Randy Jacobs, M.D. Patient Education

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Some people have naturally clear skin. Others have to work at it. With time, patience, and the right doctors to guide you, this blessing can be yours.

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You or someone you love may have eczema. But what is eczema?  And what can you  do about it? How do you control the itch?  Stop the rash?  How do you start back on the road to comfort and recovery?  This patient education sheet was written to help answer questions and concerns like these. Dr. Jacobs wants to help you understand eczema because, by understanding the disorder, you can take your first step towards living comfortably within your skin. By the way, the words “Eczema” and “Dermatitis” mean the same thing. They can be used interchangeably, and, like “water” and “H2O,” they are synonymous.


What is Eczema?

A famous Austrian doctor named Hebra described it well years ago when he said,  "Eczema is what looks like eczema." Sound confusing?  It's not really. What Hebra meant was that eczema is not defined by what causes, it, but by what it looks  like.  You see, eczema is really just a general term covering a group of 10 or 12 skin disorders that all look alike, but are caused by different factors. But interestingly, even though different factors can cause each type of eczema, there is one common factor that is shared by all types of eczema. That factor is: Each type of eczema has, in some way, a damaged, dysfunctional, or perturbed skin barrier. To learn more about the skin barrier, and, when it comes to eczema, the skin barrier’s role in “keeping the peace,” Please take a few minutes to read the patient education sheet titled, “Dry Skin and Skin Barrier Education,” and my booklet, “The ABC’s of Dry and Sensitive Skin.”


Quite simply, eczema, like a fire, begins when the skin barrier is damaged or perturbed, allowing the passage of allergens, toxins, and infectious agents that call forth white blood cells, dryness, and the whole eczematous inflammatory process that results in what you see and what Hebra descrided as "Eczema is what looks like eczema."


What Does Eczema Look Like?

Eczema has three different stages, each with its own distinctive features.  You may experience only the first stage, only the first and second, or you may go through all three stages.  Dermatologists call these three phases of eczema acute, subacute, and chronic. Acute eczema is stage number one, starting with some redness, swelling, and itching.  The redness quickly changes into blisters which, when they break, promptly begin oozing or weeping.  The itching can become severe at this point, but you must try hard not to scratch.  Scratching only intensifies the itching and worsens your condition. Album:Eczema 2.jpg In the second phase, subacute eczema, the blisters and oozing have lessened and crusts have formed.  Redness, itching, and some marks from scratching, however, are still prominent. The third phase is called chronic eczema.  The skin has endured so much irritation by now that it has finally thickened, becoming tougher and darker.  Often this toughened skin is lined like leather, and it may actually crack and form deep and painful grooves and fissures.  Itching, unfortunately, is still a persistent symptom. In every phase of eczema, you have to wage a constant battle with your self-control:  to scratch.  Although it's difficult, do not scratch!   The more you scratch and the more your skin is irritated, the more your eczema changes for the worse and the more likely it is to get infected.




Contact Eczema or Dermatitis

As the name "contact" implies, this type of eczema is the result of an outside irritant making contact with your skin.  Contact eczema is usually an allergic reaction.  A person only rarely develops a rash after only one contact.  This is the nature of allergy.  The first contact almost never irritates.  It is the second or the third of fourth or tenth or hundredth contact that irritates.  Sometimes the rash develops with the next encounter, and sometimes it takes years for the skin to suddenly become sensitive to a certain substance.  It also works the other way what a person reacts to now may, after a few years, hardly bother him at all he has "outgrown" his allergy. Sometimes the placement and the shape of the rash can give a clue as to the cause.  For example, sensitivity to a certain dye in shoe leather will affect only the tops and sides of the feet.  Or, a rash due to a low shrub could mark the legs in a horizontal streak. Substances that commonly cause reactions in some people, or may be causing a reaction in you, are:

 -  plant (like poison ivy)

 -  foods (like nuts and shellfish)

 -  industrial chemicals

 -  medications applied to the skin

 -  perfumes

 -  cosmetics

 -  fabrics

 -  household cleaners

 -  polishing agents


Almost anything can cause contact dermatitis. A person is never allergic to something the first time they use it. It takes many repeated exposures before the body can develop a true allergy to a substance. Often, a person will say, “Dr. Jacobs, I can’t understand how I can be allergic to my perfume, I have been using it for 10 years.” Dr. Jacobs explains that the person has used the perfume for 10 years, and has finally acquired an allergy due to repeated exposure. The same holds true for allergic reactions to all things. A person needs to be exposed to a substance repeatedly before an allergy can occur.


Most of the time, Dr. Jacobs can take a simple history and can find out what you are allergic to. Sometimes, Dr. Jacobs may have to order blood tests or do special skin testing to determine your allergies.


Primary Irritant Eczema or Dermatitis

This form of eczema is a close cousin of contact dermatitis.  The difference lies in the fact that primary irritant dermatitis is not an allergic reaction the first contact, if it is long enough and strong enough, will cause eczema to develop in everyone.  Examples of substances causing primary irritant dermatitis are strong acids and alkali (like battery acid and Bleach), solvents (like turpentine), and strong soaps and detergents.

Atopic Eczema or Dermatitis

This type of eczema differs from the fist two that we've just discussed because it is a hypersensitivity that can be amplified by contact.  It is a tendency or disorder that runs in families and often occurs together with other types of allergic disorders.  Infants, for example, who have eczema may outgrow it by the age of 5 or 6 but often develop asthma or hay fever later.  Atopic eczema is a chronic type of dermatitis, but acute flare-ups are often triggered by a number of factors, a few of which are heat, cold, rapid changes in temperature, sudden sweating, stress, and fatigue.


:::Downloads:shutterstock_106764923.jpg Incidentally, one trait that almost every person with atopic eczema has is a tendency towards very dry, sensitive skin.  So sensitive is the skin, in fact, that even a light touch or breeze can bring on intense itching, and, the desire to scratch.


Eczematous Dermatitis

An umbrella title, “eczematous dermatitis” covers any form of eczema not easily classified into the preceding categories. These eczemas or “dermatitides” (plural of dermatitis) can be due to many different factors and appear in many different patterns.  For example, infective eczematous dermatitis is a rash developing in the patch of a draining bacterial, fungal, or viral infection.  In contrast, stasis dermatitis, a rash stemming from poor circulation due to varicose veins. Stasis dermatitis usually occurs in swollen legs with poor circulation. Xerotic eczema or nummular eczema occurs in skin that is chronically dry and inadequately moisturized. Hand eczema may occur from frequent hand washings or from use of strong solvents at home or work. Eczemas may occur in a variety of different patterns, and may require different treatments.




Eczema can occur at any age and on almost any part of the body, with some areas being more sensitive than others. Contact eczema usually affects the area where contact was made with an irritating substance.  Some good examples are diaper rash in infants, detergent hands in adults, or a poison ivy reaction in any age group.




:::Downloads:shutterstock_145332343.jpg Atopic eczema, however works on a very different principle. Remember, the rash of atopic eczema does not begin with contact.  It begins with a perturbed skin barrier. Thus, people with atopic eczema all show a similar pattern of skin irritation.  This pattern varies at different ages, but is still easily identifiable as an atopic eczema.  For instance, let's say you and a friend both have mild atopic eczema.  If that were the case, you both would more than likely experience the same rash in the same areas with the same itch. Dr. Jacobs categorizes all atopic rash patterns into three groups.  The first phase is called infantile.  Babies from 2 months to 2 years of age develop a rash that tends to be red and oozing, and concentrated particularly on the scalp, face, and neck with scattered patches in other areas. The second group is called the childhood  phase.  Children from ages 4 through 10 experience patches of eczema on  and around the scalp, neck trunk, and genitals, and less often on the elbows, knees, ankles, and on the top of the hands, and feet.  The childhood phase can be a continuation of the infantile stage, or it may start first in the older child. The third group combines teenagers and young adults into the adult phase.  This eczema chiefly affects the insides of the elbows, the backs of the knees, the face, and  is often chronic. The skin can become chronically dry and scaly.



How to Care for Sensitive Skin,

Atopic Skin, Allergic Skin, or Eczematous Skin


Dry and sensitive skin problems are among the most common reasons for coming to the dermatologist. Dry skin is a problem for many people, especially in cool weather when the air is dry and furnaces are turned on. How does dry skin develop? Normally, your skin moisture is protected by your skin barrier lipids filling the intercellular spaces between skin cells. Soap can wash these protective bio-oils away, and your skin can lose moisture. Dry air further causes the skin to lose moisture, and your dried skin can scale, flake, and crack. The tiny cracks in the skin are also called “fissures” and occur within the lines of the skin. As tiny dry fissures deepen within the skin lines, inflammation and sometimes infection develops, leading to a medical condition called: asteatotic or xerotic eczema, the medical names to describe severely dry skin. The words “eczema” or “dermatitis” are the same and refer to inflamed skin. Eczema or dermatitis can be due to allergic or irritating substances, infections, low oxygen, drugs, and dryness. The chapped, cracked “eczematous” areas may become irritated and itchy. The skin can appear scaled like fish scales, a condition called “icthyosis.” If sensitive skin is a problem, the dry eczematous skin rash can form patches that resemble ringworm. This condition is called “nummular” eczema. At times, the skin may peel like parchment paper. Other times, the skin may appear red and flaky. If low oxygen is a problem as with swollen or varicose legs, the condition is called “stasis dermatitis.” If asthma, allergies, or hay fever is in the family history, the dry skin problem may be magnified. This dry skin condition is called atopic dermatitis. The dry skin care principles explained in this handout apply to all people who suffer with dry skin, sensitive skin, allergic or atopic skin, icthyotic skin, nummular skin, or any type of eczema, including stasis.





The most important part of therapy is to first restore moisture to the skin. It’s like filling a dry lake bed. Skin lubrication will restore your skin’s moisture. How is this done? Just add water! Water alone will briefly moisturize your skin, but the new moisture is soon lost to the air by routine evaporation. How to prevent evaporation? Creams and ointments provide a protective film or coating of oil that prevents skin water from evaporating. The oils can also seep deep into the intercellular spaces and can temporarily refill your skin barrier so that it can once again function. This protective oil coating prevents dryness. Any type of oil can prevent water loss. Bath oils can be an effective way to prevent loss of moisture. You can rub bath oil onto your skin after a shower or bath. You can add it directly to your bath water: CAUTION: Slippery tub! When applying bath oil directly to your skin, first, soak in your tub and wipe your skin with a moist towel. Second, pour a small amount of bath oil into your hands. Liberally spread it around. Three large tablespoons of bath oil is enough for the entire body of an average adult male. If you prefer to use bath oil in the tub, after you have soaked for 10 minutes, add a tablespoonful of oil to the bath water and soak for 10 to 20 minutes more. Do not use soap, as you will be cleansed by soaking in the oil-water combination. After soaking, pat yourself dry with a damp towel. Enough bath oil will remain on your skin to prevent moisture loss. You can ask your pharmacist to show you OTC bath oils or mineral oil. If you don’t like bath oil, you can moisturize with OTC Cetaphil Moisturizing Cream or plain Vaseline with good results. Sesame oil is also nice. The most important point to remember: Any skin lubricant is best applied after your skin has been wettened in the bath or shower, so as to trap and hold moisture in. Think of yourself as a bone dry sponge that has been soaked or dipped in water. The sponge is then dipped in oil to tightly seal the moisture in. Here is a recipe for an excellent home made moisturizer: Mix one pound of Vaseline ointment with sixteen ounces of any fragrance free mineral oil. Add a small amount of pure water to your liking. Mix them together, well, with an electric mixer. Apply liberally to your body each day after your bath. You will find this recipe to be effective and economical.


Treating the Dry Skin Rash

When dry skin has developed into an itchy rash, a cortisone cream or ointment usually brings quick relief. The cortisone may be applied liberally to the rash and deeply massaged in, usually at bedtime, or after bathing, and one or two other times during the day. As your rash improves, the cortisone is decreased. Remember, dry skin requires topical therapy. Many patients would like to treat their dry skin with either a pill, an injection, or diet. Some patients have asked if fat intake improves dry skin. Excessive fat consumption can cause poor health. Please remember, when treating dry skin, there is no safe substitute for conscientious topical moisturization. If you want an oral cure, water is the best oral substance to help with dry skin. Pills aren’t available. Topical care is best. First, soak the water inside. Second, prevent evaporation with a film of oil.



Soap is bad for dry or sensitive skin. Dial, Zest, Lever, Safegaurd, Ivory, gels, and Irish Spring are among the worst. Soap removes skin oils needed to hold in moisture. If oils are removed, the skin develops cracks, fissures, and dry inflammation. Soap should not be used on dry or sensitive skin. Most of us use far too much soap. Actually, plain water is often just enough to cleanse the skin. If you can't live without soap, it's OK to use Dove soap for your face, feet, armpits, and groin.


Avoid Allergic Items

Sensitive skin can become itchy when exposed to allergic type substances such as perfumes, dyes, conditioners, powders, anti-perspirants, hair sprays, grasses, plants, fragranced products, shampoos, unrinsed laundry detergents, fabric softener sheets, dog or cat hairs, carpets, chemicals, Aloe Vera, PABA, detergents, acrylic nails, polishes, nickel, elastic, latex, etc. Hair conditioners can induce itch! Please avoid perfumes.



Persons with dry skin may bathe

~ or shower once daily:

1. Use no soap on dry or sensitive skin areas. You may use mild Cetaphil or Aquanil soapless soaps, instead of soap.

2. After bathing, thoroughly lubricate your skin using one of the methods described in this educational sheet.

3. After your bath, you should not towel dry. Wipe off the water with your hands, then, apply a thin film of moisturizing cream to your entire body. This film will seal in your new moisture.

4. For shampoo, use OTC fragrance free DHS Clear Shampoo.


Long-term Control

Dry or sensitive skin is usually a long-term problem that may recur often, especially in winter. When you notice your skin getting dry or itchy, resume your lubricating routine, proper bathing technique, and avoid soap. If you are a dry or sensitive skin person, avoid allergic items, especially perfumes and antibacterial soaps. Aim to restore your protective skin barrier lipids.




What is Dry and Sensitive Skin?


What is dry and sensitive skin? Dry skin is common problem, especially in cool weather when hot furnaces are turned on and the air is dry. Young and old, infants and adults, millions of people suffer with dry and sensitive skin. It may be you or your spouse, your children, your parents, or even a friend. At highest risk are babies, seniors, diabetics, frequent hand washers, eczema prone people, atopics, psoriatics, and people on water pills, acne meds, or wrinkle creams. These people usually suffer with dry and extra sensitive skin.



If you look in the dictionary, there is no good definition for the term" sensitive skin," but those of you who have it sure know what it is. Sensitive skin dries out ever so easily, can ignite like a hot match, and any allergic thing can set it off. If this skin type is neglected and exposed to soap, dry air, and allergens, simple dry skin can deteriorate into itchy eczema or the "Dry Skin Rash." Eczema, the Dry Skin Rash, and most dry and sensitive skin problems can be traced to an easily damaged skin barrier located in the upper layers of the skin. Microscopically, the skin barrier resembles tiny bricks and mortar. Here is a simplified diagram of the human skin barrier.



If you are a dry and sensitive person and you neglect your skin barrier, you will have problems forever. The truth is, your skin barrier needs daily care, but ironically, most dry and sensitive people are unaware of their skin barrier organ. A well-tuned skin barrier will keep body water inside and will prevent allergens and microbes from entering your body. The "bricks" are the corneocyte skin cells. The "mortar," situated between skin cells, is made of three lipid-oils: Free fatty acids, ceramide, and cholesterol. For normal skin barrier functioning to occur, the three lipids must be "organized" into precise layers called "lipid bilayers."


Here is an example of well organized, healthy, skin barrier lipids:

Lipid Bilayers organ smaller


Here is an example of disorganized, unhealthy, skin barrier lipids:


Lipid Bilayers disorg leaky


How Do You Get Dry Skin?


If cholesterol, ceramide, and free fatty acids are stripped away as with excessive soap use, the lipid bilayers will break down and the skin barrier is damaged.


In this depleted state, the skin barrier will leak, and thus, water will evaporate, allergens will penetrate, and microbes can enter to infect. The skin becomes dry, inflamed, and infected. A rash ensues: The Dry Skin Rash. Help! Some people try calamine, but dry calamine does nothing for dry skin. Some people head to the shower and scrub their bodies with soap. This only adds fuel to the fire. Hoping for relief, some splash rubbing alcohol all over their lipid-depleted body.

Itchy Man ps no hat

They don't realize that soap and alcohol are only stripping more lipids and causing more skin barrier damage. Finally, the dry person goes to a local urgent care and gets cortisone pills. But, cortisone is only a short-term fix for a long-term skin problem. What this suffering dry and sensitive soul really needs is the ABC Skin Care.

Album:Eczema 1.jpg