Eczema is not a single disease. It is a term frequently used to describe a group of skin problems, and sometimes used interchangeably with dermatitis. Each has different causative factors, is characterised by different signs of inflammation, and almost invariably causes itchiness. Its features depend on the cause, the area affected, and whether it is acute or chronic in time.

Possible Signs of Eczema

• Redness
• Blisters
• Weeping
• Dry scabs
• Scratch marks
• Dry and broken skin
• Thickened skin

Features of Eczema	Blisters in Acute Eczema

Acute eczema is red, may weep and has blisters. When the inflammation subsides, the redness decreases and dry scabs begin to form.

If the inflammation is allowed to continue, the eczema will become chronic. The skin is thickened and hardened because of the continual scratching. The skin lines are deepened, the skin colour is darkened, and the surface is broken.

The causes of eczema may simply be divided into internal and external factors, but in practice, most cases have many different causing factors, both internally and externally. Because of this, there are many types of eczema, the prevalence of each is different in different age groups. This is a rough distribution below:

Infantile Seborrhoeic Eczema

It does not have an apparent cause. It usually happens in the first 2 months of life, affecting mainly the scalp, and occasionally the flexures of arms and legs.

Signs

There are some greasy looking scales on the scalp. In the arms and legs the affected areas look red but smooth. This is usually not itchy and the baby does not normally feel disturbed by this.

Management & Treatment

This problem usually settles by itself within a few months, and does not normally recurs. Therefore the parents can try to manage this with, for example olive oil to speed up the sloughing of the scales on the scalp, and simple moisturisers on the flexures on the arms and legs.

If the situation is more severe, it is better to see the doctor, who may prescribe a very mild steroid cream, for example 0.5% Hydrocortisone. If there is infection on top, it is necessary to add in antibiotics or anti-fungals.

Parents may feel reluctant to put on steroid cream for the baby. However, it needs to emphasise that a little mild steroid such as 0.5% Hydrocortisone is pretty safe to use for just a few days.

Obviously it happens in babies and young children. This is because of prolonged contact of the skin with urine and faeces under an occlusive environment, and results in essentially a contact eczema caused by ammonia, and the effects of gut bacteria.

It is not so common in the first month of life but becomes increasingly common afterwards. It affects the nappy area - buttocks, genitalia, lower abdomen, and upper inner thighs, but sparing the skin creases, where the skin is folded and has not been in contact with the excreta.

Signs

Napkin eczema is a red rash easily diagnosed by its distribution. Usually it is mild with some redness. Occasionally it can be severe with ulcers and blisters.

Thrush is a yeast infection of the skin that is also common in children at the nappy stage. It also gives a red rash, but is most obvious deep in the skin creases, so in theory making the two conditions distinguishable. In practice, they often co-exist.

Management & Treatments

Hygiene is the most important part. Modern disposable nappies have good moisture-absorbing properties, but still need to be changed often if skin irritation is to be avoided. Some barrier creams can also be applied in the napkin area to act as a block of the contact.

The affected area should be washed with water added with some mild moisturiser. Soap or disinfectant should not be used. Mild cases will get better on their own and there is no need to seek medical attention.

If the situation does not improve or is severe, you should take the baby to see the doctor who may use a mild steroid cream. If there is secondary infection with bacteria or fungi, then a cream with antibiotics or anti-fungals would be used.

It is not a problem to use steroid as long as you apply the mildest preparation and for the shortest time necessary. 0.5 % hydrocortisone cream is very safe if used this way.

This is a chronic skin disease affecting about 2 - 5 % of children. Usually there is a family history of allergy problems. We call this Atopy, which includes asthma, hay fever, and rhinitis, sometimes referred to as the triad.

75% of the affected children begin to have problems between 3 - 6 months old, although the eczema can start in late childhood or sometimes even in adulthood. Most of the affected children will grow out of it, as they get older, while some of them will have the eczema continue into later life.

Causes Of Atopic Eczema

This is related to genetics. The immune system seems to be over sensitive and it results in one or more of the atopic reactions.

The skin also lacks the oily or moisturising substances that are present in normal skin. It may be this reason that, the skin surface easily harbours a large number of bacteria called staphylococcus aureus. They secret toxins, which will stimulate the over sensitive immune system, and lead to a whole cascade of allergic reactions. We call these toxins super-antigens.

Signs & Affected Areas

This depends on the age of the patient when the atopic eczema starts, but all of them in general have dry, flaky, and itchy skin.

In babies, it usually begins on the cheek, or other areas like the abdomen or the napkin area. It appears red and inflamed, and is very itchy. Scratching will make the skin break and weep, then crusting follows. The area can be infected on top, in which case the dry crusting is thick and looks yellow, and there may be pus collected underneath.

The itch is a useful feature to distinguish this and infantile seborrhoeic eczema, which is generally not itchy at all.

From about 18 months onwards, the affected areas will shift to the flexures of the limbs, i.e. the wrists, front of elbows, ankles, and back of knees, and also the neck. The acute features will turn chronic with dry, rough and thickened skin because of continual scratching. Areas around the eyes will also, because of rubbing, become rough with deep lines.

Atopic	Eczema

External Aggravating Factors

Weather

Atopic eczema is usually better in summers and worse in winters, because of the low humidity. Heating used indoors will also reduce the humidity in the environment, and taking hot bath will excessively remove the protective oily substances on the skin surface. All these contribute to make the skin lose its moistures.

However, sometimes the hot and humid weather in summers can also make the skin itchy, and increases the chance of scratching and deterioration.

Mood

Anxiety makes the patient uneasy, less tolerant of itch, and therefore again increase the chance of scratching and deterioration.

Foodstuffs

This is a controversial issue regarding their effects on atopic eczema. In general, most doctors will agree that atopic eczema will not improve by restricting the food or diet.

However, if the patient or parents find that a certain kind of food will really make the eczema worse, for example, milk, eggs, shrimps, or crabs, it is reasonable to avoid them if necessary. Over restriction should not be done, otherwise it may affect the absorption of nutrients. There is also no evidence to show food additives, such as artificial colourings or preservatives, will make the eczema worse.

Breast feeding the babies in the first 3 months will delay the onset of atopic eczema, but will not stop it completely.

Pets & Dusts

Fluffy pets, such as dogs, cats, and rabbits, will make the eczema worse if they are allergic to them.

Carpets and fluffy toys will accumulate large amount of dusts, and so the dust mites, which are confirmed to be a significant factor in aggravating the eczema.

Infections

Staphylococci and Streptococci can easily infect the eczema skin and make the whole situation much worse. Herpes simplex virus may even cause a life threatening complication. These all need urgent medical attention.

Others

Soaps that contain perfumes, residual detergent on clothing, over cleaning of skin, and disinfectants that dry skin up, all can make eczema worse.

Management & Treatment

For mild cases, the patients or the parents can try to manage the problems themselves. The most important thing of all is to avoid those external aggravating factors mentioned above:

• Adult patients should wear protecting gloves while doing household duties, so as not to come into contact with harmful chemicals. It is even better to add cotton gloves underneath. Otherwise it is easy to have irritant or allergic contact dermatitis.

• Clothing with wool material will irritate skin and make it itchy. 100% cotton is more appropriate.

• Try to avoid sofas, carpets, and toys that may attract and hide dusts. Frequent cleaning with a vacuum cleaning will reduce the amount of dusts and dust mites.

• Residual detergent on the clothing should be completely rinsed off.

• Babies and small children can put on a cotton mitten while sleeping. This will keep the damages from scratching to a minimum.

• To reduce the skin dryness, ordinary soap should be avoided, because they are too alkaline. There are soaps formulated with moisturizers and with a pH value between 5.5 - 7. Extra moisturising oil can be added into bath water if bathtub is used. Plenty of moisturisers should be applied after bath, or even at any other time, in order to keep the skin supple.

If the eczema is more severe, difficult to control, or there are obvious signs of infection, then medical attention is necessary. The doctor may initially prescribe a steroid cream to contain the inflammation. Those on the face should only use the mildest strength, such as hydrocortisone 0.5% or 1%. Other places can use a stronger one, and gradually reduce the strength.

A lot of people think that the side effects of steroids are so great that they refuse to use them at all. Of course, to use a strong preparation for a long time should not be encouraged. If used correctly for a short time, there is actually not much side effects, and the inflammation can quickly improve. So a complete avoidance is not necessary.

Because of the worries on the side effects of steroids, there comes another group of medication, which affects the immune system responses. These include Tacrolimus and Pimecrolimus. They are supposed to be free of those side effects of steroids, while being effective to treat atopic eczema. However, the improvement is rather slow to come, and initially there may be a lot of skin irritation, which is not very acceptable to patients. Also they are very expensive, and it costs a fortune if to apply on large affected areas.

In 2005, there were some reports, which warned the possibility of these causing skin cancers. Although it is yet to be unconfirmed, these medicines should only be used when necessary, and be stopped when situation improves. It should not be over used, and only under the instruction of the doctors.

The choices between this and steroids, or the combination of them, can be discussed with the doctors.

If the skin is too itchy that disturbs sleeping, some anti-histamines can be used which will cause some drowsiness, reduce the itch and promote sleep. If there is bacterial infection, then either a topical antibiotic cream or oral antibiotics will be need, otherwise steroid alone will not make it better.

To tackle some severe cases affecting the limbs, a method called wet wrap can be applied for a few days. The method is to soak some long strips of cloths or gauze into water enriched with moisturising oil, and then wrap these around the affected areas for a few hours or even overnight. This can prevent scratching, calm down the inflammation, and moisturise the skin. The effect can be fast and excellent.

This is a very common chronic skin disorder with no known causes, and usually happens in children between the ages of 6 to 12. This can be a localised but not obvious eczema, and there is some lose of pigment after the inflammation。

Signs

The rash is characterised by patches of lighter skin, mainly on the face, although the neck, upper chest, and arms are sometimes involved. The borders of the rash are not clearly defined, with the affected area blending gradually into normal skin. The surface is usually smooth, but is sometimes covered with very fine skin flakes.

It is not itchy and the patient does not feel anything at all. After exposure to sunlight, the lightened colour is enhanced because the normal skin will become tanned.

It can be distinguished from vitiligo by the border of the rash. The rash of vitiligo has a very distinct border with a sharp line between normal and lighter-coloured skin.

Management & Treatments

Treatment is not necessary since it will resolve on its own as the child gets older. Hydrocortisone may make the patch go away faster but very often it does not help much, and it still takes months to resolve. Avoiding too much sun exposure will reduce the contrast between the patch and surrounding normal skin.

Discoid eczema is usually associated with dry itchy skin, together with a tendency to uncontrolled scratching because of a stressed temperament. Sometimes it is referred to as neurotic eczema.

Signs

It can affect all age groups, but usually in middle-aged or older people. It happens in areas, which are easy to be reached and scratched, such as the limbs, and back of the neck.

It appears as discrete, coin-shaped, well-defined patches of eczema. Usually the pattern on the limbs is symmetrical. The lesions are felt as very itchy, so thickening of the skin (lichenification) is common after prolonged scratching.

Because of their well-defined margins, lesions of discoid eczema can be confused for fungal infections of the skin or for contact eczema.

Management & Treatments

Treatments are essentially the same as for other types of eczema. It is a must to try to control scratching, which is the main culprit and make the problem recur. Lots of moisturisers should be applied which will keep the affected area thin and not so itchy.

Because the skin is usually thickened, more potent steroid cream would be needed, often mixed with salicylic acid to promote the penetration into the skin. The newer anti-inflammatory creams should also be effective, and reduce the need for steroids. If necessary the area can be occluded with cling film, which will further enhance the penetration and absorption, with the problem resolving within weeks.

Infection is common in discoid eczema, topical or oral antibiotic treatment may be required.

Asteatotic means lack of oiliness. This type of eczema is initiated by dry skin, particularly in the elderly people, whose skin loses the oily protection as the skin ages, together with perhaps improper skin care. The dry skin is itchy, and scratching will complicate the situation with more inflammation. Eventually eczema sets in.

Using excess soap, especially if it is not completely washed off, may contribute to asteatotic eczema by drying out the skin too much. The use of ‘water pills’ (diuretics) is possibly an extra factor in elderly people who may need diuretics to help correct a range of other medical conditions such as high blood pressure.

Sometimes an under-active thyroid gland, which is also common in the elderly, can be an extra cause of this.

Signs

The eczema is usually seen on the legs of elderly people. This is because the legs lose more moisture when the circulation is more stagnant in this age group, and the legs are easily reachable to be scratched. Sitting too close for long periods to radiant heat sources, such as electric fires, is also a contribution to eczema in the legs.

The skin is very itchy and red, with much superficial scaling and splitting. The pattern of scaling is often described as looking like ‘crazy paving’.

Typical Crazy Paving	Bacterial Infection

Management & Treatments

This is essentially the same as for other types of eczema, namely moisturisers, steroid cream, and antibiotics cream.

To reduce the skin dryness, ordinary soap should be avoided, because they are too alkaline. There are soaps formulated with moisturizers and with a pH value between 5.5 - 7. Extra moisturising oil can be added into bath water if bathtub is used. Plenty of moisturisers should be applied after bath, or even at any other time, in order to keep the skin supple.

If the eczema is more severe, difficult to control, or there are obvious signs of infection, then medical attention is necessary. The doctor may initially prescribe a steroid cream to contain the inflammation.

If the skin is too itchy that disturbs sleeping, some anti-histamines can be used which will cause some drowsiness, reduce the itch and promote sleep. If there is bacterial infection, then either a topical antibiotic cream or oral antibiotics will be need, otherwise steroid alone will not make it better.

This is also called gravitational eczema, and as this name suggests, this affects the lower legs as a result from gravity's effect on the pressure of blood within the veins. This is most often seen in middle-aged to older age groups. Being overweight and female increases the risk.

Normal veins have a series of internal valves that keep the blood in the legs moving back towards the heart, and keep the pressure inside the veins at a low level. In the elderly, these valves are not functioning properly and so the pressure of blood within the veins increases considerably in the legs. The veins are distended and bulge out from under the skin, known as varicose veins.

The reduced blood flow has a knock-on effect on the nourishment of the skin; and increases the skin temperature so that more moisture is lost. These result in the eczema.

Signs

The eczema is usually located around the inner sides of each ankle, sometimes can extend to a wider area. Apart from the typical signs of eczema, namely dry cracking lines, redness, and inflammation, there may be oedema around the ankles.

The blood stasis and high pressure will force blood leaking from capillaries into the surrounding tissue. This leaked blood will be broken down and release iron, which precipitates in the skin and makes it appear as reddish-black.

Management & Treatments

Effective treatments involve helping the function of the valves, so that the pressure in the lower legs veins can be reduced. Unfortunately there is no cure, and can only be indirectly achieved by avoiding prolonged standing; leg elevation while sitting down; and compression bandaging.

The compression bandages provide a graded pressure, reducing from below upwards, and help to promote blood flow back into the heart. There are different sizes and pressure gradients, and purchasing these may require the help of the medical professionals.

Moisturisers and mild steroid creams relieve scaly and inflamed skin. Ordinary soap should be avoided because of the high alkalinity, and plenty of moisturisers should be applied after washing.

People with bad varicose veins and gravitational eczema are also at risk of developing skin ulcers around the ankle because of poor oxygen delivery by the blood stream in the affected areas. Varicose ulcers can be extremely troublesome and difficult to heal. Again, leg elevation and compression bandaging are the most helpful treatments to speed up the healing process.

For some reasons, skin affected by varicose eczema is rather sensitive and can become allergic to a range of skin medicaments, for example lanolin and some antibiotics. Lanolin is actually very moisturising and is a common ingredient for many moisturizers. If the eczema seems not to improve or even deteriorates, think of this possibility and try switching to a moisturiser free of lanolin.

Seborrhoeic eczema has nothing to do with sebum, the oily secretion on the skin, and so the name is not appropriate. It affects all age groups from young adults to the elderly. A type of seborrhoeic eczema is also seen in babies during the first year of life, and has been described earlier.

Skin infection by yeast called Pityrosporum Ovale is thought to play a part. It is a commensal organism present on the skin of almost everyone. Normally it does not cause any symptoms, and only when someone turns allergic or sensitive to its presence, then problems arise.

There is some correlation between this and a nervous or anxious life style and personality.

Signs

The most common places are the scalp, eyebrows, centre of eyebrows, sides of nose, and cheeks. Less commonly, it affects the centre of chest and back. Occasionally it is present in skin folds such as the groins and under the breasts.

On the scalp and face, the skin is greasy, red and scaly. The condition varies in severity. A mild case would be a little bit of dandruff and flaky skin over the face. In severe cases, the skin is widely affected and very itchy; the scalp is itchy, oily and, if very inflamed, there is much scaling of the scalp skin.

On the chest, there is a red scaly patch over the breastbone; while on the back, there are multiple red raised dots across and between the shoulder blades. Because of the trapped moisture, there is seldom any scale in the skin folds, rather a moist red skin is seen in the groins, under the breasts and in the armpits.

Management & Treatments

A lot of people rely on steroid cream to control the itchiness and flakiness. This only suppresses the allergic component, while leaving the Pityrosporum Ovale unaffected, and could even increase. Therefore the situation can get much worse once the steroid cream is stopped, with rebound redness affecting the whole face, and more difficult to treat.

A correct regime is to use mild steroid (1% hydrocortisone) only, with added anti-fungal cream such as Miconazole, Clotrimazole, which will reduce the number of Pityrosporum Ovale.

As Pityrosporum Ovale is a normal commensal, it is not possible to eradicate them all. The aim is to control the eczema with the least frequent application of cream, as in using anti-dandruff shampoo twice a week to control dandruff.

Medicated shampoos containing anti-yeast medication may keep mild activity under control. The preparations include tar, selenium sulphide, and ketoconazole. If there is a lot of scaling, additional treatments with some steroid solutions can be needed.