Eczema Research News – Do Antihistamines work?

Will Antihistamine Work for Eczema?

Will Antihistamine Work for Eczema?

This is part of a quarterly round-up of some of the recent eczema-related studies, so that we can be aware of possible treatments and their efficacy (and I can also keep myself updated with the latest eczema research!)

Today’s topic is on Antihistamines, do they Work? I’ve read in forums that some patients swear it helps with the itch, while others swear at it for being totally useless. What’s the research in this area? I’ve found a few studies online, but before we go into them, let’s get some Antihistamines’ basics.

What are Antihistamines?

Antihistamines are medication that are taken orally to block the activity of histamine at skin H1 receptor sites, thus alleviating itch. The older generation of antihistamines is sedative, usually prescribed to relieve itch and scratching at night.

Backtrack a step for some of you to understand the rationale – One of the characteristic of eczema is itch, which triggers patients and children with eczema to scratch at the inflamed skin/ lesion. Scratching worsens the skin inflammation, exacerbating the itch-scratch cycle. Scratching also thickens the skin, further breaks down the skin barrier and risks infection. Thus antihistamines are prescribed to alleviate the itch, to reduce scratching.  More on scratching here.

There are broadly two types of antihistamines,

1) the sedating types such as alimemazine, chlorphenamine, cyproheptadine, hydroxyzine and promethazine.

2) the non-sedating types such as cetirizine, levocetirizine, loratadine, desloratadine and fexofenadine. Supposedly, the non-sedating type can bind more selectively to the H1 receptors and last longer for 24 hours but many reported not effective.

How are Antihistamines supposed to help Eczema patients?

Oral H1 antihistamines have been prescribed for eczema patients, usually for their sedative effects. It appears that the sedating type is more commonly concurred to relieve itch better than the non-sedating. However, longer than 2 weeks’ use have been described to render sedating antihistamine ineffective to the patient.

Can Antihistamines be prescribed for Children with Eczema?

Yes, studies had been conducted for children from age 1, and different antihistamines have different age limits and the dosage depends on the weight of the child. Read that hydroxyzine is not recommended for below 6-month eczema baby and promethazine and alimemazine not for children under 2 years old.

Are there side-effects to Antihistamines?

Antihistamines may cause side effects such as drowsiness, headaches, constipation, dry mouth and blurred vision, and worsen condition such as glaucoma and retention of urine.

What’s the verdict on Antihistamine on Eczema?

After reviewing PubMed, it appears that it is difficult to isolate the effect of antihistamine as trials undertaken had used antihistamines as an add-on therapy (imagine which eczema patient would take part in a study that prohibit you from moisturizing and treating your eczema, insisting you consume only antihistamines!). Therefore, there is no conclusion as to whether antihistamines work. Based on a selection of antihistamines’ studies published on PubMed, cetirizine improved eczema (along with topical treatment) while chlorphenamine did not show difference in alleviating scratching at night. Hydroxyzine reported to work better than cyproheptadine in another study.

As you can see, there’s no clear conclusion on whether antihistamine is useful, neither is there clear study on whether the sedating type is more useful than the non-sedating. What is your experience? Do share in the comments, greatly appreciate!

Antibiotics given to Baby linked to Eczema

antibiotics eczema baby linkThis is a new study published in the British Journal of Dermatology, but I’m having a tough time finding the actual study thank you to EndEczema for directing me to the original study. From what I’ve read in UK online news, the results of the study are:

1. Babies given antibiotics in the 1st year are more likely (40%) to develop eczema

2. The reason is not fully known, though “One potential explanation is that broad-spectrum antibiotics alter the gut microflora and that this in turn affects the maturing immune system in a way that prompts allergic disease development,” said researcher Dr Teresa Tsakok, who works at St Thomas’s hospital in London.(taken from Guardian).

3. Study is based on systematic review of 20 studies, not a ‘study’ in itself.

4. Nina Goad, spokeswoman for British Association of Dermatology, said this study did not imply withholding antibiotics when necessary, but instead provide insight into possible causes of eczema.

5. Caution is this review does not necessarily indicate a causal relationship, because it could be eczema children require antibiotics as they have a higher chance of skin infection.

As to the gut flora being linked with eczema, there’s increasing evidence of there being a link between gut flora, skin flora and immune system though the exact mechanism of how it affects and what to do to prevent eczema is still not known. For more on diet studies, refer to Diet and Eczema Studies.

Update on July 2015 study that concluded eczema could lead to an increased infection risk, with a possible reason due to lack of microbial exposure during critical periods in early postnatal life… and overprescription of antibiotics could have a direct effect on the susceptibilities of organisms to commonly used antimicrobials.

Eczema Medication Series – Prednisolone

Marcie says 'Prednisolone worked for me!' MarcieMom says THANK YOU GOD

Marcie says ‘Prednisolone worked for me!’ MarcieMom says THANK YOU GOD

This is a series on some of the medication that I’ve collated from parents who shared in forums. For this week on Prednisolone, my baby with eczema had been prescribed a one-time 3 week reducing dosage course at about 7 month old, and it had cleared her eczema which then became manageable after the course. I know of many other young children, who did not respond well after the course, and some who did – please freely share your experience in the comments, your sharing can help encourage and comfort another parent.

What is Prednisolone?

Prednisolone is a type of corticosteroid which is prescribed to control inflammatory and allergic conditions like eczema, severe psoriasis and severe seborrheic dermatitis, colitis, asthma and rheumatoid arthritis. It works by stopping the release of chemicals that cause inflammation. Prednisolone is also used to treat blood cancer and lymphoma, to reduce the destruction of platelets by the body’s immune system.

It is usually an oral prescription (for my girl, it was solution) that must be complied strictly. Self-altering the dosage is not acceptable as the dosage is decided by a skilled physician, taking into account a combination of factors such as the skin condition and weight. If you are in a highly stressed season in life, do let your doctor know as that is a factor for deciding on the dosage.

From personal experience, the skin of the baby changes during the course – it may get better than worse, for my child, better again. Terminating halfway on your own, due to fear of oral steroid or deterioration of eczema, will make it more difficult for the doctor to make an assessment of how the course worked (or not).

Monitoring

Monitor your child’s growth and if concerned, discuss with the doctor. Steroid course may slow a child’s growth if used over long period or cause thinning of bones (osteoporosis), as it impairs calcium absorption and new bone formation. Look out also for signs of vision changes.

Warning

There are interactions with other medications so it’s best to let your doctor know of medication, vitamins and supplements that you or your baby/child is taking. Taking steroid over a long period can lower the body’s immunity. Avoid contact with people who are ill (esp. with chicken pox, measles or shingles), and also those who have taken a recent live vaccine (also check with the doctor before your child gets vaccinated). Wash hands also to prevent infection.

Side Effects

Watch for side effects, one of which is adrenal issue whose symptoms are fainting, irregular heartbeat, thirst, irritability or unusual fatigue. Click here for a list of common to less seen symptoms.

There is no particular diet to follow (except avoid liquorice), unless directed by your doctor.

Most Importantly, Does it Work?

I’ve found a study of 21 patients, only 1 achieved stable remission of eczema versus a higher rate (6 out of 17) for those prescribed cyclosporine. I find it strange though that I couldn’t find more study on Pubmed for prednisolone than for other medications in this series, which are licensed for use later. I’m glad that oral steroid course worked for my child, and love to know how it worked out for you.

For previous posts in this series, see

Cyclosporine

Methotrexate

Cellcept

Eczema Medication Series – Cellcept

cellcept eczemaThis is a series on some of the medication that I’ve collated from parents who shared in forums. My baby with eczema hadn’t been prescribed these, but my usual investigative self got interested after reading mixed feedback on these medicines. Do share in the comments your child’s experience, and the effect on his/her eczema.

What is Cellcept?

Cellcept is the product name for mycophenolate mofetil, which is an immunosuppressant. Similar to cyclosporine, it is prescribed to lower the risk of organ (kidney, heart or liver) transplant rejection via lowering the activity of the immune system.  It is also prescribed for Crohn’s disease. It may also be prescribed for those with severe eczema who has not been responded to conventional treatments over prolonged periods.

It can be taken orally or by intravenous infusion, and patient needs to follow the prescription carefully, including how many hours to take it before food. The capsule or tablet should be swallowed whole, not crushed or chewed and thus ask for a suspension if you have problems swallowing whole. For the medication in this series that work on the immune system, altering the dosage of the same drug can be used to treat different conditions. Thus, it is important to follow the dosage and frequency designed by your doctor and not to self-adjust through your own observation of the skin’s condition. Doing so not only risks side effects, it also makes it difficult for your doctor to prescribe a follow-up treatment.

Monitoring

Certain tests may be requested by your doctor to assess the side effects of Cellcept, such as blood tests (blood count and chemistry panel), particularly to monitor the blood count of white blood cells, red blood cells and platelets.

Warning

There are medications that can reduce the amount of the active ingredient of Cellcept in the bloodstream, thus making it less effective. Some of these are antacids, colestyiramne, iron tablets, ciclosporin and rifampicin. It’s best to let your doctor know of medication, vitamins and supplements that you are taking.

There is associated risk of   lymphoma and skin cancer, so sun protection measures are important. Also take good care of your gums and visit dentist regularly as swollen gums is a possible side effect. Do not drive as a possible side effect is dizziness. Avoid contact with people who are ill, and also those who have taken a recent live vaccine (also check with the doctor before getting vaccinated) as Cellcept is an immunosuppressant. Wash your hands also to prevent infection.

Side Effects

Watch for side effects, and let your doctor know; some of the side effects are:

Constipation, stomach upset, gas, chills, fever, rash, swelling, headache, vomiting, diarrhea, nausea, loss of appetite, hair loss,  swollen gums, bleeding, bruising, paleness, difficulty breathing, excessive fatigue, yellowing of skin or eyes, muscle cramps, water retention and increased heartbeat.

Symptoms of flu such as sore throat, fever, night sweats, or painful urination, vision changes, reddened skin that cannot heal or sore may indicate infection that warrant seeing your doctor.  Stomach or intestinal bleeding is also a side effect, and signs to look out for are stomach pain, blood in your stool, or dark, sticky stools. There are also reports of risk of brain infection (progressive multifocal  leukoencephalopathy) whose symptoms include visual loss, seizures, movement and speech difficulties, weakness, confusion and headaches. Do call your doctor immediately.

Refer here for a list of more to less common side effects.

There is no particular diet to follow, unless directed by your doctor.

Most Importantly, Does it Work?

I’ve found a few studies online, and the various conclusions are:

  1. In a retrospective case series of 14 children with severe eczema, 1 failed to respond to treatment while others improved significantly.
  2. In a study of 16 patients over 34 weeks, 1 had pancreatic cancer and the rest had improved significantly.
  3. In a retrospective study of 20 patients, 17 improved over 4 weeks of the course, but 7 patients developed various infections.
  4. In a study of 12 patients with paediatric severe eczema at the University of North Carolina at Chapel Hill pediatric dermatology clinic, 8 out of 12 reported significant improvement.
  5. In this study of 10 adult patients, mycophenolate mofetil is found to be effective in reducing the severity of eczema after 12 weeks.

A point to note is above studies were small sample sizes (and I’ve found a few others of even smaller sizes), possibly due to methotrexate prescribed only for severe instances that had not responded to corticosteroids or cyclosporine. Do share your experience in the comments!

Eczema Medication Series – Methotrexate

Sharing your experience can Help

This is a series on some of the medication that I’ve collated from parents who shared in forums. My baby with eczema hadn’t been prescribed these, but my usual investigative self got interested after reading mixed feedback on these medicines. Do share in the comments your child’s experience, and the effect on his/her eczema.

What is Methotrexate?
Methotrexate is an antimetabolite which slows down the metabolism of new cells (for instance prescribed to reduce growth of cancer cells). It works via inhibiting dihydrofolate reductase (DHFRase), an enzyme involved in the synthesis of DNA, RNA. It may be prescribed for advanced stages of cancer, severe active rheumatoid arthritis and certain types of cancers. It is also used to treat skin conditions – severe psoriasis, whereby methotrexate decreases the formation of skin cells to prevent the formation of scales. It may also be prescribed for those with severe eczema whose treatment using cyclosporine or corticosteroids are discontinued, as methotrexate has anti-inflammatory properties. Methotrexate also lowers the activity of the immune system.

It can be taken orally or by injection, and patient needs to follow the prescription carefully, especially the dosage or frequency (may be weekly for treatment of skin condition). The dosage prescribed will be determined by the doctor, usually for skin-related, it will be a low dosage, and dosage may vary during the course. It is important to follow-through with the prescription, and not terminate it once you self-assessed your condition has improved.

Monitoring
Certain tests may be requested by your doctor, to assess the side effects of methotrexate, such as blood and liver tests.

Warning
Check with your doctor how much fluid you need to be taking during the course as drinking more water can help to reduce toxicity in kidneys. If you are on non-steroidal anti-inflammatory medication such as aspirin, ibuprofen, choline magnesium or magnesium salicylate, do check with the doctor the safety of these medications as they can increase the level of methotrexate in the blood. Also check on medication such as acitretin, azathioprine, isotretinoin, sulfasalazine or tretinoin that may increase concentration of methotrexate in the blood or increase toxicity for certain body organs – liver, kidney and bone marrow (better to tell the doctor of drugs, medicines, supplements and vitamins you are taking). There is associated risk with liver damage, so do check on alcohol consumption.

There may also be sensitivity to light, so take sun protection measures and avoid sunlight. Do not drive as a possible side effect is dizziness. Avoid contact with people who are ill, and also those who have taken a recent nasal flu vaccine or who has chickenpox (also check with the doctor before getting vaccinated) as methotrexate has mild immune suppressive effect. Also check on what sports you can engage in, to prevent cuts or injury. Wash your hands also to prevent infection.

Side Effects
Watch for side effects, and let your doctor know; some of the side effects are:
Chills, fever, rash, peeling skin, headache, mouth sores, vomiting, diarrhea, nausea, loss of appetite, hair loss, swollen gums, red eyes, sore throat, bleeding, bruising, paleness, difficulty breathing, excessive fatigue, yellowing of skin or eyes, seizures, fainting, difficulty with body movements, vision changes and painful urination.
Symptoms such as diarrhea, black, tarry or bloody stools or bloody vomits may be related to damage to the lining of intestine due to Methotrexate. Do call your doctor immediately. Also, if you had stomach ulcers or previous medical conditions related to intestines, do inform your doctor.
Refer here for which side effects are more common, and which are less.

Diet
Folic acid may be prescribed as a supplement during the course, but this depends on your doctor as studies are not definitive in this area. Folic acid may in some ways reduce the effectiveness of methotrexate, thus may be prescribed on days when patient need not take methotrexate.

Most Importantly, Does it Work?
I’ve found a few studies online, and the various conclusions are:
1. In this study of 60 patients, methotrexate found to improve mild to moderate eczema
2. In a study of 42 patients, both methotrexate and azathioprine showed clinical improvement in eczema for adult patients in the short term.
3. In a study of 25 patients with paediatric discoid eczema, about 19 children showed improvement after 10.5 months.
4. In this study of 20 patients, methotrexate found to be effective, but there were also patients who dropped out from the study due to side effects.

A point to note is above studies were small sample sizes (and I’ve found a few others of even smaller sizes), possibly due to methotrexate prescribed only for severe instances, which had not responded to corticosteroids or cyclosporine. Do share your experience in the comments!

Eczema Medication Series – Cyclosporine

Cyclosporine EczemaThis is a series on some of the medication that I’ve collated from parents who shared in forums. My baby with eczema hadn’t been prescribed these, but my usual investigative self got interested after reading mixed feedback on these medicines. Do share in the comments your child’s experience, and the effect on his/her eczema.

What is Cyclosporine?

Cyclosporine is an immunosuppressant, and slows down the immune system (thus frequently prescribe to prevent organ rejection after a transplant). It is registered in certain countries to treat skin conditions – psoriasis and atopic dermatitis (eczema). It may be prescribed for those with severe eczema that has not responded to other treatments for prolonged period. Cyclosporine works by reducing inflammation on the skin, through its effect on immune cells (lymphocytes). It is taken orally, and patient needs to follow the prescription carefully and take the medication at same time. The dosage prescribed will be determined by the doctor, usually for skin-related, it will be a low dosage, and dosage may vary during the course. It is important to follow-through with the prescription, and not terminate it once you self-assessed your condition has improved.

Monitoring

Certain tests may be requested by your doctor, to assess the side effects of cyclosporine, such as blood pressure test, blood and urine tests (to monitor creatinine levels) and tests to monitor potassium, blood count, fasting lipid, uric acid and liver function.

Warning

Care ought to be taken to ensure that the prescription of Cyclosporine is the right one, as it can be in different form – original vs modified. Different form of cyclosporine is to be mixed with different liquids, so do check with your doctor too. Also check with your doctor on what other medication to avoid, especially those that affect the immune system, such as azathioprine, methotrexate and tacrolimus. There is associated risk with high blood pressure, kidney damage, lymph and skin cancer, so do check with the doctor if your child should take additional sun protection measures, and for adults, avoid phototherapy during the medication. Do not drive as side effect of cyclosporine is dizziness. Avoid contact with people who are ill, and also those who have taken a recent nasal flu vaccine (also check with the doctor before you/ your child get vaccinated).

Side Effects

Watch for side effects, and let your doctor know; some of the side effects are:

Headache, vomiting, diarrhea, nausea, increased hair growth on face or body,  swollen gums, acne, trembling, flushing, cramps, joint pains, pin and needle sensation, flu, sore throat, facial pain and increased blood pressure .

The serious side effects to call your doctor immediately are bleeding, bruising, paleness, yellowing of skin or eyes, seizures, fainting, difficulty with body movements, swelling and vision changes, painful urination.

Refer here which side effects are more common, and which are less.

Diet

Grapefruit and juice is to be avoided as it can increase the amount of cyclosporine in your blood stream. Foods such as bananas, prunes that are high in potassium are to be limited as cyclosporine can also increase the amount of potassium in the bloodstream. Check also if you need to take magnesium supplement, as cyclosporine may reduce the level of magnesium in the blood.

Most Importantly, Does it Work?

I’ve found a few studies online, and the various conclusions are:

  1. Studied to offer relief for those with severe eczema, but the effect is not long-lasting, similar conclusion in this study.
  2. Review article of 15 studies found cyclosporine to be effective for 6-8 weeks.
  3. One study that tracked up to 1 year continued to show eczema in remission, but this study was without control group.
  4. In a study involving 40 children, cyclosporine found to be effective and well-tolerated. In this study involving 35 children, cyclosporine found to be more effective for those whose eczema are triggered by skin infection (than those triggered by others)

A point to note is above studies were small sample sizes, possibly due to cyclosporine prescribed only for severe instances. Do share your experience in the comments!

Friday Dr Q&A with Prof Hugo – Oral Steroid

Prof Hugo Van Bever

Prof. Hugo Van Bever is the Head of National University Hospital’s Pediatric Allergy, Immunology & Rheumatology Department. He is also an active member of the board APAPARI (Asian Pacific Association of Paediatric Allergy, Respirology and Immunology) and has published more than 250 papers in national and international journals. His main research interest areas are paediatric allergy and paediatric respiratory infections.

Marcie Mom: Good day, Prof Hugo. I must thank you again for helping Marcie with her eczema. I noticed that it got much better after the one-time oral steroid course you prescribed (read more in this post).

Oral steroid such as prednisolone is sometimes prescribed for children with severe eczema. Can a child only be prescribed oral steroid once? I’ve read horror stories online of how some doctors negligently keep prescribing oral steroid to the point that it no longer works for the child. How can a parent assess if the doctor is taking due care in his prescription for their child?

Prof Hugo: Oral steroids should be avoided, especially because eczema is a chronic disease, and oral steroids cannot be used chronically. Only in severe flare-ups a short course (5 to 7 days) is recommended. In some children (exceptionally) a longer treatment can be needed. However, this should be given in an EOD dose (= every other day). It is all a matter of trust in your doctor. If your child has severe eczema, needing oral steroids, I advise to see a paediatric allergist or paediatric dermatologist.

Marcie Mom: Thanks, so a note to parents to trust your doctor, for a list of doctors in Singapore, you can refer to this post.

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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