This month I’m talking about eczema: what it actually is, and how it’s treated. Eczema (and simply having dry, sensitive skin) is a super common problem that I see in my job as a GP, and tends to effect more children than adults.

I think it’s really useful to understand a bit of the science behind what goes on in the skin of someone with eczema, as for me it makes knowing how to treat it effectively make a lot more sense!

{Types Of Dry Skin & Eczema}

Dry Skin

Normal skin is made up of layers, and the main function of the thin, outer layer, called the epidermis, is to form a waterproof barrier to prevent moisture escaping, and to stop bacteria and allergens from getting in. In eczema, the cells making up the epidermis are packed less closely together and so do not act as an effective barrier, resulting in moisture being lost, and making the skin more susceptible to infection and allergens.


As you can imagine, the result of this is the first stage of the complications of eczema: dry and sensitive skin. Therefore the first stage of treatment is to replace the skin’s lost moisture regularly, and also add an artificial waterproof barrier, in the form of moisturisers (emollients). This needs to be done as frequently as required for the individual, to avoid the skin drying out, which may be as little as once a day or as much as every few hours. In theory, if this first stage is treated effectively, application of regular emollients (and other measures to avoid the skin drying out, such as using soap substitutes and a bath additive) may be the only treatment required to keep the dry, itchy, sensitive skin of those with eczema under control, and prevent it getting worse.

Inflamed Skin

If moisture continues to be lost from the epidermis, inflammation of the skin then occurs through a few different routes. One is through scratching: dry skin becomes very itchy, and scratching irritates the skin, releasing chemicals called cytokines that cause redness, heat, swelling, and ironically more itching. Another is through allergens entering the skin, causing an inflammatory response (an allergic reaction in the skin) which results in the same: redness, swelling, heat, itching and sometimes pain. This kind of reaction may be called acute eczema or simply an eczema flare up.


The next stage of treatment, in addition to replacing moisture even more intensively with emollients, is to reduce the inflammation. A cold flannel/ice pack may provide some temporary relief to hot, angry itchy skin, but the medication that your GP will prescribe to settle a flare up is a topical (applied to skin) steroid. These come in varying strengths, depending on the severity of the flare up and where on the body the inflammation is, and your GP should advise you how often and how much to use, and for how long. Generally steroid creams should only be used to treat a flare up, and will not be beneficial in the first stage of eczema as described above. Steroid creams are very safe when used short term, but prolonged or continuous use can cause thinning of the skin and other side effects. An antihistamine may also help itching, and scratching should be avoided at all costs – in young children this may mean wearing thin cotton mitts at night.

Infected skin

The next complication that you may encounter is infection of the skin, and results from bacteria entering the epidermis – more likely if repeated scratching has resulted in raw, broken skin, or if the skin is very inflamed. This causes more redness and pain, sometimes weeping or crusting on the skin, and can lead to you/your child becoming generally unwell. You should suspect infection whenever there is significant or widespread redness of the skin, any pus or yellow crusting visible, or if your child has eczema and is also unwell with a fever.


You should always see your GP urgently if you suspect infected eczema, and you will generally be prescribed a course of oral antibiotics. If your child is very young or the infected eczema is severe, they may be admitted to hospital for this.

Chronic Eczema

The final stage of the complications of eczema is called chronic (develops over a long time) eczema, where repeated episodes of inflammation and scratching cause thickening of the skin, called lichenification.

In cases of severe, widespread or persistent eczema, your GP should consider referring your child to paediatrics or dermatology for a specialist review. An allergy should also be suspected when eczema is very resistant to treatment. Sometimes severe flare ups in children may also require an admission to hospital: wet wraps are sometimes used, where bandages soaked in emollients are applied, to constantly replace moisture as well as making it impossible to scratch!


I’m going to talk a little bit about the different types of emollients, as there are so many out there that it can be difficult to know what is best to use on yourself or your child.

The main problem I encounter with emollients is that they are underused: I can completely understand how this happens, as applying creams over the whole of your body several times daily is time consuming, messy and inconvenient, let alone chasing after an irritable toddler who hates having creams applied. However, if applied regularly, they can reduce itching, and reduce the number of flare ups leading to a reduced need for topical steroid treatment. In eczema, emollients should be used continuously, even after a flare up has cleared.

Emollients can be classed on their water content, or greasiness(!) as follows:

Lotions  – Creams/gels - Ointments
Least greasy – Most greasy

Non-greasy emollients i.e. lotions are easier and quicker to apply, and sink into the skin leaving minimal residue. However, the greater water content of an emollient, the more preservatives must be added which may cause irritation to very sensitive skin, and as they are less effective at replenishing the skin with moisture they must be applied more regularly.

A common lotion that may be prescribed by your GP is E45 lotion (not a first line emollient as it does not provide enough of a barrier).

Greasy emollients i.e. ointments are thicker, messier and more time consuming to apply, and leave a greasy residue on the skin. However, they contain less or no preservatives and are more effective emollients, so require less frequent application.

Some common ointments that may be prescribed by your GP are emulsifying ointment or Zeroderm ointment.

For many people, creams, the ‘middle of the road’ in terms of greasiness, are a happy medium.

Some common creams that may be prescribed by your GP are Epimax cream, Aquamax cream, Zerocream, Soffen cream, Ultrabase cream, Zerodouble cream or Oilatum cream. Some other well known creams such as Diprobase, Doublebase and Cetraben may also be prescribed but as they are similar to some of the creams mentioned above, but more expensive, they may only be offered if the first-line recommended creams do not suit you.

As a rough guide, the recommended quantity of emollient used for a child with generalized eczema is 250-500g per week (quite a large amount!)

Remember to use a soap substitute and bath additive as well as an emollient, as soap can dry out and irritate eczematous skin. Your regular emollient may be suitable for this, or your GP can prescribe these in addition. When I worked in the paediatrics department, one consultant used to always suggest adding a handful of oats or oatmeal to a bath (the active ingredient in Aveeno) – effective, if you can cope with fishing them out of your plughole afterwards!

I’m going to quickly slip in a note regarding costs of emollients, as most commissioning groups (the powers above that decide how much of the NHS budget each GP practice area can have) now stipulate some creams that cannot be prescribed on the NHS by GPs, as they are not proven to be any more effective than similar creams and cost the NHS significantly more. These rules are different in different areas of the UK, just to complicate things. As an example, in the area that I work, Aveeno cream is no longer prescribable other than in special circumstances (it costs the NHS £11.33 per bottle vs £2.49 for Epimax cream, which adds up to a lot extra over a year’s worth of prescriptions). This often causes frustration to parents, especially if they have had Aveeno on prescription in the past and are now being declined it, so I thought it would be useful to explain why this is.

Please let me know if you have any questions about anything I have mentioned in this post, and I hope it has been useful to you! Next month’s post will be my last for RMF for the time being, as in the next few months I will be both completing my GP training and welcoming my second baby into the world! I’ve really enjoyed being part of the RMF team this year, and thank you all so much for your wonderful positive comments every month.

Hannah x

{Childhood Eczema}

How To Diagnose And Treat Childhood Eczema

Image by Little Beanies.