It’s fairly common to hear eczema patients lamenting that their doctors seem to be just prescribing creams and not listening enough. It can be even more difficult for parents, particularly as we are not the one ‘experiencing’ the eczema but we’ve got the responsibility to learn as much from the doctor (while keeping our toddler quiet)! MarcieMom is privileged to know Dr Susan J. Huang, the chief resident at the Harvard Dermatology Residency Program, who works at multiple prestigious hospitals in the United States.
More on Dr Susan J. Huang – Dr Huang is the chief resident of Harvard Dermatology Residency Program, and works at many hospitals including the Massachusetts General Hospital, Brigham and Women’s Hospital, Beth Israel Deaconess Medical Center, Childrens’ Hospital of Boston, Boston VA Medical Centers, and the Lahey Clinic. She is also the author of DermBytes.com, an online resource and blog on dermatology. Dr. Huang has written book chapters, published peer-reviewed articles, and presented at multiple national conferences on issues and topics in dermatology.
Marcie Mom: Thank you Dr Huang for last week’s pre-consultation preparation, this week we are focusing on the communication during consultation.
MarcieMom: Most parents would have heard about allergy testing and after supposedly sharing with the doctor various suspected food & non-food triggers, he/she may expect to have an allergy test conducted for the child. Is that a reasonable expectation? Are there justifiable circumstances when a doctor would say that an allergy test is not needed? And should a parent always insist to have one? (as to how doctors decide on what triggers to test, refer to Prof Hugo and Dr Liew Q&A)
Dr Susan Huang: The decision whether or not to allergy test is one that is based on your child’s particular situation. During your consultation, your physician will ask you questions about triggers to your child’s eczema. Triggers may include food & non-food triggers as you mentioned.
As we discussed in the last post, it’s important to have the details of these triggers ready in preparation for the visit. The visit will also include a physical examination to see whether findings are consistent with a food allergy. If certain foods or other exposures are suspected, your physician can then work to help confirm the trigger and come up with an appropriate panel of tests. Testing may include skin prick, RAST, or oral challenge testing. If a contact dermatitis is suspected, patch testing is performed (this is where small quantities of different contactants are placed on the skin).
The role of allergy testing in eczema is still a debated topic but we certainly do know that allergies, asthma and eczema run together, creating the “atopic triad.” Now, studies have shown that 1 in 28 suspected food allergies are not true food allergies, but rather “intolerances.” So, it’s important to know whether one truly has a food allergy or not, because you don’t want to limit your child’s diet unnecessarily (providing well-balanced nutrition is important for the growth of your child!)
MarcieMom: The prescription given by the doctor is typically moisturizing creams with topical steroid treatment and the instruction usually to moisturize frequently while steroid is to be used sparingly and not more than twice a day. What would you advice the parent to find out more from the doctor? For instance, asking how the eczema rash would appear after a week of application? And when it’d be cause to come back earlier than scheduled for another consultation? (I think doctors usually refrain from talking too much about specific creams, parents can refer to this Q&A with Dr Verallo to identify the top irritants in creams and also this Q&A with Dr Bridgett to learn how to apply topical cream and steroid, and this post on steroid strength and steroid-phobia.)
Dr Susan Huang: Great question. Questions about the use of topical steroids frequently come up. Make sure you review an Eczema Action Plan with your physician before you and your child leave from your consultation. Having this information written down is important so that you don’t forget the details. Action items may include non-medication therapies (e.g. moisturizing, bathing techniques include bleach baths, wet wraps or wet pajamas, etc) as well as medications (e.g. topical steroids). It is important to clarify how much of the lotion/cream/ointment, to where is should be applied, and when it should be applied and for how many days. As you mentioned, also ask what you should expect to see at the end of the treatment course that your physician has detailed to you. It is important to have this information written down because it’s hard to remember all these details! We provide these written eczema action plans in our clinics.
Absolutely clarify follow-up plans before you leave for your visit. Your physician may tell you when to come back or may say to come back if the rash does not get better. In addition, she/he may give you a list of warning signs to look out for, e.g. if your child’s rash doesn’t get better after the treatment course, develops fever/chills, the rash becomes crusty, weepy or ulcerated — showing signs of infection, etc.
MarcieMom: Thank you Dr Huang, it’s good to know your point of view as to what is acceptable to be asked during a consultation, as some parents may be too shy and leave promptly with many questions still unanswered and then (worse), not carry out the treatment as directed cos they are fearful of what has been prescribed!