Excoriation, and What It Means for People With Atopic Dermatitis

Excoriation: It’s a scary word for a really common problem among people with unrelenting itch due to atopic dermatitis.

“Excoriations really mean scratch marks,” said Adelaide Hebert, MD, professor of dermatology and pediatrics at the University of Texas Health Science Center in Houston.

It’s an issue, she said, because when people with this chronic, inflammatory skin condition scratch themselves, they further destroy their already defective skin barrier.

The trouble is atopic dermatitis is extremely itchy. People who have it often cannot resist the urge to dig their nails into their skin, and scratching can worsen skin symptoms, which causes more itching.

"Say you have an itch you can’t scratch. I have that feeling all the time," confessed Natalie Zill, a 24-year-old resident of Ventura, Calif., whose atopic dermatitis reemerged three years ago.

“It’ll be so bad that I’m scratching ‘til I’m bleeding,” she said. “It looks probably like I’m a burn victim.”

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The skin is the body’s largest organ. Normally, it retains moisture and hinders external threats, preventing germs and allergens from entering the body. But in people with atopic dermatitis—the most common form of eczema—their suit of armor is compromised. Scientists think it has something to do with defects in the skin due to a genetic mutation of the fillaggrin gene.

As a result, allergens and irritants that trigger skin symptoms can sneak through.

"I tell my patients to think about their skin being covered in polka dots. The water can come out and the trigger factors can come in," Dr. Hebert said.

Scratching also creates a port of entry for viral and bacterial infections. And people with atopic dermatitis have more Staphylococcus aureus (a common bacterial cause of skin infections) residing on their skin, so "when they scratch, they introduce the Staph into their skin," she said.

Other germs can invade the body as well.

When the herpes simplex virus (which causes cold sores or fever blisters) enters the skin though a deep scratch or open wound, eczema sufferers can acquire eczema herpeticum, a dangerous complication that can lead to widespread infection and even death.

Relentless scratching also thickens the skin, and those thick skin patches don’t respond to topical treatments, says Jon Hanifin, MD, professor of dermatology at Oregon Health & Science University in Portland.

"We don’t want them to thicken their skin; we want them to stop scratching. But we can’t tell them to do that; we have to use good medicines to make them stop,” he said.

There’s a greater risk of scarring if the excoriations become infected, Dr. Hebert cautioned. Fortunately, skin is resilient. It can rebound from superficial scratch marks. And most excoriations aren’t deep enough to leave a scar, anyway, she said.

“Most often, these excoriations will resolve,” she says. “They can indeed scar, but for the most part they do not.”

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People can also get post-inflammatory hyperpigmentation. That’s a temporary darkening where the skin was inflamed or injured due to eczema rashes or scratching. It goes away, but it may take a couple of years for the discoloration to fade, Dr. Hebert said, who is at Houston's McGovern Medical School and Children's Memorial Hermann Hospital.

Patients with excoriations can begin the healing process by taking steps to repair their damaged skin barrier. Having an action plan for dealing with excoriations and preventing symptom flare-ups, including a rigorous bathing-and-moisturizing routine, is crucial.

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Taking bleach baths may be one way to prevent infection in people with excoriations. The American Academy of Allergy, Asthma & Immunology recommends adding one-half cup of household bleach to a full tub of water. Soak for 10 minutes twice a week. Rinse with fresh water, pat dry, and moisturize. (Parents, consult your pediatrician or dermatologist before giving your child a bleach bath.)

To repair the skin barrier, people with eczema also need to replenish the skin’s ceramides, which are naturally occurring fat molecules that help keep skin moist. People with atopic dermatitis have lower levels of these fatty substances in their skin, even when their skin looks normal and isn’t itchy, Dr. Hebert explained. Applying ceramide-containing creams 2 to 3 times a day is very helpful, she said.