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Atopic eczema

What are the aims of this leaflet?
This leaflet has been written to help you understand more about atopic eczema. It tells you what it is, what causes it, what can be done about it, and where you can find out more about it.

What is atopic eczema?
‘Atopy’ is the term used for the tendency to develop eczema, asthma and/or hayfever.

Atopic eczema is a dry, itchy inflammation of the skin. The words ‘eczema’ and ‘dermatitis’ are interchangeable and mean the same thing. Atopic eczema, therefore, is the same thing as atopic dermatitis. For simplicity we shall stick to the word ‘eczema’ in this leaflet.

Atopic eczema can affect any part of the skin, including the face, but the areas most commonly affected are the bends of the elbows, around the knees, and around the wrists and neck. These are known as ‘flexural’ areas. It affects both sexes equally and usually starts in the first weeks or months of life. It is most common in children, affecting at least 10% of infants, although it can carry on into adult life or come back in the teenage or early adult years.

What causes atopic eczema?
This is still not fully understood. Atopy runs in families (see below) and is part of your genetic make-up. Atopic people have an overactive immune system and their skin easily becomes inflamed (red and sore). Their skin ‘barrier’ does not work well, so that their skin may become dry and prone to infection.

Atopic eczema is not catching.

What are the symptoms of atopic eczema?
The main symptom is itch. Scratching in response to this may be responsible for many of the changes seen on the skin. Itching can be bad enough to interfere with sleep.

What does atopic eczema look like?
If you have eczema, it is likely your skin will be red and dry. When the eczema is very active (during a ‘flare-up’) you may develop small water blisters on the hands and feet or your skin may become wet and weepy. In areas that are repeatedly scratched, the skin may thicken in response - a process known as lichenification.

How is atopic eczema diagnosed?
It is usually easy for health care professionals, such as health visitors, practice nurses and general practitioners, to make the diagnosis when they look at the skin. However, sometimes the pattern of eczema patches in older children and adults is different, and the help of a hospital specialist may be needed. Blood tests and skin tests are usually not necessary. Occasionally the skin may need to be swabbed (by rubbing a sterile cotton bud on it) to check for bacterial or viral infections.

Can atopic eczema be cured?
No, it cannot be cured, but there are many ways of controlling it. Most children with atopic eczema improve as they get older (75% clear by their teens). However, many of those who have had eczema continue to have dry skin and need to avoid irritants such as soaps or bubble baths. Eczema may persist in adults it but should be controllable with the right treatment.

How can atopic eczema be treated?
You will need the advice of a health care professional on the best treatment for your eczema and on how long this should continue. The treatments used most often are moisturisers, and topical steroid creams or ointments.

Moisturisers (emollients) should be applied every day to stop your skin becoming dry. Many are available, and it is important that you choose one you like to use.

Topical steroid creams or ointments will settle the redness and itching of your eczema when it is active. They come in different strengths (potencies), and your doctor will advise you which type needs to be used where, and for how long. Topical steroids should be used in combination with moisturisers in a skin care ‘regime’.

Topical steroids are safe as long as they are used in the right way - using the right strength to improve a flare up and stopping them or reducing their strength once things have improved. Stopping topical steroids abruptly may allow the eczema to flare up again, and it may be helpful to go on using them on 2 consecutive days a week for a few weeks after a flare of eczema has settled.

Skin thinning from topical steroid preparations should not be a problem if they are used properly. It usually arises only when too strong a steroid has been used for too long, or in a ‘delicate’ area where the skin is thin. Weaker topical steroids should be used where the skin is particularly thin, such as on the face, eyelids, and armpits: stronger steroids can be used at other sites.

Steroids are classed as mild, moderate, potent and very potent; and it is sometimes recommended to have a range of suitable creams of different strengths and to move up and down through different strengths like a ladder, depending on how the skin is flaring up. In this way stronger creams may be used while your skin is flaring up, and milder ones as your eczema settles.

Antibiotics. If your eczema becomes wet and weepy, it may mean that it is infected and that antibiotics are needed.

Topical immunosuppressants, Some people benefit from the newly introduced non-steroid creams, tacrolimus (Protopic) and pimecrolimus (Elidel), which can reduce inflammation in the skin. They are effective treatments for atopic eczema. They do not thin the skin or cause the side effects associated with topical steroids. The commonest side effect is stinging on application and they may increase risk of skin infections. They should not be applied to sun-exposed sites in the long term, or used at the same time as ultraviolet light treatment. Although, theoretically, they might increase the risk of skin cancer they have been safe in use for up to 4 years.

Antihistamines, particularly the so-called ‘non-sedating’ types used to treat hay fever, are of no benefit to people with eczema. The only antihistamines that may help control atopic eczema are those that make people sleepy. They are less effective if used in the long term.

Bandaging can sometimes help, particularly for the arms and legs. ‘Wet wraps’ are cooling bandages that are sometimes helpful for short periods in treating children.

Ultraviolet light. Some people with chronic eczema benefit from ultraviolet light treatment, which is usually given in a specialist hospital department and supervised by a dermatologist. There are three types of ultraviolet light treatment, narrow band UVB, UVA and PUVA.

Stronger treatments. People with severe or widespread eczema sometimes need stronger treatments, which will usually be given under the close supervision of a health care professional. Oral steroids (usually prednisolone) are sometimes used for a very short time if the eczema has flared badly. They work well but cannot be used in the long term as they may cause side effects. More severe forms of eczema may need longer courses of other tablets that calm down the immune system, such as azathioprine or ciclosporin. They too have side effects that need to be monitored with regular blood tests and visits to the hospital. Details of these treatments and how they are used are also provided on the patients’ section of the BAD website (http://www.bad.org.uk/public/leaflets/pil_index.asp).

Chinese herbs are an alternative therapy that can be effective. Most doctors would not recommend their use, as their ingredients are not regulated. Potential side effects are therefore unpredictable. Liver problems have been known to occur with Chinese herbs, and patients taking them should be monitored for side effects.

Dealing with allergies.

The NHS systematic review of atopic eczema treatments is free on:
http://www.ncchta.org/execsumm/summ437.htm

Other useful websites include:
www.nlm.nih.gov/medlineplus/eczema.html
www.aad.org/pamphlets/eczema.html

The British Skin Foundation fund vital research into all skin diseases.  To find out how you can help, please visit the British Skin Foundation website here.

(While every effort has been made to ensure that the information given in this leaflet is accurate, not every treatment will be suitable or effective for every person. Your own doctor will be able to advise in greater detail)

BRITISH ASSOCIATION OF DERMATOLOGISTS
PATIENT INFORMATION LEAFLET
PRODUCED OCTOBER 2004