|Classification and external resources|
Dermatitis of the hand.
Dermatitis (from Greek δέρμα derma "skin" and -ῖτις -itis "inflammation") or eczema (Greek: ἔκζεμα ekzema "eruption") is inflammation of the skin. It is characterized by itchy, erythematous, vesicular, weeping, and crusting patches. The term eczema is also commonly used to describe atopic dermatitis or atopic eczema.
In some languages, dermatitis and eczema are synonyms, while in other languages dermatitis implies an acute condition and eczema a chronic one.
The term eczema is broadly applied to a range of persistent skin conditions. These include dryness and recurring skin rashes that are characterized by one or more of these symptoms: redness, skin swelling, itching and dryness, crusting, flaking, blistering, cracking, oozing, or bleeding. Areas of temporary skin discoloration may appear and are sometimes due to healed injuries. Scratching open a healing lesion may result in scarring and may enlarge the rash. Treatment is typically with moisturizers and steroid creams. If these are not effective, creams based on calcineurin inhibitors may be used. The disease was estimated as of 2010 to affect 230 million people globally (3.5% of the population).
- 1 Classification
- 2 Signs and symptoms
- 3 Cause
- 4 Diagnosis
- 5 Prevention
- 6 Management
- 7 Prognosis
- 8 Epidemiology
- 9 History
- 10 Society and culture
- 11 References
- 12 External links
The term "eczema" refers to a set of clinical characteristics. Classification of the underlying diseases has been haphazard and unsystematic, with many synonyms used to describe the same condition. A type of eczema may be described by location (e.g. hand eczema), by specific appearance (eczema craquele or discoid), or by possible cause (varicose eczema). Further adding to the confusion, many sources use the term eczema for the most common type of eczema (atopic dermatitis) interchangeably.
The European Academy of Allergology and Clinical Immunology (EAACI) published a position paper in 2001, which simplifies the nomenclature of allergy-related diseases including atopic and allergic contact eczemas. Non-allergic eczemas are not affected by this proposal.
There are several different types of dermatitis. The different kinds usually have in common an allergic reaction to specific allergens. The term may describe eczema, which is also called dermatitis eczema and eczematous dermatitis. An eczema diagnosis often implies atopic dermatitis (which is very common in children and teenagers) but, without proper context, may refer to any kind of dermatitis.
In some languages, dermatitis and eczema are synonyms, while in other languages dermatitis implies an acute condition and eczema a chronic one. The two conditions are often classified together.
- Atopic dermatitis (aka infantile e., flexural e., atopic dermatitis) is an allergic disease believed to have a hereditary component, and often runs in families whose members also have asthma. Itchy rash is particularly noticeable on head and scalp, neck, inside of elbows, behind knees, and buttocks. Experts are urging doctors to be more vigilant in weeding out cases that are, in actuality, irritant contact dermatitis. It is very common in developed countries, and rising. (ICD-10 L20)
- Contact dermatitis is of two types: allergic (resulting from a delayed reaction to an allergen, such as poison ivy, nickel, or Balsam of Peru), and irritant (resulting from direct reaction to a detergent, such as sodium lauryl sulfate, for example).
- Some substances act both as allergen and irritant (wet cement, for example). Other substances cause a problem after sunlight exposure, bringing on phototoxic dermatitis. About three quarters of cases of contact eczema are of the irritant type, which is the most common occupational skin disease. Contact eczema is curable, provided the offending substance can be avoided and its traces removed from one's environment. (ICD-10 L23; L24; L56.1; L56.0)
- Xerotic eczema (aka asteatotic e., e. craquele or craquelatum, winter itch, pruritus hiemalis) is dry skin that becomes so serious it turns into eczema. It worsens in dry winter weather, and limbs and trunk are most often affected. The itchy, tender skin resembles a dry, cracked, river bed. This disorder is very common among the older population. Ichthyosis is a related disorder. (ICD-10 L30.8A; L85.0)
- Seborrhoeic dermatitis or Seborrheic dermatitis ("cradle cap" in infants) is a condition sometimes classified as a form of eczema that is closely related to dandruff. It causes dry or greasy peeling of the scalp, eyebrows, and face, and sometimes trunk. The condition is harmless except in severe cases of cradle cap. In newborns it causes a thick, yellow, crusty scalp rash called cradle cap, which seems related to lack of biotin and is often curable. (ICD-10 L21; L21.0)
- Dyshidrosis (aka dyshidrotic e., pompholyx, vesicular palmoplantar dermatitis, housewife's eczema) only occurs on palms, soles, and sides of fingers and toes. Tiny opaque bumps called vesicles, thickening, and cracks are accompanied by itching, which gets worse at night. A common type of hand eczema, it worsens in warm weather. (ICD-10 L30.1)
- Discoid eczema (aka nummular e., exudative e., microbial e.) is characterized by round spots of oozing or dry rash, with clear boundaries, often on lower legs. It is usually worse in winter. Cause is unknown, and the condition tends to come and go. (ICD-10 L30.0)
- Venous eczema (aka gravitational e., stasis dermatitis, varicose e.) occurs in people with impaired circulation, varicose veins, and edema, and is particularly common in the ankle area of people over 50. There is redness, scaling, darkening of the skin, and itching. The disorder predisposes to leg ulcers. (ICD-10 I83.1)
- Dermatitis herpetiformis (aka Duhring's Disease) causes intensely itchy and typically symmetrical rash on arms, thighs, knees, and back. It is directly related to celiac disease, can often be put into remission with appropriate diet, and tends to get worse at night. (ICD-10 L13.0)
- Neurodermatitis (aka lichen simplex chronicus, localized scratch dermatitis) is an itchy area of thickened, pigmented eczema patch that results from habitual rubbing and scratching. Usually there is only one spot. Often curable through behavior modification and anti-inflammatory medication. Prurigo nodularis is a related disorder showing multiple lumps. (ICD-10 L28.0; L28.1)
- Autoeczematization (aka id reaction, autosensitization) is an eczematous reaction to an infection with parasites, fungi, bacteria, or viruses. It is completely curable with the clearance of the original infection that caused it. The appearance varies depending on the cause. It always occurs some distance away from the original infection. (ICD-10 L30.2)
- There are also eczemas overlaid by viral infections (eczema herpeticum or vaccinatum), and eczemas resulting from underlying disease (e.g. lymphoma). Eczemas originating from ingestion of medications, foods, and chemicals, have not yet been clearly systematized. Other rare eczematous disorders exist in addition to those listed here.
Signs and symptoms
Dermatitis symptoms vary with all different forms of the condition. They range from skin rashes to bumpy rashes or including blisters. Although every type of dermatitis has different symptoms, there are certain signs that are common for all of them, including redness of the skin, swelling, itching and skin lesions with sometimes oozing and scarring. Also, the area of the skin on which the symptoms appear tends to be different with every type of dermatitis, whether on the neck, wrist, forearm, thigh or ankle. Although the location may vary, the primary symptom of this condition is itchy skin. More rarely, it may appear on the genital area, such as the vulva or scrotum. Symptoms of this type of dermatitis may be very intense and may come and go. Irritant contact dermatitis is usually more painful than itchy.
Although the symptoms of atopic dermatitis vary from person to person, the most common symptoms are dry, itchy, red skin. Typical affected skin areas include the folds of the arms, the back of the knees, wrists, face and hands.
Dermatitis herpetiformis symptoms include itching, stinging and a burning sensation. Papules and vesicles are commonly present. The small red bumps experienced in this type of dermatitis are usually about 1 cm in size, red in color and may be found symmetrically grouped or distributed on the upper or lower back, buttocks, elbows, knees, neck, shoulders, and scalp. Less frequently, the rash may appear inside the mouth or near the hairline.
The symptoms of seborrheic dermatitis on the other hand, tend to appear gradually, from dry or greasy scaling of the scalp (dandruff) to hair loss. In severe cases, pimples may appear along the hairline, behind the ears, on the eyebrows, on the bridge of the nose, around the nose, on the chest, and on the upper back. In newborns, the condition causes a thick and yellowish scalp rash, often accompanied by a diaper rash.
Perioral dermatitis refers to a red bumpy rash around the mouth.
The cause of eczema is unknown but is presumed to be a combination of genetic and environmental factors.
The hygiene hypothesis postulates that the cause of asthma, eczema, and other allergic diseases is an unusually clean environment. It is supported by epidemiologic studies for asthma. The hypothesis states that exposure to bacteria and other immune system modulators is important during development, and missing out on this exposure increases risk for asthma and allergy.
While it has been suggested that eczema may sometimes be an allergic reaction to the excrement from house dust mites, with up to 5% of people showing antibodies to the mites, the overall role this plays awaits further corroboration.
Eczema occurs about three times more frequently in celiac disease and about two times more frequently in relatives of those with celiac disease, potentially indicating a genetic link between the two conditions.
Diagnosis of eczema is based mostly on the history and physical examination. However, in uncertain cases, skin biopsy may be useful. Those with eczema may be especially prone to misdiagnosis of food allergies.
There is no good evidence that a mother's diet during pregnancy, the formula used, or breastfeeding changes the risk. There is tentative evidence that probiotics in infancy may reduce rates but it is insufficient to recommend its use.
There is no known cure for eczema, with treatment aiming to control symptoms by reducing inflammation and relieving itching.
There has not been adequate evaluation of changing the diet to reduce eczema. There is some evidence that infants with an established egg allergy may have a reduction in symptoms if eggs are eliminated from their diets. Benefits have not been shown for other elimination diets, though the studies are small and poorly executed. Establishing that there is a food allergy before dietary change could avoid unnecessary lifestyle changes.
People can also wear clothing designed to manage the itching, scratching and peeling. Soaps and detergents should not be used on affected skin because they can strip natural skin oils and lead to excessive dryness.
Moisturizing agents (also known as emollients) are recommended at least once or twice a day. Oilier formulations appear to be better and water based formulations are not recommended. It is unclear if moisturizers that contain ceramides are more or less effective than others. Products that contain dyes, perfumes, or peanuts should not be used. Occlusive dressings at night may be useful.
There is little evidence for antihistamine and they are thus not generally recommended. Sedative antihistamines, such as diphenhydramine, may be tried in those who are unable to sleep due to eczema.
If symptoms are well controlled with moisturizers, steroids may only be required when flares occur. Corticosteroids are effective in controlling and suppressing symptoms in most cases. Once daily use is generally enough. For mild-moderate eczema a weak steroid may be used (e.g. hydrocortisone), while in more severe cases a higher-potency steroid (e.g. clobetasol propionate) may be used. In severe cases, oral or injectable corticosteroids may be used. While these usually bring about rapid improvements, they have greater side effects. Long term use of topical steroids may result in skin atrophy, stria or telangiectasia. Their use on delicate skin (face or groin) is therefore typically with caution. They are, however, generally well tolerated.
Topical immunosuppressants like pimecrolimus and tacrolimus may be better in the short term and appear equal to steroids after a year of use. Their use is reasonable in those who do not respond to or are not tolerant of steroids. Treatments are typically recommended for short or fixed periods of time rather than indefinitely. Tacrolimus .1% has generally proved more effective than picrolimus, and equal in effect to mid-potency topical steroids.
The United States Food and Drug Administration has issued a health advisory a possible risk of lymph node or skin cancer from these products, however subsequent research has not supported these concerns. A major debate, in the UK, has been about the cost of these medications and, given only finite NHS resources, when they are most appropriate to use.
When eczema is severe and does not respond to other forms of treatment, systemic immunosuppressants are sometimes used. Immunosuppressants can cause significant side effects and some require regular blood tests. The most commonly used are ciclosporin, azathioprine and methotrexate.
Light therapy using ultraviolet light has tentative support but the quality of the evidence is not very good. A number of different types of light may be used including UVA and UVB. Overexposure to ultraviolet light carries its own risks, particularly that of skin cancer.
There is currently no scientific evidence for the claim that sulfur treatment relieves eczema. It is unclear whether Chinese herbs help or harm. Dietary supplements are commonly used by people with eczema. Neither evening primrose oil nor borage seed oil taken orally have been shown to be effective. Both are associated with gastrointestinal upset. Probiotics do not appear to be effective. There is insufficient evidence to support the use of zinc, selenium, vitamin D, vitamin E, pyridoxine (vitamin B6), sea buckthorn oil, hempseed oil, sunflower oil, or fish oil as dietary supplements.
Other remedies lacking evidential support include chiropractic spinal manipulation and acupuncture. There is little evidence supporting the use of psychological treatments. While dilute bleach baths have been used for infected dermatitis there is little evidence for this practice.
Globally eczema affected approximately 230 million people as of 2010 (3.5% of the population). The lifetime clinician-recorded prevalence of eczema has been seen to peak in infancy, with female predominance of eczema presentations occurring during the reproductive period of 15–49 years. In the UK about 20% of children have the condition, while in the United States about 10% are affected.
Although little data on the rates of eczema over time exists prior to the Second World War (1939–45), the rate of eczema has been found to have increased substantially in the latter half of the 20th Century, with eczema in school-aged children being found to increase between the late 1940s and 2000. In the developed world there has been rise in the rate of eczema over time. The incidence and lifetime prevalence of eczema in England has been seen to increase in recent times.
Dermatitis affected about 10% of U.S. workers in 2010, representing over 15 million workers with dermatitis. Prevalence rates were higher among females than among males, and among those with some college education or a college degree compared to those with a high school diploma or less. Workers employed in healthcare and social assistance industries and life, physical, and social science occupations had the highest rates of reported dermatitis. About 6% of dermatitis cases among U.S. workers were attributed to work by a healthcare professional, indicating that the prevalence rate of work-related dermatitis among workers was at least 0.6%.
Society and culture
The terms "hypoallergenic" and "doctor tested" are not regulated, and no research has been done showing that products labeled "hypoallergenic" are in fact less problematic than any others.
- "Eczema". ACP medicine. Retrieved 9 January 2014.
- Bershad, SV (1 November 2011). "In the clinic. Atopic dermatitis (eczema)". Annals of internal medicine 155 (9): ITC51–15; quiz ITC516.
- McAleer, MA; Flohr, C; Irvine, AD (23 July 2012). "Management of difficult and severe eczema in childhood". BMJ (Clinical research ed.) 345: e4770.
- Ring, Johannes; Przybilla, Bernhard; Ruzicka, Thomas (2006). Handbook of atopic eczema. Birkhäuser. p. 4.
- Carr, WW (Aug 2013). "Topical calcineurin inhibitors for atopic dermatitis: review and treatment recommendations". Paediatric drugs 15 (4): 303–10.
- Hay, RJ; Johns, NE; Williams, HC; Bolliger, IW; Dellavalle, RP; Margolis, DJ; Marks, R; Naldi, L; Weinstock, MA; Wulf, SK; Michaud, C; J L Murray, C; Naghavi, M (28 October 2013). "The Global Burden of Skin Disease in 2010: An Analysis of the Prevalence and Impact of Skin Conditions.". The Journal of investigative dermatology 134 (6): 1527–34.
- Johansson SG, Hourihane JO, Bousquet J, et al. (September 2001). "A revised nomenclature for allergy. An EAACI position statement from the EAACI nomenclature task force". Allergy 56 (9): 813–24.
- ICD 10: Diseases of the skin and subcutaneous tissue (L00-L99) – Dermatitis and eczema (L20-L30)
- "Balsam of Peru contact allergy". Dermnetnz.org. 28 December 2013. Retrieved 5 March 2014.
- "Neurodermatitis". Retrieved 2010-11-06.
- "Contact Dermatitis Pictures". Retrieved 2010-11-06.
- "Dermatitis". Retrieved 2010-11-06.
- "Symptoms". Retrieved 2010-11-06.
- "Atopic dermatitis". National Institute of Health. Retrieved 27 September 2011.
- Bufford, JD; Gern JE (May 2005). "The hygiene hypothesis revisited". Immunology and Allergy Clinics of North America 25 (2): 247–262.
- Carswell F, Thompson S (1986). "Does natural sensitisation in eczema occur through the skin?". Lancet 2 (8497): 13–5.
- Henszel Ł, Kuźna-Grygiel W (2006). "[House dust mites in the etiology of allergic diseases]". Annales Academiae Medicae Stetinensis (in Polish) 52 (2): 123–7.
- Atopic Dermatitis at eMedicine
- Paternoster et al. (2011). "Meta-analysis of genome-wide association studies identifies three new risk loci for atopic dermatitis". Nature Genetics 44 (2): 187–92.
- Caproni, M; Bonciolini, V; d'Errico, A; Antiga, E; Fabbri, P (2012). "Celiac Disease and Dermatologic Manifestations: Many Skin Clue to Unfold Gluten-Sensitive Enteropathy".
- Ciacci, C; Cavallaro R; Iovino P; Sabbatini F; Palumbo A; Amoruso D; Tortora R; Mazzacca G. (June 2004). "Allergy prevalence in adult celiac disease".
- Atkins D (March 2008). "Food allergy: diagnosis and management". Primary Care 35 (1): 119–40, vii.
- Jeanne Duus Johansen, Peter J. Frosch, Jean-Pierre Lepoittevin (2010-09-29). Contact Dermatitis. Retrieved 2014-04-21.
- Alexander A. Fisher. Fisher's Contact Dermatitis. Retrieved 2014-04-21.
- Torley, D; Futamura, M; Williams, HC; Thomas, KS (Jul 2013). "What's new in atopic eczema? An analysis of systematic reviews published in 2010–11". Clinical and experimental dermatology 38 (5): 449–56.
- Kalliomäki, M; Antoine, JM; Herz, U; Rijkers, GT; Wells, JM; Mercenier, A (Mar 2010). "Guidance for substantiating the evidence for beneficial effects of probiotics: prevention and management of allergic diseases by probiotics". The Journal of nutrition 140 (3): 713S–21S.
- "CDC Smallpox | Smallpox (Vaccinia) Vaccine Contraindications (Info for Clinicians)". Emergency.cdc.gov. 2007-02-07. Retrieved 2010-02-07.
- "Daily Skin Care Essential to Control Atopic Dermatitis article at American Academy of Dermatology's EczemaNet website". Retrieved 2009-03-24.
- Bath-Hextall, F; Delamere, FM; Williams, HC (23 January 2008). Bath-Hextall, Fiona J, ed. "Dietary exclusions for established atopic eczema". Cochrane database of systematic reviews (Online) (1): CD005203.
- Institute for Quality and Efficiency in Health Care. "Eczema: Can eliminating particular foods help?". Informed Health Online. Institute for Quality and Efficiency in Health Care. Retrieved 24 June 2013.
- Ricci G, Patrizi A, Bellini F, Medri M (2006). "Use of textiles in atopic dermatitis: care of atopic dermatitis". Current Problems in Dermatology. Current Problems in Dermatology 33: 127–43.
- Jungersted, JM; Agner, T (Aug 2013). "Eczema and ceramides: an update". Contact dermatitis 69 (2): 65–71.
- Hoare C, Li Wan Po A, Williams H (2000). "Systematic review of treatments for atopic eczema". Health Technology Assessment 4 (37): 1–191.
- Bewley A; Dermatology Working, Group (May 2008). "Expert consensus: time for a change in the way we advise our patients to use topical corticosteroids". The British Journal of Dermatology 158 (5): 917–20.
- Shams, K; Grindlay, DJ; Williams, HC (Aug 2011). "What's new in atopic eczema? An analysis of systematic reviews published in 2009–2010". Clinical and experimental dermatology 36 (6): 573–7; quiz 577–8.
- "FDA Issues Public Health Advisory Informing Health Care Providers of Safety Concerns Associated with the Use of Two Eczema Drugs, Elidel and Protopic". FDA. 10 March 2005. Archived from the original on 2007-09-17. Retrieved 2007-10-16.
- "Pimecrolimus cream for atopic dermatitis". Drug and Therapeutics Bulletin 41 (5): 33–6. May 2003.
- Gambichler, T (Mar 2009). "Management of atopic dermatitis using photo(chemo)therapy". Archives of dermatological research 301 (3): 197–203.
- Meduri, NB; Vandergriff, T; Rasmussen, H; Jacobe, H (Aug 2007). "Phototherapy in the management of atopic dermatitis: a systematic review". Photodermatology, photoimmunology & photomedicine 23 (4): 106–12.
- Stöppler MC (31 May 2007). "Psoriasis PUVA Treatment Can Increase Melanoma Risk". MedicineNet. Retrieved 2007-10-17.
- "Sulfur". University of Maryland Medical Center. 4/1/2002. Retrieved 2007-10-15.
- Armstrong NC, Ernst E (August 1999). "The treatment of eczema with Chinese herbs: a systematic review of randomized clinical trials". British Journal of Clinical Pharmacology 48 (2): 262–4.
- Bath-Hextall, FJ; Jenkinson, C; Humphreys, R; Williams, HC (15 February 2012). Bath-Hextall, Fiona J, ed. "Dietary supplements for established atopic eczema". Cochrane database of systematic reviews (Online) 2: CD005205.
- Bamford, JT; Ray, S; Musekiwa, A; van Gool, C; Humphreys, R; Ernst, E (30 April 2013). Bamford, Joel TM, ed. "Oral evening primrose oil and borage oil for eczema". The Cochrane database of systematic reviews 4: CD004416.
- Boyle RJ, Bath-Hextall FJ, Leonardi-Bee J, Murrell DF, Tang ML (2008). Boyle, Robert John, ed. "Probiotics for treating eczema". Cochrane Database of Systematic Reviews (Online) (4): CD006135.
- Eldred DC, Tuchin PJ (November 1999). "Treatment of acute atopic eczema by chiropractic care. A case study". Australasian Chiropractic & Osteopathy 8 (3): 96–101.
- Ersser, SJ; Latter, S; Sibley, A; Satherley, PA; Welbourne, S (18 July 2007). Ersser, Steven J, ed. "Psychological and educational interventions for atopic eczema in children". The Cochrane database of systematic reviews (3): CD004054.
- Barnes, TM; Greive, KA (Nov 2013). "Use of bleach baths for the treatment of infected atopic eczema.". The Australasian journal of dermatology 54 (4): 251–8.
- Vos, T (15 Dec 2012). "Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010". Lancet 380 (9859): 2163–96.
- Osman M, Hansell AL, Simpson CR, Hollowell J, Helms PJ (February 2007). "Gender-specific presentations for asthma, allergic rhinitis and eczema in primary care". Primary Care Respiratory Journal 16 (1): 28–35.
- Taylor B, Wadsworth J, Wadsworth M, Peckham C (December 1984). "Changes in the reported prevalence of childhood eczema since the 1939–45 war". Lancet 2 (8414): 1255–7.
- Simpson CR, Newton J, Hippisley-Cox J, Sheikh A (2009). "Trends in the epidemiology and prescribing of medication for eczema in England". J Roy Soc Med 102 (3): 108–117.
- Luckhaupt, SE; Dahlhamer, JM; Ward, BW; Sussell, AL; Sweeney, MH; Sestito, JP; Calvert, GM (June 2013). "Prevalence of dermatitis in the working population, United States, 2010 National Health Interview Survey". Am J Ind Med 56 (6): 625–634.
- Henry George Liddell, Robert Scott. "Ekzema". A Greek-English Lexicon. Tufts University: Perseus.
- Textbook of Atopic Dermatitis. Taylor & Francis. 2008-05-01. p. 1.
- Murphy LA, White IR, Rastogi SC (May 2004). "Is hypoallergenic a credible term?". Clinical and Experimental Dermatology 29 (3): 325–7.
- Dermatitis at DMOZ