Thank you so much for dropping by my blog (it may look weird now as I’m changing its layout). If you are new to EczemaBlues, let me do a quick introduction – my daughter Marcie had eczema at 2 weeks old, and at around one year old, her eczema improved and I decided to pour my heart into creating this blog – as a resource that parents could visit for practical tips, and hopefully, change some of those eczema blues to bliss.
I stopped updating regularly when Marcie started grade school, as after 5 years of blogging, EczemaBlues already had over 850 posts and it was no longer helpful to write for the sake of keeping up a blog (& more in my farewell post in January 2016).
During the time that I stopped updating this blog, I continued to reply to comments from parents and eczema patients around the world, engaged my G+ eczema community, moderated pro bono for Talkhealth eczema forum and facilitated face-to-face sharing session at a national skin center. All this time, I had the nagging feeling that something was broken in the way eczema patients received their care – Why with all the information out there (including my blog!) are eczema sufferers still suffering? Why are patients not getting the information that they need from their doctors (and have to search forums for answers)? Why do certain patients have such a positive consultation experience, while others felt written off by their doctors? Why do patients testify that certain products, prescriptions and treatment plans work so well for them (even if they are not the conventional doctors’ recommendations)?
With above in mind, I decided to open my mind and re-look a few things below:
New research for eczema, in particular, findings that reverse what we thought would work or couldn’t work
Patient, doctor and the consultation experience, i.e. is there anything that we can do to increase the odds of a positive consultation
Products, prescriptions and treatment plans, including non-conventional ones which had not been supported by sufficient clinical studies
I’m working on setting up some sort of community forum or review, and will also be posting (affiliate) links to products as I find out more about different products that others use for their eczema. I’d also be coming up with a series of guides for various needs, and working on my e-book. During the time-off from this blog, I’ve taken an interest in hand-lettering and I may just be converting some of these into digital products that you can purchase to encourage your friend with eczema. All in all, it’s a shift from practical tips to practical tools… with the same purpose of turning eczema blues to bliss.
& Always remember – You are the best parent for your eczema child
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.
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!
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.
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
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.
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:
Today, it felt like coming home – sharing on this blog again after taking a year break from regular posting. I took a break when Marcie started grade school last year and I didn’t feel that it would help you by posting for the sake of posting. As such, for the past year:
I took an interest in hand lettering and visual notes, and you’d see more of these for this year’s posting.
In 2017, I’d post twice a week, a lighter posting schedule compared to three times a week in the past. I feel that this feels a little like coming home, returning to what this blog is about, i.e. turning blues to bliss.
Sharing verses from a poem Coming Home by American poet, Vern Rutsala (from January 1985 Poetry Magazine)
We thought we knew these
sidewalk cracks by heart
but even they have altered
in our absence, branching out
on their own. The yard too
has a new identity -some
plants dead, others new.
Inside, the knives and forks
don’t seem the same and feel
wrong in our hands. The design
is more extreme than we remember and there has been
I’m privileged to interview the lead researcher for the study, Dr Donald J Davidson MBChB PhD. Dr Davidson is the MRC Senior Research Fellow and University of Edinburgh Senior Lecturer. The Davidson Group within the MRC Centre for Inflammation Research focuses on understanding the physiological importance of cationic host defence peptides (CHDP) to host defences against bacterial and viral infections. Dr Davidson is a medical graduate of the University of Edinburgh who chose to pursue a scientific research career. He completed a PhD at the MRC Human Genetics Unit, studying the pathogenesis of cystic fibrosis lung disease, then was awarded a Wellcome Trust Travelling Research Fellowship to undertake post-doctoral training in innate immunity research at the University of British Columbia, Vancouver. You can read more of his research interests here.
MarcieMom: Thank you Dr Davidson for taking the time to help with the questions. The questions will be based on the study, but more focused on its practical implications.
Staphylococcus aureus is a resilient bacteria found on the skin that can survive in dry condition and on dry skin with little oxygen. It tends to involve areas that are warm and moist especially such as skin near mucous membranes such as the nose, mouth, genitals and anal area. It is found in less than 30% of healthy adults and generally does not cause an infection in those with healthy skin. However, as pointed out in the study, 75% to 100% of atopic dermatitis patients have staph bacteria on their lesional skin and 30% to 100% of atopic dermatitis patients have staph bacteria on their non-lesional skin (Breuer et al., 2002; Gong et al., 2006; Park et al., 2013). The problem with staph bacteria is that it secretes toxins and proteases that can worsen atopic dermatitis.
MarcieMom: From your study, protease V8 was of interest which showed it led to skin barrier dysfunction. Can you explain what you learnt about staphylococcus aureus’ interaction with atopic dermatitis skin/ normal skin and how does it damage skin integrity?
Dr Davidson:In our study we did not use the whole live bacteria, but concentrated instead on its harmful proteases. Using skin cells grown in the laboratory and collecting the substances made by the bacteria Staphylococcus aureus, we were able to show that the bacterial protease V8 was the most powerful product when it came to breaking down and damaging the skin barrier. Together with studies from other research groups, this suggested that one of the main ways these bacteria can damage skin is by producing V8, and that finding ways to block this damage may help to maintain and/or restore the skin integrity in atopic dermatitis.
Natural Skin Defence
In your study, it was mentioned that human beta defensin 2 (hBD2) is a substance on our skin that have antimicrobial properties and able to protect against skin integrity damage caused by staph bacteria protease V8. It was further noted that the level of hBD2 on atopic dermatitis skin was significantly lower than normal skin, therefore atopic dermatitis skin may be more prone to infection and unable to defend itself against staph bacteria.
MarcieMom: I hope I have understood hBD2’s role correctly; can you explain more about what you have found out about hBD2, for instance, how important is its role in maintaining skin integrity, fighting infection and the effects of protease V8?
Dr Davidson:Our bodies can make quite a wide range of substances we call antimicrobial host defence peptides (HDP). The skin is one site that produces these. These HDP have a lot of different roles in protecting us from infection and disease. hBD2 is an HDP from the defensin family. hBD2 was already known to be capable of killing bacteria in the laboratory. It is less clear if it definitely does this in normal functioning on our skin. However, it has been suggested by other researchers that the failure of atopic dermatitis skin to make as much hBD2 as one would expect (for the amount of skin inflammation or damage), could be one reason that atopic dermatitis skin lesions are prone to infection. What our new MRC-funded research discovered was that hBD2 can also stop V8 from damaging laboratory-grown skin. This worked both when we instructed the skin to make extra hBD2 (using genetic modification) and when we added hBD2 in the style of a treatment. Just how important this is in a living human remains to be seen, but it has obvious potential and shows that hBD2 can protect the skin barrier as well as kill bacteria.
MarcieMom: The interesting part of your study was its demonstration that application of hBD2 was found to be protective, and therefore a possible future eczema therapeutic. How does the application of hBD2 work? What are its protective effects?
Dr Davidson:At this point we don’t know how hBD2 protects this skin barrier integrity and we are currently applying for more funding so that we can start to work this out. It may act directly on the V8 to block the damaging effects of this bacterial protease, but we’ve found that it can also help to speed up repair where damage has occurred. So hBD2 may work in more than one way.
Is this something you foresee that can be easily added into a moisturizer or would it be more likely to be a non-steroidal topical prescription?
Dr Davidson: At this stage we are still in the discovery science phase of the research, so it is too early to predict how, and even whether, it will turn out to be a useful treatment. However, in the best case scenario for the outcome of our research, I would envisage adding hBD2 (or drugs made to mimic some of its functions) into prescription moisturizer-type creams or ointments.
How would the application of hBD2 be compared with the existing eczema measures such as bleach bath to kill staph bacteria?
Dr Davidson: I’m afraid it is too early to be able to make comparisons of that kind, until we have a better understanding of exactly how hBD2 functions to protect the skin barrier.
MarcieMom: Thank you Dr Davidson once again for your time and will certainly look forward to further breakthroughs and more studies done in this area.
Wang B, McHugh BJ, Qureshi A, Campopiano DJ, Clarke DJ, Fitzgerald JR, Dorin JR, Weller R, Davidson DJ, IL-1beta-induced protection of keratinocytes against Staphylococcus aureus-secreted proteases is mediated by human beta defensin 2, The Journal of Investigative Dermatology (2016), doi: 10.1016/j.jid.2016.08.025.
Breuer K, S HA, Kapp A, Werfel T (2002) Staphylococcus aureus: colonizing features and influence of an antibacterial treatment in adults with atopic dermatitis. Br JDermatol 147:55-61.
Gong JQ, Lin L, Lin T, Hao F, Zeng FQ, Bi ZG, et al. (2006) Skin colonization by Staphylococcus aureus in patients with eczema and atopic dermatitis and relevant combined topical therapy: a double-blind multicentre randomized controlled trial. Br J Dermatol 155:680-7.
Park HY, Kim CR, Huh IS, Jung MY, Seo EY, Park JH, et al. (2013) Staphylococcus aureus Colonization in Acute and Chronic Skin Lesions of Patients with Atopic Dermatitis. Ann Dermatol 25:410-6.
This is a continuation oflast week’s interviewwith Dr Steve Xu MD MSc where we discussed contact dermatitis, the differences between irritant and contact dermatitis, the top 10 pediatric contact allergens in personal hygiene products and practical consideration of when to suspect contact dermatitis in a child.
Dr Steve Xu, MD MSc is currently a 2nd year dermatology resident at McGaw Medical Center of Northwestern University. He earned his MD from Harvard as a Soros Fellow, and a Masters in Health Policy and Finance from The London School of Economics as a Marshall Scholar. He completed a BS in bioengineering at Rice University. For his academic interests, Steve is focused on consumer education and the intersection between health policy and clinical medicine. His publications have appeared in The New England Journal of Medicine, and PLOS Medicine garnering broad press attention from sources such as CNN, The Washington Post, and The Los Angeles Times. Dr Steve has created a web resource for patients with eczema and contact dermatitis at itchyrash.org. See also Dr Steve’s publications at the end of last week’s post.
Yet, practically (I’m finding myself using this word so frequently in this 2-part interview! It must be that it is so hard to take practical steps when it comes to skincare products and figuring out irritants, allergens and pushing through the myriad of chemical names!) and yes, practically it can be difficult to find a skincare product with less than 10 ingredients! Pharmaceutical companies seem to add more ingredients to their formulation in order to ‘upgrade’ their product to one that can restore your skin’s lipids, ceramides, reduce itch and bacterial infection.
MarcieMom: Is there a trend towards more ingredients in the formulation of skincare products? And is it a real risk or can consumers assume that product companies would have tested their increasingly complex formulation that it would not lead to contact dermatitis?
Dr Steve Xu: Again, labels such as ‘hypo-allergenic’ or ‘sensitive skin’ really don’t mean anything. The Food and Drug Administration do not regulate this definition. Consumers have to be aware of this.
I wouldn’t say there’s a trend towards more ingredients in skincare products. Skincare products aren’t produced for hypo-allergenicity. These products are successful because they smell nice (fragrances), feel good on the skin, and stay fresh (preservatives). I think for individuals with patch-test proven allergic contact dermatitis, it’s really important to follow the safe list. But, if you haven’t been patch tested yet and have very sensitive skin, then looking for products with as few ingredients as possible AND do not have common skin allergens is a reasonable consideration.
MarcieMom:Staph bacteria has been covered in my blog, and we know that eczema skin that has staph bacteria colonization will not recover well due to inflammatory toxins from the bacteria.Are moisturizers for eczema/ dry skin incorporating antiseptic properties? Which antiseptics are now recommended for eczema children and how likely are these to irritate skin?
Dr Steve Xu:Absolutely, treating staph colonization is a big component of successfully treating atopic dermatitis. Moisturizers typically don’t have anti-bacterial ingredients. But, we do know that impaired or broken skin barrier facilitates the colonization and growth of staph. Thus, moisturizers play a big role in keeping the skin barrier intact so that staph can’t cause problems.
At least in the U.S., we hardly ever specifically recommend an ‘anti-septic’ moisturizer. It’s interesting to see that there are products out there marketed as such. We separate the use of moisturizers (barrier protection) and the elimination of colonizing bacteria (mupirocin ointment, bleach bathes). Typically for our patients, we always recommend moisturizers for skin barrier preservation but tend to be more reactive when it comes to recommending bleach bathes or mupirocin ointment at the sign of super infection (formation of pustules).
With that being said, lauric acid is certainly an ingredient that is becoming more and more popular. It is the key component in coconut oil, which has shown to have a broad range of antibacterial properties.
Long-story short, I think there’s probably a benefit from using antiseptics more regularly in managing atopic dermatitis. We know that the skin of eczema children have less anti-microbial peptides, natural bacteria fighting proteins produced by the skin. There’s no great head to head studies comparing coconut oil (moisturizer + anti-septic properties) vs. a regular moisturizer in managing atopic dermatitis. But, I think there is some benefit here that may be real for some patients that have a particular sensitivity to staph colonization.
Also, common over-the-counter topical antibiotics such as neomycin and bacitracin are notorious agents for causing allergic contact dermatitis. We typically do not recommend these for children with atopic dermatitis. In the United States, we prefer topical mupirocin (prescription only). This medication rarely causes allergic contact dermatitis compared to neomycin or bacitracin.
Age of Allergic Contact Dermatitis
In the article1, it was mentioned that studies have shown that there are different age (timing) where there is peak prevalence of contact allergy among children, being
0 – 3 years old – could be due to immature skin barrier, including lower lipid content, fewer natural moisturizing components, higher pH and thinner epidermis
6 – 7 years old
MarcieMom: Are there a certain group of children who is more likely to have contact dermatitis? Narrowing this further, is there a particular profile of eczema children who are more likely to also have contact dermatitis?
Dr Steve Xu: This is a great question. I think certainly, older children and adolescents will have had greater exposure to potential allergens over time. However, an allergic contact dermatitis can occur at any age including toddlers. I think the most important thing is to have ahigh index of suspicion for allergic contact dermatitis in children with atopic dermatitis.
Is your child’s atopic dermatitis not getting better despite the best therapy?
Is your child’s atopic dermatitis appearing in areas that it never appeared before?
Are there eczematous rashes that seem to happen in the same locations such as the belly button, neck, waistband or wrist? Do the rashes appear linear (straight) or rectangular?
We’ve had plenty of pediatric patients with stable atopic dermatitis that would inexplicably get worse or not respond to therapy. After patch testing, we would identify a common allergen such as nickel. The rashes won’t get better unless nickel is avoided.
In the article1, it was mentioned that the most “allergenic” corticosteroids are:
The least allergenic are those with halogenated C16-methylated molecules and in order of increasing potency:
Again, there is the possibility of children with atopic dermatitis using more topical steroids and therefore getting hypersensitive to it overtime.
MarieMom: The article mentioned classifying topical steroid creams using different groups, based on their likelihood of being contact allergens. The likelihood can be due to different molecular (steroid) structure, the other non-steroid ingredients in the prescription cream, how long it is used and how occlusive it is (topical steroid creams are not recommended with wet wraps as absorption rates are higher than intended when occluded).
MarcieMom: What are the common steroid creams prescribed for young children with eczema? And how likely will they cause contact dermatitis?
Dr Steve Xu: Overall, a true allergic contact dermatitis to topical steroids is quite rare. Aclomethasone and desoximethasone are both popular choices.
I will say that sometimes it’s better judicious to not always reach for the least hypo-allergenic topical steroid at first. In the vast majority of time, a children will not have a contact allergy to a topical steroid. If we reach for a hypo-allergenic topical steroid and a contact allergy does develop, we have less therapeutic options in the future.
MarcieMom: Thank you Dr Steve for your time to help with this series; really glad for this interview as it has certainly raised my awareness of contact dermatitis in children (where previously thought to be remote). Also appreciate the work that you’re doing at itchyrash.org
Hannah Hill, Alina Goldenberg, Linda Golkar, Kristyn Beck, Judith Williams & Sharon E. Jacob (2016): Pre-Emptive Avoidance Strategy (P.E.A.S.) – addressing allergic contact dermatitis in pediatric populations, Expert Review of Clinical Immunology, DOI: 10.1586/1744666X.2016.1142373
Eczema is a skin condition with many parts to the puzzle – it is linked to hereditary skin condition, allergens (food, inhaled, contact and airborne), environmental factors (heat, humidity), bacteria colonization on skin (and how gut microbiome may affect allergic conditions), lifestyle factors (stress, hormonal change) and also suspected to be linked with diet/ water.Very often we may think of what we have eaten, rather than what we have applied on our skin. A moisturizer or topical prescription tend not to fall under our usual ‘list of suspects’ when we try to figure out what’s triggering the eczema.
This 2-part blog series aim to bring greater awareness of contact allergens, and how some of these may be the ingredients in your skincare products. Especially for pediatric patients, we have to be even more careful because:
I’m privileged to have dermatologist Steve Xu, MD MSc to help with this series. Dr Steve is currently a 2nd year dermatology resident at McGaw Medical Center of Northwestern University. He earned his MD from Harvard as a Soros Fellow, and a Masters in Health Policy and Finance from The London School of Economics as a Marshall Scholar. He completed a BS in bioengineering at Rice University. For his academic interests, Steve is focused on consumer education and the intersection between health policy and clinical medicine. His publications have appeared in The New England Journal of Medicine, and PLOS Medicine garnering broad press attention from sources such as CNN, The Washington Post, and The Los Angeles Times. Dr Steve has created a web resource for patients with eczema and contact dermatitis at itchyrash.org. See also Dr Steve’s publications at the end of this post.
Allergic Contact Dermatitis – What is it?
MarcieMom: Contact dermatitis refer to skin rash that is triggered by contact with an allergen/ irritant. If the immune response is that related to IgE, it would be allergic contact dermatitis; conversely, if the response is due to overtime exposure to the irritant (leading the skin to develop delayed-type hypersensitivity), it is irritant contact dermatitis.
The thing is a child can have all the different types of dermatitis – atopic, allergic contact and irritant contact.
MarcieMom: Dr Steve, thank you for joining me for this series. The different terms can get very confusing for parents of eczema children.How would you explain the different types of dermatitis to a patient?
Dr Steve Xu:Right now even within the scientific community, there’s a big debate on what exactly we should call ‘eczema’. At our institution (Northwestern University), this is how we break it down.
The term ‘eczema’ itself actually describes how a certain rash looks.Atopic dermatitis, allergic contact dermatitis, and irritant contact dermatitis all can cause an ‘eczema’ rash that looks exactly the same. Eczema used as a standalone term isn’t really specific.
For classic childhood‘eczema’, we refer to this as atopic dermatitis. Allergic and irritant contact dermatitis is defined as a condition where an external agent leads to an eczematous rash.We define the difference between allergic and contact dermatitishere. Basically, an allergic contact dermatitis is defined by an immune-mediated response to an external agent applied to the skin. These reactions typically require only a very small amount of the agent to lead to a rash. Irritant contact dermatitis is not immune related but leads to an indistinguishable eczematous reaction. Typically, more of an external agent must be applied to cause a rash in irritant contact dermatitis.
MarcieMom: In practical terms, is diagnosing the type of dermatitis important? Or knowing the triggers are adequate for management of eczema?
Dr Steve Xu: Yes, definitely. An irritant contact dermatitis usually requires more of the external agent to cause a rash.This is practically important because if you only have an irritant contact dermatitis you may be able to tolerate products that are wash off or rinse off.If you have an allergic contact dermatitis, then we recommend avoidance altogether. Even a little exposure can cause a miserable rash.
Prevalence of Allergic Contact Dermatitis
There is increasing evidence that allergic contact dermatitis is underreported in children and while traditionally thought as unlikely for children, contact dermatitis is becoming more common.
MarcieMom: In the article1, the top ten pediatric allergens found in personal hygiene products are listed (with the first as having most percentage of children being hypersensitive to it):
Neomycin – topical antibiotic, another contact allergen is over-the-counter antibiotic Bacitracin
Balsam of Peru – also known as Myroxylon pereirae, chemically related to fragrance and thus used to screen for fragrance allergy
Fragrance mix – Of the flowering plants, the Comositae family is the most likely to cause skin sensitization, such as chamomile, dandelion and ragweed; also cross-reactive with propolis (beeswax)
Benzalkonium chloride – ammonium compound used as preservative, including in disinfecting wipes and eye drops
Lanolin – natural oil from sebum of wool-bearing animals
Formaldehyde – preservative, also associated with quaternium 15, imidazolindinyl urea (most common), diazolidinyl urea, bronopol, dimethyl-dimethyl hydantoin (this can get very tricky to memorize, readers can refer to this table created by dermapathologist in a previous interview)
Methylchlorsothiazolinone (MCI)/ Methylisothiazolinone (MI) – likely to be in bubble baths, soaps, cosmetic products, and baby wipes
Propylene glycol – previously common in moisturizers (but many brands stopped including propylene glycol: it has humectant properties and also an emulsifier) and topical steroids
Corticosteroids – when using steroid creams, we have to be aware of its potency, but we may now have to know its likelihood of being contact allergen (we will discuss this next week)
Other than the above 10, the other well-known contact allergens arecetylstearyl alcohol, sodium lauryl sulphate, pehnoxyethanol, parabens, TEA (triethanolamine) and vitamin E.
Nickel and cobaltare also common contact allergens but less likely that children will come into contact with them.
MarcieMom: It is interesting to note that the above can be found in personal care products, even in those marketed for children. I’m wondering if there is an increase in sensitization in personal hygiene/ skincare products? If so, why? (for instance, is it the increased use of products? Or increased awareness/ patch testing/ consultation)
Dr Steve Xu: The prevalence of contact dermatitis has remained stable overall but certain chemicals are representing a larger share of problems. This is related to industry trends. For example, as formaldehyde was phased out over the past 20 years in personal care products, we’ve seen a growing use of methylisothiazolinone as a preservative. It’s unsurprising that methylisothiazolinone contact allergy is rising rapidly.
Pediatric dermatologists have really worked hard to raise awareness among pediatricians and allergists about contact dermatitis in kids with atopic dermatitis. More than half of kids with atopic dermatitis will have a relevant positive patch test. In general, we’re arguing thatkids with atopic dermatitis should be patch tested more and tested for food allergies less.
Parents need to know that just because a product is labeled “For babies” or “Safe for kids”, it doesn’t mean it’s any different than what products are sold for adults. These are just marketing claims. Statements like “sensitive skin safe” or “organic” also aren’t regulated. Even carefully reading the labels may not be completely fool-proof. Often times, manufacturers do not have to be specific about which fragrance they are using (different fragrances can cause contact dermatitis).
MarcieMom: Practically, this feels like being caught between a rock and a hard place. The baby’s skin loses more moisture, has less lipids and for babies with dry skin, even more so we have to moisturize. Now, we know the common contact allergens to avoid and of course, should take the effort to read the product label and make sure we’re not putting something on our babies with these allergens. YET, the more we put something on our babies, the more likely the skin can become sensitized to it overtime! (for instance, lanolin, CAPB weren’t previously contact allergens)
MarcieMom: Is there a strategy to moisturizing to reduce likelihood of contact dermatitis? For instance, rotating skincare products which one expert has previously mentioned.
Dr Steve Xu: We often have patients come into our clinic with classic allergic contact dermatitis and exclaim: “I haven’t changed my products in years!”. In truth, this is exactly how a contact allergy develops. It’s true that small, continued exposures over time train your immune system to develop an allergy.
With that being said and to the best of my knowledge, there are no well-designed clinical studies showing that rotating skincare products reduces the risk of future allergic contact dermatitis. I’m hesitant to recommend this strategy.
Here’s some practical advice to perhaps help answer this question. Let’s say you have a child with atopic dermatitis and it’s fairly well controlled. Over the course of a period of time, let’s say the atopic dermatitis has taken a turn for the worst and is not getting better with optimal therapy. Or, let’s say that that the atopic dermatitis is appearing in areas it never has before (e.g. belly button, waistband, wrist). Then, this is a time to consider whether there is a simultaneous allergic or irritant contact dermatitis. Patch testing would be recommended.
If there is a relevant positive patch test, than this is the time to follow a safe list. Severely limiting what skincare products or household products can be used in the absence of a patch-test proven allergen may be overkill.
MarcieMom: Thank you Dr Steve for helping us to understand more about contact dermatitis; for me, I’ve learnt that there is practical benefit of knowing the type of dermatitis one is suffering from, and being mindful of the possible development of contact dermatitis for an eczema child. Look forward to next week where we will discuss more about skincare product, prevalence of contact dermatitis in kids and corticosteroids.
Hannah Hill, Alina Goldenberg, Linda Golkar, Kristyn Beck, Judith Williams & Sharon E. Jacob (2016): Pre-Emptive Avoidance Strategy (P.E.A.S.) – addressing allergic contact dermatitis in pediatric populations, Expert Review of Clinical Immunology, DOI: 10.1586/1744666X.2016.1142373
For some of Dr Steve’s publications, see below:
Xu S, Walter JR and Bhatia A. Online Reported User Satisfaction with Laser and Light Treatments: Need for Caution. Dermatologic Surgery. Published online September 9th, 2016. DOI: 10.1097/DSS.0000000000000862.
Xu S, Kwa M, Agarwal A, Rademaker A, and Kundu RV. Sunscreen Product Performance and Other Determinants of Consumer Preference. JAMA Dermatology. 2016. 152(8):920-927.
Walter JR and Xu S. Therapeutic Transdermal Drug Innovation from 2000-2014: Current Status and Future Outlook. 2015. Drug Discovery Today. 2015. 20(11):1293-1299.
Walter JR and Xu S. Topical Drug Innovation from 2000 through 2014. JAMA Dermatology. 2015. 151(7):792-794.
In March 2015, the National Eczema Association (NEA, in US) published a study on steroid addiction in patients with atopic dermatitis. This was by members of its task force, who looked into the evidence regarding steroid withdrawal as many eczema sufferers were asking about the steroid addiction syndrome, along with many cautioning and enquiring on this online and over social media. The use of steroid creams remains a common treatment option, and the phobia of steroids has also stopped eczema sufferers, including children, from receiving treatment. The questions we are exploring with Professor Hugo centered on:
What is steroid addiction?
What is steroid withdrawal and its symptoms?
Is steroid addiction/ withdrawal common?
What are the treatment options for eczema?
Professor Hugo is no stranger to this blog – He has previously helped in Friday Doctor Q&A in 2012 and is my co-author for our book “Living with Eczema – Mom Asks, Doc Answers”. Professor Hugo van Bever is the Professor in Paediatrics (MD, PhD) at the National University Singapore, and also the Senior Consultant in its Division of Paediatric Allergy, Immunology & Rheumatology.
The questions are loosely structured based on the paper published by the National Eczema Association, to address the above questions that are surely on the minds of many parents with eczema children.
What is Steroid Addiction?
MarcieMom: Steroid addiction is used broadly to refer to eczema sufferers whose skin are “addicted” to the topical corticosteroids, and therefore, when they stop applying the steroid creams, they experience steroid withdrawal and its adverse symptoms.
MarcieMom: I looked up the meaning of addiction online and found a broader definition by MedicineNet.com that defines addiction as
“An uncontrollable craving, seeking, and use of a substance such as alcohol or another drug. Dependence is such an issue with addiction that stopping is very difficult and causes severe physical and mental reactions.”
Medical definitions of addiction linked addiction to a brain disease, rather than a skin disease. Is it even possible for the skin to crave topical corticosteroids and be dependent on it to the extent that stopping is difficult?
Professor Hugo: I disagree with the word “addiction”, as the situation here doesn’t refer to a mental state (addiction always refers to a mental state). As for the possibility of the skin being addicted, the answer is NO!
To me, it is more a “bad habit” of using topical corticosteroids (TCS), mainly because of wrong expectations of this treatment. When used inappropriately (such as too long, too high, too frequent, or too strong), every medication (even a simple anti-fever medication) can cause side effects or unwanted (unexpected) effects. That’s why it doesn’t surprise me that inappropriate usage of TCS can cause withdrawal effects or, at least, unexpected side effects – I strongly doubt the existence of a withdrawal syndrome (especially when there are no specific biopsy features).
(1) A rash that has appeared within days to weeks of discontinuing topical corticosteroid that has been used for many months. This flare may be worse than the pre-treatment rash. Before stopping the topical corticosteroid, the skin is typically normal or near-normal, although localised itch, ‘resistant’ patches of eczema or prurigo-like nodules may be present; and
(2) The rash must be only where the topical corticosteroid was being applied, at least initially, although it can later spread more widely.
(1) Eythematoedematous type – meaning redness (thus topical steroid withdrawal is also referred to as the Red Skin Syndrome), typically found in patients with an underlying eczema-like skin condition like atopic or seborrheic dermatitis; or
(2) Papulopustular type – meaning with bumps and pimples, typically found in patients who used topical corticosteroids for cosmetic purpose like acne or pigment.
The withdrawal symptoms include:
Burning and stinging
Mostly on the face and genital area of women
Exacerbation with heat or sun
Facial hot flashes
Both types of rash primarily affect the face of adult females and are mostly associated with inappropriately using mid- to high-potency topical corticosteroids daily for more than 12 months.
MarcieMom: First of all, it is important to understand what a review article is. It is not a controlled trial, meaning there are no two groups of people that are given different treatments and thereafter the results are evaluated. Instead, it systematically reviews other studies. The limitation of the study is that the quality of evidence in regard to topical corticosteroid withdrawal in the studies reviewed were very low.
MarcieMom:Is there a way to study topical steroid withdrawal definitively?
Professor Hugo: The article is a collection of case reports, and not a study. There are no studies on the subject. Therefore, the quality of the science behind this is very low. It is a misuse of TCS, and you cannot ask patients (is not ethical) to misuse a treatment in order to prove side effects. Better is to look for its existence in patients who didn’t misuse TCS, but I assume the prevalence will be close to zero.
MarcieMom: It is also briefly discussed in the review article that the signs and symptoms of atopic dermatitis may be confused with that of steroid withdrawal. It is suggested in the review article that if:
(1) Burning is the prominent symptom, and
(2) Confluent erythema (meaning continuous red patches) occurs within days to weeks after stopping topical corticosteroids, with
(3) History of frequent, prolonged topical corticosteroid use on the face or genital region, then the symptoms are more likely to be from topical steroid withdrawal (rather than other forms of dermatitis).
MarcieMom: How do we know if the rash is caused by steroid withdrawal and not something else? Would you contact patch testing for contact allergens?
Professor Hugo: The so-called withdrawal syndrome (as a consequence of misusage of TCS) is mainly made-up by a re-occurrence of eczema lesions, as shown by looking at the results of the biopsy studies: the withdrawal syndrome has no specific biopsy features, but mainly features of eczema. Therefore, I am not sure whether the withdrawal syndrome is a separate entity, or whether it is mainly an expression of re-occurrence of eczema. Indeed, I strongly doubt of its existence.
I think the withdrawal syndrome is NOT a new syndrome, but merely a flare-up of eczema on an altered skin (because of the long-term usage of TCS).
It is not a new syndrome because:
It has no specific clinical features (all manifestations might be manifestations of a re-occurring eczema)
It has no biological marker (blood)
It has no solid underlying mechanism – hypothesis
Biopsy finding are similar of findings in eczema (no specific biopsy)
It is merely a re-manifestation eczema, but on an altered skin, because of the long-term usage (misusage) of TCS.
Alterations of the skin can be summarized as following:
A thinner epidermis (as a consequence of misuse of TCS)
Higher Staphylococcus aureus colonization, as TCS do not affect Staph colonization – this explains the papular / pustular (infected) features of the lesions
A concomitant contact dermatitis (to TCS or other substances)
Contact dermatitis is a possibility, but is not common in children (more in adults), especially after years of usage of creams.
Is Steroid Addiction/ Withdrawal common?
In the review article, there were various factors that contributed to topical corticosteroid withdrawal, namely:
Mid or high potency use of topical corticosteroids
Daily use of topical corticosteroids (only one out of the 34 studies recorded frequency)
Duration of use longer than a year
From the studies reviewed, only 7.1% of the cases reported (in these studies) were of patients 18 years and younger. Only 0.3% were for children younger than 3 years.
MarcieMom: The general guideline in topical corticosteroid use for children is using a mild to (no higher than) mid potency, no more than twice a day, for a two week period. Professor Hugo, do you think that it is likely that children will suffer from topical steroid withdrawal even with the right use of prescribed steroid cream?
Professor Hugo: Patients should know that eczema (or atopic dermatitis) is a non-curable disease and that no doctor in the world can cure eczema today (perhaps in the future a cure will be found, mainly through immunomodulatory treatments, but not for the moment i.e. at the time of this interview in September 2016).
TCS are effective in controlling inflammation of the skin, and are, therefore, a part of the therapeutic approach to eczema. However: 1) TCS are ONLY (!) part of the treatment, which constitutes of offering a holistic package to the patient (focused on life style, and on usage of other treatments), and 2) once TSC are stopped the lesions will re-occur, as TCS do not cure, but only control inflammation, and 3) the rule is to use mild TCS (according to age and severity of the patches), in combination with antiseptics (TCS on a clean eczema patch) and NEVER more than 2 x day.
The main observation here is that this withdrawal effect is not caused by the TCS on itself, but by the inappropriate usage (i.e. misusage, leading to over-usage) of it. The unwanted effect was mainly seen in adult women (in more than 90%) who were using their TCS as if it was a kind of moisturizer. In other words, every time they felt a little itch or saw a little flare-up they put their TSC on it, many times per day, and during long periods (in 85.2% for more than 1 year).
The main point here is that TCS were misused, mainly because patients had wrong expectations of TCS, which I assumed is due to lack of correct information on eczema and on the role of TCS in its treatment. Who is to blame? I guess, both the doctor and the patient, and, for sure, the wrong doctor-patient relationship and wrong communication. Correct information on eczema and on the role of TCS is pivotal.
When TCS are used appropriately, as part of the holistic treatment of eczema, and according to correct expectations, it is extremely unlikely that a withdrawal syndrome will occur. I even dare to state that it is even (almost) impossible. However, I recommend close monitoring of all children with eczema, with appropriate individualization of treatment, focused on offering a treatment package in which TCS have a role, but only as a controller of acute inflammation, and with strict rules on their usage.
What are the treatment options for eczema?
MarcieMom: There are many brands and types of topical corticosteroid creams available, with varying potency and with different chemicals, and functions (for instance, with the added ingredients to reduce bacteria or fungus). Often, there is a trial and error process to see if a certain prescription cream works.
MarcieMom: How would a patient know if the steroid cream is not working for his rash? Is there a safe period of trial before stopping?
Professor Hugo: TCS are only PART of the treatment, and usually have a fast effect on acute inflammation (1 – 3 days). For each patient the optimal TCS needs to be selected (based on severity and age) and needs to fit into the whole package of treatment.
MarcieMom: There are many other eczema therapeutics that can be used alongside topical corticosteroids or in place of topical corticosteroids, for instance:
MarcieMom: I’m a believer that one ought to diligently practice good bathing and moisturizing regime, reduce staph bacteria colonization, along with healthy lifestyle (non-inflammatory diet and exercise). However, I find that sometimes we tend to discuss topical corticosteroids exclusively, i.e. use topical corticosteroids or (do something else). What are your top 3 eczema therapeutics in your practice and how effective has these reduce the use of topical corticosteroids in your young patients?
Professor Hugo: My top 3 are: allergen avoidance (airborne food, house dust mites – which is an outdoor life style) – usage of antiseptics (swimming – baby spa) and extensive usage of moisturizers have important additional effects and are therefore TCS-sparing.
MarcieMom:In summary, topical corticosteroid withdrawal is increasingly acknowledged by the dermatological community as evident by NEA taking the step to conduct a systematic review. However, we have seen that it is not easy to diagnose topical steroid withdrawal, and at the same time, removing topical corticosteroids completely as one of the eczema therapeutics may make it harder to treat the eczema/ skin inflammation. It is therefore important to recognize both the dangers of steroid misuse and underuse. Physicians should adopt an open attitude when hearing about patients’ steroid fears as totally ignoring steroid phobia would possibly alienate patients and without trust, it is making controlling eczema an uphill battle.
This is the time I waved goodbye to you (at least for 2016) as I’ve decided to stop updating this blog with 3 posts a week. There are 859 posts on this blog for the past 5 years, with the first blog post in January 2011. Marcie (my daughter with eczema from 2 weeks old) has just started Primary 1 this year and it is very stressful to continue with the blogging commitments while helping her with school. I also feel that this year is a year of change for me and nothing can change if all my free time is used to update this blog.
This blog has comprehensive information you need to care for your child with eczema, and use the (i) search box, (ii) categories on the right side bar and also the (iii) drop down list under Eczema Tips in the menu bar to find the eczema information you need. It has come to the point when my blog has so much information that there’s little value-add I can provide by committing to a 3 blog posts/week – trying to squeeze knowledge into this blog for the sake of fulfilling blogging commitments won’t be helpful to you.
I’m not sure if I will blog in 2016, nor the plans for 2017 onward. This is a blog I believe is a blessing from God, often he brings expert guests to me and help me be able to complete the blog posts. As and when I’m called to add more to this blog, I’d do so.
For now, thank you to all of you who read this blog, to all of you who commented and emailed me, to all the GPs and dermatologists who recommended this blog to parents, to all the experts and friends who helped out and are a part of this blog, thank you for this 5-year journey with me.
This week, we’re looking at the research surrounding Surfactants on Atopic Dermatitis. First a recap of eczema skin and its ‘compromised’ characteristics that warrant special care during skin cleansing.
– Reduced antimicrobial peptides (AMP) expression, possibly resulting in higher incidences of infection
– Elevated skin pH
The above makes eczema skin more prone to irritants and more vulnerable to the ‘harsh’ effects of surfactants, discussed last week:
Alkalization – Elevated skin pH has the impact of (i) reducing skin lipids (ii) allows for growth of harmful bacteria like staph bacteria and (iii) increases transepidermal water loss (TEWL)
Damage to Skin Lipids
Damage to Skin Cells
Toxic to Skin Cells
Irritation to Skin
Research on Surfactant Impacts on Eczema Skin
Much of the research focuses on certain surfactant ingredients, as below:
(I) Chlorhexidine Gluconate is the antiseptic for use on eczema skin as it causes the least atopic dermatitis skin lesions.
This is from a study examining the Effect of Hand Antiseptic Agents Benzalkonium Chloride, Povidone-Iodine, Ethanol, and Chlorhexidine Gluconate on Atopic Dermatitis in NC/Nga Mice. The four common antiseptic agents in hand sanitizers are:
Benzalkonium Chloride (BZK): A Cationic detergent with strong antiseptic activity, more gentle than that of ethanol-based BUT with reported contact dermatitis cases
Povidone-iodine (PVP-I) – Commonly use in mouthwash and in disinfection before surgery, low toxicity in humans BUT with reported contact dermatitis cases
Ethanol (Et-OH) – Broad antibacterial and antiviral spectrum BUT result in rough hands because of its strong defatting effect on the skin
Chlorhexidine gluconate (CHG) – Broad antibacterial spectrum AND with low incidences of contact dermatitis
(II) Reduce the use of Sodium Lauryl Sulphate (SLS)
In a study involving twenty volunteers with atopic dermatitis, it was found that repeated exposure to sodium lauryl sulphate and sodium hydroxide lead to a more pronounced impairment of the skin barrier function and significant transepidermal water loss.
SLS is a known skin irritant that damages the lipid barrier, causing inflammation and detachment of the skin layers (denaturation discussed last week).
(III) Reduce Cocamidopropyl Betaine (CAPB)
In another study involving 1674 patients, atopic dermatitis was associated with contact hypersensitivity to cocamidopropyl betaine (CAPB), but not to cocamide diethanolamide DEA or amidoamine. CAPB is an amphoteric surfactant, that is considered milder than SLS and a very common surfactant in many products. However, CAPB is cytotoxic, i.e. toxic to skin cells.
(IV) The Use of Hydrophobically modified polymers (HMPs)
The recent studies on surfactants are in agreement that for patients with skin conditions, a gentle liquid cleanser containing HMPs are more appropriate. Addition of cationic polymers to skin cleansers can further protect the skin and improve moisturization. To further improve cleanser mildness, adding hydrophobically modified polymers (HMPs) to cleansers make it less irritating to the skin. This is due to the formation of larger micelle of the surfactant, i.e. the larger the less likely to penetrate and remove skin lipids.
Above is similar to the care to note when cleansing baby skin, as well as what to use/ avoid to limit the harmful effects of surfactants on skin discussed in the previous two weeks. For all the posts in this Surfactant Skincare Series, see:
This month, we’re looking at surfactants – the chemical agents in cleansing products. It is important because while surfactants play an important cleansing function, they also potentially cause skin irritation. Last two weeks, we have understood:
Damage to Skin Lipids – Surfactants are able to clean dirt and sebum that are oil-soluble. However, this property also means that surfactants may inadvertently solubilize the skin natural lipid membranes (ceramides). Stronger anionic surfactants like Sodium Lauryl Sulphate (SLS) enhances penetration into the skin and able to affect the deeper skin cells (skin lipids).
Damage to Skin Cells – During washing, the surfactants interact with the skin cells and collagen fibers and cause temporarily swelling and hyper-hydration. Once the water evaporates, there is destruction of the skin protein structures (known as denaturation) and leads to skin dryness, roughness, tightness and scaling. This is an adverse effect of anionic surfactant.
Toxic to Skin Cells – Known as cytotoxicity, surfactants can permeate skin cells and cause irreparable alteration. Certain surfactants such as benzalkonium chloride and cocamidopropyl betaine (CAPB) are known to be more cytotoxic than SLS. CAPB is an amphoteric surfactant, a group of surfactant less irritating than anionic surfactant (SLS belongs to anionic group) but nonetheless can be cytotoxic. CAPB is also associated with allergic contact dermatitis.
Irritation to Skin – This is related to the duration of exposure, frequency, concentration and individual skin type. SLS is a known irritant that can cause skin inflammation (irritant contact dermatitis) and when combined with triclosan (an antibacterial and antifungal agent in products), can stay on the skin for hours/days. Amphoteric and nonionic surfactants are considered to be less irritating to skin. (Note: Skin irritation and cytotoxity are different concepts.)
What to Note when Choosing Cleansing Products
Based on the above surfactant interaction with skin, it follows that we ought to choose:
Products close to the skin pH (even water is not, either neutral pH 7 or sometimes more alkali)
It follows then to avoid soaps, which by nature are alkaline
Avoid SLS, as it can penetrate, damage and irritant skin
Avoid CAPB as it is cytotoxic
Choose products with larger micelles as they do not penetrate the skin cells as much (product packaging may not indicate this information so it’s quite hard to know; look out for Polyethylene oxide (PEO)/ PEO Sorbitan Laurate which forms larger micelles in the surfactant or for the term Hydrophobically Modified Polymers (HMPs))
Choose cleansing products that are moisturizing and moisturize right after washing
Reduce washing for prolonged time and frequent washing
Avoid alcohols, gels and alphahydroxy acids that can cause stinging
Avoid perfume, benzoyl peroxide, preservatives, parabens, propylene glycol, lanolin, methylisothiazolinone and other top irritants in this post
Avoid ingredients ending with sulfates
It is not easy to find a cleanser without any of the above-mentioned ingredient. For those with sensitive skin, it may be better to not wash as often and take care to choose a hypoallergenic product. Try to read the ingredient label of your product and be sure that the first few ingredients are at least not those in this post.
In the Skin Fact series, we’ve discussed much about baby skin structural differences. Below is a recap of certain baby skin characteristics that increase its vulnerability during skin cleansing:
Higher transepidermal water loss due to thinner stratum corneum – More vulnerable to water loss during bathing and skin barrier breakdown when there’s excessive friction (from over-washing or from rubbing skin when toweling dry).
High surface-area to volume ratio – along with a thinner stratum corneum and immature drug matebolism, make baby skin more vulnerable to harmful chemicals used during bathing
Less total lipids– make it vulnerable to further reduction of skin lipids lost during washing
Cleansing Baby Skin – Research on What’s Best
From a search on Pubmed for review articles on the research for baby skin cleansing, there’s actually not much research on it. From a 2009 European round table meeting, the consensus is:
Liquid cleansers in bathing are beneficial over water alone – Water cannot remove dirt, oil that can only be removed by oil. Prolonged washing with water dries the skin and depending on the pH of the water itself, it may be more alkaline than the natural pH of the skin.
Liquid cleanser are preferred, rather than soap which alters the skin pH and affect the skin lipids, increase skin drying and irritation – Learn more about soap and its impact on skin pH in the skin pH series. The pH of skin can affect its skin lipids, which (a lower skin lipids) in turn causes drying, itchiness and skin inflammation.
Liquid cleanser should be mild, non-irritating, non-stinging (especially to the eyes as babies may not be able to blink fast enough) and non-pH altering, and contains moisturizing function
For cleansing of baby’s skin, I’ve found two other articles that offer recommendation on what’s best for baby skin.
Apart from the three points above, additional points are:
4. AvoidAnionic Surfactants, these are those that cleanse very well but most irritating to skin, an easy way to identify them is to look out for those chemicals ending with Sulfates.
5. Choose those with large head groups and have the ability to form larger micelles. Surfactants organize into groups of molecules called micelles and generally the larger these micelles are, the less irritating the surfactant is. This is related to larger micelles being less able to penetrate the outer layer of skin (stratum corneum).
6. No preservatives is not best as bacterial growth can happen in such products
7. No scent does not mean no fragrance (potential irritant) is used, it can be one fragrance masking that of another.
Why Baby Skin needs Cleansing
Just like last week we asked the question ‘Why not just use water to clean?‘ (because 40% of dirt, oil can only be removed by oil), we also have to understand why baby skin needs cleansing. Baby skin has saliva, nasal secretions, urine, feces, germs and dirt which can potentially irritate the skin when left on the skin. It is also possible that both skin allergy and the body (ie food allergy) can develop from foods being left on the skin for too long. It is therefore important to clean baby skin. However, baby skin, given its structural vulnerabilities, should not be over-washed and to avoid using baby wipes on face or baby wipes that are non-hypoallergenic, especially those containing fragrance and MI.
Next week, I’d (make a brave) attempt to look into how surfactants affect skin and in particular, impact on eczema skin. It’s a very ‘chemical’ topic and not easy, so appreciate if there’s feedback to improve on the blog post, and share your best cleanser!