Eczema

Eczema is a common skin problem in individuals with brown skin including those of Asian, Latino and African descent. It is felt to be the second most common skin disease in African-Americans. Although it is unknown if the incidence of eczema is increased in Latinos, one study found a significantly higher percent of Mexican American adolescents with eczema than white and African American adolescents. A study of Chinese, Vietnamese and white infants found a higher incidence in the Chinese and Vietnamese infants. Eczema can be a difficult and embarrassing challenge for anyone, but for a person of color with eczema, there are multiple concerns including disfiguring discoloration of the skin (hyperpigmentation or hypopigmentation). Also, in brown skin, eczema may appear differently than in white skin thus making the correct diagnosis more difficult.

In cases in which eczema is inherited along with the conditions, asthma and hay fever, it is termed, atopic dermatitis. Eczema usually appears in childhood or adolescence and frequently continues throughout adulthood. The course of eczema varies with intermittent flares which are precipitated by the following factors:

  • Extremes of temperature
    • cold, dry weather
    • hot, humid weather
  • Stress
    • emotional
  • Excessively dry skin
    • over bathing
    • long, hot showers or baths
    • dry home heating systems
  • Irritants
    • skin care products (soaps or cleansers)
    • wool clothing
    • laundry detergents and dryer sheets
  • Allergies
    • food (dairy, shellfish etc)
    • plants (poison ivy, oak, sumac)
    • medications
    • dust and dust mites
    • pollen

Eczema is a diverse disease that can range from mild skin irritation to severe rashes. In skin of color, eczema may not have the typical appearance of red, flaky patches. Instead, it may appear as dry ashen, brown or gray patches. In addition, in black skin, eczema may appear as rough, brown papules (bumps) near follicles which is termed, follicular papules.

There are three stages of eczema: acute, subacute and chronic. An individual with eczema may have only one stage or the stages may progress from one to another.

Acute Eczema

Stages Characteristics Symptoms Location
Acute Red, raw, irritated or blistered skin or brown bumps Severe itching, burning, pain Trunk, extremities, hands, feet
Subacute Dry, flaky, red or dark, cracked skin; follicular bumps Mild to moderate itching, stinging, burning Neck, behind elbows and knees, trunk, fingertips
Chronic Dark, thickened skin with prominent skin lines; scratch marks Moderate to severe itching, chronic rubbing and scratching Neck, trunk, behind elbows and knees, feet, fingertips
Dyshidrotic Small pinpoint blisters or pus-bumps Itching, oozing Hands, fingers, toes
Lichen Simplex Chronicus Very thick, dark patches with prominent skin lines Itching with rubbing Wrists, trunk, extremities

A major symptom of eczema is very intense itching. Scratching is a natural response to the itching. However, melanin in brown skin makes it more reactive to itching, irritation and inflammation. When scratched or rubbed, the inflamed skin can become hyperpigmented, thickened and crusted. It is important to break the itch-scratch cycle to prevent further hyperpigmentation.

Treatment
Once eczema flares in brown skin, treating it promptly is key to not only eliminating the itch, but also avoiding hyperpigmentation or hypopigmentation. While there is no cure for eczema, the condition can be kept under control by modifying certain daily routines and receiving prompt treatment.

Prevention of eczema is as important as prescription medication. Understanding the causes of eczema, trigger factors and proper skin care techniques are the first step to treating eczema. Some individuals with eczema will need to avoid certain foods, allergens or medicines.

  • Common foods associated with eczema:
    • Milk
    • Eggs
    • Peanuts
    • Soybeans
    • Wheat
    • Seafood
    • Fruit with seeds

Avoiding skin irritants, including chemicals and clothing, is an important preventative measure for individuals with eczema.

  • Tips to Avoid Skin Irritants
    • Wear soft cotton clothes
    • Do not wear wool, polyester or nylon clothing
    • Double rinse clothes to remove detergent residue
    • Do not use fabric softeners
    • Use PVC gloves for wet work
    • Use cotton gloves for housework and under PVC gloves
    • Do not use soap
    • Do not use or spray perfume
    • Do not use make-up on weeping lesions

All individuals with eczema will need to modify bathing habits, skin care products and other chemicals that come into contact with the skin. The following patient education tips are commonly recommended by dermatologists.

  • Eczema Tips
    • Take a short, warm (not hot) shower only once a day
    • Avoid hard water, salt water and chlorinated water
    • Use a mild cleanser that does not contain fragrance
    • Do not use bubble bath or fragranced body wash
    • Apply moisturizer to damp skin within three minutes of showering to lock in moisture
    • Use a humidifier to counter dry indoor heat
    • Don’t scratch or rub!
    • Use cool water or milk compresses to soothe itchy skin
    • Exercise in cool well ventilated areas

Corticosteroids topical, oral and injected are the mainstay of treatment of eczema. The selection of the formulation depends upon the severity of the eczema. For mild to moderate eczema, topical corticosteroids, formulated as creams, ointments, lotions, foams or oils are commonly prescribed. These agents, which come in many different strengths from class 1 (superpotent) to class 7 (low potency), are usually prescribed twice daily for a two to three week period. Low potentcy corticosteroids are commonly used to treat the face, body folds (groin, axillary) and in the diaper area. More potent steroids are applied on other parts of the body. For lichenified plaques and regions such as the palms and soles superpotent steroids are often prescribed. Although topical steroids treat the inflammation that is characteristic of eczema, serious complications can develop from overuse or prolonged use, especially those that are superpotent.

Complications of topical steroidsThinning of the skin

  • Thinning of the skin
  • Stretch marks on the skin
  • Growth of unwanted hair
  • Acne-like bumps
  • Redness

For severe eczema, oral steroids (Prednisone) or injected steroids (Kenalog, Aristocort) may be necessary. They are prescribed for a limited period of time only and are reserved for the most severe cases.

TIMS or Topical Immunomodulators are topical agents (calcineurin inhibitors) that are used for the treatment of eczema. They do not contain steroids and therefore do not carry the risks associated with that medications. There are two types of immunomodulator creams: Tacrolimus (0.03% and 0.1% Protopic) and pimecrolimus (1% Elidel). Immunomodulators are applied twice daily until the eczema clears. Itching, burning and irritation are possible side effects. There has been concern raised regarding cancers in laboratory animals fed immunomodulators orally. Further long-term human studies are needed to completely understand the side effects with topical immunomodulator therapy.

Non-TIMS are non-steroid, non-tims topical creams that have been recently developed for the treatment of eczema. One of the most recently approved is Mimyx. It is not only a good emollient, but treats eczema and can be used for chronic cases or eczema.

Phototherapy or light treatment is an effective treatment for eczema. With phototherapy, various wavelengths of sunlight (UVB, UVA, combined UVA/UVB, UVA1, or narrow-band) are administered in a unit that is similar to a telephone booth but which is lined by fluorescent appearing light bulbs. The type of phototherapy that you will receive will be determined by your dermatologist. It is usually administered twice weekly. Possible side effects of phototherapy are redness, sunburn, or dryness. Long-term side effects, which are more likely with white skin, are possible skin cancers and enhanced aging.

Antihistamine pills relieve itching associated with eczema. There are three classes of antihistamines (H1, H2, H3). Type H1 antihistamines (e.g. hydroxyzine, diphenhydramine) are helpful in breaking the itch-scratch cycle. Since they may cause drowsiness, they should be given at bedtime. Type H2 and H3 antihistamines are generally non-sedating and are also helpful in treating eczema. Your doctor will select the antihistamine that is most appropriate for your eczema.

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