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Eczema (ex-zeh-ma) can be divided into two general groups: the contact dermatitis group and the atopic dermatitis group. Contact Dermatitis When some substances come into contact with skin, they may cause a rash called contact dermatitis. Some of these reactions are the result of an allergic reaction that involves the immune system, but many are the result of a non-allergic, or irritant, reaction. Often, it is difficult to tell the difference between these allergic and irritant reactions. The hallmark of allergic contact dermatitis is that it is very itchy and occurs almost exclusively where the offending agent, such as a plant or chemical, comes into contact with the skin. Allergic contact dermatitis is best described as an itchy, red, blistered reaction that is most commonly seen after touching a plant in the "rhus" family, which includes poison ivy, poison oak or poison sumac. This allergic reaction is caused by a chemical in the plant called urushiol. You can have a reaction from touching other items with which the plant has come into contact, including yard tools or the family dog. However, once your skin has been washed, you cannot get another reaction from touching the rash or blisters. Allergic contact dermatitis reactions can occur 24 to 48 hours after contact. Once a reaction starts, it takes 14 to 28 days to resolve, even with treatment. Other agents that frequently cause allergic contact dermatitis include nickel (mostly seen with jewelry), perfumes and fragrances, dyes, rubber (latex) products and cosmetics. Some ingredients in medications applied to the skin also can cause an allergic reaction, most commonly neomycin, an ingredient in antibiotic creams. To avoid reactions, any cream that ends in "caine" should never be applied to damaged skin. In contrast, irritant contact dermatitis is often more painful than itchy, and is the result of an offending agent that actually damages the skin with which it comes into contact. The reaction occurs within minutes of exposure. The longer the skin is in contact, or the more concentrated the offending agent, the more severe the reaction. Water with added soaps and detergents is the most common cause of irritant dermatitis. Thus, it is not surprising that these reactions appear most often on the hands and are frequently work-related. Atopic Dermatitis A common allergic reaction often affecting the face, elbows and knees is atopic dermatitis, also known as atopic eczema. This red, scaly, itchy rash is usually seen in young infants, but can occur later in life in individuals with personal or family histories of atopy, meaning asthma or allergic rhinosinusitis (commonly referred to as hay fever). Eczema may at times ooze, or look very dry. A physician will rarely have difficulty diagnosing atopic dermatitis, based on three factors: 1) itchy; 2) "eczematous" or bubbly rash; 3) an allergic individual. If one of these three features is missing, your physician should consider other causes. Identifying the cause of the itch is essential in managing symptoms. Common triggers include overheating or sweating, and contact with irritants such as wool, pets or soaps. In younger children food allergies are a common cause. In older individuals, emotional stress can cause a flare-up. Eczema is diagnosed by your physician depending of the distribution of the rash on your body and the type of symptoms you have. Tests to identify possible causes of eczema include food, dust mite, pollen and animal dander skin testing and another type of skin test called a patch test. A patch test examines possible chemical sources in your environment that might cause the rash on contact. These tests are applied to your back with a tape and left in place for 48 hours. They are then read at that time and daily for up to seven days.
The basis to any eczema treatment is to find the cause and stop it. Sometimes there are allergen causing a rash, and sometimes there are none. An allergist will help define if there are any allergens acting as triggers of eczema so they can be isolated and avoided. Nevertheless, the key to eczema treatment, no matter what the cause, is to keep the skin barrier as intact as possible. As such, it is of the utmost importance to focus attention on everything that comes into contact with the skin. This includes environmental agents such as soap and detergents, fabric softeners, bacterial infections, inhalant allergens such as house dust mites, and the topical formulations used to treat eczema. Exposure to soap and detergents has been recognized as an exacerbating environmental factor in eczema for more than 40 years. Ensuring that the washing regimen of persons with eczema is completely free from any damaging type of soap or detergent wash product is therefore very important. Soap and detergent wash products can be replaced with emollient wash products. Fabric softeners can be eliminated from the wash. For some products, such as shampoos, it is not possible to eliminate all detergents. However, it is possible to reduce the chance that they will damage the skin barrier by using the mildest in the lowest concentrations. Because shampoos inevitably flow onto the face, the careful selection of these products is important. We recommend the following emollient products designed for the shower, bath and for hand washing, as well as emollients to be used especially after bathing to keep the skin well hydrated:
Emollient bath, shower, and wash products should be combined with emollient creams and ointments to improve skin barrier function. In view of the damaging effect of detergents, it is important to select appropriately formulated products that work for you. The ideal approach is to let you select which product or products you find most suitable for your or your child’s skin. Any emollient product you choose should be applied right after a bath or shower when the skin is still wet. For acute flares, this process of bathing and application of emollients can be increased from one to as often as three times a day. Remember, the payoff for helping your skin maintain a better skin barrier is less itching, less need for medications and a better quality of life. Treatment for allergic contact dermatitis depends on the severity of the symptoms. Cold soaks and compresses can offer relief for the acute, early, itchy blistered stage of the rash. When the rash is limited to small areas of the skin, topical steroid creams may be prescribed to offer relief. When large areas of the body are involved, oral corticosteroids may be prescribed for a brief period. If prescribed, it is important to continue to take oral medications for the entire duration of the reaction (one to 28 days). To prevent the reaction from recurring, make sure to avoid contact with the offending substance. For example, if you are allergic to poison oak and must walk in an area where poison oak is prevalent, wear long sleeves and long pants and wash your clothes immediatelywhen you get home or preferably have someone else do the washing.If the patient and allergist/immunologist cannot determine the substance that caused the reaction based on the patient's history, the allergist/immunologist may conduct a series of patch tests to help identify it. When eczema starts in early infancy or childhood, the rash almost always improves considerably by puberty or resolves completely. However, even in the best of circumstances, the tendency to develop eczema will last a lifetime. Preventing the eczema itch is the primary goal of treatment. People with atopic eczema typically will be sensitive to nickel (especially in earrings), wool and poison oak, so avoidance of these items is essential. The patient must stop scratching and rubbing the rash. Lubricating the dry skin with cream or ointment, especially during dry seasons, is essential. Patients should remove all irritants that aggravate the condition from their environments. If a food is identified as the culprit, it must be eliminated from the diet. Topical steroid cream medications are most effective in treating the rash once all preventative measures are taken. Sometimes, antihistamines or oral corticosteroids are also prescribed, and if a secondary infection has been introduced by scratching, antibiotics are required A new class of topical medications for eczema has been recently released called topical immunomodulators (TIMs). Protopic and Elidel are the only TIMs available for treating moderate to severe eczema. Protopic and Elidel are not steroids, so they won't cause thinning of the skin or side effects sometimes seen from long-term steroid use. One of the advantages of Protopic and Elidel is that they can be used anywhere you have eczema, even on your face, neck, hands, and other places where you can't use many prescription creams. And you don't have to use additional medications along with Protopic or Elidel to help them work better. For parents, another advantage of Protopic and Elidel is that they’re gentle enough for a two-year old. Regardless, this drug should only be used under the strict guidance of a physician. Eczema is a genetically directed skin disorder. Since genetic engineering is not yet possible, the only way to avoid eczema currently is to identify triggers and avoid them, control itching, reduce skin inflammation, and maximize skin lubrication. Your allergist/immunologist often teams with a dermatologist to provide eczema sufferers with the best possible care. 
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