Eczema-Types, Causes, Risk Factors and Treatment

Last Updated on August 9, 2021

Eczema is a common name for a group of conditions that result in dry, itchy, and inflamed skin. It is also called dermatitis which refers to inflammation of the skin.

It is a very common condition. Different types of eczema affect around 10% of the population in the United States.

In common usage, the word eczema is used interchangeably with atopic dermatitis. Atopic dermatitis is actually the most common type of eczema.

Besides atopic dermatitis, eczema can be of various types.

Types of Eczema:

• Atopic dermatitis
• Contact dermatitis
• Neurodermatitis
• Dyshidrotic eczema
• Nummular eczema
• Seborrheic dermatitis
• Stasis dermatitis

A person can have more than one type of eczema at the same time. Although all types of eczema involve itchy and inflamed skin, each one has its own causes, risk factors, and triggers. Accordingly, the treatment also varies for each type. It is important to consult a dermatologist who can identify the different types of eczema and guide regarding the treatment and prevention of future episodes.

Atopic Dermatitis

It is the most common type of eczema. It usually begins in childhood. Most children outgrow the disease as they get older, while in some cases, the disease may persist into adulthood. Rarely the disease begins in adulthood.

Many people with atopic dermatitis also have asthma and hay fever.

Signs and Symptoms

• Dry skin
• Itching: may be severe and disrupt sleep during night time.
• Rash: red to brownish itchy and scaly patches. Common sites are creases of the elbows or knees. It may also involve the scalp, face or cheeks in infants and children.
• Severe itching may cause scratch marks.
• Scratching may cause the skin to become raw, sensitive, and swollen.
• The scratched skin may ooze fluid, show crusting or become infected.
• Over a period of time, the skin may become thicker or lichenified.

The dryness of the skin can worsen the itching and rash. An “itch-scratch cycle” usually occurs in which scratching the skin results in more irritation, and hence, more itching.

Causes and Risk Factors

The exact cause of atopic dermatitis is not known.

• It is thought to result from a combination of genetic and environmental factors.
• The disease is known to run in families. It is also associated with other atopic disorders such as hay fever (seasonal allergies), allergic rhinitis and asthma
• Many children who outgrow atopic dermatitis as they grow older can go on to develop asthma or hay fever in adulthood. This is known as ‘atopic march’.
• Patients of atopic dermatitis appear to have a misguided immune response. They have either a reduced quantity of or a defective form of a protein called filaggrin in their skin which is important in maintaining the integrity and hydration of normal skin. As a result, the skin is not able to protect against irritants and allergens.
• Common environmental triggers that can aggravate atopic dermatitis include seasonal allergies, exposure to harsh soaps, detergents or chemicals, house dust mite, pollens, animal dander, air pollution, dry and cold weather, etc.
• Stress is also known to aggravate the condition.

Read more about Atopic Dermatitis: Causes, Self-care Tips and Treatment

Read more about Allergic Rhinitis-Types, Clinical Features, Prevention, and Treatment

Read more about Allergy skin tests- Indications, Procedure , and Interpretation

Contact Dermatitis

Contact dermatitis is a condition in which the skin comes in direct contact with a chemical or a substance that causes an allergic reaction.

Usually, the allergic reaction is not severe or life-threatening but it can be very uncomfortable.

Signs and Symptoms

• Rash: red, itchy
• Dry, cracked, scaly skin
• Itching: may be severe
• Bumps and blisters, sometimes with oozing and crusting
• Swelling of the affected area
• Burning sensation or pain

It is of two types

Allergic contact dermatitis: It is seen in genetically predisposed persons who are previously sensitized to a substance (allergen). The allergen can trigger an immune reaction in the skin at even very low concentrations.

Only the area that comes in contact with the allergen is usually affected. However, it can also occur by a food substance or a medicine (systemic contact dermatitis).

Irritant contact dermatitis: It is more common. It may occur either after a single exposure to a strong irritant or after repeated exposures to even mild irritants.

Common substances which can cause contact dermatitis include:

• jewelry
• nickel
• soaps
• detergents
• bleach
• perfumes
• deodorants
• hair dyes
• cosmetics, sunscreen, and other skincare products
• latex
• clothings with dyes
• paint
• poison ivy and other poisonous plants
• solvents
• airborne substances, such as sawdust, wool dust, pollen, and spray insecticides
• tobacco smoke
• diapers or baby wipes (in children)
• sunscreens and oral medicines (cause a reaction when a person is in the sun – photoallergic contact dermatitis)

Neurodermatitis

Neurodermatitis is a skin condition that produces thick scaly, itchy patches on the skin. Scratching worsens the itching. This results in an itch-scratch cycle that causes the affected skin to become thick and leathery.

It is also known as lichen simplex chronicus. It is most common between 30 to 50 years of age. Females are more commonly affected than males. Intense itching can disrupt sleep and impair the quality of life.

Signs and Symptoms

• Scaly patches on the skin that have a thick and leathery texture. These patches are red or darker than the rest of the skin.
• Commonly affected sites are arms, legs, hands, feet, back of neck, scalp, genitals, etc.
• Itching of the skin patches may be severe.
• Severe scratching can cause bleeding from the skin.
• The skin lesions may get infected.

Causes and Risk factors

The exact cause is unknown. Anything that irritates the skin may initiate an itch-scratch cycle in which scratching the skin results in more irritation, and hence, more itching.

The following are the risk factors for neurodermatitis.

• Dry skin
• Personal or family history of atopy, other types of eczema, or psoriasis.
• Stress and anxiety as they can trigger itching of neurodermatitis.

Dyshidrotic Eczema

It is a type of eczema in which small blisters appear on the palms and fingers of the hands or soles of the feet.

It is also called pompholyx (meaning “bubble” in Greek), foot-and-hand eczema, or vesicular eczema.

It is more commonly seen in women than in men. Younger individuals (between 20 to 40 years of age) are more frequently affected.

Signs and Symptoms

• Small fluid-filled blisters on hands and feet
• Itching or burning sensation may occur prior to the appearance of blisters
• The skin around the blisters may be sweaty
• Drying and redness of the skin once the blisters heal
• Tenderness, cracks, and painful fissures on the skin after blister healing
• The skin may become infected.

Causes and Risk factors

Several factors can trigger dyshidrotic eczema. These include:

• Contact with metals like nickel, cobalt, or chromium
• Stress
• Sweaty hands and feet
• Prolonged wetting of hands (in professions such as hair stylists or health care workers)
• Environmental factors (eg, seasonal changes, hot or cold temperatures, warm and humid weather)
• Personal or family history of atopy (atopic dermatitis, allergic sinusitis, hay fever, asthma).
• A person receiving intravenous immunoglobulin therapy

Nummular Eczema

It is a type of eczema which results in circular, coin-shaped itchy spots on the skin. It is also known as discoid eczema or nummular dermatitis. The word “nummular” is a Latin word that means coin.

It can occur at any age. Males are affected more commonly than females.

Signs and Symptoms

• Round, coin-shaped lesions on the skin
• The extremities, particularly the legs are affected most commonly but they may also occur on the trunk, hands, or feet. The face and scalp are not involved.
• Itching of skin lesions
• The skin around the lesions may become scaly or inflamed.

Causes and Risk factors

The exact cause is not known. The following factors are known to trigger nummular eczema.

• Dry or sensitive skin.
• Trauma to the skin from insect bites or chemical burns.
• Allergic reaction to metals like nickel.
• As a reaction to other types of eczema like contact dermatitis or atopic dermatitis.
• Poor blood flow in the lower body may trigger nummular dermatitis on the legs.

Seborrheic Dermatitis

It is one of the most common skin diseases. It produces flaky scales, red skin, and an itchy rash. It mainly affects the oily areas of the body such as the scalp, face, sides of the nose, eyebrows, ears, eyelids, and chest.

It is also called dandruff, seborrhea, seborrheic eczema, or seborrheic psoriasis. In infants, it is known as cradle cap and results in scaly and crusty patches on the scalp or diaper area.

It can affect people of any age. However, it is most common in infants and adults between the ages of 30 and 60. It is more common in males. The disease tends to flare-up in cold and dry seasons. The disease is not caused by poor hygiene.

Read more about Seborrheic Dermatitis- Clinical Features, Causes, and Treatment

Read more about Cradle Cap: Clinical Features, Causes, Home Remedies and Treatment

Signs and Symptoms

• Skin flakes (dandruff) on scalp, hair, eyebrows, hair-bearing areas of the face like beard or mustache.
• Patches of greasy skin covered with yellow-white flakes or crust.
• Red skin with swollen appearance
• Itching
• The most common sites of involvement include the scalp, face, eyebrows, ears, sides of the nose, eyelids, chest, groin area or under the breasts.
• In babies, scaly, greasy patches form on the baby’s scalp (cradle cap) or the diaper area. The condition is harmless and usually goes away on its own within a few months.
• In adults, the disease can come and go throughout the person’s life. Flare-ups can occur with triggers such as cold and dry weather, stress, etc.

Causes and Risk factors

Malassezia yeast, ( a fungal organism that normally lives on the surface of the skin ), is thought to be responsible for causing seborrheic dermatitis. Overgrowth of this fungus and the overreaction of the body’s immune response to it produce an inflammatory reaction that results in skin changes.

Common triggers for seborrheic dermatitis include:

• Cold and dry weather
• Stress
• Hormonal changes or certain medical conditions such as psoriasis, acne, rosacea, eating disorders, Parkinson’s disease, epilepsy, alcoholism, recovery from a stroke or heart attack.
• Weakened immune system as seen in patients of HIV, organ transplant recipients, or some cancers.
• Certain medications, including psoralen, interferon, and lithium
• Exposure to harsh detergents, soaps, or chemicals

Stasis Dermatitis

Stasis dermatitis tends to develop in people with chronic venous insufficiency that results in poor blood circulation in the legs. Venous insufficiency occurs due to the weakening of the valves in leg veins (that help push blood back to the heart). As a result, blood can flow backward and pool in the lower legs causing pressure and swelling in the veins, producing symptoms of stasis dermatitis.

The common causes of venous insufficiency include:

• Aging
• Being overweight
• Lack of exercise
• Multiple pregnancies
• Standing or sitting for prolonged periods
• Kidney disease
• Congestive heart failure
• Hypertension
• Any condition that affects blood circulation
  • Deep vein thrombosis (DVT) ( clotting of blood in the lower leg)
  • Varicose veins (enlarged and swollen veins)
  • Congestive heart failure
  • Injury to the lower leg
  • Any surgery that affects the veins in the lower leg

Read more about Stasis Dermatitis – Causes, Symptoms, and Treatment

Self-care Tips and Home Remedies For Eczema

• Use skin creams, petroleum jelly, or emollients frequently to moisturize your skin and prevent dryness. It is best to apply these immediately after a bath when the skin is still damp so that the moisture gets locked within the skin.
• Avoid frequent baths. In the case of cradle cap, however, the scalp needs to be washed frequently.
• Use lukewarm water for bathing in cold weather. Do not use hot water as it irritates the skin.
• Oatmeal can be added to water for bathing.
• Very dilute bleach baths (in a proportion of one quarter to one-half cup of bleach mixed with 150 liters of water bath) once or twice weekly can improve the rash and prevent skin infections.
• Use a mild soap for bathing. The soap used should not rob the skin of its natural moisture or irritate your skin.
• Cleansing agents or soaps used should have a low pH so as to maintain the acidic pH of the skin. This helps to preserve the skin barrier function and reduces skin irritation.
• Use sunscreens when out in the sun to prevent sunburns and skin damage.
• Avoid fabrics that irritate the skin, such as wool and synthetics. Use cotton clothing and bedsheets. Even in winters, do not let the woolen clothes come in direct contact with the skin. Always wear a layer of cotton clothing underneath the woolens.
• Always wear light and loose-fitting clothes. Avoid wearing tight or restrictive garments.
• Warm and dry air tends to make the skin dry. So avoid excess use of heaters or air conditioners. You can also use a humidifier to prevent the air from becoming dry.
• Try to avoid common allergens like pollen, pet dander, dust mites, and mold. At home, dust and vacuum regularly. Wash bedding weekly in hot water. Avoid using heavy drapes and carpeting at home or workplace.
• Avoid contact with chemicals, solvents, or metals that can trigger contact dermatitis.
• Regular exercise and maintaining proper body weight can help to prevent stasis dermatitis.
• Avoid sitting or standing for prolonged periods to prevent stasis dermatitis.
• Wear compression stockings to promote blood circulation and relieve swelling of the legs.
• Sleeping with legs elevated and elevating the legs for 15 minutes once every 2 hours can help to improve the blood circulation in the lower legs in case of stasis dermatitis
• Avoid hot or spicy foods or alcoholic beverages.
• Resist the temptation to scratch your skin. Try pressing on the skin rather than scratching.
• Keep your fingernails short. This may prevent damage to the skin if you can’t resist the urge to scratch
• To relieve itching, place a cool cloth or some ice over the skin that itches.
• Cooling lotions like calamine, menthol, and camphor provide a soothing effect to the irritable skin. They stimulate the nerve fibers which transmit the sensation of cold, and hence mask the itchy sensation.
• Avoid stress and anxiety. Taking care of your emotional health by practicing meditation and other behavioral modification techniques can help to prevent eczema flare-ups.

Treatment

Treatment aims at relieving the symptoms and regular moisturizing of the skin.

If regular moisturizing and other home remedies don’t provide relief, prescription medicines or other treatments may be recommended.

Topical corticosteroid ointments

They are applied after moisturizing the skin. They are quite effective. Commonly used steroids are hydrocortisone, triamcinolone, or betamethasone valerate. However, they shouldn’t be used for prolonged periods as they may cause thinning of the skin.

Anti-allergic medicines

Oral H-1 receptor blockers or antihistaminics are effective as they tend to break the scratch-itch cycle. Commonly used drugs are hydroxyzine, diphenhydramine, chlorpheniramine, cetirizine, and loratadine. Due to their sedative effect, they are particularly useful in patients who face problems in sleeping due to intense itching. However, their effects can persist into the daytime and can impair cognitive function, such as alertness learning, and memory. Non-sedative alternatives like fexofenadine may be used if sedation is not acceptable to the patient.

Antibiotics

Antibiotic cream is applied if the skin shows a bacterial infection.  In some cases, oral antibiotics may be prescribed for a short duration to treat an infection.

Antifungals 

Antifungal gels, creams, or shampoos may be prescribed for treating seborrheic dermatitis. 2% ketoconazole or 1% ciclopirox are commonly used. In severe cases, oral antifungal medication may be prescribed.

Oral steroids

Oral drugs such as prednisone may be rarely prescribed in very severe cases to control inflammation. Although effective, they can’t be used for a long time because of serious side effects.

Read more about Side Effects of Corticosteroid Therapy 

Wet-wrap therapy

It is used in patients with severe eczema having widespread skin lesions. Topical medications (steroids or other medications as described above) are applied to the affected areas of the skin. Then, a wet dressing (wet gauze or clothing) is placed over it. On top of it, a dry wrap material, such as elastic bandage is placed.

This is an effective treatment usually carried out in hospital settings under nursing expertise.

Light therapy

This treatment is reserved for people who either don’t respond to other treatments or who rapidly flare again after adequate treatment.

Ultraviolet light – UV-A, UV-B, a combination of both, psoralen plus UV-A (PUVA), or UV-B1 (narrow-band UV-B) therapy may be used.

Though effective, this therapy has side effects, such as premature aging of the skin and an increased risk of skin cancer. Hence it should not be used in children or infants.

Long–term Outlook

Home remedies and lifestyle changes along with intermittent use of medications can help to relieve dry skin, provide relief from itch and rashes, and prevent future flare-ups.

With adequate care and treatment, most of the patients can enjoy a high quality of life and participate in all activities.

References

• Sundaresan S, Migden MR, Silapunt S. Stasis Dermatitis: Pathophysiology, Evaluation, and Management. Am J Clin Dermatol. 2017 Jun. 18 (3):383-390.
• Eichenfield LF, Tom WL, Chamlin SL, Feldman SR, Hanifin JM, Simpson EL, et al. Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol. 2014 Feb. 70(2):338-51.
• Carlsten C, Dimich-Ward H, Ferguson A, Watson W, Rousseau R, Dybuncio A, et al. Atopic dermatitis in a high-risk cohort: natural history, associated allergic outcomes, and risk factors. Ann Allergy Asthma Immunol. 2013 Jan. 110(1):24-8.
• Bonamarte D, Oti C, Vestita M, Ranieri LD, Angelini g. Nummular eczema and contact allergy: a retrospective study. Dermatitis. 2012 Jul – Aug. 23(4):153-7.
• Gerstenblith MR, Antony AK, Junkins-Hopkins JM, Abuav R. Pompholyx and eczematous reactions associated with intravenous immunoglobulin therapy. J Am Acad Dermatol. 2011 May 19.
• Spergel JM. From atopic dermatitis to asthma: the atopic march. Ann Allergy Asthma Immunol. 2010 Aug. 105(2):99-106.
• Zisova LG. Malassezia species and seborrheic dermatitis. Folia Med (Plovdiv). 2009 Jan-Mar. 51(1):23-33.