Eczema

Eczema is a skin problem in which patches of skin become rough, red, and inflamed with blisters causing itching. At times, severe itching and scratching can lead to bleeding. In eczema, there is inflammation of the thick layer of the skin called dermis. The condition can affect any part of the body at any age. The word eczema comes from the Greek word “ekzema”, which means “to boil out". In eczema, the skin literally appears to be boiling, therefore, early doctors and medical practitioners regarded eczema as a name that fits perfectly for this skin condition.

Clinically, there are many types of eczema. Doctors need to identify the type of eczema as this is important in ensuring an effective treatment strategy.

The types of eczema are:

• Atopic eczema
  A person with atopic eczema has an immune system that is genetically predisposed to produce excessive amounts of an antibody (a defence protein usually release during allergies) called IgE (Immunoglobin E). The body produces IgE in response to inhaled, injected or ingested antigens (irritants). People with high IgE levels have a tendency of developing other allergic diseases like asthma, hay fever, urticaria (a skin rash triggered by food or medicine), and other allergic conditions as well. Atopic eczema can occur at any stage of life; however, its incidence is more in children than in adults. In most people, atopic eczema occurs along with hay fever and asthma, thus forming a triad of medical conditions. The condition flares up periodically.
• Seborrhoeic eczema
  In this type of eczema there is a red scaly rash, which typically affects the scalp (dandruff), the central facial region, folds around the nose, eyebrows, and central chest region. The condition may occur due to a fungal infection caused by a type of yeast (Pityrosporum ovale) that spreads to such areas in the body. It often runs in families. This type of eczema is a classic feature in people suffering from AIDS and can take on a severe form.
• Discoid eczema (Nummular dermatitis)
  This is a common form of eczema in which there are distinct coin-shaped patches. In adults, discoid eczema is most commonly seen on the arms and legs of elderly males and young people who drink excessive amounts of alcohol. In children, it can be associated with atopic eczema.
• Asteatotic eczema
  This form of eczema most commonly occurs in old and hospitalized people. It is a result of excessively dry skin and low humidity caused by central heating, over-washing, and prolonged use of diuretics (medicines that remove excess water from the body). It also has a French name- eczema craquelé. Due to its’ dry appearance, asteatotic eczema is also known as xerotic eczema. In this type, lesions appear as a fine fissuring with a rippled or ‘crazy paving’ pattern in a reddish background.
• Stasis eczema
  Stasis eczema, also known as venous eczema or gravitational eczema, is associated with venous insufficiency (swelling, red or bluish discolouration due to a fault in the walls of leg veins leading to a difficulty in sending the blood back to the heart), loss of hair, induration (lipodermatosclerosis), and ulceration (development of open sores). It affects the lower limbs. Itchy red blisters and crusted plaques or dry fissures and scaly plaques are present in this form of eczema. Atrophie Blanche (white irregular scars with red spots) are characteristic features of stasis eczema.
• Lichen simplex eczema
  Also known as neurodermatitis, lichen simplex eczema is a localized area of chronic, thickened and leathery eczema caused by repeated rubbing or scratching due to a habit or due to stress. The most common sites of occurrence of this form of eczema are the nape of the neck, lower legs, and anogenital (around the anus and genitals) area.
• Pompholyx
  This is a type of eczema that is mainly restricted to the hands and feet. In this form, small and large blisters (vesicles and bullae) form repeatedly on the palms, inner or palmar surface of the fingers, and the soles. Pompholyx can be extremely itchy with a burning sensation of heat and prickling in the affected areas. It can be triggered by heat, stress, and allergens like nickel. Other features of this form of eczema include multiple small blisters, which can turn into bigger reddish blisters. These larger blisters can get infected and become painful with peeling off the skin.
• Irritant eczema
  This form of eczema can be further differentiated into 2 sub-types:
  • Irritant contact eczema
    This is frequently seen in the majority of industrial workers. Elderly people with fair skin and suffering from atopic eczema can also be affected by this type of irritant eczema. Irritants like detergents, acids, alkalis, solvents, and abrasive dust are common causes of this type of eczema. In this form of eczema, hands are the most commonly affected region as they are the most common body parts to be in contact with various irritant substances. Sometimes, irritant contact eczema can appear as a red patch with a swelling.
  • Allergic contact eczema
    This is caused due to a delayed hypersensitivity reaction following contact with allergens or haptens. Previous exposure to the allergen is required for sensitization. Eczema occurs due to the same allergen or closely related chemicals. It occurs at places that are in contact with allergens. If the original site is not treated, eczema can spread to other areas of the body. Some common allergens are nickel, rubber chemicals, paraphenylenediamine (hair dyes), neomycin among others.

There are several patterns of eczema. Some of these have identifiable environmental causes whereas others are more complex. The clinical signs and symptoms are similar in all types of eczema and vary according to the duration of the rash i.e., acute or chronic. They are:

• Atopic eczema in babies involves the face and the trunk. Due to scratching of the affected areas by the infant, skin can become scaly and red. In atopic eczema, dry skin is also seen. The cheeks are frequently the first region that is affected. Diaper areas are usually not affected. In childhood, the rashes settle on the back of the knees, the front of the elbows, wrists, and ankles. Sometimes, atopic eczema can also affect the genitals. In adults, a diffuse pattern is seen with dry and scaly skin that is confined to hands, eyelids, flexures, and the nipples.
• Seborrhoeic eczema appears as small skin flakes on the scalp, face, and the upper trunk. In infants, it causes cradle cap (diffuse and greasy scaling on the scalp) with the rash spreading to the armpit and the groin region. These patches of rash are pink in appearance and are normally less itchy. In adults, blepharitis (scaly red and swollen eyelid margins) is commonly seen. Patches in adults are less itchy and eczema appears more commonly during the winter season.
• Discoid eczema appears either as the exudative acute type or a dry type. Both forms commonly appear on the trunk. In discoid eczema, distinct circular or oval-shaped lesion are seen, which are reddish in colour. These lesions are painful.
• In irritant contact eczema, initially, the patch or lesion is generally limited to the area that has come in contact with the irritant. The lesion appears as a blazing red patch forming blisters and scaling of the involved area. The area subsequently becomes dry and the skin develops cracks.
• Allergic contact eczema is seen in areas, which have been in contact with allergic substances. However, it may spread to other areas if proper care is not taken. The lesion resolves after the site is kept away from the allergen for a few days. Skin appears to be red, itchy, swollen or dry, and bumpy. Commonly affected sites include earlobes and wrists due to contact with allergens like nickel (in jewellery).
• Asteatotic eczema occurs most commonly in the lower legs as fine fissuring with a rippled or ‘crazy paving’ pattern on a reddish background. It appears as diamond shaped patches that are interrupted by red coloured bands that appear like a network. Extreme cases are accompanied by swelling and blistering.
• Stasis eczema is also termed as venous eczema as it is caused due to venous insufficiency. They present as rashes, blisters, dark skin, discoloured thick skin on legs, dry skin, ulcers etc. Lesions can be extremely painful and itchy.
• Lichen simplex eczema appears mostly on the nape of the neck, lower part of the legs, and anogenital area. It presents as a single plaque, which is either well-demarcated and linear or is oval in shape. It causes intense itching. It consists of dry skin or pigmented lesions with scratch marks due to itching.
• Pompholyx affects the palms and soles. The lesions appear as recurrent vesicles and bullae. These lesions can be excruciatingly itchy and can also cause a burning sensation. The blisters, on bursting, leave behind a dry and reddish skin, which is often painful and has cracks.

Causes

There is no strong evidence regarding the definitive underlying cause of eczema. It occurs due to many reasons that are interdependent on each other. But, it is presumed that genetics and environmental conditions along with abnormal functioning of the immune system can trigger the occurrence of eczema. In eczema, there is a defect in the functioning of the epidermis (the outermost layer) of the skin, which allows germs to enter the body. Specifically, the different types of eczema mentioned earlier have some pertinent causes that are as follows:

• Normally, the skin retains moisture due to which bacteria and other pathogens cannot enter it. But in atopic eczema, due to a certain genetic barrier, moisture is increasingly released away from the skin. As a result, the skin becomes dry and causes itchiness. This is mostly a genetic disorder, which you can inherit from your parents and it can be triggered by a number of factors like irritants, environmental factors, food allergies, specific cloth fabrics, hormonal changes, and skin infections in general.
• Seborrhoeic eczema is caused mainly due to a fungal infection by Pityrosporum ovale (a type of yeast).
• Discoid eczema is caused due to infection of a localized injury, such as a scratch or bites or burns and more by Staphylococcus aureus (a type of bacteria).
• Irritant contact eczema and allergic contact eczema are caused due to irritants like detergents, alkalis, acids, solvents, and abrasive dust particles and allergens like nickel, rubber items, paraphenylenediamine, resins, neomycin and more.
• Asteatotic eczema is a result of water loss from the stratum corneum (one of the layers of the epidermis) of the skin due to genetic factors. Low humidity and excessive bathing using soaps and other detergents cause the skin to become dry, which leads to this type of eczema.
• Stasis eczema is caused due to fluid accumulation in the tissues of the lower limbs, which results in a decreased supply of nutrients and oxygen to the skin making it prone to dryness. As a result, it activates some kind of immune response. Deep vein thrombosis, where there is clot formation in the deep veins of the legs can also cause stasis eczema.
• Lichen simplex is caused due to repeated scratching or rubbing of an itchy area which leads to the formation of a plaque.
• Pompholyx has many triggering factors like sweating in hot and humid weather, emotional disturbances, irritants like nickel, stress among others.

Risk Factors

A risk factor is anything that increases the chances of you developing a disease. Since the exact cause of eczema is still not known, there are many risk factors believed to increase the risk of eczema. Possible risk factors for eczema are:

• Heredity (from parents to children).
• Genetic factors (a disorder of the immune system).
• Age is another risk factor. Young children and infants are more prone to develop eczema.
• Excessive exposure of the skin to irritants like detergents and soaps.
• Prolonged exposure to allergens like nickel and rubber materials.
• Dry climate.
• Fungal and bacterial infections on skin lesions.
• Obesity.

Eczema is a long-standing skin problem, which is difficult to cure completely. But, certain measures can be taken to prevent the recurrence. These include:

• Moisturizing the skin
  Dry skin is a characteristic feature of most types of eczema. So, keeping the skin well-hydrated is the best method to prevent recurrence (repetitive episodes) and provide relief from the symptoms.
• Avoid triggers
  Factors that cause the onset of episodes need to be controlled.
• Limit water exposure
  Limiting showers and shower time to prevent losing skin moisture.
• Avoiding scratching the lesions/plaques
  Scratching must be avoided as it worsens the affected areas, as well as increases the chances of infections.
• Wearing comfortable clothing
  Wearing clothes made of soft materials is advised. Cotton clothes are best suited for such people who are allergic to certain fabrics.
• Managing stress
  Stress management is very important. Sometimes stress causes hormonal imbalance, which is a trigger factor for the onset of episodes or an increase in the intensity of the symptoms.
• Drink plenty of water
  Drinking enough water will not only flush out toxins from the body but will also help in preventing dryness of the skin, which is the most common triggering factor for the development of eczema.
• Make necessary lifestyle changes
  Certain lifestyle changes are needed if advised by the doctor, such as in case of allergic contact eczema or irritant contact eczema.

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A clear diagnosis of eczema is mainly established on the basis of family history of the person as eczema is passed on from parents to their children in most cases. Personal history is also important to know about allergies from any substances that have been experienced anytime in life. Also, the doctor assesses the stress levels that a person with eczema may be going through. Any medications that the person is taking as well as sleeping habits are noted. Certain other specific tests pertaining to eczema, which may be helpful in accurate diagnosis include Patch test, Prick test, IgE and specific IgE blood test, skin swabs for microscopy and culture of the causative microorganism. Patch test and prick test are done by administering low levels of an allergen to know if you elicit an immune response to them. In some people, biopsies are also performed in which a small skin sample is taken and examined under the microscope. A dermatologist will also be able to identify the type of eczema by looking at the affected lesions and examining them and then suggest an appropriate treatment.

There is no cure for eczema due to the unknown nature of its cause. The basic treatment is to relieve the symptoms, such as itching, and to prevent infections of the eczematous patches. Certain general measures that need to be undertaken:

• Explanation, reassurance, and encouragement.
• Avoidance of contact with irritants.
• Regular use of greasy emollients.
• Appropriate use of corticosteroid creams and lotions.

Besides these, certain specific measures are undertaken for various types of eczema. These are as follows:

• Atopic eczema
  Explanation and support to the person, regular use of moisturisers, and the least possible use of topical corticosteroids. Bandaging with ‘wet wraps’, tar, and ichthammol paste bandages. Medicines such as antihistamines, topical antiseptic applications in case of infected lesions
• Seborrhoeic eczema  
  Products, such as ketoconazole shampoo and creams, form the basis of treatment, supplemented with weak corticosteroids if needed. Treatments may be repeated at intervals.
• Irritant contact eczema and Allergic contact eczema
  Avoid any possible contact with the irritants or allergens. Make necessary lifestyle changes if needed.
• Stasis eczema
  Local corticosteroids like 1% hydrocortisone or 0.05% clobetasone butyrate or 30 g of a potent corticosteroid like 0.1% betamethasone valerate, 0.1% mometasone furoate are used at eczematous areas. Using these on ulcerated areas should be avoided. Associated peripheral swelling should be treated by elevation of legs and graded compression bandages.
• Asteatotic eczema
  Avoid dry skin by using moisturisers and bathe less frequently. Also, topical corticosteroids may be used to relieve the symptoms.
• Lichen simplex eczema
  Topical steroids are used to treat the plaque, steroid injections are needed every 4-6 weeks, moisturisers and cooling creams, antihistamines or antidepressants are also used.
• Pompholyx eczema
  Wet dressings over affected areas, mainly the palms and soles, with potassium permanganate is used for treatment. Also, comfortable footwear with socks, antiperspirants (to tackle excessive sweating), topical corticosteroid creams, systemic corticosteroids are used.

Lifestyle management

There are a few measures, which you can take to prevent eczema or limit the recurrence of the same. Here are some important things to keep in mind:

• Always keep your skin moisturised.
• Avoid any exposure of the skin to irritants.
• Limit temperature fluctuations.
• Manage stress and mood swings by meditating and other relaxation techniques.
• Maintain a healthy weight and follow healthy eating habits.
• If any skin surface of your body is affected by eczema, avoid scratching it. Therefore, it’s better to trim your nails frequently.

Prognosis

Since eczema is a chronic health problem, the outcome generally depends on the lifestyle modifications and the appropriate treatment advised by the dermatologist. Atopic eczema has a good prognosis as it slows down or diminishes at or around 30 years of age. Irritant and allergic contact eczema have an excellent prognosis if the irritant or allergen is identified and eliminated. Seborrhoeic eczema has the worst prognosis as it may be present life-long and treatment can provide only symptomatic relief.

Complications

Managing eczema through symptomatic treatment is very easy but sometimes it can cause certain unexpected complications. These complications include bacterial, viral, and fungal infections on the lesions, asthma, and allergies. Irritant reactions due to defective barrier functions, sleep disturbances, and self-esteem or body-image issues can also occur in affected individuals. However, proper management of the symptoms and adequate care can ease any issues, which can complicate the already affected body parts.