The Australasian Society of Clinical Immunology and Allergy

Eczema occurs in around 1 in 5 infants, but usually improves with age. Most people who have eczema will either have or will develop other allergies. Eczema can be effectively treated.  However, there is currently no cure available.   

Eczema is common in infants, but also occurs in other age groups

Eczema (also known as atopic dermatitis) occurs in around 1 in 5 infants.  Infantile eczema usually starts between 4 to 6 months of age and symptoms include a red rash which appears on the cheeks and may spread to the forehead and the backs of arms and legs. In severe cases it can involve the whole body. Heavy scaling similar to cradle cap may occur. Rashes may weep, particularly if scratched, and these can sometimes get infected. Infantile eczema usually disappears between the ages of 3 to 5 years.

Childhood eczema may follow or can start for the first time between the ages of 2 to 4 years. The rash is usually found in the creases of the elbows, behind the knees, across the ankles and may also involve the face, ears and neck. This form of eczema usually disappears by the age of 10 years, but may continue into adult life.

Adult eczema symptoms include large areas of very itchy, reddened weeping skin with the elbow creases, wrists, neck, ankles and behind the knees being especially affected. The condition tends to improve in middle life and is unusual in the elderly.

Eczema can be associated with other allergic disorders

People with eczema frequently have other family members with allergic disorders such as asthma, allergic rhinitis (hay fever) or eczema. This suggests that inherited (genetic) factors  increase the tendency to develop eczema.

Eczema is often called atopic eczema or allergic eczema. This is because many people with eczema either already have other allergies, such as allergic rhinitis (hay fever), asthma and/or food allergy, or will go on to develop them later. Many people with eczema are either allergic to dust mite already or become so with time. In some studies it has been reported that up to 1 in 20 infants with eczema and a family history of allergy will develop food allergy and up to 4 in 10 develop asthma and/or allergic rhinitis (hay fever).

What can trigger eczema?

Having eczema means that your skin has a lower oil and water content than usual and is much easier to irritate than normal skin. When damaged, moisture evaporates from the skin, cells shrink and cause cracks.  Allergens and irritants can get in, triggering your skin to release certain chemicals that make your skin fell itchy. If you scratch more chemicals are released and the itchier your skin feels.  This "scratch and itch" cycle can be most distressing.

Known triggers (or aggravating factors) for eczema include:

• Dry skin
• Scratching (night gloves and clipped fingernails may be needed in young children)
• Viral or bacterial infections
• Food allergy
• Other allergies (such as dust mites, animals)
• Food irritants 
• Other irritants (such as perfumes, soap, chemicals, woollen or synthetic fabrics)
• Urticaria (hives)
• Temperature changes (such as heat)
• Stress (this can make it worse but eczema is not a psychological condition).

Contact with allergens can worsen eczema

Contact with allergens can worsen eczema, and allergen avoidance or minimisation often brings about improvement. For example, close contact with animals can cause itching and sometimes urticaria (hives), as can sitting and playing on the grass. Worsening of eczema in spring and summer may also be due to pollen sensitivity. Contact with house dust mite allergen on the skin can increase inflammation.

Not all eczema is due to allergies

Constant exposure to irritants like water, soap, grease, food or chemicals can damage the protective barrier function of the skin. Once the protective barrier of the skin is lost, eczema frequently develops. Certain foods and drink may aggravate eczema even if the person is not food allergic. Common triggers of eczema include spicy foods, curries, alcohol (especially red wine), strawberries, tomatoes and the food colouring tartrazine.

The 3 steps for eczema skin care

1. Eczema under control - maintain the protective barrier function of the skin

Keep skin soft and supple (not red and itchy) by regular moisturising and avoidance of triggers/irritants.

2. Moderate eczema flare - protect and repair if skin is red, itchy, dry, flaking

Use thicker moisturisers regularly and avoid triggers/irritants.  Reduce inflammation of eczema with corticosteroid ointments if needed.  Watch for signs of infection (weeping, oozing, crusting, pustules, unresponsive eczema, fever and malaise) as this may require antibiotics prescribed by a doctor.

3. Moderate to severe eczema flare - intensive treatment

When eczema is not responding to the above treatments a greasy cream will be required and applied throughout the day, as recommended by your doctor.

For further detailed information on the 3 steps for eczema skin care, ASCIA Action and Care plans are available on the ASCIA website: www.allergy.org.au/content/view/345/284/

Applying corticosteroid ointment for eczema

If your doctor has prescribed corticosteroid ointment to reduce inflammation when your eczema flares, this needs to be used in the amount suggested by your doctor.  A guide is included in the ASCIA action plan for eczema.  These ointments are applied to inflamed red and itchy areas and are the only medications that will reduce the inflammation of eczema.  However, they do not cure eczema. Directions should be carefully followed to avoid side effects, such as shiny or thin skin, stretch marks or easy bruising. The skin of the face and neck tends to be more sensitive to the side effects of corticosteroid ointments.

Other forms of therapy

• Cortisone tablets are only rarely used to treat eczema, and even then only for short periods.
• Antihistamines are generally of little use in reducing the itch of eczema. Older, drowsy antihistamines sometimes help people sleep through their itch.
• Immune suppressants are sometimes needed when the inflammation of eczema is very hard to control. They need to be used carefully and under close medical supervision.
• Ultraviolet light ("PUVA") reduces inflammation
• Relaxation therapy may help when stress pays a role. Stress management courses sometimes help.
• Evening Primrose Oil is very popular to moisten the skin. Evidence of effectiveness is controversial.
• Specific medication is available for patients suffering from hereditary angioedema.

Eczema and food allergy

Food allergy does not cause eczema, but can worsen it in some children. It only occasionally aggravates eczema in adults. The most common causes are cow's milk, soy protein, egg, nuts, seeds, wheat and seafood, although sometimes other foods are involved. Fortunately, most food allergies that aggravate eczema will disappear within the first few years of life.

The majority of children with food allergy will get intensely itchy with large hives within an hour or less of eating. Sometimes infants will have more subtle symptoms, such as irritability or a slightly worse rash after a feed. Occasionally, infants will even react to small amounts of food present in their mother's breast milk. If the mother avoids the food in her diet, the baby's eczema may improve.

Identification of the offending food (or foods) with skin prick tests or blood allergen specific IgE (RAST) allergy tests can help to identify the culprit(s) in many cases. However, since not all positive skin tests and positive RAST tests are clinically relevant, the test results are best assessed by a medical specialist (Allergist / Clinical Immunologist). The final answer is often provided by a temporary elimination diet of the offending foods, under medical supervision. If the skin improves, foods are introduced one at a time to see whether the eczema flares up. If there is no improvement in two weeks on the elimination diet, it means that food is unlikely to be a problem.

Less commonly, reactions will be delayed over several days. Allergy testing is less reliable in this situation. Taking young children off wheat and milk is not appropriate for the majority. Long term unsupervised (and often unnecessary) dietary restriction can lead to malnutrition. Elimination and challenge with foods should only be undertaken under medical supervision.

© ASCIA 2010

The Australasian Society of Clinical Immunology and Allergy (ASCIA) is the peak professional body of Clinical Immunologists and Allergists in Australia and New Zealand.

Website: www.allergy.org.au

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Disclaimer

ASCIA Education Resources (AER) information is reviewed by ASCIA members and represents the available published literature at the time of review.  The content of this document is not intended to replace professional medical advice and any questions regarding a medical diagnosis or treatment should be directed to a medical practitioner.

Content last updated January 2010