News & Research

Does Your Child have Severe Eczema? Here is what You Should Know about Dupilumab

What is Dupilumab?

Dupilumab is the first biologic used to treat moderate-to-severe eczema. It is marketed under Dupixent. You may not have heard of it as it was only recently approved for use in older children.

Younger children may have access to it soon. Positive results came in from a clinical trial for children from 6 to 11 years old. Therefore, we cannot rule out that governments will approve it for younger children.

Let’s look at when various countries approved Dupilumab:

How does Dupilumab Work?

For those of us who do not know the (possibly) billion types of proteins in our body, Dupilumab works by targeting two cytokines. These cytokines (IL-4 and IL-13) regulate the body’s immune response to inflammation. Dupilumab works by injection and its list price is US$3019.50 per 4-week supply.

Update on 26 Oct 2019: This is another company that is working on Etokimab that targets IL-33, and improvement seen after single dose (study).

What is the Current Dosage for Older Children with Eczema?

Similar to oral medication, the weight of your child is one factor that determines the dosage. listed the dosage as:

For Adolescents lighter than 60 kg

  • Initial dose: 2 injections (each 200 mg) at different part of the body
  • Maintenance dose (each 200 mg) injected every other week

If your child is 60 kg and heavier, each dosage is 300 mg.

What if My Child does not like Needles?

Biologic drug means it is made from proteins – interesting, it is made from Chinese hamster! (I found out this from Australia TGA’s information leaflet.) Dupilumab cannot be taken orally, otherwise, our body will break down the proteins before the medication can get to work. Its molecules are also too large to be absorbed through the skin (that I learnt from US National Eczema Association).

Dupilumab can only be taken via injection

Does Dupilumab Work?

From the studies, yes, Dupilumab works.

It works by effectively targeting the two proteins that have been studied to be the most related to Atopic Dermatitis. These proteins cause more itch and inflammation, so targeting them will mean ‘short-circuiting’ the pathway that the skin gets hypersensitive.

Side-track: Dupilumab is also approved for use for asthma patients and those with chronic rhinosinusitis with nasal polyposis

Should I request this for my Child?

Hang on. Even if you can afford it, certain conditions must be met before a doctor can prescribe Dupilumab. And not any doctor – it has to be a specialist e.g. dermatologist.

What ‘Moderate-to-Severe Eczema’ Means?

Dupilumab can only be prescribed for moderate to severe eczema, that cannot be controlled with topical medicines.

I cannot find information on whether your dermatologist has to prove the eczema severity. I guess that a dermatologist is assumed to have both the expertise and the duty to prescribe only when needed.

So what does Moderate to Severe Eczema look like?

Several guidelines are helpful in giving a common understanding of mild vs moderate vs severe eczema, one of which is UK’s NICE guideline.

Moderate eczema means:

  • Areas of dry skin
  • Frequent itching
  • Redness (with or without excoriation (skin picking) and localised skin thickening)
  • Moderate impact on everyday activities
  • Frequently disturbed sleep.

Severe eczema means:

  • Widespread areas of dry skin
  • Incessant itching
  • Redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation)
  • Severe limitation of everyday activities
  • Nightly loss of sleep.

For those of us, who are into something quantifiable, you can work out your child’s eczema severity through SCORAD. If the score is from 25 to 50, your child has moderate eczema and above 50, is severe.

Many Moderate Eczema Cases

My child’s eczema would fall under moderate. And I suspect, there are many children with moderate eczema. Does this mean all these children would be prescribed Dupilumab?

Proof that Topical Medicines Do Not Work

Approval for use specifically states that Dupilumab can only be prescribed if topical medicines had not worked. My deduction, therefore, is that your child first has to have tried topical corticosteroids or topical calcineurin inhibitors, in order for the dermatologist to CONCLUDE that these have not worked.

To put it simply, if you are scared of steroids and have not applied it for your child, the dermatologist may not be able to prescribe Dupilumab.

No need for History of Eczema Oral Medications

Your child do not need to have taken oral medications for eczema, before the dermatologist can prescribe you Dupilumab. My guess is that the current oral medications are not optimal for eczema treatment. They come with side effects that are severe enough that they cannot be taken over a long duration.

Oral systemic steroids is usually for 2-week dose and side effects can include hypertension, glucose intolerance, gastritis, weight gain etc. Rebound flares are also common. Read more in this journal.

Similarly, systematic immunosuppressive treatments have many side effects which require blood testing to monitor toxicity and organ functioning.

Is Dupilumab Safe and Effective?

I have compiled recent studies on Dupilumab in this forum post, and it is considered safe and effective. There are side effects though, but given its efficacy, the side effects are acceptable.

Just from the studies in the second half of 2019, 11 studies concluded it is effective, including for hand eczema, for reducing staph bacteria and not increasing skin infections. 3 studies focused on its side effects, which are mainly injection site reactions (pain, redness), conjunctivities and herpes infection. You can see the statistics from

If you are considering Dupilumab, you should first inform your dermatologist of any eye problem. You may be asked to consult an eye doctor to establish a baseline for your eye condition before starting Dupilumab.

The Other Thing – Duration

Because of the way Dupilumab works, it is an ongoing treatment. Meaning, if you stop the injections, the protein cells in your body may go back to triggering skin inflammation. You should give it 16 weeks to see if the treatment works for you (National Eczema Society’s fact sheet).

To Dupilumab or Not?

There is no easy answer.

It is a decision to consider based on:

  • Affordability
  • Severity of your child’s eczema
  • Emotional aspect of injection
  • Possible side effects, including the current eye condition (for instance, if your child already has dry eyes, it may worsen)
  • Whether topical prescription has been properly explored (because applying something is still safer than injecting something)
  • Whether other treatments and triggers have been sufficiently explored. For instance, allergen avoidance, control of staph bacteria colonization and other therapeutics.

Currently, Dupilumab is very expensive because it is generally not subsidized nor included in insurance. But should it be more affordable, I still believe that given it is via injection and comes with side effects, we have to be sure that it is only prescribed as needed.

To put it bluntly, it should not be an easy (or lazy) way out of the due care needed for your eczema child.

Have you tried Dupilumab? It helps for fellow eczema patients to read of your experience, so please do share in the comments below or in the forum post.

News & Research

Eczema News – ‘Lipid fingerprint’ Treatment Approach

At end September 2015, it was announced on various medical new sites that Oregon State University’s researchers have developed a new approach to treat eczema that is

  • Personalized; and based on
  • Individual lipid deficiencies (akin to lipid fingerprint)

The new system patented (yet to be developed) requires testing of skin and lipid samples (from sticking and pulling off a piece of tape on/from the skin), using a mass spectrometry. The testing is non-invasive and suitable for infants and elderly as well.

Target Lipid Deficiency for Eczema Treatment
Target Lipid Deficiency for Eczema Treatment

It is established that eczema skin is often lacking in lipids, the reason why many moisturizers have active ingredients to restore the skin lipid levels such as ceramides, cholesterol and free fatty acids. However, there are many types of skin lipids and researchers at OSU believe that choosing the skincare and therapeutic product that specifically target one’s deficient lipids will help eczema sufferers.

Hopefully when developed, the ‘lipid fingerprint’ system will address:

  • Steroid usage which has side effects with long-term use
  • ‘One size fits all’ method of moisturizer selection
  • Reduce costs associated with doctor consultation and that of using the ‘wrong’ products – when the deficient lipids can be identified, it can then be known which lipid composition is missing, i.e. those that serve protective or barrier or antimicrobial function.

Associate Professor Arup Indra explained in an interview that “Lipids in our skin help retain moisture, they act like a blanket that protects against irritation and infection, You could think of skin cells as the bricks of a wall, but lipids are the mortar that prevent things from getting through the cracks. When they are deficient, problems can develop.”

Previous research by A/P Indra and other researchers has identified a protein (Ctip2) that is critical for forming and maintaining the skin barrier in mice, and for skin lipid metabolism. Mice that had Ctip2 removed had dry and scaly skin, and developed skin lesions. The removal of Ctip2 also led to increased inflammation, with presence of high levels of inflammatory proteins, enlarged lymph nodes and spleen in the mice. Without Ctip2, TSLP (another protein that has been known to activate other cells to be pro-inflammatory, linked to eczema and asthma) also became 1000-fold higher in the mice.

It is interesting research by the College of Pharmacy at OSU and my personal thought is that even if targeting deficient lipids alone may not ‘cure’ eczema for everyone, it will definitely help to reduce the cost of buying moisturizers that are not the ‘right lipid fit’. Keeping fingers crossed that R&D in atopic dermatitis will have breakthrough in the next few years to provide relief for all eczema sufferers.

News & Research

Eczema News – Review of Clinical Trials for Eczema Therapeutics in Children

Recently, Hong Kong researchers published a review article ‘Eczema therapeutics in children: what do the clinical trials say?‘ in Hong Kong Medical Journal. Categorized by major treatment methods, previous clinical trials were examined for each individual treatment option. Below is my quick and dirty summary, for the full paper that is available for free, see here.

Clinical Trials Review on Eczema Treatment

#1 Emollient

There is no evidence to show that any emollient is superior to their counterparts, including a small trial that compared the results of using a (cheap) petroleum-based cream versus an (expensive) ceramide-based cream. >> Use a cream you can afford

Aqueous cream has been shown to cause skin irritation, thinning of the cornea stratum (ie skin layer), and increased transepidermal water loss following twice daily application for a few weeks. >> Avoid aqueous cream and sodium lauryl sulphate

There is a lack of evidence for other bathing practices like addition of emollients to bathing water, while use of emollients immediately after bathing as ‘soak and seal’ can help maintain hydration >> You were right about the ‘3 minutes, quickly moisturize after shower!

I hope I don't look like a crazy mom charging my eczema daughter to shower after swimming!
I hope I don’t look like a crazy mom charging my eczema daughter to shower after swimming!

Two studies showed that the use of emollients might prevent development of atopic dermtitis in high-risk patients >> Moisturize your next baby from young

#2 Topical Corticosteroids (TCS)

Guidelines on use of topical steroids – NICE guidelines for children recommend use of the
corresponding potency of TCS for severity of atopic eczema; mild potency for the face and neck and moderate potency only for short-term (3-5 days) use in severe flares; moderate or potent preparations for short periods only (7-14 days) for flares in vulnerable
sites such as axillae and groin.

Potent fluorinated corticosteroids should be avoided for infants and sensitive skin areas.

Systematic reviews of studies that compared the frequency of application of newer-generation moderately potent to very potent steroids identified no benefit in outcome for more frequent applications over once-daily application. >> Keep to once a day, no more than twice.

Topical corticosteroids are generally safe with few serious reported adverse effects. Risks of side-effects increase with higher potency, occlusion, thinner skin areas, severity of eczema, young age and longer duration of use. >> Be careful if your usage falls into these categories!

#3 Wet Wrap

All studies reported improvement in eczema scores, though the methods of wet wrap vary, for e.g., some used diluted steroid + moisturizer while another used chlorhexidine + moisturizer.

The most common reported adverse effects include discomfort, mostly due to chills, and
folliculitis more commonly caused by ointment.

#4 Topical immunomodulants

There is strong evidence that TCIs have a steroid-sparing effect and long-term use up to 12 months can prevent flares. Topical calcineurin inhibitors are particularly useful for sensitive sites including the face, neck, and skin flexures. It’s now studied that there is no statistically significant cancer risk.

#5 Proactive approach with topical anti-inflammatory therapy

The results suggested that for a patient with moderate-to-severe eczema and chronic relapsing lesions, maintenance treatment with topical anti-inflammatory therapy twice a week may be a better strategy to prevent eczema flares and topical corticosteroids more effective than topical calcineurin inhibitors. The rationale is that there is inflammation in the underneath layer of skin that is not visible, ie has not presented itself as rash.

#6 Antimicrobials and antiseptics

Bacteria count was reduced and there was significant improvement in mean eczema EASI (Eczema Area and Severity Index) for those using diluted bleach bath. >> I use chlorhexidine-wash for my daughter with eczema twice a week. More research news on bleach bath here.

#7 Antihistamines

There is no strong evidence that oral antihistamines are effective anti-pruritics. They are safe to use and their sedative effects, where present, may be useful to promote better sleep quality.

More treatment options that are less often prescribed are covered in the review article, like oral medication. Read up and let me know what you think!

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)!

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
Wet Wrap
Medication TherapiesTopical steroid
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.

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.

Living with Eczema

SOMEONE Managed Wet Wrapping for Child with Eczema

Stephanie's beautiful girl in wet wrap
Stephanie’s beautiful girl in wet wrap

This is a series focused on personal journey with eczema while managing a certain aspect of life. Today, we have Stephanie, whose daughter has eczema since 18-month old and shares how she manages wet wrapping for her. Stephanie is the founder of Allerchic, an online store for eczema, allergy and asthma.

Marcie Mom: Hi Stephanie, thanks for taking part in my Friday blog series ‘Someone has Eczema’! Let’s start with you sharing your family eczema history, who has eczema and what’s the level of severity for your daughter?

Stephanie: Thanks Mei!

Sadly the eczema comes from my side of the family, I had eczema as a child not what I would class severe, more the typical spots you expect, backs of knees, elbow creases. It disappeared for a long time then came back in my 30s on my eyelids.
My husband & my other daughter don’t have eczema (Thankfully)
My beautiful girl Jade has the triple threat of atopic conditions she has anaphylaxis, asthma & moderate to severe eczema.

Marcie Mom: I understand that you believe that wet wraps had helped improve your daughter’s eczema. How did you discover wet wrapping, and what improvement to your daughter’s skin did you notice?

Stephanie: Wet Wrapping has made a Huge difference to my daughters eczema! I first discovered Wet Wrapping when working in Children’s Ward (almost 20yrs ago), thankfully things have changed a lot since then – there is no more wresting a small child while trying to wrap bandages! For my daughter the Wet Wraps have an overnight effect on her eczema. The next morning without a doubt we see improvement, It may still take a couple of nights to get a flare up under control, but it is definitely quicker than cream application alone.

Marcie Mom: Quality of life is a big issue for eczema families. What do you think about your quality of life and your daughter’s before and after wet wrapping?

Stephanie: Before I started Wet Wrapping during a flare up neither of us had a great quality of life (or sleep!). Jade was often crying during cream applications, she was itchy, hot & irritated during the night & although fast asleep I knew she wasn’t getting the deep restful sleep needed as she was so agitated all night. This then of course flows over into the day, Lack of concentration, irritability & of course constant irrepressible scratching was sending us both crazy. As a mother it breaks your heart to see your child like this, so of course I had to find better way.

Wet Wrapping took the sting out of cream application, they take the heat of the rash & seem to generally make her a lot more settled & calm & as we apply her wet wraps before bed they without a doubt have improved her quality of sleep too.  So once again this flows into the day. Now I have a much happier, less itchy & irritable little girl.  And a happy eczema child = a very happy mummy!

Marcie Mom: One final question – did you daughter take well to her first wet wrap? Any tricks you used?

Stephanie: The first time I applied the Wet Wraps she was very miserable & irritated but it was almost like someone had waved a magic wand & she calmed very quickly once they were in place. Because we started using Wet Wraps fairly early on my daughter she is happy with the process, she knows it makes her feel better & so she is happy to wear them.

The advice I always give people when starting to Wet Wrap is:

  • Watch the Youtube Video on how to Wet wrap, do this a couple of times until you feel comfortable with the process.
  • Use the Tubifast Garments they are so much easier to use than bandages
  • Plan to Wet Wrap about an hour or two before Bedtime for best results
  • Have EVERYTHING ready to go before you even bath your child – This includes thinking about where you are going to apply Wet wraps, for little ones also think about a song you can sing or put their favorite movie on to help keep them distracted.
  • Explain to your child that it will feel a little funny at first, but it will stop them feeling so itchy.
  • Get them to have a good soak in either a water soluble bath oil (or bleach bath if prescribed)
  • Apply the steroid (if prescribed), thick Layers of emollient, Wet Wrap & clothing
  • For Babies feed them straight after Wet Wrapping (Breast or bottle) to help them settle, For older children a reward such as a game on the ipod, a special story & cuddles are a great idea. I truly believe, It is so important to set up positive reinforcement around Wet wrapping.
  • For Parents – Don’t stress or beat yourself up about getting the technique perfect. You will figure out the best routine for you & your child!
    Eczema parents are so amazing & I think sometimes we all just need to be told that 🙂

Marcie Mom: Thanks Stephanie for taking time to share your wet wrapping journey, indeed many have positive feedback on it.

Stephanie: Thank You Marcie Mom its been Great Talking with you!

Eczema Tips

Recommend Your Baby’s Eczema Doctor (Singapore)

Prof Hugo with Marcie

Many moms have asked who to recommend for their baby’s doctor – whoever we decide on, I feel that the doctor must be specialist in children and have the best interest of the child. It is also very important that we, as parents, be confident and partner with our child’s doctor. This is particularly the case if you’re prescribed oral steroid, you have to trust your doctor and follow through, giving up halfway makes it more difficult to decide on the next treatment step.

So, here’s the list of doctors who see eczema children, take the poll at the end or add in your own in the comments.

1. Prof Hugo Van Bever – My baby’s doctor, Head and Senior Consultant, Division of Paediatric Allergy, Immunology & Rheumatology, at NUH. (Please see below, Dr Lynette Shek is the current Head and Senior Consultant of the department.) He’s from Belgium 🙂 During his consultation, I find that he takes time to understand and form a proper diagnosis; I never told him this, but I was really afraid of bringing my baby to a hospital to get a skin prick test. Borrowed his book ‘Allergic Diseases in Children‘ from the Singapore’s library and felt more assured when I read that he cares deeply for his chronically ill patients.

2015 update: I’ve co-authored “Living with Eczema: Mom Asks, Doc Answers!” book with Prof Hugo. Prof Hugo is also an author of a fiction trilogy, how cool is that!

2. Dr Lee Bee Wah – Consultant Paediatrician and Clinical Paediatric Immunologist/Allergist, The Child and Allergy Clinic, Mount Elizabeth Medical Centre. She’s recommended by my general practitioner whose children have allergies and see Dr Lee. I’m not sure about charges though, my GP told me charges depends on duration of consultation.

3. Dr Liew Woei Kang – Paediatrician, Special Interest in Allergy & Immunology, SBCC Baby & Child Clinic. We’ve met and he’s active in driving initiatives related to allergy children. He also consults in several of Singapore’s hospital with children clinics. Dr Liew is the past president of Asthma Allergy Association in Singapore.

2012 update: We also collaborated to set up Singapore Eczema Fund.

Hospitals with Children Clinic

4. KK Women’s and Children Hospital – They have an allergy specialty that manages eczema, food allergy and intolerance. Adj Assoc Prof Mark Koh is the head of pediatric dermatology. A/Prof Anne Goh Eng Neo is the Head & Senior Consultant. Also have another specialty in rheumatology & immunology, A/Prof Thaschawee (Tash) Arkachaisri is the Head & Senior Consultant.

You can read the notes that I took from an eczema forum with A/P Mark Koh as one of the speakers here.

5. National Skin Centre – They have a Paediatric Dermatology Clinic, and some of the doctors listed here also do visit consultation there.

I facilitate quarterly eczema support group sessions at the NSC, please contact me if you’d like to be on the mailing list.

6. Raffles Children Centre, Raffles Hospital – They have a paediatric medicine specialty, with atopy (allergic conditions) and dermatology sub-specialties.

7. Mt Alvernia Hospital – They have different children clinics within the same hospital, do check first the doctor’s specialty before making appointment. Kinder Clinic is one of the clinics with a branch in Mt Alvernia; they have an paediatric allergy, immunology and rheumatology specialty. Here’s a list of their doctors, with doctors listed for specialties in pediatric allergy, immunology and dermatology should you want to make an appointment.

8. Gleneagles Hospital – Likewise, double-check doctor’s specialty.

9. Polyclinics in Singapore – I think they have doctors who treat eczema, though not specializing in children. For those who don’t mind a longer waiting time, you can go to polyclinic first and get a referral to NUH. As far as I know, the difference between going to NUH straight, or getting a referral, is the latter may be a longer waiting time. The last time I attended an eczema support group session at NUH, I was told that subsidized patients will also have the same doctor to follow-up on their condition. The other doctor, A/Prof Lynette Shek, same dept as Prof Hugo, also has many positive feedback from moms in forums (and she is the current Head  and Senior Consultant, Division of Paediatric Allergy, Immunology & Rheumatology, NUH)

A final reminder

Generally, I recommend parents with severe eczema child to see specialists and not just pediatricians or general practitioners. This is particularly so as skin prick/blood test is administered in hospitals. Do note that Changi Hospital, Tan Tock Seng and Singapore General Hospital do not have a children clinics. If your favorite doctor has been left out, do leave their names in the comments!

2017 update: Apart from eczema, Marcie has had various conditions over the years that affect the skin such as shingles, chickenpox, HFMD, impetigo and the latest in 2017 was ringworm (and allergy to ringworm that resulted in rashes all over her body). I realized from the recent experience that a dedicated general practitioner (who is experienced, and actively studies information such as Dermnetnz, can accurately diagnose and formulate the right treatment as well.

2018 update: All links updated

Eczema Facts

Are you suffering from Steroid-Phobia?

Eczema on baby’s face

You may be fearful of using steroids, as many parents (myself included) are. The fear could partly arise due to the negative news on steroid abuse by athletes and partly due to its side effects. If you have googled steroids, you will find numerous websites ‘promising’ treating eczema without using steroids. When Marcie’s doctor put her on oral steroid, I had a lot of reservations and fear and remembered scaring myself to death googling all the side effects.

But after going through resisting steroid use to using mild steroid lotion & cream and a 3-week oral steroid course for Marcie, I like to encourage you not to fear using steroids but instead use it under the instruction of your doctor, preferably a specialist.

How much steroid is ok?

Where there is no inflammation, just dry skin that’s itchy – I’d recommend using lots of moisturizer. Keeping the skin cool helps to relief the itch, so try turning the air-conditioner colder. (I sometimes give Marcie a cold drink bottle to hold and its works!)

Where there is inflammation and the skin is reddish and itchy – I’d clean the skin with cool liquid chlorhexidine (antiseptic) and apply mild steroid lotion or cream. For areas with delicate skin such as the face, I’d apply a 0.5% hydrocortisone and for other areas like the knees or elbows or hands, I’d apply a 1% elomet cream. Marcie’s doctor’s instructions were not to apply more than twice a day. So far, I have only needed to apply 2 to 3 days in a row, not exceeding twice a day, and the skin will go back to normal.

You can refer to this chart extracted from for how much to apply, measured using fingertip units (ftu):

For a 3-6 month old child

  • Entire face and neck – 1 FTU
  • An entire arm and hand – 1 FTU
  • An entire leg and foot – 1.5 FTUs
  • The entire front of chest and abdomen – 1 FTU
  • The entire back including buttocks – 1.5 FTUs

For a 1-2 year old child

  • Entire face and neck – 1.5 FTUs
  • An entire arm and hand – 1.5 FTUs
  • An entire leg and foot – 2 FTUs
  • The entire front of chest and abdomen – 2 FTUs
  • The entire back including buttocks – 3 FTUs

What happened to Marcie after taking oral steroid?

You may be wondering why I’m encouraging parents to be open to using steroids when I initially did not even apply steroid on Marcie. It was very difficult to get the eczema under control and her eczema will suddenly just flare and affect her whole body. However, a one-time 3 weeks reducing dosage of oral steroid, prednisolone, really helped to keep the eczema manageable.  Marcie’s rashes disappeared within the first 2 days of the oral steroid, but gradually came back as the dosage is reduced. I worried a lot after reading the side effects of steroids such as thinning of skin, acne and damage of blood vessels. I am very glad that I chose to trust Marcie’s doctor and persisted with the 3 weeks course despite being fearful everyday. After the 3 weeks course, Marcie’s doctor said he will not give Marcie any treatment that is not 100% safe and will not give her another oral steroid course because that will not be safe. I read later that stopping an oral steroid course halfway causes more harm than following through and makes it more difficult for the doctor to decide on the next step.

After the oral steroid course, there are still rashes on and off, triggered by hot weather, sweat but never affecting her whole body with no reason. This makes it a lot easier to manage and Marcie has been a much happier baby since.