Dr. Yoram C. Padeh
Eczema, also known as atopic dermatitis (AD), is a complex skin condition which affects children more than adults and whose primary symptom is itching. It is the itching that leads to scratching after which most of the other symptoms such as skin redness, thickening, cracking, flaking, oozing, etc. follow. Doctors commonly refer to eczema as the “itch that rashes” as opposed to the “rash that itches” which is typical of most other skin rashes. The main cause of itchy skin in eczema is thought to be skin dryness. The reasons for skin dryness are only recently being understood and explained, and will be discussed further below.
So the sequence of events becomes the following: the skin becomes dry, which leads to itching, which leads to the skin rash, and so forth. That means if the skin can be prevented from drying out, the rest of the symptoms can be prevented, which is what research and experience has taught us. The top three treatments of eczema are: 1) moisturize, 2) moisturized, and 3) moisturize. The mistake often made is that people limit the moisturizing to once or twice a day, perhaps after a bath or shower. In moderate to severe cases of eczema, this is likely not nearly enough. In fact one should moisturize often and frequently enough to keep the skin from drying out, even if it means moisturizing every hour or more often! It is important to note that petroleum jelly seals skin but does not moisturize it.
There are other triggers of skin itching in eczema which must also be addressed. These includes soaps which can be very drying, chlorinated pools which are also drying and irritating, certain fabrics which may cause irritation, dyes and perfumes which are added to detergents which can be irritating, and just about all fabric softeners which can be irritating. A misconception often made is that baths or showers should be very short and limited because they can worsen the eczema. However, it is not the water which does so but rather the soaps. A simple water bath with a 15-20 minute soak can be helpful in moisturizing the skin. The soaping and shampooing (if needed) should be left for the very end and done quickly.
Frequently adults and parents of children with eczema are concerned about a food allergy as a trigger of flaring eczema symptoms. The statistics show that up to 40% of children up to the age of 3-4 years old can have a food allergy as a trigger. An egg allergy is the cause in about 90% of such cases, followed by cow’s milk at 5%. All other foods represent the remaining 5%. Once a child is older than 3-4 years-old, the likelihood of a food allergy trigger drops below 10% or even lower.
For older children and adults, environmental allergies are much more common triggers, the primary one being dust mites. Other environmental allergens such as cats, dogs, feathers, mold, and even pollen can be triggers as well. Avoiding food and environmental allergy triggers becomes necessary to better control eczema symptoms in these cases. Studies have shown that allergy shots can successfully reduce environmental allergy triggers and lead to significant and long-term improvements of eczema symptoms.
Moving beyond the basics of moisturizing and avoidance of irritants and triggers, classic treatments also involve the use of topical anti-inflammatory creams or ointment, including topic steroids and another non-steroid topical abbreviated as TCI. Topical steroids are useful in short bursts to control flaring symptoms but have long-term side effects which prevent its safe long-term use. TCI’s have their own black box warning but some doctors feel comfortable recommending it for long-term use. A new topical cream called Eucrisa (Crisaborole) seems safer for long-term use. Except for low-potency topical steroids, the rest are by prescription only.
Alterations of skin bacteria have also been shown to trigger flaring eczema symptoms, particularly the overgrowth of Staph aureus. Therefore some doctors recommend oral and topical antibiotics, especially when the skin is very inflamed and appears infected. Bleach baths are also recommended though recent studies suggest they do not actually kill skin bacteria. New research is being done on topical probiotic creams which have been shown to repel Staph aureus by introducing “good” bacteria to the skin. Speaking of probiotics, there are medical studies since the early 2000’s showing that certain oral probiotics can also improve eczema symptoms. However, there does not seem to be a “one size fits all” probiotic which helps everyone with eczema.
Other natural treatments which have been shown in medical studies to benefit eczema symptoms are Vitamin D, topical sunflower oil, and topical coconut oil (refined). Other oils such as olive oil have been shown to worsen, not improve, symptoms. Another therapy called light therapy has also shown to have limited benefit for eczema symptoms.
Recently research has found that there are changes in the skin of people with eczema, even in places where there are no rashes, which includes disruptions of proteins in the skin barrier allowing it to dry out as well as activation of inflammatory immune cells. Research has also shown that scratching also worsens the skin barrier by disrupting more of these barrier proteins and just makes things worse. One very new (and expensive) injectable treatment, Dupixent (Dupilumab), directly targets some of the inflammatory molecules in the skin and has shown significant benefit in moderate to severe eczema cases. Now that more is known about the type of inflammation in eczema skin, there will likely be new targeted treatments available in the future.
To summarize, eczema is a condition of itchy skin which when scratched causes skin rashes and other symptoms. Skin dryness is a main trigger and can be due to skin barrier breakdown, including scratching. Irritants and allergens can also flare symptoms and their avoidance can improve symptoms. Moisturizing is key but sometimes other anti-inflammatory treatments are needed. Consider natural treatments like Vitamin D, probiotics, and topical oils.
Dr. Yoram C. Padeh joined Asthma and Allergy Associates of Florida in April 2012. He graduated from Columbia University in New York, NY summa cum laude and Early Phi Beta Kappa and attended the Albert Einstein School of Medicine in the Bronx, NY, where he received his medical degree. He completed his internship and residency at Mount Sinai Medical Center in Miami Beach, FL where he served as the Internal Medicine Chief Resident. He then returned to Albert Einstein for a fellowship in Pediatric Allergy/Immunology and Adult Allergy/Immunology. Dr. Padeh is currently Board Certified in Allergy and Immunology. He is fluent in both English and Spanish and has been treating patients in our specialty for over six years.