The Australasian Society of Clinical Immunology and Allergy

Eczema, also referred to as Atopic Dermatitis, is an inflammation (reddening and swelling) of the skin which is very itchy. Symptoms vary from mild to severe. It is a chronic condition, lasting for many months or years and is very common, affecting at least five per cent of the people at some time in their lives. Other skin conditions associated with allergy are Contact Dermatitis, Urticaria (hives) and Angioedema (swelling of various parts of the body).

Eczema is often associated with a family history of allergy

Although the reason why people get eczema is unknown, patients with eczema have a tendency to react to a wide range of environmental agents. This state is known as atopy. The cause of atopy is not known, but inherited factors are important. In atopic people there is usually a strong family history of asthma, allergic rhinitis (hay fever) or eczema. As a consequence, eczema often occurs in company with other allergic disorders such as asthma and hayfever, and it may become worse when asthma improves and the other way around.

Infantile eczema usually disappears by age five

Infantile eczema usually starts between 4 to 6 months of age and the baby develops a red rash, which may weep. It appears on the cheeks and may spread to the forehead and the backs of arms and legs. In severe cases it may involve the whole body. Heavy scaling similar to cradle cap may occur. Eczema usually disappears between the ages of three and five years.

Childhood eczema may follow the infantile phase

Childhood eczema may follow the infantile phase almost immediately, or it may start for the first time between the ages of 2-4 years. In childhood eczema, the rash is found in the creases of the elbows, behind the knees, across the ankles and may involve the face, ears and neck as well. This form of eczema usually disappears by the age of ten, but may continue into adult life.

Adult eczema improves in middle life

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

Several factors can aggravate eczema

1. Contact with allergens
Contact with allergens such as dust mites, animal danders (in particular cats and dogs), grass pollen and mould spores are known to provoke flare-ups of eczema. Avoidance of the allergens often brings about improvement.

The importance of dust mite sensitivity is becoming better recognised as a potent aggravator of eczema. Dust mite counts are usually very high in the homes of people with eczema because of the large amount of skin scales shed, giving an abundant food supply for the mites. Strict dust avoidance measures may often help. Worsening of eczema in spring, between the months of September and January may be due to pollen sensitivity. Avoid sitting or playing on grass, and avoid being outside for too long.

2. Food allergies
Infants can react to food allergens present in mother's breast milk. If the mother avoids the offending food in her diet the baby's eczema will improve.

The identification of the offending food (or foods) is made by skin prick testing or RAST (blood) testing the baby to a limited number of staple foods (eg the most common food allergens are egg, cow's milk, wheat, fish, soy and peanut products).

Egg is usually the culprit in breast fed babies and once identified the mother can easily go without eggs and avoid them in cooking. In toddlers where the diet is being widened, parents will often observe an immediate flare up with particular foods. Once identified, these can be avoided. However, when a food is being eaten every day it is not easy to identify the food which makes the eczema worse. Skin prick testing to a panel of everyday foods will help to point the way. But not all positive skin prick tests and positive RAST tests are clinically relevant and results need to be assessed by an experienced doctor.

The final answer is provided by a strict elimination diet. If the skin improves on the elimination diet, foods are introduced one at a time to see whether the eczema flares up. Elimination and challenge with foods should be undertaken only under medical supervision. If there is no improvement in two weeks on the elimination diet, it means that food is unlikely to be a problem.

Most children grow out of food allergies within one to three years and diets can be relaxed. Food allergy is seldom related to eczema in adults.

Certain foods and drink may aggravate eczema by causing the skin to itch. Such foods include spicy foods, curries, alcohol (especially red wine), strawberries, tomatoes and the food colouring tartrazine.

3. Stress

4. Weather changes

5. Irritants
These include woollen clothes, perfumes, soaps and chemicals.

Effective management of eczema will relieve symptoms

1. Avoid known aggravating agents such as allergens and coarse woollen and synthetic clothes. Wear loose fitting cotton clothes which are washed with true soap. Always wash bed clothes in hot water and rinse thoroughly.
2. Avoid long hot showers and do not use soap. Take a short cool shower once a day and use non greasy lotions or soap substitutes to cleanse the skin. Use moisturisers such as sorbolene on the skin at least 3-4 times daily.
3. Try not to scratch! If the itch is very severe get into a cool bath containing soothing bath oil or oatmeal.
4. Use steroid creams or ointments in the lowest possible strength that keeps the affected skin comfortable, but treat the severe flare-ups with higher strength preparations or ointments sooner rather than later.
5. Sedating antihistamines at night may help some, but not all, people with eczema to sleep and prevent scratching. Non sedating antihistamines (eg Claratyne, Telfast or Zyrtec) may be used during the day.
6. Skin infections require prompt medical attention, as they can cause worsening of eczema. Avoid people with cold sores, shingles and chicken pox.
7. Stress can make eczema worse. Learn to manage your stress better. A course in stress management may be helpful.
8. Consult your doctor, dermatologist or allergy specialist, who may prescribe
   appropriate medications for your eczema, especially if there is a change for the worse.
9. Your pharmacist can also recommend certain medications, suitable moisturisers and soap substitutes and will tell you when medical advice is necessary.

Contact Dermatitis

The most common cause of acutely blistered, reddened and painful burning lesions on exposed skin is contact with chemicals used in industry, cosmetics and cleaning agents. Many plants can cause such lesions and two of the most common are the Rhus tree and Robyn Gordon Grevillea. Dermatitis can also occur from windblown fragments of members of the daisy family and usually presents as a more generalised rash on exposed parts such as the face and arms. The diagnosis is made by means of patch testing by a dermatologist or allergist. The treatment is avoidance of the identified cause, use of cortisone creams and in severe cases cortisone type oral medications.

Angioedema

Angioedema is a condition which may occur on its own, or together with Urticaria (hives).
It causes swelling of various parts of the body, such as the lips, eyes, hands, soles of feet and the groin. When angioedema involves the tongue and throat, breathing can become obstructed (blocked) and urgent medical treatment is required. However, this is not a common condition.

Urticaria occurs frequently in children

Urticaria, commonly called hives, occurs frequently in children and seldom lasts more than two weeks. The rash may consist of small very itchy spots that look like mosquito bites or may develop into larger itchy welts. The most common causes are infections, particularly viral illness, or processed foods containing additives such as preservatives and artificial colours. Attacks due to food additives occur often after children's parties and around Christmas time. Allergies to food such as peanut, egg, fish or milk and some fruits may trigger hives. Acute Urticaria in adults and adolescents has the same causes as in children. Occasionally antibiotics or other medications cause hives.

Urticaria persisting for longer than six weeks is known as chronic Urticaria. The cause is often difficult to find and investigations are needed to make sure it is not some illness (eg glandular fever) that is causing the hives. Antihistamines on their own or in combination with other medications, are the first line of treatment, but if these do not relieve symptoms other measures may be needed.

Disclaimer
The content of this article has been reviewed by ASCIA members, represents the available published literature at the time of review and is not intended to replace professional medical advice. Any questions regarding a medical diagnosis or treatment should be directed to a medical practitioner.

For further information on allergy, asthma or immune diseases,
visit http://www.allergy.org.au/ - the web site of
ASCIA is the peak professional body of Clinical Allergists and
Immunologists in Australia and New Zealand.

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© ASCIA 2004

 Content Last updated 1 January 2004