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What to do when your skin erupts…treatment for eczema
What to do when your skin erupts…treatment for eczema The early Greeks recognized this condition and called it “ekzein”, to break out or boil over.

“Good grief! My face feels like it is boiling over,” Linda said as I entered her exam room. I told her she couldn’t have come up with a better description for the red, oozing, and crusted rash on her cheeks. The early Greeks recognized this condition and called it “ekzein”, to break out or boil over. We call the rash “eczema.” Eczema is a broad general term that is often used interchangeably with “dermatitis.”

“I’m sure we can get you better, but we need to start with some investigation to find out what may have started this problem,” I explained. Unfortunately, rashes can have multiple causes and identical end results! To make matters more confusing, there can be many different reasons for eczema getting worse.

Some people are more prone than others to develop eczema. These people frequently have a personal or family history of atopy (allergies, asthma, or hay fever). Their rashes often start in early childhood and persist to some degree into adulthood. When I asked Linda if she or any family members had any of these problems, she told me about her childhood rashes on the bends of her arms and legs and her chronic problems with hay fever. Since Linda has been an adult, she reports that her skin has been more sensitive, but she is certain that this rash is a new problem. She did recall that both her mother and sister have had many problems with allergies.
Since Linda has been an adult, she reports that her skin has been more sensitive, but she is certain that this rash is a new problem. She did recall that both her mother and sister have had many problems with allergies.
In addition to frequently having an inherited component, eczema is usually aggravated by the environment, i.e. “contact” eczema. The contact may be either an irritant or a true allergy. Something like full strength bleach is an obvious irritant because it will injure everybody’s skin. In contrast, atopic individuals might be so sensitive that they develop an irritant eczema to much lower concentrations of chemicals such as those levels found in drugstore skin care products. These products usually cause no problems for the majority of people who use them. However, if the skin has had an initial irritation from something as simple as cold windy weather, only a little exposure from the much milder chemicals may further aggravate the skin, which develops eczema. Sometimes people who initially tolerate drug store products with ingredients like benzoyl peroxide, salicylic acid, or alpha-hydroxy find they can no longer use them in the winter.

I asked Linda how she had been caring for her skin. She explained that now that she was in her 40’s she was worried about the new wrinkles she was seeing around her eyes. She had started a program with an astringent, a toner, and a topical vitamin C. Because these were all “natural” products, she was sure that they were unrelated to her eczema. She did notice some flakes on her skin and she added an exfoliating scrub. She was a bit concerned when she noticed some red-crusted areas, but they initially got better with a triple antibiotic ointment once a day. Without any more changes in her regimen, her skin suddenly became redder, moist, and crusty. She started to itch miserably. Nothing she was doing for her skin seemed to help, so she called our office.

With her barrier defense weakened, skin germs that were previously not a problem could over multiply resulting in a secondary skin infection.
“My goodness,” I said. “It sounds like we have quite a number of possible causes for your skin problems. In retrospect, we probably should have talked about your goals for your skin before you started your new skin care regimen.” I let her know that after we got her rash cleared up, I would be glad to work with her. I reminded her that physicians who are trained in dermatology are the skin care experts. As part of our training, we can work with patients who want to repair previous damage from too much sun exposure as well as help them prevent future damage. We also know that everybody has a budget, and we can usually come up with some easy steps to fit everybody’s price range. The best programs start with a mild non-medicated moisturizer, a gentle cleanser to remove any make-up, and a daily sun block with at least an SPF-30 for all skin that is exposed to daylight. When the skin is healthy, a dermatologist would next add a prescription strength retinoid such as Retin-A™. In addition to prescription medications, many dermatology offices offer additional treatments that can be more aggressive in targeting photo-damage with less risk of irritation for patients with sensitive skin.

However for Linda, I suspected that her starting too many new products at the same time caused a mild irritant reaction that had gotten much worse with the addition of the exfoliant. I did remind Linda that just because a product was labeled “All Natural” there was no guarantee that it would never be a problem for her skin. “Remember, poison ivy is also all natural!” I added.

Once her skin had become irritated, the skin barrier function was also broken. This loss of the barrier function now allowed minor things like washing her face to continue the eczema reaction. I often tell people that their skin has a memory like an elephant. It can easily recall things that aggravate eczema, allowing the skin to continue to break out.

With her barrier defense weakened, skin germs that were previously not a problem could over multiply resulting in a secondary skin infection. This bacterial overgrowth is called “secondary” because it follows as a complication to the original eczema problem. I told Linda I think she had been on the right thought process when she started using the triple antibiotic ointment after the initial rash. Many times adding an antibiotic will help treat the secondary infection allowing the barrier to repair and the eczema to resolve.

Unfortunately for Linda, the triple antibiotic ointment was not a good antibiotic choice. I suspected that her rash had gotten suddenly much worse due to an allergy to one or more ingredients in the antibiotic ointment. Both neomycin and bacitracin in this ointment can cause a poison ivy like rash (allergic contact dermatitis). This problem is more frequently found in the setting of applying the ointment to skin that already has a bit of eczema.

I suggested that she stop all of her skin care products including her make-up while we were getting things sorted out. She began a regimen of cold-water compresses with white petrolatum as often as possible to help repair her skin barrier. I also gave her prescriptions for a steroid ointment to reduce the inflammation, an antibiotic capsule to treat the secondary bacterial infection, and an antihistamine tablet to help relieve the itching.

We also discussed scheduling an appointment for allergy testing to help find out if she was allergic to any of the products that she had used at home. She was very happy to learn that patch testing does not require any needles. Patch testing involves taping on healthy back skin a thin tray of a standard series of potential allergens (antibiotics, metals, preservatives, fragrances, etc.). If a person is truly allergic, we are likely to see a tiny area of eczema reproduce on the back by the small amount of the chemical in the test square. In addition to the standard series of test chemicals, I suggested that we use dabs of the products she had recently used on her skin. I told her it was fine to leave her cleansers at home, but to bring with her all products that were designed to be left on the skin. Unfortunately, we do not have allergy shots to prevent or reduce skin allergic contact eczema. However, if we could identify a specific chemical that would always cause eczema on Linda’s skin; she could become a compulsive label reader to avoid contact with that allergen.

The story had a successful conclusion. Linda’s patch testing showed she was only truly allergic to the neomycin in the triple antibiotic ointment. She found out that she could use the over the counter product bacitracin if she needed an antibiotic ointment. Her face was looking great, and she had quickly been able to restart her usual make-up without difficulty. She had also found a sun block that she liked and was using it daily. I was happy to give her a prescription for a low dose Retin-A™ cream. She will initially be using just a dot of the prescription cream with extra moisturizer every other evening on totally dry skin to prevent irritation. Neither of us wants to see her facial eczema again!

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"What to do when your skin erupts…treatment for eczema"
   authored by:
Dr. Rebecca L. Bushong is both a pharmacist and a board-certified dermatologist. After receiving her BS. in Pharmacy and her Pharm D degree, she returned at age 30 to the Medical School of the University of Kentucky. Following medical school she comp...

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