Eczema overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Edzel Lorraine Co, D.M.D., M.D.
Overview
Eczema is a dermatological lesion which involves redness, skin edema, itching and dryness, crusting, flaking, blistering, cracking, oozing, or bleeding. Areas of temporary skin discoloration are sometimes due to healed lesions, although scarring is rare.
Historical Perspective
Over the years, dermatological conditions have become manifested in individuals. It was in the earlier part of the 20th century when the term atopic dermatitis was coined. The evolution of concepts from the standpoint of historical perspectives was observed, wherein significant insights as to the nature of the disease were derived.
Classification
Eczema can be classified in different forms. It could be based on location (hand eczema), specific appearance (discoid), or etiology (varicose eczema). A simplified nomenclature of allergy-related diseases was released by the European Academy of Allergology and Clinical Immunology (EAACI) in 2001.
Pathophysiology
There are two main theories on the existence of atopic dermatitis, also known as atopic eczema. These are the inside-out theory, and the outside-in hypothesis.
Causes
There are several possible causes of eczema, majority of which are genetic in origin. Adverse drug effects also manifest as eczema.
Differentiating Eczema from other Diseases
Several medical conditions can mimic eczema, with overlapping features. These conditions could be due to an inflammatory, infectious, immunodeficiency, or a nutritional deficiency problem. It is important to differentiate one from another to render proper medical treatment.
Epidemiology and Demographics
Eczema has been noted to have affected 1-3% of the adult population and 15-20% of the children population worldwide. In the United States, the prevalence is 10.7% in children and 7.2% in adults. Eczema is more commonly observed in males, particularly in those with severe cases, and has a late-onset.
Risk Factors
Family history and genetic mutation in the FLG gene are the two main risk factors of acquiring eczema.
Screening
Using the Hanifin and Rajka criteria as the gold standard, eczema is commonly diagnosed when 3 out of 4 major criteria, or 3 out of 23 minor criteria have been satisfied. United Kingdom Working Party diagnostic criteria is another alternative method of diagnosing eczema, which only requires 1 mandatory criterion, and 5 major criteria, and no laboratory testing is required. To assess the long-term control of this disease, three methods are used, namely the repeated measurement of outcomes, the number of medications used, and the occurrence of flares or remissions.
Natural History, Complications, and Prognosis
Bacterial, viral and fungal infections, as well as some psychological problems are some known complications of eczema.
Diagnosis
History and Symptoms
A number of things should be ascertained when diagnosing eczema. A thorough history taking must be done to elicit family history, dietary habits, lifestyle habits, and allergies. If the patient is positive for any of these, this disease can be detected through its clinical manifestations.
Physical Examination
Eczema is a chronic, relapsing dermatologic disease. Patients with eczema have pruritus which is an essential feature of this disease.
Laboratory Findings
Other Diagnostic Studies
No particular biomarker is reliable to diagnose eczema. However, the current practice is by using the laboratory levels of IgE, which when elevated, can also be associated with allergy, aside from parasitic infections, autoimmune diseases, and certain carcinomas.
Treatment
Medical Therapy
Topical corticosteroids are the mainline treatment for eczema. Different potencies of steroids are rendered specifically for the severity of eczema. Other drug treatments oftenly used for eczema include topical calcineurin inhibitors,crisaborole, antimicrobials, and antifungals.
Surgery
Surgical treatment is not commonly used as a means of management for eczema.
Primary Prevention
Primary prevention is the most effective means to avoid complications of eczema. This can be achieved by applying emolients on the skin, and consumption of probiotics and prebiotics.
Secondary Prevention
Prevention of further trans-epidermal water loss is the cornerstone of management of eczema. Since dysfunctional skin barriers could lead to water loss, daily replenishment of skin moisture is needed. This can be achieved through different modalities such as emollients, occlusives, and humectants.
Cost-Effectiveness of Therapy
The economic impact of eczema causes a burden to patients suffering from this disease. A recent study showed that an average of $274 ($199 indirect cost, and $75 direct cost) is spent by each patient for eczema.
Social Impact
The quality of life of patients suffering from eczema can be tremendously affected, as the pruritus and consequent scratching can bring about sleep disturbance, daytime fatigue, attention-deficit/hyperactivity disorder, headaches, and stunted growth. Ultimately, patients could develop poor self-esteem, embarrassment, and hence, an overall reduced social life.
Future or Investigational Therapies
More emphasis on genetic studies will be given in the future to unfold the remaining majority of unexplained heritability in eczema. However, the challenge still lies in the economical and computational requirements.