Atopic eczema is like an ‘asthma of the skin’

Good news: New medicines coming out will greatly help in the treatment of atopic eczema

Eczema and dermatitis are both terms with the same meaning: inflammation, redness, and itching of the skin. Atopic eczema (a.k.a. atopic dermatitis) is a skin disease. The first sign of eczema tends to be patches of dry or red, itchy skin. Atopic eczema is controlled by a combination of genetic and environmental factors.

Unfortunately, because dermatitis can be so itchy, aggressive scratching can injure the skin and worsen the condition. Sometimes the itch can precede the rash. Some doctors say atopic eczema is “the itch that rashes.”

Atopic eczema usually begins very early in life as a condition affecting infants or young children, but it can occur at any age. It is most common in infants and young children, and most people who get eczema will have it before they turn five years old. It is rare for eczema to appear for the first time in adults.

Eczema can be more common and problematic in persons of color. In fact, 25 percent of all children of color (and large percentages of other children as well) can be affected by atopic eczema.

Eczema tends to come and go, often without warning. A treatment plan that includes skin care can reduce flare-ups and ease much of the discomfort.

The good news is that there are excellent new treatments for atopic eczema available now and coming out this summer. I will discuss those shortly.

What causes eczema?

Atopic eczema is a genetic condition. It is often seen in patients whose family members have it or other related conditions such as asthma, hay fever or allergic rhinitis. Some patients may have atopic eczema alone or with several or all of these other conditions.

There is emerging evidence that patients with atopic eczema may have a mild disability to repair their skin barrier. Also, excessive bacteria on the skin with bacterial enzymes (proteases) can make eczema worse. These are two important targets in controlling the disease.

Atopic eczema is not contagious. Dry skin, dry weather, perspiration and illness are several things that can cause atopic eczema to get worse.

How can I tell if my child has eczema?

Atopic eczema presents as red, flakey, itchy patches. In children, it commonly appears on the folds of the elbows and knees and on the scalp, forehead and cheeks, but it can be present anywhere. Atopic eczema itches so much that infants commonly rub their cheeks on bed linens or even carpeting for relief.

In extreme cases, a yellow fluid may even weep from the involved areas. Scratching over extended periods of time will cause the skin to become tough and thicken up. This is a common finding in patients with longstanding eczema that has not been completely controlled.

If you think that your child has atopic eczema, visit a board-certified dermatologist to make sure the diagnosis is correct. A dermatologist can often diagnose eczema by examining the patient’s skin, as well as by asking historically significant questions about a family history of similar skin rashes or asthma or hay fever.

How long will my child have eczema?

In most children, atopic eczema may get better over time, but their skin will always be more sensitive than those without atopic eczema, even as adults.

How is eczema treated?

A dermatologist will create a specific treatment for the patient with atopic eczema. Most treatment plans consist of:

• General skin-care program to maintain the skin barrier
• Medical treatments
• Tips to avoid flare-ups

There is no one treatment for atopic eczema. It is important to follow the treatment plan designed by your dermatologist, and the success in adequately managing atopic eczema depends on carefully following the treatment plan. Dermatologists will develop plans that are both safe and effective for long-term use.

In February of 2017, the FDA has approved a new ointment called Crisaborole (Eucrisa) for the treatment of atopic dermatitis. It is an ointment that is applied twice daily to the affected areas. Many patients are seeing remarkable improvements in just one or two weeks.

Over the past 10 years, there has been an explosion of medicines called “biologic treatments” for psoriasis. A promising new medication from this class is called Dupilumab. This medicine blocks a special protein receptor (interleukin-4) that controls regulatory proteins (interleukin-4 and interleukin-13) that control how certain white blood cells (type 2 helper T-cells) create inflammation in the skin, the hallmark of atopic eczema. This medicine, and others like it, may be available as soon as this summer.

What will the treatment plan include?

• Extreme moisturizer and emollient. I recommend bathing DAILY and then immediately sealing in the skin hydration with a rich cream; some call this “soak and seal.” Keeping the skin hydrated is one of the safest and most effective strategies for treating atopic eczema. It minimizes flare-ups and makes the skin more comfortable.
• Gentle non-detergent cleanser to reduce irritation and skin dryness
• Topical steroidal or non-steroidal creams or ointments for inflammation and itch control
• Antihistamine for itch and sleep
• Wet wraps for the skin to hydrate and make the other medicines penetrate and work better
• Bleach baths (very diluted) to reduce the bacteria on the skin that can make atopic eczema worse. It is important to also wash pajamas and bed linens on the same day as the weekly bleach bath for maximum effectiveness.
• Antibiotics to reduce bacteria and also work as a non-steroidal anti-inflammatory medicine
• Systemic medications when the condition is severely flaring and other agents are not helping. These medicines can be very strong, and your dermatologist will explain the risks and benefits of such a treatment.
• Phototherapy treatments. This is a very safe, effective, steroid-sparing treatment that can greatly help in the treatment of atopic eczema.

Why see a dermatologist?

When a child has atopic eczema, it is a condition that affects the entire family. It takes time away from other siblings and caregivers and can affect performance in school.

As a dermatologist, I like to tell parents atopic eczema is like having “asthma of the skin.” Just like asthma, it can wax and wane and have certain triggers. Just like asthma, it is a lifelong condition that needs attention but over time may improve.

With so much information out there, much of it misleading or downright inaccurate, it can be challenging for a parent to know exactly what to do. Dermatologists specialize in treating skin conditions and can help parents make the best-informed decisions for their children.

A dermatologist can develop a specific treatment plan for the atopic eczema patient. With new medicines being approved and released, in combination with the other classic treatments listed above, we will be able to treat atopic eczema better than ever before.

Research has shown that parents who develop a good relationship with their dermatologist and follow a designed treatment plan will have the most success in treating their child’s atopic eczema over time.

Charles E. Crutchfield III, MD is a board certified dermatologist and Clinical Professor of Dermatology at the University of Minnesota Medical School. He also has a private practice in Eagan, MN. He received his M.D. and Master’s Degree in Molecular Biology and Genomics from the Mayo Clinic. He has been selected as one of the top 10 dermatologists in the United States by Black Enterprise magazine. Dr. Crutchfield was recognized by Minnesota Medicine as one of the 100 Most Influential Healthcare Leaders in Minnesota. He is the team dermatologist for the Minnesota Twins, Vikings, Timberwolves, Wild and Lynx. Dr. Crutchfield is an active member of both the American and National Medical Associations.