Eczema (atopic dermatitis) is a chronic inflammatory disease (National Eczema Society, 2022) that is characterised by pruritic, erythematous and scaly lesions (Berke et al, 2012; Jabbar-Lopez et al, 2021). The condition can range from mild to severe and may be persistent or present in flare-ups (Berke et al, 2012; Jabbar-Lopez et al, 2021). While there are multiple elements that contribute to the development of eczema (immunological, environmental, and genetic) (Ardnt et al, 2008), it is estimated that 1 in 5 children and 1 in 10 adults in the UK will experience some form of eczema (National Eczema Society, 2022).
Within the skincare community, daily management of eczema can be challenging. It can be difficult to know which habits are helpful and which may worsen the condition. This article aims to briefly discuss regular habits for those with eczema that may assist in the management and reduction of eczema flare-ups.
Reduce water temperature when bathing
The outer layer of the skin, the stratum corneum, is composed of dead skin cells (anucleated corneocytes) surrounded by a lipid matrix (Lin et al, 2017). Hot water can interfere with these lipids and compromise skin barrier function. It has been reported that skin damage after cleansing is higher with increased water temperatures (~40°C) (Berardesc et al, 1995). This leads to inflammation, erythema and transepidermal water loss (TEWL), and can affect DNA synthesis and lipid production in the skin (Berardesc et al, 1995; Lin et al, 2017).
For those with eczema, consistently reducing water temperatures when showering, bathing, washing hands or cleansing the face can protect against addition skin barrier disruption.
Avoid water-based moisturisers
The skin is naturally structured to bind and store water molecules, and hydration of the skin barrier is essential for its proper functioning (Lin et al, 2017). However, depending on skin health, TEWL increases; therefore, it is very common for eczema suffers to have xerosis (skin dryness) (Berke et al, 2012; Lin et al, 2017).
Many moisturisers contain high amounts of humectants (hyaluronic acid, glycerin, sodium PCA) that bind water and draw it into the skin (Draelos, 2010). However, without proper occlusion, humectants can increase TEWL (Draelos, 2010). To maintain the skin barrier and avoid excessive TEWL, those with eczema should regularly and liberally apply emollient-based moisturiser over the entire body, even when symptoms are not present (Berke et al, 2012). Regular use of emollients improves skin barrier function with eczema (Patzelt et al, 2012) and can decrease the requirement for management with topical corticosteroids (Grimalt et al, 2007). Hydrators containing skin barrier repairing ceramide lipids can also provide benefit (Berke et al, 2017).
Reduce cleansing frequency and intensity
Skin cleansers are essential for basic hygiene as they function to remove unwanted materials, such as dirt, sweat, sebum and other oils, from the skin (Ananthapadmanabha et al, 2004). Cleansers are composed of surfactants that solubilise dirt and oils; however, in many cases, surfactants can disrupt the lipid components and pH of the skin barrier (Ananthapadmanabha et al, 2004). This causes immediate tightness, dryness, erythema, irritation, and itching skin (Ananthapadmanabha et al, 2004), which can aggravate eczema flare-ups.
Reducing cleansing frequency and substituting soaps with emollient-based cleansers promotes skin barrier function, and emollient-based cleansers are regularly prescribed for eczema patients (Berke et al, 2012). Cleansing should always be followed with protective emollient moisturisers.
Manage psychological stress
While there are many factors that contribute to the development of eczema, stress (both mental and physical) plays a role in the condition (Ardnt et al, 2008). During periods of stress, the skin barrier is impaired, as stress influences skin cell shedding alongside skin cell cohesion (Ardnt et al, 2008). Stress also induces inflammatory (T helper Type 2) and allergic responses within the skin and the release of inflammatory neuropeptides (Ardnt et al, 2008).
Incidence and severity of eczema lesions has been linked with periods of psychological stress (King et al, 1991; Ardnt et al, 2008); therefore, finding effective ways to manage stress can help reduce eczema flare-ups over time. There are numerous studies linking different psychological stress-relieving techniques with improvements of eczema lesions (Ehlers et al, 1995; Chida et al, 2007; Ardnt et al, 2008).
Manage gut health
The gastrointestinal (GI) microbiome is an extensive array of commensal bacteria, viruses, fungi and protozoa, which varies between individuals and colonises the inside of GI tract (Rusu et al, 2019). Alteration of gut health and microbiome have been linked with the increased severity of eczema. For example, a decrease in microbe diversity in the GI tract (Isolauri, 1997; Rusu et al, 2019) and an increase in intestinal permeability (Wollina, 2017; Rusu et al, 2019) have been reported with eczema. In addition, an increased sensitivity to the commensal fungi, Candida. albicans, has been reported in those with eczema showing high IgE antibody titres to C.albicans (Savolainen et al, 1993; Khosravi et al, 2009).
Regular supplementation with probiotics to promote balance, and diversity in the GI microbiome can help to manage eczema. Probiotics not only modulate the microbiome, but improve the intestinal barrier, and have been reported to reduce the severity of eczema (Kim et al, 2014; Lin et al, 2015; Rusu et al, 2019).
Overall, eczema is a very complex skin condition that affects the daily lives of many. This article aimed to provide a brief and accurate discussion of some habits that can be regularly implemented to assist patients in the management of their eczema. Further research into our understanding of the condition will increase our ability to provide more targeted daily care.