National Eczema Association – 8 Survival Tips for Caring for Baby

My eczema survival tips shared on NEA

My eczema survival tips shared on NEA, experience gained from caring for my daughter

Here’s another article that I shared on National Eczema Association website which is a great resource. Read my 8 survival tips for caring for eczema baby, and the many more by other eczema friends around the world.

Surfactant Skincare Series – Impact on Eczema Skin

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.

The defective skin barrier in atopic dermatitis makes it:

–    Increased skin permeability

–    Increased transepidermal water loss

–    Increased bacterial colonization

–    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

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:

  1. Surfactants and Functions
  2. Cleansing Baby Skin
  3. Impact on Skin

References

Surfactant Skincare Series – Impact on Skin

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:

  1. Different groups of surfactants and their functions – Anionic, Cationic, Amphoteric and Non-ionic surfactants
  2. What to Look out for when Cleansing Baby Skin – Discussion on the use of liquid cleanser being preferable to water, and what to look out for in the choice of liquid cleanser

Today, we’re looking more in-depth into how surfactants interact with skin and the potential harm to our skin.

Surfactants, while cleanse and remove oil soluble dirt/sebum, also potentially damage skin cells and lipids

Surfactants, while cleanse and remove oil soluble dirt/sebum, also potentially damage skin cells and lipids

Alkalization – The traditional soap is alkaline in nature (pH of 9 and above) and the alkalinity will increase the skin pH (which is of pH 4.6 to 5.6). Modifying the skin pH to more alkaline than it is supposed to be has the impact of (i) reducing skin lipids, including ceramides (ii) allows for growth of harmful bacteria like staph bacteria that thrives in a more alkaline environment and (iii) increases transepidermal water loss (TEWL). Alkaline soap is able to dissolve both fat and water-soluble components of skin. Synthetic cleansers are of varying pH and able to modify the pH of the cleansing product.

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.

References

Surfactant Skincare series – Cleansing Baby Skin

Last week, we briefly looked at the different types of surfactants and understand their functions. This week, we’re looking deeper into baby skin and the research around cleansing baby skin.

Baby Skin Structural Vulnerabilities

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

Learning about cleansers for Baby Skin

  1. 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.
  2. 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.
  3. 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?

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. Avoid Anionic 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!

References

Surfactant Skincare series – Surfactants and Functions

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 – learning about this group of ingredients that can clean but also irritate eczema skin

Surfactants perform different functions, namely:

  1. Cleansing
  2. Emulsification – arrange itself at interface between two immiscible liquids to create an emulsion
  3. Solubilization – blending oily solution into clear liquid
  4. Conditioning
  5. 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:

  1. Anionic
  2. Cationic
  3. Amphoteric
  4. 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.

Phosphate esters – Alkyl aryl ether phosphates; alkyl ether phosphates

Cationic Surfactants – Positive charge

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!).

References

Top 5 Q&A from Living with Eczema: Mom Asks, Doc Answers

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

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.

MarcieMom: How long should a patient use the prescribed corticosteroid before giving feedback to the physician of no noticeable improvement in the eczema?

Professor Hugo: Although corticosteroids are still the cornerstone treatment of eczema patches, they are only part of the holistic treatment of 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.

Prof Hugo and MarcieMom

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

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

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

In the video, the key points covered are:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In the video, the key points covered are:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Selection of Moisturizer (II) – Moisturizer and Ingredients

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, 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!

Brands Ingredients Irritants Free from Irritants/ pH
Aqueous cream

Functions: Occlusive

Number of ingredients: 7

Liquid Paraffin 6% w/w, White Soft Paraffin 15% w/w, purified water, emulsifying wax (containing cetostearyl alcohol, sodium lauryl sulfate), chlorocresol 0.1% w/w Sodium lauryl sulfate, Cetostearyl alcohol, Paraffin may irritate Free from perfume, propylene glycol, lanolin, colorpH 6.5 to 7.5
QV cream

Functions: Occlusive, Humectant

Number of ingredients: 14

Aqua (Water), Paraffinum Liquidum, Glycerin, Petrolatum, Cetearyl Alcohol, Squalane, Dimethicone, Ceteth-20, Glyceryl Stearate SE, Stearic Acid, Laureth-3, Glyceryl Stearate, Methylparaben, Dichlorobenzyl Alcohol 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

pH 6

QV Intensive Moisturiser

Functions: Occlusive, Humectant

Number of ingredients: 7

Aquaphor Healing Ointment

Functions: Occlusive, Humectant (bisabolol enhance healing)

Number of ingredients: 7

QV Intensive Moisturizer

Light Liquid Paraffin (Paraffinum Liquidum), Petrolatum, Isopropyl Myristate, Polyethylene, Cetearyl Alcohol, Silica, Dimethicone

Aquaphor Healing Ointment

Petrolatum (41%), Mineral Oil, Ceresin, Lanolin Alcohol, Panthenol, Glycerin, Bisabolol

Polyethylene, silica (mineral oil) may irritateLanolin QV

Free from perfume, propylene glycol, lanolin, lanolin, paraben, colorpH not disclosed

Aquaphor

Free from perfume, propylene glycol, paraben, color

pH not disclosed

Physiogel AI cream

Functions: Occlusive, humectant, repair

Number of ingredients: 16

Aqua, Olea Europaea Fruit Oil, Glycerin, Pentylene Glycol, Olus Oil, Elaeis Guineensis Oil, Hydrogenated Lecithin, Squalane, Betaine, Palmitamide MEA (PEA), Sarcosine, Acetamide MEA, Hydroxyethylcellulose, Carbomer, Sodium Carbomer, Xanthan Gum Free from perfume, propylene glycol, lanolin, paraben, colorpH not disclosed
Physiogel Daily Moisture Therapy Cream

Functions: Occlusive, humectant, repair

Number of ingredients: 13

 

 

 

 

 

Cerave Moisturizing Cream

Functions: Occlusive, humectant, repair

Number of ingredients: 25

Physiogel

Aqua, Caprylic/Capric Triglyceride, Glycerin, Pentylene Glycol, Cocos Nucifera Oil, Hydrogenated Lecithin, Butyrospermum Parkii Butter, Hydroxyethylcellulose, Squalane, Carbomer, Xanthan Gum, Sodium Carbomer, Ceramide 3

Cerave

Purified Water, Glycerin, Ceteareth-20 and Cetearyl Alcohol, Caprylic/Capric Triglyceride, Behentrimonium Methosulfate, Cetearyl Alcohol, Cetyl Alcohol, Ceramide 3, Ceramide 6-II, Ceramide 1, Hyaluronic Acid, Cholesterol, Petrolatum, Dimethicone, Potassium Phosphate, Dipotassium Phosphate, Sodium Lauroyl Lactylate, Disodium EDTA, Phenoxyethanol, Methylparaben, Propylparaben, Phytosphingosine, Carbomer, Xanthan Gum

Cetearyl Alcohol, petrolatum, parabens Physogel

Free from perfume, propylene glycol, lanolin, paraben, color

pH not disclosed

 

 

 

 

 

 

Cerave

Free from perfume, propylene glycol, lanolin, color

pH not disclosed

Cetaphil moisturizing cream

Functions: Occlusive, humectant

Number of ingredients: 20

Water, glycerin, petrolatum, dicaprylyl ether, dimethicone, glyceryl stearate, Cetearyl alcohol, prunus amygdalus dulcis (sweet almond) oil, PEG-30 stearate, tocopheryl acetate, acrylates/C10-30 alkyl acrylate crosspolymer, dimethiconol, benzyl alcohol, phenoxyethanol, methylparaben, propylparaben, glyceryl acrylate/acrylic acid copolymer, propylene glycol, disodium EDTA, sodium hydroxide 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

Number of ingredients: 15

 

Water, glycerin, PEG-2 stearate, cetearyl alcohol, Butyrospermum parkii (shea butter), ethylhexyl methoxycinnamate, oleth-12, dimethicone, stearyl alcohol, glyceryl stearate, PEG-100 stearate, methylparaben, tocopherol, arginine PCA, chlorhexidine digluconate Parabens, Cetearyl alcohol may irritate Free from lanolin, propylene glycol, fragrancepH not disclosed
Cetaphil RestoraDerm Eczema Calming Body Lotion

Functions: Occlusive, humectant, repair

Number of ingredients: 28

Water, Glycerin, Caprylic/Capric Triglyceride, Helianthus Annus (Sunflower) Seed Oil, Pentylene Glycol, Butyrospermum Parkii (Shea Butter), Sorbitol, Cyclopentasiloxane, Cetearyl Alcohol, Behenyl Alcohol, Glyceryl Stearate, Tocopheryl Acetate, Hydroxypalmitoyl Sphinganine, Niacinamide, Allantoin, Panthenol, Arginine, Disodium Ethylene Dicocamide PEG-15 Disulfate, Glyceryl Stearate Citrate, Sodium PCA, Ceteareth-20, Sodium Polyacrylate, Caprylyl Glycol, Citric Acid, Dimethiconol, Disodium EDTA, Sodium Hyaluronate, Cetyl Alcohol Cetearyl alcohol may irritate Free from perfume, lanolin, propylene glycol, paraben, colorpH not disclosed
Ezerra cream

Functions: Occlusive, humectant, repair (contain antihistamine for itch relief)

Number of ingredients: 17

Water, Oleic/Linoleic Triglyceride, Saccharide Isomerate, Hydrogenated Polydecene, Pentaerythrityl Distearate, Glycerin, Cetearyl Alcohol, Dimethicone, Spent Grain Wax, Butyrospermum Parkii (Shea Butter) Extract, Argania Spinosa Kernel Oil, Phenoxyethanol, Sodium Stearyl Glutamate, Acrylates/ C10-C30 Alkyl Acrylate Crosspolymer, Ethylhexylglycerin, Octadecyl Di-t-butyl-4-hydroxyhydrocinnamate, Disodium EDTA Cetearyl Alcohol may irritate 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:

Methylparaben
Ethylparaben
Propylparaben
Butylparaben
Benzyl-parahydroxybenzoate (p-hydroxybenzoate)
Methyl-parahydroxybenzoate (p-hydroxybenzate)
Ethyl-parahydroxybenzoate (p-hydroxybenzoate)
Propyl-parahydroxybenzoate (p-hydroxybenzoate)
Butyl-parahydroxybenzoate (p-hydroxybenzoate)
Parahydroxybenzoate (p-hydroxybenzoate)

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.)

Skin Expert Tips on Selection of Moisturizer

In June 2015, there was an eczema public forum held at the National Skin Centre Singapore and one of the talks wasMaking 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

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.

2. The fewer the ingredients, the less likelihood for hypersensitive skin reaction

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.

4. Use product within expiry date and period after opening date

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.

References:

Skin pH with Dr Cheryl Lee – Over Acidic or Over Alkaline

Skin pH with Dr Cheryl Lee – Eczema and Skin pH

Sensitive Skin Product series with Dr Verallo-Rowell and Laura Verallo Rowell Bertotto – How many ingredients

Sensitive Skin Product series with Dr Verallo-Rowell and Laura Verallo Rowell Bertotto – What ingredients to avoid

Sensitive Skin Product series with Dr Verallo-Rowell and Laura Verallo Rowell Bertotto – Understanding ingredients and patch test

Science of skincare products with Dr Elisabeth Briand – Eczema Supportive Care

Science of skincare products with Dr Elisabeth Briand – Stability 

Science of skincare products with Dr Elisabeth Briand – Safety and Product Expiry Date

Reinforcing amount to moisturize eczema child with Dr Jeff Benabio

International Dermal Institute – Repairing Ingredients

Dermascope – Healthy skin starts with a healthy barrier

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