Eczema: The Basics

Many of us experience dry skin, especially during the winter. When the skin is dry and flaky, it can also become itchy. At its most basic, eczema is just a more severe version of that dry, itchy skin known by most people. However, unlike the occasional dryness and itch, for patients with more severe eczema this becomes a chronic issue: dry, cracked skin, red rash, and terrible itch that disturbs sleep, and–at its worst–open, oozing sores that can become infected. Sometimes called “Atopic Dermatitis”, there is a strong connection with allergies for patients with eczema as well: foods, animals, grasses and molds, and other chemicals in the environment are more likely to cause allergy in these people, further complicating things and making life even more difficult. If this were a rare disease, it would be pretty terrible, but it’s actually worse than that: over 30 million American have eczema, making it an incredibly common skin problem.

Eczema can appear all over the body. Many people have it on the elbow creases or behind their knees. Babies often have eczema on the face, especially the cheeks and chin. They can also have it on the scalp, trunk (chest and back), and outer arms and legs. Children and adults tend to have eczema on the neck, wrists, and ankles, and in areas that bend, like the inner elbow and knee. People with eczema are usually diagnosed with it when they are babies or young children, but sometimes develop it for the first time as an adult. 

Fortunately, eczema symptoms often become less severe as children grow older, but for some, eczema continues into adulthood. Less often, it can start in adulthood. Most patients have an intermittent course: sometimes it is bad, other times better. The most severe cases almost never seem to improve on their own.

There has been a lot of discussion about what causes eczema. The most honest answer is, sadly, that we don’t really know. In the past decade, however, we’ve learned more about its causes than ever before, and now understand that–for at least a large group of sufferers–the problem lies in “leaky skin”. What this means is that genetically some people have a mutation in a gene for a protein called “filaggrin”.  This protein is important to keep the skin barrier strong and healthy. That keeps moisture in and keeps allergens, irritants and bacteria out. When people have a mutated version of this gene, their skin is “leaky”: moisture can get out and unwanted things can get in. For some, this seems to lead to the immune issues (such as allergies) that arise, and can start the “itch-scratch cycle” that can continue to worsen even if nothing is causing allergy at the time. There are probably multiple forms of eczema, which is why we are always suspicious when someone makes a claim for an eczema “cure”: it’s almost certainly not just one disease, but rather a group of related issues that appear similar on the skin.

There is no cure for eczema, but, in most cases, it is manageable.  No matter what the cause, we know that the skin barrier is leaky, and so moisturizers (including natural oils) and other skin protectants are critical to keeping water in and keeping bacteria, allergens, and irritants out. Additionally, avoiding any known triggers can play a huge role: harsh soaps and cleansers, fragranced products, certain types of clothing that can be itchy, extreme temperatures (such as hot showers), and even certain foods for some. For milder cases, that might be all that is needed. In that case, we are very happy. If there are signs of infection, we must aggressively treat it to help re-balance the healthy bacteria on the skin, and sometimes maintenance treatments such as dilute bleach baths can be used to prevent bacterial overgrowth.

However, for many this is not enough. Despite diligent moisturization, careful avoidance of all triggers, anti-bactieral treatment, and giving things ample time to heal, they still suffer. In such cases, we often find that the immune system is in an inflammatory state, causing active damage to the skin and resulting in itch. Here, anti-inflammatory medicines can be life-changing: to calm the inflammation and allow the skin to heal deeply. Topical corticosteroids, topical calcineurin inhibitors (such as Protopic or Elidel) and even some natural anti-inflammatory preparations can all be of use. The secret here is that we do not want dependence on these: they are best used to quench the fire to allow healing, and then stopped. In very difficult cases, it is not so easy, and the scratch-itch cycle takes a number of on-off-on-off periods with the anti-inflammatory treatments in order to have deep, prolonged healing. In those cases, the key is to use them for a bit (maybe up to a week), and then take a break for roughly as long as you’ve used them. So if it takes 3 days of topical corticosteroids to calm the skin, it’s important to take at least 3 days off to rest the skin. Used this way, these preparations are very safe and generally do not cause any significant side effects. Used incorrectly–for long periods without breaks–they can cause a number of side effects, including skin-thinning, stretch marks, and even some problems for the rest of the body if a lot is absorbed. 

Fortunately, most patients do get better and do so safely. The best part of treating eczema is having patients come in for an annual follow up who report not having a single flareup for the entire year, and not having used any medications since the last visit. That is truly a reason to celebrate!

As research progresses, there is hope that the fundamental causes will be isolated and we will close in on a cure. Working together with patient groups such as the National Eczema Association, this seems more possible than ever before!