Eczema is the most common skin condition seen in day-to-day practice. It is a pattern of inflammatory response (dermatitis) of the skin characterised by itching, redness, flaking of the skin and raised, fluid filled lesions (papules and vesicles). The condition may be induced by a wide variety of external and internal factors acting alone or in combination.
Based on the causes, eczema can be classified as exogenous eczema or endogenous eczema. A detailed history of a patient with eczema is very important to identify the underlying cause/s, as long term remissions can be achieved only by eliminating the underlying cause/s. Sometimes, the tendency for eczema runs in the family and therefore occurrence of eczema in family members does not imply that it is contagious.
- Irritant dermatitis (detergents, soaps, chemicals)
- Allergic dermatitis (rubber, cement, dyes, plants)
- Photo-sensitive dermatitis (dermatitis caused or precipitated by sunlight and photosensitive agents)
- Polymorphic light eruption (caused only by UV radiation present in the sunlight)
- Infective dermatitis (dermatitis occurring in and around the infected wound)
- Atopic (dermatitis occurring in a person with personal or family history of asthma, allergic rhinitis)
- Seborrhoeic dermatitis (dermatitis seen in areas rich in sebaceous glands; usually after puberty)
- Asteatotic eczema (eczema associated with decrease in skin surface oils; common in the elderly)
- Gravitational eczema (eczema associated with varicose veins; seen around the ankles)
- Hand eczema (most common eczema; causes can be many)
- Forefoot eczema (common eczema seen in childhood, involving predominantly the forefoot)
- Pityriasis alba (dry, white patches seen on the face and sometimes elsewhere; occurs during childhood)
- Metabolic eczema (eczema due to nutritional deficiencies of EFA, zinc, niacin, proteins)
- Drug eruptions (exfoliative dermatitis)
Two or more types of eczema may be present in the same patient simultaneously or consecutively. Certain eczema are common in particular age groups:
- Infants – atopic
- Childhood – atopic, forefoot eczema, pityriasis alba
- Adolescence – seborrhoic dermatitis, allergic and irritant dermatitis to cosmetics
- Middle age – Stasis eczema, irritant and allergic dermatitis (occupational)
- Elderly – asteatotic eczema
Based on the clinical presentation, eczemas are termed as-
- Acute (when there is oozing, with tiny fluid filled lesions and swelling)
- Subacute (scaly and red)
- Chronic (thick and hyperpigmented skin)
|Asteatotic eczema||Asteatotic eczema|
A detailed history is important to determine the cause (exogenous/ endogenous) and precipitating factors. Eczemas have to be differentiated from other common skin diseases like
- Tinea (fungal infection/’ring worm’)
- Lichen planus etc.
Differentiation from Tinea is very important as the treatment is entirely different.
- Eczemas are usually not sharply demarcated
- Eczemas do not show clearance in the centre (unless partially treated)
- Eczemas are usually bilateral and if unilateral, correspond to the site of contact with exogenous agent (contact dermatitis)
- In acute stage, eczema is characterised by oozing.
In case of doubts, scraping should be taken from the scales to demonstrate the fungal elements.
Patch testing is required if clinical presentation (history and site of involvement) is suggestive of an exogenous cause. It is also indicated if eczema of endogenous origin does not respond to treatment or is persistent in spite of treatment.
Biopsy is required in unusual cases and unusual presentations.
Treatment should aim at removing or reversing the cause. Treatment should be such that the patient should have a long term remission with minimum or no side effects to the medications.
In the presence of acute exacerbation, compresses (potassium permanganate) should be given to reduce the oozing and oedema, following which bland preparations should be applied. Topical steroids can be used for quicker resolution. In the presence of infection (yellow crusting) topical steroids with antibiotics (other than gentamicin and neomycin) can be used. Oral antibiotics (targeting Streptococci and Staphylococci) and antihistamines (to reduce itching) may be required.
Subacute eczema: Sometimes eczemas can present in this stage or acute eczema after partial treatment may manifest in this form. Treatment includes avoidance of rubbing, use of emolients/moisturizers regularly during the day and topical steroids with or without moisturizers in the evenings.
Chronic eczema: Long term rubbing and scratching of eczematous or normal skin leads to chronic eczema. Treatment obviously includes avoidance of rubbing or scratching, emolients/moisturizers to protect and soothe the damaged skin during the day and topical steroids with salicylic acid, urea, lactic acid in the night. In addition, the area should be made inaccessible for scratching by occlusion of the area with clothing.
Maintenance therapy includes regular use of moisturizers, best suited for the type and site of the skin.
Points to remember regarding eczema:
- Do not try self-medication or home remedies
- Do not use potent topical steroids for long without doctor’s advice (not more than 2 weeks)
- Avoid the likely cause/precipitating factors
- Use the treatment for the specified duration continuously without interruption. Do not stop the treatment after the itching disappears; continue treatment until the skin comes back to its normal texture.
- Topical steroid is not the only form of treatment. It has to be continued or replaced with emolients/moisturizers simultaneously or later
- Stress can aggravate eczema