Doctor Q&A

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. (

Dr Donald Davidson Dr Donald J Davidson

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

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

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.


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.

Doctor Q&A

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.

On ‘Bland’ Skincare Products Dermatologist Dr Steve Xu MD

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)

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

Staph Bacteria and Antiseptic Moisturizer

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.


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).

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

Doctor Q&A

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:

  • Increasing research showing that a strong skin barrier has protective effect against eczema, and reduce likelihood of food sensitization
Contact allergens is of particular importance to pediatric patients
Contact allergens is of particular importance to pediatric patients
Dermatologist Dr Steve Xu MD

Dr Steve Xu, Northwestern University

I am privileged to have dermatologist Steve Xu, MD MSc to help with this series. He is a board-certified dermatologist and a faculty member at Northwestern University’s Feinberg School of Medicine. He is also the medical director of the Center for Bio-Integrated Electronics at 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 New York Times.

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. 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 under-reported 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

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.

Sensitization to Personal Care products

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 to 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” or “organic” also 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)

Strategy to reduce contact dermatitis in children

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

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.


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:

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.

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.

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.

Walter JR and Xu S. Topical Drug Innovation from 2000 through 2014. JAMA Dermatology. 2015. 151(7):792-794.

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:

Doctor Q&A

Topical Corticosteroid Withdrawal – Q&A with Prof Hugo

In March 2015, the National Eczema Association (NEA, in US) published a study on steroid addiction in patients with atopic dermatitis. This was by members of its task force, who looked into the evidence regarding steroid withdrawal as many eczema sufferers were asking about the steroid addiction syndrome, along with many cautioning and enquiring on this online and over social media. The use of steroid creams remains a common treatment option, and the phobia of steroids has also stopped eczema sufferers, including children, from receiving treatment. The questions we are exploring with Professor Hugo centered on:

  1. What is steroid addiction?
  2. What is steroid withdrawal and its symptoms?
  3. Is steroid addiction/ withdrawal common?
  4. What are the treatment options for eczema?

Professor Hugo is no stranger to this blog – He has previously helped in Friday Doctor Q&A in 2012 and is my co-author for our book “Living with Eczema – Mom Asks, Doc Answers”. Professor Hugo van Bever is the Professor in Paediatrics (MD, PhD) at the National University Singapore, and also the Senior Consultant in its Division of Paediatric Allergy, Immunology & Rheumatology.

The questions are loosely structured based on the paper published by the National Eczema Association, to address the above questions that are surely on the minds of many parents with eczema children.

Topical corticosteroid withdrawal

What is Steroid Addiction?

MarcieMom: Steroid addiction is used broadly to refer to eczema sufferers whose skin are “addicted” to the topical corticosteroids, and therefore, when they stop applying the steroid creams, they experience steroid withdrawal and its adverse symptoms.

MarcieMom: I looked up the meaning of addiction online and found a broader definition by that defines addiction as

“An uncontrollable craving, seeking, and use of a substance such as alcohol or another drug. Dependence is such an issue with addiction that stopping is very difficult and causes severe physical and mental reactions.”

Medical definitions of addiction linked addiction to a brain disease, rather than a skin disease. Is it even possible for the skin to crave topical corticosteroids and be dependent on it to the extent that stopping is difficult?

Professor Hugo: I disagree with the word “addiction”, as the situation here doesn’t refer to a mental state (addiction always refers to a mental state). As for the possibility of the skin being addicted, the answer is NO!

To me, it is more a “bad habit” of using topical corticosteroids (TCS), mainly because of wrong expectations of this treatment. When used inappropriately (such as too long, too high, too frequent, or too strong), every medication (even a simple anti-fever medication) can cause side effects or unwanted (unexpected) effects. That’s why it doesn’t surprise me that inappropriate usage of TCS can cause withdrawal effects or, at least, unexpected side effects – I strongly doubt the existence of a withdrawal syndrome (especially when there are no specific biopsy features).

What is Steroid Withdrawal and its Symptoms?

MarcieMom: From Dermnetz, topical corticosteroid withdrawal refers to:

(1)   A rash that has appeared within days to weeks of discontinuing topical corticosteroid that has been used for many months. This flare may be worse than the pre-treatment rash. Before stopping the topical corticosteroid, the skin is typically normal or near-normal, although localised itch, ‘resistant’ patches of eczema or prurigo-like nodules may be present; and

(2)   The rash must be only where the topical corticosteroid was being applied, at least initially, although it can later spread more widely.

From the review article by NEA, there are two types of rash:

(1)   Eythematoedematous type – meaning redness (thus topical steroid withdrawal is also referred to as the Red Skin Syndrome), typically found in patients with an underlying eczema-like skin condition like atopic or seborrheic dermatitis; or

(2)   Papulopustular type – meaning with bumps and pimples, typically found in patients who used topical corticosteroids for cosmetic purpose like acne or pigment.

The withdrawal symptoms include:

  1. Burning and stinging
  2. Erythema (redness)
  3. Mostly on the face and genital area of women
  4. Exacerbation with heat or sun
  5. Pruritus (itch)
  6. Pain
  7. Facial hot flashes

Both types of rash primarily affect the face of adult females and are mostly associated with inappropriately using mid- to high-potency topical corticosteroids daily for more than 12 months.

MarcieMom: First of all, it is important to understand what a review article is. It is not a controlled trial, meaning there are no two groups of people that are given different treatments and thereafter the results are evaluated. Instead, it systematically reviews other studies. The limitation of the study is that the quality of evidence in regard to topical corticosteroid withdrawal in the studies reviewed were very low.

MarcieMom: Is there a way to study topical steroid withdrawal definitively?

Professor Hugo: The article is a collection of case reports, and not a study. There are no studies on the subject. Therefore, the quality of the science behind this is very low. It is a misuse of TCS, and you cannot ask patients (is not ethical) to misuse a treatment in order to prove side effects. Better is to look for its existence in patients who didn’t misuse TCS, but I assume the prevalence will be close to zero.

MarcieMom: It is also briefly discussed in the review article that the signs and symptoms of atopic dermatitis may be confused with that of steroid withdrawal. It is suggested in the review article that if:

(1) Burning is the prominent symptom, and

(2) Confluent erythema (meaning continuous red patches) occurs within days to weeks after stopping topical corticosteroids, with

(3) History of frequent, prolonged topical corticosteroid use on the face or genital region, then the symptoms are more likely to be from topical steroid withdrawal (rather than other forms of dermatitis).

MarcieMom: How do we know if the rash is caused by steroid withdrawal and not something else? Would you contact patch testing for contact allergens?

Professor Hugo: The so-called withdrawal syndrome (as a consequence of misusage of TCS) is mainly made-up by a re-occurrence of eczema lesions, as shown by looking at the results of the biopsy studies: the withdrawal syndrome has no specific biopsy features, but mainly features of eczema. Therefore, I am not sure whether the withdrawal syndrome is a separate entity, or whether it is mainly an expression of re-occurrence of eczema. Indeed, I strongly doubt of its existence.

I think the withdrawal syndrome is NOT a new syndrome, but merely a flare-up of eczema on an altered skin (because of the long-term usage of TCS).

It is not a new syndrome because:

  1. It has no specific clinical features (all manifestations might be manifestations of a re-occurring eczema)
  2. It has no biological marker (blood)
  3. It has no solid underlying mechanism – hypothesis
  4. Biopsy finding are similar of findings in eczema (no specific biopsy)

It is merely a re-manifestation eczema, but on an altered skin, because of the long-term usage (misusage) of TCS.

  1. Alterations of the skin can be summarized as following:
  2. A thinner epidermis (as a consequence of misuse of TCS)
  3. Higher Staphylococcus aureus colonization, as TCS do not affect Staph colonization – this explains the papular / pustular (infected) features of the lesions
  4. A concomitant contact dermatitis (to TCS or other substances)

Contact dermatitis is a possibility, but is not common in children (more in adults), especially after years of usage of creams.

Is Steroid Addiction/ Withdrawal common?

In the review article, there were various factors that contributed to topical corticosteroid withdrawal, namely:

  1. Mid or high potency use of topical corticosteroids
  2. Daily use of topical corticosteroids (only one out of the 34 studies recorded frequency)
  3. Duration of use longer than a year

From the studies reviewed, only 7.1% of the cases reported (in these studies) were of patients 18 years and younger. Only 0.3% were for children younger than 3 years.

MarcieMom: The general guideline in topical corticosteroid use for children is using a mild to (no higher than) mid potency, no more than twice a day, for a two week period. Professor Hugo, do you think that it is likely that children will suffer from topical steroid withdrawal even with the right use of prescribed steroid cream?

Professor Hugo: Patients should know that eczema (or atopic dermatitis) is a non-curable disease and that no doctor in the world can cure eczema today (perhaps in the future a cure will be found, mainly through immunomodulatory treatments, but not for the moment i.e. at the time of this interview in September 2016).

TCS are effective in controlling inflammation of the skin, and are, therefore, a part of the therapeutic approach to eczema. However: 1) TCS are ONLY (!) part of the treatment, which constitutes of offering a holistic package to the patient (focused on life style, and on usage of other treatments), and 2) once TSC are stopped the lesions will re-occur, as TCS do not cure, but only control inflammation, and 3) the rule is to use mild TCS (according to age and severity of the patches), in combination with antiseptics (TCS on a clean eczema patch) and NEVER more than 2 x day.

The main observation here is that this withdrawal effect is not caused by the TCS on itself, but by the inappropriate usage (i.e. misusage, leading to over-usage) of it. The unwanted effect was mainly seen in adult women (in more than 90%) who were using their TCS as if it was a kind of moisturizer. In other words, every time they felt a little itch or saw a little flare-up they put their TSC on it, many times per day, and during long periods (in 85.2% for more than 1 year).

The main point here is that TCS were misused, mainly because patients had wrong expectations of TCS, which I assumed is due to lack of correct information on eczema and on the role of TCS in its treatment. Who is to blame? I guess, both the doctor and the patient, and, for sure, the wrong doctor-patient relationship and wrong communication. Correct information on eczema and on the role of TCS is pivotal.

When TCS are used appropriately, as part of the holistic treatment of eczema, and according to correct expectations, it is extremely unlikely that a withdrawal syndrome will occur. I even dare to state that it is even (almost) impossible. However, I recommend close monitoring of all children with eczema, with appropriate individualization of treatment, focused on offering a treatment package in which TCS have a role, but only as a controller of acute inflammation, and with strict rules on their usage.

What are the treatment options for eczema?

MarcieMom: There are many brands and types of topical corticosteroid creams available, with varying potency and with different chemicals, and functions (for instance, with the added ingredients to reduce bacteria or fungus). Often, there is a trial and error process to see if a certain prescription cream works.

MarcieMom: How would a patient know if the steroid cream is not working for his rash? Is there a safe period of trial before stopping?

Professor Hugo: TCS are only PART of the treatment, and usually have a fast effect on acute inflammation (1 – 3 days). For each patient the optimal TCS needs to be selected (based on severity and age) and needs to fit into the whole package of treatment.

MarcieMom: There are many other eczema therapeutics that can be used alongside topical corticosteroids or in place of topical corticosteroids, for instance:

  1. Moisturizing – with a quality emollient that does not contain major irritants and have humectant properties and lipids to help with skin lipid deficiency
  2. Bathing – Basic good bathing routine like no hot water, no soap, no longer than ten minute, pat dry and not rub dry AND moisturizing immediately after
  3. Wet wrap or dry wrap
  4. Ways to reduce staph bacteria, such as swimming, using diluted zinc sulphate or chlorhexidine gluconate
  5. Non-steroidal prescriptions like topical calcineurin inhibitors
  6. Antihistamines (non-conclusive research)

MarcieMom: I’m a believer that one ought to diligently practice good bathing and moisturizing regime, reduce staph bacteria colonization, along with healthy lifestyle (non-inflammatory diet and exercise). However, I find that sometimes we tend to discuss topical corticosteroids exclusively, i.e. use topical corticosteroids or (do something else). What are your top 3 eczema therapeutics in your practice and how effective has these reduce the use of topical corticosteroids in your young patients?

Professor Hugo: My top 3 are: allergen avoidance (airborne food, house dust mites  – which is an outdoor life style) – usage of antiseptics (swimming – baby spa) and extensive usage of moisturizers have important additional effects and are therefore TCS-sparing.

MarcieMom: In summary, topical corticosteroid withdrawal is increasingly acknowledged by the dermatological community as evident by NEA taking the step to conduct a systematic review. However, we have seen that it is not easy to diagnose topical steroid withdrawal, and at the same time, removing topical corticosteroids completely as one of the eczema therapeutics may make it harder to treat the eczema/ skin inflammation. It is therefore important to recognize both the dangers of steroid misuse and underuse. Physicians should adopt an open attitude when hearing about patients’ steroid fears as totally ignoring steroid phobia would possibly alienate patients and without trust, it is making controlling eczema an uphill battle.

Doctor Q&A Youtube EczemaBlues Channel

AAD A:Z Videos with Dr Lawrence F. Eichenfield – How to Treat Diaper Rash

In 2013, I’ve featured American Academy of Dermatology (AAD)’s Dermatology A: Z Videos (here). Since then, AAD has added several other videos which are informative and practical. AAD’s public relations team has once again been most helpful in introducing me to the dermatologists who assisted with my questions, making it possible to bring this special AAD Dermatology A:Z video series to you!

The video covered today is “How to Treat Diaper Rash”. For this video, I interviewed Dr Lawrence F. Eichenfield, M.D., who is the Chief of Pediatric and Adolescent Dermatology of Rady’s Pediatric Eczema Center, and Professor of Pediatrics and Medicine (Dermatology), at the University of California, San Diego (UCSD) School of Medicine. Dr. Eichenfield’s clinical interests include atopic dermatitis, and serves on the editorial boards of several journals and periodicals, and is Co-Editor in Chief of Pediatric Dermatology.

In the video, the key points covered are:

  • Always change the soiled diapers, even if it’s just wet
  • Gently cleanse the bump area, such as using moist cloth or alcohol-free and fragrance-free baby wipes
  • Use diaper cream that is zinc oxide based
  • Watch for signs of infection

MarcieMom: Thank you Dr Lawrence for helping parents to learn more about diaper rash this week (and on eczema bleach bath therapy last week). Although diaper rash is common, we still need to learn the proper care for diaper rash and when it is no longer a rash to be self-treated.

Questions answered by Dr Lawrence Eichenfield on How to Treat Diaper Rash
Questions answered by Dr Lawrence Eichenfield on How to Treat Diaper Rash

I understand that diaper rash is a layman’s term and the rash is most likely to be contact dermatitis, caused by close contact of the baby’s skin with the urine/stool that act as skin irritant.

MarcieMom: Is irritant contact dermatitis the most common form of diaper rash? What are other potential irritants apart from urine/stool? For instance, can the diaper itself irritate?

Dr Lawrence: It is true that irritant contact dermatitis is the most common form of diaper rash, with irritation from urine and stools being the most profound irritants. Occasionally children can get inflamed due to other factors, including allergy to diaper contents, though rare, infections such as yeast, which has occurred commonly after courses of oral antibiotics, and many other less common causes of irritation.

MarcieMom: We know that babies have underdeveloped sweat glands and thus occlusion and sweat can lead to heat rash/ miliaria.

MarcieMom: Is it possible that the diaper rash is a heat rash? What are the other possible diagnosis of diaper rash?

Dr Lawrence: It is uncommon for diaper rash to be “heat rash” as the anatomy of the diaper region is different. Aside irritant and occasionally allergic contact dermatitis, there is a broad set of causes of diaper rash which includes yeast infection, psoriasis, and in unusual cases, a broad set of more serious diseases. There are textbook chapters with long list of potential causes of diaper rash, though fortunately, these are uncommon.

MarcieMom: We saw in the video that cleaning the baby’s bum is part of caring for diaper rash. Many parents clean with baby wipes which may end up irritating the baby’s skin if the wipes contain methylchloroisothiazolinone (MI) or methylisothiazolinone. MI was named 2013 “Allergen of the Year” by the American Contact Dermatitis Society.

MarcieMom: What precautions should parents take when cleaning their baby’s bottom to ensure that the cleaning itself will not further irritate the skin? How can parents tell if it’s their cleaning that cause the rash instead of the contact with the soiled diaper?

Dr Lawrence: Parents may be less concerned now, as standard products have dropped MI or MCI from standard wipes. Parents don’t need to be concerned about potential allergy to their cleaning products if diaper rashes respond quickly to standard cleansing and moisturizing regimens, or even interventions with a few days of diaper cream and/or over-the-counter hydrocortisone. If rashes persist with the use of cleansing products and do not respond to standard treatment, then this may be a different story.

MarcieMom: It is recommended in the video to use a zinc-oxide based diaper cream. The diaper cream can act as a barrier that limits the contact of the urine/stools with the baby’s skin. Again, we want to avoid the situation where the cream itself becomes the source of irritant contact dermatitis or even allergic contact dermatitis (where the skin reacts to allergen in the cream).

MarcieMom: What are the ingredients to avoid when selecting a diaper cream? Apart from the obvious ingredients to avoid such as alcohol and fragrance, can ‘good’ ingredients like vitamin E also trigger a rash? Is it better to stick to a ‘basic’ diaper cream that is mainly zinc oxide, instead of a ‘fancy’ one with more ingredients?

Dr Lawrence: Diaper creams that are zinc-oxide based are a tried and true remedy. These produces a barrier layer that protects the skin and also aids in healing of mild irritation or inflammation. Most commercial products have been tested to be safe, with a tendency to be “bland”, meaning a minimal amount of additives being included in the preparations. Parents should be careful with some “organic-based products”, as these sometimes contain contact sensitizers, meaning chemicals that children can become allergic to.

Thank you Dr Lawrence for helping with the questions – we certainly are more informed about to care for our baby’s diaper rash and not aggravate it.

Doctor Q&A Youtube EczemaBlues Channel

AAD A:Z Videos with Dr Lawrence F. Eichenfield – Eczema Bleach Bath

In 2013, I’ve featured American Academy of Dermatology (AAD)’s Dermatology A: Z Videos (here). Since then, AAD has added several other videos which are informative and practical. AAD’s public relations team has once again been most helpful in introducing me to the dermatologists who assisted with my questions, making it possible to bring this special AAD Dermatology A:Z video series to you!

The video covered today is “Eczema: Bleach Bath Therapy”. For this video, I interviewed Dr Lawrence F. Eichenfield, M.D., who is the Chief of Pediatric and Adolescent Dermatology of Rady’s Pediatric Eczema Center, and Professor of Pediatrics and Medicine (Dermatology), at the University of California, San Diego (UCSD) School of Medicine. Dr. Eichenfield’s clinical interests include atopic dermatitis, and serves on the editorial boards of several journals and periodicals, and is Co-Editor in Chief of Pediatric Dermatology.

In the video, the key points covered are:

  • Bleach bath is useful for children whose eczema is frequently infected.
  • Always ask the dermatologist before starting on bleach bath therapy.
  • Preparation of the diluted bleach bath – Half cup of bleach for a full tub of water or 1 teaspoon of bleach per gallon of water
  • Soak 5 to 10 minutes and to check with doctor on the frequency (per week) for the bath

Questions answered by Dr Lawrence Eichenfield on Eczema: Bleach Bath Therapy
Questions answered by Dr Lawrence Eichenfield on Eczema: Bleach Bath Therapy

MarcieMom: Dr Lawrence, thank you for helping out in this AAD video series once again. In our previous interview on Eczema Tips, I asked the question on what infected eczema looks like. Your reply was

Infected eczema can appear as unusual oozing or honey-colored crusting.  It can occasionally show as pus bumps, or as tender, red, warm skin.  Inflammation can also appear red, as well as “rashy” and scaly.  The bleach baths are usually recommended for children who have problems with skin infections, rather than just the inflammation seen with simple eczema flares.

MarcieMom: In another interview with Dr Clay Cockerell, readers of this blog learnt that there are both good and bad bacteria on the skin. The common ones are (1) Staphylococcus epidermidis, (2) Staphylococcus aureus, (3) Streptococcus pyogenes (4) Corynebacteria and (5) Mycobacteria. We also learn that

Bacteria multiply exponentially, so when its population is temporarily decreased, as after the use of hand cleanser, it re-grows quite quickly and returns to its normal concentration.

MarcieMom: We know that the main benefit of bleach bath is to reduce the harmful bacteria, in particular, staphylococcus aureus that often colonizes eczema skin and promotes skin inflammation.

MarcieMom: Will reducing staph bacteria via a bleach bath be only effective for a short time and the harmful bacteria quickly proliferate after the bath? 

Dr Lawrence: Bleach baths appear to decrease the quantity of bacteria on the skin, probably transiently. There have also been some studies to show that hypochlorous solution, the active ingredient in bleach bath, may have anti-inflammatory effect. We don’t really “wipe out” bacteria on the skin with bleach bath, but only tame it down for a period of time. However, they have been shown very useful as part of therapy in eczema that gets frequently infected

MarcieMom: It is mentioned in the video to consult the doctor before starting on bleach bath therapy. What are the factors that a doctor will consider when deciding whether bleach bath is a suitable (or not suitable) treatment for a child with eczema?

Dr Lawrence: When considering bleach bath, doctors will usually consider the overall degree of eczema, the tendency to have secondary infection, which can present as honey-colored crusting, as well as the age of the child. Bleach baths, while very useful, are usually therapy used in addition to regimens of moisturizing and topical anti-inflammatory therapies, as “add-on” for more difficult eczema to manage.

MarcieMom: In the video, we saw that household bleach is used for the bleach bath and we should check that there is no more than 6% sodium hypochlorite in the bleach. I realized that many household products (including bleach) do not label their contents (not mandatory requirement in every country) and that many bleach products have fragrance.

MarcieMom: What is your suggestion on how to get the right bleach product? In the event that parents can’t find a bleach product that is fragrance-free with clear labeling, what is the alternative product?

Dr Lawrence: You are correct to bring up the issue that there is variability in concentrations of bleach bath, as well as bleach not being available in all countries. Also, we have become aware that there are more concentrated forms of bleach being sold to decrease shelf space in grocery stores. Parents need to take a look at the percentage of sodium hydrochlorite, and if there are using a more concentrated version adjust the formula. There are commercial alternatives, including some readily available non-prescription products that have sodium hypochlorite solution as their active ingredient. For instance, CLn body wash, marketed by TopMD that offered this product through their website or This product has had several studies that have shown benefits in pediatric atopic dermatitis.

MarcieMom: Staph bacteria is the cause of many other skin infections such as cellulitis, impetigo, folliculitis and staphylococcal scalded skin syndrome. Using bleach bath can be preventive, so that there is less likelihood of an infection. It is better than treating an infection using antibiotics that may lead to antibiotic resistance. However, a bleach bath can be drying for the skin since bleach has a pH level of 11 to 13, thus considerably alkaline. Alkaline products can also lead to reduction of ceramide-producing enzymes, decreased skin lipid production and dry skin.

MarcieMom: Is there a way to adjust the skin pH after the bleach bath? For instance, will rinsing off residual bleach bath water be useful or will it decrease the effects of the bleach bath?

Dr Lawrence: When using bleach bath, it is important to handle the skin as with regular baths, with use of emollients/moisturizers after bathing. Some experts will rinse off the residual bleach bath water, while others will leave it on the skin. In studies, it does not appear to make a significant difference, though experts do vary in their suggestions. Certainly application of moisturizers will help, and in any case, the application of moisturizers after bathing will help to improve the skin function, including recovering the pH to normal level.

Thank you Dr Lawrence for helping us to increase our understanding of the bleach bath and clarify questions and reservations we parents have.

Doctor Q&A Youtube EczemaBlues Channel

AAD A:Z Videos with Dr Daniela Kroshinsky – Cold Sores

In 2013, I’ve featured American Academy of Dermatology (AAD)’s Dermatology A: Z Videos (here). Since then, AAD has added several other videos which are informative and practical. AAD’s public relations team has once again been most helpful in introducing me to the dermatologists who assisted with my questions, making it possible to bring this special AAD Dermatology A:Z video series to you!

The video covered today is “How to Treat Cold Sores”. For this video, I interviewed Dr. Daniela Kroshinsky M.D., MPH, who is an Associate Professor of dermatology at Harvard Medical School in Boston and the director of pediatric dermatology and director of inpatient dermatology, education, and research at Massachusetts General Hospital.

MarcieMom: Thank you Dr Daniela for helping us with treatment of cold sores this week (and last week’s interview on pain management in shingles). For parents with eczema kids, we’re very vigilant about cold sores because of the risk of eczema herpeticum. We are looking forward to learn more about limiting the spread of cold sores at home and how to minimize the likelihood of eczema herpeticum.

Key points in the AAD Video

  • Half of population carry the cold sore herpes simplex virus (HSV)
  • Symptoms of cold sores – Burning, itching or tingling, small blisters on the lips or around the mouth which may merge, burst and crust over
  • Triggers of cold sores – stress, fatigue, flu/fever, sun exposure, hormonal changes, trauma (shaving cuts, cosmetic surgery)
  • Treatment – Apply topical anti-viral cream to slow the reproduction of the virus, cool the sores at home with a cool wet towel
  • Reduce pain by taking aspirin and ibuprofen
  • Avoid acidic fruits, such as tomatoes and citric fruits that can irritate the open skin
  • Anti-viral medication used within 72 hours of rash appearing may shorten the period of cold sores or be used for prevention for those with recurrent cold sores
  • Highly contagious – avoid kissing, sharing towel, cups, shavers, toothbrush or any other object that come into contact with the cold sores

Questions answered by Dr Daniela Kroshinsky on How to Treat Cold Sores
Questions answered by Dr Daniela Kroshinsky on How to Treat Cold Sores

MarcieMom: Dr Daniela, cold sores are quite common but often, the people getting cold sores may not be aware of the severity of spreading to someone, for instance to a young child or to a person with severe eczema.

How contagious is cold sore? For instance, is my child safe as long as she doesn’t share anything with or touch the person with cold sore? Or is it super contagious? (The minute I see someone with cold sore, say in a train, I would leave the cabin. I imagine that he could have touched his cold sores, hold on to the train handle, and if I touch that or somewhere else in the train cabin that has contact with the cold sore, I would get it and possibly pass on to my child with eczema!) Is hand-washing sufficient to get rid of the cold sore virus? (Does anti-microbial product kill the virus or high temperature?)

Dr Daniela: The virus that causes cold sores spreads by direct contact so someone with a cold sore in the same cabin as a person with eczema would not pose a risk.  Spread through shared items depends on if and how much bister or wound fluid could be transmitted. Usually this is very unlikely to take place in public spaces.  In general, it’s a good idea not to touch strange fluids on trains! Handwashing and antimicrobial products would help to minimize this risk.

MarcieMom: I read on Mayo Clinic that the first-time getting the cold sore tend to be more serious that subsequent outbreaks; often, first-time cold sores may be accompanied by:

  • Fever
  • Painful eroded gums
  • Sore throat
  • Headache
  • Muscle aches
  • Swollen lymph nodes
  • Cold sores inside their mouths (for children under age 5)

Is each cold sore outbreak due to the same virus and therefore, there’s increased immunity with each outbreak? Will cold sores affect young children differently?

Dr Daniela: The first outbreak tends to be more severe with each subsequent outbreak being less involved.  Just like the varicella virus of chickenpox can lie dormant in a nerve root and then cause shingles, the cold sore virus, herpes simplex, can lie dormant and reactivate.  Children are less likely to be affected by cold sores but most people have been exposed to the virus by the time they reach adulthoods.

MarcieMom: For someone with severe eczema, the herpes simplex virus can infect compromised skin causing  eczema herpeticum. Dr Daniela, what are the factors that increase the likelihood of someone with eczema getting eczema herpeticum from cold sores? Is any child with eczema at higher risk or is he/she at higher risk only if the eczema is severe or generalized over the whole body?

Dr Daniela: Close contact with caregivers who are prone to cold sores can increase the risk of transmission of the virus.  Uncontrolled eczema leads to increased risk of open skin that could facilitate the virus spreading to the areas that are affected by eczema.  This can happen with any open area but would be more likely depending on how extensive the eczema is and as a result how much of the skin barrier has been compromised. 

MarcieMom: There are many parents whose eczema kids keep getting repeated episodes of eczema herpeticum. Apart from being on long-term anti-viral medication, are there other measures a child can take to reduce the likelihood of getting recurrent cold sores/eczema herpeticum?

Dr Daniella: Eczema herpeticum is the general term for when eczema is infected by herpes simplex virus, regardless of cause.  The best thing to do to minimize risk is to keep the eczema well-controlled and well-hydrated, minimizing dry or open patches that could allow the virus to enter more readily.

Thank you Dr Daniela for being so patient with these questions on cold sores and bearing with me (a paranoid mom!) and my questions on eczema herpeticum. We have learnt much from you and understand better the preventive measures to take to limit the spread of cold sores.

Doctor Q&A Youtube EczemaBlues Channel

AAD A:Z Videos with Dr Daniela Kroshinsky – Shingles

In 2013, I’ve featured American Academy of Dermatology (AAD)’s Dermatology A: Z Videos (here). Since then, AAD has added several other videos which are informative and practical. AAD’s public relations team has once again been most helpful in introducing me to the dermatologists who assisted with my questions, making it possible to bring this special AAD Dermatology A:Z video series to you!

The video covered today is “Shingles: Pain Management”. For this video, I interviewed Dr. Daniela Kroshinsky M.D., MPH, who is an Associate Professor of dermatology at Harvard Medical School in Boston and the director of pediatric dermatology and director of inpatient dermatology, education, and research at Massachusetts General Hospital.  

MarcieMom: Dr Daniela, thank you for helping out in this AAD video series. Shingles affects about 1 in 5 people and more common in people over the age of 50. However, it’s possible to get it at any age though, as my daughter with eczema and chickenpox (at age 2) had shingles at the age of 4! We’d like in this interview to learn more about managing the pain and the rash associated with shingles and pointers for an eczema child/patient with shingles.

Key points in the AAD Video

    • Anyone can get shingles if they have the chicken pox virus (varicella zoster), either from having had chicken pox or from chicken pox vaccination
    • Shingles rash – More pain experienced than chickenpox, commonly in one region of the body and usually confined to one side of the body
    • Symptoms of Shingles – Area of skin that burns, tingles, itches or sensitive; begins as red spots that turn to raised areas and blisters in the same area. This is followed by crusting.
    • 2 to 3 weeks for the blisters to heal with reducing pain
    • If pain, itch, numbness or tingling develops, it can last months to years
    • Anti-viral medication used within 72 hours of rash appearing may shorten the course of the rash and lessen the pain. After 72 hours, anti-viral medication can still lessen the pain.
    • At home – Cool the rash, apply calamine lotion, do not peel, pick at or pop the blisters, cover the rash with loose, sterile bandage and wear loose-fitting, cotton clothing
  • Shingles is contagious – can spread in the form of chicken pox to someone who has not had chicken pox or to the fetus of a pregnant person.

Questions answered by Dr Daniela Kroshinsky on Shingles : Pain Management
Questions answered by Dr Daniela Kroshinsky on Shingles : Pain Management

MarcieMom: Shingles is caused by reactivation of an infection that is dormant in a nerve and the area of skin supplied by the nerve. Dr Daniela, can you explain which nerves get infected most often and is that why most people get the shingles rash on their torso? In the video, it is mentioned that some people get it on their face – does a person’s age and immune system affect which nerves will get infected? Once infected, can it spread from one part to another of the body?

Dr Daniela: In general, shingles will arise in the area of the body that had the greatest concentration of blisters at the time of the chicken pox but it varies widely.  Most chickenpox blisters arise on the torso.  Once someone is infected, they can spread the lesions to other parts of theirs skin through contact with the blister fluid which contains active virus.  In addition, people who have compromised immune systems may experience widening of the affected area beyond the initial skin patch fed by the nerve. This is called “disseminated zoster” and requires urgent attention and treatment.

Reducing Pain in Shingles

MarcieMom: We learnt in the video that anti-viral medication can help to reduce pain and pain relief measures at home can help. Why do certain people feel more pain than others? (Age, immune system, or existing medication they are on?) Are there any measures one can take to reduce the likelihood of prolonged pain, ie months after the rash has healed (Postherpetic neuralgia or PHN)?

Dr Daniela: There are many factors that can influence people’s perception of pain, many that we are still starting to understand.  Starting antiviral medication as soon as possible is the most helpful tool to help minimize the risk of pain.  If PAIN develops, seeking medical attention as soon as possible, including with a pain specialist if needed, can help to better manage these symptoms.

Lowering Likelihood of Shingles’ Complications

Apart from postherpetic neuralgia, there are other complications such as

    1. Skin infection, from bacteria/germs
    1. Shingles at the eye can cause eye inflammation
  1. Muscle weakness (palsy) due to shingles infection of the motor nerve

MarcieMom: Of particular interest is skin infection. What are the factors that will increase the chance of skin infection and what measures should one take to reduce the chances of skin infection?

Is someone with eczema skin that is already colonized with staphylococcus aureus bacteria more likely to suffer from skin infection? If yes, is it advisable to clean the shingles rash with chlorhexidine?

Dr Daniela: Picking or touching the lesions can introduce bacteria that could create bacterial infection of the shingles. Keeping the lesions clean and covered helps to minimize this.  With eczema in general, keeping eczema controlled and minimizing wounds helps to prevent secondary infection.  It is not necessary to clean shingles with a medicated soap.  Chlorhexidine can be irritating and can dry out skin, further exacerbating eczema and as such I would not recommend it be used for shingles.  Keeping the lesions covered and clean with gentle care is usually sufficient.

Managing Shingles for those with Active Eczema

For some eczema children and adults, they may be on various courses of corticosteroids or immunosuppressant, such as prednisolone, mycophenolate mofetil and cyclosporine. Will taking such medication increases the risk of getting shingles? 

Is it possible that shingle rash will appear over a patch of skin with eczema flare-up? If so, what topical medication should be applied? (still ok to apply topical corticosteroid over the eczema if shingles appear on the same patch?)

Dr Daniela: Immune-lowering medications can make it more likely that someone will have their shingles spread more widely so it is important to watch shingles as it develops to assess whether the eruption is spreading more widely, warranting more aggressive treatment. Once antiviral treatment has been started, topical steroids can be used cautiously to the eczema around the shingles lesions but it is important not to rub the viral lesions as it is possible to spread the viral particles and extend the infection.  Anti-itch medications like antihistamines can be very helpful to control the symptoms of itch that can accompany eczema.

Thank you Dr Daniela for helping us to understand how to manage shingles and offering clarity for those suffering with eczema who also get shingles.

Doctor Q&A Youtube EczemaBlues Channel

AAD A:Z Videos with Dr Thomas Rohrer – How to Treat Sunburn

In 2013, I’ve featured American Academy of Dermatology (AAD)’s Dermatology A: Z Videos (here). Since then, AAD has added several other videos which are informative and practical. AAD’s public relations team has once again been most helpful in introducing me to the dermatologists who assisted with my questions, making it possible to bring this special AAD Dermatology A:Z video series to you!

The video covered today is “How to Treat Sunburn”. For this video, I interviewed Dr. Thomas E. Rohrer, M.D., who is a dermatologic surgeon at SkinCare Physicians, and previously served as the Chief of Dermatologic Surgery at Boston University Medical Center and Boston Veterans Administration Hospital for eight years and as the Director of the Boston University Center for Cosmetic and Laser Surgery. Dr Rohrer is passionate about education and is the editor of six cosmetic and laser surgery textbooks and guest editor of numerous journals.

MarcieMom: Thank you Dr Rohrer for helping us with how to shave last week. This week, we are learning about how to treat sunburn and at the same time, learn about how sunburn affects eczema skin.

In the video, the key points on the treatment of sunburn were covered: (note: AAD has amended the video on Treatment of Sunburn but the contents in this blog post was still based on the previous video which is no longer available on Youtube. The video above features AAD’s updated video)

  1. Get out of the sun
  2. Take cool baths
  3. Pat dry, moisturize while there’s still a layer of water on the skin
  4. Choose creams with aloe vera
  5. Apply hydrocortisone cream to reduce inflammation but do not treat with benzocaine
  6. Take aspirin and ibuprofen
  7. Drink extra water as the sunburn draws water from the skin and rest of the body
  8. If there’re blisters from the sunburn, do not pop them but let them heal
  9. Watch for signs of infection

The way to shower and moisturize looks the same for both sunburned skin and eczema skin – not hot bath, not rubbing dry (but pat dry), trapping more moisture on the skin after shower and moisturizing right after.

In a previous interview with Dr Robin Schaffran, we learnt that ultraviolet light rays penetrate through the epidermis and dermis layers of the skin and damage the DNA in skin cells, collagen and elastin in the dermis.

How to treat sunburn AAD Video with Dr Thomas Rohrer
How to treat sunburn AAD Video with Dr Thomas Rohrer

MarcieMom: Dr Rohrer, what is it about the sunburned skin that makes it important to maximize the retention of skin moisture? What are the factors that affect the recovery of sunburned skin? (for instance, do certain conditions like eczema and psoriasis take longer to recover? Or whether skincare measures are taken after the sunburn?)

Dr Thomas: It is a good idea to try to maximize retention of skin moisture in everyone’s skin.  When the skin is burnt it becomes even more important as there is increased loss of water through the damaged skin. Similarly, with eczema or other conditions that result in dry scaling skin, the increased permeability of the skin makes it more important to keep the skin well moisturized. Keeping the skin moisturized will allow it to function more normally and recover more quickly.

In the video, it seemed that hydrocortisone is applied liberally on the sunburned skin to reduce inflammation. A few questions to provide some guidelines to patients who have access to mild hydrocortisone cream and want to self-treat at home.

Potency – What % of hydrocortisone should the lotion/cream be?

Frequency – How frequent (in a day) can it be applied onto sunburned skin?

Duration – What would be the duration and is there a decreasing frequency of application during this period?

Amount – How much of hydrocortisone can be applied? What is the sunburned skin covers a large skin area?

Dr Rohrer: Hydrocortisone can help reduce inflammation. On the face, no more than the over the counter 1% hydrocortisone should be used.  On other parts of the body a slightly stronger 2.5% formulation may be used.  It is best not to use either more than twice a day and only for a short period of time.  Most of the time only a couple of days are necessary before the burn feels much better.    

MarcieMom: Benzocaine is mentioned not to be used. However, I read on Mayoclinic that benzocaine is used for sunburn and on Pubmed that benzocaine is effective for treating the pain (but not the itch) on sunburned skin. What are the reasons why benzocaine should not be used for sunburn treatment?

Dr Rohrer: While benzocaine preparations do help reduce pain, many people are or become sensitive to it.  We frequently see allergic skin reactions to benzocaine and therefore do not recommend it for use with the majority of patients. 

MarcieMom: Lastly for those with eczema, sun exposure is not recommended during eczema flare-ups.

How does sun exposure affect eczema skin?

Dr Rohrer: Sun exposure and sunburn are not recommended for anyone.  While some people do find that mild sun exposure improves their eczema, it is not recommended as it adds to the cumulative radiation effect of the sun and can lead to skin cancers. 

Thank you Dr Thomas for helping us with treatment of sunburn and clarifying questions we have on self-treating at home. Sun protection is important (see AAD Video on How to Apply Sunscreen with Dr Sonia Badreshia-Bansal MD on this blog).

Doctor Q&A Youtube EczemaBlues Channel

AAD A:Z Videos with Dr Thomas Rohrer – How to Shave

In 2013, I’ve featured American Academy of Dermatology (AAD)’s Dermatology A: Z Videos (here). Since then, AAD has added several other videos which are informative and practical. AAD’s public relations team has once again been most helpful in introducing me to the dermatologists who assisted with my questions, making it possible to bring this special AAD Dermatology A:Z video series to you!

The video covered today is “How to Shave”. For this video, I interviewed Dr. Thomas E. Rohrer, M.D., who is a dermatologic surgeon at SkinCare Physicians, and previously served as the Chief of Dermatologic Surgery at Boston University Medical Center and Boston Veterans Administration Hospital for eight years and as the Director of the Boston University Center for Cosmetic and Laser Surgery. Dr Rohrer is passionate about education and is the editor of six cosmetic and laser surgery textbooks and guest editor of numerous journals.

MarcieMom: Dr Rohrer, thank you for helping out in this AAD video series. Shaving is something most men and women have to do regularly and it is not as simple as it looks – complications can arise from shaving and shaving can be complicated for those with existing skin conditions. We’d first cover how to shave safely and what those with eczema have to pay attention to when shaving.

Proper Way to Shave

In the video, the key steps in shaving are covered:

  1. Wet your skin and hair before shaving
  2. Apply shaving cream or gel
  3. Shave in the direction of hair growth
  4. Change blades after 5 to 7 shaves to minimize skin irritation
  5. Use shaver with sharp blades
  6. Not to try to shave off acne

I read that wetting the facial hair will allow it to absorb the moisture and a swollen hair is softer and easier to cut. It appears that warm water is best, either a few minutes from a moistened towel or after shower. I also come across that showering will open up the hair follicle and makes it easier to shave. The idea is that the easier it is to shave, the more likely a one-time pass is sufficient and thus, less likely to irritate the skin. Conversely, showering too long will cause the skin to wrinkle and harder to shave.

Questions answered by dermatologist Dr Thomas Rohrer on Shaving
Questions answered by dermatologist Dr Thomas Rohrer on Shaving, including that for eczema and sensitive skin

MarcieMom: Dr Rohrer, it seems to get quite ‘technical’ if one starts thinking about temperature and timing of wetting skin and hair before shaving. Can you explain

What happens to the skin, hair and hair follicles when they are wet

Why wet skin, hair and follicle makes shaving easier

Whether there is an optimal wetness and how important it is to get this right

Dr Rohrer: You are correct; when hair is wet, it absorbs a little water and becomes softer. This allows the razor to cut the hair more easily.  In general, things expand when they are warmed.  So using warm water will expand the hair, skin, and pores more than cold water. This allows more water to be absorbed into the skin and hair and makes the hair softer than if cold water was used. In addition, water in and of itself is a slight lubricant so it helps the razor glide over skin better than dry skin. It is difficult to wet the skin on the face, underarms, or legs too much.  These areas do not tend to get bloated like the fingers may after long water exposure.    

MarcieMom: Likewise for the application of shaving cream or gel, there appears to be ‘good practices’ such as leaving the shaving cream on the skin for 3 minutes, brushing the cream into the hair with a shaving brush to lift the hairs and to ensure that the hairs get coated with the cream.

Is a shaving cream necessary for all parts of the body or only facial hair for men? If lubricating is the main purpose of shaving cream, will showering with bath oil achieve the same purpose? Is there an issue of too much shaving cream?

Dr Rohrer: I don’t think one can use too much shaving cream.  The point of a shaving cream is to soften the skin and hair and act as a lubricant and barrier between the razor and the skin. If someone does not experience discomfort when using bath oils in the shower then that would be fine to use.  If they do have some irritation then they could add a shaving cream or gel.

Shaving for those with Sensitive Skin

Throughout the shaving process, there are quite a few steps that may lead to irritation for those with sensitive skin. For instance,

Shaving cream – using a shaving cream that contain irritants (for instance, fragrance and Triethanolamine) or having surfactants that are common allergens

Act of shaving – irritation from friction, damage to epidermis, or repeated shaving?

MarcieMom: Dr Rohrer, what should someone with sensitive skin take note of when shaving?

Dr Rohrer: Shaving foams out of a store bought can contain a great deal of alcohol and can dry the skin out.  If someone has sensitive skin it makes sense to use a shaving gel, cream, or soap. These products contain more glycerin than alcohol and do not dry the skin out.  It is also important to moisturize the skin right after shaving.  Men should use a moisturizer that contains sunscreen with an SPF of 15 or 30 in it.  This will give a good base coat on the face every morning.      

Shaving for those with Dry Skin and Eczema

One issue with dry shaving is that the razor may get clogged up with dead skin cells. A clogged razor doesn’t give a close shave and there is a risk of nicks. For those with dry skin or eczema, there may be more dead skin cells. Also shaving can cause micro-tears in the skin and eczema patients may get the micro-tears more easily or more prone to infection at the micro-tears.

MarcieMom: Dr Rohrer, should shaving over skin that has active eczema flare-up be avoided? What should an eczema sufferer take note of during shaving?

Dr Rohrer: If someone has eczema or any other skin condition, it should be treated and controlled medically.  There are great treatments for these diseases that can get them under control. The AAD is a wonderful resource for people to use to get more information about their particular condition. If there is a flare-up, then caution should be used when shaving over these areas. An electric razor is less likely to cut skin than a typical blade razor.  These devices can be used in areas that have been compromised by a dermatologic condition.  Moisturizing after shaving will also help.

Thank you Dr Thomas for helping us to understand shaving and how preparation is important. For those of us with eczema or sensitive skin, it is also most helpful to understand how shaving affects our skin.

Doctor Q&A

Hand Eczema with Dr Lynn Chiam – Skincare

This is a 3-part series focused on hand eczema, with the privilege of having Dr Lynn Chiam, of Children & Adult Skin Hair Laser Clinic, to help explain further the type of hand eczema, its cause, treatment options and daily hand care. Dr Lynn is a consultant dermatologist who subspecializes in paediatric skin conditions at Mount Elizabeth Novena Specialist Medical Centre, Singapore. Apart from paediatric dermatology, her other subspecialty interests include adult pigmentary conditions and laser dermatology. 

The first 2 part of the series are:

  1. Basics of hand rash and different types of hand eczema, its symptoms and triggers
  2. Treatment of Hand Eczema

Hand Eczema - Skincare for the Sensitive Hand with dermatologist Dr Lynn Chiam
Hand Eczema – Skincare for the Sensitive Hand with dermatologist Dr Lynn Chiam

Hand Eczema that Does Not Go Away

If the skin at the hand is too thick and hard, it will be more difficult for medication to penetrate deeply enough to improve the skin inflammation. This increases the likelihood of untreated and persistent hand eczema. Another reason why hand eczema does not go away could be the continued exposure to an irritant which has yet to be identified. Patch testing is then recommended.

MarcieMom: Dr Lynn, what are the ways to treat hand eczema when the skin has thickened?

Dr Lynn: For thickened skin, topical steroids of higher potency should be used. Ointment based steroids can be used instead of cream based steroids. Liberal and regular use of moisturizers should be emphasized. The use of wet wraps (occluding the creams with a wet glove) can also help to increase the penetration of the creams across the thickened skin.

Phototherpy (controlled use of UVA or UVB light) is sometimes used in this type of hand eczema.

MarcieMom: How often do you see in your practice that patients cannot recover due to continued exposure to allergens in their moisturizers or topical medication? When should one suspect that is the case and request for a patch test?

Dr Lynn: Allergy to topical medication and moisturizers are extremely rare. If patient had avoided all other possible irritants or allergens and have been compliant with medication and not getting better but worse, then the unlikely possibility of allergy to medication/ moisturizer can be considered and a patch test performed.

Daily Hand Care for Those with Sensitive Skin

Some skincare tips for those with hand eczema or sensitive skin are:

  • Avoid frequent hand-washing or washing hands in hot water
  • Moisturize after exposure to water
  • Avoid irritants and triggers

MarcieMom: Dr Lynn, for those with hand eczema, should they be using an ointment instead of a lotion so that more of the moisturizer can be retained even with hand washing? Also, an ointment will be more protective against irritants.

Dr Lynn: Generally, ointment tend to be better absorbed and lock in the moisturizer for a longer period as compared to lotions. By repairing the skin barrier function faster than lotion, they tend to protect the skin and allow the skin to heal faster. They generally contain fewer preservatives and additives than creams.

MarcieMom: For occupations such as caterers, hair dressers, nurses and mechanics, will wearing gloves during their jobs help to reduce contact dermatitis? If yes, what type of gloves should they wear?

(I read some recommendations for vinyl gloves while others recommend cotton-lined gloves. Avoid latex gloves.) Are there any guidance on how long one should wear glove (since that trap sweat which is a possible irritant)?

Dr Lynn: Yes, wearing gloves is recommended for those in certain occupations where contact with certain irritants is repeated and prolonged. I will generally recommend cotton gloves as they generally do not cause irritation. However, if contact with water is necessary, use a water- proof gloves. If wearing latex gloves makes the rash worse, a patch test can be done to determine latex allergy.

Glove choice should be appropriate to the situation. Alternative to latex gloves include vinyl, nitrile and chloroprene. However, some of the chemicals used in the manufacture of non-latex gloves can also cause hypersensitivity.

I will advise patients to remove the gloves after about 20 minutes to allow sweat to evaporate. Dry the gloves inside out when not in use.

Thank you Dr Lynn for sharing with us skincare for hand eczema and understanding possible reasons why hand eczema is persistent. Hand eczema affects many adults and learning more about it help to manage the rash better.

Doctor Q&A

Hand Eczema with Dr Lynn Chiam – Treatment

This is a 3-part series focused on hand eczema, with the privilege of having Dr Lynn Chiam, of Children & Adult Skin Hair Laser Clinic, to help explain further the type of hand eczema, its cause, treatment options and daily hand care. Dr Lynn is a consultant dermatologist who subspecializes in paediatric skin conditions at Mount Elizabeth Novena Specialist Medical Centre, Singapore. Apart from paediatric dermatology, her other subspecialty interests include adult pigmentary conditions and laser dermatology. 

Last week, we covered the basics of hand rash and different types of hand eczema, its symptoms and triggers. This week, we will focus on treatment.

Common treatment for Hand Eczema

  1. Topical corticosteroids
  2. Topical calcineurin inhibitors e.g. tacrolimus and pimecrolimus
  3. Antihistamines
  4. Phototherapy

Treatment for Hand Eczema with dermatologist Dr Lynn Chiam
Treatment for Hand Eczema with dermatologist Dr Lynn Chiam

MarcieMom: Dr Lynn, a few questions on common treatment options for hand eczema:

  • For topical corticosteroids, are there typical potencies or type of corticosteroids (such as anti-fungal/ anti-bacterial) that are commonly prescribed for hand eczema?

Dr Lynn: Topical steroids are the mainstay of treatment for hand eczema. Topical steroids reduce the redness and itch effectively by decreasing skin inflammation. Due to the thickness of the skin on the hands, higher potency steroid creams are usually used. When used for the correct duration and in the correct amount, side effects are very minimal. Steroid creams should only be used on the affected areas and are prescribed for twice a day use. When the condition has improved, lower potency creams can be used. Sometimes, decreasing the frequency of the creams is also practiced. Topical steroids should always be used together with moisturizers in the treatment of hand eczema.

In cases with secondary bacterial infection (especially in those with oozing and cracked skin), topical antibiotic creams can be used in conjunction with steroid creams.

  • For topical calcineurin inhibitor, should sunscreen be used on sun-exposed part of the hand?

Dr Lynn: Topical calcineurin inhibitors (TCIs) are an alternative to steroid creams. As they have a slow onset of action, topical steroids are still used in the initially period. Topical calcineurin inhibitors are better used as maintenance agents. Side effects include a mild and temporary burning sensation. They are safe to use and in many studies over many years, they have not been associated with any major side effects or cancers.

Eczema guidelines propose that appropriate sun protection measures, such as minimisation of the time in the sun, use of sunscreen after applying TCI and covering the skin with appropriate clothing.

  • Are there any precautions to take after applying the topical medication? e.g. not touch food, water?

Dr Lynn: I will normally advise my patients to allow about 15-30 minutes for the creams to be absorbed and to avoid washing hands during this period. Wearing a cloth glove can aid in the absorption and penetration of the creams and allows the person to do work without the creams getting in the way.

  • Does avoidance of triggers play a larger role in management of hand eczema than medication? Is it likely that without exposure to triggers, skin inflammation at the hands will heal itself?

Dr Lynn: Although avoiding triggers does help significantly to prevent the eczema from progressing or being more severe, the use of anti-inflammatory agents like topical steroids and calcineurin inhibitors together with moisturizers are still essential to heal the skin.

MarcieMom: I read online of a new drug, oral alitretinoin, that has been reported to help with severe hand eczema. However, it has side effects such as headache, dry and flushing skin. It is also not recommended for pregnant women due to possibility of birth defect.

What is Alitretinoin (taken orally) and is it accepted among the dermatology community to prescribe it for severe hand eczema cases? When should a patient stop using it (ie when can one tell the side effects are too strong to justify taking the medication?)

Dr Lynn: Alitretinoin has been approved in certain countries for the treatment of severe hand eczema that has not responded to strong topical steroids. It belongs to a group of medicine known as retinoids. Currently, it is still not available in Singapore.

Certain blood tests need to be monitored while taking this medicine. Dryness, cracked lips, headache and hair loss may occur. If there is an increase in the liver enzymes and cholesterol levels, the dose of alitretinoin should be reduced/ stopped.

In view of the side effects to a fetus, women of child-bearing age should be properly counseled before starting the medicine and contraception advised.

Thank you Dr Lynn for explaining the treatment options for hand eczema. Next week we look forward to learning more about skincare and help for those whose hand eczema just won’t go away.

Doctor Q&A

Hand Eczema with Dr Lynn Chiam – Types, Symptoms, Triggers

3-part series on Hand Eczema with Dr Lynn Chiam

Dr Lynn Chiam

Dr Lynn is a consultant dermatologist who subspecializes in paediatric skin conditions at Mount Elizabeth Novena Specialist Medical Centre, Children & Adult Skin Hair Laser Clinic, Singapore. Apart from paediatric dermatology, her other sub-specialty interests include adult pigmentary conditions and laser dermatology. 

Is it really Hand Eczema?

Rashes on your hand may not be eczema although hand eczema/ hand dermatitis is the most common type of hand rash. Various other rashes can be:


Psoriasis is a chronic skin condition characterized by clearly defined white, silvery or reddish thick patches. Apart from the palms, look for other typical signs of psoriasis such as scalp involvement and nail deformities.

Tinea Manuum

This refers to fungal infection of the hands which can look similar to hand eczema. Fungal infection needs to be excluded if only one hand is affected. A fungal scrape (skin test) will be positive in tinea manuum.

MarcieMom: Dr Lynn, how frequent are the above in causing hand rashes? Are there other common differential diagnosis from hand dermatitis?

Dr Lynn: Hand eczema has been identified as one of the most common frequent dermatological disorder encountered in clinical practice. It is caused by a combination of internal (genetics, individual predisposition) and external factors (exposure to irritants and allergens). It is estimated that about 10% of the general population suffer from hand eczema. It is reported to be more common in women and in certain occupations like hairdressers, healthcare workers and domestic workers.

Other conditions that can mimic hand eczema include psoriasis (which affects about 1% of the local population) and tinea manuum, a fungal infection of the hands which is uncommon.

Different types of Hand Eczema/ Dermatitis

Hand eczema results in inflammation of the skin which can present with dryness, scaling, redness, vesicles( bubbles), fissures, thickening, pain and itch. Even within hand eczema, there are various forms of dermatitis:

Hand Eczema - Types, symptoms and triggers with dermatologist Dr Lynn Chiam

Irritant Contact Dermatitis

This is the most common form of dermatitis, caused by repeated exposure to irritants like water (from repeated hand washing), soaps, detergents, food products or chemicals frequently exposed to in a job, such as solvents, lubricants, oils and coolants. Friction and repetitive rubbing of the skin also increases the likelihood of irritant contact dermatitis. The rash is typically found on the knuckle surface of the hands. Avoidance of the irritant material can bring about a significant improvement.

Allergic Contact Dermatitis

Allergic contact dermatitis only happens to a small number of people who are sensitized to a certain material. This means that in the past, they may have been in contact with the offending material and even though on the first contact, there may have been only a little or mild reaction, the skin “remembers” the material as an allergen. On the repeated contact with the same material, a worse rash will result. Common allergens include nickel, fragrances, preservatives and rubber. A patch test can confirm the allergy.

Atopic Dermatitis

Patients who have atopic eczema when young are more likely to develop atopic dermatitis on the hands as an adult. Look for involvement of the other areas on the body.


Pompholyx has a distinctive appearance of itchy small blisters on the palms of the hands. It is also more closely associated with excessive sweating and can be found on the soles and toes.

Nummular Hand Dermatitis

This shows up as circular areas of redness, scaling on the backs of the hands and can appear oozy.

Symptoms of Hand Eczema

Symptoms include redness (erythema), itch (pruritus), pain, dry, peeling/ flaking skin, blisters (vesicles) and cracks (fissures), weeping (exudation) and swelling (oedema).

MarcieMom: Dr Lynn, there are quite a few types of dermatitis – do they have similar symptoms or can it be difficult to diagnose which type of dermatitis one suffers from? Does age, gender or occupation affect which type of dermatitis one suffers from?

Dr Lynn:Yes, the different types of hand eczema can have similar symptoms. However, there are certain clues to look out for. From the history of the onset of the rash, contact with certain materials, improvement with avoidance, one may be able to distinguish between irritant and allergic contact dermatitis. A positive or family history of atopy (allergic tendencies) and involvement of the feet points to atopic hand eczema.

More women are affected by hand eczema than men. The prevalence of hand eczema is also higher in certain occupations like healthcare workers, hairdressers and domestic workers. This is due to prolonged and repeated contact with certain harsh materials resulting in irritant contact dermatitis. In irritant contact dermatitis, the knuckles, finger tips and web-spaces are commonly affected. Improvement is noted with avoidance of the material.

In allergic contact dermatitis, the rash may persist even with further avoidance of the allergen. Patch testing can help determine the allergen.

In adults with atopic eczema affecting the hands, other areas of the body can also be affected. In the acute stage, red spots, oozing and excoriations can be seen. In the later stages, the skin becomes dry, cracked and thick. Secondary infections can also set in.

Triggers of Hand Eczema

Triggers of hand eczema are typically water, sweat, soaps, detergents, food products, solvents, lubricants, oils and coolants.

MarcieMom: Dr Lynn, regardless of whether it is irritant contact dermatitis, allergic contact dermatitis or atopic dermatitis, are the triggers similar? If yes, will avoiding these triggers be actions a hand eczema sufferer should take?

What are the factors that affect what form of dermatitis one get?

Dr Lynn: Yes, there are certain common triggers that will adversely affect the hands. Over-washing (even with just plain water), harsh soap, detergents and lubricants should generally be avoided by people with hand eczema. Wearing of gloves to reduce the contact of water and soaps with the skin is recommended if prolonged wet work is necessary.

Regular use of moisturizer can help prevent flares in people with hand eczema. Gentle soap in small amounts is recommended.

Keeping fingernails short prevent further damage of the skin while scratching. It is advisable to remove rings and bangles before hand-washing and wet work as they can trap moisturizer, dirt and bacteria.

MarcieMom: Thank you Dr Lynn for helping us to understand the different types of hand rash, hand eczema and its common triggers. Next week, we will look forward to learning about treatment of hand eczema.

Doctor Q&A

Science of Skincare Products – Eczema Supportive Care

This is a 4-part series focused on understanding the science behind skincare products so that parents of eczema children and eczema sufferers can better understand what goes into the bottle. Read more about Dr Briand here.

  1. Science behind Skincare Products
  2. Skincare Product safety and expiry date
  3. Skincare Product stability
  4. Eczema Supportive Care
Lotion, Cream or Ointment as Eczema Moisturizer

MarcieMom: Thank you Elisabeth for joining me again for this last part of our skincare products. I’ve covered in this blog that moisturizer has preventive effect on eczema and for those with eczema, moisturizing frequently is able to reduce the use of corticosteroid cream. What I would like to focus in this interview is whether the type of cream, how we apply and when we apply will make a difference in the functions of the moisturizer.

We are aware that the more liquid a moisturizer is, the shorter time it will last but it is more comfortable to apply than an ointment (which has little to no water content), especially in hot and humid weather like Singapore or during summer. Does the nature of whether it is lotion, cream or ointment affects the efficacy of the skincare product? For instance, does being lotion meant it is more easily absorbed and being ointment meant it will be longer-lasting?

Dr Elisabeth: Many kinds of products are indeed available to help and promote skin health. The same principles as those described earlier work for all of them: products with few ingredients and safe ones will be better for sensitive and fragile skins.

Various kinds of products will, as you said, give different kind of feel and the aim may (or may not) be different as well. The purpose of the two products is different, while ointment is often used to bring a lot of fatty acids to the skin and add an occlusive layer to reduce the TEWL (Transepidermal Water Loss or water that is lost through the skin), cream is more used to bring water to the epidermis, as well as other hydrophilic compounds that could be of interest. Creams bring also hydrophobic compounds (fatty acids, hydrophobic active ingredients, …) but to a lesser extent.

The long-term efficiency of a product will depend on how it is structured and how quickly the compounds are delivered to the skin and absorbed.

For ointment, they generally have an occlusive layer that will remains on top of the skin, which is the purpose of these ingredients so that it can prevent water to evaporate from skin. So the feel it gives and that specific function will last for a rather long time. On the contrary, water and active compounds are delivered quickly and evaporate or absorbed quickly by skin. As a consequence, the moisturizing feel disappears rather quickly

One of the achievements that may be reached by using innovative structure is to make cream that have a feel comparable to a classical cream, but will display a long-lasting delivery of the active ingredients, and then combined some of the advantages from an ointment (long-lasting relief and effect) and from a classical cream (pleasant feel, bringing water to the skin).

Ceramides in Moisturizer for Eczema, Dry Skin

MarcieMom: The other ‘big’ question that all parents have is each skincare company claims that their product is able to hydrate, build the skin structure better. These typically belong to the group of moisturizers that contain ceramides or have the ability to restore the skin lipids. In your view Elisabeth, is there certain characteristic (such as ingredients or process) that will differentiate a category of moisturizer as being better at restoring skin functions than others?

Dr Elisabeth: Efficiency is claimed by all companies, of course, because all products will bring the element that will help skin moisturizing, at least in the short term. It is clear however that some products will be more efficient than others; just like some products will have better feel than others etc. As mentioned in our previous discussion, this is why scientific innovation and knowhow comes into play: in our view, they are the key to make better, more efficient and safer products

Ceramides are indeed one of the components that enter in the composition of skin membranes and seems to play a role in its restoration. There are however several types of ceramides and all of them do not seem to display the same efficiency according to various recent publications. What will help skin to be restored is to protect it from threats, and nourish it with proper ingredients. A general appellation of Natural Moisturizing Factor has been created to describe these ingredients that can play a positive role in skin restoration. Ceramides are only one of them. For example, vegetal oils are mainly made of fatty acids that interact with skin cell membrane and help it to be “nourished”. Some of these oils also have additional compounds that will play a positive role.

Glycerin and other Natural Moisturizing Factors

Glycerin, urea, aminoacids, cholesterol, and many other ingredients can play a role in restoring skin functions. What is important is to determine which ingredients will be helpful in a specific situation, and how you can maximize the efficiency of this ingredient in the molecular structure that you create inside the product.

Skincare Moisturizing Routine – Any Tricks?

MarcieMom: Readers of this blog are familiar with basic skincare, such as moisturizing right after shower and making sure to moisturize enough. Either due to cost or belief of effectiveness of certain way of moisturizing, some parents may

  • apply brand A moisturizer in the day, and brand B at night; or
  • apply brand A on certain days of the week and brand B on others (or alternate by weeks);
  • apply brand A (a lotion) and brand B (an ointment) over it.

In your view, which is the skincare moisturizing method that make sense? For instance, with constraints that many families have, such as budget and time to moisturize (e.g. child in school or simply to reduce the number of times moisturizing is needed).

Dr Elisabeth: A daily moisturizing routine is indeed driven by various factors, lifestyle included. A product can be efficient, but if it is a hassle to use it, it won’t be used properly and will become inefficient. I would say there is no “you have to” routine, just find one that is working for you. If you keep in mind the principles I already described: using efficient products with few and safe ingredients, you can find what works the best for you. And it may be completely different from what works for another person. And it can be the same product or products for a very long period of time.

Skincare Moisturizer as Eczema Support

Regularly changing skincare products from time to time can be a good idea when you are using products that contain a lot of ingredients. or that contain an ingredient you are slightly sensitized to. So you will give a rest to your skin that would otherwise be exposed to some ingredients that could become unhealthy with time and regular use.

MarcieMom: Many eczema sufferers feel that rotating the emollient seems to make it more effective than always using the same emollient. Is there some basis for that?

Dr Elisabeth: The efficiency of a product is determined by its ability to bring what is needed by the skin to be protected to help restore its functions. Rotating products can be a way to bring various efficient ingredients that are not found in only one products. But as I just mentioned before, there can be other reasons that can make an emollient less efficient, so you have to switch from it for a while. Some ingredients can lead to some sensitization of the skin. Not strong enough to give a rash, but strong enough to lead to some irritation if used over long periods of time, that would explain why a product would become less efficient. Reducing the number of ingredients can decrease this risk and in that case, your emollient will work for a longer time.

Thank you Elisabeth of being ever so patient in this series of interviews on skincare products, tackling specifically the science behind it. It is truly enlightening and practical!

Doctor Q&A

Science of Skincare Products – Stability

This is a 4-part series focused on understanding the science behind skincare products so that parents of eczema children and eczema sufferers can better understand what goes into the bottle. Read more about Dr Briand here.

  1. Science behind Skincare Products
  2. Skincare Product safety and expiry date
  3. Skincare Product stability
  4. Eczema Supportive Care
Stability in Skincare Product

MarcieMom: Is it possible that a moisturizer has not spoilt but is no longer effective? Is technology required to ‘hold the ingredients’ together to be stable?

Dr Elisabeth: Generally yes. The best skincare products can be quite sophisticated, “high tech” products, so if the structures that hold the different ingredients are degraded, then there can be a significant loss of efficiency. To make a parallel, if you stomp onto your mobile phone and it is crushed, you will still have all the components of the phone, but the structure will be destroyed and the phone may not work any more! Using industrial processes enable to make structures that will increase the stability of a product. You will not be able to achieve these structures with a bowl and a mixer. A lot of scientific and industrial knowledge is necessary to make products that will last for a long period of time.

At Skintifique, we have developed products that have very novel internal structures, which is what give them distinctive properties, be it for moisturizing the skin, protecting it from common allergens and irritants such as Nickel and other metals, or providing long lasting moisturizing and soothing.

Stability in Skincare Product ingredients
Tips on Buying a Safe and Stable Skincare Product

MarcieMom: Any tips for parents to make sure that they are buying a product that is safe and stable and not using one which has stopped being so?

Dr Elisabeth: Choosing a product that is safe and efficient is a major concern for parents and people with sensitive skins. The first tip I would recommend is to choose skincare with the least number of ingredients. No ingredient is completely safe for everyone, and by reducing the number of ingredients you are exposed to, you minimize the probability your skin will react to one of the constituents. So in that case, fewer means safer. Of course, the better known the ingredients, the safer the products: a skincare product that would only contain 8 ingredients but 3 of which no one has ever heard of, or used in a skincare, would not necessarily be the safest choice…

Fewer ingredients means Safer

I would recommend buying skincare from a brand you trust and that must fulfill stringent regulation. It can be established brands but also new ones (and as a representative of a new brand, I can only emphasize that some new brands can be even safer and better than established ones!), a key point is : do I trust this brand or do I have reasons to? Of course, one sometimes needs to try new products, if only to get better benefits than with current products, so then another key point is: can I make a test, eg buying initially 1 tube, or getting a sample etc. Some tips can help to reassure about the professionalism of a company: is there an easy way to contact them, are there some credential that tell you who is behind, are they prone to answer your question to one of their products, are their products manufactured in reliable places

EU Regulated Sensitive Skin Product Labeling

Use products that have been designed for sensitive skins or children. They have been assessed by independent experts in toxicology with more stringent criteria, especially in the EU. Since 2013, there is a new regulation (European cosmetic regulations) that have clarified what is necessary for a product, and fair labeling is a major part of it. Evidence has to be provided before a product can be labeled as suitable for children and sensitive skin. An independent toxicologist expert is mandated to consider all the evidences claimed for a product. What is not done yet is a previous approval of cosmetic product before it is commercialized, but you have to give all these information as soon as a state authority requests it. So if you are a serious skincare company, you have all the tests done, certificates needed and so on in a « cosmetic file » that is ready to be consulted by state authority.

There can always be untrusted company that are selling  products with not all the tests made but if it is discovered, consequences can serious…   What is not described in the regulation is the exact method and tests you have to performed to build your evidence, but some consensual recommendations are coming out from bench of experts in toxicologist. As an example, one of these recommendations is to use much more stringent safe limit for a product destined for a child. To illustrate it, this is roughly how is estimated the toxicology profile of a cosmetic product for an adult and a child:   To determine if a product is safe for an adult and how much of this product, at the maximum, it is advised to applied on skin, you determine the exact concentration of each ingredient, and how much of each of these compound is applied on the skin. You have toxicological profile for each ingredient allowed in cosmetics, with the maximal dose at which it is not toxic. The limit of exposure for each of the component of the cream is determined, and the maximum amount of a skincare that can be applied daily is determined by the ingredient with the lower dose of exposure allowed.   To determine if a product is safe for a child, you make the same analysis, but with more stringent criteria. For exemple, the maximal dose of each ingredient allowed per day is divided by a factor of 2.3 and since you have to take into account the various mass of people (generally a factor 12 between a child and an adult), the overall factor of safety is about 27 compare to a product designed for an adult.

As long as it is within the expiry date or period after opening (PAO), and unopened, it should be safe, but as soon as the product has changed in color, odor, aspect, throw it away.

MarcieMom: Thank you Elisabeth – now we all know what to look out for especially when most of us have so many creams and lotions at home for our eczema child and after keeping for some time, we struggle whether to throw it out or still use it.

Doctor Q&A

Science of Skincare Products – Safety and Product Expiry Date

This is a 4-part series focused on understanding the science behind skincare products so that parents of eczema children and eczema sufferers can better understand what goes into the bottle. Read more about Dr Briand here.

  1. Science behind Skincare Products
  2. Skincare Product safety and expiry date
  3. Skincare Product stability
  4. Eczema Supportive Care
Skincare Product Expiry Date

MarcieMom: Thank you Elisabeth for joining me again for this series. Quite a few times I look at a product and wonder what will happen after the expiry date, and if it will spoil without visible change.

How is this expiry date determined? Is there a real need for an expiry date, as in will certain ingredients really spoil?

Dr Elisabeth: Every product sold in established market must pass mandatory regulatory requirements that are essentially designed to ensure safety of the products for consumers. Expiry date of a product is one of the aspects that is often covered by regulatory requirements. I will talk here more about products produced or sold in European Union, which is one of the most stringent worldwide. It means the product must pass several tests that prove it will not spoil during that period of time.

To ensure the safety of a product, you can strictly follow the regulations that are mandatory, or you can also add extra care to that aspect. Regulation is the minimum required, and you can always do better by putting yourself higher internal requirements.

In products produced and/or sold in E.U., you can have two mentions of expiry, one is an actual expiry date, and the second one is Period After Opening or PAO.

If a product has passed tests that will prove it is stable for at least 36 months, expiry date is optional, but you have to indicate how long this product can be used safely after it has been opened. 

Period after opening symbol skincare

Some other products will display an expiry date. There are multiple reasons to indicate an expiry date. It can be because 1. the products did not pass the test for a period corresponding to 36 months, 2. it has not been tested for this long period of time, 3. it has passed the test for that period of time, but for various reasons, it has been decided to shorten its shelf life.

In the last case, the reason behind is often to ensure a maximum of safety. The tests that mimic product aging are well known and well controlled but are still tests. Real life can be quite different than what has been modelized in a lab, and adding an expiry date is a way to ensure a maximum safety for customers.

Using a product for a longer period that is indicated may not be necessarily harmful, and the product can still be good, but you are on your own. There is no data to support the fact that it is safe or not…

Safety and Expiry Date in Skincare Product
Quality of Raw Materials – Product Spoilage

MarcieMom: I suspect that an organic skincare lotion I bought may have got bacteria because after a few weeks of using, my daughter developed impetigo (or of course, the impetigo could simply be a complication from eczema and the scratching everywhere). What are the factors that increase the chance a skincare product will spoil? Is it the type of ingredients, where they are made and flown to, or what temperature they are kept in?

Dr Elisabeth: A serious skincare company will take great care of offering products with the best quality, to avoid risk of products spoiling.

The first factor that will induce spoiling of the product is the quality of raw ingredients used in the product and the quality of the manufacturing process. Having strict controls over these factors will help to avoid problems of contamination and oxidation, which are the most frequent causes of product degradation.

The quality of raw ingredients is obviously essential, as any contaminant present in the ingredients with contaminate the final products. Another source of contamination can be the material that is used to manufacture or package the product. Finally, the last main source of contamination is humans that work on the preparation of the cream. They must take great care of personal hygiene before working (washing hands, using single-use gloves, round cap and masks) and only do so under the highest safety and quality standards. The preservatives used in the skincare provide a good reassurance and generally protect the products reasonable well, but reducing the amount of microbiological contamination from the start, ie from the moment the ingredients are sourced and they are manufactured, is the best way to avoid spoiling later on. In E.U., manufacturers of skincare have to follow “good manufacturing practices” regulation, and at Skintifique, for instance, we have applied extremely strict criteria when choosing our suppliers of raw materials and our industrial partners, precisely so as to have the highest assurance on the quality and safety of our products

Stability Tests on Skincare Product

Stability tests are made to ensure a safe use of the product, but as I said earlier, these tests are designed to mimic quite standard situations. Real life conditions can be harder than what has been modelized. For example, sunscreen creams that have been forgotten in the car on a back sit, and stayed for a long time in a very warm environment, under the sun, have experience several cycles of heat/cooling, which is one of the harder conditions a skincare product can experience. These conditions exceed what have been tested in a lab, and the product can go bad earlier than what is said on the packaging. To ensure that a product will not spoil, you should keep them away from heat and UV. Putting them in a fridge can help keeping them, but may induce a change in the structure of the product (its texture won’t be the same).

To ensure that a product will not spoil, you should keep them away from heat and UV.

MarcieMom: Thank you Elisabeth for sharing about safety and expiry dates of skincare products – next time when I’m offered the chance to visit a skincare company’s plant, I shall look out for these areas! Next week, we will touch on the stability of a product. Can’t wait to learn more!

Doctor Q&A

Science of Skincare Products – Science in the Bottle

Science Behind Skincare Products with Dr Briand

Dr. Elisabeth Briand, R&D manager at Skintifique. Elisabeth holds an Engineering Master’s degree in food industry and a PhD in chemistry. She had 10 years experience in academic research as a physico-chemist, in France at Paris VI and Paris XI faculty of Pharmacy and in Sweden, at Chalmers University of Technology.

Science of Skincare Products with Dr. Elisabeth Briand

This is a 4-part series focused on understanding the science behind skincare products so that parents of eczema children and eczema sufferers can better understand what goes into the bottle.

  1. Science behind Skincare Products
  2. Skincare Product safety and expiry date
  3. Skincare Product stability
  4. Eczema Supportive Care

MarcieMom: Thank you Elisabeth for joining me for this series. I’m really excited about it because most parents (me included) wonder the differences between skincare products and whether it’s better to get one from a company with the ‘science’ background (or home-made is better).

Let’s start with what’s in the bottle – the ingredients. From a previous interview series, we have learned a few general principles relating to skincare products, to choose those

  1. Without the common irritants, such as fragrance, preservatives, parabens, propylene glycol, lanolin and dye
  2. With as few ingredients as possible, to reduce the likelihood of sensitivity to ingredients
  3. Whether labeled as natural or organic, the overriding factor is whether these ingredients lead to hypersensitive reaction for our skin
Science in skincare product bottle
Skincare Product Ingredients – Active & Support

MarcieMom: How is the selection process of ingredients determined? For instance, is there always a need for a ‘base’ for a skincare product and then add on active ingredients? Do these ingredients have to work together?

Dr Elisabeth: The choice of ingredients is indeed key to develop a skincare product. Some ingredients will be chosen for their activity, some others for making a support for these active ingredients. Ideally, a very strict and rigorous selection process should be carried out. Each company has its own priority for this; for instance, some will prioritize on ingredients they believe give a distinctive feel (texture, fragrance) when applying a product, some others will focus their research on how improving the efficiency of a product by using one specific ingredient. At Skintifique, we focused on a new innovative approach: using both a minimum number of ingredients and very safe ingredients. Making a product safe, efficient and pleasant to use within these constraints require a lot of skills and knowledge in various fields (physic-chemistry, formulation, microbiology and pharmacology).

One way to make a skincare product is to add a set of ingredients with a specific function (eg moisturizing, or protecting the skin from specific allergens or irritants) to a “base” that has a well-known profile of safety, texture and efficiency. In that case, the base will bring the safety and the basic functions a moisturizer must have (generally, humectant, emollient and occlusive function, it sustains stability and safety tests) and the added specific ingredients will bring the specific features of a product (soothing, …).

At Skintifique, we have focused our work on how developing new materials that will enable the use of very few ingredients while maximizing their effects. It means developing products with a new approach, based on how molecules can interact with each other. That’s why the composition of our products may seem very simple, but the products are actually based on very sophisticated science, both in the base(s) that we use, in the functions we add to them and in the ability to mix these functions into the base.

Functions of Skincare Product Ingredients
  1. Occlusive, as protection for the skin
  2. Humectant, the ability to draw water from the environment into the skin
  3. Moisturize, smooth the skin and fill in cracks

MarcieMom: I noted that your product has patent technology. Does a patent technology that enable the functions of the moisturizer to be better than non-patent technology? In other words, what is it about being developed in a lab that makes the skincare product more effective than just the sum of ingredients?

Dr Elisabeth: A lab facility is required when you want to make innovative products.

Developing a skincare product can be done rather easily if you are looking for a product with basic moisturizing functions or just a feel good benefit. There is a long history in the process of making a cream and the principles that drive the stability and the efficiency of classical moisturizer are rather well known.

If you want to add extra features to a product, for example a release in time of active ingredients, a longer stability, or something revolutionary such as having a activity that reflects the needs of the skin (eg the cream is more active when the skin needs it), while using a very low number of ingredients, then you have to think differently of how it is traditionally made. It requires a lot of research.

This is the type of products we strive to do at Skintifique and that is why we protect, with patents and otherwise, the technologies that are used in our products. To achieve the development of our products, we have to make numerous tests and iterations that are possible only in a lab. We needed specific equipment to process and also analyze the various formulations.

It is a little bit like in cooking. Using eggs, flour, milk and sugar, you can make simple cakes (which will not harm you if you eat them, but which will not provide anything special in terms of taste and feeling), or you can also achieve a new culinary chef d’oeuvre, if you put a lot of knowledge, expertise and skills only a chef can bring in making it.

Development Process for Skincare Product

MarcieMom: Can you briefly describe the key processes to make a skincare product from sourcing to making the final cream/lotion. How is it different for a company like Skintifique versus say, a company that does not have the laboratory or facilities?

Dr Elisabeth: The general process to make a skincare product is simple at high level: decision on what the properties of the skincare should be and how to make it (e.g. a highly moisturizing product with few ingredients for people with sensitive skin vs a skin tanning product for fun), then identify, or invention of, the best technologies to do the product, including choice of raw ingredients that must fulfill strict criteria in terms of safety and purity, then a lot of trials in the lab and with real life volunteers, then industrial production, quality check and then, commercialization. For serious skincare companies, quality is a major priority and a lot of quality-check procedures are made all through the process (raw ingredients, industrial process, finished products…)

Making innovative products requires a lot of research and development work, and the results will condition the industrial process. For instance, using only a few ingredients to make a product like our Hydrating Gel requires modifying a lot the various steps needed to process a product. That is why a strong effort is made both on the invention work in the lab and on industrial scale-up phases. For more classical cream, this scale-up process is less critical.

MarcieMom: Thank you Elisabeth for helping us in this post – it is enlightening as we now understand the key components of a skincare product and how having technology and laboratory affects the final product. I look forward to next week’s interview where we learn more about the safety and stability of a product.

p.s. Declaration of no self-interest – I just want to let readers know that Dr Elisabeth left a comment on my blog and I felt she was very helpful. When I realized her area of expertise, I suggested that we could collaborate on a ‘science-y’ series as I’ve always been intrigued by it. No money has changed hands, only time invested to bring this series to you all!

Doctor Q&A

Feeding Kids Healthy series – Eating a Balanced Diet

Traditionally, parents worry about whether children are eating enough but based on the rise in childhood obesity (2011 – 11% and updated in 2017 – increased to 13% in Singapore), parents also have to be mindful of overeating AND eating the wrong types of foods.

For this 2-part series focused on feeding kids healthy, Abbott facilitated the interviews with nutrition experts. Last week, we covered what and how much a child should eat. This week, we will focus on how we can get the child to eat a healthy and balanced diet. We have Anna Jacob, Director of Nutrition from Abbott.

Health and balanced diet for children with Anna jacobs director of nutrition abbott

MarcieMom: Thank you Anna for helping us figure out how we can actually get our kids to eat the healthy meal we’ve prepared. We assume that parents have the knowledge to serve a healthy meal of half plate fruits and vegetables (the more colour, the better), a quarter of protein and a quarter of whole grains. Let’s overcome the potential obstacles in each food group!

Getting Fruits Rights for Children

For fruits, the common ones in Singapore are apples, oranges, pears, grapes, strawberries and mangoes. Within these fruits, we have red, orange, green, purple and yellow! Would you reckon it is more attractive to kids to be served a variety of colours within a meal or rotating each fruit? What is the serving size in each case? Must they be organic?

Anna Jacob: Fruits are rich in many vitamins, some minerals and dietary fibre. Brightly colored fruits also have many natural plant compounds that are now known to be beneficial to health. For example, beta-carotene in yellow-orange fruits supports healthy skin and anthocyanins in red fruit may benefit heart health.

Beta-carotene in yellow-orange fruits supports healthy skin and anthocyanins in red fruit may benefit heart health.

There are basically five colored types of fruit:

  • Green:  Green apples, pears, kiwi, honeydew
  • White: Bananas, lychees, longans, mangosteens
  • Yellow and Orange: Oranges, papaya, cantaloupe, mango
  • Red: Cherries, watermelon, red apples
  • Blue and Purple: Blueberries, purple grapes

Parents can add color to their children’s meals with a variety of fruits, making recipes more attractive and nutritious.  However, we do not have to serve up all the colored fruits on one plate all the time. Incorporating them through different meals and snacks will help your child appreciate and eat them too.

Dietary guidelines from around the world recommend that fruit should be part of a child’s diet – starting with just half a serving after 6 months and progressing to 2 servings by 7 years. 

Examples of a serving of fruit, as defined by Singapore’s Health Promotion Board, is 1 medium banana, 1 medium apple, pear or orange, 1 wedge of watermelon, papaya or melon or 10 grapes or longans.

Fruits in Singapore are safe and rinsing the fruit in clean running water before cutting and eating it is sufficient. Therefore, it is not necessary for parents to buy only organic fruit for their children. But for those who want it and can afford it, organic fruit – free of synthetic fertilizers and pesticides – may provide peace of mind.

Getting Vegetables Right for Children

MarcieMom: For vegetables, the leafy green ones, cruciferous (broccoli, cauliflower and Brussel sprouts) are packed with nutrients. What is the best method of preparation that retains the nutrients yet appealing to kids? Do you recommend hiding vegetables?

Anna Jacob: Indeed, green leafy vegetables are rich in many nutrients including iron, vitamin C, folate, calcium and fibre.  However, many vitamins are sensitive to light and exposure to air. In addition, the water soluble vitamins and many minerals are soluble in water.

Vegetables retain their nutrients best when they are eaten fresh and not processed. To preserve the nutrients in fresh vegetables, prepare them just before eating; do not soak or cook them in water for too long, prepare just before eating, cut into larger pieces and do not overcook vegetables.

Cooking destroys some nutrients, especially the fragile, water soluble ones.  However, many children eat more vegetables when they are served up cooked. Of the many cooking methods commonly used to prepare vegetables, microwaving and steaming conserve nutrients best.  On the other hand, some nutrients in vegetables are better absorbed when prepared with some fat.  For example, tomatoes cooked in oil make lycopene (the natural red pigment) more available to the body. Cooking also makes many otherwise inedible vegetables suitable for a child’s diet – think potatoes, yam, beets and more.

Your Cooking Method Matters

So, use several cooking methods to prepare vegetables to increase your child’s exposure to a variety.  Aim to provide ½ serving of vegetables a day to a child over 6 months and, gradually progress this to 2 servings by the time he / she enters school.  A serving is defined as ¾ of a 250-ml mug of cooked or non-leafy vegetable, 150 g of raw leafy vegetables and 100 g of non-leafy vegetable.

Ideally, children should accept all food including vegetables. However, some reject vegetables due to color, taste, texture. Some scientists also suggest that a few kids are ‘super-tasters’ and may be more sensitive to the bitter notes of leafy green and cruciferous (broccoli, cauliflower and Brussel sprouts) vegetables – causing rejection of these nutrient-dense foods.

Patience is the key when you want to inculcate healthy habits – offer the same vegetable over and over again, without forcing, so that the vegetable becomes familiar. Model eating the same food item at family meal times and, vary the presentation, cooking method and flavoring.  If and when all these suggestions for introducing vegetable fail or take time to achieve, parents may have to be creative and incorporate vegetables in foods. So, ‘hiding’ vegetables is a last resort and not the best option.  But, it is still a valid option and, so, do not feel guilty if you are doing it. Just keep working on all the suggestions listed above, and, soon over time, you will succeed – at least to some degree.

Getting Grains Right for Children

MarcieMom: For grains, whole grains like whole wheat, brown rice, quinoa are better than white rice. As there is less natural sugar in these than white rice, how should they be prepared to be appealing?

Anna Jacob: Natural grain foods – whole grain and polished – do not contain natural or added sugars. All carbohydrates in grain foods, after digestion are absorbed into the blood stream as simple sugars. This is unavoidable as it is the way the body handles carbohydrates. Sugars and starches are not all bad – they do help provide energy to keep children active. In the right proportion, they ensure that children get the energy they need to grow and be active. One advantage of whole grains is that it has more fibre, vitamins, minerals and natural plant components than refined grains. So, definitely, whole grains are more nutritious and therefore, the healthier choice. Here are some tips on how to cook them:

  • Brown rice can be steamed or boiled. However, you need to adjust cooking time and added water volume to achieve a soft and edible grain suitable for your child’s eating ability.
  • Whole wheat grains can be boiled to prepare porridge or milled to make whole meal flour. The flour is versatile and you can make a variety of breads and biscuits with it.
  • Quinoa, usually prepared by the absorption method, requires two-times the volume of water as quinoa and cooks in 10 – 15 minutes.

As these are staple foods and, we eat a good portion of them at each meal, so, it is best to prepare them simply with less fat, salt or sugar. They can be eaten with vegetables and lean proteins as side dishes.  In addition, for variety, you can toss whole grains with fresh or cooked vegetables, nuts, lean meat and some natural seasonings to prepare delicious one-dish meals or snacks.

5 Tips to Get your kid to experiment

MarcieMom: Apart from the food preparation, can you share your top 5 tips for getting children to experiment different foods and eat the foods served to them? What are the top 3 pitfalls to avoid when getting a child to eat his/her meal?

Anna’s Top 5 Tips for Getting Kids to Experiment Foods
  1. Involve your child in food preparation. From gardening to shopping and cooking, involving your child will help him/her learn about food, become familiar with it and, even develop a sense of pride and ownership. Time spent together over these activities will offer you many opportunities to teach your child about the nutrient-goodness of food as well.
  2. Eat with your child. Children learn about nutrition best by modeling healthy eating behaviors. As you eat a wide variety of food, your child will learn to do so too. You can use these special moments to teach table manners and to bond.
  3. Offer healthy foods. As a parent, you need to ensure age-appropriate and healthy foods are available at regular meal and snack times. However, you need to allow your child to select the portion he wants to eat. Encourage independent eating too. Over time, your child will develop a healthy attitude towards food and eating.
  4. Be creative but do not become a short-order cook. Offer your child a variety of food items, cooked in various styles. You can do this by becoming a creative cook or introducing your child to various food choices out of home. But, once the menu is set, and the food is on the table, do not entertain preparation of special dishes for your child.
  5. Allow your child to occasionally eat with peers. Kids also learn fast by watching their friends. Eating a meal or two with peers helps your child pick up skills he never had.
Anna’s Top 3 Pitfalls of Feeding Kids
  1. Do not abdicate responsibility for your child’s nutrition. Many working parents do not have the luxury to be at home with their child at every meal time. But, set the menu. Know what is served and what is eaten. Talk to your child’s caregivers and, tell them what you would like your child to eat so that they can work with you to ensure good nutrition.
  2. Do not force feed. While you decide when, where and what your child eats, please give your little one the right to select how much he wants to eat. Force feeding is counterproductive as it stresses the caregiver and, scares the child or causes defiance.
  3. Do not distract your child while eating. It is another common practice to let children watch television or play computer games during meals while the caregiver feeds the child. This feeding style does not develop a child’s self-feeding ability – to know and appreciate what is served and learn to be conscious of how much he is eating.

While you should encourage healthy and appropriate eating, this takes time and much effort, you should track growth with your child’s physician at regular visits; and, in the interim you may provide a complete and balanced supplement to fill nutrient gaps, if any – to achieve optimal growth during the critical periods of life.

MarcieMom: Thank you so much to Anna Jacob for sharing these tips. Even for families who are already eating healthy, it is a good reminder to keep up the effort, try new foods and enjoy a healthy life!

Doctor Q&A

Feeding Kids Healthy series – What and How Much is Right?

Traditionally, parents worry about whether children are eating enough but based on the rise in childhood obesity (2011 – 11% and updated in 2017 – increased to 13% in Singapore ), parents also have to be mindful of overeating AND eating the wrong types of foods.

Feeding Kids Healthy - Right portion and types of food with Dr Chu Hui Ping

For this 2-part series focused on feeding kids healthy, Abbott facilitated the interviews with nutrition experts. Today, we have Dr Chu Hui Ping, Paediatrician from Raffles Children’s Centre with a clinical interest in pediatric gastroenterology.

MarcieMom: Thank you Dr Chu for helping us in this series to clarify for parents how to feed our children. Firstly, in Singapore, we are familiar with the growth charts included in our child’s health booklet. Parents can work out the weight and height percentile of their child against the right chart for their age and gender.

Should growth charts be used as a gauge of how much to feed a child?

For instance, being above 95% percentile for weight means that the child should cut back and below 5% means parents should feed more?

Dr Chu: It’s probably not that simple and straight-forward just to use the growth percentile to decide on how much the child should be eating. Generally we don’t only look at the percentile for weight; we also consider the height percentile, i.e. whether the child is proportionate for weight and height, as well as the growth of the child over the last few months or a year.

Some children are genetically bigger in size, for instance they are already born bigger and have always been growing along the 95th percentile for their weight and height. So it will not be appropriate to put these kids on a diet. It is more important to ensure that children who are at above 95th percentile and who are at less than 5th percentile for weight are being assessed by their doctors or paediatricians to exclude any medical conditions which make them gain or lose weight respectively. Even if there aren’t any underlying medical conditions, it is also essential to review the various components of their diets and ensure that the diet is well-balanced and consists of the essential nutrients rather than just cutting down or feeding more.

Getting Food Portion Right for Children

MarcieMom: Growth charts don’t take into account the fats a child has (since obesity is defined as excess fats) nor do growth charts take into account physical activity levels. How should parent figure out if their child should be eating more or less based on the amount of exercise they have?

Dr Chu:The child should be able to regulate his intake of food depending on the amount of exercise he has. Generally if the child is active, i.e. participates in active play or exercise for 60 minutes in a day, he will feel hungry and ask for food if his current diet is insufficient to meet his activity level. It is more common for parents to give too much food in proportion to the amount of exercise that the child has, resulting in the child being overweight due to the excess unutilised calories. If the parent feels that the child is not eating sufficient for the amount of physical activity he has, he can increase the proportion of complex carbohydrates or whole grains which can help to release energy in a slow manner, as well as proteins in the form of lean meat for muscle growth.

Getting Food Types Right for Children

MarcieMom: How much to eat is only one part of the equation. What about the type of foods? While we know that excess sugar, trans-fat and processed foods are bad for health, what can parents do to ensure that their child have an optimal diet? Do share your top 5 tips on eating healthy for the child (and family)!

Dr Chu’s Top 5 Tips for Healthy Eating
Kids Healthy Diet
  1. Eat fresh –try to avoid processed foods and to prepare your meals using fresh ingredients.
  2. Ensure that half of your meal should be consisting of vegetables and fruits.
  3. Choose wholesome foods such as brown rice and wholemeal bread.
  4. Reduce unhealthy fats/oils by cooking in a more healthy manner – steaming, boiling, stewing etc.
  5. Drink water for hydration instead of sweetened juices and soft drinks.
Dr Chu’s 5 Recommended Dishes at Kopitiam Coffee Shops

MarcieMom: In Singapore, there are many food courts and coffee shops but these usually don’t meet the healthy plate guideline of half a plate of fruits and vegetables. Which 5 common dishes found in coffee shops would you recommend and which 5 dishes would you discourage for children?

Dr Chu: Choosing health food options in food courts and coffee shops may be tough but not impossible. I would recommend these food choices:

  1. Rice with mixed dishes (choosing at least 1 vegetable and 1 lean meat)
  2. Fish soup with additional vegetables, soup noodles with additional vegetables
  3. Grilled fish or chicken with salad and mashed potato (instead of French fries)
  4. Freshly cut fruit platter
Dr Chu’s 5 Dishes to Avoid at Kopitiam Coffee Shops
  1. Chicken rice (because too oily and little vegetables)
  2. Char kway teow (because too oily and too much salt)
  3. Fried economic beehoon with luncheon meat (because too oily and lots of MSG in the processed meat)
  4. Laksa (because high saturated fats from the coconut milk)
  5. Black fried carrot cake (because too much salt and sugar from the black sauce used)

MarcieMom: Thank you Dr Chu for enlightening us on the types of foods beneficial for our child’s growth. Next week, we will check back on how to actually get our child to eat them!

Doctor Q&A

Skin pH with Cheryl Lee Eberting, M.D.– Eczema and Skin pH

Skin pH interview with skin barrier expert, Cheryl Lee Eberting, M.D.of
Skin pH interview with skin barrier expert, Cheryl Lee Eberting, M.D.of

This is the 5th and last post of Skin pH series: Read the 1st post on Understanding Skin pH and its Impact here, 2nd post on Overly Acidic and Alkaline Skin here, 3rd post on Diet, Environment on Skin here and 4th post on Moisturizing and Skincare Products’ impact on Skin and Skin pH here.

We are privileged to have Board Certified Dermatologist Cheryl Lee Eberting, M.D. again for this 5-week skin pH series. Read more on Dr Cheryl Lee here. Dr. Eberting invented the TrueLipids skin barrier optimization and repair technology; a technology that helps the skin to repair itself by recreating its own natural environment.  

MarcieMom: Thank you Dr Cheryl Lee for being with us for the past 4 weeks and today, we focus on eczema skin – a topic which parents/readers of this blog would most certainly be keen to find out!

Eczema and Skin pH

MarcieMom: I read that alkaline pH is associated with skin dryness. Since eczema is characterized by skin dryness, does this mean all eczema skin is too alkaline? Came across a study that even the uninvolved skin of eczema adults have higher alkaline pH than those without eczema. It was stated as 6.13±0.52 on the eczema lesions, 5.80±0.41 on perilesional skin and 5.54±0.49 on uninvolved skin. In the control group, the mean pH of the skin surface was 5.24±0.40.

Dr Cheryl: Yes.  If you have dry skin, eczema, a rash, or an infection on your skin, then the pH is too high.  In atopic dermatitis, there are 7 major problems that lead to the abnormal skin barrier and they are all interrelated with each other.  The problems are as follows:

  1. Skin lipid deficiencies (phytosphingosine, phytosphingosine-containing ceramides like Ceramide 3, cholesterol esters, and very long chain fatty acids have been shown to be particularly deficient in atopic skin, dry skin and aged skin).
  2. Excessive loss of water due to skin lipid deficiencies. (white petrolatum in the gold standard water loss inhibitor.  Paraffin is likely even more effective than petrolatum however.  Certain lipids have also been shown to be very good at inhibiting water loss.  The lipid isostearyl isostearate is one of the most effective lipids as preventing water loss from the skin.
  3. Abnormal pH (partly caused by the lipid deficiencies above, but also then CAUSES a lipid deficiency because the enzymes that make epidermal lipids only work within the optimal skin pH range)
  4. Susceptibility to infection (caused by the lipid deficiencies—some of these lipids are anti-staphylococcal—and caused by the overly alkaline pH).
  5. Inflammation (cause by lipid deficiencies that cause desiccation and entrance of allergens and infection into the lower levels of the epidermis which then leads to infection.)
  6. Allergy (atopic skin is susceptible to allergic contact dermatitis to certain chemicals at higher rates than non-atopic skin.  This is also a result of all of the above problems.)
  7. Abnormal calcium gradients.  (The epidermis has calcium gradients that lead to lipid production and to normal cell cycling.  In atopic dermatitis, these gradients are disrupted and contribute to lower levels of lipid production and dysfunctional cell cycling.)

These 7 problems are present in the entire skin barrier of an atopic and this is why is it so very important to focus on skin barrier optimization that addresses all 7 of these problems simultaneously.

MarcieMom: What skincare measures (if any) should parents of eczema children take to help the child’s skin to reduce its alkalinity?

Eczema and Skin pH - Steps to take

Dr Cheryl Lee:

1. Bleach Baths Really Work:

As I discussed in this post, I think bleach baths work as part of the eczema skin care regimen, but they also alkalinize the skin a little bit too.  The target concentration of a bleach bath is .005% hypochlorite ion.  Because there are different sizes of bathtubs around the world, it is difficult to just tell you how much bleach to put it.  In the United States, we have a standard-sized tub that most people have in their homes. (And we have ridiculously large tubs too).  For the regular-sized American tub, I recommend 1/8 cup if the tub is 1/4 full, or 1/4 cup is the tub is 1/2 full or 3/8cup is the tup is 3/4 full.  For very mild cases of eczema, bleach baths may not be needed, but if there is any crusting or scabbing, try taking the bath three times a week.  The more severe it is, the more frequently you should take a bleach bath.

Special Trick for Babies with eczema:  If your child will not stay in the bathtub long enough to have an effective bleach bath (about 20 minutes), then try using a large tupperware/plastic container INSIDE your shower for your child to play in.  I recently discovered this on my own children and now I can’t get them to STOP taking a bath (which is bad for eczema too;  too many baths can dry out the skin and make it worse).

Of note, we have always thought that the bleach bath is working because it is killing the Staph. aureus on the skin.  Well, recent studies showed that it is not only the killing of the Staph, but it is also due to the low level oxidation exposure.  When the skin is exposed to very low levels of oxidation, the skin then turns on anti-inflammatory and reparative pathways.  This is totally counter-intuitive, but is very, very interesting and makes me thing that our creator really knew what he was doing!

2. pH-Adjustment After Bathing and After Bleach Baths OR If you Don’t Have Access to Bleach:

After taking a bleach bath, use a pH-protecting gel with vinegar in it or use a vinegar spray diluted with one part vinegar and six parts water to all affected areas.  (white vinegar or apple cider is best—no rice or balsamic vinegar).  This should then be covered with a pH-optimized moisturizer (pH 4.6 to 5.6….a little more acidic may be beneficial, but more alkaline is bad).

Of note, I had a patient come to see me all the way from Cambodia.  When she went home to Cambodia, she was unable to find bleach anywhere.  If this is the case, I have seen similar benefits from vinegar baths (it takes A LOT of vinegar–around 6 cups to a half-full regular American-sized tub).  Or, you can do the vinegar spray or pH-protecting vinegar gel if you cannot take a bath.

3. Moisturize the Skin Barrier AT LEAST Two Times a Day With Skin Barrier Optimizing Moisturizers, But Four Times Works Better and Faster:

I think it is very important to moisturize atopic skin at least twice a day WHEN IT IS NORMAL LOOKING.  When it is broken out AT ALL, I always advise that my patients use their eczema products (we use the TrueLipids Eczema Experts 1% Hydrocortisone Cream followed by the TrueLipids Relieve & Protect Ointment) up to four times a day UNTIL the skin is normal looking.  Once the skin LOOKS and FEELS normal, then my patients switch to the TrueLipids Ceramide+ Cream followed by the ointment twice a day for maintenance.  It is very important to treat ALL affected areas and not just the areas that are scabby looking.  What I mean by this is that even the areas of the body like the stomach and back that may look a lot better that the worst areas on the arms and legs, must also be treated until they ARE normal; normal looking and normal feeling.

The skin on the trunk often has what we call folliculocentric atopic dermatitis where each little hair follicle is more accentuated and is a little bit lighter in color than the skin around it.  This is active disease and needs to be treated just as much as the scabby, inflamed areas do.  The skin on the trunk usually heals much more quickly than does the skin on the arms and legs and, as it heals and goes to normal, the hydrocortisone can be replaced with the Ceramide+ Cream.

4. The Maintenance Moisturization Phase is Just as important as Treatment Phase:

I cannot stress the importance of maintenance moisturization.  Plan on at least twice daily moisturization for the rest of your life.  You must avoid all common allergens in your skin care products too.  There are certain allergenic chemicals that are known to be more common in people who have atopic dermatitis and you should at the very least avoid them.  I will write more about this in a later post.  By optimizing the skin barrier, you can prevent it from breaking down into eczema and can probably also control other allergic diseases like asthma and hay fever too.

5. Wet Wrap Therapy if Your Eczema is Severe:

If your eczema is very, very severe, you will need to do wet wrap therapy where you take your bleach bath, then do your pH adjustment and then wrap the skin in WHITE COTTON (not wrinkle-free type fabric because is often has formaldehyde in it) pajamas or bandages every day.  I have even had a few patients who have needed to do wet wraps during the day too.  Don’t use ACE wraps or anything that has latex or spandex in it as this can be allergenic for atopic skin too.  Once the wraps or pajamas are on, spray them down with water and cover with a layer of dry clothing and go to bed.

6. Break Through Low Dose Steroid Maintenance in Severe Cases:

For more severe cases, once the skin is completely back to normal, I recommend using the TrueLipids 1% hydrocortisone cream twice as part of your maintenance routine.  Studies have shown that low levels of hydrocortisone like this can keep one in remission and prolong time between relapse. Studies have also shown this benefit from treatment a few times a week with Elidel or Protopic, but I do not prefer them as I don’t find them to be very effective, they are very expensive and they are not the safest drugs in the world. (That being said, if you are allergic to glucocorticoids, then Elidel and Protopic can be a lifesaver.)

Also very important is that of glucocorticoid allergy.  Studies have shown that between 24 and 90% of children with atopic dermatitis who are patch tested are allergic to at least one glucocorticoid.  If your child is one who seems to either not get better with hydrocortisone or who gets a little better but then seems to get worse, he/she may be allergic to it.  It is always a good idea in this case to get your child patch tested to see what they are allergic too and to learn what classes of gluccocorticoids that your child can use.

7. Allergen Avoidance and Patch Testing if Needed:

I cannot stress enough how important it is so avoid allergens in your skin care products, soaps, detergents AND in the products that family members are using.  Find a dermatologist who is experienced in patch testing (not prick testing) for allergic contact dermatitis (ACD).  ACD is an allergy to a chemical that is coming in contact with the skin.  For example, fragrance allergy is one of the most common allergens in atopic dermatitis.  If daddy is wearing cologne and baby touches his shirt, this can equal a month of eczema flare for baby.

The whole family needs to avoid the allergen triggers.  In addition to fragrance (which cross reacts with essential oils and many plant extracts), common allergens in atopic dermatitis include nickel, formaldehyde releasing preservatives, propolis (in beeswax), neomycin, bacitracin and more.

Thank you Dr Cheryl Lee for going through with us the factors that affect skin pH with practical steps on what parents can do. It will definitely help parents to be committed to these measures with the right understanding of why to take them. Thank you once again!