Eczema News – Gene Mutation Identified

Scientists from the National Institute of Allergy and Infectious Diseases (NIAID) have identified a gene mutation called CARD11 that led to atopic dermatitis/ eczema. Their findings were recently published in Nature Genetics (June 2017)1. Gene sequencing was performed for 8 individuals from 4 families, and the researchers found that although each family had a distinct mutation affecting a different region of the CARD11 protein, each mutation disrupted its normal function in T cells – an essential type of white blood cell.

The potential of this study was that glutamine may correct the defective signally mechanism of the mutated CARD11. Glutamine is available as a supplement, and the researches intend to study the effects of glutamine consumption on individuals with CARD11 mutations/ severe eczema. If the future study proved conclusive, it would open an easy therapeutics method for treating eczema!

Genetic mutation Eczema

References:

Germline hypomorphic CARD11 mutations in severe atopic disease
Chi A Ma, Jeffrey R Stinson, Yuan Zhang, Jordan K Abbott, Michael A Weinreich, Pia J Hauk
Nature Genetics; Jun 19, 2017

Science Daily New genetic mutations linked to eczema

Independent trial showed No Significant Benefit of Silk Clothing for Eczema kids

An eczema study1 published in April 2017 showed that there was

little evidence of clinical or economic benefit of using silk garments in addition to standard care, compared with standard care alone, in children with moderate to severe eczema.

As always, the team of researchers from the University of Nottingham in the U.K had taken on clinical studies that address questions raised by doctors and patients, with the view of having a direct impact on clinical practice. They had conducted very practical studies like softened water eczema trial and compared the efficacy of a short burst of potent topical corticosteroids versus prolonged period of mild corticosteroids. Their website also maps out the systematic reviews on eczema and list their ongoing studies (also found at the bottom of this post).

For this study, the key points are below:

Nature of study: Parallel-group, randomised, controlled, observer-blind trial

Participants: Children aged 1 to 15 year old with moderate to severe eczema; 300 children were included: 42% girls, 79% white, mean age 5 year old

Randomized groups: Participants were randomised to receive standard eczema care plus silk clothing (100% sericin-free silk garments; DermaSilk or DreamSkin) or standard care alone.

Measurement: At baseline, 2, 4 and 6 months against the Eczema Area and Severity Index (“EASI”)

Outcome: No evidence of a difference between the groups in eczema severity (EASI score) assessed by research nurses

Purpose of the study: Silk clothing is available on prescription (and online) but the randomized controlled trials previously done were for small group of participants. To provide direction for clinical practice as to whether to recommend silk clothing, this study was taken on. Silk garment claimed beneficial for eczema as they are smooth, helped regulate humidity and temperature, reduce scratching damage and have anti-microbial properties. These are important qualities that would benefit eczema to reduce scratching (versus a ‘scratchy’ fabric like wool), keep the skin cool and reduce likelihood of flucuating temperature triggering eczema flareups and reduce bacteria load as eczema skin is prone to staph bacteria colonization. However, from the outcome of this study, it would appear that standard eczema care such as regular emollient use and topical corticosteroids (or topical calcineurin inhibitors) for controlling inflammation would be adequate.

Study by the researchers at the University of Nottingham, UK on Efficacy of Silk Clothing for Eczema Children

Study by the researchers at the University of Nottingham, UK

Practical implication:

In my view, this study would really get parents who are spending a lot of money on silk clothing/ bedding to question if such money needs to be spent. These silk garments are not cheap but parents pay for them due to positive testimonies, anti-inflammatory/ anti-microbial properties of silk and that these clothing are soft, free of dye and will not irritate the skin (interviewed Dermasilk here). However, a lower-cost alternative of cotton may work as well, with standard care for eczema.

I’ve also contacted Professor Kim Thomas who is part of the research team for this study and she kindly shared this video on University of Nottingham’s website

Please refer to the CLOTHES Trial page here for information sheets for children of various age group.

My personal take is if you’re seeing benefits for your child with silk clothing and can afford it, there is no reason to stop using the clothing. However, if it hasn’t seemed to make much difference and you feel confident that the eczema therapeutics measures that you use for your child are sufficient, then it makes sense not to spend that money. See this post for the review of various eczema therapeutics and also the review study that Nottingham University had done.

References:

Silk garments plus standard care compared with standard care for treating eczema in children: A randomised, controlled, observer-blind, pragmatic trial (CLOTHES Trial) Thomas KS, Bradshaw LE, Sach TH, Batchelor JM, Lawton S, et al. (2017) Silk garments plus standard care compared with standard care for treating eczema in children: A randomised, controlled, observer-blind, pragmatic trial (CLOTHES Trial). PLOS Medicine 14(4): e1002280. https://doi.org/10.1371/journal.pmed.1002280

Ongoing studies at Centre of Evidence Based Dermatology at Nottingham University:

Bath Additives in the Treatment of Childhood Eczema

Barrier Enhancement for Eczema Prevention (The BEEP Study)

Understanding the long-term management of eczema

Skincare intervention in Nurses

A is for Atopic March

A for Atopic March - Does Atopic Dermatitis march off to something else?We’re still at the letter A and the last one was on the confusing nomenclature of Eczema versus Atopic Dermatitis. This week (pardon last week’s absence, can’t promise it won’t happen again though as I’m so tied up with work, family and doing other things I enjoy) we’re onto Atopic March. Sometime last year, DrFelix.co.uk (a registered online UK doctor and pharmacy service) contributed a write-up on Atopic Triad, which covers eczema, asthma and allergic rhinitis (hay fever).

Atopy is a genetic tendency to develop certain allergies. Most commonly, Eczema, Asthma and Hay Fever. In fact, if either parent has at least one of the three, there is a high chance that their child will also develop the condition. In these three ailments, the body areas become inflamed and produce excess immunoglobulin E (IgE) in response to harmless stimuli such as dust or pollen.

It is very common for people who experience eczema to also have asthma and hay fever. The connection between these conditions can be summarised by one word: hypersensitivity.

The body including the skin and respiratory system are over sensitive towards certain substances and they overreact when exposed. Rashes on the skin and a congested nose are all ways in which the body is trying to protect itself from something that it deems to be harmful. Unfortunately, this overreaction can be very uncomfortable and unnecessary.

There are also other connections between the Eczema and the development of Asthma. 50-70% of children with Eczema go on to develop Asthma. Recent research undertaken by Washington University School of Medicine has discovered that Eczema damaged skin produces a protein called thymic stromal lymphopoietin (TSLP). TSLP has also been found to directly cause asthma symptoms. This research is still in its early stages and this mechanism has not yet been fully confirmed in humans, but it shows a promising new direction for pharmaceutical research that may be able to stop the development of secondary conditions in their tracks.

Byline: Dr Samuel Malloy, Medical Director at DrFelix.

We understand that atopic conditions are related, in the sense one’s hypersensitivity may manifest in other than skin. But what about the term Atopic March? Does one condition literally marches your child off to another?

While it is more commonly noted that Atopic Dermatitis (Eczema) progresses to asthma and hay fever, the progression is not the same for every child.

Some recent research on this:

Skin Barrier Dysfunction and Atopic March 1 – It was noted in the study that the atopic conditions should be viewed as causally related, as they are conditions related to the lack of filaggrin gene. Recent studies on skin barrier dysfunction suggest that if we can treat the skin defects early, there is a chance of stopping the progression to other atopic conditions.

The Atopic March: Progression from Atopic Dermatitis to Allergic Rhinitis and Asthma 2 – It was noted that the “concept of the atopic march has been supported by cross-sectional and longitudinal studies“; however, “whether AD in the march is necessary for progression to other atopic disorders remains to be defined”. The conclusion was that it is important to identify infants at risk as it presents a critical window of opportunity for therapeutic intervention.

Increasing Comorbidities Suggest that Atopic Dermatitis Is a Systemic Disorder 3 – The associations (even though causality is not proven) showed that AD is linked to the whole body, not just the skin.

Thus, while we see a progression of atopic conditions in a majority of children with eczema, it may not be a “march” of one onto another – not all children undergo the progression, and a few conditions may co-exist. What looks certain (and practical) is that there is urgency to treat the skin during infants as untreated eczema increases risks in many ways > scratching resulting in infection, dry and ‘porous’ skin to more opportunities for sensitization. Extract from WorldAllergy.org below:

From WorldAllergy.org

Atopic March is frequently misunderstood as the development from minor symptoms over a mild disease expression towards more severe chronic manifestations. It also has been misinterpreted as the exclusive development from atopic dermatitis in infancy to airway disease, particularly asthma in school-age. These interpretations have been shown to underestimate the variations and heterogeneity of atopy development during the first decade of life.

References:

  1. Clausen, ML., Agner, T. & Thomsen, S.F. Curr Treat Options Allergy (2015) 2: 218. doi:10.1007/s40521-015-0056-y

  2. Zheng T, Yu J, Oh MH, Zhu Z. The Atopic March: Progression from Atopic Dermatitis to Allergic Rhinitis and Asthma. Allergy Asthma Immunol Res. 2011 Apr;3(2):67-73. https://doi.org/10.4168/aair.2011.3.2.67

  3. Increasing Comorbidities Suggest that Atopic Dermatitis Is a Systemic Disorder Brunner, Patrick M.Bagot, Martine et al. Journal of Investigative Dermatology , Volume 137 , Issue 1 , 18 – 25

A is for Atopic Dermatitis

Atopic Dermatitis or Atopic Eczema

An A that is as confused as our nomenclature

Well, the first step of recovery is acknowledging the problem. Borrowing from Alcoholics Anonymous, their 1st of the 12 steps is We admitted we were powerless over alcohol – that our lives had become unmanageable.

In our case, it is difficult to fully acknowledge the problem when we don’t know what the problem is. The irony is that there is difficulty defining the problem – in fact, the very term “atopic dermatitis” seems to be somewhat a matter of contention.

Mostly, we understand atopic dermatitis to refer to a chronic skin condition characterized by itch (pruritus), dry skin and inflammation, which waxes and wanes (with flare-ups). It is a multi-factorial condition, with causes and triggers linked to autoimmune and genetic factors, defective skin barrier, staph aureus bacteria colonization and hypersensitivity to allergens (including environmental ones like inhaled allergens, food allergens and contact allergens).

The difficulty is that there are many forms of dermatitis, and there are overlaps in symptoms and treatment. Broadly speaking, we want a way to differentiate whether we get the skin inflammation/ rashes because it is linked to immunoglobulin E (IgE) (antibodies produced by the immune system which defend the body but our immune system can wrongly recognize harmless substances as something to fight against, thus leading to allergic reaction). For instance, there are other forms of dermatitis where IgE is not involved, notably irritant contact dermatitis (where your skin develops rashes because it is in contact with a substance over a prolonged period).

There was an article published1 in European Journal of Allergy and Clinical Immunology in August 2016 which suggested the use of the term atopic dermatitis in literature, to differentiate from eczema which is commonly used to cover all forms of inflammatory rashes. Quoting from the article that reviews the existing literature:

Atopic dermatitis is the most commonly used term and appears to be increasing in popularity. Given that eczema is a nonspecific term that describes the morphological appearance of several forms of dermatitis, we strongly suggest the use of a more specific term, AD, in publications, healthcare clinician training, and patient education.

On the other hand, another article2 published in the Acta Dermatovenerol Croat highlighted that the Nomenclature Review Committee Of The World Allergy Organization recommended the term “eczema”. As extracted from World Allergy Organization website,

The umbrella term for a local inflammation of the skin should be dermatitis. What is generally known as “atopic eczema/dermatitis” is not one, single disease but rather an aggregation of several diseases with certain characteristics in common. A more appropriate term is eczema.

…eczema in a person of the atopic constitution, should be called atopic eczema.

The non-allergic variety can also be described by terms like irritant/toxic contact dermatitis.

I wonder why it seemed to be difficult to agree on whether it ought to be atopic dermatitis or atopic eczema, but inserting atopic does help to clarify that the skin condition should be rooted in IgE. Atopy as defined by the World Allergy Organization is:

Atopy is a personal and/or familial tendency, usually in childhood or adolescence, to become sensitized and produce IgE antibodies in response to ordinary exposure to allergens, usually proteins. As a consequence, such individuals can develop typical symptoms of asthma, rhinoconjunctivitis, or eczema. The terms ‘atopy’ and ‘atopic’ should be reserved to describe the genetic predisposition to become IgE-sensitized to allergens commonly occurring in the environment and to which everyone is exposed but to which the majority do not produce a prolonged IgE antibody response.

The “good news” is no matter what you call it, the way to treat it is the same – finding out the triggers, avoidance, moisturizing, steroidal and non-steroidal options, and lifestyle changes to reduce inflammation and staph bacteria colonization. The bad news is we will continue to wonder at the back of our mind whether we are contributing to misleading literature if we fail to clearly define what we’re writing about – well, at least for an eczema/ atopic dermatitis blogger like me, I certainly struggle. A cartoon for it:

Atopic dermatitis or man? Both are as confused!

Atopic dermatitis or man? Both are as confused!

References:

  1. Kantor R, Thyssen JP, Paller AS, Silverberg JI. Atopic dermatitis, atopic eczema, or eczema? A systematic review, meta-analysis, and recommendation for uniform use of ‘atopic dermatitis’. Allergy 2016; 71: 1480–1485.

  2. Zbigniew Samochocki, Rożalski M, Rudnicka L, Atopic and Non-atopic Eczema. Acta Dermatovenerol Croat 2016 Jun;24(2):110-5.

A is for Anxiety – Atopic Dermatitis ABC

Anxiety for Parents with Eczema Children

Anxiety – was it the first emotion when Atopic Dermatitis was diagnosed in your baby?

This year’s series is Atopic Dermatitis ABC – a lighthearted, be-there-with-you companion where the ABCs will act as your eczema survival guide. In just 5 minutes, I came up with 15 words that start with A that are related to atopic dermatitis (AD). I disregarded all of them (not because they’re wrong since we’d get to what is atopic dermatitis, autoimmune, allergies and avoidance), but because I remembered when I first learnt of my baby’s eczema, it’s not the medical terms that come to mind. It’s ANXIETY, and it comes from the heart. Your heart, my heart, the hearts of all parents who suddenly find themselves in a challenging situation. Something like this.

Atopic Dermatitis - Anxiety in Parents with Eczema Babies

This needs no caption.

It is normal to feel anxious when something has gone wrong, when something is happening to your baby, and when you’re not sure what that something is (didn’t the delivery hospital say rashes are to be expected? and ok?) and when even when you know what that something is, you can’t cure it and you’re never sure when it would come back? If your heart has started beating faster like mine, it may be that all these feelings and thoughts are anxious ones that come when we’re not in control. And the most paradoxical part is atopic dermatitis is about controlling the eczema, since you can’t quite cure it.

Wait, do you agree with me?

IS THIS ANXIETY EVEN REAL?

Fortunately, we’re not self-deluded. In an October 2016 study published in the Asia Pacific Allergy1 by researchers at Inha University Hospital, South Korea, 78 children with their parents took part in a study to examine the family quality of life (QoL). The mean age of parents was 37 years old (majority 87% mothers), and the mean age of their children was 5+ years old, having atopic dermatitis for about 2 years. The tests included questionnaires (including Satisfaction with Life Scale survey) and using score card to measure eczema severity (SCORAD index).

It was found that a low family quality of life was related to the eczema severity, when the children with atopic dermatitis were girls and the negative emotionality of parents. Parents of children with AD is known to be associated with depression and stress in previous studies.

In another study2 more than a decade earlier, published in British Journal of Dermatology in Feb 2004, researchers examined the psychosocial well-being of parents caring for a young child with AD. Out of 187 parents, it was observed that parents of children with a higher severity of atopic dermatitis reported a significantly higher impact on family functioning and a greater financial burden. The results showed the need to focus on parental well-being and ability to cope with stress and social strain.

The latest study3 on this was published in Acta Derm Venereol in February 2017 which concluded that quality of life was affected mothers more as moms spent more time caring for the eczema child and carried out more household duties.

NOW THAT YOU KNOW THE ANXIETY IS REAL, HOW DO YOU THINK YOU WOULD FARE ON THE SATISFACTION WITH LIFE SCALE?

Here’s the test4 that you can take:

Below are five statements that you may agree or disagree with. Using the 1 – 7 scale below, indicate your agreement with each item by placing the appropriate number on the line preceding that item. Please be open and honest in your responding.
7 – Strongly agree
6 – Agree
5 – Slightly agree
4 – Neither agree nor disagree
3 – Slightly disagree
2 – Disagree
1 – Strongly disagree

____ In most ways my life is close to my ideal.

____ The conditions of my life are excellent.

____ I am satisfied with my life.

____ So far I have gotten the important things I want in life.

____ If I could live my life over, I would change almost nothing.

31 – 35 Extremely satisfied
26 – 30 Satisfied
21 – 25 Slightly satisfied
20 Neutral
15 – 19 Slightly dissatisfied
10 – 14 Dissatisfied
5 –  9 Extremely dissatisfied

I hope you end up on the satisfied end of the scale, but if not, don’t be anxious – 5 questions are not going to determine your life’s happiness. Your child’s eczema condition is. (One question, in this eczema context).

References:

  1. Jang HJ, Hwang S, Ahn Y, Lim DH, Sohn M, Kim JH. Family quality of life among families of children with atopic dermatitis. Asia Pacific Allergy. 2016;6(4):213-219. doi:10.5415/apallergy.2016.6.4.213.

  2. Warschburger, P., Buchholz, H.TH. and Petermann, F. (2004), Psychological adjustment in parents of young children with atopic dermatitis: which factors predict parental quality of life?. British Journal of Dermatology, 150: 304–311. doi: 10.1111/j.1365-2133.2004.05743.x

  3. Acta Derm Venereol. 2017 Feb 16. doi: 10.2340/00015555-2633

  4. Ed Diener, Robert A. Emmons, Randy J. Larsen and Sharon Griffin as noted in the 1985 article in the Journal of Personality Assessment

Atopic Dermatitis ABC

Atopic dermatitis, well it starts with “A” – how uncanny to start this year’s blog series on Atopic Dermatitis ABC! I’ve got the inspiration to work on a ABC series from reading the book “The Middle Class ABC – a toilet loo book” which shared funny facts about the British middle class – I love its hand lettering and cartoons, and would love this year’s blog posts to be filled with more lighthearted moments. And even more disturbingly coincidental, the first page of the book is on A for Allergies!

A is for Allergies

Page from the book “The Middle Class ABC” by Fi Cotter Craig and Zebedee Helm

I’d be working on my blogging calendar over this weekend, and hope to bring you regular blog posts from next week. Have a lovely weekend, and anyone has a fave letter to work on, leave a comment!

Coming Home

Today, it felt like coming home – sharing on this blog again after taking a year break from regular posting. I took a break when Marcie started grade school last year and I didn’t feel that it would help you by posting for the sake of posting. As such, for the past year:

On this blog:

I only worked on a few series centered on new studies on topical corticosteroid withdrawal, contact dermatitis and skin defences, and organizing my archive posts into Google Collections.

On other pursuits:

I took an interest in hand lettering and visual notes, and you’d see more of these for this year’s posting.

In 2017, I’d post twice a week, a lighter posting schedule compared to three times a week in the past. I feel that this feels a little like coming home, returning to what this blog is about, i.e. turning blues to bliss.

2017 Blog on Eczema Atopic Dermatitis

Blogging on EczemaBlues.com – feels like coming home after a long vacation

Sharing verses from a poem Coming Home by American poet, Vern Rutsala (from January 1985 Poetry Magazine)

We thought we knew these

sidewalk cracks by heart

but even they have altered

in our absence, branching out

on their own. The yard too

has a new identity -some

plants dead, others new.

Inside, the knives and forks

don’t seem the same and feel

wrong in our hands. The design

is more extreme than we remember and there has been

some subtle change in scale

too. The touch of familiar

things is strange, surfaces

feel foreign as if we had

brought back some art

of foreignness. Even the old

companions – tables and chairs,

the light through a window –

seem alien. We are back

but not back all the way.

Skin Defences against Staph Bacteria – Q&A with Dr Donald Davidson

I came across this study “IL-1 beta-induced protection of keratinocytes against Staphylococcus aureus-secreted proteases is mediated by human beta defensin 21” where the researchers studied how the skin protected itself against staphylococcus aureus (“staph bacteria”). This research is important because staph bacteria is known to colonize atopic dermatitis skin, and in doing so, have resulted in worsened control of atopic dermatitis. (Note to readers: Due to many types of eczema, it is recommended to use atopic dermatitis to avoid confusion with other types of eczema like contact dermatitis).

I’m privileged to interview the lead researcher for the study, Dr Donald J Davidson MBChB PhD. Dr Davidson is the MRC Senior Research Fellow and University of Edinburgh Senior Lecturer. The Davidson Group within the MRC Centre for Inflammation Research focuses on understanding the physiological importance of cationic host defence peptides (CHDP) to host defences against bacterial and viral infections. Dr Davidson is a medical graduate of the University of Edinburgh who chose to pursue a scientific research career. He completed a PhD at the MRC Human Genetics Unit, studying the pathogenesis of cystic fibrosis lung disease, then was awarded a Wellcome Trust Travelling Research Fellowship to undertake post-doctoral training in innate immunity research at the University of British Columbia, Vancouver. You can read more of his research interests here.

MarcieMom: Thank you Dr Davidson for taking the time to help with the questions. The questions will be based on the study, but more focused on its practical implications.

Staphylococcus Aureus

Staphylococcus aureus is a resilient bacteria found on the skin that can survive in dry condition and on dry skin with little oxygen.  It tends to involve areas that are warm and moist especially such as skin near mucous membranes such as the nose, mouth, genitals and anal area. It is found in less than 30% of healthy adults and generally does not cause an infection in those with healthy skin. However, as pointed out in the study, 75% to 100% of atopic dermatitis patients have staph bacteria on their lesional skin and 30% to 100% of atopic dermatitis patients have staph bacteria on their non-lesional skin (Breuer et al., 2002; Gong et al., 2006; Park et al., 2013). The problem with staph bacteria is that it secretes toxins and proteases that can worsen atopic dermatitis.

MarcieMom: From your study, protease V8 was of interest which showed it led to skin barrier dysfunction. Can you explain what you learnt about staphylococcus aureus’ interaction with atopic dermatitis skin/ normal skin and how does it damage skin integrity?

Dr Davidson: In our study we did not use the whole live bacteria, but concentrated instead on its harmful proteases. Using skin cells grown in the laboratory and collecting the substances made by the bacteria Staphylococcus aureus, we were able to show that the bacterial protease V8 was the most powerful product when it came to breaking down and damaging the skin barrier. Together with studies from other research groups, this suggested that one of the main ways these bacteria can damage skin is by producing V8, and that finding ways to block this damage may help to maintain and/or restore the skin integrity in atopic dermatitis.

Interview with Dr Donald J Davison, MRC Senior Research Fellow and Senior Lecturer at University of Edinburgh on his published study on skin defences against staphylococcus aureus bacteria

Interview with Dr Donald J Davison, MRC Senior Research Fellow and Senior Lecturer at University of Edinburgh on his published study on skin defences against staphylococcus aureus bacteria

Natural Skin Defence

In your study, it was mentioned that human beta defensin 2 (hBD2) is a substance on our skin that have antimicrobial properties and able to protect against skin integrity damage caused by staph bacteria protease V8. It was further noted that the level of hBD2 on atopic dermatitis skin was significantly lower than normal skin, therefore atopic dermatitis skin may be more prone to infection and unable to defend itself against staph bacteria.

MarcieMom: I hope I have understood hBD2’s role correctly; can you explain more about what you have found out about hBD2, for instance, how important is its role in maintaining skin integrity, fighting infection and the effects of protease V8?

Dr Davidson: Our bodies can make quite a wide range of substances we call antimicrobial host defence peptides (HDP). The skin is one site that produces these. These HDP have a lot of different roles in protecting us from infection and disease. hBD2 is an HDP from the defensin family. hBD2 was already known to be capable of killing bacteria in the laboratory. It is less clear if it definitely does this in normal functioning on our skin. However, it has been suggested by other researchers that the failure of atopic dermatitis skin to make as much hBD2 as one would expect (for the amount of skin inflammation or damage), could be one reason that atopic dermatitis skin lesions are prone to infection. What our new MRC-funded research discovered was that hBD2 can also stop V8 from damaging laboratory-grown skin. This worked both when we instructed the skin to make extra hBD2 (using genetic modification) and when we added hBD2 in the style of a treatment. Just how important this is in a living human remains to be seen, but it has obvious potential and shows that hBD2 can protect the skin barrier as well as kill bacteria.

Skin defences against staph bacteria protease v8

Skin defences against staph bacteria protease v8

Topical Application

MarcieMom: The interesting part of your study was its demonstration that application of hBD2 was found to be protective, and therefore a possible future eczema therapeutic. How does the application of hBD2 work? What are its protective effects?

Dr Davidson: At this point we don’t know how hBD2 protects this skin barrier integrity and we are currently applying for more funding so that we can start to work this out. It may act directly on the V8 to block the damaging effects of this bacterial protease, but we’ve found that it can also help to speed up repair where damage has occurred. So hBD2 may work in more than one way.

Is this something you foresee that can be easily added into a moisturizer or would it be more likely to be a non-steroidal topical prescription?

Dr Davidson: At this stage we are still in the discovery science phase of the research, so it is too early to predict how, and even whether, it will turn out to be a useful treatment. However, in the best case scenario for the outcome of our research, I would envisage adding hBD2 (or drugs made to mimic some of its functions) into prescription moisturizer-type creams or ointments.

How would the application of hBD2 be compared with the existing eczema measures such as bleach bath to kill staph bacteria?

Dr Davidson: I’m afraid it is too early to be able to make comparisons of that kind, until we have a better understanding of exactly how hBD2 functions to protect the skin barrier.

MarcieMom: Thank you Dr Davidson once again for your time and will certainly look forward to further breakthroughs and more studies done in this area.

Reference:

  1. Wang B, McHugh BJ, Qureshi A, Campopiano DJ, Clarke DJ, Fitzgerald JR, Dorin JR, Weller R, Davidson DJ, IL-1beta-induced protection of keratinocytes against Staphylococcus aureus-secreted proteases is mediated by human beta defensin 2, The Journal of Investigative Dermatology (2016), doi: 10.1016/j.jid.2016.08.025.

  2. Breuer K, S HA, Kapp A, Werfel T (2002) Staphylococcus aureus: colonizing features and influence of an antibacterial treatment in adults with atopic dermatitis. Br J Dermatol 147:55-61.

  3. Gong JQ, Lin L, Lin T, Hao F, Zeng FQ, Bi ZG, et al. (2006) Skin colonization by Staphylococcus aureus in patients with eczema and atopic dermatitis and relevant combined topical therapy: a double-blind multicentre randomized controlled trial. Br J Dermatol 155:680-7.

  4. Park HY, Kim CR, Huh IS, Jung MY, Seo EY, Park JH, et al. (2013) Staphylococcus aureus Colonization in Acute and Chronic Skin Lesions of Patients with Atopic Dermatitis. Ann Dermatol 25:410-6.

Allergic Contact Dermatitis in Children (II) – Q&A with Dr Steve Xu

This is a continuation of last week’s interview with Dr Steve Xu MD MSc where we discussed contact dermatitis, the differences between irritant and contact dermatitis, the top 10 pediatric contact allergens in personal hygiene products and practical consideration of when to suspect contact dermatitis in a child.

Dr Steve Xu, MD MSc is currently a 2nd year dermatology resident at McGaw Medical Center of Northwestern University. He earned his MD from Harvard as a Soros Fellow, and a Masters in Health Policy and Finance from The London School of Economics as a Marshall Scholar. He completed a BS in bioengineering at Rice University. For his academic interests, Steve is focused on consumer education and the intersection between health policy and clinical medicine. His publications have appeared in The New England Journal of Medicine, and PLOS Medicine garnering broad press attention from sources such as CNN, The Washington Post, and The Los Angeles Times. Dr Steve has created a web resource for patients with eczema and contact dermatitis at itchyrash.org. See also Dr Steve’s publications at the end of last week’s post.

Dermatologist Dr Steve Xu MD

Dr Steve Xu MD, MSc

On ‘Bland’ Skincare Products

MarcieMom: I’ve emphasized in my blog that the fewer the ingredients, the less likely it is to irritate (such as in this expert interview and also in the moisturizer selection post)

Yet, practically (I’m finding myself using this word so frequently in this 2-part interview! It must be that it is so hard to take practical steps when it comes to skincare products and figuring out irritants, allergens and pushing through the myriad of chemical names!) and yes, practically it can be difficult to find a skincare product with less than 10 ingredients! Pharmaceutical companies seem to add more ingredients to their formulation in order to ‘upgrade’ their product to one that can restore your skin’s lipids, ceramides, reduce itch and bacterial infection.

MarcieMom: Is there a trend towards more ingredients in the formulation of skincare products? And is it a real risk or can consumers assume that product companies would have tested their increasingly complex formulation that it would not lead to contact dermatitis? 

Dr Steve Xu: Again, labels such as ‘hypo-allergenic’ or ‘sensitive skin’ really don’t mean anything. The Food and Drug Administration do not regulate this definition. Consumers have to be aware of this.

I wouldn’t say there’s a trend towards more ingredients in skincare products. Skincare products aren’t produced for hypo-allergenicity. These products are successful because they smell nice (fragrances), feel good on the skin, and stay fresh (preservatives). I think for individuals with patch-test proven allergic contact dermatitis, it’s really important to follow the safe list. But, if you haven’t been patch tested yet and have very sensitive skin, then looking for products with as few ingredients as possible AND do not have common skin allergens is a reasonable consideration.

Moisturizer Selection

Moisturizer Selection – Reducing possible contact allergens

MarcieMom: Staph bacteria has been covered in my blog, and we know that eczema skin that has staph bacteria colonization will not recover well due to inflammatory toxins from the bacteria. Are moisturizers for eczema/ dry skin incorporating antiseptic properties? Which antiseptics are now recommended for eczema children and how likely are these to irritate skin?

Dr Steve Xu: Absolutely, treating staph colonization is a big component of successfully treating atopic dermatitis. Moisturizers typically don’t have anti-bacterial ingredients. But, we do know that impaired or broken skin barrier facilitates the colonization and growth of staph. Thus, moisturizers play a big role in keeping the skin barrier intact so that staph can’t cause problems.

At least in the U.S., we hardly ever specifically recommend an ‘anti-septic’ moisturizer. It’s interesting to see that there are products out there marketed as such. We separate the use of moisturizers (barrier protection) and the elimination of colonizing bacteria (mupirocin ointment, bleach bathes). Typically for our patients, we always recommend moisturizers for skin barrier preservation but tend to be more reactive when it comes to recommending bleach bathes or mupirocin ointment at the sign of super infection (formation of pustules).

With that being said, lauric acid is certainly an ingredient that is becoming more and more popular. It is the key component in coconut oil, which has shown to have a broad range of antibacterial properties.

Long-story short, I think there’s probably a benefit from using antiseptics more regularly in managing atopic dermatitis. We know that the skin of eczema children have less anti-microbial peptides, natural bacteria fighting proteins produced by the skin. There’s no great head to head studies comparing coconut oil (moisturizer + anti-septic properties) vs. a regular moisturizer in managing atopic dermatitis. But, I think there is some benefit here that may be real for some patients that have a particular sensitivity to staph colonization.

Skin of eczema children is more susceptible to staph bacteria colonization

Skin of eczema children is more susceptible to staph bacteria colonization

Also, common over-the-counter topical antibiotics such as neomycin and bacitracin are notorious agents for causing allergic contact dermatitis. We typically do not recommend these for children with atopic dermatitis. In the United States, we prefer topical mupirocin (prescription only). This medication rarely causes allergic contact dermatitis compared to neomycin or bacitracin.

Age of Allergic Contact Dermatitis

In the article1, it was mentioned that studies have shown that there are different age (timing) where there is peak prevalence of contact allergy among children, being

  1. 0 – 3 years old – could be due to immature skin barrier, including lower lipid content, fewer natural moisturizing components, higher pH and thinner epidermis
  2. 6 – 7 years old
  3. Adolescence

MarcieMom: Are there a certain group of children who is more likely to have contact dermatitis? Narrowing this further, is there a particular profile of eczema children who are more likely to also have contact dermatitis?

Dr Steve Xu: This is a great question. I think certainly, older children and adolescents will have had greater exposure to potential allergens over time. However, an allergic contact dermatitis can occur at any age including toddlers. I think the most important thing is to have a high index of suspicion for allergic contact dermatitis in children with atopic dermatitis.

Is your child’s atopic dermatitis not getting better despite the best therapy?

Is your child’s atopic dermatitis appearing in areas that it never appeared before?

Are there eczematous rashes that seem to happen in the same locations such as the belly button, neck, waistband or wrist? Do the rashes appear linear (straight) or rectangular?

We’ve had plenty of pediatric patients with stable atopic dermatitis that would inexplicably get worse or not respond to therapy. After patch testing, we would identify a common allergen such as nickel. The rashes won’t get better unless nickel is avoided.

Corticosteroids

In the article1, it was mentioned that the most “allergenic” corticosteroids are:

  1. Budesonide
  2. Trixocortal pivalate
  3. Hydrocortisone butyrate

The least allergenic are those with halogenated C16-methylated molecules and in order of increasing potency:

  1. Aclomethasone dipropionate
  2. Beta-methasone valerate
  3. Memoetasone furoate
  4. Desoximethasone
  5. Clobatesol propionate
Corticosteroids - Potency and Allergenicity

Corticosteroids – Potency and Allergenicity

Again, there is the possibility of children with atopic dermatitis using more topical steroids and therefore getting hypersensitive to it overtime.

MarieMom: The article mentioned classifying topical steroid creams using different groups, based on their likelihood of being contact allergens. The likelihood can be due to different molecular (steroid) structure, the other non-steroid ingredients in the prescription cream, how long it is used and how occlusive it is (topical steroid creams are not recommended with wet wraps as absorption rates are higher than intended when occluded).

MarcieMom: What are the common steroid creams prescribed for young children with eczema? And how likely will they cause contact dermatitis?

Dr Steve Xu: Overall, a true allergic contact dermatitis to topical steroids is quite rare. Aclomethasone and desoximethasone are both popular choices.

I will say that sometimes it’s better judicious to not always reach for the least hypo-allergenic topical steroid at first. In the vast majority of time, a children will not have a contact allergy to a topical steroid. If we reach for a hypo-allergenic topical steroid and a contact allergy does develop, we have less therapeutic options in the future.

MarcieMom: Thank you Dr Steve for your time to help with this series; really glad for this interview as it has certainly raised my awareness of contact dermatitis in children (where previously thought to be remote). Also appreciate the work that you’re doing at itchyrash.org

References:

  1. Hannah Hill, Alina Goldenberg, Linda Golkar, Kristyn Beck, Judith Williams & Sharon E. Jacob (2016): Pre-Emptive Avoidance Strategy (P.E.A.S.) – addressing allergic contact dermatitis in pediatric populations, Expert Review of Clinical Immunology, DOI: 10.1586/1744666X.2016.1142373

Allergic Contact Dermatitis in Children (I) – Q&A with Dr Steve Xu

Eczema is a skin condition with many parts to the puzzle – it is linked to hereditary skin condition, allergens (food, inhaled, contact and airborne), environmental factors (heat, humidity), bacteria colonization on skin (and how gut microbiome may affect allergic conditions), lifestyle factors (stress, hormonal change) and also suspected to be linked with diet/ water. Very often we may think of what we have eaten, rather than what we have applied on our skin. A moisturizer or topical prescription tend not to fall under our usual ‘list of suspects’ when we try to figure out what’s triggering the eczema.

This 2-part blog series aim to bring greater awareness of contact allergens, and how some of these may be the ingredients in your skincare products. Especially for pediatric patients, we have to be even more careful because:

  1. Babies’ skin barrier is thinner than that of an adult- making it extra vulnerable to chemical irritants (also greater transepidermal water loss and therefore, moisturizing is important)
  2. Increasing research showing that a strong skin barrier has protective effect against eczema, and reduce likelihood of food sensitization
  3. Babies have a larger surface area to volume ratio, therefore potentially the risk associated with chemical absorption is higher
Contact allergens is of particular importance to pediatric patients

Contact allergens is of particular importance to pediatric patients

I’m privileged to have dermatologist Steve Xu, MD MSc to help with this series. Dr Steve is currently a 2nd year dermatology resident at McGaw Medical Center of Northwestern University. He earned his MD from Harvard as a Soros Fellow, and a Masters in Health Policy and Finance from The London School of Economics as a Marshall Scholar. He completed a BS in bioengineering at Rice University. For his academic interests, Steve is focused on consumer education and the intersection between health policy and clinical medicine. His publications have appeared in The New England Journal of Medicine, and PLOS Medicine garnering broad press attention from sources such as CNN, The Washington Post, and The Los Angeles Times. Dr Steve has created a web resource for patients with eczema and contact dermatitis at itchyrash.org. See also Dr Steve’s publications at the end of this post.

Dermatologist Dr Steve Xu MD

Dr Steve Xu MD, MSc

Allergic Contact Dermatitis – What is it?

MarcieMom: Contact dermatitis refer to skin rash that is triggered by contact with an allergen/ irritant. If the immune response is that related to IgE, it would be allergic contact dermatitis; conversely, if the response is due to overtime exposure to the irritant (leading the skin to develop delayed-type hypersensitivity), it is irritant contact dermatitis. 

The thing is a child can have all the different types of dermatitis – atopic, allergic contact and irritant contact.

MarcieMom: Dr Steve, thank you for joining me for this series. The different terms can get very confusing for parents of eczema children. How would you explain the different types of dermatitis to a patient?

Dr Steve Xu:  Right now even within the scientific community, there’s a big debate on what exactly we should call ‘eczema’. At our institution (Northwestern University), this is how we break it down.

The term ‘eczema’ itself actually describes how a certain rash looks.  Atopic dermatitis, allergic contact dermatitis, and irritant contact dermatitis all can cause an ‘eczema’ rash that looks exactly the same. Eczema used as a standalone term isn’t really specific.

For classic childhood ‘eczema’, we refer to this as atopic dermatitis. Allergic and irritant contact dermatitis is defined as a condition where an external agent leads to an eczematous rash. We define the difference between allergic and contact dermatitis here. Basically, an allergic contact dermatitis is defined by an immune-mediated response to an external agent applied to the skin. These reactions typically require only a very small amount of the agent to lead to a rash. Irritant contact dermatitis is not immune related but leads to an indistinguishable eczematous reaction. Typically, more of an external agent must be applied to cause a rash in irritant contact dermatitis.

MarcieMom: In practical terms, is diagnosing the type of dermatitis important? Or knowing the triggers are adequate for management of eczema?

Dr Steve Xu: Yes, definitely. An irritant contact dermatitis usually requires more of the external agent to cause a rash. This is practically important because if you only have an irritant contact dermatitis you may be able to tolerate products that are wash off or rinse off. If you have an allergic contact dermatitis, then we recommend avoidance altogether. Even a little exposure can cause a miserable rash.

Prevalence of Allergic Contact Dermatitis

There is increasing evidence that allergic contact dermatitis is underreported in children and while traditionally thought as unlikely for children, contact dermatitis is becoming more common.

MarcieMom: In the article1, the top ten pediatric allergens found in personal hygiene products are listed (with the first as having most percentage of children being hypersensitive to it):

  1. Neomycin – topical antibiotic, another contact allergen is over-the-counter antibiotic Bacitracin
  2. Balsam of Peru – also known as Myroxylon pereirae, chemically related to fragrance and thus used to screen for fragrance allergy
  3. Fragrance mix – Of the flowering plants, the Comositae family is the most likely to cause skin sensitization, such as chamomile, dandelion and ragweed; also cross-reactive with propolis (beeswax)
  4. Benzalkonium chloride – ammonium compound used as preservative, including in disinfecting wipes and eye drops
  5. Lanolin – natural oil from sebum of wool-bearing animals
  6. Cocamidopropyl betaine (CAPB) – used as a surfactant
  7. Formaldehyde – preservative, also associated with quaternium 15, imidazolindinyl urea (most common), diazolidinyl urea, bronopol, dimethyl-dimethyl hydantoin (this can get very tricky to memorize, readers can refer to this table created by dermapathologist in a previous interview)
  8. Methylchlorsothiazolinone (MCI)/ Methylisothiazolinone (MI) – likely to be in bubble baths, soaps, cosmetic products, and baby wipes
  9. Propylene glycol – previously common in moisturizers (but many brands stopped including propylene glycol: it has humectant properties and also an emulsifier) and topical steroids
  10. Corticosteroids – when using steroid creams, we have to be aware of its potency, but we may now have to know its likelihood of being contact allergen (we will discuss this next week)
Top 10 Pediatric Contact Allergens in Personal Hygiene Products

Top 10 Pediatric Contact Allergens in Personal Hygiene Products

Other than the above 10, the other well-known contact allergens are cetylstearyl alcohol, sodium lauryl sulphate, pehnoxyethanol, parabens, TEA (triethanolamine) and vitamin E.

Nickel and cobalt are also common contact allergens but less likely that children will come into contact with them.

MarcieMom: It is interesting to note that the above can be found in personal care products, even in those marketed for children. I’m wondering if there is an increase in sensitization in personal hygiene/ skincare products? If so, why? (for instance, is it the increased use of products? Or increased awareness/ patch testing/ consultation)

Dr Steve Xu: The prevalence of contact dermatitis has remained stable overall but certain chemicals are representing a larger share of problems. This is related to industry trends. For example, as formaldehyde was phased out over the past 20 years in personal care products, we’ve seen a growing use of methylisothiazolinone as a preservative. It’s unsurprising that methylisothiazolinone contact allergy is rising rapidly.

Pediatric dermatologists have really worked hard to raise awareness among pediatricians and allergists about contact dermatitis in kids with atopic dermatitis. More than half of kids with atopic dermatitis will have a relevant positive patch test. In general, we’re arguing that kids with atopic dermatitis should be patch tested more and tested for food allergies less

Parents need to know that just because a product is labeled “For babies” or “Safe for kids”, it doesn’t mean it’s any different than what products are sold for adults. These are just marketing claims. Statements like “sensitive skin safe” ororganicalso aren’t regulated. Even carefully reading the labels may not be completely fool-proof. Often times, manufacturers do not have to be specific about which fragrance they are using (different fragrances can cause contact dermatitis).

MarcieMom: Practically, this feels like being caught between a rock and a hard place. The baby’s skin loses more moisture, has less lipids and for babies with dry skin, even more so we have to moisturize. Now, we know the common contact allergens to avoid and of course, should take the effort to read the product label and make sure we’re not putting something on our babies with these allergens. YET, the more we put something on our babies, the more likely the skin can become sensitized to it overtime! (for instance, lanolin, CAPB weren’t previously contact allergens)

MarcieMom: Is there a strategy to moisturizing to reduce likelihood of contact dermatitis? For instance, rotating skincare products which one expert has previously mentioned.

Dr Steve Xu: We often have patients come into our clinic with classic allergic contact dermatitis and exclaim: “I haven’t changed my products in years!”. In truth, this is exactly how a contact allergy develops. It’s true that small, continued exposures over time train your immune system to develop an allergy.

Interview with dermatologist Dr Steve Xu, MD

Interview with dermatologist Dr Steve Xu, MD

With that being said and to the best of my knowledge, there are no well-designed clinical studies showing that rotating skincare products reduces the risk of future allergic contact dermatitis. I’m hesitant to recommend this strategy.

Here’s some practical advice to perhaps help answer this question. Let’s say you have a child with atopic dermatitis and it’s fairly well controlled. Over the course of a period of time, let’s say the atopic dermatitis has taken a turn for the worst and is not getting better with optimal therapy. Or, let’s say that that the atopic dermatitis is appearing in areas it never has before (e.g. belly button, waistband, wrist). Then, this is a time to consider whether there is a simultaneous allergic or irritant contact dermatitis. Patch testing would be recommended.

If there is a relevant positive patch test, than this is the time to follow a safe list. Severely limiting what skincare products or household products can be used in the absence of a patch-test proven allergen may be overkill.

MarcieMom: Thank you Dr Steve for helping us to understand more about contact dermatitis; for me, I’ve learnt that there is practical benefit of knowing the type of dermatitis one is suffering from, and being mindful of the possible development of contact dermatitis for an eczema child. Look forward to next week where we will discuss more about skincare product, prevalence of contact dermatitis in kids and corticosteroids.

References:

  1. Hannah Hill, Alina Goldenberg, Linda Golkar, Kristyn Beck, Judith Williams & Sharon E. Jacob (2016): Pre-Emptive Avoidance Strategy (P.E.A.S.) – addressing allergic contact dermatitis in pediatric populations, Expert Review of Clinical Immunology, DOI: 10.1586/1744666X.2016.1142373

For some of Dr Steve’s publications, see below:

  1. Xu S, Walter JR and Bhatia A. Online Reported User Satisfaction with Laser and Light Treatments: Need for Caution. Dermatologic Surgery. Published online September 9th, 2016. DOI: 10.1097/DSS.0000000000000862.
  2. Xu S, Kwa M, Agarwal A, Rademaker A, and Kundu RV. Sunscreen Product Performance and Other Determinants of Consumer Preference. JAMA Dermatology. 2016. 152(8):920-927.
  3. Walter JR and Xu S. Therapeutic Transdermal Drug Innovation from 2000-2014: Current Status and Future Outlook. 2015. Drug Discovery Today. 2015. 20(11):1293-1299.
  4. Walter JR and Xu S. Topical Drug Innovation from 2000 through 2014. JAMA Dermatology. 2015. 151(7):792-794.
  5. Xu S, Heller M, Wu PA and Nambudiri VE. Chemical Burn Caused by Topical Application of Garlic Under Occlusion. Dermatology Online Journal. 2014. 20(1). URL: https://escholarship.org/uc/item/88v527wg.
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