Eczema is the common name for atopic dermatitis, a persistent, chronic skin condition that involves dry, red and itchy skin. It a common ailment, affecting about 1 in 10 people, and also one of the more common conditions among my patients seeking laser treatment for eczema.
Eczema is usually characterised by the following signs and symptoms:
- Thick, dry, scaly/flaky skin
- Persistent, itchy rashes which often worsens at night
- Reddish, raw inflamed skin from scratching
- Small red bumps on the skin
- Reddish, brownish or greyish patches of skin around the inside of joints such as elbows and knees
Eczema can significantly affect the quality of life for those afflicted. The itchy rashes can keep people up at night, preventing them from getting restful sleep. It can also limit their lifestyle choices, especially outdoor activities under the sun. The conspicuous rashes can also affect confidence and self-esteem.
In this article, let us explore the causes of eczema, and how the condition can be treated.
The stratum corneum and the skin barrier function
Before we discuss eczema in depth, we need to first have a basic understanding of the skin barrier function.
Our skin is divided into 3 main layers – the epidermis, dermis and subcutaneous tissue respectively, each of which are divided into further sub-layers. Out of these, the outermost layer – the epidermis, specifically the stratum corneum(SC) sub-layer, is responsible for the skin barrier function.
The SC is the outermost sub-layer of the skin. It has 2 main components:
- Corneocytes – Keratinised denucleated skin cells. These are colloquially referred to as “dead skin cells” even though they are technically considered alive.
- Intercellular lipids – An oily secretion which fills up the extracellular space between the corneocytes.
The largely impermeable keratin in the corneocytes and the oily intercellular lipids make the SC highly waterproof. This prevents most external bodies like pathogens, allergens and irritants from entering our body via the skin, as well as preventing the loss of moisture from the deeper skin layers. Surface corneocytes shed off naturally as they age, also via regular wear and tear. The shed-off skin is regularly replaced via a process named cornification, where regular keratinocytes are transformed into corneocytes. This shedding and replenishment ensures that there is always a fresh layer of corneocytes to maintain a healthy, functional skin barrier.
Skin processes involved in the development of eczema rashes
Eczema is caused by an impaired barrier function of the stratum corneum and is largely believed to be a result of genetics. The broken skin barrier causes the skin to lose moisture excessively and become dry. Also, the skin becomes more susceptible to foreign allergens and irritants. This triggers an immune response in the skin, causing itching and inflammation. The dryness also causes the topmost layer of the skin to flake off. Overall, these lead to the red, flaky and itchy rashes of eczematic skin.
While there is currently no definitive answer on the ultimate root cause of eczema, medical research does indicate that it is closely related to the 4 factors below.
1. The cornification process replenishing the corneocytes
The cornification process is the main process replenishing the stratum corneum. Disruption in this process can cause this sub-layer to thin out as natural shedding of corneocytes outpaces the replacement rate. This can significantly impair the skin barrier function.
2. Rate of shedding of old corneocytes
Like how a disruption in SC replenishment can thin out the layer, an increase in the rate of shedding of corneocytes leads to the same outcome as well. There are many possible reasons for this, the most common being a loss of function in the intercellular connections in the SC makes individual corneocytes more likely to detach from their surrounding tissue, accelerating the rate of shedding and thinning out the SC.
3. Ratio of the components in the intercellular lipids
Other than the keratinised corneocytes, the oily intercellular lipids also contribute to waterproofing the skin, retaining moisture and shielding out foreign matter. In healthy skin, these lipids consist of a precise ratio of ceramides, free fatty acids and cholesterol. If this balance is disturbed however, the permeability of the SC is increased, allowing moisture to escape and foreign matter to enter.
4. Activity of the immune system
Eczema rashes are fundamentally similar to allergic reactions, as they are both essentially inflammation reactions. Hence, a hyperactive immune system can trigger excessive inflammation reactions, which can disrupt the processes forming the skin barrier.
In addition, eczema is known to be very persistent because the processes involved form a positive feedback loop. When the skin barrier function is impaired, allergens and irritants cause the skin to itch and become inflamed, which further impedes the formation of the skin barrier. This loop reinforces itself, making it hard for eczema flare-ups to subside without interference.
Treatment
Eczema treatment mostly revolves around 2 approaches: suppressing the inflammation reaction and restoring the skin barrier function. With these in mind, below are some of the treatments I would recommend for my eczema patients.
Medication
• Corticosteroids
Fundamentally, eczema rashes are very similar to an allergic reaction. Hence, we can control it using similar measures like corticosteroids to suppress the inflammation reaction. These typically come in the form of a topically applied cream with varying concentrations from 0.1% to 2.5%. Generally, doctors will assess the severity of the rashes and prescribe a cream with a suitable percentage, only moving on to stronger, higher percentage ones if there is no improvement. This is because excessive use of corticosteroids can weaken and thin out the skin, making it more prone to injury and subsurface lesions. For the same reason they should only be used during an eczema flare-up and should cease once rashes have subsided. If there is no improvement even after extended use, I would advise my patients to move on to other forms of treatment.
• Clifford Intensive Cream
While corticosteroids target the inflammation reaction, Clifford Intensive Cream aims to restore the skin barrier function.
Clifford intensive cream is an emollient specially formulated for eczema patients. It replenishes the correct ratio of ceramides, fatty acids and cholesterol in the SC to help restore and the skin barrier function, preventing excessive loss of moisture and shielding the skin from external irritants. Together, these reduce the likelihood of future eczema flare-ups.
VBeam Laser Treatment
I will also advise my patients to undergo VBeam Laser Treatment. This laser uses a dual wavelength of 595nm and 1064nm to specifically target vascular tissue, making it especially effective at addressing vascular and inflammatory conditions of the skin like eczema with practically no side effects. Specifically, VBeam laser treatment targets 2 components of the skin to reduce eczema flare-ups:
- Vascular tissue: The laser treatment collapses capillaries in the inflamed tissue and decreases the expression of blood vessel forming proteins. This helps keep existing inflammation under control and prevent them from worsening.
- Immune response: VBeam laser also targets and partially suppresses key proteins in the skin closely associated with the immune system. Reduced activity of these proteins inhibits inflammation, reducing the likelihood of eczema flare-ups.
We can see that VBeam laser addresses both the eczema rash itself by limiting blood supply to the inflamed skin, and also inhibits the upstream immune response leading to the inflammation. This 2-pronged effect is what makes VBeam laser especially potent at treating both active eczema rashes and preventing future flare-ups.
In my experience, patients who underwent VBeam Laser Treatment usually see improvements within the first 2 weeks of treatment. For optimal results however, I will usually advise my patients to continue treatment for at least 4 to 6 weeks.
Bellasonic
Other than medication and laser treatment, I would also recommend Bellasonic Ultrasound Therapy to my eczema patients. I have imported this device from South Korea after seeing how effective it is at stimulating skin rejuvenation.
While VBeam laser targets the inflammatory response, Bellasonic aims to restore the skin barrier function by enhancing natural skin regenerative processes. In many cases, eczema-afflicted skin has trouble healing naturally. The rapid loss of moisture due to the damaged skin barrier interferes with the natural healing process. Bellasonic applies a 1-10MHz ultrasound to the skin, creating tiny vibrations which stimulate skin regenerative processes. The vibrations increase the activities of key molecules involved in the natural regeneration of the skin, specifically Glycosaminoglycans (GAGs) and Heat-Shock Proteins (HSPs). The increased activity of these 2 enhances skin hydration, replenishing the lost moisture and simultaneously promotes the repair of the skin barrier.
Bellasonic treatment takes several weeks to see results, usually after 2 or more sessions.
Final words
Eczema is a common, yet very persistent ailment. It may simply be a mild annoyance for some, but there are many whose quality of life are significantly affected by it. If you are troubled by persistent eczema, you are welcome to arrange a consultation with me at my clinic. My team and I will be more than willing to assist you.
