Eczema and COVID-19: Questions and answers

“I think it is incredibly difficult for someone with eczema on their face to completely avoid touching their face. I also have eczema on my face and scalp and I have probably touched my face several times already typing this reply. There are techniques like registering the habit part of face touching and keeping your hands busy. The worst thing you can do is to tell your daughter “don’t scratch” as this will only make her more anxious and scratch more. Here is a good article on how to avoid touching your face https://www.bbc.com/future/article/20200317-how-to-stop-touching-your-face

Once at home, my honest view is that it is impractical to try and enforce your daughter not to touch her face. The reason why avoiding the eyes, nose and mouth is important is because they are a common route for the coronavirus to enter the body after contact from the hands. So the key thing is to make sure she washes her hands after outside contact and that she washes her face as well, so that both face and hands are “decontaminated” and therefore safe in the home again to do what she likes. But remember, although soap and water is the best way to wash off and kill the virus from the hands and face, it will also dry out the skin a lot, so it is really important to put plenty of moisturiser on the hands and face after washing. And if your daughter’s facial eczema is not in good control, then get control of it again with your anti-inflammatory creams

Sorry to hear that your hands are sore. It is difficult to say whether this is eczema without seeing your hands, but if they are red and itchy and sore as a result of frequent washing in soap and water, it could well be what we call irritant contact eczema. In other words, the soap and water has removed so much of the protective natural oils from your skin that it can’t take more. Tiny cracks appear that cause skin inflammation giving rise to dryness and red patches – usually starting in the finger webs, beneath a ring (if worn) and on the backs of the hands and wrists. If you have developed this for the first time, then I think it is worth having a telephone consultation with your doctor – sending them a photo if you can. Its sounds as if you definitely need a good emollients and if you have broken out in eczema, then you will need a topical steroid to get it under control again. Aggressive treatment of early hand eczema is important to avoid it getting a hold, and the most important thing is to apply plenty of emollient to your hands after washing – see the video that I did.

 For more information, please see https://dermnetnz.org/topics/irritant-contact-dermatitis/

And https://www.nhs.uk/conditions/contact-dermatitis/causes/

Good question, but probably not. Usually we use the term ”trigger” to describe something that sets of asthma in those that have already got asthma. Now there is evidence that viral infections can trigger worsening of asthma in someone who has already got it, but I could not find any evidence that a viral infection such as COVID-19 can start off asthma for the first time. There is a possible increase in asthma if your child had severe RSV infection in early life. The strongest risk factors for a child to develop asthma include parental asthma, environmental tobacco smoke before birth and prematurity.

 For more information, see https://www.asthma.org.uk/advice/triggers/

And https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5107168/

Good point, as alcohol is flammable. Hand sanitizers use alcohol because it is very good at penetrating the outer lipid coat of COVID-19 and killing it. Although most of the alcohol content quickly evaporates from your warm hands, I would suggest keeping your hands away from naked flames such as a candle, cigarette or gas hob if you have just applied some.

 https://safety.lovetoknow.com/Hand_Sanitizer_Fire_Hazard

Washing the hands in soap and water and alcohol-based sanitizers certainly reduces the overall load and disrupts the natural balance of microbes on the skin surface (harmful ones and beneficial ones). Nearly all of our knowledge on the skin microbiome of the hands is based in bacteria rather than viruses like COVID-19. Unlike some bacteria, COVID-19 is not a natural organism that normally lives on the skin of our hands, so it is unlikely that it would somehow multiply on the skin surface and take up a position where some of the normal skin microbiome was lost. COVID-19 needs mucous membranes (linings of the lungs, nose and eyes and mouth) not skin in order to multiply. Hands that are damaged from repeated washing can carry higher bacterial counts, but the significance in terms of disease transmission is still unclear. My advice remains the same for hand washing during the coronavirus pandemic - soap and water or sanitisers are probably the best way to reduce the possibility of spreading the virus from our hands.

https://www.ncbi.nlm.nih.gov/pubmed/19249642

Yes, that would be exactly my advice. The issue of what to do about people who need to take medicines that suppress the immune system for their skin problem has been thought about a lot by dermatologists and also those working in other specialties like rheumatology and gastroenterology where medicines like methotrexate are used a lot. A group of us in dermatology, led by Dr. Nick Levell, put a lot of work into this issue and came up with a grid on who or who might not need shielding during the pandemic which you can find here. It looks a bit complicated, but in a nutshell, as a young person on a single agent, your son does not need shielding unless there are other complicating factors such as diabetes, kidney disease or asthma. Your son should of course observe social distancing and observe good hygiene practices like everyone else. And if he did develop symptoms of COVID-19, he should stop his medication until well again. You can ask for a telephone consultation with your dermatologist or specialist nurse if needed. UK dermatologists would have by now looked through all their patients taking immunosuppressive medications and written to them if they were at increased risk. Some people might have had a similar letter from Public Health England. There is a useful list of frequently asked questions about skin patients taking immune suppressing medicines produced by the Guys and St. Thomas’ Hospital Dermatology team which you can find here.

That does not sound quite right. If you are otherwise fit and well, and only taking just methotrexate, then shielding is not considered necessary as was specified in the recent British Association of Dermatology Guidelines, reinforced by a NICE rapid guideline. Given the rush to try and protect the vulnerable during the pandemic, some people have been contacted in error, so if you are in doubt about whether you should be shielding or just observing normal social distancing, just check with your hospital consultant or the specialist nurse that normally looks after you.

I don’t think anybody knows if allergic conjunctivitis is a risk factor for infection, as none of the risk factor studies have collected this degree of detail to date. On an empirical basis, I would say that any breach of the conjunctival barrier (eg through allergic conjunctivitis) does make it easier for any pathogen to invade the mucous membrane (including staph aureus and viruses like herpes). But whether wearing eye protection decreases that risk is another unknown. I suspect that the dominant risk is failing to wash hand and then touching the eyes. Treating the underlying inflammation could also restore the conjunctival integrity to some degree. So great question but so many unknowns

It is true that some case reports from over the world suggest that a skin rash could be the first sign of COVID-19, although most reports suggest that COVID-19 associated rashes seem to start a few days after the infection has started. We don’t really know enough about the relationship between the various types of rash that have been suggested to be due to COVID-19 and the timing of the infection. What we do know is that the main types of rashes described don’t really look like eczema at all. So the commonest rash suggested to be associated with COVID-19 is a typical “viral” rash ie just non-itchy red blotches and little bumps on the skin, usually starting on the inside of both arms and legs and sides of the body. Some have reported a rash like hives (urticaria). Some have reported chilblain-like skin rashes too. But nobody has described a rash that looks like eczema or existing eczema worsening due to the virus. The rashes are almost always associated with other things like fever and/or new onset dry cough. Parents and young people are pretty good at recognising what eczema looks like and when it is getting worse, so I don’t think there is too much to worry about.

What a great question. COVID-19 is a new disease, so I am always cautious in coming out with dogmatic statements in the middle of learning more about it. The studies that have been published to date do not indicate that people with eczema are more at risk of contracting COVID-19, and there is no signal that they are more at risk of getting multi-organ failure and dying from the disease. So good news so far.

There is no evidence at present that COVID can cause eczema, or that it causes eczema to flare in someone who already has eczema. That does not mean it could not, but nobody has noticed it across the world yet in a convincing way.. Eczema seems to go up and down of its own accord, so if other things are happening around the time of a flare, it is easy to blame them for the flare whereas in fact it is a just the immune system going up and down. And if your child does get a flare, make sure you get control with a one week blast of your safe topical steroid cream and plenty of moisturisers. Constant hand washing can cause a flare for people with hand eczema, or it can bring on hand eczema for the first time -  but that is due to soap and water not COVID, and we give some advice about what to do for hand washing during the pandemic here.

Alcohol, usually in the form of isopropyl alcohol - not the alcohol you find in drinks, is included in sanitizer gels because it is effective in killing coronavirus. All sanitizer gels containing alcohol will sting the hands if the skin is broken in tiny places with eczema – whether it is 10% or 70%. Rather than search for lower alcohol gels, it is probably better here if Mum asks for a letter from her doctor/dermatologist to find an alternative means of sanitation at School such as soap and water followed by emollient as per our video PLUS getting much better control of the hand eczema cracks that are causing the problem with sanitizers in the first place. Stubborn hand eczema often requires stronger anti-inflammatory cream eg for a couple of weeks and plenty of emollients to get it under control. The key is then to keep it under control with weekend treatment as we explain in our online leaflet. Get control then keep control.

Thank you for an excellent question. Wearing a face-mask can certainly contribute to eczema flaring up on the face, and is more likely to happen in people with active eczema on their face. Wearing a mask, whether it is a standard surgical mask or a homemade cotton one, makes the skin around the mouth warmer and much more moist than usual. Normally, your breath moves away from your mouth in front of you, but a facial mask diverts the air into the space next to your skin that is relatively enclosed by the mask. Our breath is warm and moist - that is why you can see a cloud of vapour on a really cold day when you breathe out. Wearing a mask means that instead of your breath leaving the body, that warmth and moisture is pushed back all over your face, increasing the surface temperature (local heat can make eczema more irritable) and increasing the local humidity of the skin around your mouth and nose. When I wear an ordinary lightweight surgical mask at work in our hospital, my glasses mist up each time I breathe out – which just shows how much moisture is in our breath. My face also feels damp after wearing the mask even for a short time. And although adding moisture to dry eczema skin sounds like a good thing, it is the repeated wetting and drying of the facial skin that eventually wears down the skin barrier leading to worsening of eczema on the face. There are other problems with wearing masks including irritation around the tops of the ears and bridge of the nose – these are unlikely to be allergies but just irritations from close physical contact which can spark off eczema in these sites.

• Thinking about what can happen with face masks in people with an eczema tendency, and how it can happen helps us to understand how to prevent and treat facial eczema problems with wearing face masks. Here are my tips:
• Find or make a mask that fits comfortably for you ie that does not pull on your ears too hard or rubs the bridge of your nose.
• Only wear the mask for short periods when you really have to.
• If you have dry skin and/or eczema on your face, then use a light moisturises on your face each day, and re-apply it before and after taking your mask off – that will help to protect your skin barrier and stop it getting soggy then dry, or too warm and irritated.
• If your facial eczema does flare up, get on top of it by treating the skin inflammation properly with a mild topical corticosteroid like 1% hydrocortisone (which is very safe) for say 3 days and then go back to using lots of moisturiser.

Our facial skin is very special and is not used to being enclosed in a warm moisture chamber, so it is important to think about how to adapt to wearing masks during the pandemic and to invest some time into preventing and treating the problems that can occur.