Key learning points:
– Types of eczema
– Assessment: history and diagnosis
– Clinical presentations
Eczema is a common inflammatory, dry, scaly skin condition that can affect anyone from early infancy to old age. Another name for eczema is dermatitis – “derma” means skin and “titis” means inflammation. Both terms are used interchangeably.1 In the UK eczema affects one-in-12 adults and one-in-five children.2 There are several types of eczema and these will be covered within this article.
Diagnosis and history
Eczema diagnosis is made based on the appearance of the skin and history. The history should include the following questions and identify any trigger factors:
· Onset and duration.
· Skin sites affected.
· Family history of skin disease, eczema, asthma, hay fever.
· Past medical history.
· Medicines taken regularly, prescribed or purchased from a variety of sources.
· Treatments applied to the skin frequently.
· To drugs, products used or applied to the skin and foods.
· Current and previous occupation.
· Objects, materials and substances used regularly.
· Special or protective clothing worn.
· Does the condition improve away from work?
Hobbies and leisure time
Hobbies and materials used.
Contact with animals or pets.
Gardening – plants, flowers and weeds can be allergenic.
· Does exposure to sunlight cause or make the problem worse?
· Overheating: after exercise (sweat) and/or direct heat.
· Low humidity and extreme changes in temperature.
Clothing, skincare and jewellery
· Clothing fabrics worn i.e. gloves.
· Products used on a daily basis - shampoo, skincare products, make-up, perfumes and aftershave.
· Watches and jewellery.
· Do foods make the eczema worse? What sort of reaction occurs?
· Pain, itching and soreness can impact daily activities.
· History of infections and treatments used.
Impact on quality of life
· How does the eczema affect daily activities? For example school, work, family and relationships? There are specific quality of life questionnaires available at: cardiff.ac.uk/dermatology/quality-of-life/
Additional diagnostics will be based on the history, assessment and skin examination (see Box 1).
Skin examination and clinical presentation of eczema
The clinical presentation of eczema varies depending on the type of eczema, site affected and skin type. When assessing the skin ensure all areas are examined and documented using a body chart. Clinically eczema can be classified into:
· Acute: the skin is erythematous (red) inflamed, oedematous, dry and flaky. There may be vesicles (small fluid filled blisters), which may coalesce to form large bullae (blisters), which ooze and crust.
· Sub-acute: shows features of acute and chronic eczema.
· Chronic: the skin is lichenified (thickened) with accentuated skin markings from repeated scratching, picking and rubbing. It is often darker than the surrounding skin and fissures (splits and cracks) may be present.2
In asian, black caribbean and black african patients, atopic eczema can affect the extensor surfaces rather than the flexures, and discoid (circular) or follicular (around hair follicles) patterns may be more common with lesions, which in white skin appear red or brown, and appear black or purple in pigmented skin. Mild degrees of redness (erythema) may be masked completely and post inflammatory hypo-pigmentation (reduced) and hyper-pigmentation (increased) may persist after the eczema has settled.2
Types of eczema
Atopic eczema (AE) is the most common form of eczema, especially in children. It affects 1-2% of adults and 15-20% of schoolchildren, 2% of people aged 16-40 years are affected, and less than 0.2% of adults over the age of 40 years. Around 70% of children develop their atopic eczema in the first five years of life, and 60-70% of children will be free of the disease by their early teenage years.1 Atopic is a term used to describe a tendency to develop eczema, asthma or hay fever. It is multifactorial with a genetic and environmental component. These include defects in the skin barrier function making the skin more susceptible to irritation by soap and other contact irritants including: the weather, temperature and non-specific triggers.3
Seborrhoeic dermatitis is a common, harmless, scaly rash affecting the face, scalp and other areas occurring in 1-5% of the population. It is believed to be an inflammatory reaction related to a proliferation of a normal skin inhabitant, yeast called Malassezia (formerly known as Pityrosporum ovale).
It commonly affects infants under six months of age. It is characterised by yellow, waxy scales, which are thick and confluent on the scalp and hair and are difficult to remove (Cradle Cap). It may also affect other areas of the body (salmon pink flaky patches) such as behind the ears, in the creases of the neck, armpits and nappy area. It is not usually itchy and often doesn’t bother the child at all, although it may look unpleasant.1
In adults is more common in males than in females with a peak incidence in adolescents and young adults, and in adults over the age of 50. The scalp, nasolabial folds, eyebrows, ears, axillae and groins, chest and upper back can be affected. In the scalp there are salmon-pink flat or skin coloured patches with yellowish or white bran-like scale. It can affect the entire scalp.1
Contact dermatitis is caused by substances coming into contact with the skin and can be localised or generalised. Many different substances can cause contact dermatitis, including common things in the home or work environment. It can be divided into two types:
Irritant contact dermatitisis very common, accounting for more than three quarters of cases of contact dermatitis. It occurs as a direct result of physical damage or by cumulative damage to the skin from substances such as detergents, soaps, solvents and diluted acids or alkalis. It is commonly seen on the hands, especially around the finger webs where the skin is delicate and prone to damage. Occasionally the fingernails can become thickened and dented if it affects the hands for any length of time. The skin changes range from mild dryness to severe redness, fissuring and blistering.1
Allergic contact dermatitisis much less common than irritant contact dermatitis, accounting for around a fifth of cases of contact dermatitis overall1 and accounts for 85-98% of occupational skin disease.2 It is a type 4 (cell-mediated or delayed) hypersensitivity. This means that the first contact with a substance causes no immediate problems over a period of time, however, the allergen entering the skin sets up an immune response with further subsequent exposures resulting in an inflammatory eczematous reaction. Common sensitisers (allergens) are: nickel, chromate, rubber, and fragrances. It is often seen on the hands but can affect any area of skin. If the skin around the nails is affected then the nails can again become abnormal and thickened.
Stasis, gravitational, varicose eczema
Gravitational eczema is related to increased pressure in the veins of the legs. It is more common in women than men because female hormones and pregnancy both increase the risk of developing the condition. It is most common in adults who have varicose veins, or who have a history of leg ulcers or deep vein thrombosis in the legs. Patients who are overweight or spend a lot of time standing up are at risk. The skin becomes shiny, red, itchy and flaky. It can arise as discrete patches or affect the leg all the way around. Sometimes the eczema can become weepy and oozy, and yellow crusts and cellulitis can occur. Overtime the skin can become very lichenified and leathery with hyperpigmentation. There may be lipodermatosclerosis (woody texture), narrowing of the ankles and atrophie blanche (white scarred areas surrounded by tiny red spots). There may be oedema, ulceration and an autosensitisation with spread to other areas of skin.2
Discoid or nummular eczema
Discoid eczema (nummular eczema) is a common type of eczema in which there are round or oval blistered or dry skin lesions. The exact cause of discoid eczema is not known. Discoid eczema can occur at any age and affects males and females equally. It is also a pattern seen in children with atopic eczema. Several red, coin-shaped lesions appear, usually on the lower legs, trunk or forearms. At first these patches are slightly raised but after a few days they may develop raised papules or vesicles, which start to ooze. Later on, the surface of the discs becomes scaly with a clear centre. Discoid eczema can be very inflamed, itchy, crusted and infected.1
Pompholyx (dishydrotic or vesicular) eczema
Pompholyx is a common type of eczema affecting the hands and feet. The exact cause is not known but is aggravated by heat, stress, metals and perfumes. It affects about one-in-20 patients who have eczema on their hands. It is less common after middle age and in older people. Tiny blisters (vesicles) develop deep in the skin of the palms, fingers, instep or toes. The condition can be acute and chronic, it may be mild with only a little peeling, or very severe with large bullae, fissures and nail involvement.2
Lichen simplex (neurodermatitis)
Lichen simplex is a localised area of eczema caused by repeated rubbing or scratching. It occurs in 12% of the population and is more common in mid to late adulthood, peaking between 30 to 50 years. The trigger to scratch may be an existing skin condition, a compressed nerve leading to the skin (neuropathic itch or pruritus), or at times of stress and worry. It tends to be very persistent, and reoccurs. It presents as a localised demarcated plaque more than 5cm in diameter with scaling, excoriations and lichenification. Common sites are the calf, elbow, behind the neck, and genitalia (vulva or scrotum).2
Eczema craquelé or asteatotic eczema
Asteatotic eczema is a type of eczema associated with very dry skin and occurs most commonly in people over the age of 60 years. Elderly people living in dry heated rooms or those exposed to winter weather or excessive bathing or showering are at risk of developing this type of eczema.1 It commonly affects the shins, but sometimes involves other areas: thighs, arms, tummy and back. The skin becomes rough and scaly with a criss-cross pattern of cracks that look like ‘crazy-paving’ or ‘a dried river bed.’
Eczema and infections
All types of eczema can become infected and are often related to persistent scratching and damage to the skin and contamination of skin care products. Its important to identify the cause/type of infection and initiate the correct treatment, taking samples to confirm the infection may be required.
Signs of infection range from an acute flare of the eczema with vesicles, pustules, oozing and crusting. Other bacterial infections include folliculitis, impetigo and cellulitis.
The herpes simplex virus (cold sore virus) can spread very rapidly in people with atopic eczema (eczema herpeticum). Although it is rare, it is important to recognise because it can be a serious potentially fatal viral illness, requiring hospitalisation and treatment with systemic or intravenous antivirals: aciclovir. In the early stages vesicle (small blisters filled with clear fluid) surrounded by a bright red halo on the surface of the skin will appear. These vesicles leave punched out erosions on the skin surface which spread very quickly, especially across the face. The patient will feel generally unwell with the skin feeling sore, and painful rather than itchy. If eczema herpeticum is suspected, the patient should be seen by a dermatologist, ophthalmologist (if near eyes) GP or A&E doctor so treatment can be given promptly. Other viral infections include molluscum contagiosum and viral warts.
Fungal and yeast infections
Fungal and yeast infections occasionally cause secondary infection in people with eczema. Yeast infections such as candida (thrush) can secondarily infect eczema in warm moist sites such as under the breasts or around the genital area. Fungal infections (tinea) or ring worm (dermatophyte) can develop and often discoid eczema is misdiagnosed as ring worm. Tinea pedis (athletes foot) is common and other tinea infections are named based on site of body. If a fungal infection is suspected, skin scrapings, hair and nail samples should be taken for mycology to identify the fungi.2
Eczema is a common skin condition with many types. The diagnosis is important to ensure appropriate management and treatment.
National Eczema Society:
Nottingham support group for carers of children with eczema:
British Association Dermatologists:
British Dermatological Nursing Group:
New Zealand Dermatology Society:
NICE Clinical Knowledge Summaries:
Primary Care Dermatology Society:
Centre Evidence Based Dermatology:
The Global Resource of Eczema Trials:
1. Charman, C and Lawton, S Eczema. The treatments and therapies that really work Constable & Robinson, London; 2006.
2. National Eczema Society. Eczema and its Management. A Nurses Guide, 2014.
3. New Zealand Dermatology Society. Atopic Eczema, 2015. dermnetnz.org/dermatitis/atopic.html (accessed 14 August 2015).
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