Eczema (also called 'dermatitis') is a common skin condition that can affect up to 10% of the population at some time of their lives. In certain cases the condition may be severe and incapacitating. The word 'eczema' is derived from an ancient Greek word meaning 'to boil over'. Although many patients who have eczema have dry, sometimes flaky skin, when the condition flares up vesicles and blisters that may weep and crusts appear. Although eczema may become infected, in itself it is not contagious. There are several different types and causes of eczema. The commonest type is called 'atopic eczema'. The word 'atopy' was introduced by Coca 1 in 1923 as a convenient collective term for a group of diseases, chief among which are asthma, hay fever and eczema, which occur spontaneously in individuals who have a family history of susceptibility. In fact some 75% of patients with atopic eczema have a personal or family history of asthma or hay fever or both. Atopic eczema usually appears before the age of one year however it may develop later in childhood or even in adulthood.peer-reviewe

Boffa, Michael J.

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ATOPIC ECZEMA - MALTA ECZEMA SOCIETY SET UP DR. MICHAEL J. BOFFA CONSULTANT DERMATOLOGIST INTRODUCTION Eczema (also called 'dermatitis') is a common skin condition that can affect up to 10% of the population at some time of their lives. In certain cases the condition may be severe and incapacitat-ing. The word 'eczema' is derived from an ancient Greek word meaning 'to boil over'. Although many patients who have eczema have dry, sometimes flaky skin, when the condition flares up vesicles and blisters that may weep and crusts appear. Although eczema may become infected, in itself it is not contagious. There are several different types and causes of eczema. The commonest type is called 'atopic eczema'. The word 'atopy' was intro-duced by Coca 1 in 1923 as a convenient collective term for a group of diseases, chief among which are asthma, hay fever and eczema, which occur spon-taneously in individuals who have a family history of susceptibility. In fact some 75% of patients with atopic eczema have a personal or family history of asthma or hay fever or both. Atopic eczema usually appears before the age of one year however it may develop later in childhood or even in adulthood . Causation2 The underlying cause of atopic eczema is still unknown. There is no convincing evidence that food intolerance, including food allergy, is more than occasionally present or relevant. Raised se-rum IgE concentrations appear to be a secondary phenomenon due to imbalance of immunoregulatory T-cells, defined by a preponderance of the CD4+ TH2 helper T -cell subset. The skin of patients with eczema appears to be intrinsically hyper-reactive, resulting in a lower than normal itch threshold to chemical, mechanical and other stimuli, analogous to individuals with asthma who develop bronchos-pasm at much lower concentrations of inhaled histamine or metacholine than do normal individu-als . Clinical features The diagnosis of eczema is usually clinical and straightforward. Diagnostic guidelines that are use-ful in epidemiological studies are available (Table 1).3 In very young children, the first symptom is often slightly red or dry skin on the forehead and cheeks (Fig la). The dry skin then becomes itchy, red and inflamed. Sometimes the skin in only a few JUNE 2001 7 places is affected but in more severe cases the eczema may cover the whole body. Most com-monly affected are the neck, cheeks, hands, wrists, ankles, feet and the skin in the creases of the elbows and the back of the knees (Figs1b, c). The main symptom of eczema is itching. This can be severe and distressing both for the patient and, particularly in the case of children, for their parents who may feel unable to help. The itch can be so irritating that children are naturally driven to scratch - even babies, too young to scratch, will rub their faces against anything close enough in a desperate attempt to relieve the itching. Unfortu-nately this breaks the skin and leaves it open to infection. The affected skin may also blister, weep and crust. If the eczema is repeatedly scratched or rubbed the skin may become thickened and rough (lichenification) . General Management Although the tendency to eczema cannot be cured, correct management can make a big differ-ence to keep the patient comfortable and prevent complications. Aggravating factors should be iden -tified and avoided where possible. Various emol -lients are available to reduce the dryness of the skin. Other useful treatments include steroid creams and ointments, antibiotics to treat infection and antihistamines to reduce itching. Factors that may aggravate eczema There are many external factors that may influ-ence eczema on a day-to-day basis. Aggravating factors should be identified and avoided where possible. Contact eczema may be caused by both irritant and allergic factors. Irritant factors include soaps and detergents (especially 'bubble-baths'), solvents, alkalis, abrasive dusts, heat, woollen cloth-ing and even chlorine in swimming pool water. Occupations where there is a greater risk of devel-oping irritant contact eczema include any form of wet or persistently dry work such as food handling, hairdressing, nursing, housework and building work. Allergic contact eczema results from a delayed hypersensitivity (type IV) reaction. This requires prior exposure to the allergen, leading to formation the family physician / it-tabib tal-familja of 'memory' T -cells that recognize the antigen on re-exposure and then become activated to produce cytokines that recruit more inflammatory cells. The inflammatory reaction thus arises after a latent period, often taking up to 48 hours and occasion -ally longer to appear. Contact eczema may be investigated using patch testing. Suitably prepared dilutions of potential allergens in a bland vehicle are applied to the patient's back in small alu -minium chambers, kept in place with hypoallergenic adhesive tape. These are normally removed after 48 hours and the skin examined for eczematous reactions at the test sites. A further reading is made at 96 hours to help differentiate irritant from aller-gic reactions. Some common skin allergens and their sources are listed in Table 2. It is worth noting that patch testing is of no value in the investigation of urticaria. Eczema may also be aggravated by stress, furry animals such as cats and dogs, and pollen and tends to be worse in spring. Sunshine in moderation usually helps. Children who have eczema may attend a normal school but may need to take certain precautions to avoid flaring up their condi -tion. The role of diet in atopic eczema has long been controversial. Although some patients, especially young children, undoubtedly appear to react to certain foods, food allergy is not as relevant as generally thought. Furthermore no reliable screen-ing tests exist so far. Response to diet is not more common in patients with high IgE, nor in those with positive prick or RAST tests to suspect foods. The advice of a qualified dietician should be sought before embarking on exclusion diets in young chil-dren. Emollients Eczematous skin is usually dry and has a re-duced barrier function. Various excellent emol-lients are available which if used regularly help reduce the dryness, restore the barrier function and protect the skin from further damage. In general, moisturizing ointments (which are greasy) are more effective than creams or lotions; however the latter rub into the skin more easily and are less messy so most patients find them more convenient. A rea -sonable compromise is to use a cream or lotion during the day and an ointment in the evening. Emollients can in fact be used as often as neces-sary. It is particularly important to apply emollients after bathing and hand washing because washing the skin tends to cause further dryness. Bath oils are a lso helpful leaving a light film of oil on the skin surface that supplements natural oils and reduces moisture loss. Some bath oils also have a cleansing effect on the skin reducing the need to use soap. Patients should be warned that bath oils might make the bath slippery. Ordinary soap and 'bubble JUNE 200 1 8 - baths ' dry the skin and should be avoided. After bathing the skin should be dried by gently patting with a soft towel rather than towelling vigorously. Topical steroids Topical steroids are very useful and many times essential in the management of atopic eczema. Nevertheless they can cause several problems and should be treated with respect. Patients should use the weakest strength necessary to control their eczema and apply the steroid only when required. Make sure patients do not use a topical steroid where a simple emollient will do . Potential local complications of topical steroids include skin atro-phy (striae (Fig 2), purpura, telangiecteses and poor wound healing) , hypertrichosis , folliculitis, pigmentary changes , spread of fungal infections and worsening of acne and rosacea . Inhibition of the pituitary-adrenal axis and other side-effects from systemic absorption of topically applied ster-oids are documented but uncommon. Potent ster-oids applied around the eyes may cause cataracts and glaucoma and should be strictly avoided . In general, the adverse effects of topical steroids are related to their potencies although some new ster-oids are claimed to produce less skin atrophy and other side-effects than older products of similar strengths. Allergic contact dermatitis to the steroid molecule may also occur and is easily overlooked. 4 Promising non-steroid immunomodulatory topical drugs are being developed at present and these may well revolutionise the treatment of eczema and other dermatoses in future. Infections, superantigens and antibiotics. 5 The skin in atopic eczema is frequently colo-nized by bacteria particularly staphylococcus aureus . These bacteria can produce exotoxins with superantigenic properties. This results in stimula-tion of the immune system with T -cells being acti-vated to release cytokines. The cytokine interleukin -4 (IL-4) is found in high levels in patients with atopic eczema. IL-4 stimulates B-cells to produce IgE, which binds to mast cells. These release pro -inflammatory mediators, which lead to inflamma-tion and then eczema . Combinations of topical antibiotics and steroids are useful in the manage-ment of mildly infected eczema especially in chil-dren; severe infections should be treated with sys-temic antibiotics. Eczema sufferers are also prone to infection with the poxvirus (causing molluscum contagiosum) and the herpes simplex virus (caus -ing 'eczema herpeticum'). Eczema herpeticum may be a severe illness and should be treated with systemic antivirals. the family physiCian / it-tabib tal-familja L 00(; 3Nnr ID JUN E 2001 Figure 2 Previous Page: Figure 1 a, b & c: Eczema on the face and in the creases of the elbows and knees (Leo pharma -ceuticals, Denmark) Left & Bottom: Figure 2a & b: Topical steroid-induced striae, folliculitis and acne. the family physician / it-tabib tal-famiija " Antihistamines Both sedating and non sedating antihistamines are useful in the management of atopic eczema, especially if there is an urticarial element. Other treatments Phototherapy, systemic steroids and drugs such as cyclosporin and azathioprine have a place in the management of severe eczema. Prognosis Atopic eczema tends to improve with age how-ever it is impossible to prophesy the prognosis in a particular child: 50% of children are clear by the age of 6 years, and 90% are clear by the age of 15 years. 6 In many cases, however, individuals who had eczema in childhood continue to have skin that is more dry and 'sensitive' than normal. In some the eczema will reappear later on in life and this em-phasizes the importance of long-term follow up when one talks of prognosis in atopic eczema. Older children who still have eczema should be given career advice early and encouraged to avoid occupations such as food handling and catering, hairdressing, nursing, building work and others likely to make their condition worse. Malta Eczema Society Unfortunately keeping eczema under control can sometimes be difficult (and expensive). Eczema is often chronic and may have a pro-found effect on the quality of life of affected individuals and their families. Although eczema is of course not contagious, those affected may feel isolated and even embarrassed by their condition. To help those affected cope with their condition, a voluntary support group for persons with eczema and their families has recently been set up in Malta and named the Malta Eczema Society. The need for such a group in Malta, as found in other countries, has been felt for some time. An inaugural meeting of the new society was held on Monday 30th April 2001 at the Catholic Institute, floriana and was well attended. It is hoped that the society will be able to help by providing support, information and practical adVice. Another aim is to increase awareness throughout society about eczema and the problems it may cause. There is a lot that can be done to improve the quality of life for persons with eczema and hopefully the group will be successful. The members of the organ-izing committee are all volunteers. If you have JUNE 2001 9 any patients who you feel would benefit from joining the Malta Eczema Society or who would like to be informed about future activities please encourage them to contact one of the following members of the organizing committee for fur -ther information: Mrs Anna Baldacchino (tel 386850), Mrs Marlene Bongalais (tel 435649) or Mr Herbert Debono (tel 335140). Dr M. J. Boffa is Consultant Dermatologist at Sir Paul Boffa Hospital and founder of the Malta Eczema Society. REFERENCES 1. Coca AF, Cooke RA. On the classification of the phenomena of hypersensitiveness. J Immunol 1923;8: 163-182. 2. Bos JD, Kapsenberg ML, Sillevis Smitt JH. Pathogenesis of atopic eczema. Lancet 1994;343: 1338-1341. 3. Williams HC, Burley PG, Pembroke AC et al. The UK Working Party's Diagnostic Criteria for At-opic Dermatitis. Br J Dermatol 1994; 131 :406-416. 4. Boffa MJ, Wilkinson SM, Beck MH. Screening for corticosteroid contact hypersensitivity. Contact Dermatitis 1995;33: 149-151. 5. McFadden JP , Noble WC, Camp RD. Superantigenic exotoxin-secreting potential of staphylococci isolated from atopic eczematous skin. Br J Dermatol 1993; 128:631-632. 6. Vickers CFH . The natural history of atopic ec-zema . Acta Dermatol. Venereol. (Stockh) 1980; Suppl92:113-115. the family physician / it-tabib tal-famiija Table 1 Diagnostic guidelines for atopic eczema Must have: An itchy skin condition (or parental report of scratching or rubbing in a child) Plus three or more of the following: * History of involvement of the skin creases, such as folds of elbows, behind the knees, fronts of ankles or around the neck (including cheeks in children under ten) * A personal history of asthma or hay fever (or history of atopic disease in a first degree rela-tive in children under four) * A history of a generalised dry skin in the last year * Visible flexural eczema (or eczema involving the cheeks/forehead and outer limbs inchil-dren under four) * Onset under the age of two (not used if child is under four) JUNE 2001 10 Table 2 Common contact allergens and their sources Allergen Source Nickel Costume jewellery, watch straps Chromate Cement, leather Rubber chemicals Gloves, shoes, tyres Colophony Sticking plaster Wool alcohoIs Lanolin, moisturizing creams, cosmetics Balsam of Peru Perfumes Paraphenylenediamine Hair dyes, clothing dyes Parabens Preservative in creams, cosmetics Epoxy resins Adhesives Neomycin Topical antibiotic Benzocaine Topical local anaesthetic the family physician / it-tabib tal-Jamilja 

Atopic eczema : Malta Eczema Society set up

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Atopic eczema : Malta Eczema Society set up

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