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

Topical Corticosteroid Withdrawal – Q&A with Prof Hugo

In March 2015, the National Eczema Association (NEA, in US) published a study on steroid addiction in patients with atopic dermatitis. This was by members of its task force, who looked into the evidence regarding steroid withdrawal as many eczema sufferers were asking about the steroid addiction syndrome, along with many cautioning and enquiring on this online and over social media. The use of steroid creams remains a common treatment option, and the phobia of steroids has also stopped eczema sufferers, including children, from receiving treatment. The questions we are exploring with Professor Hugo centered on:

  1. What is steroid addiction?
  2. What is steroid withdrawal and its symptoms?
  3. Is steroid addiction/ withdrawal common?
  4. What are the treatment options for eczema?

Professor Hugo is no stranger to this blog – He has previously helped in Friday Doctor Q&A in 2012 and is my co-author for our book “Living with Eczema – Mom Asks, Doc Answers”. Professor Hugo van Bever is the Professor in Paediatrics (MD, PhD) at the National University Singapore, and also the Senior Consultant in its Division of Paediatric Allergy, Immunology & Rheumatology.

The questions are loosely structured based on the paper published by the National Eczema Association, to address the above questions that are surely on the minds of many parents with eczema children.

Topical corticosteroid withdrawal

What is Steroid Addiction?

MarcieMom: Steroid addiction is used broadly to refer to eczema sufferers whose skin are “addicted” to the topical corticosteroids, and therefore, when they stop applying the steroid creams, they experience steroid withdrawal and its adverse symptoms.

MarcieMom: I looked up the meaning of addiction online and found a broader definition by MedicineNet.com that defines addiction as

“An uncontrollable craving, seeking, and use of a substance such as alcohol or another drug. Dependence is such an issue with addiction that stopping is very difficult and causes severe physical and mental reactions.”

Medical definitions of addiction linked addiction to a brain disease, rather than a skin disease. Is it even possible for the skin to crave topical corticosteroids and be dependent on it to the extent that stopping is difficult?

Professor Hugo: I disagree with the word “addiction”, as the situation here doesn’t refer to a mental state (addiction always refers to a mental state). As for the possibility of the skin being addicted, the answer is NO!

To me, it is more a “bad habit” of using topical corticosteroids (TCS), mainly because of wrong expectations of this treatment. When used inappropriately (such as too long, too high, too frequent, or too strong), every medication (even a simple anti-fever medication) can cause side effects or unwanted (unexpected) effects. That’s why it doesn’t surprise me that inappropriate usage of TCS can cause withdrawal effects or, at least, unexpected side effects – I strongly doubt the existence of a withdrawal syndrome (especially when there are no specific biopsy features).

What is Steroid Withdrawal and its Symptoms?

MarcieMom: From Dermnetz, topical corticosteroid withdrawal refers to:

(1)   A rash that has appeared within days to weeks of discontinuing topical corticosteroid that has been used for many months. This flare may be worse than the pre-treatment rash. Before stopping the topical corticosteroid, the skin is typically normal or near-normal, although localised itch, ‘resistant’ patches of eczema or prurigo-like nodules may be present; and

(2)   The rash must be only where the topical corticosteroid was being applied, at least initially, although it can later spread more widely.

From the review article by NEA, there are two types of rash:

(1)   Eythematoedematous type – meaning redness (thus topical steroid withdrawal is also referred to as the Red Skin Syndrome), typically found in patients with an underlying eczema-like skin condition like atopic or seborrheic dermatitis; or

(2)   Papulopustular type – meaning with bumps and pimples, typically found in patients who used topical corticosteroids for cosmetic purpose like acne or pigment.

The withdrawal symptoms include:

  1. Burning and stinging
  2. Erythema (redness)
  3. Mostly on the face and genital area of women
  4. Exacerbation with heat or sun
  5. Pruritus (itch)
  6. Pain
  7. Facial hot flashes

Both types of rash primarily affect the face of adult females and are mostly associated with inappropriately using mid- to high-potency topical corticosteroids daily for more than 12 months.

MarcieMom: First of all, it is important to understand what a review article is. It is not a controlled trial, meaning there are no two groups of people that are given different treatments and thereafter the results are evaluated. Instead, it systematically reviews other studies. The limitation of the study is that the quality of evidence in regard to topical corticosteroid withdrawal in the studies reviewed were very low.

MarcieMom: Is there a way to study topical steroid withdrawal definitively?

Professor Hugo: The article is a collection of case reports, and not a study. There are no studies on the subject. Therefore, the quality of the science behind this is very low. It is a misuse of TCS, and you cannot ask patients (is not ethical) to misuse a treatment in order to prove side effects. Better is to look for its existence in patients who didn’t misuse TCS, but I assume the prevalence will be close to zero.

MarcieMom: It is also briefly discussed in the review article that the signs and symptoms of atopic dermatitis may be confused with that of steroid withdrawal. It is suggested in the review article that if:

(1) Burning is the prominent symptom, and

(2) Confluent erythema (meaning continuous red patches) occurs within days to weeks after stopping topical corticosteroids, with

(3) History of frequent, prolonged topical corticosteroid use on the face or genital region, then the symptoms are more likely to be from topical steroid withdrawal (rather than other forms of dermatitis).

MarcieMom: How do we know if the rash is caused by steroid withdrawal and not something else? Would you contact patch testing for contact allergens?

Professor Hugo: The so-called withdrawal syndrome (as a consequence of misusage of TCS) is mainly made-up by a re-occurrence of eczema lesions, as shown by looking at the results of the biopsy studies: the withdrawal syndrome has no specific biopsy features, but mainly features of eczema. Therefore, I am not sure whether the withdrawal syndrome is a separate entity, or whether it is mainly an expression of re-occurrence of eczema. Indeed, I strongly doubt of its existence.

I think the withdrawal syndrome is NOT a new syndrome, but merely a flare-up of eczema on an altered skin (because of the long-term usage of TCS).

It is not a new syndrome because:

  1. It has no specific clinical features (all manifestations might be manifestations of a re-occurring eczema)
  2. It has no biological marker (blood)
  3. It has no solid underlying mechanism – hypothesis
  4. Biopsy finding are similar of findings in eczema (no specific biopsy)

It is merely a re-manifestation eczema, but on an altered skin, because of the long-term usage (misusage) of TCS.

  1. Alterations of the skin can be summarized as following:
  2. A thinner epidermis (as a consequence of misuse of TCS)
  3. Higher Staphylococcus aureus colonization, as TCS do not affect Staph colonization – this explains the papular / pustular (infected) features of the lesions
  4. A concomitant contact dermatitis (to TCS or other substances)

Contact dermatitis is a possibility, but is not common in children (more in adults), especially after years of usage of creams.

Is Steroid Addiction/ Withdrawal common?

In the review article, there were various factors that contributed to topical corticosteroid withdrawal, namely:

  1. Mid or high potency use of topical corticosteroids
  2. Daily use of topical corticosteroids (only one out of the 34 studies recorded frequency)
  3. Duration of use longer than a year

From the studies reviewed, only 7.1% of the cases reported (in these studies) were of patients 18 years and younger. Only 0.3% were for children younger than 3 years.

MarcieMom: The general guideline in topical corticosteroid use for children is using a mild to (no higher than) mid potency, no more than twice a day, for a two week period. Professor Hugo, do you think that it is likely that children will suffer from topical steroid withdrawal even with the right use of prescribed steroid cream?

Professor Hugo: Patients should know that eczema (or atopic dermatitis) is a non-curable disease and that no doctor in the world can cure eczema today (perhaps in the future a cure will be found, mainly through immunomodulatory treatments, but not for the moment i.e. at the time of this interview in September 2016).

TCS are effective in controlling inflammation of the skin, and are, therefore, a part of the therapeutic approach to eczema. However: 1) TCS are ONLY (!) part of the treatment, which constitutes of offering a holistic package to the patient (focused on life style, and on usage of other treatments), and 2) once TSC are stopped the lesions will re-occur, as TCS do not cure, but only control inflammation, and 3) the rule is to use mild TCS (according to age and severity of the patches), in combination with antiseptics (TCS on a clean eczema patch) and NEVER more than 2 x day.

The main observation here is that this withdrawal effect is not caused by the TCS on itself, but by the inappropriate usage (i.e. misusage, leading to over-usage) of it. The unwanted effect was mainly seen in adult women (in more than 90%) who were using their TCS as if it was a kind of moisturizer. In other words, every time they felt a little itch or saw a little flare-up they put their TSC on it, many times per day, and during long periods (in 85.2% for more than 1 year).

The main point here is that TCS were misused, mainly because patients had wrong expectations of TCS, which I assumed is due to lack of correct information on eczema and on the role of TCS in its treatment. Who is to blame? I guess, both the doctor and the patient, and, for sure, the wrong doctor-patient relationship and wrong communication. Correct information on eczema and on the role of TCS is pivotal.

When TCS are used appropriately, as part of the holistic treatment of eczema, and according to correct expectations, it is extremely unlikely that a withdrawal syndrome will occur. I even dare to state that it is even (almost) impossible. However, I recommend close monitoring of all children with eczema, with appropriate individualization of treatment, focused on offering a treatment package in which TCS have a role, but only as a controller of acute inflammation, and with strict rules on their usage.

What are the treatment options for eczema?

MarcieMom: There are many brands and types of topical corticosteroid creams available, with varying potency and with different chemicals, and functions (for instance, with the added ingredients to reduce bacteria or fungus). Often, there is a trial and error process to see if a certain prescription cream works.

MarcieMom: How would a patient know if the steroid cream is not working for his rash? Is there a safe period of trial before stopping?

Professor Hugo: TCS are only PART of the treatment, and usually have a fast effect on acute inflammation (1 – 3 days). For each patient the optimal TCS needs to be selected (based on severity and age) and needs to fit into the whole package of treatment.

MarcieMom: There are many other eczema therapeutics that can be used alongside topical corticosteroids or in place of topical corticosteroids, for instance:

  1. Moisturizing – with a quality emollient that does not contain major irritants and have humectant properties and lipids to help with skin lipid deficiency
  2. Bathing – Basic good bathing routine like no hot water, no soap, no longer than ten minute, pat dry and not rub dry AND moisturizing immediately after
  3. Wet wrap or dry wrap
  4. Ways to reduce staph bacteria, such as swimming, using diluted zinc sulphate or chlorhexidine gluconate
  5. Non-steroidal prescriptions like topical calcineurin inhibitors
  6. Antihistamines (non-conclusive research)

MarcieMom: I’m a believer that one ought to diligently practice good bathing and moisturizing regime, reduce staph bacteria colonization, along with healthy lifestyle (non-inflammatory diet and exercise). However, I find that sometimes we tend to discuss topical corticosteroids exclusively, i.e. use topical corticosteroids or (do something else). What are your top 3 eczema therapeutics in your practice and how effective has these reduce the use of topical corticosteroids in your young patients?

Professor Hugo: My top 3 are: allergen avoidance (airborne food, house dust mites  – which is an outdoor life style) – usage of antiseptics (swimming – baby spa) and extensive usage of moisturizers have important additional effects and are therefore TCS-sparing.

MarcieMom: In summary, topical corticosteroid withdrawal is increasingly acknowledged by the dermatological community as evident by NEA taking the step to conduct a systematic review. However, we have seen that it is not easy to diagnose topical steroid withdrawal, and at the same time, removing topical corticosteroids completely as one of the eczema therapeutics may make it harder to treat the eczema/ skin inflammation. It is therefore important to recognize both the dangers of steroid misuse and underuse. Physicians should adopt an open attitude when hearing about patients’ steroid fears as totally ignoring steroid phobia would possibly alienate patients and without trust, it is making controlling eczema an uphill battle.

Eczema News – High Blood Pressure Drug teamed with Corticosteroids

Hypertension drug with Steroid use reduces skin thinning

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

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

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

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

Rise and Shine Feature – Eczema Skin Function and Care

More eczema questions for Dr Lynn after the Rise and Shine Expo

More eczema questions for Dr Lynn after the Rise and Shine Expo

For the past 3 weeks, we have covered Dr Lynn Chiam’s talk ‘All about Children’s Skin’ at the Rise and Shine Expo, Singapore. Today, we are asking follow-up questions from her talk, specifically to help parents with eczema children.

Dr Lynn Chiam of Children & Adult Skin Hair Laser Clinic is a consultant dermatologist who subspecializes in paediatric skin conditions at Mount Elizabeth Novena Specialist Medical Centre, Singapore. She was formerly the head of paediatric dermatology at National Skin Centre, Singapore before leaving for private practice. She has vast experience in childhood atopic dermatitis and childhood birthmarks. She has previously shared her expertise in this blog on Teen Eczema and Facial Eczema.

MarcieMom: Thanks Dr Lynn for spending some time here, and helping to address follow-up questions to your talk. You mentioned that the skin function includes protection against sun, and that baby’s skin offers less protection. How about skin of an eczema infant? And the skin of an eczema adult? Do they offer even less protection against the sun as the skin barrier of eczema patients are already defective?

Dr Lynn: Protection against the sun depends on the integrity of the skin as well as the amount of pigment cells in the skin. In general, a baby’s skin is less mature and contains less pigment cells compared to an adult and thus is more susceptible to the adverse effects of the sun. Darker- skinned individual tend to get less sun burn as compared to fair-skinned individuals.

In infants and adults with eczema, their skin barrier functions is defective and they can get broken skin as a result of scratching. This can make them more susceptible to sunlight and exposure to excessive amount of sunlight is known to trigger or aggravate the eczema.

MarcieMom: You also mentioned that the skin forms part of our body’s immune system. Is this due to the skin flora? Does the ‘porous’ eczema skin means that babies with eczema have a lower immunity and does this lower immunity translate to falling sick often? What is the implication for parents in caring for the general health of an eczema baby?

Dr Lynn: The skin contains cells which are involved in the reaction that our body mounts in response to an infection and inflammation. They are known as “B” cells and “T” cells. They can be thought of as “soldier cells” that defend our body when it is “attacked”. The skin flora on the other hand describes the bacteria, fungi and viruses that reside on our skin without causing any harm to our body. They are not part of the immune system.

The “porous” eczema skin allows bacteria and viruses to penetrate more easily and thus eczema patients are at a higher risk of getting skin infections. The skin of patients with eczema do have lower immunity to prevent skin infections but in general this not lead to overall decrease in their body’s  immunity. Children with eczema  do not fall sick more often as compared to their peers.

It is important for parents and health care providers to recognise eczema superimposed with skin infection as the skin infection has to be cleared for the eczema to heal well.

MarcieMom: Is wet wrap/dressing recommended for infants below 6 month old? Does the thinner skin of babies affect whether they ought to be wet wrapped?

Dr Lynn: As the skin of an infant below 6 months has a larger surface area: volume and is thinner as compared to adults, they tend to absorb a larger percentage of creams that is applied. Thus it may lead to side effects as a consequence of more creams that is absorbed via the skin into their system. Thus I will generally not advise wet wraps for infants unless the eczema is very severe and the creams used are very gentle.

MarcieMom: Similarly for steroid potency, is there a certain age by which the skin is thick enough to consider stronger potency steroid cream?

Dr Lynn: There are no guidelines for the potencies of steroids to be used according to age. In general, I will not use anything stronger than a mid-potency steroid in children less than 8 years old. The potency of the steroid used also depends on the thickness of the skin and the severity of the eczema. The neck, inner aspects of elbows, back of knees and wrist are generally considered to have thin skin and only low to mid-potency steroids should be used. Contrary to this, more potent steroids have to be used on the palms, soles and areas where the skin is thick as a result of the eczema.

For more severe eczema, a more potent steroid should be used to control the inflammation before tailing to a less potent one.

Thank you Dr Lynn for sharing your thoughts on the above questions, and thank you for the wealth of information you’ve provided in this blog.

For the 3 previous posts of this series, see

Children Skin Functions

Common Children Skin Conditions

Children Skin Conditions and FAQ

SOMEONE Manages Baby with Severe Eczema

Lauren Son Eczema Blues

Lauren shares about managing severe eczema for her son in his first year

This is a 2013 series focused on personal journey with eczema while managing a certain aspect of life. Today, we have Lauren, whose 3 year old son has severe eczema in his first year, and shares how she manages eczema for a newborn. Lauren plays and teaches bassoon in Traverse City, Michigan.

Marcie Mom: Hi Lauren, it’s good to have you share in this series! Let’s start with you sharing a little of your son’s eczema – when did it start and how was his skin at his worst then?

Lauren: Hi, Mei. Rhys developed cradle cap (a yellow, scaly crust on his scalp) around two months of age and developed body-wide severe eczema at three months of age.  I first noticed a problem when one day he started to repeatedly rub his eyes and face with his hands.  He was not yet coordinated enough to truly scratch.  The red skin and rashes followed, at first on his face, and later nearly everywhere else.  At its worst, his skin was inflamed, crusty, and oozing and the plasma would soak through his clothes and bed sheets.  It was quite similar to a very bad reaction to poison ivy.

Marcie Mom: Allergy testing isn’t accurate in the first few months of a newborn’s life  – did you have difficulty finding out his triggers in the first year?

Lauren: My husband and I had tremendous difficulty and often had disagreements stemming from the mystery of it all.  That first year we took Rhys to three different doctors and also to non-traditional (in the American sense) healers.  I stopped consuming dairy for about a month because I was breastfeeding, we eliminated all detergents from our home – even shampoos and toothpastes containing detergents, and we kept Rhys away from our cats.  No lifestyle change seemed to make an obvious improvement.

Marcie Mom: How and when did the eczema improve?

Lauren: During the first year, it was a combination of two events.  First, Rhys’s pediatrician realized he couldn’t fully help and referred us to a dermatologist.  The dermatologist prescribed Triamcinolone, a strong topical steroid, and frequent moisturizing.  I believe he gave us samples of CeraVe. Second, around the same time, I spoke with a friend whose son has food allergies.  She told me dairy consumption was often a trigger for eczema breakouts and other allergic reactions and convinced me to again eliminate dairy from my diet.  She also told me about a friend of hers whose child had severe eczema.  The pediatric dermatologist in that case had advised to (1) give the child three lukewarm baths a day, using cleanser only on soiled areas, (2) use topical steroid as needed on “hot spots” after the bath, and (3) moisturize on still-damp skin.  The triamcinolone broke the cycle of inflammation and the frequent bathing and moisturizing helped his skin’s resiliency.  Moisturizing red and oozing skin never worked; it was really only effective at maintaining healthy skin.

As you mentioned, Rhys is now three.  We no longer give him baths three times a day, but we do moisturize after baths and as needed throughout the day and we use the steroid Fluticasone Propionate Cream for break-outs.  We still avoid detergents and products with synthetic scents.  Rhys underwent allergy testing late last summer and due to the results and personal experience, we now avoid peanuts, tree nuts, legumes, dairy, and eggs.  If Rhys begins to scratch uncontrollably, the dermatologist gave us permission to give him children’s strength antihistamine.  We have so many more pieces of the puzzle figured out now, not all, but many.  Most of Rhys’s skin is now smooth and healthy.

Marcie Mom: One final question – what advice would you give to a mom who has a family history of eczema/allergy and preparing for the newborn?

Lauren: Eat the healthiest possible foods while pregnant.  Some might even advise you to eat as much chemical-free and organic food as possible while pregnant.  If your baby develops the symptoms I mentioned, do your best to keep the baby from scratching and seek help.  If your child’s healthcare provider has never seen such a severe case of eczema, find a healthcare provider who has already seen and treated a case like your child’s before.  And don’t blame yourself.  Your baby will outgrow some triggers, like the drooling that accompanies teething.

Marcie Mom: Thank you Lauren for your sharing, many moms can identify with it and hopefully every baby grows out of eczema.

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

Sharing Treatment for Eczema Children

Elomet ointment

Last Friday’s lunch sharing session with Dr Lynn Chiam was a fruitful one – the topic was Treatment for Kids’ Eczema and we had pizza and chicken wings for lunch at the NSC!

The few notes shared:

1. Moisturizing within 3 Minutes After Shower

This is inline with Dr Jennifer Shu’s tip here, so it appears that it’s an international recommended practice. Dr Lynn shared that should it be difficult to do so, or if skin is still dry, wet wrap can be implemented. For practical purpose, should the child not be able to tolerate wet wrap overnight, instead implement at least an hour, 5 times a week. Even a dry wrap will retain moisturizer better for the skin.

2. Removing House Dust Mite (if it is an allergen for your child)

Dust mite can be killed either by extreme cold or heat – so wash bedsheet in at least 60 deg C water (read this post) and for stuff toys, freezing them may help decrease the amount of dust mite as they are affected by extremes of temperature. Dr Lynn recommended sunning mattresses and changing mattress once per year, i.e. don’t get a thick and very expensive one. Remove carpets.

3. Use of Topical Steroid – Don’t be Steroid-Phobia

I shared that there is a lot of fear out there among parents on using even the mildest steroid cream, and I’ve heard of increasing number of children hospitalized for infections due to fear of using steroid. Read more here on ‘Is Steroid Cream Safe?’. Dr Lynn explained 4 side effects of topical steroid (i) skin thinning (ii) easy bruising, (iii) fragile blood vessels and (iv) excessive hair growth. However, these can be avoided if patients ensure they use (1) the right steroid (2) at the right part of skin and (3) for the right amount of time. 

For anyone who emailed me (and we’re talking many!) who ask if steroid cream is safe because they’ve read about the side effects (which further reinforces FEAR spread like FIRE), you know my reply is the side effects of MISUSE should not be confused with Right Use. There are also many who have an agenda for propagating fear – to sell a steroid-alternative. Again, there is no need to use one and not the other. You can use steroid safely to treat flare-ups and skin inflammation, while at the same time, moisturize, wet wrap, have healthy diet, healthy lifestyle, distract your child, protect their skin, covering their fingers..

Dr Lynn shared that steroid treatment should be used pro-actively, to treat skin inflammation even after the rash disappear, and this is also consistent with what Dr Bridgett shared in this post. Protopic can be used for maintenance, and I’ve clarified with Dr Lynn that the stinging sensation that some experienced with Protopic will not be manifest as rashes. For more on Protopic, see here.

4. On Oral Steroid

This is usually a treatment for severe active cases, not lightly prescribed due to its side effects of osteoporosis, stunting growth and increased vulnerability to infection. Tomorrow’s post is on prednisolone, and you can also refer to previous post on cyclosporine.

5. This is my afterthought – Don’t Jump from Fear to Fire

I’ve shared earlier that Fears spreads like Fire, and I like to remind parents not to jump from fear into fire – for instance:

Is someone telling you not to use steroid but something natural? If so, do ask them and search Pubmed for studies. I’m not against natural and I’m not against any parent wanting to try something natural. Do check 1. It’s safe to consume/apply, 2. Keep up the standard treatment.

Is someone telling you that a steroid cream is not working and that the flare is caused by it? Think back – did your child have rashes before the steroid? and Dr Lynn shared that each steroid cream has its own molecular structure, suited for different purpose. You may wish to work with your doctor on another cream.

Is someone telling you their skin recovers after doing a,b,c and d? Ask them, did they do a,b,c and d while applying the steroid?

Is your doctor (I really hope not) telling you that established clinically trialed cream is no good and their own concoction is better? I do not know if it is/not, how would anyone know if it’s kept a secret, even without a medical name. If it doesn’t work for your child, it’d be impossible for the next doctor to understand what your child has been prescribed and how the skin reacted.

This is a very long summary of the discussion. But as you can see, I’m really AGAINST people who spread fear of steroid – again, I’m not saying steroid is the only way, I’m saying it has its place and fear shouldn’t be propagated for personal means.

Dermatology addressed at Rise and Shine and Carnival GIVE-AWAY

I’m one of the partner bloggers for Singapore’s Rise and Shine Expo, and the neat part of this expo is that they also address dermatology (read one of the founder’s eczema journey here).

Their expert panel includes dermatologist, Dr Audrey Tan, who has answered two dermatology questions on their site here. Below is an extract, do read Dr Audrey’s full reply:

What are the side effect of applying steroids on a baby less than 2 years old and what are other effective cures other than steroids?

Dr Audrey Tan: It is safe to use a topical steroid on your son’s skin as long as the steroid is of the potency appropriate for the degree of skin inflammation, and it is applied only on affected skin…

What kind of baby products should I use on my baby who has mild eczema problem? Are there any special ingredient I should look out for or avoid when buying products? Can my baby continue with swimming since swimming will dry out the skin?

Dr Audrey Tan: Applying a moisturizer is an important part of the daily skin care routine for your baby with mild eczema…

Rise and Shine is also holding a carnival on 3rd March 2013, Sunday, 8.30am to 12.30 pm, at The Lawn @ Marina Bay. Dr Amy Khor is the guest of honor, and there’s goodie bags, fun activities and talks relevant for kids, see below poster on how to register!

AND the FIRST TWO PEOPLE (in Singapore with valid email address) to COMMENT in this post will receive TWO Adult tickets FREE for the Carnival. The early bird ticket is worth S$8 each. Giveaway ends at 3pm this Thursday 28 Feb 2013.

Rise and Shine Carnival

Facial Eczema with Dr Lynn Chiam: What Treatment can I put on my Face?

Dr Lynn Chiam, a consultant dermatologist who subspecializes in paediatric skin conditions

This is a series focused on facial eczema, with the privilege of having Dr Lynn Chiam, of Children & Adult Skin Hair Laser Clinic, to help explain further the type of facial rashes, its treatment options and daily facial care. Dr Lynn is a consultant dermatologist who subspecializes in paediatric skin conditions at Mount Elizabeth Novena Specialist Medical Centre, Singapore. Apart from paediatric dermatology, her other subspecialty interests include adult pigmentary conditions and laser dermatology. More on Dr Lynn can be found here.

What can I do about the rashes on my face?

Treatment options for the face may differ slightly from the rest of the body due to the thinner skin and higher concentration of superficial blood vessels found in the face. Before Dr Lynn helps with the treatment specific for facial eczema, let’s run through good skin care routine that’s applicable for the whole body.

1. Moisturizing – Dry skin needs moisturizing and as there is a high concentration of sebaceous glands on the face, it will be good to choose a product that is non-comedogenic. A non-comedogenic product does not lead to the formation of whiteheads or blackheads.  As always, choose one that does not contain an ingredient that you are allergic to and always choose one that has been clinically tested. Read this post for the top allergens and here for a better understanding of product label. For the face, you may also want to use a sunscreen that protects your face and not irritate it, read here for sunscreen selection.

2. Cleaning – As with the body, you will have to clean the face. Choose a facial cleanser that works for you, without abrasive materials. There’s no need to exfoliate your face more than how it is naturally exfoliating on its own. Moisturize after cleaning. Pat dry your face, do not rub and always avoid hot water.

3. Cold Presses – If you have an itchy rash on your face, you can apply a cooling pack on the area to reduce the itch. Dr Lynn advises not to use a hot pack as this may make the rash and itch worse. A cooling pack can be placed to temporarily reduce the itchiness on the face.

4. Avoiding Irritants and Allergens – Avoid harsh soap, common allergens which you are sensitive to.

Dr Lynn’s Advice on Facial Eczema Treatment

Question: Help! I have more than one type of eczema on my face! How do I treat both atopic dermatitis and seborrhoeic dermatitis? What if I have both irritant contact and atopic dermatitis?

Dr Lynn: It is not uncommon to see patients with eczema also having seborrhoeic dermatitis. These two conditions can be treated with similar creams. A thin layer of low-to mid potency steroid cream  can be applied to the rash for a limited amount of time. Alternatively, a steroid-sparing cream like calcineurin-inhibitors (Tacrolimus or Pimicrolimus) can also be used. It is important to use moisturizer regularly together with the steroid cream/ Tacrolimus as it will help improve the barrier function of the skin. In order not to over-dry the skin, use a gentle soap and avoid facial scrubs.

Atopic dermatitis makes an individual more susceptible to irritant contact dermatitis. This is because people with atopic dermatitis have a suboptimal skin barrier which makes them more sensitive to chemical and physical agents. It is important to identify which substances/products are responsible for the irritant contact dermatitis. It is advisable to see your dermatologist. Avoidance of the irritant product and application of a suitable steroid cream and moisturizer are needed to treat both the irritant contact dermatitis and atopic dermatitis. Sometimes, if the dermatitis is severe, a course of oral steroids may be required.

Question: Help! I’m told to use only mild steroids but the eczema on my face isn’t getting better! Are there other treatment options?

Dr LynnIn general, only low to mid potency steroids should be used on the face for a limited amount of time (1-2 weeks). There are certain mid-potency steroids with minimum side effects that can be used on the face. I will advise starting with a mid-potency steroid cream if the eczema is persistent then tailing down to a low potency steroid once the rash is better.  Another alternative is to use topical Calcineurin- Inhibitors like Tacrolimus and Pimicrolimus. This is a group of creams that have similar effect as steroids but without the steroidal side effects. They can be used for a longer period of time compared to steroid creams.  It is important to see your dermatologist to decide on which cream is suitable for you. The regular use of a good moisturizer and gentle soap is also important.

Protopic – Is a Non-Steroid Cream Better for your Child?

Picture from protopic-la.com

This is a post that I wanted to write for some time because I’ve been reading parents’ differing views on whether Protopic has worked for their child. I did a quick internet search on forums, and 10 out of 14 parents said it worked, 3 mentioned it gave a stinging sensation and 1 believed it led to herpes virus. Of course, my limited browsing of forum posts is not a scientific study but it certainly has piqued my interest to find out more about Protopic (something I didn’t research earlier because a mom with eczema child is busy! and also Marcie doesn’t use nor has been prescribed Protopic).

So What’s Protopic and what does it do?

According to its website, Protopic is a topical calcineurin inhibitor (TCI) that is available upon prescription. Calcineurin activates the T-cells of the immune system, which when over-produced attacks the skin leading to inflammation (read more in this post). Protopic, whose drug name is tacrolimus, belongs to a class of drugs known as calcineurin inhibitors and works to decrease the effects of, or suppresses, the immune system. Tacrolimus is also known as FK-506 or fujimycin and typically prescribed to reduce the likelihood of new organs being rejected in a transplant operation. Tacrolimus was discovered in 1984 from the fermentation broth of a Japanese soil sample that contained the bacteria Streptomyces tsukubaensis. Protopic is a product of Japanese pharmaceutical company, Astellas Pharma, and its ingredients are tacrolimus, mineral oil, paraffin, propylene carbonate, white petrolatum and white wax.

Who can and How to use Protopic?

It is recommended for moderate to severe eczema and to be prescribed by doctors, who are to prescribe it only when topical corticosteroids are not effective. It is only to be used for short periods, generally not more than 6 weeks. It comes in two strengths, 0.1% and 0.03% but for children (at least 2 years of age), only the 0.03% is recommended. The application of Protopic ought to be thin and improvement (if any) is usually seen in two weeks.

Protopic is not to be used with wet wraps, lest there’s over-absorption into the body. Protopic should also not be used on eczema that is infected as there’s no study relating to its safety in infected eczema. Going outdoors in the sun and tanning beds are also to be avoided because of shorter time to tumor formation when applying Protopic, as disclosed on their website. Hands ought to be washed after applying Protopic. The long-term use of Protopic has not been studied and thus, its application as a maintenance topical treatment to prevent flare-ups need to be advised by doctors. It is also not recommended for nursing moms or moms who are trying to be pregnant.

Pros and Cons of Protopic

Various studies have been conducted on Protopic, and it appears to be more effective than low-potency steroid creams. The other advantages over steroid creams is that it doesn’t cause skin thinning and therefore can be used on parts of other where skin is generally thinner, such as the face, eyelids and neck. However, as it suppresses the immune system, there’s increased risk of viral infection, in particular from herpes/ eczema herpeticum/ chickenpox/ shingles virus. Skin burning and itching sensations are the most common side effects (usually in its initial use) of using Protopic. It is also possible to be allergic to tacrolimus or other ingredients in Protopic, such as mineral oil and paraffin. Furthermore, a number of cases of cancer of skin or of lymphocytes cells have been reported, resulting in FDA issuing a black box cancer warning (read more on webmd post). Protopic may also interact with certain medications, including some antibiotics such as azithromycin which is commonly prescribed to children. You can read the product leaflet here.

Update in Feb 2015 – 10 year follow-up study on children who use pimecrolimus showed no significant cancer risk.

MarcieMom’s Take?

Marcie hasn’t been prescribed Protopic but from various talks that I’ve attended, it appears that though calcineurin inhibitors are mentioned, it’s always fairly down in the list of treatment options. One thing I feel is clear is that I wouldn’t opt to use Protopic just because I’m worried about the side effects of steroids as a drug that works on the immune system would surely has its own sets of side effects.

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