Finding the right preschool for your eczema child can be a challenge – you wonder about whether the teachers have the time to ‘monitor’ and help to control your child’s scratching, and you worry about possible triggers at the preschool.
Another article that I have shared on NEA is about finding the right preschool for your eczema child.
Inform the school of your child’s eczema
Visit the school before making a decision
Ask about the class sizes—the smaller, the better
Watch the teachers and students interact
Ask about their experience with eczema kids
Make sure the preschool is a NO BULLYING zone
Volunteer to raise awareness around eczema
Sign up for a trial run with the preschool
If your child has eczema, it is possible that they may be teased or feel embarrassed by the appearance of their skin. Preschools that take bullying seriously will be mindful about creating a respectful environment not just between the students and the teachers, but also among the children themselves.
I know that it is not easy to find a preschool that you can trust with your child. Sometimes it takes a leap of faith, but you can always exercise judgment and due diligence. Once you have committed to it, work with the preschool on the right environment instead of working against them through fault-finding. We know that it is not easy to care for a child with eczema, and it would be even harder for the preschool teachers who have many more children to take care.
If you are a parent of eczema child, please read the comments on our support group page where hundreds of parents have shared their greatest challenges and best parenting moments in caring for their child.
It is difficult to care for an eczema baby, therefore when National Eczema Association asked me to share my journey, I gladly shared my 8 survival tips below.
National Eczema Association – Eczema Warriors
As I shared in the previous post on my first article with National Eczema Association, the NEA is doing a great job giving eczema warriors all over the world a sense of solidarity – through the stories we hear each other share, of our struggles, how we figure out parts of the puzzle to improve our quality of life and inspire us to hold on to the hope of a better day tomorrow.
My eczema survival tips shared on NEA, experience gained from caring for my daughter
Feed smart
Secure the baby’s hands
Do less washing and cooking
It’s partly in the mind
Sleep cool, literally
Don’t be afraid to start over
Look at quality of life, not quality of skin
Put the ‘care’ into skincare
If you are a parent of eczema child, please read the comments on our support group page where hundreds of parents have shared their greatest challenges and best parenting moments in caring for their child.
This week, we’re looking at the research surrounding Surfactants on Atopic Dermatitis. First a recap of eczema skin and its ‘compromised’ characteristics that warrant special care during skin cleansing.
– Reduced antimicrobial peptides (AMP) expression, possibly resulting in higher incidences of infection
– Elevated skin pH
The above makes eczema skin more prone to irritants and more vulnerable to the ‘harsh’ effects of surfactants, discussed last week:
Alkalization – Elevated skin pH has the impact of (i) reducing skin lipids (ii) allows for growth of harmful bacteria like staph bacteria and (iii) increases transepidermal water loss (TEWL)
Damage to Skin Lipids
Damage to Skin Cells
Toxic to Skin Cells
Irritation to Skin
Research on Surfactant Impacts on Eczema Skin
Much of the research focuses on certain surfactant ingredients, as below:
A defective skin barrier requires careful selection of cleansing product
(I) Chlorhexidine Gluconate is the antiseptic for use on eczema skin as it causes the least atopic dermatitis skin lesions.
This is from a study examining the Effect of Hand Antiseptic Agents Benzalkonium Chloride, Povidone-Iodine, Ethanol, and Chlorhexidine Gluconate on Atopic Dermatitis in NC/Nga Mice. The four common antiseptic agents in hand sanitizers are:
Benzalkonium Chloride (BZK): A Cationic detergent with strong antiseptic activity, more gentle than that of ethanol-based BUT with reported contact dermatitis cases
Povidone-iodine (PVP-I) – Commonly use in mouthwash and in disinfection before surgery, low toxicity in humans BUT with reported contact dermatitis cases
Ethanol (Et-OH) – Broad antibacterial and antiviral spectrum BUT result in rough hands because of its strong defatting effect on the skin
Chlorhexidine gluconate (CHG) – Broad antibacterial spectrum AND with low incidences of contact dermatitis
(II) Reduce the use of Sodium Lauryl Sulphate (SLS)
In a study involving twenty volunteers with atopic dermatitis, it was found that repeated exposure to sodium lauryl sulphate and sodium hydroxide lead to a more pronounced impairment of the skin barrier function and significant transepidermal water loss.
SLS is a known skin irritant that damages the lipid barrier, causing inflammation and detachment of the skin layers (denaturation discussed last week).
(III) Reduce Cocamidopropyl Betaine (CAPB)
In another study involving 1674 patients, atopic dermatitis was associated with contact hypersensitivity to cocamidopropyl betaine (CAPB), but not to cocamide diethanolamide DEA or amidoamine. CAPB is an amphoteric surfactant, that is considered milder than SLS and a very common surfactant in many products. However, CAPB is cytotoxic, i.e. toxic to skin cells.
(IV) The Use of Hydrophobically modified polymers (HMPs)
The recent studies on surfactants are in agreement that for patients with skin conditions, a gentle liquid cleanser containing HMPs are more appropriate. Addition of cationic polymers to skin cleansers can further protect the skin and improve moisturization. To further improve cleanser mildness, adding hydrophobically modified polymers (HMPs) to cleansers make it less irritating to the skin. This is due to the formation of larger micelle of the surfactant, i.e. the larger the less likely to penetrate and remove skin lipids.
Above is similar to the care to note when cleansing baby skin, as well as what to use/ avoid to limit the harmful effects of surfactants on skin discussed in the previous two weeks. For all the posts in this Surfactant Skincare Series, see:
This month, we’re looking at surfactants – the chemical agents in cleansing products. It is important because while surfactants play an important cleansing function, they also potentially cause skin irritation. Last two weeks, we have understood:
Damage to Skin Lipids – Surfactants are able to clean dirt and sebum that are oil-soluble. However, this property also means that surfactants may inadvertently solubilize the skin natural lipid membranes (ceramides). Stronger anionic surfactants like Sodium Lauryl Sulphate (SLS) enhances penetration into the skin and able to affect the deeper skin cells (skin lipids).
Damage to Skin Cells – During washing, the surfactants interact with the skin cells and collagen fibers and cause temporarily swelling and hyper-hydration. Once the water evaporates, there is destruction of the skin protein structures (known as denaturation) and leads to skin dryness, roughness, tightness and scaling. This is an adverse effect of anionic surfactant.
Toxic to Skin Cells – Known as cytotoxicity, surfactants can permeate skin cells and cause irreparable alteration. Certain surfactants such as benzalkonium chloride and cocamidopropyl betaine (CAPB) are known to be more cytotoxic than SLS. CAPB is an amphoteric surfactant, a group of surfactant less irritating than anionic surfactant (SLS belongs to anionic group) but nonetheless can be cytotoxic. CAPB is also associated with allergic contact dermatitis.
Irritation to Skin – This is related to the duration of exposure, frequency, concentration and individual skin type. SLS is a known irritant that can cause skin inflammation (irritant contact dermatitis) and when combined with triclosan (an antibacterial and antifungal agent in products), can stay on the skin for hours/days. Amphoteric and nonionic surfactants are considered to be less irritating to skin. (Note: Skin irritation and cytotoxity are different concepts.)
What to Note when Choosing Cleansing Products
Based on the above surfactant interaction with skin, it follows that we ought to choose:
Products close to the skin pH (even water is not, either neutral pH 7 or sometimes more alkali)
It follows then to avoid soaps, which by nature are alkaline
Avoid SLS, as it can penetrate, damage and irritant skin
Avoid CAPB as it is cytotoxic
Choose products with larger micelles as they do not penetrate the skin cells as much (product packaging may not indicate this information so it’s quite hard to know; look out for Polyethylene oxide (PEO)/ PEO Sorbitan Laurate which forms larger micelles in the surfactant or for the term Hydrophobically Modified Polymers (HMPs))
Choose cleansing products that are moisturizing and moisturize right after washing
Reduce washing for prolonged time and frequent washing
Avoid alcohols, gels and alphahydroxy acids that can cause stinging
Avoid perfume, benzoyl peroxide, preservatives, parabens, propylene glycol, lanolin, methylisothiazolinone and other top irritants in this post
Avoid ingredients ending with sulfates
It is not easy to find a cleanser without any of the above-mentioned ingredient. For those with sensitive skin, it may be better to not wash as often and take care to choose a hypoallergenic product. Try to read the ingredient label of your product and be sure that the first few ingredients are at least not those in this post.
In the Skin Fact series, we’ve discussed much about baby skin structural differences. Below is a recap of certain baby skin characteristics that increase its vulnerability during skin cleansing:
Higher transepidermal water loss due to thinner stratum corneum – More vulnerable to water loss during bathing and skin barrier breakdown when there’s excessive friction (from over-washing or from rubbing skin when toweling dry).
High surface-area to volume ratio – along with a thinner stratum corneum and immature drug matebolism, make baby skin more vulnerable to harmful chemicals used during bathing
Less total lipids– make it vulnerable to further reduction of skin lipids lost during washing
Cleansing Baby Skin – Research on What’s Best
From a search on Pubmed for review articles on the research for baby skin cleansing, there’s actually not much research on it. From a 2009 European round table meeting, the consensus is:
Learning about cleansers for Baby Skin
Liquid cleansers in bathing are beneficial over water alone – Water cannot remove dirt, oil that can only be removed by oil. Prolonged washing with water dries the skin and depending on the pH of the water itself, it may be more alkaline than the natural pH of the skin.
Liquid cleanser are preferred, rather than soap which alters the skin pH and affect the skin lipids, increase skin drying and irritation – Learn more about soap and its impact on skin pH in the skin pH series. The pH of skin can affect its skin lipids, which (a lower skin lipids) in turn causes drying, itchiness and skin inflammation.
Liquid cleanser should be mild, non-irritating, non-stinging (especially to the eyes as babies may not be able to blink fast enough) and non-pH altering, and contains moisturizing function
For cleansing of baby’s skin, I’ve found two other articles that offer recommendation on what’s best for baby skin.
Extracted from http://www.hindawi.com/journals/drp/2012/198789/tab2/ – Review article on The Infant Skin Barrier: Can We Preserve, Protect, and Enhance the Barrier?
Apart from the three points above, additional points are:
4. AvoidAnionic Surfactants, these are those that cleanse very well but most irritating to skin, an easy way to identify them is to look out for those chemicals ending with Sulfates.
5. Choose those with large head groups and have the ability to form larger micelles. Surfactants organize into groups of molecules called micelles and generally the larger these micelles are, the less irritating the surfactant is. This is related to larger micelles being less able to penetrate the outer layer of skin (stratum corneum).
6. No preservatives is not best as bacterial growth can happen in such products
7. No scent does not mean no fragrance (potential irritant) is used, it can be one fragrance masking that of another.
Why Baby Skin needs Cleansing
Just like last week we asked the question ‘Why not just use water to clean?‘ (because 40% of dirt, oil can only be removed by oil), we also have to understand why baby skin needs cleansing. Baby skin has saliva, nasal secretions, urine, feces, germs and dirt which can potentially irritate the skin when left on the skin. It is also possible that both skin allergy and the body (ie food allergy) can develop from foods being left on the skin for too long. It is therefore important to clean baby skin. However, baby skin, given its structural vulnerabilities, should not be over-washed and to avoid using baby wipes on face or baby wipes that are non-hypoallergenic, especially those containing fragrance and MI.
Next week, I’d (make a brave) attempt to look into how surfactants affect skin and in particular, impact on eczema skin. It’s a very ‘chemical’ topic and not easy, so appreciate if there’s feedback to improve on the blog post, and share your best cleanser!
Kicking off Wednesday posts in 2016, like to explore this group of ingredients which is present in all cleansers but also have the potential to irritate skin.
Surfactants are ingredients that are active on surfaces, mainly to lower the surface tension on the skin and remove dirt, sebum, oil from cosmetic products, microorganisms and exfoliated skin cells in an emulsified form to be washed off. The different type of surfactants affect their cleansing, foaming/ lathering, emulsifying, solubilizing abilities as well as its potential to irritate.
Why not just Water?
Before we go on, the simple question to ask is why not just use water to clean our skin. This is because water alone is not effective in removing dirt which can be removed only by oil. Hydrophilic dirt can be removed only by water, and fat-soluble lipophilic dirt only by oils.
Groups of Surfactants
Surfactants are divided into hydrophilic (water loving), hydrophobic (water repelling) and lipophilic (oil loving). Surfactants consist of a fat-soluble (lipophilic) part and a water-soluble (hydrophilic) part. The lipophilic part sticks to oil and dirt, and the hydrophilic part allows it to be washed away.
Surfactants – learning about this group of ingredients that can clean but also irritate eczema skin
Surfactants perform different functions, namely:
Cleansing
Emulsification – arrange itself at interface between two immiscible liquids to create an emulsion
Solubilization – blending oily solution into clear liquid
Conditioning
Wetting – increase contact between the product and dirt
Apart from functions, manufacturers also consider mildness, biodegradability, toxicity, moisturization, skin appearance and feel, smell (fragrance) and lubrication when formulating their products.
There are four major groups of surfactants, classified by their polar hydrophilic (water loving) head group:
Anionic
Cationic
Amphoteric
Non-Ionic
Anionic Surfactants – Negative charge
Give effective cleansing and foam, good wetting properties, excellent lather characteristics, but moderate disinfectant properties and also likely to irritate skin.
E.g. Carboxylic acids – Stearic acid for stick products like deodorants and antiperspirants; Sodium stearate for soap
Sulfates – give effective cleansing, foaming and cheap; common irritant, e.g. Sodium lauryl sulfate (SLS), an alkyl sulfate used in detergents; Sodium laureth sulfate (SLES), an alkyl ether sulfate used in shampoo
Sulfonic acid surfactants – more expensive than sulfates but less irritating, e.g. dioctyl sodium sulfosuccinate, alkyl benzene sulfonate
Taurates (derived from taurine), Isethionates, Olefin sulfonates, and Sulfosuccinates.
Effective for conditioning cosmetics,positive charge makes the surfactants electrostatically attracted to the negative (damaged) sites on hair and skin protein which makes them resist rinse-off. Difficult to ‘mix’ with Anionic Surfactants. Also irritate. May be used as antimicrobial preservatives due to ability to kill bacteria.
E.g. Amines
Alkylimidazolines
Alkoxylated Amines
Quaternized Ammonium Compounds (or Quats). e.g. Cetrimonium chloride and Stearalkonium Chloride
Amphoteric surfactants – both positive and negative charge (depending on environment)
Help improve foaming, conditioning and reduce irritation. Moderate antimicrobial activity. Used in mild cleansing products, but not effective cleansers and emulsifiers. Both Alkaline and Acid, help to adjust the pH of the water used in solution.
E.g. Sodium Lauriminodipropionate and Disodium Lauroamphodiacetate.
Cocamidopropyl betaine, cocoamphoacetate and cocoamphodiacetate
Non ionic Surfactants – No charge
Used in heavy thick creams, such as hand or body creams, as emulsifiers, conditioning ingredients, and solubilizing agents.
Relatively low potential toxicity and they are considered the most gentle surfactants, but they are also the most expensive
Able to solubilize fatty acids and cholesterol in skin, thus may remove skin lipids
E.g. Cocamide DEA (coconut diethanolamide), widely used in personal care products for its thickener property and foam booster
Fatty acid esters of fatty alcohols, sorbitan esters, sucrose and cholesterol derivatives used like emulsifiers
In the following Wednesdays of this month, we will explore the impact of surfactants on skin, baby and eczema skin and some of the research in this area. I’m learning much about this as I read as well and it’s not all so easy to understand! Any expert reading this who would like to help out are welcomed, do leave a comment if you have expertise in this area or there’s something to correct in my post (no offense will be taken!).
Most of you would know that I co-authored with Professor Hugo, NUH, a book ‘Living with Eczema: Mom Asks, Doc Answers‘ published last year. As an end of the year special, I picked five questions asked and Professor Hugo’s reply (almost half the book is Q&A, I picked these 5 based on being common questions parents of eczema children asked). The book is structured with information surrounding key topics like diagnosis, prevention, triggers, treatment including things that don’t work and future research, followed by Q&A. None of the questions I asked were ‘screened’ as we wanted to keep it as an authentic exchange between a mom and the doctor of her eczema child.
Top 5 Q&A Living with Eczema- Mom Asks, Doc Answers
MarcieMom: The Hygiene Hypothesis has been interpreted by some to mean they should expose their infants to dirt, and possibly, avoid the use of anti-bacterial products. Is this recommended?
Infants with defective skin barrier or lower immunity would be even more susceptible to the penetration of irritants or allergens, or more susceptible to bacterial infection. So, should a mother take more hygiene precautions for her high-risk infant?
Professor Hugo: In theory this is correct, but the problem is that every baby is unique and needs a different degree of exposure of immune stimuli. This is very difficult to assess in a baby. However, in general, products that destroy the body’s own bacteria, such as antibiotics, should be avoided and only given if necessary (in case of a bacterial infection). There have been studies showing that early administration of antibiotics increases the risk for subsequent allergy, including eczema. Hygiene precautions taken by parents seem to have little impact on the development of eczema.
MarcieMom: While the skin prick test (SPT) is a faster, more reliable and cheaper option than the blood test, I have heard of parents avoiding it because the name “skin prick” test sounds traumatising for the child. What do you do in your practice to encourage fearful parents to let heir children take the SPT?
Professor Hugo: A good SPT, performed by an experienced person, should be painless. In our department we say that a SPT should be associated with no blood and no cry, even in infants.
MarcieMom: In your experience, how reliable are patients’ observations in relation to what is triggering his/her eczema?
Professor Hugo: Most parents fail to identify the triggers of their child’s eczema, or come up with lists that are non-reliable. Don’t forget that eczema is a chronic disease, needing a chronic or regular trigger. This is very diffi cult to identify, especially when a house dust mite allergy is involved, which can mimic multiple food allergies.
Professor Hugo: Although corticosteroids are still the cornerstone treatment of eczema patches, they are only part of the holistic treatmentof eczema. If all measures are taken appropriately, an effect of corticosteroids should be seen within one week. Most children can be treated with mild corticosteroids; only in severe eczema are more potent corticosteroids necessary.
MarcieMom: How do you build trust and relationship with your patient?
Professor Hugo: In a nutshell: be honest, don’t lie, and focus on limitations.
There are many more Q&A in the book and if you like to read it for free and you live in Singapore, it’s available in our national libraries island-wide. Wishing all families with eczema kids a happy new year and your encouragement keeps me going and faith that I’m storing treasures in heaven in this blog ministry. Just like the book, this blog is also dedicated to you.
We dedicate this book to
all children with eczema and
their families and hope that
this book will help all of them.
Last week, we’ve covered the 10 Moisturizer Selection Tips. This week, (as promised!), I’ve compiled ingredient listing for common moisturizers found in pharmacy (in Singapore/Asia as some brands are marketed under different brand names in the US/UK).
There are broadly 3 generations of moisturizers:
1st, 2nd and 3rd generation moisturizers – Pros and Cons
1st generation moisturizers are occlusive – these act as a layer to prevent transepidermal water loss (TEWL). These ingredients are petrolatum, mineral oil, paraffin and triglycerides. Creams/ointments with higher concentration of these are sometimes termed ‘intensive’, ‘suitable for very dry skin’ as the ointment does not evaporate as quickly as lotion but it often leaves a stain on clothing or doesn’t feel as comfortable as lotion.
2nd generation moisturizers are humectant – these are sometimes referred to having natural moisturizing factors (NMFs) as they can pull moisture from the environment to the upper layer of skin (and also from inner layer of skin to the upper layer). These ingredients include glycerin, hyaluronic acid, sodium salt of pyrrolidone carboxylic acid, sorbitol, lecithin, panthenol, salicornia extract, amino acids and urea.
3rd generation moisturizers have skin repair properties – often a combination of both occlusive and humectant, these moisturizers include ingredients that help to repair the skin barrier, either by replacing lost skin components (ceramides and skin lipids) or reduce inflammation, itch and bacterial activity.
A moisturizer’s quality is also dependent on how well it delivers these properties (stability and structure) and what ingredients it does not have (which are allergens). Safety and product quality control are also important considerations.
Let’s zoom into the ingredient list of the below common moisturizers and see what we can understand they contain!
Parabens, Dichlorobenzyl alcohol (preservatives that kill microbes so that product won’t spoil before expiry), Paraffin, petrolatum, Cetearyl alcohol may irritate
Free from perfume, propylene glycol, lanolin, color
Parabens, propylene glycol, Benzyl alcohol is a natural grape preservative and scent, Petrolatum, cetearyl alcohol may irritate, Sodium hydroxide is to modulate pH of product and can be an irritant
Free from lanolin, colorpH not disclosed
Cetaphil intensive moisturizing cream
Functions: Occlusive, humectant, repair
Shea butter is a plant lipid, Chlorhexidine to reduce bacteria
Free from perfume, lanolin, paraben, propylene glycol, colorpH not disclosed
MarcieMom’s take:
On 1st generation moisturizer – The low cost emollient tend to perform mainly occlusive function, with ingredients such as petrolatum, paraffin and emulsifying agent to thicken the moisturizer. If you don’t have sensitive skin, or patch tested not to be affected by these ingredients, basic creams can help prevent moisture loss. However, if you have eczema skin, it is not suitable as these mosturizers tend to be more alkaline than our skin pH and the ingredients may irritate your skin. There is also no ingredient in these creams to help repair your skin barrier.
Pros: Low cost, perform basic occlusive function
Cons: Irritate sensitive skin, drying for skin for alkaline products, no skin barrier repair function
On 2nd generation moisturizer – If water is the first ingredient, it is likely that preservatives have to be used to keep the product from spoiling. Paraben is the ingredient that has received a lot of negative press due to its linkage with cancer. This is not proven but paraben is one of the more common irritants. Other names for parabens from (Derm Net NZ) are:
I like to look at the number of ingredients and the absence of common irritants when comparing second generation moisturizer. For the same price range, I’d prefer to choose one with fewer ingredients and less irritants to reduce likelihood of irritating my eczema child’s skin. Another way is to rotate your moisturizer (in the hope!) to reduce the duration which your skin is exposed to the irritant.
Pros: Hydrate skin, some brands are affordable
Cons: Granted for the price range, you may not get ingredients like ceramides, lipids that repair your skin. But don’t choose one with many ingredients or irritants.
On 3rd generation moisturizer – These more costly moisturizers are less likely to have irritants (still check though, don’t take for granted!) but whether it is worth the price is another matter. % of ingredients is not listed and the stability of how long the reparative function last is not known. Personally, I use these on weeks where my child’s skin tend to be persistently dry or itchy despite moisturizing regularly with 1st & 2nd generation moisturizer.
Pros: Repair skin
Cons: Cost prohibitive + paying so much means you want to be sure that ingredients are not common irritants
I have to admit that this post is a very amateur attempt to analyse skincare products. Many websites that specialize in skincare products do a much better job, such as Paula’s Choice and EWG’s Skin Deep. What I hope to have helped is a way for lay(mom and dad) to make sense of products’ ingredient list and choose a better product for your child. I’d be contacting the brands mentioned in this post and see if they have more to add on their products. (If you don’t see updates or comments in this post, it means the brands mentioned have not responded.)
In June 2015, there was an eczema public forum held at the National Skin Centre Singapore and one of the talks was “Making the Right Choices for Your Skincare – Expert tips on Selection of the Right Moisturizer and Skincare Products” by A/P Professor Giam Yoke Chin. There was a segment of her talk where she shared about the evolution of moisturizer and what key ingredients are in them.
Seeing the high level of interest that the audience had in moisturizers, I’m inspired to write a post on the common moisturizers found in pharmacy (in Singapore/Asia as some brands are marketed under different brand names in the US/UK). So this 2-post series is mix of what I’ve learnt in Prof Giam’s talk and my own compilation of moisturizer’s ingredients; let me know (in the comments) what moisturiser has worked for you/ your child with eczema!
10 Moisturizer Selection Tips
We are blessed with many dermatologists and skincare experts sharing their views on moisturizer in this blog, here are the 10 Moisturizer’s Must Know I’ve learnt from them:
Selecting a right moisturizer can be tricky and confusing! Here are 10 selection tips, suited for those with eczema or sensitive skin
1. Labeling such as the term ‘natural‘, ‘hypoallergenic‘, ‘organic‘ (if no certification is mentioned), ‘dermatologist-tested’ (one dermatologist is also ‘dermatologist-tested’), ‘for sensitive skin’, ‘for baby skin’ are unregulated and up to the product company to define.
3. The first ingredient has the highest content – typically, if it’s water, it means it’s lotion form. Having water in the ingredients will mean requiring preservatives to keep it from spoiling. A lotion/cream can deliver the ingredients to the skin faster as it’s easier to be absorbed vs ointment that’s longer lasting.
5. Do not use moisturizer that is too expensive to use of sufficient amount for your skin (Eczema skin requires quite a lot of moisturizing!)
6. Avoid top irritants in a moisturizer such as perfume, fragrance, preservatives, parabens, propylene glycol, lanolin, colorant/dye, sodium lauryl sulphate
7. Moisturizers should hydrate your skin. if you’re not able to apply it frequently, you may want to opt for ointment (for longer lasting effect). If you can apply frequently (and depending on the weather/season), a lotion/cream may feel better on hot, humid days. Look out for ingredients such as cross-linked hyaluronic acid, sodium salt of pyrrolidone carboxylic acid, panthenol, salicornia extract, glycerin, amino acids and urea that can hydrate your skin. These are typically called natural moisturizing factors, referring to moisturizers with humectant property that attract water from environment to the skin.
8. If you can afford, use moisturizer that has the ability to repair the skin barrier. These ingredients that help restore the skin barrier, especially in increasing the ceramides, fatty acids and cholesterol in skin which is deficient for those with eczema.
9. Select products that are close to the skin pH which is slightly acidic from 4.6 to 5.6. The more alkaline a product, the more drying it is for the skin. It has been studied that the skin pH can affect enzyme balance on our skin and the more alkaline a product, the less enzymes are produced that are able to increase our skin’s ceramides and lipids. Reduced ceramides lead to our skin not being able to protect against skin inflammation and bacteria.
10. There are creams that have ingredients to reduce itch, inflammation and bacteria, for instance, antioxidants, oatmeal, acetyl-hexapeptide-15 and honey.
For those in the US, it is almost back to school after the summer break. And those of us living in Singapore, Malaysia and tropical countries, it’s summer all year (and especially hot these days!). I’ve shared ‘Back to School” Eczema tips with my friend Alana Mitchell, at her Skincare by Alana blog, that covers:
Eczema Prevention in School
Eczema Skincare
Eczema Triggers in School
Eczema Skincare Tips in School
Meanwhile, here are tips in table form, read the full post on Alana’s blog for further suggestions on prevention and skincare for eczema kids in school.
For this 3-post series, we have Alana Mitchell, the founder of SkincarebyAlana.com. She’s the most suitable expert I know for this topic on makeup for sensitive skin, where we will be covering not just the basics of makeup, but very practical steps on applying and removing makeup and even how to mask the appearance of scars or pigmented skin.
More on Alana – Alana acquired her esthetician license from the State Board of Barber and Cosmetology of California, allowing her to practice skincare in the California state in her spa business. Alana has worked in the beauty industry for over 15 years, and teaches advanced education classes for esthetician students.
Eczema Skin
Eczema Makeup – What You Have to Take Note Of!
Eczema skin is quite difficult to manage when it comes to make-up; for one, the cause of the eczema could be irritant or contact dermatitis, whereby the eczema rash is triggered by contact with allergens. Secondly, the nature of eczema skin is dry and the skin barrier is defective. It requires applying emollient for moisturizing, protection from moisture (occlusion) loss and increase moisture absorption (humectant). Thirdly, eczema skin may have more scars/ blemishes or even lichenified/ thickened skin from prolonged scratching.
MarcieMom: Thank you Alana for helping us for the past two weeks on:
Today, we are focusing on eczema skin. Let’s tackle the above difficulties one by one and round-up with your makeup tips for eczema skin.
Eczema Skin and Makeup Ingredients
We mentioned in our previous posts that there are ingredients we can avoid for those with sensitive skin. What in your experience are the ingredients not to have for makeup on eczema skin type?
Alana:Amongst the most common are: alcohol, artificial fragrances, harsh sulfates (such as sodium lauryl sulfate), chemical preservatives, and chemical sunscreens (such as octinoxate and oxybenzone).
Ingredients to Avoid in Eczema Makeup
Moisturizer and Implications on Makeup
MarcieMom: Assuming that an eczema sufferer has very dry skin and needs frequent moisturizing – what is the practical way to go about this? (since it’s not practicable to constantly remove makeup and apply moisturizer, then apply makeup again)
Alana: That is super easy! Find a tinted moisturizerthat you love! There are many brands that have tinted moisturizers that will not only deliver SPF protection, but will also provide vital hydration and beautiful coverage to your skin. Granted, the coverage on these products is typically rather light. But if you are doing what is right for your skin, and keeping it healthy, odds are you will only need a light coverage product. If you need heavier coverage, again, do some research. As long as your skin does not tend to get oily with reapplication, and as long as the product you are using is quality, reapplication should not be an issue at all.
MarcieMom: Is there makeup step to avoid for eczema skin? e.g. not to use mascara or adopt a simplified makeup routine
Alana: I wouldn’t say there is anything eczema skin needs to avoid. That is, of course, if you’ve found the right products for your skin type. As I’ve mentioned before, there are products out there for you! It is simply a matter of finding those products.Of course, if something in your makeup regimen is bothering you, or causing an eczema flare-up, discontinue use immediately!
Covering Scars, Pigmented Skin and Blemishes on Eczema Skin
Prolonged scratching of eczema skin can lead to scars, pigmented skin and thickened skin. It is important not to scratch eczema patch due to infection risk as well as scarring and discoloration.
MarcieMom: Alana, what are your makeup tips to cover these scars and blemishes on eczema skin? Are these concealers typically more irritating to skin than the usual foundation?
Alana: Much like foundation, there are many fabulous concealer options that not only mask but heal your skin. Do not, no matter how tempting, apply the first concealer you see in an effort to mask your eczema! This can lead to a negative reaction that will cause you even more problems. Take time to research brands that are especially good for sensitive, eczema prone skin, and take the time to patch test it before slathering it on the effected area. What many people don’t know is that irritated skin is often broken skin, and you do not want to be quick to slap a product on top of that. You will want a product that is specifically indicated to be able to be worn on irritated skin. Many of my eczema clients have had success using Lycogel’s Breathable Camouflage, which was designed specifically for users with rosacea (yes, even when it is in a reactive state).
Alana’s Makeup Removal tips for Eczema Skin
MarcieMom: Can you share your makeup removal tips for eczema skin? (with a view to minimize skin irritation and hydrate skin)
Makeup Removal tips for Eczema Skin
Alana: My makeup removal recommendation for eczema skin is honestly the same as it would be for eczema skin (and normal skin), just with different products! If you go beyond simply having sensitive skin, and have eczema prone skin as well, use products that are indicated to be good for super sensitive skin, and more importantly, for eczema skin as well. Just because a product does not indicate these things does not mean it cannot be used, but you should discuss it with your skin care professional before use. As I mentioned before, fewer and more natural ingredients are usually better. If you know your skin agrees with a certain oil (coconut oil is fantastic), you can use this to remove your eye and lip makeup before cleansing.
Thank you so much Alana for being with us for these past three weeks, it’s been such a pleasure and a great learning experience!
For this 3-post series, we have Alana Mitchell, the founder of SkincarebyAlana.com. She’s the most suitable expert I know for this topic on makeup for sensitive skin, where we will be covering not just the basics of makeup, but very practical steps on applying and removing makeup and even how to mask the appearance of scars or pigmented skin. See last week’s post on Skin Types and Makeup
More on Alana – Alana acquired her esthetician license from the State Board of Barber and Cosmetology of California, allowing her to practice skincare in the California state in her spa business. Alana has worked in the beauty industry for over 15 years, and teaches advanced education classes for esthetician students.
Sensitive Skin
There is no strict definition for sensitive skin but generally, it means being more prone to getting a hypersensitive reaction to ingredient/chemicals. You can find out which ingredient you’re sensitive to via a patch test and your patch test results can be entered into the CAMP (Contact Allergen Management Program) database in the US to obtain a list of products you can use.
Applying and Removal of Makeup for Sensitive Skin
Applying Makeup – Moisturizer and Foundation
MarcieMom: Alana, thanks for helping out this week with application and removal of makeup. We are getting into the specifics of makeup for those with sensitive skin this week.
Can you share with us how we can figure out our skin tone and choose the right foundation (color, texture)?
Alana: If I’m being totally honestly, there is a lot of guesswork that goes into finding your perfect shade. Foundation shades are typically crafted on the most common skin tones, and you will notice that there are usually only 10-20 shades in a typical range. Since everyone has their own unique skin tone, it is usually a matter of trying a shade that looks closest to yours. Another option is to buy one shade darker, and one shade lighter, so you can blend them to meet your exact skin tone.
For brands that label based on undertone, finding your exact shade might be much easier. The first step in figuring out your skin tone is knowing your skin’s undertone, which is a lot easier than many people might think! Simply look at the inside of your wrist and observe the color of your veins. If they appear to be blue, you are likely cool toned. If they appear to be green, you are likely a warm undertone. If you notice both blue and green, or something in between, you are likely a neutral undertone. Whichever tone you observe, you will want to lean towards that range (warm ranges are usually labeled with a W, cool with a C, and neutral with a N). After that, it is all a matter of finding the right shade. Just because it matches your undertone, does not mean it will be an exact match. It might still be too dark or too light – so trial and error will come into play yet again.
How do you tell your Undertone?
When in doubt, there are two things you can do: ask you local makeup artist or esthetician. They should be able to give you some recommendations, and might even be able to test products on you in an effort to find your exact match. When it comes to testing makeup, I am a huge advocate of doing so in a safe manner. If you head down to your local department store, see if they have small, sealed samples that you can test in-store or take home to test. If you feel comfortable allowing a makeup artist to test products on you in-store, make sure you understand the risks (those products are tested on many people, not just yourself) and watch them sanitize both the product and the makeup brush properly. I am not personally an advocate of using in-store testers, unless they are housed in an airless pump container, which most makeup products are not. But is very much a matter of personal preference.
MarcieMom: What about for those with sensitive skin? How can sensitive skin types choose the right foundation and what ingredients should sensitive skin types look for or avoid in foundation?
Alana: When it comes to sensitive skin, I always recommend seeking the advice of a dermatologist or medical esthetician. They are going to be able to give you the best recommendations for your skin type, because they have an understanding of the ingredients that go into skin care and makeup, and also have an understanding of sensitive skin in general.
As far as things to avoid: many sensitive skin types don’t do well with harsh chemicals, alcohol, artificial fragrances, and the like. However, each person is different, and an ingredient that does not irritate one sensitive skin user might irritate another. Brands like YoungBlood Cosmetics and Glo Minerals are fabulous options for sensitive skin users. YoungBlood Cosmetics, founded by Pauline Youngblood, delivers a range that can cover raw, inflamed or discolored skin while allowed it to breath and heal! So yes, most sensitive skin types can definitely use this ultra-gentle makeup range. Glo Minerals bills itself as being a “clinically advanced mineral makeup that covers, corrects, and protects”. They indicate on their site that they are suitable for “even the most sensitive skin,” and I have seen great success with sensitive skin clients using this brand.
MarcieMom:Moisturizing the skin and sun protection are important. How do these go with make-up? e.g. apply them all separately or it’s better to choose makeup that is both moisturizing and offers broad-spectrum UV protection?
Alana: While I am a firm believer in keeping moisturizing and makeup separate, you can definitely combine SPF protection with beautiful skin coverage. As I mentioned in my last post, I am a huge fan of tinted sunscreen. If dry skin is a concern for you, you can definitely reach for products that are more moisturizing.
There are many products that offer full coverage results with SPF foundation. I do urge users to be selective when it comes to picking out a brand and formulation, and to really consider if this option is best for them. Full coverage products are typically “heavier”, meaning most people will not want to reapply it throughout the day. Reapplying SPF every 2 hours (at least) is crucial for optimal sun protection, which is where product selection comes into play.
Lastly, powdered sunscreens make for a great and easy option! Though these are typically on the lighter side of the coverage spectrum, they do a great job of masking imperfections, while absorbing excess oil and mattifying the skin. I happen to be a huge fan of this method for touch-ups (after applying my tinted sunscreen in the AM).
Alana’s Makeup Removal tips for Sensitive Skin
MarcieMom: Alana, what would be your top makeup removal steps/ pointers for those with sensitive skin? (with a view to minimize skin irritation from the products, the beauty tools used e.g. brush and cross-irritation)
Alana: Makeup removal should always be a priority, but I personally like to keep it simple (and enjoyable) to make it feel less tedious at the end of a long day. First and foremost, be sure to remove any makeup around your eye area. There are many eye and lip makeup removers out there that are gentle enough for sensitive skin, and many that are actually indicatedfor sensitive skin. After you remove makeup in these areas, it’s time to cleanse your face. If you are not the proud owner of a skin cleansing device, make sure you cleanse twice a night to ensure you get any excess dirt, oil, and makeup off of your skin. That is about it! Of course, be sure to follow your cleansing up with your typical skin care routine.
Makeup Removal Tips for Sensitive Skin
Thank you so much for sharing the makeup basics for those with sensitive skin. It’d give those of us with sensitive skin so much more confidence when we approach makeup. Next week, we will focus on makeup for those with eczema, an area that many eczema sufferers struggle with.
For this 3-post series, we have Alana Mitchell, the founder of SkincarebyAlana.com. She’s the most suitable expert I know for this topic on makeup for sensitive skin, where we will be covering not just the basics of makeup, but very practical steps on applying and removing makeup and even how to mask the appearance of scars or pigmented skin.
More on Alana – Alana acquired her esthetician license from the State Board of Barber and Cosmetology of California, allowing her to practice skincare in the California state in her spa business. Alana has worked in the beauty industry for over 15 years, and teaches advanced education classes for esthetician students.
Skin Types and Makeup
Skin Types and Makeup with Alana Mitchell, the founder of SkincarebyAlana.com
If you check out product labels, you will generally find that they cater to (i) normal skin, (ii) dry skin, (iii) oily skin or (iv) sensitive skin. In this blog, we have always been focused on eczema skin that typically belongs to the dry skin type, sensitive skin (when we cover and irritants to avoid) and to some extent oily skin, when we discussed about acne.
MarcieMom: Alana, thank you so much for helping out with this series on makeup! I’m excited to learn more about it, especially when I’m clueless when it comes to makeup (I hardly use any!).
I read that the first step to figuring out what makeup and beauty products to use is to figure out your skin type. From WebMD, I noted that the different skin types are characterized by:
Normal Skin Type – (i) No or few imperfections, (ii) no severe sensitivity, (iii) barely visible pores and (iv) radiant complexion
Dry Skin Type – (i) Almost invisible pores, (ii) dull, rough complexion, (iii) red patches, (iv) less elasticity, (v) more visible lines and (vi) when exposed to drying factors, skin can crack, peel, or become itchy, irritated, or inflamed.
Oily Skin Type – (i) Enlarged pores, (ii) dull or shiny, thick complexion, (iii) blackheads, pimples, or other blemishes
Alana, most people may have difficulty figuring out their skin types or have a combination of skin types. Moreover, certain conditions such as skin disorders, smoking, medications, diet, stress, sun exposure, pollution, climate and existing beauty products may mask the real skin type. What is your advice on how we can figure out our skin type and how important is it to get the skin type right?
Alana: First, finding your right skin type is so important. Many people purchase products that aren’t necessarily right for their skin type, which can be either useless, orcounterproductive in terms of achieving desired results. For instance: if someone with dry skin were to purchase a product specifically designed for oily skin, they are not likely to get the level of hydration they want (and more importantly, need). Figuring out your skin type is not always easy, which is where dermatologists and medical estheticians come into play! Going to one of these professionals may seem extreme, but it is the best first line of action in realizing your skin type and finding products that will work best for your skin type!
It’s important to figure out your skin type to get the right make-up
MarcieMom: I’m interested to find out what are the key differences in the formulation when a company label its product as suitable for (i) dry skin, (ii) oily skin and (iii) sensitive skin? Are there any regulations that govern when a company can label itself as such?
Alana: Key differences in these formulations typically address the markers of each skin type. For instance: dry skin formulas are typically more emollient. Many of these products use oils to nourish the skin, which is essential when you are dealing with any type of dryness or dehydration. In regards to makeup, dry skin users will want to lean more towards liquid formulations more than powder. I highly recommend looking into mineral makeup brands like YoungBlood Cosmetics, which use only the finest minerals while catering to even the most sensitive skin types.
Products designed for oily skin types are typically more mattifying. These formulas are often oil free, and lightweight, which helps to absorb excess oil and regulate oil production. Many people with oily skin will favor makeup that comes in powder form, but there are many fabulous mattifying liquid options that have recently hit the market as well.
Sensitive skin products are known as the more “gentle” formulas. These are typically (though not always) formulated with fewer harsh ingredients, and have been made with sensitive skin types in mind. It is important to note that just because a product is designed for sensitive skin, that does not mean your skin will take a liking to it! All skin is different, so even with sensitive or gentle products, you will still want to apply a patch test 24-48 in advance to using the product to ensure your skin will react well to it.I have not typically seen brands that put out a “sensitive” range for makeup. They are either friendly to sensitive skin as a whole, or they don’t formulate with sensitive skin in mind at all. Because of this, it is essential to look into the brands you are buying from, before you actually make your purchase. I have had wonderful experience with brands such as 100% Pure, Blinc Cosmetics, Glo Minerals, La Bella Donna, and again, YoungBlood Cosmetics.
There aren’t any firm regulations when it comes to labeling products for skin types. That being said, companies do have reputations to uphold, so it is important that they label their products for the right skin types accordingly. Your best bet is to ask your esthetician or dermatologist, and reading product reviews can also be very helpful as well!
What to Note for Makeup when You have Dry, Oily or Sensitive Skin
MarcieMom: I’m the sort of gal whose makeup is just foundation and lipstick. Alana, what in your view, are the must-haves for makeup and are there certain types makeup (foundation, blusher, mascara, eyeliner) that certain skin types should not use or is it possible to find something for every skin type?
Alana: My three essentials are: mascara, tinted sunscreen, and lip gloss. Being a busy mom and business owner, I know all about getting ready on-the-go, and these three things are fantastic for making you look and feel confident in a pinch!
Makeup must-haves are always a personal thing, but if I could list one essential, it would be some form of tinted SPF. Tinted sunscreens are a great way to get coverage, protection, and hydration. If oily skin is more of a concern for you, you can also reach for a powdered sunscreen brush! These brushes are amazing, because they are so easy to keep in your purse, so easy to touch up, and will mop up oil without making your face look cakey or over-done.
The good news is: regardless of you skin type, there is bound to be an option out there for you. It is all a matter of research and recommendation. If you have had little to no luck, call an esthetician! My medical estheticians and I are available during business hours via phone, chat, and email to help shoppers in finding the perfect products for their skin type. It may sometimes be difficult, but I guarantee you it can be done.
Thank you so much for sharing your expertise on skin types and makeup with us. I think we all benefit from knowing more about skin types and understanding how that relates to selecting makeup. Next week, we will focus on sensitive skin, can’t wait!
If you’ve been following this blog, you’d know I don’t jump into eczema (miracle) cures. I still don’t.
But as I read journeys of how eczema sufferers are cured, I realized that there are common approaches they take. These may not be THE (or even an) eczema cure but I think there’re certain situations which they may help improve eczema. I hazard a guess and this series is more about a holistic approach to controlling eczema – I suppose you can call it a cure if one approach singularly works well for you!
The Water Not to Use – HOT
Hot water strips moisture from the skin and it is never recommended by dermatologists. It may feel good because the heat temporarily numbs the (itch) nerves and so a hot shower offer temporarily relief – avoid at all costs. Consider other bath options that are more beneficial for eczema, dry skin and relief such as a cool compress.
Does the Water Type Matter?
Drinking water – There was a study in 2005-2006 in the US that showed a possible link between the chemical dichlorophenol present in tap water and higher incidence of food allergy. If the food allergy manifest as skin rash, then it’s possible that changing the water we drink help our eczema. Apart from this one study, no other study was found in Pubmed. Apart from tap water, fruits and vegetables also contain this chemical, found in pesticides. (note: See Singapore PUB link on Singapore Drinking Water Quality, dichlorophenol is present)
Updated on 27 Oct 2016 – For those of you wondering about the benefits of alkaline water, interesting read on MedicalNewsToday – no benefit and even showed harm!
Bathing water – Too Alkaline – Tap water is alkaline with an average pH value of 8. As the skin pH is slightly acidic, washing with alkaline contribute to skin dryness. Thus, another reason to limit your shower time. Read more from dermatologist Dr Cheryl Lee on vinegar bath increases the acidity of the bath water.
Hard water vs soft water – Hard water is caused by limestone (calcium carbonate) dissolving in the water and it is the white deposit that is seen in kettles, bath tubs and steamer. Hard water has been associated with higher incidences of eczema and identified as environmental trigger. However, in a randomized-controlled trial, there was no significant difference in families whose eczema children use hard water versus soft water (via a water softener). However, many eczema sufferers personally feel better about using soft water, partly due to lower pH level and less detergent needed in soft water washing.
Spring water – A well-known spring water spa for eczema sufferers is La Roche-Pasay in France. It’s possible that a higher selenium content or the presence of a certain bacteria (Vitreoscilla filiformis) in spring water is beneficial for dry skin.
What Matters for Shower
The important thing is to moisturize immediately after a shower – this one step outweigh the type of water you use or even what you use to shower with (no soap). Immediately moisturizing traps moisture on the skin and limits the evaporation of moisture from the skin after bath. Leave some moisture on the skin, don’t rub very dry and trap some of that with an emollient cream/ointment right after bath.
For me, I don’t use any special water but always limit the time taken to shower. It’s usually quite fast like within 5 minutes, followed up moisturizing. What’s your experience on water you use at home? Do share in the comments! Also if you missed the rest of the Eczema ‘Cure’ Series, below are the links:
If you’ve been following this blog, you’d know I don’t jump into eczema (miracle) cures. I still don’t.
But as I read journeys of how eczema sufferers are cured, I realized that there are common approaches they take. These may not be THE (or even an) eczema cure but I think there’re certain situations which they may help improve eczema. I hazard a guess and this series is more about a holistic approach to controlling eczema – I suppose you can call it a cure if one approach singularly works well for you!
There is a fair amount of suggestions by the dermatological community on how and what to bathe with to help eczema skin. Some eczema sufferers also shared on what they use, though in general, it is less often cited as a ‘cure’ compared to the first 3 series of this post on:
Personally, I alternate between an oatmeal-based bath, a chlorhexidine-based bath lotion and a hypoallergenic cleanser for my eczema child (Marcie, who’s 6 years old now!). I haven’t dared to try a bleach bath nor mixing vinegar though these two have also been recommended by dermatologists. Let’s explore the various baths for eczema sufferers!
Bath to Try #1 – Soaking
If you have a bath tub or your child still fit into one, soaking in a bath tub (not hot water, but use lukewarm or room temperature) for not more than 10 minutes can help the skin to absorb water. Especially for those of you who have to endure dry, winter months, possibly dissolve a thick emollient into the bath as well! Note: Don’t soak your head in the tub!
Bath to Try #2 – (Colloidal Oatmeal) Bath Oil
Bath oil – Try colloidal oatmeal bath or other bath oils but be sure they do not contain the key irritants such as fragrance. Oatmeal bath can relieve eczema itch. Bath oil tend to leave a film on the skin and possibly a quick rinse will suffice instead of trying to wash the ‘film’ away – I guess that’s a bit defeating the purpose of using a bath oil. Here’s a study on bath oil for infants.
Bath to Try #3 – Bleach Bath
The main purpose of bleach bath is to kill the staph bacteria that often colonizes eczema skin. I’ve the privilege of interviewing dermatologist Dr Cheryl Lee who is an early proponent of bleach bath (more here). Bleach bath is to be limited to no more than 3 times a week. A study on bleach bath here and updated research news on bleach bath here.
Bath to Try #4 – Chlorhexidine
I used to wipe my child’s skin with chlorhexidine when I noticed persistent itch or redness. Since I’ve been prescribed a chlorhexidine-based shower lotion, I’d use it say once a week especially as my child has quite a few ‘high bacterial’ habits! More on chlorhexidine and bleach bath from my interview with dermatologist Dr Clay Cockerell.
Bath to Try #5 – Vinegar Bath
If bleach sounds too aggressive/ chemical/ toxic to you, consider vinegar. I’ve had an informative interview with Dr Cheryl Lee where she shared how vinegar balances the skin pH level on top of killing the staph bacteria. Vinegar bath may be stinging for some eczema skin/wounds, check with your doctor first.
Other Baths
Some like to add magnesium flakes into bath, while others use salt.
Bath NOT to Take #1 – Hot
So many eczema sufferers SUFFER FROM ITCH and sometimes, uses hot water to numb the itch for a relief during shower. However, hot water strips moisture from skin, avoid at all costs.
Bath NOT to Take #2 – Soap
Soap is drying because it’s way too alkaline for our skin, more here on soap here. It often causes skin irritation too.
Bath NOT to Take #3 – Too Long
Too long a shower strips moisture from skin – it’s a bit mind boggling when you first heard of it, shouldn’t the longer you shower be more moisturizing? It’s not – think of it as a thunderstorm washing off the cement in the brick wall.
Bath NOT to Take #4 – Bubble Bath
Most of the bubble bath solutions contain irritants, avoid bubble bath for children with eczema.
Bath NOT to Take #5 – Exfoliating Bath
Our skin exfoliates on its own – using scrubs can further break down the skin barrier which is already ‘weak’ for eczema sufferers.
Bath NOT to Take #6 – Bath without Moisturizing After
Pat dry (not rub dry), moisturize within 3 minutes after shower. More in this video.
If bathing is so troublesome, why not forgo bathing? First of all, that’s downright unbearable, especially for us in hot weather cities (Singapore, Asia, Australia and parts of US too!). Secondly, bathing has a purpose to remove dirt, sweat and skin debris which can also be irritating if left to accumulate on the skin. Instead, you can try shortening the length of a shower or reducing the number of times you shower (in a day, not a week! – No way I can don’t shower everyday in Singapore!).
Do share your bathing tips in the comments, we love to hear more of what you’re doing!
If you’ve been following this blog, you’d know I don’t jump into eczema (miracle) cures. I still don’t.
But as I read journeys of how eczema sufferers are cured, I realized that there are common approaches they take. These may not be THE (or even an) eczema cure but I think there’re certain situations which they may help improve eczema. I hazard a guess and this series is more about a holistic approach to controlling eczema – I suppose you can call it a cure if one approach singularly works well for you!
There are some eczema sufferers that report an improvement in their eczema after ‘cleaning’ their homes of all chemicals (no pun intended!). Personally I don’t use much chemicals at home, for instance, my floor is cleaned with water and we don’t use anti-bacterial wash every time. It can be very difficult to adopt a zero-tolerance for chemical in your life, given how they are in a lot of products, even baby wipes! I do believe though that some individuals’ skin are more sensitive to chemicals than others and therefore for them, eliminating chemicals work well for their eczema. For the rest of us, perhaps a moderated approach to limit chemicals only in certain areas. These are my suggestions!
Chemical Alert #1 – Detergent
This is likely one area you have to be careful with because detergent residue can be irritating to child’s sensitive skin and it is also worn in close contact with the skin. Detergent residue can make up 2% of the weight of a clothing and it contains irritants such as
These chemicals irritant and can cause contact dermatitis. What I do is wash using a longer cycle and use a hypoallergenic detergent. It may also mean that the clothes don’t get cleaned as it would with stronger detergent but it beats having eczema. Be careful of new clothes too, wash them before wearing as they also contain chemicals (read this mom’s sharing on trying on new clothes for her eczema child).
Chemical Alert #2 – Anti-microbial Products
This is one of those oxymoron – we want to clean to be safe but the cleaning leads to more danger. Generally speaking, the concerns are:
Increased use of antimicrobial products (ingredient triclosan and triclocarban) lead to prolonged contact through the use of everyday products like dish washing detergent, hand sanitizer, deodorant and soap. This overtime can lead to contact eczema where the skin starts to develop rash when in contact with these, for instance, occupations that involve frequent hand washing tend to get this.
Constantly using anti-microbial products to kill bacteria can actually lead to bacteria becoming resistant to cleaning, partly contributing to why hospitals have higher rate of staph bacteria infection although they clean the hospital often (see this study)
Also the hygiene hypothesis, whereby the more ‘ bacteria cleaning’ we do, the less our body is capable of dealing with foreign matters thus sometimes going into an overdrive when exposed to something harmless
Chemical Alert #3 – Fragrance
Fragrance is undoubtedly the top irritant – avoid fragrance for the whole family with a baby with sensitive skin, as advised by dermatologist Dr Cheryl Lee MD in Eczema and Skin pH, point 7 on allergy avoidance. Other chemicals to avoid are nickel, formaldehyde releasing preservatives, propolis (in beeswax), neomycin and bacitracin. For alternative names to fragrance, see the compiled list from dermatologist Dr Verallo Rowell on Sensitive Skin Products – Top Irritants.
Other common irritants for children with eczema is listed in Contact Dermatitis for your Eczema Child and nickel is one that showed up in quite a few studies. Coins and jewelry of nickel has to be avoided for those sensitive to nickel.
Chemical Alert #4 – Hair Dyes and Tattoos
It would unlikely be affecting eczema children but teens and adults should take care of the potential dangerous effects from using hair dyes (with A-List Celebrity Hairstylist Kristan Serafino on alternative hairstyling tips) and tattoos.
Chemical Alert #5 – Chemical in the Air
Chemicals that we breathe in can also affect allergic condition, like asthma. Read how dermatologist Dr Cheryl Lee avoid VOC paint and redo her home carpeting. Avoid polyaromatic hydrocarbons as well.
Chemical Alert #6 – Baby Wipes
Baby wipes are a life-saver, especially when traveling. Be careful not to use it on the face though as the skin is thinner on the face and an ingredient in baby wipe methylchloroisothiazolinone or methylisothiazolinone has been linked to cause skin rash overtime.
On the point about the air, many food allergens can come into contact with our skin from the air. Especially if you or your child has egg allergy, it’d be best to dine in a restaurant with good air ventilation instead of hawker centre where the ‘egg’ content in the air is higher (something my co-author Prof Hugo Van Bever shared in our book launch). What other chemicals are you avoiding? Share in the comments!
If you’ve been following this blog, you’d know I don’t jump into eczema (miracle) cures. I still don’t.
But as I read journeys of how eczema sufferers are cured, I realized that there are common approaches they take. These may not be THE (or even an) eczema cure but I think there’re certain situations which they may help improve eczema. I hazard a guess and this series is more about a holistic approach to controlling eczema – I suppose you can call it a cure if one approach singularly works well for you!
Many eczema sufferers are wary of chemical and steroids. I agree but am also wary of going into extremes of attributing everything bad to chemicals and steroids, especially given that eczema is a condition that comes about from many factors (so would focusing on just one aspect be over-simplification?). But I’m definitely supportive of home remedies that work – if they work without side effect!
Home Remedy #1 – Moisturize
Moisturizing is one approach that most would agree is beneficial. It’s accepted that eczema patients (adults and children) have defective skin barrier and a moisturizer have various functions to
Protect skin from drying/ losing too much moisture
Protecting skin from irritants
Absorbing water into the skin
Filling up the ‘holes’ in the skin or restoring the skin lipids (that help keep the skin cells together and prevent infection, learn more from dermatologist Dr Cheryl Lee in this Over-Alkaline skincare interview)
See also the research on moisturizing where it had been shown to reduce steroid usage and preventive effect on babies with high risk
Home Remedy #2 – Don’t Moisturize (with Irritants)
There are also sharing by eczema sufferers that their eczema improved after STOPPING moisturizer use. My guess is that there could be ingredients in the moisturizers that they have been using that are triggering the eczema, a form of contact dermatitis. There is a test to determine which ingredient in skincare product that you could be sensitive to, known as patch test (interview with Laura Verallo Rowell, CEO of VMV Hypoallergenics).
There are indeed individuals whose skin are sensitive to many common ingredients and therefore, it would make sense for this selected group to stop moisturizer use. Not for general population with dry skin though.
I wouldn’t really call it a ‘home remedy’ as clothing products that are able to trap moisture close to the skin and studied to improve eczema usually have invested money into the technology behind the clothing. One such technique is Wet Wrap which had been shown to help eczema and if you’d like to know more about what goes into the wrap and how to use it, read here. My national (Singapore) eczema support group also runs regular wet wrap session, do sign up at the top right box of my blog to be kept posted!
Home Remedy #4 – Ways to Kill Staph Bacteria
Staph bacteria is a common cause for eczema where increasing research showed that eczema skin is colonized by this bacteria which produces toxins that can worsen skin inflammation. There are ‘natural’ ways to kill the bacteria, for instance swimming or bleach bath or shower with a chlorhexidine-based bath wash.
If you don’t like the idea of bleach, read this interview with dermatologist Dr Cheryl Lee on vinegar spray.
Home Remedy #5 – Oils
Though no conclusive research, there are eczema patients whose skin improved after primrose and borage oil (see dermatologist Dr Cynthia Bailey’s comment in the post) and virgin coconut oil (see this very informative interview with dermatologist Dr Verallo Rowell on different types of coconut oil – make sure you get the right type!)
Home Remedy #6 – Anti-Inflammatory Natural Ingredients
There are also quite a few natural ingredients that have anti-inflammatory properties like honey, lavendar or able to protect skin like colloidal oat (interview with dermatologist Dr Claudia Aguirre).
Personally, I feel that the biggest home remedy is to avoid triggers. Logically it makes sense to identify these triggers because no treatment or remedy can be helpful if the skin is under constant ‘attack’. After which, I do believe in moisturizing and as for using natural ingredients, I’m all for it as long as it’s not something that irritate you (beware that natural does not equal no hypersensitive reaction) nor past expiry (as a home-made product may be less stable so the expiry date matters more).
If you’ve been following this blog, you’d know I don’t jump into eczema (miracle) cures. I still don’t.
But as I read journeys of how eczema sufferers are cured, I realized that there are common approaches they take. These may not be THE (or even an) eczema cure but I think there’re certain situations which they may help improve eczema. I hazard a guess and this series is more about a holistic approach to controlling eczema – I suppose you can call it a cure if one approach singularly works well for you!
Now, many eczema sufferers report curing their eczema from eliminating certain foods from their diet, typically these are (i) diary, (ii) wheat and (iii) sugar. Is there a basis for this? Think along with me!
Suspect #1 – Allergy to Diary and Wheat Undetected
This is the most straightforward reason why cutting certain foods from diet heal your eczema – it’s possible that you have an allergy to certain foods but you’re not aware of it. The unawareness could be due to:
You have not taken an allergy test, be it either skin prick test or blood IgE test. Watch the video on allergy testing and #SkinishMom column on why sometimes doctors don’t get you tested (other than the other obvious reason which is they don’t have the facility to test and don’t want to refer you to another doctor..)
Foods like diary and wheat are so prevalent in our diet that you may not notice. Generally speaking the more common something is, the less likely that you can identify it on your own as the trigger for your eczema. That is why although house dust mite is a very common trigger, parents tend to not associate their child’s eczema flare up with it. For common allergens for children of different age, see here (extracted from Professor Hugo Van Bever’s article – Prof Hugo is my co-author for Living with Eczema Mom Asks, Doc Answers!)
Suspect #2 – Food Intolerance or Hypersensitivity not Easily Tested
While allergy testing (for increased blood IgE immunoglobulin) is straight forward, detecting food intolerance or hypersensitivity is a whole different ball game. Even allergist or your nutritionist can be floored by it. For instance, reaction to a food intolerance can be gradual, not necessarily in small amount (unlike allergy) and can be intolerant only when certain foods are in certain state (eg raw versus cooked). Learn more on the differences between allergy and food intolerance.
As such, it could well be that your intolerance reaction is in the form of skin rash but because it is delayed reaction, no doctor has told you that a certain food is the culprit. However, when it is removed from your diet, your skin condition improves.
Here’s an interesting research on how children have tummy ache but didn’t get diagnosed as related to food sensitivity.
Suspect #3 – Gluten Sensitivity comes in Many Forms
Similar to the above, gluten sensitivity can come in many forms – Celiac Disease, Non-Celiac Gluten Sensitivity or Wheat Allergy. While there are tests for celiac disease and wheat allergy, testing for non-celiac gluten sensitivity is not straightforward. This could be why many reported their eczema improving after cutting gluten yet they are not tested to be allergic to it.
There has been some (small scale, not conclusive) research suggesting that eczema sufferers tend to have gluten sensitivity which is why cutting gluten has worked for them.
Suspect #4 – Sugar Intolerance
For other eczema patients, cutting out sugar improves their eczema – a possible reason is that they have an intolerance to fructose or sucrose. This is due to the lack of digestive enzyme frutase and sucrase. However, tests for these are more expensive and being in many of processed foods and foods we eat, you may not think of testing for it.
Also cut the soda, read its harmful effects in this Soda and Child series.
Suspect #5 – Milk Intolerance
Similar to above, one could also be intolerant to milk from a lack of digestive enzyme lactase. It’s possible that the intolerance reaction gets triggered from different amounts and therefore, you may not know it’s from milk.
Read also alternative food sources from nutritionist Natalia Stasenko if your child is intolerant to milk.
Suspect #6 – Cutting out Inflammatory Foods
I’m personally very careful about NOT eating inflammatory foods and if your child with eczema is obese too, read tips from nutritionist Rania Batayneh on an anti-inflammatory diet.
The basic concept of inflammatory foods is that these foods promote the production of substances that put stress on our body, being increasingly recognized as the cause of many health conditions which are linked to prolonged inflammation (chronic inflammation). To understand this better, see interview with nutritionist Toby Amidor.
I’m not clear how inflammatory foods directly link with eczema but the general link is that eczema is skin inflammation (rash) and the overall reduction of inflammatory foods may have a greater impact on certain individuals than others (my own guess).
Suspect #7 – Eating Clean
This term ‘clean eating’ is quite ambiguous but generally taken to mean that we don’t eat processed foods, fried foods nor trans fat. There are also people that said once they cut out processed foods, cook and eat healthy, their eczema improved. I’m a big supporter of that, not so much for improving eczema but more for general health. In terms of research that supports doing so, there is a large scale association study that showed children who ate fast food more than 3 times/week are 30% more likely to have more severe allergic conditions. (side point – Prof Hywel Williams who led the study also wrote the foreword for my Living with Eczema book!)
Suspect #8 – Going Vegan
Some eczema sufferers choose to go vegan or cut down on meat. There is a basis for this as explained by dermatologist Dr Cheryl Lee in this post on Diet and Environment on Skin. Animal proteins and sugar are pro-inflammatory and give rise to excess free radicals that damage our body and our skin. My own guess is that some people get affected by animal protein more than others which is why going vegan works wonders for their skin!
Suspect #9 – Being Able to Take Action reduces Stress
This is my own guess – it is known that stress triggers eczema flare-ups (see dermatologist Dr Claudia Aguirre’s interview on Stressed Skin is Skin Deep) and most patients also feel helpless especially when there is no clear trigger or solution offered by their doctor. Being able to take proactive steps to eat healthy, cut sugar or figure out gluten-free recipes may reduce stress and inspire new interest in cooking. So the reduced stress possibly helps the eczema and for more on stress affecting acne, see dermatologist Dr Verallo-Rowell’s interview on Diet and Lifestyle.
Above is my thoughts on why eczema sufferers or parents of eczema children feel that changing diet ‘cured’ their eczema. Did diet change work for you? Share in the comments!
One reader, from Odylique Essential Care shared this post that they compiled from research papers and their infographic (Credit:www.odylique.com)
Ask #SkinishMom any question – parenting, skin, eczema or plain venting!
My kid has eczema and we haven’t figured out what is the trigger. I’ve been asking the doc about taking an allergy test but the doctor either say that my kid’s eczema is only at a certain area, so no testing is needed or say that it’s those common allergens that affect almost every child, so again no testing is needed. But there’s no CONCRETE EVIDENCE of WHAT’S TRIGGERING MY CHILD’S ECZEMA – why can’t the doc just give me the test?
Frustrated Mom
I totally understand, many moms feedback the same and many docs replied the same. The short reply is if taking an allergy test is on your mind 24/7, just demand it. If the dermatologist that you’re seeing refuses to prescribe one, go to another doctor. After all, eczema is a long-term situation that requires much working and communication with your doc; if you can’t even agree on something as basic as whether or not to allergy test, it’s unlikely that this is a doctor that you can work with.
On presenting both sides of the story:
From the parents’ view:
You’re tearing your hair out figuring out the triggers, you need an allergy test to get some answers.
You’re growing day by day fearful of applying corticosteroid cream on your child, figuring out the trigger means less flare-ups and less need for the steroid.
You’re breastfeeding still and you seriously are going nuts on what you can or cannot eat.
From the doctors’ view:
Your child’s eczema is localized, say on the face, thus likely due to saliva or food residue irritating the child’s skin.
Allergy testing is unlikely to be accurate for a baby (less than 6 months) and therefore, testing and working on the inaccurate results may turn out to be even more confusing for the parents.
It is true that most of the children are affected by the common allergens of cow’s milk, egg, soy, wheat, seafood, dust mite, pet dander and pollen. Younger children are more affected by food while older children are commonly affected by dust mite. It is therefore a waste of money to be testing for something when you’d already know the test results.
SkinishMom’s view:
Go for allergy testing, even if it’s going to turn out results you’d expect (so you know for sure).
Go for allergy testing at the clinic/hospital where you’d want to see the doctor, because the results have to be interpreted and collaborated, with future action plan for eczema care
Don’t go for allergy testing online or some ‘innovative’ allergy tests – skin prick, blood IgE and skin patch are the standard tests
Do what you (as a mom/dad) think it’d give you peace,
Skin pH interview with skin barrier expert, Cheryl Lee Eberting, M.D.of CherylLeeMD.com
This is the 4th 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 and 3rd post on Diet, Environment on Skin 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 TrueLipidsskin 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 helping us understand skin pH and sharing with us last week on what to watch out for in our diet and environment. Today we focus on the skin’s itself and the products we use on it!
Endogenous Factors and Skin pH
I understand that newborn baby’s skin is of higher pH of about 7. Moreover, certain parts of the body is more acidic/alkaline than others.
MarcieMom: What are the key endogenous factors parents should note to help manage the child’s skin pH? For instance, not let sweat stay on skin? What about ethnic and genetics?
Dr Cheryl:Babies are born with a relatively alkaline skin pH because they’ve been incubating inside the mother’s more alkaline amniotic fluid. Newborn skin is covered with an amazing moisturizer called vernix caseosa; a waxy coating that obviously works to make the babies relatively waterproof while in the womb. Within days of birth, the pH of the newborn skin begins to dry out, acidifies and then the acid mantle becomes intact. For this reason, it is important to use moisturizers that are in the optimal pH range for babies too. In a recent preventative study of the infant siblings or children of those who have atopic dermatitis, twice daily moisturization with a hypoallergenic (meaning no fragrances, no essential oils, no plant extracts, no formaldehyde-releasing preservatives, no lanolin, no neomycin, no bacitracin, no methylchloroisothiazolinone) moisturizer in these newborn babies lead to an approximately 50% reduction in rates of new onset atopic dermatitis. I love this study because it tells us a lot about the connection between our skin barrier and our immune system. By optimizing your skin barrier and sealing it off from the outside world, and by avoiding as many chemical exposures as possible, we can prevent the immune system from developing the inflammation associated with eczema!
I would also venture to say that this may be the way to avoid asthma as well. When allergens come in contact with the skin, then the allergic type of inflammation is turned on. On the other hand, it has been shown that if you can avoid letting allergens (including foods!) from coming in contact with the skin long enough, then your child’s immune system will build up tolerance to the food when it is presented to the immune system of the gut. What this tells us is that, in susceptible populations, the skin barrier needs a little help as it is maturing. By using a pH-optimized and hypoallergenic moisturizer twice a day, you may be able to help your baby to build an effective skin barrier that is not as overreactive as it is in eczema. Our skin is truly the window to our immune system and skin barrier optimization (SBO) is extremely important in treating and preventing atopic dermatitis.
As for ethnic variability in the skin barrier, there have been documented differences in relative concentrations of lipids in the skin of caucasian versus asian versus black skin thought the relative ratios are all the same. To my knowledge, there is no interethnic difference in the optimal skin pH.
Genetics absolutely play a role in the propensity to develop atopic dermatitis. Conditions like ichthyosis vulgarism predispose one to dry skin, an overly alkaline skin pH and to the development of atopic dermatitis.
As for sweat, the biggest problem is the irritancy of the sweat itself. The salts from sweat can crystalize and act as an irritant to the skin. If you can see that your baby’s sweat has dried and has a salty residue, then I would recommend rinsing it off with plain water (no soap) to prevent it from becoming an irritant. If the sweat is not crystalized, I wouldn’t worry about it much.
Food on the skin; again this is another issue of major importance in atopic dermatitis. Studies have shown that when food is left on the skin for extended periods of time in early infancy, the child is more likely to develop an allergy to that food. Be sure to wash your child’s hands and face after eating!
Products and Skin pH
Marcie Mom: Many products are marketed as of ‘skin’s natural pH’ or ‘pH-balanced’. What does this mean? When can a parent start moisturizing baby’s skin (given the pH changes)?
Dr Cheryl: The term “pH-balanced” is completely unregulated and could mean anything—including that the product could actually be alkaline. The consumer has no way to knowing what the pH of a product is unless they actually test is with a pH meter or if the manufacturer were to put the pH ON the package. As for the TrueLipids products, we conducted long term stability studies on the pH of our formulations so we know that they are within the optimal range of 4.6 to 5.6 for extended periods of time and even in high-heat environments. Additionally, many products contain benzoic, lactic, sorbic or citric acids to bring the pH down to the acidic levels. These acids can sometimes be allergens (sorbic acid and benzoic acid can cause hives when they come in contact with the skin. Benzoic acid can cross react with those who have fragrance or balsam of Peru allergies which are common in atopic dermatitis) or these acids can act as an irritant if they are formulated in such a way that the acid can precipitate and turn into a salt easily. The pH system in the TrueLipids products employs and acid called gluconolactone. I chose this poyhydroxy acid in my formulations because it is not only an effective way to acidify a formulation without crystallization of the acid (in my own experimentation), but it has also been shown to reduce the loss of water from the skin and has anti-oxidant and DNA-repairative properties as well.
As for the appropriate time to start moisturizing the skin of a newborn, the skin of the newborn acidifies within the first few days of life. Three weeks of age has been shown by Simpson et. al., to be a safe and effective time to start moisturizing the skin of a newborn who is at high risk of developing atopic dermatitis. In this study, the babies were moisturized at least once a day and 50% fewer cases of atopic dermatitis were noted by the age of six months! The skin of a newborn acidifies within the first few days of life and so I do not think it is necessary nor beneficial to use a more alkaline moisturizer on a newborn. It is probably best to leave the skin of brand new babies alone until they are three weeks old. Of note, studies have shown olive oil to be detrimental to the newborn skin barrier, so it is best avoided.
MarcieMom: Which products are clearly bad for skin due to its pH level? For instance, detergent and soaps? These anti-bacterial products (containing benzoyl peroxide, triclosan, sodium lauryl sulphate and sodium laureth sulphate) help to kill staph bacteria but its pH level (and ingredients) lead to skin irritation. What is the skincare approach to ensure killing staph bacteria adequately without causing skin dryness?
Dr Cheryl: First of all, it is best to limit the use of soaps altogether when possible. Soap should only be used when needed to remove dirt or oils that don’t belong on the skin. Otherwise, soaps should be revered for washing of hands and hair when it is dirty.
Soaps, cleansers, shampoos and body washes should all be in the optimal acidic range of 4.6 to 5.6 and should be non-alkaline. Products that deposit and oil as you use them can also be beneficial.
Avoid any surfactants with the word “sulfate” at the end. Sulfates have been demonstrated to be very destructive to the skin barrier and remove the lipids from the skin barrier leading it to dry out and to develop allergies to chemicals more easily.
As for optimal soap surfactants, there is a lot of very interesting science that can direct us to make the best choices for our sensitive skin. Surfactants are designed to remove dirt and oils from the skin, but the problem is that they can also remove the lipids from the skin as well. This leads to disruption in the skin barrier and exacerbates all the skin barrier problems in atopic dermatitis.
The best Soap to use for atopic dermatitis:
It has been postulated that charged anionic surfactants may be more detrimental to the skin barrier than nonionic surfactants, but it has been noted that nonionic surfactants more efficiently remove stearic acid (a fatty acid in the epidermis) than to anionic surfactants. Anionic surfactant-based cleansers also alter the lipids of the epidermis more than do the anionic surfactant sodium cocoyl isethionate. Another factoid about surfactants is that the larger the polar head group on the surfactant, then the less it is able to interact with and remove lipids from the skin barrier.
Of note, a recent study by Belsito et. al., showed that the surfactant cocamidopropyl betaine (CAPB) is more likely to cause allergic contact dermatitis in people with atopic dermatitis than in those who do not have atopic dermatitis.
I also like to avoid the glucoside surfactants as they are also relatively common allergens in the general population and can cause eczema of the eyelids and hands that can be very tricky to figure out. I have been working on a cleanser that is optimized for atopic skin and it will be available next spring. It will have the best surfactants for sensitive skin.
One more little note in regards to cleansing atopic skin; never use anything to scrub the skin other than your hands or a very gentle wash cloth. Loofah sponges, and scrubbing brushes do not belong on atopic skin (or normal skin for that matter).
Thank you Dr Cheryl for sharing what to look out for in cleaning and moisturizing our eczema child’s skin. Next week, we will focus on Eczema and Skin pH, and how to reduce the alkalinity of eczema skin.
