Eczema is a skin condition that causes itchy, red, dry, and flaky skin. It’s common – affecting almost 1 in 5 children in the UK and up to 1 in 10 adults. The term eczema is often used interchangeably with dermatitis. There are a number of different types of eczema or dermatitis, with the most common ones being:
Atopic eczema/dermatitis is typically genetic and often goes alongside other conditions like hay fever, asthma, and food allergies. Many children will grow out of eczema, although for some it can be more persistent.
Irritant dermatitis - caused by use of harsh chemicals - such as repeated handwashing, or cleaning products.
Allergic Contact dermatitis - occurs as an allergy to a substance coming into contact with the skin such as nickel in belts or jewellery, or fragrance within skincare.
Eczema is a combination of 3 factors:
1) Skin barrier changes
2) Abnormal activation of the skin’s immune system
3) Changes in the skin’s microbiome
The skin barrier is the outer layer of skin, holding essential moisture within the skin and keeping irritants out. Genetically, some people have drier skin (due to a less efficient barrier), and this can result in an increased risk of eczema. In addition, skin barrier is affected by harsh skincare, detergents and environmental conditions such as cold weather and indoor heating. Once the skin barrier is compromised, the risk of eczema increases.
Cutaneous immune system:
Our skin has a very active immune system. For those genetically prone to eczema, the skin’s immune system is too active (in the same way it is in the airways in hay fever or asthma). This can result in red, itchy patches which are collections of immune cells under the skin. The skin’s immune system can also become activated after disruption of the skin barrier or in allergic contact dermatitis – resulting in the inflamed patches of eczema.
The skin is home to billions of bacteria and other microorganisms which live in synergy with skin cells. We need a healthy microbiome to facilitate normal skin functioning. When the microbiome shifts, this can drive changes of eczema. Disruption of the skin barrier and inflammation can also have an impact on the microbiome and all of these 3 factors are interchangeably linked.
How to treat eczema:
Exclude an underlying cause. This is much more likely to be something coming into contact with the skin, rather than food. With multi-step skincare routines, I’ve seen an increase in facial eczema. Common culprits are acids, retinoids or highly fragranced products. Ease back on active products if eczema develops.
Skincare is essential to help strengthen the skin barrier. If you are prone to eczema, avoid harsh foaming washes, soaps and scrubs. Use a gentle, pH balanced synthetic detergent or even moisturiser as your wash. Moisturisers (emollients) are key in eczema management and should be applied regularly to both treat and prevent eczema. During flares, emollients need to be applied multiple times per day, whilst during calmer periods twice per day is adequate. Use non-fragranced moisturiser and avoid essential oils. Moisturisers are very personal, and you need to find a formulation that works for you. Thicker ointments and creams are often better for eczema and more efficient at reducing water loss from the skin.
Optimise your environment. Heat - particularly at night - can exacerbate the itching of eczema, so keep bedrooms cool and turn down the heating. Choose natural fibres for clothing and bed linen such as cotton or silk and wash clothes with an extra rinse cycle to avoid detergent residue and irritation.
Boost your bacteria. Whilst oral probiotics have been a promising intervention for eczema, there is currently no evidence that they can treat eczema once it has developed. However, it’s important that you support your skin’s microbiome by ensuring your skincare routine is gentle and pH balanced. Maintain a healthy diet with a good balance of protein, vegetables, and fibre.
Use medicated creams. When eczema becomes very active and itchy, medical anti-inflammatory treatment is needed to calm the inflammation. The most widely used treatment is topical steroid cream (such as hydrocortisone), some of which can be bought over the counter. Steroid creams should be used daily during flares and then can be used intermittently to maintain its benefit. In most cases, topical steroids can be used in a safe and effective way, however for some, they may need to seek alternatives.
Discuss with your Doctor. Eczema can be very distressing and significantly affect quality of life, impacting on sleep, work, and concentration. There are many different medical treatment options if your eczema is not well controlled with lifestyle and simple skincare. Steroid creams, non-steroid medicated creams, light therapy, tablets and injections can all be used, depending on the individual case.
Words by Consultant Dermatologist, Dr Emma Wedgeworth