Practical help for eczema-prone skin

Eczema, also known as atopic dermatitis, is a chronic inflammatory skin condition characterised by itchy, red, dry, and inflamed skin. It often occurs in cycles, with flare-ups followed by periods of remission. Eczema can affect people of all ages but is most common in children.

Key symptoms include:

• Dry, sensitive skin
• Intense itching (pruritus)
• Red, inflamed patches
• Thickened, scaly skin (in chronic cases)
• Blisters or oozing lesions (in acute flare-ups)

Eczema is multifactorial: a combination of genetic, immune system, and environmental factors.

• Genetic factors, for example a mutation in the filaggrin (FLG) gene, and a family history of atopic conditions like eczema or asthma.
• Immune system dysfunction: an overactive immune response to harmless substances (like dust or pollen), overexpressed cytokines such as IL-4, IL-13 and IL-31 that promote inflammation and itch, and a Type 2 helper T cell (Th2) dominance that contributes to allergic reactions.
• Environmental triggers: allergens (pollen, dust mites, pet dander), weather changes (heat, cold, humidity), and irritants (soaps, detergents, fragrances).
• Lifestyle and psychological factors: stress, infections, sleep deprivation, and for some people, certain foods such as dairy, eggs or nuts.

Topical Steroid Withdrawal (TSW), also called Topical Steroid Addiction (TSA) or Red Skin Syndrome (RSS), can develop after prolonged or frequent use of topical corticosteroid creams, which are commonly prescribed for eczema. When people stop using them, they may experience a severe rebound, with symptoms often worse than the original condition.

Common symptoms:

• Red, burning skin (often called "red sleeve" when it affects the arms)
• Severe itching, burning or stinging
• Swelling and oozing
• Peeling, shedding or flaking skin
• Poor sleep and fatigue
• Temperature dysregulation, feeling hot or cold

Anyone who uses topical steroids for extended periods or in high doses is at risk. The exact mechanism isn't fully understood yet; research suggests a combination of skin barrier dysfunction, immune dysregulation and vascular instability.

Topical steroids suppress inflammation and immune responses in the skin. Over time, skin can become:

• Dependent on steroids to maintain normal function
• Desensitised, needing stronger or more frequent doses for the same effect
• Thinner and more fragile

When steroids are stopped, the suppressed inflammation can rebound aggressively.

The itch-scratch cycle is a loop where itching prompts scratching, which in turn makes the itch worse:

1. Itch stimulus: inflammation, dryness, allergens, irritants or nerve signals.
2. Scratching: brings brief relief, but often damages the skin barrier.
3. Barrier damage: leads to more inflammation, nerve sensitisation, and sometimes infection.
4. Stronger itch: damaged skin releases more inflammatory mediators (e.g. histamine), and the cycle repeats.

It is driven by nerve and immune signals, and reinforced by habit and stress. Strategies that can be used together:

• Environmental control (reducing allergens, keeping cool)
• Steroid-free moisturisers
• Behavioural approaches such as habit-reversal training and meditation
• Antihistamines, though these often don't help chronic itch, which isn't caused by histamine alone

These organisations are good starting points:

• National Eczema Association
• ITSAN – International Topical Steroid Addiction Network
• Mayo Clinic – Atopic Dermatitis
• American Academy of Dermatology

SkinMatters shares lived experience, not medical advice. Please speak with a healthcare professional before changing any treatment.