Understanding and Managing Dermatitis: Insights from Dr Tim Russell

Over the next while I would like to talk about a condition which is close to my heart, having a wife and daughter who have both suffered with it to a severe degree over many years. As a result I have learnt a lot about what it is like to live with this condition, and learnt ways to manage it over and above what we get taught in medical school and postgraduate GP training, despite not having any formal specialist dermatology qualifications.

Dermatitis

Your skin is the largest organ in your body but, unfortunately, often one of the most neglected. One of the most common skin problems GPs are presented with is dermatitis, which simply means skin inflammation. 

There are different types and different causes of dermatitis but everyone is likely to experience it during their lifetime. It rarely causes serious illness but for many people it can be a source of persistent discomfort, interfering with their jobs, hobbies and activities of daily life to the point where their general wellbeing is significantly impaired.

Normal, healthy skin has the ability to stretch (elasticity), regulate the body's temperature and moisture content, and protect against invasion from micro-organisms and harmful substances. In dermatitis some or all of these functions are impaired as a result of reduced skin elasticity and the presence of tiny cracks in the skin's surface (epidermis) and inflammation of the deeper layer (dermis). 

The commonest symptom is itch (which can be severe) and the affected areas usually appear as pink or red patches of varying size which may be dry or cracked, or even sticky and weeping. In non-white-skinned people the eczema usually appears as areas which are darker than the normal skin.

Most cases of dermatitis can be managed successfully by GPs, but sometimes specialist input is required in the more difficult cases. As a GP I come across dermatitis every day, but for the purposes of this article I will talk about two of the main types of dermatitis with which I am most familiar.

Atopic Eczema

Atopic eczema is the commonest form of dermatitis and is very common in babies and children. Thankfully most children grow out of it but many will continue to have eczema to some extent throughout the rest of their lives.

Atopy is usually hereditary and many sufferers experience more than one of the following conditions: eczema, asthma, hayfever, food allergies. In people who have more than 1 of these, often a flare of one condition will lead to a flare of the other(s), hence many people with asthma and/or eczema will find their symptoms get worse when they have hayfever. Atopy is considered by many to be an autoimmune condition (where the body's immune system is not regulating itself properly).

Sometimes babies will develop dermatitis as a result of intolerance to cow's milk proteins or lactose found in milk formulae and present in small amounts in breastmilk. Once they are weaned they may exhibit dermatitis as a sign of intolerance or allergy to other foodstuffs. Therefore it is important for the clinician to consider food intolerance as a possible cause of the dermatitis in this age group before making a diagnosis of atopic eczema.

Treatments for Atopic Eczema/Dermatitis

1. Moisturisers

The main treatment for most types of dermatitis is regular use of emollients/moisturisers. 

Strictly speaking emollients soften the skin, whereas moisturisers add moisture. In practice these terms are used interchangeably as most of the creams used to treat dermatitis do both, and for the purposes of these articles I shall just use the term moisturiser as this is more familiar to most people.

In addition to using moisturisers, it is vital to try and avoid substances which can encourage skin dryness, particularly soaps (such as those found in handwash, bubble bath and shower gel) and cleansing gels/sprays that contain alcohol.

Moisturisers work in two ways: they reduce moisture loss from the skin by providing a thin layer of oil on its surface, and they increase the water-holding capacity of the skin’s surface.

There are 3 main classes of moisturiser, which are largely defined by how much oil they contain:

Lotions are the least oily, so are generally used for the mildest conditions and/or where regular application (eg. after frequent hand washing) is desired.

Creams have a higher oil content and are probably used most frequently as they provide good moisturisation without being too greasy

Ointments are suitable for more difficult areas of skin. Whilst they are usually very effective they can sometimes be unacceptably greasy, especially for teenagers and adults. In these cases application at night is often recommended so as to not interfere with everyday activities.

A more recent form of moisturiser is oil sprays/mists, which can be useful in certain situations (such as quick application after a shower when there isn't time or privacy to properly apply cream such as in a gym/swimming pool), but are not as moisturising as lotions.

Moisturisers are often added to bath water in place of soaps and other bath products which make skin more dry. In older children who shower, many moisturisers can be used in place of shower gel/bodywash.

Moisturisers need to be used at least once a day, but ideally twice a day, or more often in severe cases.

Some moisturisers have a high paraffin content which makes them flammable, so care needs to be taken in the presence of naked flames.

Commonly prescribed moisturisers include Dermol, Cetraben, Oilatum & Epaderm. Others which tend to be prescribed less often, or may not be available on NHS prescription at all (as they are much more expensive) include Aveeno and Cerave.

Some moisturisers contain other components such as anti-microbials and anti-itching ingredients, as well as preservatives to prolong their lifespan and reduce the chances of them becoming contaminated with potentially harmful micro-organisms, especially bacteria. 

Urea is sometimes added as this is a powerful moisturiser and emollient, as well as being able to break down very hard skin (keratolytic) and reduce itching (anti-pruritic).

Whilst reactions to the moisturising oils are extremely rare, reactions to these other ingredients can sometimes occur, although this is usually after prolonged use (many days or weeks) rather than on first application. Occasionally this can be mistaken for an eczema flare up so it is important for the patient and clinician to consider this should the skin get worse for no obvious reason. 

It is not unusual for badly flared eczema to become stingy or more red immediately after applying a moisturiser - this usually settles after half an hour or so and is not usually a sign of allergy or intolerance.

2. Steroids

The other main treatment for eczema is topical (applied directly to the skin) steroids. 

Topical steroids are anti-inflammatory and formulated to penetrate to the dermis where they reduce the skin's exaggerated inflammatory reaction. They can enter the body's main circulation and, if not used carefully, can cause unwanted side effects, not only on the skin, but in the whole body. Thankfully these are rare so long as the creams are prescribed appropriately and the prescription instructions followed!

Steroids also have a key role to play in treating many other skin conditions that will not be discussed here.

Steroids come in different strengths (potencies), and the choice of which to use is based on the severity and location of the problem. They are also available in various forms, most commonly creams and ointments, but also lotions, mousses and sticky tape.

The only mildly potent steroid that is commonly used is hydrocortisone (up to 2.5%), occasionally you might see Synalar 1in10

Medium potency includes Eumovate (clobetasone), Betnovate RD (betamethasone), Modrasone (alclometasone), Synalar 1in4 (fluocinolone)

High potency includes Betnovate, Elocon (mometasone), Locoid (hydrocortisone butyrate), Synalar, Diprosone, Betamousse

Very high potency includes Dermovate (clobetasol), Nerisone Forte (diflucortolone), Etrivex shampoo.

Nowadays most of the above are prescribed in their generic (non-branded) versions.

As with moisturisers, topical steroids frequently have other ingredients added to them, particularly anti-bacterials and/or anti-fungals, and others such as urea or salicylic acid (another keratolytic).

Frequently used examples are Fucidin H and Fucibet (steroid + anti-bacterial), Canesten HC, Daktacort and Timodine (steroid + anti-fungal), Trimovate (steroid + anti-bacterial + anti-fungal), Hydromol (steroid + urea), Diprosalic (steroid + salicylic acid).

Owing to the risk of side effects, particularly discolouration and thinning of the skin, it is important that the clinician prescribes the lowest strength that is likely to be effective, for the shortest duration. Often 2 or 3 different strengths of steroid are prescribed, with the most potent being used first in order to get the condition under control as rapidly as possible, followed by a medium strength, then a lower strength. Typically a course like this lasts 2-4 weeks. Once the condition is well-controlled, it is usually advised that low or medium potency steroids are used on an 'as required' basis, perhaps 2-3 times per week, to prevent the skin from flaring.

An alternative to steroids are tacrolimus and pimecrolimus, usually known as Protopic and Elidel cream/ointment. This works in a different way to steroids and is not always suitable or as effective as steroids, but for some people can be a way to control their eczema without the risks associated with regular, long-term steroid use. It is especially useful when eczema affects the more fragile skin of the face (particularly around the eyes), where steroid side-effects can occur more easily and be more noticeable.

It used to only be prescribed by specialists but, as its use has become more commonplace, many GPs are now comfortable prescribing it. It is not licensed for use in children under 2, although it can still be used in this age group where other treatments have failed or are unsuitable - usually on the advice of a specialist.

On occasion it is necessary to use oral steroids (e.g. prednisolone). These are usually only prescribed on the advice of a specialist (although some GPs will have the necessary experience to prescribe when appropriate). They can bring about fairly rapid improvement in severe flare-ups but should only be used rarely as they can have significant side effects if used often.

Using Steroids

Steroids work best when the skin they are applied to is not too dry, otherwise they may not penetrate deep enough. For this reason when the skin is particularly dry/cracked, it is usually recommended that moisturisers are applied to the skin first, allowed to soak in for 5-10 minutes, then the steroids applied second. It's best not to apply them simultaneously as this can cause dilution of the steroid in the moisturiser, making the steroid less potent. If the skin is only slightly dry the order of application probably doesn't make too much difference.

Steroids should be applied once or twice a day. Often a careful, once-daily application is sufficient.

Managing Itch

As anyone who has experienced dermatitis will tell you, usually the most troublesome symptom is itch. Imagine having an itch you can't scratch, but over much of your body, for weeks on end.

Obviously you can scratch it, but scratching inflamed skin makes it worse, as it creates more cracks in the skin, allowing germs to creep in and cause even more inflammation and, often, infection. Moisturisers and steroids will reduce itch, but often it is necessary to take oral anti-histamine medication as well.

There are two main types of anti-histamine - sedating and non-sedating.

When the eczema is severe, patients (especially children), will scratch themselves in their sleep, often leading to rapid worsening of the condition, as well as nightly blood-stained bedsheets and pyjamas. In addition this can lead to extreme tiredness as a result of sleep deprivation and persistent itch can quickly cause low mood and frustration. Babies will often be generally irritable as a result of itch.

This is where sedating anti-histamines such as Phenergan (promethazine), Piriton (chlorphenamine) and Atarax (hyroxyzine) come in, as they not only reduce itch, but they encourage sleep. They are best taken 1-2 hours before bedtime or sometimes earlier. If given too late they can cause drowsiness the following morning.

Non-sedating anti-histamines can be used at any time of today, and can be used in addition to sedating anti-histamines if necessary.

In cases of severe itch it may be necessary to use up to 3 different anti-histamines at the same time, but this should only be done on medical advice.

Other Treatments

In particularly troublesome cases of eczema, occlusive bandages made from viscose can be very helpful as these not only help protect the skin from trauma caused by scratching, but also help to reduce creams/ointments being rubbed off onto clothing/bedsheets. In children these are available in a variety of shapes including vests, leggings, gloves and socks. In adults they come as cylindrical bandages of varying sizes. The most well-known brands are Tubifast and Comfifast.

Sometimes these are applied damp as 'wet wraps' or along with a soothing paste (such as ichthopaste) which can be very effective at breaking the itch-scratch cycle. This is normally done under the guidance of a dermatology specialist nurse.

Occasionally severe eczema patches can develop into open sores which can be intensely itchy and very difficult to heal. For these lesions occlusive dressings such as Duoderm can also be very helpful. Duoderm is a thin, rubbery, self-adhesive dressing which slightly resembles skin. It is cut into the required size and can be left on for several days to allow the underlying sore to heal.

In order to reduce the quantity of potential irritating microbes on the skin's surface, a 'bleach bath' may be recommended. This involves adding half a capful of something like Milton sterilising fluid to every 10cm depth of water (in a standard size bath, not a baby bath) and bathing in this 1-2 times per week.

Occasionally eczema can become infected and topical antibiotics will not be effective. In these cases it is important for any infected areas to be swabbed, then oral antibiotics can often bring about rapid improvement in symptoms. Infected eczema is usually very red, incredibly itchy and slightly weepy/moist. Infected eczema can occasionally lead to more widespread infection and, very rarely, sepsis so it is important that it is treated early.

Despite the above, many children (and adults) need to have their eczema managed by a dermatologist, who has access to other treatments not available to GPs, such PUVA (ultra-violet light therapy) and immunosuppressive treatments such as methotrexate and ciclosporin.

We also now have a number of other immunosuppressive treatments (known as 'biological' treatments) which are proving to be very effective. These treatments can have side-effects and patients taking them are at greater risk of becoming seriously ill from infections, so require careful monitoring. Patients on these medications must also ensure they remain fully up-to-date with immunisations (especially against COVID).

Hand Eczema

Hand eczema can be a particularly unpleasant and difficult to manage type of dermatitis, usually requiring the use of more aggressive treatments at an earlier stage than atopic eczema.

During the COVID pandemic there was a notable increase in the incidence of hand eczema, largely due to the sudden increase in hand-washing and use of hand sanitisers which, although good at killing COVID, can be a disaster for eczema-prone skin as they cause it to become extremely dry and more prone to cracking.

Individuals with atopy are prone to hand eczema, but hand eczema more usually occurs not as a consequence of atopy, but due to occupational factors. Any job or activity which requires frequent handwashing, regular exposure to chemicals or irritants (such as detergents, alcohols, paints and dust) and/or wearing of rubber gloves can trigger hand eczema. Common examples are hands-on healthcare workers, mechanics, builders, farmers and hairdressers.

All the principles and treatments mentioned above apply to hand eczema, but there are some additional factors that need to be considered.

Hand eczema is frequently triggered by the sufferer becoming sensitised (allergic) to a substance with which their hands are in frequent contact ('contact' dermatitis). The substance may be difficult to identify, requiring the use of 'patch-testing' (performed in dermatology outpatients) in order to determine the culprit(s).

'Irritant' dermatitis is similar, except there is no allergy, and the dermatitis is simply caused by a substance which is recognised to cause skin irritation (such as those mentioned above).

Contact and irritant dermatitis often occur together. 

The most important treatment in these cases is limiting contact with the culprit as much as possible which, in some cases, may necessitate the patient making drastic lifestyle changes or even changing their job.

Because the hands are in constant use it can be difficult to ensure frequent and effective application of topical treatments. For this reason it is often best to apply these only at night with the wearing of cotton gloves overnight to ensure the creams don't rub off and trauma due to scratching is minimised. 

Moisturisers should alway be applied after hand-washing, even if only in water.

A common problem in hand eczema is the formation of hacks on the fingertips. These can be extremely painful, prone to bleeding and becoming infected, and stubborn to heal. 

A useful treatment for hacks is steroid-impregnated sticky tape/dressings such as Haelan and Betesil, which can be stuck over the hacks, delivering steroid into the skin and also protecting them. It is usually most convenient to use these overnight. Beware that they can fall off easily if moisturisers applied beforehand haven't fully soaked in.

Another reason for treating hand eczema more aggressively is that it can sometimes cause long-lasting damage to the nailbeds, resulting in deformed fingernails. Thankfully this is relatively rare.

In very resistant cases of hand eczema a relatively new oral treatment called Toctino has been found to be effective. Toctino is an oral retinoid and is very similar to Roaccutane, which is a fairly well-known treatment for severe acne. It is not an immunosuppressant but can only be prescribed by a specialist, and how it works is still a bit of a mystery!

Final Thoughts

One of the most overlooked aspects in the management of dermatitis is the fact that dermatitis is nearly always exacerbated by underlying illness and stress, as well as unhealthy lifestyle factors such as smoking, too much alcohol, poor diet, poor hygiene and lack of sleep. This is because dermatitis is an inflammatory and, in most cases, auto-immune condition, and these lifestyle factors can lead to increased inflammation and affect our immune responses.

My wife and daughter have both found that their skin generally improves when they are taking care to eat healthily, get plenty of rest and ensure they are proactively managing stress.

Having a diet high in fibre (fruit, vegetables, nuts, seeds, pulses), low in sugar/white carbohydrates and low in processed foods can definitely help with managing eczema.

Thankfully, with the right treatment eczema can be managed, so please don't suffer (or watch your loved ones suffer) in silence or put up with sub-optimal treatment.

Personally speaking I love helping people who are suffering from dermatitis, and I am very grateful to the expert help my wife and daughter have received from their GP and dermatologists which has made a huge difference to their quality of life.