ATOPIC DERMATITIS
Eczema
is only a descriptive term to describe the appearance of a rash. It is not a
diagnosis per se. The following information is designed to help clarify if the
"eczema" you are experiencing is atopic dermatitis. Doctors use very
specific criteria to confirm that your eczema is not due to other causes like a
fungal infection, irritation due to a chemical, etc.
Diagnostic criteria for atopic dermatitis (proposed by Hanafin
and Lobitz) include itching, eczema appearance and long lasting. It must also
have past or family history of atopy, skin test reactivity, white
dermatographism and/or delayed blanch to cholinergic agents, a particular type
of cataracts (anterior subcapsular). Confirming features include
xerosis/hyperlinear palms, white patches on cheeks (pityriasis alba), rough
bumpy skin on back of arms (keratosispilaris), dark circles under the eyes
(infraorbital congestion)darkening an extra crease under the eye called a
Dennie-Morgan fold, elevated total blood IgE level, a deformity of the cornea
called keratoconus, a tendency toward nonspecific hand dermatitis , and a
tendency toward repeated cutaneous infections.
Some
other causes of eczema include:
- Seborrheic
dermatitis
- Contact
dermatitis
- Nummular
dermatitis
- Scabies
- Psoriasis
(guttate form in children often associated with acute streptococcal
infection
- Immunodeficiency
states
- Histiocytosis X
(infantile form is called Letterer-Siwe disease and is characterized by
scaly waxy eruption of the scalp, nape, underarms (axilla), and groin.
Resembles seborrheic dermatitis but usually displays purpura and may have
signs of hepatosplenomegaly, lymphadenopathy, and weight loss. Skin biopsy
shows atypical histiocytes.)
- Acrodermatitis
enteropathica (erosive weeping patches about the mouth, perineum, and
acral areas. Always with diarrhea and failure to thrive. Low serum zinc
confirms.)
Complications of Atopic Dermatitis include secondary
infections with Streptococci, Staphylococci, dermatophytes, and viruses.
Impaired delayed hypersensitivity may be the cause of increased incidence of
warts and molluscum. Life threatening HSV (eczema herpeticum) or vaccinia
(eczema vaccinatum) may occur. Contact dermatitis occurs more commonly. The
need and complications associated with corticosteroids. Anterior subcapsular
cataracts
Home
management of acute flares: wet, cool dressings soaked with aluminum
acetate (Burrow's solution, Domeboro's ) and normal saline or tap water for
oozing, crusted, and exudative lesions. Apply 20- 30" every 4-6 hours.
Evaporative action causes vasoconstriction, reduces itching and inflammation.
Tepid water baths with oatmeal (plain or oilated Aveeno), starch, tar (LCD,
Zetar, Balnetar), or bath oil (added after patient immersed for 10-20" to
allow hydration of keratin layers) also reduces itching and inflammation. These
can be used in addition to wet dressings or as a substitute. Between dressings
and/or baths, small amounts of topical corticosteroids should be applied to
affected areas. Fluorinated steroids should not be used in the face or groin
due to their potential for atrophy and visible spider-like veins
(telangiectasias). Use antihistamines to allow you to relax and to reduce
itching.
SKIN CARE FOR PATIENTS WITH ECZEMA
BATHING INSTRUCTIONS: Bathing is better than showering, and
bathing at is best. Soap should not be used in the tub; wash armpits and
groin with mild cleansers (Dove, Aquanil, Aveeno, etc.) with a moist white
cotton diaper at the sink. Avoid areas that are active. Remove all cleanser
with a separate moist diaper before entering the bathtub.
Bathe
in lukewarm (tepid) water for 10-15 minutes every other day. Try to remain
immersed under water as much as possible. Do not use any additives in the
water.
Immediately
upon getting out of the tub, apply moisturizing lotions while your skin is
still damp. Pat dry the excess water; rubbing will not only remove the
moisturizing cream but may irritate your skin. Use an all cotton Turkish
towel that has been washed in mild soap (see below).
SCALP CARE: If the scalp is involved, Sebulex, Ionil,
Fostex, or Zincon shampoo should be used for 5 - 10 minutes before rinsing
thoroughly. If possible, shampooing should be performed over the sink rather
than in the shower.
GENERAL MEASURES: Reducing irritation, sweating, sweat gland
blockage, and itching are important. Loose fitting 100% cotton is best.
Avoid all wool, mohair, and silk. Wash all of your clothes, sheets, blankets,
towels, etc. with a mild soap (We used to recommend Dreft and Ivory Flakes but Ivory
Snow ceased to be a soap flake product ~10
years ago and is a detergent just like all the others. Many of the
medical professionals making recommendations do not know this. Dreft is
also not a soap flake, it is a detergent (in fact, I think the first one
invented). It is not a very powerful
detergent, which is why it is less irritating than many on the market
today, but it is more problematic than true soap flakes for infants
with eczema or the potential for eczema. There are companies that
still make old-fashioned soap flakes.
Thanks to A.J. Lumsdaine for this information) and be sure to rinse thoroughly.
Fabric softeners, bleach, starch, and
strong detergents should be avoided. Wash
all new clothes before wearing for the first time.
Try
to keep the temperature of the home and work steady, especially in the bedroom.
Temperature changes and overheating may aggravate your eczema by increasing
sweating, dryness, and itching. Increasing the humidity by adding a
humidification unit to your central heating system or using a portable
humidifier during dry periods (such as the winter when the heating system dries
the air in your home) may be beneficial for you. It is very important, however,
to keep your humidifier clean and free of mold.
Emotional
stress and fatigue often seem to flare eczema. Stability and harmony at home,
work, or school can help tremendously.
Because
patients with eczema are susceptible to a particular type of skin bacteria
(Staph. aureus), keeping fingernails trimmed and clean reduces the chance of
infecting your eczema.
FOODS and DIET: While the role of food allergy in eczema
remains controversial, there is increasing evidence that avoiding certain foods
during early infancy may reduce the risk of developing allergies, eczema, and
allergic asthma. Since breast milk passes many of the protein allergens eaten
by the mother, dietary restriction during lactation may be worth considering.
The foods most commonly implicated include eggs, cow's milk, wheat, chocolate,
corn, nuts, fish, and citrus fruits. Deciding which foods to avoid requires
trial and observation.
Once
eczema has developed, the relationship of food to causing or exacerbating
eczema is less clear. Egg whites are often implicated as an important
factor in eczema, even if the skin test did not show a true
"allergy." Strawberries, foods with a high nitrate content such as
potato chips and other highly seasoned foods, crawfish, lobster, alcoholic
beverages, certain medications (codeine, Demerol, hydrocodone, barbiturates,
etc.) release factors (histamine) which may aggravate eczema. Other foods
contain factors (histamine, tyramine) which may aggravate itching and eczema.
These include tomatoes, citrus fruits, spinach, soybean proteins, chocolate.
Complete avoidance of all these foods for two to four weeks
should be considered. Keep a diary to determine what changes have occurred, if
any. If any change is noted, then one particular food can be added back
into the diet every two weeks. Continue your diary. If the eczema gets worse (itching,
redness, or size of eczema), stop that particular food and wait an additional
week or two before trying a different food.
SPECIFIC MEDICATIONS: Eczema is often called the itch that
rashes. Thus, one of our goals is to reduce itching with an antihistamine.
Since most people itch especially at night and many antihistamines cause
drowsiness, we recommended an increased dose at night.
As
mentioned above, patients with eczema are especially susceptible to skin
infection with bacteria (Staph. aureus) and certain viruses (Herpes, molluscum,
etc.) and fungi. During a flare of eczema, an antibiotic ointment or pill may
be recommended. If you have a flare and a fever, call the doctor for further
instructions.
The
inflammation seen in eczema may require a topical steroid cream or ointment.
These medications should be used sparingly but frequently. Caking
the medication on the affected area is less effective than gently rubbing it
into the eczema. When an ointment is prescribed, it is usually for especially
difficult, dry, or scaly areas. Ointments should not be used on the face or
groin, or areas that appear moist or weepy.
Occasionally
a short course of systemic steroids (prednisone, etc.) are required to
control a severe exacerbation. While the effects are usually dramatic, long
term use of systemic steroids is to be avoided because of serious and often
irreversible side effects.
THE NATURAL COURSE OF ECZEMA: When eczema appears
within the first year of life (the infantile form), about 2/3 clear
spontaneously by 3 - 5 years of age. If the eczema appears in an older child,
many still recover completely by the age of 10. Unfortunately 1 in 2 develops hay
fever (allergic rhinitis) and up to 1 in 3 develops bronchial asthma.
COMPLICATIONS: Infections of the skin are a frequent
complication and must be treated with either a prescription antibiotic or an
effective anti-microbial. Because of an increased susceptibility to Herpes, you
should stay clear of people with active Herpes, cold sores, etc. or consider
using nutritional support that reduces Herpes replication.
NON-DRUG MANAGEMENT OF ECZEMA is a slow process
that requires an individualized and comprehensive approach. The use of specific essential fatty acids,
bowel flora optimization, dietary restrictions, nutritional support,
Traditional Chinese medicine and homeopathic remedies are often recommended.
