ECZEMA - A GUIDE FOR PATIENTS AND PARENTS

Introduction

Eczema is an itchy and unsightly skin disorder. It usually develops in childhood but can affect people of either sex, and at any age. It is common in all ethnic groups and affects several million people in the UK. This article deals mainly with the type of eczema known as "atopic" or "infantile" eczema.

Eczema is not infectious. It may be associated with asthma and hay-fever. The tendency to develop eczema is often inherited. People unfamiliar with skin diseases often associate eczema with dirt and poor hygiene. There is no truth whatever in this belief. At the present there is no simple cure for eczema, but with regular treatment patients should be greatly improved and not be prevented from leading a normal life.

Treatments
Emollients

Moisturising or softening the skin is both helpful and safe. Emollients should be applied all over the body at least once a day. There are a wide range of suitable oily creams such as:

• Ultrabase
• Aqueous Cream
• E45 Cream
• Calmurid (10% Urea) Cream
• Unguentum Merck
• Emulsifying Ointment

Bath or emollient oils should be used, instead of soap, for washing. Widely available products are:

• Oilatum
• Balneum
• Alpha-Keri
• Hydromol

Steroid creams

These are widely prescribed for patients with eczema and are available as creams, ointments, gels and lotions. They should be applied only to affected skin areas. We try to use the weakest possible preparations. Steroid creams can damage the skin if used unwisely and this is something that should be discussed with a doctor. Steroids are occasionally prescribed as tablets or injections but only under strict medical supervision.

Anti-histamines

These drugs are not treatments for eczema itself but can reduce itching and help sleeping at night. Many drugs of this type are available both in tablet or liquid form. The most commonly used are:

• Promethazine (Phenergan)
• Trimeprazine (Vallergan)
• Hydroxyzine (Atarax)

Anti-histamines are safe enough to prescribe to children, although the exact dose should be discussed with a doctor. In adults antihistamines should not be mixed with alcohol and most are unsuitable for patients driving or operating machinery.

Antibiotics

Eczema is not infectious (transmissible from one patient to another) but it may become infected (allow harmful germs, bacteria, to grow on the damaged skin). Infected eczema will be greatly improved if an antibiotic tablet or medicine is prescribed. Among the common antibiotics used are:

• Penicillin (Broxil, Crystapen V)
• Flucloxacillin (Floxapen)
• Erythromycin (Erythocin)
• Cephradine (Velosef)

Eczema can be severely worsened by infection with the cold sore virus (herpes simplex). Patients, and in particular children, with eczema should avoid close contact with people suffering from active cold sores.

Other treatments

Long standing dry thickened patches of eczema may be helped by the use of coal tar containing ointments and pastes. These preparations are messy but are entirely safe, even for regular use in childhood. Some patients with eczema may be helped by artificial sun-light treatment. This can be given in addition to the other treatments mentioned already.

Alternative medicine

Because eczema is persistent and difficult to cure it is understandable that sufferers seek the advice of alternative medical practitioners such as hakims, vaids, herbalists and homeopaths. It is difficult for doctors and nurses trained in orthodox Western medicine to discuss the claims of alternative practitioners impartially but it is advisable to discuss prospective treatment of any type with a family doctor. Be understanding if the doctor or dermatologist whom you consult feels unable to "share" your care with an alternative practitioner.

Recently "allergic clinics" have set up in business offering to diagnose allergies from hair samples, an approach which appears to be both expensive and futile.

Washing

Baths are an important part of soothing the skin in eczema, a warm bathroom and hot water are essential. Emollients and bath oils should be added to the water and used instead of soap. Other useful advice is:

• do not have the water too hot
• do not rub the skin with a rough towel; pat it dry
• keep finger nails short and clean
• avoid perfumed cosmetics, bubble-baths, deodorants, etc.

Patients with very sore and cracked skin may find a bath which has had table salt added to the water less likely to cause stinging. Discuss this with a doctor.

Clothing

Patients with eczema find it best not to wear wool next to the skin because they find it rough and irritating. Use cotton or a cotton and acrylic mixture whenever possible. Aim for cool, loose fitting comfortable clothes. It is an excellent idea to wear cotton gloves or mittens at night when itching and scratching are at their worst. Cotton socks can also be worn. Open leather shoes or sandals seem best for patients with eczema. Many patients find that putting tubular bandages on the skin after the application of creams helps keep finger-nails off the skin and creams off the bed-clothes.

Food

Some patients with eczema, especially young children, seem to be made worse by certain foods. Milk, eggs, wheat flour, and artificial dyes are often blamed. Dietary treatment may not be as helpful as certain reports in the press would suggest, but an elimination diet can be arranged for patients with severe eczema unresponsive to simple treatments. The dietary control of eczema should only be undertaken under the expert supervision of a dietitian. Withdrawing important foodstuffs, like dairy products, from the diet of young children may not be safe. Simply adding a product, like goats' milk, to an existing diet is unlikely to help.

Bedding

Sheets should be cotton or a cotton and polyester mix. Frequent changes are needed if sheets become soiled with blood, skin scales or old creams. Pillows and duvets should be feather-free and covered in cotton or a cotton and polyester mix. They should be washed frequently. Many patients with eczema are allergic to the house-dust mite. Fitted polythene mattress and pillow covers can be bought to help prevent affected patients coming into contact with the mites. Mattresses should contain synthetic or vegetable fibres rather than horse-hair or feathers. Vacuum the mattress weekly.

At home
Laundry

Avoid biological washing powders and detergents. Use pure soap flakes wherever possible. All clothes should be very thoroughly rinsed.

As house-dust contains mites, to which some people are allergic, it is important to keep the house as dust-free as possible. Ideally vacuum and wipe all surfaces with a damp duster when the person with eczema is out of the room. Do not let affected children play on the floor.

Pets

Many patients with eczema are sensitive to pet hair (especially cat fur). The enjoyment that a pet brings to a child may be thought to outweigh the disadvantages.

At work

Patients with atopic eczema, even if this is confined to the hands, should avoid occupations that bring them into prolonged and regular contact with irritants such as solvents, detergents, acids, coolant fluids and lubricating oils. Trades and occupations that seem to cause most problems are:

• hair dressing
• nursing
• motor car maintenance
• chemical plant work
• engineering and machine tool operation

People working in the food and catering industries may be involved in two difficulties. Many foods, such as onions, garlic, chillies, prawns and meats have irritating juices which may make hand eczema worse. Also patients with active hand eczema are more likely to have harmful germs on their skin which could contaminate food and be the cause of food-poisoning.

Among occupations that would be suitable for patients suffering from eczema are:

• retail trades
• teaching
• health care (except nursing)
• clerical or secretarial
• electrical trades
• VDU operation
• telecommunications

The present economic situation makes finding employment very difficult. If you develop eczema and are already employed, a change of occupation is not advisable. Instead try, with treatment, to improve the skin sufficiently to let existing work continue.

Tests

At some stage during your visits to the skin department you may be asked to agree to some investigations or tests. Blood tests and skin tests may give some indication of allergies. Skin swab tests may tell the staff if any germs are growing on the skin.

Sadly it is very unlikely that any tests will totally alter the treatment of your eczema or lead to a permanent cure. On the whole tests are not performed unless there is a good reason. If no tests are suggested, do not think this results from lack of interest or sympathy on the part of the staff.

The child with eczema
Babies

Perhaps half the children with atopic eczema will clear by the time they are adult. This is, of course, no reason to delay treatment in the hope that the child will grow out of the problem. Eczema often develops in babies between the ages of 3 to 6 months. A baby's skin is naturally very sensitive and cannot tolerate the more powerful creams used in adults and older children. Normally the - following are prescribed:

• an emollient and a bath oil
• a soothing and protective cream for the nappy area such as Zinc and Castor Oil Cream
• a cream or ointment containing the safe drug hydrocortisone

Babies should be given a daily oil bath. Be careful because the oils may make bath and baby more slippery. Apply the hydrocortisone- containing preparation to all affected areas after the bath. Emollient creams can be used on the skin as often as you wish. If itching is a very major problem an anti-histamine medicine may be useful, although it is preferable not to give regular medicines to babies. Caring for an itchy, sleepless child with extensive eczema is very distressing for parents and indeed the parents may be more upset than the baby. Sometimes, but only with the parents' full co-operation and consent, a short period of treatment in hospital may enable intensive therapy to be given. It may also enable the rest of the family to get a few nights uninterrupted sleep.

Immunisations

Babies and children with eczema should not be vaccinated against smallpox. Fortunately this disease has now been eliminated. Babies with eczema may safely be immunised against other infectious diseases, like polio, diphtheria, tetanus and measles. If you are worried discuss this with your doctor or health visitor.

School children

It is sensible to inform teaching staff of your child's problem. They will almost certainly realise the effects that eczema and its treatment will produce. For example, itching may impair concentration in class, and anti-histamine medicines may produce sleepiness.

Scratching

Scratching is damaging to the skin but will not be stopped by telling the child not to scratch. Cut the child's nails short, use plenty of emollient creams and try to keep the child amused and occupied. Bringing up children with eczema is not easy.

Swimming

The water of indoor swimming baths can be quite irritating but swimming should not be ruled out if it gives your child pleasure. Ask if a fresh-water shower can be taken after swimming and provide an emollient to be rubbed into the skin before dressing.