Atopic eczema

What happens?

Atopic eczema is the most common type of eczema. There are other types, for example, varicose eczema (which is seen in older people who have varicose veins) or discoid eczema (where the patches of eczema are in distinct round or oval patches) but these are less common.

Why do I have eczema?

The cause is not known, but we do know that it can run in families. It also seems to be becoming more common, we don’t know why but pollution, allergy to house dust mites or even climate change may influence this. If you have eczema, you are also more likely to suffer with the related conditions of asthma or hayfever and itchy nose symptoms.

Some people are aware of their “triggers”. This means they know what will bring on a flare of eczema, for example, certain soaps, bubble bath or animal hairs are classic irritants.

Our skin is a big, thick barrier to protect our body. It controls temperature and hydration and is also a barrier to some infections. In eczema, the oily barrier breaks down, water is lost from the skin and it becomes dry, cracked and itchy. It then becomes more susceptible to infection.

Eczema usually starts in childhood but two out of three children will grow out of it. That still leaves about one in 20 adults who have atopic eczema. For most, it is a mild condition which just occasionally flares up. For a few, it can be very severe and require constant treatments and hospital referral.

What does eczema look and feel like?

1. The skin is generally dry
2. There are patches of red, rough and itchy skin
3. If infected, the skin can become weepy, tender, blisters may form or the itch may worsen considerably
4. In chronic eczema the skin becomes hard and thick. This is an overgrowth of skin in reaction to scratching

Where does atopic eczema occur?

Most commonly in the elbow and knee skin folds (front of the elbow and back of the knee) All areas of the skin can be affected.

Eczema skin care - top four tips

1. Use lots of emollients every day to repair damaged skin
2. Use a soap substitute such as aqueous cream instead of soap
3. Don’t use bubble bath
4. Occasional use of small amounts of steroid creams or ointments for flare ups

More skin care advice

USE LOTS OF EMOLLIENTS (emollients are un-perfumed moisturisers). If you do nothing else, remember to use emollients, it’s the most important weapon against eczema! A 500g pot of emollient, such as Diprobase, should only last one week, if you have eczema all over your body.

Regular moisturising (this means at least twice a day, every day) will help build up the barrier function of the skin and so prevent flare ups and infection. This means it’s important to care for your skin all the time, not just when you have a flare up

Other important points

1. Avoid triggers wherever possible
2. Avoid using soap, bubble bath or perfumed moisturisers. Use aqueous cream instead (this is known as a soap substitute). You could also use oil in the bath
3. Intermittent use of steroid creams or ointments are good for flare ups. Steroids are great for short term use, but have too many serious side effects to be used regularly
4. If you think your skin may be infected, see your GP to ask whether you need antibiotics

Steroid creams and ointments

These work by reducing inflammation in the skin. They tend to work quickly and so are popular, and unfortunately can often be used too much. Unlike emollients, they should only be used intermittently when the skin has flared up. They should be used for a short time (ideally only one to two weeks) and then stopped, usually for at least a month. This is because of their side-effects.

You should continue to use your emollients while using the steroids, rubbing the emollient in a few minutes before you rub in the steroid.

The steroid should only be used in small quantities, for example, one fingertip unit (see below) should cover the inside of both elbows for most people. Remember, unlike steroids, your emollient should be used generously.

Steroid creams and ointments come in different strengths; mild, moderate, potent and very potent. The more potent ones are effective more quickly, but come with a higher risk of side-effects. In general, it is common practice to start with a lower strength and build up as needed. However, sometimes it is useful to use a few days of a strong steroid cream or ointment to get the itch under control quickly and then cut back to a milder one once symptoms are better controlled.

Different types of steroid creams and ointments

Hydrocortisone 1% is a very common, mild steroid and is available over the counter in small quantities, in certain situations. You will need a prescription for the stronger, more potent steroid preparations. Betnovate RD and Eumovate are examples of moderate skin steroids. Betnovate and Synalar are examples of potent skin steroids. Dermovate is an example of a very potent skin steroid.

Cream or ointment - does it matter?

Creams are better for moist areas of skin. Ointments are better to treat areas of skin which are dry or thickened. Most people with eczema should use ointments. However, some patients say that ointments are too oily and they prefer creams. If you have a particular preference and it works, then that’s the most important factor.

Side-effects of topical steroids

Short courses of topical steroids are safe and should not cause problems. However, if used consistently or you frequently repeat the course then the skin can be damaged, sometimes irreversibly. This is particularly of concern for potent and very potent preparations (we do not currently sell very potent steroids). It is very unusual in the weaker steroid groups.  Possible side-effects are:

1. Red marks called striae developing on the skin
2. The skin can become thin and therefore easily damaged
3. Certain skin conditions can be worsened (acne, rosacea, dermatitis around the mouth)
4. Extremely rarely the potent and very potent topical steroids can be absorbed into the blood. This is only when large amounts are used over large parts of the body. It is usually only relevant in children, where growth could be affected. You should speak to your doctor or dermatologist if you are worried this could affect you.

Infected eczema

Eczema is more prone to infection than normal skin. If you think your eczema is infected, you should contact your GP to discuss the need for antibiotics. Any of the following maybe a sign of infection:

1. Painful and weeping skin
2. Pustules or tender blisters developing
3. Rapidly worsening eczema
4. Fever or high temperature

You should contact your GP if any of the above develop. Using a steroid cream on infected skin may worsen a skin infection, unless you use an antibiotic as well.

What if the treatments don't work?

See your doctor if a flare-up of eczema is getting worse or not clearing with your usual treatments. Things to think about are:

1. Is this really eczema? Other unusual conditions, such as fungal infections or even scabies, can initially look like eczema.
2. Are you using enough emollient?
3. Do you need a stronger steroid?
4. Has the inflamed skin become infected and now needs an antibiotic?
5. Have you become allergic to an ingredient in a cream or ointment (such as a preservative)?

Finger Tip Unit (FTU)

One FTU= the amount of steroid squeezed out from a standard sized tube, from the tip of your finger to the first finger crease.

One FTU should be enough for an area the size of two hand prints.