The Australasian Society of Clinical Immunology and Allergy

Eczema occurs in around 1 in 5 infants, but usually improves with age. Many people who have eczema, especially infants, either have, or will develop other allergies.  Although eczema can be effectively treated, no cures are currently available.  

The skin in people with eczema differs from those who do not have eczema

In people with eczema the skin barrier is less effective than in people who do not have eczema.  In eczema there is a reduced production of fats and oils and the skin therefore has less water retaining properties. This means that skin with eczema does not provide the protection from the environment that normal skin does.

The National Eczema Society (UK) explains that skin is like a brick wall, with skin cells being the bricks, whilst oils and fats are the mortar. People with eczema make less ‘mortar’, meaning skin cells can shrink, causing gaps and loss of moisture. For a diagrammatic explanation of this, go to www.eczema.org/aboutskin.html

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 in the first 6 months of age and symptoms include a red rash and dry skin appearing on the cheeks. This 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 improves significantly 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 and dryness are 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 improves significantly by the age of 10 years, but may continue into adult life.  Although some children will completely outgrow their eczema, most will continue to have the tendency for dry and sensitive skin into adulthood.

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

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. However, not all people with eczema have a family history of 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 3 in 10 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 when your skin is damaged, moisture evaporates and cells shrink, and this causes cracks.  Allergens and irritants can get in, triggering the skin to release certain chemicals that make the skin itchy. If you scratch, more chemicals are released and the skin feels even itchier.  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
• Swimming in chlorinated swimming pools
• Teething
• Playing in sand and particularly sandpits
• Sitting on carpets at school
• Food allergy
• Other allergies (such as dust mites, animals)
• Food intolerances  
• 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 food additives such as benzoates, sodium metabisulfite and tartrazine.

The 3 steps for eczema skin care

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

• The term ‘emollient therapy’ is the use of the wash/oil AND the application of moisturisers afterwards and this is recommended to maintain the protective barrier of the skin.
• Use a non-soap based wash or oil in the bath or shower. It helps replace the oil content of the skin and is an essential part of eczema management. Products should be purchased from a pharmacy. Soap and bubbly products damage and dry the skin further.
• Keep skin soft and supple (not red and itchy), by regular moisturising and avoidance of triggers and irritants.

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

• Use emollient therapy, but include thicker moisturisers (applied regularly)
• Avoid triggers and irritants. 
• Reduce inflammation of eczema with corticosteroid creams or ointments, if needed. 
• Watch for signs of bacterial and/or fungal infection (weeping, oozing, crusting, pustules, unresponsive eczema, fever and malaise) as this may require antibiotics and/or antifungal cream, 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 need to be applied several times throughout the day.
• Prescribed topical corticosteroids will be required.
• Wet wraps may be recommended, unless the child is unwell or the eczema is infected.

Information about wet wraps is available at www.dermnetnz.org/procedures/wet-wraps.html

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

Applying corticosteroid cream or ointment for eczema

If your doctor has prescribed corticosteroid cream or 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 www.allergy.org.au/content/view/345/284/ 

Corticosteroid creams or ointments are applied to inflamed red and itchy areas and are the main 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 creams or ointments.

It is still important to moisturise the skin, even when your doctor has prescribed corticosteroid cream. However it is best to apply moisturiser a short time (ideally around 10 minutes) after the corticosteroid cream or ointment has been applied.

Other forms of eczema treatments

• Cortisone tablets are generally not recommended and are only rarely used to treat eczema, and even then only for short periods.   
• Antihistamines sometimes reduce the itch of eczema, however, they generally do not completely stop it. Sedating antihistamines are sometimes suggested to help people sleep through their itch, but are generally not recommended and should not be used in young children without specialist supervision.
• Anti-Staphylococcal (bacterial) measures are sometimes required in addition to regular skincare and antibiotics.
  • 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") can reduce 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.
  • Oral fish oil tablets are often used to help skin with eczema, but are not recommended if you have seafood allergy.
  • Goat’s milk products for washes, moisturisers and formulas are not usually recommended for people with severe cow’s milk allergy, as most of the proteins in goat’s and cow’s milk are the same.

Eczema and food allergy

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

The majority of children with food allergy will get intensely itchy with large hives within an hour or less of eating the offending food. 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 food/s in many cases. However, since not all positive skin tests and positive RAST tests are clinically relevant, the test results need to be assessed by a medical specialist (Allergist/Clinical Immunologist).

The final answer is often provided by a temporary elimination diet of the offending foods, usually under the supervision a medical specialist (Allergist/Clinical Immunologist), and often in association with an accredited practising dietitian, with specialised knowledge in food allergies. If the skin improves, foods are introduced one at a time (food challenges) 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 can be delayed over several days. Allergy testing is less reliable in this situation. Eliminating wheat and milk from the diet is inappropriate for the majority of children and long term unsupervised (and often unnecessary) dietary restriction can lead to malnutrition. It is important that elimination and challenge with foods is only conducted under medical supervision.

Useful websites

Eczema Association of Australasia www.eczema.org.au

New Zealand Dermatological Society www.dermnetnz.org

National Eczema Society (UK) www.eczema.org

© 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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Content last updated April 2010