Today the eczema community is one step closer to having a new treatment option. The U.S. Food and Drug Administration (FDA) has approved Opzelura (ruxolitinib) cream, from manufacturer Incyte, for the short-term and non-continuous chronic…
Published On: May 18, 2018
Last Updated On: Jul 13, 2021
Ah, the joys of pregnancy! While some women sail right through it, others endure morning sickness, varicose veins and hemorrhoids, to name just a few common afflictions of that blessed state. And a history of eczema may add one more source of distress into the mix.
The worsening of eczema symptoms during pregnancy has to do with the influence of female sex hormones—specifically estrogen—on a woman’s immune system, said Dr. Jenny Murase, a dermatologist on the faculty of the University of California-San Francisco.
“During pregnancy, a shift takes place in a woman’s body from Th1-dominant to Th2-dominant immunity,” Murase explained. “Th1 cells specialize in defending our bodies against foreign invaders such as bacteria, viruses and anything recognized as ‘non-self’ that try to penetrate our cells. Half of the fetus’s genetic material comes from the mother and half from the father. So the Th1-dominant response, left to its own devices, will mount an attack against the half that’s from the father and cause the fetus to abort.
“To protect the growing fetus,” Murase continued, “a pregnant woman’s body temporarily shifts to Th2-dominant immunity. Th2 cells are all about fighting off allergens and toxins that circulate outside our cells.”
The upshot is that Th2-dominant immunity keeps the fetus safe but makes the mother more sensitive to allergens—in other words, to triggers that aggravate asthma, food allergies and eczema.
In her research, Murase has found that the high levels of estrogen seen in pregnancy are responsible for the shift from Th1- to Th2-dominant immunity. Estrogen, then, is at least partly to blame when the happiest of events turns a woman’s skin inflamed and itchy and her nights sleepless and miserable.
Pregnancy affects eczema differently in women
Carol Kim, a 28-year-old Asian American from Puyallup, Washington, has had eczema all her life. As a child, she’d scratch in the creases inside her elbows and behind her knees. “Usually, a small application of steroid cream would keep it under control,” she said. “In fact, my eczema was only a minor problem until I got pregnant with my first child about two years ago.”
Kim was “ecstatic” about the pregnancy. But soon, her eczema reared its ugly head, and it erupted full force after her son was born. “A couple of months into breastfeeding, I woke up covered with eczema from top to bottom. The skin all over my face and body was flaking, oozing, itchy and painful. I had cuts at each corner of my mouth and on my earlobes and eyes. My eyes were so swollen that they wouldn’t close.
“At its worst,” she added, “I couldn’t sleep, get out of bed, go out in public and, worst of all, I couldn’t be the mother I wanted to be with my newborn baby.”
Kim made several visits to an urgent care facility, where she received corticosteroid shots. These provided relief, but when their effects wore off, her eczema returned with a vengeance. Soon after a new treatment was approved, she went on the new biologic and experienced “five glorious months of normal skin.” But Kim couldn’t tolerate the side effects she experienced, so she had to stop taking it.
Thankfully, her eczema isn’t as severe now as it was right after giving birth. She still struggles with her “full face of eczema” and outbreaks here and there on her body. Topical steroids help her stay afloat while she considers other options, such as immunosuppressants. And she hasn’t given up hope that one day, she’ll find her way back to something resembling normal skin.
Meg Waterston* hasn’t given up either. The 24-year-old from London gave birth to a baby boy a little more than a year ago. But unlike Kim, whose skin erupted after childbirth, eczema hit hard during Waterston’s pregnancy. “Sometimes, my skin itched so bad that I’d scratch until I bled. I also developed a staph infection and a bad case of hives. At a certain point, I decided to go on oral steroids,” she said.
That’s when anxiety started to take over. Waterston was told by her doctors that her son might be born addicted to steroids, in which case he’d need steroid injections right after birth and for some time thereafter. Torn between her urgent need for relief and her baby’s risk for addiction, she took the steroids and hoped for the best.
To Waterston’s relief, her newborn son didn’t need injections after all. And his skin is “perfect,” she said. “As for my own skin, I’m under the care of a really good dermatologist now. I’m taking oral steroids once a week or once every two weeks, and that seems to be keeping my eczema under control**.”
*Not her real name.
** Note: Routine use of oral or injectable steroids is generally discouraged and should be reserved for special circumstances.
Dr. Peter Lio, a member of the faculty of Northwestern University’s Feinberg School of Medicine, who has a clinical practice in Chicago, estimates that about 50 percent of pregnant women with a history of eczema experience worsening symptoms during pregnancy.
He often prescribes phototherapy for his pregnant patients with eczema, insisting that they also take folic acid, an important nutrient that can easily become depleted by light treatment.
According to Murase, topical steroids are safe to use during pregnancy, especially at low-to-medium potency levels. “There’s a slightly higher incidence of low birth weight with steroid use, but only if a woman were to apply more than 300 grams of it over the course of her entire pregnancy,” she said. “That’s more than most patients would ever need.”
To stay on the safe side, Murase suggests diluting a topical steroid with moisturizer to achieve a ratio of four parts moisturizer to one part steroid. “I advise my patients to avoid using it on areas that will expand during pregnancy, such as the belly and breast. That’s because topical steroids can worsen the appearance of stretch marks.”
Both Lio and Murase stressed the importance of keeping eczema under control during pregnancy. A sleep-deprived mother offers a less-than-favorable environment for her unborn child, and the negative effects of maternal stress on the developing fetus have been well documented, Murase said.
Having a healthy pregnancy is within reach, even when eczema is on the warpath. During pregnancy and after childbirth, a woman needs to be well-nourished, well-rested and as free from stress as possible. Excellent self-care, the doctors agreed, is the greatest gift a woman can give herself and her newborn.
As if eczema weren’t enough of a burden, the widespread idea that it’s a “silly” disease bothers Allison Cast almost as much as the condition itself does.
A 59-year-old from Houston, Texas, Cast had eczema as a teenager, but it went away—until two years ago, when it came back full-tilt.
During adolescence, she had painful outbreaks of eczema between her fingers and in the crooks of her elbows. Now, it attacks different places—mainly, her palms and forearms. “I’ve tried many things, but it never seems to heal,” Cast said.
Cast has two grown children and two grandsons. She also works full-time. “Being covered with welts and bruises is embarrassing, especially at work,” she said. She’s also self-conscious about the blood blisters that form under her skin when she scratches, aware that her skin has become more fragile since menopause.
Having treated hundreds of older patients, Murase noted that the immune system tends to deteriorate with age. As in pregnancy, a shift takes place in the older body from Th1 to Th2 immunity, making older adults—both men and women—more vulnerable to eczema flares, even after many years without symptoms.
“Know your triggers,” Murase advised, “including surfactants, emulsifiers, preservatives and perfumes. And go beyond a regular allergy test to a comprehensive patch test, which covers a broader range of potential allergens than prick testing.
“Some of my older patients turn out to have contact dermatitis, a condition that can mimic atopic dermatitis but is far easier to treat. In any case, avoiding triggers is the first line in eczema treatment as well.”
Fluctuating hormone levels during and even after menopause may be partly responsible for the re-emergence of eczema, but, said Murase, more research is needed to confirm or rule out estrogen as a major driver of eczema flares later in life.
Because eczema is never “silly” at any age.