Eczema is a general term for numerous non-contagious types of skin inflammation (dermatitis) and allergic-type skin rashes.1 Referred to as neurodermatitis, atopic dermatitis, or endogenous eczema, this skin condition is a very common and long-lasting skin disease that affects many people throughout the world. Approximately 10-20 percent of children show symptoms as well as about 3-5 percent of adults.3 It is estimated that 65 percent of individuals develop symptoms in the first year of life and 90 percent before 5 years of age.10 Indications include itching, scaly skin patches, and a rash, found in the folds of the arms, back of the knees, wrists, face, or hands.10 More severe symptoms worsen the condition. Continuous rubbing and itching exacerbates the sensitivity.10 This response leads to a continuous cycle of reaction from an over activated immune system.
There are commonly three associated conditions occurring in the same person: eczema, allergies, and asthma.10 While each may not occur at the same time, individuals tend to be prone to all three conditions.10 A poorly developed immune system during childhood appears to be the catalyst for later acquired sensitivity towards atopic diseases like neurodermatitis, hay fever, and allergic asthma.10 There are numerous triggers that can promote additional inflammation and/or attacks. They include smoke, stress (physical and mental), milk products, citrus fruits, allergens (dust mites, pollen, animal hair, textiles), other skin sensitisers, microbial infections and environmental changes (climatic).2 The propensity for allergies tends to be greater in big cities than in rural areas.2
The immune system
Most everyone recovers from infections thanks to our innate immune system. We rely on it to defend against bacteria and viruses such as colds, the flu, and when we have an injury. Unfortunately, other individuals are born with a defective immune defense system and identified as having a primary immunodeficiency (PI). 13 The World Health Organization lists more than 70 types of immune deficiencies, varying from mild to severe. All have a commonality in that they open the door to multiple infections. More than half of all PIs are a result of the lack of infection-fighting antibodies (immunoglobulins). 13 Continuous infections are a tell tale sign of PI, including ear and sinus infections and more severe life-threatening illnesses such as pneumonia.13 In severe cases of PI, both antibodies and T cells are disabled causing a major immunodeficiency making any infection life threatening.13
There are numerous characteristics associated with PIs including a connection with other immune disorders, such as anemia, arthritis, or autoimmune diseases.13 Some may also be associated with the heart, digestive tract, or the nervous system with others increasing cancer risks.13 Given the complexity of a developing immune system during foetal growth, it also means that hundreds of things can go wrong. Even the cell backup systems that normally correct genetic mishaps may not be working efficiently. These errors can make people susceptible to pathogens. When genes are working correctly the body develops and maintains health. Small changes or mutations, however, in just a single gene can have a vast effect on a developing foetis resulting in a birth defect and/or a compromised immune system leading to diseases.13
PI diseases are normally inherited and can be passed from parent to child and occur when genes are being copied.13 Even when parents show no signs of a defect, one or both may be caring a defected or mutated gene and pass it to the child. The child can show signs of immunodeficiency if it doesn’t have a normal gene to compensate the defective gene.13 Furthermore, immune deficiencies can be acquired later in life when there damage to the immune system. HIV is an example. Congenital AIDS may occur (passed down by the mother). The disease in this case is viral and not inherited.
Since our focus in this article is eczema, skin treatment therapists should be aware that the activity of atopic dermatitis and other skin conditions/reactions can easily occur due to the fact that one or more essential parts of the immune system is missing or not working properly at birth due to a genetic defect.13 We must become aware of this health condition during our initial skin analysis and be mindful that there may be numerous reasons for it. Skin conditions involving atopic dermatitis and/or psoriasis may require medical supervision. When this skin anomaly is in remission, we must also be aware that if the client checks “yes” to allergies, psoriasis, dermatitis, etc. that it serves as an indicator of possible conditions occurring within the skin barri
Table 1 – Types of Eczema 11, 14
|Atopic dermatitis||A type of eczema, it is an inflammatory, chronically relapsing, non-contagious and pruritic (itchy) skin disorder. 5 AD is a specific set of three associated conditions occurring in the same individual: eczema, allergies, and asthma. Not all is present concurrently but the patient is prone to all three conditions. Cause: Hereditary predisposition.|
|Contact eczema||A reaction that is localized and displays itching, redness, and burning. Cause: Skin contact with an allergen or with an irritant, i.e., an acid, cleansing agent, chemical, jewelry (nickel, or other metals). 11|
|Allergic contact eczema||A reaction when the skin is comes in contact with poison ivy, poison oak, certain ointments, creams, adhesive tape, and preservatives. The skin becomes red, itchy, and weepy. Cause: A misguided reaction by our immune system in response to bodily contact with certain foreign substances. 10|
|Seborrheic eczema (seborrheic dermatitis or seborrhea)||Prevalent to 3-5% of world population, this is a common form of mild skin inflammation found on the sebum-rich scalp, face, or trunk. Visual observation: yellowish, oily, red, itchy scaly patches of skin on the scalp, face, ears, and other parts of the body. An example is cradle cap on infants or dandruff in adults. Cause: Linked with Malassezia (Pityrosporum yeast), immunologic abnormalities, trauma (scratching), and emotional stress. May worsen in the presence of disease such as Parkinson or AIDS.10|
|Coin-shaped isolated patches of irritated, crusty, scaling, and extremely itchy skin normally found on the arms, back, buttocks, and lower legs. 1 “Nummus” means coins.Cause: The cause is not known with the exception that there is a family history of allergies, asthma, and atopic dermatitis. 7 Appears to be associated with exposure to drying soaps, and exposure to irritating fabrics, i.e., wool. 8 It is considered a long-term (chronic) condition.6|
|Dermatitis artefacta||A condition in which skin lesions are inflicted solely by the patient. Fingernails, sharp or blunt objects, and caustic chemicals may be used to inflict skin. Commonly occurs in teens or young women that may be experiencing interpersonal challenges that require psychosocial support.14|
|Neurodermatitis||Known as Lichen simplex chronicus this condition produces a very intense itch caused by irritation of nerve endings in the skin.12 A chronic scratch-itch cycle continues the irritation. It can develop on skin that was previously affected by atopic or contact dermatitis. Open sores can be a result of chronic itching and scratching. Constant scratching causes the skin to thicken and darken with lines of scaring. There is susceptibility to infection. It normally can occur in mid-to-late adulthood between 30 – 50 years of age.10
Cause: Emotional stress, insect bite, or poor blood flow (circulation).
|Dyshidrotic eczema||Irritation found on the palms of hands and soles of the feet characterised by clear, deep blisters that itch and burn.|
|Stasis dermatitis||Irritation of the skin on the lower legs appearing as darker pigmentation, light brown, or purplish-red discoloration.
Cause: Related to circulatory problems and congestion of the leg veins.10 Sometimes seen in legs with varicose veins.
|Psoriasis||Sometimes difficult to distinguish between seborrheic eczema (SE) that is located on the head, the scales of psoriasis are thicker and somewhat dryer than the scales in SE. Considered a hyperproliferative disease, psoriasis usually affects more than one area of the body such as elbows, knees, hands or feet, including nail changes (pitting). Instead of the normal cell desquamation that takes place in the skin, cells pile up and don’t slough off. Cells in a psoriasis condition mature about five times faster than cells in normal skin.9Cause: A genetic miscommunication and malfunction of the immune system. T cells appear to be at the root of the cause that overgrow and attack the area of the skin at the location of the psoriasis.9 The immune system is supposed to protect the skin. In cases of psoriasis, T cells end up proliferating and attacking at the site of psoriasis. Biopsies show that there are many T cells underneath the plaque. 9 Inflammation is the result as well as continuous propagation of skin cells.
Research shows that the release of cytokines (signal messengers) is a normal process during an immune response, however, in psoriasis, there appears to be a malfunction in the signaling process. 9 The area has increased cell buildup, becomes red and irritated.
|Atopic||Atopic syndrome is a predisposition toward developing certain allergic hypersensitivity.|
|Dermatitis||Inflammation of the skin.|
|Stasis||Motionless, stoppage of flow of body fluids.|
|Xerosis||Dryness of the skin and barrier dysfunction.|
There are several treatments used for treating dermatitis conditions and we will review just a few. Common remedies include corticosteroid creams and ointments, antihistamines, systemic corticosteroids (prednisone), antibiotics and other anti-inflammatory substances. Bases in certain brands may become irritating and also can cause thinning of the skin.10 Cortisone has an anti-inflammatory effect and urea reduces the itching effect as well as hydrates. Unfortunately, cortisone can cause skin atrophy after long-term use. Consequently, there is an increased susceptibility towards substances with allergenic potential. When the symptoms are so severe, the treatment program may not be effective enough to alleviate the condition. Continued use of these remedial substances may produce increased sensitivity towards external influences including the potential for infection. 10
More severe cases of atopic dermatitis may be treated with immune modulators, Tacrolimus (Protopic), cyclosporine A, interferon-ϒ, and pimecrolimus (Elidel) ointments.10 They are very powerful drugs. The FDA has placed special warning on immune modulator drugs due to cancer and other immune-system suppression issues.10
Phototherapy treatments with UVA or UVB wavelengths have been used for mild to moderate dermatitis in children over 12 years of age and in adults.
Eczema from a dermaviduals® point of view
Dehydrated skin with a high TEWL is very characteristic of eczematic skin. Seasonal weather changes can also play havoc with this skin condition. The result is a barrier disorder that leaves the skin in a more vulnerable state with an increased susceptibility for penetration of external substances such as microorganisms (fungi, bacteria and viruses).10 The stratum corneum exhibits a deficiency in ceramide-1 (linoleic acid), a main barrier component of the skin.10 Understanding the synthesis pathway for essential fatty acids, the presence of dermatitis serves as an indicator of an enzyme defect that inhibits the transformation of linoleic acid into gamma-linoleic acid (refer to our article on “Essential Fatty Acids”).10 Given that dermatitis attacks are cycling, using the intermittent times when flare-up is minimal is an ideal time to use preventative measures in order to mitigate continuous deterioration of the skin barrier. Moreover, when correct corneotherapy actives are used, they may help support the skin by increasing its barrier function. The good news is that this could easily reduce the requirement for more drug intervention.
The choice of skin care is imperative to supporting dry and scaly skin conditions. Most products contain a host of ingredients to stabilise their components as well colourants and fragrance that add to the marketing appeal of the product. Some, however, are counter-indicated for dry skin and for individuals suffering from dermatitis and/or other allergy conditions. Mineral oils and other petrolatum substances, silicones, and ceresin wax slow down the self-regenerating capability of the skin.2
Emulsifiers are used in most modern skin care products. They combine fat and water substances into a cream preventing separation of oil and water. Unfortunately, they have a wash out affect in the skin, dissolving ingredients of creams along with the natural skin lipids out of the skin.2 With each cleansing more of the natural skin lipids end up being removed. Eventually and with continuous application of the skin care cream, the barrier (NMF) actually becomes impaired and unable to self-correct. The skin begins to feel dry with increased TEWL. The tendency is to continue to re-apply more cream to correct the dry skin condition. This senseless cycle eventually places the skin in a cycle of imbalance.
Following the guidelines of corneotherapy, correcting dry skin conditions requires application of emulsifier free products to reduce and balance TEWL. Linoleic acid containing ceramide 1 is very important for the skin layers and must be readily available to the cell membranes and bilayers of the skin. When there is a reduction in ceramide 1, there is a propensity for dry and scaly skin.
Emulsifying agents can be replaced with liposomes and nanoparticles for penetrating actives. To soothe the itching in irritated skin, urea has positive effects. These specialised delivery spheres increase the permeability of the skin for the delivery of actives. They should be followed by an application of derma membrane cream (DMS®) whose chemical composition mimics the natural skin barrier. They are ideal for dermatitis conditions since they do not contain water and are free of preservatives. Dermatitis clients tend to tolerate pure vegetable oils and waxes, i.e., olive and jojoba oil in skin care that is free of water and preservative systems. Vegetable oils, lipids and waxes are able to integrate into the stratum corneum and begin to support barrier repair are generally well received in these skins.
A primary goal of introducing corneotherapy products onto eczematic skin is to reduce the amount of drugs that may further break down an already compromised barrier. Cleansers should contain very mild surfactants. Sodium lauryl sulfate type surfactants have been shown to be an irritant. They denature proteins and have hemolytic effects (destruction of cell membranes of red blood cells). 4 Cleansing milks contain membrane substances and increased oil content and avoid the washout of the natural barrier substances. These recommendations are not only for the face but also for the rest of the body. Water pH should remain neutral.
Cosmetic ingredients can be effective toward inhibiting inflammatory reactions. Sensitive skin should be protected against direct sunlight as it can degrade the active affects of a formula. Inflammatory conditions from eczema, dermatoses, and dermatitis respond well to Evening Primrose Oil, Linseed Oil, Boswellia, D-panthenol, phosphatidylcholine (nanodispersions), and Echinacea Extracts, as well as Lotion N and Novrithen.
In conclusion, treatment choice for irritated skin types requires careful analysis of the individual skin type. The goal is to rebuild the barrier as much as possible
Figure 13 Treatment of Fissures with dermaviduals®
- Alai, N. MD, (June 2008) Atopic Dermatitis. Retrieved from http://www.medicinenet.com/script/main/art.asp?articlekey=353&pf=3&page=1
- Lautenschläger, H. (2001) Neurodermatitis – specific prevention. Kosmetik International (11), 44-47.
- Lautenschläger, H. (2005) Skin care for the neurodermitic skin – supporting the skin barrier. Kosmetische Praxis (1), 9-11
- Lautenschläger, H. (2008) Skin reactions – cosmetics and their effects. P. 2
- Medical-dictionary.the free dictionary.com/atopic
- Nummular eczema (May 13, 2011) A.D.A.M. Medical Encyclopedia. PubMed Health. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001873/
- Nummular eczema, MedlinePlushttp://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&query=nummular+eczema&x=0&y=0
- Nummular Dermatitis Retrieved from http://www.skinsight.com/adult/nummularDermatitis.htm
- Stuart, A., Nazario, B. Psoriasis Treatments: Now and in the Future: What Causes Psoriasis? WebMD Retrieved from http://www.webmd.com/skin-problems-and-treatments/psoriasis-treatment-11/causes
- Szeftel, A. MD (2008) Atopic Dermatitis. MedicineNet.com. Retrieved from http://www.medicinenet.com/script/main/art.asp?articlekey=353&pf=3&page=1
- Table adapted from Alai, N. MD (2 June 2008). What is the difference between atopic dermatitis and eczema? Retrieved from http://answers.webmd.com/answers/1172930/what-is-the-difference-between-atopic
- Types of Eczema: Neurodermatitis. EczemaNet. Retrieved from http://www.skincarephysicians.com/eczemanet/neurodermatitis.html
- When the Body’s Defenses Are Missing: Primary Immunodeficiency. National Institute of Child Health and Human Development, National Institutes of Health. Retrieved from http://www.nichd.nih.gov/publications/pubs/primary_immuno.cfm
- Atopic eczema, Dermatitis artefacta – DermNetNZ Retrieved from http://www.dermnetnz.org/dermatitis/dermatitis-artefacta.html
Photos: 1, 2, 3, 4, 5, 6, 8, 10 – Wikipedia
Photo: 7 Sourced from DermNet NZ
Photos: 9 – U.S. NATIONAL LIBRARY OF U.S. National Library of Medicine NIH National Institutes of Health and MedLine Plus (a service of NIH)
Photo: 11 – Simone Vescio
Photo: 13 – Kathryn Mazierski
This dossier has been prepared on behalf of dermaviduals Australia and New Zealand as a reference that relates to various skin conditions. In no way does it replace the advice of your medical practitioner or a dermatologist. All views represent the research and findings of the writer in conjunction with derma aesthetics.