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Jennadine asked...

I have suffered with extreme hay fever and eczema all over my forehead, eyelids and arms...

I have suffered with extreme hay fever and eczema all over my forehead, eyelids and arms for the past six years, but it is getting worse the older I get. I have an air purifier and special plants in the house to allieviate my symptoms, I also make sure I live a clean house with no pets. I have used steriod several creams and I only use Diprobase to wash my skin. However, I have noticed that the eczema has started to move onto my neck and shoulders. I take antihistamines every day. Without them my eyes swell and I have to use antihistamine eye drops twice a day. Would you suggest would help as I have no idea what bring on the symptoms? Should I consider immune therapy?

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The answer

Sometimes it is difficult to identify the exact cause of allergies. Often eczema related allergy is known as contact dermatitis or atopic dermatitis.

Contact dermatitis occurs when your skin is in direct contact with an allergen.

Have you changed your shampoo, conditioner or other hair styling products over the last 6 years? We realise this may seem an odd question but allergy to products that you use on your hair can produce the eczema on the forehead and eyes.

We are sure you by now you have been through all the different items and foods that may be contributing to your eczema.

Atopic dermatitis also known as atopic eczema is the most common form of eczema.

It is often overlooked as ‘just eczema’ but it can be a major cause of depression, disrupt sleeping, disrupt working and general day-to day living so we do sympathise.

Atopic eczema is usually treated in a stepwise manner depending on the severity of your condition.

Mild atopic eczema is treated using;

  • moisturizing soap substitutes and
  • moisturizing creams and
  • mild steroid creams or ointments for flare up.

Moderate atopic dermatitis involves using;

  • Moisturizing soaps substitutes and
  • moisturizing creams and
  • mild steroid creams or ointments for flare up
  • Antihistamine that do not cause drowsiness
  • Tacrolimus or pimecrolimus cream
  • And bandages if needed.

Severe atopic dermatitis is treated using;

  • Moisturizing soaps substitutes
  • moisturizing creams and
  • mild steroid creams or ointments for flare up
  • Antihistamine that do not cause drowsiness
  • Tacrolimus or pimecrolimus cream
  • And bandages if needed
  • Antihistamine that cause drowsiness
  • Using phototherapy using ultraviolet light or your doctor may give you medicines that supress the immune system such as ciclosporin and azathioprine
  • And steroid tablets.

These steps can be stepped up or down as the condition changes.

Immunotherapy may not help you because the source of your allergy has not been identified. Often immunotherapy involves subjecting you to a small amount of the known allergen so that your body can build up immunity to it.

There are two new promising treatments that are about to break onto the market that may help, Dupilumab and Crisborole.

Dupilumab is the first monoclonal antibody for treatment of moderate to severe atopic eczema.

It is given as an injection twice weekly. In clinical trials it has shown to greatly reduce inflammation.

Crisaborole is available as an ointment for the treatment of mild to moderate atopic eczema. It works by inhibiting an enzyme that is involved in atopic eczema.

We have provided more detailed information below which may be of interest to you.

What is Eczema?

Eczema is defined as a medical condition where patches of skin can become inflamed itchy and sore and may go on to form blisters.

As you may be aware the skin is made up of three layers the top layer epidermis (top layer), dermis (middle layer) and subcutaneous layer the bottom layer).

Normally the skin cells in the upper (epidermal) layer are tightly packed so they help create a barrier. With eczema, the layers do not provide the normal barrier function. This can lead to exposure to the elements and so produce inflammation.

During flare up of eczema the skin becomes red, inflamed and itchy. This inflammation process can lead to swelling of the skin which can produce tiny blisters. These blisters can then rupture.

Inflamed skin can be very itchy and prolonged rubbing and scratching leads to thickening of the epidermis making the skin appear thick and leathery. Sometimes inflamed skin can become infected especially the areas of skin that have more folds and creases.

Atopic eczema (or atopic dermatitis) is the most common form of eczema. Atopic describes sensitivity to allergens.

Unfortunately there is no cure for eczema. It is a matter of avoiding allergens and preventing the skin from becoming dry by using medical moisturisers. Different people react to different allergens so you need to find out what you are allergic to and try and avoid it. However there are several ways you can manage atopic eczema.

What can aggravate eczema?

Eczema can be aggravated by:

  • Extremes in temperature
  • Irritants such as sweat, soap, detergents, shower gels, bubble baths and water
  • Stress
  • Infections, either bacterial or viral
  • Things that you may be allergic to such as food, the material your underwear is made from or any other substances your skin may be in contact with, such as latex in condoms
  • Friction from tight clothing.

How to Manage Atopic Eczema

Although there is no cure for atopic eczema you can manage the condition by avoiding flare up. The best way to do this is by avoiding soap. You can use emollients such as Oilatum bath additive, Oilatum shower gel, Cetraben bath additive, Oilatum plus shower gel Doublebase shower gel or Doublebase bath additive may be used. We understand that you are using Diprobase to wash. You do not say whether this is cream or ointment. You may find that substituting Diprobase for the products specially adapted to use in the bath or the shower may help. Alternatively you may benefit from using Dermol 200 shower gel or Dermol 600 bath additive which contains antiseptic agent.

Ironically, after washing it is important to dry yourself thoroughly before applying any medical moisturiser.

Medical moisturiser creams or ointments applied on normal skin areas, will help to repair damage to the skin’s natural barrier, which can often occur when the skin becomes dry and cracked. They can help to reduce redness, swelling and itching. They protect the skin from becoming irritated and from infections.

There are several medical moisturiser creams available on the market. They can be prescribed or bought over the counter from pharmacies. Some examples include;

  • Aveeno cream
  • Cetraben cream
  • Diprobase cream or ointment
  • Doublebase cream
  • Epaderm cream or ointment
  • Hydromol Cream or ointment
  • Oilatum cream
  • Zerobase cream or ointment

Is there a difference between creams and ointments?

The difference between ointment and cream is that creams are water soluble so they rub into the skin very easily whilst ointments tend to be greasy so they do not readily rub into the skin. The advantage of using an ointment is that because it is difficult to was them away they retain moisture for longer.

Why take an antihistamine tablet?

Taking an antihistamine tablet will help to stop the itching and reduce the urge to scratch. When you scratch the skin it becomes irritated, increasing your risk of infection and making the eczema worse.

How can I manage Eczema Flare up?

The way to avoid flare ups is to work out if any of these can be aggravating your condition and then avoid them.

This may not be an easy matter. Inflamed areas of skin tend to flare up from time to time and then tend to settle down. The severity and duration of flare-ups varies from person to person and from time to time in the same person.

During flare ups, applying steroid creams or ointments can help to reduce the inflammation.

  • It is usual to start using the mild strength steroid such as Hydrocortisone and then go on to using the more moderately potent strength steroid such as Eumovate if the eczema has not cleared. This is known as moderately potent 2.5times stronger than Hydrocortisone.
  • Stronger or potent steroid creams such as Betnovate are ten times stronger than hydrocortisone. They often work quicker than a mild steroid cream so your doctor may choose to prescribe short course of the stronger steroid cream to treat or prevent eczema. Your doctor may want to use a very potent steroid such as Dermovate cream or ointment. This is around 50 times as strong as Hydrocortisone. It is important to follow your doctor’s advice.

Steroid creams or ointments should be spread thinly on the inflamed skin only using a very small amount of the cream or ointment once or twice daily. It should be used continuously on a daily basis until the eczema has disappeared altogether.

Once the eczema has cleared it is important to continue to keep the area clean, dry and moisturised on a daily basis. Your doctor may prescribe moisturisers such as Oilatum, Diprobase cream or ointment, Doublebase cream, Epaderm, Hydromol Zerobase or Zerocream.

Long-term use of steroid creams can lead to thinning skin and other side effects. Normal regular use during flare up is unlikely to lead to thinning skin. If the skin does thin then stopping the use often reverses this effect.

Immunotherapy

  • Allergic rashes

Rashes such as eczema and nettle rash cannot be treated with immunotherapy. Research is ongoing into whether certain forms of immunotherapy might be helpful in severe atopic eczema.

  • Hayfever and other allergic reactions

For people with severe hay fever with potentially life threatening allergic reactions where all other medications have failed to control the symptoms then immunotherapy can be offered under the specialist supervision. This can be in the form of injections or sublingual preparations.

Your doctor will refer you to an allergy specialist who will determine the particular allergen you are sensitive to by performing an allergy test.

You will then receive injections that contain that particular allergen extracts that you are sensitive to. You will be injected under the skin of the upper arm.

These injections will be given at a clinic or a hospital with resuscitating facility in case you have an anaphylaxis reaction. Once you have the injection you will be asked to wait for about an hour or so depending on the hospital or the clinic protocol to check you are ok.

Subsequent injections are given at weekly intervals until you are stabilised. Each time the allergen dose will increase. Once you are stabilised you will have injections every few weeks for at least 2 years.

You may get itching and swelling at the injection site. You may get an itchy rash and or a runny nose. The newer injections are more purified so they tend to be better tolerated.

Omalizumab injections are used to prevent severe persistent allergic asthma.

Pollinex injection is used for the treatment of allergic hay fever due to tree-pollen in those patients who have tried all other anti-allergy medicines.

Sublingual desensitized immunotherapy (SLIT) is an alternative to immunotherapy injections. SLIT includes Grazax tablets and Staloral drops. These contain grass pollen. The tablets or the drops are placed under the tongue and allowed to disperse. They encourage your immune system to form antibodies so allow your body can get used to the grass pollen. You can have a mild allergic reaction so the first dose is given under medical supervision and the patient is observed for half an hour to one hour after the dose. The treatment with Grazax needs to begin 2-3months before and during the hay fever season. It needs to continue for three years to gain the maximum benefit.

If you have allergies to two or more components then immunotherapy may not be an option.

The web links below have further information on the subject.

Eczema (atopic) - NHS

Allergy management - Allergy UK

Desensitization - Allergy clinic

We suggest you discuss this matter with your GP.

Answered by the Health at Hand nurses