihistamines are pills taken by mouth that help patients with eczema get to sleep. Antihistimines do not make the skin better, but they can produce a degree of sleepiness or drowsiness to help the patient get to sleep at night if itching is a problem. It is best to take these medications ½ hour before sleep. One should be careful about taking these agents before driving or operating machinery. The consumption of alcoholic beverages, may have an additive effect when taken with antihistamines. A common example that can be purchased over-the-counter is Benadryl and the generic equivalent dipheniramine. Read the label for the correct dosage.

Wet wraps

When eczema is widespread or severe, wet clothes can be used to keep the skin wet constantly. The medical term for this is “wet wraps”. This involves using cotton long johns or cotton warm-up suits and moistening them with water. After a topical steroid is applied to the skin, the damp clothes are worn on the affected areas overnight. The evaporation of water cools the skin and reduces the itching, and the damp clothes help the skin stay moist for long periods of time. This generally is needed for only a few days, but can be very helpful in treating a flare-up.

Trim your nails

This sounds like a little thing, but it can make a big difference because patients tend to do a lot of their scratching in their sleep. When the fingernails are trimmed short, the patient can rub, but the skin is not broken. Unbroken skin lessens the chance of secondary infection. Cotton gloves on the hands of small children can help if scratching is a big problem. Signs of infection are a honey-yellow crust or drainage, swelling, redness, pain, and tenderness. Skin infection needs to be treated with an antibiotic and you should contact the office if you suspect a secondary infection is present.

Humidify your home

Keep a humidifier in the bedroom to raise the amount of water in the air. This is most helpful in the winter when the home heating system dries out the air in the house and the humidity is very low.

Sunshine

Sunlight improves eczema by “toughening” the skin and a light tanning of the skin is helpful in this regard.  One must bear in mind that this will also contribute to sun damage of the skin in later years and sun exposure should be used sparingly. Sun exposure is one reason why eczema improves in the summer months, especially in the Tri-Cities. During the winter months artificial light sources can be used if the eczema is not responding to topical steroid therapy.

Steps in treatment:

1. Hydrate the skin by soaking in the bathtub or covering the area with wet towels. The water should be cool.
2. Apply the prescribed medicine to the area. Put the medicine on before the skin dries out.
3. Cover this with a bland moisturizer. A thick moisturizer like plain Vaseline can be used or a thinner lotion like Cetaphile, Moisturel, Lubriderm, or Nutraderm may be preferred.
4. Be observant for infection of the skin, which takes place quite easily with eczema if the skin is broken. Signs of infection are oozing or sticky drainage from the area, pain, tenderness and swelling of the skin. You should contact the office if you experience these symptoms.

Other resources

• AAD pamphlet about Eczema
• EczemaNet is a comprehensive resource from the American Academy of Dermatology.
• National Eczema Association has educational information about eczema and ways to support eczema research.