What Is Severe Eczema?

Eczema symptoms can range from mild to severe. For some adults, atopic dermatitis (the most common type of eczema) can affect over 40% of their body surface area. Severe eczema can impair quality of life. This chronic inflammatory skin condition affects more than 31 million Americans.

Itchiness is the most common symptom of eczema. Other possible symptoms include dry skin, rashes, blisters, and scaly patches. About half of people with moderate to severe eczema also have asthma, allergic rhinitis (hay fever), or food allergies.

Eczema usually begins in childhood, but it can start at any age. About 60% of children with atopic dermatitis will go into remission by adolescence, but about 3% to 10% of adults have the condition.

Severe eczema can be managed with the help of a board-certified dermatologist who can determine an effective treatment plan.

This article discusses how to recognize severe eczema, its types, symptoms, and diagnosis, and what can be done to relieve it.

Types of Severe Eczema

The seven types of eczema are:

• Atopic dermatitis: This common type causes inflammation, itchiness, and dry skin.
• Contact dermatitis: This type of eczema is brought on by environmental triggers.
• Neurodermatitis: Also called discoid eczema, it causes small patches of itchy and scaly skin.
• Dyshidrotic eczema: This type causes small, itchy blisters on the hands and/or feet.
• Nummular eczema: This type causes small, rounded lesions all over the body, primarily on arms and legs.
• Seborrheic dermatitis: This type affects the scalp.
• Stasis dermatitis: This type causes skin discoloration on the legs and looks similar to varicose veins.

Unless a different type is specified, "eczema" often refers to atopic dermatitis.

Severe Eczema Symptoms

Specific symptoms depend on the type of eczema. Symptoms that may indicate eczema include:

• Itchy skin, can be severe
• Dry, sensitive, and/or inflamed skin
• Blisters
• Oozing and crusting of blisters or skin
• Red skin around blisters
• Weeping (thin draining) clear fluid
• Scaling or thickened skin
• Lichenification (areas that are dry, leathery, and darker or lighter than the person's normal skin tone)
• Raw areas or bleeding, caused by scratching
• Areas of swelling

Eczema can look different depending on skin tone. On lighter skin, it may appear red. On darker skin, eczema may appear as ashen skin, gray skin, darker brown, or purple in color. Black Americans are more likely to experience severe symptoms.

Severe eczema can cause symptoms intense enough to affect your quality of life. The itchiness, pain, and other symptoms can cause loss of sleep, make it difficult to focus at school or work, and make it hard to participate in activities. With severe eczema, the itching can be constant and difficult to control.

Periods when symptoms are worse are called flare-ups. Between flare-ups, the skin heals, and symptoms are milder or not present.

The eczema rash is usually the same on both sides of the body. Where the eczema presents depends on the type of eczema and the person's age, such as:

• Infants and children under 2: Cheeks, face, sometimes outer arms and legs
• Older children and adults: In joint creases, especially wrists and the inside of the knees and elbows

Eczema can cause skin to become infected, especially from scratching. Talk to your healthcare provider if you see signs of infection, including:

• Oozing
• Crusting
• Pus or pus bumps
• Blisters
• Worsening rash
• Symptoms that are not improving with your usual treatment
  

Causes

Eczema results from problems with the skin barrier allowing moisture to "leak out."

The exact cause of eczema isn't known, but it is believed to result from a combination of genetic, immune, and environmental factors. Eczema often occurs along with hay fever, allergic asthma, and/or food allergies.

Risk factors for eczema include:

• Young age (about 65% of eczema cases occur before age 1, and about 90% occur before age 5)
• Living in a low-humidity climate
• Living in an urban area
• Skin exposure to harsh conditions
• Certain vitamin and mineral deficiencies (such as zinc)
• A personal or family history of atopy, which includes asthma, hay fever, conjunctivitis (inflammation of the membrane covering the white of the eye, which is often infectious but may be due to allergies), or food allergies
  
• Faults in the Filaggrin gene (may cause moderate to severe eczema in up to a third of people of North European and Eastern Asian descent)

Eczema flare-ups often have triggers, which means something in the body or the environment is causing a flare-up.

Diagnosis

To make a diagnosis, your dermatologist or healthcare provider will:

• Examine your skin
• Talk to you about your symptoms
• Ask about your personal and family medical histories (it is especially important to mention if you have asthma or allergies)
• Ask about potential triggers such as stress, your diet, soaps you use, chemicals you are exposed to, etc.
• Refer you to a specialist if needed

They may also look for other conditions that could be causing your symptoms or that might affect treatment. This may include running tests such as:

• Blood tests
• Allergy testing
• Skin lesion biopsy (a small piece of skin is removed)
  

If a food allergy is suspected, your healthcare provider may suggest removing the suspected food for two weeks to see if the symptoms improve. If the eczema gets better, the food is added back into the diet to see if a flare-up occurs within two hours of eating the food. Talk to your healthcare provider before trying this with your child.

Treatment

Treatment depends on the severity of the symptoms. While milder eczema can sometimes clear up on its own or with a simple skin care routine, more severe eczema may require medical treatment.

Skin Care

A good skin care routine that helps hydrate your skin is vital for managing eczema. Your individual skin care regime should be determined with your dermatologist if you have severe eczema.

Key components of basic eczema skin care include:

• Baths and showers help hydrate skin, removes crusts and scales, wash away irritants.
• Moisturizer that's applied within three minutes of getting out of the water and frequently during the day helps hydrate skin, reduce itch and other symptoms such as redness and swelling, heal cracks in the skin, and prevent skin thickening.

Look for products that are fragrance-free, and choose creams or ointments over lotions. Eucerin cream, Moisturel cream, and Cetaphil cream may be good starting options.

Medication

Severe eczema often requires medication in addition to avoiding triggers and using a thorough skincare routine.

Topical Treatments

Medicated creams and ointments are available, both over-the-counter (OTC) and by prescription.

Hydrocortisone is one option available for infants, children, and adults. It is a steroid that can help reduce the symptoms of eczema. It's important to use only the amount directed. Avoid using it on areas that have thinner skin, such as some areas of the face, neck, armpit, or groin, unless advised by your healthcare provider.

Topical steroids should be used short term. Long-term use can cause adverse effects such as thinning of the skin, depigmentation (a change in the color of skin), and acne-like eruptions.

Topical immunomodulators are another option. They help calm the immune system, similar to topical steroids, but do not cause skin thinning. They can be used for people aged two and older.

Currently, two topical immunomodulator drugs are available:

• Protopic (tacrolimus) ointment 
• Elidel (pimecrolimus) cream

Topical products that contain menthol or pramoxine, such as Aveeno cream, Pramasone cream/lotion, or Prax lotion may help relieve itching.

Oral Medications

Oral steroids may be used for severe eczema flares but should be used sparingly because of potentially serious side effects. It's also possible that severe flares will happen when they are discontinued. To help prevent this, an intensified skin care routine should be used while tapering off oral steroids.

Antihistamines may help make itching more bearable and let you get a better night's sleep. They may not work directly on the itch, but they have sedative effects and can make you drowsy.

Injectable Medications

Dupixent (dupilumab) is an injection approved by the Food and Drug Administration (FDA) for treating moderate-to-severe atopic dermatitis. It is intended to be used when topical therapies aren't working well enough or cannot be used.

Procedures and Further Treatment

For adults and children over age 12 who have severe eczema, phototherapy or photochemotherapy may be helpful, as follows:

• Phototherapy uses ultraviolet light. There are typically two to three sessions a week for several weeks.
• Photochemotherapy involves phototherapy with the use of a drug called psoralen that increases sensitivity to ultraviolet light. This type of therapy is called PUVA.

Treatments are done under professional supervision. Never attempt to give yourself phototherapy by sun exposure or tanning beds. This can make eczema more itchy and it increases your risk of skin cancer.

Prognosis

Eczema is a chronic condition, but it tends to get better with age. Eczema that is more severe and persistent in childhood is more likely to persist into adulthood. People who have other signs of atopy, such as asthma or allergic rhinitis, may also experience persistent eczema.

Treatments may not completely eliminate severe eczema flare-ups, but they can help improve symptoms.

Coping

Although it is hard to do, try to resist scratching. Scratching can make the itch worse and lead to infection.

Wet wrap therapy can help during a flare to treat the skin and keep it covered so you can't scratch. You soak the area for 15 to 20 minutes in lukewarm water, pat dry, and apply topical medications. Then you apply a wet dressing and cover it with a dry dressing. Leave this in place for two to six hours.

Talk to your healthcare provider about other tactics to cope with the itching. Stress management techniques may help to reduce stress as a trigger for flares.

If you find you have symptoms of anxiety or depression, talk to your healthcare provider. These mental health conditions are more likely in people with eczema, and depression risk increases with the severity of eczema.

Summary

Eczema is a chronic, inflammatory skin condition primarily characterized by itching. For some people, eczema symptoms are severe and disruptive during flare-ups. Severe eczema can be managed with a good skin care routine and with treatments such as medication and/or phototherapy.