A Close Look at Eczema

Written by Brenda Linday in January 2020 Dermascope

Aestheticians frequently encounter clients with sensitive skin conditions. While a professional’s scope of practice does not allow them to treat eczema, rosacea, or psoriasis, they can provide treatments that supplement the care the client receives from their medical provider. By gaining an in-depth knowledge of each condition, its causes, and standard treatment options, professionals can combine empathy and understanding with superior skin health services to deliver first-rate therapies to this select group of clients.

ECZEMA Eczema, or dermatitis, is the name for a group of non-contagious skin conditions that present with symptoms of inflammation, pruritis (itchiness), and erythema (redness). Over 30 million Americans suffer from one or more forms of eczema which primarily appears on the hands, feet, face, and torso.

The most common form seen in the spa, atopic dermatitis, affects over 18 million Americans. It can present in infancy, teenage years, or adulthood. Individuals with a family history of atopic dermatitis, asthma, or hay fever have a higher risk of developing atopic dermatitis.

Symptoms include itchiness, redness, rash, dry or scaly skin, and open, crusty, or weepy lesions. If an infection develops from scratching, small pustules may form. Lichenification (skin thickening) can occur from excessive scratching and rubbing.

Contact dermatitis has two sub-classifications dependent on exposure to an irritant or allergen. Allergic contact dermatitis occurs with exposure to pollen, dust mites, or other allergens. Irritant contact dermatitis occurs with exposure to irritants like household cleaners. Symptoms include itchiness, redness, rash, swelling, bumps, and blisters. The best treatment for contact and irritant dermatitis is to avoid the offending agent.

Cause The exact cause of eczema is unknown. However, genes and certain triggers are factors. Individuals with eczema have an immune system that over-reacts to outside stimuli producing inflammation. In turn, inflammation triggers the erythema, discomfort, and pruritis.

Researchers have discovered that some individuals suffering from eczema have a mutation of the FLG gene responsible for creating the protein filaggrin. Filaggrin is found in the granules in epidermal skin cells of the stratum granulosum. The epidermis acts as a barrier, inhibiting penetration of toxins, allergens, and bacteria. Filaggrin plays an essential role in the skin’s barrier function. Filaggrin attracts and binds structural proteins, forming tight bundles, flattening, and strengthening the cells to create a strong barrier. The breakdown of the filaggrin proteins leads to the production of molecules, including pyrrolidone carboxylic acid (PCA), that are part of the skin’s natural moisturizing factor which helps to maintain skin hydration. Filaggrin also assists with the maintenance of the slightly acidic pH of the skin (approximately 5.5) which is another essential aspect of barrier function.

Without adequate amounts of filaggrin, a weakened skin barrier can allow moisture to escape through transepidermal water loss. Additionally, bacteria, viruses, toxins, and allergens can penetrate with ease. The weakened barrier causes dry and infection-prone skin.

Latest Advances Research using probiotics to alter the skin’s microbiome is promising. A study discovered that parabens, commonly used as preservatives in skin care products, inhibit the growth of roseomonas mucosa (a gram-negative bacteria), suggesting that parabens might hinder the skin’s defenses against eczema.

Prevention of Flareups The best way to prevent flareups is to recognize and avoid the triggers.

Treatments The type and severity of eczema often determine the treatment. The medical provider determines the appropriate regimen based on the client’s condition. Knowledge of both clinical care and homecare remedies can help the aesthetician identify the best aesthetic regimens to complement the client’s current medical treatment.

Homecare A regular bathing and moisturizing routine using a gentle, soap-free cleanser and an emollient cream with humectant and occlusive ingredients is recommended to seal in the desperately needed hydration. Pat the skin dry with a towel (no rubbing) and apply moisturizer while the skin is slightly damp. Well-moisturized skin decreases dryness and keeps out allergens.

A 10-minute lukewarm bleach bath (using unconcentrated bleach) sounds harsh but can be calming and can prevent infection. The amount of chlorine is similar to the amount found in a swimming pool: approximately half a cup of bleach for a standard 40-gallon bathtub. The client should only utilize this therapy with their health care provider’s permission and must be sure to thoroughly rinse the skin with fresh warm water to remove all bleach residue.

Wet wrap therapies are beneficial for rehydration. They also help topical medication to penetrate more efficiently. To use this option, clients should apply moisturizer and any topical medications, followed by wrapping dampened gauze or cotton to the affected skin. Then, the client should follow the damp wrap layer with a dry cloth over the top of the dampened wrap and complete the process with nighttime clothing to keep the wraps in place. They should leave this on for several hours, staying moist, or overnight.

Many over-the-counter products – including gentle cleansers, mild steroids, moisturizers, petroleum jelly, mineral oil, and coal-tar-based products, amongst many others – are available to help prevent and control eczema flareups. Clients must be sure to read the labels and follow directions.

Clients should apply all topical over-the-counter and prescription medications as directed by the healthcare provider. Topical steroids reduce cutaneous inflammation. They also tighten and constrict the capillaries, which decreases erythema. They are not intended for long-term use; sensitive areas, including eyelids and genitals, should always be avoided. Topical calcineurin inhibitors (TCIs) can be used for extended periods to control symptoms and reduce flareups because they do not contain steroids. TCIs inhibit the stimulation of the inflammatory cascade, keeping eczema in check. Prescription-grade topical skin barrier medications made from lipids and ceramides help prevent transepidermal water loss and protect against irritants penetrating the skin’s barrier. Topical phosphodiesterase 4 (PER) inhibitors block the PDE4 enzyme, reducing inflammation both on and below the skin’s surface and can be used for extended periods.

Clinical Care Biologics are injectable drugs engineered from proteins derived from living cells or tissues. Biologics target the immune system to slow down its reaction, enabling the reduction of inflammation, redness, itchiness, and rashes.

Phototherapy, or light therapy, incorporates ultraviolet light to slow inflammation and mitosis. A hand-held device or a walk-in light source somewhat similar to a tanning booth may be used. Treatments take place in a doctor’s office several times a week and therapy can last weeks or months.

Immunosuppressant medications suppress the immune system, which reduces inflammation. They can be taken orally or by injection. Methotrexate, cyclosporine, and mycophenolate are three current medications used off label to treat eczema.

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