How do I know if I have eczema?

Eczema is a reaction of the skin to inflammation. It becomes dry, sore, itchy, red, and eventually raw and blistery. It can look different in different parts of the body and on different skin types. If you have a new skin rash and are unsure if it is caused by eczema, it is best to consult with a GP.

What's the difference between dermatitis and eczema?

These two terms are often used to describe the same skin condition. Dermatitis strictly means inflamed skin. Eczema is a term which is used to describe the changes caused by the inflammation. In reality they can be used interchangeably.

I think I have eczema - should I see a GP?

If you develop a new skin rash, which does not settle quickly or is worsening, it is best to consult with a GP. Any type of rash will benefit from using emollient moisturisers but you should not use a steroid on a rash without a doctor's diagnosis.

What is the best treatment for eczema?

The best treatment is frequent use of emollient moisturisers. If a flare-up of eczema is not improving with these then a steroid cream can be used.

Is my eczema mild, moderate, severe, or very severe?

People with eczema often get used to having dry sore skin patches and it can be difficult to determine how far on the scale from mild to very severe it is.

For a rough guide:

• Mild - some areas of dry skin, occasional itching, small red patches.
• Moderate - areas of dry, thickened skin, itching, redness, scratch marks.
• Severe - large areas of thickened dry skin, constant itching, redness, scratch marks and raw areas, bleeding, mild weeping, cracking, and skin colour changes.
• Very severe - as severe above but more widespread changes, not responding to treatment.
• Infected - weeping, crusted, pus spots, and fever or feeling generally unwell - contact a GP.

A useful questionnaire to help assess severity of eczema is the Patient-Oriented Eczema Measure (POEM).

What's the difference between an ointment and a cream?

An ointment is greasier and more difficult to rub in but is better for eczema as it has a soothing and barrier effect which holds moisture in the skin. It is often better used at night. Creams have a higher water content so are absorbed more easily, but the moisture doesn't stay for long. Lotions contain the most water, but also most preservative, which can trigger or aggravate eczema. See below 'What is the difference between an emollient and moisturiser?'

What's the difference between an emollient and a moisturiser?

The terms are often used to mean the same thing but in fact emollient refers to the skin softening effect and moisturiser refers to taking water into the skin. Most products contain some of each. Ointments contain up to 80% emollient and creams are about 50% emollient and 50% moisturiser.

Why are emollients so important?

Emollients reduce dry skin symptoms, protect the skin and decrease the need for other treatments. Applying emollient regularly, as often as is required to keep the skin soft, and not scaly, has important benefits.

In eczema the number of flare-ups is reduced. This means less time having itchy eczema and more time having normal skin. It also means less need for steroid treatment. Emollients are also used to protect eczematous skin to decrease severity of eczema. They are used long term.

In psoriasis using moisturiser clears superficial scale. Cosmetically, the plaques look better and there is less shedding of skin on clothing. Scale removal allows easier application, and enhanced penetration of other topical treatments. Softening is another benefit as flexible patches are more comfortable and less likely to crack.

In itchy psoriasis, emollients can relieve irritation. In other dry skin conditions reversing the dryness by moistening can also decrease symptoms such as itchy painful cracked skin and skin scale shedding.

Whilst applying emollient is time consuming and laborious people often find it is worth the effort.

How do emollients and moisturisers work?

Skin contains natural oils which keep it supple and hydrated and contribute to it's barrier function. It can become dry for a variety of reasons including eczema.

Emollients soften the skin and moisturisers replace the fluid loss. Most products combine both in varying quantities. An ointment is the greasiest but most effective as it replaces more oils not just moisture. Lotions contain more water but need more preservatives, which may make some skin worse.

Which emollient should I choose?

The best product for you is really the one you like best.

The products available range from lotions to creams, gels and ointments. These are on a continuum, in which the water content decreases. The greasier the preparation the more effective it will be, so your choice depends on how dry your skin is, but also on acceptability. Use of greasy products, at the ointment side of the scale, may be limited during the day as they appear shiny on the surface and stick to clothing. They are more difficult to apply as they are thick. They are also impractical for hair bearing skin such as the scalp. A less oily preparation could be better for daytime use, for larger areas or on visible areas such as the face.

Creams and lotions contain water and also contain preservatives, a potential cause of irritation.

Listed below are a range of emollients typically recommended for dry skin. Other preparations are also available - your GP or a pharmacist will be able to advise.

When is the best time of day to apply emollient?

Emollients can be used as often as required. When the skin feels dry, you can re-apply. This is especially important after washing, as the water itself, as well as any detergents (soap, shower gel, or shampoo) dry the skin. You can use emollient as a soap substitute and use oil in the bath to negate this drying effect. It is often best to use an ointment overnight and a cream as often as necessary during the day.

How much should I be using?

This will vary according to the dryness of your skin and the preparation used. As a rough guide, you may need 500gm per week - this would cover trunk and limbs twice daily for an average sized adult.

Which do I apply first: emollient or steroid?

When eczema flares-up, a topical steroid (ointment or cream applied to the skin) is often prescribed to calm the inflammation. Your skin will improve more quickly if you apply emollients too. If you apply the steroid first, rubbing on emollient after could spread it from where it had been applied. If you put the steroid on immediately after the emollient it cannot be absorbed.

Apply the emollient, then wait for 15 minutes and apply the steroid.

When should I use steroid on my eczema?

If the eczema is not responding to frequent use of emollient moisturising, then steroid would be the next step. The weakest strength of effective steroid cream or ointment should be used sparingly for as short a time as possible and for no longer than 2 weeks at a time. Frequent emollient use should be continued whilst using steroid creams and ointments.

How do I choose which steroid to use?

Dr Fox provides a range of steroid creams and ointments. The ointments are usually more effective but greasier.

Choose the weakest effective steroid and use for the shortest time.

Should I stop my emollient/moisturiser if I'm using steroid on my eczema?

No. Emollients and moisturisers should be continued. They moisturise and soften the skin. The steroid just reduces inflammation in the skin.

What happens if I keep using steroid on my skin for a long time?

Using steroid creams or ointments long term on the skin can cause permanent skin damage. This includes thinning the skin, and developing stretch marks or thread veins. To prevent damaging healthy skin, you should use the weakest effective steroid for the shortest time needed. Use emollients between courses of steroid, to reduce the frequency of eczema flare-ups. Very occasionally someone will need to use a steroid cream or ointment once or twice a week to reduce flare-ups.

What is a fingertip unit (FTU)?

A fingertip unit is a way of measuring the amount of cream or ointment to use. One FTU is the amount needed to squeeze a line from the tip of an adult finger to the first crease of the finger. In an adult male one FTU will contain about 0.5g of cream or ointment.

Amount of cream/ointment needed for an adult for each area in FTUs:

• Genital area 0.5 FTU
• Hand 1 FTU
• Elbows 1 FTU
• Knees 1 FTU
• Feet, including the soles 1.5 FTU
• Face and neck 2.5 FTU
• Hand and arm together 4 FTU
• Buttocks 4 FTU
• Leg, including the foot 8 FTU
• Chest 7 FTU
• Back 7 FTU

The steroid works better than emollient - can't I just keep using that?

It is tempting to keep using the steroid cream or ointment as it can work so well at clearing eczema. However, in the long term it will cause more problems. See What happens if I keep using steroid on my skin? Emollient moisturiser should be used alongside the steroid and continued once the eczema has settled. It can be frustrating to have to keep using emollients but used frequently, even when skin seems fine, can reduce the number of eczema flare-ups.

My skin feels dry after I wash - why?

Water dries the skin and so it is best to have shorter baths or showers. Heat can aggravate dry skin, so try warm or cool water. Foaming cleaning preparations contain soap or detergent, which strip natural oils from the skin, leaving it even drier. Avoiding soap and switching to an emollient wash moisturises rather than dries the skin.

Washing with soap substitute feels different to normal soap and can take time to get used to. Some patients are attracted to antimicrobial preparations, however any emollient can be used as a soap substitute. After your wash, use a soft towel and pat dry rather than rub.

How can I prevent an eczema flare-up?

Avoid irritants and apply emollients frequently. You may recognise triggers. Common irritants are soap, household cleansers, detergents, aftershave lotions, and solvents. Don't use these or wear gloves when handling. Avoid itchy clothing e.g. wool. The weather may also affect the skin, especially cold or dry conditions. In some people stress or exercise (possibly from salty sweat) will worsen skin. Sunshine helps some people's skin but can aggravate eczema in others. Diet is more likely to play a role in children. If you notice certain foods affect your skin, it would be best to avoid them.

What should I do in an eczema flare-up?

Avoid triggers, apply emollient, and apply any active treatments you have been prescribed, e.g. steroids. If this is not helping, or if you are very red all over and feeling unwell and shivery, see your doctor.

Can eczema be cured?

Unfortunately not. Eczema is a long-term condition but it does come and go. Common triggers for a flare-up include soap, household cleansers, detergents, aftershave lotions, solvents, itchy clothing (especially wool), cold weather, and very occasionally certain foods in children. In most cases of childhood eczema, it becomes less troublesome in adult life.

Does drinking lots of water help eczema?

Keeping well hydrated by drinking lots of water is good for the skin generally. However in eczema additional direct skin moisturising with emollient creams or ointments will be needed as well.

Is eczema worse at night?

Eczema often feels worse at night as warmth and bed clothes can irritate already inflamed skin. This can lead to itching and scratching in your sleep.

Body cortisol (a steroid) levels drop at night. This reduces the natural anti inflammatory effect, which may also contribute to more irritation from eczema at night.

It is helpful to apply an emollient ointment to the skin before going to bed and sometimes antihistamine tablets can reduce the overnight itching. Wearing cotton gloves in bed can reduce scratching damage.

What can I do to stop scratching at night?

Itching can be an extremely unpleasant sensation that disturbs sleep and can cause low mood. Applying emollients will soothe your skin, but you should see your doctor too, to make sure that there isn't a treatable cause. Your doctor will look at your skin for signs of skin disease, and may do blood tests to identify diseases which cause itching. Some medications can cause itch as a side effect, and if you take any, they would be considered too. It is not always possible to make a diagnosis. A lot of itchy skin does not have an identifiable cause. Skin dryness certainly contributes to itchiness. The advice is: not to scratch and keep fingernails short, keep cool, and avoid over-clothing. Avoid hot baths and shorten water (bath/shower) contact time and avoid soaps/alcohol cleansers/wet wipes. Your doctor may prescribe creams to further soothe or numb the skin, or tablets to help with sleep.

Does sunshine help eczema?

Many people find that their eczema improves with warmth and sunshine. However overheating and sweating can make it worse as can air conditioning and use of some sun creams.

Are there any other treatments for eczema?

There are some newer anti-inflammatory treatments for eczema. These include pimecrolimus and tacrolimus. They are usually prescribed by a GP skin specialist or dermatologist.

Dermatologists may sometimes suggest using strong anti-immune system medications including azathioprine, ciclosporin, methotrexate, or steroid tablets. They may also offer a course of special UV light if eczema is particularly resistant to treatment.

Antihistamines can help severe itching.

Do Chinese herbs work for eczema?

Chinese herbs have been reported to help in some people. However they are unregulated and not recommended by doctors. Some have been linked to serious side effects such as liver or spleen disease and at times others have been shown to contain strong steroids.

Is aqueous cream still recommended for eczema?

No. Aqueous cream was widely prescribed for many years as an emollient or soap substitute for eczema. However it is an inefficient moisturiser and also contains sodium lauryl sulphate (sodium lauryl sulphate) which is now known to irritate skin and worsen eczema. It is no longer recommended.

Are eczema treatments flammable?

Many emollients and creams contain paraffin and so are flammable. Clothing and bedding will often absorb some of the ointment or cream. They should be washed frequently and regularly to reduce the risk of catching fire. Keep eczema treatments away from naked flames and cigarettes.

What is a soap substitute?

Soap substitutes are used in dry skin conditions and eczema. All normal soaps, shower gels, and bubble baths lead to skin drying and can make dry skin conditions and skin inflammation worse. Any emollient/moisturiser can be used as a soap substitute. It will not produce a lather and so may take some getting used to, but is rubbed over the skin in the same way as soap or shower gel. It will both clean the skin and leave it slightly greasy. Moisturising creams can also be mixed with a little warm water and used as a shaving cream. Moisturising creams can be used instead of soap for hand washing.

Should I use a bath oil/emollient bath additive?

Many people like to use a product in the bath as the simple act of wetting the skin can dry it out. Adding small amounts of an emollient oil to the bath water can help to prevent this drying. Some bath emollients contain an antiseptic that can be useful where a person is prone to infections of their eczema. Bath emollients do not replace moisturising the skin directly with creams and ointments and you should continue to apply your usual emollients straight on the skin.

Caution: adding oil to the water makes a bath slippery.

Eczema treatment