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Doctor Q&A

Skin Health Series – Diet and Lifestyle

This is the fourth of a much-awaited series, where I get to work with Dr Verallo-Rowell again (we last worked on Sensitive Skin Product Series in 2012). Dr Verallo-Rowell is a dermatologist, dermatopathologist and dermatology/laser surgeon, founder of VMV Hypoallergenics, and is also an author, esteemed researcher and speaker. 

Skin Health Connection Interview series with Dr Vermen Verallo Rowell VMV Hypoallergenics

Skin Appearance and Health Conditions

Some people’s skin seem to look more wrinkled, less glowing, dark colors under the eyes if they are not sleeping well. Smokers may have a grayish tone to their skin.  Having a diet heavy with sugar can make it prone to acne. Deficiency of certain vitamins and minerals can also cause the skin to be dry.

MarcieMom: Dr Verallo-Rowell, I know you are deeply passionate about nutrition.

Which are the worst foods you would seriously object to for skin?

MarcieMom: And out of curiosity, could you tell if someone is a chocolate addict or fan of soda from the look of their skin? I’m hoping an occasional indulgence in ice cream can’t be detected by you!

Dr Verallo-Rowell: Hahaha. One look at a patient with adult acne tells me I have to look at her history closely to see which of the stressors – see my last winding paragraph below – is causing the adult acne.

Processed foods are the MOST

pro-inflammatory

In food, the most pro-inflammatory are processed foods because the oils used in processing them are generally more pro-inflammatory. Polyunsaturated they make the lipid bilayer of cell walls more fluid such that the cell wall’s protein receptors/signals do not function well. This is such a No NO NO for saturated oils.  Yet plant derived saturated fats like those from coconut oil are cholesterol free and more stable than polyunsaturates, are not as vulnerable to oxidation by reactive oxygen species our body makes, do not have trans fats because they need not be hydrogenized.  Note that less than 0.5 mg of trans fats does not have to be declared, hence everything now is “trans fat free”. 4 servings of a “trans fat free” product can readily reach 2 Gm. Remember any trans fat in our food is not good. Look instead at the Nutrition Facts and if says it has partially/hydrogenated oil in it – don’t use.

If (nutrition label) states partially/ hydrogenated oil, don’t use it

Also, omega 6 at too high an amount – which is what the seed oils contain at a ratio of 1:100 or more of the omega 3 they contain – is very pro-inflammatory because they are converted into pro-inflammatory eicosanoids. We need them – inflammation is needed to clear up bugs, and react to environmental assaults – but too much becomes too inflammatory and may continue into an inflammatory pathway of disease.

Foods to eat for Healthy Body and Skin

Like everything else in nature, balance is important, as it is in food. So the bit of ice cream and chocolate you indulge in wont make me recognize a skin change with you. Besides the mood elevating effect is also good for you. BUT, balance…eat  more fruits and veggies, brown rice, brown bread, oily fish and shellfish. (all rich in omega 3, anti-oxidants) Cook with coconut oil for high heat, with olive oil for low heat and minimize that canola oil – it’s a genetically altered long chain polyunsaturated flaxseed oil.

Cook with coconut oil for high heat, with olive oil for low heat and minimize that canola oil

Acne and Diet

In acne – the studies out there now show: high carb diets, and dairy products are more acnegenic. Interestingly of dairy products, the skimmed ones are more acnegenic, probably because of the sugar (more carbs) they add to add taste after the yummy oil is removed.

Can you tell you are Stressed from your Skin?

MarcieMom: Ending this series on a more serious note – we know stress is a trigger for eczema, and so is sleep-deprivation. For say someone who has a tough job/ running a business, taking care of kids and elderly, working through the night, could you tell that from his/her skin? And if someone wants to look into the mirror and know ‘Gosh, I need a break!’, what would you ask him/her to look at? (note: I’m being very fair here, both male and female can suffer from this!)

Look for Skin Inflammation

Dr Verallo-Rowell: Look for inflammation. This is the process that is now seen as the basic pathogenetic pathway in our cells triggered by stress. Most people think of stress in terms of the mental and emotional stresses of personal life and work. Very true, yet this kind of stress you are aware of, familiar with, share and moan about to your family and friends. It is stressful but other causes of stress that are not so obvious, hidden and may not be addressed by you and/or your physician.  Examples are the stress from recurring low grade infections – like being a streptococcal carrier with mild but recurrent sore throat or dental problems or UTI, or stones in the gall bladder; or less than 6 and more than 8 hours sleep; lack of exercise, obesity and of course a diet with more pro-than anti-inflammatory elements in it, or too much weight loss.

Look for markers of inflammation: your acne flaring up, rosacea attacks becoming frequent, the eczema bigger, wider spread; those with psoriasis too – the lesions are bigger and persistent; boils recurring more often. These may indicate a lowered immunity from such things as too much exercise.

MarcieMom: Thank you Dr Verallo-Rowell, I can feel so MUCH Passion in you about nutrition and anti-inflammatory vs pro-inflammatory foods, I’m inspired to learn more!

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Doctor Q&A

Skin Health Series – Veins and Bruises and Moles

This is the third of a much-awaited series, where I get to work with Dr Verallo-Rowell again (we last worked on Sensitive Skin Product Series in 2012). Dr Verallo-Rowell is a dermatologist, dermatopathologist and dermatology/laser surgeon, founder of VMV Hypoallergenics, and is also an author, esteemed researcher and speaker. 

Skin Health Connection Interview series with Dr Vermen Verallo Rowell VMV Hypoallergenics

This week we are investigating more into what the appearance of our veins, bruises, moles and hair growth tell us about our health.

Veins

MarcieMom: I’m looking at my own veins now, and I can see veins on my hands (as I’m typing), on my wrist (so that if I ever need a drip, the (hopefully experienced) nurse knows where to poke, and my feet. There are veins which are swollen with blood in older individuals, such as varicose veins, due to the valve not working and blood gets pooled due to gravity

Apart from varicose veins, are there instances when the skin can get thinner or more transparent, thereby making the veins suddenly more apparent? I’m thinking maybe aged, sun-damaged skin may play a part too.

Dr Verallo-Rowell: You are absolutely right! The thinner the skin, often from photoaging on the more exposed skin of the hands, the easier the veins of the hands appear and wrists. Some people use steroid creams continuously for eczema and other chronic itchy skin conditions. Steroids are notorious for making the skin thin. I have seen so many of these and yes the veins literally pop out in these steroid thinned out skin areas.

Steroids are notorious for making the skin thin.

Bruises

Brown patches on the skin are characteristic of diabetic dermopathy, where the capillaries are injured from knocks and ‘leaked’ leading to formation of rough, brown patches.  Lines on the palm or soles are also symptom of an endocrine disorder, known as the Addison’s disease.

How long does a bruise take to heal? Could say, having a bruise on a day down with flu cause it to look worse than normal?

Dr Verallo-Rowell: Bruises behave more or less in a certain pattern.  First the extravasation of red blood cells from the damaged or inflamed vessels shows bright red color of blood leaked out into the extra-vascular compartment of skin, often with swelling and warmth of the skin. By about the 5th day the redness gives way to a bluish or purplish color as the red colored hemoglobin breaks down into hemosiderin. By the 7th day billiverdin makes it color greenish, then changes to a yellowish color by the 7th to about the 10th day from the bilirbin in the blood. As these pigments become cleared by our scavenging cells, the area becomes brownish before going back to our regular color. The more intense colors will come from bruising or damage of more superficial skin areas.

Moles

When moles take on a different shape, darker color or irregular edges, it can be a sign of skin cancer. I’ve read that hairdressers have spotted changing moles for their clients, and safe them from cancer via prompt consultation with doctor!

Does the presence of the mole itself create the additional risk of skin cancer?

Dr Verallo-Rowell: NOT all moles become skin cancer. The risk factors for moles that may become skin cancer or melanoma are

(1)  many (more than  50)

(2) often with A for Assymetry; B for border irregularity; C for irregular pigment distribution ; D for diameter of 6 mm or more; E for evolving or changing noted in size

(3) the “ugly duckling sign” – in a field of moles it is the one that looks different from the other;

(4) history of melanoma in the family;

(5) evidence of photoaging.

MarcieMom: Thank you Dr Verallo Rowell, your 5 points for moles are a very good takeaway, at least I would stop warning everyone just because I see a mole on them!

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Doctor Q&A

Skin Health Series – Functions of Skin – Dry, Hot/Cold and Collagen

This is the second of a much-awaited series, where I get to work with Dr Verallo-Rowell again (we last worked on Sensitive Skin Product Series in 2012). Dr Verallo-Rowell is a dermatologist, dermatopathologist and dermatology/laser surgeon, founder of VMV Hypoallergenics, and is also an author, esteemed researcher and speaker. 

Skin Health Connection Interview series with Dr Vermen Verallo Rowell VMV Hypoallergenics

Understanding Skin & Health – Functions of Skin

The skin has a few important functions, (i) it protects the body from foreign particle, bacteria and it prevents moisture loss, (ii) the skin regulates body temperature, and (iii) the skin gives us a sense of touch.   We understand that in atopic dermatitis, the immune cells in the skin mistook a (harmless) allergen to be harmful, resulting in skin inflammation.

Dry Skin – Eczema or Health Condition?

MarcieMom: Does dry skin indicate possibility of eczema and other skin or health issues?

Will a person’s diet, lifestyle, smoking, drinking (caffeine or alcohol) affects the dryness of skin?

Dr Verallo-Rowell: People with the inherited form of eczema called atopic dermatitis almost always have dry skin but not all people with dry skin have skin or other health issues. Some people just have Congenital Dry Skin while others have Acquired Dry Skin from environmental agents such as too much hot water and strong detergents use; friction from clothing; frequent air travel, pollution, exposure to chemicals at work or play, or frequently staying in highly air-conditioned rooms.

Impact on Diet and Smoking on Skin

Yes definitely – the diet is very important because what we eat forms the structure of our cells, in particular the lipid bi-layer of our cells where a balance of saturated and unsaturated oils, short and long chain fatty acids, omega 3 and omega 6 oils or transfats can contribute to inflammation at the molecular level to eventually manifest itself as skin dryness. Smoking is a strong oxidizing agent. Many studies have now shown it to therefore show much faster aging changes including dryness, wrinkles, toughening of the texture of skin. Too much alcohol affects the liver and caffeine dehydrates.

Smoking is a strong oxidizing agent

Skin being Hot and Cold to Touch

An infected skin patch feels warm to touch. Are there health conditions that affect how cold or hot our skin feels or cause a change in how cold or hot an object feels to us?

Dr Verallo-Rowell: Our skin when compared with skin of others in the same room or under the same environmental circumstances may feel hotter to touch when: febrile from any cause usually infections; in hyperthyroid persons; in rosacea ; when perspiring heavily. The opposite – feel colder to touch may occur in anemic, cachectic, hypothyroid people, or very sedentary people or anyone with lowered metabolism.

A change in how cold or hot an object feels to a person is affected primarily by the condition of the peripheral nerves. One sees this in Hansen’s disease, diabetic neuropathy, metal poisoning, and any other form of neuropathy affecting the peripheral nerves.

Collagen – Consume or Apply on Skin?

MarcieMom: The dermis contains collagen fibers that maintain the elasticity of the skin. In the subcutis, there are fat cells, nerve cells and blood vessels. There are many products that are marketed as containing collagen, be it to be consumed or applied on skin.

How does the collagen from a drink find itself to the skin? And how does the collagen on a skincare product ‘dig’ itself to the collagen fibers of skin? Will it bind with the existing collagen fibers? Are they even the same collagen?

Dr Verallo-Rowell: Collagen are coarser fibers in the dermis that give skin its bulk or structure. Elasticity of the skin is given to it by the elastic fibers. The ingredients in the above products are soluble forms of collagen meant to add bulk, or elastin, meant to give elasticity.  These ingredients are usually from animal or plant proteins with similar bulk forming effects though more likely just texturizing or moisturizing effects. They are extracts that blend into the formulation and not the collagen fibers or fibrils themselves.  Many years ago collagen from cows (called Xyderm or Xyplast) were popular fillers that were what we used to inject into the skin. The molecules of collagen are too large to penetrate the skin and its barriers by topical application.

MarcieMom: Thank you Dr Verallo-Rowell, it is a reminder for me to eat healthily and also understand how our skin interacts with the environment!

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Doctor Q&A

What does Your Skin tell you about Your Health?

This is a much-awaited series, where I get to work with Dr Verallo-Rowell again (we last worked on Sensitive Skin Product Series in 2012). Dr Verallo-Rowell is a dermatologist, dermatopathologist and dermatology/laser surgeon, founder of VMV Hypoallergenics, and is also an author, esteemed researcher and speaker. 

Skin Health Connection Interview series with Dr Vermen Verallo Rowell VMV Hypoallergenics

This series is exciting because ever since Laura (Dr Verallo-Rowell’s daughter, CEO of VMV Hypoallergenics) told me during our meeting in Singapore that her mom identified underlying health problems after seeing the skin of her friends, I started to scrutinize everyone’s skin! I became interested in the relationship between skin and health, and discovered through Laura that her mom is very passionate about improving skin and health and also have a nutritionist in her dermatology practice.

So for this series, we are discovering skin, health and health issues that can be identified by changes in skin. Of course, these are not meant to be medical diagnosis and it is always good to look in the mirror and say, ‘Yay! I’m glowing and healthy!’

Understanding Skin and Health – Skin Color

The skin is the largest organ of our body, and has the largest surface area. It consists of 3 layers – the epidermis, the dermis and the hypodermis. The epidermis protects the skin from penetration of foreign matter and also prevents water loss. It has keratinocytes, melanocytes and Langerhans cells. One way to describe skin is its color, for which the melanocytes are responsible for.

How Skin Color Changes during Suntan

MarcieMom: Dr Verallo-Rowell, does a person’s skin stay the same color? For instance:

Sun Tan/ Sun Burn – which layer of skin is affected and how does the skin reverse to its original color?

Dr Verallo-Rowell: Yes. A person’s original, also called constitutive color – under normal/healthy conditions – essentially remains the same throughout one’s life. This is best illustrated by the Fitzpatrick Skin Phototypes I to VI ( from I with very fair, blond or red hair, light colored eyes , often with freckles, thru III with light brown colored skin to VI with black skin). Following a sun tan or sun burn the melanosomes or pre-formed melanin in the epidermis darkens so an immediate pigment darkening occurs – immediately. The radiation reaches the melanocytes in the basal cell layer and stimulates them to form more melanosome which rapidly become melanin granules to contribute to the delayed skin darkening called the tan which in Phototypes I may not happen at all, II, appears and lasts a week, V appears and lasts for 6 months or longer. Once the pigment generated by that sun tan/burn clears up, the color of the skin goes right back to its original – constitutive color.  The tan by the way is called skin’s facultative coloring.

How Skin Changes with Age

From birth to death – does the skin color (assuming good health) stay the same or does the skin color change from an infant to a child, and when entering into old age?

Dr Verallo-Rowell: Even with good health the skin color undergoes natural changes from aging (time on earth) and photoaging ( with the addition of sun/light exposure). Of these two types of aging, photoaging is the one that changes the skin color more.  Notice: the buttocks skin color which most closely resembles the original color throughout life.  Note also the outer arms compared with the inner, the V of the chest up to the neck though sparing the under the chin area which is not exposed to sun/light. Those exposed areas tend to freckle and discolor ( dark and white discolorations) from photoaging effects.

Skin Color as a Reflection of Health Issues

The one some experienced as an infant will be jaundice. Jaundice is the yellow color skin, caused by an accumulation of bilirubin in the newborn’s blood due to the liver not removing it. You may also have heard of babies turning orange after eating too many carrots. This is known as carotenemia due to excess beta-carotene that cannot be processed by the thyroid (hypothyroidism). The skin can also turn blue, a condition called cyanosis, due to lack of oxygen in the blood.

Do the above conditions change the melanocytes of the skin or affect other parts of the skin cells or affect the blood which can be ‘seen through’ the skin? 

Dr Verallo-Rowell: NO. The bilirubin accumulates in the baby who you cited above – whose liver may not be mature enough to remove it. The yellow colored hydrophilic pigment in a sense stains the epidermis and/or its presence in the upper dermis is seen through the epidermis, but it does not affect the melanocytes. Neither does the carotenoids which are lipophilic become prominent in the lipid compartments of the stratum corneum the top most layer of the skin. Melanocytes are unaffected unless for some reason an inflammatory reaction occurs in which case a post-inflammatory hyperpigmentation may occur to temporarily darken the skin from melanocytes reacting to the inflammation.

Pale Skin vs Fair Skin

We know some people like it tanned, but there are others who like it fair. I’ve seen skinny ladies with pale skin, and it doesn’t look healthy to me. There is this condition known as anemia, which is due to iron deficiency for elderly or people without a healthy diet.

How can, say, a lady who is trying for weight loss, be able to spot if it has ‘gone too far’ from observing her skin? Does the same happen for a child (who may for various health reasons not eat well)?

Dr Verallo-Rowell: In ladies (and gentlemen too) who aspire and become successful at losing weight without taking care that they reduce calories but continue to have enough vitamins, minerals and other essential nutrients – iron may become deficient so anemia which gives a pale unhealthy white color develops. Children with poor appetites who likewise lack the above nutritional components also can become pale white from the anemia. Anemia means lowered number of red blood cells hence the pallor.

Thank you Dr Verallo Rowell, I learnt much from your reply! For one, I’ll note my own skin color too as I’m losing weight (and lost quite a fair bit through exercise!)

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Doctor Q&A

Parent (Patient) Eczema Consultation Tips with Dr Susan J. Huang – After Consultation

Eczema Consultation How to Talk to Your Child Dermatologist Dr Susan Huang

I am 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. She 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 tips on during consultation, this week we are focusing on after the consultation when the parent is now to manage and treat the child’s eczema, as advised by the doctor.

When to Call Your Child’s Dermatologist

A common scenario is that he/she would be doing all as told, but find that the child is still scratching incessantly (and sometimes, with blood and tears daily)! Eczema is a chronic condition to be managed and parent shouldn’t be expecting miraculously smooth skin just because a doctor has been consulted.

Under what circumstances would it be justified to call the doctor before the next consultation? 

Dr Susan Huang: Hopefully, the physician has talked about what to expect from treatment during the visit. As you said, eczema is indeed a chronic condition and does not go away overnight. Setting expectations for the short term and long term period is a good idea at every visit. However, if there are any questions after you go home, you should feel comfortable calling the doctor’s office to get those questions answered and to see whether you need a visit to the office sooner.

Setting expectations for the short term and long term period is a good idea at every visit

Should the Eczema Treatment include Lifestyle?

MarcieMom: As advised by Prof Hugo, I bring my child for swimming regularly to reduce the staph bacteria. Lately, after learning more about nutrition from Toby Amidor and Julie Daniluk, I also feed my toddler with more anti-inflammation food and flaxseed oil. I know that there is no conclusive study on nutrition’s impact on eczema, but can and should a doctor advice outside of standard treatment options to include lifestyle and nutrition?

Dr Susan Huang: While we often think of pills and medications when we think about the practice of medicine, medicine really is much more. There are many lifestyle practices that can help in eczema and learning about these practices is helpful. Bleach baths, wraps, use of emollients are all treatments that are behavioral and can help in eczema. It is always a good idea to ensure good nutrition for all patients as well.

Sharing Relevant Information to Dermatologist

MarcieMom: Some eczema patients do feedback that their doctors don’t seem interested to listen to what the parents have to say regarding the child’s skin and eczema. It may truly be the case but does a parent have to be mindful to share what’s relevant to the doctor? For instance, is it possible that parents worry too much and discuss too many (remote) triggers? What is a clear sign of a disinterested doctor or one that shows no empathy for eczema?

Dr Susan Huang: It is important to have a good relationship with your child’s eczema doctors since eczema is a chronic disease. This patient/parent-doctor relationship will be one that extend beyond the initial visit! Every patient/parent-doctor relationship is different and the dynamics of the conversation of each visit depends on this relationship as well. If you find that there is difficulty in communication, you should find a doctor with whom you feel comfortable communicating with.

What to Do if You are Changing Your Doctor

MarcieMom: Suppose a parent has found another doctor and wishes to stop seeing the current one. What should he/she ‘take-away’ from this doctor to the next? For instance, asking for the client-file? Does that belong to the hospital/doctor or to the patient? Also, I know that if a child is prescribed oral steroid, the follow-up consultations by the same doctor is important to assess the follow-up treatment options (and also completing the course as prescribed) Should a parent stick to the same doctor till the oral steroid course is over? (Do read my toddler’s positive experience with oral steroid)

Dr Susan Huang: It is helpful for your new doctor to know what evaluation has been done (including any lab tests, allergy tests) and what treatments have been tried. This way, you won’t “reinvent the wheel.”

Don’t Reinvent the (Eczema Treatment) Wheel

In the United States, patients can request a copy of their medical files. This can be done through the doctor’s office, or if you are in a larger hospital, you may need to go through the medical records department.

Since eczema is a chronic disease, it is helpful for the doctor to get a sense of what the course of the disease has been and what the response to a certain treatment has been (whether it is oral steroids or another treatment). This is often easier if it is the same doctor, but sometimes that is not possible. If it is not possible to stick with the same doctor, make sure to have the documents pertaining to your child’s care. Photos can help as well.

Thanks Dr Huang, it has been a very helpful 3 weeks and I’m sure many parents will find this series helpful; My take is no matter what, don’t forget to enjoy our children with eczema (despite the eczema)!

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Doctor Q&A

Parent (Patient) Eczema Consultation Tips with Dr Susan J. Huang – During Consultation

Eczema Consultation How to Talk to Your Child Dermatologist Dr Susan Huang

I am 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. She has written book chapters, published peer-reviewed articles, and presented at multiple national conferences on issues and topics in dermatology.

MarcieMom: This week, we will focus on communication during the consultation. 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)

Allergy Testing for Your Child with Eczema

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!)

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

What to Ask after Getting a Prescription

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 it 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.

Make sure you review an Eczema Action Plan with your physician before you and your child leave from your consultation.

Your Child’s Eczema Action Plan

Eczema Action Plan Items
Non-Medication TherapiesMoisturizing
Bathing
Wet Wrap
Medication TherapiesTopical steroid
TCIs
Clarify 1. how much to apply
2. where it should be applied
3. when it should be applied
4. for how many days
What to expect at end of treatment
When to call the dermatologist

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.

From American Academy of Dermatology

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.

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Doctor Q&A

Parent (Patient) Eczema Consultation Tips with Dr Susan J. Huang – Before Consultation

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)!

Eczema Consultation How to Talk to Your Child Dermatologist Dr Susan Huang

I am 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. She 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 taking your time to offer tips to our parents on what they can do before, during and after consultation, as well as what they need to consider if changing their doctor. Let’s start right away with preparing for a doctor consultation.

How to Prepare for Your Eczema Consultation

MarcieMom: I’m assuming that the child has already been diagnosed with eczema and the parent is looking for a suitable doctor. In Singapore, there are many good doctors, some of whom listed here. I note that each doctor has their own specialty/ interest apart from being a pediatrician – immunology, allergy, asthma and/or dermatology.

Must a parent specifically ask for a doctor in a particular specialty?

Dr Susan Huang: When looking for a doctor for your child with eczema, it is important that the physician has taken care of many children with eczema and thus has sufficient experience and knowledge about eczema.  In the U.S., physicians who routinely take care of children with eczema consist primarily of dermatologists, allergists/immunologists, and pediatricians.  The relationship between the physician and the parent(s) and child is also very important.  Treatment of eczema involves many behavioral components and these take time to review and demonstrate at the visit.  You will likely be seeing this physician many times over years (unless you don’t like him/her!), so it’s important to have a good patient-physician relationship.

Communicating Your Child’s Eczema History

MarcieMom: One of the key reasons why I brought my baby to see a specialist in a children hospital was because allergy tests are not available at a general practitioner or even pediatric clinic. Read here for preparation before a skin prick test. Apart from physical preparation (no antihistamine, good health), how can a parent help the doctor who is seeing the child for the first time to learn as much about the eczema/skin condition?

How can a parent help the doctor who is seeing the child for the first time to learn as much about the eczema/skin condition?

Keep a food diary versus skin condition? If yes, for how long? Write down suspected triggers? Write down how the parent has been managing the skin, for instance, already using hypoallergenic detergent or vacuuming weekly?

Dr Susan Huang: Your physician will ask you questions to get your child’s eczema history. You will likely review whether there are any exacerbating or ameliorating factors to your child’s eczema.  These may include ingested foods or contact allergens.  Having details such as the temporal relationship between the trigger and effect on eczema is helpful. Note that the role of food allergy and food allergy testing in eczema is still a debated one.

Allergy Testing & Eczema Plan of Action

We do know that there is a tendency for allergy, asthma and eczema run together.  Many patients will also recall a clear history of a certain food triggering eczema. In this case, it is important to confirm this potential trigger through allergy testing.  Keep in mind that food allergy testing is not perfect (as is the case for any testing) and can lead to what we call “false positives.” So although it may be tempting to test to all allergens and via skin prick, RAST or oral challenge, it is important to discuss with your physician to come up with the appropriate testing for your child.

Regarding whether food allergy testing should be performed, the guidelines state that testing for milk, egg, peanut, wheat and soy allergy should be considered in “a child younger than 5 years old, and has eczema that does not go away with treatment, or has eczema and a history of allergic reactions to a specific food. Children with moderate to severe eczema are at risk for developing food allergy, especially allergy to mild, egg, and peanut. These children may benefit from a food allergy evaluation.”  If testing is performed, it is important to review with your physician what the plan of action will be.  It is a matter of figuring out which tested allergens are affecting your child’s eczema, and your child’s nutrition should be taken into account as well.

If allergy testing is performed, it is important to review with your physician what the plan of action will be. 

Keep a List of Prior Eczema Treatments

Also have a list of prior treatments on hand. These include medical and non-medical treatments.  In terms of medical treatments, make note of what medication was used, for how long, where it was used (for topical medications), how frequently and how much was used, and the effect the medication had.  Remember to also tell your provider about other treatments such as bleach baths, wet wraps, etc.

MacieMom: Thank you Dr Huang, you raised some points that I didn’t think of such as bleach bath, wet wrap, treatments that the parent may have implemented prior to seeing the doctor. Excited to read your tips for during consultation next week.

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Doctor Q&A

Common Summer Skin Rashes in Kids Series: Insect Bites

This is a 3-week series with Dr. Robin Schaffran, M.D., a caring mom and Pediatric Dermatologist. She is a board-certified Dermatologist and attending staff physician at Cedars Sinai Medical Center. She attended the University of Toronto Medical School where she graduated as a member of the Alpha-Omega-Alpha Honors Medical Society.

Common Summer Children Skin Rashes with Dr Robin Schaffran Pediatric Dermatologist

Rash is a common result from an insect bites, and during summer time, there are some insects that grow more, or come out during summer. There are various common insect bites, such as bed bug, mosquito bites, chigger bite.

What Insect Bites are likely for Kids?

MarcieMom: From your more than 10 years of practice, which insect bites (name two) are most common during summer, and most commonly affecting children?

Dr Robin: During the summer months, the 2 most common insect bites are mosquito bites and bee stings.

MarcieMom: How does the insect’s bite become a rash? Is it interaction with certain saliva or parts of the insect that trigger an inflammation?

Dr Robin: When an insect bites the skin it usually deposits a small amount of saliva into the skin. The rash or bump that results from the bite is due to an immune reaction in the skin directed against the foreign proteins in the saliva.

Appearance of Insect Bite Rash

MarcieMom: How is an insect bite diagnosed? And is it possible to know which insect the bite is from? Will the appearance of bites differ on eczema skin?

Dr Robin: There is a distinct look to an insect bite that makes it easy for a dermatologist to distinguish from eczema. Most bites appear as discrete red bumps that have a small spot in the center from where the insect bit. It is usually impossible to tell from the bite what insect caused the bite (other than certain spiders which result in a very distinct skin eruption).

How to Protect Your Child from Insect Bites?

MarcieMom: Can insect bite be prevented? Using insect repellent? For my toddler with eczema, I don’t put insect repellent on her (are these hypoallergenic?), instead I would put on the insect repellent patch. Are they equally effective?

Dr Robin: Insect bites are best prevented by using insect repellent. This is challenging with eczema skin because the insect repellents can irritate the skin, especially sensitive skin. If it’s not too hot, you can wear long sleeves and pants and spray the clothing with the insect repellent. Avon makes a product called ‘skin so soft’ which acts as an insect repellent (albeit not a very effective one). The repellent patches are okay but not as effective as the sprays.

Insect repellents irritate sensitive eczema skin

Treatment of Insect Bite Rash

MarcieMom: I understand that complications can occur from insect bites, such as anaphylaxis, shock, diarrhea, cramps, swelling, hives and confusion.

What are the complications that are due to the skin rash from insect bite?

Dr Robin: Most insect bites do not result in any complications other than itchy bumps that can result in a secondary skin infection from  repeated scratching.

MarcieMom: How should an insect bite be treated, and when will seeing a doctor be warranted?

Dr Robin: Insect bites are best treated with topical cortisone creams to treat the inflammation that leads to the itching. If the itching is severe or if the bite is suspected of being infected then it is best to see a doctor for evaluation and further treatment.

MarcieMom: Thank you Dr Robin, it is a very timely and protective series to know what to look out for during summer time while having fun with our children.

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Doctor Q&A

Common Summer Skin Rashes in Kids Series: Heat Rash

This is a 3-week series with Dr. Robin Schaffran, M.D., a caring mom and Pediatric Dermatologist. She is a board-certified Dermatologist and attending staff physician at Cedars Sinai Medical Center. She attended the University of Toronto Medical School where she graduated as a member of the Alpha-Omega-Alpha Honors Medical Society.

Common Summer Children Skin Rashes with Dr Robin Schaffran Pediatric Dermatologist

Is Heat Rash in Kids due to Sweat, Clothes or Foods?

Heat rash is a common term, and in Asia, it may be thought of rashes that come out from consuming ‘heaty’ foods. Is that right? Let’s find out, with the help of Dr Robin.

Heat rash’s scientific term is Miliaria, also known as sweat rash or prickly rash. It is common during summer, especially if it’s hot and humid. It affects children especially due to their underdeveloped sweat glands, which are more prone to becoming blocked and therefore causing rash.

Can you explain to us the interaction of heat and sweat, and the glands that cause a rash in miliaria?

Dr Robin: Miiaria occurs under conditions of high heat and humidity that lead to excessive sweating. Occlusion of the skin from too much clothing or blankets can aggravate the pooling of sweat on the skin surface leading to overhydration of the skin. In susceptible persons such as infants who have immature sweat glands, this often leads to transient blockage of the sweat ducts. Therefore, as more sweat is produced, there becomes and inability to secrete the sweat because of the blockage. This results in the appearance of a rash called miliaria.

What is Child Eczema is Triggered by Rash?

MarcieMom: For a child with eczema whose eczema is triggered by sweat, what is the difference between atopic (to sweat?) versus a heat rash?

Dr Robin: Eczema is an inflammation of the skin, usually genetic, which is often aggravated by sweat and looks completely different than the appearance of miliaria. Eczema triggered by sweat looks like eczema triggered by any other trigger. Miliaria (heat rash) on the other hand, looks like small, tiny red bumps or vesicles which is usually asymptomatic.

Appearance of Heat Rash

Heat rash looks like dots or tiny pimples, and usually doesn’t require medical attention.

MarcieMom: Dr Robin, can you share with us where are the common body parts where heat rash occur? Is it more likely to be inside clothing due to heat trapped from wearing too much?

Dr Robin: The most common area of involvement for heat rash is the trunk area because of occlusion from clothing and blankets.

Treatment of Heat Rash

MarcieMom: When will heat rash require seeing a doctor?

Dr Robin: Heat rash is usually self limiting and asymptomatic so there is no reason to treat it. The reason to see a doctor is to ensure that the eruption is indeed heat rash and not something else that would require treatment.

MarcieMom: How should heat rash be treated at home?

I’ve read that calamine lotion can be applied to sooth the irritability but will that be drying for the skin (thus not suitable for a child with eczema)?

Dr Robin: The mainstay of managing heat rash involves controlling heat and humidity so that sweating is not stimulated. Measures include removing occlusive clothing, limiting activity or providing air conditioning. Topical treatments involve lotions containing calamine and menthol and are for soothing purposes only and are not necessary. They can be drying to the skin and would not recommended to a patient with eczema.

Calamine and Menthol can be Drying for Eczema Skin

Does Drinking Water help with Heat Rash?

MarcieMom: Drinking water is important in hot weather to prevent dehydration. Does drinking more water help prevent heat rash?

Dr Robin: Drinking water is important for hydration but heat rash is not a result of dehydration so drinking more water would have no effect on preventing heat rash.

MarcieMom: Thank you Dr Robin, your reply helps parents understand more about heat rash, and next week, we will be covering insect bites.

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Doctor Q&A

Common Summer Skin Rashes in Kids Series: Sunburn

This is a 3-week series with Dr. Robin Schaffran, M.D., a caring mom and Pediatric Dermatologist. She is a board-certified Dermatologist and attending staff physician at Cedars Sinai Medical Center. She attended the University of Toronto Medical School where she graduated as a member of the Alpha-Omega-Alpha Honors Medical Society.

Common Summer Children Skin Rashes with Dr Robin Schaffran Pediatric Dermatologist

Sun and Child’s Skin

MarcieMom: Finally, there’s sun everyday and it is a great season to have family activities outdoors. We know that the ultraviolet rays damage the skin, and have seen images whereby a middle-aged twin who likes to suntan looks visibly years older than one who doesn’t. I also understand that skin damaged by the sun, is not only more prone to skin cancer but loses some ability to heal itself.

Can you explain to us how the sun interacts with the child’s skin?

For instance, which layer of skin does it penetrate? Does the sun have some function, for instance, synthesis of Vitamin D? Does sun exposure also carry risk?

Dr Robin: Ultraviolet light are rays from the sun that penetrate through the epidermis and dermis layers of the skin and do damage at all levels. Ultraviolet light damages DNA in skin cells  in the epidermis and damages collagen and elastin in the dermis. Ultraviolet light is necessary for the skin to synthesize Vitamin D. And yes we know that too much sun exposure carries risk of skin cancer and premature aging later in life.

Should Child Eczema Skin have Sun Exposure?

For a child with eczema, should he/she have fewer hours under the sun? How does the sun interact differently on eczema skin?

Dr Robin: A child with eczema does not need fewer hours under the sun than other children. If anything, ultraviolet light has some benefit for eczema skin and is often used to treat recalcitrant eczema. However, the side effects of ultraviolet light (i.e. premature aging of the skin and skin cancer) make this a less desirable treatment.

What to do if your Child get Sunburn?

A child may get sunburn, and the appearance of the skin may differ at various times after being outdoors, generally from pinkish to turning burned the next day. There are also instances that warrant calling the doctor, for instance, an infant’s skin (below a year old) turning pink may require a check with the doctor or when there are signs of blisters, swelling, infection, fever or extreme pain in an older child.

MarcieMom: Dr Robin, how would a parent recognize that the child’s skin is burned, and what is happening to the skin?

Under what circumstances would you recommend them to see a doctor?

Dr Robin: The first signs of a burn are usually redness of the skin. A sunburn is like a burn from any other cause. The skin is injured/ burned by the ultraviolet light (specifically UVB rays). The severity of the burn is based on how deep the burn is. If it’s a deeper injury it usually results in blistering and will likely need medical attention to help with wound care.

Will the appearance of sunburn look different for a child with eczema?

Dr Robin: A sunburn looks the same regardless of eczema skin or not.

MarcieMom: How should sunburn be treated at home? I’ve also read that thick ointment will prevent heat from escaping, and best to use lotion instead to prevent peeling. Why is this so and does it mean that a child with eczema should use only lotion to moisturize before sunburn recovers?

Dr Robin: A sunburn is best treated with soothing lotions such as aloe vera, cool compresses or cool baths. Anti-inflammatory medication such as ibuprofen can also be helpful. Thick ointments such as Aquaphor are best for skin healing and do not prevent heat from escaping.

What Sun Protection Tips For Your Kid?

Apart from not going to the sun during the hottest time of the day, there are sun protection measures such as applying sunscreen, wearing hat, sunglass and light long sleeve shirt and pants.

For a child, what sunscreen lotion would you recommend?

Eg. Sunscreen ingredients – physical reflectors, SPF. Also what would be the common wrong way to wear sunscreen and the right way to do it?

Dr Robin: For children, I recommend mineral based, chemical-free sunscreens that include either zinc oxide and/or titanium dioxide as the active ingredients. These are considered to be physical blockers of the ultraviolet rays. The right way to wear sunscreen is to apply a lot of it and rub it all over so all exposed body surfaces are covered and to remember to reapply after 2 hours of being outside or after swimming or sweating.

MarcieMom: For protection when in contact with water, say at the pool or sea, what would be the additional or different sun protection measures? Does water reflect more light onto the skin (despite feeling cool in it)?

Dr Robin: When in contact with water, protection is the same, ie. Liberally use sunscreen and remember to reapply after emerging from the water. It’s best to use a water resistant sunscreen when in the water. Water does reflect more rays onto the skin so there is more exposure when in the water.

MarcieMom: Thank you Dr Robin for taking time to help protect our child from sun eg sunscreen, something I know you are deeply passionate about. Next week, we will be discussing heat rash.

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Doctor Q&A Support Group

Sharing Treatment for Eczema Children

Eczema Treatment for Children Dr Lynn Chiam dermatologist Singapore
Elomet ointment

Last Friday’s eczema support group session with Dr Lynn Chiam was a fruitful one – the topic was Treatment for Kids’ Eczema and we had pizza and chicken wings for lunch at the National Skin Centre Singapore!
Dr Lynn is a consultant dermatologist who subspecializes in paediatric skin conditions at Mount Elizabeth Novena Specialist Medical Centre, Children & Adult Skin Hair Laser Clinic, Singapore.

Eczema Tips for Children

1. Moisturizing within 3 Minutes After Shower

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

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

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

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

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

Topical Corticosteroid Withdrawal Children

Read this interview with Professor Hugo where we go through the review paper conducted by National Eczema Association on Topical Corticosteroid Withdrawal

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


Side effects of MISUSE should not be confused with Right Use

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

4. On Oral Steroid

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

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

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

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

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

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

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

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

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Doctor Q&A

Doctor Claudia Video – Eczema: Scratching the Surface

Aging Skin Eczema Skin Videos of Dr Claudia Aguirre Neuroscientist

Dr. Claudia Aguirre is a neuroscientist, a TED speaker and creator of Ted Education lessons. She is passionate about skincare, psychodermatology and frequently lectures worldwide. Also check out last week’s video on Aging Skin.


This video showcasing Dr Claudia Aguirre was when she worked at Dermalogica

Marcie Mom: In the video, Doctor Claudia explained atopic dermatitis and that elevated IgE (immunoglobulin E) triggered allergic response in certain people. There is no single cause of eczema identified, and no cure for the condition. It is instead a multi-factorial condition characterized by defective epidermal barrier that is more alkaline and has more enzyme activity that reduces the connectivity of the skin layers. Filaggrin is a protein that aids in the formation of skin layers (do watch the video to see the animated filaggrin) and converts to natural moisturizing factors. Dry skin lacks this normal functioning filaggrin gene, and has been linked to atopic diseases such as eczema, asthma and allergies.

Sweat and Eczema

Marcie Mom: Dr Claudia, in the video you mention that sweat is an irritant for many with eczema.

Can you explain how the chemicals in our sweat can cause the allergic reaction? Shouldn’t our skin be used to our sweat?

Dr Claudia: Well an irritant reaction is not the same as an allergic reaction. I explained that sweat can be irritating to eczema skin, as this epidermal barrier may not be fully functional. This is an interesting question though, as we are still understanding the chemical composition of sweat (be that eccrine or apocrine).

In general, sweat is composed of water, minerals (like sodium and magnesium), lactate, ammonia and various amino acids. It could be one of these compounds, the combination of them, the changing pH of the skin, or even the sweat’s water content that can cause the itching and stinging sensations to some people with Eczema.  Digging deeper, I found an interesting study that suggested the amino acid composition of sweat is similar to the composition of the protein profilaggrin (which is later converted to filaggrin). This is interesting because scientists can study filaggrin by using human sweat as a potential chemical model. In the end, sweat can make eczema skin uncomfortable, so I suggest bringing a cool damp towel to your workout, or maybe spritzing a hydrating spray, instead of rubbing or scratching this sensitive skin.

Aromatherapy, Stress and Eczema

MarcieMom: Stress is also a common trigger for eczema and suggestion such as aromatherapy is mentioned in the video. Out of curiosity, does the aroma work the same way as fragrance in skin care products, which is to be avoided? Or is there a specific type of aromatherapy for those with eczema?

Dr Claudia: No, aroma in skin care products varies widely. What you want to avoid are synthetic fragrances which can cause an irritant or allergenic reaction in the skin. Some people use perfume for years before they get a skin reaction. Aromatherapy typically employs essential oils, which are natural compounds. However these can be quite potent, so a trained professional with a background in aromatherapy should be consulted before any treatment. The act of breathing deeply alone can also reduce stress.

Water in Skincare Products to be Avoided?

MarcieMom: In the video, you also recommended water-free barrier repairing products and oatmeal compress. Is water to be avoided in skin care due to preservatives being required if there is a high water content or is it because the eczema skin ‘loses’ the more liquid product easily? As for oatmeal compress, do explain to us (I’m using oatmeal bath oil, but not sure how an oatmeal compress works).

Dr Claudia: Great question. I suppose it could be both. Paraben alternatives are preservatives that have a greater potential of being irritating than parabens. So ‘paraben-free’ formulations may actually be more irritating. The amount of water lost to a skin care product from the skin is most likely negligible, so I recommend anhydrous barrier-repairing products because they contain silicones to protect skin. Our skin has a lipid (oil) layer, so you want to replenish those oils to ensure a properly working barrier.

Colloidal oatmeal for Eczema

Colloidal oatmeal is a wonderful ingredient for eczema skin. There are many scientific studies on oats and dermatitis – and this should be your eczema skin’s best friend. Look for clinical colloidal oatmeal for best results. The compress is basically a wet wrap. This is used to lock in moisture and keep the actives on the skin. On wet skin, apply oat or other active ingredient, follow with a damp gauze and cover with dry wraps. This dry covering could be pajamas (good for kids), or other dry covering. Alternatively, a colloidal oatmeal masque is a really nice add-on to a skin treatment for hydrating and soothing skin.

Vitamin D and Eczema

Marcie Mom: Vitamin D has been mentioned much to boost immunity and for the skin.

How exactly can one with eczema get vitamin D, and what’s your recommended minutes of sun exposure for those with eczema?

Doctor Claudia: Everyone has different needs, so there is no single recommended amount of sun exposure. I advise those wanting to know to consult with a dermatologist trained in a bit of photobiology. Or you could ask a scientist (they are hard to find!). At a recent conference I met Prof. Brian Diffey, an expert in this field. In a recent paper, he concluded “Messages concerning sun exposure should remain focused on the detrimental effects of excessive sun exposure and should avoid giving specific advice on what might be ‘optimal’ sun exposure”.

Vitamin D is an essential hormone and we all need a good dose of it. So speak to a dietician or doctor to find which vitamin D supplements are good for you and be sun smart!

Marcie Mom: Thanks Doctor Claudia, your explanation is so helpful, as even though we can’t cure eczema – it doesn’t hurt to understand more of it in order to manage it confidently. I’m looking forward to more of your videos!

If you have something to share about the topics covered in this post, share in the comments or send this article to someone who has a similar experience. Your sharing will help others.

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Doctor Q&A

Doctor Claudia Video – Aging Skin

Aging Skin Eczema Skin Videos of Dr Claudia Aguirre Neuroscientist

Dr. Claudia Aguirre is a neuroscientist, a TED speaker and creator of Ted Education lessons. She is passionate about skincare, psychodermatology and frequently lectures worldwide. Also check out next week’s video on Eczema Skin.


This video showcasing Dr Claudia Aguirre was when she worked at Dermalogica

Why Skin Aged

Marcie Mom: In the video, Doctor Claudia pointed out the growth of anti-aging skin products and treatments such as botox, dysport and hyaluronic acid injections. Topics covered in the video include (i) the difference between intrinsic and extrinsic aging and (ii) the biology of aging skin. Dr Claudia explained in the video that cells age due to oxidative stress and also pollution, lifestyle (smoking, stress) and ultra-violet rays (exposure to sun).

Characteristics of Aged Skin

Dr Claudia, I’ve been hearing of more and more elderly getting eczema, and scratching till they bleed. I saw in your video that ageing skin is drier, due to less renewed cells and a higher trans-epidermal moisture loss. Aged skin, as you pointed out, is characterized by epidermal thinning, wrinkles, flattened dermal-epidermal junction and collagen fragmentation. There is also less nutrient transfer and reduced sensation.

For eczema in elderly, is the thinner and weaker skin making the skin more vulnerable to allergens, thus triggering skin rashes?

Dr Claudia: The aging skin process can certainly make older skin more vulnerable to disease, but it’s important not to confuse dehydrated skin with eczema. Aged skin can be both dehydrated and dry, which can decrease the barrier function and allow more irritants and allergens to penetrate. In the elderly, another form of eczema known as asteatotic dermatitis commonly occurs on the shins, hands and trunk. This looks like a dry riverbed – dry, cracked and polygonally fissured skin. This can be due to aging, dehydrated skin and malnutrition. Overuse of soap and water can also trigger this. There may be other factors at play, so it’s important to get a proper medical diagnosis.

Prescription Medicine leading to Chronic Eczema

An interesting factor in elderly eczema has to do with the medication regimen older people often take. Prescription medications including diuretics and calcium channel blockers (CCB) can lead to chronic eczema. In fact, a recent French study concluded that “the long-term use of CCB is a risk factor for chronic eczematous eruptions of the elderly.” Those deficient in vitamin B6 may also have an increased risk of developing dermatitis. Since our skin needs essential fatty acids, those whose diets do not contain enough healthy fats may suffer from dry skin as well.

Menopause and Eczema

Marcie Mom: Can you also explain how menopause affects the skin of older women? Does this make the skin more susceptible to eczema?

Dr Claudia: Hormones sometimes play a role in developing eczema. In pregnancy, one of the most common skin conditions is eczema, where the hormonal changes shift the body’s immunity and predispose it towards allergic reactions and eczema. Of course, not all women suffer from this. For more read this post I wrote on the topic.

Hormones and Dry Skin

The female menopause results in a marked decrease in many hormones, and this decline can happen of a number or years. The decrease in hormones like estrogen and progesterone can lead to dry and dehydrated skin, and uneven pigmentation. Since the epidermal barrier required proper moisture and lipid content, this can cause more sensitivity and enhanced penetration of irritants and allergens. A decrease in thyroid hormones can also lead to dry skin. So reduced levels or female hormones can lead to dry, itchy, flaky skin – but not necessarily eczema skin.

For more info on hormones and skin, check out this article I wrote here.

Modern Diet Changes and Eczema

MarcieMom: Aging skin and menopause are part of natural body  growth (age) yet I kept having friends tell me they never knew of eczema starting at elderly till it happened to their parents! Is there such a phenomenon in the US and could it have anything to do with our diet? As you pointed out in your video, too many free radicals (unstable molecules) create oxidative stress that lead to wrinkles, hyper-pigmentation and inflammation.

Dr Claudia: See my answer to Q1!

Marcie Mom: Thanks Doctor Claudia, your explanation will certainly help clarify some questions for those with elderly family members with eczema.

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Doctor Q&A Other treatments

TCM Series – Understanding Eczema from TCM’s Perspective

TCM Physician Lau Kiew Teck with Raffles Medical Group

For this TCM Series, I’ve the privilege of interviewing TCM Physician Lau Kiew Teck of Raffles Medical GroupRaffles Chinese Medicine Clinic, whose special interests include respiratory conditions, dermatology, pediatrics, diabetes and digestive system disorders.

Refer to the first part of this interview here and the second part here.

Understanding Herbal Bath & Cream

MarcieMom: I read that herbal bath and creams are also prescribed by TCM physicians. What are the ingredients of the herbal bath & cream? Given that there is so much transparency being pushed for in labeling ingredients of skin care products, are ingredients in TCM products fully labeled?

Physician Lau: In my practice at Raffles Hospital, our products are fully labeled and certified by Singapore Health Science Authority.

MarcieMom: Moisturizers, bath oil, bleach bath and steroid topical creams are treatment prescribed by western medicine. Is herbal cream, herbal bath similar? (as in have properties to repair the skin barrier, kill staph bacteria and reduce inflammation)

Physician Lau: As the properties are different between the western medicine and the herbal cream, we are unable to compare. The herbal bath definitely helps in reducing the inflammation thus creating an environment for the skin to recover. Repairing of skin largely depends on the individual body’s nature.

MarcieMom: Acupuncture is also a treatment option used for eczema; how does acupuncture treat eczema and is it recommended for children?

Physician Lau: As mentioned previously, TCM focuses on the holistic approach where a combination of treatment of acupuncture and herbs are used. For instance, if you are suffering from eczema due to weak digestive health, TCM, be it herbs or acupuncture or both, is administered to treat the indigestion problems and subsequently, through the holistic approach, it will speed up the recovery of eczema. I will not recommend acupuncture for children.

MarcieMom: Also, where are TCM medicine produced in? How can a patient check the harvesting of the herbs (whether using insecticide), the manufacturing facility (use of chemicals) and the packing facility?

Physician Lau: Patients can check the manufacturer’s label to see where the medicine is produced in. It is impossible to check on the harvesting of the herbs with the looks of it. Such assessments have to undergo testing.

Physician Lau: Based on the guidelines of Singapore Health Science Authority, all TCM products dispensed in Raffles Hospital are certified.

MarcieMom: Thank you Physician Lau for helping us understand a little more on TCM in the treatment for eczema for the past three weeks.

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Doctor Q&A

Staph Bacteria Series with Dr. Clay Cockerell: Prevention of Staph Infection

Staph Bacteria series with Dr Clay Cockerell Eczema Child Skin

This is a 4-week series focused on bacteria found on our skin, in particular Staphylococcus aureus, a bacterium that can lead to infection and complications in eczema patients. I’m honored to have Dr. Clay Cockerell, former clinical professor of dermatology and pathology and the former director of the Division of Dermatopatholgy at University of Texas Southwestern Medical Center in Dallas, Texas, to help in this series.

How Staph Bacteria Passes From One To Another

Staph bacteria, including MRSA, are spread from skin-to-skin or by contact with surfaces and objects. Staph bacteria present in mucous lining of the nose can be passed to another if the other person touches the mucus from the former’s sneezes (and kindly not dig your nose!). Measures such as hand washing, disinfecting, particularly on surfaces such as doorknobs, mobile phone and keyboards, kill the Staph bacteria.

Infection Prevention and Hygiene Tips for Kids

Marcie Mom: Dr. Clay, here are a series of practical questions on regular cleaning and hygiene!

1. For cleaning of door knobs/mobile phones – how regular should the cleaning be? And is any disinfectant effective against Staph bacteria?

Dr. Clay: The common household antiseptics that contain bleach and other products, such as Lysol, are very effective at killing Staph. There is no “right” answer to how frequently to clean these areas, but if there is a person at high risk of getting an infection or becoming colonized with MRSA, such as a child with eczema, perhaps as often as once or more per day might be a good idea.

2. A hospital setting or being in a confined area with a patient with infected wounds, is a venue with a higher rate of MRSA.

Should a child not be brought to a hospital at all, especially a child with eczema skin?

Dr. Clay: Yes, if the eczema is flared, it would probably be wise to avoid such settings. If for some reason the child must be in those areas, I would strongly recommend that he or she wear protective clothing, such as a gown, and consider taking a bleach bath or shower afterward.

3. Towels should not be shared but washed with detergent and preferably warm water.

What is the temperature a washing machine ought to be set to kill Staph bacteria?

Dr. Clay: The temperature is not the most important aspect of killing the bacteria, but rather the presence of the detergent – especially if it contains bleach is very important. Even if the clothing is washed in cool water, if it contains bacteria-killing detergent, that will be effective. Most washing machines have a hot/warm cycle, but the temperature of the water is not hot enough alone to kill bacteria.

4. Pets can also be infected with Staph bacteria and pass to humans through contact.

Should regular checking of the pet be conducted for Staph bacteria?

Dr. Clay: Yes, especially if there is a child at home with eczema. Most pets that are infected with Staph have some sort of skin compromise like crusting and oozing, and a veterinarian should evaluate those. Just as with humans, washes with bleach-containing products coupled with antibiotics are quite effective.

5. For someone who had a prior Staph infection, is he/she more prone to a repeat case?

Dr. Clay: Yes. Unfortunately, this indicates that the person is prone to get Staph and that their body chemistry is conducive to Staph colonization.

Bleach Bath & Alternative Preventive Measures

Bleach bath has been shown to be effective in reducing Staph bacteria, more in this post.

How does the bleach act against the bacteria on the skin? Kill it and it’s drained with the water?

Dr. Clay: Bleach differs from antibiotics in its killing mechanism as it acts to physically destroy the bacterial cell wall and proteins. Antibiotics interact with the proteins and nucleic acids to cause the bacteria to make abnormal cell structures. As such, they can develop resistance. Once the bacteria are killed with bleach, the residual cell structures are no longer viable, and yes, they will degenerate and be washed away.

For parents who are resistant to bleach bath (like me), I use chlorhexidine.

How much chlorhexidine to put on the cotton pad (soaking wet or squeezed dry wet) and how many ‘swipes’ are required to kill the bacteria?

Dr. Clay: Chlorhexidine is also effective at killing bacteria and basically, all one needs is to coat the area and rinse with water. There is no “right” amount to use, just use enough to cover the area and wash it off. Different products come with different instructions, so follow those as it may be necessary to leave it on a bit longer before washing.  Chlorhexidine is not supposed to be used on the head and neck or in the groin area, however, and unfortunately, these are areas where Staph thrives. For this reason, bleach-containing products like CLn® BodyWash, which can be used in those areas, is a very good alternative. It’s much easier to use than a traditional bleach bath and is much more cosmetically elegant.

Are there other alternatives? Especially for a child with eczema who ought to avoid frequent hand washing with soap?

Dr. Clay: As noted above, a bleach-containing product such as CLn® BodyWash could help to decrease the use of harsher products because of their efficacy in killing bacteria such as Staph and MRSA, which would lessen the risk of causing irritation. For general cleansing, mild cleansers like Cetaphil can be used instead of soap and water, which also lessens the risk of irritation – although, this has no antibacterial effect.

MarcieMom: Thank you so much Dr Clay Cockerell for teaching us lots on how to manage the bacteria on our child’s skin. I’ve learned much in this series and I’m sure many parents do and appreciate your advice!

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Doctor Q&A Other treatments

TCM Series – Understanding Eczema from TCM’s Perspective

TCM Physician Lau Kiew Teck with Raffles Medical Group

For this TCM Series, I’ve the privilege of interviewing TCM Physician Lau Kiew Teck of Raffles Medical GroupRaffles Chinese Medicine Clinic, whose special interests include respiratory conditions, dermatology, pediatrics, diabetes and digestive system disorders.

Refer to the first part of this interview here.

Herbal Medicine & its Compounds & Prescription

Herbs such as Flos Lonicerae (Jingyinhua), Herba menthae (Bohe), Cortex Moutan (danpi), Rhizoma Atractylodis (Cangzhu) and Cortex Phellodendri (hungbai) are herbs commonly prescribed by TCM physicians for eczema. They have anti-allergic, anti-inflammatory and reducing itchiness effects.

MarcieMom: Physician Lau, could you explain to us what compounds are made up in the herbs that you commonly prescribe to eczema children? (Compounds meaning containing which Vitamin or which carotenoid)

Physician Lau: These compounds are extensive and it is not possible to list them all down.

Marcie Mom: I searched for studies on TCM and effects on atopic dermatitis and it appear that studies which indicate positive results (meaning lower severity of eczema or less reliance on cortisteroids) have relatively small sample size (see here and here). In this review article, the authors from The Chinese University of Hong Kong, Pediatrics and Institute of Chinese Medicine departments, concluded that the “beneficial effects of Chinese medicine on children with atopic dermatitis have not been consistently demonstrated”. I would think this is due to limited studies, both in number of studies and the sample size of studies, which led to inconclusive results and the ambivalence of non-TCM practitioners to recommend their patients to explore TCM.

MarcieMom: Physician Lau, do you know of any conclusive large-scale study of TCM on eczema?

Physician Lau: Not that I know of.

I also read that the TCM prescription is individualized and not standardized across eczema patients. Why is it not possible to be standardized? Would prescribing the common herbs for eczema and in a standard dosage makes it easier for studies to be conducted and also for greater transparency in TCM medicine?

Physician Lau: Each patient requires different attention and treatment and TCM does that. It customizes the treatment for the patient so patient can recover speedily.

MarcieMom: Related to the above, the individualized treatment characteristic of TCM makes it scarier for parents, what if their TCM physician prescribes the wrong potency or frequency? I’m thinking about western steroid creams, a mom would easily google the strength of the steroid and know if it ought not be used daily. Can you advise (1) what questions a parents should ask their TCM physician about the medicines given to their child and (2) what are the common dosage and length of taking these meds?

Physician Lau: Each consultation differs from patient to patient so there is no common dosage or length of taking these medications. The most frequently asked question is “are they safe?” Yes, they are safe and there are no known side effects.

MarcieMom: I read quite a few studies preparing for this interview and found that all of them measure the toxicity level in kidney and liver (and most conclude no toxicity effect). Why is this mentioned in the studies of TCM? Is there a risk of toxicity because the compounds in the herbal medicine are too potent?

Physician Lau: In fact, all medications including western medicine measures the toxicity level in the kidney and liver as these are important and immediate organs that has reactions to the medicine. All medication concoctions follow this benchmark.

MarcieMom: Thank you Physician Lau for the reply. Next week, we’d explore herbal bath and cream treatment options.

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Doctor Q&A

Staph Bacteria Series with Dr. Clay Cockerell: Understanding Treatment Options & MRSA

Staph Bacteria series with Dr Clay Cockerell Eczema Child Skin

This is a 4-week series focused on bacteria found on our skin, in particular Staphylococcus aureus, a bacterium that can lead to infection and complications in eczema patients. I’m honored to have Dr. Clay Cockerell, former clinical professor of dermatology and pathology and the former director of the Division of Dermatopatholgy at University of Texas Southwestern Medical Center in Dallas, Texas, to help in this series.

Treatment for Staph Infection

A common treatment for Staph infection is the use of an antibiotic either topical or oral. Pus may also be drained (only by doctor!). Dr. Clay, what are the common types/names of antibiotics prescribed for Staph infection? And if an antibiotic cream is prescribed, what is the frequency and duration of topical application? Should a parent consult the doctor again if there’s no improvement within the first two days (for possibility of different strain of bacteria involved)? Can a parent apply the same cream the next time a similar-looking rash occurs on the child’s skin?

Dr. Clay: There are a number of antibiotics that are effective against Staph, but unfortunately, many strains of Staph are now resistant to the antibiotics that have been used for years. The most commonly used antibiotics are in the penicillin family, and one of the best is methicillin. Cephalosporins, such as cephalexin, are also good for sensitive strains. Topical antibiotics include bacitracin, Neosporin and mupirocin (Bactroban). These are usually applied two to three times a day. It usually takes several days for improvement to be noted, and there may be redness that lasts for several more days than that. There should be no further spreading of the process, and the pain and redness should start to resolve in two to three days.

What if there is no improvement after treatment?

If there is no improvement, it should be checked by a doctor as it is possible that it is being caused by another rare organism or fungus, or it may be a sign that the patient’s immune response is too weak to help eradicate it with a topical antibiotic alone. In general, if the patient is doing well and develops a similar process, the family can try to treat topically at first. If it does not improve in a few days, the doctor should be notified.

Methicillin-Resistant Staph Aureus (“MRSA”) Infection

A worrying trend is that there is a strain of Staph bacteria, namely the MRSA, which has developed resistance against the commonly prescribed antibiotics noted above. As explained on Dermnet NZ, there is a mec gene in the bacterium that “alters the site at which the methicillin binds to kill the bacteria.” As such, the binding is rendered ineffective, and the MRSA cannot be killed by antibiotics such as methicillin, floxacillin, lactamase-resistant pencillin and amoxicillin.

What are the antibiotics that can be given to a child that can kill the MRSA?

I read that Vancomycin is one such antibiotic, but there are also strains of Staph bacteria that have become resistant to it. What about Bactrim DS (double-strength sulfamethoxazole trimethoprim)?

Dr. Clay: Yes, vancomycin is a commonly used antibiotic that is effective against MRSA, but it cannot be taken orally. If the infection is relatively mild, we generally use Bactrim DS, as it can be taken by mouth and is effective. It is also important to supplement this with measures to try to eradicate it from the skin such as the use of bleach-containing cleansers, like CLn® BodyWash.

MarcieMom: Thank you Dr Cockerell, next week we shall learn about prevention – definitely beats having to treat a staph infection!

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Doctor Q&A Other treatments

Traditional Chinese Medicine (TCM) Series – Understanding Eczema from TCM’s Perspective

TCM Physician Lau Kiew Teck with Raffles Medical Group

Many parents have asked me “What about TCM?” while others have suggested that I explore TCM as an eczema treatment option for my child. I’ve looked into TCM briefly in this archive post, but felt I didn’t know enough to evaluate it. For this TCM Series, I’ve the privilege of interviewing TCM Physician Lau Kiew Teck of Raffles Medical Group, Raffles Chinese Medicine Clinic, whose special interests include respiratory conditions, dermatology, pediatrics, diabetes and digestive system disorders.

More on Physician Lau: Physician Liu Qiao De graduated from Singapore College of Traditional Chinese Medicine in 1977 and has been practising TCM since. In the early 90’s, Physician Liu pioneered a Quit Smoking programme using auricular acupuncture. Physician Liu’s special interests include treating skin problems such as eczema and psoriasis. In pediatrics, he specializes in treating asthmatic conditions.

Eczema – A Multi-Factorial Condition

Eczema is a condition which is contributed by multiple factors like genetics, over-active immune system, damaged skin barrier, allergy, environment and persistence of staph bacteria residing on eczema skin. It is also a chronic condition, meaning treatment options are meant to manage the eczema instead of curing it.

From what I’ve read on the web, eczema is due to weaknesses or imbalances in body organs, in particular, the spleen, the lungs and the stomach, which leads to skin with eczema rash. Thus, various TCM options, such as herbal medicine and acupuncture, are ways to detoxify and strengthen these organs, specifically to (1) clear heat, (2) remove dampness and (3) remove wind.

Marcie Mom: Physician Lau, is this also TCM’s stand on eczema – that it is multi-factorial and chronic? Kindly help us understand the factors (from TCM’s perspective) that contribute to eczema and whether TCM is a treatment option to manage or to cure eczema. Can the factors/ causes of eczema be reconciled between TCM and western medicine?

Physician Lau: Eczema is both multi-factorial and chronic condition that is contributed by genes, immune system, damaged skin, allergy and environment. TCM focuses on the holistic approach where a combination of treatment of acupuncture and herbs are used. Patients can choose to use either TCM or western medicine or both to treat eczema; we don’t enforce any specific arrangement.

Foods to Avoid for an Eczema Patient

I read from the web that food and beverage such as alcohol, coffee, sugar, spicy food and deep-fried food are to be avoided. Also for fruits deemed “heaty” such as durian, mango, longan and lychee. Foods that are “cooling” such as green beans are encouraged.

MarcieMom: Physician Lau, can you help to explain “heaty” versus “cooling” food? Most of us in Asia are familiar with the use of “heaty” and “cooling” but it’s seldom heard of by our readers in US, UK and Canada.

Physician Lau: Food only becomes heaty or cooling when your body reacts to the food. In general, the food in its nature is heaty or cooling based on its properties.

MarcieMom: Above foods such as alcohol and spicy food are top triggers of eczema, while sugar and deep-fried food are inflammatory (further explained in this post). Green bean is an anti-inflammation food, featured in this post. Anti-inflammatory foods include those that contain anti-oxidants, Vitamin C, carotenoids, flavonoids, quercetin and kaemferol that can reduce oxidation, fight free radicals and inflammation.  Can I then understand the “heaty” food that TCM recommends to avoid as being inflammatory and those to have more as having anti-inflammatory compounds? 

Physician Lau: Fried and spicy food and alcohol in general.

MarcieMom: Thanks Physician Lau for replying to these questions – TCM still seem to be a complicated topic to understand and hope to learn more in next week‘s interview.

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Doctor Q&A

Staph Bacteria Series with Dr. Clay Cockerell: Understanding Staph Bacteria on Eczema Skin

Staph Bacteria series with Dr Clay Cockerell Eczema Child Skin

This is a 4-week series focused on bacteria found on our skin, in particular Staphylococcus aureus, a bacterium that can lead to infection and complications in eczema patients. I’m honored to have Dr. Clay Cockerell, former clinical professor of dermatology and pathology and the former director of the Division of Dermatopatholgy at University of Texas Southwestern Medical Center in Dallas, Texas, to help in this series.

Last week, Dr. Clay Cockerell gave us some basics about the type of bacteria found on our skin. This week, we will discuss Staphylococcus aureus (“Staph”) and other harmful bacteria.


Staphylococcus aureus worsens Eczema Skin

Staph aureus is not normally found on our skin, but in some people such as those who are colonized, it may be. When it is, 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 about 25-30% of healthy adults who are known as carriers and generally does not cause an infection in those with otherwise healthy skin. It is a very resistant bacterium and it can survive in dry conditions such as on dry skin and with little oxygen.

Marcie Mom: Dr. Clay, I understand that Staph is a main factor causing skin inflammation in eczema skin.

Can you detail for us where Staph bacteria reside, how it penetrates and attacks the (i) skin and (ii) body of our child with eczema?

Dr. Clay:  As noted in the first post of this series, Staph likes warm, moist, dark areas like the nose and groin, which are known as “reservoir” sites where it resides. In patients with eczema, it can affect any area of the skin that is compromised or affected with the dermatitis. Because the skin is compromised, it does not have a normal barrier, and the immune response is abnormal. The Staph grows in the skin and releases toxins that cause inflammation, which further worsens the eczema.

Staph bacteria likes warm, moist, dark areas like the nose and groin

It can begin growing in the skin and establish infection in the form of boils, cellulitis and folliculitis (“pus bumps”) in these individuals, as well. Rarely, it can actually enter the lymph and blood vessels and spread throughout the body, but it tends to remain localized at the site of entry.


Streptococcus Pyogenes Bacteria & Skin Infections

Marcie Mom: Another harmful one is the streptococcus pyogenes bacteria (“strep”), found in our throat and skin and in about 20% of healthy adults. Staph or strep bacteria can lead to skin infections such as folliculitis, furunculosis, impetigo, cellulitis, MRSA and Staphylococcal scalded skin syndrome (read more here). A skin culture can be performed which will diagnose which bacteria is present on the skin.

Marcie Mom: There are various symptoms of bacterial skin infection listed below, can you share with us the severity of the infection, e.g. when a parent ought to (i) seek a general practitioner’s consultation or (ii) rush to emergency?

Dr Clay’s Skin Infection Symptoms

Symptoms – itchy red rashes. This is the most common manifestation of eczema and may or may not be infected with bacteria. This can be treated at home using the prescribed treatment regimen.

Symptoms – skin turns painful, warm to touch/tenderness, swelling. This is a sign of a skin infection and needs to be seen by a doctor soon. If there is fever, this is something that a doctor should be notified about and an oral antibiotic should be started. It probably does not require a visit to an emergency room, but it should be called to the attention of a doctor who would evaluate the severity and might recommend that the patient be seen. These infections can arise at any time during the course of the disease.

Symptoms – infected area is filled with pus/blister/boil. As above, this is a sign of an infection and should be treated with an antibiotic. These are usually localized, but may require drainage. A caregiver should be notified who will prescribe a regimen such as applying warm compresses, topical antibiotics and possibly oral antibiotics. Generally, the patient should be seen soon and a culture performed. This is not usually an emergency, but if there is fever or redness that is spreading like above, it might require more urgent attention than a follow-up in a clinic.

Symptoms – lymph node on neck or armpit becomes protruding/ sore. This is also another sign of infection and would generally be treated like cellulitis. This is not usually an emergency, but would require antibiotics and culture.

Symptoms – fever/ chills, low blood pressure. This is a sign of a serious systemic infection, and the patient should be taken to an emergency room by an ambulance.  This could be a manifestation of Toxic Shock Syndrome, which can be caused by some forms of Staph, or could possibly be necrotizing fasciitis, which might need emergency surgery.

MarcieMom: Thank you Dr Cockerell for helping us understand which symptoms we ought to be aware of. Next week, we will explore the treatment options and learn more about MRSA.

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Doctor Q&A

Staph Bacteria Series with Dr. Clay Cockerell: Bacteria on Your Skin

The Invisible Factor affecting your Child’s Eczema Rash – Skin Bacteria

Dr. Clay Cockerell on Staph Bacteria on Child's Skin - Board-certified Dermatologist and Dermatopathologist

This is a 4-week series focused on bacteria found on our skin, in particular Staphylococcus aureus, a bacterium that can lead to infection and complications in eczema patients. I’m honored to have Dr. Clay Cockerell, former clinical professor of dermatology and patholgy and the former director of the Division of Dermatopatholgy at University of Texas Southwestern Medical Center in Dallas, Texas, to help in this series.

More on Dr. Cockerell – Dr. Clay Cockerell was the president of the American Academy of Dermatology in 2005. He is a renowned medical educator having overseen an educational program designed to train the next generation of dermatologists and dermatopathologists and the author of numerous papers and textbooks. He is a board-certified dermatologist and dermatopathologist licensed in many states throughout the U.S.His clinical expertise is in skin disorders and his passion has led him to co-found TopMD Skin Care, the company behind CLn® BodyWash.

Your Child has both Good and Bad Bacteria on Eczema Skin

Our skin is home to about 1 trillion microscopic organisms such as bacteria and fungi, and not all are bad – some are beneficial to us and some are harmless, but some are harmful like the Staphylococcus aureus bacterium (“Staph”) and Streptococcus pyogenes (“Strep”) that can cause skin infections. You can read more about the Human Microbiome Project of National Institutes of Health in this interview with Elizabeth Grice.

Marcie Mom: Dr. Clay, I read from this table that the bacteria commonly found on our skin are (1) Staphylococcus epidermidis, (2) Staphylococcus aureus, (3) Streptococcus pyogenes (4) Corynebacteria and (5) Mycobacteria.

Which bacteria are good for us (for instance, prevent colonization of harmful bacteria) and which bacteria are harmful?

Dr. Clay: Staphylococcus epidermidis is part of the normal bacterial flora that lives on our skin and is a beneficial bacterium. In fact, they serve in many ways to “police” the skin and prevent dangerous ones such as S. aureus and S. pyogenes from growing and “setting up shop”. These latter two may cause boils, folliculitis, cellulitis and erysipelas, all examples of skin infections.

Corynebacteria exist in several different species. C. acnes lives in hair follicles normally, but plays a role in the development of acne in acne-prone individuals. Other forms of Corynebacteria can also cause more serious infections such as C. minutissimum, which causes pitted keratolysis and juvenile plantar dermatosis, and C. diphtheria, which can cause cutaneous diphtheria, a rare form of cellulitis. There are also many different species of Mycobacteria, some of which are harmless and live in certain areas of the body such as the groin (M. smegmatis).

Others are harmful and can cause cutaneous tuberculosis and atypical mycobacterial infections such as Swimming Pool granuloma (M. marinum) and infections acquired from getting pedicures when exposed to infected water in nail salons (M. fortuitum).

Do We Need More Good Bacteria?

Most bacteria tend to reside in moist areas of skin, along skin folds. I read that diet, health, age and environment also affect the amount of bacteria on our skin. Let’s tackle the good bacteria on our skin first – is there anything that one can do (and should one try) to increase the amount of good bacteria on our skin?

Conversely, will frequent hand washing and use of sanitizers and anti-septic sprays remove good bacteria that our body needs? For a child whose immunity has yet to be fully developed, should he or she be washing hands more frequently or less than an adult?

Dr. Clay: The best way to increase the “good” bacteria is to have good hygiene, which prevents exposure to the “bad” bacteria (i.e., wash with a good soap and water and use hand sanitizers periodically). The good bacteria will naturally grow on your skin and live in harmony with our bodies naturally, as our body has certain factors, such as local immunity and chemicals on the skin surface, that create just the right environment. 

Bacteria Population and Hand Washing

Bacteria multiply exponentially, so when its population is temporarily decreased, as after the use of hand cleanser, it re-grows quite quickly and returns to its normal concentration. The only way to truly “sterilize” so that the normal bacteria would not return would be to wash many, many times a day and even then, it is virtually impossible to get the skin totally sterile. In fact, individuals who do over-wash often cause significant skin irritation, which paradoxically can cause the “bad” bacteria to enter and colonize the skin and even cause an infection.

Staph Bacteria Colonizes Eczema Skin

There are individuals who have certain skin diseases that predispose them to become colonized with “bad” bacteria like Staph, especially those with atopic dermatitis, also known as eczema. These patients need to use more aggressive measures to get rid of these bacteria, as they can worsen the skin condition and lead to more serious infections. These patients often require systemic antibiotics or topical antibacterial agents including bleach, as administered in bleach baths, or bleach-containing body washes like the one I have been involved in developing, CLn® BodyWash, which can be used in a shower also.

Children don’t really need to wash their skin more than adults, as their immunity to bacteria develops very soon after birth. In fact, children’s skin can be more sensitive than adult skin, so care should be taken not to over wash with harsh soaps and detergents. Skin in elderly individuals also is less able to tolerate dryness, so the same caution should be taken by them, too.

Children and Elderly’s Skin should not be over-washed with harsh soaps

People who are Staph carriers (i.e. abnormally harbor Staph on their skin) are prone to developing boils and other infections and can spread the Staph to family members.  They, too, should take measures to try to decrease the spread of Staph by using topical antibiotics and antiseptic washes.

MarcieMom: Thank you Dr Cockerell for the detailed explanation of the various bacteria on our skin. Next week, we will discuss specifically on staph bacteria.