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Pathophysiology of eczema = why we get eczema
We do not understand all the reasons why people develop eczema but the main underlying cause is a disrupted skin barrier. This leads to trans-epidermal water loss and progresses to inflammation. Most consider this condition a genetic disease that is very much influenced by the environment. A gene that is a major factor in developing atopic dermatitis is Filaggrin - which is an essential protein in the epidermis responsible for bringing keratin filaments together. Unfortunately, eczema is very common, in fact, it is the most common chronic inflammatory skin disease worldwide.
The inflammatory response the body produces when the skin barrier is impaired produces: redness, weeping, scaling, lichenification and pruritus (itching). Also due to the disrupted skin barrier, eczema lesions are much more prone to get infected - this leads to the additional conditions of impetigo, eczema herpeticum and molluscum contagiosum.
Clinical symptoms of eczema
Infantile Eczema
Mostly acute lesions - red bumps and plaques that ooze, are very itchy and get crusty
Typically develops 2 months after birth and lasts up until 2 years of age
Face and neck are commonly affected, also can develop on extensor surfaces, trunk and diaper area
Infants may rub to try and relieve the itching, also can affect sleep
Childhood Eczema
This time frame is between 2-12 years old
Often eczema lesions are not as wet and oozy, but become more lichenified (from all the scratching)
The flexural regions are common sites of involvement in this age group (behind the knees and in the crease of the elbows) as well as the wrists, neck, hands and feet
Kids also tend to have overall dry skin (xerosis)
Adult Eczema
This time frame is after 12 years of age
Lesions tend to come and go and there is still development of lichenified lesions
The flexural regions are common sites of involvement (behind the knees and in the crease of the elbows) as well as the hands. Eyelid, behind the ears, chest and neck flares can occur.
Dark nodules may develop from constant scratching (prurigo nodules)
Post inflammatory hyperpigmentation is often a remnant from prior lesions
Medications that can help
Topical Steroids: topical steroids are anti-inflammatory agents that can help combat inflammation and pruritus in eczematous lesions. Ointments work the best because they penetrate deeper into the skin and don’t burn when applied. There are a range of strengths with topical steroids: hydrocortisone being the weakest and clobetasol being one of the strongest. One note of caution is that when applied for long periods of time topical steroids can thin the skin.
Calcineurin-inhibitors: topical calcineurin-inhibitors are anti-inflammatory agents as well. The main two are tacrolimus ointment and pimecrolimus cream. These work well in sensitive areas, as they do not thin the skin. One side-effect of these agents is that they can sting/burn initially so for young children it may be uncomfortable at first.
JAK-inhibitors: topical JAK-inhibitors are a newer treatment for eczema. They are very effective, but are not approved for children under 12 years old. There is no thinning of the skin so this cream is safe for all areas of the body.
PDE4 inhibitors: topical PDE4 inhibitors also have a very good side effect profile, the main adverse effect being a burning sensation. Based on my clinical experience I think these are very good for mild eczema, especially on the face, neck and in some cases the hands and feet.
Systemic Agents: there are actually systemic medications that are FDA approved for atopic dermatitis that are not just full immuno-suppressants, which means you are not suppressing your entire immune system with these medications - they target specific pathways in the eczema inflammatory cascade. Dupilumab is an injectable medication that has been revolutionary for the treatment of eczema but it is a treatment and thus these injections are for life. The side effects are mainly injection site reactions and conjunctivitis. Oral JAK inhibitors are also a relatively new oral treatment for eczema and have been fantastic for patients who failed Dupilumab or cannot take injections. The side effect profile for oral JAK inhibitors is a little more intense and necessitates lab work. The main side effects are acne, increased cholesterol, increased herpetic outbreaks, but does have a warning that it may increase the risk of cancer and blood clots. There are several other biologic injectable medications that are now approved for atopic dermatitis but these two are the most common.
NBUVB: often referred to as light therapy, narrow band UVB treatment can be wonderful for those who suffer from atopic dermatitis. It is more time intensive, typically patients need to go 2-3 times a week for 20+ weeks. There is no medication here though, so those that prefer a more natural route of treatment - this is a great option. The main risks with NBUVB are: burning, so that is why we recommend doing this treatment with a dermatologist, as there is a very well established protocol to prevent burning; and, there is a very small risk of skin cancer as you are being exposed to UV radiation.
OTC products/Behaviors for eczema patients
As I am sure most eczema patients would agree - you have to develop a skin care routine. What this means is:
You need to moisturize ideally 2 times a day.
And that is not with just any moisturizer, you need moisturizers that are creams or ointments - lotions often do not provide you with enough moisture.
Apply moisturizers within 3 minutes of getting out of the shower
Fragrance-free is best
Ingredients to look for: petrolatum, glycerol, urea, ceramide, , fatty acids
Soaps need to be gentle - non-alkaline cleansers are best
Showers need to be short and lukewarm
Consider humidifiers in the house if you live in a dry climate
Watch for triggers - nail polish, nickel-containing jewelry, wet wipes, etc. = many patients with atopic dermatitis are prone to sensitive skin and can develop allergic contact dermatitis which acts very similar to regular eczema.
A great website for OTC products: https://nationaleczema.org/eczema-products
If you are suffering from eczema - please see a dermatologist! Atopic Dermatitis affects your entire well-being and we want to help.
Please call for an appointment at Aislyn Dermatology 719-992-0127
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