The Eczema Epidemic:

An Intersection Between Social, Environmental, and Genetic Issues

What is Eczema?

Eczema is defined as a group of chronic skin diseases characterised by dry skin, intense itching, inflammatory skin lesions, and has a considerable impact on quality of life (1). It is commonly used as a synonym for atopic dermatitis (AD) (the most common form of eczema); however, eczema is a broader and nonspecific term that describes the morphological appearance of several forms of dermatitis (2). It is possible to have more than one type of eczema on your body at the same time, and each form of eczema has its own set of triggers and treatment requirements (3).  There is debate surrounding the causality of the illness, but it is likely that both genetic and environmental factors hold merit and that the cause of eczema is multifaceted (4)(5)(6).

The article firstly discusses the epidemiology of eczema and its rising prevalence; the morphology of the condition and how it presents in varying manners across a wide population; and the impacts and impairments the illness has on individuals. The second section analyses the environmental, socio-geographic, and cultural risk factors of eczema before moving to a discussion of the therapies and treatments available for the condition. Finally, the article gives a call-to-action to its readers, seeking to establish modes of positive action that can help ease the burden of eczema as a disease. It should be noted that a majority of the literature reviewed in this article uses ‘eczema’ as an umbrella term for what is typically considered atopic dermatitis.

An Increase in the Global Prevalence of Eczema

“The prevalence of AD has been increasing progressively in developed countries since the 1940s.” (as seen in 6). There are worrying reports on the growing prevalence of eczema and allergic responses in the young global population (7) with metropolitan living presumed a significant factor in predicting a higher prevalence of eczema in children (8). Studies have shown a prevalence of 16-20% in children 1-11 years old (9)(10). There is some evidence to suggest that eczema in children is a part of an atopic march or a development of asthma and rhinoconjunctivitis from food allergies and eczema (11). This relationship between allergy-related diseases of increasing severity is of great concern for the global population as it may mark the beginnings of an epidemic of non-communicable diseases.

An Ever-Changing Illness

As an illness, eczema is inconsistent in its morphology, often lasting for years and, within that time frame, progressing through a variety of symptoms (3). Any damage to the epidermis is likely to trigger inflammation in those predisposed to atopic dermatitis (4). Additionally, the skin of an individual can change with treatment, with long-term use of topical steroids having the potential to thin the skin barrier and leave it prone to further damage (12). The itch-scratch cycle is also particularly dangerous: damage to the skin barrier was found to lead to the production of cytokines, and in turn inflammation and the presentation of atopic dermatitis, restarting the itch-scratch cycle (4). To the same effect, the model for disease progression given by Leung (5) suggests that patches of skin unaffected by atopic dermatitis are prone to affection with exposure to irritants. Hence, the condition can be understood as a dormant disease, rather than a spreading contagion.

Living with Eczema

Eczema manifests as an uncomfortable and irritating disease and requires constant care - this can detract from an individual’s ability to adapt to a wide range of social scenarios, including working, exercising, or even relaxing. Eczema is reported to cause depression and anxiety (13). The severity of eczema and its impairment of quality of life is thought to be second only to cerebral palsy (14), mainly due to persistent itching and pain, sleep disturbance and emotional distress (15).

Eczema management can be especially challenging during adolescence and early adulthood, as young people must bear responsibility for care. They experience new demands, including understanding and adhering to complex treatment regimens; financing, acquiring and testing effective medical treatments; interacting with health professionals and negotiating healthcare systems. Such demands can  disrupt their health and well-being.

Risk Factors: Why is it getting worse?

Eczema is seen clearly as a major concern for global health, especially in Latin America and Southeast Asia, regions with rising prevalence of eczema (16). Gene-environment interactions are thought to be the leading cause of this increase in prevalence, particularly among populations who were historically (genetically) less prone to developing eczema as one in three infants develop eczema before reaching 12 months of age (17). Cork et al. (6) suggest that, the more genetic mutations relating to eczema there are within a body, the fewer environmental triggers are required for development of the disease. Therefore, severe eczema sufferers may need to control for a wider variety of environmental factors than those who are less prone to the condition.

There are many indicators showing environmental pollution, which serves as a potential explanation for the increase in the prevalence of atopic dermatitis in urban areas (18). Low exposure to soil and microorganisms from living in urban areas may compromise the development of immune system responses (19). Additionally, environmental risk factors for atopic dermatitis in infants include: low outdoor temperature, living in an urban setting, eating fast-food, delayed weaning, obesity, tobacco smoke, and pollution (20).

Other factors such as socio-economic status, sex, and race were also found to be risk factors for eczema (21). A study found that there was a positive correlation between the prevalence of eczema and a region’s economic condition (22). Stress and anxiety play an important role in the eczema cycle and it has been found that psychological stress can both lead to the development of atopic dermatitis and is also caused by the condition itself (23). Moreover, negative emotional states are the main personality component of patients with neurodermatitis (24). The COVID-19 pandemic has marked a notable increase in anxiety across the general population (25) and an increase in the prevalence of hand eczema, as caused by overzealous hand washing (26). In addition, the effects SARS-CoV-2 virus has on the immune system may also exacerbate or complicate eczema symptoms (27). Ultimately, the range of risk factors affecting eczema is broad, requiring a holistic approach to tackling the eczema epidemic.

Therapies and Treatments: What can we do?

Treatments for the management of eczema have been classified into 10 groups, including commonly prescribed medicines, but also complementary therapies such as Chinese herbal medicine, homoeopathy, and aromatherapy (28). Pharmacists’ guidelines for the treatment of atopic dermatitis suggest a wide range of available treatments and note the patients’ role in choosing treatments, particularly with moisturisers, is finding a product that patients will use “liberally and regularly” (29). 

Despite the variety of treatments available to eczema sufferers, there are several limitations to their accessibility, since the choice between pharmaceutical treatment or complementary and alternative therapies is complex. A study by Chowdhuri and Kunu (30) suggested that demographic, social, cognitive, and philosophical factors are important determinants of choosing complementary and alternative medicine as a treatment for acute and chronic diseases over conventional medicine. Topical corticosteroids and oral antihistamines are two of the most common treatments given to patients with atopic dermatitis (31)(28). Daily use of these drugs can be expensive, taking into account that in the US only it has been estimated that atopic dermatitis costs over $5 billion dollars annually (32). Whilst development of new medicines, such as monoclonal antibodies, are promising in their effectiveness in treating eczema, they also present a large barrier to access with their high price tag (33).

 Seeking Longer-Lasting Solutions

Due to its complexity and many as yet unanswered questions, managing the global spread of eczema requires a holistic approach. Although pharmaceutical developments may create increasingly effective treatments for eczema, prevention, destigmatisation, and alternative forms of support are key to minimising the impact of eczema on the global community.

Eczema prevention can begin as early as during pregnancy, by using predictors such as dry skin and allergen tests, and can extend beyond the impact on the individual by accounting for environmental risk factors. However, advocacy, destigmatisation, and managing environmental factors can prove to reduce the burden of eczema that has already developed. Eczema can be present early in infants - one study found that dry skin in 3 month old infants was a predictor of developing atopic dermatitis at 6 months old (34) - and importantly, use of probiotics during pregnancy and infancy has been found to prevent the development of atopic dermatitis (35). As well as this, presentation of atopic dermatitis is related to exposure to food allergens, and limiting exposure to these allergens has been found to reduce - to a degree - the severity of atopic dermatitis (5). Other methods of prevention include day-care attendance, consumption of unpasteurised milk in the first two years of life, exposure to dogs in the early years of life,  controlled UV light exposure, eating fish and fresh fruits (during pregnancy), and breastfeeding (20). Acting on these in a timely manner and minimising exposure to these risk factors can mitigate the development of eczema and aid with the management of the condition.

Whilst adjustments to lifestyle in early life may prevent the development of eczema, it is important to consider long term solutions for those who are unable to benefit from proactive action. As stated above, environmental risk factors are numerous, many of which unavoidable. Concerning the COVID-19 pandemic, overzealous hand washing and sterilisation of the working and living environments may be detrimental to those prone to developing eczema, yet necessary while facing the greater threat of the infectious disease.

Furthermore, destigmatisation of and public education about eczema may help reduce the psychological impacts for those that suffer from the condition; the expression or sharing of individuals’ experience of eczema may reduce psychological stress and ease the burden of the disease on the patient. Imber-Black (36) discusses the impacts of secrecy on chronic illness, arguing that the inability to discuss and share the experience of chronic illness can be detrimental to treating it. Eczema is incredibly common, yet it weighs heavily on the sufferers’ self-image. Therefore, being outspoken and sharing experiences about the condition and treatment - particularly because treatments can affect everyone differently - can reduce the stigmatisation surrounding eczema.

By

Jovana Ilkic and Joseph Blakemore

 Acknowledgements

We would also like to thank Israel Herrera-Ramirez, Irene Blomquist, Thembi Adams and Andjela Timotijevic for their comments and support in reviewing and editing the original manuscript.

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