It's been one year since NEA, in collaboration with four peer patient advocacy organizations, hosted the landmark patient-focused drug development (PFDD) meeting dedicated to eczema.
Published On: Jan 9, 2015
Last Updated On: Jan 9, 2015
As a doctor, I learn continuously from my patients, and I know that all of my patients and families are unique. Each person is an individual; each family has their individual issues. But you are not alone. Birds of a feather who flock together are happier. You are fortunate to have a support organization like the National Eczema Association. Not all patients do.
I’m sure many of you go to the doctor, and think, “You have perfect skin, so how do you know what it’s like to be itchy all the time?” I actually did grow up as an itchy kid. While I have not had the severity of full-body eczema that some patients suffer with, I relate to having really sensitive skin and contact allergies.
Some of the tips that I’ve come up with to help patients with atopic dermatitis come from things that I have benefited from myself or would be willing to try.
Eczema is actually a diagnosis that’s derived from the words that mean “to erupt” or “to boil” and is a bit more broad than atopic dermatitis: eczema is a term that refers to a group of skin conditions that share the symptoms of itchy, flaky, inflamed skin.
A basic skin care regimen should focus on the fundamental aspects of atopic dermatitis. In atopic dermatitis there’s a skin barrier function problem. The people with the worst atopic dermatitis have absent or abnormal skin proteins in which the cells at the upper layers of the skin, called keratinocytes, are not producing appropriate proteins. That can reduce the skin’s ability to do all of the things that it’s supposed to do.
For example, because we’re mostly made of water, normally the skin is supposed to keep water in. When you have the impaired skin barrier that comes with atopic dermatitis, the skin isn’t able to hold water in, and so it gets very dry. (Dry skin is the leading cause of itch for anyone, whether they have atopic dermatitis or not.)
What’s more, that compromised skin barrier allows for the penetration of many chemical irritants and potential allergens, which may become true allergens for an individual. On top of that, once those microbes have gotten through, an increased number of microbes can penetrate the skin barrier, and the skin is less capable of combatting bacteria and viruses to prevent a full-blown infection.
People with atopic dermatitis skin are fundamentally more physically sensitive to sensations and itch. Over the years, publications have shown that with atopic dermatitis, you may have increased proteins that signal for itch and increased nerve endings that help pick up the itch sensation and transmit that sensation to your brain.
Think of maintaining healthy atopic dermatitis skin as supported by a three-legged stool that simultaneously requires attention toward limiting bacteria, causes of inflammation, and itching/scratching. If you can’t manage, maintain, or fight any of these individual things, you can worsen an already impaired skin barrier, which then causes problems in the other two areas. It becomes a vicious cycle of discomfort, leading to that eruption of fiery inflammation.
How do we fight a house fire? With water. We also use water when tending to atopic dermatitis. We need to rehydrate that dry skin — and no moisturizer is as effective at rehydrating dry skin than plain water.
You need to bathe and soak in lukewarm water for 10 to 15 minutes, which is long enough to rehydrate but not so long as to further weaken the skin barrier significantly. When you add bleach (sodium hypochlorite) to the water, you have a low-risk treatment that bacteria can never become resistant to.
Another way to fight fire is with a fire extinguisher. That’s how I think of topical steroids and other anti-inflammatory medications. We must learn to use them cautiously but effectively, in pulses, like fire extinguishers.
You also can fight fire by smothering it — my analogy for eczema skin occlusion with barrier ointments, clothing, or plastic wrap. Occlusion helps retain moisture, blocks entry of irritants, allergens and microbes, and promotes healing by creating a physical barrier against scratching.
In order to prevent the fire, or eczema flare-ups from appearing, many of the same strategies apply: you need to soak in water to hydrate, reduce microbes with bleach or soap-free cleansers, and protect the skin barrier with barrier creams, ointments, and other forms of occlusion.
For some patients who have eczema that really bounces back, using the fire-extinguisher approach — short, strong bursts of corticosteroid or regular pulsed use of medications — can be very helpful. A schedule can be worked out with your physician, and just how many medications are included in the regimen depends on the patient.
There are many products designed to maintain skin moisture and it can be overwhelming to choose. Every now and then, I cruise through the pharmacy aisles, just to see the options for patients. The truly hypoallergenic products are not always organized together.
To help make the process a little less daunting, I recommend a few products that can help. (And, I’d also like to disclose that I’m not being paid to talk about any of the specific products I mention here.)
My favorite thing to talk about is actually vegetable shortening because most people don’t think about using it to help their skin and it’s really inexpensive. If you think about what all these barrier compensation creams or ointments do, it’s to help seal the water into your skin once it’s already wet from the bath or the shower. Vegetable shortening does the same thing. If you have a lot of food allergies, however, make sure you’re not allergic to the vegetable ingredients that the oil is derived from, because we can’t speak to how well it’s purified.
Dermatologists also recommend petroleum jelly a lot because it is generally well tolerated, even for patients who are truly sensitive and for whom many products sting. Of course, petroleum jelly can be tricky in that it’s heavy, sticky, and can get onto furniture and clothing. So while smearing petroleum jelly all over the body can be particularly messy, I encourage applying it on what I call your “hot spots,” places on the body where the fire tends to recur, because those patches of skin are going to be the most sensitive to chemical irritants and other ingredients.
Because ointments like petroleum jelly, Hydrolatum, and Aquaphor don’t contain the type of ingredients that are added to cream and lotion moisturizers to keep them emulsified and creamy, they can often be tolerated by a lot of people. But again, everyone’s an individual. I’ve had patients or parents tell me that Hydrolatum stings. And since Aquaphor contains a lanolin derivative, people theoretically could become allergic to it. It’s a good idea to work with your physician to figure out what’s best for you.
For those who are worried about impurities in petroleum (though Vaseline Petroleum Jelly is highly purified, and we don’t know of problems with impurities in it), or the environmental impact of using petroleum products, there are products like Un-Petroleum Multi-Purpose Jelly. California Baby products are popular, as are a few other products that bill themselves as being “organic” and “all natural.”
However, for severely atopic and allergic patients, make sure that there are no allergies or sensitivities to the plant derivatives that are in some of these natural or organic products. Also keep in mind that such patients are at increased risk of developing new plant allergies from these products. Remember, poison ivy is “all natural,” too. These “all natural” products can also be more expensive, at an approximate cost of $7 per ounce as compared to a petroleum product at about 35 cents per ounce.
More expensive creams aren’t necessarily better. I say, save the money for college or a vacation!
Parents have seen that when it comes to babies’ skin, the diaper area tends to be the smoothest and most hydrated. When it comes to babies with atopic dermatitis, more often than not, we often see that their skin can be the best in the diaper area. If we could diaper the whole body, then kids suffering with atopic dermatitis would do really well. But since we can’t diaper the whole body, what we need to do is come up with other ways to compensate by providing a physical barrier for that inherently impaired atopic dermatitis skin.
Everybody has to try different things and decide what works for them, but I like plastic wrap for focal rashes. I don’t suggest securing the wrap onto the skin with tape because a lot of kids can develop allergies to the adhesive in tape itself. In order to conceal the plastic wrap and make the look more fun for kids, covering the wrap with colorful duct tape sold at hardware stores (though not in a way that the tape could stick on the skin) helps disguise the weird-looking wrap, possibly creating something kids might be willing to wear to school.
When we prescribe wet-wrap therapy, that doesn’t necessarily mean using gauze wraps on the skin; you can use clothing to help seal in moisture. Soft, smooth cotton clothing with reduced seams can be great to cover the child for bedtime. For another alternative, long sleeve cotton thermal underwear can be flipped inside-out so the seams don’t touch the skin.
Sometimes you perform the whole wet wrap or wet pajama routine and you’re okay for a while. If you wake up itchy in the middle of the night because the wet wrap cloth has dried out, you may need to start over, wetting the skin again and applying more barrier cream or ointment. Reassess what you are covering the wet wrap/ clothes with. It can be challenging if sweating occurs, so trial and error is needed to find what works for you during different seasons.
If you have hand or wrist dermatitis, wearing fingerless gloves can help protect the skin while still allowing for finger dexterity, e.g., for holding pens and pencils.
We love to recommend bleach baths but know these don’t work for everyone. Bleach baths can be painful because they’re often called for at the time when the skin is flaring and has a lot of open wounds.
One tip I like to suggest is to get into the bath with dressings still on. This will allow the skin to re-equilibrate and help alleviate some of that initial discomfort of getting into the bath, before you start pulling the wraps off.
Another way to help tolerate getting into bleach baths is to put a little antibacterial ointment or petroleum jelly in the cracks of the skin.
For children, you can distract the child with toys or an activity during the first couple of minutes of a bleach bath, so they’re focused on something other than the changing skin sensation that takes place in the first few minutes after getting in the tub.
I encourage older kids and adults to use the evening bath time as their “spa treatment.” It’s a time to say, “This is how I’m taking care of myself. I’m really going to relax, decompress, and get ready for bed.” Bedtime is usually the most itchy time for people.
Just as you all should have a plan for when you see a fire starting in your home, you and your whole family should have a plan for when you see that you’re having a more significant degree of itching or repeated itching in a particular place. You want to stop the sparks before the fire starts. And we all know that the command, “stop scratching” doesn’t work, right? If anything, it might actually make your child more anxious, which can lead to anxiety and more scratching.
I came up with something called the “Instant Itch Intervention Plan” to help find an active, behavioral replacement for scratching constantly itchy skin:
This can vary per person, but your skin action might mean applying a moisturizer and paying attention to how that helps. Or try wetting your skin before applying a moisturizer. Some may want to use a cold compress, or take a shower in order to rinse off sweat, irritants, and allergens, and to rehydrate dry skin. Others might want to adjust the bath routine so as to take a couple of really short baths or showers on that day, if needed.
We know from studies that applying a moisturizer or wrap is not as effective in long-term control of itch as using a corticosteroid. You still can get a lot of comfort from moisturizing and wrapping the skin because you’re doing barrier compensation — even if it’s just for 30 minutes, just to get over the itch episode.
If putting on moisturizer or adding a wrap isn’t quite enough, then you might want to use a steroid before you see the rash (and you know that if you keep scratching, that rash is bound to appear). I like to use the steroid on a hot spot just before it really flares up. You and your health provider can talk about where or when you can also use a corticosteroid for maintenance control.
As soon as you’ve treated the skin the way that is right for you, know that the itch isn’t going to settle down instantaneously. Treatment needs a few minutes to work. While your skin action(s) take effect, do something fun to distract the mind from the itch. (This is one of the few times I would advocate playing video games.)
Try a relaxing activity before bed, like reading a book or telling a story, doing meditation, or listening to music. The idea is to find as many healthy ways as possible to forget about scratching. Laughing and doing fun or relaxing things increases dopamine, serotonin, and endorphins. All these brain chemicals can make you feel better and reduce itch.
Sometimes you might be able to notice that you’re itchy, accept that you’re an itchy person, and just let it be. If you’ve taken action to help provide relief, believing in it and giving it time to work can sometimes quell the compulsion to scratch. There is no “one answer.” You’ve got to find what works for you.
Margaret Lee, M.D., Ph.D., is an instructor in Dermatology at Harvard Medical School and pediatric dermatologist at Boston Children’s Hospital.