>> Atopic

Atopic Eczema patient information leaflet

You can also download this leaflet by clicking here

What is Eczema?

Eczema describes an itchy, inflamed skin rash. The word eczema comes from a Greek word meaning to 'boil over' and is used interchangeably with the term dermatitis. There are several types of eczema but this leaflet concentrates on atopic eczema which is the common type of childhood eczema, sometimes referred to as 'allergic eczema'. Atopic eczema suffers may also develop atopic asthma, or hay fever, or may have relations who have those conditions.

What is Atopic Eczema?

The word 'atopic' means that a person is extra sensitive to substances, usually invisible proteins, called allergens in their environment. The commonest allergens in these people are house dust mite (more accurately the droppings of house dust mite), grass, tree and weed pollen, proteins on cat and dog fur, feathers and occasionally foods, such as egg, milk or nuts. Atopic people have a hypersensitivity of their immune system and produce too much of the allergy or IgE antibody. They have no other problem with their immune system.

What causes Atopy?

The occurrence of atopic eczema or asthma seems to be mainly due to one's genetic make up, in other words a person inherits a tendency to develop these conditions. That is why there is very often a positive history of similar conditions in the family. Other factors, such as stress, dry environments, contact with irritants on the skin and infections, such as colds, seen to produce or worsen atopic eczema.

What does Atopic Eczema look like?

It causes patches of red, dry, scaly and itchy skin. In babies this often starts on the face and spreads then to the outside of the limbs and the body (Fig 1 Atopic eczema on the arms and legs of an infant). It can cause scaling and crusting on the scalp and typically the nappy area is not affected. In older children eczema tends to settle on the creases of the limbs on both sides of the body, especially at the front of the elbow and behind the knee (Fig 2 Atopic eczema on the knee creases). However, it can occur on virtually any part of the skin. If it persists into adult life, it may continue to affect the creases and also involve the face and hands. This pattern of involvement means that atopic eczema is usually quite easy to recognise.

What can I expect?

Atopic eczema tends to start at about the age of 2-3 months and may continue for the first two or three years of life. In fortunate individuals it disappears during that time and certainly the majority of children are only mildly affected by the time they go to school. Children who have severe atopic eczema may suffer repeated attacks through childhood and even into their teens. As a rule of thumb half of children with eczema should be much improved by school age and three-quarters by their teens. However, eczema can flare up at any age and an atopic eczema sufferer always has a risk of re-activation, even after years of normal skin. This is especially so for those people who enter occupations where the hands and face come into contact with irritant chemicals, or detergents, which may bring out eczema again.

Why is it so Common?

Most experts agree that atopic eczema and asthma are becoming more common in the UK and that 15% of young children suffer from atopic eczema. It is slightly more common in urban areas than in rural areas, in small families than in large families and in wealthier families, for reasons which are unclear.

What investigations are done for Atopic Eczema?

As atopic eczema is usually diagnosed on skin examination, the majority of people with it do not require any investigations. It can occasionally be helpful to do blood allergy tests but they seldom alter the treatment of eczema. This is because it can be very difficult to avoid things like house dust mite and also because a positive blood allergy test, for example to food allergens, may not predict what happens in reality. Skin prick tests are sometimes done but, again, are limited in their value. A person with atopic eczema may develop another type of eczema, called 'allergic contact eczema'. The commonest type of allergic contact eczema is nickel (jewellery) eczema. For this type of eczema, patch testing may be advised. For a person with infected atopic eczema, skin swabs and full blood count may be helpful in deciding treatment.

What is the Treatment for Atopic Eczema?

Moisturisers and Soap Substitutes
There is no single treatment that works for everybody with atopic eczema. However moisturisers are important since the skin is usually dry and lacks the natural oily protective barrier. Fortunately, there are several different moisturisers available, either as creams, ointments, lotions or bath oils, and each patient may be prescribed different moisturisers depending on their particular preference, their age and their type of eczema. Moisturisers soften and smooth the skin and improve itching. They must be used frequently, at least twice during the day, on all areas of the skin; even where there is no visible eczema. Soap is a mild detergent which is drying and irritating to the skin, therefore a soap substitute such as aqueous cream which also reduces the irritation of bath water will help.

Steroid Treatment
Steroid treatments are used in eczema because they are anti-inflammatory and reduce the itch, which is so troublesome. For most eczema sufferers, topical (externally applied) steroids work very well. Rarely steroids may be given by mouth or injection. There are very many steroid preparations that are classified as mild, moderate or potent or very potent. As with moisturisers, steroid treatments for the skin come in form of creams, ointments, lotions or gels. The strength and type of steroid that is prescribed for atopic eczema skin depends on the age of the patient, the site of the skin affected by eczema, the severity of the eczema and whether or not infection is present. Therefore, you will need to be guided by a doctor as to what the best and safest treatment is.

Many patients and families are afraid to use steroid treatments on the skin because they believe that it will cause damage, such as thinning or stretch marks. This was a problem in the past when very strong steroids were used to treat atopic eczema. Nowadays strong topical steroids are avoided as much as possible and regular supervision of people who require ongoing treatment has meant that side effects on the skin are very rare indeed. As a rough guideline a mild topical steroid, for example 1% hydrocortisone cream or ointment is used to treat young children and delicate areas of skin such as the face and neck. A moderately strong steroid is used in older children or adults with more severe eczema. The very potent topical steroids may occasionally be used in adults with severe eczema on the hands and feet. Steroid gels, lotions and mousse are especially designed to treat eczema in the scalp.

Anti-histamine treatment
The more sedating anti-histamines, such as trimeprazine and hydroxyzine reduce the itching of atopic eczema which is generally at its worst in the warmth of the bed and which can often interfere with sleep. The non-sedating anti-histamines are not very helpful unless a person also has urticaria, or nettle rash.

Treatment of Infection
Once the skin has been scratched and broken, it is common to get infection on top of the eczema. You will recognise this by the development of yellow, crusted patches, or raw oozing areas of eczema (Fig 3 Infected atopic eczema on the foot). This often affects the legs, wrists, hands and face, makes a person feel unwell and limits movement. Infected atopic eczema may be treated either with an antibiotic applied to the skin, often combined with a topical steroid, or with an oral antibiotic such as flucloxacillin prescribed by a doctor.


Other Treatments
Applying a dry tubular bandage over topical steroids, or a using wet or paste bandage on severe eczema can be very helpful and soothes the discomfort. This can take the form of a tubegauz body sock, or wet wraps or tar paste bandages applied to the limbs. The dermatology nurse will need to demonstrate how to apply them and advise as to how long to use them.

Evening Primrose Oil capsules, taken for 2-3 months, help a small number of people with atopic eczema.

Are there other treatments for severe eczema?

Yes, in older children and adults artificial sunlight (ultraviolet light or UV) treatment may be used. It is known by many sufferers that a holiday in a sunny climate usually improves their eczema. The sunlight treatment, or phototherapy, can take form of UVB twice a week for at least six weeks, narrowband UVB for short courses, or PUVA where a medicine that sensitises the skin is taken two hours before UVA treatment. You will need the assessment and advice from your dermatologist before you can be referred for phototherapy.

In rare cases of severe eczema, which has not responded to standard treatments, medicines which suppress the immune system, such as cyclosporin or azathioprine, may be considered for short courses. These are powerful drugs with potential side effects and their use is supervised by a dermatologist. People on these medications need to have regular blood tests to make sure that the drugs are not adversely affecting the kidneys, liver or blood.

A number of Chinese herbal remedies have been tried in the treatment of atopic eczema and some seem to work quite well. Chinese herbal treatments typically combine a number of different ingredients and, as the formula may vary for each patient, it is very difficult to research this type of treatment and to assure its safety. Therefore, in the UK most doctors are not experienced in the use of these and some patients of their own accord attend Chinese medicine clinics. Regular blood tests are advised for people taking oral Chinese herbal treatments as they have occasionally caused liver damage.

A number of experimental treatments are being developed at the moment but none of these are sufficiently well researched to be recommended as regular treatment for severe atopic eczema.

Are there any other complications I should know about?

People with atopic eczema are more likely to develop virus infections of the skin. Common hand warts caused by papilloma virus seem to be more persistent than in non atopic people. Molluscum contagiosum which is another variety of virus wart often induces an eczema reaction around some of the pearly warts. Both of these conditions tend to disappear on their own but may linger for months or years.

Another virus infection, which is more serious in atopic eczema sufferers, is the cold sore virus or herpes simplex. This can spread quite dramatically within eczema skin and make a sufferer very ill indeed. This complication may necessitate hospital admission and oral or drip treatment with anti-virus antibiotics such as acyclovir. Therefore, atopic eczema sufferers should avoid contact with people who have active cold sores.

People with atopic eczema are no more likely to develop allergic contact eczema than others but is has recently been noted that atopic people can develop acute or immediate allergic reactions to nuts, especially peanuts and rarely to rubber, i.e. latex. People with these allergies develop weals or nettle rash, almost immediately on contact with these substances and they must learn to avoid contact once the condition has been identified.

Is lifestyle important in Atopic Eczema?

Eczema skin is often dry and sensitive. People with eczema should avoid contact with soap, detergents and other irritants. This means wearing rubber gloves for household wet work, or cotton gloves for cleaning. They should avoid jobs or occupations which expose their skin to irritants, such as in hairdressing, catering, mechanical engineering and perhaps nursing, especially if eczema affects the hands.

Since atopic eczema sufferers seem to over react to house dust mite, it may be helpful to reduce the population of house dust mites in the home by regular dusting and vacuuming of the carpets. Dust mite bed covers have benefited some eczema patients and frequent airing and changing of bed linen should reduce the house dust mite population in bedding. Bed clothes should be washed at 500C or more to kill house dust mites. Old mattresses are more likely to harbour large populations of house dust mite, furry toys are also another source of exposure. Shaking soft toys vigorously, or placing them into a plastic bag in the freezer for a few hours, helps.

Some atopic people are sensitive to cat or dog fur, and it makes sense to avoid having these as pets when a family member suffers from atopic eczema.

The use of make up can irritate facial skin in a person with eczema and these preparations should be used with care. It is best to keep the central heating turned as low as is comfortable, as it has a tendency to dry out the skin. Cotton clothes are less irritating on eczema skin than polyester and wool. Bathing and showering are safe, providing that a soap substitute such as aqueous cream is used, or a bath oil is added. Bubble baths should be avoided, as it is a detergent. The moisturiser that the person uses should be applied after the skin has been patted dry. Holidays in a warm environment are beneficial as the skin's moisture is improved and, of course the person is more relaxed. Although sunlight is usually helpful, atopic eczema may make the skin more sun sensitive and covering up with cotton clothes and using a sunblocking cream are advised in hot climates to avoid burning.

Is diet important in Eczema?

In very young children atopic eczema may be worsened by cow's milk formulae and so infants with eczema are often put onto soya milk, or low allergy milk feeds. This problem generally settles in the second year of life and cow's milk may then be tolerated in slowly increasing amounts. Eggs may worsen eczema, although they may be tolerated in highly processed form, such as in cakes. Families may feel that other food items are important and if several foods are suspected or you decide to put your child on a restricted diet, then it is wise to discuss this with a dietician to make sure your child is getting enough protein, calcium and calories. Fortunately, most apparent food allergies get better during childhood. One food item that continues to cause problems in a few atopic individuals is peanut. Tomato sauce and citrus fruits seem to worsen facial eczema because they irritate broken skin and can produce weals around the mouth.

There is some evidence that prolonged breast feeding delays the onset of atopic eczema in infants but it does not prevent its development. Altering the diet of a mother who is breast-feeding by for example excluding cow's milk and egg may have additional benefits for the baby.

Any other questions?

A child's nails should be kept short to lessen skin damage. Anti-scratch mitts may be helpful in infants. People wonder about the differences between creams and ointments. Creams have a higher water content and are better for skin that is not too dry, or for wet and infected areas of eczema. Ointments are more greasy and some people prefer them if their skin is very dry and thickened. Ointments should be applied last because they will prevent other treatments from penetrating. You should obtain sufficient quantities of moisturisers and steroids. Most moisturisers come in quantities of 500 grams and with regular use this should last for one or two weeks in an adult. Steroids are usually given in quantities of 30 grams or 100 grams, depending on the area to be treated and the duration of treatment. People worry about anti-histamines becoming addictive but there is no indication that this happens, although their effect may wane with time.

Children with eczema can go swimming and they may find that putting an emollient ointment, or barrier cream on their skin before and after swimming reduces the irritation.

It is safe to vaccinate children with eczema in the usual way. If a child has a proven egg allergy, their MMR vaccination may be given within a hospital setting in case there are any problems, although this is very rare in practice.

As children with severe eczema have considerable stresses and worries about their skin, it is advisable to talk to the child's teacher and explain the situation so that the child can be helped at school. Some children with atopic eczema appear to be hyperactive and this may be because they are upset by itching, or by the appearance of their skin. They may also be suffering from sleep depravation and all of these factors must be discussed and tackled if possible.

Is there a Support Association of Eczema?

Yes, the National Eczema Society, Hill House, Highgate Hill, London N19 5NA, phone 020 7281 3553, is a very helpful and professional society that would be very pleased to hear from you. They have a small annual joining fee and publish a useful newsletter regularly, in addition to information leaflets on several facets of management of atopic eczema. Local eczema support groups have been set up in many areas and hold regular meetings. Enquire at your local community-nursing department or at the Dermatology Department.

Legends for figures
Fig 1. Atopic eczema on the knees and legs of an infant.
Fig 2. Atopic eczema on the knee creases.
Fig 3. Infected atopic eczema on the foot.