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Eczema

Eczema

Eczema is a condition that causes the skin to become itchy, red, dry and cracked. ‘Atopic’ eczema is the most common form of the condition. It mainly affects children – about one in five children in the UK has eczema – and it often gets better as they get older. However, adults can be affected as well. Symptoms can range from mild to severe. It is usually treated with creams to keep the skin soft or to reduce swelling and redness during flare-ups.

Introduction

Eczema is a condition that causes the skin to become itchy, red, dry and cracked. It is a long-term, or chronic, condition.

Atopic eczema, also known as atopic dermatitis, is the most common form of eczema. It mainly affects children, but can continue into adulthood.

Atopic eczema commonly occurs in areas with folds of skin such as:

  • behind the knees
  • on the front of the elbows
  • on the side of the neck
  • around the eyes and ears

See Atopic eczema - symptoms for more information.

What causes atopic eczema?

The exact cause of atopic eczema is unknown. However, it often occurs in people who get allergies ("atopic" means sensitivity to allergens).

Atopic eczema can run in families and often occurs alongside other conditions such as asthma and hay fever.

See Atopic eczema - causes for more information.

How common is atopic eczema?

About one in five children in the UK has eczema. In 8 out of 10 cases, atopic eczema occurs before a child reaches five years of age. Many children develop it before their first birthday.

The number of people diagnosed with atopic eczema has increased in recent years. This could be due to changes in lifestyle or environmental factors that cause eczema, or because healthcare professionals are now more aware of the symptoms.

Males and females are affected equally. There is some evidence that eczema may be slightly more common in people from African-Caribbean backgrounds. 

Outlook

Atopic eczema can vary in severity. Most people are only mildly affected and have small areas of dry or red skin, which are occasionally itchy.

Other people have more severe symptoms, such as cracked, sore and bleeding skin.

A person with atopic eczema usually has periods when symptoms are less noticeable, and flare-ups when symptoms become more severe and require additional treatment.

Atopic eczema clears up or significantly improves in many children as they get older. In about 53% of cases, atopic eczema clears up by the time a child reaches 11 years of age, and in 65% of cases it clears up by 16 years of age.

Severe eczema often has a significant impact on daily life and may be difficult to cope with physically and mentally. However, many different treatments can be used to control symptoms and manage the eczema.

See Atopic eczema - treatment for more information.

 

Symptoms and Causes

The symptoms of atopic eczema may always be present. Symptoms become worse during a flare-up, and you or your child may need stronger treatment when this happens.

Atopic eczema can cause your skin to become:

  • itchy
  • dry
  • red
  • broken
  • thickened 
  • cracked

During a flare-up, your skin may be:

  • extremely itchy, red, hot, dry and scaly
  • wet, weeping and swollen
  • infected with bacteria, usually Staphylococcus aureus (see Atopic eczema - complications)

The symptoms of atopic eczema vary according to how severely you or your child are affected by the condition.

People with mild atopic eczema normally have only small areas of dry skin, which are occasionally itchy. In more severe cases, atopic eczema can cause widespread dry skin, constant itching and oozing fluid.

Scratching can disrupt your sleep and make your skin bleed. It can also make itching worse, and a cycle of itching and regular scratching may develop. In children, this can lead to sleepless nights and difficulty concentrating at school.

Where atopic eczema occurs

Atopic eczema can occur in small patches all over the body. It is most common:

  • in infants: on the face and scalp, and on the outer surface of the arms and legs
  • in children: around joints on the arms and legs, such as the folds of the elbows or the backs of the knees 
  • in adults: in the joints, such as inside the elbows or the backs of the knees, and on the hands 

Causes of atopic eczema

There is no single cause of eczema. It probably has a mixture of inherited and environmental causes that act together at different times.

You may be born with an increased likelihood of developing eczema, which you inherit from your parents. When you are exposed to environmental factors, such as dust or pollen, this causes eczema to appear.

There are also several triggers, which can make your symptoms worse.

Genetic factors

Research suggests that atopic eczema is largely an inherited condition. This means that the cause lies in the genes that you inherit from your parents.

If a child's parents have atopic eczema, it is highly likely that the child will also develop the condition. Studies have shown that 60% of children who have a parent with atopic eczema also have the condition. If both parents have atopic eczema, there is an 80% chance that a child will also have the condition.

It is not yet known exactly which genes are responsible for eczema, although a protein called filaggrin is involved. Filaggrin attaches to a tough substance called keratin in cells and, along with other structures, forms a barrier at the skin's surface. If there is a problem with your filaggrin, the skin barrier can no longer provide effective protection from the environment.

There may be a problem with your filaggrin if you have inherited a defect in the gene responsible for making filaggrin. In this case, you have a higher risk of developing atopic eczema. The filaggrin gene may account for up to one in five cases of eczema. Other genes responsible for skin inflammation may also be responsible.

Environmental factors

If your genes make you more likely to develop atopic eczema, the condition will develop after you are exposed to certain environmental factors, such as allergens.

Allergens are substances that can cause the body to react abnormally. This is known as an allergic reaction. Some of the most common allergens that can cause atopic eczema include:

  • house dust mites
  • pet fur
  • pollen

Atopic eczema can sometimes be caused by food allergens, especially in the first year of life. Foods that typically cause allergic reactions include:

  • cows' milk
  • eggs
  • nuts
  • soya
  • wheat

Some studies of children and young people with atopic eczema, which were not carried out in the UK, found that one-third to nearly two-thirds also had a food allergy. Having a food allergy increases the likelihood of your atopic eczema being severe.

See the Heath A-Z topic about Food allergies for more information.

Allergies do not appear to play a role in many people with eczema. Other non-allergic factors may be just as important in bringing out eczema in someone who is likely to get it. These factor could include: 

  • cold weather
  • dampness
  • harsh soaps
  • washing too much 
  • rough clothing

Triggers

Triggers can make atopic eczema worse, although they may not cause the condition. 

Hormonal changes in women

Hormones are powerful chemicals that are produced by the body and have a wide range of effects. Changes in the levels of certain hormones can affect the symptoms of atopic eczema in some women.

Many women's eczema is worse at certain times during their menstrual cycle. Some women have a flare-up of their eczema in the days before their period.

Pregnancy, which causes hormonal changes, can also affect atopic eczema:

  • More than half of all pregnant women find their symptoms get worse.
  • One-quarter of pregnant women find their symptoms improve.
Stress

While stress is known to be associated with atopic eczema, it is not fully understood how it affects the condition. Some people with eczema have worse symptoms when they are stressed. For other people, their symptoms cause them to feel stressed.

See the Health A-Z topic about Stress for more information and ways to manage stress.

Exercise

After vigorous exercise, sweating may make your eczema symptoms worse. Try to keep cool when you are exercising by drinking plenty of fluids and taking regular breaks.

Irritants

Irritants can make your symptoms worse. What irritates you may be different to what irritates someone else with the condition, but could include:

  • soaps and detergents, such as shampoo, washing-up liquid or bubble bath
  • some types of clothing, especially wool and nylon 
  • overheating 
  • very cold, dry weather
  • dust 
  • unfamiliar pets
Other triggers

Other possible triggers include:

  • substances that touch your skin - such as perfume-based products or latex (a type of naturally occurring rubber)
  • some food products - such as fish, peanuts and kiwi fruit, which can make your symptoms worse, although this does not mean you are allergic to them  
  • environmental factors - such as tobacco smoke, living near a busy road or having water that contains lots of minerals (hard water)
  • the changing seasons - most people with atopic eczema find that their symptoms improve during the summer and get worse in the winter

Inflammation

Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

Diagnosis

Your GP will usually be able to diagnose atopic eczema by assessing your or your child's skin and asking some questions about the condition, such as:

  • whether the rash is itchy
  • when the symptoms first began
  • whether you have flare-ups of severe symptoms and periods when your symptoms are less severe 
  • whether there is a history of atopic eczema in your family
  • whether you have any other conditions that may be related to your eczema, such as allergies or asthma
  • whether it has affected the typical areas, such as skin creases, in the past

Your GP will also assess the severity of your eczema, such as how much the itching is bothering you and how widespread the areas of dry skin are. Tell your GP if your condition is affecting your quality of life, for example if you have difficulty sleeping or if it is limiting your daily activities.

Checklist for diagnosing atopic eczema

To confirm a diagnosis of atopic eczema, your GP may assess the appearance of your skin against a checklist of symptoms.

Typically, to be diagnosed with atopic eczema, you must have had an itchy skin condition in the last 12 months, as well as three or more of the following signs and symptoms:

  • You have itchiness and irritation in the creases of your skin, such as the front of your elbows, behind your knees, the front of your ankles, around your neck or around your eyes.
  • You currently have asthma or hay fever, or you have had them in the past. For children who are less than four years old, they must have an immediate relative, such as a parent, brother or sister, who has asthma or hay fever.
  • Your skin has been generally dry in the last 12 months.
  • Your condition started when you were two years of age or younger (this does not apply if your child is less than four years of age).
  • There is eczema on the skin in your joints, such as your elbow, knees and wrists, or on the forehead, cheeks or outer surface of the arms or legs in children under four years of age.

If your symptoms do not meet these criteria, you may still have atopic eczema, although other types of skin problems may be more likely. 

Establishing triggers

Your GP will work with you to establish what triggers make your eczema worse (see Atopic eczema - causes). They may ask you about your diet and lifestyle to see if any obvious factors may be contributing to your symptoms. For example, you may have noticed that some soaps or shampoos make the eczema worse.

Your GP may use other methods to try to determine what is triggering your eczema. For example, they may ask you to keep a food diary for four to six weeks to find out whether a specific food makes your symptoms worse.

A food diary involves writing down everything you eat and making a record of any eczema flare-ups that you have. Your GP can see if there are any patterns between your symptoms and what you eat.

Diagnosing a food allergy

Some types of food can make your eczema symptoms worse within 24-48 hours, and you may be allergic to some types of food. A food allergy can cause: 

  • vomiting 
  • diarrhoea 
  • an itchy red rash, like nettle rash
  • worsening of eczema symptoms

These symptoms usually develop within a few minutes to an hour after exposure to the food. See the Health A-Z topic about Food allergy - symptoms for more information.

If you or your child develop these symptoms immediately after coming into contact with a particular food, you may have a food allergy.

Treatment

Although there is no simple cure for atopic eczema, a variety of treatments can ease the symptoms of an eczema flare-up. Children with atopic eczema normally find that their symptoms naturally improve over time. 

Medication used to treat atopic eczema includes:

  • emollients - used all the time for dry skin
  • topical corticosteroids - used to reduce swelling and redness during flare-ups

These two medicines provide effective treatment for most cases of eczema, even severe eczema.

Your GP will prescribe emollients for dry skin, and the weakest effective topical corticosteroid. Different strengths are needed for different parts of the body.

Other medicines that may be used include:   

  • antihistamines, for severe itching 
  • oral corticosteroids, for severe symptoms
  • antibiotics, for infected eczema  
  • topical calcineurin inhibitors, such as pimecrolimus and tacrolimus

Your GP will prescribe additional medication as and when it is needed.

As well as medication, the following self-care advice should also help.

Self-care

You can use several self-care treatments at home to manage your or your child's eczema symptoms. 

Reducing scratching

Eczema is often itchy. Scratching it will aggravate the skin more and will eventually cause it to thicken, like a piece of leather. If you scratch your skin, it increases the risk of your eczema becoming infected with bacteria. See Atopic eczema - complications for more information.  

There may be times when you or your child cannot help scratching. Keeping nails short will minimise any damage to the skin. If your baby has atopic eczema, anti-scratch mittens may stop them scratching their skin. Other techniques for avoiding skin damage from scratching include tapping or pinching the skin until the itch has gone.

Avoiding triggers

Your GP will work with you to establish what triggers your or your child's eczema flare-ups, although eczema may get better or worse for no obvious reason. See Atopic eczema - diagnosis for more information.

If you establish what triggers a flare-up, you can try to avoid contact with the triggers. For example:

  • If wool or some man-made materials irritate your skin, avoid wearing these and stick to natural materials, such as cotton.
  • If heat aggravates your eczema, keep the rooms in your home cool.
  • Avoid using any soaps or detergents that you think may affect your skin.

Although house dust mites have been shown to trigger eczema flares, you are not recommended to try to get rid of dust mites from your home. The process is very time consuming and difficult to carry out effectively, and there is no clear evidence that it helps.

Similarly, although living in an area that has hard water is associated with slightly higher levels of eczema in younger children, installing a water softener does not seem to make any difference.

Diet

If you or your child have atopic eczema, do not make any significant dietary changes without first speaking to your GP. Some foods, such as milk, eggs and nuts, have been shown to trigger eczema symptoms. However, it may not be healthy to cut these from your diet without medical advice, especially in young children who need plenty of calcium, calories and protein provided by these foods.

If your GP suspects that you have a food allergy, you may be referred to a dietitian. This is a healthcare professional who specialises in diet and nutrition.

If you are breastfeeding a baby who has atopic eczema, get medical advice before making any changes to your regular diet.  

Emollients

Emollients are substances that help soften and smooth your skin to keep it supple and moist. They are the most important treatment for dry skin associated with atopic eczema. See the Health A-Z topic about Emollients for more information.

As atopic eczema can cause your skin to become dry and cracked, it is important to keep it moisturised to prevent it from becoming more irritated. Emollients stop water being lost from the outer layer of the skin, and add water to the skin. They act as a protective barrier to keep the moisture in and the irritants out.

Choice of emollient

Several different emollients are available, some of which you can buy over-the-counter without a prescription. Your GP can recommend a suitable product.

You may need to try a few different emollients to find one that suits you. You may also be prescribed different emollients for different uses, such as:

  • an ointment for very dry skin 
  • a cream or lotion for less dry skin
  • an emollient to use on your face and hands 
  • a different emollient to use on your body  
  • an emollient to use instead of soap 
  • an emollient to add to bath water or use in the shower

The difference between lotions, creams and ointments is the amount of oil and water they contain. Ointments contain the most oil so can be quite greasy, but they are the most effective at keeping moisture in the skin. Lotions contain the least oil so are not greasy but can be less effective. Creams are in the middle.   

If you have been using a particular emollient for some time, it may eventually become less effective or it may start to irritate your skin. If this is the case, speak to your GP as another product can be prescribed instead. The most common reason for emollients not working is that they are used for inflamed skin without the help of an anti-inflammatory treatment, such as topical corticosteroids.

How to use emollients

Use your emollient all the time, especially between flare-ups, even when you do not have symptoms. Keeping separate supplies of emollients at work or at school can be a good idea.

To apply the emollient:

  • Use a large amount.
  • Smooth the emollient into the skin in the same direction that the hair grows. 
  • Do not rub the emollient in.
  • For very dry skin, apply emollient every two to three hours. 
  • After a bath or shower, gently dry the skin and then immediately apply the emollient, while the skin is still moist. 
  • Do not share emollients with other people.
  • Do not put your fingers into an emollient pot, but instead use a spoon or pump dispenser. This reduces the risk of spreading infection.

Creams and lotions tend to be more suitable for red, inflamed areas of skin. Ointments are more suitable for areas of dry skin that are not inflamed. 

It is very important to keep using your emollients during a flare-up because this is when the skin needs the most moisture. During a flare-up, apply emollients frequently and in generous amounts.

An adult with moderate eczema over quite a lot of their body should use around 500-600g (1.1-1.3lb) of emollient a week. A child should use about half this amount. Check the amount of your emollient on the packaging to work out roughly how long the pot or tube should last.

Side effects

The most common side effect of using emollients is stinging, which is often due to eczema not being sufficiently treated. Emollients alone rarely control eczema unless the eczema is very mild.

It is also possible for the emollient to block your pores, which is why you should apply it in the same direction that the hair grows.

If you have atopic eczema, your skin is very sensitive and can sometimes react to certain ingredients within an emollient. If your or your child's skin reacts to the emollient, speak to your GP. They will check to see if you are using enough topical corticosteroids or can prescribe an alternative product.

Some emollients contain paraffin and can be a fire hazard. As some emollient products are highly flammable, they should not be used near a naked flame.

Emollients that are added to your bath can make your bath very slippery, so take care getting in and out of the bath.

As long as you are aware of these hazards, you should be able to use emollients safely. 

Topical corticosteroids

When your or your child's skin is red and inflamed from an atopic eczema flare-up, your GP will probably prescribe a topical corticosteroid. Topical means something that is applied directly to your skin. Corticosteroids work by quickly reducing inflammation.

Corticosteroids are any type of medication that contains steroids, a type of natural hormone. Hormones are powerful chemicals that have a wide range of effects on the body. See the Health A-Z topic about Topical corticosteroids for more information.

You may be concerned about using medication that contains steroids. However, corticosteroids are not the same as anabolic steroids, which are sometimes used illegally by bodybuilders and athletes. When used correctly, corticosteroids are a safe and effective treatment for eczema.

Choice of topical corticosteroid

Topical corticosteroids can be prescribed in different strengths, depending on the severity of your atopic eczema. They can be very mild, such as hydrocortisone, moderate, such as clobetasone butyrate, strong or very strong. Severe cases of atopic eczema will require a stronger corticosteroid than milder cases. You may be prescribed: 

  • a cream to be used on visible areas, such as the face and hands
  • an ointment to be used at night or for more severe flare-ups

If your atopic eczema is moderate to severe, you may need to apply topical corticosteroids between flare-ups, such as at weekends, as well as during them.

If you need to use corticosteroids frequently, see your GP regularly so they can check that the treatment is working effectively and that you are using the right amount. 

How to use topical corticosteroids

Apply the treatment sparingly to the affected areas. Always follow the directions on the patient information leaflet that comes with the corticosteroid. This will provide details about how much you should apply, such as the number of fingertip units (see box, above left). 

During an atopic eczema flare-up, do not apply the corticosteroid more than twice a day. Most people only have to apply it once a day. To apply the topical corticosteroid:

  • Apply your emollient at a different time of the day to the topical corticosteroid, otherwise you will make the corticosteroid inactive or weaker, or spread it to areas where it is not needed.   
  • Apply a small amount of the topical corticosteroid to the affected area - see the box, above left, for a guide to the amount you should use. 
  • Use the topical corticosteroid once a day for 5-10 days, or for 5 days if the affected area is on your face or genitals, or in your armpits. 
  • Apply the treatment for 48 hours after the flare-up has cleared so that the eczema under the skin is treated.

If you or your child are using corticosteroids for a long time, you may be able to apply them less frequently. Your GP will advise you about how often you should apply them.

Speak to your GP if you have been using a topical corticosteroid and your symptoms have not improved.

Side effects

Topical corticosteroids may cause a mild burning or stinging feeling as you apply them.

If strong topical corticosteroids are used for too long, they may also cause:

  • thinning of the skin, particularly in the crease of the elbow or knee joint
  • visible blood vessels, particularly on the cheeks  
  • acne
  • increased hair growth

Generally, using a stronger topical corticosteroid or using a large amount of topical corticosteroid may increase your risk of side effects. For this reason, use the weakest preparation that controls your symptoms well.

Antihistamines 

Antihistamines are a type of medicine that stops the effects of a substance in the blood called histamine. Your body often releases histamine when it comes into contact with an allergen.

Antihistamines may be prescribed during flare-ups to help you cope with the itching that atopic eczema causes. Antihistamines can be sedating, which cause drowsiness, or non-sedating. See the Health A-Z topic about Antihistamines for more information.

Non-sedating antihistamines

You may be prescribed a non-sedating antihistamine to take once a day for a month if you have severe itching or associated hay fever. If this helps, you may continue taking the non-sedating antihistamine in the long term. You should be reviewed every three months to see if you still need the medication.

These antihistamines may still cause some drowsiness. For example, loratadine can cause drowsiness in 1 in 100 people.  

Sedating antihistamines

If your itching affects your sleep, you may be prescribed a sedating antihistamine to reduce the itching at night and improve your sleep. Sedating antihistamines are prescribed on a short-term basis, usually for a maximum of two weeks at a time, as they seem to lose their effect quickly.

You or your child may still feel drowsy the following day, so make sure you let your child's school know that they may not be as alert as normal. If you are taking sedating antihistamines, avoid driving the next day if you still feel drowsy. The sedative effect is likely to be stronger if you drink alcohol.

Oral corticosteroids

In rare cases, if you have a severe flare-up, your GP may prescribe oral corticosteroids. These are also used for flare-ups of asthma. They contain steroids, as topical corticosteroids do, but are swallowed. See the Health A-Z topic about Corticosteroids for more information.

You may be prescribed prednisolone to take once a day, usually in the morning, for one to two weeks.

If oral corticosteroids are taken often or for a long time, they can cause side effects, such as:

For this reason, your GP is unlikely to prescribe oral corticosteroids more than once a year without referring you to a specialist (see referral, below).

Infected eczema

Infected eczema is often sore, very red and oozing with occasional yellow pus spots in it. If your or your child's eczema has become infected, you will usually be prescribed an antibiotic. 

Oral antibiotics

If you have an extensive area of infected eczema, your GP may use a swab to take a sample of the skin. A swab is a small piece of absorbent material, such as gauze or cotton, attached to the end of a stick or wire. The sample can then be tested to see what is causing the infection and which antibiotic it will respond to.

You will usually be prescribed an antibiotic to take by mouth. The antibiotic most commonly prescribed is flucloxacillin, which is usually taken four times a day for seven days. If you are allergic to penicillin, you may be prescribed:

  • erythromycin - to take four times a day for seven days 
  • clarithromycin - to take twice a day for seven days

If your infection is severe or does not improve after one week, you may be given antibiotics to take for another week.

Topical antibiotics

If you have a small amount of infected eczema, you will normally be prescribed a topical antibiotic. This medicine, which is an ointment or cream, is applied directly to the affected area of skin.

Topical antibiotics should not be used for longer than two weeks because the bacteria may become resistant to the medication. 

If you use topical antibiotics for longer than two weeks, your skin may also become sensitive to the product and become irritated. If your symptoms get worse, stop using the topical antibiotic and return to your GP.

Preventing infections

Once your infection has cleared, your GP will prescribe new supplies of any topical medication or treatments that you use, such as emollients or topical corticosteroids. This is in case your old ones are infected. Once you have received the new supplies, dispose of your old treatments safely.

The most important way to control infection is to control the underlying inflammation with topical corticosteroids. The inflammation causes the bacteria to live in this area of skin and needs to be treated.

If areas of your eczema are prone to infection, you may be prescribed a topical antiseptic. This type of treatment is also applied directly to your affected skin and works by helping to kill bacteria. Commonly prescribed topical antiseptics include chlorhexidine and triclosan. 

Referral 

In some cases of atopic eczema, your GP may refer you for assessment and treatment by a dermatologist, a specialist in treating skin conditions. Your GP may refer you if:

  • Your GP is not sure what type of eczema you have. 
  • The prescribed treatments are not successfully controlling your eczema. 
  • You have eczema on your face that is not responding to treatment. 
  • The eczema is causing significant problems in your daily life, such as disturbing your sleep. 
  • It is not clear what is causing your eczema.

Further treatments

Some of the treatments a dermatologist may offer you are explained below. These types of treatments are not suitable for everyone, and can only be carried out by experienced skin-care specialists.

Possible treatments include: 

  • more support on using your treatments correctly - including demonstrations from nurse specialists on how to apply the preparations in adequate quantities
  • phototherapy - where your eczema is exposed to ultraviolet (UV) light
  • bandaging - where medicated dressings or wet wraps are applied to your skin
  • topical calcineurin inhibitors - a type of medicine that reduces inflammation
  • an immunosuppressant medication - which suppresses your immune system, the body’s natural defence system
  • very strong topical corticosteroids - to treat areas that have not responded to treatment
  • psychological support
  • alitretinoin (see below)
Alitretinoin

Alitretinoin, sold under the brand name Toctino, is a medication for severe, long-term hand eczema that has not responded to other treatments, such as topical corticosteroids. Treatment with alitretinoin must be supervised by a dermatologist and can only be used by people who are 18 years of age or over.

Alitretinoin is a type of medication called a retinoid. Retinoids reduce the levels of irritation and itchiness associated with eczema.

Alitretinoin comes as a capsule that most people are recommended to take once a day for 12-24 weeks.

Alitretinoin should never be taken during pregnancy because it can cause severe birth defects. Also, avoid taking alitretinoin when breastfeeding because the medication can enter your breast milk and harm your baby.

Due to the risk of birth defects, the use of alitretinoin is not recommended for women of child-bearing age. If you are a woman of child-bearing age, you will only be prescribed alitretinoin if you agree to the following strict rules:

  • You fully understand why you should not get pregnant and what you need to do to prevent it.
  • You agree to use one or preferably two methods of contraception, including a barrier form of contraception, such as condoms.
  • You must start using these contraception methods from one month before starting treatment until one month after finishing treatment.
  • You agree to have pregnancy tests before, during and after treatment.
  • You must confirm that you are aware of the risks and the precautions you need to take, for example by signing a form stating this.

Some common side effects of alitretinoin include:

  • headaches
  • dry mouth 
  • a reduced number of red blood cells, known as anaemia
  • warm and red skin
  • increased levels of fatty substances called cholesterol and triglyceride in the blood 
  • joint pain or muscle pain
  • dry eyes or eye irritation

Uncommon side effects of alitretinoin include nose bleeds and sight problems, such as blurred vision. If you have vision problems, stop treatment immediately and contact your dermatologist.

There have also been reports of people suddenly having thoughts of hurting or killing themselves while taking retinoids, which are related to alitretinoin. However, this has never been reported with alitretinoin.

It may be helpful to tell a close friend or relative that you are taking alitretinoin and ask them to tell you if they notice changes in your behaviour or are worried about the way you are acting. If you have any concerns, let you dermatologist know.

For a full list of side effects, see the patient information leaflet that comes with your medicine or the alitretinoin medicines information above.

Complementary therapies

Some people choose to use complementary therapies to treat atopic eczema, such as food supplements or herbal remedies. Although some people find these therapies helpful, there is a lack of evidence to show that they are effective in treating atopic eczema.

If you are thinking about using a complementary therapy, speak to your GP first to ensure that the therapy is safe for you to use. For example, some herbal treatments can cause serious side effects of the liver and may require blood tests for monitoring. Continue to use any other treatments your GP has prescribed.

 

Inflammation

Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

Complications of atopic eczema

Atopic eczema can cause several complications, which can be physical or psychological. Possible complications are explained below.

Infection

As atopic eczema can cause your skin to become dry and cracked, the risk of getting a skin infection is increased. The risk is higher if you scratch your eczema and if you do not use treatments as advised.

Bacterial infections can cause more severe symptoms. The most common type of bacteria that infects atopic eczema is Staphylococcus aureus. If your skin becomes infected with Staphylococcus aureus, it can make your eczema worse, causing: 

  • increased redness
  • fluid that oozes out of the cracked skin and crusting where the fluid dries
  • a high temperature and a feeling of being unwell

Your skin will be unable to heal naturally from this type of infection and you will need to take antibiotics (see Atopic eczema - treatment).

Eczema herpeticum

It is possible to have an infection caused by the herpes simplex virus, which normally causes cold sores. This can develop into a serious condition called eczema herpeticum. Symptoms of eczema herpeticum include:

  • areas of painful eczema that quickly get worse 
  • groups of fluid-filled blisters that break open and leave open sores on the skin 
  • a high temperature and generally feeling unwell, in some cases

Contact your GP immediately if you think you or your child may have eczema herpeticum. If you cannot contact your GP, call NHS Direct on 0845 4647 or go to your nearest hospital. 

Psychological effects

As well as affecting you physically, atopic eczema may also affect you psychologically.

Preschool children with atopic eczema are more likely to have behavioural problems than children who do not have the condition. They are also more likely to be more dependant on their parents compared with children who do not have the condition.

Bullying

School children may experience teasing or bullying if they have atopic eczema. Any kind of bullying can be very traumatic and difficult for a child to deal with. Your child may become quiet and withdrawn. Explain the situation to your child's teacher and encourage your child to tell you about how they are feeling.

The National Eczema Society provides information about regional support groups, where you may be able to meet other people living with atopic eczema.

Also see the Live Well section about bullying

Sleep disturbance

Research suggests that sleep-related problems are very common among young children with eczema.

A lack of sleep may affect your child's mood and behaviour. It may also make it more difficult for them to concentrate at school, which may lead to them falling behind with their work. Again, it is important to let your child's teacher know about their condition so that they can take this into consideration.

During an eczema flare-up, your child may need to take time off from school. This may also affect their ability to keep up with their studies.

Self-confidence

Atopic eczema can affect the self-confidence of both adults and children. Children may find it particularly difficult to deal with their condition, which may result in them having a poor self-image.

If your child is severely lacking in confidence, it may affect their ability to develop their social skills. Support and encouragement will help boost your child's self-confidence and give them a more positive attitude about their appearance.

Speak to your GP if you are concerned that your child's eczema is severely affecting their confidence.

Treatment options for atopic eczema

TreatmentProsCons
Self-care techniques

Do not scratch and avoid triggers, such as soaps, detergents, woollen or rough clothing, temperature extremes and dusty environments



  • Not scratching will reduce the risk of infection and cause less skin inflammation
  • Avoiding triggers can prevent a flare-up of symptoms

  • May need to keep a diary to work out what your triggers are
  • Not possible to avoid all triggers, for example dust mites cannot be effectively removed from your home
  • Self-care techniques alone may not be effective in controlling eczema
Emollients (moisturisers)

Creams, lotions and oils that reduce the loss of water from the skin



  • An important background treatment for all types of eczema
  • Provide a protective barrier to keep moisture in your skin and irritants out
  • Large number of products to choose from
  • Soap substitutes available
  • Some emollients can be added to the bath  

  • Need to be used every day
  • Some ointments and oils can be greasy, which makes them less acceptable
  • Some, such as aqueous cream, can irritate your skin
  • Some products are highly flammable and should not be used near a naked flame
  • Emollients added to the bath can make it very slippery
  • Emollients alone do not control eczema - inflamed, itchy skin needs an anti-inflammatory treatment such as a topical corticosteroid
Steroid creams and ointments

Creams and ointments containing steroid medication, which reduce inflammation



  • The most effective treatment for eczema flare-ups
  • Safe if appropriate strengths are used in the right place for the right amount of time
  • Can be used on weekends between flare-ups to control eczema in the most severe cases
  • Different formulations, such as creams or ointments, are available at different strengths for different parts of the body

  • Can cause mild burning or stinging as you apply them 
  • May cause thinning of the skin, visible blood vessels, acne and increased hair growth if the wrong preparation is used in the wrong place for too long (for example, a very strong preparation used on the face for several months)
Antihistamines

Medicine that stops the effects of histamine in the blood, which causes itching



  • Can be used to relieve itching during flare-ups
  • Sedating antihistamines, which make you drowsy, can be used to relieve itching at night
  • Non-sedating antihistamines are sometimes used to relieve long-term itching

  • Will not treat eczema flare-ups
  • Drowsiness caused by sedating antihistamines may affect ability to drive and will be worse after alcohol, and may affect school work in children 
  • Non-sedating antihistamines can still cause drowsiness in around 1 in 100 people
  • Evidence to support the benefit of antihistamines is not as strong as for other treatments
Calcineurin inhibitor cream or ointment

Cream or ointment that reduces inflammation



  • May be effective for moderate to severe eczema or eczema that does not respond to other treatments 
  • Does not thin your skin
  • Useful for people with eczema who cannot use topical steroids
  • Useful for facial eczema, for example around the eyelids, where topical steroids cannot be used for long periods

  • Only available from a dermatologist  
  • Long-term safety is still being evaluated 
  • Can cause side effects, such as burning, and makes skin more sensitive to sunlight 
  • If you drink alcohol this may cause facial flushing and skin irritation
Bandaging

Medicated dressings or wet wraps applied to the skin



  • May be useful for severe eczema or eczema on the legs or arms that does not respond to other treatments 

  • Only available from a dermatologist or from your GP if they have expertise in this area
Steroid tablets

Tablets containing steroids, which reduce inflammation



  • Effective for severe flare-ups

  • Your GP is unlikely to prescribe these more than once a year without referring you to a dermatologist
  • Your GP is unlikely to prescribe these for more than a few weeks at a time
  • If taken for a long time or taken often, they can affect the growth rate of children or cause high blood pressure or brittle bones 
Phototherapy

Exposing the eczema to artificial ultraviolet light



  • May be effective for severe eczema or eczema that does not respond to other treatments 

  • Only available from a dermatologist at a regulated phototherapy unit
Immunosuppressant medication

A medicine that suppresses your immune system, such as ciclosporin, methotrexate or azathioprine



  • May be effective for severe eczema or eczema that does not respond to other treatments

  • Only available from a dermatologist 
  • Not all immunosuppressants are licensed for atopic eczema, which means the medicine may not have undergone clinical trials to see if it is effective and safe in the treatment of this condition 
  • Can cause nausea and muscle pain
Alitretinoin capsules

Capsules to reduce irritation and itchiness



  • May be effective for severe long-term eczema on the hands that has not responded to other treatments

  • Only available from a dermatologist  
  • Only available for people over 18 
  • Can cause birth defects so women must avoid pregnancy, ideally by using two methods of contraception, and must have pregnancy tests throughout treatment 
  • Can cause side effects, such as headaches, a dry mouth and dry eyes 
  • More serious potential side effects include sight problems and suicidal thoughts
Antibiotic cream or ointment

Applied to kill bacteria on skin



  • Effective in treating small areas of infected eczema

  • Over-using antibiotics to treat minor conditions can make them less effective in treating more serious or life-threatening conditions 
  • Can only be used for two weeks or your skin can become sensitive to the product and irritated 
  • Antibiotics will not treat the eczema itself
Antibiotic tablets

Tablets to treat eczema that has become infected with bacteria



  • Effective in treating large areas of infected eczema

  • Over-using antibiotics to treat minor conditions can make them less effective in the treatment of more serious or life-threatening conditions
  • Antibiotics will not treat eczema

Viewpoints

'I hope she'll grow out of the eczema'

Ruby was diagnosed with eczema at six weeks old. Her mum, Daniella, explains how they’ve learned to cope with Ruby’s condition.

“At only 10 days old, Ruby developed a rash all over her, a bit like teenage spots with white pimples.

"Doctors thought it was her sebaceous glands not working properly and said it would go away. It did. However, as there's a history of eczema in my husband’s family and mine, and it's a hereditary condition, I always thought she would develop it.

"Doctors tell me not to use any of the commonly marketed baby products, perfumed products or soap. Now, her treatment involves two baths daily, using oil. Before the bath I also cover her body in aqueous cream. I wash her body with a flannel rather than a sponge because flannels can be washed daily.

"She doesn’t sleep with many cuddly toys in her cot as they can carry dust, and I don’t let her near animals as they can irritate and aggravate her skin.

"Some foods have had an effect on her skin too, so I have to make sure she doesn’t eat them and other people don’t give them to her. I also have to be careful with sun lotions and not to let her go in the sun too often.

"At its worst, the eczema on her right arm became infected and her skin went yellow and filled with pus. We quickly took her to the GP and she was put on antibiotics. I spoke to the nurses at the hospital, who suggested trying a wet wrapping with some support, which is like a sports bandage, but I decided to cover the arm in moisturiser with a dry bandage over the top to try to stop her scratching in the night.

"You can’t really stop a baby from scratching. You can distract them where possible and keep them occupied, keep their nails short by trimming them morning and night, and as a last resort I keep Ruby in long sleeves and cover her arms in a wet wrap.

"Once I was driving home in the evening after Ruby’s normal bath time and she was tired and irritable. I noticed in my rear mirror that she was scratching and scratching, and her arm was bleeding. I was stuck in traffic and still far from home, so the best I could do was to sing songs to try to distract her. That was the hardest incident.

"I hope she will grow out of the eczema. I grew out of it and so did other members of my family. However, some of the people on my husband’s side of the family still have it in their old age."

'A lot of things work for a while, then lose their effectiveness'

Battling against eczema for most of his life, 30-year-old John Fuller has tried just about every treatment option available.

John’s eczema began when he was a baby. “It was always there as far back as I can remember,” he says. “My skin would turn red raw and I would scratch and scratch. We tried everything from creams to salt baths. I have a very strong memory of sitting for ages in a salt bath because our GP suggested it. Luckily, I wasn’t bullied for having eczema like many children seem to be.”

When John was 11, the family went to Barbados for a holiday. While they were there, they discovered the aloe vera plant.

“Someone suggested it might help my eczema and we were ready to try anything. Aloe vera is everywhere now, but back then nobody had heard of it. When we got back, we started growing it in our garden. I’d have to rub the plant juice all over me. Amazingly, the eczema cleared up for the next nine years.”

John hoped he’d grown out of the condition. However, his eczema came back when he was finishing university. “The redness and the itching began again,” he says. “Soon it was all over my arms and legs, and it’s been there ever since.”

John says he’s tried every treatment going, including steroid pills and creams, and cyclosporin, a strong drug used mainly to stop transplant patients rejecting their new organs. It works by damping down the immune system.

“That was effective for a couple of years but it can damage your internal organs, so you can’t stay on a high dose for too long,” he explains. “I had to have regular blood tests to make sure everything was working properly, and eventually had to go on such a low dose that it wasn’t worth it.

“I’ve been in hospital three times. In hospital you get the same treatment that you do at home, but it’s more intensive and it’s also cleaner.”

He also experimented with complementary therapies. “I went to a Chinese herbalist, who gave me some disgusting-tasting tea to drink every night,” he says. “For a while, it seemed to work. Then the eczema came back. I found a lot of things work for a while but then lose their effectiveness.”

John tries his best to live a normal life, but says it’s not easy. “When the itching is really bad, it’s very hard to concentrate at work,” he says. “Sometimes I have to take time off. Employers don’t like that, and it has an impact on everyone I work with. Sometimes sleeping is just impossible and that affects my daily life as well. I love playing cricket but direct sunlight turns me bright red. I look like a tomato.”

John is resigned to living with his condition, but he still has hope. “Nobody knows why I have eczema and as yet there’s no cure, but you never know. One day I could wake up and the eczema will be gone. Until then, I have to make do with the treatments we have.”

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Map of Medicine: eczema