Understanding Eczema Part 4: Patterns and Phases
There are a couple of ways to categorize the phases (stages) of eczema: by patient age and/or by duration of illness.
By patient age:
- Infant Phase (under age 2): Atopic eczema typically first appears in infants, though it may change over the course of time . Babies with rashes should always be evaluated by a physician and in this case it is helpful to differentiate eczema from seborrheic dermatitis (“cradle cap”) miliaria rubra (heat rash). In the infantile phase of eczema, lesions most often appear on the cheeks, forehead and scalp, though may include the limbs and torso. Itchiness can lead to scratching which worsens the lesions. They can become crusty and the discomfort from itching can lead to much crying and disturbance of sleep for the baby.
- Childhood Phase (age 3 to age 12/puberty): In this phase lesions most often are seen in the creases at the elbows and knees, around the neck, and at wrists and ankles. Poor eating habits begun during this phase make it more likely that the patient will continue to suffer eczema during adolescence.
- Adolescent/Adult Phase (puberty to early 20’s and beyond): The lesions are most often found in the creases at the elbows and knees as well as around the neck. Skin becomes drier and thicker where scratched. Hands may become involved after coming into contact with irritants that trigger the eczema.
By duration of illness:
- Acute eczema (original onset or an acute flare-up): Original onset of atopic eczema typically occurs in infancy and most cases appear by the early 20’s. Acute flare-ups can occur at any time during the course of the disease. Various types of skin lesion may be present during this phase: erythema (redness and inflammation), papules (tiny bumps), and vesicles (little bumps filled with fluid). During this stage, lesions are progressing in severity of symptoms; growing in number; and/or covering a larger area or more areas of the body. The lesions can become infected.
- Subacute eczema: In this phase, there is less redness and swelling, fewer vesicles or less exudate, smaller papules (bumps), and more dryness developing. Subacute eczema can revert back to the acute stage if it becomes more severe or it can linger on to develop into chronic eczema.
- Chronic eczema: This stage occurs when the illness has existed for some time. The lesions are drier, thicker, rougher, have scaling, and there may be more fissuring or cracks in the skin. The lesions may stay hyperpigmented (darker) after healing.
With regard to Traditional Chinese Medicine (TCM), there are many possible TCM patterns that correspond to the western diagnosis of atopic eczema. Practitioners should differentiate based on the presentation of lesions and patient history, and not just adhere to the list of TCM patterns I cover here. Treatment should definitely include internal herbal medicine as atopic eczema definitely has underlying imbalances that cannot be effectively treated just using topical substances; though topical herbs can be quite helpful to ease symptoms such as itching, oozing, flaking and redness. Diet improvements must also be considered for each patient.
In both infants and children, the most common TCM pattern is Damp Heat. For internal herbal treatment, it is important to determine which pathogenic factor is more predominant: Damp or Heat. More exudate or weepy/oozing lesions indicate more Damp. When Heat predominates, there may be more redness but there will also be more itching and dryness. Chubbier babies who tend to sweat more tend to be more prone to a Damp condition. Their eczema will likely have more exudate and lesions will form yellow crusts when they dry. Thinner or weaker babies have a tendency to develop the drier type of eczema where Heat is more predominant (some sources differentiate this from Damp Heat and call it Fetal Heat). In this type, the lesions will not be very weepy and there will be more dry, flaky crusts that look like white or gray “bran-like” scales on top of the lesions. There might be cracking (fissuring) of the skin or even bloody scabs if scratching is intense. In infants who are dependent on formula or in children who have a poor diet (lots of sugary foods, milk and dairy products, fatty or greasy foods), there will also be underlying Deficiency of Spleen and Stomach. The TCM pattern of Damp Heat accounts for most cases of acute eczema regardless of the age of the patient. Both Damp Heat and Deficiency of Spleen and Stomach are a possibility in subacute stages of eczema.
The TCM pattern of Heat in the Blood is also a possibility during the childhood phase as well as the adolescent/adult phase. Though some Damp Heat may also be present, this pattern presents as the drier type of eczema, with more redness and more intense itching than when there is only Damp Heat. Heart Heat is typically the source of the Heat in the Blood. Heat in the Blood pattern can occur in the acute or subacute stages of eczema.
Most chronic stages of eczema are seen in the adolescent/adult phase. The skin is thicker, drier, rougher and may have scaling. These cases are most often (but not always) diagnosed in TCM as Blood Dryness Due to Damaged Yin with Accumulation of Dampness. This develops over a long period of time from Damp Heat. The Heat damages Yin (the moistening and cooling factor in our bodies). When the Damp accumulates in the skin and oozes out, this exudation also damages Yin. This all leads to dryness. There may also be Blood Stasis if the lesions remain hyperpigmented after healing. This condition can be quite complicated. We must first Eliminate Dampness and then also Tonify/Move Blood and Nourish Yin.
In addition to addressing the patterns described above, most eczema presentations are also accompanied by Fire Toxins and Wind. Herbal formulas for eczema should also include herbs to Resolve Toxins (to treat the over-proliferation of staph bacteria often present) and to Dispel Wind (to address the itching).
Publish Date: November 16, 2010 *Articles may include updates since original publishing.