Allergic Contact Dermatitis in Children (II) – Q&A with Dr Steve Xu

This is a continuation of last week’s interview with 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.

Dermatologist Dr Steve Xu MD

Dr Steve Xu MD, MSc

On ‘Bland’ Skincare Products

MarcieMom: I’ve emphasized in my blog that the fewer the ingredients, the less likely it is to irritate (such as in this expert interview and also in the moisturizer selection 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.

Moisturizer Selection

Moisturizer Selection – Reducing possible contact allergens

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.

Skin of eczema children is more susceptible to staph bacteria colonization

Skin of eczema children is more susceptible to staph bacteria 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

  1. 0 – 3 years old – could be due to immature skin barrier, including lower lipid content, fewer natural moisturizing components, higher pH and thinner epidermis
  2. 6 – 7 years old
  3. Adolescence

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 a high 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.

Corticosteroids

In the article1, it was mentioned that the most “allergenic” corticosteroids are:

  1. Budesonide
  2. Trixocortal pivalate
  3. Hydrocortisone butyrate

The least allergenic are those with halogenated C16-methylated molecules and in order of increasing potency:

  1. Aclomethasone dipropionate
  2. Beta-methasone valerate
  3. Memoetasone furoate
  4. Desoximethasone
  5. Clobatesol propionate
Corticosteroids - Potency and Allergenicity

Corticosteroids – Potency and Allergenicity

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

References:

  1. 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

Allergic Contact Dermatitis in Children (I) – Q&A with Dr Steve Xu

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:

  1. Babies’ skin barrier is thinner than that of an adult- making it extra vulnerable to chemical irritants (also greater transepidermal water loss and therefore, moisturizing is important)
  2. Increasing research showing that a strong skin barrier has protective effect against eczema, and reduce likelihood of food sensitization
  3. Babies have a larger surface area to volume ratio, therefore potentially the risk associated with chemical absorption is higher
Contact allergens is of particular importance to pediatric patients

Contact allergens is of particular importance to pediatric patients

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.

Dermatologist Dr Steve Xu MD

Dr Steve Xu MD, MSc

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 dermatitis here. 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):

  1. Neomycin – topical antibiotic, another contact allergen is over-the-counter antibiotic Bacitracin
  2. Balsam of Peru – also known as Myroxylon pereirae, chemically related to fragrance and thus used to screen for fragrance allergy
  3. 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)
  4. Benzalkonium chloride – ammonium compound used as preservative, including in disinfecting wipes and eye drops
  5. Lanolin – natural oil from sebum of wool-bearing animals
  6. Cocamidopropyl betaine (CAPB) – used as a surfactant
  7. 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)
  8. Methylchlorsothiazolinone (MCI)/ Methylisothiazolinone (MI) – likely to be in bubble baths, soaps, cosmetic products, and baby wipes
  9. Propylene glycol – previously common in moisturizers (but many brands stopped including propylene glycol: it has humectant properties and also an emulsifier) and topical steroids
  10. 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)
Top 10 Pediatric Contact Allergens in Personal Hygiene Products

Top 10 Pediatric Contact Allergens in Personal Hygiene Products

Other than the above 10, the other well-known contact allergens are cetylstearyl alcohol, sodium lauryl sulphate, pehnoxyethanol, parabens, TEA (triethanolamine) and vitamin E.

Nickel and cobalt are 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 that kids 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” ororganicalso 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.

Interview with dermatologist Dr Steve Xu, MD

Interview with dermatologist Dr Steve Xu, MD

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.

References:

  1. 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:

  1. 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.
  2. 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.
  3. 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.
  4. Walter JR and Xu S. Topical Drug Innovation from 2000 through 2014. JAMA Dermatology. 2015. 151(7):792-794.
  5. Xu S, Heller M, Wu PA and Nambudiri VE. Chemical Burn Caused by Topical Application of Garlic Under Occlusion. Dermatology Online Journal. 2014. 20(1). URL: https://escholarship.org/uc/item/88v527wg.

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

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

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

In the video, the key points covered are:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

#SkinishMom Investigates – Apple Watch and Skin Irritation

There were quite a few reports of users getting skin irritation from wearing Apple Watch and this got #SkinishMom into an investigative mode. It’s not news that items we wear can cause skin irritation, for instance, nickel in jewelry is a common irritant. It’s also not news that wrist bands can lead to skin irritation, for instance, there was a voluntary recall for Fitbit Force after news of rashes last year. As for Apple, there was also a reported instance of a child getting skin irritation after using iPad (due to nickel allergy). So what’s with these materials and their contact with our skin?

Skin Irritation and Apple Watch - Top 6 Suspects

Suspect #1 – Allergic Contact Dermatitis to Nickel

Allergic contact dermatitis involves the immune system by which a hypersensitive reaction (rash) results from a previous contact with the allergen. Of the metal materials, nickel is one of the most common cited that cause this rash. In 2013, when UK issued new coins containing higher level of nickel, it was reported to pose an allergy risk.

For both Fitbit and Apple, there are nickel in the wristbands. From Apple website,

Apple Watch, the space gray Apple Watch Sport, the stainless steel portions of some Apple Watch bands, and the magnets in the watch and bands contain some nickel. However, they all fall below the strict nickel restrictions set by European REACH regulation.

REACH stands for Registration, Evaluation, Authorisation and Restriction of Chemicals. It is a regulation of the EU, which is known for setting strict standards on safety. EU had restricted the amount of nickel in jewelry and products that come into contact with skin in the ‘EU Nickel Directive’.

If Nickel is so much trouble, why do jewelry and wristband manufacturers continue to use it? It is usually selected for its corrosion resistance, toughness, strength at high and low temperatures, magnetic and electronic properties that are superior to other metals.

Suspect #2 – Allergic Contact Dermatitis to Methacrylates 

Methacrylates is a polymer that is commonly used in adhesives and also in both Fitbit and Apple Watch. From Apple website:

The Apple Watch case, the Milanese Loop, the Modern Buckle, and the Leather Loop contain trace amounts of methacrylates from adhesives. Methacrylates are found in many consumer products that come in contact with the skin, such as adhesive bandages. Some people may be sensitive to them, or may develop sensitivities over time. Apple Watch and its bands are designed so that parts containing methacrylates are not in direct contact with your skin.

Suspect #3 – Irritant Contact Dermatitis to Sweat

Irritant contact dermatitis is a delayed hypersensitive reaction due to prolonged exposure to an irritant. There is a wide range of possibilities that trigger irritant contact dermatitis, almost anything is possible including our sweat. Since Apple Watch and fitness trackers are worn to keep track of heart rate and fitness goals, it is likely that it comes into contact with sweat. From an interview with dermatologist Dr Cheryl Lee, she explained:

The salts from sweat can crystalize and act as an irritant to the skin. If you can see that your baby’s sweat has dried and has a salty residue, then I would recommend rinsing it off with plain water (no soap) to prevent it from becoming an irritant. If the sweat is not crystalized, I wouldn’t worry about it much.

Suspect #4 – Irritant Contact Dermatitis to Soap

Those familiar with eczema skincare know that soap is not recommended as it is drying (alkaline) and often irritate sensitive skin. In fact, soap is seldom patch tested as it is almost a certainty that leaving it on your skin for 2 days (norm period for patch test) will result in a rash. If your Apple Watch happens to trap the soap and you’re wearing it without removing, the soap may be the culprit behind the rash.

Suspect #5 – Heat Rash

If it’s hot and humid weather and your Apple Watch is constantly in contact with your skin, it may result in blocked sweat ducts. Similar to a common baby rash Miliaria (as babies have immature sweat ducts, thus more prone to blockage), your blocked sweat ducts can trigger skin rash.

Suspect #6 – Constant Friction

I couldn’t find a Pubmed article on friction and skin rash but from my understanding, it could be

  • Constant friction causes chafing that can be painful. Moreover, exposed skin is more vulnerable to irritants.
  • The sweat residue increases the friction.
  • Wet (sweaty) skin makes the chafing worse.

So What to Do if You Really WANT AN APPLE WATCH?

If you have not bought the Apple Watch

You can take a patch test to see if your skin will react to materials in Apple Watch, especially nickel. A patch test is quite expensive and take 2-4 days for the patch results to show and require repeat consultations to view how your skin has reacted. I read from WSJ that you can try taping a nickel coin on the inside of your arm for 2 days and see if a rash appear. (I’m not sure if it’s accurate reflection though as the nickel quantity or type of nickel alloy may be different.)

Or decide not to take the risk or take the risk with a later generation of Apple Watch (where possibly nickel and other improvements to apps would have been made!)

If you have bought the Apple Watch > No reaction – Good for you!

If you have bought the Apple Watch > Skin rash – Top 6 tips to Try

Skin Irritation and Apple Watch - Top 6 Tips to Limit Skin Rash

  1. Place a barrier between your skin and the wristband – you can put a layer of emollient over but be sure that your skin is clean. Slapping moisturizer on top of sweat and irritant may worsen the rash. Of course, use a moisturizer that will not irritate your skin in the first place (ingredients to avoid).
  2. Clean your sweat off and put on the watch only when your skin is clean and dry.
  3. Make sure to wash soap off or use a gentle non-soap cleanser if you have sensitive skin.
  4. If it’s hot and humid, you may want to take off the watch for a few hours. (Maybe when you’re sitting down and not exercising?)
  5. Not wearing it too tight or too loose – Apple had provided guidelines on this; both too tight and too loose can cause skin rash, think of a waist band that’s too tight or a watch that’s too loose and created friction.
  6. Keep the Apple Watch clean – it somewhat defeat the purpose of cleaning your own skin and then putting on something that has a host of sweat residue and debris for hours a day. Apple also has guidelines on cleaning their watch.

I’m actually glad that I didn’t go out to get an Apple Watch (it’s not available in Singapore anyway!) because I always get skin rash with watches (leather or metal) and a gym mate told me you can’t play all your iTunes songs on the Apple Watch and can’t blue tooth the songs from the watch to the earphone (gasp! That’s the main reason why I want an Apple Watch). Do share your experience in the comments!

Update on 29 June 2015 – Apple Watch is available in Singapore and one reader Nicholas pointed out in the comments below that you can blue tooth your iTunes songs to earphone. (Hmmm.. should I get one?)

Sticking to watch-free (skin rash free) wrist,

#SkinishMom

p.s. I’m not sure if Apple is reading this post, comments are my own, from understanding of skin, rashes and reading online. But if Apple is reading this, do amend a formatting error on your guideline – REACH, not REACh (sorry, but I kinda get irritated by formatting error!)

Skin pH with Cheryl Lee Eberting, M.D.– Eczema and Skin pH

Skin pH interview with skin barrier expert, Cheryl Lee Eberting, M.D.of CherylLeeMD.com

Skin pH interview with skin barrier expert, Cheryl Lee Eberting, M.D.of CherylLeeMD.com

This is the 5th and last post of Skin pH series: Read the 1st post on Understanding Skin pH and its Impact here, 2nd post on Overly Acidic and Alkaline Skin here, 3rd post on Diet, Environment on Skin here and 4th post on Moisturizing and Skincare Products’ impact on Skin and Skin pH here.

We are privileged to have Board Certified Dermatologist Cheryl Lee Eberting, M.D. again for this 5-week skin pH series. Read more on Dr Cheryl Lee here. Dr. Eberting invented the TrueLipids skin barrier optimization and repair technology; a technology that helps the skin to repair itself by recreating its own natural environment.  Dr. Eberting’s expertise in treating eczema  has led people to come from all over the world to seek her care and to the development of a dedicated eczema care clinic online.

MarcieMom: Thank you Dr Cheryl Lee for being with us for the past 4 weeks and today, we focus on eczema skin – a topic which parents/readers of this blog would most certainly be keen to find out!

Eczema and Skin pH

MarcieMom: I read that alkaline pH is associated with skin dryness. Since eczema is characterized by skin dryness, does this mean all eczema skin is too alkaline? Came across a study that even the uninvolved skin of eczema adults have higher alkaline pH than those without eczema. It was stated as 6.13±0.52 on the eczema lesions, 5.80±0.41 on perilesional skin and 5.54±0.49 on uninvolved skin. In the control group, the mean pH of the skin surface was 5.24±0.40.

Dr Cheryl: Yes.  If you have dry skin, eczema, a rash, or an infection on your skin, then the pH is too high.  In atopic dermatitis, there are 7 major problems that lead to the abnormal skin barrier and they are all interrelated with each other.  The problems are as follows:

  1. Skin lipid deficiencies (phytosphingosine, phytosphingosine-containing ceramides like Ceramide 3, cholesterol esters, and very long chain fatty acids have been shown to be particularly deficient in atopic skin, dry skin and aged skin).
  2. Excessive loss of water due to skin lipid deficiencies. (white petrolatum in the gold standard water loss inhibitor.  Paraffin is likely even more effective than petrolatum however.  Certain lipids have also been shown to be very good at inhibiting water loss.  The lipid isostearyl isostearate is one of the most effective lipids as preventing water loss from the skin.
  3. Abnormal pH (partly caused by the lipid deficiencies above, but also then CAUSES a lipid deficiency because the enzymes that make epidermal lipids only work within the optimal skin pH range)
  4. Susceptibility to infection (caused by the lipid deficiencies—some of these lipids are anti-staphylococcal—and caused by the overly alkaline pH).
  5. Inflammation (cause by lipid deficiencies that cause desiccation and entrance of allergens and infection into the lower levels of the epidermis which then leads to infection.)
  6. Allergy (atopic skin is susceptible to allergic contact dermatitis to certain chemicals at higher rates than non-atopic skin.  This is also a result of all of the above problems.)
  7. Abnormal calcium gradients.  (The epidermis has calcium gradients that lead to lipid production and to normal cell cycling.  In atopic dermatitis, these gradients are disrupted and contribute to lower levels of lipid production and dysfunctional cell cycling.)

These 7 problems are present in the entire skin barrier of an atopic and this is why is it so very important to focus on skin barrier optimization that addresses all 7 of these problems simultaneously.

MarcieMom: What skincare measures (if any) should parents of eczema children take to help the child’s skin to reduce its alkalinity?

Eczema and Skin pH - Steps to take

 

Dr Cheryl Lee:

1. Bleach Baths Really Work:

As I discussed in this post, I think bleach baths work as part of the eczema skin care regimen, but they also alkalinize the skin a little bit too.  The target concentration of a bleach bath is .005% hypochlorite ion.  Because there are different sizes of bathtubs around the world, it is difficult to just tell you how much bleach to put it.  In the United States, we have a standard-sized tub that most people have in their homes. (And we have ridiculously large tubs too).  For the regular-sized American tub, I recommend 1/8 cup if the tub is 1/4 full, or 1/4 cup is the tub is 1/2 full or 3/8cup is the tup is 3/4 full.  For very mild cases of eczema, bleach baths may not be needed, but if there is any crusting or scabbing, try taking the bath three times a week.  The more severe it is, the more frequently you should take a bleach bath.

Special Trick for Babies with eczema:  If your child will not stay in the bathtub long enough to have an effective bleach bath (about 20 minutes), then try using a large tupperware/plastic container INSIDE your shower for your child to play in.  I recently discovered this on my own children and now I can’t get them to STOP taking a bath (which is bad for eczema too;  too many baths can dry out the skin and make it worse).

Of note, we have always thought that the bleach bath is working because it is killing the Staph. aureus on the skin.  Well, recent studies showed that it is not only the killing of the Staph, but it is also due to the low level oxidation exposure.  When the skin is exposed to very low levels of oxidation, the skin then turns on anti-inflammatory and reparative pathways.  This is totally counter-intuitive, but is very, very interesting and makes me thing that our creator really knew what he was doing!

2. pH-Adjustment After Bathing and After Bleach Baths OR If you Don’t Have Access to Bleach:

After taking a bleach bath, use a pH-protecting gel with vinegar in it or use a vinegar spray diluted with one part vinegar and six parts water to all affected areas.  (white vinegar or apple cider is best—no rice or balsamic vinegar).  This should then be covered with a pH-optimized moisturizer (pH 4.6 to 5.6….a little more acidic may be beneficial, but more alkaline is bad).

Of note, I had a patient come to see me all the way from Cambodia.  When she went home to Cambodia, she was unable to find bleach anywhere.  If this is the case, I have seen similar benefits from vinegar baths (it takes A LOT of vinegar–around 6 cups to a half-full regular American-sized tub).  Or, you can do the vinegar spray or pH-protecting vinegar gel if you cannot take a bath.

3. Moisturize the Skin Barrier AT LEAST Two Times a Day With Skin Barrier Optimizing Moisturizers, But Four Times Works Better and Faster:

I think it is very important to moisturize atopic skin at least twice a day WHEN IT IS NORMAL LOOKING.  When it is broken out AT ALL, I always advise that my patients use their eczema products (we use the TrueLipids Eczema Experts 1% Hydrocortisone Cream followed by the TrueLipids Relieve & Protect Ointment) up to four times a day UNTIL the skin is normal looking.  Once the skin LOOKS and FEELS normal, then my patients switch to the TrueLipids Ceramide+ Cream followed by the ointment twice a day for maintenance.  It is very important to treat ALL affected areas and not just the areas that are scabby looking.  What I mean by this is that even the areas of the body like the stomach and back that may look a lot better that the worst areas on the arms and legs, must also be treated until they ARE normal; normal looking and normal feeling.

The skin on the trunk often has what we call folliculocentric atopic dermatitis where each little hair follicle is more accentuated and is a little bit lighter in color than the skin around it.  This is active disease and needs to be treated just as much as the scabby, inflamed areas do.  The skin on the trunk usually heals much more quickly than does the skin on the arms and legs and, as it heals and goes to normal, the hydrocortisone can be replaced with the Ceramide+ Cream.

4. The Maintenance Moisturization Phase is Just as important as Treatment Phase:

I cannot stress the importance of maintenance moisturization.  Plan on at least twice daily moisturization for the rest of your life.  You must avoid all common allergens in your skin care products too.  There are certain allergenic chemicals that are known to be more common in people who have atopic dermatitis and you should at the very least avoid them.  I will write more about this in a later post.  By optimizing the skin barrier, you can prevent it from breaking down into eczema and can probably also control other allergic diseases like asthma and hay fever too.

5. Wet Wrap Therapy if Your Eczema is Severe:

If your eczema is very, very severe, you will need to do wet wrap therapy where you take your bleach bath, then do your pH adjustment and then wrap the skin in WHITE COTTON (not wrinkle-free type fabric because is often has formaldehyde in it) pajamas or bandages every day.  I have even had a few patients who have needed to do wet wraps during the day too.  Don’t use ACE wraps or anything that has latex or spandex in it as this can be allergenic for atopic skin too.  Once the wraps or pajamas are on, spray them down with water and cover with a layer of dry clothing and go to bed.

6. Break Through Low Dose Steroid Maintenance in Severe Cases:

For more severe cases, once the skin is completely back to normal, I recommend using the TrueLipids 1% hydrocortisone cream twice as part of your maintenance routine.  Studies have shown that low levels of hydrocortisone like this can keep one in remission and prolong time between relapse. Studies have also shown this benefit from treatment a few times a week with Elidel or Protopic, but I do not prefer them as I don’t find them to be very effective, they are very expensive and they are not the safest drugs in the world. (That being said, if you are allergic to glucocorticoids, then Elidel and Protopic can be a lifesaver.)

Also very important is that of glucocorticoid allergy.  Studies have shown that between 24 and 90% of children with atopic dermatitis who are patch tested are allergic to at least one glucocorticoid.  If your child is one who seems to either not get better with hydrocortisone or who gets a little better but then seems to get worse, he/she may be allergic to it.  It is always a good idea in this case to get your child patch tested to see what they are allergic too and to learn what classes of gluccocorticoids that your child can use.

7. Allergen Avoidance and Patch Testing if Needed:

I cannot stress enough how important it is so avoid allergens in your skin care products, soaps, detergents AND in the products that family members are using.  Find a dermatologist who is experienced in patch testing (not prick testing) for allergic contact dermatitis (ACD).  ACD is an allergy to a chemical that is coming in contact with the skin.  For example, fragrance allergy is one of the most common allergens in atopic dermatitis.  If daddy is wearing cologne and baby touches his shirt, this can equal a month of eczema flare for baby.

The whole family needs to avoid the allergen triggers.  In addition to fragrance (which cross reacts with essential oils and many plant extracts), common allergens in atopic dermatitis include nickel, formaldehyde releasing preservatives, propolis (in beeswax), neomycin, bacitracin and more.

Thank you Dr Cheryl Lee for going through with us the factors that affect skin pH with practical steps on what parents can do. It will definitely help parents to be committed to these measures with the right understanding of why to take them. Thank you once again!

Eczema News – Is Baby Wipes causing the Rash?

Contact dermatitis_ rash_baby_MI

In the beginning of the year, there was a ‘scare’ – news circulated that baby wipes is the cause of terrible rash on the face of babies. This is in response to a study published from observations of 6 children, with ‘disfiguring patches to crusting, swelling, blistering and tiny cracks in the mouth, cheek, hands and/or buttocks’. Even though it’s half a year since that news, many parents are still very wary about baby wipes. Now, let’s admit it – baby wipes do come in very handy, so let’s take it as we still need baby wipes. So what do we know about these rash-causing baby wipes in order to choose the ones that are safe?

Putting it into Perspective

The rashes can be various types of dermatitis –

Atopic dermatitis where the child is allergic to ingredient, and rashes develop very quickly even for small amount of contact.

Contact dermatitis where sensitization occurs overtime, i.e. the irritant has been in contact with the skin for some time. This is more common.

In both types of dermatitis, the ingredient to look out for (and avoid) is methylchloroisothiazolinone or methylisothiazolinone. The treatment is similar – avoidance + prescription to reduce skin inflammation. The potency of the cream will depend on each patient and also where the rashes are. Avoid wiping the baby’s face (more sensitive, thinner skin) with wet wipes, especially when you are not clear about its ingredients.

Research Studies

I looked through the research on methylisothiazolinone published in 2013 and 2014, the more common conclusions are:

1. Increasing reports of sensitization to methylisothiazolinone (MI), with many studies citing it as an ‘epidemic’. MI is also named 2013 “Allergen of the Year” by the American Contact Dermatitis Society.

2. MI is an ingredient contained in baby wipes, and it is a preservative used in cosmetics, household, and industrial products to prevent bacterial and fungal contamination.

3. The % of sensitization range from about 2% to 4%, so it is not a sure thing that your child will react to it.

4. A patch test can be requested to check if there is hypersensitivity to methylisothiazolinone and in this regard, improvements to patch test for this have been suggested to modify the test solution concentration and also to increase the length of observation to 7 days.

5. The age group most susceptible to this is female above 40 years (6% sensitization), on the face due to cosmetics. Certain occupations are painters and beauticians. Parents are also affected due to the use of baby wipes, so not just the kids! Studies here and here.

So my take is if your child or yourself doesn’t react to baby wipes, you can continue using but take care to use less often, not on the face, and find those brands without MI if possible. What’s your favorite brand?

Contact Dermatitis – Can a Child have Eczema and this?

Double whammy? Contact dermatitis in atopic dermatitis child

Double whammy? Contact dermatitis in atopic dermatitis child

Can my Child have both Atopic and Contact Dermatitis?

Contact dermatitis is more common in adults, but it is possible that a patient with atopic dermatitis also have contact dermatitis. The logic is that eczema skin barrier is defective, thus more vulnerable to hypersensitive reaction to chemicals. The chemicals which I’ve found from recent years’ studies which affect eczema patients (not necessarily children) more than non-eczema patients are

Surfactants cocamidopropyl betaine (CAPB), from AAD study. Also quaternium-15, imidazolidinyl urea, DMDM hydantoin, and 2-bromo-2-nitropropane-1,3-diol (from another AAD study)

How does dermatologist treat Contact Dermatitis?

The treatment is similar to atopic dermatitis, so in a sense it may not be as critical if the two cannot be differentiated. The difference is that without avoiding the substance that is causing the hypersensitive reaction, it is then not possible to keep it from causing the rash. Moisturizing, medicated cream, compresses to relieve itch and soothe skin, and antihistamines for reduced scratching at night may be prescribed.

In finding out which are the irritants involved in contact dermatitis, a patch test can be carried out (read more here). Patch test involves placing the suspected irritants/chemicals (note: there is a ‘science’ as to how much to put and how to prepare the liquid, don’t try to do this yourself) on paper tape on your child’s back or arm. The tape will be left on for about 48 hours and observation be noted by the dermatologist.

Is my child more likely to have contact dermatitis as an adult?

I haven’t come across such study, but it makes sense to figure out the irritants early and to avoid them. Also to treat the eczema promptly and take measure to protect the child’s skin barrier so that it is more robust against irritants when the child is older. (At the same time, I’m thinking she has got to fend for herself when old, I’m not going to say ‘Stop Scratching’ till I’m 60 year old!)

What are the preventive measures for contact dermatitis?

Avoidance is key, especially once you or your child has undergone patch testing and knows which substance triggers the hypersensitive reaction. There are common chemicals that are present in contact dermatitis in children (US), and these are nickel, neomycin, cobalt, fragrance, Myroxylon pereirae, gold, formaldehyde, lanolin/wool alcohols, thimerosal, and potassium dichromate. Also for those without any allergy, but has eczema (known as ‘intrinsic eczema’), this study suggest the possibility of nickel and cobalt allergy.

This study provides a percentage of common allergens for eczema children, nickel (16.3%), cobalt (6.9%), Kathon CG (5.4%), potassium dichromate (5.1%), fragrance mix (4.3%), and neomycin (4.3%).

The above chemical names may be too difficult to remember, so below is a compilation of where they may be commonly present in:

Soaps and detergents

Saliva

Urine (common cause of diaper rash)

Baby lotions, avoid perfume/fragrance products, preservatives

Latex, e.g. rubber products

We’ve covered the basics and the conclusion may be to be aware of contact dermatitis and promptly remove the suspected irritants. When the child is older, say 5 year old, bring him/her to a patch test.

Read last week: Contact Dermatitis, does your Eczema Child have it?

Contact Dermatitis – does your Eczema Child have it?

The things that can be irritant! Eczema child and contact dermatitis

The things that can be irritant!

So far we have not gone ‘technical’ in this blog to differentiate between atopic dermatitis and contact dermatitis, simply because when we talk about eczema, we are referring to atopic dermatitis. So what’s the difference between the two? And more importantly, are our eczema children also suffering from contact dermatitis? Is the treatment the same? And are they more likely to have contact dermatitis when older?

Phew, this already sounds like a stressful topic (everything is stressful the minute I think about anything from primary school/ grade school onwards!) These topics will be broken into two manageable reading posts, with a focus to share about the research on relationship between atopic and contact dermatitis (at least what I can find from past 3 years!)

What is Contact Dermatitis?

To complicate matters, there are two types of contact dermatitis – allergic and irritant. Allergic contact dermatitis involves the immune system by which a hypersensitive reaction (rash) results from a previous contact with the allergen. Irritant contact dermatitis, on the other hand, does not involve the immune system being sensitized to the irritant. It is a delayed hypersensitive reaction due to prolonged exposure to the irritant.

How is it different from Atopic Dermatitis?

Irritant contact dermatitis is different from atopic dermatitis in that usually more than a minuscule amount of the irritant is required to generate the hypersensitive reaction, whereas in atopic dermatitis, a very small amount can cause a severe flare-up. The mechanism of which the rashes appear differ – contact dermatitis is known as type IV delayed hypersensitivity reaction which does not involve the (IgE) immune system whereas atopic dermatitis is type 1 IgE-mediated reaction.

Which one is my Child suffering from?

This can be difficult to figure out because the symptoms of eczema and contact dermatitis are similar, such as red rashes, blisters, thickening of skin (lichenification), scaly skin and itch.

Atopic dermatitis (eczema) is more common in children, however when the child does not respond to treatment, it may be worthwhile exploring if he/she is having rashes from the chemicals the skin comes into contact with. The relationship and prevalence of the two is still not super clear, as it may be due to the much higher amount of lotions and medication used on the eczema child’s skin. This study suggest that there is increasing prevalence of contact dermatitis in children, whereas previously thought to be uncommon. Patients with atopic dermatitis are more likely to be sensitive to quaternium-15, imidazolidinyl urea, DMDM hydantoin, and 2-bromo-2-nitropropane-1,3-diol in this study.

Check back next week on Wednesday to learn of the treatment and prevention of contact dermatitis in children.

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