Do you feel like you have tried everything to help your child manage his eczema but your efforts seem to be futile? Turn your attention to the skin microbiome, in particular, staphylococcus aureus (staph bacteria).
This is a 2-week series focused on Gladskin’s targeted approach in improving eczema skin, through maintaining a healthy skin microbiome. I’m honored to have the President of Gladskin USA, Skyler Stein, to help in this series. Read his bio here.
We were alerted early that staph bacteria is a harmful bacterium that colonizes eczema skin, that makes the eczema treatment less effective. Since my daughter was seven months old, she started chlorhexidine wipes and swimming. Now at ten years old, she is still using an anti-microbial cleanser.
An Enemy that is Hidden in Plain Sight & Cannot be Killed
Yet, when my daughter recently had skin swap tests on an infected persistent eczema rash, she was tested positive for staph bacteria. This was even with the thrice weekly anti-microbial skin wash. I was shocked that with all that regular anti-microbial cleansing (which I already feared may be a bit too much), the staph bacteria were still proliferating. It almost felt like we were battling with a hidden in plain sight enemy that cannot be killed!
Gladskin’s Targeted Approach – Taking out the Bad Bacteria, without taking down the Good Bacteria
The prevalence and proliferation of staph bacteria on eczema skin is a tricky situation. You have to remove the staph bacteria but doing so through bleach bath, swimming (chlorine) or anti-microbial wash would mean killing the good bacteria on the skin as well. And very often, these methods may be drying for the skin.
Gladskin has developed a patented smart protein Micreobalance which rebalances the skin microbiome in a very targeted way. while protecting the good bacteria on the skin.
A Step Back: What is the Big Deal with Skin Bacteria?
Reduces the biodiversity of skin microbiome, which would also reduce beneficial bacteria and upset the skin’s healthy microbiome
Produces byproducts that causes inflammation
Severity of eczema correlates with increased staph bacteria
MarcieMom: I really like the targeted approach for Gladskin product because it makes perfect sense! The main benefit versus anti-microbial products would be not killing the beneficial bacteria. Can you give us an idea of how long it takes for the good bacteria to ‘grow’ back on our skin?
Skyler Stein: Yes, the targeted approach with Gladskin is what makes it truly a new category of treatment for people with eczema.
The answer to this question about how long it takes for good bacteria to grow is complicated as there are thousands of different types of “good” bacteria, and different types of bacteria take different amounts of time to grow. The most important thing to realize is that if you kill the good bacteria, it creates an environment more favorable for the bad bacteria to thrive – so it’s really important to maintain a healthy skin microbiome for long term skin health.
MarcieMom: I’m thinking about the ‘practical’ logic behind using Gladskin. For instance, if I were to use an anti-microbial wash daily on my child to kill staph bacteria, would it be difficult for the good bacteria to build up on her skin?
Skyler Stein: Yes, if you use a broad spectrum antimicrobial on the skin, it will kill both the good and bad bacteria. In a healthy rainforest with lots of biodiversity, the ‘good’ plants naturally keep invasive weeds from growing out of control. If you burn down the rainforest, killing all the biodiversity, it is much more likely for invasive weeds to grow out of control. It works the same way on your skin, if you kill the good bacteria, it creates an environment that allows the bad bacteria to take over!
MarcieMom: Can you explain how daily washing of beneficial bacteria may hurt the child’s skin?
Skyler Stein: The beneficial bacteria on the skin are like little chemical factories that produce lipids, vitamins, nutrients, etc. that are essential for healthy skin, AND they keep the bad bacteria in check. If you kill the good bacteria, the skin will miss out on the essential ingredients produced by those bacteria that are needed for healthy skin, and creates an opportunity for the bad bacteria to grow out of control.
If you kill the good bacteria, the skin will miss out on the essential ingredients produced by those bacteria that are needed for healthy skin, and creates an opportunity for the bad bacteria to grow out of control.
Spotlight on the Active Ingredient – Micreobalance™
MarcieMom: I read on your FAQ page that the ideal temperature for storage is below 75 ºF. Is this going to affect whether you sell the products in tropical countries, or affect storage during the hot summer months? Would you discourage parents from bringing your cream out to the park on a hot day?
Skyler Stein: Gladskin can withstand temperatures of over 100ºF for a week, and 3 months at room temperature. If you plan to keep Gladskin longer than 3 months we recommend storing it in the refrigerator. It’s safe to take with you to the park on a hot summer day, but we don’t recommend keeping it in a hot car for months.
Thank you Skyler for giving us a broad understanding of the beneficial and harmful bacteria on eczema skin and why it’s so important to keep a healthy balance of bacteria for healthy skin. You can learn more about Gladskin’s science and read reviews from current Gladskin users at www.gladskin.com
For those of us who do not know the (possibly) billion types of proteins in our body, Dupilumab works by targeting two cytokines. These cytokines (IL-4 and IL-13) regulate the body’s immune response to inflammation. Dupilumab works by injection and its list price is US$3019.50 per 4-week supply.
Update on 26 Oct 2019: This is another company that is working on Etokimab that targets IL-33, and improvement seen after single dose (study).
What is the Current Dosage for Older Children with Eczema?
Similar to oral medication, the weight of your child is one factor that determines the dosage. Drugs.com listed the dosage as:
For Adolescents lighter than 60 kg
Initial dose: 2 injections (each 200 mg) at different part of the body
Maintenance dose (each 200 mg) injected every other week
If your child is 60 kg and heavier, each dosage is 300 mg.
What if My Child does not like Needles?
Biologic drug means it is made from proteins – interesting, it is made from Chinese hamster! (I found out this from Australia TGA’s information leaflet.) Dupilumab cannot be taken orally, otherwise, our body will break down the proteins before the medication can get to work. Its molecules are also too large to be absorbed through the skin (that I learnt from US National Eczema Association).
Dupilumab can only be taken via injection
Does Dupilumab Work?
From the studies, yes, Dupilumab works.
It works by effectively targeting the two proteins that have been studied to be the most related to Atopic Dermatitis. These proteins cause more itch and inflammation, so targeting them will mean ‘short-circuiting’ the pathway that the skin gets hypersensitive.
Hang on. Even if you can afford it, certain conditions must be met before a doctor can prescribe Dupilumab. And not any doctor – it has to be a specialist e.g. dermatologist.
What ‘Moderate-to-Severe Eczema’ Means?
Dupilumab can only be prescribed for moderate to severe eczema, that cannot be controlled with topical medicines.
I cannot find information on whether your dermatologist has to prove the eczema severity. I guess that a dermatologist is assumed to have both the expertise and the duty to prescribe only when needed.
So what does Moderate to Severe Eczema look like?
Several guidelines are helpful in giving a common understanding of mild vs moderate vs severe eczema, one of which is UK’s NICE guideline.
Moderate eczema means:
Areas of dry skin
Redness (with or without excoriation (skin picking) and localised skin thickening)
Moderate impact on everyday activities
Frequently disturbed sleep.
Severe eczema means:
Widespread areas of dry skin
Redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation)
Severe limitation of everyday activities
Nightly loss of sleep.
For those of us, who are into something quantifiable, you can work out your child’s eczema severity through SCORAD. If the score is from 25 to 50, your child has moderate eczema and above 50, is severe.
Many Moderate Eczema Cases
My child’s eczema would fall under moderate. And I suspect, there are many children with moderate eczema. Does this mean all these children would be prescribed Dupilumab?
Proof that Topical Medicines Do Not Work
Approval for use specifically states that Dupilumab can only be prescribed if topical medicines had not worked. My deduction, therefore, is that your child first has to have tried topical corticosteroids or topical calcineurin inhibitors, in order for the dermatologist to CONCLUDE that these have not worked.
To put it simply, if you are scared of steroids and have not applied it for your child, the dermatologist may not be able to prescribe Dupilumab.
No need for History of Eczema Oral Medications
Your child do not need to have taken oral medications for eczema, before the dermatologist can prescribe you Dupilumab. My guess is that the current oral medications are not optimal for eczema treatment. They come with side effects that are severe enough that they cannot be taken over a long duration.
Oral systemic steroids is usually for 2-week dose and side effects can include hypertension, glucose intolerance, gastritis, weight gain etc. Rebound flares are also common. Read more in this journal.
If you are considering Dupilumab, you should first inform your dermatologist of any eye problem. You may be asked to consult an eye doctor to establish a baseline for your eye condition before starting Dupilumab.
The Other Thing – Duration
Because of the way Dupilumab works, it is an ongoing treatment. Meaning, if you stop the injections, the protein cells in your body may go back to triggering skin inflammation. You should give it 16 weeks to see if the treatment works for you (National Eczema Society’s fact sheet).
To Dupilumab or Not?
There is no easy answer.
It is a decision to consider based on:
Severity of your child’s eczema
Emotional aspect of injection
Possible side effects, including the current eye condition (for instance, if your child already has dry eyes, it may worsen)
Whether topical prescription has been properly explored (because applying something is still safer than injecting something)
Currently, Dupilumab is very expensive because it is generally not subsidized nor included in insurance. But should it be more affordable, I still believe that given it is via injection and comes with side effects, we have to be sure that it is only prescribed as needed.
To put it bluntly, it should not be an easy (or lazy) way out of the due care needed for your eczema child.
Have you tried Dupilumab? It helps for fellow eczema patients to read of your experience, so please do share in the comments below or in the forum post.
So, You are Pregnant and You know that Your Family has an Eczema/ Allergy History. Is there anything that you can do?
This February 2018 UK study investigated how maternal or infant diet can influence risk of allergic disease. The conclusion was maternal probiotic and fish oil supplementation may reduce risk of eczema and allergic sensitisation to food, respectively.
However, in the US, the American Academy of Pediatrics (AAP) in their 2019 paper did not support maternal dietary restrictions during pregnancy and lactation to prevent atopic disease.
Recommendations on impact of maternal diet for atopic dermatitis do vary by country
For instance, World Allergy Organization guideline recommended probiotic (for high-risk cases) and prebiotic (for not exclusively-breastfed infants) supplements for eczema prevention, but European (EAACI), North American and Australasian guidelines do not support this.
So, check with your doctor on probiotic and omega-3 for reducing the chance your baby will have eczema
How Long Should You Breastfeed?
Now your baby is born, how long should you breastfeed?
The AAP recommendation is that breastfeeding beyond 3 to 4 months does not help prevent atopic disease for your baby. So, if like me, you are finding breastfeeding a struggle, you can stop without feeling guilty. (Phew!)
Because allergy testing is not accurate for infants newborn, there is the chance that pediatricians may recommend switching to HA milk if newborn is diagnosed with eczema rash. Please check if your pediatrician or see an allergist to confirm if that is still the right recommendation.
On the other hand, in Singapore, a study in 2018 showed evidence that feeding partially hydrolyzed milk to high-risk infants did reduce the incidence of eczema. This is helpful if :
Your baby is high-risk, meaning his parent or his sibling has eczema, and
You are unable to feed 100% breast milk and have to use formula milk, then
Choosing a partially hydrolyzed milk formula is preferred over cow’s milk and calculated in the study to be cheaper (notwithstanding the partially hydrolyzed milk is more expensive than cow’s milk).
Now Back to Breast Milk…
Interestingly, there are quite a few news on how breast milk is applied on skin to treat eczema rash!
This 2015 Iran study undertook a randomized control trial to determine if APPLYING breast milk onto eczema rash is helpful. The finding? Human breast milk improve infant atopic eczema with the same results as 1% hydrocortisone ointment.
Human Breast Milk as good as mild topical corticosteroid?!
Maybe it is not that hard to believe, considering breast milk has
Is there anything that can be fed to your baby to reduce eczema risk? So far, it seemed that fish and probiotics can be helpful.
This August 2019 Norway study concluded that eating fish at least once a week at 1 year-old was less likely to have eczema, asthma, and wheeze at 6 years-old.
Consuming cod liver oil at least 4 times per week at 1 year old also helps reduce allergy risk.
The other study looked into probiotics – a December 2018 New Zealand study concluded that taking Lactobacillus rhamnosus HN001 in early childhood was associated with significant reductions in the 12-month prevalence of eczema at age 11 years and hay fever.
This exciting feeding milestone for many parents usually ends up a stressful one for parents with eczema children. Is it the food that trigger the rashes?
Wait. It is even more confounding because it is possible that the defective skin barrier can somehow increase sensitization to food.
The latest AAP recommendation in 2019 is there is no need to delay the introduction of allergenic foods beyond 4 to 6 months for the prevention of atopic disease. However, early introduction of peanuts (4 – 6 months old) may prevent peanut allergies in high-risk infants. (check out this forum post for updated study.
This study examined the skin microbiome (skin bacteria) of 75 Egyptian patients with atopic dermatitis (AD), compared to 20 health controls. It was found that the bacterial diversity of skin microbiome in patients with AD was less than those of the healthy subjects. Eczema children, adolescents and adults have bacteria, Streptococcus, Cutibacterium, and Corynebacterium, while Staphylococcus was noted as a potential biomarker candidate for AD. These bacteria also exacerbated eczema. Total immunoglobulin E (IgE – antibodies that reacts to an allergen, causing allergic reaction) levels were positively correlated with certain Staph bacteria.
What it means for Eczema Skincare
The skin microbiome of eczema children is different from normal skin, which has been covered in-depth in this Staph Bacteria on Eczema Skin series with past president of American Academy of Dermatology, Dr Clay Cockerell. Limiting staph bacteria colonization on eczema skin is one of the recommended therapeutics, with one of the most commonly heard of ways to reduce staph bacteria being the bleach bath. Reducing staph bacteria is also one of the skincare aspect which my daughter’s doctor (and also co-author for Living with Eczema: Mom Asks, Doc Answers) recommended us to work on.
You can talk the same to your doctor whether the use of anti-microbial cleanser, swimming (literally a ‘fun’ way to kill the harmful skin bacteria, while splashing and soaking in the pool!) or chlorhexidine gluoconate wipe (it is cheaper if you purchase a bottle at the pharmacy and pour on disposal cotton pad to wipe skin, rather than buy the ready-made wipes. The bottle can be stored in fridge) at eczema lesions area are appropriate. We tried all the above, and even now, regularly uses an anti-microbial cleanser. You can also explore some baby clothing made with silver or bamboo material with anti-microbial properties.
In this study, it was noted that Staphylococcus aureus colonization on AD skin had been directly correlated to eczema severity. It was thus important to study how skin bacteria affect skin inflammation.
It was also noted in this study that skin bacterial diversity is smaller than in healthy subjects. Through a panel of Canadian dermatologists, the consensus was that:
(1) In atopic patients, the skin microbiome of lesional atopic skin is different from nonlesional skin in adjacent areas.
(2) Worsening atopic dermatitis and smaller bacterial diversity are strongly associated.
(3) Application of emollients containing antioxidant and antibacterial components may increase microbiome diversity in atopic skin.
Have you found something that works? Share in the comments if you have found reducing staph bacteria to be helpful in managing your child’s eczema. I’m bringing back a new season of Someone has Eczema series, please let me know if you like to share your story to encourage all of us.
Finding the right preschool for your eczema child can be a challenge – you wonder about whether the teachers have the time to ‘monitor’ and help to control your child’s scratching, and you worry about possible triggers at the preschool.
Another article that I have shared on NEA is about finding the right preschool for your eczema child.
Inform the school of your child’s eczema
Visit the school before making a decision
Ask about the class sizes—the smaller, the better
Watch the teachers and students interact
Ask about their experience with eczema kids
Make sure the preschool is a NO BULLYING zone
Volunteer to raise awareness around eczema
Sign up for a trial run with the preschool
If your child has eczema, it is possible that they may be teased or feel embarrassed by the appearance of their skin. Preschools that take bullying seriously will be mindful about creating a respectful environment not just between the students and the teachers, but also among the children themselves.
I know that it is not easy to find a preschool that you can trust with your child. Sometimes it takes a leap of faith, but you can always exercise judgment and due diligence. Once you have committed to it, work with the preschool on the right environment instead of working against them through fault-finding. We know that it is not easy to care for a child with eczema, and it would be even harder for the preschool teachers who have many more children to take care.
If you are a parent of eczema child, please read the comments on our support group page where hundreds of parents have shared their greatest challenges and best parenting moments in caring for their child.
It is difficult to care for an eczema baby, therefore when National Eczema Association asked me to share my journey, I gladly shared my 8 survival tips below.
National Eczema Association – Eczema Warriors
As I shared in the previous post on my first article with National Eczema Association, the NEA is doing a great job giving eczema warriors all over the world a sense of solidarity – through the stories we hear each other share, of our struggles, how we figure out parts of the puzzle to improve our quality of life and inspire us to hold on to the hope of a better day tomorrow.
Secure the baby’s hands
Do less washing and cooking
It’s partly in the mind
Sleep cool, literally
Don’t be afraid to start over
Look at quality of life, not quality of skin
Put the ‘care’ into skincare
If you are a parent of eczema child, please read the comments on our support group page where hundreds of parents have shared their greatest challenges and best parenting moments in caring for their child.
For many of us, reading a story shared by a fellow eczema sufferer or parent can be just the thing we need to carry us through the day. Eczema can be an isolating experience, when others around you will not be able to identify with the constant itch, the effect on appearance and the anxiety and stress it places on your relationships or lifestyle. I shared my journey on National Eczema Association where they have done a great job giving eczema warriors all over the world a sense of solidarity. The first of my sharing “Getting through the Darkest Moments..” is published on NEA’s website, with the following tips to help us get through the emotional battle.
Mental resolve to never give up
Stand with your spouse
Quality of life, not of skin
Sleep was of course trying. We did our best to keep Marcie cool, moisturized and calm before bedtime. However, after barely two hours of sleep, she would wake up scratching and crying for help. We could empathize, after all, we were crying for help in our hearts.
I was often asked, “So how did you get through it?”
If you are a parent of eczema child, please read the comments on our support group page where hundreds of parents have shared their greatest challenges and best parenting moments in caring for their child.
Scientists from the National Institute of Allergy and Infectious Diseases (NIAID) have identified a gene mutation called CARD11 that led to atopic dermatitis/ eczema. Their findings were recently published in Nature Genetics (June 2017)1. Gene sequencing was performed for 8 individuals from 4 families, and the researchers found that although each family had a distinct mutation affecting a different region of the CARD11 protein, each mutation disrupted its normal function in T cells – an essential type of white blood cell.
The potential of this study was that glutamine may correct the defective signally mechanism of the mutated CARD11. Glutamine is available as a supplement, and the researches intend to study the effects of glutamine consumption on individuals with CARD11 mutations/ severe eczema. If the future study proved conclusive, it would open an easy therapeutics method for treating eczema!
Nature of study: Parallel-group, randomised, controlled, observer-blind trial
Participants: Children aged 1 to 15 year old with moderate to severe eczema; 300 children were included: 42% girls, 79% white, mean age 5 year old
Randomized groups: Participants were randomised to receive standard eczema care plus silk clothing (100% sericin-free silk garments; DermaSilk or DreamSkin) or standard care alone.
Measurement: At baseline, 2, 4 and 6 months against the Eczema Area and Severity Index (“EASI”)
Outcome: No evidence of a difference between the groups in eczema severity (EASI score) assessed by research nurses
Purpose of the study: Silk clothing is available on prescription (and online) but the randomized controlled trials previously done were for small group of participants. To provide direction for clinical practice as to whether to recommend silk clothing, this study was taken on. Silk garment claimed beneficial for eczema as they are smooth, helped regulate humidity and temperature, reduce scratching damage and have anti-microbial properties. These are important qualities that would benefit eczema to reduce scratching (versus a ‘scratchy’ fabric like wool), keep the skin cool and reduce likelihood of flucuating temperature triggering eczema flareups and reduce bacteria load as eczema skin is prone to staph bacteria colonization. However, from the outcome of this study, it would appear that standard eczema care such as regular emollient use and topical corticosteroids (or topical calcineurin inhibitors) for controlling inflammation would be adequate.
In my view, this study would really get parents who are spending a lot of money on silk clothing/ bedding to question if such money needs to be spent. These silk garments are not cheap but parents pay for them due to positive testimonies, anti-inflammatory/ anti-microbial properties of silk and that these clothing are soft, free of dye and will not irritate the skin (interviewed Dermasilk here). However, a lower-cost alternative of cotton may work as well, with standard care for eczema.
I’ve also contacted Professor Kim Thomas who is part of the research team for this study and she kindly shared this video on University of Nottingham’s website
My personal take is if you’re seeing benefits for your child with silk clothing and can afford it, there is no reason to stop using the clothing. However, if it hasn’t seemed to make much difference and you feel confident that the eczema therapeutics measures that you use for your child are sufficient, then it makes sense not to spend that money. See this post for the review of various eczema therapeutics and also the review study that Nottingham University had done.
Silk garments plus standard care compared with standard care for treating eczema in children: A randomised, controlled, observer-blind, pragmatic trial (CLOTHES Trial) Thomas KS, Bradshaw LE, Sach TH, Batchelor JM, Lawton S, et al. (2017) Silk garments plus standard care compared with standard care for treating eczema in children: A randomised, controlled, observer-blind, pragmatic trial (CLOTHES Trial). PLOS Medicine 14(4): e1002280. https://doi.org/10.1371/journal.pmed.1002280
Ongoing studies at Centre of Evidence Based Dermatology at Nottingham University:
I’m privileged to interview the lead researcher for the study, Dr Donald J Davidson MBChB PhD. Dr Davidson is the MRC Senior Research Fellow and University of Edinburgh Senior Lecturer. The Davidson Group within the MRC Centre for Inflammation Research focuses on understanding the physiological importance of cationic host defence peptides (CHDP) to host defences against bacterial and viral infections. Dr Davidson is a medical graduate of the University of Edinburgh who chose to pursue a scientific research career. He completed a PhD at the MRC Human Genetics Unit, studying the pathogenesis of cystic fibrosis lung disease, then was awarded a Wellcome Trust Travelling Research Fellowship to undertake post-doctoral training in innate immunity research at the University of British Columbia, Vancouver. You can read more of his research interests here.
MarcieMom: Thank you Dr Davidson for taking the time to help with the questions. The questions will be based on the study, but more focused on its practical implications.
Staphylococcus aureus is a resilient bacteria found on the skin that can survive in dry condition and on dry skin with little oxygen. It tends to involve areas that are warm and moist especially such as skin near mucous membranes such as the nose, mouth, genitals and anal area. It is found in less than 30% of healthy adults and generally does not cause an infection in those with healthy skin. However, as pointed out in the study, 75% to 100% of atopic dermatitis patients have staph bacteria on their lesional skin and 30% to 100% of atopic dermatitis patients have staph bacteria on their non-lesional skin (Breuer et al., 2002; Gong et al., 2006; Park et al., 2013). The problem with staph bacteria is that it secretes toxins and proteases that can worsen atopic dermatitis.
MarcieMom: From your study, protease V8 was of interest which showed it led to skin barrier dysfunction. Can you explain what you learnt about staphylococcus aureus’ interaction with atopic dermatitis skin/ normal skin and how does it damage skin integrity?
Dr Davidson:In our study we did not use the whole live bacteria, but concentrated instead on its harmful proteases. Using skin cells grown in the laboratory and collecting the substances made by the bacteria Staphylococcus aureus, we were able to show that the bacterial protease V8 was the most powerful product when it came to breaking down and damaging the skin barrier. Together with studies from other research groups, this suggested that one of the main ways these bacteria can damage skin is by producing V8, and that finding ways to block this damage may help to maintain and/or restore the skin integrity in atopic dermatitis.
Natural Skin Defence
In your study, it was mentioned that human beta defensin 2 (hBD2) is a substance on our skin that have antimicrobial properties and able to protect against skin integrity damage caused by staph bacteria protease V8. It was further noted that the level of hBD2 on atopic dermatitis skin was significantly lower than normal skin, therefore atopic dermatitis skin may be more prone to infection and unable to defend itself against staph bacteria.
MarcieMom: I hope I have understood hBD2’s role correctly; can you explain more about what you have found out about hBD2, for instance, how important is its role in maintaining skin integrity, fighting infection and the effects of protease V8?
Dr Davidson: Our bodies can make quite a wide range of substances we call antimicrobial host defence peptides (HDP). The skin is one site that produces these. These HDP have a lot of different roles in protecting us from infection and disease. hBD2 is an HDP from the defensin family. hBD2 was already known to be capable of killing bacteria in the laboratory. It is less clear if it definitely does this in normal functioning on our skin. However, it has been suggested by other researchers that the failure of atopic dermatitis skin to make as much hBD2 as one would expect (for the amount of skin inflammation or damage), could be one reason that atopic dermatitis skin lesions are prone to infection. What our new MRC-funded research discovered was that hBD2 can also stop V8 from damaging laboratory-grown skin. This worked both when we instructed the skin to make extra hBD2 (using genetic modification) and when we added hBD2 in the style of a treatment. Just how important this is in a living human remains to be seen, but it has obvious potential and shows that hBD2 can protect the skin barrier as well as kill bacteria.
MarcieMom: The interesting part of your study was its demonstration that application of hBD2 was found to be protective, and therefore a possible future eczema therapeutic. How does the application of hBD2 work? What are its protective effects?
Dr Davidson:At this point we don’t know how hBD2 protects this skin barrier integrity and we are currently applying for more funding so that we can start to work this out. It may act directly on the V8 to block the damaging effects of this bacterial protease, but we’ve found that it can also help to speed up repair where damage has occurred. So hBD2 may work in more than one way.
Is this something you foresee that can be easily added into a moisturizer or would it be more likely to be a non-steroidal topical prescription?
Dr Davidson: At this stage we are still in the discovery science phase of the research, so it is too early to predict how, and even whether, it will turn out to be a useful treatment. However, in the best case scenario for the outcome of our research, I would envisage adding hBD2 (or drugs made to mimic some of its functions) into prescription moisturizer-type creams or ointments.
How would the application of hBD2 be compared with the existing eczema measures such as bleach bath to kill staph bacteria?
Dr Davidson: I’m afraid it is too early to be able to make comparisons of that kind, until we have a better understanding of exactly how hBD2 functions to protect the skin barrier.
MarcieMom: Thank you Dr Davidson once again for your time and will certainly look forward to further breakthroughs and more studies done in this area.
1.Wang B, McHugh BJ, Qureshi A, Campopiano DJ, Clarke DJ, Fitzgerald JR, Dorin JR, Weller R, Davidson DJ, IL-1beta-induced protection of keratinocytes against Staphylococcus aureus-secreted proteases is mediated by human beta defensin 2, The Journal of Investigative Dermatology (2016), doi: 10.1016/j.jid.2016.08.025.
2. Breuer K, S HA, Kapp A, Werfel T (2002) Staphylococcus aureus: colonizing features and influence of an antibacterial treatment in adults with atopic dermatitis. Br JDermatol 147:55-61.
3. Gong JQ, Lin L, Lin T, Hao F, Zeng FQ, Bi ZG, et al. (2006) Skin colonization by Staphylococcus aureus in patients with eczema and atopic dermatitis and relevant combined topical therapy: a double-blind multicentre randomized controlled trial. Br J Dermatol 155:680-7.
4. Park HY, Kim CR, Huh IS, Jung MY, Seo EY, Park JH, et al. (2013) Staphylococcus aureus Colonization in Acute and Chronic Skin Lesions of Patients with Atopic Dermatitis. Ann Dermatol 25:410-6.
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.
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.
Staph Bacteria and Antiseptic Moisturizer
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.
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
0 – 3 years old – could be due to immature skin barrier, including lower lipid content, fewer natural moisturizing components, higher pH and thinner epidermis
6-7 years old
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.
In the article1, it was mentioned that the most “allergenic” corticosteroids are:
The least allergenic are those with halogenated C16-methylated molecules and in order of increasing potency:
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).
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
Eczema is a skin condition with many parts to the puzzle – it is linked to hereditary skin condition, allergens (food, inhaled, contact and airborne), environmental factors (heat, humidity), bacteria colonization on skin (and how gut microbiome may affect allergic conditions), lifestyle factors (stress, hormonal change) and also suspected to be linked with diet/ water. Very often we may think of what we have eaten, rather than what we have applied on our skin. A moisturizer or topical prescription tend not to fall under our usual ‘list of suspects’ when we try to figure out what’s triggering the eczema.
This 2-part blog series aim to bring greater awareness of contact allergens, and how some of these may be the ingredients in your skincare products. Especially for pediatric patients, we have to be even more careful because:
Babies’ skin barrier is thinner than that of an adult- making it extra vulnerable to chemical irritants (also greater transepidermal water loss and therefore, moisturizing is important)
Increasing research showing that a strong skin barrier has protective effect against eczema, and reduce likelihood of food sensitization
I am privileged to have dermatologist Steve Xu, MD MSc to help with this series. He is a board-certified dermatologist and a faculty member at Northwestern University’s Feinberg School of Medicine. He is also the medical director of the Center for Bio-Integrated Electronics at 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 New York Times.
Allergic Contact Dermatitis – What is it?
MarcieMom: Contact dermatitis refer to skin rash that is triggered by contact with an allergen/ irritant. If the immune response is that related to IgE, it would be allergic contact dermatitis; conversely, if the response is due to overtime exposure to the irritant (leading the skin to develop delayed-type hypersensitivity), it is irritant contact dermatitis.
The thing is a child can have all the different types of dermatitis – atopic, allergic contact and irritant contact.
MarcieMom: Dr Steve, thank you for joining me for this series. The different terms can get very confusing for parents of eczema children. How would you explain the different types of dermatitis to a patient?
Dr Steve Xu: Right now even within the scientific community, there’s a big debate on what exactly we should call ‘eczema’. At our institution (Northwestern University), this is how we break it down.
The term ‘eczema’ itself actually describes how a certain rash looks. Atopic dermatitis, allergic contact dermatitis, and irritant contact dermatitis all can cause an ‘eczema’ rash that looks exactly the same. Eczema used as a standalone term isn’t really specific.
For classic childhood ‘eczema’, we refer to this as atopic dermatitis. Allergic and irritant contact dermatitis is defined as a condition where an external agent leads to an eczematous rash. Basically, an allergic contact dermatitis is defined by an immune-mediated response to an external agent applied to the skin. These reactions typically require only a very small amount of the agent to lead to a rash. Irritant contact dermatitis is not immune related but leads to an indistinguishable eczematous reaction. Typically, more of an external agent must be applied to cause a rash in irritant contact dermatitis.
MarcieMom: In practical terms, is diagnosing the type of dermatitis important? Or knowing the triggers are adequate for management of eczema?
Dr Steve Xu: Yes, definitely. An irritant contact dermatitis usually requires more of the external agent to cause a rash. This is practically important because if you only have an irritant contact dermatitis you may be able to tolerate products that are wash off or rinse off. If you have an allergic contact dermatitis, then we recommend avoidance altogether. Even a little exposure can cause a miserable rash.
Prevalence of Allergic Contact Dermatitis
There is increasing evidence that allergic contact dermatitis is under-reported in children and while traditionally thought as unlikely for children, contact dermatitis is becoming more common.
MarcieMom: In the article1, the top ten pediatric allergens found in personal hygiene products are listed (with the first as having most percentage of children being hypersensitive to it):
Neomycin – topical antibiotic, another contact allergen is over-the-counter antibiotic Bacitracin
Balsam of Peru – also known as Myroxylon pereirae, chemically related to fragrance and thus used to screen for fragrance allergy
Fragrance mix – Of the flowering plants, the Comositae family is the most likely to cause skin sensitization, such as chamomile, dandelion and ragweed; also cross-reactive with propolis (beeswax)
Benzalkonium chloride – ammonium compound used as preservative, including in disinfecting wipes and eye drops
Lanolin – natural oil from sebum of wool-bearing animals
Formaldehyde – preservative, also associated with quaternium 15, imidazolindinyl urea (most common), diazolidinyl urea, bronopol, dimethyl-dimethyl hydantoin (this can get very tricky to memorize, readers can refer to this table created by dermapathologist in a previous interview)
Methylchlorsothiazolinone (MCI)/ Methylisothiazolinone (MI) – likely to be in bubble baths, soaps, cosmetic products, and baby wipes
Propylene glycol – previously common in moisturizers (but many brands stopped including propylene glycol: it has humectant properties and also an emulsifier) and topical steroids
Corticosteroids – when using steroid creams, we have to be aware of its potency, but we may now have to know its likelihood of being contact allergen (we will discuss this next week)
Other than the above 10, the other well-known contact allergens are cetylstearyl alcohol, sodium lauryl sulphate, pehnoxyethanol, parabens, TEA (triethanolamine) and vitamin E.
Nickel and cobalt are also common contact allergens but less likely that children will come into contact with them.
Sensitization to Personal Care products
MarcieMom: It is interesting to note that the above can be found in personal care products, even in those marketed for children. I’m wondering if there is an increase in sensitization to personal hygiene/ skincare products? If so, why? (for instance, is it the increased use of products? Or increased awareness/ patch testing/ consultation)
Dr Steve Xu: The prevalence of contact dermatitis has remained stable overall but certain chemicals are representing a larger share of problems. This is related to industry trends. For example, as formaldehyde was phased out over the past 20 years in personal care products, we’ve seen a growing use of methylisothiazolinone as a preservative. It’s unsurprising that methylisothiazolinone contact allergy is rising rapidly.
Pediatric dermatologists have really worked hard to raise awareness among pediatricians and allergists about contact dermatitis in kids with atopic dermatitis. More than half of kids with atopic dermatitis will have a relevant positive patch test. In general, we’re arguing that kids with atopic dermatitis should be patch tested more and tested for food allergies less.
Parents need to know that just because a product is labeled “For babies” or “Safe for kids”, it doesn’t mean it’s any different than what products are sold for adults. These are just marketing claims. Statements like “sensitive skin safe” or “organic” also aren’t regulated. Even carefully reading the labels may not be completely fool-proof. Often times, manufacturers do not have to be specific about which fragrance they are using (different fragrances can cause contact dermatitis).
MarcieMom: Practically, this feels like being caught between a rock and a hard place. The baby’s skin loses more moisture, has less lipids and for babies with dry skin, even more so we have to moisturize. Now, we know the common contact allergens to avoid and of course, should take the effort to read the product label and make sure we’re not putting something on our babies with these allergens. YET, the more we put something on our babies, the more likely the skin can become sensitized to it overtime! (for instance, lanolin, CAPB weren’t previously contact allergens)
Strategy to reduce contact dermatitis in children
MarcieMom: Is there a strategy to moisturizing to reduce likelihood of contact dermatitis? For instance, rotating skincare products which one expert has previously mentioned.
Dr Steve Xu: We often have patients come into our clinic with classic allergic contact dermatitis and exclaim: “I haven’t changed my products in years!”. In truth, this is exactly how a contact allergy develops. It’s true that small, continued exposures over time train your immune system to develop an allergy.
With that being said and to the best of my knowledge, there are no well-designed clinical studies showing that rotating skincare products reduces the risk of future allergic contact dermatitis. I’m hesitant to recommend this strategy.
Here’s some practical advice to perhaps help answer this question. Let’s say you have a child with atopic dermatitis and it’s fairly well controlled. Over the course of a period of time, let’s say the atopic dermatitis has taken a turn for the worst and is not getting better with optimal therapy. Or, let’s say that that the atopic dermatitis is appearing in areas it never has before (e.g. belly button, waistband, wrist). Then, this is a time to consider whether there is a simultaneous allergic or irritant contact dermatitis. Patch testing would be recommended.
If there is a relevant positive patch test, than this is the time to follow a safe list. Severely limiting what skincare products or household products can be used in the absence of a patch-test proven allergen may be overkill.
MarcieMom: Thank you Dr Steve for helping us to understand more about contact dermatitis; for me, I’ve learnt that there is practical benefit of knowing the type of dermatitis one is suffering from, and being mindful of the possible development of contact dermatitis for an eczema child. Look forward to next week where we will discuss more about skincare product, prevalence of contact dermatitis in kids and corticosteroids.
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
For some of Dr Steve’s publications, see below:
Xu S, Walter JR and Bhatia A. Online Reported User Satisfaction with Laser and Light Treatments: Need for Caution. Dermatologic Surgery. Published online September 9th, 2016. DOI: 10.1097/DSS.0000000000000862.
Xu S, Kwa M, Agarwal A, Rademaker A, and Kundu RV. Sunscreen Product Performance and Other Determinants of Consumer Preference. JAMA Dermatology. 2016. 152(8):920-927.
Walter JR and Xu S. Therapeutic Transdermal Drug Innovation from 2000-2014: Current Status and Future Outlook. 2015. Drug Discovery Today. 2015. 20(11):1293-1299.
Walter JR and Xu S. Topical Drug Innovation from 2000 through 2014. JAMA Dermatology. 2015. 151(7):792-794.
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:
What is steroid addiction?
What is steroid withdrawal and its symptoms?
Is steroid addiction/ withdrawal common?
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.
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).
(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.
(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:
Burning and stinging
Mostly on the face and genital area of women
Exacerbation with heat or sun
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:
It has no specific clinical features (all manifestations might be manifestations of a re-occurring eczema)
It has no biological marker (blood)
It has no solid underlying mechanism – hypothesis
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.
Alterations of the skin can be summarized as following:
A thinner epidermis (as a consequence of misuse of TCS)
Higher Staphylococcus aureus colonization, as TCS do not affect Staph colonization – this explains the papular / pustular (infected) features of the lesions
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:
Mid or high potency use of topical corticosteroids
Daily use of topical corticosteroids (only one out of the 34 studies recorded frequency)
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:
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.
This week, we’re looking at the research surrounding Surfactants on Atopic Dermatitis. First a recap of eczema skin and its ‘compromised’ characteristics that warrant special care during skin cleansing.
– Reduced antimicrobial peptides (AMP) expression, possibly resulting in higher incidences of infection
– Elevated skin pH
The above makes eczema skin more prone to irritants and more vulnerable to the ‘harsh’ effects of surfactants, discussed last week:
Alkalization – Elevated skin pH has the impact of (i) reducing skin lipids (ii) allows for growth of harmful bacteria like staph bacteria and (iii) increases transepidermal water loss (TEWL)
Damage to Skin Lipids
Damage to Skin Cells
Toxic to Skin Cells
Irritation to Skin
Research on Surfactant Impacts on Eczema Skin
Much of the research focuses on certain surfactant ingredients, as below:
(I) Chlorhexidine Gluconate is the antiseptic for use on eczema skin as it causes the least atopic dermatitis skin lesions.
This is from a study examining the Effect of Hand Antiseptic Agents Benzalkonium Chloride, Povidone-Iodine, Ethanol, and Chlorhexidine Gluconate on Atopic Dermatitis in NC/Nga Mice. The four common antiseptic agents in hand sanitizers are:
Benzalkonium Chloride (BZK): A Cationic detergent with strong antiseptic activity, more gentle than that of ethanol-based BUT with reported contact dermatitis cases
Povidone-iodine (PVP-I) – Commonly use in mouthwash and in disinfection before surgery, low toxicity in humans BUT with reported contact dermatitis cases
Ethanol (Et-OH) – Broad antibacterial and antiviral spectrum BUT result in rough hands because of its strong defatting effect on the skin
Chlorhexidine gluconate (CHG) – Broad antibacterial spectrum AND with low incidences of contact dermatitis
(II) Reduce the use of Sodium Lauryl Sulphate (SLS)
In a study involving twenty volunteers with atopic dermatitis, it was found that repeated exposure to sodium lauryl sulphate and sodium hydroxide lead to a more pronounced impairment of the skin barrier function and significant transepidermal water loss.
SLS is a known skin irritant that damages the lipid barrier, causing inflammation and detachment of the skin layers (denaturation discussed last week).
(III) Reduce Cocamidopropyl Betaine (CAPB)
In another study involving 1674 patients, atopic dermatitis was associated with contact hypersensitivity to cocamidopropyl betaine (CAPB), but not to cocamide diethanolamide DEA or amidoamine. CAPB is an amphoteric surfactant, that is considered milder than SLS and a very common surfactant in many products. However, CAPB is cytotoxic, i.e. toxic to skin cells.
(IV) The Use of Hydrophobically modified polymers (HMPs)
The recent studies on surfactants are in agreement that for patients with skin conditions, a gentle liquid cleanser containing HMPs are more appropriate. Addition of cationic polymers to skin cleansers can further protect the skin and improve moisturization. To further improve cleanser mildness, adding hydrophobically modified polymers (HMPs) to cleansers make it less irritating to the skin. This is due to the formation of larger micelle of the surfactant, i.e. the larger the less likely to penetrate and remove skin lipids.
Above is similar to the care to note when cleansing baby skin, as well as what to use/ avoid to limit the harmful effects of surfactants on skin discussed in the previous two weeks. For all the posts in this Surfactant Skincare Series, see:
This month, we’re looking at surfactants – the chemical agents in cleansing products. It is important because while surfactants play an important cleansing function, they also potentially cause skin irritation. Last two weeks, we have understood:
Damage to Skin Lipids – Surfactants are able to clean dirt and sebum that are oil-soluble. However, this property also means that surfactants may inadvertently solubilize the skin natural lipid membranes (ceramides). Stronger anionic surfactants like Sodium Lauryl Sulphate (SLS) enhances penetration into the skin and able to affect the deeper skin cells (skin lipids).
Damage to Skin Cells – During washing, the surfactants interact with the skin cells and collagen fibers and cause temporarily swelling and hyper-hydration. Once the water evaporates, there is destruction of the skin protein structures (known as denaturation) and leads to skin dryness, roughness, tightness and scaling. This is an adverse effect of anionic surfactant.
Toxic to Skin Cells – Known as cytotoxicity, surfactants can permeate skin cells and cause irreparable alteration. Certain surfactants such as benzalkonium chloride and cocamidopropyl betaine (CAPB) are known to be more cytotoxic than SLS. CAPB is an amphoteric surfactant, a group of surfactant less irritating than anionic surfactant (SLS belongs to anionic group) but nonetheless can be cytotoxic. CAPB is also associated with allergic contact dermatitis.
Irritation to Skin – This is related to the duration of exposure, frequency, concentration and individual skin type. SLS is a known irritant that can cause skin inflammation (irritant contact dermatitis) and when combined with triclosan (an antibacterial and antifungal agent in products), can stay on the skin for hours/days. Amphoteric and nonionic surfactants are considered to be less irritating to skin. (Note: Skin irritation and cytotoxity are different concepts.)
What to Note when Choosing Cleansing Products
Based on the above surfactant interaction with skin, it follows that we ought to choose:
Products close to the skin pH (even water is not, either neutral pH 7 or sometimes more alkali)
It follows then to avoid soaps, which by nature are alkaline
Avoid SLS, as it can penetrate, damage and irritant skin
Avoid CAPB as it is cytotoxic
Choose products with larger micelles as they do not penetrate the skin cells as much (product packaging may not indicate this information so it’s quite hard to know; look out for Polyethylene oxide (PEO)/ PEO Sorbitan Laurate which forms larger micelles in the surfactant or for the term Hydrophobically Modified Polymers (HMPs))
Choose cleansing products that are moisturizing and moisturize right after washing
Reduce washing for prolonged time and frequent washing
Avoid alcohols, gels and alphahydroxy acids that can cause stinging
Avoid perfume, benzoyl peroxide, preservatives, parabens, propylene glycol, lanolin, methylisothiazolinone and other top irritants in this post
Avoid ingredients ending with sulfates
It is not easy to find a cleanser without any of the above-mentioned ingredient. For those with sensitive skin, it may be better to not wash as often and take care to choose a hypoallergenic product. Try to read the ingredient label of your product and be sure that the first few ingredients are at least not those in this post.
In the Skin Fact series, we’ve discussed much about baby skin structural differences. Below is a recap of certain baby skin characteristics that increase its vulnerability during skin cleansing:
Higher transepidermal water loss due to thinner stratum corneum – More vulnerable to water loss during bathing and skin barrier breakdown when there’s excessive friction (from over-washing or from rubbing skin when toweling dry).
High surface-area to volume ratio – along with a thinner stratum corneum and immature drug matebolism, make baby skin more vulnerable to harmful chemicals used during bathing
Less total lipids– make it vulnerable to further reduction of skin lipids lost during washing
Cleansing Baby Skin – Research on What’s Best
From a search on Pubmed for review articles on the research for baby skin cleansing, there’s actually not much research on it. From a 2009 European round table meeting, the consensus is:
Liquid cleansers in bathing are beneficial over water alone – Water cannot remove dirt, oil that can only be removed by oil. Prolonged washing with water dries the skin and depending on the pH of the water itself, it may be more alkaline than the natural pH of the skin.
Liquid cleanser are preferred, rather than soap which alters the skin pH and affect the skin lipids, increase skin drying and irritation – Learn more about soap and its impact on skin pH in the skin pH series. The pH of skin can affect its skin lipids, which (a lower skin lipids) in turn causes drying, itchiness and skin inflammation.
Liquid cleanser should be mild, non-irritating, non-stinging (especially to the eyes as babies may not be able to blink fast enough) and non-pH altering, and contains moisturizing function
For cleansing of baby’s skin, I’ve found two other articles that offer recommendation on what’s best for baby skin.
Apart from the three points above, additional points are:
4. AvoidAnionic Surfactants, these are those that cleanse very well but most irritating to skin, an easy way to identify them is to look out for those chemicals ending with Sulfates.
5. Choose those with large head groups and have the ability to form larger micelles. Surfactants organize into groups of molecules called micelles and generally the larger these micelles are, the less irritating the surfactant is. This is related to larger micelles being less able to penetrate the outer layer of skin (stratum corneum).
6. No preservatives is not best as bacterial growth can happen in such products
7. No scent does not mean no fragrance (potential irritant) is used, it can be one fragrance masking that of another.
Why Baby Skin needs Cleansing
Just like last week we asked the question ‘Why not just use water to clean?‘ (because 40% of dirt, oil can only be removed by oil), we also have to understand why baby skin needs cleansing. Baby skin has saliva, nasal secretions, urine, feces, germs and dirt which can potentially irritate the skin when left on the skin. It is also possible that both skin allergy and the body (ie food allergy) can develop from foods being left on the skin for too long. It is therefore important to clean baby skin. However, baby skin, given its structural vulnerabilities, should not be over-washed and to avoid using baby wipes on face or baby wipes that are non-hypoallergenic, especially those containing fragrance and MI.
Next week, I’d (make a brave) attempt to look into how surfactants affect skin and in particular, impact on eczema skin. It’s a very ‘chemical’ topic and not easy, so appreciate if there’s feedback to improve on the blog post, and share your best cleanser!
Happy New Year and look forward to this year’s first session on the topic of Skincare for Kids.
Skincare for young children is important as they are able to understand skincare, and have to take care of their own skin for those who are schooling. Young children may also resist moisturizing and parents have to teach children how to moisturize and understand its benefits. Children who are in primary school also have to be aware some of the school activities that may trigger their eczema flare-ups and learn the basics of managing their eczema in school.
The speaker for this session is dermatology nurse Sister Wong, who is the Senior Nurse Educator at National Skin Center and trained in Dermatology and STI (Sexually Transmitted Infections) Nursing in UK. She had spent many years in the inpatient nursing care in CDC and currently based in outpatient services in National Skin Centre. She is also in charge of training programmes for the nurses in Dermatology.
Block your Friday lunch, on
22 January 2016 (Friday) – Venue, NSC Room 401, 12.15 noon to 1.15pm
Do note though that this is not a consultation session. For those bringing your child, there will be balloons for sculpturing, puzzles and coloring to occupy your children.
You must RSVP so that we can order lunch and arrange the layout for the seats. If you’re coming, please email [email protected] your name, mobile and email, number of adults & kids coming.
One last thing, the session would be starting on-time and information on my blog is not pre-approved by NSC.
Kicking off Wednesday posts in 2016, like to explore this group of ingredients which is present in all cleansers but also have the potential to irritate skin.
Surfactants are ingredients that are active on surfaces, mainly to lower the surface tension on the skin and remove dirt, sebum, oil from cosmetic products, microorganisms and exfoliated skin cells in an emulsified form to be washed off. The different type of surfactants affect their cleansing, foaming/ lathering, emulsifying, solubilizing abilities as well as its potential to irritate.
Why not just Water?
Before we go on, the simple question to ask is why not just use water to clean our skin. This is because water alone is not effective in removing dirt which can be removed only by oil. Hydrophilic dirt can be removed only by water, and fat-soluble lipophilic dirt only by oils.
Groups of Surfactants
Surfactants are divided into hydrophilic (water loving), hydrophobic (water repelling) and lipophilic (oil loving). Surfactants consist of a fat-soluble (lipophilic) part and a water-soluble (hydrophilic) part. The lipophilic part sticks to oil and dirt, and the hydrophilic part allows it to be washed away.
Surfactants perform different functions, namely:
Emulsification – arrange itself at interface between two immiscible liquids to create an emulsion
Solubilization – blending oily solution into clear liquid
Wetting – increase contact between the product and dirt
Apart from functions, manufacturers also consider mildness, biodegradability, toxicity, moisturization, skin appearance and feel, smell (fragrance) and lubrication when formulating their products.
There are four major groups of surfactants, classified by their polar hydrophilic (water loving) head group:
Anionic Surfactants – Negative charge
Give effective cleansing and foam, good wetting properties, excellent lather characteristics, but moderate disinfectant properties and also likely to irritate skin.
E.g. Carboxylic acids – Stearic acid for stick products like deodorants and antiperspirants; Sodium stearate for soap
Sulfates – give effective cleansing, foaming and cheap; common irritant, e.g. Sodium lauryl sulfate (SLS), an alkyl sulfate used in detergents; Sodium laureth sulfate (SLES), an alkyl ether sulfate used in shampoo
Sulfonic acid surfactants – more expensive than sulfates but less irritating, e.g. dioctyl sodium sulfosuccinate, alkyl benzene sulfonate
Taurates (derived from taurine), Isethionates, Olefin sulfonates, and Sulfosuccinates.
Effective for conditioning cosmetics,positive charge makes the surfactants electrostatically attracted to the negative (damaged) sites on hair and skin protein which makes them resist rinse-off. Difficult to ‘mix’ with Anionic Surfactants. Also irritate. May be used as antimicrobial preservatives due to ability to kill bacteria.
Quaternized Ammonium Compounds (or Quats). e.g. Cetrimonium chloride and Stearalkonium Chloride
Amphoteric surfactants – both positive and negative charge (depending on environment)
Help improve foaming, conditioning and reduce irritation. Moderate antimicrobial activity. Used in mild cleansing products, but not effective cleansers and emulsifiers. Both Alkaline and Acid, help to adjust the pH of the water used in solution.
E.g. Sodium Lauriminodipropionate and Disodium Lauroamphodiacetate.
Cocamidopropyl betaine, cocoamphoacetate and cocoamphodiacetate
Non ionic Surfactants – No charge
Used in heavy thick creams, such as hand or body creams, as emulsifiers, conditioning ingredients, and solubilizing agents.
Relatively low potential toxicity and they are considered the most gentle surfactants, but they are also the most expensive
Able to solubilize fatty acids and cholesterol in skin, thus may remove skin lipids
E.g. Cocamide DEA (coconut diethanolamide), widely used in personal care products for its thickener property and foam booster
Fatty acid esters of fatty alcohols, sorbitan esters, sucrose and cholesterol derivatives used like emulsifiers
In the following Wednesdays of this month, we will explore the impact of surfactants on skin, baby and eczema skin and some of the research in this area. I’m learning much about this as I read as well and it’s not all so easy to understand! Any expert reading this who would like to help out are welcomed, do leave a comment if you have expertise in this area or there’s something to correct in my post (no offense will be taken!).
Most of you would know that I co-authored with Professor Hugo, NUH, a book ‘Living with Eczema: Mom Asks, Doc Answers‘ published last year. As an end of the year special, I picked five questions asked and Professor Hugo’s reply (almost half the book is Q&A, I picked these 5 based on being common questions parents of eczema children asked). The book is structured with information surrounding key topics like diagnosis, prevention, triggers, treatment including things that don’t work and future research, followed by Q&A. None of the questions I asked were ‘screened’ as we wanted to keep it as an authentic exchange between a mom and the doctor of her eczema child.
MarcieMom: The Hygiene Hypothesis has been interpreted by some to mean they should expose their infants to dirt, and possibly, avoid the use of anti-bacterial products. Is this recommended?
Infants with defective skin barrier or lower immunity would be even more susceptible to the penetration of irritants or allergens, or more susceptible to bacterial infection. So, should a mother take more hygiene precautions for her high-risk infant?
Professor Hugo: In theory this is correct, but the problem is that every baby is unique and needs a different degree of exposure of immune stimuli. This is very difficult to assess in a baby. However, in general, products that destroy the body’s own bacteria, such as antibiotics, should be avoided and only given if necessary (in case of a bacterial infection). There have been studies showing that early administration of antibiotics increases the risk for subsequent allergy, including eczema. Hygiene precautions taken by parents seem to have little impact on the development of eczema.
MarcieMom: While the skin prick test (SPT) is a faster, more reliable and cheaper option than the blood test, I have heard of parents avoiding it because the name “skin prick” test sounds traumatising for the child. What do you do in your practice to encourage fearful parents to let heir children take the SPT?
Professor Hugo: A good SPT, performed by an experienced person, should be painless. In our department we say that a SPT should be associated with no blood and no cry, even in infants.
MarcieMom: In your experience, how reliable are patients’ observations in relation to what is triggering his/her eczema?
Professor Hugo: Most parents fail to identify the triggers of their child’s eczema, or come up with lists that are non-reliable. Don’t forget that eczema is a chronic disease, needing a chronic or regular trigger. This is very diffi cult to identify, especially when a house dust mite allergy is involved, which can mimic multiple food allergies.
Professor Hugo: Although corticosteroids are still the cornerstone treatment of eczema patches, they are only part of the holistic treatmentof eczema. If all measures are taken appropriately, an effect of corticosteroids should be seen within one week. Most children can be treated with mild corticosteroids; only in severe eczema are more potent corticosteroids necessary.
MarcieMom: How do you build trust and relationship with your patient?
Professor Hugo: In a nutshell: be honest, don’t lie, and focus on limitations.
There are many more Q&A in the book and if you like to read it for free and you live in Singapore, it’s available in our national libraries island-wide. Wishing all families with eczema kids a happy new year and your encouragement keeps me going and faith that I’m storing treasures in heaven in this blog ministry. Just like the book, this blog is also dedicated to you.
We dedicate this book to
all children with eczema and
their families and hope that
this book will help all of them.