Combined Approach Series – Topical Treatment

This is a 4 post series centered on ‘The Combined Approach’ that is explained in the ‘Atopic Skin Disease’, a manual for practitioners authored by Christopher Bridgett, Peter Noren and Richard Staughton (copy of book viewable by joining here). The Combined Approach uses habit reversal to stop habitual scratching in atopic eczema. Dr Christopher Bridgett has previously helped in Friday Doctor Q&A from November 2011 to February 2012 and MarcieMom has invited him to share more about the Combined Approach.

Explaining Topical Treatment – Moisturizer

As we understand last week, The Combined Approach includes topical treatment using emollient and steroid. Moisturizing is a HUGE part of topical treatment, as emollients both lubricate and moisturize. Dr Bridgett’s advice on moisturizing is Thinly, Gently, Quickly and Often. There are a few other points mentioned in the ‘Atopic Skin Disease’:

  1. Thinnest possible application without ‘rubbing it in’
  2. More on exposed areas such as the head, neck and hands
  3. Pump dispensers preferable to open tubs due to bacteria infection
  4. Applying topical steroid first, then emollient over both the skin and the steroid
  5. Cream preferred over lotion

Can you explain why thinnest possible application is preferable for emollient? (I’d usually slather on my child as I find applying a thin layer leads to more rubbing to spread the emollient)

Also, can you explain why topical steroid first? (I’d written on this here and it does generate some discussion!)

Can you explain why cream is preferable over lotion?

Dr Bridgett:

Your three questions answered:

  • Thin applications of moisturizer allows heat to escape, but insulates against water loss.
  • If moisturizer is applied often enough, when the steroid is applied directly onto the eczema, it is applied to skin that has been recently moisturized. We get then the best results by putting moisturizer on over topical steroid, and moisturizing all the skin, not just that which has the eczema.
  • The thicker the moisturizer, the better the moisturizing effect. Also, often there are less additives in thicker moisturizers, as thicker moisturizers “keep” longer. There is less chance that a sensitivity reaction will occur with an ointment, compared with a cream. See http://atopicskindisease.com/articles/20110801

Explaining Topical Treatment – Steroid

It is stated in ‘Atopic Skin Disease’ manual that steroid cream work by inhibiting protein synthesis, secretion of products, cell division and migration of cells. The epidermis can benefit from reduced cell division, and the dermis from reduced cellular and lymphokine activity. Can you explain what this means, and why it is important to continue steroid treatment after epidermis healing (‘2-stage in steroid effect’)?

Dr Bridgett:

It seems the steroid anti-inflammatory effect is partly achieved by reducing over-activity in the skin, allowing natural healing then to lay down healthy skin again. By the time the seems good to look at, the healing is not complete through and through – there is more that is needed under the surface, so we recommend continuing with the topical steroid, beyond The Look Good Point: do not stop too soon. See http://atopicskindisease.com/articles/TT7

Many parents are very concerned with the skin-thinning side effects of steroid and also the ‘withdrawal’ symptoms once steroid treatment is discontinued. I read in your manual that side-effects are associated with inappropriate use of topical steroid and the risk is usually inadequate treatment (i.e. stopping steroid cream too early or using one of too low strength). How do you normally convince parents that steroid cream is safe? And what guidelines would you give them to gauge if the steroid cream of correct potency, frequency and amount is used?

Dr Bridgett:

Steroid side-effects come especially from using topical steroids long-term and in an unsupervised way. The method we use in The Combined Approach includes more supervision than is usually given, with a programme of several clinic visits, involving careful discussion of all anxieties and concerns. Using The Combined Approach, including therefore habit reversal, which allows natural healing alongside the good steroid effect. Then less topical steroid is used overall, for good effects, not side effects!

We offer information about the potency groups of the topical steroids, and how they are usually used. The thicker the skin, the stronger the topical steroid to be used. See http://atopicskindisease.com/categories/20110423_11

Each application of any cream needs to be sparingly applied – whether it is an emollient or a topical steroid: only a shine is required.

MarcieMom: Thank you Dr Christopher Bridgett for explaining the topical treatment that is part of The Combined Approach. In our next post, we will understand more on habit reversal techniques.

Combined Approach Series – Habit Reversal

 

Before The Combined Approach

This is a 4 post series centered on ‘The Combined Approach’ that is explained in the ‘Atopic Skin Disease’, a manual for practitioners authored by Christopher Bridgett, Peter Noren and Richard Staughton (copy of book viewable by joining here). The Combined Approach uses habit reversal to stop habitual scratching in atopic eczema. Dr Christopher Bridgett has previously helped in Friday Doctor Q&A from November 2011 to February 2012 and MarcieMom has invited him to share more about the Combined Approach. 

Why is it a Combined Approach?

The Combined Approach is about using conventional topical treatment (steroids and moisturizers) together with the elimination of self-damaging behavior using habit reversal techniques. ‘Atopic Skin Disease’ was published in 1996 as there was much success using The Combined Approach, which was reported at the European Congresses on Dermatology and Psychiatry in 1991 and 1995.

MarcieMom: Dr Bridgett, can you briefly explain the difference between The Combined Approach versus an eczema patient using his/her own ways to divert attention from scratching? Also, if an eczema patient or parent of eczema child comes to know of your approach, can he/she simply pass your manual to a dermatologist that he/she is seeing?

Dr BridgettThe Combined Approach is an exercise in behavioral medicine, and has two elements combined:

1. Optimized conventional treatment (emollients and topical steroids usually) : this is an important part of the approach, and cannot be overlooked!

2. Habit reversal: a formal behaviour modification technique: it requires, when offered to Adults and Older Children, first a period of registration using a hand tally counter – this is continued, as habit reversal is introduced. The inventiveness of the eczema patient is very useful in introducing new successful habit reversal behaviours, but some structure, discipline and supervision is linked to the success reported by many patients, and this requires reference to written material, and is often usefully supported by contact with others.

The manual is available for anyone to consult and follow if they wish, and both nurse practitioners and medical practitioners are successfully using The Combined Approach. An important alternative is to use the self help format set out in the book The Eczema Solution by Sue Armstrong-Brown.

When is Habit Reversal Most Effective?

The main idea is that scratching can often become a habit – that is, the adult or child with eczema then scratches not only because of itch. It is mentioned that adults with severe eczema can benefit most from The Combined Approach. Why is this so? Can you share with us pictures of before and after eczema and what was the habit that was eliminated that led to an improvement?

Dr Bridgett: Habit reversal is most effective

  • in combination with optimized conventional treatment, and
  • when there is evidence of chronic eczema – in adults or children – that is to say, the thickened skin called lichenification, which is due to regular rubbing and scratching that has become a habit, complicating atopic eczema. Any rubbing and scratching of the skin can become a habit, but each person can have their own particular problem. 

In the first pictures below the patient was habitually picking the skin of her forehead when watching TV, resulting in chronic eczema. When habit reversal was added to optimized topical treatment the skin healed very quickly.

Before and After The Combined Approach

In the next pictures, the patient had developed a habit of using the rivets on her jeans to scratch against:

Before The Combined Approach

Before The Combined Approach

After The Combined Approach

 

 

 

 

 

 

 

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Not Neglecting Topical Treatment

I note that The Combined Approach does start with understanding and explaining the importance of topical treatment, as eliminating scratching is not a stand-alone treatment. Would explaining the structure of the skin and how a weak skin barrier is prone to water loss be important in the first visit? If yes, could you do a quick introduction for our parents to understand?

Dr Bridgett: Yes, The Combined Approach always covers the importance of skin as a barrier, and the importance of optimal topical treatment.

The skin has two layers, epidermis and dermis. The outer epidermis, which carefully replaces itself every four weeks, is important in preventing water getting out from inside, and irritation and infection getting in from outside.

Acute eczema involves inflammation of the epidermis. It’s structure then becomes weakened, allowing excessive water to escape. Extra moisturizers are then needed to stop excessive water loss, and anti-inflammatory topical steroids are also needed. And that’s not the whole story: the inflammation releases itchy substances that cause scratching – and this scratching stimulates over-activity of the epidermal cells. If the emollients and topical steroids are used correctly the situation quickly returns to normal. If not, the scratching continues, becomes a habit and the damaged and sensitive skin of chronic eczema is the result.

For more on skin structure, acute and chronic eczema see http://atopicskindisease.com/articles/FF3

MarcieMom: Thank you Dr Christopher Bridgett for giving us an understanding of the Combined Approach and showed us some of the successful cases. In our next post, we will understand more on the use of moisturizers and steroids as explained in the manual ‘Atopic Skin Disease’.

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.

Friday Dr Q&A with Prof Hugo – Steroid Cream

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: Thanks Prof Hugo for taking time to be part of our Friday Q&A with Doctors. I’m so glad that you can take time to answer some of the questions that have been on my mind. Let’s start with the one that most parents are concerned with – steroid.

Many parents are worried about applying steroid cream for their child’s eczema. Recent research has shown that there is no major negative effect on the skin of children who have applied topical steroid over approximately 10 months, including no evidence of skin thinning.

What guidelines will you provide parents when applying steroids for their child (in terms of when to apply, how much to apply and which part of the skin to apply which steroid’s strength)?

Prof Hugo: Use mild steroids (for children) maximum 2 x day. Use them only on active inflammation (= “red” patches) and use them after cleaning the patches. Don’t use steroids on a dry skin or on old lesions.

Marcie Mom: Thanks, I’ve been using chlorhexidine to clean the patches before applying steroid, just as you’ve advised. I find that it’s more effective and the eczema patch usually disappears within few days.

Friday Feature – Eczema Q&A with Dr. B

Q&A with Dr Christopher Bridgett

MarcieMom (@MarcieMom) met Dr Christopher Bridgett (@ckbridgett) through Twitter – and learnt that he had a special interest of using behavioural interventions to help people with atopic eczema. DrB trained in medicine at Corpus Christi College, Oxford and St Bartholomew’s Hospital, London, then as a psychiatrist in Oxford. He now works in private practice in London. He has co-authored several publications on The Combined Approach, that proposes using habit reversal to stop habitual scratching in atopic eczema. To find out more about behavioural dermatology, click http://www.atopicskindisease.com/articles/PeterNoren to read DrB’s interview with Peter Norén MD, the Swedish dermatologist who created The Combined Approach.

Marcie Mom: Morning Dr B, today’s question is commonly asked. Some child’s skin turn brown where it frequently itches, being scratched and steroid creams have been applied. Some parents think it’s the steroid cream that causes the change in skin colour but I’ve read that the brown patch is caused by cells in skin (‘melanocytes’) releasing extra pigments from scratching. Which is true? Particularly it’s important to dispel any misperception of steroid when the risk of under-treatment due to steroid phobia is real.

Dr B: Both are true!

In the first case, yes steroid creams will change the colour of skin – they very slowly reduce the pigmentation, lightening the colour of the skin. The anti-inflammatory effect of the steroid reduces the activity of all skin cells, including the pigment cells – the “melanocytes”.

In the second case, cellular activity in skin is stimulated by habitual scratching, and this affects all cells, including the pigment cells – the “melanocytes”. So habitual scratching causes the skin to thicken up – lichenification – and colour up – hyperpigmentation. Both are characteristic of chronic atopic eczema. This is tackled by The Combined Approach to atopic eczema as described at www.atopicskindisease.com – DrB.

Questions I asked Dr Sears, hosted by USAWeekend

Dr Jim Sears (picture taken from askdrsears.com)

Wow, it’s the first time I participated in a live Q&A over twitter, and I’m so glad it’s such a fruitful one answered by Dr Jim Sears and hosted by USAWeekend. A recap of all the things learnt from the one-hour Q&A will be published on usaweekend.com, I’ve listed the questions I asked Dr Jim and his answers below for you!

Marcie Mom: My baby’s eczema improved after a one time oral steroid at 7 month old, another mom told me her baby got worse. What’s her option now?
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Dr Jim Sears: Remember that eczema is chronic allergic problem. Trigger avoidance, moisturizing and anti-inflammatory creams.
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Marcie Mom: Everytime I use naughty corner on my eczema baby, she’d be scratching. How should I discipline her? She’s 2 year old.
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Dr Jim Sears: Time-out (naughty corner) will probably need to be on your lap so you can keep her from scratching the eczema.
 
Marice Mom: After shower, my eczema baby always scratches her head, whether using cradlecap/organic shampoo, even water. Why?
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Dr Jim Sears: Why head itches? MAYBE water too warm?
 
Marcie Mom: Water not warm, mindful that will reduce moisture. Really a puzzle! Other moms told me likewise!
(p.s. a mom asked Dr Jim what’s the best way to get rid of cradle cap for her 16 month old, his reply was to use OTC dandruff shampoo, just be careful to keep out of the eyes. Use 2x per week for few weeks)
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Marcie Mom: Many parents of eczema children cosleep to stop scratching at nite. Does cosleeping reduce stress?
 
Dr Jim Sears: Here is more about baby eczema: http://www.askdrsears.com/topics/skin-care/eczema
 
Marcie Mom: Thanks! Btw my baby loves watching TheDoctors. We think she likes the male doctors!
p.s. 1: When I’m a SAHM, The Doctors was aired at noon and my baby always stopped her scratching and crankiness and got very excited once the male doctors appeared, particularly Dr Travis Stork.
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p.s. 2: There’s a section on attachment parenting on Dr Sears’ website. I also read on this page of his website that addresses co-sleeping concerns that  “Infants who sleep near to parents have more stable temperatures, regular heart rhythms, and fewer long pauses in breathing compared to babies who sleep alone.  This means baby sleeps physiologically safer.”
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Here’re some more questions I asked but didn’t get answered, anyone has comments?
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Marcie Mom: Is oral steroid safe if used once for 0-3 year old? So if under a doc it didn’t work, another doc can’t prescribe?
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Marcie Mom: My baby has eczema, so does my hubby (family tree) will my 2nd child have? Will taking LGG help?
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Marcie Mom: Baby scratches most at bedtime and her body also feels warmer. She doesn’t sleep for more than 3 hrs though her eczema is well controlled, why?
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Marcie Mom: What’s the earliest age for skin prick test? 2 weeks old too early?

Is steroid cream safe?

Elomet cream

In my post on “Are you suffering from Steroid-Phobia?”, I have encouraged parents to be open to using steroids under the doctor’s supervision. My baby girl Marcie has taken a one-time 3 weeks oral steroid course and has been applying steroid cream prescribed by her specialist doctor, like the o.1% Elomet Cream.

A recent research study confirmed that there is no major negative effect on the skin of children who have applied topical steroid over approximately 10 months. I couldn’t find the original study, supposedly published in Pediatric Dermatology. You can however find a summary of the report, widely published by numerous online news websites here. Main points reported by the online news are:

– 70 children tested versus a control group of 22 children

– 10 months’ usage with experts checking on skin transparency, flattening, shiny ‘glazed’ appearance or dilated blood vessels

– Result is no evidence of skin thinning, stretch marks or scars

– Do note that there is also comment that the sample size is too small, with information such as their age, doses not provided

For parents fearing the use of too potent steroid, below is a potency ranking chart from National Skin Centre’s website.

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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