A proactive approach to eczema

MALAYSIA - Mommy, please help me stop the itch!" pleaded the four-year-old in between tears.

It was 3am when Rachel (not her real name) was awakened by her daughter's cries from the next bed. Struggling to keep her eyes open, she staggered out of bed to find the little girl scratching herself bloody in tears.

Her heart aching, she grabbed a tube of moisturiser nearby and gently applied it onto her daughter's skin to soothe it and reduce the chronic itchiness.

The weather was hot, but Rachel restrained herself from turning on the air-conditioner as it would dry the air and aggravate her daughter's skin condition.

Both mother and daughter woke up tired and poorly rested the following morning as a result of their interrupted sleep.

As she applied more moisturiser on her daughter after her shower, Rachel noted with relief that last night's scratches left minimal red and brown spots.

There was a time when the scratch marks were so bad, her little girl was ostracised by her friends. They were afraid to sit near her because she kept scratching herself.

Such is the life of a parent caring for children with atopic dermatitis, a condition more commonly known as eczema.

Anyone who has encountered eczema can tell you this: the impact of eczema is more than skin-deep.

As singer LeAnn Rimes aptly put it: "Eczema scarred my life, inside out. I wouldn't even wish it on my enemy."

Eczema explained

'Atopic' is a word suggesting hereditary elements to certain types of hypersensitivity, while 'dermatitis' simply means an inflammation of the skin.

It is the most common skin disease around the world, comprising 15-25 per cent of all skin problems.

In atopic dermatitis, the skin rashes can be caused by either external factors or internal triggers.

According to Hospital Kuala Lumpur Institute of Paediatrics dermatologist Dr Leong Kin Fon, it is important to first identify the kind of eczema the child has.

In children with endogenous (or genetic) eczema, the skin barrier is dysfunctional due to a defective gene that codes the skin proteins. These children need to focus more on skincare strategies, such as using specially-formulated cleansers and moisturisers.

For others, their eczema is related to an immune disorder, where a trigger sets off an alert in the brain and causes skin inflammation.

Common symptoms include dry and red skin, scaling, extreme itchiness and inflammation.

Scratching worsens the condition by aggravating the inflammation on the upper layer of the skin.

However, most patients find the itch to be intolerable, which results in a vicious cycle of itch-and-scratch, and ends up with bleeding and pain.

The problem usually begins before the age of five. According to University of Texas-Houston Medical School professor of dermatology and paediatrics Dr Adelaide Ann Hebert, this chronic skin condition usually starts with red, itchy patches on the face, but moves to the front of elbows and back of the knees as the child grows.

In 30 per cent of cases, the condition persists into adulthood.

Family history is believed to play a role, especially in families with asthma and hay fever. However, Prof Hebert points out that eczema has multi-factorial causes, including environment, weather conditions and living standards.

Developed countries with high standards of living are found to have a higher prevalence, for example, Japan, where up to 30 per cent of the paediatric population is believed to suffer from eczema.

This is attributed to the Hygiene Hypothesis, where researchers believe living environments that are too clean and sterile deprive the body of beneficial bacteria that are essential for daily living.

This results in the body creating a hypersensitive reaction to common everyday triggers, such as heat, sweat and dust.

Dr Leong thinks there may be truth to this hypothesis, as 2001 statistics show that 12.6 per cent of Malaysian primary school pupils have eczema, compared to 22 per cent of Singaporeans - our highly industrialised neighbour with more stringent hygiene practices.

With Malaysians and Singapo-reans sharing similar genetic heritages, the significantly higher levels of eczema down south are evidence that lineage is not a key factor in eczema prevalence.

Dr Leong also shares his experience in rural Sabah, where his young eczema patients only require simple treatments, compared to patients in the city who usually require stronger remedies.

He adds that eczema sometimes goes into remission as a child grows and his immune system matures. However, those with a family history of eczema are more likely to relapse in adulthood.

Staying moisturised

As eczema has no cure, the main goals of treatment are to relieve discomfort by reducing the itch and increasing the number of flare-free days for the patient.

Indeed, an Eczema Patient Impact Survey suggests that Rachel is just one of the 62 per cent of caregivers who are constantly worried about their child's next flare-up.

Both Dr Leong and Prof Hebert agree that a paradigm shift is needed in the treatment of eczema.

Traditionally, treatment has focused solely on treating flare-ups when they occur, with clinicians prescribing short-term doses of topical steroids and advising the use of moisturisers to keep the skin moist.

"When there is an eczema flare-up, we have to prescribe steroids to manage and calm the skin back into remission (when the red patches and sores subside), which is not advisable for long-term usage due to its accompanying side-effects," says Dr Leong.

He stresses the importance of acting proactively to ensure that the skin remains moisturised, even when the patient's eczema is under control.

As Prof Hebert explains: "A damaged eczematous skin is like having your skin covered in polka dot holes.

"Precious water from your skin is lost through these tiny polka dot holes, making your skin dry and itchy when pathogens (allergens) enter the skin via the broken skin barrier."

The application of emollients or moisturisers will seal these "polka dot holes", and provide a barrier to protect the child's skin from water loss and further damage, whilst keeping the skin supple.

"It is crucial that parents choose a moisturiser with the right formulation, and most importantly, is effective to help treat the child's condition, and prevent the skin from entering the infamous scratch-itch cycle," she states.

As an eczema patient herself, Prof Hebert uses Atopiclair, a non-steroidal moisturiser. She says: "Essentially, patients can expect a dramatic reduction in flare-ups, whilst reducing the need for topical steroids in 91 per cent of patients, according to a paediatric clinical study."

Numerous clinical trials comparing both the traditional reactive and proactive approaches have shown that the proactive approach is better in managing eczema. In one such study, patients were 7.7 times less likely to experience a flare-up with the proactive approach.

Education is key

Patients also need to be educated on eczema and its causative effects, so as to better manage their daily habits that may trigger or aggravate the condition.

"When we give this education, it empowers the parents to really take hold of the disease, and once they know what to do, they would know when to do it - this would be through night and day in their child's life," says Dr Leong.

Most parents who have children with eczema tend to be very conscious about food as they try to identify and eliminate foods that trigger an eczema attack.

In Prof Hebert's experience however, parents are frequently unable to correctly identify the trigger for their child's eczema, especially with the amount of processed foods we consume.

Also, removing food triggers is only effective in the early years for the 10 per cent of atopic eczema patients in whom food is a trigger.

This is because the body's immune system and skin remains dynamic throughout one's lifetime, hence, one builds up tolerance as they grow, says Dr Leong.

He stresses that there is no one-size-fits-all management method for eczema, as the patient's condition may change with age and their environment.

Physicians today use a combination of inside-out and outside-in therapies, where dietary control and effective moisturising are both used to achieve the best results in disease control.

Inside-out therapies refer to finding out the triggers that cause a flare-up and making dietary changes to reduce the incidence, while outside-in involves treating the condition from the outside (on the skin surface) using topical products and strategies.

For Rachel, her daughter's condition improved after she stopped using harsh soap in the shower, switching instead to gentle and specially formulated cleansers and moisturizers without fragrance, preservatives or strong sanitisers.

Prof Hebert shares that baths should be limited to about 10 minutes to prevent loss of lipids in the skin.

Emollient creams should also be applied immediately following a bath, to trap water in the skin, as bathing without moisturizing can be drying to the skin.

Working together

Ideally, parents, physicians and the child should sit down together to discuss the therapies they prefer, as it involves their daily regimen.

Prof Hebert says that parents should be given specific guidelines to help them while allowing them to explore what method suits them and their child best.

Patients and parents also need to know how to use topical corticosteroid creams and ointments carefully, as excessive and prolonged usage can result in thinning of the skin.

This includes using only a thin layer once a day, and no longer than two to four weeks of continuous application.

Patients also need to be careful to avoid using potent topical steroids on the face, as the skin there is thinner and more likely to absorb higher amounts of the cream.

Once the inflammation subsides, patients should switch strategies and embark on proactive management with moisturisers that have anti-inflammatory and anti-itch properties to further suppress the "invisible inflammation", which remains within the skin.

Prof Hebert stresses that parents or patients cannot expect to find an immediate solution by making a one-time trip to a clinic.

Patients often have to try several treatments to determine which one works.

Sometimes, they even have to rotate different regimens to prevent drug tolerance that may develop when using the same treatment over a prolonged period.

Both Prof Hebert and Dr Leong agree that a common problem is that most parents and patients get impatient when they do not see fast results on anti-inflammation drugs or antibiotics, so they take a shortcut by purchasing a steroid cream or an intramuscular injection at the pharmacy for immediate relief. Some even resort to alternative therapies such as homeopathy.

While they may gain immediate relief, Dr Leong warns that they will miss out on learning more about their disease progression, and how they can better manage their next flare-up, manage itchiness, taper down the inflammation, how to reduce colonisation of bacteria, and how to reduce the impact of different kinds of moisturising cleansers.