Dry Skin (Eczema/ Atopic Dermatitis)

Imagine you have two containers of water. One has plastic wrap covering it and the other does not. Now let’s place both containers inside a hot oven. Both will lose water because the plastic wrap is not air tight. However, intuitively, we know that the container with the cover will lose less water. Your skin is the plastic wrap barrier protecting you against the environment. If the plastic wrap has holes in it (due to environmental or genetic stressors), it will not provide appropriate daily protection.

Thus, the two main scientific theories for dry skin (aka: eczema/ atopic dermatitis) are:

Outside-in Theory: the saran wrap has holes in it or is missing

This theory states that the integrity of the epidermis and dermis (our top two skin layers) is the most important factor in maintaining a healthy barrier from environmental exposures.  If our skin barrier is made of brick and mortar; the bricks are proteins (filaggrins) and the mortar is lipids (ceramides). Anything that disrupts this barrier can cause a skin crisis.  Deficiencies in vitamins, lipids/cholesterols, free fatty acids, proteins and human growth factors weaken our skin barrier.  Dysfunctional or missing proteins  have been shown to be a risk factor for severe eczema.

Inside-out Theory: the water boils over and melts the saran wrap

This theory states that the integrity of the epidermis and dermis (our top two skin layers) is the most important factor in maintaining a healthy barrier from environmental exposures.

1. Optimize Hydration

When we are in water for a long time our finger tips get wrinkled. This is a sign that we have actually over-hydrated our skin. The skin barrier works best at repairing itself when it is optimally hydrated (not too wet and not too dry). While drinking water is useful for many other reasons, rehydrating the skin requires more direct measures. Showers may cause micro trauma to our skin and do not allow for appropriate skin hydration. Baths, without soaps or oils (soaps coat the skin and prevent absorption of water), are the best choice.   Using a moisturizing soap for ‘dirty’ areas – genitals and hairy areas- in the last five minutes of one’s bath prevents disruption of the brick and mortar building blocks of our skin. Towel drying (with a clean unused towel to prevent biofilm transfer from others) with patting, rather than rubbing decreases trauma to our skin.

2. Apply Emollients (moisturizers)

Lathering the skin with an emollient within the first 60 seconds of leaving a bath helps lock in moisture. Emollients should be applied frequently and in large quantities up to four to five times per day. Optimizing emollients decreases the need for medicated cream application (see number five).

3. Avoid Triggers

Triggers can be external and internal and they are different for everyone. Becoming body aware is an important first step in solving your skin crisis. I choose to mention only a few of the more common triggers here.

4. Avoid The Itch-Scratch Cycle

Preventing the itch-scratch cycle is important for allowing our skin barrier to repair. Any disruption in our skin barrier will cause our cells to release histamine, which in turn causes itch. Scratching your itch further releases histamine, which only causes more itching and more inflammation. This vicious cycle does not allow for repair of the skin barrier. Therefore we must STOP the itch. We can use over the counter anti-histamines or prescription topical or oral medications to help stop itching. Talk to your doctor if you are having trouble controlling the urge to itch.

5.  Medicated Topical Creams

An over the counter 1% hydrocortisone (a steroid) cream is available for use with eczema. This should not be used if you suspect an infection or see fluid filled vesicles on your skin, unless a physician has advised. Stronger prescription corticosteroids and non-steroid alternative creams are available from your doctor. Applying these medicated creams ten minutes AFTER emollients allows for best absorption. If you notice any signs of infection in your skin- areas of extreme redness, pain or yellow honey colored crust- a physician may prescribe either oral or topical antibiotics. A visit to your doctor will help determine if it is just inflammation or something more insidious like bacterial or fungal infection. If you see an annular ring, fine scales sloughing off your skin, or  any pigmentary changes, a topical anti-fungal cream might be prescribed by your doctor.

6. Bleach Baths

We all have a naturally occurring bacterial flora over our skin. Biofilm refers to the balance in numbers of the different types of bacteria found on our skin. Healthy skin has been found to have a different balance than un-healthy skin. Adults also have different biofilms than children (hence we often “grow out” of certain illnesses). Bleach baths (Table 1) consist of a couple of capfuls of bleach in a tub of lukewarm water. Two to three baths per week will decrease the number of Staph Aureus (a bacteria found naturally on skin) found on your skin and re-adjust your biofilm without the use of antibiotics. However, there should be no active infection or open sores present while bathing.  It is also very important to use freshly laundered towels and clothing afterward to prevent recontamination with new microbes. Finally, emollient application directly after any bath remains the standard.

Bleach contains sodium hypochlorite and is normally available in 6% concentration.  Patients can add 118 ml of 6% bleach to a full bathtub of water (200L) to achieve a final concentration of 0.005%. One should soak from the neck down in the dilute bleach bath for 5 to 10 minutes twice weekly.   Avoid getting the bleachsolution in your eyes or ingesting it. Use of the dilute bleach baths is not recommended if you have breaks in your skin.