Eczema (Atopic Dermatitis)

Eczema is a condition where patches of skin become inflamed, itchy, red, cracked, and rough. Blisters may sometimes occur. Eczema is a term for a group of medical conditions that cause the skin to become inflamed or irritated. The most common type of eczema is known as atopic dermatitis, or atopic eczema. Atopic refers to a group of diseases with an often inherited tendency to develop other allergic conditions, such as asthma and hay fever.
Symptoms can vary from a mild rash that disappears quite quickly to a more severe condition that’s present for a long time. The main goal of treatment is to eliminate itching which, if left untreated, can provoke or worsen the other symptoms.
What is the cause of Eczema?
The cause of atopic dermatitis and many forms of eczema is unknown but is potentially due to a dysfunction in filaggrin, a protein that maintains the membrane of skin cells.  It is also thought that genetics (inheritance) and an improperly functioning of the local immune system contribute to the development of atopic dermatitis. Environmental factors also likely play a role. Atopic dermatitis tends to be more common in industrialized nations and urban areas, and the incidence appears to be increasing in developing nations as they become more Westernized. Xerotic eczema is due to very dry skin. In contact dermatitis, an irritant or allergen directly causes the rash.  However, in many cases of allergic or irritant contact dermatitis, a clear trigger cannot be found.
There are several types of eczema or dermatitis, some of which are discussed below:
Atopic Dermatitis:
(a.k.a. atopic eczema), often used synonymously with eczema, is a disease of unknown cause. It usually starts in infancy and is characterized by itchy, scaly lesions, xerosis (dry skin), and lichenification (accentuation of skin markings). Atopic dermatitis is commonly associated with other atopic diseases such as asthma or allergic rhinitis. The frequency of atopic dermatitis appears to be increasing and appears to be more common among Blacks, Asians, and Pacific Islanders. In infants, eczema is usually seen on the forehead and cheeks. In children, eczema is seen on the hands, wrists, ankles, feet, and elbow and knee creases. In adults, eczema is usually seen on the face, neck, upper arms and back, elbow and knee creases, and back of the hands, feet, fingers, and toes.
Nummular Dermatitis:
(a.k.a. nummular eczema) appears as itchy “coin-shaped” areas of inflammation and can be crusty or scaly.
Xerotic (asteatotic) Eczema:
(a.k.a asteatotic eczema), in this type of eczema, extremely dry skin becomes inflamed and may require treatment beyond moisturizers.
Contact Dermatitis:
In this form of eczema, skin irritation can form from excessive contact with irritants (e.g., soap, detergents, harsh chemicals) and allergens (e.g., poison ivy, nickel, fragrances, etc.)
Eczema can also look different in darker skinned patients. Some of the unique forms of eczema seen more commonly in darker skin include papular eczema (bumps) and eczema with follicular prominence.3
A major concern for people of color is the skin discoloration associated with eczema. Eczema or scratching secondary to the itch of eczema can lead to darkening (hyperpigmentation) or lightening (hypopigmentation) of the skin. This discoloration can last for months to years, even after the eczema is treated.  Darkening of the skin is especially visible in children with skin of color.  If the patient’s underlying eczema and inflammation is treated, however, the changes in skin color can be improved.

INCIDENCE OF ATOMIC DERMATITIS IN NIGERIA
The incidence of atopic dermatitis rose from 0.3% in 1962 at the University College Hospital, Ibadan, Nigeria, to 2.6% in 1972. A prospective study was designed to find the incidence nearly three decades after, as well as the presenting clinical features, factors influencing the disease, and the laboratory profile. The analysis of the 64 patients diagnosed during the 1.5-year study period is documented and discussed. The incidence of atopic dermatitis was 6.1%. The increase was attributed partly to increased hospital awareness in this university town and partly to a fall in infective dermatoses. There was paucity of the history of atopic diseases. Sixty-two and one half percent of parents and patients had post primary education. Two thirds of the people belonged to the middle and high social classes. Self-medication was a frequent finding. No seasonal influence was implicated in 49 cases (76.5%). Heat was the most implicated aggravating factor (21.8%). Post inflammatory dyspigmentation was a common clinical feature. The proportion of patients with significantly high serum IgE stood out clearly (George AO, 1989)
Eczema and gender
Eczema is more common in females than males.
Eczema mortality
Hospitalization due to AD flares and associated infections and/or viruses is associated with an 8-year reduction in lifespan.
GENERAL INFORMATION
Eczema generally occurs in babies and children, although it can occur at any time of life.  Eczema usually develops in the first year of life. Most children have a substantial improvement in their eczema by their mid-teens but, in some, severe eczema persists into adulthood.

Eczema usually starts on the face followed by the hands and feet. Older children tend to be affected in the elbow and knee creases, neck, wrists, ankles and feet. The hands and feet tend to be the most commonly affected areas in adults. Eczema is not a contagious condition.

Eczema tends to develop in people with allergies such as asthma and hay fever and often runs in families.  Skin affected by eczema may be more vulnerable to infections such as warts and cold sores.  Eczema is not contagious. Children are more likely to develop eczema if a parent has had the condition or another atopic disease. If both parents have an atopic disease, the risk is even greater.
How do I know if I have Eczema?
Eczema is usually diagnosed clinically. Direct physical examination and taking of a medical history allow dermatologists to accurately recognize the different forms of eczema. They may also ask about family history of eczema and associated diseases.
Healthy skin acts as a barrier to retain moisture and to protect the body from environmental challenges.  Any factor that disrupts the ability of the skin to act as an effective barrier can lead to the loss of moisture, causing dryness and the entry of allergens, irritants and bacteria, which can result in inflammation and infection.

POTENTIAL CAUSES OF ECZEMA
• Irritants: These include soaps, detergents, shampoos, disinfectants, juices from fresh fruits, meats, or vegetables.
• Allergens: Dust mites, pets, pollens, mold, and dandruff can lead to eczema.
• Microbes: These include bacteria such as Staphylococcus aureus, viruses, and certain fungi.
• Hot and cold temperatures: Very hot or cold weather, high and low humidity, and perspiration from exercise can bring out eczema.
• Foods: Dairy products, eggs, nuts and seeds, soy products, and wheat can cause eczema flare-ups.
• Stress: This is not a direct cause of eczema but can make symptoms worse.
• Hormones: Women can experience increased eczema symptoms at times when their hormone levels are changing, for example during pregnancy and at certain points in the menstrual cycle.

Consultation with your doctor may be helpful in identifying the triggers.

Pollen is one of the many potential triggers of eczema.
(The specific cause of eczema remains unknown, but it is believed to develop due to a combination of genetic and environmental factors).

SYMPTOMS OF ECZEMA
No matter which part of the skin is affected, eczema is almost always itchy. Sometimes the itching will start before the rash appears, but when it does, the rash most commonly appears on the face, back of the knees, wrists, hands, or feet. It may also affect other areas as well.
Affected areas usually appear very dry, thickened, or scaly. In fair-skinned people, these areas may initially appear reddish and then turn brown. Among darker-skinned people, eczema can affect pigmentation, making the affected area lighter or darker.
In infants, the itchy rash can produce an oozing, crusting condition that happens mainly on the face and scalp, but patches may appear anywhere.
The symptoms of atopic dermatitis can vary, depending on the age of the person with the condition.
Atopic dermatitis commonly occurs in infants, with dry and scaly patches appearing on the skin. These patches are often intensely itchy.
Most people develop atopic dermatitis before the age of 5 years. Half of those who develop the condition in childhood continue to have symptoms as an adult.
However, these symptoms are often different to those experienced by children.
People with the condition will often experience periods of time where their symptoms flare up or worsen, followed by periods of time where their symptoms will improve or clear up.
Symptoms in infants under 2 years old
• Rashes commonly appear on the scalp and cheeks.
• Rashes usually bubble up before leaking fluid.
• Rashes can cause extreme itchiness. This may interfere with sleeping. Continuous rubbing and scratching can lead to skin infections.
Symptoms in children aged 2 years until puberty
• Rashes commonly appear behind the creases of elbows or knees.
• They are also common on the neck, wrists, ankles, and the crease between buttock and legs.
Over time, the following symptoms can occur:
• Rashes can become bumpy.
• Rashes can lighten or darken in color.
• Rashes can thicken in a process known as lichenification. The rashes can then develop knots and a permanent itch.
Symptoms in adults
• Rashes commonly appear in creases of the elbows or knees or the nape of the neck.
• Rashes cover much of the body.
• Rashes can be especially prominent on the neck, face, and around the eyes.
• Rashes can cause very dry skin.
• Rashes can be permanently itchy.
• Rashes in adults can be more scaly than those occurring in children.
• Rashes can lead to skin infections.
Adults who developed atopic dermatitis as a child but no longer experience the condition may still have dry or easily-irritated skin, hand eczema, and eye problems.
The appearance of skin affected by atopic dermatitis will depend on how much a person scratches and whether the skin is infected. Scratching and rubbing further irritate the skin, increase inflammation, and make itchiness worse.
The classic symptoms of eczema are: 
• Itching.  This is the worst aspect because it can be upsetting for the child.  It also makes the child scratch causing further rawness of the skin and possible infections to develop.
• Redness caused by extra blood flowing through the blood vessels in the skin in the affected area.
• A grainy appearance to the skin, caused by tiny fluid filled blisters just under the skin called “vesicles.”
• Weeping when the blisters burst, either by themselves or because of scratching, and the fluid oozes on to the surface of the skin.
• Crusts or scabs that form when the fluid dries.
• Children with eczema often have dry, scaly skin.  This may be the result of the disease or it may also be the natural skin type of the family.  Dry skin can be a predisposing factor to developing eczema.
• Pale patches of skin may appear because eczema can disturb the production of pigment which controls skin colour. The effect does fade and disappear.
Lichenification - a leathery, thicker skin area in response to scratching
TREATMENT

Regularly moisturizing the skin can help treat eczema
There is no cure for eczema. Treatment for the condition aims to heal the affected skin and prevent flare-ups of symptoms. Doctors will suggest a plan of treatment based on an individual's age, symptoms, and current state of health.
For some people, eczema goes away over time. For others, it remains a lifelong condition.
HOME CARE
There are numerous things that people with eczema can do to support skin health and alleviate symptoms, such as:
• taking lukewarm baths; Avoid extremely hot or extremely cold showers/baths
• applying moisturizer within 3 minutes of bathing to "lock in" moisture
• moisturizing every day
• wearing cotton and soft fabrics, and avoiding rough, scratchy fibers and tight-fitting clothing
• using a mild soap or a non-soap cleanser when washing
• air drying or gently patting skin dry with a towel, rather than rubbing the skin dry after bathing
• where possible, avoiding rapid changes of temperature and activities that make you sweat
• learning and avoiding individual eczema triggers
• using a humidifier in dry or cold weather
• keeping fingernails short to prevent scratching from breaking the skin
• Medications
There are several medications that doctors can prescribe to treat the symptoms of eczema, including:
• Topical corticosteroid creams and ointments: These are a type of anti-inflammatory medication and should relieve the main symptoms of eczema, such as skin inflammation and itchiness. They are applied directly to the skin. If you want to buy topical corticosteroid creams and ointments, then there is an excellent selection online with thousands of customer reviews.
• Systemic corticosteroids: If topical treatments are not effective, systemic corticosteroids can be prescribed. These are either injected or taken by mouth, and they are only used for short periods of time.
• Antibiotics: These are prescribed if eczema occurs alongside a bacterial skin infection.
• Antiviral and antifungal medications: These can treat fungal and viral infections that occur.
• Antihistamines: These reduce the risk of nighttime scratching as they can cause drowsiness.
• Topical calcineurin inhibitors: This is a type of drug that suppresses the activities of the immune system. It decreases inflammation and helps prevent flare-ups.
• Barrier repair moisturizers: These reduce water loss and work to repair the skin.
• Phototherapy: This involves exposure to ultraviolet A or B waves, alone or combined. The skin will be monitored carefully. This method is normally used to treat moderate dermatitis.
Even though the condition itself is not yet curable, there should be a particular treatment plan to suit each person with different symptoms. Even after an area of skin has healed, it is important to keep looking after it, as it may.
In severe cases, phototherapy or ultraviolet (UV) treatment may be suggested.  This involves controlled exposure to UV-A and/or UV-B for a few minutes, two to three times each week.  A course of treatment may continue for several months.
Skin that is broken and damaged is more likely to be infected by bacteria or yeasts.  One common type of bacterium (staphylococcus aureus) produces yellow crusts or pus filled spots.
Should bacterial infection occur, this can be treated with a course of antibiotics.  Antibiotics can be taken orally in the form of syrup, capsules or tablets.

HOW IS ECZEMA DIAGNOSED?
A pediatrician, dermatologist, or your primary care provider can make a diagnosis of eczema. While there are no tests to determine eczema, most often your doctor can tell if it's eczema by looking at your skin and by asking a few questions.
Since many people with eczema also have allergies, your doctor may perform allergy tests to determine possible irritants or triggers. Children with eczema are especially likely to be tested for allergies.
How Can Eczema Flare-ups Be Prevented?
Eczema outbreaks can sometimes be avoided or the severity lessened by following these simple tips:
• Moisturize frequently.
• Avoid sudden changes in temperature or humidity.
• Avoid sweating or overheating.
• Reduce stress.
• Avoid scratchy materials, such as wool.
• Avoid harsh soaps, detergents, and solvents.
• Be aware of any foods that may cause an outbreak and avoid those foods.
• Use a humidifier in the room where you sleep.

             Additional Resources.   
            American Academy of Dermatology




References
1. Halder, R.M., Grimes, P.E., McLaurin, C.I., Kress, M.A., & Kenney, J.A. (1983). Incidence of common dermatoses in a predominantly black dermatologic practice. Cutis, 32, 388-390.
2. Spergel JM, Paller AS. Atopic dermatitis and the atopic march. The Journal of allergy and clinical immunology. 2003;112(6 Suppl):S118-27.
3. Desai, N., & Alexis, A.F. (2009). Atopic Dermatitis and Other Eczemas. In A.P. Kelly & S.C. Taylor (Eds.), Dermatology for Skin of Color. China: McGraw-Hill.
4. Kang, K., Polster, A.M., Nedorost, S.T., Stevens, S.R., & Cooper, E.D. (2008). Atopic Dermatitis. In J.L. Bolognia, J.L. Jorizzo & R.P. Rapini (Eds.), Dermatology (2nd ed.). Spain: Mosby.
5. Dermatology atlas for skin of color. New York: Springer; 2014.
6. Boguniewicz M, Eichenfield LF, Hultsch T. Current management of atopic dermatitis and interruption of the atopic march. The Journal of allergy and clinical immunology. 2003;112(6 Suppl):S140-50.
7. Silverberg JI, Lee-Wong M, Silverberg NB. Complementary and alternative medicines and childhood eczema: a US population-based study. Dermatitis : contact, atopic, occupational, drug. 2014;25(5):246-54.
8. George AO. Int J Dermatol. (1989). Atopic dermatitis in Nigeria.