WHAT IS ECZEMA?

Dr Diana Purvis
Paediatric Dermatologist
What is eczema?
• Clinical features
• Epidemiology
• Prognosis
• Etiology and pathogenesis
• Immunology
• Skin barrier
Eczema
• From the Greek: ‘to boil over’
Eczema
• From the Greek: ‘to boil over’

• Pruritic papulovesicular dermatitis characterised by

erythema, oedema and a serous exudate in the
epidermis, an inflammatory infiltrate in the dermis, oozing
and vesiculation, and crusting and scaling; and later by
lichenification, thickening, signs of excoriations and
altered pigmentation.
• TheFreeDictionary.com
Eczema
• From the Greek: ‘to boil over’

• Pruritic papulovesicular dermatitis characterised by

erythema, oedema and a serous exudate in the
epidermis, an inflammatory infiltrate in the dermis, oozing
and vesiculation, and crusting and scaling; and later by
lichenification, thickening, signs of excoriations and
altered pigmentation.
• TheFreeDictionary.com

• “The itch that rashes”

Diagnostic criteria for atopic eczema

• Itchy skin condition plus three of

• History of involvement of the
creases
• Personal history of atopy (or 1st
degree relative if <4 years)
• Generally dry skin
• Visible flexural eczema
• Onset under 2 years of age
• UK Working Party, BJD 1994
Features of eczema
Major features:
• Pruritis
• Rash
• face and extensors in
infants
• flexural in older children
• Chronic or chronically
relapsing
• Personal or family history
of other atopic disease
Other common
features:
• Dryness
• Dennie-Morgan folds
• Allergic shiners
• Facial pallor
• Pityriasis alba
• Keratosis pilaris
• Icthyosis vulgaris
• White dermatographism
• Conjunctivitis
• Keratoconus and cataracts
• Elevated serum IgE
• Skin prick test positivity
Eczema - subtypes
• Eczema / atopic dermatitis
• Seborrhoeic dermatitis
• Discoid, nummular eczema
• Dyshidrotic eczema / pompholyx
• Contact dermatitis
• Varicose eczema
• Asteatotic eczema
Infant Child/adolescent Adult
Prognosis
• Outcome of any individual is difficult to predict
• Spontaneous resolution in 40-60% of infants, especially with mild
disease
• 20% have resolved by adolescence, 65% less severe
• Prevalence is 2 – 3% in adults
• Adults whose childhood eczema has remitted can present with
hand dermatitis

• Poor prognosis:
• Generalised eczema
• Associated asthma and hayfever, high IgE levels
• Family history of troublesome eczema
• Early age of onset
Epidemiology of eczema
• Prevalence of has increased three-fold since 1960s
• 10-20% of children in industrialised countries eg Europe, USA
• 1-3% of adults
• Lower prevalence in agricultural economies eg China, Africa

• Environmental factors seem critical in disease expression

• Risk factors include:

• Small family size
• Increased income and education
• Migration from rural to urban environments
• Increased use of antibiotics
The hygiene hypothesis
• The ‘Western lifestyle’ predisposes to allergic disease
• Lack of early childhood exposure to infectious agents, symbiotic
microorganisms and parasites
• Suppresses the natural development of Th1 predominant
immune response
• Promotes a Th2 dominant or allergic response

• Supported by reduced risk of eczema with:

• owning a pet
• attending daycare
• use of probiotics
The atopic march
How atopic is atopic eczema?
• Up to 50% of hospital eczema patients are not sensitised,
even higher in community settings
• Population attributable risk for allergic sensitisation
causing eczema <50% in affluent countries, as low as
zero in non-affluent countries (ISAAC)
H Williams, C Flohr J All Clin Imm 2006

• Genetic risk
• “atopic disease” asthma, eczema, allergic rhinitis do tend to cluster
in families
Pathogenesis of eczema
Two hypotheses:
1) Inside-out
Immunological disturbance causes IgE-
mediated sensitisation, epithelial barrier
dysfunction is secondary

2) Outside-in
Epidermal barrier dysfunction allows
irritants and allergens into the skin, with
immunological disturbance secondary
 Immune
Itch
dysfunction

Soap
Eczema
Irritants
Infection
Allergens Inflammation Scratch
House dust mite
Cat/dog fur

Leaky skin
barrier
 Immune
Itch
dysfunction

Soap
Eczema
Irritants
Infection
Allergens Inflammation Scratch
House dust mite
Cat/dog fur

Leaky skin
barrier
 Immune
Itch
dysfunction

Soap
Eczema
Irritants
Infection
Allergens Inflammation Scratch
House dust mite
Cat/dog fur

Leaky skin
barrier
The skin as a barrier
The skin as a barrier
The stratum corneum
The skin barrier

• Skin barrier function maintained by:

• Regular desquamation
• Intercellular lipid bilayers
• Natural Moisturising Factors
• Production of antimicrobial peptides
The skin barrier is impaired in eczema
• Genetic defects
• Filaggrin gene mutation in 30% of eczema patients
• Filaggrin involved in production of natural moisturising factors
• Other genes affecting stratum corneum function eg SPINK5, loricrin

• Reduced ceramides and water binding

• Decreased sebaceous secretion

• Impaired production of antimicrobial peptides

• Defensins and cathelicidins
• Staphylococcus aureus colonisation in 90%
• Increased viral infections
The skin in eczema
Gene-environment interaction
Genetic Environmental
background factors
Microbiological Allergens
agents (inhalative, food, contact)
(bacteria, virus, etc,)
Skin Climate
barrier Stress
Irritants

Immune
system

New discovery: filaggrin gene mutation

1. Irvine et al. J Invest Dermatol 2006; 126: 1200–02. 2. Bieber T. N Engl J Med 2008; 358: 1483–94.
 What causes eczema?
Immune
Itch
dysfunction

Soap
Eczema
Irritants
Infection
Allergens Inflammation Scratch
House dust mite
Cat/dog fur

Leaky skin
barrier
 What causes eczema?
Immune
Itch
dysfunction

Soap
Eczema
Irritants
Infection
Allergens Inflammation Scratch
House dust mite
Cat/dog fur

Leaky skin
barrier
 What causes eczema?
Immune
Itch
dysfunction

Triggers

Soap
Eczema
Irritants
Infection
Allergens Inflammation Scratch
House dust mite
Cat/dog fur

Leaky skin
barrier
 Brick wall model of
the skin
Brick => Corneocyte

Mortar => Lipid Lamellae

3/26/09 Cork MJ, Hunter LW & Danby SG; Academic Unit of Dermatology Research, The University of Sheffield. 41
The Normal Skin Barrier

3/26/09 Cork MJ, Hunter LW & Danby SG; Academic Unit of Dermatology Research, The University of Sheffield. 42
 Irritants &
allergens

2/10/2015 Cork MJ, Hunter LW & Danby SG; Academic Unit of Dermatology Research, The University of Sheffield. 43
 The skin barrier in atopic dermatitis

Broken
mortar
in AD

3/26/09 Cork MJ, Hunter LW & Danby SG; Academic Unit of Dermatology Research, The University of Sheffield. 44
 Irritants &
TEWL allergens

2/10/2015 The Academic Unit of Dermatology Research, The University of Sheffield. 45

 Emollients

46
Cork MJ, Hunter LW & Danby SG; Academic Unit of Dermatology Research, The University of Sheffield.
Address allergens
Treat
minimise exposure,
inflammation,
immune modulation NO immune
NO itch cool,
dysfunction
antihistamines

NO eczema
NO NO
inflammation scratching
Avoid soap Treat itch,
and irritants, physical
treat barriers,
infection, distraction
treat with Effective
skin barrier
steroids,
immuno-
suppressant Emollients, treat inflammation