Dermatitis

Dermatitis is a broad term used to describe a range of common skin conditions that cause inflammation of the skin. It is characterised by itchy, red, and swollen skin. While dermatitis is not contagious, its persistent and often uncomfortable symptoms can significantly impact an individual's quality of life.

In this guide, we will provide detailed information on its types, causes, symptoms, diagnosis, treatment, and practical tips for managing life with dermatitis. 

Dermatitis refers to an inflammation of the skin. This inflammation can manifest in various ways, including redness, swelling, itching, blistering, cracking, and scaling. The term includes several conditions, each with its own distinct triggers, patterns of presentation, and course. 

While the exact mechanisms underlying dermatitis can differ depending on the specific type, they all involve an abnormal response of the skin to internal or external factors.

The inflammatory reaction in dermatitis disrupts the normal barrier function of the skin, making it more susceptible to irritants, allergens, and infection. This compromised barrier also leads to increased water loss, contributing to the dryness often associated with dermatitis. 

The chronic nature of many forms of dermatitis means that individuals may experience recurring flare-ups of symptoms interspersed with periods of relative calm. Effectively managing dermatitis involves identifying triggers, reducing inflammation, restoring the skin barrier, and alleviating uncomfortable symptoms like itching.

Dermatitis is an incredibly common group of skin conditions. In India, its prevalence is substantial, with various studies indicating that it is one of the most common reasons for dermatological consultations. Worldwide, the prevalence of dermatitis is also high. 

Dermatitis is an umbrella term encompassing several distinct types, each with its own characteristic features and underlying causes:

Atopic Dermatitis (Eczema): This is a chronic, relapsing inflammatory skin condition often starting in childhood. It is characterised by intense itching, redness, dryness, and cracked skin. Common locations include the creases of the elbows and knees, neck, wrists, and ankles. Atopic dermatitis is often associated with a personal or family history of asthma, hay fever, and allergies (the "atopic triad").
 

Contact Dermatitis: This type occurs when the skin comes into contact with an irritant or an allergen.

• Irritant Contact Dermatitis: This is caused by direct damage to the skin from irritants such as harsh soaps, detergents, solvents, acids, or prolonged exposure to water. Symptoms include redness, dryness, cracking, and sometimes blistering at the site of contact.
• Allergic Contact Dermatitis: This is a delayed hypersensitivity reaction where the immune system reacts to a specific allergen, such as poison ivy, nickel, fragrances, or preservatives. Symptoms include an itchy rash, redness, swelling, and sometimes blisters, typically appearing 24-48 hours after exposure.

Seborrheic Dermatitis: This common, chronic form primarily affects sebum-rich areas of the skin, such as the scalp (causing dandruff), face (around the nose and eyebrows), chest, and back. It is characterised by scaly, flaky, red skin. It is thought to be related to a yeast called Malassezia and an inflammatory response.
 

Dyshidrotic Eczema (Pompholyx): This type causes small, intensely itchy blisters to develop on the palms of the hands, soles of the feet, and sides of the fingers and toes. The blisters can be followed by scaling and cracking of the skin. The exact cause is unknown but may be linked to stress, allergies, or fungal infections.
 

Nummular Dermatitis (Discoid Eczema): This presents as coin-shaped patches of itchy, red, scaly skin, often appearing on the arms, legs, and trunk. The cause is not fully understood but may be triggered by dry skin or insect bites.
 

Stasis Dermatitis: This occurs on the lower legs in people with poor circulation (venous insufficiency). It is characterised by itchy, red, swollen skin, often with varicose veins, and can lead to skin thickening, discolouration, and ulceration.
 

Perioral Dermatitis: This causes a red, bumpy rash around the mouth, often sparing the area directly around the lips. It can also affect the skin around the nose and eyes. The exact cause is unknown but may be linked to topical steroid use, cosmetics, or fluoridated toothpaste.

The causes of dermatitis are varied and depend on the specific type. Often, a combination of genetic and environmental factors plays a role:

• Genetic Predisposition: Atopic dermatitis has a strong genetic component. Individuals with a family history of eczema, asthma, or hay fever are more likely to develop it. Genes involved in skin barrier function and immune regulation are implicated.
• Immune System Dysfunction: In atopic dermatitis, the immune system overreacts to environmental triggers, leading to inflammation. An imbalance in the types of T helper cells and the production of cytokines contribute to the skin inflammation and barrier dysfunction.
• Skin Barrier Dysfunction: In atopic dermatitis, the skin's outer layer (stratum corneum) does not function as effectively as it should. This allows irritants and allergens to penetrate more easily and leads to increased water loss, causing dryness.
• Environmental Triggers: Various environmental factors such as irritants, allergens, climate, and stress can trigger or worsen dermatitis flare-ups.

• Itching (Pruritus): Often intense; disrupts sleep and daily life.
• Redness (Erythema): Inflamed, red patches on affected areas.
• Dryness (Xerosis): Skin feels dry, rough, and scaly.
• Rash: Visible eruptions; may appear as bumps or patches.
• Blisters (Vesicles): Fluid-filled bumps; may ooze or crust.
• Swelling (Oedema): Puffy, inflamed skin due to irritation.
• Thickened Skin (Lichenification): From chronic scratching; skin appears leathery.
• Cracked Skin (Fissures): Painful splits, especially on hands/feet.
• Scaling: Flaky or peeling skin; common in chronic types.
• Oozing/Crusting: Leaking fluid that dries into crusts.

Diagnosis of dermatitis typically involves a thorough medical history and a physical examination of the skin by a doctor, often a dermatologist. The doctor will ask about the onset of symptoms, their location and pattern, any known triggers, personal and family history of allergies and skin conditions, and medications used.

Based on the appearance and distribution of the rash, the doctor can often determine the type of dermatitis. In some cases, further tests may be needed to confirm the diagnosis or identify specific triggers:

• Patch Testing: This is used to identify the specific allergens causing allergic contact dermatitis. Small amounts of various potential allergens are applied to the skin under adhesive patches for 48 hours. The skin is then examined for a reaction.
• Skin Biopsy: In some cases, a small sample of the affected skin may be taken and examined under a microscope to help differentiate between different types of dermatitis or rule out other skin conditions.
• Allergy Testing (Prick Tests, Blood Tests): These tests may be used to identify potential airborne or food allergens that might be contributing to atopic dermatitis, although these tests are not always conclusive.
• Scrapings: In cases of suspected seborrheic dermatitis, skin scrapings may be examined under a microscope to look for the yeast Malassezia.

The goals of dermatitis treatment are to relieve itching and inflammation, heal the skin, prevent flare-ups, and prevent infections. Treatment strategies often involve a combination of approaches tailored to the specific type and severity of dermatitis:

Topical Corticosteroids: These are the mainstay of treatment for many types of dermatitis. They reduce inflammation and itching and come in various strengths, ranging from mild to very potent. The strength used depends on the location and severity of the affected skin.(Brands available: Betnovate N, Betnovate C, Surfaz SN, Quadriderm RF)

Emollients (Moisturisers): Regular and liberal use of emollients is crucial for all types of dermatitis, especially atopic dermatitis. They help to hydrate the skin, restore the skin barrier function, and reduce dryness and itching. Fragrance-free and hypoallergenic emollients are recommended.
 

Topical Calcineurin Inhibitors (TCIs): These medications, such as tacrolimus and pimecrolimus, are steroid-sparing anti-inflammatory drugs often used for atopic dermatitis, especially on the face and in skin folds where topical steroids may have side effects with prolonged use.
 

Antihistamines: Oral antihistamines can help to relieve itching, particularly nocturnal itching, which can disrupt sleep. Sedating and non-sedating options are available.
 

Topical Phosphodiesterase-4 (PDE4) Inhibitor: Crisaborole is a non-steroidal topical cream approved for mild to moderate atopic dermatitis. It works by reducing inflammation.
 

Systemic Medications: For severe or widespread dermatitis that does not respond to topical treatments, systemic medications may be necessary:

• Oral Corticosteroids: These are potent anti-inflammatory drugs that can provide rapid relief but are typically used for short periods due to potential side effects.
• Immunosuppressants: Medications like ciclosporin, methotrexate, and azathioprine can suppress the overactive immune system and are used for severe atopic dermatitis or other forms of dermatitis. They require careful monitoring.
• Biologics: Dupilumab is an injectable biologic medication that targets specific inflammatory pathways involved in atopic dermatitis and is used for moderate to severe cases.

Phototherapy (Light Therapy): Exposure to specific wavelengths of ultraviolet (UV) light, such as UVB or UVA, can help to reduce inflammation and improve dermatitis symptoms. It is often used for moderate to severe atopic dermatitis and other forms of dermatitis.
 

Wet Wrap Therapy: This involves applying topical medications and then covering the affected skin with moist bandages followed by dry bandages. It can be very effective for severe atopic dermatitis.
 

Trigger Avoidance: Identifying and avoiding known irritants and allergens is crucial for managing contact dermatitis and preventing flare-ups of other types of dermatitis.
 

Infection Management: If secondary skin infections (bacterial or viral) develop, they need to be treated with appropriate antibiotics or antiviral medications.

 Some commonly explored alternative therapies include:

• Dietary Changes: While food allergies can trigger atopic dermatitis in some individuals, broad dietary restrictions are generally not recommended without clear evidence of a specific food allergy identified through testing.
• Herbal Remedies: Various herbs, such as chamomile, calendula, and evening primrose oil, are sometimes used topically or orally for their potential anti-inflammatory or skin-soothing properties. However, their effectiveness for dermatitis is not well-established, and some herbal remedies can cause skin irritation or allergic reactions.
• Probiotics: Some studies suggest that probiotics may have a role in modulating the immune system and potentially improving atopic dermatitis, but more research is needed.
• Stress Management Techniques: Since stress can worsen dermatitis, techniques like yoga, meditation, and mindfulness may be helpful for some individuals in managing their condition indirectly.
• Acupuncture: There is limited scientific evidence to support the effectiveness of acupuncture for treating dermatitis.

It is crucial to remember that alternative therapies should not replace evidence-based medical treatments prescribed by a dermatologist, especially for moderate to severe dermatitis. Always prioritise treatments with proven efficacy and safety.

Several factors can increase a person's risk of developing dermatitis:

• Family History: A personal or family history of atopic diseases (eczema, asthma, hay fever) is a major risk factor for atopic dermatitis.
• Genetics: Specific genes involved in skin barrier function and immune regulation increase susceptibility to atopic dermatitis.
• Exposure to Irritants and Allergens: Frequent or prolonged exposure to irritants and allergens increases the risk of contact dermatitis.
• Occupation: Certain occupations involving exposure to chemicals, solvents, or frequent hand washing increase the risk of irritant contact dermatitis.
• Poor Circulation: Venous insufficiency is a risk factor for stasis dermatitis.
• Age: Atopic dermatitis often starts in childhood. Contact dermatitis can occur at any age. Seborrheic dermatitis is common in infants and adults.

Dermatitis can lead to several complications:

• Secondary Skin Infections: The broken skin barrier in dermatitis increases the risk of bacterial infections (e.g., impetigo), viral infections (e.g., herpes simplex eczema herpeticum), and fungal infections.
• Sleep Disturbances: Severe itching can significantly disrupt sleep, leading to fatigue and impacting quality of life.
• Scarring and Skin Thickening: Chronic scratching and inflammation can lead to permanent skin changes, such as lichenification (thickened, leathery skin) and scarring.
• Eye Problems: Individuals with atopic dermatitis, especially around the eyes, have an increased risk of certain eye conditions, such as conjunctivitis and keratitis.
• Psychological Impact: The visible nature of dermatitis and the persistent itching and discomfort can lead to anxiety, depression, low self-esteem, and social isolation.
• Allergic Contact Sensitisation: Chronic skin inflammation can increase the risk of developing new allergies (allergic contact sensitisation).
• Asthma and Hay Fever: Atopic dermatitis is often a precursor to or occurs alongside asthma and hay fever (the atopic march).

Living with dermatitis requires ongoing management and self-care:

• Stick to Your Treatment Plan: Follow your doctor's instructions for medications and skin care.
• Moisturise Frequently: Make emollient application a regular part of your daily routine.
• Avoid Scratching: Try to resist the urge to scratch, as this can worsen inflammation and increase the risk of infection. Keep nails short and consider wearing gloves at night.
• Identify and Avoid Triggers: Pay attention to what seems to worsen your dermatitis and try to avoid those triggers.
• Wear Soft Clothing: Choose loose-fitting clothing made from soft, natural fabrics like cotton. Avoid wool and synthetic materials that can irritate the skin.
• Use Lukewarm Water for Washing: Hot water can dry out the skin.
• Pat Skin Dry: After washing, gently pat your skin dry instead of rubbing it vigorously.
• Manage Stress: Find healthy ways to cope with stress.
• Get Enough Sleep: Adequate sleep is important for overall health and can help manage stress.

“Dermatitis is Contagious.”

This is false. Dermatitis is not an infection and cannot be spread from person to person.

"Dermatitis is Caused by Poor Hygiene."

Dermatitis is not related to cleanliness. It is often due to genetic factors, immune system issues, or reactions to irritants or allergens.

“You Can Outgrow All Forms of Dermatitis.”

While some children with atopic dermatitis may see their symptoms improve as they get older, many continue to experience it into adulthood. Other forms of dermatitis can also be chronic.

"All Red Rashes are Dermatitis."

Many different skin conditions can cause red rashes. A proper diagnosis from a doctor is essential.

It is important to see a doctor, preferably a dermatologist, if you experience any of the following:

• A rash that is widespread, severe, or painful.
• A rash that does not improve with home care.
• Signs of skin infection, such as increased redness, warmth, swelling, pus, or fever.
• Intense itching that interferes with sleep or daily activities.
• A rash that affects your face or genitals.
• If you suspect a specific trigger for your dermatitis.
• If you have any concerns about your skin condition.

• What type of dermatitis do I have?
• What are the treatment options for my condition?
• What are the potential side effects of the treatments?
• How should I use topical medications and emollients?
• Are there any specific triggers I should avoid?
• What are the best ways to manage the itching?
• Will my dermatitis go away completely?

• Help Identify Triggers: If the person is trying to identify triggers, offer to help them track potential irritants or allergens.
• Encourage Them to Follow Their Treatment Plan: Support them in adhering to their doctor's recommendations.
• Avoid Judgment: Dermatitis can be visible and may affect self-esteem. Be accepting and avoid making comments about their skin.
• Offer Help: Assist with tasks that may be difficult due to skin irritation, such as household chores.
• Promote Self-Care: Encourage them to engage in activities that help them relax and manage stress.

Dermatitis includes a range of inflammatory skin conditions that can significantly impact an individual's life. By prioritising gentle skin care, avoiding triggers, and working closely with a doctor, individuals with dermatitis can find relief from their symptoms and improve their overall well-being.