Eczema

Eczema, also known as atopic dermatitis, is a long-lasting (chronic) skin condition categorized by scaly, itchy rashes, and red and dry skin patches.

• Eczema affects over 30 million Americans of all age ranges, but primarily targets children and adolescents.
• A family history of eczema or other conditions such as asthma or hay fever is common.
• There is no cure, and treatment usually involves emollients and topical steroids, avoidance of triggers like harsh soaps, and the use of prescription medications such as calcineurin inhibitors or injectable biologic agents in more severe cases.

What Causes Eczema?

Contrary to popular belief, eczema is rarely linked to food allergies. Researchers are not sure what exactly causes eczema, but there appears to be a genetic abnormality in the outermost layer of the skin which lowers its protective effect from allergens, irritants and the environment. A family history of eczema may make the condition more likely for an individual.

Eczema is most common in infants (where it is known as infantile eczema) and at least half of those cases clear by age 3. In children, eczema tends to occur by age five. In adults, it is generally a chronic (long-lasting) or recurring condition.

Inflammation causes the skin to become red, itchy and scaly. Chronic irritation and scratching can cause the skin to thicken and have a texture like leather.

Triggers can worsen symptoms, such as:

• dryness of the skin
• exposure to environmental irritants
• excessive exposure to water (especially hot water)
• temperature changes
• stress and anxiety.

Symptoms

Symptoms can vary widely and may occur in different areas of the body depending upon age.

• Infants tend to have symptoms in the area of the forearms, legs, cheeks, and scalp.
• In children under 2 years old, skin lesions may begin on the cheeks, elbows, or knees.
• Older children and adults may experience symptoms on the neck, inside the elbow, wrists, behind the knees, the face and forearms. The eyelids can be affected.

Eczema is an ongoing condition, but symptoms can come and go in periods of “flares” where symptoms may worsen.

Typical symptoms include:

• intense itching which may worsen at night
• blisters with oozing and crusting
• skin redness or inflammation around the blisters
• rash
• dry, leathery skin areas
• skin darkening and creases around the eye are
• raw areas of the skin due to intense scratching
• secondary infections due to scratching

For some patients, the itching may be so intense they are unable to sleep and it can affect their daily routine at home, work, or school. Prescription or over-the-counter antihistamines can be used to help with itching, but the effectiveness of these agents are in question if urticaria or other atopic conditions are not present.

If itching is interfering with sleep, diphenhydramine or hydroxyzine, which cause drowsiness, may be the preferred agent, and given only at bedtime. It is important to remember the use of sedating antihistamines in children may interfere with school performance, so check with your doctor first.

Topical antihistamines, for example diphenhydramine (Benadryl) cream, have been tried for the treatment of eczema but have not been shown to be effective and are not recommended by the American Academy of Dermatology.

Common Eczema Triggers

• irritants, chemicals or common household items, such as cleaners, soaps, detergents, wool, lanolin, scents, dust or smoke.
• rapid change in temperatures, such as going from a warm house to very cold outside temperatures.
• stress, anxiety
• dry air without humidity
• sweating

Anything that aggravates (“triggers”) the symptoms should be avoided whenever possible. Dry skin often makes the condition worse. When washing or bathing, keep water contact as brief as possible and use less soap than usual. After bathing, it is important to trap the moisture in the skin by applying emollients on the skin while it is damp.

Diagnosis

Consult your health care provider for a diagnosis of eczema because it can be difficult to differentiate from other skin disorders. Your primary care doctor may be able to manage your treatment; in some cases, a dermatologist may need to be consulted.

• A diagnosis of eczema is primarily based on the appearance of the skin and on personal and family history of certain medical conditions, such as eczema, asthma or hay fever.
• Your doctor will examine the lesions to rule out other possible causes.
• Lab tests are not usually needed. A skin lesion biopsy may be performed, but is not always required to make the diagnosis.

Complications from Eczema

Coping with eczema is a challenge, both physically and emotionally. Eczema can lower self-esteem, interfere with social, work and school activities, and may be especially hard for teens and young adults due to embarrassments from skin lesions.

Complications include:

• asthma and hay fever development in childhood
• avoidance of socialization or other daily activities
• anxiety, depression
• skin discoloration and thickening due to chronic itching
• skin infections
• dermatitis due to irritants or allergens
• poor sleep quality due to chronic itching

A large study published in Annals of Allergy, Asthma and Immunology looked at over 300,000 people and found that those with the condition had a 44% higher risk of suicidal thoughts compared with people without the skin disease. In addition, researchers found a 36% higher rate of suicide attempts. Suicidal risk may increase with the severity of the disease. However, research has shown that newer treatments, such as the immune-targeted medications, have been shown to decrease symptoms of depression and anxiety in patients.

Treatments for Eczema

Treatment options for eczema range from over-the-counter (OTC) creams and ointments, to anti-itch medications, to prescription biologic injections. Common topical prescription treatments include various strengths of corticosteroids, calcineurin inhibitors, and PDE-4 inhibitors.

Use of thick creams and ointments (emollients) can help control dry skin and itching. Self-care, lifestyle and home remedies can also play an important part in treatment.

The use of a dressing or wrap over any area of skin you’re treating will increase the potency and absorption of a medication into your skin. This is especially a concern with topical steroids, where side effects may worsen. Only use dressings, bandages or wraps with medications applied to your skin if recommended by your doctor.

Emollients

Emollients soften and smooth dry, itchy and scaly skin. Most emollients can be bought at the pharmacy without a prescription. They include thick creams and ointments that contain a low percentage of water. Products used for eczema may also contain humectants, such as glycerin, which help to draw water to the top layer of skin, and agents that help to smooth the skin such as urea.

Dry skin occurs because moisture is lost from the top layer of skin, know as the epidermis. These agents should be applied immediately after bathing while skin is still slightly damp to help seal in moisture in this layer of skin. Ingredients such as urea, glycerol, propylene glycol or lactic acid will help to hold water in the top layer of skin. Avoid products with fragrances, dyes and lanolin.

Ointments are effective but can be more messy than creams and may be better used at bedtime. Products labeled as lotions may be less effective as they contain a higher percentage of water.

Use these agents as directed by your doctor, usually apply at least twice a day. Regular use of emollients may reduce your need for active topical treatments such as topical corticosteroids or other prescription medications. Many dermatologists recommend emollients that contain petrolatum. Less expensive generic and store brands may be available, so if cost is an issue, ask your pharmacist about other options.

Table 1. Emollients Often Recommended by Dermatologists

Brand Name Examples	Main Ingredient(s)
Aquaphor	petrolatum
Aveeno	glycerin, colloidal oatmeal
Carmol	urea
Cetaphil	petrolatum
CeraVe	ceramides, colloidal oatmeal
Curel	ceramides, glycerin
Eucerin	colloidal oatmeal
Lubriderm	mineral oil, glycerin
Vaseline	petrolatum

Corticosteroids

Topical corticosteriods

Corticosteroids (often just called "steroids") are often used in mild to moderate eczema to help relieve redness, swelling and itching. Agents applied to the skin are preferred over oral drugs due side effects. These products may come as ointments, creams, lotions, shampoos or sprays, and are usually applied one to two times per day.

• Topical corticosteroids have a wide range of potency. Mild, low potency topical corticosteroids such as 1% hydrocortisone cream or ointment is available without a prescription.
• Stronger prescription products are also available and range up to super-high potency.
• Chronic thickened areas may be treated with both corticosteroids (medium to very high potency) and emollients. Use of topical steroids should be limited as long-term use can lead to thinning (atrophy) of the skin.
• Once the redness, swelling and itching is under control, your doctor may recommend that you stop using the steroid but continue with your emollients.

Table 2. Topical Corticosteroids Used for Eczema

Generic name	Brand Name Examples	Potency
amcinonide ointment 0.1%	Cyclocort	high
clobetasol 0.05%	Temovate	very high
desonide 0.05%	Desonate, DesOwen	low
desoximetasone 0.25%	Topicort	middle
fluocinolone acetonide 0.025%	Synalar	lower to middle
hydrocortisone 1% (over-the-counter)	Cortizone-10, others	least
mometasone furoate 0.1%	Elocon	medium
triamcinolone acetonide 0.025%	Kenalog, Aristocort A	low

Related: Full Listing for Topical Corticosteroids Used for Eczema

Oral corticosteroids

Short-term and tapered use of oral corticosteroids, usually over one week or less, may be prescribed to reduce inflammation in some severe eczema cases.

• Prolonged oral use is avoided due to severe side effects.
• Side effects include adrenal gland (hormone) problems with symptoms of dizziness, irritability, insomnia, nausea, joint pain, and low blood pressure.
• Commonly prescribed oral corticosteroids include prednisone (Rayos) and methylprednisolone (Medrol Dosepak).

Related: Corticosteroid Options for Atopic Dermatitis

Topical Calcineurin Inhibitors

Topical calcineurin inhibitors (TCIs) block calcineurin and slow down the immune system T-cells (a type of white blood cell) to help control eczema symptoms like itching and redness. These agents are typically used to treat severe eczema when other medications have not worked well.

• Because TCIs do not contain steroids they can be used in more sensitive areas like the face and around the eyes and can be used over a longer time to control symptoms.
• These products for the skin are approved for use in children 2 years and older as directed by your doctor.
• Common side effects might include stinging, burning, or itching where it is applied.
• Protect your skin from the sun when you are using these agents and do not use with occlusive dressings (bandages, wraps, dressings).

Topical calcineurin inhibitors have been linked with rare cases of skin cancer or lymphoma, but this risk has not been proven. Ask your doctor about the risks compared to benefits of using these drugs.

Table 3. Topical Calcineurin Inhibitors Used for Eczema

Generic Name	Brand Name
pimecrolimus	Elidel
tacrolimus	Protopic

Topical PDE4 Inhibitors

Currently, the only FDA-approved topical phosphodiesterase 4 (PDE-4) inhibitor is crisaborole (Eucrisa).

• Eucrisa ointment is used to treat mild to moderate eczema in adults and children who are at least 3 months of age. It is not a steroid medication.
• It is applied topically (to the skin) twice daily in a thin layer. Do not use it in your mouth, eyes or in the vagina.
• In studies, those receiving Eucrisa had clear or almost clear skin after 28 days of treatment.

The most common side effect of Eucrisa, occurring in at least 1 out of every 100 patients (1%), is pain where it is applied. Serious side effects such as allergic reactions have also been reported.

Table 4. Topical PDE4 Inhibitors

Generic Name	Brand Name
crisaborole	Eucrisa Ointment

Interleukin-4 (IL-4) receptor alpha antagonist

Dupilumab (Dupixent) injection was FDA-approved in 2017 to treat adults with moderate-to-severe eczema who do not have adequate results with or cannot use topical therapies such as calcineurin inhibitors or topical PDE-4 inhibitors. Since that time its uses have expanded to include eczema treatment in children down to age six, use in asthma in patients aged 12 years and older, and chronic rhinosinusitis with nasal polyposis in adults

• Dupixent is classified as an interleukin-4 receptor alpha (IL-4Rα) antagonist and is a biologic monoclonal antibody. Blocking IL-4Rα with Dupixent inhibits IL-4 and IL-13 cytokine-induced inflammatory responses. Through this action, dupilumab inhibits certain inflammatory immune actions that may lead to symptoms of eczema.
• Dupixent is given every other week as an injection under the skin (subcutaneously). It can be used with or without topical corticosteroids or topical calcineurin inhibitors, but calcineurin inhibitors should be reserved for problem areas only, such as the face, neck, intertriginous sites (places where skin rubs together) and genital areas.
• Three studies looking at the safety and effectiveness of Dupixent in adults with moderate-to-severe eczema found that patients receiving Dupixent 300 mg given SQ every 2 weeks had clear or almost clear skin (ranging from 36% to 39% of patients) as compared to placebo (ranging from 9% to 12% of patients), with a reduction in itch, after 16 weeks of therapy. In one of these studies, Dupixent was combined with a topical corticosteroid.

Dupixent side effects are reported as allergic reactions, injection site reactions, cold sores on the mouth or lips, and eye conditions like conjunctivitis or keratitis. Dupixent is expensive, so be sure to speak with your doctor, check with your health insurer about coverage or check with the manufacturer for patient assistance if you do not have insurance.

Table 5. Interleukin-4 receptor alpha (IL-4Rα) antagonist

Generic Name	Brand Name
dupilumab	Dupixent

Phototherapy

Ultraviolet (UV) light therapy, or phototherapy for eczema consist of natural sunlight or artificial light (UV-A or UV-B light). Treatment can help to relieve itch and reduce redness. It can be used just on one area or for the whole body. It takes one to two months of regular light therapy to see improvements.

Due to the fact that UV light therapy can be linked with sunburn, skin aging and skin cancer, this form of therapy is usually reserved for eczema that does not respond to other treatments. It is not commonly used in children due to the risk of cancer. It should never be used in infants.

Self Care and Home Remedies for Eczema

There are many home care options to help relieve the chronic itching that goes along with eczema.

• Bathing: Moisture does not stay in the upper levels of the skin in eczema, leading to dry skin. A daily routine of bathing and moisturizing right after your bath or shower will help to keep your skin smooth and lessen your eczema symptoms. Use lukewarm (not hot) water and limit your time in the water to 10 to 15 minutes. Use a gentle cleanser (not soap). Avoid scrubbing.
• Moisturize: Apply your emollient within several minutes after your bath. If you use a topical medication, apply that first, wait 3 minutes, then apply your emollient.
• Baking soda: Adding a quarter-cup of baking soda to tub full of  lukewarm water can relieve itching.
• Colloidal Oatmeal: Colloidal oatmeal added to a bath can also relieve itching.
• Wet dressings: Wet dressings, or wet wrap therapy can help to sooth and add hydration to the skin. It can also relieve itching and redness. Dampened gauze or cloth is wrapped around an area, then covered with a dry garment. They can be left on during the day or worn overnight. Change your dressings every 8 hours, and check with your doctor or nurse before starting this therapy.

Bleach Bath for Eczema

A diluted bleach bath 1 or 2 times per week may help to quiet symptoms of inflammation as well as act as an antibacterial, lowering risk of infections, according to dermatologists. If properly diluted and used as recommended by your doctor, a bleach bath is safe for both children and adults. Always check with your doctor first before using this method.

• Never apply bleach directly to your eczema.
• To prepare a bleach bath for an adult, use regular 6% strength plain bleach (don’t use splashless, concentrated, or fragranced bleach).
• Use 1/4 cup (59 milliliters) to 1/2 cup (118 milliliters) of bleach for a full 40-gallon (~150 liter) bathtub of warm water. Use lukewarm (not hot) water, as this can aggravate your skin. These directions are for a standard-sized tub filled to the overflow drainage holes. 
• Only soak from the neck down or the affected areas. Ask your primary care doctor or dermatologist how long you should soak; a 5- or 10-minute soak is usually recommended. 
• When you are done, rinse your skin with lukewarm water but do not use soap. Gently dry your skin. 
• If your eczema requires medication, apply it immediately after the bath, then apply your moisturizer.
• Do not take more than three bleach baths per week, or as directed by your doctor.

Can You Prevent or Cure Eczema?

While there is no known cure for eczema, the control of stress, nervousness, anxiety, and depression can be beneficial in treating and helping to avoid an eczema flare-up in some cases.

Studies have shown that children who are breast-fed are less likely to get eczema, as well as children whose mother's did not ingest cow's milk while breast-feeding.

If eczema runs in a baby’s family, using moisturizing creams or ointments on infants may help to delay eczema symptom onset, but it is not known if this will prevent long-term eczema. Check with your pediatrician before using any medication for your newborn.

To lessen the effects from eczema:

• avoid harsh soaps
• moisturize regularly and within 10 minutes of taking your bath; if you use prescription medications, apply these first and wait 10 minutes
• identify and avoid known eczema triggers
• use lukewarm water instead of hot water in the bath or shower
• limits baths and showers to 15 minutes or less
• dry off gently after your baths.

Contact Your Doctor If:

Call and make an appointment with your healthcare provider if your eczema does not respond to OTC moisturizers or avoidance of known allergens, your treatment is ineffective, you have signs of infection (such as fever, redness, pus, or pain), or your symptoms worsen.