Hello and welcome to this latest Skin Deep podcast, where we look at skin-related issues, conditions and treatments in an interesting and informed way. I'm Dr Roger Henderson, and I'm a GP with a long-standing interest in this particular area of health. And I'm Dr George Moncrieff, I was also a GP, although I've now retired from my practice. I'm also the past Chair of the Dermatology Council for England.
Today, Roger and I will be talking about the basics of the very common skin condition, eczema, and this is the first of a two-part podcast. Next time we'll be looking at how eczema is treated, including some self-help tips and how to prevent the condition from flaring, along with appropriate skin treatments. Okay. So for today though, George, let's just start with the basics, and perhaps the most obvious question of them all, and one which you and I have both been asked many times by patients.
What do we actually mean when we talk about atopic eczema? Well, eczema is a dry, itchy skin condition, and the word comes from two Greek stems. 'Ec-' meaning out of and 'zema', a boil. So, in eczema you get little bubbles coming through the skin. Which then rupture onto the surface, the skin splits, and that fluid is lost, rendering the skin drier. And the word 'atopic' simply means, without a place.
When doctors first recognised, a hundred years ago, that eczema was associated with asthma and hay fever, what we now call the 'atopic march', and so these conditions, patients go through one to the other very often. They didn't know where to put it in their textbooks, they had nowhere to classify it, so without a place they called it 'atopic'.
But atopic eczema is a very itchy skin condition, one of the most itchy skin conditions associated with dry skin and associated with this link to asthma and hay fever. It typically starts in a young child, but we'll come on to that and how it looks. Compared to when I was a medical student, far too many decades ago, I've seen in practice, a really rampant increase in the number of patients in the last few decades, presenting with eczema and there's all sorts of reasons for this.
Now the skin is our biggest organ which might surprise a lot of people and understandably, it is an absolutely crucial barrier, in stopping things getting in and also stopping things getting out. It might be worth just mentioning, why the skin barrier is so important for our good health, I think. Well, the skin barrier is the very top layer of the top part of the skin, the epidermis. So it's the top part of the epidermis.
In some parts of our body, like, for example, the stratum corneum on the eyelids, is exceptionally thin, it is half as thick as a piece of paper, and it's very vulnerable. It is a beautifully constructed barrier that retains water, prevents water from escaping, but also, very importantly, prevents pathogens, that's bacteria and viruses, penetrating the skin, or allergens, penetrating the skin. So we have this barrier, which is very sophisticated, even though it's really thin.
If you haven't got that, newborn babies haven't got a skin barrier. When you're very first born, you haven't got a skin barrier because you've been living in a very sterile, humid environment inside the womb. They've only got a few hours to switch on the processes that make a skin barrier, and if they can't do that, they will die of dehydration. So it's a really critical part of existing in this dry, hostile world that we live in.
So the skin barrier is there, it's very delicate, but it's very sophisticated. You're right to say that the number of cases is increasing fast, because I think our lifestyle today challenges that barrier disastrously. We live in a very dry world. We have central heating, dry carpets, dry walls, even air conditioning. We're putting soaps and detergents on the skin, which actually do enormous damage to the skin barrier.
So somebody who's got a vulnerable skin barrier, and then they use soaps and detergents on their skin, they can break the barrier, allow pathogens to come through, and then if they react to those pathogens, things that cause an allergic reaction, react to those in an abnormal way, they will manifest with eczema. And once you get eczema, it's itchy, you scratch it, you damage the barrier further, and you're into a vicious cycle.
Now, antibiotics are a huge hot topic, at the moment, and I still remember my jaw hitting the ground when I heard you talking about eczema, when you said that if you take one antibiotic, once in your life, at one time, your skin makeup, the microbiome, is never the same. Is that absolutely right? That's what I've heard. Yep. In fact, and your gut microbiome, both your skin and your gut microbiome, will never recover.
Which is obviously one of the reasons why we don't hand out antibiotics willy-nilly, you know, to everyone because of the impact in so many areas, including, on our skin. But I suppose what we're saying is if you assault, this extra sensitive part of our body, the skin, which as you say, is so thin in parts.
If you assault that, either through our lifestyle, through unnecessary antibiotics, through infections, through detergents, you name it, we are going to sort of, potentially, set up the risk of that skin reacting and getting the eczema that we typically see. I couldn't agree more. We have evolved over millennia to live with the bacteria in our gut and the bacteria on our skin, and they play a vital role.
Healthy skin has a healthy microbiome, and that microbiome competes with the bad bacteria and prevents the bad bacteria getting a foothold. So, if you take an antibiotic and you wipe out all those bugs for a bit, then sometimes the bad bacteria come back first and they then cause problems. So, using an antibiotic, or in our modern world with all the antiseptics, as you say, we live in this very sterile world as much as we can, we are causing havoc with our microbiome.
And I'm sure over the next decade or two, more will be discussed about the importance of maintaining a healthy gut and a healthy skin microbiome. You know, we're actually outnumbered. The number of bacteria in our body outnumber our own cells 10 to 1. Only 10% of the cells in your body are you. 90%, or more, are actually bacteria.
They're very small, so they only constitute a few kilograms, but we have evolved to live with these, they are critical, they're not just there just riding on us, they're actually playing critical roles, as we're beginning to discover. Absolutely, there's going to be a whole new, exciting area, in our understanding of eczema in that, I suspect. Now, I suspect some of the people listening will be listening because they have eczema, so we may be sort of, teaching them to suck eggs, when we're
talking about the main symptoms of eczema. But for people who don't have eczema, the ones I see in my surgery, absolutely typically it's itch and it's scratch. Those are the two terms that patients with eczema always will talk about. The itch-scratch cycle, and one will get better, and then they will have a day or two or a week or two, and then it's back again, we get the flares. So those are the symptoms that I'm seeing and I'm guessing they're the ones that you're seeing in clinic as well.
Itch is a horrible symptom isn't it, and atopic eczema is one of the most itchy skin conditions, and the desire to scratch it is sometimes overwhelming. Patients will prefer the pain, from scratching and tearing their skin, to living with that itch, and unfortunately, as you scratch the skin, you damage it. Damaged skin is more itchy, and so you can get into a vicious cycle, that you're scratching it because it's damaged, and it's damaged because you're scratching it.
So that can cause a flare, and of course, once it becomes inflamed, the ability of the skin to preserve itself and to make that barrier is compromised. So things then get worse. The broken skin allows bacteria to get through, so it gets infected, and then you have a flare, and all flares of eczema have bacteria growing there. This itch then disturbs sleep, not just for the individual, but for their entire family, their household, and that means that they don't function so well the next day.
It's a huge disturbance there for everybody, with tiredness, and the risk of not getting good education or having a road accident or whatever. And of course, the other consideration we haven't really given much thought to in the past, is the amount of time spent, not just with their skin care regimen, which can be huge, but also accessing health care. Making appointments to see doctors, collecting their prescriptions, going to appointments in hospital, having their treatments.
This all takes up time and money, and so, there are enormous consequences to eczema. Interrupted sleep, though, and interrupted study and itch are the main ones. The other thing, in fact, is, of course, their skin feels uncomfortable. It feels dry and can be a bit scaly and just doesn't feel comfortable to touch. Clothes will stick to it and things like that, particularly woollen clothes.
And I think it's also worth mentioning, because there is still this, almost medieval, myth that some people do have, until you sort of correct them, that eczema is infectious. It is absolutely, categorically not infectious. You cannot catch eczema.
But again, as if people with eczema don't have enough on their plate, every now and then I will hear about them being shunned by colleagues at work, or in social situations if they've got severe eczema because people feel that, somehow, they're going to catch eczema off them. It's absolutely awful, but it just further diminishes their self-esteem. People don't want to sit next to them on the tube or whatever. Yes, and of course, dry, cracked skin makes sporting activities more difficult.
The skin tears and things, in the cold weather, and splits. Yep, the ramifications are enormous. Yep. So, what it looks like. You and I both know what it looks like. But typically, we'd be thinking about, red, inflamed, dry, slightly rough skin, often on the very thin parts of the body, often on places like the knees, the elbows, around the neck, places that can easily be scratched. If it's not infected, it tends to be fairly obvious when you're looking at it, doesn't it?
Yes, and it's mostly on the face in infants, around the mouth, but not right up to the edge of the mouth, onto the cheeks, that's where it's most severe, but rapidly settles, as you say, into the fronts of the elbows and the backs of the knees, particularly in white skin actually. You get different patterns in skin of colour, you can get a reverse pattern where it's on the fronts of the knees and the backs of the elbows.
You can get a follicular pattern where you just get tiny little bumps around hair follicles. It looks trivial, very hard to see, but intensely itchy and very severe active eczema there. So there are different patterns in skin of colour.
Where the eczema is affected, it typically has a background redness and looks cracked with a fine surface cracking to it, maybe a little bit of scaling, occasionally oozing a bit, and often get secondary infections in it, and get some crust on top of it, like impetigo. There's a honey-coloured crust if it's badly infected. Interestingly, the background skin colour is often quite pale, in eczema. I'm sure you've seen this. The face of somebody with eczema, they have pallor.
It affects the circulation of the blood vessels in the skin. Certainly the treatments can as well, steroids can cause a pallor in the skin. They affect the arteries. They can cause the arteries to constrict. So you get a sort of paleness to the skin, as well as the areas looking a bit redder where it's affected. Yeah, now, I can't ever remember doing tests to diagnose eczema. It's usually very obvious when you see someone.
As you mentioned, it can be a little trickier if we've got someone with skin of colour. But as a general point, and sometimes patients will say, well, can I be tested for eczema? Usually there's no reason at all to test, is there? No. The diagnosis is based on a history of itch and typically, starting in the first two years of life, this is atopic eczema.
And then, an association with asthma and hay fever, maybe in a first-degree relative, particularly in children under four, we look for relatives with that atopic tendency, and then generally dry skin. And then it's a clinical diagnosis, there's no specific test for it. Of course, as you mentioned, skin of colour can be particularly challenging because you can't see that redness very easily, in skin of colour. And nor can you see that paleness in the skin.
And then they get these very subtle patterns, which can be very hard, to know that is what eczema can look like, so you get these variable patterns where it looks different. But as a general point, if you go and see your doctor or a healthcare professional with eczema, you're likely to get a diagnosis there and then without needing to go for any specialised tests. I'd like to briefly pause today's podcast, to mention our kind sponsor AproDerm®, and their range of emollients and barrier creams.
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It's such a great range of products, all are suitable from birth and free from common irritants and sensitisers. Yeah, and I have to say I love them even more now and actually use them myself.
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Now at the start, I also mentioned that patients with eczema often have repeated flares throughout the year and it can really drag them down when they get better. They're almost waiting for the next flare. What are the triggers that cause people with eczema to then get a subsequent flare?
They've been running along quite nicely and then suddenly, bang, their skin is itching, they're scratching it again, and they're, they're literally scratching their head saying, "I wonder what's caused this?" There are a number of common triggers, in my experience, and adherence, you know, actually are they taking their treatment properly? Are they using things that dry their skin? Even stress, stress is a word we use all the time.
But I think, you know, I have seen, and just last week I saw someone, with purely stress-related eczema. We could absolutely clearly link it to that. These are the big ones that we would see most of the time, aren't they? Absolutely, yes, certainly stress, yep, and of course, having severe eczema is pretty stressful, so you're into a vicious cycle there. Your sleep's going to be disturbed, and so the stress is going to be made even worse.
But many people will tell you it's the time of going through a divorce, or buying a new house, or doing exams, or whatever, that eczema is the last thing they need, and it then becomes even worse. I suspect sometimes flares could be driven by exposure to detergents. So, they had a bubble bath or they were using some shampoo which then rinsed over their skin, and we'll come on to that in management.
So I'm sure detergents, soaps, shower gels, shampoos and bubble baths will all cause the eczema to get worse. And because once it gets worse, bacteria get in, and then they drive it as well. So all flares are infected. You mentioned not adhering to treatment. I think that's a big issue, which again, we'll discuss in our next podcast.
But our skin is constantly trying to cope with the world we live in, this dry world that we live in, and this world of detergents and shampoos, it's constantly challenging the skin. And then a stressful event comes along and it flares and you're into a vicious cycle. I hope you can see from this chat that there's a lot more to eczema than seen at first sight. And we hope you found it helpful and interesting.
Roger and I look forward to you joining us next time in the second part of this podcast when we'll be talking about the treatment of eczema, including self-help tips, and how to prevent it flaring. We'd also like to thank our sponsor, AproDerm®, for all their help in putting these Skin Deep podcasts together. So until the next time, it's goodbye from George. Goodbye. And it's goodbye from me. Goodbye.