What is eczema and how does it differ from atopic dermatitis?
The word “eczema” describes not just one disease, but a type of inflammatory reaction of the skin. All options have one thing in common: the skin barrier is damaged. Normally, the stratum corneum works like brickwork, where the cells are the bricks and the lipids between them are the mortar. With eczema, the “solution” is not enough: water evaporates, the skin dries and cracks, and through microcracks, detergents, allergens and bacteria get inside. The immune system responds with inflammation, inflammation increases itching, scratching destroys the barrier even more - this is how a vicious circle closes, which makes the disease chronic.
Atopic dermatitis is a special case of this large group, and confusion between it and “eczema in general” occurs constantly. The difference is practical, not terminological: atopic dermatitis begins in childhood, is closely associated with a hereditary predisposition, is often accompanied by allergic rhinitis or asthma and has characteristic locations - the bends of the elbows and knees, the neck, and the face in children. Eczema in an adult, which first appeared at the age of 35 on the hands of a dishwasher or hairdresser, usually has nothing to do with atopy: daily contact with water and irritants plays a leading role. All tactics depend on which option this is - whether to look for an allergen, whether to change working conditions, whether tests are needed at all.
- True eczema - symmetrical lesions with small blisters, weeping and crusts, often on the hands and face; the spots do not have a clear boundary
- Dyshidrotic - dense deep blisters on the palms, sides of the fingers and soles, severe itching, then peeling and cracks
- Contact - a reaction to a specific substance: cleaning agent, metal, rubber, cosmetics; the focus follows the shape of the contact
- Microbial and coin-shaped - rounded lesions, often around wounds, abrasions, trophic ulcers
- Seborrheic - on the scalp, eyebrows, wings of the nose, in the folds behind the ears
- Varicose veins - on the legs with chronic venous insufficiency, with swelling and darkening of the skin
Hand eczema: work, water and detergents
The hands are the most common and most problematic location in adults, and in most cases the reason is prosaic: the hands get wet too often. Each wash with soap or gel washes away the lipids of the stratum corneum, and the water, evaporating, takes away moisture and makes the skin drier than before washing. If this is repeated twenty times per shift, the barrier does not have time to recover. Doctors call this wet work, and it includes not only obvious contact with water, but also wearing impermeable gloves for long periods of time, under which the skin becomes wet from your own sweat.
- Medical workers, cooks, dishwashers, cleaners, hairdressers, manicurists, builders, auto mechanics are the highest risk groups
- Harmfulness indicator: hands are wet for a total of more than two hours per shift or washed more than 20 times a day
- Rubber and latex gloves themselves may be the cause: both as an irritant underneath and as an allergen.
- Nickel is one of the most common contact allergens: buckles, jewelry, keys, coins, metal parts of tools
- Cement, chrome salts, hair dyes, epoxy resins, preservatives in cosmetics are typical occupational allergens.
- In winter, exacerbations are naturally more frequent: cold, dry air and heating additionally dehydrate the skin
Practical conclusion: until the conditions are changed, any ointment provides only temporary improvement. It begins to work when a person simultaneously treats inflammation and removes what supports it. It is better to wash your hands with warm, not hot water and a mild, fragrance-free solution; thoroughly wipe the spaces between the fingers; Apply emollient cream immediately after each wash. Thin cotton gloves are worn under rubber gloves, and the gloves themselves are not worn for more than 20-30 minutes at a time. The wedding ring is removed during an exacerbation: water and soap residues accumulate under it, and this is where the outbreak often lasts the longest.
What does it look like and why does it itch so much?
An exacerbation of eczema unfolds in stages, and understanding this sequence helps not to be scared. First, redness and swelling appear, then small blisters appear, they open and give a wet, shiny surface. Gradually, the weeping area dries out in crusts, and then the lesion moves into a dry phase with peeling and cracks. In the chronic course, the skin thickens, the pattern on it becomes rough and emphasized - this is called lichenification, and this is the result of many years of scratching.
- Itching intensifies in the evening and at night, prevents you from falling asleep and wakes you up - this is one of the main causes of exhaustion with eczema
- Scratching provides short-term relief, after which the itching returns stronger: mechanical irritation triggers the release of new inflammatory mediators
- Cracks on the fingertips are painful and interfere with work: it is difficult to fasten a button, type text, or pick up a small object
- Over a long period of time, the nails change - transverse grooves and irregularities appear.
- Dark or, conversely, light spots after healing are not scars, but temporary pigmentation disorders
- Sleep is disturbed in almost everyone with the common form, and lack of sleep, in turn, increases itching
It is worth mentioning separately why itching due to eczema is so poorly relieved by conventional antiallergic tablets. Itching here is associated not so much with histamine, but with the inflammation itself and with changes in the functioning of nerve endings in damaged skin. Therefore, the tablet helps little, but a good anti-inflammatory agent and a thick layer of emollient cream are noticeably better. Some first-generation antiallergic drugs do alleviate the condition at night, but due to their hypnotic effect, and not due to their effect on eczema itself.
Examination: what is needed and what is unnecessary
The diagnosis of eczema is made clinically - by the appearance of the rash, its location, course and history. There is no universal blood test for eczema, and it is worth knowing this in advance so as not to waste money on long panels that will not change anything in treatment.
- Осмотр дерматолога с подробным разбором: когда началось, где именно, с чем совпало, как менялось, что уже применялось и с каким результатом.
- Соскоб на патогенные грибы — обязателен при поражении кистей и особенно стоп: грибковая инфекция может выглядеть почти так же, а лечится принципиально иначе.
- Посев с очага при подозрении на бактериальное осложнение — гнойные корки, боль, температура.
- Аппликационные, или патч-тесты — наклейки с набором стандартных аллергенов на спину на двое суток; это единственный способ доказать контактную аллергию на никель, консерванты, резину, краски.
- Общий анализ крови и оценка функции щитовидной железы, железа, глюкозы — при упорном течении и распространённом зуде.
- Обследование вен ног при экземе голеней, поскольку без коррекции венозного застоя очаг возвращается снова и снова.
- Биопсия кожи — редко, только когда картина нетипична и нужно исключить другие болезни.
Emollients: the main treatment that is underestimated
Emollients - emollients - are not an addition to treatment or cosmetics, but its basis. They replenish missing lipids, retain water in the stratum corneum and physically close microcracks. Their regular use has been proven to reduce the frequency of exacerbations and reduce the need for anti-inflammatory drugs. The problem is almost always one of quantity: people apply a thin layer once a day and conclude that the product does not work.
- The guideline for an adult with widespread eczema is approximately 250-500 grams per week; for hands at least several tens of grams per week
- Apply at least two to three times a day and always after contact with water, ideally within three minutes after washing while the skin is still damp.
- The cream is applied in the direction of hair growth, gently, without rubbing until completely absorbed - the goal is to leave a film and not “spread it dry”
- The drier the skin, the more oily the base is needed: lotion is suitable for mild dryness, cream - for medium dryness, ointment - for severe and for night use
- The product should be free of fragrances, dyes and plant extracts: it is flavorings and preservatives that most often become allergens themselves
- Emollients continue to be applied even when the skin looks healthy - this is what keeps remission
- Soap is replaced with a mild product without alkali; hot water, washcloths, scrubs and long baths worsen the condition
There is an easy way to check whether you are using enough cream: a jar of 200-250 milliliters, if used correctly on the whole body, runs out in about a week, not three months. If the tube has been in the bathroom since last year, this is the main reason that the skin is not restored. The second typical omission is to stop care as soon as the rashes fade. The skin barrier takes longer to restore than the redness disappears, and the first weeks after an exacerbation are the most vulnerable.
Hormonal ointments: analysis of the main fear
Topical corticosteroids are the most studied anti-inflammatory agents for the skin, and at the same time the most demonized. People refuse them, stall for time, treat themselves with herbs, and end up with a common process that already requires much more intervention. Let's figure out where fear comes from and what is true in it.
Thinning skin is a real side effect, but it develops with long-term continuous use of strong drugs, most often on the thin skin of the face, eyelids, neck and folds, for months and without medical supervision. A short course of adequate force on the lesion does not give such an effect. Moreover, untreated chronic inflammation itself also changes the skin - it thickens, becomes rough, cracks, and this change is much more permanent.
- The strength of the drug is selected according to localization: on the face, eyelids and folds - only weak agents and in short courses; on the palms and soles, where the skin is thick, stronger
- The principle of “short and strong enough” works instead of “long and weak”: insufficient force leads to prolonged use, and this is precisely the path to side effects
- It is convenient to measure the dose using the fingertip rule: a strip of ointment, squeezed from the tip of the index finger to the first fold, covers an area of approximately two adult palms
- After the exacerbation subsides, they switch to a maintenance regimen - application to previous lesions twice a week, which reduces the frequency of relapses
- There are also non-hormonal anti-inflammatory topical products that are especially useful for the face, eyelids and folds and do not cause thinning of the skin
- Hormonal ointment does not treat fungus or scabies, but temporarily masks them and makes the picture unrecognizable - therefore it is not advisable to apply it “at random” before examination
In case of severe, persistent disease, the arsenal does not end with external means: phototherapy is used, as well as systemic drugs, including modern targeted agents aimed at specific parts of inflammation. This is the doctor’s decision after assessing the prevalence, severity and previous treatment. Another thing is important: between “endure for years” and “take hormones internally” there is a wide range of possibilities, and in the vast majority of cases, eczema is well controlled with proper external treatment plus care.