Eczema News – Hydrolyzed Milk Impact on Childhood Eczema

What milk to give a baby with eczema or a baby who is at high risk of eczema is ONE question that all parents ask – there are various options when it comes to milk:

(i) Breast milk – Recognized as the milk for babies up to six months of age, due to the natural protective benefits of breast milk and its ease of digestion, coupled with no artificially added sugar, salt and fats

(ii) Cow’s milk – An alternative to breast milk or supplement for breast milk; however, cow’s milk protein is the most common food allergen in young children (where the protein size is 10kD and more to act as an allergen)

(iii) Partially hydrolyzed milk – Commercially available, whereby the milk protein is broken down to protein size of less than 5kD; however, there is no strict definition of what qualifies as partially hydrolyzed formula and some partially hydrolyzed milk formula have about 20% of the peptides exceeding 6kD (kD is a measurement of its molecular weight)

(iv) Extensively hydrolyzed milk – Not commercially available in some countries, on prescription, whereby the milk protein is extensively broken down to protein size of less than 3kD.

(v) Other non cow’s milk formula, excluding goat’s milk as the goat milk protein is similar to that of cow’s milk

The Key Question is whether partially hydrolyzed milk protein is effective in preventing eczema. This is often examined alongside the questions of (i) whether it is cost effective to be put on hydrolyzed formula and (ii) inferior nutritional value of hydrolyzed formula.

Limited evidence (there's still some evidence) of protective effect of partialy hydrolyzed formula for high risk babies

Limited evidence (there’s still some evidence) of protective effect of partialy hydrolyzed formula for high risk babies

Let’s examine the research on whether partially hydrolyzed milk protein is effective in eczema prevention.

  1. I have briefly looked into this in 2011 (post) and the research then showed that partially hydrolyzed milk is recommended for high-risk babies but not if there is a proven milk allergy. For those interested in learning more about hydrolyzed formula, refer to FDA archived presentation.
  2. In 2013 (post), research’s recommendation was for high-risk infants who cannot be 100% breast-fed, partially hydrolyzed milk is recommended.
  3. Other more recent research: Allergic manifestation 15 years after early intervention with hydrolyzed formulas – the GINI Study where it is concluded that eczema is reduced in children who took partially and extensively hydrolyzed formula, with lower prevalence up to adolescents (11 to 15 year old).  The GINI Study is German Infant Nutritional Intervention program study of birth cohorts, with many other interesting allergic conditions’ studies here
  4. In a paper published in Clinical and Translational Allergy, Partially hydrolysed, prebiotic supplemented whey formula for the prevention of allergic manifestations in high risk infants: a multicentre double-blind randomised controlled trial, it was found that there was no preventive effect to early feeding with a partially hydrolyzed formula with added prebiotics.
  5. In a paper published in the Expert Review of Clinical Immunology, The Role of Partially Hydrolyzed Whey Formula for the Prevention of Allergic Disease, authors warned that due to limitations on studies on partially hydrolyzed milk, the recommendation should still be ‘breast is best’.

On the question of costs,

In a paper published in the Annals of Nutrition and Metabolism, Cost-Effectiveness of Partially Hydrolyzed Whey Protein Formula in the Primary Prevention of Atopic Dermatitis in High-Risk Urban Infants in Southeast Asia, the finding was that overall costs (even after including the cost of milk formula) of taking partially hydrolyzed formula (as opposed to cow’s milk formula) for high-risk infants would be lower than the costs of managing eczema.

On the question of nutritional value,

Dr Sears (this blog has featured several of his and his sons’ talks, tweet chat and collaborated blog series), Dr Sears’ view is that unless recommended by doctor, parents should not opt for hydrolyzed milk on their own due to

  • High content of sweeteners to make hydrolyzed formula palatable
  • Artificially carbohydrates in the form of corn syrup, sucrose, corn starch or tapioca
  • High salt content
  • Artificially added fats

It seems though that partially hydrolyzed milk formula is in practice recommended by doctors due to cow’s milk being the most common food allergen in infants. Research wise, there has yet to be a conclusion due to difficulty of conducting unbiased studies with sufficient (mother and baby) participants. What’s your experience in this? Do share in the comments!

Skin Facts – Water Loss from Children and Eczema Skin

This is the third week of ‘Skin Facts’ and last week, we’ve looked into the sun protection function of children vs adult skin, and how the sun affects eczema skin. Today, we’re looking into another critical function of skin and one that is very relevant for eczema skin – our skin’s moisture retention property. One can also view it as how much moisture is lost from our skin, known as Transepidermal Water Loss (TEWL). TEWL is studied by dermatologists, as excessive TEWL points to a defective skin barrier, and in severe cases, affect the ability of the body to function. Let’s go “water deep” into this skin function!

Water and our Body
Water makes up a large point of our body weight, here are some interesting facts about the water in our body from water.USGS.gov (the US Geological Survey website):

Water content in our Body

  • Lungs 83%
  • Muscle 79%
  • Kidneys 79%
  • Brain 73%
  • Heart 73%
  • Liver 71%
  • Skin 64%
  • Bones 31%

Percentage of Body Weight that is Water

  • Fetus 94%
  • Infant at birth 78%
  • One-year old 65%
  • Female 55% (due to higher fat content)
  • Male 60%
  • Elderly 50%

Functions of Water in our Body

  • Forms the building material of cell
  • Regulates body temperature by sweating and respiration
  • Transport via the bloodstream
  • Flushes waste via urination
  • Absorbs shock for brain and spinal cord, also lubricates joints
  • Forms saliva
Moisture Loss and Retention from Children, Normal and Eczema Skin

Moisture Loss and Retention from Children, Normal and Eczema Skin

Water Loss from our Skin
Our skin allows water to be lost through it, as part of insensible perspiration (or transepidermal diffusion) and sweating. Insensible refers to us not being aware of it (another insensible loss of water is from respiration). Sweating helps regulate our body temperature, via cooling of the skin. However, sufficient intake of water is required in order for sweating to not dehydrate the body and continue to be effective in cooling our body temperature.

Much of the water is lost through the stratum corneum, the upper most layer of the epidermis made up of a dead cell layer. A defective stratum corneum layer will allow excessive epidermal water loss and potentially, increase risk of irritant and allergen sensitivity. Water loss from evaporation from our skin is about 400ml daily in an adult. For research news on how the skin can be a channel for allergy, see Food Sensitization from Eczema.

Transepidermal Water Loss (TEWL) from Children Skin
TEWL from baby skin is higher than normal adult skin, due to their thinner stratum corneum. For premature infants less than 30 weeks, there are also fewer layers of stratum corneum resulting in increase fluid and heat loss. Interestingly, infant skin is found to have higher water content and able to absorb more water but lose excess water faster than adult skin. TEWL was also strongly predictive of AD at 12 months (study here). The natural moisturizing factor (protein breakdown products such as small amino acids, urea, pyrrolidone carboxylic acid, ornithine, citrulline, urocanic acid) in infant is also lower than an adult.

How this Impact Parents Caring for Baby Skin
Protection of the stratum corneum is important, and this can be via:

Reduced bathing – Washing baby skin with a washcloth during the first 4 weeks of life is associated with increased TEWL and decreased stratum corneum hydration compared with simply soaking in water. The recommendation is to use a mild liquid cleanser with water (less drying than water alone), and that bathing should be brief (10 minutes or less) and no more than every other day with spot cleaning in between.

Good bathing regimen – Includes not using hot water, not scrubbing the skin dry (but pat dry), keeping it short to 10 minutes, not using soap and moisturizing right after (see video)

Good skincare regimen – Moisturizing protects the skin barrier (see video). It is important to note that given the thinner stratum corneum of infants, their higher surface area to body ratio, infants are more vulnerable to toxicity of products. Therefore, be sure you understand the product label (there’s a comprehensive Sensitive Skin Products blog series to help you with that).

Transepidermal Water Loss (TEWL) from Eczema Skin

TEWL is studied to be higher in eczema skin and also dry skin (without eczema). The water content of stratum corneum is also lower in adults with eczema than normal skin. It is also studied at the natural moisturizing factor of eczema skin is defective, lacking in proteins that are able to play a role in the skin’s humectant property – the ability to pull moisture from the environment and retain this water (which is why 2nd generation moisturizers incorporated humectant property, learn more here).

Drinking Water and Skin
A myth. Dehydration will affect skin but drinking excess water will not lead to ‘glowing’ skin. Drinking enough water will also not prevent skin aging or wrinkles as these are related to genetics, sun and oxidative stress brought on by pollutants. Read this #SkinishMom Investigation! – Drinking water for dry skin

To round-up, we learnt that water is integral to our body and to our skin. We have insensible water loss and a thinner stratum corneum in baby skin and a defective stratum corneum in eczema skin both results in increased transepidermal water loss (TEWL). This knowledge should encourage (not discourage!) us to be more committed to a good bath and skincare routine.

What’s your take in this?

References

Eczema News – Do Elimination Diets Work?

Elimination diets are often tried out at home to see if the child’s eczema improved after eliminating certain foods. The common food allergens for young children are eggs, cow’s milk, soy and wheat and in certain cases, parents may

  • (Scenario 1) eliminate such foods when tested positive in allergy tests, or
  • (Scenario 2) eliminate such foods even when allergy tests didn’t return positive (for many reasons such as suspecting it’s food intolerance which doesn’t show in allergy test or not trusting that the tests are accurate), or
  • (Scenario 3) eliminate such foods without testing for allergies, either because doctors didn’t recommend allergy testing or such facility is not easily available where the family lives.

The question then is whether Scenario 2 and 3 are valid for parents trying out elimination diets for their child. A paper published in July 2015, in the College of Family Physicians of Canada sought to study the papers that have been published on elimination diets, specifically with regard to eliminating eggs and cow’s milk.

Insufficient evidence to support elimination diets

Insufficient evidence to support elimination diets

Result of study: There is insufficient evidence about the benefit of eliminating cow’s milk in unselected patients with atopic dermatitis (AD). Some evidence suggests that egg elimination might benefit those children with AD who are suspected of being allergic to eggs and who are sensitized to eggs.

MarcieMom’s digest on the paper:

#1 Go for allergy testing

I’m a supporter of allergy testing, simply because given that tests are fairly accurate and you can always take a few tests at different development stages of the child to corroborate what he is allergic (or not allergic to), I feel that taking allergy test beats the worry that comes with second-guessing.

#2 Outside-in versus Inside-out

It has been covered in this blog before on the possibility (and doctors are accepting that possibility with more research) that food sensitization can come from outside-in: meaning it is the defective skin barrier that allows food allergens in the air (on the skin) to result in the body being sensitized to the food allergen. It reinforces the importance of protecting the child’s skin barrier with good skincare routine, even from birth for infants at high risk.

#3 Observations can be misleading

Elimination diets rely on observing if there’s any change in the skin/ increase in rashes after consumption of food. However, this can be misleading because (i) allergic reactions may not show up immediately and (ii) prevailing allergens such as to house dust mite can ‘confuse’ the observations because it triggers eczema flares from time to time.

#4 Lesser case for elimination diet

It is mentioned in the paper that40% to 90% of infants with moderate to severe AD are food sensitized based on positive results of skin-prick tests to 1 or more food allergens” but “only 35% to 40% of food-sensitized children with AD have clinical signs and symptoms of food allergy according to multiple double-blind, placebo-controlled food challenge studies“. This means that it is more likely that a child will be tested positive to a food that he can actually consume and not trigger a food allergic reaction. As such, it seems to not justify eliminating a food when it is not even tested positive in the first place.

#5 Studies where elimination diets improve eczema

There were two studies mentioned in the paper that reported an improvement in eczema after elimination diet, (i) was eliminating eggs for infants who are sensitized to eggs, and (i) was using hydrolyzed milk.

#6 Elimination diet risks

The risks of elimination diets are

  1. Nutritional deficiency – the paper mentioned that calcium, vitamin D and E were deficient.
  2. Turning intolerance due to elimination – the paper mentioned that early low-dose cutaneous exposure to food allergens leads to allergic sensitization, whereas early oral consumption of food proteins induces immune tolerance. This means that taking a food, suspecting it is an allergen for the child and eliminating it, make it more likely to have a food allergy as opposed to not eliminating that food.

The above is why the medical community generally only recommend elimination diets when tested positive, and after reviewing various test results and understanding the roles that other allergens play. When evaluating all the double-blind placebo-controlled food challenges, only about 6% of the children with eczema had a reaction to the suspected food allergen. It is therefore, more likely than not, that the eczema rash is not due to the suspected food.

What’s your experience in elimination diet? Has it improved your child’s eczema? Do share in the comments especially when many parents are interested in how other eczema families cope with diet.

Skin Facts – Sun Protection in Adult, Infant and Eczema Skin

We have started learning skin facts last week, specifically on the skin (surprise) isn’t the largest organ and that well, we don’t really know what’s in our dust. This week, we’re taking up a notch on going ‘intensive’ into the difference in the sun protection function of adult, child and eczema skin.

Normal Adult Skin

Sun Protective Function of our Skin

Sun Protective Function of our Skin and how it differs for Baby Skin and Eczema Skin

Adult skin has a fully developed sun protection function, in the form of pigment melanin which gives the skin its color. Therefore, the darker one’s complexion, the higher the sun protection. Melanocytes are the melanin-producing skin cells and it is the activity of the melanocytes, i.e. the amount of melanin produced, and not the number of melanocytes that determine the skin color.

When one is exposed to sun, more melanin is produced to help protect the skin against UV rays, thus giving a ‘tan’. Melanin can reduce the oxidative damage caused by UV rays but isn’t able to fully protect from the damaging effects of UV rays (see this news on potential harm of ‘sun-activated’ melanin to our skin).

Children Skin

An infant’s skin has not fully developed in many ways that make a baby more vulnerable to the damaging effects of UV rays – it has less pigment/ melanin, thinner skin/ stratum corneum and a higher surface area to body ratio.

Studies have also pointed to infants with exposure to UV rays will show skin pigmentation on exposed skin from as young as one year old (first summer). This was true even for infants who used sun protection when outdoors but not when in the car, in the shade or on a cloudy day. There are also studies showing that exposure to UV during childhood and adolescence can lead to skin cancer later in life.

Eczema Skin

There is no study that points to differences in melanocytes/ melanin due to eczema. However, the sun is known to both improve and aggravate eczema, for instance:

  • Some eczema sufferers report improved eczema during holiday when outdoors more often (no study confirmed why holiday seems to improve eczema).
  • Phototherapy is used as an eczema therapy for adults.
  • Active eczema flare-up should stay away from the sun as it can worsen eczema, and increase vulnerability to sun burn.
  • Certain skincare products increase sensitivity to sun, such as those containing ingredients alpha-hydroxy acids (AHAs), beta-hydroxy acids (BHAs), salicyclic acid, glycolic acids, Retin-A and hydrocortisone. Moisturized skin may get sun burn more easily, thus put on moisturizer and wait for 30 minutes before applying sunscreen.

Sun – We need it, but not too much of it.

Our skin play an important role in the synthesis of vitamin D, where vitamin D can increase the production of skin proteins (cathelicidin) and antimicrobial peptide (AMP) which protects against skin infection. However, just 15 minutes a day is enough and it’s referring to getting sun on the face and arms (i.e. no need to be in a bathing suit!). During summer, 2-3 direct sun exposures of 20 minutes per week is sufficient. Short frequent sun exposure is better than long exposure.

Rays from the Sun

There are 3 different rays from the sun:

  1. UVA – 320 to 400 nm : passed through the atmosphere
  2. UVB – 290 to 320 nm : passed through the atmosphere
  3. UVC – 100 to 290 nm : most dangerous, but filtered and do not pass through the atmosphere

UVA – UVA activates melanin already present in the upper skin cells but the tan is lost quickly. Penetrates deeper into the skin, damages the dermis (middle skin layer), accelerates aging, causes wrinkles, increases oxidation and suppresses cutaneous immune function.

UVB – UVB stimulates the production of new melanin, and a longer lasting tan. Also stimulates a thicker epidermis. Absorbs by the epidermis (top skin layer).

It’s not just the sun, it’s also the ozone.

We all know that the ozone layer is thinning and the thinner ozone has allowed more UVB rays to come through the atmosphere.

Sun protection

Sun protection has been covered in various interviews with dermatologists on this blog but the point to emphasize is that for babies, it is very important to avoid the sun and practice sun protection because:

  1. Thinner skin
  2. Less melanin-producing skin cells
  3. Larger surface area to body ratio
  4. Increased absorption of chemicals and vulnerability to irritants in sunscreen products make sun avoidance a wiser choice

Lips and eyes are also affected by UV rays, thus wearing a wide-brimmed hat and sunglasses are also part of sun protection.

More in interviews with dermatologists:

Sunscreen

It is recommended to use physical blockers/ inorganic filters such as zinc oxide (more UVA protection) and titanium dioxide (more UVB protection). As opposed to chemical absorbers, physical blockers do not penetrate more than two layers of stratum corneum and therefore less likely to induce skin irritation and sensitization. Moreover, infants tend to rub their eyes and may inadvertently rub the sunscreen into their eyes and won’t be able to ‘get rid’ of it as (i) their tear secretions and (ii) their blinking mechanism are not fully developed.

A note on SPF

SPF is the measure of ratio of UV rays before sunburn and SPF 30 means that the skin is able to take 30 times higher dose of UV rays before sunburn. The amount of sunscreen to apply is 2mg/cm2. Broad spectrum refers to additional UVA absorbers (avobenzone and octocrylene) being added to the physical blockers.

References

Eczema News – Childhood Eczema linked to Headaches

In a paper published August 2015 Journal of Allergy and Clinical Immunology, Dr Jonathan Silverberg studied an association between eczema and headaches. The cause of headaches could have come from (i) sleep disturbances or (ii) fatigue that eczema children suffer from.

Method of study: Analysis of data from 401,002 children and adolescents in 19 US population-based cross-sectional studies from the National Survey of Children’s Health 2003/2004 and 2007/2008 and the National Health Interview Survey 1997-2013.

Childhood Eczema and Headaches

Childhood Eczema and Headaches

Results: From the analysis, eczema was associated with headaches in 14 of 19 studies. It was found that eczema children had a higher prevalence and likelihood of headaches. In particular, children with eczema that was associated with atopy, fatigue, excessive daytime sleepiness, insomnia, and only 0 to 3 nights of sufficient sleep had even higher odds of headache than eczema alone.

MarcieMom’s take – I couldn’t find other studies on Pubmed that examine this association but it wouldn’t come as a surprise that there is one; after all, how many of us adults don’t have a headache if we’re chronically deprived of sleep? A few other thoughts on sleep and headaches:

#1 Don’t mistake the headache for other illness

In adults, we may reach for the painkiller but this probably isn’t suitable for a child and can’t be taken long-term. Possibly explore antihistamines to see if it help with a better night sleep and of course, treating the eczema to reduce the itch.

#2 Sleep better

Easier said than done – it is still something that our family struggles with, though to a much lesser extent than when the eczema was severe. A few posts that may give you ideas on how to improve sleep at night:

I’ve recently found that dry wrap (as opposed to wet wrap which I have not tried) seemed to reduce the scratching at night. Singapore is pretty humid so instead of wet wrap, sometimes I put a layer of moisturizer (again) before sleep time, and put over a wrap bandage. Marcie’s skin usually appear better the next day and there’s less scratching on the wrapped spot at night. More on wet wrap in link.

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. More on Dr Lynn can be found here.

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.

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. More on Dr Lynn can be found here.

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.

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

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. More on Dr Lynn can be found here.

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

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 1 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

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

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.

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.

Teledermatology – Was your Remote Eczema Skin Consultation helpful?

This is the final post of the 5-part series and today, I will try to apply all that we have learnt in the past 4 posts to eczema skin consultations. I have presented it in survey format for each step of teledermatology and look forward to hearing your experience!

Teledermatology Checklist - Did you Remote Eczema Consultation go well?

Teledermatology Checklist – Did you Remote Eczema Consultation go well?

Before the Teledermatology Process

Q1 Were you given a leaflet to explain teledermatology and what form of teledermatology is available to you?

Q2 Were you aware that you do not have to consent to teledermatology?

Q3 Were you told that if an in-person consultation is deemed required during the process, you will have access to the dermatologist?

Q4 Were you told if it is going to be stored and forward or live videoconferencing?

Q5 Were you told that your eczema is suitable or not suitable for teledermatology? For instance, full body eczema, or rashes in scalp, private parts or pigmented rash are difficult to capture fully in images. Or that your eczema is localised and can be clearly identified in image.

Q6 Were you told that teledermatology may not be as accurately diagnosed than face-to-face consultation?

Starting the Teledermatology Process

Q7 Were you told who is the dermatologist and his/her licensure and board certification?

Q8 Were you told what images of your eczema will be taken and how these will be stored and protected?

Q9 Were you given the instructions on how you can access your own patient record?

Q10 Did you feel that the referring physician is comprehensive in recording your medical history?

Q11 Were you asked these questions on your eczema?

  • Previous treatment for eczema and response to medication
  • Personal and family history of skin disease and atopy
  • Known allergies
  • Active problem list
  • Body map is recommended to show the site of lesions and the extent of inflammation at each site

Q12 Did you feel you were treated with dignity during the photography session?

Q13 Were you told that you can have a companion during the consultation with the referring physician?

Skin Management Plan

Q14 Were you provided with a skin management plan? e.g. what medication, for how long/ which part of skin/ frequency/ how much to use

Q15 Was it made clear to you who is responsible for your care? e.g. to communicate with you and ensure that treatment is clearly communicated

Q16 Was there nursing staff to help you with skin care? e.g. guidance on how to moisture and wet wrap

Q17 Could your referring physician explain clearly which type of eczema you have, and the steps to reduce flare-ups e.g. allergy avoidance, active steps to reduce staph bacteria

Follow-up with Face-to-Face Skin Specialist Consultation

Q18 Did you have to wait longer than traditional referral to see the dermatologist who has provided the skin management plan?

Q19 Did you have to provide the same information again at the skin specialist clinic?

If you were referred for videoconferencing with the dermatologist,

Q20 Did the dermatologist have your information and referral form?

Q21 Was the videoconferencing set up in advance and smooth?

Q22 Were you told beforehand where you would need to uncover for the skin to be imaged?

Q23 Were all the persons in the room identified?

In instances where the set up or preparation for teledermatology is inadequate, the dermatologist may only confirm a diagnosis/ provide a treatment plan in-person. As such, it may end up being more time consuming to engage in teledermatolgy. What’s your experience? How many of the 23 questions were ‘checked’ for you?

For all other posts in this 5-part series, see

Teledermatology – Advantages of Remote Skin Consultation

Last 3 weeks we have covered 3 posts in this 5-part series on Teledermatology:

Teledermatology takes away the need to travel and meet in person with the skin specialist. This brings about numerous advantages such as:

Many advantages of teledermatology but the set-up at both doctors' clinics have to support it

Many advantages of teledermatology but the set-up at both doctors’ clinics have to support it

Shorter wait time – Compared to traditional referrals, a referring physician that a patient sees (nearer and more accessible) can help to capture, store and transmit the patient information and skin images to a dermatologist. The access to a dermatologist is therefore faster.

Accessibility for patients who live in areas without dermatology care – Singapore is small but in many other countries, specialist dermatology department may only be available in certain areas and teledermatology is a way for patients living in more remote areas to have access to specialist care.

Familiarity – For skin issues that both the referring clinician and the dermatologist feel that it is appropriate for the dermatologist to prescribe a skin management plan and the referring clinician to administer and be responsible for the patient interaction and care, the patient will then be seeing the same doctor (referring clinician) who he/she has already established a relationship with.

Convenience – Potentially faster, cheaper and less stressful than to travel and visit another doctor.

More detailed record – As the process of teledermatology is reliant on the transmission of patient information, images and then the relay of the diagnosis and treatment plan, followed with the outcome of previous treatment, there is a well documented record of the patient information and the skin condition. This record may be more detailed in in-person consultation.

Reduction of waiting lists at dermatology clinics – As certain skin conditions do not warrant establishing a relationship with dermatologist but rather straightforward in the diagnosis and treatment, the waiting lists at dermatology clinics can be shortened.

However, it is NOT ALWAYS that these advantages can materialize and both the referring physician and dermatologist can take actions and have systems in place to ensure success in teledermatology:

At the Referring Physician

  1. Proper record of patient information, medical history and the history of the skin lesions
  2. Staff to take skin images that meet the guidelines of images in teledermatology – dermatology nurse trained to take high quality skin images
  3. Integrated system at the referring physician to incorporate teledermatology
  4. Proper planning of the consultation process at the referring physician to take the images required after the consultation
  5. Selection of patient – Patients who are resistance to teledermatology, for instance, elderly, shy or young patients, or with rash at private parts should not be pressured to consent to teledermatology
  6. Educational materials on the diagnosed skin condition to be available for the patient and the care team

At the Dermatologist

  1. Dermatologists who signed up for teledermatology should have the resources to promptly feedback on the information provided by the referring clinician
  2. Dermatologists should have resources for the referring clinician and his/her clinic on various skin conditions
  3. Close communication and record of patient care with a system to obtain feedback and address weakness in the process
  4. Patients should not have to furnish information all over again if referred for an in-person consultation at the skin specialist clinic, i.e. teledermatology should be integrated with the specialist clinic system
  5. Patients should have a shorter waiting time for in-person specialist skin consultation compared to traditional referral
  6. Patients should have easy access to dermatologist for face-to-face session
  7. Patients should be given clear skin management plan

If traveling to the dermatologist is not an issue to begin with and the mode of teledermatology is video conferencing, there may not be much cost/time-savings involved. On the other hand, it benefits certain situations such as elderly living in a home who may not have access to specialist care if not for teledermatology.

If you want to understand more of the quality standards in teledermatology, do read British Association of Dermatologists’ standards. Share in the comments if you have benefited from teledermatology and what advice you have for patients to get the most out of it, your sharing will help another!

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