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Eczema is not really a single disease of the skin. Rather, "eczema" is a generic name for a particular kind of skin reaction where you see itching, fluid weeping or oozing from the rash, and lichenification (skin thickening where the normal fine lines on the skin surface become deeper and stand out more).

Like other diseases, eczema can be acute (happening relatively suddenly) or chronic (happening for a long time). Acute eczema usually comes with redness, oozing and weeping, and microscopic vesicles (fluid-filled pockets) in the epidermis (the outermost layer of our skin). Chronically eczematous skin is usually thickened, scaly, and dry; the skin colour may change (lighter or darker), and lichenification may be more severe. Eczema is often an allergic reaction to something that contacts the skin, and people with eczema also tend to have allergic rhinitis, asthma, or both.

The term "eczema" is generic: there are several different varieties, with different causes, different appearance, and sometimes different treatments.

Contact Dermatitis

As the name suggests, contact dermatitis is caused by noxious things coming in contact with the skin. The skin injury may be irritant (resulting from direct chemical or mechanical damage to the skin) or allergic (caused by an allergic reaction to something that contacts the skin). The two kinds are not entirely separate -- the main difference is that allergic reactions occur mainly in those people who have become allergic to the substance they touch, while irritants are irritating to just about everyone who touches them. That's not much of a difference: the oils produced by poison ivy, poison oak, and poison sumac are technically allergens, but you become sensitive to them so quickly that they might as well be irritants.

Irritant-based contact dermatitis is more common than allergic-based, especially in children. Lots of things can irritate the skin, including:

This is probably the irritant I see most often in babies. The combination of saliva and (partly-digested) formula or milk that babies spit up and drool seems to be especially irritating to skin, and drooling while asleep makes things worse since the drool ends up on the bedclothes where it sits in contact with the baby's cheek. The solution to this that I prefer is to keep the baby's face clean at all times and change the bedclothes as soon as you notice any drool on them. (And I will be the first to admit that this may be nearly impossible, practically speaking.)
Soaps, detergents, fabric softeners, bubble baths, perfumes...
Babies are especially sensitive to chemical irritants, and sometimes even the slight residue from detergents and fabric softeners will lead to irritation. Dryer-sheet softeners are especially notorious in this regard; even if you are not using them on the baby's clothes, if you use dryer sheets on your own clothes the sheets leave a residue on the inside of the dryer which then comes off on the baby's wash in the next load (the residue can persist for several loads after the sheets are used, as a matter of fact). The solution is to avoid all potential irritants; this means that you may not be able to use dryer sheets for any laundry in your dryer.
Poison ivy, poison oak, and poison sumac
Although these are three different plants, the oils they produce have just about the same (nasty) effect, and once you become sensitive to one you are sensitive to all of them. As I mentioned above, these are technically allergens, since you have to become sensitive to them before your skin reacts. However, it takes a very short time to become sensitive to these oils. Another nasty thing about the oils is that they are not easy to remove from your skin -- soap and water can spread them to other parts of your body if you're not careful -- and they will also stick to clothes and other things, then come off on your skin some time after you've left the plants behind.

Atopic Dermatitis

Atopic dermatitis, practically speaking, is a dermatitis whose cause is not known. Often it appears along with contact dermatitis, but persists long after you've eliminated every possible allergen and irritant. Often atopic dermatitis appears as unusually dry skin. Mild atopic dermatitis and contact dermatitis can be aggravated by anything that dries out the skin -- including cold weather, and including soap and water. And, although atopic dermatitis can appear without other allergy problems, it often occurs in children who later develop asthma or respiratory allergies.

Treating Atopic and Contact Dermatitis

Mild cases of atopic dermatitis can often be treated with just a good moisturizing hand or body lotion. The "greasier" lotions often work better: washing with soap and water removes dirt from your skin, but also removes the natural oils from your skin and makes it drier. Some people are so sensitive to dry skin that they must apply lotion to their entire body right after each bath or shower, before the water left on their skin dries out (water actually dries skin out very quickly as it evaporates; that's why you need to replenish the oils as well). Compulsive hand-washers -- including doctors, nurses, and other health-care workers -- often have dry-skin problems that approach that of people with atopic dermatitis. My own hands often crack and sometimes bleed by the end of a day in the office or hospital, which isn't surprising since I may have to wash my hands 50-100 times on a busy day; I usually apply a good, greasy hand lotion (such as Eucerin® or Aveeno®), or both an ordinary hand lotion and Vaseline®, to my hands at bedtime just to replenish all the natural oils I've washed out of my hands during the day.

For more severe atopic dermatitis, we sometimes have to resort to steroid treatment. Usually we start with mild "topical" (applied to the skin) steroid creams or lotions -- so mild that they can be bought over-the-counter without a prescription -- and in many cases that's all that is needed. (I do suggest to my patients, and to you, that you not use even over-the-counter steroids without talking to your doctor first. Even the over-the-counter steroids can be hazardous, especially if you don't use them properly.) If the OTC steroids don't work, we may then suggest more potent topical steroids, which do have to be prescribed by your doctor. Sometimes -- very rarely -- a patient may need oral steroids; I usually send patients of mine who need oral or the very strong topical steroids to a dermatologist. One possible side effect of using topical steroids for a long time, especially on the face, is atrophy of skin tissue; therefore, we try to avoid long-term topical steroids whenever we can, using them only for bad flare-ups.

Really bad atopic dermatitis may not respond very well to steroids. Some of these patients respond to tacrolimus, a medicine originally developed to treat certain kinds of cancer, or pimecrolimus, which is similar to tacrolimus but was intended mainly for treatment of severe eczema. Like all cancer drugs, tacrolimus and pimecrolimus have potential side effects, and we do not prescribe these medications unless everything else fails.

Contact dermatitis can sometimes be treated the same way we treat atopic dermatitis. First, though, you need to identify the irritant or allergen and get it away from you -- it's always better to remove the cause of a rash than to use medicines to get rid of the rash. In most cases removing the irritant is all the treatment you need.

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PLEASE NOTE: As with all of this Web site, I try to give general answers to common questions my patients and their parents ask me in my (real) office. If you have specific questions about your child you must ask your child's regular doctor. No doctor can give completely accurate advice about a particular child without knowing and examining that child. I will be happy to try and answer general questions about children's health, but unless your child is a regular patient of mine I cannot give you specific advice.

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Copyright © 2000, 2007, 2013 Vinay N. Reddy, M.D. All rights reserved.
Written 03/13/00; major revision 04/16/07; last revised 09/12/13 counter