Eczema News – ‘Lipid fingerprint’ Treatment Approach

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

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

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

Target Lipid Deficiency for Eczema Treatment

Target Lipid Deficiency for Eczema Treatment

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

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

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

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

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

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

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

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

Clinical Trials Review on Eczema Treatment

#1 Emollient

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

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

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

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

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

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

#2 Topical Corticosteroids (TCS)

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

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

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

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

#3 Wet Wrap

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

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

#4 Topical immunomodulants

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

#5 Proactive approach with topical anti-inflammatory therapy

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

#6 Antimicrobials and antiseptics

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

#7 Antihistamines

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

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

Parent (Patient) Eczema Consultation Tips with Dr Susan J. Huang – After Consultation

Dermatologist Susan Huang interview with EczemaBlues Eczema

Dr Susan Huang interview with MarcieMom, EczemaBlues.com

It’s fairly common to hear eczema patients lamenting that their doctors seem to be just prescribing creams and not listening enough. It can be even more difficult for parents, particularly as we are not the one ‘experiencing’ the eczema but we’ve got the responsibility to learn as much from the doctor (while keeping our toddler quiet)! MarcieMom is privileged to know Dr Susan J. Huang, the chief resident at the Harvard Dermatology Residency Program, who works at multiple prestigious hospitals in the United States.

More on Dr Susan J. Huang – Dr Huang is the chief resident of Harvard Dermatology Residency Program, and works at many hospitals including the Massachusetts General Hospital, Brigham and Women’s Hospital, Beth Israel Deaconess Medical Center, Childrens’ Hospital of Boston, Boston VA Medical Centers, and the Lahey Clinic. She is also the author of DermBytes.com, an online resource and blog on dermatology. Dr. Huang has written book chapters, published peer-reviewed articles, and presented at multiple national conferences on issues and topics in dermatology.

Marcie Mom: Thank you Dr Huang for last week’s tips on during consultation, this week we are focusing on after the consultation when the parent is now to manage and treat the child’s eczema, as advised by the doctor.

A common scenario is that he/she would be doing all as told, but find that the child is still scratching incessantly (and sometimes, with blood and tears daily)! Eczema is a chronic condition to be managed and parent shouldn’t be expecting miraculously smooth skin just because a doctor has been consulted. However, under what circumstances would it be justified to call the doctor before the next consultation? 

Dr Susan Huang: Hopefully, the physician has talked about what to expect from treatment during the visit. As you said, eczema is indeed a chronic condition and does not go away overnight. Setting expectations for the short term and long term period is a good idea at every visit. However, if there are any questions after you go home, you should feel comfortable calling the doctor’s office to get those questions answered and to see whether you need a visit to the office sooner.

MarcieMom: As advised by Prof Hugo, I bring my child for swimming and chlorhexidine-d her regularly, to reduce the staph bacteria. Lately, after learning more about nutrition from Toby Amidor and Julie Daniluk, I also feed my toddler with more anti-inflammation food and flaxseed oil. I know that there is no conclusive study on nutrition’s impact on eczema, but can and should a doctor advice outside of standard treatment options to include lifestyle and nutrition?

Dr Susan Huang: While we often think of pills and medications when we think about the practice of medicine, medicine really is much more. There are many lifestyle practices that can help in eczema and learning about these practices is helpful. Bleach baths, wraps, use of emollients are all treatments that are behavioral and can help in eczema. It is always a good idea to ensure good nutrition for all patients as well.

MarcieMom: Some eczema patients do feedback that their doctors don’t seem interested to listen to what the parents have to say regarding the child’s skin and eczema. It may truly be the case but does a parent have to be mindful to share what’s relevant to the doctor? For instance, is it possible that parents worry too much and discuss too many (remote) triggers? What is a clear sign of a disinterested doctor or one that shows no empathy for eczema?

Dr Susan Huang: It is important to have a good relationship with your child’s eczema doctors since eczema is a chronic disease. This patient/parent-doctor relationship will be one that extend beyond the initial visit! Every patient/parent-doctor relationship is different and the dynamics of the conversation of each visit depends on this relationship as well. If you find that there is difficulty in communication, you should find a doctor with whom you feel comfortable communicating with.

MarcieMom: Suppose a parent has found another doctor and wishes to stop seeing the current one. What should he/she ‘take-away’ from this doctor to the next? For instance, asking for the client-file? Does that belong to the hospital/doctor or to the patient? Also, I know that if a child is prescribed oral steroid, the follow-up consultations by the same doctor is important to assess the follow-up treatment options (and also completing the course as prescribed) Should a parent stick to the same doctor till the oral steroid course is over? (Do read my toddler’s positive experience with oral steroid)

Dr Susan Huang: It is helpful for your new doctor to know what evaluation has been done (including any lab tests, allergy tests) and what treatments have been tried. This way, you won’t “reinvent the wheel.”

In the United States, patients can request a copy of their medical files. This can be done through the doctor’s office, or if you are in a larger hospital, you may need to go through the medical records department.

Since eczema is a chronic disease, it is helpful for the doctor to get a sense of what the course of the disease has been and what the response to a certain treatment has been (whether it is oral steroids or another treatment). This is often easier if it is the same doctor, but sometimes that is not possible. If it is not possible to stick with the same doctor, make sure to have the documents pertaining to your child’s care. Photos can help as well.

Thanks Dr Huang, it has been a very helpful 3 weeks and I’m sure many parents will find this series helpful; My take is no matter what, don’t forget to enjoy our children with eczema (despite the eczema)!

For previous posts in this series, see

Before Consultation

During Consultation

Parent (Patient) Eczema Consultation Tips with Dr Susan J. Huang – During Consultation

Dermatologist Susan Huang interview with EczemaBlues Eczema

Dr Susan Huang interview with MarcieMom, EczemaBlues.com

It’s fairly common to hear eczema patients lamenting that their doctors seem to be just prescribing creams and not listening enough. It can be even more difficult for parents, particularly as we are not the one ‘experiencing’ the eczema but we’ve got the responsibility to learn as much from the doctor (while keeping our toddler quiet)! MarcieMom is privileged to know Dr Susan J. Huang, the chief resident at the Harvard Dermatology Residency Program, who works at multiple prestigious hospitals in the United States.

More on Dr Susan J. Huang – Dr Huang is the chief resident of Harvard Dermatology Residency Program, and works at many hospitals including the Massachusetts General Hospital, Brigham and Women’s Hospital, Beth Israel Deaconess Medical Center, Childrens’ Hospital of Boston, Boston VA Medical Centers, and the Lahey Clinic. She is also the author of DermBytes.com, an online resource and blog on dermatology. Dr. Huang has written book chapters, published peer-reviewed articles, and presented at multiple national conferences on issues and topics in dermatology.

Marcie Mom: Thank you Dr Huang for last week’s pre-consultation preparation, this week we are focusing on the communication during consultation.

MarcieMom: Most parents would have heard about allergy testing and after supposedly sharing with the doctor various suspected food & non-food triggers, he/she may expect to have an allergy test conducted for the child. Is that a reasonable expectation? Are there justifiable circumstances when a doctor would say that an allergy test is not needed? And should a parent always insist to have one? (as to how doctors decide on what triggers to test, refer to Prof Hugo and Dr Liew Q&A)

Dr Susan Huang: The decision whether or not to allergy test is one that is based on your child’s particular situation.  During your consultation, your physician will ask you questions about triggers to your child’s eczema.  Triggers may include food & non-food triggers as you mentioned.

As we discussed in the last post, it’s important to have the details of these triggers ready in preparation for the visit.  The visit will also include a physical examination to see whether findings are consistent with a food allergy.  If certain foods or other exposures are suspected, your physician can then work to help confirm the trigger and come up with an appropriate panel of tests.  Testing may include skin prick, RAST, or oral challenge testing.  If a contact dermatitis is suspected, patch testing is performed (this is where small quantities of different contactants are placed on the skin).

The role of allergy testing in eczema is still a debated topic but we certainly do know that allergies, asthma and eczema run together, creating the “atopic triad.”  Now, studies have shown that 1 in 28 suspected food allergies are not true food allergies, but rather “intolerances.”  So, it’s important to know whether one truly has a food allergy or not, because you don’t want to limit your child’s diet unnecessarily (providing well-balanced nutrition is important for the growth of your child!)

MarcieMom: The prescription given by the doctor is typically moisturizing creams with topical steroid treatment and the instruction usually to moisturize frequently while steroid is to be used sparingly and not more than twice a day. What would you advice the parent to find out more from the doctor? For instance, asking how the eczema rash would appear after a week of application? And when it’d be cause to come back earlier than scheduled for another consultation? (I think doctors usually refrain from talking too much about specific creams, parents can refer to this Q&A with Dr Verallo to identify the top irritants in creams and also this Q&A with Dr Bridgett to learn how to apply topical cream and steroid, and this post on steroid strength and steroid-phobia.)

Dr Susan Huang: Great question.  Questions about the use of topical steroids frequently come up. Make sure you review an Eczema Action Plan with your physician before you and your child leave from your consultation.  Having this information written down is important so that you don’t forget the details. Action items may include non-medication therapies (e.g. moisturizing, bathing techniques include bleach baths, wet wraps or wet pajamas, etc) as well as medications (e.g. topical steroids).  It is important to clarify how much of the lotion/cream/ointment, to where is should be applied, and when it should be applied and for how many days.  As you mentioned, also ask what you should expect to see at the end of the treatment course that your physician has detailed to you.  It is important to have this information written down because it’s hard to remember all these details!  We provide these written eczema action plans in our clinics.

Absolutely clarify follow-up plans before you leave for your visit. Your physician may tell you when to come back or may say to come back if the rash does not get better. In addition, she/he may give you a list of warning signs to look out for, e.g. if your child’s rash doesn’t get better after the treatment course, develops fever/chills, the rash becomes crusty, weepy or ulcerated — showing signs of infection, etc.

MarcieMom: Thank you Dr Huang, it’s good to know your point of view as to what is acceptable to be asked during a consultation, as some parents may be too shy and leave promptly with many questions still unanswered and then (worse), not carry out the treatment as directed cos they are fearful of what has been prescribed!

Parent (Patient) Eczema Consultation Tips with Dr Susan J. Huang – Before Consultation

Dermatologist Susan Huang interview with EczemaBlues Eczema

Dr Susan Huang interview with MarcieMom, EczemaBlues.com

It’s fairly common to hear eczema patients lamenting that their doctors seem to be just prescribing creams and not listening enough. It can be even more difficult for parents, particularly as we are not the one ‘experiencing’ the eczema but we’ve got the responsibility to learn as much from the doctor (while keeping our toddler quiet)! MarcieMom is privileged to know Dr Susan J. Huang, the chief resident at the Harvard Dermatology Residency Program, who works at multiple prestigious hospitals in the United States.

More on Dr Susan J. Huang – Dr Huang is the chief resident of Harvard Dermatology Residency Program, and works at many hospitals including the Massachusetts General Hospital, Brigham and Women’s Hospital, Beth Israel Deaconess Medical Center, Childrens’ Hospital of Boston, Boston VA Medical Centers, and the Lahey Clinic. She is also the author of DermBytes.com, an online resource and blog on dermatology. Dr. Huang has written book chapters, published peer-reviewed articles, and presented at multiple national conferences on issues and topics in dermatology.

Marcie Mom: Thank you Dr Huang for taking your time to offer tips to our parents on what they can do before, during and after consultation, as well as what they need to consider if changing their doctor. Let’s start right away with preparing for a doctor consultation.

MarcieMom: I’m assuming that the child has already been diagnosed with eczema and the parent is looking for a suitable doctor. In Singapore, there are many good doctors, some of whom listed here. I note that each doctor has their own specialty/ interest apart from being a pediatrician – immunology, allergy, asthma and/or dermatology. Must a parent specifically ask for a doctor in a particular specialty?

Dr Susan Huang: When looking for a doctor for your child with eczema, it is important that the physician has taken care of many children with eczema and thus has sufficient experience and knowledge about eczema.  In the U.S., physicians who routinely take care of children with eczema consist primarily of dermatologists, allergists/immunologists, and pediatricians.  The relationship between the physician and the parent(s) and child is also very important.  Treatment of eczema involves many behavioral components and these take time to review and demonstrate at the visit.  You will likely be seeing this physician many times over years (unless you don’t like him/her!), so it’s important to have a good patient-physician relationship.

MarcieMom: One of the key reasons why I brought my baby to see a specialist in a children hospital was because allergy tests are not available at a general practitioner or even pediatric clinic. Read here for preparation before a skin prick test. Apart from physical preparation (no antihistamine, good health), how can a parent help the doctor who is seeing the child for the first time to learn as much about the eczema/skin condition? Keep a food diary versus skin condition? If yes, for how long? Write down suspected triggers? Write down how the parent has been managing the skin, for instance, already using hypoallergenic detergent or vacuuming weekly?

Dr Susan Huang: Your physician will ask you questions to get your child’s eczema history. You will likely review whether there are any exacerbating or ameliorating factors to your child’s eczema.  These may include ingested foods or contact allergens.  Having details such as the temporal relationship between the trigger and effect on eczema is helpful. Note that the role of food allergy and food allergy testing in eczema is still a debated one (http://www.nationaleczema.org/blog/allergy-tests-eczema-complex-controversial-topic).

We do know that there is a tendency for allergy, asthma and eczema run together.  Many patients will also recall a clear history of a certain food triggering eczema. In this case, it is important to confirm this potential trigger through allergy testing.  Keep in mind that food allergy testing is not perfect (as is the case for any testing) and can lead to what we call “false positives.” So although it may be tempting to test to all allergens and via skin prick, RAST or oral challenge, it is important to discuss with your physician to come up with the appropriate testing for your child. Our National Institute of Allergy and Infectious Diseases (NIAID) has put out guidelines for food allergy testing (http://www.niaid.nih.gov/topics/foodallergy/clinical/Pages/default.aspx).

Regarding whether food allergy testing should be performed, the guidelines state that testing for milk, egg, peanut, wheat and soy allergy should be considered in “a child younger than 5 years old, and has eczema that does not go away with treatment, or has eczema and a history of allergic reactions to a specific food. Children with moderate to severe eczema are at risk for developing food allergy, especially allergy to mild, egg, and peanut. These children may benefit from a food allergy evaluation.”  If testing is performed, it is important to review with your physician what the plan of action will be.  It is a matter of figuring out which tested allergens are affecting your child’s eczema, and your child’s nutrition should be taken into account as well.

Also have a list of prior treatments on hand. These include medical and non-medical treatments.  In terms of medical treatments, make note of what medication was used, for how long, where it was used (for topical medications), how frequently and how much was used, and the effect the medication had.  Remember to also tell your provider about other treatments such as bleach baths, wet wraps, etc.

MacieMom: Thank you Dr Huang, you raised some points that I didn’t think of such as bleach bath, wet wrap, treatments that the parent may have implemented prior to seeing the doctor. Excited to read your tips for during consultation next week.

SOMEONE Managed Wet Wrapping for Child with Eczema

Stephanie's beautiful girl in wet wrap

Stephanie’s beautiful girl in wet wrap

This is a 2013 series focused on personal journey with eczema while managing a certain aspect of life. Today, we have Stephanie, whose daughter has eczema since 18-month old and shares how she manages wet wrapping for her. Stephanie is the founder of Allerchic, an online store for eczema, allergy and asthma.

Marcie Mom: Hi Stephanie, thanks for taking part in my Friday blog series ‘Someone has Eczema’! Let’s start with you sharing your family eczema history, who has eczema and what’s the level of severity for your daughter?

Stephanie: Thanks Mei!

Sadly the eczema comes from my side of the family, I had eczema as a child not what I would class severe, more the typical spots you expect, backs of knees, elbow creases. It disappeared for a long time then came back in my 30s on my eyelids.
My husband & my other daughter don’t have eczema (Thankfully)
My beautiful girl Jade has the triple threat of atopic conditions she has anaphylaxis, asthma & moderate to severe eczema.

Marcie Mom: I understand that you believe that wet wraps had helped improve your daughter’s eczema. How did you discover wet wrapping, and what improvement to your daughter’s skin did you notice?

Stephanie: Wet Wrapping has made a Huge difference to my daughters eczema! I first discovered Wet Wrapping when working in Children’s Ward (almost 20yrs ago), thankfully things have changed a lot since then – there is no more wresting a small child while trying to wrap bandages! For my daughter the Wet Wraps have an overnight effect on her eczema. The next morning without a doubt we see improvement, It may still take a couple of nights to get a flare up under control, but it is definitely quicker than cream application alone.

Marcie Mom: Quality of life is a big issue for eczema families. What do you think about your quality of life and your daughter’s before and after wet wrapping?

Stephanie: Before I started Wet Wrapping during a flare up neither of us had a great quality of life (or sleep!). Jade was often crying during cream applications, she was itchy, hot & irritated during the night & although fast asleep I knew she wasn’t getting the deep restful sleep needed as she was so agitated all night. This then of course flows over into the day, Lack of concentration, irritability & of course constant irrepressible scratching was sending us both crazy. As a mother it breaks your heart to see your child like this, so of course I had to find better way.

Wet Wrapping took the sting out of cream application, they take the heat of the rash & seem to generally make her a lot more settled & calm & as we apply her wet wraps before bed they without a doubt have improved her quality of sleep too.  So once again this flows into the day. Now I have a much happier, less itchy & irritable little girl.  And a happy eczema child = a very happy mummy!

Marcie Mom: One final question – did you daughter take well to her first wet wrap? Any tricks you used?

Stephanie: The first time I applied the Wet Wraps she was very miserable & irritated but it was almost like someone had waved a magic wand & she calmed very quickly once they were in place. Because we started using Wet Wraps fairly early on my daughter she is happy with the process, she knows it makes her feel better & so she is happy to wear them.

The advice I always give people when starting to Wet Wrap is:

  • Watch the Youtube Video on how to Wet wrap, do this a couple of times until you feel comfortable with the process.
  • Use the Tubifast Garments they are so much easier to use than bandages
  • Plan to Wet Wrap about an hour or two before Bedtime for best results
  • Have EVERYTHING ready to go before you even bath your child – This includes thinking about where you are going to apply Wet wraps, for little ones also think about a song you can sing or put their favorite movie on to help keep them distracted.
  • Explain to your child that it will feel a little funny at first, but it will stop them feeling so itchy.
  • Get them to have a good soak in either a water soluble bath oil (or bleach bath if prescribed)
  • Apply the steroid (if prescribed), thick Layers of emollient, Wet Wrap & clothing
  • For Babies feed them straight after Wet Wrapping (Breast or bottle) to help them settle, For older children a reward such as a game on the ipod, a special story & cuddles are a great idea. I truly believe, It is so important to set up positive reinforcement around Wet wrapping.
  • For Parents – Don’t stress or beat yourself up about getting the technique perfect. You will figure out the best routine for you & your child!
    Eczema parents are so amazing & I think sometimes we all just need to be told that 🙂

Marcie Mom: Thanks Stephanie for taking time to share your wet wrapping journey, indeed many have positive feedback on it.

Stephanie: Thank You Marcie Mom its been Great Talking with you!

SOMEONE has Eczema and Better the Future

Amanda of NSGCCE shares on how patients who participate in studies contributes lots!

Amanda of NSGCCE shares on how patients who participate in studies contributes lots!

This is a new series focused on personal journey with eczema while managing a certain aspect of life. Today, we have Amanda, who is a return guest to my blog; a previous interview with her was on building a vibrant support group, something which Amanda had successfully done through her twitter efforts for Nottingham Support Group for Carers of Children with Eczema (NSGCCE). This interview is special in that it’s not about Amanda (who also has eczema), but about the many eczema patients she knows who have helped better the future for eczema sufferers through their participation in eczema studies.

Marcie Mom: Hi Amanda, thanks for participating in this blog series.  I understand that NSGCCE and Professor Hywel Williams are supportive of research studies on eczema. As with all studies, the more participants, the stronger the conclusion for the study. How do patients normally become aware of a study that they can possibly participate in?

Amanda: That is such a good question, Mei.  If a researcher wants you, or your child, to be the subject of a trial, they should approach you with sufficient information (which generally has been approved by an Ethics Board) so that you will know what they are testing, what the alternative treatments in the trial might be, how long the trial is, how you can leave the trial early if you need to, and what the potential problems of participating might be for you. 

The other way of taking part in a trial is to take on a shaping role for the trial.  You might be invited to give the patient perspective on the design of the trial, you may be a co-applicant for the trial or you may join the management team which ensures the research follows its plan and monitors for problems. Quite honestly this side of participation has less of an obvious route.  It is, however, essential that patients help shape research – to ensure that it is going to be appropriate and meaningful for our future eczema treatment.

We all know that everyone with eczema finds that the eczema affects us in different ways different combination of triggers, different ways of life, different places the eczema affects, different skins which react in different ways.  And, yes, colour matters.  Research needs to reflect this diversity: get involved! So be proactive – speak to your dermatologist, join a patient group like that of the Centre of Evidenced Based Dermatology

Marcie Mom: For research studies to be effective, I’m sure variables have to be controlled and managed. What is the role of involvement of eczema patients in planning and developing the study?

Amanda: As a patient, you will be in an advisory position and will not be expected to do the work – but there will be a time commitment for periodic telephone conferences or meetings, over the length of the project.  The kind of questions you will be considering will be: are the outcomes meaningful, is the commitment from subjects realistic, is the patient information appropriate?  It is your chance to make this research really useful.

Marcie Mom: I suppose that certain actions need to be taken by the patient throughout the length of the study in order to collate the results. What are some difficulties that parents would have to deal with, in order to ensure that they are complying with the actions required?

Amanda: The difficulties for research subjects will vary depending on the trial of course.  But obvious concerns would be the length of the trial, whether the child has been allocated to a placebo (non-active intervention), inconvenience of testing (the test may be done some way from the child’s home, or may be done during school time for instance), the child’s eczema may flare or become unmanageable, family life may make it awkward to participate, perhaps the child might not so-operate (for instance if they need to use a stinging topical treatment or a horrid tasting medicine) – the list could be endless.  This is where a patient being involved in the design of the trial will make a huge difference by flagging up potential problems and trying to minimize them.

Marcie Mom: One final question – is there a study that has better-ed the life for eczema patients?

Amanda: Most research is building on research that has been done before, Gradually research moves us forward to a better place.  There is no doubt that I would rather have eczema now than 50 years ago because there is so much more known about eczema. And, of course, there is often a huge time lag between publication of results and implementation of findings.  Have a look at the GREAT database http://www.nottingham.ac.uk/greatdatabase/index3.php where there are some very interesting trials.

To my mind the eczema research priority setting partnership was one of the most interesting things done in recent years to attempt to prioritise what is really important to find out for eczema treatment in the future.

Marcie Mom: Thanks Amanda for taking time to share this important aspect of eczema study with us and I’m sure parents reading this will be more open to helping out in a future study!

Recommend Your Baby’s Eczema Doctor (Singapore)

Prof Hugo with Marcie

Many moms have asked who to recommend for their baby’s doctor – whoever we decide on, I feel that the doctor must be specialist in children and have the best interest of the child. It is also very important that we, as parents, be confident and partner with our child’s doctor. This is particularly the case if you’re prescribed oral steroid, you have to trust your doctor and follow through, giving up halfway makes it more difficult to decide on the next treatment step.

So, here’s the list of doctors who see eczema children, take the poll at the end or add in your own in the comments.

1. Prof Hugo Van Bever – My baby’s doctor, Head and Senior Consultant, Division of Paediatric Allergy, Immunology & Rheumatology, at NUH. He’s from Belgium 🙂 During his consultation, I find that he takes time to understand and form a proper diagnosis; I never told him this, but I was really afraid of bringing my baby to a hospital to get a skin prick test. Borrowed his book ‘Allergic Diseases in Children‘ from the Singapore’s library and felt more assured when I read that he cares deeply for his chronically ill patients.

2.Dr Lee Bee Wah – Consultant Paediatrician and Clinical Paediatric Immunologist/Allergist, The Child and Allergy Clinic, Mount Elizabeth Medical Centre. She’s recommended by my general practitioner whose children have allergies and see Dr Lee. See a post here contributed by her and as far as I read in Singapore Mom’s forums, it’s all positive. I’m not sure about charges though, my GP told me charges depends on duration of consultation.

3. Dr Liew Woei Kang – Paediatrician, Special Interest in Allergy & Immunology, SBCC Baby & Child Clinic. We’ve met and he’s active in driving initiatives related to allergy children. He also consults in several of Singapore’s hospital with children clinics. Dr Liew is the President of Asthma Allergy Association in Singapore.

Hospitals with Children Clinic

4. KK Women’s and Children Hospital – They have an allergy specialty that manages eczema, food allergy and intolerance. A/Prof Anne Goh Eng Neo is the Head & Senior Consultant. Also have another specialty in rheumatology & immunology, A/Prof Thaschawee (Tash) Arkachaisri is the Head & Senior Consultant.

5. National Skin Centre – They have a Paediatric Dermatology Clinic, and some of the doctors listed here also do visit consultation there.

6. Raffles Children Centre, Raffles HospitalThey have a paediatric medicine specialty, with Dr Veronica Toh and Dr Lim Yit Jean listed. Do check if they have specialists in child dermatology, allergy/immunology.

7. Mt Alvernia Hospital – They have different children clinics within the same hospital, do check first the doctor’s specialty before making appointment. Kinder Clinic is one of the clinics with a branch in Mt Alvernia; they have an paediatric allergy, immunology and rheumatology specialty. Here’s a list of their doctors, do check with them who is the specialist in the above field should you want to make an appointment.

8. Gleneagles Hospital – Likewise, double-check doctor’s specialty.

9. Polyclinics in Singapore – I think they have doctors who treat eczema, though not specializing in children. For those who don’t mind a longer waiting time, you can go to polyclinic first and get a referral to NUH. As far as I know, the difference between going to NUH straight, or getting a referral, is the latter doesn’t allow you to choose which doctor and possibly, a longer waiting time. The other doctor, A/Prof Lynette Shek, same dept as Prof Hugo, also has many positive feedback from moms in forums.

A final reminder

Generally, I recommend parents with severe eczema child to see specialists and not just pediatricians or general practitioners. This is particularly so as skin prick/blood test is administered in hospitals. Do note that Changi Hospital, Tan Tock Seng and Singapore General Hospital do not have a children clinics. If your favorite doctor has been left out, do leave their names in the comments!

[polldaddy poll=5690172]

Are you suffering from Steroid-Phobia?

Eczema on baby's face

You may be fearful of using steroids, as many parents (myself included) are. The fear could partly arise due to the negative news on steroid abuse by athletes and partly due to its side effects. If you have googled steroids, you will find numerous websites ‘promising’ treating eczema without using steroids. When Marcie’s doctor put her on oral steroid, I had a lot of reservations and fear and remembered scaring myself to death googling all the side effects.

But after going through resisting steroid use to using mild steroid lotion & cream and a 3-week oral steroid course for Marcie, I like to encourage you not to fear using steroids but instead use it under the instruction of your doctor, preferably a specialist.

How much steroid is ok?

Where there is no inflammation, just dry skin that’s itchy – I’d recommend using lots of moisturizer. Keeping the skin cool helps to relief the itch, so try turning the air-conditioner colder. (I sometimes give Marcie a cold drink bottle to hold and its works!)

Where there is inflammation and the skin is reddish and itchy – I’d clean the skin with cool liquid chlorhexidine (antiseptic) and apply mild steroid lotion or cream. For areas with delicate skin such as the face, I’d apply a 0.5% hydrocortisone and for other areas like the knees or elbows or hands, I’d apply a 1% elomet cream. Marcie’s doctor’s instructions were not to apply more than twice a day. So far, I have only needed to apply 2 to 3 days in a row, not exceeding twice a day, and the skin will go back to normal.

You can refer to this chart extracted from patient.co.uk for how much to apply, measured using fingertip units (ftu):

For a 3-6 month old child

  • Entire face and neck – 1 FTU
  • An entire arm and hand – 1 FTU
  • An entire leg and foot – 1.5 FTUs
  • The entire front of chest and abdomen – 1 FTU
  • The entire back including buttocks – 1.5 FTUs

For a 1-2 year old child

  • Entire face and neck – 1.5 FTUs
  • An entire arm and hand – 1.5 FTUs
  • An entire leg and foot – 2 FTUs
  • The entire front of chest and abdomen – 2 FTUs
  • The entire back including buttocks – 3 FTUs

What happened to Marcie after taking oral steroid?

You may be wondering why I’m encouraging parents to be open to using steroids when I initially did not even apply steroid on Marcie. It was very difficult to get the eczema under control and her eczema will suddenly just flare and affect her whole body. However, a one-time 3 weeks reducing dosage of oral steroid, prednisolone, really helped to keep the eczema manageable.  Marcie’s rashes disappeared within the first 2 days of the oral steroid, but gradually came back as the dosage is reduced. I worried a lot after reading the side effects of steroids such as thinning of skin, acne and damage of blood vessels. I am very glad that I chose to trust Marcie’s doctor and persisted with the 3 weeks course despite being fearful everyday. After the 3 weeks course, Marcie’s doctor said he will not give Marcie any treatment that is not 100% safe and will not give her another oral steroid course because that will not be safe. I read later that stopping an oral steroid course halfway causes more harm than following through and makes it more difficult for the doctor to decide on the next step.

After the oral steroid course, there are still rashes on and off, triggered by hot weather, sweat but never affecting her whole body with no reason. This makes it a lot easier to manage and Marcie has been a much happier baby since.

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