Eczema Treatment

There is no known cure for eczema, thus treatments aim to control the symptoms: reduce inflammation and relieve itching.

Medications

Corticosteroids

Dermatitis is often treated with corticosteroids. They do not cure eczema, but are highly effective in controlling or suppressing symptoms in most cases.

For mild-moderate eczema a weak steroid may be used (e.g. hydrocortisone or desonide), whilst more severe cases require a higher-potency steroid (e.g. clobetasol propionate, fluocinonide). Medium-potency corticosteroids such as clobetasone butyrate (Eumovate), Betamethasone Valerate (Betnovate) or triamcinolone are also available. Generally medical practitioners will prescribe the less potent ones first before trying the more potent ones. In many countries, weak steroids can be purchased 'over the counter' (e.g., hydrocortisone in UK, United States, Germany, Czech Republic, Australia, Iceland), while the more potent ones require a prescription.

Side effects

Prolonged use of topical corticosteroids is thought to increase the risk of possible side effects, the most common of which is the skin becoming thin and fragile (atrophy).

Because of this, if used on the face or other delicate skin, only a low-strength steroid should be used. Additionally, high-strength steroids used over large areas, or under occlusion, may be significantly absorbed into the body, causing hypothalamic-pituitary-adrenal axis suppression (HPA axis suppression).

Finally by their immunosuppressive action they can, if used without antibiotics or antifungal drugs, lead to some skin infections (fungal or bacterial). Care must be taken to avoid the eyes, as topical corticosteroids applied to the eye can cause glaucoma or cataracts.

Because of the risks associated with this type of drug, a steroid of an appropriate strength should be sparingly applied only to control an episode of eczema. Once the desired response has been achieved, it should be discontinued and replaced with emollients as maintenance therapy. Corticosteroids are generally considered safe to use in the short- to medium-term for controlling eczema, with no significant side effects differing from treatment with non-steroidal ointment.

However, recent research has shown that topically applied corticosteroids did not significantly increase the risk of skin thinning, stretch marks or HPA axis suppression (and where such suppression did occur, it was mild and reversible where the corticosteroids were used for limited periods of time). Further, skin conditions are often under-treated because of fears of side effects. This has led some researchers to suggest that the usual dosage instructions should be changed from "Use sparingly" to "Apply enough to cover affected areas," and that specific dosage directions using "fingertip units" or FTU's be provided, along with photos to illustrate FTU's.

Other forms

In severe cases, oral cortisosteroids such as prednisolone or injections such as triamcinolone injections may also be prescribed. While these usually bring about rapid improvements, they should not be taken for any length of time and the eczema often returns to its previous level of severity once the medication is stopped.

In the case of triamcinolone injections, a waiting period between treatments may be required!

Immunomodulators

Topical immunomodulators like pimecrolimus (Elidel and Douglan) and tacrolimus (Protopic) were developed after corticosteroid treatments, effectively suppressing the immune system in the affected area, and appear to yield better results in some populations.

The U.S. Food and Drug Administration has issued a public health advisory about the possible risk of lymph node or skin cancer from use of these products, but many professional medical organizations disagree with the FDA's findings;

The postulation is that the immune system may help remove some pre-cancerous abnormal cells which is prevented by these drugs. However, any chronic inflammatory condition such as eczema, by the very nature of increased metabolism and cell replication, has a tiny associated risk of cancer (see Bowen's disease).
Current practice by UK dermatologists is not to consider this a significant real concern and they are increasingly recommending the use of these new drugs. The dramatic improvement on the condition can significantly improve the quality of life of sufferers (and families kept awake by the distress of affected children). The major debate, in the UK, has been about the cost of such newer treatments and, given only finite NHS resources, when they are most appropriate to use.
In addition to cancer risk, there are other potential side effects with this class of drugs. Adverse reactions including severe flushing, photosensitive reactivity and possible drug interaction in patients who consume even small amounts of alcohol.

Antibiotics

When the normal protective barrier of the skin is disrupted (dry and cracked), it allows easy entry for bacteria. Scratching by the patient both introduces infection and spreads it from one area to another. Any skin infection further irritates the skin and a rapid deterioration in the condition may ensue; the appropriate antibiotic should be given.

Immunosuppressants

When eczema is severe and does not respond to other forms of treatment, immunosuppressant drugs are sometimes prescribed. These dampen the immune system and can result in dramatic improvements to the patient's eczema. However, immunosuppressants can cause side effects on the body. As such, patients must undergo regular blood tests and be closely monitored by a doctor. In the UK, the most commonly used immunosuppressants for eczema are ciclosporin(Cyclosporine), azathioprine and methotrexate. These drugs were generally designed for other medical conditions but have been found to be effective against eczema.

Commonly prescribed as an immunosuppressant in the United States for Eczema is the steroid Prednisone.

Itch relief

Anti-itch drugs, often antihistamine, may reduce the itch during a flare up of eczema, and the reduced scratching in turn reduces damage and irritation to the skin (the ''Itch cycle'')., however,in eczema, the itch relief is often due to the sedative side effects of these drugs, rather than their specific antihistamine effect. Hence, sedating antihistamines such as promethazine (Phenergan) or diphenhydramine (Benadryl) are more effective at relieving itch than the newer, nonsedating antihistamines.

Capsaicin applied to the skin acts as a counter irritant (see: Gate control theory of nerve signal transmission).

Hydrocortisone applied to the skin aids in temporary itch relief.

Avoiding dry skin

Moisturizing

Eczema can be exacerbated by dryness of the skin. Moisturizing is one of the most important self-care treatments for sufferers of eczema. Keeping the affected area moistened can promote skin healing and relief of symptoms.

Soaps and harsh detergents should not be used on affected skin because they can strip natural skin oils and lead to excessive dryness. Instead, the use of moisturizing body wash, or an emollient like aqueous cream, will maintain natural skin oils and may reduce some of the need to moisturize the skin. Another option is to try bathing using colloidal oatmeal bath treatments. In addition to avoiding soap, other products that may dry the skin such as powders or perfume should also be avoided.

Moistening agents are called 'emollients'. In general, it is best to match thicker ointments to the driest, flakiest skin. Light emollients like aqueous cream may not have any effect on severely dry skin. Some common emollients for the relief of eczema include ''Oilatum'', ''Balneum'', ''Medi Oil'', ''Diprobase'', bath oils and aqueous cream. ''Sebexol'', ''Epaderm'' ointment, ''Exederm'' and ''Eucerin'' lotion or cream may also be helpful with itching. Lotions or creams may be applied directly to the skin after bathing to lock in moisture. Moisturizing gloves (gloves which keep emollients in contact with skin on the hands) can be worn while sleeping. Generally, twice-daily applications of emollients work best. While creams are easy to apply, they are quickly absorbed into the skin, and therefore need frequent reapplication. Ointments, with less water content, stay on the skin for longer and need fewer applications, but they can be greasy and inconvenient. Steroids may also be mixed in with ointments.

For unbroken skin, direct application of waterproof tape with or without an emollient or prescription ointment can improve moisture levels and skin integrity which allows the skin to heal. This treatment regimen can also help prevent the skin from cracking, as well as put a stop to the itch cycle. The end result is reduced lichenification (the roughening of skin from repeated scratching). Taping works best on skin away from joints.

There is a disagreement whether baths are desirable or a necessary evil. For example, the Mayo Clinic advises against daily baths to avoid skin drying.. On the other hand,

the American Academy of Dermatology claims "it is a common misconception that bathing dries the skin and should be kept to a bare minimum" and recommends bathing to hydrate skin. They even suggest up to 3 short baths a day for people with severe eczema. According to them, a moisturizer should be applied within 3 minutes to trap the moisture from bath in the skin.

U.S. National Eczema Association and the Eczema Society of Canada make similar recommendations. Recently, ceramides, which are the major lipid constituent of the stratum corneum, have been used in the treatment of eczema. They are often one of the ingredients of modern moisturizers. These lipids were also successfully produced synthetically in the laboratory.

Eczema and skin cleansers

One of the recommendations is that people suffering from eczema should not use detergents of any kind on their skin unless absolutely necessary. Eczema sufferers can reduce itching by using cleansers only when water is not sufficient to remove dirt from skin.

However, detergents are so ubiquitous in modern environments in items like tissues, and so persistent on surfaces, "safe" soaps are necessary to remove them from the skin in order to control eczema. Although most eczema recommendations use the terms "detergents" and "soaps" interchangeably, and tell eczema sufferers to avoid both, detergents and soaps are not the same and are not equally problematic to eczema sufferers. Detergents, often made from petrochemicals, increase the permeability of skin membranes in a way that soaps and water alone do not. Sodium lauryl sulfate, the most common household detergent, has been shown to amplify the allergenicity of other substances ("increase antigen penetration").

Unfortunately there is no one agreed-upon best kind of skin cleanser for eczema sufferers. Different clinical tests, sponsored by different personal product companies, unsurprisingly tout various brands as the most skin-friendly based on specific properties of various products and different underlying assumptions as to what really determines skin friendliness. The terms "hypoallergenic" and "doctor tested" are not regulated, and no research has been done showing that products labeled "hypoallergenic" are in fact less problematic than any others. It may be best to avoid soaps and detergent clensers all together, except for the armpits, groin and perianal areas, and use cheap bland emolients in the bath or shower, for example aqueous cream.

Dermatological recommendations in choosing a soap generally include:

Avoid harsh detergents or drying soaps
Choose a soap that has an oil or fat base
Use an unscented soap
Patch test your soap choice, by using it only on a small area until you are sure of its results
Use a non-soap based cleanser

Instructions for using soap:

Use soap sparingly
Avoid using washcloths, sponges, or loofahs, or anything that will abrade the skin
Use soap only on areas where it is necessary
Soap up only at the very end of your bath
Use a fragrance-free barrier-type moisturizer such as petroleum jelly before drying off
Use care when selecting lotion, soap, or perfumes to avoid suspected allergens; ask your doctor for recommendations
Never rub your skin dry, or else your skin's oil/moisture will be on the towel and not your body; pat dry instead

Environmental measures

While it has been suggested that eczema may sometimes be an allergic reaction to the excrement from house dust mites, with up to 5% of people showing antibodies to the mites, the overall role this plays awaits further corroboration.

Various measures may reduce the amount of mite antigens, in particular swapping carpets for hard surfaces. Effectiveness of vacuum cleaners is dependent upon the characteristics of the carpet pile, but in other studies daily vacuuming did not affect levels of mites. However it is not clear whether such measures actually help patients with eczema. A controlled study suggested that a number of environmental factors such as air exchange rates, relative humidity and room temperature (but not the level of house dust mites) might have an effect on the condition.

Staphylococcus aureus colonies are developed by overly scratching excema. In a 2009 study from Northwestern University, children with moderate or severe eczema were giving diluted bleach baths and this reduced the severity of the disease. Diluted bleach has been know to have antibacterial qualities. In the study, diluted meant a half cup of bleach to a full tub of water and a bath meant soaking for 5–10 minutes. Antibacterial bath oils containing agents such as triclosan or benzalkonium chloride are available to both moisturise the skin and suppress Staphylococcus aureus. Brand names include Oilatum Plus and QV Flareup Oil.

Light therapy

Light therapy (or Deep penetrating light therapy) using ultraviolet light can help control eczema. UVA is mostly used, but UVB and Narrow Band UVB are also used. Overexposure to ultraviolet light carries its own risks, particularly potential skin cancer from exposure.

When light therapy alone is found to be ineffective, the treatment is performed with the application (or ingestion) of a substance called psoralen. This PUVA (Psoralen + UVA) combination therapy is termed photo-chemotherapy. Psoralens make the skin more sensitive to UV light, thus allowing lower doses of UVA to be used. However, the increased sensitivity to UV light also puts the patient at greater risk for skin cancer.

Diet and nutrition

Recent studies provide hints that food allergy may trigger atopic dermatitis. For these people, identifying the allergens could lead to an avoidance diet to help minimize symptoms, although this approach is still in an experimental stage.

Dietary elements that have been reported to trigger eczema include dairy products and coffee (both caffeinated and decaffeinated), soybean products, eggs, nuts, wheat and maize (sweet corn), though food allergies may vary from person to person.

However, in 2009, researchers at National Jewish Medical and Research Center found that eczema patients were especially prone to misdiagnosis of food allergies.

Recently Margitta Worm ''et al.'' discovered that a diet rich in omega-3 (and low in omega-6) polyunsaturated fatty acids may be able to reduce symptoms.

Alternative therapies

Non-conventional medical approaches include traditional Chinese medicine and Western herbalism. There are a wide variety of treatments, each of which may vary from individual to individual as to efficacy or harm. Patients should inform their doctor/allergist/dermatologist if they are pursuing one of these treatment routes.

Alleged remedies include:

Oatmeal is a common remedy to relieve itching, and can be applied topically as a cream or, as a colloid, in the bath. It is also part of many commercially available products intended for eczema treatment and for other skin conditions. But some recent studies say that oat can provoke a flare-up on some patients.
Sea water: According to the British Association of Dermatologists, there is considerable anecdotal evidence that salt water baths may help some children with atopic eczema. One reason might be that seawater has antiseptic properties. The Dead sea is popular for alleviating skin problems including eczema.
Sulfur has been used for many years as a topical treatment in the alleviation of eczema, although this could be suppressive. It was fashionable in the Victorian and Edwardian eras. Recently sulfur has regained some popularity as a homeopathic alternative to steroids and coal tar. However, there is currently no scientific evidence for the claim that sulfur treatment relieves eczema.
Probiotics are live microorganisms taken by mouth, such as the ''Lactobacillus'' bacteria found in yogurt. They are not effective for treating eczema in older populations, but some research points to some strains of beneficial microorganisms having the ability to prevent the triad of allergies, eczema and asthma, although in rare cases they have a very small risk of infection in those with poor immune system response.
Traditional Chinese medicine: According to American Academy of Dermatology, while certain blends of Chinese herbal medicines have been proven effective in controlling eczema, they have also have proven toxic with severe consequences. In Chinese Medicine diagnosis, eczema is often considered a manifestation of underlying ill health. Treatment aims to improve the overall health of the individual, therefore not only resolving the eczema but improving quality of life (energy level, digestion, disease resistance, etc.). A recent study published in the British Journal of Dermatology describes improvements in quality of life and reduced need for topical corticosteroid application. Another British trial with ten different plants traditionally used in Chinese medicine for eczema treatment suggest a benefit with herbal remedy, but reviewers noted that the blinding was not maintained, leaving the results invalid.
Other remedies lacking scientific evidence include chiropractic spinal manipulation.

Patients can also wear clothing designed specifically to manage the itching, scratching and peeling associated with eczema.

Behavioural approach

In the 1980s, Swedish dermatologist Peter Noren developed a behavioural approach to the treatment of long term atopic eczema. This approach has been further developed by dermatologist Richard Staughton and psychiatrist Christopher Bridgett at the Chelsea and Westminster Hospital in London.

Patients undergo a 6 week monitored program involving scratch habit reversal and self awareness of scratching levels. For long term eczema sufferers, scratching can become habitual. Sometimes scratching becomes a reflex, resulting in scratching without conscious awareness, rather than from the feeling of itchiness itself. The habit reversal program is done in conjunction with the standard applied emollient/corticosteroid treatments so that the skin can heal. It also reduces future scratching, as well as reduces the likelihood of further flareups. The behavioural approach can give an eczema sufferer some control over the degree of severity of eczema.