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.

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.