A rash that's pink or red, rough to the touch, itchy and persistent may be eczema (sometimes called dermatitis).
Eczema is an inflammatory condition that can occur in people of all ages, commonly in the wrists and ankles. It may also arise in spots near the joints, such as the inside of the elbow or the back of the knee. In children, eczema frequently appears on the cheeks, explains Keith Choate, MD, PhD, a Yale Medicine dermatologist.
With many doctors listed among the best dermatologists in the country, Yale Medicine dermatologists receive thousands of referrals a year to evaluate and treat challenging skin conditions, including eczema. Treatment is always individualized for each patient's needs.
What causes eczema?
Someone who develops eczema is genetically predisposed to the condition and then exposed to environmental factors such as allergens that activate it. Eczema’s underlying genetic predisposition is also related to the development of asthma and allergies more broadly—the three conditions together are known as “the atopic triad.”
“The mechanism of eczema is something that we're learning more and more about as immunologists decipher the immune responses that lead to different types of skin conditions,” says Dr. Choate. We are coming to understand that there are certain inflammatory molecules that circulate in the body and are also present in the skin that lead to chronic immune response.”
Are there different kinds of eczema?
There are many different kinds of eczema that vary in appearance and their location on the body:
- Atopic Dermatitis: The most common form of eczema, it presents as recurring, sometimes flaky, red rashes that typically appear on the inside of the elbows, backs of the knees, wrists, ankles and cheeks. “The more common type of atopic dermatitis typically looks like a sort of confluent red, either scaly or weepy plaque on the affected body surface area,” says Dr. Choate. “When it's chronic, it tends to be scalier. When it's acute or a new onset, it tends to be flatter, redder. But in all cases, it's incredibly itchy.”
- Dyshidrotic Eczema: More common in women than men, it presents as very small blisters on the hands and feet.
- Nummular Dermatitis: This is an oval or coin shaped, scaly rash that affects men more than women and usually presents on the legs, backs of the hands, forearms, lower back and hips.
How is eczema diagnosed?
A dermatologist will diagnose eczema based the appearance and location of the rash. As opposed to contact dermatitis, eczema tends to appear in specific locations on the body: behind the knees, the inside of the elbows, on the wrists and on the ankles. Eczema also presents symmetrically, meaning that it will appear on both sides of the body simultaneously.
How is eczema treated?
Eczema is treated in a variety of ways depending on the type and its severity, says Dr. Choate. “We begin with moisturization, skin care products and mild topical steroids,” he says. “As you move up the therapeutic ladder, you would move into more potent topical steroids for people with localized disease. If it becomes more widespread, we consider phototherapy. There are also systemic therapies, which are medications that people take typically by mouth to treat their eczema.”
Moisturization, which improves the skin’s barrier function, helps prevent water loss and immune reactions. Moisturizing the skin is also an important way to help keep eczema under control. Localized eczema responds very well to topical steroids. In some severe cases, eczema is so widespread that it’s not possible for people to apply topical steroids. Phototherapy, the application of “medical sunlight,” or narrow-band ultraviolet (UV) light, can help in those cases to the point of inducing remission.
“For people who have widespread eczema, all over their body, we can actually treat their entire body," Dr. Choate says.
These treatments are done in our phototherapy center, which is adjacent to our clinical practices. They're short, less than 15 minutes. They really are life-changing for people. They can go from having full-body eczema to being completely cured by this treatment, which proves to be safe and effective when supervised by a dermatologist.”
If none of those other treatments are possible, there are systemic therapies using oral medications that slightly suppress the immune system, thus minimizing the response that brings on the rashes.
Because research on eczema is progressing rapidly, there are drugs currently in advanced clinical trials that are able to treat the condition in a much more targeted way—at the molecular level. “Because we know more about the immunopathogenesis of eczema, there are a series of clinical trials that are in late stages right now,” Dr. Choate says. “That will lead to much more effective molecular targeted therapy for eczema than we've ever had before.”
What lifestyle changes are necessary for managing eczema?
In addition to specific treatments, it’s important to know about the many circumstances that can aggravate symptoms. Dry, cold environments, staph infections and some skin care products can all worsen eczema. Even products that seem like they would be good for skin generally can be problematic for people with eczema.
“Many soaps are actually very bad for people who have trashy skin," says Dr. Choate. "Synthetic soaps tend to be much better. Focus on having gentle skin care, avoiding fragrances and dyes that can cooperate with an eczema predisposition to make things worse.”
Are there any risks or other conditions associated with eczema?
Because eczema can affect the skin over large areas of the body, it can hurt the skin’s ability to protect against infection. That’s why people with eczema tend to be more susceptible to viral and bacterial infections: when they occur, those infections can exacerbate eczema symptoms.
“People with bad eczema are more susceptible to certain things,” says Dr. Choate. “They are more susceptible to herpes infections like cold sore viruses that can disseminate all over the body rather than being just on the mouth. They also are susceptible to bacterial infections that can lead to super infections, which require treatment with an antibiotic.”
Is eczema related to diet?
“While food allergies can play a role in skin disease, people tend to be overemphasized as a cause of eczema,” says Dr. Choate. “As such, people can really take on horrible elimination diets that actually can be dangerous, when, in fact, we could very easily treat their skin disease without doing anything at all with their diet.”
What makes Yale Medicine’s approach to treating eczema unique?
At Yale Medicine, the most unique aspect of our eczema treatment is our willingness to pursue treatment until we see positive results. “We're very comfortable using advanced systemic therapies here to ensure that people are better,” says Dr. Choate. “But, of course, when we do that, we take on a certain degree of risk. It's a balance between risk and benefit. I think we're uniquely qualified to help patients to assess that and to ultimately manage the risk in order to get a better quality of life.”