- Atopic dermatitis / eczema is a common, chronic, itchy skin rash that tends to affect people with other allergies like hay-fever and asthma.
- Eczema most often begins in infancy and may persist into adulthood, but can also develop at any time.
What is Atopic Eczema?
- The rash of eczema starts because the skin cells don’t fit together properly and this lets water out, making the skin dry and itchy.
- The abnormal skin barrier function not only lets water out, but it also lets irritants (like soap and water) and allergens (like pollens or house dust mites) penetrate into the skin.
- The immune system responds to this by becoming sensitised to allergens and by an increase in inflammation.
- The skin then reacts easily to irritants and occasionally to food and environmental allergens.
- The skin of a person with eczema has “flares”: episodes where it becomes red, flaky and very itchy and vulnerable to infections caused by bacteria and viruses.
- It usually starts after the 3rd month of life as a red, oozing rash on the face and outer surfaces of arms and legs. In later childhood, the rash usually changes to a dry scaly itchy rash on the inner creases of the elbows and knees. The rash may not be limited to these specific areas and any flexural area (skin folds) may be involved.
- Eczema in young babies may be confused with cradle cap and in older children and adults may be confused with psoriasis.
How can Atopic Eczema be treated
Although there is no cure for eczema, it can be treated through a combination of a rigorous personal treatment plan, learning what triggers the allergic reactions and medical therapy.
Heat and Cold
- Hot humid weather and cold dry weather can make the rash worse. Getting overheated and sweating a lot can cause a problem.
- Woollen or synthetic clothing may irritate the skin.
- Cotton underwear, clothing and bedlinen are recommended.
Soaps and detergents
- Soaps dry out the skin. People with eczema should not use soap at all.
- Emollients or aqueous cream should be used as soap substitutes. See our website page for examples of emollients with the AFSA Seal of Approval.
- The chlorine in swimming pools may irritate and dry out the skin. Rinse the skin off after swimming and apply moisturisers immediately.
- For washing of clothes, non-biological washing powders should be used, and fabric softeners should be avoided completely.
- Bubble baths, household antiseptics and medicated soaps are best avoided.
- Bath water should be lukewarm rather than hot.
- Soak in a bath for a maximum of 5-10 minutes not more than once a day and apply a moisturising emollient (see below) within 3 minutes of patting the skin dry (never rub the skin dry).
- Hair should be washed over a bath/basin to avoid shampoo coming into contact with the skin
- Cover as much skin as possible with lightweight cotton clothing, taking care not to overdress or overheat.
- Cotton gloves and cutting the fingernails short may reduce skin damage from scratching.
- If house dust mite allergy is present, use special bedding to reduce the amount of house dust mites in the bed. (see house dust mite allergy)
- Routine childhood immunisations should be given.
- Consult your doctor if you have any concerns about these immunisations.
- The skin becomes dry because of the abnormal barrier function.
- Moisturising ointments are the most important treatment for eczema. One way they work is by making an oily layer on top of the skin, creating an artificial barrier that prevents the water from getting out and the skin from becoming dry. Another way it works is by replacing the moisture in the skin.
- Moisturising is the single most effective regular treatment.
- Emollients are safe. The moisture does not penetrate the skin; rather it’s the layer on top of the skin that counts… so when the emollient can’t be seen or felt properly, it’s time to apply some more!
- They should be applied in large quantities and frequently. In severe eczema applying it as many times as 6-8 times a day will make a huge difference.
- A nice tip is that every time the skin itches … instead of scratching apply more emollient.
- There are many different emollients available. Most people have their own personal favourite emollient, depending on how it makes them feel. The best emollient is one that the patient and family likes because they are then likely to use it more often!
- Aqueous cream (with sodium lauryl sulphate) should not be used as a moisturiser as it is likely to irritate the skin if it is left on. It is used as a soap substitute and then rinsed off but is not an emollient.
Treating a flare
- Steroid / cortisone / corticosteroid creams and ointments work against the inflammation in the skin.
- They are the most effective therapy for rapid relief and are used to settle eczema flare-ups.
- Steroid ointments must be used when there is a flare. During a flare, the skin is being damaged by the eczema and the steroid ointment will prevent that damage.
- Once a flare is under control a lower strength ointment should be used and then slowly reduced until it can be stopped and just the emollient continued.
- Emollients must be continued at the same time as steroid ointments are used. Most doctors advise the steroid ointment is applied directly to the skin with a layer of the emollient put on top of this to seal it in.
- Non-steroid ointments and creams include the topical calcineurin inhibitors and PDE4 inhibitors. They are not as strong as topical steroids; however, they cannot cause severe side effects and are useful for sensitive skin areas such as the eyelids, around the mouth, in the groin and under the arms. They are wonderful for prevention (pro-active) therapy.
Prevention (pro-active) therapy
- Once a flare is under control, the strength of the steroid ointment can be reduced or switched to a non-steroid cream or ointment.
- Once the skin is healed, the ointments can be reduced and stopped altogether. We aim to limit daily steroid use to 2 weeks, but a maximum of 4 weeks is allowed.
- For areas that are prone to recur, prevention therapy can stop flares from recurring or reduce their frequency.
- Prevention therapy is long-term, low dose topical anti-inflammatory therapy used intermittently a few times a week in normal-looking skin that has been previously affected areas.
- Prevention therapy with steroids and non-steroid creams and ointments has been shown to be safe and effective at preventing or reducing flares.
- Wet wraps or occlusive dressings are used to treat severe atopic eczema or severe flares. (See wet wraps – Kiddy Calmwear | AFSA Shop (allergyfoundation.co.za))
- To use wet wraps, apply a medicated cream or ointment to the affected skin, and then cover it with slightly wet bandages or our Allergy Foundation’s Kiddy-Calmwear clothing.
- The wet layer helps to keep the medication in contact with the skin for longer, which can be especially helpful for severe or persistent symptoms. Never use wet wraps if there is a skin infection.
- Steroids can be used with “the fingertip method” so that enough is used, but not so much as to waste it. A fingertip unit is the amount of ointment squeezed from a tube from the last skin-crease to the tip of the index finger of an adult. The number of fingertip units you need on different parts of the body depends on the child’s age.
- Steroids come in different strengths, from very mild to very strong.
- Very strong steroid ointments must not be used all the time, especially on normal skin as they can then have side effects such as thinning of the skin. Mild steroids have very few side effects.
- Cortisone tablets or injections are not recommended. While they may provide short term improvement, they may also cause a worsening of eczema when stopped and have very unpleasant long-term side effects.
- Eczema sufferers are more prone to infections of the skin. These can be caused by bacteria, fungi and viruses such as herpes and the common wart.
- Antibiotic creams and occasionally oral antibiotics are used to treat infected eczema which may present as sudden development of yellow crusting, oozing and redness of the skin.
- The older sedating-type antihistamine tablets or syrups may make you sleepy so that you scratch less at night.
- Antihistamine creams are usually not effective and can irritate the skin. They should be avoided.
General allergy prevention measures should be done for “high risk infants”: those with parents or siblings who have allergy (see preventing allergy).
- Parents should not smoke during pregnancy and after birth. Children should preferably be exclusively breastfed until at least 4 months of age.
- The evidence for the use of prebiotics or probiotics during and after pregnancy is not clear, but it seems as if it may have some effects on reducing eczema.
- It may be useful to apply emollients on the skin of high-risk babies even before any symptoms of eczema occur.
- About 30% of young children with moderate to severe or difficult to control eczema will develop food allergy. This is much rarer in children with mild or moderate eczema.
- It is important that a proper diagnosis of food allergy is made before making any changes to the diet of young infants. This is best assessed by a doctor with a special interest in food allergy (see brochures on food allergy).
A medical specialist with a special interest and skill in allergy might be able to help. See the list of health professionals with skills in allergy on the AFSA website.
Learn more about Atopic Eczema
What is the cause of Atopic Eczema?
The words “dermatitis” and “eczema” both simply refer to “inflammation of the skin”. Atopic eczema (also called atopic dermatitis) is the most common cause. Let’s just call it ‘eczema’ for simplicity. Atopy is the genetic tendency to get allergic conditions. Eczema occurs more commonly in people with allergies, but not everyone with eczema has other allergies.
Eczema may co-occur with other atopic conditions such as asthma and hay fever and causes the skin to be itchy, red, and inflamed. Eczema can occur in people of all ages, ranging from new-born babies to adults. Atopic eczema usually gets better as a child grows older, but it can also come and go throughout an individual’s life and sometimes occurs for the first time in adults.
Many factors can contribute to eczema, including the environmental and genetic factors. When an individual with a predisposition for eczema is exposed to an allergen from the environment, like pollen or dust mites for example, this switches on the immune system from a state of normal functioning to an over-active state causing inflammation. Inflammation causes the symptoms of eczema – redness, oozing and itch.
Inflammation causes itch and the skin becomes red and inflamed. In pigmented skin, the redness is less noticeable and may appear brown, purple or grey rather than reddening, but the itching remains a problem.
Atopic eczema and your genes
A person is more likely to develop eczema if close family members also have the condition. This could be because your family has genes for allergic inflammation, or because your family has genes which affect the skin barrier function. One of the genes that may cause eczema is the gene coding for the filaggrin protein. The filaggrin protein is responsible for keeping the skin barrier healthy. An abnormal filaggrin protein causes a disrupted skin barrier, which causes loss of moisture in the skin. This leads to itchy, dry/scaly patches of skin, and in severe cases oozing, crusting, blistering, redness, swelling and other symptoms of inflammation.
The skin barrier in atopic eczema
The major feature of eczema is an abnormal skin barrier. We often use the brick wall model of the skin barrier to explain this. Skin cells are like bricks. In between our skin cells we have an oily layer which functions like the cement. Individuals with atopic dematitis have an abnormal skin barrier which results in breakdown of the skin, and an increased loss of water from the skin. If we use the brick wall model we would say that the brick wall is broken down and that it can’t do its work as a barrier. This means that the water can leak out of the skin leading to dryness and that bad things like infections and allergens, like pollens and housedust mite, can come into the skin sparking up the immune system further and again leading to breakdown of the skin’s barrier – a vicous cycle
Atopic eczema and your immune system
At the same time, eczema is also caused by a disrupted immune system – let’s say a hyperactive immune system. The abnormal skin barrier in eczema allows water to leak out of the skin, but also allows irritants (like soap and chemicals) and allergens (like pollens and housedust mite) to enter. The immune system responds to this by an increase in inflammation. The inflammation can directly contribute towards breaking down the skin’s natural barrier by stopping the development of skin cells and preventing them from producing the cement to hold the bricks together.
Atopic eczema and allergies
People with eczema are more likely to be allergic. Asthma, hay-fever and food allergies are all much more common in people with atopic eczema. In addition, the broken skin barrier leads to the inflammation and sensitization which can make allergies worse. Factors that make the condition worse are known as triggers, and exposure to triggers may cause a flare. A flare is when the eczema get worse and with eczema we see that this happens at times – even without any extra triggers. Even if we were to live in a bubble and never be exposed to anything that could be bad for the skin, the rash in eczema will vary with time, and may come and go. Triggers include irritants that mostly affect the skin barrier directly like heat, cold, sweat, scratchy clothing, soaps that foam and perfumed skin products and allergens like pet dander, pollens, housedust mites and very occasionally foods.
Is eczema contagious?
A misconception about eczema is that it is contagious, perhaps due to the appearance of skin in severe patients. Eczema is not contagious and can therefore not be passed on from one person to the next. It’s an immune-mediated inflammatory condition with complex causes such as: genetics, immune system problems and environmental exposures, that all contribute to skin that has a dysfunctional barrier.
People with eczema can get infections on their skin. These must be treated quickly to avoid further skin damage
What are the symptoms of Atopic Eczema?
Eczema causes a red, dry and itchy rash that comes and goes. Sometimes itching occurs before the rash appears. The itch can range from mild to severe. Because of the itchiness, most people scratch their skin, which damages the skin barrier further leading to more inflammation. This then leads to more itching, and scratching. This is known as the “the itch-scratch cycle”.
Eczema symptoms include:
- Dry sensitive skin
- Skin discolouration due to inflammation (usually red, purple or gray)
- Oozing clear fluid and crusting
- Leathery or scaly skin patches
We also see that it looks different in different age groups. In children up to the age of about 2 years red scaly lesions develop typically on the cheeks and usually spares the area around the nose. This is known as “The Headlight sign”. From childhood, the rash typical involves the inside surfaces of the elbows, knees and other flexures. The rash may become more dry and scaly. Eczema in adulthood has many of the same features as in childhood eczema but in addition often includes eczema of the hands, eyelids, and nipples. Chronic, dark, thick and leathery areas of eczema are often found in adults after years of inflammation and scratching.
Can I avoid eczema triggers?
It is important to try to identify what triggers your eczema, and then to try and avoid those triggers. These include irritants such as shampoo, soaps that foam, cleaning products, certain extreme environments like cold areas, or hot areas and certain allergens like pet danders, dust and pollens.
Eczema manifests differently in each person. One person’s triggers may not be the same as another person’s triggers. Irritant triggers do not involve the immune system, rather they directly effect the skin, so they are harmful for everyone with eczema. Allergic triggers, on the other hand, are specific for each person with eczema. People with eczema must avoid all their irritant triggers, but must only avoid their allergen triggers if a doctor has indicated that they are sensitive to a particular allergen.
The atopic march is a medical term used to explain how many patients with allergy start with eczema, and then go on to experience asthma, hayfever, urticaria and food allergy. Some of the overlap between these conditions is because you may be from a very allergic family with genes that cause a specific type of inflammation, called type 2 inflammation. Some of the overlap is caused by the skin barrier problem in eczema allowing irritants and allergens to enter. The immune system responds to this by an increase in inflammation.
Type II inflammatory conditions
Type 2 inflammatory conditions include asthma, allergic rhinitis, urticaria and food allergies. Always make sure that all of your allergic conditions are being treated in the best way possible.
It is very important to understand the relationship between eczema and food allergy. A food allergy is a hypersensitivity reaction (an over-reaction) that involves the immune system. The most common type of food allergy occurring in children with eczema is an immediate-type food allergy. This occurs in about 1/3rd of children with very severe eczema, but is much less common in mild-moderate eczema. This means that if you or your child have mild eczema, food is less likely to play a role. The common signs are an urticarial rash (hives) and swelling of the body. Food allergy can range from mild reactions to severe, life-threatening severe (anaphylactic) reactions.
In a small proportion of children with eczema, a delayed skin reaction occurs, where there are no hives but the eczema just gets worse some time after exposure to the food. It is uncommon for eczema to get worse due to foods. Food allergies worsening eczema is usually seen in children with very severe eczema, especially with early-onset eczema, or in children with eczema that is resistant to good topical treatments. Before making any changes to a child’s diet, it is very important to consult with a doctor who has special skills in food allergy. Do not do any allergy tests without being guided by an expert doctor because allergy tests only show “sensitization” to an allergen. In fact, more than half of the children with eczema who have raised antibodies to a food (which is what we test for using skin test or allergy blood tests) are not actually allergic to those foods!
Many patients have irritant reactions to skin contact with foods but not to ingestion with the same food. These foods can still be eaten but should not be put onto the skin. For patients with isolated and mild flaring of eczema with ingestion of some foods (without hives, swelling, or other severe symptoms), it is often best to improve topical skin care and continue to ingest the foods to ensure the child develops proper tolerance. Tolerance means your body gets used to the food, and you outgrow the tendency to have problems when eating it.
Infections frequently complicate eczema due to immune dysfunction and the disruption of the skin barrier. Infections can also cause flares of eczema, producing a vicious cycle of inflammation and infection. The commonest infection is with Staphylococcus Aureus. Herpes Simplex (the same virus that causes cold sores) can cause a severe life-threatening infection. Other infections include Molluscum Contagiosum, Scabies, Candida, and Malassezia.
Bacterial infection, usually with streptococcus and staphylococcus, require treatment with antiseptics, and often an oral antibiotic is required. We try to prevent future infections by cutting nails short and keeping them clean, making sure the bath is thoroughly cleaned, by using bleach baths, and sometimes by putting topical antibiotic ointments (like mupirocin or fucidic acid) in the nose.
Infection with Herpes Simplex virus causes a severe painful rash with blisters and ulcers. This must be treated quickly with oral or intravenous acyclovir – see your doctor as soon as possible
Eczema can be severe and cause anxiety and depression. Some patients have a poor self-image and are embarrassed to expose their affected skin, and may even limit their sports and social activities. Children who sleep poorly may be diagnosed with attention-deficit/hyperactivity disorder and other behavioral problems.
Support groups are very useful for patients with eczema. Consider joining the Facebook (Meta) support group: https://www.facebook.com/groups/saeczemasupport/ to learn more about how to control your eczema and cope with the burden of eczema.
Overview Of Management Of Atopic Eczema
The most important managment of eczema symptoms is to treat the skin barrier problem with emollients. Also try to reduce exposure to triggers that may cause a flare. The inflammation can be treated with topical corticosteroids or other non-corticosteroid topical agents (creams or ointments), when the rash occurs and as maintenance therapy to reduce the frequency of a flare. More troublesome eczema can be treated with ultraviolet light, anti-inflammatory pills or injections.
Management of eczema typically includes a combination of the following:
- Moisturizing the skin: Using a moisturizer regularly helps to keep the skin hydrated and creates a barrier to prevent the skin from becoming dry.
- Avoiding triggers: Identifying triggers and avoiding soaps, detergents, or scratchy fabrics, can help to reduce flare-ups.
- Medications: Topical corticosteroids, topical calcineurin inhibitors and topical PDE4 inhibitors can be used to reduce inflammation and itching. Antihistamines do not play a part in eczema management because the itch of eczema is due to dry skin and not caused by histamine release.
- Phototherapy: UV light therapy may be used under the guidance of a dermatologist to reduce symptoms of eczema.
- More severe eczema may require systemic therapy. Options include methotrexate, cyclosporine, azathioprine and mycophenolate mofetil. These are immune suppressant medications working on many parts of the immune pathways.
- Dupilumab is a monoclonal antibody that targets the key inflammatory signalling molecules that are involved in causing eczema. This 2weekly injection blocks the inflammation in eczema,reduces symptoms and improves quality of life. It is safe and causes very few side effects. The use of dupilumab does not result in increased risk of infections
- Upadacitinib is a JAK inhibitor that blocks a signalling molecule involved in inflammation. This pill should be taken daily, is effective and is not associated with many side effects. It relieves itching from eczema within days of starting.
It is important to work closely with a healthcare professional to develop an individualized treatment plan that is appropriate for you and your specific needs.
Emollients are ointments or creams that protect the skin and improve the skin barrier. Emollients should be applied ALL OVER the body – not just on the eczema patches. Most of them contain ingredients to improve skin hydration along with ingredients to prevent evaporation. There are different types of emollients. Creams and lotions may be less effective as they contain less oil. The “best” emollient is the one that the patient likes, because they will be more likely to apply it more often. Either use a pump action container or remove the emollients from the pot with a clean utensil like a spoon or a spatula to avoid bacterial contamination of the content of the container – this we refer to as ‘pot hygiene’. The use of emollients decreases dryness, helps reduce itchiness and improves barrier function. Emollients should be used in large amounts, preferably with the soak and seal technique. (See how to use emollients).
Managing itch in atopic eczema
Managing itch is a crucial aspect of managing atopic eczema, as itch can be a major symptom of the condition and can lead to scratching, which can further irritate the skin and exacerbate the condition.
Here are some strategies for managing itch in eczema:
- Moisturize the skin: Keeping the skin moisturized can help reduce dryness and itching. It’s recommended to use a fragrance-free moisturizer multiple times a day, especially after bathing or showering.
- Treat itchy and inflamed areas quickly: Topical corticosteroid medications are effective to rapidly treat inflamed skin. Calamine lotion, menthol cream and topical antihistamines will not be effective and may have side effects.
- Use a cold compress: Applying a cold compress to the affected area can help relieve itching.
- Avoid triggers: Identify and avoid things that trigger flare-ups, such as certain types of clothing, soaps, and detergents.
- Avoid scratching: Scratching can further irritate the skin and make the itching worse. Trimming nails and using a moisturizer can help reduce the urge to scratch.
How to use topical medications
Topical corticosteroids (cortisone creams or ointments) are the most effective therapy for rapid relief of symptoms. They can be used to treat inflamed skin or as a prevention strategy once or twice a week to prevent flares. It is important to treat eczema according to severity, with slightly different strategies used at different times, or even in different areas of the body. Topical corticosteroids used at the correct strength protect the skin by healing the inflammation. Your doctor will choose the correct strength to ensure that damage does not occur, and may give you different corticosteroids for different parts of your body. We often start with a strong to moderate strength steroid for 3 to 5 days (depending on body site), followed by a weaker steroid for a few more days before stopping. Sometimes the skin requires a stronger corticosteroid for longer. One should try to limit this to no more than a month.
Topical corticosteroids come in different forms like ointments, creams, lotions and gels. Ointments may be better for very dry areas. Creams might be better for wetter areas. Lotions and gels may be better for hairy areas. Corticosteroids should be applied in a thin layer directly onto the skin and then covered with a thick layer of emollient to seal it in. To avoid wasting the corticosteroid we recommend you use a thin layer. You can see how much is required to cover different areas of your body by looking at the finger-tip unit pamphlet. Make sure to apply your corticosteroid cream in the direction of hairgrowth, just as you would the emollient. This way you will need less and is least likely to cause inflammation in the hair follicles. Do not mix your corticosteroid with the emollient because this will make it weaker and you wont be able to target the specific area of the body that has inflammation. Ideally one should apply the emollient all over the body and the corticosteroid cream/ointment/lotion/gel ONLY on the inflamed areas.
Topical calcineurin Inhibitors include tacrolimus & pimecrolimus. They are nonsteroidal anti-inflammatory prescription medication creams and ointments. They are especially useful in sensitive areas such as eyelids, around the mouth, in the groin and under the arms. PDE4 Inhibitors such as crisaborole are also nonsteroidal topical medication. Calcineurin inhibitors and PDE4 inhibitors are not as strong as topical corticosteroids, however they do not cause the side effects such as skin thinning. To avoid a burning sensation when they are applied on the skin, they can be stored in the fridge so that it is cold when it is applied.
Topical corticosteroids and the nonsteroid anti-inflammatory creams/ointments can be used as preventative therapy on areas that are prone to having the rash. They can be used twice a week to prevent the flare from coming back. This is called proactive management and is for maintenance of eczema.
Bath Tips for Eczema
Bath water should be lukewarm rather than hot. Soak in the bath for about 5-10 minutes. As soon as you get out the bath, pat the skin dry dry with a soft towel (never rub the skin dry) and apply a moisturising emollient to the skin within 3 minutes. Hair should be washed over a bath/basin to avoid shampoo coming into contact with the skin. Soaps dry out the skin. People with eczema should never use soaps that foam. Emollients or aqueous cream can be tried as a soap substitute. Some skincare companies have therapeutic soap substitutes – make sure they are perfume and colourant free. Look out with those with the AFSA seal of approval. Never use bubble baths.
Sometimes we recommend adding some oil to the bath. This can be done with liquid paraffin oil. Never use bath oils with fragrances. Be careful of slipping in the bath.
Bleach baths may be helpful if your skin has had frequent skin infections but it is important to use them correctly and only when your doctor tells you to. Use a very dilute solution: A large bath may require ½ cup of standard kitchen bleach. Reduce the amount for smaller or less full baths. If there is any burning or irritation, the concentration is too strong. It should smell like a swimming pool.
Wet wraps in atopic eczema
Wet wrap therapy is a technique that can be used to help control the symptoms of eczema. The basic idea is to apply a medicated cream or ointment to the affected skin, and then cover it with slightly wet (damp) bandages or our Allergy Foundation’s Kiddy-Calmwear clothing. The damp layer helps to keep the medication in contact with the skin for longer, which can be especially helpful for severe or persistent symptoms. Never use wet wraps if the skin is infected. See our wet wraps brochure for more information.
It is important to note that eczema is a chronic condition, and treatment may need to be adjusted over time, and different treatment plans may work differently for different people. A combination of treatments and a consistent skin care routine is typically the most effective way to manage the condition. Remember to always use a moisturizer, even when the skin is clear.
How severe is my Eczema?
Eczema substantially affects a patient’s quality of life. Itching can be severe and may affect sleep quality which can also affect the entire family. Children with even moderate condition wake often at night due to the itching, negatively impacting mental health and growth. Other effects include pain, permanent scarring and skin damage, poor self-image, anxiety, depression and attention-deficit/hyperactivity disorder and other behavioral problems. Eczema often causes absence from work or school.
It is important to monitor condit severity in order to guide appropriate treatment choices and properly assess response to treatment. Various scoring systems are used, some of which are performed by the treating doctor, and some that are reported by the patients themselves.
What is the IGA?
The simplest scoring scale is the Investigator Global Assessment scale. Pictures and a description are used to grade the eczema on a scale from 1 (mild) to 4 (severe).
The IGA does not account for the amount of body surface area involved or for variation in different body areas, and doesn’t include any patient reported outcome measures or impact on quality of life.
Patient reported outcomes and the atopic dermatitis control tool (ADCT)
Itch and sleep disturbance are among the most frequent and severe patient reported problems. These can be assessed with a numerical rating scale to allow for comparison of changes over time.
The Atopic Dermatitis Control Tool is a newer way of assessing disease control. To use the ADCT correctly, patients must answer all 6 questions by selecting the most appropriate answer on a 4 point scale. The questions include severity of symptoms, days of itching, how eczema affects your daily functioning, and impairment of sleep and mood. The ADCT considers AD to be uncontrolled if the total score is at least 7 points or the total score has increased by 5 points or more since the prior assessment. Use the ADCT brochure or visit https://www.adcontroltool.com/adct-inline to determine your level of disease control
What if my Eczema is not getting better?
Basic active therapy
If your eczema is not getting better you may have to check that all the basic measures are being done properly. Never underestimate the power of the basic measures. Disease management education can have a strong therapeutic effect for eczema patients. Make sure you are using emollients very frequently, that you are avoiding triggers as much as possible and that you are using enough of the correct strength topical corticosteroids to get rapid control. Make sure you are using wet wraps and prevention therapy with topical corticosteroids, topical calcineurin inhibitors or PDE4 inhibitors. Fill in the ADCT and show it to your doctor to make sure they are aware of how controlled or uncontrolled your eczema actually is. If all of these are being done correctly and disease control is not achieved, you may need a systemic therapy. Phototherapy is a therapeutic option in some patients but is not widely available. It can improve skin lesions, cause less itching and allow better sleep. It is mainly used for adults and children (who can stand on their own in the phototherapy unit) with chronic eczema.
More severe eczema may require systemic therapy. This is often referred to as “stepping up” therapy.
Traditional immunosuppressive medications: These include methotrexate, cyclosporine, azathioprine and mycophenolate mofetil. They work broadly on many parts of the immune pathways. For many years this has been the only systemic medications available for eczema patients.
Newer systemic treatments include targeted biologics and JAK inhibitors.
These treatments have really changed the future for eczema and are improving quality of life on a daily basis. There are many more new products in development for eczema. South Africa is also included in new medication studies on a regular basis where patients get access to free medication for periods of time. Contact AFSA or have a look on the support group for information on where you can become involved in this.
An example of a biologic is dupilumab. Dupilumab is the only biologic registered for eczema in South Africa so far. It targets the key inflammatory signaling molecules that are involved in causing atopic eczema and asthma (both are type 2 inflammatory conditions). It is an injection that is usually administered 2-weekly, although some patients may receive it monthly.
Dupilumab blocks the inflammation in eczema and reduces symptoms, thereby improving quality of life. Abroad it has been approved for babies 6 months and above. In South Africa, it is registered for the treatment of atopic eczema from the age of 6 and from the age of 12 for asthma. It is safe and causes very few side effects such as injection site reactions and conjunctivitis. Dupilumab is an immunomodulator and not an immunosuppressant. Therefore, the use of dupilumab cannot result in an increased risk of infections. Dupilumab is a very specific immunomodulator, so much so that it requires no monitoring (such as blood tests and X-rays).
Upadacitinib is an example of a JAK inhibitor. Upadacitinib blocks a signaling molecule involved in inflammation.
This is also an anti-inflammatory medication, is a tablet taken daily and is thus very convenient. This pill is effective, relieves the itch within days and therefore improves the quality of life quite rapidly. The most frequent side effects include headaches, nausea, and acne. It requires regular blood and X-ray monitoring.
Before starting a JAK inhibitor, patients must be screened for infections like tuberculosis and are best avoided in patients with cardiovascular issues (with current evidence).
More resources for Eczema
A written treatment plan makes it easier to understand the different things you need to do to control your eczema. It describes what to avoid, and which ointments to use and when. Sometimes people with eczema also need injections or pills, in addition to their moisturisers. Medications can never take the place of moisturiser and moisturisers must be used regularly even when the skin appears to be normal.
Please see AFSA’s eczema action plan.
Wet wraps are used to treat severe atopic eczema or severe flares. The Allergy Foundation’s Kiddy Calmwear Clothing can be used to improve skin hydration by the cooling effect of water, to help the emollient penetrate the skin better, to help the steroid ointment work better, to stop the child from scratching, to improve sleep and to reduce the long-term use of steroids.
Please see AFSA’s wet wraps brochure
Patient reported outcomes
The IGA and the ADCT can help you grade the severity and control of your eczema and reflect whether there is a need to review the basics or move on to a systemic therapy.
Download AFSA’s atopic dermatitis control tool (ADCT) to assess your control
View our educational videos