29 September 2020
If you have persistent dry; itchy; and red skin patches, you might be suffering from a dermatological condition called eczema. Also known as atopic dermatitis, eczema is a common skin condition that affects 10-20% of children. Eczema can also present in adults and studies estimate 1-2% of adults are affected by eczema.
Patients who have eczema often experience itching, dryness and hypersensitivity of their skin. Some of the complications of eczema include skin infections and premature skin aging. Finding the right skincare routine that protects the skin without causing further irritation can be challenging for sufferers. This review on eczema/ atopic dermatitis will look at the causes of eczema, skincare and treatments for atopic dermatitis.
Atopic dermatitis is the most common type of eczema. Patients who have atopic dermatitis have dry, itchy, red and scaly patches. These eczema flares are triggered by exposure or contact with allergens.
Eczema is caused by the immune system’s reaction to triggers. These triggers cause eczema flares. In the skin, atopic dermatitis is characterised by abnormal barrier function. People who suffer from eczema tend to have reduced ceramide levels in the skin. Ceramides are a type of fats (lipids) that are a part of this skin’s natural protective barrier against water loss, infections and chemicals. When this natural protective barrier of the skin is damaged, there is increased transepidermal water loss, hypersensitivity to chemicals, increased susceptibility to infections and premature aging.
Patients who suffer from atopic dermatitis also have reduced immune defenses against bacteria, viruses and fungi. This puts patients with eczema at risk of skin infections.
Recent studies have also linked eczema to a genetic mutation in the Filaggrin gene. This gene is necessary for normal cell organisation. Patients with haphazard cell organisation tend to have ‘leaky’ skin barriers. A leaky skin barrier worsens transepidermal water loss and risk of infections.
Many triggers have been identified as causes of eczema flares- temperature changes, soaps, fragrances, detergents, chemicals…etc. The most common trigger is dust mites. Emotional stress, heat and perspiration can also worsen eczema flares. Conditions that cause dry skin (e.g. excessive prolonged hand washing/ bathing) can lower the threshold for eczema flare ups. Allergy tests and skin patch tests may be performed to confirm the triggers for eczema.
What are the symptoms and signs of eczema/ atopic dermatitis? Patients who have eczema /atopic dermatitis have recurrent, itchy skin rashes. These rashes are dry and flaky. Often, scratching aggravates the rash and causes dark marks and thickening of the skin. Repeated scratching can also cause skin infections.
In babies and young children, eczema tends to occur on the cheeks, scalp and the front of their arms and legs. For adults, eczema can affect any part of the body. In particular, atopic dermatitis occurs on the face, sides of the necks, back of knees, elbow creases and hands.
Currently, there is no cure for eczema. The main aims of treating atopic dermatitis are centered around:
1. Avoiding eczema flare ups and triggers
2. Treating symptoms of atopic dermatitis
3. Strengthening skin barrier
Avoid eczema triggers and flares
Identifying and avoiding triggers is one of the tenets of treating atopic dermatitis.
Skincare for eczema/ atopic dermatitis
Eczema is marked by poor skin barrier and dry skin, so one of the priorities of your skincare routine is to reinforce the skin barrier and up the ante on moisturising skin.
Two ingredients that I’d recommend including in your moisturisers for eczema are ceramides and hyaluronic acid. In patients who have atopic dermatitis, the skin barrier is disrupted due to reduced ceramide levels in the skin, causing increased transepidermal water loss, hypersensitivity and vulnerability to skin infections. Using barrier repair creams that contain ceramides in a physiologic ratio (i.e. ceramides, cholesterol and fatty acids) can reduce symptoms of eczema. Conversely, if the ratios of lipids are not physiological, skin dryness can increase. You can read about these details and how to choose skincare products with ceramides in Ceramides in Skincare: A Relief for Sensitive and Dry Skin.
Another ingredient that is safe and affordable for atopic dermatitis is hyaluronic acid. Hyaluronic acid is a humectant that draws water into the epidermis. Some studies recommend combining hyaluronic acid together with ceramides in moisturisers to improve the symptoms of dryness in atopic dermatitis. You can read more about hyaluronic acid in this blogpost Everything You Need to Know About Hyaluronic Acid. For my reviews and recommendations of affordable hyaluronic acid products, please read this blogpost 5 Cult Favourite Hyaluronic Acid Serums and Moisturisers Reviewed.
Atopic dermatitis flare ups can also be triggered by allergens in skincare products. Some common irritants are fragrances and preservatives.Look for unscented skincare and products that contain limited preservatives. Some chemical sunscreen filters can also trigger hypersensitivity in eczema, so choose sunscreens with organic/ physical filters instead. You can read about sunscreen filters and my recommendations in this blogpost Sunscreen Reviews: the Best, the Worst and Unsafe Ones I’ve Tried. If you have very dry skin, you can use ointments instead of gels or lotions over these dry patches. Ointments have a higher content of oil, which acts as an occlusive to reduce water loss from the skin. If these skincare strategies are not working for your atopic dermatitis, your doctor can help with medications and treatments.
For moderate to severe cases of eczema, medications are often needed to control the inflammation. One of the first line medications for eczema is topical steroids. Topical steroids are one of the most effective ways to reduce the inflammation and itch in atopic dermatitis. Some of the side effects of prolonged and inappropriate topical steroid therapy are skin atrophy (skin thinning); acne rosacea and striae. To avoid these complications of steroid use, non-steroid containing medications (calcineurin inhibitors) are used; especially over areas of thin skin (e.g. eyelids).
For more severe cases of atopic dermatitis, oral steroids may be required to control the inflammation and flare ups of eczema. Antihistamines to control the itch and antibiotics for concomitant skin infections can also prescribed.
Phototherapy for eczema
Phototherapy or light therapy involves shining a narrow band of UVB rays to the skin. Light therapy is also used to treat conditions like psoriasis and vitiligo.
Injectable moisturisers to relieve dry skin
For patients who suffer from eczema, skin dryness and cracked skin can be distressing. Due to the damaged skin barrier in atopic dermatitis, the high rates of transepidermal water may not be adequately replaced with copious use of moisturisers. In such instances, injectable moisturisers are an option to improve skin hydration and improve skin texture.
Injectable moisturisers involve placing hyaluronic acid into the dermis of the skin. Hyaluronic acid is a substance that is naturally present in our skin. It attracts and binds to water molecules to maintain skin hydration and firmness. Hyaluronic acid is depleted in our skin as we age; this causes dryness and thinning of the skin. Replenishing the skin’s hyaluronic acid molecules with injectable moisturisers can help to improve skin hydration and reduce skin roughness in eczema. Examples of injectable moisturisers available in Singapore are Skinboosters, Profhilo and Rejuran Healer.
One of the issues with applying moisturisers to the skin is poor penetration of the skincare ingredients into the dermis. Hyaluronic acid molecules are large molecules and cannot diffuse through the basement membrane that separates the epidermis from the dermis. Injectable moisturisers bypass this problem by directly introducing hyaluronic acid into the dermis to keep the skin plump and moist. Skinboosters is one of the most popular injectable skincare treatments in Singapore and Korea. This treatment improves skin hydration and is well received for its additional skin brightening and pore-refining benefits.
The newest injectable moisturiser that is the buzzword in Singapore right now is called Profhilo. Profhilo contains a mixture of high and low molecular weight hyaluronic acid molecules. Injecting this combination of hyaluronic acid into the deep dermis of the skin has been found to also increase collagen and elastin formation in the skin, on top of hydrating the skin. As the product bioremodels the skin i.e. lift and improve skin wrinkles and firmness, Profhilo has an effect of reversing signs of aging in the skin. Besides the face, Profhilo can be injected into the skin of the neck and hands to improve skin hydration.You read more about Profhilo and see how I do it in my clinic in Singapore in Is Profhilo the Injectable Skincare of the Future?
Vitamin D and eczema
Vitamin D supplements may be helpful in controlling symptoms of eczema. Some studies have shown that a lower vitamin D level is associated with increased severity of symptoms of atopic dermatitis.
Probiotics and eczema
The role of probiotics and control of atopic dermatitis is controversial. Although some studies show that oral probiotics improve eczema outcomes, a review of 39 randomised controlled trials showed little or no improvement in symptoms of eczema with probiotic use.
Evening Primose Oil and Omega-3 Fatty Acids and eczema
The role of primrose oil and omega-3 fatty acids in eczema is still uncertain. The results of studies on these supplements and control of atopic dermatitis have been equivocal.
Atopic dermatitis is the most common type of eczema to affect adults and children. Although the exact causes of eczema are unknown, research findings point towards multifactorial causes of atopic eczema- genetics, environmental and social factors.
Eczema flare-ups are caused by exposure to triggers, which cause an inflammatory response by the body’s immune system. Common triggers include exposure to dust mites and allergens in skincare products. Eczema flare ups cause redness, itching, dryness and hypersensitivity in the skin. In the skin, atopic dermatitis disrupts the normal organisation of skin cells and ceramides in the skin. These changes lead to a damaged skin barrier which predisposes to increased transepidermal water loss and vulnerability to skin infections and hypersensitivity to allergens.
Currently, there is no cure for eczema. Research into immunotherapy and monoclonal antibodies to moderate the inflammatory response may offer a shot at a cure for eczema. For now, treatment of atopic dermatitis boils down to identification and avoidance of triggers; reduction of the inflammatory response and hydration of the skin. Left untreated, atopic dermatitis can result in skin infections.
Using moisturisers that contain ceramides and hyaluronic can help to improve skin dryness and itching. Injectable moisturisers such as Profhilo and Skinboosters can improve hydration of the dermis in the skin and reverse some signs of aging in the skin. Topical steroids to reduce inflammation remain as the mainstay of medical treatment of eczema. For patients who have atopic dermatitis that is severe or uncontrolled with topical steroids; other medications like calcineurin inhibitors, oral steroid therapy and phototherapy may be needed.
The link between dietary supplementation and eczema control remains tenuous. Vitamin D supplements may help with reducing the severity and frequency of eczema flare ups. For probiotics, evening primrose oil and omega-3 fatty acids, the role of supplementation is less certain.