The Stages of Eczema Suffering & Healing

The beginning stages of an eczema flare may be subtle, but early identification is crucial to prevent the condition from progressing further. Signs and symptoms in the early stages of eczema can include:

• Dry, flaky skin

• Small bumps or papules

• Mild itching and redness

These early symptoms can be easily mistaken for other skin conditions or simply dry skin. They typically occur shortly after exposure to a trigger and are indicative of a histamine and Th2 immune response.^{(BEI 2012)}

The first few days of a flare we call the “early flare”. You could think of this as your moment of “sixth sense” where you think a flare might be coming, all the way to where you are starting to think of a doctor’s visit a few days later. 

Treatment in the early flare stage should focus on reducing or removing the trigger and calming additional inflammation. A symptom journal can help identify the trigger. Treatment options to consider in the early flare stage include: 

• Antihistamines to reduce itching and swelling

• Trigger avoidance and management

• Icing to sooth inflammation

• Moisturizing

• Dietary adjustments diet and nutrition

• Topical steroids to reduce inflammation, prescription strengths may be used in more severe cases

In the mid-flare stage, if triggers have been removed (which may be hard to do), the flare is now being driven largely by skin barrier “weakness” and the immune system itself.

All of the above treatment options still apply. Consider adding the following in the mid flare stage:

• Phototherapy - specifically UV-A1 ^{(BEI 2012)}

• Topical calcineurin (TC) inhibitors for control

• Immune modulators

The subacute stage, also known as the "healing stage," occurs as the skin begins to heal. Symptoms in this stage include itching, dryness, scaliness, thickening of the skin, and cracking or weeping. The skin is less red and inflamed compared to the acute stage but may still experience occasional flares meaning the healing is not necessarily linear. 

Treatment during the subacute stage focuses on moisturizing dry skin and facilitating the healing of the skin barrier. This can be achieved through:

• Continued use of moisturizers

• Topical steroids, potentially weaning off their use

• Maintenance phase of TC inhibitors

• Soothing baths, wet wraps, washing and other symptom management

• Trigger avoidance and lifestyle adjustments

• Continued use of antihistamines

Escalations in treatment to more systemic immunomodulatory medication may be considered for severe and enduring cases. See the ‘medical treatments’ in the immune control part of treatments and discuss this with your doctors if you think this is applicable for you.

If a flare persists for an extended period of time, it can enter the chronic stage where a feedback loop occurs and the flare persists. Symptoms include thickened, scaly skin, discoloration, and persistent itching and dryness. This stage takes months to establish and can be caused by ongoing triggers, genetic susceptibility, or constant scratching.

Chronic eczema requires a different treatment approach to acute and subacute eczema, focusing on identifying the changes necessary to break the cycle of symptoms while maintaining daily skin care. Chronic eczema can lead to a heightened Th1 immune response, with a delayed hypersensitivity.^{(BEI 2012)} Treatment should involve:

• Review of trigger avoidance with careful investigation into stress, outstanding lifestyle changes, environment, allergies and intolerances and food

• Support healthy gut through proportionate review of diet and nutrition

• Consistent moisturizing

• Increased potency topical steroids

• Continued use of TC inhibitors

• Microbiome support

• Phototherapy, ideally NB UV-B

For moderate and severe cases which do not respond to first-line treatments, escalating to systemic immunomodulatory medication will be necessary. The objective is to interrupt the inflammatory processes which are preventing the skin from healing. Some options include:

• Monoclonal antibodies

• JAK inhibitors

• Immunosuppressants

• In certain circumstances, oral steroids