Should I be worried about fractures?

This article was first published in the March 2020 edition of National Eczema Society’s membership magazine, Exchange.

A major new study has found a clear link between eczema and bone fractures. But what does it mean for people with eczema? Eleanor Stanley gets the detail behind the headlines.

There has long been speculation that fracture rates seem higher in people with eczema. But when the London School of Hygiene and Tropical Medicine published findings based on nearly three million people’s medical records, including 526,808 with eczema, it became clear: there is undoubtedly a link.

Causal or correlative?

What is less clear is what is causing it. Does having eczema directly cause an increased fracture risk – in other words, is it a direct result of eczema? Or is the increased risk due to something else associated with having eczema, such as treatment or other factors?

The researchers were careful to check one important element: had people ever taken a high dose of oral steroids. This is to make sure the results were not actually to do with people receiving these medications, as they are already known to increase risk of fracture. But the risk of fracture persisted even when the researchers took into account high doses of oral steroids.

They also adjusted the data to take into account other factors such as age, body mass index (which helps assess if someone is over- or underweight), alcohol use and socioeconomic status. But they found that there was still an increased fracture risk in people with eczema – particularly in hip, pelvic, spinal and wrist fractures. Among people with severe eczema, the risk was higher.

The question of whether eczema causes fractures is an important one because many people living with eczema make adjustments to their lifestyle – such as diet or exercise – to help manage the symptoms of eczema or other conditions that are common in people with eczema, such as allergies. And it is possible that these lifestyle choices could make them at higher risk of fractures.

For example, cutting out dairy foods might result in a diet that is low in calcium, which could increase the risk of osteoporosis. For some people, sweat increases the itch so much that they avoid exercise – again, increasing the risk. Diet and exercise were not included in this study and will hopefully be looked at in future research as we do not know how they affect fracture risk in people with eczema.

Bone density

When we look at fractures, the key issue is bone density – literally how much space there is between the structures of the bone. The more dense the bone, the stronger it will be and the less likely it is to fracture or break. Where bone density is low and brittle, this is known as osteoporosis.

Many different groups are at higher risk of this, including women over 65, men over 75 and people who have been taking high doses of oral steroids over a long period of time. There are a host of other risk factors, including smoking and early menopause.

NICE guidelines already recommend that GPs screen people at higher risk of fracture, using tools such as FRAX and QFracture, to see if they need bone scans to test bone density.
The findings do not yet show whether further screening is needed, explains the study’s lead researcher Professor Sinéad Langan: ‘There are still questions to be addressed by future focused research about what is driving the increased fracture risk identi ed in this study and whether additional screening is warranted in those with atopic eczema, beyond the existing recommendations from NICE (the National Institute for Health and Care Excellence).’

Navigating health risks

When it comes to health, statistical risk can sometimes cause unnecessary concern. The study found that the risk of fracture was up to 13% higher for people with eczema.

And among people with severe eczema, the risk was ‘dramatically’ higher: 50% more hip fractures, 66% more pelvis fractures and more than 100% more spine fractures.

For anyone with eczema, those gures would raise alarm bells. But, Langan emphasises: ‘The overall risk is still very low.’

To put it into context, if you compared a group of 100,000 people with eczema with another group of 100,000 people without eczema, there would be 164 more fractures or breaks in the eczema group. Overall, then, the risk is still very small but higher than for the general population.

What you can do

At present the NICE guidelines for osteoporosis screening do not include people with eczema. However, if you have severe eczema and are concerned, talk to your GP about your risk and mention the NICE guidelines.

In the meantime, what this research may do is offer a nudge to make sure that you or your loved ones with eczema follow the general guidelines to strengthen your bones, which reduces the risk of osteoporosis.

Langan highlights that the study only tells the first part of the story: ‘If a risk existed, we wanted to identify it. Our next job is to determine what is driving the risk.’

Building up the evidence base on health is a painstakingly slow business, and what happens next will be down to the next piece of research.

Tips to reduce risk of osteoporosis – NHS guidelines

  • Take regular exercise, including aerobic exercise (such as cycling or swimming), weight-bearing exercise (such as brisk walking or dancing) and exercises to increase muscle strength (such as press ups or pilates).
  • Take a daily vitamin D supplement.
  • Don’t smoke.
  • Eat a balanced diet that includes foods rich in calcium and vitamin D.
  • Keep alcohol consumption within the government guidelines of up to 14 units per week for men and women, with some alcohol- free days.