Eczema affects millions of people worldwide. It has vexed and intrigued researchers since the dawn of human history. It is a significant source of disability and anxiety, and its prevalence appears to be growing.
Despite the many advances in our understanding of inflammatory skin disorders, they are still some of the most poorly-understood health conditions. What we do know about these disorders often defies belief. Here, we’ll present some facts about eczema that are not as widely-known.
Eczema: One Name, Many Disorders
“Eczema” is not one disorder, but an umbrella term that covers several different chronic, inflammatory skin disorders. The most prevalent type of eczema is atopic dermatitis, which afflicts 223 million worldwide. Around 43 million of those people are between the ages of 1 and 4; this demonstrates the disorder’s shocking prevalence among children.
The term “eczema” was coined in 1817 by English doctors Robert Willan and Thomas Bateman. They took it from the Greek word ekzein, meaning “to boil out,” a reference to the weepy blisters found in some rashes.
Today, “eczema” may refer to: atopic dermatitis, contact dermatitis, dyshidrotic dermatitis · nummular dermatitis, neurodermatitis, seborrheic dermatitis and stasis dermatitis Each of these disorders has features that distinguish it from the others. However, they are all dermatoses (plural of dermatitis), inflammatory disorders of the skin. Each of these disorders share characteristics such as redness, dryness, itching, and swelling.
Eczema is Mentioned In the First Medical Text
Skin disorders that would likely be called eczema today were first mentioned over 3,000 years ago in the Ebers Papyrus, an ancient Egyptian text describing various ailments and their treatment. The Ebers Papyrus is one of the earliest known medical texts. The Egyptians favored topical applications of sulfur and tar for treatment, as well as compresses of ground beans and onions; coal tar and sulfur continue to be used for treating eczema today.
More recently, a chronic, itchy skin condition was noted 2500 years ago by the Ancient Greek physician Hippocrates. Hippocrates described treating a patient for dry, scaly skin with thickened areas and an intense itch over his entire body.
Atopic Dermatitis: A Disorder by Any Other Name
In 1572, what we would now call atopic dermatitis was described by Italian physician Girolamo Mercuriali in his De morbis cutaneis, the first comprehensive handbook of skin disorders.
From the 19th Century onward, descriptions of inflammatory dermatological disorders with symptoms consonant with atopic dermatitis appeared with increasing frequency.
The British physician Robert Willan provided the first detailed description of atopic dermatitis in 1808. French physician Ernest Henri Besnier wrote of a disorder he called dermatitis multiformis pruriginosa In 1892; Besnier was the first to note the frequent co-occurrence of this skin disorder with hay fever and asthma.
The names given to this itchy, red, weepy skin inflammation have varied over time: eczema rubrum, constitutional prurigo, prurigo diatésique, prurigo Besnier are just a few of these terms.
It was not until 1903 that atopic dermatitis was mentioned separately from other dermatoses and given its own, widely-accepted name. French dermatologist Luis-Anne-Jean Brocq called the disorder we now know as atopic dermatitis “neurodermatitis;” he believed that the disorder was rooted in nervous disorders, as he had noticed that many of his patients were prone to anxiety and depression.
By this time, a link between inflammatory skin disorders and asthma, hay fever, and food sensitivities was well-known; doctors in England had even developed a prescriptive diet, free of bread, dairy, and red meat, to treat children with severe eczema. That did not prevent doctors across Europe from accepting Brocq’s postulation that neurodermatitis was a psychiatric illness.
While this term for atopic dermatitis has been dropped in France and the Anglosphere, it is still used in Germany and Austria (although it is no longer believed to be a psychiatric ailment in those countries).
The condition was not called atopic dermatitis until 1933, when American dermatologists Fred Wise and Marion Sulzberger renamed it based on the word atopy.
Allergologists Arthur Coca and Robert Cooke coined the term atopy in 1923, from the Greek word atopos, which meant “out of place.”
They used it to describe hay fever, asthma, and food allergies, which they collectively referred to as “strange diseases.” Their work marked a major advance in our understanding of immunology and allergy.
Sulzberger and Wise noted a connection, overlooked by Coca and Cooke, between these “strange diseases” and the skin disorder we recognize as atopic dermatitis.
What We Now Know
This collective knowledge continues to inform our study of eczema today. We recognize now that eczema is the result of an inflammatory process resulting from immune system dysregulation. Although not all eczema is atopic, immune system dysregulation always plays a role.
Eczema is Always a Multifactorial Disorder
Throughout the centuries–millennia, really–we have sought a distinct etiology for eczema. What we have found instead is that multiple factors contribute to these disorders. Eczema flares are caused by two major factors: an inability to regulate and shut down inflammation, and a damaged skin barrier. Several different issues underlie these two factors, though.
Many different lipids and proteins bolster the skin’s barrier function. One such protein, filaggrin, was discovered in 1977. Filaggrin is secreted by the keratinocytes, the most abundant skin cells found in the skin’s outermost layer. It fills in the spaces between the keratinocytes and works with other proteins to make the stratum corneum waterproof.
Amino acids, fatty acids, urea, and other chemicals are produced as filaggrin breaks down; collectively, these chemicals are called the natural moisturizing factor, or NMF. The NMF is hygroscopic, drawing water to the skin cells and keeping them hydrated.
When filaggrin breakdown is disordered, or if the skin cells do not produce enough filaggrin in the first place, the skin’s ability to attract moisture is diminished, and it becomes dry and prone to cracking–a major contributing factor to eczema flares.
The gene responsible for coding filaggrin production, the FLG gene, was identified in the 1980s. Its connection to atopic dermatitis was noted even then.
In 2006, the FLG gene was completely sequenced, allowing researchers to identify the mutations that cause inadequate filaggrin synthesis and breakdown. Without adequate amounts of this vital protein, it is harder for the skin to maintain the moisture needed to protect against inflammation secondary to dryness and scaling.
About 50% of people with atopic dermatitis have mutations on FLG. While this doesn’t guarantee the development of atopic dermatitis, it is a major predisposing factor, and this predisposition can be inherited.
Chronic inflammation is associated with genetic mutations on several genes responsible for immune system dysregulation, which is also a significant contributing factor for eczema.
Atopy is rooted in immunological dysfunction. Even in non-atopic dermatitis, the characteristic inflammation is a feature of innate immune system dysregulation (although this dysfunction has different mechanisms from atopy). Inflammation is meant to repel foreign antigens and repair damaged tissues. When the immune system is dysregulated, harmless particles can trigger inflammation, and the body has a hard time bringing it to a halt once the threat is neutralized.
Interestingly, stress, a major trigger for eczema, is also associated with increased levels of IgE, the antibodies associated with atopy.
A person with a faulty FLG gene may never have a compromised skin barrier. A person with a compromised skin barrier might never develop eczema. However, if someone predisposed to skin barrier dysfunction or immune system dysregulation is exposed to an illness, allergen, or toxin, the confluence of factors can very easily trigger a flare.
Air pollution is a major trigger for eczema; excessive levels of particulate matter or volatile organic compounds (VOCs) are associated with spikes in eczema flares, as reported by both doctors and patients. This is corroborated independently of doctors’ or patients’ self-reporting by comparing documentation of clinical visits for eczema symptoms with reports for air pollution within the same period.
Dust mites, molds, and pet dander are other environmental factors that can trigger eczema flares. As you can see, eczema’s root causes are complex!
Eczema Is Intimately Linked to Stress, Anxiety, and Depression
The Good Doctor Brocq was not entirely wrong: while eczema is not a psychiatric disorder, it is strongly linked to mood disorders.
Seventy-three percent of eczema sufferers report that stress triggers eczema flares or worsens symptoms. People with eczema are two to five times more likely than the general population to develop anxiety disorders.
People with severe eczema are more likely than the general population to develop depression. The severity of symptoms correlates with severity of mood disorders: suicidality is strongly associated with the most severe eczema symptoms.
Excessively high levels of serotonin are associated with both eczema and anxiety disorders, as are elevated levels of corticotropin-releasing hormone. These can be seen in stains of skin samples taken from eczema lesions.
Eczema also worsens stress, creating a vicious cycle. According to Dr. Steve Harlan, a board-certified dermatologist with years of experience in treating inflammatory skin disorders,
“A good dermatologist can diagnose stress-flared eczema from across the room.”
There is also a correlation between eczema and high academic achievement. “Atopic people are often good students, and successful over-achievers,” Dr.Harlan notes,
People with lifelong eczema are at increased risk for eye problems. They should have an eye exam yearly, including the “puff test” for eye pressures. This is especially true when they’ve needed corticosteroid products near the eye.
Every patient with eyelid eczema for more than a few weeks needs regular supervision by a dermatologist and should see the ophthalmologist yearly.
Dr. Harlan says that while prescription pimecrolimus cream (Elidel circleR) often has high copays, it’s important for atopic eyelid dermatitis. It reduces the need for topical steroids, and is safer for the eye.
…And Your Bones!
Studies suggest that eczema sufferers have slightly higher rates of wrist, hip, pelvis, and spine fractures as compared with people who don’t have eczema. Rates of hip fracture are a 50% higher among people with severe eczema.
Those with severe eczema are 66% more likely to experience pelvis fractures than people who don’t have eczema. The rate of spine fractures is 109% higher for people with severe eczema–their risk of spine fractures is more than double that of people without eczema!
It bears acknowledging that these studies were observational, and we don’t know why eczema correlates so strongly with specific types of fractures. However, if you have eczema, especially severe eczema, you may consider talking to your doctor about ways to improve bone health and prevent fractures.
Eczema Has The Highest Burden of Disease
It is tempting to think of eczema as a minor disorder of the skin–a vanity issue. However, eczema has profound immunological and psychiatric implications for sufferers. While it may not be a serious, fatal disorder, it has a significant impact on social lives, economy, and quality of life; this is true for both people with eczema and those who must care for them, such as parents of children with eczema.
Effects of Eczema Similar to Cystic Fibrosis or Cancer For Children
This sounds outrageous, but these effects do not refer to the seriousness or mortality rate of the disorder. The effects in question concern quality of life. This is based on how much children’s daily lives are affected by chronic or long-term diseases.
Children with eczema consistently report difficulties that negatively affect their quality of life. For instance, eczema frequently affects children’s ability to independently dress or groom themselves. It also has deleterious effects on social participation and self-esteem.
This should not be regarded as a dismissal of severe, life-threatening illnesses such as cystic fibrosis or cancer. To the contrary, it should signify the far-reaching effects of pediatric eczema
Eczema Is Linked to Autism Spectrum Disorder
Parents, teachers, and doctors of children with neurodevelopmental conditions (such as those on the autism spectrum) have always noticed how often these conditions occur along with disorders of the skin and bowels.
Rates of allergy, eczema, and bowel disorders are far higher among children with neurodevelopmental disorders. In 2023, neuroscience researchers presented what they called “a novel model for the developing brain, inflammation, and neurodevelopmental conditions.”
They posit that, since epidermal and neural tissue originate from the same molecular foundations during embryonic development, a disorder in one of these systems could predispose a person to disorders in the others.
This could allow parents and healthcare providers to intervene at an earlier, more advantageous stage in any one of the associated conditions. For example, parents of an infant with severe atopic dermatitis could be alerted to the possibility of ASD or other neurodevelopmental conditions allowing them to recognize the signs earlier. The authors also note the correlation between severity of neurodevelopmental symptoms and severity of skin disorders.
According to the authors of this paper, “skin barrier integrity may represent an accessible and novel biomarker to aid in the early detection of neurodevelopmental divergence. We further propose that skin barrier integrity may play a crucial role in mediating the relationship between environmental triggers of infection, immune processes, and neurodevelopment, with potential to reduce the impact of such environmental triggers by improving skin barrier integrity.”
What Does It All Mean?
These seemingly random bits of “eczema trivia” suggest that eczema has always had profound implications. It also hints at even more profound connections between eczema and overall mental, physical, and neurological health.
The long, recorded history of inflammatory skin conditions and their treatments demonstrate that eczema is a persistent, significant issue. Debates about nomenclature point to the difficulty in identifying the underpinnings of these disorders and the evolution of our understanding of them.
Eczema is not a mere irritation or aesthetic concern. The skin is our largest organ, and it is our first defense against pathogens and foreign antigens. Disorders in this organ arise from multiple factors and suggest far-ranging effects on the entire body.
This has been a recurring theme in the discussion of eczema since the ancient Egyptians first made note of eczema symptoms and tried to treat them. Today, we recognize that eczema is related to mood disorders and to neurodevelopmental conditions–even if we don’t understand how. We recognize that these disorders deleteriously affect sufferers and their families in a multitude of ways.
Why Treatment and Prevention Matter
For all the reasons laid out above, it is of utmost importance that we treat eczema in a timely and effective way. It is also important that we understand how to prevent it.
The skin barrier’s importance to the immune system is indisputable. Regular moisturization is one of the best, most accessible ways to support the skin barrier. Skin should be moisturized twice daily, at least–during flares, more frequent applications of eczema cream may be needed depending on severity.
A good moisturizer should provide some of the same benefits as a healthy skin barrier; it should both draw moisture into the cells and prevent moisture loss, it should soften skin cells, and it should promote a healthy skin microbiome.
Perfect Repair™ moisturizing cream provides an excellent example of a thoughtfully-developed moisturizer that addresses each of these concerns. Glycerin and natural ceramides keep skin soft and draw in moisture, acting similarly to the NMF. Coconut oil prevents moisture loss. It has prebiotic ingredients that foster the skin’s healthy microbiome, and it is free of fragrances, dyes, and harsh emulsifiers. It behaves similarly to the natural skin barrier, and it also promotes healing of damaged skin.
“Many people with eczema simply need good moisturizing, and something very safe like SmartLotion, for problem spots,” Dr. Harlan tells us.
The Importance of Treating Eczema Quickly
Prior to releasing Perfect Repair,™ Dr. Harlan developed SmartLotion®, a safe, effective, over-the-counter cream to treat chronic, long-term skin disorders regardless of the frequency or duration of treatments.
SmartLotion® is formulated with prebiotic ingredients. It uses a low dosage (0.75%) of a mild corticosteroid to interrupt inflammation and reduce itch. When used properly under a physician’s guidance, it is safe to add to most prescription eczema treatments.
This makes it helpful for treating refractory symptoms, a common source of anxiety and diminished quality-of-life for eczema sufferers. Used at the first sign of a flare, it can help eczema patients get the upper hand over their symptoms.
“Many people requiring powerful prescriptions for their eczema need something very safe like SmartLotion for breakthrough areas,” Dr. Harlan tells us.
Dr. Harlan goes on to say that SmartLotion® gives patients a measure of control over their symptoms, allowing them to treat their eczema safely at the first sign of symptoms. “For itching, flaking skin, SmartLotion at the bedside makes a big difference,” he advises.
Treating eczema symptoms quickly has ramifications well beyond skin-deep aesthetic concerns. Our immune system depends upon our skin barrier, so bringing inflammation under control and reestablishing the health of the skin barrier are of utmost importance. This is backed up by 3,000 years of history.