What doctors wish patients knew about managing eczema

For many people, persistent itching, red patches and dry skin are more than just minor annoyances—they’re the hallmark signs of eczema, a chronic skin condition that affects more than 31 million people in the U.S. While eczema, aka atopic dermatitis, can significantly impact daily life, the good news is that there are effective ways to manage and soothe its symptoms. 

By understanding triggers, using proper skin care routines, and seeking medical advice, people with eczema can find relief and improve their skin's health. Managing eczema often requires a personalized approach, but with the right strategies, flare-ups can be kept under control. 

The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.

In this installment, Edward Esparza, MD, PhD, a dermatologist at Viriginia Mason Franciscan Health in Seattle, Washington, discusses what patients need to know about managing eczema.

Virginia Mason Franciscan Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

Eczema is “a very common allergic skin reaction that feels itchy, dry, and can be painful. Eczema can be localized or widespread,” Dr. Esparza said. “Patients are most bothered by an insatiable itch that can disturb sleep and interfere with personal and professional interactions.”

“It is naturally gratifying to scratch an itch due to a habitual reward system our body has evolved that becomes maladaptive.  Scratching actually injures the skin and creates more eczematous rash,” Dr. Esparza said, noting that an eczema rash is “often red, can be blistery, often weeps and can get infected, which can change the appearance to have a yellowish crust.” 

Eczema “tends to happen in drier areas of the skin and tends to spare areas that are naturally more moist,” Dr. Esparza said. This observation “emphasizes what our natural body moisturizing properties can do to prevent eczema.” 

“It can be frustrating to patients to always hear from their dermatologist or their physician that they need to moisturize consistently to get their eczema better and they don’t conceptually understand why—it’s a lot of work and moisturizers only last for a few hours and can feel greasy or hard to absorb,” he said. 

“Eczema can be broken down into smaller subgroups. Some people have it only on the hands with itchy blistery bumps along the sides of fingers and palm called dyshidrotic eczema,” Dr. Esparza said. “Others have dry skin eczema.  Another subset will have eczema that is provoked by certain things in contact with their skin causing contact eczema or contact dermatitis.”

“There are a lot of different triggers to eczema, but in general, people who are eczema-prone tend to have more sensitive skin than the average person and they tend to have drier skin than the average person,” he said, adding that these patients also “often have conditions such as asthma and seasonal allergies known as the atopic triad. We know through genetic studies that there is a fundamental inherited defect in the barrier function of the skin and the airways of the nose and the lungs in such patients where they did nothing wrong to be born with the tendency to have eczema.”

“Eczema and psoriasis often have overlapping appearances, but the type of inflammation your body produces is different,” Dr. Esparza said. “Eczema is more allergic-based inflammation whereas psoriasis is more autoimmune with different types of immune cells and mediators.”

“This is why there are some overlaps in the treatment approach that eventually diverge with the newer treatment options we have for eczema and psoriasis,” he said.

“In general, people with eczema might do better if they lived in a warmer, tropical environment,” said Dr. Esparza. “People often experience their first round of eczema when they’ve moved to a different geographical location with different humidity levels, sunshine levels and stress levels. 

“Seasonal changes and “the environment plays a big role in when and how we get eczema,” he added. 

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If eczema is left untreated, the condition “can place people at risk for serious infections caused by antibiotic resistant bacteria such as methicillin-resistant Staphylococcus or MRSA and severe outbreaks of herpes or shingles,” Dr. Esparza said. “That can land people in the hospital.”

“The safest treatments are moisturizers. We often rely on brands such as Vanicream or Eucerin Eczema Relief cream that have natural hydrating properties,” Dr. Esparza said. But when it comes to choosing a moisturizer, “different people will like different moisturizers for different reasons.” 

“What is most important is finding one that works to minimize outbreaks and using that consistently regardless of whether their disease is flaring or not,” he said. “We try to tailor the moisturizer for the specific problem and be systematic, pragmatic and results-focused about our approach. 

“If I make a suggestion that I encounter resistance to, it does no good to not explore that further and to try to redirect to a practical approach that the patient buys into and believes will work,” Dr. Esparza added.

“Topical corticosteroids range in potency from mild, such as hydrocortisone, up to strong like clobetasol,” Dr. Esparza said. “Topical steroids control inflammation and eczema is an overreaction of the immune system, so the steroids quiet inflammation down.” 

“Think of it like a fire extinguisher putting out a fire of inflammation,” he explained. “There can be some challenges with overusing steroids on normal skin where it can thin the skin out. If you apply steroids robotically on normal skin, you can create stretch mark-like areas.  

“In general, I find the challenges are more with patients underutilizing their topical steroids and suffering with eczema for far longer than they ever have to and that goes back to using the right strength medicine for the right amount of time,” Dr. Esparza added. “Topical steroids are among the safest medicines one can ever use because it’s localized treatment in the area that’s only being affected.” 

“For most eczema patients, topical steroids are used in limited locations for a limited time and are very safe medicines to use provided patients stop using them when the eczema goes away,” he said. For those who cannot or would rather not use topical steroids, “there are now nonsteroidal options that have been developed such as topical tacrolimus, crisaborole, and ruxolitinib” that can provide more relief to patients who struggle with eczema.

With eczema, “there can be some lifestyle modifications” that can help, said Dr. Esparza. For example, “smoking can be problematic for eczema patients because all the smoke that's produced can be irritating to people's skin.” 

“There can also be workplace exposures that people may have challenges avoiding, even with protective equipment,” Dr. Esparza said. “So, we try to come up with actionable approaches for patients that are realistic and practical.”

“Heat is very stimulating to patients who have eczema. I try to encourage them to turn the temperature down to more lukewarm or cooler temperatures” when bathing, doing dishes or washing hands, Dr. Esparza said. “People often use heat to drown out the itch … but in the long run, patients will stimulate more itch down the road by taking hotter showers. 

“I recommend limiting showers to five-minute duration, which is the same duration as your favorite pop song. And try to limit the temperature to lukewarm and be gradual in reducing temperature if patients live in a cold environment,” he added. It’s about “just turning it down a notch with each shower and eventually getting to a temperature that the heat is not injuring their skin.”

The same goes for bath time, Dr. Esparza said. “Try to limit bath time to five minutes, especially for children.”

When eczema flare-ups do occur, Dr. Esparza’s advice “is to go to a dermatologist or to a primary care physician with experience treating eczema.” 

“Start the right strength of medicine, use them, treat for a couple of weeks, then transition towards moisturizing to prevent the next flare-up,” he said, noting it is important to “understand when people tend to have triggers. A lot of times these flares are seasonal in nature.” 

For example, “when the heater turns on in the wintertime is a common trigger for people’s eczema,” Dr. Esparza said. “We have great tools available for patients and if you’re struggling, we’re here to adjust the strength of medicines to have the eczema under better control.”

“A good skin care routine would be those products that are listed as fragrance-free and dye-free,” Dr. Esparza said. “Try not to rely on terminology such as hypoallergenic because that’s not a regulated term in the personal care product industry.

“Ask your dermatologist or your primary care physician for safe options. Try not to go to sources such as TikTok or YouTube for the latest option because they’re just trying to sell you products,” he added. “They’re not understanding your skin the way someone who works with you is obligated to tailor your treatment toward a safe and effective product to use.”

“The main thing is to actually implement the recommendation. Moisturizers don’t work when they stay in the tube,” Dr. Esparza said. “A good moisturizer, you get a big tub, and that tub should be used up within a month. If you’re saving it to last you through its expiration date, you’re probably not using it enough and if you’re having active symptoms, it’s time for a change or better implementation.”

“People will have the expectation that their eczema is going to go away within a week. It doesn’t happen that way,” he said. “It’s something that you have to invest in. Just as you brush your teeth to keep your teeth, you need to moisturize to keep your skin happy.”

Beyond the physical effect of eczema, there are also mental health implications that people can experience. 

For example, “patients often have sleep disturbances. They’re often falling asleep in their studies or at their job. They’re often crabbier and more irritable because, let’s face it, if you don’t have a good night’s sleep, everyone’s going to be crabby at some point,” Dr. Esparza said. “So, eczema definitely can have a quality-of-life impact on patients.”

Eczema can also “make people’s anxiety worse and can make their depression worse,” he said. But it is important “to understand that there’s hope for these patients with newer tools available and acknowledging when one can get overwhelmed by their symptoms.”

“Furthermore, uncontrolled anxiety and depression can make eczema symptoms feel worse and therefore make the eczema worse as patients cannot refrain from scratching and are less motivated to treat their eczema,” Dr. Esparza said. “I often coordinate with my primary care partners and make them aware of the impact that psychiatric diseases may be having on patients’ eczema and that we need to have a holistic approach if their skin is going to get better.”

“Studies have shown that breastfeeding can protect babies with first degree relatives with eczema having eczema,” Dr. Esparza said. “So, this observation just adds to all the positive benefits our children receive from breastfeeding, and we should be encouraging of this practice.”

Visit your doctor “when you’re feeling overwhelmed by the rash that you’re treating,” Dr. Esparza said, emphasizing that “it’s never too early to treat eczema. It’s better to prevent complications of eczema upfront than to have to come in when you’re at the ER level of care.” 

It is important to acknowledge “that the skin is an important part of health and not to neglect it. Skin is not just for cosmetics,” he said. But, luckily, “it’s a great time to be treating eczema for patients.

“There’s a lot of newer tools available that we have that are very safe, very effective. There’s a lot of hope for people who have eczema,” Dr. Esparza added. “So, just reach out. We’re here to help you.”