Perhaps no named rash is more common in infancy than eczema.

At least 1/3, maybe more babies have it at some point.  In nearly every instance, no one ever knows why.  Some lotion, some cream, and if it goes away over time, as it often does, the mystery is forgotten.

But for many, many infants, children, adolescents, and adults, eczema is a scourge that cracks skin, causes terrible itching, really a source of misery.

What is it, what causes it, what can be done?

What is Eczema?

Eczema is a particular type of inflammation, found only on the skin, and by itself, does not scar.

To understand eczema it could be helpful to contrast it to a common inflammation of skin, hives.  Hives are a welt like rash that comes and goes rapidly.  In a second you could see half a dozen of these welts suddenly appear, and an hour later they could all be gone.  Hives wash in and out because they are simply the visible effect of a blush of histamine in the skin.  Histamine makes the blood vessels in the skin leaky, causing swelling and itch where the histamine washes in, and causes the welts to disappear when the histamine washes away.

Eczema has nothing to do with washes of chemicals like histamine. Eczema happens when immune cells in the skin attack the skin.  Think about our immune system and what a challenge it faces, every moment of our lives.

Our immune system must be ready to attack and kill enemy cells, like germs, whenever they might appear, immediately.    Imagine you cut your finger, immune cells must be there right away to wipe out all the germs that suddenly can pour into the cut.  If they fail, the bacteria infect, if they succeed, all is well.

To do this, the immune system must have zillions of soldier cells ready to mount a full scale attack, across all of our skin, everywhere.

At the same time, these huge armies of attacking immune cells must remain in their barracks at ease if no enemy is present.

And so our skin is a scene of massive military build-up on a very hair trigger.

As result, it is very common for those armies to jump the gun and fire when no enemy is present.

In the skin, if the immune system goes on attack mode with no cut or problem present, it’s our own skin that gets attacked.  That attacks makes the skin redder, coarser, flaky, in short, eczema.

What Causes Eczema?

In most cases, we never know.  Young infants almost always have their eczema on their scalp (that is what cradle cap is) or face.  Older kids and adults on the inner creases of elbows and knees, hands and feet.

For some people, they will see eczema only if certain triggers are present, like particular foods (cow’s milk), or cloth (wool), or seasons (pollen), or illnesses.  For them, the cause is known, and can be avoided or treated.

But for nearly all babies, except those with fairly severe eczema, it is typically the case that even after many trials of avoiding suspected triggers, or evaluation by allergist, the eczema does not change, and we never find the triggers.

At its root, however, all eczema is the result of an attack of the immune system on our skin.

What to Do?

There are many steps one can take to treat and help clear eczema:

1. Keep the skin lubricated.  Skin is like a sponge, it can dry out.  And eczema makes it easier to dry and crack.  Put some vaseline over eczema and it can keep it from drying and cracking more, many see their eczema flare go away.
2. Fight the attack.  This is where steroid ointments come in.  The 1% hydrocortisone and stronger ointments actually kill the attacking immune cells, and often will clear milder flares.
3. Clever bathing.  When you get out of a bath, you dry in two swipes.  One to dry off dripping water, one to dry the skin.  Before the second swipe, while the skin is still moist, apply your lubricant or steroid ointment.  Another step that can help is to add 1/2 cup of laundry liquid bleach to a tub of bath water.  That often helps a lot of people.
4. Kill the bothersome germs.  Cracked eczema skin can help hide and encourage the flourishing of really irritating bacteria that can make eczema really flare.  Try applying a topical antibiotic every night on very cracked eczema.

The bad news is that all these and other treatments fail to keep eczema from coming back.

And flares are what eczema is all about.  It comes and goes.  Over and over.

None of the treatments in use now keep flares from happening.

Sneak Preview

New antibodies to the attack molecules of inflammation hold a promise that one day, we will be able to administer such antibodies to people with eczema and end the eczema.

This is many years off, but in early 2017 reports of success with this method were indeed reported.

BOTTOM LINES

1. Eczema may be the single most common rash caused by our immune systems.  It is especially common in early infancy, at least 1/3 of all young babies experience cradle cap and/or eczema
2. The existence of eczema comes from the fact that our immune system is a vast army, ready anywhere and anytime to destroy an invading enemy, and a key borderland for those risks and battles is our skin.
3. The mechanism of eczema are cells of the immune system, they go on attack mode, then attack, and the skin gets coarse, thick, flaky, red, and very itchy.
4. There are several approaches to therapy that help a lot of people, including use of ointments to reduce cracking and drying, and topical medications to reduce bacterial counts, and the attack.
5. On the horizon, indications are that science will in not the too far distant future, treatments that truly end these attacks, the end of eczema is being pursued effectively.
6. Unless the eczema rash gets infected, the best news is that the inflammation is superficial and does not scar, once the eczema flare goes away, skin does go back to normal.

To your health,
Dr. Arthur Lavin