Occurrence of Atopic Eczema

Atopic eczema, the most common form of eczema, affects an estimated 15 million people (Dermatology Times, October 1998). It manifests itself as an inflammation of the skin, which tends to flare-up from time to time, usually starting in early childhood. Typical skin symptoms include dryness, thickening, excoriation, and even scarring (Hall 79).There is no 'cure', but treatment will usually control or ease symptoms. The predisposition for atopic eczema is an inherited condition that is usually triggered by an allergic reaction. This chronic condition is not contagious and often begins in infancy as a rash on the scalp, face, or upper extremities of the baby. Atopic eczema is most commonly located in areas where the body bends or experiences contact thus creating friction that can cause eczema.

The word 'atopic' describes people with certain 'allergic' tendencies. However, atopic eczema is not just a simple allergic condition. People with atopic eczema have an increased chance of developing other 'atopic' conditions such as asthma and hay fever.

Atopic eczema affects each person differently, both in terms of onset and severity of symptoms. In infants, atopic eczema typically begins around 6 to 12 weeks of age. It may first appear around the cheeks and chin as a patchy facial rash, sometimes progressing to red, scaling, oozing skin, which can become infected. Once the infant becomes more mobile and begins crawling, exposed areas such as the knees and elbows may also be affected. An infant with atopic eczema may be restless and irritable because of the itching and discomfort. Many infants improve by 18 months of age, although they remain at greater than normal risk for dry skin or hand eczema later in life.

In childhood, the rash tends to occur behind the knees and inside the elbows, on the sides of the neck, and on the wrists, ankles, and hands. Often, the rash begins with papules that become hard and scaly when scratched. The skin around the lips may be inflamed, and constant licking of the area may lead to small, painful cracks. Severe cases of atopic eczema may affect growth, and the child may be shorter than average.

Atopic eczema most often affects infants and young children, but it can continue into adulthood or first show up later in life. In most cases, there are periods of time when the disease is worse, called exacerbations or flares, which are followed by periods when the skin improves or clears up entirely, called remissions. Many children with atopic eczema enter into a permanent remission of the disease when they get older, although their skin often remains dry and easily irritated. Environmental factors can activate symptoms of atopic eczema at any time in the lives of individuals who have inherited this disease trait.

The disease may go into remission. The length of a remission varies, and it may last months or even years. In some children, the disease gets better for a long time only to come back at the onset of puberty when hormones, stress, and the use of irritating skin care products or cosmetics may cause the condition to flare.

Although a number of people who developed atopic dermatitis as children also experience symptoms as adults, it is unusual (but possible) for the disease to show up first in adulthood. The pattern in adults is similar to that seen in children; that is, the disease may be widespread or limited. In some adults, only the hands or feet may be affected and become dry, itchy, red, and cracked. Sleep patterns and work performance may be affected, and long-term use of medications to treat the condition may cause complications. Adults with atopic dermatitis also have a predisposition toward irritant contact dermatitis, especially if they are in occupations involving frequent hand wetting, hand washing, or exposure to chemicals. Some people develop a rash around their nipples. These localized symptoms are difficult to treat, and people often do not tell their doctor because of modesty or embarrassment. Adults may also develop cataracts that are difficult to detect because they cause no symptoms. Therefore, the doctor may recommend regular eye exams.

Atopic eczema affects males and females equally and accounts for 10 to 20% of all referrals to dermatologists. It is estimated that 65 percent of patients develop symptoms in the first year of life, and 90 percent develop symptoms before the age of 5. Onset after age 30 is less common and often occurs after exposure of the skin to harsh conditions. People who live in urban areas and in climates with low humidity seem to be at an increased risk for developing atopic dermatitis.

About 10% of all infants and young children experience symptoms of the disease. Roughly 60 percent of these infants continue to have one or more symptoms of atopic dermatitis even after they reach adulthood. This means that more than 15 million people in the United States have symptoms of the disease.

It is estimated that one in three people are affected by atopic eczema. However, the development of atopic eczema in a person who has a predisposition to it is likely to be greatly influenced by the environment.

Causes of Atopic Eczema

It is thought that people with atopic eczema are sensitive to certain allergens in the environment, which are harmless to others. In atopic eczema, there is an excessive reaction by the immune system producing inflamed, irritated and sore skin.

Atopic eczema occurs when an individual inherits the capacity to produce excessive antibodies called immunoglobulin E (IgE). These antibodies are particularly aggressive and attack foreign substances that enter the body. Eczema, asthma and allergic rhinitis are the most common atopic conditions. These antibodies exist to defend the body against attack. In atopic eczema the large number of antibodies are encountering alien substances or allergens and reacting to them in the form of inflammation and itchiness. These allergens can include dust, pollen, chemicals, food, or drink.

The role of allergies to dust mites, pets, and food in atopic eczema is controversial. In a high proportion of sufferers, the application of a dust mite allergen to the skin will worsen their condition. The condition of a child may improve in a hospital where mite counts are low. It is thought that environmental exposure and lifestyle may be as much a factor in the development of childhood eczema as genetic factors. With atopic eczema, it is believed that a predisposition to the condition is inherited and then triggered by allergens.

In the industrialized world, allergies are a growing problem. The changes in society which may be contributing to the incidence of allergies include: the levels of nitrogen oxides (from diesel engines), ozone in the air, central heating, double insulation in homes, soft furnishings, fumes from gas cookers, sprays, and cigarettes.

The role of food allergy is controversial. The most reliable means of establishing a food allergy is to keep a food diary and then to eliminate the suspected item from the diet. If the eczema improves, the suspect food can be re-introduced. If the condition worsens again, this provides reasonable proof of the cause.

In the past, it was thought that atopic eczema was caused by an emotional disorder. However, we now know that while emotional factors such as stress can exacerbate the condition, but they do not cause it.

Atopic eczema appears to result from a combination of hereditary and environmental factors. Research indicates that the disease is associated with other so-called atopic disorders such as hay fever and asthma, which many people with atopic eczema also have. In addition, many children who outgrow the symptoms of atopic eczema go on to develop hay fever or asthma. Although one disorder does not cause another, they may be related, thereby giving researchers clues to understanding atopic eczema.

Trigger factors for atopic eczema may include soap, harsh chemicals, heat and humidity, stress, certain foods (most common offenders include eggs, milk, wheat, soy protein, and peanut). Many of these ingredients can turn up in unusual places, such as all-natural soaps, makeup, creams, or lotions. Inhalant allergens such as house dust mites, pets, pollen, and cut grass are also triggers that can cause eczema. Atopic eczema is normally associated with a family history of asthma or allergic rhinitis accompanied by chronic or recurrent dry, extremely itchy, inflamed lesions.

Symptoms of Atopic Eczema

One of the most common symptoms of atopic eczema is itchiness, which can be almost unbearable. Other symptoms include overall dryness of the skin, redness, and inflammation. Constant scratching can also cause the skin to split, leaving it prone to infection. In infected eczema, the skin may crack and weep creating a condition known as wet eczema.

One of the more pronounced features of atopic eczema is very dry skin that is sensitive. When this dryness becomes extreme, cracks appear in the skin that can be extremely sore. For example, when this occurs on the backs of the knees it is very difficult to walk. If the skin cracks at the side of the mouth, it is difficult to talk. It is therefore understandable that people with the condition can become irritable and stressed because of the discomfort they are enduring. The importance of routine skin care should not be underestimated.

Atopic eczema may affect the skin around the eyes, the eyelids, and the eyebrows and lashes. Scratching and rubbing the eye area can cause the skin to change in appearance. Some people with atopic eczema develop an extra fold of skin under their eyes, called an atopic pleat or Dennie-Morgan fold. Other people may have hyper-pigmented eyelids, meaning that the skin on their eyelids darkens from the inflammation or hay fever (a.k.a. allergic shiners). Patchy hair loss in the eyebrows and eyelashes can also result from scratching or rubbing.

The most common symptoms of atopic eczema are dry, itchy skin, cracks behind the ears, and rashes on the cheeks, arms, and legs. The itchy feeling is an important factor in atopic eczema, because scratching and rubbing in response to itching worsens the skin inflammation that is characteristic of this disease. People with atopic eczema seem to be more sensitive to itching and feel the need to scratch longer in response. They develop what is referred to as the "itch-scratch" cycle. The extreme itchiness of the skin causes the person to scratch, which in turn worsens the itch, and so on. Itching is particularly a problem during sleep, when conscious control of scratching decreases and the absence of other outside stimuli makes the itchiness more noticeable.

As a rule, inflamed areas of skin tend to 'flare-up' from time to time, and then tend to settle down. The severity and duration of 'flare-ups' varies from person to person, and from time to time in the same person.

Currently, there is no single test that says unequivocally "this is atopic eczema" and there is no single symptom or feature that can be used to identify the disease. Each patient may experience a unique combination of symptoms, and the symptoms and severity of the disease may vary over time. The diagnosis of atopic eczema is based on the individual's symptoms. Therefore, it is important to rule out other diseases and conditions which might cause skin irritation. In some cases, the family doctor or pediatrician may refer the patient to a dermatologist or allergist for further evaluation.

Some people with the atopic eczema develop red, scaling skin in affected areas. Others develop thick and leathery skin as a result of constant scratching and rubbing. This condition is called lichenification. Still others develop papules, or small raised bumps on their skin. When the papules are scratched, they may open (excoriations) and become crusty and infected. It is interesting to note that these conditions can also be found in people without atopic eczema or with other types of skin disorders.

Differences in the skin of people with atopic eczema may contribute to the symptoms of the disease. The epidermis, which is the outermost layer of skin, is divided into two parts: the inner part, which contains moist, living cells; and the outer part, which consists of dry, flattened, dead cells. Under normal conditions, the outer layer of skin acts as a barrier, keeping the rest of the skin from drying out and protecting other layers of skin from damage caused by irritants and infections. When this barrier is damaged or is naturally thin, irritants act more intensely on the skin.

The skin of a person with atopic dermatitis loses too much moisture from the epidermal layer. This allows the skin to become very dry, which reduces its protective abilities. In addition, the skin is very susceptible to recurring disorders, such as staphylococcal and streptococcal bacterial skin infections, warts, herpes simplex, and molluscum contagiosum (which is caused by a virus).

Skin Features of Atopic Eczema

  • Lichenification: thick, leathery skin resulting from constant scratching and rubbing
  • Papules: small raised bumps that may open when scratched, becoming crusty and infected
  • Ichthyosis: dry, rectangular scales on the skin
  • Keratosis pilaris: small, rough bumps, generally on the face, upper arms, and thighs
  • Hyperlinear palms: increased number of skin creases on the palms
  • Urticaria: hives (red, raised bumps), often after exposure to an allergen, at the beginning of flares, or after exercise or a hot bath
  • Cheilitis: inflammation of the skin on and around the lips
  • Atopic pleat (Dennie-Morgan fold): an extra fold of skin that develops under the eye
  • Hyperpigmented eyelids: eyelids that have become darker in color from inflammation or hay fever
  • Neurodermatitis is a chronic eruption of the skin that results from continuous scratching

In mild cases, a flare up may cause just one or two small, mild patches of inflammation. These often occur behind the knees or in front of elbows or wrists. Flare-ups may occur only occasionally. Characteristics of the mild stages of atopic eczema include:

  • Early age of onset
  • Dry, rough skin
  • High levels of immunoglobulin E (IgE), an antibody, in the blood
  • Ichthyosis
  • Hyperlinear palms
  • Keratosis pilaris
  • Hand or foot dermatitis
  • Cheilitis
  • Nipple eczema
  • Susceptibility to skin infection
  • Positive allergy skin tests

In severe cases the flare-ups can last several weeks or more, and cover many areas of skin. This can cause great distress. Symptoms of severe atopic eczema include:

  • Intense itching
  • Rash in locations typical of the disease
  • Chronic or repeatedly occurring symptoms
  • Personal or family history of atopic disorders (eczema, hay fever, asthma)

Many people with atopic eczema are somewhere in between these extremes. Emotional factors and some infections can also influence atopic eczema.

Controlling Atopic Eczema

Exposure to certain substances (such as chlorine, mineral oil, or solvents) or to irritants (such as dust or sand) may also aggravate the condition. Cigarette smoke may irritate the eyelids. Because irritants vary from one person to another, each person has to determine for him or herself what substances or circumstances cause the disease to flare.

Common irritants include:

  • Wool or synthetic fibers
  • Soaps and detergents
  • Some perfumes and cosmetics
  • Substances such as chlorine, mineral oil, or solvents
  • Dust or sand
  • Cigarette smoke

Allergens are substances from foods, plants, or animals that provoke an overreaction of the immune system and cause inflammation (in this case, the skin). Inflammation can occur even when the person is exposed to small amounts of the allergen for a limited time. Some examples of allergens are pollen and dog or cat dander (tiny particles from the animal's skin or hair). When people with atopic eczema come into contact with an irritant or allergen to which they are sensitive, inflammation-producing cells permeate the skin from elsewhere in the body. These cells release chemicals that cause itching and redness. As the person scratches and rubs the skin in response, further damage occurs.

Certain foods act as allergens and may trigger atopic eczema or exacerbate it (cause it to become worse). Food allergens clearly play a role in a number of cases of atopic eczema, primarily in infants and children. An allergic reaction to food can cause skin inflammation (generally hives), gastrointestinal symptoms (vomiting, diarrhea), upper respiratory tract symptoms (congestion, sneezing), and wheezing. The most common allergy-causing (allergenic) foods are eggs, peanuts, milk, fish, soy products, and wheat. Although the data remains inconclusive, some studies suggest that mothers of children with a family history of atopic diseases should avoid eating commonly allergenic foods themselves during late pregnancy and (if breastfeeding) while they are breastfeeding the baby. Although not all researchers agree, most experts think that breastfeeding the infant for at least 4 months may have a protective effect for the child.

If a food allergy is suspected, it may be helpful to keep a careful diary of everything the patient eats, noting any reactions. Identifying the food allergen may be difficult if the patient is also being exposed to other allergens, and may require supervision by an allergist. One helpful way to explore the possibility of a food allergy is to eliminate the suspected food and then, if improvement is noticed, reintroduce it into the diet under carefully controlled conditions. A two-week trial is usually sufficient for each food. If the food being tested causes no symptoms after two weeks, a different food can be tested in like manner afterwards. Likewise, if the elimination of a food does not result in improvement after 2 weeks, other foods may be eliminated in turn.

Some airborne allergens called aeroallergens may also play a role in atopic eczema. Common aeroallergens include dust mites, pollens, molds, and dander from animal hair or skin. These aeroallergens, particularly the house dust mite, may worsen the symptoms of atopic dermatitis in some people. Although some researchers think that aeroallergens are an important contributing factor to atopic eczema, others believe that they are insignificant. Scientists also don't understand the way in which aeroallergens affect the skin; whether the aeroallergen affects the person internally after being inhaled, or whether the aeroallergen actually penetrates the patient's skin.

If an aeroallergen is suspected of contributing to a patient's symptoms, it may be beneficial to reduce exposure to the offending agents. For example, encasing mattresses and pillows in special dust-proof covers, frequently washing bedding in hot water, and removing carpeting can limit the presence of the house dust mite. However, there is no way to completely rid the environment of aeroallergens.

In addition to irritants and allergens, other factors, such as emotional issues, temperature, climate, and skin infections can affect atopic eczema. Although the disease itself is not caused by emotional factors or personality, it can be exacerbated by stress, anger, and frustration. Interpersonal problems or major life changes, such as divorce, job changes, or the death of a loved one, can also make the disease worse. Often, emotional stress seems to prompt a flare of the disease.

Bathing without proper moisturizing afterward is another common factor that can trigger a flare of atopic eczema. The low humidity of winter or the dry year-round climate of some geographic areas can intensify the disease, as can overheated indoor areas and long or hot baths and showers. Alternately sweating and chilling can induce an attack in some people. Bacterial infections can also prompt or increase the severity of atopic eczema. If a patient experiences a sudden onset of illness, the doctor may check for a viral infection (such as herpes simplex) or fungal infection (such as ringworm or athlete's foot).

Treatments may include emollients such as jojoba oil to maintain skin hydration and to reduce inflammation. An emollient is an agent that softens and soothes the skin to make it softer. They are usually produced from a combination of water, oil, fat, and wax. Emollients are an essential element in the successful treatment of the dry skin found in eczema, and are safe and effective.

There are three main goals in treating atopic eczema: healing the skin and keeping it healthy, preventing flares, and treating symptoms when they occur. Much of caring for the skin involves developing skin care routines, identifying exacerbating factors, and avoiding circumstances that stimulate the skin's immune system and the itch-scratch cycle. It is important for the patient and family members to note any changes in skin condition in response to treatment, and to be persistent in identifying the most effective treatment strategy.

Healing the skin and keeping it healthy are of primary importance both in preventing further damage and enhancing the patient's quality of life. Developing and following a daily skin care routine is critical to preventing recurrent episodes of symptoms. Key factors are proper bathing and the application of lubricants, such as creams or ointments, within 3 minutes of bathing. People with atopic eczema should avoid hot or long (more than 10 to 15 minutes) baths and showers. A lukewarm bath helps to cleanse and moisturize the skin without drying it excessively. It may be wise to limit the use of skin cleansers to a mild bar soap or non-soap cleanser because soaps can dry the skin. Bath oils are not usually helpful.

Another key to protecting and restoring the skin is taking steps to avoid repeated skin infections. Although it may not be possible to avoid infections altogether, the effects of an infection may be minimized if they are identified and treated early. Patients and their families should learn to recognize the signs of skin infections, including tiny pustules (pus-filled bumps) on the arms and legs, appearance of oozing areas, or crusty yellow blisters.

Some treatments reduce specific symptoms of the disease. Antibiotics to treat skin infections may be applied directly to the skin in an ointment, but are usually more effective when taken by mouth in pill form. Certain antihistamines that cause drowsiness can reduce nighttime scratching and allow more restful sleep when taken at bedtime. This effect can be particularly helpful for patients whose nighttime scratching aggravates the disease. If viral or fungal infections are present, the doctor may also prescribe medications to treat those infections.

In rare cases, when no other treatments have been successful, the patient may have to be hospitalized. A five to seven day hospital stay allows intensive skin care treatment and reduces the patient's exposure to irritants, allergens, and the stresses of day-to-day life. Under these conditions, the symptoms usually clear quickly if environmental factors play a role or if the patient is not able to carry out an adequate skin care program at home.

Adults with atopic dermatitis can enhance their quality of life by caring regularly for their skin and being mindful of other effects of the disease and how to treat them. Adults should develop a skin care regimen as part of their daily routine, which can be adapted as circumstances and skin conditions change.

Stress management and relaxation techniques may help decrease the likelihood of flares due to emotional stress. Developing a network of support that includes family, friends, health professionals, and support groups or organizations can be beneficial. Chronic anxiety and depression may be relieved by short-term psychological therapy.

Recognizing the situations when scratching is most likely to occur may also help. For example, many patients find that they scratch more when they are idle. Structured activity that keeps their hands occupied may prevent further damage to the skin. Occupational counseling also may be helpful to identify or change career goals if a job involves contact with irritants or involves frequent hand washing, such as kitchen work or auto mechanics.

Although symptoms of atopic eczema can be very difficult and uncomfortable, the disease can be successfully managed. People with atopic eczema, as well as their families, can lead healthy, normal lives by:

  • Avoiding soaps, bubble baths, etc, when bathing. These can dry out the skin and make it more prone to irritation. Instead, use a soap substitute plus a bath/shower emollient.
  • Wearing cotton clothes next to the skin rather than irritating fabrics such as wool. However, it is probably the smoothness of the material rather than the type of the material, which helps. Some smooth man-made fabrics are probably just as good as cotton.
  • Avoiding getting too hot or too cold as extremes of temperature can irritate the skin.
  • Rinsing clothes well after washing them with detergent. Some 'biological' detergents are said by some people to be irritating. But there is little proof that commonly used detergents, which are used in the normal way make eczema worse.
  • Reducing the number of dust mites in their homes by regularly cleaning and vacuuming with particular attention to bedrooms, mattress, and bedclothes.
  • Applying Eczema-Ltd III patented topical skin conditioner disks to the affected areas.