Atopic Eczema – a brief overview

What is Eczema?

Eczema or dermatitis refers to a non-infectious disorder that is characterised by water between the skin cells if examined under the microscope. The term eczema encompasses a group of heterogeneous conditions that have many different and overlapping clinical features and many of these features may be found in one individual.  It is possibly for this reason members of the public and non-dermatologists sometimes find it difficult to diagnose eczema. Sometimes even the most experienced dermatologists need a skin biopsy to make the diagnosis of eczema. The skin in eczema is more susceptible to irritation by soaps, contact irritants, coarse fibers in clothes, high ambient temperature and weather changes.  In this article we will use pictures to briefly describe the different conditions that are referred to as eczema and their associated or differentiating features.

What is Atopy?

Atopy is a general term used to describe an inherited susceptibility to allergies on the skin, lungs and mucosal surfaces. The conditions that make up atopy are eczema, hay fever (or sinuses as sometimes incorrectly referred) and asthma. If one of the parents has personal or family history of these conditions their children a predisposed to develop eczema. If this applies to both parents, the life-time risk for their children is even higher. “Atopic march” or “allergic march” refers to the natural history or typical progression from one to the other of the three allergic diseases during a life-time.

Atopic eczema is common and, in some countries, affects up to 20% of children.

What are the features of Atopic Eczema?

The character of the lesions and their distribution in atopic eczema, varies markedly between individuals, age groups and affected parts of the body.  In infancy, the cheeks are usually the first to be affected becoming red, sometimes weepy, dry and scaly. The nose is usually spared. Overtime the rash spreads to other parts of the body. 

As the child mobilizes and up to starting school, the rash tends to mainly affect extensor surfaces of arms and legs as well as the groin. In later preschool years and school-going age, the body folds tend to be the most affected. The most notable folds are the elbows and knees. Other body folds that may be affected include eyelids, earlobes, angle of the mouth, the neck and greases of the buttocks. 

In adulthood, the rash is more variable. The childhood patterns may be maintained with additional involvement of the nipples, lips and hands.  With time and scratching, the skin in the affected areas changes colour and become thickened, a feature called lichenification. 

Both children and adults with atopic eczema may develop recurring intensely itchy ‘coin-like’ or ‘ring-like’ lesions called nummular eczema, most often on the arms and legs. Depending on the age of the lesions these can be weepy or dry and scaly. With time and scratching, the lesions of nummular eczema can become darker and thickened.

Is Atopic Eczema curable?

Although most atopics outgrow their eczema, it persists in about 5% of patients who had the disease as children. However, the predisposition of atopics to skin sensitivity and susceptibility to allergic reaction persists for life.

Comment

The diagnosis and management of atopic eczema can be difficult and an initial consultation with your dermatologist to get a definitive diagnosis and a management plan may save your family large amounts of money and years of discomfort.  

Professor Rannakoe J Lehloenya

Alopecia series - Traction

Traction alopecia

The word alopecia refers to loss of hair regardless of cause.

What is Traction Alopecia?

Traction alopecia is just one type of alopecia caused by repeated or prolonged pulling of the hair. Traction most often affects the hairline, the front and the sides being the most common. 

What causes Traction Alopecia?

The pulling of hair creates tension that extends deep to the roots of the hair. Traction creates inflammation around the root of the hair (also called hair follicle). The hair follicle is effectively the factory that produces hair. If the factory, in this case the hair follicle, is damaged, it will either produced abnormal or reduced quantities hair. In extreme cases, the damage is permanent, and that area will never grow hair again.

In the case of traction alopecia, the persistent traction results in inflammation of the hair follicle and over time the cells that invade the hair follicle to repair the damage end up causing permanent damage to the hair follicle (the hair factory), resulting in permanent hair loss. 

Who gets Traction Alopecia?

Traction alopecia is related to hair grooming practices or hairstyles as they are more commonly known. Females of African descent tend to be the most affected because of the type of hairstyles they prefer. These include braids, weaves, twisted dreadlocks, tight ponytails and hair extensions. Other less recognized causes of traction alopecia include hair pins, tight fitting headwear and heavy ornaments attached to hair. A study conducted in Langa, Cape Town by my colleagues Professor Nonhlanhla Khumalo and Doctor Sue Jessop showed that people who pulled their hair while it was relaxed, tended to have more severe traction alopecia over time. People who give a history of relaxing their hair, pain, itch, pimples and burning after one of the above-mentioned hairstyles are at a higher risk of developing traction alopecia.

How does Traction Alopecia look like?

This depends on the stage of the disease. In early stages, the hair loss may not be visible to a naked eye, only a slight reduction in hair density. What may be visible is inflammation of the hair follicle, called folliculitis, seen as redness, pimples, pustules and scale in the affected area.  Often this is associated with pain or itch. The typical picture is repeated patting of the scalp in the affected area or using cold compresses after the hairstyle to relieve the symptoms. At this stage, the alopecia is usually reversible.

With progression, the hair in the affected area progressively thins until there is complete loss. On close inspection, early on the hair follicles are still visible but with time only a shiny smooth surface results. The smooth surfaces indicates irreversible damage of the hair follicles and scarring of these follicles and surrounding tissues. There is often a fringe of fine hair that is preserved at the edge. This hair was too small to be incorporated into the hairstyle, thus it was spared the traction.  

What can you do to prevent Traction Alopecia

Change hair grooming practices to safer ones

If you still wish to have any of these hairstyles:

§  Tell your hairdresser in advance and clearly what you want

§  Make sure the pulled hair is comfortably loose enough and not too tight

§  Listen to your scalp or your child’s complaints – if it is uncomfortable, it is not good for your scalp

§  If it is uncomfortable, undo it as soon as possible regardless of cost

How do we manage Traction Alopecia

Correct diagnosis by a doctor and staging of the disease are essential before embarking on any treatment.

Available treatments include topical steroids, topical minoxidil, oral antibiotics and hair transplantation. All these become increasingly less effective with advancing Traction Alopecia. Even hair transplantation is not effective in advanced disease because of the scarring that affects the surrounding tissues. It is equivalent to planting a seed on barren rock.

Last word

The best treatment for Traction Alopecia is prevention by using correct hair grooming practices from childhood. As I often say to my patients with early disease – Listen to me now or you will forever have a bigger face to wash and a smaller head to comb.

Professor Rannakoe Lehloenya

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