ECZEMA

ECZEMA
As the days shrink, the dry winds blow and furnaces work overtime at night, many families experience sleepless nights, because a crying child with an itchy, dry, inflamed skin keeps the family awake. November is eczema month and one can see why—there is a shift in the environment that is unfriendly to the skins of children prone to this condition.

It is estimated that the prevalence of eczema is close to 18 %. Out of this group, seven out of ten patients experience eczema in a mild manner. It can be dealt with by primary care physicians. The balance of patients experience moderate to severe eczema and may need to see a skin specialist.

In the March 2013 edition of the Journal of Allergy and Clinical Immunology, authors from the UK, South Africa, Germany and the USA published data on the management of Difficult-to-Treat Atopic Dermatitis. The main point about this condition is that the use of moisturizers remain the first line of treatment; topical corticosteroids are used once the skin gets inflamed ; non-steroidal skin products which treat inflammation—known as topical calcineurin inhibitors—are alternative options.
The causes of eczema must be considered prior to treating this irritating, itchy condition some refer to as, “The itch that has a rash.”

Genetic predisposition plays a major role. A dry, harsh environment may aggravate eczema and 90% of the foods which may trigger it include milk, soy, egg and wheat. New studies suggest that too-frequent bathing may increase an infant’s risk for eczema. Some Dermatologists and the American Academy of Pediatrics recommend baths no more than two or three times a week to avoid drying out a baby’s skin.

It is important to avoid fragrances, shampoos and soaps which have irritating agents such as sodium lauryl sulfate. Dr. Meghan Tollefson, one of the authors of an upcoming clinical report from the Academy of Pediatrics, underscores the importance of maintaining the skin’s normal protective barrier.

The first domino which gets knocked over, starting the process of eczema has to do with the breakdown of the normal skin barrier. The amount of protein, called filaggrin, is reduced thus allowing the skin to hold less moisture. Ceramides are the main lipid constituents in the skin and play an essential role in the barrier function of the skin. Once these lipids are reduced the skin becomes more vulnerable.

Through a complex dance between our genes and the environment the process of inflammation follows when the normal skin barrier is broken down—I use the analogy of leaving the garage door open at night and if there are no thieves in the neighborhood one may get away without a break-in. However, in the presence of the wrong environment, trouble may ensue.

As far back as 2,000 years BC, the Egyptians were aware of the beneficial properties of using oats as a way to keep moisture in the skin. Oats were introduced in North America at the beginning of the 17th century. In the 1930’s finely grounded oat flour started to be used for its cosmetic benefits in facial masks. In the 1950’s colloidal oatmeal was marketed in a mix from with emollient oils to add lubricating qualities.

Today a product containing colloidal oatmeal has provided many patients significant improvement in their eczema. Colloidal oatmeal works by moisturizing the dry skin, providing anti-inflammatory qualities and antihistaminic activities. The skin becomes less itchy and many parents, leery of the use of steroid creams and ointments, are reassured by data showing that the long-term use of colloidal oatmeal may lead to a 40% reduction in steroid use.

Quality of life scores devised by dermatologists reveal that many patients with eczema, treated sub-optimally, may experience insomnia, fatigue, poor self-esteem, bullying, anxiety and depression.

When a patient experiences these symptoms and when moisturizers alone fail to keep the skin healthy, the lowest potency topical steroid is used sparingly. What is called a “fingertip unit” is sufficient to cover twice the area of a handprint. Compliance is critical. It is enhanced when patients are given written plans and shown how to apply the steroids correctly. Compliance falls apart when patients are in a rush, become complacent, worry needlessly about safety and when children too young to apply the medication are given the task of daily application.

Forty-two percent of parents have explored the use of alternative therapies, such as aroma therapy, hypnotherapy, bio-feedback and massage therapy. More trails are needed in future, but for now the consensus is that good outcomes from using alternative therapies are based upon uncontrolled studies. Parents should be aware of the risk of contact dermatitis caused by some herbal products.

Although 85% of eczema present by 5 years of age, 70% remit by adolescence. It remains difficult to predict who will outgrow their eczema and who will continue to be bothered by this irritating, dry and inflamed condition. The Eczema Society of Canada provides useful information for families.(www.eczemahelp.ca)

DR. NIEMAN IS A COMMUNITY-BASED PEDIATRICIAN. HE HOSTS WWW.HEALTHYKIDS.CA AND IS A BI-WEEKLY CONTRIBUTOR ON CTV MORNING LIVE. HE CAN BE FOLLOWED ON TWITTER @DrPeterNieman