Treating Eczema with Steroids

Treatment with steroid-based corticosteroids can mean relief from the constant itching and accompanying red, scaly skin patches of eczema.

Yet, many patients and their families are fearful of using steroids due to potential side effects associated with the medications. This fear, or “steroid-phobia,” among patients can be lessened by working with a dermatologist who is trained in prescribing these medications, can monitor patients closely, and knows how to incorporate creative treatment strategies to minimize side effects.

Eczema, a chronic disease in which the skin becomes itchy and inflamed, affects about 15 million Americans. One of the most common forms of eczema is atopic dermatitis, or AD, which can occur on just about any body part. AD takes a physical and emotional toll because it can be painful and physically unattractive, causing skin redness, swelling, cracking, weeping, and scaling.

The majority of patients have a “mild” form of the disease, meaning the AD affects less than 20 percent of the body surface area. Still, left untreated, even the mild form can result in itching and rashes that become a significant and visible reminder of the disease. For people whose AD affects more than 20 percent of their bodies, the disease can be a physically painful problem.

Goals of Treatment
One of the most important goals of eczema treatment is to prevent the development of rashes by avoiding those things that trigger itching. In the mildest form of the disease, simple moisturizers and cold compresses may help relieve and prevent the dry, itchy skin of eczema. However, experts note, once skin inflammation occurs, prevention is less effective and anti-inflammatory agents, such as corticosteroids, become necessary to effectively manage the condition.

It has been shown time and time again that the key to the safe and effective use of these agents is to use them under the watchful eye of a dermatologist experienced in prescribing them. Despite the potential side effects, studies have shown that severe side effects are rare when dermatologists prescribe long-term continuous low-potency corticosteroid treatment for up to 10 years, or intermittent mid-potency topical treatment for moderate to severe eczema. It is important that dermatologists carefully monitor patients using corticosteroids for any period of time. Another essential element of successful treatment is that patients consistently take or apply their medications as prescribed by their dermatologists.

Topical Corticosteroids: Types and Uses
Corticosteroids, including nonprescription and prescription forms, are widely used in the treatment of eczema. This class of substances is related to a natural hormone that can diminish an inflammatory response. In particular, glucocorticosteroids (GCSs), which have been used since 1951 for a wide variety of inflammatory skin diseases, offer very effective anti-inflammatory properties.

For the treatment of mild to moderate inflammatory skin diseases, dermatologists usually first use topical GCS therapy, meaning patients apply the medication to their skin. These preparations include less potent nonprescription and more potent prescription forms. Topical types of the medication can be delivered to the skin in many different forms including as an ointment, lotion, cream, and foam.

The medications are classified according to their potency, or strength. Topical hydrocortisone, which is a low-potency GCS available in non-prescription and prescription forms, is used on areas of sensitive skin, such as the face or in the skin folds. Mid-potency GCSs, such as flurandrenolide and betamethasone dipropionate in lotion form, are prescribed by dermatologists and are appropriate for lesions on the torso. Prescription-only high-potency topical GCSs, such as fluocinonide, betamethasone dipropionate, in lotion, cream or ointment form, and clobetasol propionate, are reserved for short treatments of up to two weeks for stubborn lesions, as well as rashes on the palms of the hands or soles of the feet.

Dermatologists strive to use the mildest forms of topical medications possible in order to minimize potential side effects. However, they might use a higher-potency corticosteroid for a short period to address an acute situation; then continue with milder forms.

Dermatologists generally use the topical form of corticosteroids to treat atopic dermatitis rashes that do not have open or crusted sores. They might use the higher-strength preparations for tougher-to-treat thickened skin, and scaly or oozing rashes. The creams, lotions, ointments, or foams are usually applied one to two times a day, depending on the patient’s age and the strength of the preparation.

Corticosteroid treatments usually significantly clear intermittent rashes in two to three days. Dermatologists may use topical corticosteroids for only a short time — until the rash is cleared. In general, intermittent treatment with high potency topical corticosteroids will last seven to 10 days; while low- to mid-strength corticosteroid treatment can last two to three weeks.

Oral/Systemic Corticosteroids: Treatments of Last Resort
Dermatologists usually will not prescribe oral or injected (systemic) forms of corticosteroids unless the atopic dermatitis, or other chronic eczema, is severe or topical agents have not worked. Still, the oral medications have their places in treatment. For example, they are often effective in reducing inflammation and itching, and a high initial dose can eliminate rashes quickly. In addition to recalcitrant severe chronic disease, oral/systemic steroids may be indicated to treat widespread acute eczema, such as severe allergic contact dermatitis to poison ivy. Systemic corticosteroids include: methylprednisolone, hydrocortisone, prednisone, and prednisolone.

These medications are not recommended for use during pregnancy due to studies that show birth defects, such as cleft lip and cleft palate, may be associated with the use of systemic corticosteroids during pregnancy. 

Infected eczema: Diagnosing, Treating, Prevention of Infection

What does infected eczema look like?
Infected atopic eczema looks red and angry, and is usually ‘weepy’ with a yellowish crust. Yellow pus-filled spots may also be present and small red spots around the body hairs (folliculitis). The skin feels hot, itchy and sore, which leads to more scratching. Scratching damages the outer layers of the skin and creates cracks allowing more bacteria to grow.

Occasionally the glands may swell and there may be an enlargement of lymph nodes in the neck, groin and armpits. Lymph nodes filter out bacteria and stop them from entering the bloodstream. Swollen lymph nodes can be tender to the touch. Infection should always be suspected if the eczema suddenly worsens or does not respond to emollient or topical steroid treatment.

Candida appears red, itchy and sore and there may also be tiny yellow pustules.

Eczema herpeticum produces small blisters, containing clear fluid or yellow pus, which break open and ulcerate the skin. Mild attacks are fairly common but in more serious cases, the virus spreads quickly on first infection. A high temperature and a general feeling of being unwell usually accompany it.

This form of eczema herpeticum is very dangerous and it is essential to contact a doctor immediately and to ask him or her if the symptoms could be eczema herpeticum.

Diagnosing Infection
Dermatologists, dermatology nurses and general practitioners with a special interest in dermatology may be able to tell if eczema is infected just by looking at it. Patients who have already experienced infection are also likely to recognize the signs and symptoms.

However, it is not always clear if eczema is infected, which can make diagnosis difficult. Your doctor may take a swab from the skin to be sent to the microbiology laboratory. This is a quick, painless procedure and can help to confirm what is causing the infection and can also show what antibiotics should be effective as treatment. Skin swabs frequently show the presence of Staph. aureus on the skin, but may also reveal additional bacteria called streptococci.

Treating Infected Eczema
Treatment depends upon the type of infection. Staph. aureus can be treated in several ways. For mild infections emollients and topical steroids, together with a bath oil containing an antiseptic may be sufficient. Sometimes a combination cream or ointment may be prescribed.

Combination creams and ointments contain both a topical steroid to help combat inflammation and an antibiotic to fight the infection. If the eczema is heavily infected, oral antibiotics may be prescribed that help to quickly bring the infection under control, but it is important to continue to use emollients to help restore the skin barrier.

Antiviral drugs such as acyclovir are used to treat eczema herpeticum orally, by injection or in the form of a cream or ointment. If the eczema herpeticum is severe, a few days in the hospital may be needed to get the infection under control.

Candida is usually treated with an antifungal cream that can be prescribed by your doctor or dermatology nurse or bought over the counter from a pharmacist.

Using a medicated shampoo or an anti-yeast shampoo can treat Pityrosporum ovale on the scalp but will depend on the severity of the eczema. These shampoos are available from pharmacies. Several antifungal creams, with or without a mild steroid, are available to treat seborrheic eczema on other parts of the body.

There is no specific medicine to clear molluscum contagiosm. It is up to the body’s own immune system to get rid of the infection and unfortunately this can take months.

Infection and Your Other Treatments
Eczema patients who are using the topical immunomodulators Protopic and Elidel should not continue to use them if their eczema becomes infected. Speak to your doctor if you are using these products and suspect that your eczema may be infected.

Never use wet wrap bandages with infected eczema, as the moist, warm environment created by wet wraps is a perfect breeding ground for bacteria.

If your eczema is infected and you normally use emollient ointments, it may be worth asking your doctor to consider prescribing in addition an emollient cream to use some or all of the time while the infection persists. This is because in some people the ointment – which is occlusive – can also ‘trap in’ the infection.

Whatever emollients you are using, remember that it is easy to spread infection – both on your own skin and your child’s skin – and also to pass it from one person to another.

Pump dispensers reduce the risk, as does good hand hygiene before and after putting on emollients. If you do not have a pump dispenser, use a clean spoon to take the emollient out of the pot, rather than using your fingers.

Prevention of Infection in Eczema
Restoring the skin’s barrier to infection, be reducing dryness and cracking will help to reduce the entry points for bacteria. Intensive emollient therapy, with moisturizing creams and ointments, soap substitutes and emollient bath oils are essential. Daily baths and showers can help to prevent infection.

If someone in the family has a cold sore, it is important to refrain from sharing towels and face cloths. Ensure that you change bed linen regularly and wash it in a hot wash.

Even if you take preventative measures it is not always possible to stop eczema becoming infected. However, by treating with the most appropriate medication, the infection can be cleared and the eczema can be kept under control.

Infection and Eczema

We all know that eczema is not infectious – one of the UK National Eczema Society’s messages for very many years. Damaged skin is vulnerable to infection, however, and infected eczema is one of the most common issues raised with the UK National Eczema Society’s helpline. In this article our information team looks at why this might be and what we can do about it.

Broken skin provides an environment where micro-organisms can flourish. As a result, skin infections are not uncommon. Infections may be bacterial, fungal or viral.

Bacterial Infection
Atopic eczema is most often infected by a bacterium called Staphylococcus aureus, which makes the eczema worse and slower to heal. Staph. aureus is found on the skin in less than 10% of healthy individuals.

By contrast, almost everyone who has atopic eczema will have Staph. aureus on their skin somewhere, even thought their skin may not show signs of infection. It is not clear whether the bacteria migrate from the active eczema to areas of skin without eczema or whether people with atopic eczema are simply more susceptible to Staph. aureus colonization than those without eczema.

Colonization is not normally a problem unless the skin is broken. Infection occurs only when the bacteria penetrates the skin’s barrier.

It is likely that people with atopic eczema have an impaired ability to deal with infection. In addition, as we know all too well from practical experience, eczema itches and the natural responses to itch is to scratch. This in turn causes the skin to crack and split and become red and inflamed, warm and moist – a perfect home for bacteria.

This is made worse by the itch-scratch-itch cycle and the vicious cycle that follows. It is also possible that the dry skin of atopic eczema is deficient in certain fatty acids, which may encourage the growth of bacteria.

Viral Infection
The major virus that causes problems in people with eczema is the herpes simplex or cold sore virus. Many people who do not have eczema catch herpes simplex in childhood. It is usually very mild, causing a few mouth or gum ulcers that may not even be noticed.

Our bodies become immune after a first infection by herpes simplex – you tend not to catch it from anyone a second time.  However, your own initial virus can become active again causing small, itchy blisters that quickly form a cold sore. This is how herpes simplex usually affects people who do not have eczema.

Herpes simplex is highly contagious and can appear as genital inflammation or conjunctivitis as well as cold sores. For people with eczema, the herpes simplex virus can be much more serious, probably because they have a lowered resistance to viruses. People with eczema should avoid skin-to-skin contact with anyone who has herpes simplex as this virus can infect eczema, giving rise to a condition called eczema herpeticum, which can cause serious illness.

Many children get molluscum contagiosum, but it may be slightly more common in atopic eczema sufferers. Molluscum contagiosum appears as small, smooth, red or flesh-colored bumps, each with a tiny dimple in the center. They often develop on eczema-prone areas such as skin folds behind the knees.

The condition often becomes red and crusted when the body’s immune system is starting to fight against it. This can look alarming, especially if surrounded by eczema, but is in fact a good sign and means that the molluscum contagiosum will clear up soon.

Fungal Infection
Candida or ‘thrush’ is a yeast or ‘fungal’ infection that may develop on skin with eczema, but can also appear on the skin of people without eczema. Candida likes warm, moist folds of skin such as the groin, under the arms and breasts or around the diaper area in babies.

Pityrosporum ovale is also a fungal infection, from the yeast pityrosporum, and can be found on the skin of people with seborrheic eczema. It likes to live where a lot of sebum (the body’s natural grease) is produced – for example, scalp, chest, ear folds and groin. Pityrosporum ovale may well be responsible for seborrheic eczema developing in many people.