Eczema atopic

Eczema is a chronic skin condition that causes the skin to become itchy, reddened, dry and cracked.

Atopic eczema is the most common form of eczema, and mainly affects children. The exact cause of atopic eczema is unknown, but it often occurs in people who are prone to allergies ('atopic' means sensitivity to allergens).

Approximately three in 10 people who visit their GP with a skin problem are diagnosed with atopic eczema. The number of people who are diagnosed with it has increased in recent years. Males and females are affected equally, as are people from different ethnic backgrounds.

About eight in 10 atopic eczema cases occur before a child reaches five years of age. Many children develop it before their first birthday.

How will atopic eczema affect me or my child?

Atopic eczema can vary in severity. Some people are only mildly affected and have small areas of dry skin, which are occasionally itchy. Others may experience more severe symptoms, such as cracked, sore and bleeding skin.

For most children with atopic eczema, it clears up or significantly improves as they get older. In approximately 53% of young children with atopic eczema, it clears up by the time they reach 11, and in 65% of cases it clears up by the age of 16.

People with severe eczema often find that it has a significant impact on their daily lives. It may be difficult to deal with, both physically and psychologically. However, there are many different treatments that can help control symptoms and manage the eczema.

For information on the other types of eczema, see Useful links.

Symptoms of atopic eczema

The symptoms of atopic eczema may always be present, but during a flare-up they will worsen and you or your child may need more intense treatment.

Atopic eczema can cause your skin to become:

• dry,
• itchy,
• red,
• broken,
• thickened and
• cracked.

During a flare-up, your skin may be:

• extremely itchy, red, hot, dry and scaly,
• wet, weeping and swollen, and
• infected with bacteria (usually staphylococcus).

The symptoms of atopic eczema will vary according to how severely you or your child are affected by the condition.

People with mild atopic eczema will normally only experience small areas of dry skin, which are occasionally itchy. However, in more severe cases, atopic eczema can cause widespread dry skin, constant itching and oozing fluid. Scratching can disrupt your sleep and make your skin bleed. It can also make an itch worse and an itch-scratch cycle may develop, with regular scratching. In children, this can lead to sleepless nights and difficulty concentrating at school.

Causes of atopic eczema

Atopic eczema is an inherited condition, which means that you are born with it. It may be made worse by 'external' factors, such as pet fur and pollen, or 'internal' factors, such as stress and hormone levels.

Genetic factors

Research suggests that atopic eczema is primarily caused by a genetic problem. However, the exact genetic cause is not yet known.

If a child's parents have atopic eczema, there is a high probability that the child will also develop the condition. For example, studies have shown that 60% of children who have a parent with atopic eczema also have the condition. And, in cases where both parents have atopic eczema, 80% of children also have the condition.

Environmental factors

There are a number of environmental factors that can make atopic eczema worse.

Allergens are substances that can cause the body to react abnormally. This is known as an allergic reaction. Some of the most common allergens that can worsen atopic eczema include:

• house dust-mites,
• pet fur, and
• pollen.

Atopic eczema can also sometimes be aggravated by food allergens. Foods that typically cause allergic reactions include:

• cow's milk,
• eggs,
• nuts,
• soya, and
• wheat.

Approximately 10% of children with atopic eczema are affected by the food allergens listed above. It is relatively rare for food allergens to trigger atopic eczema in adults.

Hormonal changes

Many women find that their eczema is worse at certain times during their menstrual cycle. This is because hormonal changes in the body can affect the symptoms of atopic eczema.

Approximately 30% of women experience a flare-up of their eczema in the days before their period. Pregnancy can also have an adverse affect on those who have atopic eczema, with up to 50% of pregnant women finding that their eczema symptoms worsen during pregnancy.

Stress

Although it is known that stress is associated with atopic eczema, precisely how it affects the condition is not yet fully understood. Some people with eczema feel that their symptoms are worse when they are stressed. Others find that it is their symptoms that cause them to feel stressed.

Seasons

Most people with atopic eczema find that their symptoms improve during the summer months and get worse in the winter.

Exercise

After vigorous exercise, you may find that sweating makes your eczema symptoms worse. You should therefore try to keep cool when you are exercising by drinking plenty of fluids and taking regular breaks.

Treating eczema

Although there is no simple cure for atopic eczema, the symptoms during an eczema flare can usually be eased using a variety of treatments. Children with atopic eczema normally find that their symptoms naturally improve with time.

Self-care

There are a number of self-care treatments that you can use at home to help manage your or your child's eczema symptoms.

Avoid scratching

Although eczema is often itchy, scratching it will further aggravate the skin. If you scratch your skin, the risk of your eczema becoming infected with bacteria will be increased (see the 'complications' section).

However, there may be times when you or your child will not be able to help scratching your eczema. Keeping nails short will help to minimise any damage to the skin. If your baby has atopic eczema, anti-scratch mittens will help prevent them scratching their skin.

Avoid trigger factors

Your GP will work with you to try to establish what factors or foods trigger your or your child's eczema flares (see the 'diagnosis' section). If you are able to establish which factors trigger flares, you can try to avoid contact with them.

For example, if some man-made materials irritate your skin, avoid wearing synthetic fibres and stick to natural materials, such as cotton. Or, if heat aggravates your eczema, keep the rooms in your home cool. Also, avoid using any soaps or detergents that you think may affect the skin.

Although house dust mites have been shown to trigger eczema flares, it is not recommended that you try to eradicate dust mites from your home. The process is very time consuming and difficult to carry out effectively. Studies have also shown that dust mite avoidance techniques are rarely effective.

Diet

If you or your child have atopic eczema, you should not make any significant dietary changes without first consulting your GP. Some foods, such as milk, eggs and nuts, have been shown to trigger eczema symptoms. If you are breastfeeding a baby who has atopic eczema, you should also seek medical advice before making any changes to your regular diet.

Complementary therapies

Some people choose to use complementary therapies to treat atopic eczema, such as aromatherapy (using essential oils for a therapeutic effect).

Although some people find these therapies helpful, it is important to remember that there is often a lack of evidence to show that they are effective in treating conditions such as atopic eczema. Therefore, if you are thinking about using a complementary therapy, you should speak to your GP first, to ensure that the therapy is safe for you to use.

Emollients

Emollients are substances that help to soften and smooth your skin in order to keep it supple and moist. They are one of the most important forms of treatment for atopic eczema.

As atopic eczema can cause your skin to become dry and cracked, it is important to keep it moisturised to prevent it from becoming further irritated.

What emollients will be prescribed?

If you have recently been diagnosed with atopic eczema, and you or your child is receiving treatment for the first time, a number of different emollients may have to be tried before a suitable one is found.

Most people will need to be prescribed a number of different emollients for long-term use. For example, you may need to use one type of emollient on your face and hands and a different one for the rest of your body.

There are a number of different emollients that are designed for use on different skin types. For example, for very dry skin, ointments are often prescribed, and for skin that is less dry, creams and lotions are usually recommended.

If you have been using a particular emollient for some time, it may eventually become less effective, or it may start to irritate your skin. If this is the case, you should speak to your GP.

How should I use them?

Emollients should be applied by smoothing them into the skin in the same direction that the hair grows (see box). You should avoid rubbing emollients in, because doing so can irritate the skin.

After washing, make sure that you gently dry the skin. Apply the emollient as soon as the skin is dry. Do not share emollients with other people.

Creams and lotions tend to be more suitable for red, inflamed areas of skin. Ointments are more suitable for areas of dry skin that are not inflamed.

When should I use them?

Emollients should be used frequently, even when the skin appears to be clear. This should help to reduce the number of eczema flares that you or your child has. If the skin is very dry, emollients should be applied every two to three hours.

You may wish to consider keeping separate supplies of emollients at work or at school.

It is very important to keep using your emollients during a flare-up because this is when the skin needs the most moisture. During a flare-up, you should apply emollients very frequently and in generous amounts.

Emollient treatments should be used instead of soap. This is because most normal soaps irritate atopic eczema. Replacing soaps with emollients should help to reduce the risk of experiencing a flare-up. You can also get emollient bath and shower additives, which can help to prevent your skin from becoming aggravated.

Can they cause any side effects?

The most common side effect of using emollients is a rash. If you have atopic eczema, your skin is very sensitive and can sometimes react to certain ingredients within an emollient. If your or your child's skin reacts to the emollient, you should speak to your GP, who will be able to prescribe an alternative product.

It is important to be aware that some emollients contain paraffin and can be a fire hazard. As some emollient products are highly flammable, they should not be used near a naked flame.

Emollients that are added to your bath can also be easy to slip on. As long as you are aware of these hazards, you should be able to use emollients safely.

Topical corticosteroids

If your or your child's skin is red and inflamed from an atopic eczema flare, your GP may prescribe a topical corticosteroid (one that is applied directly to your skin) to help ease your symptoms. Corticosteroids work by quickly reducing inflammation.

You may be concerned about using medication that contains steroids. However, corticosteroids are not the same as anabolic steroids (which are sometimes used by bodybuilders to build muscle). When used correctly, corticosteroids are a safe and effective treatment for eczema.

The strength of corticosteroid that is prescribed will depend on the severity of your atopic eczema. Severe cases of atopic eczema will require a stronger corticosteroid than milder cases.

If your atopic eczema is moderate to severe, you may need to apply topical corticosteroids in between flare-ups, as well as during them.

If you need to use corticosteroids frequently, you should visit your GP regularly so they can check that the treatment is working effectively.

How should I use them?

When using corticosteroids, you should apply the treatment sparingly to the affected areas (see box). Always follow the directions on the patient information leaflet that comes with the corticosteroid, which will provide details about how much you should apply.

During an atopic eczema flare, you should not apply the corticosteroid more than twice a day. Most people will only have to apply it once a day. You should continue to apply the treatment for 48 hours after the flare-up has cleared up.

If you or your child are using corticosteroids on a long-term basis, you may be able to apply them less frequently. Your GP will advise you about how often you should be applying them.

Speak to your GP if you have been using a topical corticosteroid and your symptoms have not improved.

Alitretinoin

Alitretinoin (sold under the brand name Toctino) is a medication for severe, chronic hand eczema that has failed to respond to other treatments, such as topical corticosteroids.

Treatment with alitretinoin must be supervised by a dermatologist (a specialist in treating skin conditions).

Alitretinoin is a type of medication called retinoids. Retinoids help reduce the levels of irritation and itchiness associated with eczema.

Alitretinoin comes in tablet form and most people are recommended to take one tablet a day during a meal for 12-24 weeks.

Alitretinoin should never be taken during pregnancy because it can cause severe birth defects. You should also avoid taking alitretinoin when breastfeeding because the medication can enter your breast milk and harm your baby.

Due to the risk of birth defects, the use of alitretinoin is not recommended for women of child-bearing age.

If you are a woman of child-bearing age, you will only be prescribed alitretinoin if you agree to the following strict rules:

• you fully understand why you should not get pregnant and what you need to do to prevent it,
• you agree to use one, or preferably two, methods of contraception, including condoms, or a cap, plus spermicide, even if you are not currently sexually active,
• you agree to have pregnancy tests before and during treatment, and
• you sign a confirmation form stating that you are aware of the risks and what precautions you need to take.

Common side effects of alitretinoin include:

• headaches,
• inflammation of the eyes,
• muscle and joint pain,
• flushed (warm and red) skin,
• dry skin.

Uncommon side effects of alitretinoin include:

• hair loss.
• nose bleeds, and
• sight problems, such as blurred, or distorted, vision.

If you experience vision problems, you should stop treatment immediately and contact your dermatologist.

Antihistamines

Antihistamines are a type of medicine that work by stopping the effects of a substance in the blood, known as histamine. Your body often releases histamine when it comes into contact with an allergen. It can cause a wide range of symptoms, including sneezing, watery eyes and itching.

Antihistamines can either be sedating or non-sedating. Sedating anti-histamines can make people feel drowsy. They are normally prescribed during a flare to help ease itchiness at night, helping you or your child to get a good night's sleep. Sedating antihistamines are prescribed on a short-term basis, usually for a maximum of two weeks at a time.

Sedating antihistamines should usually be taken about one hour before going to bed. Drowsiness may persist the following day, so make sure you let your child's school know that they may not be as alert as normal. If you are taking sedating antihistamines, avoid driving the next day if you still feel drowsy.

Non-sedating antihistamines also help to ease itching, but will not make you feel drowsy. You can therefore use this type of medicine on a long-term basis.

Infected eczema

If you or your child's eczema has become infected with bacteria (see the 'complications' section), you will usually be prescribed antibiotic treatment.

If you have an extensive area of infected eczema, an oral antibiotic (taken by mouth) you will normally be prescribed. The antibiotic most commonly prescribed is flucloxacillin, which is usually taken for seven days. However, if you are allergic to penicillin, you will be prescribed a different antibiotic - either erythromycin or clarithomycin.

If you have a small amount of infected eczema, you will normally be prescribed a topical antibiotic. This means that the medicine is applied directly to the affected area of skin, in the form of an ointment or cream. They should not be used for longer than two weeks.

Reducing the risk of re-infection

Once your infection has cleared, your GP may have to prescribe new supplies of any topical medication or treatments that you use, such as emoillents or corticosteroids. This is in case your old ones are infected. Once you have received the new supplies, you should throw your old treatments away.

If there are areas of your eczema that are prone to infection, you may be prescribed a topical antiseptic. This type of treatment is also applied directly to your affected skin, and works by helping to kill bacteria. Commonly prescribed topical antiseptics include chlorhexidine and triclosan.

Referral

In some severe cases of atopic eczema, your GP may have to refer you for assessment and treatment by a dermatologist (a specialist in treating skin conditions). For example, your GP may refer you if you fail to respond to prescribed treatment, or if they are uncertain about what is causing your eczema.

Some of the treatments a dermatologist may be able to offer you include phototherapy, where your eczema is exposed to ultraviolet (UV) light, bandaging (where treatments such as medicated dressings or wet wraps are applied to your skin) and topical calcineurin inhibitors (a type of medicine that helps to reduce inflammation).

However, these types of treatments are not be suitable for everyone, and can only be carried out by experienced skin-care specialists.

Complications of atopic eczema

Infection

As atopic eczema can cause your skin to become dry and cracked, the risk of getting a skin infection is increased. If you scratch your eczema, the likelihood of it becoming infected is also increased.

Bacterial infections can cause more severe symptoms. The most common type of bacteria that infects atopic eczema is Staphylococcus aureus. If your skin becomes infected with S. aureus, it can make your eczema worse, with increased redness, oozing of fluid and crusting of the skin. Your skin will be unable to heal naturally from this type of infection.

Psychological effects

As well as affecting you physically, atopic eczema may also affect you psychologically.

Preschool children with atopic eczema are more likely to have behavioural problems than children who do not have the condition. They are also more likely to be more dependant on their parents compared with children who do not have the condition.

Bullying

School children may experience teasing or bullying if they have atopic eczema. Any kind of bullying can be very traumatic and difficult for a child to deal with. You may find that your child becomes quiet and withdrawn. Make sure you explain the situation to your child's teacher and encourage your child to tell you about how they are feeling.

Sleep disturbance

Research has suggested that approximately 60% of children with atopic eczema have sleep-related problems. During a flare of atopic eczema, it is thought that (on average) five nights sleep are affected.

A lack of sleep may affect your child's mood and behaviour. It may also make it more difficult for them to concentrate at school, which may lead to them falling behind with their work. Again, it is important to let your child's teacher know about their condition, so that they can take factors such as this into consideration.

During an eczema flare, your child may also need to take time away from school. This again may affect their ability to keep up with their studies.

Self-confidence

Atopic eczema can affect the self-confidence of both adults and children. Children may find it particularly difficult to deal with their condition, which may result in them having a poor self-image.

If your child is severely lacking in confidence, it may affect their ability to develop their social skills. Support and encouragement will help boost your child's self-confidence, and give them a more positive attitude with regard to their appearance.

Speak to your GP if you are concerned that your child's eczema is severely affecting their confidence.

Atopic eczema: treatment guidelines

It's important to know which sources you can rely on for more information on atopic eczema.

The National Institute for Health and Clinical Excellence (NICE) has produced healthcare guidelines on the treatment of atopic eczema.

This guidance outlines NICE’s main recommendations on how often topical steroids should be applied for this condition, and on treatment with tacrolimus and pimecrolimus (non-steroid creams and ointments).

• Download the NICE guidance on topical steroids (links to external site).
• Download the NICE guidance on tacrolimus and pimecrolimus (links to external site)