Eczema

What is eczema?

Eczema is a chronic inflammatory skin condition in which the skin barrier does not hold moisture well and reacts easily to irritants. Itch is the defining feature and drives the scratching that worsens the rash. Regular emollient use is the foundation of treatment, and topical steroids are frequently underused because of unfounded fears.

Causes

• Skin barrier dysfunction, often involving filaggrin gene variants
• Immune overactivity to environmental triggers
• Irritants such as soaps and detergents
• Allergens including house dust mite and pet dander
• Heat, sweat and stress

Symptoms

• Intense itch
• Dry, scaly, rough skin
• Red or darker inflamed patches depending on skin tone
• Typical distribution in elbow and knee creases
• Weeping or crusting during flares
• Thickened skin from long term scratching
• Disturbed sleep from night time itching

Risk factors

• Family or personal history of eczema, asthma or hay fever
• Onset in early childhood
• Living in urban or drier climates
• Frequent exposure to soaps or water at work

Diagnosis

• Clinical diagnosis from appearance, distribution and itch
• Assessment of atopic history
• Swabs if bacterial or viral infection is suspected
• Patch testing when contact allergy is suspected
• Allergy testing in selected cases

Treatment

• Frequent generous emollients, including as a soap substitute
• Topical corticosteroids matched in potency to site and severity
• Topical calcineurin inhibitors for the face and skin folds
• Treatment of bacterial or viral superinfection
• Antihistamines mainly for sleep rather than for itch itself
• Phototherapy for widespread disease
• Biologic or JAK inhibitor therapy for severe refractory eczema

Self care

• Apply emollient generously several times a day, even when clear
• Use emollient instead of soap and avoid bubble baths
• Bathe in lukewarm water and pat rather than rub dry
• Apply steroid ointment to flares promptly rather than delaying
• Keep nails short and consider cotton mittens for children at night
• Identify and reduce irritants such as detergents and wool
• Manage heat and sweating, which trigger itch

When to see a doctor

Book an appointment if:

• Flares not responding to your usual treatment
• Skin becoming weeping, crusted or painful
• Sleep disturbed by itching
• Eczema spreading rapidly
• Repeated skin infections
• To review whether stronger or different treatment is needed

Some symptoms need emergency care rather than an appointment. See the warning signs listed above.

Prevention

• Use emollients daily as maintenance, not just during flares
• Avoid soaps, fragranced products and known irritants
• Keep the home cool and humidity moderate
• Reduce dust mite exposure if this is a trigger
• Consider proactive weekend steroid use where flares are frequent

Outlook

Eczema commonly improves through childhood, and many children are clear by their teens, though the skin often stays dry and sensitive. Adult eczema tends to be relapsing but responds well to consistent emollient use and prompt treatment of flares. Severe disease that does not respond now has effective biologic and JAK inhibitor options.

Related conditions

Common questions