The term ‘eczema’ is coming from Greek, means ‘boiling’. It is a common skin condition seen by physician in out patient setting. It is describes as an acutely inflamed weeping skin with vesicles and a chronic relapsing inflammation of the skin. It usually associated with atopy (asthma, hay fever and urticaria). The patient usually presented with positive family history of atopy.

Clinical features of eczema  

• Itchy erythematous scaly patches – this is a common presentation mainly seen at flexures area as in front the elbows and ankles, around the neck or behind the knees. In infants, the lesion usually started at face
• Small vesicles – only seen in very acute lesions
• Excoriation and lichenification (skin thickening) – usually produces by repeated scratching. This may present together with exaggerated skin markings.
• Papules or follicles – seen in pigmented skin patients
• Pitting and ridging of the nails – rarely seen. Only in nail bed involvement.

What cause eczema?  
     The cause is multifactorial. It can be due to genetic cause, infection, allergen and diet. As mentioned above, a positive family history of atopy is the leading causing of eczema, hence the strong genetic component. Staph aureus colonies and staph endotoxin known organisms that acts as super antigen. This is how infection can lead to eczema. Animal dander, dust and pollens are common allergens that cause this nightmare. And it also known that a big proportion of atopy sufferer have significant food allergies, this can be varies from eggs to seafood.What are the complications?  

• Infections
• Fungal infection : candida
• Eczema herpeticum ( herpes simplex manifestation)
• Repeated scratching and excoriation lead to chronic skin scarring.
• Chronic skin depigmentation ( this often seen in pigmented skins)
• Poor performance at school is one big problem when the eczema is serious enough to keep the child from sleep at night. They will feel tired in the morning and probably fall asleep in their classes.

What about the investigations?  
     Atopic eczema usually had been diagnosed clinically from the history and the presented skin lesions. However there are some tests available such as radio-immunoabsorbent assay (RAST tests) of blood, skin prick test or peripheral blood film (to see eosinophilia). These investigations are based on the fact that high specific IgE levels will be high to certain ingested or inhaled antigens in atopy patients.  Prognosis  
     Spontaneous improvements are expected in early onset eczema to majority of children. Only some of them will still have recurrence of eczema during adult life. The late onset eczema is a bad news followed by a more chronic remitting or relapsing course.  Management at out patient setting

• Greasy emollients (e.g.: Vaseline and aqueous lotion)
• Bath oil can also be used to substitute the soap.
• Topical steroid (e.g.: 1 ‰ hydrocortisone suitable for use on the face). More potent steroids might be use in severe eczema, however it is only recommended for a short period to avoid the side effects of steroids such as skin thinning, striate and adrenal suppression.
• Appropriate antibiotics (e.g.: cloxacillin) might be use in managing the infections. We have to be careful not to abuse the usage of antibiotics to avoid resistance.
• Sedating antihistamines are useful at nighttime. Their big help probably due to the sedative properties rather than their antihistamine activity where sedation can reduce the scratching and help the patient to sleep better.
• Paste bandaging might be useful. Apart of its mechanism to help in absorption of treatment, it can also acts as a barrier to prevent scratching.
• Second lines agents such as ultraviolet phototherapy, prednisolone, cyclosporine and azathioprine may be considered in non responsive cases. However they are not without risk and risk/benefit ratio should be seriously discussed with the patient before any of this agents use.
• Referral to dermatologist should be needed if the condition failed to be managed at out patient setting.

  What can we do at home to help eczema patients?  

• Avoidance of heat ( in western countries, substitution of sheets and blankets for duvet might help)
• Avoidance of wool where some patients might be allergic to wool. Cotton underclothes might help.
• Humidification of environment either during day or overnight.
• Emollients for dry skin might help a lot in reducing itchiness apart of medication given by doctor.
• Remove the allergen that has been identified that cause the eczema or aggravate it
• This type of patient might have significant food allergies; avoidance of this type of food might give a tremendous effect.

     Tips to prevent infantile eczema  In many conditions, prevention is always better than cure. It has been suggested that breast milk can reduce the incidence of eczema in babies. We can also consider reducing allergen exposure through breast milk. This can achieve by encourage the breast feeding mothers to avoid all dairy products, eggs, fish, peanuts and possible soya bean in their diet. Taking calcium supplement can also help. Although infantile eczema is common, the children usually outgrow it once they become teenager.  References:

1. Clinical medicine, 4th edition, Kumar and Clark
2. Oxford handbook of clinical specialty, 5th edition

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