Dr. Swiner’s Medical Note of the Month II-Sept. 2010-Is every dry, flaky rash from eczema?

Is every dry, flaky rash from eczema?

Published Wednesday, September 15, 2010 7:00 am

by Nicole Price Swiner, Columnist

It would certainly seem like it, wouldn’t it? Eczema, also called atopic dermatitis, is the most common skin disorder I see in practice, particularly in the African-American population.

Eczematous rashes are all generally dry, itchy, flaky, bothersome lesions that occur most frequently in the elbow area, knees and behind the neck. I’ll often see lesions on the anterior abdomen, surrounding the ear or belly button, which can be complicated by allergies to metal like nickel. Nickel is usually present in buttons on pants (try putting tape or cloth between the skin and the button to avoid touching), watches or earrings, causing a similarly annoying itchy, sometimes sensitive and occasionally painful rash. Eczema, and possibly nickel allergy, is hereditary.

Why does it also appear to be more prevalent in black patients? Unsure. My theory is it may be due to the allergies from which we suffer in our homes, products and environments.

Dyshidrosis, or dry skin, is a cardinal symptom of eczema so directing attention to keeping the skin moist is paramount. This is why it seems harder to control the rash either in the winter or during the heat of the summer when we sweat. Interestingly, although we want the skin moist, we don’t want it wet, which is also when eczema becomes worse.

I think the hardest piece of advice for my patients to follow is shortening the time in the bathtub or shower. If a child spends 20 minutes twice daily in the water, cut it in half if you can. Also, while in the tub, the more lukewarm the water, the better. No one likes a cold shower, so keep the temp reasonable. As soon as he or she jumps out of tub, dry quickly and moisturize even more quickly.

One can imagine how difficult this is for those of us who feverishly wash our hands in scalding hot water every five minutes or use alcohol hand sanitizers to keep clean. It all dries the skin out. I’ve prescribed the strongest, highest strength steroid creams there are, but I’ve had it confirmed by dermatologists that good old petroleum jelly, i.e. Vaseline, is as good as gold. Cocoa butter and Shea butter are OK alternatives as well for twice daily moisturizing.

Over the counter, my other favorites to suggest are Eucerin and Aquaphor for their thickness and staying power. The thinner, fancier lotions seem to evaporate right into the air after putting onto the skin. Children, and adults for that matter, with histories of allergies, eczema or asthma, often have one of the others or all three. So, when I know one of my patients has asthma and they call with complaints of a dry, itchy rash in one of those special areas, I can pretty much put money on what it is.

With all of the great, sweet smelling soaps, washes and shower gels out there, it isn’t a good idea for a patient with eczema to use any of them. Because of the allergy rationale, the more pure and simple one’s soap, the better it is for sensitive skin type. I generally recommend regular and plain Dove, without scent or color, for its gentle nature on the skin. Sorry to all of the Bath and Body and Victoria Secret lovers (like me).

If decreasing water exposure and temperature, soap and lathering from head to toe in lotion won’t help, in comes the steroid treatment. The steroids work by helping the body decrease the atopic response that occurs. I explain their action by saying they help the body to stop reacting against itself, similar to how antihistamines and allergy medicines work.

The simplest one to use is an over-the-counter steroid. There are forms of generic steroid or allergy creams and ointments of varying strengths of hydrocortisone you can buy from the store without a prescription. The 2 percent strength is available OTC, and it’s a good start. You use it twice a day – sometimes mixed in with your lotion or petroleum for better absorption – for no more than two weeks in a row. If the rash is something that recurs regularly, I’ll have patients skip one or two weeks between their two-week treatment to give the body a rest from the strong steroids.

This is also why I usually suggest the ointments instead of the cream, because the ointments remain on the skin longer. However, some complain that it’s messier on clothing. If the OTC doesn’t help, we can prescribe a variety of types depending on the severity of the rash and whether it’s occurring on the body versus the face.

Now, back to my original question: Does this mean that every flaky rash is eczema? No, certainly not. Others that come to mind include yeast, psoriasis or fungal. Candidal or tinea rashes are typically more moist or wet in nature, occurring in the creases of skin, and psoriatic rashes have more of a shiny patch appearance on the surface of the elbow or knee. See your local doctor to help determine the right diagnosis and treatment.

* On Oct. 1, UNC Durham Family Practice will become Durham Family Medicine. We welcome our new patients to call us at 220-9800 and visit us at our same location at 2400 Broad St., suite 1 in Durham.

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