Eczema

What is eczema?

Eczema (ex-zeh-ma) can be divided into two general groups: the contact dermatitis group and the atopic dermatitis group.

Contact Dermatitis

When some substances come into contact with skin, they may cause a rash called contact dermatitis. Some of these reactions are the result of an allergic reaction that involves the immune system, but many are the result of a non-allergic, or irritant, reaction. Often, it is difficult to tell the difference between these allergic and irritant reactions.

The hallmark of allergic contact dermatitis is that it is very itchy and occurs almost exclusively where the offending agent, such as a plant or chemical, comes into contact with the skin. Allergic contact dermatitis is best described as an itchy, red, blistered reaction that is most commonly seen after touching a plant in the “rhus” family, which includes poison ivy, poison oak or poison sumac. This allergic reaction is caused by a chemical in the plant called urushiol. You can have a reaction from touching other items with which the plant has come into contact, including yard tools or the family dog. However, once your skin has been washed, you cannot get another reaction from touching the rash or blisters. Allergic contact dermatitis reactions can occur 24 to 48 hours after contact. Once a reaction starts, it takes 14 to 28 days to resolve, even with treatment.

Other agents that frequently cause allergic contact dermatitis include nickel (mostly seen with jewelry), perfumes and fragrances, dyes, rubber (latex) products and cosmetics. Some ingredients in medications applied to the skin also can cause an allergic reaction, most commonly neomycin, an ingredient in antibiotic creams. To avoid reactions, any cream that ends in “caine” should never be applied to damaged skin.

In contrast, irritant contact dermatitis is often more painful than itchy, and is the result of an offending agent that actually damages the skin with which it comes into contact. The reaction occurs within minutes of exposure. The longer the skin is in contact, or the more concentrated the offending agent, the more severe the reaction. Water with added soaps and detergents is the most common cause of irritant dermatitis. Thus, it is not surprising that these reactions appear most often on the hands and are frequently work-related.

Atopic Dermatitis

A common allergic reaction often affecting the face, elbows and knees is atopic dermatitis, also known as atopic eczema. This red, scaly, itchy rash is usually seen in young infants, but can occur later in life in individuals with personal or family histories of atopy, meaning asthma or allergic rhinosinusitis (commonly referred to as hay fever). Eczema may at times ooze, or look very dry. A physician will rarely have difficulty diagnosing atopic dermatitis, based on three factors: 1) itchy; 2) “eczematous” or bubbly rash; 3) an allergic individual. If one of these three features is missing, your physician should consider other causes. Identifying the cause of the itch is essential in managing symptoms. Common triggers include overheating or sweating, and contact with irritants such as wool, pets or soaps. In younger children food allergies are a common cause. In older individuals, emotional stress can cause a flare-up.

How is eczema diagnosed?

Eczema is diagnosed by your physician depending of the distribution of the rash on your body and the type of symptoms you have. Tests to identify possible causes of eczema include food, dust mite, pollen and animal dander skin testing and another type of skin test called a patch test. A patch test examines possible chemical sources in your environment that might cause or aggravate the rash on contact. Patch tests are applied to your back with tape and left in place for 48 hours. The tests are read 48 hours after application and daily for up to seven days thereafter. A positive test suggests an item for you to avoid for a period of time to see if avoidance of the substance relieves your eczema. It should be emphasized that many people have eczema that is not caused by allergies.

How is eczema treated?

The basis to any eczema treatment is to find the cause and stop it. Sometimes there are allergen causing a rash, and sometimes there are none. An allergist will help define if there are any allergens acting as triggers of eczema so they can be isolated and avoided. Nevertheless, the key to eczema treatment, no matter what the cause, is to keep the skin barrier as intact as possible. As such, it is of the utmost importance to focus attention on everything that comes into contact with the skin. This includes environmental agents such as soap and detergents, fabric softeners, bacterial infections, inhalant allergens such as house dust mites, and the topical formulations used to treat eczema. Exposure to soap and detergents has been recognized as an exacerbating environmental factor in eczema for more than 40 years. Ensuring that the washing regimen of persons with eczema is completely free from any damaging type of soap or detergent wash product is therefore very important. Soap and detergent wash products can be replaced with emollient wash products. Fabric softeners can be eliminated from the wash. For some products, such as shampoos, it is not possible to eliminate all detergents. However, it is possible to reduce the chance that they will damage the skin barrier by using the mildest in the lowest concentrations. Because shampoos inevitably flow onto the face, the careful selection of these products is important. We recommend the following emollient products designed for the shower, bath and for hand washing, as well as emollients to be used especially after bathing to keep the skin well hydrated:

• Aveeno cream and wash
• Balneum Plus cream and wash
• Cetaphil cream and cleanser
• E45 cream, bath, and wash
• Eucerin cream
• Hydromol cream and bath
• Lipobase cream
• Oilatum cream and bath.

Emollient bath, shower, and wash products should be combined with emollient creams and ointments to improve skin barrier function. In view of the damaging effect of detergents, it is important to select appropriately formulated products that work for you. The ideal approach is to let you select which product or products you find most suitable for your or your child’s skin. Any emollient product you choose should be applied right after a bath or shower when the skin is still wet. For acute flares, this process of bathing and application of emollients can be increased from one to as often as three times a day. Remember, the payoff for helping your skin maintain a better skin barrier is less itching, less need for medications and a better quality of life.

Are there natural remedies for eczema?

A basic characteristic of any eczema, particular atopic eczema, is an increase in water loss from the skin which helps to aggravate the main clinical symptoms of itching, redness, dryness, and skin sensitivity. Treatment of atopic eczema is based on avoiding skin irritants and allergens, reducing itching and inflammation, and establishing a more normal skin surface. Topic steroids remain the gold standard for controlling and reducing the inflammatory flares (e.g. redness) but a variety of active natural ingredients can be used in addition to control the dryness, itch and inflammation.

Moisturizers

Moisturizers are the most important part of the day-to-day treatment of eczema and dry skin. However, moisturizing creams marketed to consumers often contain trendy ingredients and are accompanied by exciting names and compelling claims. In truth, they should all be regarded as cosmetics and medicinal products and, as such, no one product works the best for all people. What works for one person may actually aggravate another. Our office highly recommends that before you use any product on your skin, test yourself for evidence of sensitivity. This test can be done by applying the product to your forearm and firmly placing a Band aide over it. Remove the Band aide in two days and check for evidence of inflammation (redness, itching, bumps) where the product was applied. Keep an eye on that spot for another week to make sure all is well. This does not guarantee you will or will not be bothered by the new product but it is a good start.

Oatmeal

Oatmeal contains a newly discovered component called avenanthramide that reduces the symptoms of eczema and helps to restore the skin to more natural health. Oatmeal is applied to the skin as “colloidal oatmeal.” Colloidal oatmeal is simply oats ground into an extremely fine powder. When added to bathwater, it creates a milky dispersion that prevents the oatmeal from settling rapidly. So the oatmeal stays in the water and doesn’t just sink to the bottom of the bath. When you get into the tub, the colloidal oatmeal feels silky, as it coats, moisturizes, softens, and protects your skin. Run your bath with lukewarm water, and while the tub is filling, add a packet (two to three cups) of colloidal oatmeal under the faucet to help disperse the oatmeal. A warm bath is preferable. Soak in the bath for ten to fifteen minutes. BE CAREFUL getting out of the bath because the bathtub will be slick from the oatmeal. When drying, pat yourself dry with a clean towel to keep as much moisture as possible in your skin. You can also add your moisturizer to especially dry spots at this time.

You can make your own colloidal oatmeal or buy it in the store. To make your own, you’ll need a blender, food processor or coffee grinder. Add 1 cup of instant oatmeal (unflavored), quick oats or slow cooking oats to whatever processor you are using and grind it into a fine powder. For babies, you’ll only need about 1/3 cup per bath. To test the colloid property of the oats, stir 1 tablespoon of your processed oats into a glass of warm water. If the oats readily absorb the water and give it a milky look and a silky feel, your oats are ready to use.

You can bath in colloidal oatmeal up to three times a day depending on the needs of your skin and the beneficial response you have achieved.

Nutrition and Dietary Supplements

Some foods may trigger eczema but this is unusual in adults and much more common in children, particularly children under the age of 5 years. Paying attention (even keeping a diary) to what you (or your child) eat and the effect it has on your skin (or your child’s) may help you (or your child) avoid foods that provoke flares of eczema. Potentially provoking foods include peanuts, milk, soy, fish, and eggs.

Some researchers feel that foods high in saturated fats such as meat and full fat dairy, and trans-fatty acids found in fried foods and hydrogenated oils may stimulate inflammation. High sugar and processed foods also have been touted as at-risk foods. Conversely, fresh fruits and vegetables, whole grains, and foods rich in omega-3 fatty acids such as nuts, flax, seeds, and cold-water fish may reduce inflammation in those without sensitivities to these foods. It should be emphasized that the scientific data in support of these concepts is inconsistent and remains unclear.

Gamma-linolenic acid (GLA)

GLA is an omega-6 essential fatty acid that has gathered some interest. Studies have shown that the metabolism of essential fatty acids is abnormal in people with eczema, resulting in low levels of GLA. Several early studies suggested that GLA derived from evening primrose oil (EPO) is beneficial for relieving symptoms associated with this skin condition such as itching, redness, and scaling. However, more recent studies have not had the same positive results. Some fatty acid-rich creams can reduce the severity of eczema but there is no single product that stands out.

Probiotics

Probiotics are “good” bacteria that inhabit the intestines. Studies suggest that gut bacteria in babies at high risk for allergic disorders may be different from that of other babies. Two well-designed studies of mother-infant pairs showed that babies of mothers who took probiotics while pregnant and breastfeeding were less likely to have eczema in the first two years of life. The most commonly used probiotics are Lactobacillus species. However, there remains no FDA approved standard dosing that can be recommended currently.

Sulfur

Sulfur is found abundantly in keratin, a protein that strengthens hair, nails, and skin. Sulfur baths, and other forms of sulfur applied directly to the skin, seem to benefit eczema. Use of sulfur as a supplement is not currently recommended for children.

Zinc

Eczema is one of the symptoms of zinc deficiency, but there is no indication that oral supplementation with zinc helps treat eczema.

Herbs

Herbs should always be viewed as drugs and, as such, may produce side effects or interact with other medications. They should be used with caution and only under the guidance of a professionally trained and qualified herbalist. Many people with atopic eczema are also allergic to many plants. Sometimes, the ingestion or topical application of these plant products will actually worsen eczema in some individuals. Therefore, we recommend that you proceed with caution if you choose to go in this direction to treat your eczema, especially if you have allergies. For example, ragweed, chrysanthemums, asters, echinacea, feverfew, and chamomile all cross-react because it is in the same plant family. Therefore, all of these should be avoided if you suffer from ragweed hay fever.

• Evening Primrose (Oenothera biennis) Oil: See GLA.
• Lavender (Lavandula angustifolia): Probably effective only through it relaxing effects and reducing stress, some herbal specialists prescribe oral lavender for skin conditions like eczema.
• Burdock root (Arctium lappa): When applied topically, may reduce skin inflammations
• Chamomile (Matricaria recutita and Chamaemelum nobile): Some data suggests they may reduce inflammation, ease discomfort and speed wound healing.
• Goldenrod (Solidago virgaurea): When applied topically for wound healing and has anti-inflammatory properties.
• Red clover (Trifolium pratense): When applied topically, has anti-inflammatory properties of benefit to skin conditions.
• Stinging nettle (Urtica dioica): May reduce inflammation but the data is very unclear.

Homeopathy

Very few studies have examined the effectiveness of specific homeopathic therapies and they have been generally very disappointing. Nevertheless, professional homeopaths may consider the following remedies for the treatment of eczema based on their knowledge and experience and NOT on any scientific information. Before prescribing a remedy, homeopaths take into account a person’s constitutional type. A constitutional type is defined as a person’s physical, emotional, and psychological makeup. Any remedy that causes aggravation of symptoms should be discontinued right away.

• Calendula: Applied to the skin, particularly if the affected area is inflamed; this remedy soothes but does not cure the skin condition
• Sulphur: For redness, burning, itching, and hot skin that tends to worsen with washing and scratching
• Urtica urens: For large, red rashes (particularly those related to allergies) that itch and burn intensely

Massage

The application of essential oils for treating children with eczema has some very limited information. One study concluded that massage with and without essential oils was effective in improving the dry, scaly skin lesions so it is clear that any such program must be individualized. Children with this scaly, itchy skin problem seem to experience less redness, scaling, and other symptoms if receiving massage between flares and should be avoided when the skin condition is actively inflamed. The essential oils most often chosen by the mothers in the study were: sweet marjoram, frankincense, German chamomile, myrrh, thyme, benzoin, spike lavender, and litsea cubeba.

Exercise

One study found that regular group sporting activities improved symptoms in those who participated for 3 weeks. The therapeutic effect of exercise is most likely related to the emotional benefit derived from aerobic activity. Sports should be avoided when eczema is acute and severe.

Climate

Sunlight and water have been associated with improvement in eczema. For example, eczema is usually worse in the winter and best in the summer, especially when children also swim regularly. Salt water moisture may be the most beneficial. For example, many people with eczema go to the ocean to sit in the sun and swim in the water. Studies suggest that this is a successful treatment for eczema. One study looked at the experience of more than 1,500 people with eczema and found that 95% of skin was cleared in people who had previous stays at the Dead Sea longer than 4 weeks.

Mind/Body Medicine

Flares of eczema are associated with anxiety and stress. Several studies have shown that relaxation techniques to reduce stress and anxiety can decrease eczema flares. Biofeedback seems to be a particularly useful technique. Massage therapy is also helpful.

Chinese Herbal Remedies

Although Chinese herbal treatments for eczema have been gaining popularity in both the United States and the United Kingdom, caution must be exercised when considering such remedies for skin conditions. Many of the Chinese herbal creams have been found to contain high amounts of steroids as the main active ingredient. This is worrisome and potentially dangerous because the amount of the medication in such creams is not standardized or as regulated as those available by prescription in these two countries. In a few instances, oral Chinese herbal teas used in the treatment of eczema have caused kidney damage.

How can eczema be avoided?

Eczema is a genetically directed skin disorder. Since genetic engineering is not yet possible, the only way to avoid eczema currently is to identify triggers and avoid them, control itching, reduce skin inflammation, and maximize skin lubrication. Your allergy and immunology specialist often teams with a dermatologist to provide eczema sufferers with the best possible care.

Helpful Links

• American Academy of Allergy, Asthma & Immunology http://www.aaaai.org/patients.stm
• National Eczema Society http://www.eczema.org
• National Eczema Association http://www.nationaleczema.org