What Is Severe Eczema?
Eczema is type of skin inflammation that causes red, itchy, painful rashes. It affects about 31 million Americans. But it affects each person differently.
For most people with eczema, the symptoms are mild to moderate and may clear up in time. But for some, the severe dryness, itching, and scratching can get so painful that it may cause their skin to bleed, have open sores, or get crusty and ooze. With severe eczema, you may have long-lasting flare-ups in various parts of your body at different times. And the skin setbacks may affect your mental well-being and take a toll on your overall quality of life.
Zelma Chiesa Fuxench, MD, an assistant professor of dermatology at University of Pennsylvania Perelman School of Medicine, says she takes many things into account before she diagnoses a person with severe eczema.
Chiesa Fuxench says she asks herself questions like: “What is the level of itching? What is the impact on sleep loss? Is it associated to symptoms of depression or anxiety? Is the patient able to function at work or at school? Are they going out and enjoying the things that they are doing?”
One study found that 1 in 2 participants with severe eczema reported that it affected their lifestyle. They stayed away from social interaction because of the appearance of their skin and were less able to do daily activities.
For Hall, as a teenager, the “painful rashes” made her feel self-conscious.
“I always wore long sleeves, and I would always wear pants. I would never wear dresses or skirts — very self-conscious about it, which again, kind of prevented me from really enjoying life,” Hall says.
How to Manage Eczema Triggers
The exact cause of eczema is unknown, but experts believe you’re more likely to have it if your immune system is activated by a combination of genetics and environmental causes like the weather, irritants, or allergens. A faulty skin barrier might be the culprit. To get to the root of problem, you may have to see specialists like a dermatologist, allergist, or pediatrician if it starts at a young age.
Currently, there’s no known cure for eczema. But there are things you can do to ease the itch and maybe even head off the things that may cause a flare-up in the first place. Medical treatments are an option, too.
Triggers to avoid:
Dry skin. If your skin loses too much moisture and becomes dry and scaly, it could lead to an eczema flare-up. This can happen especially in the winter months when the cool, dry air sucks the moisture from your skin.
“I really do kind of emphasize the constant use of a moisturizer on the skin; you want to do this at least once a day,” Chiesa Fuxench says.
Irritants. Product ingredients or certain natural things can make your skin itch and burn if you come in contact with them. This can include:
- Certain metals like nickel.
- Laundry detergent, chemical cleaners, and soaps.
- Some fabrics like wool and polyester.
- Cigarette smoke.
- Perfumes and fragrances.
- Dyes and tattoo inks.
Hall says salty ocean water feels fine against her skin, but spending time in a pool is just not an option for her.
“It [eczema] would just flare up completely because chlorine does not agree with my skin,” Hall says.
Sweat and heat. Your sweat contains traces of certain metals like zinc, iron, nickel, and copper. This can irritate your eczema and make it worse in hot spots like elbow, behind the knees, or neck where the sweat usually pools. While it’s impossible to avoid sweat altogether, if you do, try to rinse off with fresh water and change into a clean outfit.
Food allergy. Common foods that may make your eczema symptoms worse are eggs, milk, and peanuts. Around 20% to 40% of children with severe eczema usually have food allergies along with it. If you feel certain foods make your skin worse, talk to a doctor about it.
Asthma or hay fever. Experts know that for some, it’s common for hay fever or asthma to coexist with atopic dermatitis or to set it off. Experts don’t know why. If you’re allergic to pollen or animal dander, limit your exposure. If you’re unsure about what’s causing your allergies, speak to an allergy specialist for tests and diagnosis.
Stress. Your eczema could become worse if you feel stressed. Experts don’t exactly know why.
Since her diagnosis, Hall says it’s been a journey of trial and error to manage the condition. “There wasn’t that much information on it back in the ‘80s and ‘90s.” But now, in her 30s, she says she has a lot more control over her skin health.
“I know some of my triggers and sometimes I don’t because it’s a little chaotic, but I actually don’t go to the dermatologist or doctor as much… [be]cause I feel like I’ve gotten to a place where I can manage it,” Hall says.
Chiesa Fuxench says that she tries to go over her patients’ skin care routines to see “what are some things that they can do [at home] in terms of changing their habits to sort of manage their conditions.”
But if home remedies don’t work and your eczema symptoms are not under control, try:
Topical treatments. Your doctor may prescribe over-the-counter ointments or creams to put directly on your skin, like corticosteroids. If your eczema is mild to moderate, your doctor may prescribe crisaborole (Eucrisa). It works by blocking substances in your body that cause inflammation.
You need to use these medications exactly as your doctor asks you to. Overuse may have side effects and cause your skin to thin. In some cases, your doctor may give you stronger creams like pimecrolimus (Elidel) or tacrolimus (Protopic) to reduce inflammation, itching, and the need to use steroids.
Oral prescription drugs. If the severe eczema leaves you with open sores that may cause infection, your doctor may give you oral antibiotics for a short time to fight off bacteria that may get in through the broken skin barrier.
If the inflammation is too much, you may have to take an oral corticosteroid like prednisone. It’s a very strong drug that can’t be taken for a long time. It may have serious side effects. Take it exactly as your doctor tells you to.
Phototherapy. If topical treatments don’t work for you, your doctor may suggest phototherapy. Your skin is exposed to a controlled amount of natural sunlight for a certain amount of time. You may also be exposed to other forms of light like artificial ultraviolet A (UVA) and narrow-band ultraviolet B (UVB). You may do this therapy with or without the use of drugs.
Phototherapy raises your chances of skin cancer and may cause your skin to age early. Ask your doctor if this the right treatment for you.
If none of these treatments work for you, the FDA has approved a new drug for moderate to severe eczema called dupilumab (Dupixent). Your doctor will have to prescribe it. You take it in the form of a shot that you can give yourself at home.
If the itching and scaly dry patches affect your sense of self-image or mental health, talk to a therapist or a counselor. If the itching disrupts your sleep or gets to be a habit, you can try relaxation techniques or behavior modification.
Breaking the Itch-Scratch Cycle
There’s a saying in the dermatology world, according to Chiesa Fuxench: “We say, ‘an itch that rashes.’” Basically, it implies that the more you scratch your rash, the more it gets inflamed and comes back more aggressive, red, swollen, and painful. It creates an “itch-scratch cycle” that’s hard to break.
In some severe cases, the intense itching and scratching can irritate the nerve endings on your skin and cause it to become thick and leathery. The affected area on your skin may become darker and have distinct lines from the scratching. This is a skin disorder called neurodermatitis. If the itch gets better, your skin may heal and improve.
For itch relief, you can:
- Moisturize as often as you can.
- Use creams with ceramides, a type of fat usually found on skin, to strengthen skin barrier.
- Use skin cleansers with low pH.
- Apply a cold compress.
- Pinch and pat the part of skin that itches.
- Add apple cider vinegar to your bath.
- Soak in a bath with baking soda or oatmeal.
- Avoid contact with anything that can irritate bare skin. Don’t sit on grass, plastic chairs, or rough carpet or furniture. Wear soft, breathable clothing made of natural fibers next to your skin.
- Use a wet wrap around itchy skin.
- Try acupuncture.
If you’re just unable to control your itching and scratching, develop a skin infection from it, or find it hard to sleep, talk to a dermatologist about it. They can direct you to treatments that can suit your needs best.
Getting Your Skin Back on Track After a Setback
At the end of the day, treatments and home remedies are not foolproof. They may not all work for your severe eczema or you may need more than one type of treatment at the same time, according to Chiesa Fuxench.
But when it comes to handling eczema setbacks, Hall says it’s about knowing what you can control and preparing as much as you can. “I would say I can’t control the weather. But I do know if I’m traveling, I’ll have what I call my ‘eczema emergency kit.’”
For Hall, when she stays at a hotel or with friends or family, she makes it a point to pack “fragrance-free” products and even brings her own sheets to avoid a flare-up. But even though Hall stays away from most activities that may spark her eczema, sometimes she lets herself enjoy them despite knowing the consequences.
“It’s a moment and it’s worth it, and you just have to go with it,” Hall says.
“You really do need to clearly establish a basic skin care regimen. Typically, I say basic and simple because we don’t really want to overburden patients with treatments,” Chiesa Fuxench says.
Ultimately, if you live with lifelong eczema, Chiesa Fuxench notes that it’s important to buy into the idea that, as with other chronic diseases like diabetes or hypertension, you’ll have to stay on top of your treatments.
“We need to be thinking about how to best treat these patients in terms of a longer-term approach,” Chiesa Fuxench says. “The goal is to make [them] happy and be able to go about their day lies without thinking that they have to go back and see the dermatologist again.”