Dermatitis, sometimes referred to as eczema, is an inflammation of the skin that occurs in acute, subacute, and chronic stages. The cardinal feature is itching. There are numerous types of dermatitis, ranging from mild to chronic and affecting approximately 10% of children and from 7% to 24% of adults.

Dermatitis is caused by allergic contact (e.g., poison ivy), irritant contact (e.g., factors promoting water loss such as low humidity, organic solvents, or alkaline soaps), chemicals (e.g., nickel, cobalt, or detergent), or allergies (especially those associated with dairy products). Acute dermatitis may progress to subacute dermatitis, and chronic dermatitis either results from subacute dermatitis or appears as lichen simplex chronicus. Atopic dermatitis and dermatitis herpetiformis do not have clear etiology, but both have genetic links. Atopic dermatitis is associated with asthma and allergic rhinitis.

• Genetic risk factors (for atopic dermatitis and dermatitis herpetiformis)
• Occupation (e.g., cleaners, hair dressers, jobs requiring repeated hand-wetting)
• Allergic or irritant contact
• Gender (female, for contact dermatitis)
• Skin infections

• Mild to intense pruritus, pain, stinging, or burning
• Vesicles, blisters, scales, fissuring, thickened and lichenified skin, excoriations
• Mildly to intensely red skin

• Psoriasis
• Fungal infection
• Skin eruption from reaction to drugs, including botanicals
• Scabies
• Human immunodeficiency virus–associated dermatitis
• Cutaneous T-cell lymphoma
• Mycosis fungoides
• Exfoliative erythroderma
• Photosensitivity

The skin appears red and inflamed with serum-filled vesicles, lesions, or blisters. Excoriation causes accumulation of serum, crust, and/or purulent material. There is thickened and lichenified skin with chronic dermatitis.

• Patch testing can determine the type of allergic dermatitis, especially for environmental allegens.
• Biopsy can rule out spongiosis and lymphoma.
• Cultures reveal bacterial infections (e.g., Staphylococcus aureus).
• Blood testing may reveal elevated serum immunoglobulin E levels, which are seen in about 80% of cases of atopic dermatitis, especially those involving food allergens.

When the protective properties of the stratum corneum epidermidis are diminished, the skin decompensates and becomes eczematous. Epidermis becomes thickened.

• Rash is recognized as eczematous and not psoriasiform or lichenoid.
• Determine allergic, irritant, or endogenous source.
• The diagnosis for atopic dermatitis, in addition to itchy skin, includes flexural dermatitis, history of hay fever or asthma, and rash before the age of 2.

In addition to avoiding the triggering agent (if applicable), treatment may include one or more of the following.

• Control of symptoms
• Control of external stresses that may exacerbate the condition
• Drugs (corticosteroids, nonsteroidal immunomodulators, antihistamines, and antibiotics)
• Ultraviolet light, including photochemotherapy that combines psoralen and UVA light (PUVA)

Compresses are a good choice for controlling symptoms. Cool wet compresses cause vasoconstriction and decrease serum production, reducing inflammation and itching. The patient should replace the soaked cloth after 30 minutes. Burrow's solution (Domeboro) added to the compress reduces bacterial growth. Doak Tar and Complex 15 lotions or colloidal oatmeal (Aveeno) baths help to decrease itching.

Corticosteroids: Systemic corticosteroids reduce inflammation (e.g., prednisone 20 to 30 mg bid for 7 to 30 days, tapered gradually, depending on severity), side effects, and rebound effects. Topical corticosteroids cannot penetrate vesicles but decrease pruritus, preventing further complications (e.g., 1% to 2.5% hydrocortisone, twice daily on affected areas, decreasing the strength as the conditions improves). Side effects with more potent brands include atrophy, telangiectasia, striae, and adrenal axis suppression.

Nonsteroidal immunomodulators (e.g., tacrolimus [FK-506], phosphodiesterase inhibitors) are newer topical ointments.

Antihistamines: Antihistamines relieve itching but do not change the course of the disease (e.g., diphenhydramine [Benadryl], every 4 hours, as needed; hydroxyzine [Atarax], every four hours, as needed or 10 to 100 mg three hours before sleep for soporific effect). Newer, less sedating antihistamines include cetirizine (Zyrtec) and loratadine (Claritin).

Antibiotics: Systemic antibiotics (e.g., erythromycin, 250 mg qid for 7 to 10 days), treat secondary infections, which usually involve staphylococcus (in 90% of patients). Infections of the hand frequently occur with atopic dermatitis. Topical antibiotics are less effective than systemic antibiotics.

Discerning and eliminating exposure to the causative factor is of primary importance in treating dermatitis. Following nutritional guidelines and using herbal support as needed may be effective in reducing inflammation, hypersensitivity reactions, and relieving dermatitis.

Hypersensitivity reactions may be associated with stress and anxiety. Mind-body techniques such as meditation, tai chi, yoga, and stress management may help reduce reactivity.

Note: Lower doses are for children.

• Eliminate or reduce exposure to all known environmental or food allergens. The most common allergenic foods are dairy, soy, citrus, peanuts, wheat (may be intolerant to all gluten-containing grains), fish, eggs, corn, and tomatoes.
• Reduce pro-inflammatory foods in the diet including saturated fats (meats, especially poultry, and dairy), refined foods, and sugar.
• Increase intake of fresh vegetables, whole grains, and essential fatty acids (cold-water fish, nuts, and seeds).
• Flaxseed, borage, or evening primrose oil (1,000 to 1,500 mg one to two times/day) are anti-inflammatory. Children should be supplemented with cod liver oil (1 tsp./day). Excessive omega-6 oils may increase inflammation. In this case, omega-3 (fish oils) are more effective.
• Beta-carotene (25,000 to 100,000 IU/day), zinc (10 to 30 mg/day), and vitamin E (200 to 800 IU/day) support immune function and dermal healing.
• Vitamin C (1,000 mg bid to qid) inhibits histamine release. Vitamin C from rose hips or palmitate are citrus-free and hypoallergenic.
• Selenium (100 to 200 mcg/day) helps to regulate fatty acid metabolism and is a cofactor in liver detoxification.
• Bromelain (100 to 250 mg bid to qid) is a proteolytic enzyme that reduces inflammation.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

Flavonoids, a constituent found in dark berries and some plants, have anti-inflammatory properties, strengthen connective tissue, and help reduce hypersensitivity reactions. The following are flavonoids that may be taken in dried extract form as noted.

• Catechin (25 to 150 mg bid to tid), quercetin (50 to 250 mg bid to tid), hesperidin (50 to 250 mg bid to tid), and rutin (50 to 250 mg bid to tid).
• Rose hips (Rosa canina) are also high in flavonoids and may be used as a tea. Drink 3 to 4 cups/day.

Herbs that support dermal healing and lymphatic drainage are useful for relieving dermatitis. Use the following herbs in combination as a tincture (15 to 30 drops tid) or tea (2 to 4 cups/day). Peppermint (Mentha piperita), red clover (Trifolium pratense), cleavers (Gallium aparine), yarrow (Achillea millefolium), and prickly ash bark (Xanthoxylum clava-herculis).

Sarsaparilla (Smilax species) helps heal hot, red, inflamed skin, and gotu kola (Centella asiatica) is good for dry, scaly, crusty skin. Use 3 ml sarsaparilla and 2 ml gotu kola tincture daily, or 3 cups tea per day.

Oregon grape (Mahonia aquafolium) or red alder bark (Alnus rubra) can be taken as tincture (20 to 30 drops tid) to help liver eliminate waste.

Topical applications of creams and salves containing one or more of the following herbs may help relieve itching, burning, and promote healing. Chickweed (Stellaria media), marigold (Calendula officinalis), comfrey (Symphytum officinale), and chamomile (Matricaria recutita).

A tea made from peppermint leaf (Mentha piperita) may be cooled and applied via spray bottle to relieve itching and burning. An external ointment containing menthol can also be applied.

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

• Apis mellifica for hot, swollen vesicles that are relieved with cold applications
• Rhus toxicodendron for intense itching and burning relieved with hot applications
• Urtica urens for burning, stinging pains

Acupuncture may help restore normal immune function and reduce the hypersensitivity response.

Therapeutic massage may help reduce stress which exacerbates dermatitis.

Dermatitis worsens with pruritus and excoriation. Monitoring control of symptoms aids resolution.

Avoiding the irritating agent can prevent recurrence. Controlling symptoms can prevent scratching, thus avoiding further complications.

Uncontrolled pruritus and excoriations cause infection and scarring. Psychological problems (e.g., anxiety, anger, self-esteem) may occur. Ocular complications that may occur with atopic dermatitis include keratoconjunctivitis.

With causes of irritation removed, excoriation controlled, and no secondary infection, inflammation can be resolved without scarring. The disease can progress to being self-perpetuating and chronic. Atopic dermatitis cannot be cured, but symptoms and appearance can be controlled. Compliance with treatment ensures a more successful prognosis.

Types of pregnancy-induced dermatitis include pemphigoid gestationis, polymorphic eruption of pregnancy, prurigo of pregnancy, and pruritic folliculitis of pregnancy. Symptoms usually clear postpartum. Pemphigoidal gestation is associated with a risk of premature births and low birth weight; however, there is no correlation to spontaneous abortion or fetal mortality.

High-risk drugs during pregnancy and lactation include isotretinoin, antineoplastic agents (e.g., methotrexate), antipruritic medications (e.g., doxepin), antibiotics (e.g., tetracycline, ciprofloxacin), and nonsteroidal anti-inflammatory drugs. Analgesics and topical corticosteroids (except povidone-iodine and podophyllin) are lower risk drugs during pregnancy, and penicillins are comparatively safe antibiotics. Maternal antigen avoidance diets do not reduce the risk of giving birth to an infant with atopic dermatitis and may adversely affect fetal birth weight.

High doses of vitamin A are contraindicated during pregnancy. Nutritional support, rose hips tea, and topical herbal applications are safe, supportive treatment of dermatitis in pregnancy.

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