Eczema: Your essential guide. Regina Malan
around the ankles. In an acute case, the whole body may be affected. In her book The Eczema Solution, Sue Armstrong-Brown relates an acute episode in which the eczema crept over her whole body, even up to the soles of her feet.
In babies, eczema generally appears on facial areas, such as the cheeks and around the mouth, and on the upper bodies. It is often the baby’s drooling that prompts the rash around the mouth. As soon as the baby starts crawling, the eczema may spread to the knees and elbows as a result of the increased friction. Eczema does not generally occur in the nappy area.
•Blisters or vesicles. During an acute phase, small fluid-filled blisters or vesicles, as well as red bumps and swelling, may appear on the skin, caused by the release of too much histamine in the tissues. For this reason, antihistamines often bring relief to eczema sufferers.
•Eczema damages the skin structure. Scratching leads to oozing of the blisters and the eczema appears wet. A thin crust and scales develop where the oozing fluid dries. This phase is generally accompanied by infection that requires antibiotic treatment.
•Painful fissures. These may gradually develop on the skin as a result of excessive dryness (see Figure 2.2).
•Thickening of the skin. Adults often display thickening of the skin caused by continuous scratching and the resultant skin damage. Lichenification, or leathery skin, as well as lesions may appear. The redness and scaliness of eczema skin are most probably the result of an overactive immune system, while the thickening and lichenification are brought about by constant rubbing and scratching.
Eczema sufferers usually scratch the itching skin with their fingernails, which damages the skin and leads to infections, but this is by no means the only way of scratching. To rub the skin, with either your hands or your clothes, also causes damage. Sufferers devise all kinds of methods to scratch the skin – with a hair brush, a towel, buttons on clothes, for example. All of these are harmful to the skin.
•An atopic fold (or Dennie Morgan fold). This is an extra line or skin fold that sometimes develops under the lower eyelids of an eczema sufferer. When the eczema flares, the eyelids also become swollen, returning to normal when the acute flare-up subsides. This results in loose, sagging skin and hence the extra wrinkle beneath the eye. The Dennie Morgan fold may occur in people of all ages, even babies, who acquire an old, wise appearance as a result of it.
•Acute flare-ups. Eczema is a chronic condition with occasional acute flare-ups. An eczema sufferer will always have a tendency towards this skin condition, even though some children ‘outgrow’ it by their teen years. It is, therefore, a chronic condition. Symptoms are much more obvious during a flare-up, which may last a few hours, a few days or even longer. What remains after the acute flare-up is the chronic part, which to a lesser or greater extent may still be accompanied by a rash and discomfort. The skin of some people is so badly affected that the difference between the chronic and acute phases is merely a question of intensity (see Figure 2.3).
THE ATOPIC TRIAD: ECZEMA, ASTHMA AND ALLERGIC RHINITIS
Although eczema is not an allergic condition, it is often typically accompanied by the allergic respiratory conditions asthma and rhinitis or hay fever. All three run in families and are hereditary. Together they are known as the atopic triad (see Figure 2.4). When diagnosing your skin condition, your doctor will therefore enquire after a family history of asthma and allergic rhinitis.
A clear, radiant skin is always a sign of the body’s internal health. Skin problems may therefore signify imbalances in one or more body systems.
The eczema sufferer may not necessarily also suffer from asthma and rhinitis, but these conditions may turn up somewhere in the family history. The precise nature of the relationship between the three conditions has not yet been established, but they probably have certain gene defects in common.
Eczema sufferers often run the risk of the so-called atopic march. This refers to the fact that the pattern in which the atopic triad occurs may vary over the years. If, for instance, children under the age of three with eczema and allergies outgrow their allergies, they may develop severe asthma. The asthma symptoms may diminish during their adolescent years and hay fever may rear its head. Later in life, after the age of 40, the hay fever may in its turn subside, while eczema and asthma flare up once again.2
Self-management of eczema by the patient involves patient education by the doctor. Continuous cooperation between the medical practitioner and the patient is essential.
If a person suffers from both eczema and asthma, the two conditions act independently of each other. An acute eczema flare-up does not affect a person’s asthma, nor does an asthma attack have any influence on the eczema. The third component of the atopic triad, allergic rhinitis, also acts independently of the other two.
THE DIAGNOSIS
There is no single, indisputable test that doctors can perform to determine whether a patient has eczema. Diagnosis is done on the basis of:
•A thorough examination. Even if your only complaint when visiting the doctor is a rash on your hands, he or she may examine your entire body for signs of eczema.
•Symptoms. Taking into consideration all the symptoms listed earlier, especially the rash and accompanying itch. Itching is a significant indication of eczema.
•Family history. A complete family history to determine the tendency towards eczema, asthma and allergic rhinitis.
•An escalation in IgE levels in the blood. IgE (immunoglobulin) is a type of protein produced by the immune system. It is an antibody that only occurs in mammals and it protects the body by attacking the protein component of foreign substances. Everyone’s blood contains IgE, but some eczema sufferers show increased levels in their blood. During an allergic reaction the IgE antibodies release chemicals that damage the surrounding tissue. A blood test will be performed to determine IgE levels.
•Allergy tests. Since many people suffering from eczema also show allergies, the doctor may perform allergy tests to determine possible irritants and triggers. Especially children with eczema will most probably be tested for allergies.
•Food allergies. They can be determined by means of skin prick testing and skin patch testing. A negative reaction may result from skin prick testing, but allergies may be present in spite of the negative results. Skin patch testing can then be an effective testing method.
•Blood tests. These may also be considered, mainly to eliminate other conditions and to test IgE levels, as described above. IgE antibodies play a role in allergic reactions to food. Blood tests are also used to measure eosinophil levels. Eosinophils are antibodies that are also involved in allergic reactions, especially allergies to medicines. Raised eosinophil levels in the blood or in tissue where medicines are concentrated, can potentially cause an allergic reaction.
A study published in the Indian Journal of Dermatology, Venereology and Leprology found that eosinophil and IgE counts are significantly higher in patients with atopic dermatitis and that these raised levels also have an effect on the severity of the condition.3
A skin biopsy is a procedure in which a small sample of skin tissue is taken and sent to a laboratory to be examined under a microscope
•Skin biopsies. Dr Johan van Wyk, a Johannesburg dermatologist, says he often makes use of skin biopsies for an accurate diagnosis. According to him, a spot of eczema may sometimes show similarities with skin cancer. It is therefore essential to get clarity on the condition. Some cancers may also be accompanied by lots of itching, and the use of steroids – commonly prescribed for eczema – will worsen the cancer situation. A skin biopsy is helpful in arriving at a correct diagnosis.
•Skin swabs. A skin swab of the rash may be taken with a cotton bud and sent to a laboratory. Skin swabs are not especially functional in diagnosing eczema, but are used to determine the type of skin infection present in order to prescribe the right medication.
QUESTIONS TO ASK YOUR DOCTOR