Clinical Manifestations of an Eczema Flareup
An eczema flareup presents with erythema (redness), edema (swelling), xerosis (dry skin), erosions/excoriations from scratching, oozing and crusting, and lichenification (thickened skin), with intense pruritus (itching) being the hallmark feature. 1
Primary Clinical Features
Acute Phase Manifestations
- Erythema and edema are the initial presenting signs of an active flareup 1
- Oozing and crusting develop as the inflammatory process progresses, particularly when bacterial infection supervenes 1
- Vesiculation may occur, appearing as small fluid-filled blisters on inflamed skin 1
- Erosions and excoriations result from intense scratching behavior 1
Chronic Phase Features
- Lichenification develops with persistent inflammation, characterized by thickened, leathery skin with accentuated skin markings 1
- Hyperpigmentation occurs in chronic lesions 1
- Xerosis (generalized dry skin) persists throughout and between flares 1
Distribution Patterns by Age
Infants and Young Children (Under 4 Years)
- Cheeks, forehead, and outer limbs are predominantly affected 1
- Lesions may appear on extensor surfaces 1
Older Children and Adults
- Flexural involvement is characteristic, affecting folds of elbows, behind knees, and around the neck 1
- The face, hands, and feet may also be involved 1
Hallmark Symptom: Pruritus
Intense itching is the defining feature that distinguishes eczema from other dermatoses and is responsible for much of the disease burden 1. The pruritus often leads to a vicious itch-scratch cycle that perpetuates inflammation and skin damage 1.
Signs of Infection During Flareup
Bacterial Infection (Most Common)
- Crusting and weeping suggest secondary bacterial infection, typically with Staphylococcus aureus 1
- Golden-yellow crusting is particularly characteristic of bacterial superinfection 1
Viral Infection (Eczema Herpeticum)
- Multiple uniform "punched-out" erosions or vesiculopustular eruptions that are very similar in shape and size indicate herpes simplex infection 2
- Grouped vesicles and erosions are characteristic of eczema herpeticum, which requires urgent recognition and treatment 1, 2
Common Pitfalls in Recognition
Do not confuse eczema flareups with other conditions that may present similarly 1:
- Contact dermatitis typically has atypical or localized distribution corresponding to allergen exposure 1
- Psoriasis shows less pruritus and lacks eczematous changes like oozing/crusting 1
- Scabies presents with inguinal, axillary, and genital papules with characteristic burrows 1
- Seborrheic dermatitis shows greasy yellowish scaling without significant pruritus 1
Deterioration in previously stable eczema warrants investigation for secondary bacterial or viral infection, or development of contact dermatitis 1. Bacteriological swabs should be obtained if patients fail to respond to standard treatment 1.