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Eczema-Free for Life
By Nasir, Adnan
Eczema isn't like strep throat, which is easy to diagnose with a lab test and simple to cure with an antibiotic. There's no test to prove beyond a doubt that you have or don't have it. Instead, the diagnosis of eczema is based upon a careful search for a cluster of signs and symptoms. The itchy rash is the main symptom, but it's not the only one.
As soon as I enter the examining room, I'm looking for evidence. I analyze the signs I observe and the symptoms my patients report to see if they add up to eczema. Evidence can be found anywhere on the body, so, like me, your doctor might want to examine your whole body, even though you've come in because of a problem in a specific area. Signs of eczema can also be found in the eyes, lymph nodes, and other parts of the body, so don't be surprised if your doctor looks beyond your rash. The extent of the examination will depend upon how certain your doctor is of the diagnosis. Typical cases are easy to recognize, while atypical cases may require careful clinical evaluation.
To diagnose eczema, I ask the following questions:
- Do you itch?
- Do you now have a rash characteristic of eczema? (see pages 231232)
- Have you ever had the characteristic rash of eczema? If so, did your rash develop before you were two years old?
- Has your skin been generally dry in the lastyear?
- Has anyone in your immediate family had asthma, hay fever, or eczema?
If you answer "Yes" to two or more questions, you probably have eczema.
Skin Signs and Symptoms
While most people associate eczema with a red, itchy rash, there are other signs and symptoms, some of which are obvious even when there's no rash. The rash comes and goes, but evidence of eczema is always present.
Itch is the one symptom that must be present for a diagnosis of eczema. Itch drives patients to scratch, which triggers other symptoms commonly seen on the skin: inflammation, scaling, lichenification, scratch marks, and crust.
The redness of an eczema rash is actually inflammation. Scratching itchy skin damages cells. When the body perceives this damage, it sends defenses in the form of additional blood, immune cells, and other helper cells to speed healing. Besides turning red from increased blood flow, inflamed areas are warm to the touch and often swollen.
The degree of redness doesn't necessarily correspond with the degree of itching. For example, a bright red area may itch only slightly, while a light pink patch may be severely itchy. The brightness of the color may also depend upon complexion. In those with very light skin, any level of redness will be immediately obvious. For those with dark skin, the only clue to inflammation may be increased warmth of the skin.
Normally, the skin is a very efficient organ and requires little blood, about 2 tablespoons per minute. In the average adult, the skin is one-eighth total body weight, yet requires only one fiftieth of total heart output. This is because skin is usually metabolically inactive and the outer layers get some oxygen from direct contact with the atmosphere. With severe enough inflammation, blood flow to the skin can increase many-fold, and even deprive the body of needed oxygen and nutrients.
The skin of those with eczema reacts to scratching differently from that of those who don't have it. For example, if I write a word on a patient's back with a retracted ballpoint pen, a few minutes later the writing appears as a raised, dark red area with a subtle white halo. This reaction is found only in patients with eczema.
Occasionally, inflammation can cause your skin to hurt when touched. If it's affecting the hands, it can prevent fingers from bending and straightening properly. If there is widespread inflammation, you could feel ill. Severe inflammation is serious and should be treated immediately by your doctor.
The eczema rash is not only itchy and red, it also often looks scaly. Eczema speeds up the process of shedding and replacing dead cells. This results in more dead cells on the surface of the skin than can be naturally brushed away. In some cases, dead cells adhere to one another instead of shedding, piling up into thick mounds that crack and flake off.
Eczema scale takes several forms:
- It may be fine and white like powder. When rubbed, it balls up, leaving red skin underneath.
- It may not be evident until the skin is stretched or bent, as in around the mouth or joints.
- It may be cracked, giving the skin the appearance of a dried mud flat.
- Sometimes thin, transparent sheets peel off like dried rubber cement.
- Scale may be thin and crumbly around the eyes.
- Scale on the palms and soles tends to be thick and rigid, often interfering with movement.
- It may be thick and yellow and come off only in flakes or chips, I sometimes use this as a diagnostic clue, so don't be alarmed if your doctor scratches and picks at your skin while discouraging you from doing the same.
A person with eczema typically has dry skin, so if the skin isn't thoroughly moisturized, it's possible that scale will appear anywhere on the body regardless of itch or inflammation. Scaling typical of the eczema rash tends to develop where the skin is thin and sensitive, like the eyelids, neck, nipples, and the inside of elbows and backs of knees.
Skin that is constantly scratched or rubbed will eventually look thicker, darker, and rougher than normal skin. Thickened, or lichenified, areas range in size from a pinhead to a dinner plate, depending on the location and how often and how hard the area has been scratched. Like calluses, lichenification is an attempt by the body to protect itself. Lichenification takes weeks or months to develop; however, if the skin is left alone, it will eventually return to its normal condition ... Continues...
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