Eczema

Eczema is a chronic inflammatory condition of the skin that can occur at any age but is most common in young children and adolescents.  It occurs when cells from the immune system become overactive in the skin which then leads to a local inflammatory response.  This inflammatory response causes the skin to feel itchy and irritated.  The itching becomes so overwhelming that it starts the process of chronic skin scratching thus leading to rough, raised and discolored areas.  Because of this internal process, eczema is often described as “the itch that rashes.”

While no one knows the exact cause of eczema we do know that genetic, immune, and environmental factors contribute to the development of eczema.  Another component of eczema involves molecules called ceramides.

When you’re looking at the skin under a microscope it resembles a brick wall, where the keratinocytes (skin cells) are the bricks and they are held together by a substance containing ceramides which represent the mortar. Ceramides are responsible for holding moisture in the skin and maintaining a strong barrier from the outside world.  Patients with eczema don’t make enough ceramides or their ceramides don’t function properly thus their skin does not retain moisture effectively.

When the skin barrier is not intact this gives the opportunity for outside pathogens and irritants to get inside and cause an inflammatory response.

Eczema presents as itchy discolored (either pink/red in light skin or purple/brown in darker skin) patches most commonly in the creases of the elbows, behind the knees and neck.  Overtime, if the affected areas go untreated, continued itch can cause the skin to turn thick and bumpy.  Abnormally dry skin, a low threshold of responsiveness to irritants and itching are important features of eczema. Essentially, it’s the chronic scratching that creates most of the characteristics patterns of the skin findings.

Eczema affects nearly 28 million Americans of all ages. It affects up to 25% of children and 2 to 3% of adults. It’s estimated that 60% of people with this condition develop it in the first year of life, and 90% develop it before the age of five. Although rare, eczema can also begin during puberty or later in life.  Eczema affects males and females equally and is more common in people who have a personal or family history of asthma, environmental allergies and/or food allergies.

While there is no cure for eczema, most cases can be controlled with proper treatment.  Effective treatment often requires a multifaceted approach. Treatment for eczema includes four steps:

1. moisturization and gentle skin care
2. topical medication for flares and prevention of flares
3. treatment of itch
4. control of infection.

Skincare

People with eczema should avoid long hot baths/showers, instead bathing should be limited to 5-10 minutes using warm water.  Your skin should be patted dry with a towel leaving some residual moisture, and then a rich moisturizer generously applied.  It’s important to make sure the moisturizer you’re using has ceramides as an ingredient.

Topical Steroids

When applied to the skin, corticosteroids work to decrease inflammation. They are safe and effective when used correctly and come in various strengths /formulations.  It’s important to only use them as directed by your dermatologist since overuse can cause side effects such as atrophy (thinning of the skin), acne in the areas it was overapplied or the skin can get addicted to the steroid cream.

Oral medications

Sometimes topical steroids aren’t enough so oral medications (antihistamines, prednisone, or other non-steroidal immunomodulators) are necessary to get an acute flare under control.  These medications are safe when taken for a short interval and are prescribed under the guidance of your doctor.

Several studies have shown atopic dermatitis to be more common in individuals with skin of color compared to Caucasians. There is  no data that suggests there are any differences in the medications used to treat patients with skin of color. However, there are some nuances to consider when addressing moisturization.  Data suggests that African-American children have a greater trans-epidermal water loss (decreased ability to hold onto moisture in the skin) and lower pH in their skin (lower pH increases risk for over colonizing bacteria on the skin).   This puts patients of color at an increased risk of developing either post inflammatory hyperpigmentation (dark spot in the affected area) or post inflammatory hypopigmentation (light/white spot in the affected area) after a flare has resolved.

While most eczema patients do not have food allergies, food allergens can exacerbate skin rashes in at least a subset of patients with eczema particularly infants and young children. Eggs, milk, peanuts, soybeans, tree nuts, fish, and wheat are the most common allergens that impact eczema.