A person with eczema may need to try a number of different treatments, or possibly a combination of treatments, before they obtain maximum relief. Since eczema is a variable condition which can flare up, they may also need to modify their treatment from time to time according to the severity of their eczema.
Emollients
The frequent and regular application of emollients is the single most important factor in preventing and managing eczema. Emollients are mixtures of oils, fats and water which help to restore the oil and moisture content of the skin. They are available in the form of creams, ointments, soap substitutes, lotions and medicinal bath oils. Trial and error will show which of the wide range available is most suitable for each individual. Different preparations may need to be used on different parts of the body.
Soap substitutes should be used when showering or bathing. Emollient creams should be used after bathing when the skin is still moist, and at regular intervals as the skin becomes dry and itchy. Emollients should be used even when the skin is apparently free of eczema. Some emollients are available from pharmacists while others can be obtained on prescription.
Risks: the only possible risk is that an individual may become sensitised to one of the ingredients in the emollient. Also, extra care is necessary when bathing since the creams and oils make the bath and the person using them slippery.
Bathing
Frequent bathing is essential for people with eczema, although it is important to add special emulsifying oils to counteract the drying effects of bathing (see above). Bath water should be warm - neither too hot nor too cool.
Topical steroids
In more severe cases of eczema, constant itching and scratching can lead to inflammation of the skin. Topical steroids are carefully designed anti-inflammatory drugs which can be used to bring the condition under control quickly, thus reducing the risk of infection. They should only be used under the supervision of a doctor and it is essential to use the appropriate strength and quantity of topical steroid.
As a general rule, it is best to apply steroids sparingly, not more than twice a day and for short periods of time. However, it is equally important to use adequate amounts of topical steroid: under-use will fail to control the eczema, causing more problems in the long term. As the eczema improves, the strength of steroid should be reduced.
A wide variety of topical steroids are available, enabling GPs to prescribe specific potencies and combinations to suit each individual. One particular type of mild potency steroid, hydrocortisone, can now be bought from pharmacists. However, it may not be purchased for use on children under the age of ten, pregnant women or for use on the face or genital areas and should not be used for longer than seven days without GP supervision.
Risks: From time to time steroids receive adverse publicity and are branded as potentially dangerous medications. It is important to remember that if they are correctly used, the risk of side effects is very small. If it is under-treated, eczema itself can lead to damaged skin, or even hospitalisation, and so the benefits of using topical steroids correctly, outweigh the potential side effects associated with their misuse. 'Correct use' means using the appropriate strength of steroid to treat each flare-up within the minimum length of time.
Wet wrapping
Wet wrapping is a bandaging system used to control the symptoms of eczema. It helps to reduce the amount of itching, which can make it easier for those affected by eczema to sleep, particularly children. Wet wraps should be used on red, dry and itching skin and should never be used on infected skin. Anyone wishing to use wet wraps needs to be assessed by their dermatologists, a dermatology nurse or a GP who has had dermatology training. Usually wet wraps are suggested as an option after other treatments such as emollients and topical steroids have failed to produce results.
PUVA
Light treatments can be used for people with severe eczema. PUVA stands for psoralen and ultraviolet light. A special machine is used to administer treatment sessions. About 50% of those treated with PUVA will improve.
PUVA treatment is used in a frequent series of appointments over a short time frame. It is not available in all dermatology centres and has to be carefully monitored.
Antihistamines
These are sometimes prescribed to aid sleep and relieve itching when sleep disruption is a problem. A doctor should always be consulting before giving antihistamines to children.
Risks: Very occasionally, antihistamines can cause children to become over-active. However, they are not addictive.
Antibiotics
The severe scratching associated with eczema can leave the skin vulnerable to infection. A course of antibiotics may be required to clear up the infection. Some topical antibiotics have been added to emollients. Some bath oils contain antiseptic preparations.
Risks: A patient may be allergic to a particular antibiotics, although this is rare.
Evening Primrose Oil
This is a natural oil derived from the seeds of specific varieties of the evening primrose plant. The oil is known to be rich in the essential fatty acid gamma linolenic acid (GLA).
A number of studies have looked at the effect of giving evening primrose oil to people with atopic eczema. Unfortunately, the results of these studies have not been conclusive - some trials have seen an overall improvement in the eczema of those patients studied, while others have not.
Evening primrose oil is available on prescription for the treatment of atopic eczema under the brand name EPOGAM™. The prescription status is currently being reviewed.
Risks: This form of treatment is not suitable for people with epilepsy.
Complementary medicine
In recent years, complementary medicine has become an increasingly popular treatment for many conditions, including eczema. Acupuncture, shiatsu, herbal medicine, homoeopathy, aromatherapy massage, reflexology and hypnosis are just some of the options available.
Complementary medicine is not a cure for eczema. However, many people with eczema use complementary treatments to reduce the impact of eczema on their quality of life. It can also be useful in helping people to relax, relieving stress and helping to control symptoms. The National Eczema Society advises any eczema patients who would like to try a form of complementary therapy to discuss the issue with their GP. It is also important to check that practitioners are adequately qualified and experienced. Ask any complementary practitioner to explain their qualifications and whether they have successfully treated anyone with eczema before.
Risks: Many alternative practitioners ask the patient to stop using orthodox treatments such as emollients and steroids immediately, which can have disastrous results. Very few alternative forms of treatment have been subjected to adequately controlled trials, simply because people assume that natural therapies and medicines are safe. However, it is important to recognise that many plants and herbs can have serious side effects and should only be taken under qualified supervision (see the section below on Chinese Medicinal Plants.)
Chinese Medicinal Plants
Recent years have seen an increase in the level of interest in the use of traditional Chinese herbal medicine as a treatment for atopic eczema. Trials have taken place to examine the effect of a standardised mixture of Chinese medicinal plants on a specific form of atopic eczema. The results were encouraging but the studies demonstrated that people taking herbal decoctions should be closely monitored by their doctor and in particular, tested for liver function.
This standardised formula, known under the trademark Zemaphyte, is not yet licensed in the UK and has been 'deselected' by the Advisory Committee on NHS drugs for prescribing by general practitioners. The British Association of Dermatologists has recommended that patients should only be treated with Chinese herbal medicine as part of a formal trial.
Cyclosporin
Cyclosporin (Neoral) has been used for many years to prevent transplant organ rejection and in recent years has been used to treat severe psoriasis successfully.
Cyclosporin has undergone further stringent efficacy and safety checks and recently received a licence to treat severe cases of adult atopic eczema where conventional treatment is ineffective or inappropriate.
A two month course of cyclosporin may only be initiated by a dermatologist as it is necessary to monitor the patient carefully because of the risk of potentially severe side effects such as kidney failure.
New treatments
A number of potential new treatments for eczema are currently in development although none has yet been licenced.
Lifestyle Factors
Clothing and bedding
Wool and some synthetic fabrics can aggravate eczema. Many people with eczema find 100% cotton bedding and clothing more comfortable against the skin, although a number of synthetic new fibres are being developed which are well tolerated by people with eczema.
Many people with eczema find that over-heating can make their eczema worse. It is a good idea to layer clothes and bedding so that the level of cover can be adjusted and the temperature can be kept to a comfortable level.
Laundry products
Biological washing products contain enzymes which may exacerbate skin problems. Trial and error will help to show which products are best tolerated by each individual.
Avoidance of allergens
One form of eczema, allergic contact dermatitis, is caused by a reaction to substances such as nickel, rubber, dyes, glue, medicaments and even plants. Obviously, it is essential to avoid contact with these allergens.
The droppings of the house dust mite are another common allergen. A range of products, such as sprays, specialist vacuum cleaners or filters and bedding systems have recently been introduced to control these irritants, although opinions differ as to their efficacy. Regular damp dusting and washing of bedding at high temperatures can help to keep levels of dust mite down. In severe cases of eczema where first line treatments have failed to provide adequate control more drastic measures may be needed, such as replacing carpets with hard flooring (wood or linoleum not PVC), choosing blinds rather than curtains and avoiding upholstered furniture.
Avoidance of irritants
Everyday activities such as housework and some professions, such as catering, construction, nursing and hairdressing bring people into contact with products which may irritate the skin. Protective gloves and barrier creams can help to prevent contact with these substances, both in the home and the workplace.
Diet
Dietary management may be effective for a small percentage of people for whom food has been identified as a trigger factor. However, any changes to the diet should only be made under the supervision of a dietician or nutritional therapist, to avoid the risk of nutritional deficiencies developing and it is important to remember that diet is unlikely to be the only factor involved.
Psychological management
Many people with eczema have a low self-image and experience difficulties at home, in school, in the workplace or the community. Stress can aggravate eczema, setting up a vicious circle of negative feelings and recurring symptoms. Stress management techniques can be beneficial for some individuals but it is also important for people with eczema to develop a positive approach. Self motivation is important and enables people to take control of their treatment.
Conclusion
Eczema is a major drain on the UK's resources in terms of under-achievement at school, days lost from work and cost to the Health Service.
Despite this, dermatology is badly under-resourced and frequently ignored in health service strategy planning. Most people with eczema could be well managed by their GPs, yet medical schools offer on average just 22 hours of training in all aspects of dermatology. There is no formal requirement for postgraduate training in dermatology for GPs.
Eczema is a condition which affects the whole family and can disrupt every aspect of normal life. The National Eczema Society believes that all patients have a right to comprehensive, impartial and accurate information on their condition and on its causes, effects, management, treatment and prognosis.
The National Eczema Society
The National Eczema Society is a registered charity (number 1009671) whose purpose is to improve the quality of life for people with eczema and their carers by providing them with high quality information and support; by training health professionals in eczema and its management; by supporting and sponsoring research into eczema and its treatment and by campaigning for improvements in health services for people with skin diseases.
The National Eczema Society
163 Eversholt Street
London
NW1 1BU
Information line: 020 7388 3444 (10am - 4pm Monday, Tuesday, Wednesday and Friday, 1pm - 4pm Thursdays)
General enquiries tel: 020 7388 4097
Website: www.eczema.org
