How is atopic eczema treated?

eczema5

Eczema – the painful cycle of inflammation

Eczema cannot be cured. It can be treated and managed; key to this is caring for skin and managing the cycle of inflammation. Ensure that you discuss treatment with a medical professional; it’s also a good idea to ask what they can prescribe (as this may be free or discounted) as this often includes soap replacements and moisturisers as well as treatment creams.

Moisturise

It’s important to keep skin supple and moisturised. It’s a good idea to bathe every day (as the water will help to hydrate skin) and avoid soaps and other products that will have a drying effect. I’ve heard some people find goats milk soap to be gentler than normal soap and some emollient lotions can be used as soap replacements (though you may find they do better in a shower than a bath as I’ve found they can be kind of gluggy in bath water).

It’s a good idea to moisturise every day even when eczema isn’t flared up. Be careful when selecting moisturisers as general ones often contain alcohol that can still have a drying effect. It’s a good idea to discuss options with your doctor or pharmacist, and to look for ones endorsed by an eczema association.

Also, try different ones. You might find that some work better for you than others or that you prefer the smell or texture of some over others. I have a sorbitol/glycerin cream from the doctor which is ‘fragrance free’ but which I personally think smells so bad, v.s. one from Curash which I don’t think smells at all.

First: Emollients

eczema4

Emollients are basically moisturisers that are essential for increasing skin hydration and mimicking the barrier effect of the surface lipids the skin is lacking.

These should be used at least once a day at a different time to when corticosteroids are applied (as they will dilute these and prevent them from being as effective). It’s most effective to apply emollients after a warm bath or shower while skin is still damp.

Types of Emollients

From most effective to least effective.

  • Ointment – This provides a ‘lock-in’ protective layer. It can leave a greasy film so is often preferred at night (over day).
  • Cream –  Thinner and easier to apply. It is less effective than ointment and will need to be applied more often.
  • Lotion – Has a runny consistency and is less effective again than cream.

Generally, the rougher and drier the skin is, the thicker the emollient that is required. So a lotion may be suitable when when skin is good but cream, and then ointment, as it gets worse.

Emollients are important as part of a daily routine and will help to soothe skin during a flare-up. They will not treat the inflammation and it is important that a treatment cream is also used.

Second: Corticosteroids

eczema1-topical-corticosteriod

Topical corticosteroids (like hydrocortisone) actually treat the inflammation and help to reduce itchiness. They help to reduce blood flow in the skin and suppress over-active infection-fighting white blood cells. They imitate the effects of cortisol hormones produced naturally in the adrenal glands.

Doctors may prescribe different strength corticosteroid creams for different parts of the body (i.e. a weaker one for the face, and a stronger one for feet or hands where skin is thicker).

Additional treatments

Depending on the severity of symptoms, doctors may also discuss additional treatment options such as wet wrap, or oral anti-histamines.

There is little research supporting the effectiveness of using oral antihistamines to treat eczema but they can provide relief; for instance, night time ones can temporarily ease inflammation and also cause drowsiness.  Not only is scratching bad for the skin but chronic sleeplessness (due to lying in bed scratching) can cause a raft of flow-on troubles, especially for young children, so a night anti-histamine is something to consider discussing with your doctor.

 

Key source: “Eczema: The Essential Guide” by Sharon Dempsey

What is eczema?

img_20170114_154411.jpg

Eczema – Coming from Greek phrase “to bubble” or “to boil over”.

Eczema, also called ‘atopic dermatitis’, is a chronic skin condition characterised by inflamed, dry, and itchy skin which can have periods of acute flare ups. It’s one of three diseases that form the Atopic Triad; eczema, asthma, and allergic rhinitis are linked diseases which some people are genetically predisposed to develop. Eczema is not an allergy, however, it’s common for children that develop eczema to also have food allergies.

NOTE: Eczema is not a contagious disease. It’s not something that can be caught from touching, playing with, or bathing with someone that has eczema.

eczema3

Eczema – Cause factors

Eczema can be maddening for those that suffer from it. Skin starts off becoming swollen, red, and bumpy. The skin becomes itchy, often intensely so, and sufferers can rub the skin raw simply because the pain is easier to tolerate than the itch. The skin can also feel hot and painful. Little water blisters can appear that will burst and weep easily if scratched. It’s important not to scratch as this will damage the skin further (easier said than done, especially for young kids!).

Skin will bleed easily because of the inflammation and scratching damages the skin cells resulting in additional blood and immune cells rushing to the area.

It’s also common for areas of skin where eczema frequently flares up to become rough, scaly, chapped, and cracked. This is because dead skin cells are shed and replaced at a faster rate than healthy skin; these dead cells often sit on the skin. These areas of skin also lose moisture more easily and as it escapes the skin dries out and cracks form.

It’s important to discuss treatment options with a medical professional; eczema requires on-going management and care for the skin.

eczema5

Eczema – painful inflammation cycle

Key source: “Eczema: The Essential Guide” by Sharon Dempsey

What is the Atopic Triad?

eczema2-atopic-triad

Atopic Triad

‘Atopic’ refers to diseases that are hereditary and therefore tend to run in families; they also often occur together. It’s common for someone to have eczema, a form of allergic rhinitis (like hayfever), and asthma (though they may have these at different times of their lives); someone that is ‘atopic’ (or a family that is ‘atopic’) are also more likely to have food allergies. It’s possible to have mild cases of these diseases (like eczema) and not be atopic; it requires a doctor’s diagnosis and the demonstration of allergic antibodies.

It’s worth researching ‘atopy’ when it’s diagnosed by a doctor because it helps to have an awareness that your toddler that has eczema has a higher chance of developing asthma later in childhood (see ‘The Atopic March’).  It also means that if one parent has hayfever and another has a mild food allergy, children have a greater chance of being ‘atopic’ although they may exhibit this differently than either of their parents.

If you have suspicions of a food allergy, allergic rhinitis encompasses more than just hay fever in response to pollen. In general terms it means that an allergen has caused the inside of the nose to swell and become inflamed. This can cause cold-like symptoms, such as sneezing, itchiness, and a blocked or runny nose. Ongoing inflammation in the sinuses can also result in ‘allergy shiners‘ (like a continually bruised look beneath the eyes even if sleep hasn’t been disrupted). The problem is that under 5’s do get a let of colds and it can be hard to distinguish between an actual cold and a warning sign that there is an underlying allergy. If there’s a family history of atopic illnesses or your child has been diagnosed with other atopic illnesses (like eczema) then it’s worth reading up on the most common food allergies and discussing these with your doctor. For most children, a food allergy will result in them creating IgE antibodies which can be screened for with skin or blood testing.

 

 

Key source: “Eczema: The Essential Guide” by Sharon Dempsey

The Complicated World of Food Allergies: Allergy (immediate) v.s. Allergy (delayed) v.s. Intolerance

checklist

Identifying why your baby or toddler is miserable, screaming, unable to sleep, refluxy, colicky, vomiting, prone to rashes etc. is often a daunting task that bears with it a heavy burden of responsibility. It can feel like a frustrating, maddening,  and isolating process. You are your child’s best advocate. You are the one spending the nights pacing them through the house so that you don’t feel so horrifyingly impotent and because it seems to marginally comfort them. You are the one weeping because they are clearly so unhappy. You are the one that sees them day in and day out (and often through the night). You are the one with a niggling fear that something is wrong, even if they are your first and only, because they are nothing like the healthy, happy, peacefully sleeping babies you see with other mothers.

There can be a number of medical reasons for the circumstances above and a food allergy or intolerance is one of those (it may also be coupled with another condition such as Gastric Reflux Disease [GERDS] and be a compounding factor for the other condition). Many allergens can pass across in breast milk and even minute traces can be enough to trigger a reaction. For some, the allergy or intolerance may not be apparent until they begin eating solids, or until they’re a toddler, or until they’re almost starting school. I still have vivid memories of sitting in the car as a three or four year old wishing desperately that I could trade bodies with someone to see if they also had a sore stomach all the time; it was so constant and such a naturalized part of my young world that I never told my parents. It wasn’t until a major vomiting incident at a birthday party, triggered by a small ice-cream, that an investigative process started that identified I was intolerant to dairy.

Terms like allergy and intolerance can be bandied around interchangeably in the media, and sometimes by medical professionals, but they have quite different meanings. There are also two different types of food allergies, immediate and delayed, with the former getting more press.

Food Allergy: Immediate: IgE mediated

A food allergy is an inappropriate immune response to a particular food protein. An immediate type allergy happens very quickly after the food is eaten (or sometimes after minute traces of the food touch the skin or membranes). Reactions are caused by a particular part of the immune system causing the body to release histamine and other chemicals, leading to hives, swelling, and, in rare cases, anaphylaxis (a severe, life-threatening reaction). A skin prick or blood-specific IgE testing can be useful for diagnosis.

Oral Allergy Syndrome

A sub-set of this is Oral Allergy Sydrome which usually develops later in childhood or in adulthood. It happens after a person develops an allergy to a pollen. As well as getting seasonal hay fever, their immune system starts identifying foods that contain proteins with a similar structure to the pollen. The immune system then mistakenly identifies this food as being pollen when it is consumed and causes a mild allergic reaction in the mouth (such as itching or swelling). This can happen even with food that has previously been regularly eaten without issue. So for example, an allergy to birch tree pollen can cause a reaction when eating apple, peach, plum, cherry, potato, carrot, hazelnut, pumpkin seed and aubergine. A ragweed pollen allergy can cause a reaction to melon and banana; mugwort pollen can cause a reaction to celery and tomato; grass-pollen can cause a reaction to tomato, melon, and peach.

The process of cooking often destroys the pollen-like protein so someone may react to raw apple but have no reaction, or milder symptoms, when eating apple pie.

Food Allergy: Delayed: non-IgE mediated

The reaction can occur hours (or sometimes days) after the food is eaten, making them very difficult to diagnose. The reaction is caused by a different part of the immune system to IgE mediated reactions; one of the biggest problems is diagnosis as allergy tests are unhelpful for delayed allergy. In truth, delayed allergy is a spectrum of disease, in terms of severity and where the problems show themselves such as in the gut or skin. The most common causes are cow’s milk and soya, and less so wheat and egg. Typical symptoms may include persistent non-responsive eczema, rash, refluc, colic, diarrhoea, poor weight gain, difficulty feeding, and, less commonly, constipation. Breathing symptoms are rarer and do not occur in isolation, i.e. they may have noisy breathing or a wheezy cough in conjunction with reflux.

Diagnosing often involves detailed daily diaries (covering everything from food, sleep, bowel motions, and mood), food inclusion-exclusion challenges, and working through skin prick and/or blood-specific IgE testing. This should be done under the qualified care of a dietician and peadiatrician. It can be a long, difficult journey but it is important to keep detailed, accurate notes and to persevere.

Food intolerance

“More common than a food allergy, food intolerance is a reaction to food that does not involve the immune system. Although symptoms can mimic an allergy, the causes are different and on-set of symptoms is often slower and longer lasting. Symptoms of food intolerance can include almost anything but most commonly fatigue and gastrointestinal symptoms, such as diarrhoea and vomiting, bloating (often as part of irritable bowel syndrome) are described.”

Atopic disease

You may hear doctors talk about a family as having a family history of being atopic. “This refers to a group of illnesses, including eczema, hay fever, food allergy, and asthma that are characterised by the presence of immunoglobulin E (IgE) antibodies.”

Atopic illness in a parent(s) makes it more likely that children will also present with these – although they may be to something different. For instance,  parents might have asthma, hayfever, and an oral food allergy but their children may have eczema and an allergies or intolerances to different foods than their parents.

Resources

It is important to seek professional medical advice if an allergy is suspected.

There is of course a wide range of information on the web (some more reliable than others). The source that I have drawn on for this post, often quoting directly, is my favourite of the six allergy books that I’ve read in the past two months and the most relevant to my family: The Allergy-Free Baby & Toddler Book by Charlotte Muquit & Dr Adam Fox. I also found it the most approachable in terms of language and found it comforting that it included anecdotes from a number of other families.

My other recommendation is that if you have access to a free public library system then make use of it. Just like finding the right pair of shoes, look at a range of books until you find the one most relatable to your circumstances. If you find one that you really like, and would want to re-read, then buy just that one book. I definitely found it helpful having an understanding of what tests and diagnostic process to expect and I actually took my copy of Charlotte Muquit’s book into some appointments with me.