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Does Your Child have Severe Eczema? Here is what You Should Know about Dupilumab

What is Dupilumab?

Dupilumab is the first biologic used to treat moderate-to-severe eczema. It is marketed under Dupixent. You may not have heard of it as it was only recently approved for use in older children.

Younger children may have access to it soon. Positive results came in from a clinical trial for children from 6 to 11 years old. Therefore, we cannot rule out that governments will approve it for younger children.

Let’s look at when various countries approved Dupilumab:

How does Dupilumab Work?

For those of us who do not know the (possibly) billion types of proteins in our body, Dupilumab works by targeting two cytokines. These cytokines (IL-4 and IL-13) regulate the body’s immune response to inflammation. Dupilumab works by injection and its list price is US$3019.50 per 4-week supply.

Update on 26 Oct 2019: This is another company that is working on Etokimab that targets IL-33, and improvement seen after single dose (study).

What is the Current Dosage for Older Children with Eczema?

Similar to oral medication, the weight of your child is one factor that determines the dosage. Drugs.com listed the dosage as:

For Adolescents lighter than 60 kg

  • Initial dose: 2 injections (each 200 mg) at different part of the body
  • Maintenance dose (each 200 mg) injected every other week

If your child is 60 kg and heavier, each dosage is 300 mg.

What if My Child does not like Needles?

Biologic drug means it is made from proteins – interesting, it is made from Chinese hamster! (I found out this from Australia TGA’s information leaflet.) Dupilumab cannot be taken orally, otherwise, our body will break down the proteins before the medication can get to work. Its molecules are also too large to be absorbed through the skin (that I learnt from US National Eczema Association).

Dupilumab can only be taken via injection

Does Dupilumab Work?

From the studies, yes, Dupilumab works.

It works by effectively targeting the two proteins that have been studied to be the most related to Atopic Dermatitis. These proteins cause more itch and inflammation, so targeting them will mean ‘short-circuiting’ the pathway that the skin gets hypersensitive.

Side-track: Dupilumab is also approved for use for asthma patients and those with chronic rhinosinusitis with nasal polyposis

Should I request this for my Child?

Hang on. Even if you can afford it, certain conditions must be met before a doctor can prescribe Dupilumab. And not any doctor – it has to be a specialist e.g. dermatologist.

What ‘Moderate-to-Severe Eczema’ Means?

Dupilumab can only be prescribed for moderate to severe eczema, that cannot be controlled with topical medicines.

I cannot find information on whether your dermatologist has to prove the eczema severity. I guess that a dermatologist is assumed to have both the expertise and the duty to prescribe only when needed.

So what does Moderate to Severe Eczema look like?

Several guidelines are helpful in giving a common understanding of mild vs moderate vs severe eczema, one of which is UK’s NICE guideline.

Moderate eczema means:

  • Areas of dry skin
  • Frequent itching
  • Redness (with or without excoriation (skin picking) and localised skin thickening)
  • Moderate impact on everyday activities
  • Frequently disturbed sleep.

Severe eczema means:

  • Widespread areas of dry skin
  • Incessant itching
  • Redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation)
  • Severe limitation of everyday activities
  • Nightly loss of sleep.

For those of us, who are into something quantifiable, you can work out your child’s eczema severity through SCORAD. If the score is from 25 to 50, your child has moderate eczema and above 50, is severe.

Many Moderate Eczema Cases

My child’s eczema would fall under moderate. And I suspect, there are many children with moderate eczema. Does this mean all these children would be prescribed Dupilumab?

Proof that Topical Medicines Do Not Work

Approval for use specifically states that Dupilumab can only be prescribed if topical medicines had not worked. My deduction, therefore, is that your child first has to have tried topical corticosteroids or topical calcineurin inhibitors, in order for the dermatologist to CONCLUDE that these have not worked.

To put it simply, if you are scared of steroids and have not applied it for your child, the dermatologist may not be able to prescribe Dupilumab.

No need for History of Eczema Oral Medications

Your child do not need to have taken oral medications for eczema, before the dermatologist can prescribe you Dupilumab. My guess is that the current oral medications are not optimal for eczema treatment. They come with side effects that are severe enough that they cannot be taken over a long duration.

Oral systemic steroids is usually for 2-week dose and side effects can include hypertension, glucose intolerance, gastritis, weight gain etc. Rebound flares are also common. Read more in this journal.

Similarly, systematic immunosuppressive treatments have many side effects which require blood testing to monitor toxicity and organ functioning.

Is Dupilumab Safe and Effective?

I have compiled recent studies on Dupilumab in this forum post, and it is considered safe and effective. There are side effects though, but given its efficacy, the side effects are acceptable.

Just from the studies in the second half of 2019, 11 studies concluded it is effective, including for hand eczema, for reducing staph bacteria and not increasing skin infections. 3 studies focused on its side effects, which are mainly injection site reactions (pain, redness), conjunctivities and herpes infection. You can see the statistics from Rxlist.com

If you are considering Dupilumab, you should first inform your dermatologist of any eye problem. You may be asked to consult an eye doctor to establish a baseline for your eye condition before starting Dupilumab.


The Other Thing – Duration

Because of the way Dupilumab works, it is an ongoing treatment. Meaning, if you stop the injections, the protein cells in your body may go back to triggering skin inflammation. You should give it 16 weeks to see if the treatment works for you (National Eczema Society’s fact sheet).

To Dupilumab or Not?

There is no easy answer.

It is a decision to consider based on:

  • Affordability
  • Severity of your child’s eczema
  • Emotional aspect of injection
  • Possible side effects, including the current eye condition (for instance, if your child already has dry eyes, it may worsen)
  • Whether topical prescription has been properly explored (because applying something is still safer than injecting something)
  • Whether other treatments and triggers have been sufficiently explored. For instance, allergen avoidance, control of staph bacteria colonization and other therapeutics.

Currently, Dupilumab is very expensive because it is generally not subsidized nor included in insurance. But should it be more affordable, I still believe that given it is via injection and comes with side effects, we have to be sure that it is only prescribed as needed.

To put it bluntly, it should not be an easy (or lazy) way out of the due care needed for your eczema child.

Have you tried Dupilumab? It helps for fellow eczema patients to read of your experience, so please do share in the comments below or in the forum post.

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Is There Anything You Can Do to Prevent Eczema for Your Unborn Baby?

Should you restrict your pregnancy diet? Take some supplements to reduce the chance of your baby having eczema? Should you breastfeed longer? Should you feed your baby partially hydrolyzed formula?

Read this compilation of the recent studies, and better still, share in the related forum posts.

Pregnancy Diet and Allergy Risk

So, You are Pregnant and You know that Your Family has an Eczema/ Allergy History. Is there anything that you can do?

This February 2018 UK study investigated how maternal or infant diet can influence risk of allergic disease. The conclusion was maternal probiotic and fish oil supplementation may reduce risk of eczema and allergic sensitisation to food, respectively.

However, in the US, the American Academy of Pediatrics (AAP) in their 2019 paper did not support maternal dietary restrictions during pregnancy and lactation to prevent atopic disease.

Recommendations on impact of maternal diet for atopic dermatitis do vary by country

For instance, World Allergy Organization guideline recommended probiotic (for high-risk cases) and prebiotic (for not exclusively-breastfed infants) supplements for eczema prevention, but European (EAACI), North American and Australasian guidelines do not support this.

So, check with your doctor on probiotic and omega-3 for reducing the chance your baby will have eczema

How Long Should You Breastfeed?

Now your baby is born, how long should you breastfeed?

A retrospective cohort study (46,616 children) in Japan in September 2019 found that breastfeeding, especially colostrum, had prophylactic effects (preventive) on food allergy.

But this finding was only true for high-risk children with infantile eczema. On the other hand, prolonged breastfeeding increased the risk of food allergy.

Scary isn’t it? We seldom hear anything negative about breastfeeding, but this study highlighted risk of prolonged breastfeeding

How can prolonged breastfeeding be negative? It may be related to introducing solids later (if you are breastfeeding longer) or any other factors that are difficult to measure in a study.


There is this PROBIT trial that aims to look at the benefits of breastfeeding. It supports exclusive breastfeeding for at least 3 months as there is reduced eczema for up to teenage years.

This is consistent with what was presented in February 2019 Annual Meeting of the American Academy of Allergy, Asthma & Immunology (AAAAI) where it was concluded –

Exclusive breastfeeding may not prevent eczema or eczema diagnosis, but may play a protective role in decreasing the chronicity of eczema in childhood.

Similarly, the AAP in US recommended exclusive breastfeeding for the first 3 to 4 months as it is linked with reduced incidence of eczema in the first 2 years of life.

Should You Persist in Breastfeeding?

The AAP recommendation is that breastfeeding beyond 3 to 4 months does not help prevent atopic disease for your baby. So, if like me, you are finding breastfeeding a struggle, you can stop without feeling guilty. (Phew!)

Prolonged breastfeeding has limited evidence to support its benefits

What about the Type of Milk?

Don’t even get me started on HA hypoallergenic milk. Read this forum post on how bad an experience it was for our family. But seriously, does research support using partially hydrolyzed milk?

The AAP cites a lack of evidence that partially or extensively hydrolyzed formula can prevent atopic disease in infants and children, even in those at high risk for allergic disease.

What’s even scarier is that this French study in 2019 found that partially hydrolyzed formula was associated with higher risk of food allergy and wheezing.

Because allergy testing is not accurate for infants newborn, there is the chance that pediatricians may recommend switching to HA milk if newborn is diagnosed with eczema rash. Please check if your pediatrician or see an allergist to confirm if that is still the right recommendation.

On the other hand, in Singapore, a study in 2018 showed evidence that feeding partially hydrolyzed milk to high-risk infants did reduce the incidence of eczema. This is helpful if :

  1. Your baby is high-risk, meaning his parent or his sibling has eczema, and
  2. You are unable to feed 100% breast milk and have to use formula milk, then
  3. Choosing a partially hydrolyzed milk formula is preferred over cow’s milk and calculated in the study to be cheaper (notwithstanding the partially hydrolyzed milk is more expensive than cow’s milk).

Now Back to Breast Milk…

Interestingly, there are quite a few news on how breast milk is applied on skin to treat eczema rash!

This 2015 Iran study undertook a randomized control trial to determine if APPLYING breast milk onto eczema rash is helpful. The finding? Human breast milk improve infant atopic eczema with the same results as 1% hydrocortisone ointment

Human Breast Milk as good as mild topical corticosteroid?!


Maybe it is not that hard to believe, considering breast milk has

Here’s many interesting reads on various news channel whereby mothers have used their breast milk to cure their baby’s eczema

Lizzie bathed her baby in her breast milk

Joy used an organic soap made from breast milk

Medela also has an article on the benefits of breast milk.

Infant Diet and Eczema Risk

Is there anything that can be fed to your baby to reduce eczema risk? So far, it seemed that fish and probiotics can be helpful.

This August 2019 Norway study concluded that eating fish at least once a week at 1 year-old was less likely to have eczema, asthma, and wheeze at 6 years-old.

Consuming cod liver oil at least 4 times per week at 1 year old also helps reduce allergy risk.

The other study looked into probiotics – a December 2018 New Zealand study concluded that taking Lactobacillus rhamnosus HN001 in early childhood was associated with significant reductions in the 12-month prevalence of eczema at age 11 years and hay fever.

Here is the “fine print” – the benefit of probiotics was only seen if included directly consuming by infants. The same group of researchers also concluded that taking HN001 during pregnancy and breastfeeding alone will be enough to prevent eczema without giving it directly to the infants. Is that true for you? Share in this forum post.

Solid Introduction

This exciting feeding milestone for many parents usually ends up a stressful one for parents with eczema children. Is it the food that trigger the rashes?

Wait. It is even more confounding because it is possible that the defective skin barrier can somehow increase sensitization to food.

Investigating allergy and trigger by eczema moms
I remembered I was all nerves googling late into the night, when already tired from taking care of baby

The latest AAP recommendation in 2019 is there is no need to delay the introduction of allergenic foods beyond 4 to 6 months for the prevention of atopic disease. However, early introduction of peanuts (4 – 6 months old) may prevent peanut allergies in high-risk infants. (check out this forum post for updated study.

Now in Singapore, a lot of parents feed solids after 6 months and generally wait till one year old before attempting allergenic foods, especially peanuts. Our Singapore researchers looked into it and concluded that the infant feeding recommendation to introduce peanuts early may not be applicable for Asian population.

Where do you live? And has any of the research held true for your baby? Share in the comments or the forum posts

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Different Skin Bacteria for Children with Eczema

May 2019 Eczema Study on Egyptian Children showed Different Skin Microbiome

Study Abstract

This study examined the skin microbiome (skin bacteria) of 75 Egyptian patients with atopic dermatitis (AD), compared to 20 health controls. It was found that the bacterial diversity of skin microbiome in patients with AD was less than those of the healthy subjects. Eczema children, adolescents and adults have bacteria, StreptococcusCutibacterium, and Corynebacterium, while Staphylococcus was noted as a potential biomarker candidate for AD. These bacteria also exacerbated eczema. Total immunoglobulin E (IgE – antibodies that reacts to an allergen, causing allergic reaction) levels were positively correlated with certain Staph bacteria.

What it means for Eczema Skincare

The skin microbiome of eczema children is different from normal skin, which has been covered in-depth in this Staph Bacteria on Eczema Skin series with past president of American Academy of Dermatology, Dr Clay Cockerell. Limiting staph bacteria colonization on eczema skin is one of the recommended therapeutics, with one of the most commonly heard of ways to reduce staph bacteria being the bleach bath. Reducing staph bacteria is also one of the skincare aspect which my daughter’s doctor (and also co-author for Living with Eczema: Mom Asks, Doc Answers) recommended us to work on.

You can talk the same to your doctor whether the use of anti-microbial cleanser, swimming (literally a ‘fun’ way to kill the harmful skin bacteria, while splashing and soaking in the pool!) or chlorhexidine gluoconate wipe (it is cheaper if you purchase a bottle at the pharmacy and pour on disposal cotton pad to wipe skin, rather than buy the ready-made wipes. The bottle can be stored in fridge) at eczema lesions area are appropriate. We tried all the above, and even now, regularly uses an anti-microbial cleanser. You can also explore some baby clothing made with silver or bamboo material with anti-microbial properties.

Other Skin Bacteria Studies

Current Allergy & Asthma Reports, November 2015

In this study, it was noted that Staphylococcus aureus colonization on AD skin had been directly correlated to eczema severity. It was thus important to study how skin bacteria affect skin inflammation.

Journal of Cutaneous Medicine & Surgery, January 2016

It was also noted in this study that skin bacterial diversity is smaller than in healthy subjects. Through a panel of Canadian dermatologists, the consensus was that:

(1) In atopic patients, the skin microbiome of lesional atopic skin is different from nonlesional skin in adjacent areas.

(2) Worsening atopic dermatitis and smaller bacterial diversity are strongly associated.

(3) Application of emollients containing antioxidant and antibacterial components may increase microbiome diversity in atopic skin.

Have you found something that works? Share in the comments if you have found reducing staph bacteria to be helpful in managing your child’s eczema. I’m bringing back a new season of Someone has Eczema series, please let me know if you like to share your story to encourage all of us.

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Eczema News – Gene Mutation Identified

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

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

Genetic mutation Eczema

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

Science Daily New genetic mutations linked to eczema
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Independent trial showed No Significant Benefit of Silk Clothing for Eczema kids

An eczema study1 published in April 2017 showed that there was

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

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

For this study, the key points are below:

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

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

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

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

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

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

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

Practical implication:

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

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

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

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

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

Bath Additives in the Treatment of Childhood Eczema

Barrier Enhancement for Eczema Prevention (The BEEP Study)

Understanding the long-term management of eczema

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Eczema News #Christmas Special – Top 10 Allergy Suspects

It’s end of the year, it’s Christmas time and there are actually quite a few things about Christmas that can really spoil the season fun. Apart from visiting others’ homes (pet, mold, dust mites), eating foods that you don’t normally eat (or never eaten before), there’s the Christmas tree that can cause quite a few allergic symptoms.

This Christmas special looks at some of these ‘Christmas Allergy Suspects‘:

10 Top Christmas Allergy Suspects
Don’t let these 10 Top Christmas Allergy Suspects spoil your season fun!

Christmas allergy suspect #1: Christmas tree

Allergic contact dermatitis – reaction to colophony, also known as rosin, is the sap or sticky substance that comes from pine and spruce trees.

Allergic rhinitis – reaction to alternaria mould

Main trees are scotch pine (allergic conditions likely due to mold Penicillium spinulosum), followed by spruce tree (due to mold Epicoccum and Alternaria). Hose down the tree outdoors and handle with gloves to reduce the mold spores.

Even artificial christmas trees can cause a reaction as they have been stored and accumulated dust mites and molds in the basement.

Christmas allergy suspect #2: Poinsettia

Cross-reactivity with latex allergy observed in a case study

Christmas allergy suspect #3: Christmas cactus

Contact urticaria and rhinoconjunctivitis (of workers at a cactus nursery)

Christmas allergy suspect #4: Christmas candy

Asthma (of a candy maker) after exposure to pectin, a compound in Christmas candy

Christmas allergy suspect #5: Food, Cocktails

Common allergens are milk, eggs, soy, fish, shellfish, peanuts, tree nuts and wheat. Ask before you eat or inform the host. If you’re hosting, take care to avoid these allergens or avoid them in some of the dishes and not re-use the utensils without washing.

Allergens in cocktails include sulfites in wine, maraschino cherries, and tree nuts in beer.

Christmas allergy suspect #6: Pets

If you’re allergic to pet dander, it’d be best to check out if the home you’re visiting has pets. The concentration of pet dander allergens are usually higher during Christmas, due to more time spent indoors.

Christmas allergy suspect #7: Dust mite

Though dust mites are present all year round, it is worse during the holidays as we spent more time in our bed with the cold weather.

Christmas suspect #8: Artificial snow or Frosting

Asthma can be triggered when spraying artificial snow or any chemical spray (say on frosted window) can irritate the eyes, nose, lungs and skin.

Christmas suspect #9: Stress

Stress is a known trigger for eczema and asthma – go easy on shopping and visiting schedules.

Christmas suspect #10: Candles, air fresheners, potpourri

It may add an extra touch to your home for the holiday season but these give off compounds that irritate the nose and throat.

Enjoy Christmas, and remember it is the time for celebrating Christ’s birth and his love for us.

 For unto you is born this day in the city of David a Savior, who is Christ the Lord.

Luke 2:11

References:
  1. The sweet christmas rash
  2. No poinsettia this christmas
  3. Immediate allergic and nonallergic reactions to Christmas and Easter cacti.
  4. Christmas Tree Allergy: Mould and Pollen Studies

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Eczema News – Non-Celiac Gluten Sensitivity

Around end November 2014, I ran a blog series on Children Food Sensitivities, explaining there are various types of gluten-related food sensitivities, namely:

GLUTEN SENSITIVITY
Various types of gluten-related conditions

Celiac disease – Immune system attacks the villi in the esophagus when exposed to gluten protein gliadin, found in wheat, barley, rye, and sometimes oats. This lead to intestinal inflammation, flattening of the villi and long-term damage to the small intestine.

Non-Celiac Gluten Sensitivity (NCGS) – Diagnosis is not straightforward with no proven medical test. It is typically diagnosed after elimination of other similar conditions (for instance, wheat allergy, Irritable Bowel Syndrome) and after observation and further consultations.

Wheat Allergy – Involves an immune Ig-E mediated reaction to the wheat protein, can be diagnosed via allergy test.

It was debatable in 2014 then as to whether non-celiac gluten sensitivity (NCGS) even exists as (i) it is difficult to diagnose NCGS, and (ii) some studies concluded that it is actually sensitivity to FODMAPs rather than NCGS. (Gluten-containing grains are high in FODMAPs (fermentable oligo-, di-, and mono-saccharides and polyols) which are sugars/ carbohydrates that tend to be poorly digested, e.g. frutose.

Almost a year later in 2015, we want to examine (i) whether non-celiac gluten sensitivity (NCGS) is a clinical entity (ie we are sure there’s such a medical condition) and (ii) its impact on eczema or skin rash.

September 2015 Study – Cutaneous Manifestations of Non-Celiac Gluten Sensitivity: Clinical Histological and Immunopathological Features

Methods: 17 patients affected by NCG, median age 36, 76% females, with itchy rash similar to  eczema, psoriasis or dermatitis herpetiformis; wheat allergy and celiac disease tests were carried out to confirm that these 17 patients were not suffering from these.

Finding: Skin improvement noted after a month of gluten-free diet

July 2015 Paper – Non-celiac gluten sensitivity: Time for sifting the grain

In this paper, non-celiac gluten sensitivity is stated as a clinical syndrome characterized by both intestinal and extraintestinal symptoms, which are responsive to gluten (wheat) withdrawal from the diet.

Its estimated prevalence is 3% to 5% and a syndrome from multiple factors.

July 2015 Case study – Gluten Psychosis: Confirmation of a New Clinical Entity

In this case study, a 14-year old girl recovered from psychotic symptoms, after eliminating gluten. Other conditions linked to NCGS included:

  • Gastrointestinal symptoms: Abdominal pain, bloating, diarrhea or constipation
  • Systemic manifestations: “Foggy mind”, depression, headache, fatigue, and leg or arm numbness
  • Neuro-psychiatric disorders: Autism, schizophrenia and depression

June 2015 Study – Diagnosis of gluten related disorders: Celiac disease, wheat allergy and non-celiac gluten sensitivity

From this paper, a diagnosis pathway was suggested to determine if one suffers from NCGS. The blind gluten challenge remains a ‘gold standard’ for diagnosis; if going on a strict gluten free diet, it is maintained for at least 3 weeks to observe if symptoms improve.

Non-Celiac Gluten Sensitivity Diagnosis
NCGS Diagnosis; copyright of World Journal of Gastroenterology, June 2015; 21(23); 7110-7119; Figure 1

June 2015 Study – Diagnosis of Non-Celiac Gluten Sensitivity (NCGS): The Salerno Experts’ Criteria; The criteria is similar to above, with varying guidelines on the duration of gluten free and introduction of gluten diet.

Various research had linked NCGS to female gender and adult age.

It seemed from recent studies that NCGS remained a syndrome without an easy way of diagnosis. The latest study that noted an association between gluten and skin rash would likely be considered as being on a small scale. However, the possibility of skin rash linked to gluten cannot be dismissed and more collaboration between dermatologist and gastroenterologist would increasingly be seen as more patients suspect gluten as a source of their skin problems.

Update on 17 October 2016 – A new study showed the possible group of proteins found in wheat – amylase-trypsin inhibitors (ATIs) – to trigger an immune response in the gut that can spread to other tissues in the body. From MedicalNewsToday

ATIs only make up a small amount of wheat proteins – around 4 percent – yet the immune response they induce significantly affects the lymph nodes, kidneys, spleen, and brain in some people, causing inflammation. ATIs have also been suggested to exacerbate rheumatoid arthritis, multiple sclerosis (MS), asthma, lupus, and nonalcoholic fatty liver disease, as well as inflammatory bowel disease.

What’s your experience with gluten? Do you think your child has gluten sensitivity? Share in the comments and we can all learn from it!

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Eczema News – Does Water Hardness affect Childhood Eczema

We can’t live without water and it is an area which many parents suspect may have something to do with the eczema. Water that we drink or bathe in has been covered in this post, but today’s post is focused on Water Hardness and reviewing the research in this area.

Water Hardness and Eczema
Water Hardness and Eczema

October 2015 Study on Water hardness and eczema at 1 and 4 year of age in the INMA birth cohort (INMA refers to Infancia y Medio Ambiente, a birth cohort study in Spain)

Finding: No association between eczema and water hardness at home or bathing exposure during the first four years of life

July 2012 Study on Interactions between domestic water hardness, infant swimming and atopy in the development of childhood eczema

Finding: Exposure to hard water and infant swimming interact with atopic status increased the prevalence of childhood eczema. A breaching of the epidermal barrier by detergents or salts in hard water and by chlorine-based oxidants in swimming pool water might explain these interactions.

February 2011 Study on A randomised controlled trial of ion-exchange water softeners for the treatment of eczema in children (SWET Trial)

Finding: Water softeners provided no additional benefit to usual care in this study population.

July 2007 Study on Domestic water hardness and prevalence of atopic eczema in Castellon (Spain) school children

Finding: Water hardness in the area where 6-7 year-old schoolchildren live has some relevance to the development of eczema.

It seemed that although water hardness is believed by parents to have an impact on eczema, this is not seen in research, the most definite trial is that in Feb 2011 which was a randomised controlled trial as opposed to analysis of data.

On the study noted that swimming worsened eczema but swimming is useful for killing of staph bacteria (and a fun and fit way as opposed to bleach bath). Some advice by doctors who have addressed the topic of swimming on this blog:

Dr Christopher Bridgett on swimming Q&A

It’s good to say that swimming and atopic eczema usually go together just fine. The problem is caused by the water – it washes off a layer of the skin’s protection and leaves it very porous to water loss afterwards: a thin application of moisturizer before swimming protects against this.

Otherwise, the chemicals in the water of a swimming pool are disinfectants – chlorine, & bromine for example – they can be good for the skin, as their antibacterial effect is anti-inflammatory. However these additives can irritate too.

Dr Lynn Chiam in interview on teen eczema and sports

Swimming for long periods during a bad flare of eczema is not advisable as the swimming pool water may cause more skin dryness.

What’s your experience with hard water or did you purchase any of the water treatment kit for your home? Share in the comments so that other parents can learn from your experience!

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News & Research

Eczema News – ‘Lipid fingerprint’ Treatment Approach

At end September 2015, it was announced on various medical new sites that Oregon State University’s researchers have developed a new approach to treat eczema that is

  • Personalized; and based on
  • Individual lipid deficiencies (akin to lipid fingerprint)

The new system patented (yet to be developed) requires testing of skin and lipid samples (from sticking and pulling off a piece of tape on/from the skin), using a mass spectrometry. The testing is non-invasive and suitable for infants and elderly as well.

Target Lipid Deficiency for Eczema Treatment
Target Lipid Deficiency for Eczema Treatment

It is established that eczema skin is often lacking in lipids, the reason why many moisturizers have active ingredients to restore the skin lipid levels such as ceramides, cholesterol and free fatty acids. However, there are many types of skin lipids and researchers at OSU believe that choosing the skincare and therapeutic product that specifically target one’s deficient lipids will help eczema sufferers.

Hopefully when developed, the ‘lipid fingerprint’ system will address:

  • Steroid usage which has side effects with long-term use
  • ‘One size fits all’ method of moisturizer selection
  • Reduce costs associated with doctor consultation and that of using the ‘wrong’ products – when the deficient lipids can be identified, it can then be known which lipid composition is missing, i.e. those that serve protective or barrier or antimicrobial function.

Associate Professor Arup Indra explained in an interview that “Lipids in our skin help retain moisture, they act like a blanket that protects against irritation and infection, You could think of skin cells as the bricks of a wall, but lipids are the mortar that prevent things from getting through the cracks. When they are deficient, problems can develop.”

Previous research by A/P Indra and other researchers has identified a protein (Ctip2) that is critical for forming and maintaining the skin barrier in mice, and for skin lipid metabolism. Mice that had Ctip2 removed had dry and scaly skin, and developed skin lesions. The removal of Ctip2 also led to increased inflammation, with presence of high levels of inflammatory proteins, enlarged lymph nodes and spleen in the mice. Without Ctip2, TSLP (another protein that has been known to activate other cells to be pro-inflammatory, linked to eczema and asthma) also became 1000-fold higher in the mice.

It is interesting research by the College of Pharmacy at OSU and my personal thought is that even if targeting deficient lipids alone may not ‘cure’ eczema for everyone, it will definitely help to reduce the cost of buying moisturizers that are not the ‘right lipid fit’. Keeping fingers crossed that R&D in atopic dermatitis will have breakthrough in the next few years to provide relief for all eczema sufferers.

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News & Research

Eczema News – Hydrolyzed Milk Impact on Childhood Eczema

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

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

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

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

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

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

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

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

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

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

On the question of costs,

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

On the question of nutritional value,

Dr Sears’ view is that unless recommended by doctor, parents should not opt for hydrolyzed milk on their own due to

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

Also check out an extensive interview with registered dietitian on different types of milk for babies with eczema, allergies and reflux. It seems though that partially hydrolyzed milk formula is in practice recommended by doctors due to cow’s milk being the most common food allergen in infants. Research wise, there has yet to be a conclusion due to difficulty of conducting unbiased studies with sufficient (mother and baby) participants. What’s your experience in this? Do share in the comments!

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News & Research

Eczema News – Do Elimination Diets Work?

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

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

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

Insufficient evidence to support elimination diets
Insufficient evidence to support elimination diets

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

MarcieMom’s digest on the paper:

#1 Go for allergy testing

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

#2 Outside-in versus Inside-out

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

#3 Observations can be misleading

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

#4 Lesser case for elimination diet

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

#5 Studies where elimination diets improve eczema

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

#6 Elimination diet risks

The risks of elimination diets are

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

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

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


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News & Research

Eczema News – Childhood Eczema linked to Headaches

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

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

Childhood Eczema and Headaches
Childhood Eczema and Headaches

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

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

#1 Don’t mistake the headache for other illness

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

#2 Sleep better

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

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

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News & Research

Eczema News – Child car seats – Home for House Dust Mites

House dust mites in child car seatsHouse dust mites is one of the most common allergen triggering eczema in older children. We often think of house dust mites residing on the bed sheets, pillows and mattresses. One often overlooked area is the child car seat. This team of researchers from Ireland studied the type and amount of allergens in the child car seats and (oops, add one more thing to your to-do chores) it turned out child car seats are quite loaded with dust mites and allergens. Here’s a quick look at the study.

Sample: Dust samples collected from 106 child car seats and driver seats

Results: 12 species of mites, of which nine are known to produce harmful allergens, were recorded from 212 dust samples. Over 80% of drivers’ seats and over 77% of child car seats had house dust mites and its allergens. Over 12% of driver seats and 15% of child car seats contained house dust mite levels sufficient to be risk factors for sensitization and allergic reactions. From the samples examined, the house dust mites were breeding (not dead).

What it means: For those with eczema, asthma and rhinitis, you’d have to add car seats to your list of items to clean. Especially if you spend long hours in the car, even more critical to vacuum your car seats regularly. Plus it is compulsory for your child to be in a child car seat for safety.

Why dust mites love car seats: The researchers pointed out that the materials of the car seats, being made of polyester and/or cotton, trap shed human skin and other organic matter (like food) that are the food sources of house dust mites.

Read also these posts for more on:

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News & Research

Eczema News – Review of Clinical Trials for Eczema Therapeutics in Children

Recently, Hong Kong researchers published a review article ‘Eczema therapeutics in children: what do the clinical trials say?‘ in Hong Kong Medical Journal. Categorized by major treatment methods, previous clinical trials were examined for each individual treatment option. Below is my quick and dirty summary, for the full paper that is available for free, see here.

Clinical Trials Review on Eczema Treatment

#1 Emollient

There is no evidence to show that any emollient is superior to their counterparts, including a small trial that compared the results of using a (cheap) petroleum-based cream versus an (expensive) ceramide-based cream. >> Use a cream you can afford

Aqueous cream has been shown to cause skin irritation, thinning of the cornea stratum (ie skin layer), and increased transepidermal water loss following twice daily application for a few weeks. >> Avoid aqueous cream and sodium lauryl sulphate

There is a lack of evidence for other bathing practices like addition of emollients to bathing water, while use of emollients immediately after bathing as ‘soak and seal’ can help maintain hydration >> You were right about the ‘3 minutes, quickly moisturize after shower!

I hope I don't look like a crazy mom charging my eczema daughter to shower after swimming!
I hope I don’t look like a crazy mom charging my eczema daughter to shower after swimming!

Two studies showed that the use of emollients might prevent development of atopic dermtitis in high-risk patients >> Moisturize your next baby from young

#2 Topical Corticosteroids (TCS)

Guidelines on use of topical steroids – NICE guidelines for children recommend use of the
corresponding potency of TCS for severity of atopic eczema; mild potency for the face and neck and moderate potency only for short-term (3-5 days) use in severe flares; moderate or potent preparations for short periods only (7-14 days) for flares in vulnerable
sites such as axillae and groin.

Potent fluorinated corticosteroids should be avoided for infants and sensitive skin areas.

Systematic reviews of studies that compared the frequency of application of newer-generation moderately potent to very potent steroids identified no benefit in outcome for more frequent applications over once-daily application. >> Keep to once a day, no more than twice.

Topical corticosteroids are generally safe with few serious reported adverse effects. Risks of side-effects increase with higher potency, occlusion, thinner skin areas, severity of eczema, young age and longer duration of use. >> Be careful if your usage falls into these categories!

#3 Wet Wrap

All studies reported improvement in eczema scores, though the methods of wet wrap vary, for e.g., some used diluted steroid + moisturizer while another used chlorhexidine + moisturizer.

The most common reported adverse effects include discomfort, mostly due to chills, and
folliculitis more commonly caused by ointment.

#4 Topical immunomodulants

There is strong evidence that TCIs have a steroid-sparing effect and long-term use up to 12 months can prevent flares. Topical calcineurin inhibitors are particularly useful for sensitive sites including the face, neck, and skin flexures. It’s now studied that there is no statistically significant cancer risk.

#5 Proactive approach with topical anti-inflammatory therapy

The results suggested that for a patient with moderate-to-severe eczema and chronic relapsing lesions, maintenance treatment with topical anti-inflammatory therapy twice a week may be a better strategy to prevent eczema flares and topical corticosteroids more effective than topical calcineurin inhibitors. The rationale is that there is inflammation in the underneath layer of skin that is not visible, ie has not presented itself as rash.

#6 Antimicrobials and antiseptics

Bacteria count was reduced and there was significant improvement in mean eczema EASI (Eczema Area and Severity Index) for those using diluted bleach bath. >> I use chlorhexidine-wash for my daughter with eczema twice a week. More research news on bleach bath here.

#7 Antihistamines

There is no strong evidence that oral antihistamines are effective anti-pruritics. They are safe to use and their sedative effects, where present, may be useful to promote better sleep quality.

More treatment options that are less often prescribed are covered in the review article, like oral medication. Read up and let me know what you think!

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News & Research

Eczema News – Second-hand Smoke and Eczema

Came across this 2015 research study on Environment Tobacco Smoke Exposure Affect Childhood Atopic Dermatitis Modified By TNF-α and TLR4 Polymorphisms in which the researchers studied:

  • 3,639 children aged 7 and 8 years old
  • Survey format – 2-year follow-up
  • Participants were followed up 2 years later with blood test

Results were that children with the gene variant (that encode immune proteins TNF-alpha and TLR-4) associated with inflammatory conditions such as asthma and Crohn’s disease were more likely to develop eczema if they had been exposed to smoke in the womb. Since we wouldn’t know whether there’s gene variant in a fetus, it’s best to quit smoking and have everyone around to quit if you’re planning to have a baby. More studies on Pubmed linking second-hand smoke and eczema:

Second hand smoke increases risk of eczema in fetus baby up to adolescents

Cigarette smoking on allergic conditions – Maternal smoking in the first year of the child’s life resulted in the children having an increased chance of wheezing, exercise-induced wheezing and asthma.

Foetal exposure to maternal passive smoking is associated with childhood asthma, allergic rhinitis, and eczema – Foetal exposure to maternal passive smoking was significantly associated with wheezing, allergic rhinitis and eczema.

Improvement of Atopic Dermatitis Severity after Reducing Indoor Air Pollutants – After the completion of the program that reduced the air pollutants in kindergarten, the prevalence of atopic dermatitis and the mean eczema area and severity index (EASI) were decreased, and the changes were both statistically significant.

Pre- and postnatal exposure to parental smoking and allergic disease through adolescence – Exposure to second hand smoke during infancy was associated with an overall elevated risk of asthma, rhinitis and eczema up to 16 years.

Updated in October 2015, new study on:

Parental smoking and development of allergic sensitization from birth to adolescence -Second hand tobacco smoke exposure in infancy appears to increase the risk of sensitization to food allergens up to age 16 years as well as eczema in combination with sensitization.

It is likely that not only tobacco smoke but also outdoor air pollutants like traffic exhaust can stimulate immune cells to respond. What is your experience? I was living in a scaffolded apartment for the first two trimesters – till today, I still wonder what the effect had been on my baby…


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News & Research

Eczema News – High Blood Pressure Drug teamed with Corticosteroids

Hypertension drug with Steroid use reduces skin thinning

One of the key side effects of corticosteroid is skin thinning – this is also known as skin atrophy. Thinner skin has increased rate of transepidermal water loss (TEWL), more fragile and prone to irritation. The skin thinning is due to decreased rate of collagen and skin cell growth. The mechanism is from the activation of glucocoricoid and mineralocorticoid (MR) receptors in the epidermis by the corticosteroids.

Researchers in hypertension (high blood pressure) discovered that drugs for hypertension that contain spironolactone works as a MR antagonist by reducing the activation of the MR receptors. Based on a small randomized double-blind controlled trial of 23 individuals for 28 days, it was recorded that there was no skin thinning for those who applied spironolactone. Thus, it was an indication that corticosteroids could possibly be used without the worry of skin thinning effect if it’s applied together with the above hypertension drug. 

It is interesting to see if there’s medical advancement in this area – steroid side-effect is a concern of many parents and while generally safe to use, always bear in mind to use as indicated and check with your doctor

  • How much to use (finger tip unit)
  • How long to use (duration and frequency)
  • Where it can be used (especially for thinner areas of skin such as face and neck)
  • What appearance of rash you should see after application by week (1,2 and when to stop)
  • How it can be used – especially if you are also applying wet or dry wrap, you should not also be using corticosteroids as under occlusion, the side effects are more significant
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Eczema News – Testing Water Evaporation from Skin for Babies

I shared in this post (and the comments) that moisturizing has been studied to have a protective effect over eczema. Similarly, Dr Cheryl Lee MD shared in the Skin pH interview series that moisturizing from 3 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. 

The question is it is not always clear whether the baby has high eczema risk. If a baby can get a non-invasive test and parents are then alerted to moisturize their baby early, many babies can have a chance of not suffering from eczema. More about this test:

EST SKIN prevent eczemaTitle of study: Skin barrier dysfunction measured by transepidermal water loss (TEWL) at 2 days and 2 months predates and predicts atopic dermatitis at 1 year.

Method: Measure water evaporation in the skin of 1,903 newborn babies in Cork University Hospital, and followed them up until 12 months of age.

How: Small probe placed on the child’s arm to measure the level of water evaporation at day 2 and 2-month & 6-month old.

Results: A higher water loss at 2-day and 2 month strongly predict eczema at 12 months.

There are also other risk factors, such as family history and whether there is a low level of the filaggrin gene. Similarly to what I have posted before on the outside-in hypothesis, Prof Hourihane said that prevention of eczema may also prevent the development of asthma and food allergy, which are strongly associated with eczema, because the allergens get through the broken skin and cause the development of allergies. This view is also shared in Dr Cheryl Lee’s interview here.

This study is only published in 22 Jan 2015, I’m interested to see if this test will be adopted by pediatricians. Maybe you can bring this up to your doctor to see if such a test can be arranged for your newborn! If you did talk to your doctor, let me know the response so that other parents can benefit from it.

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Eczema News – Eczema is Cardiovascular Risk

You know when something is so stressful, sometimes we say it’s bad for our heart? Add eczema to that list.

Heart Risk for Eczema

Dermatologists Jonathan Silverberg and Philip Greenland looked at data for 27,157 and 34,525 adults aged 18 to 85 years from the 2010 and 2012 National Health Interview Survey. After the analysis, they noted that adults with eczema are likely to:

Smoke more (100 cigarettes in lifetime and still smoking)

Drink more (12 drinks annually and still drinking)

Have higher cholesterol 

Exercise less

Weigh more, measured by BMI of more than 35

Be at risk of hypertension (2 related consultation visits)

Be at risk of lifetime prediabetes

Have sleep disturbances, resulting in fatigue, daytime sleepiness or insomnia

This is a data analysis, meaning having eczema does not cause you to have a heart attack. However, it is a reminder that we have to be even more vigilant at taking care of our health and not letting eczema literally take over our life. 

If sweat triggers your child’s eczema, opt for other less sweaty exercise or find a setting that allows for showering and moisturizing after (sweat residue irritates skin for some). Keeping fit helps reduce obesity and likely improve sleep. When you’re making an effort to be healthy, it is less likely you will eat poorly, drink and smoke. Choose a diet of fresh fruits and vegetables, cut back tans fat and sugar, quit smoking and you’d reduce risk of diseases by 80%.

Eczema is bad for our skin, but not let it be bad for our heart or our life.

For encouraging stories of eczema sufferers around the world, read
the weekly stories shared in 2013.

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News & Research

Eczema News – Food Sensitization from Eczema?

Eczema Allergic Sensitization

This is a very interesting topic because it represents a major paradigm shift to how we view allergy – it’s not just what we eat (oral path) but also what’s on our skin. It is now accepted  that what is on our skin can lead to sensitization and allergy. For instance, dermatologist Cheryl Lee MD said in this post:

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.

Let’s take a closer look at this article published in Aug 2014 in Journal of Allergy and Clinical Immunology by Japanese researchers.

Article title: Eczematous sensitization, a novel pathway for allergic sensitization, can occur in an early stage of eczema

This is an article that looks at the studies being conducted, and it’s not exactly recent but I like it because it reinforces the understanding of outside-in hypothesis.

Link between Food Allergy and Eczema – From the Skin

Researchers started to look at the link between our skin and food sensitization because studies (quoting this article) demonstrated that exposure to environmental peanut protein–containing household dust and use of hydrolyzed wheat protein–containing soap significantly increased the risk of allergic sensitization to peanut and wheat, respectively. In addition, filaggrin loss-of-function mutations were a significant risk factor for peanut allergy. Those findings strongly suggest that epicutaneous exposure to proteins induces allergic sensitization…

presence of eczema is a robust risk factor for allergic sensitization to food antigens and development of food allergy

It is compiled in the article that increase in skin pH, scratching and impaired filaggrin are factors that lead to food sensitization. We have talked about the importance of skin pH for the whole of December last year and in summary, skin that is too alkaline is linked to reduced ceramides, skin lipids (good for our skin) and increase in staph bacteria (bad for our skin). Foods that come into contact on our skin can certainly trigger eczema flare-ups too!

My take: Strengthen the skin barrier – moisturize, use right products of optimal skin pH and without common irritants, treat skin promptly to reduce scratching. Keeping eczema under control or moisturizing to prevent eczema onset can have a real chance of preventing allergy.

What’s your take? Do share your take in the comment so we all can hear from each other!

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News & Research

Eczema News – Abdominal Pain and Allergy, Sensitization in Kids?

We’ve been looking at eczema research news for the past 2 weeks and this week, I came across an interesting study looking into the correlation between abdominal pain and allergy-related disease. My child sometimes complain of tummy ache and now I’m wondering if it got anything to do with her eczema. Let’s check out this study!

Study title: Allergy-related diseases and recurrent abdominal pain during childhood – a birth cohort study

Study objective: Examine the association between allergy-related diseases or sensitisation during childhood and abdominal pain at age 12 years.

Study method:  2610 children in Sweden, using questionnaires. Parents answered questions regarding asthma, allergic rhinitis, eczema and food hypersensitivity and children answered questions on abdominal pain at 12 year old. IgE blood tests were taken at ages 4 and 8. Celiac disease and inflammatory bowel disease excluded.

Why focus on Abdominal Pain?

Recurrent abdominal pain affects 8% of children in western countries and often leads to school absence and lower quality of life. Multiple factors contribute to it, including irritable bowel syndrome (IBS). It’s also related to low-grade gut inflammation and the link to asthma, eczema and rhinitis had also been studied (with no conclusive result).

Abdominal Pain Allergy Disease

What’s the Possible Link between Abdominal Pain and Allergy?

As written in the study,

Children with multiple allergy-related diseases may have a low-grade inflammation in the gut, resulting in barrier defects in the gastrointestinal tract, thus increasing the risk for disturbed motility and pain sensitivity. IBS patients with an allergic background have demonstrated increased IBS symptom scores, colonic permeability, mast cell counts and tryptase release or increased gut permeability compared to IBS patients without an allergic background.

Conclusion: Among 2610 children with complete follow-up, 9% reported abdominal pain at 12 years. All allergy-related diseases were associated with concurrent abdominal pain at 12 years and the risk increased with increasing number of allergy-related diseases. Asthma at 1 and 2 years and food hypersensitivity at 8 years were significantly associated with abdominal pain at 12 years. There was an increased risk of abdominal pain at 12 years in children sensitized to food allergens at 4 or 8 years, but in stratified analyses, this was confined to children whose parents had not reported food hypersensitivity at time of sensitisation.

My take: It’s not causal and admittedly, associations are not accurate. As pointed out in the study, it could be allergy kids already go to clinics more often or have increased anxiety and stress that lead to the recurrent tummy aches. But I do believe in benefits of a healthy gut – an area where increasingly gut influences more than just gut! Eat a low oxidation diet, fruits, vegetables and probiotics.

What’s your healthy gut diet? Do you monitor the foods for your child with allergy, asthma, eczema or rhinitis? Do share in the comment so that everyone can hear from each other!