Medical Presentation: Treatment for Resistant Cases of Eczema
Dr. Jon Dyer
University of Missouri, Columbia Department of Dermatology
What is a difficult case of eczema? What makes a case of eczema difficult to treat? What kids fall into that category? It doesn’t have to be a child who’s got horrible skin everywhere all over the body. It can be a child whose eczema is fairly limited but just does not respond to any medication. I know all of us have patients that fall under that category or there are treatment restrictions. There are issues with certain medications that we are unable to use whether that’s because of allergy issues, financial issues or insurance issues.
Is it atopic dermatitis? What things mimic atopic dermatitis? What can look like it? There are several different both acquired and inherited disorders where skin rashes that look a lot like eczema are part of that. One of the things that we do as dermatologists is we think about those things and in some cases we may even test for some of those things. For example, Netherton Syndrome which is this inherited disorder, patients usually have very brittle, short hair. Some of you may have been through this experience where a dermatologist may actually take clippings of the hair or even the eyebrows to look at under the microscope for changes that are seen in this particular syndrome. Ichthyosis vulgaris is something that I’ve seen quite a bit. Ichthyosis vulgaris is the most common form of ichthyosis, a scaly skin process and atopic dermatitis eczema can be very much a part of that. In fact now that they’ve discovered the gene that’s defective in that disorder, we found that it is also defective in patients with atopic dermatitis at least in the British studies that were done. There are some patients that I’ve seen that really their predominant problem is not inflammation in the skin but scaly skin and there are other disorders that we see as well. We’re always thinking that there could be an element of a contact allergy, something that’s getting on the skin that people are allergic to infestations or even skin infections.
What do I do to manage these patients? We see the patient, we take the history, we talk with the family and we decide no, this is eczema, we’re just dealing with really bad eczema. What do we do next? I go back over the basics because you’re dealing with this chronic disease process, this isn’t something that we cure. This is something that we deal with over years. People get into treatment regimens and they develop sort of a style for treating their eczema. Sometimes they pick up a few bad habits along the way or they forget some of the basics. What are they, the bad habits? The whole concept of the gentle skin care that we always talk about, this issue of bathing and hydrating. Daily bathing and how to do that with the warm water and the mild soaps and a short period of bathing, not these protracted baths that kids like so much, 30 minutes playing in a tubful of bubble bath. Immediate moisturization, the second they come out. That’s the other thing that’s always hard to do. You’ve spent all that time getting the kid in the tub, fighting to get them out and then to actually sit there and grease them up from head to toe is burdensome to say the least. And then the type of moisturizer that’s used is important.
What about soaps? What type is best? I get asked this question a lot. My mantra for caring for atopic dermatitis is the blander the better and that goes for any type of shampoo, any type of cleanser, any type of moisturizer. We like bland things, we like things that are fragrance-free. The pH is important. Here’s a list of the pHs of some common soaps that are out there. Skin is actually naturally a little bit acidic. That’s why there is a cream called Acid Mantle. The idea is to regenerate that sort of slightly acidic pH. Soaps are very alkaline by nature. That means that if you just leave those soaps on your skin they can be so irritating. There are actually only a few soaps on the market that approach a more neutral pH and that’s one of the reasons that dermatologists are always saying Dove or Cetaphil soap because those are ones that are a more neutral pH. I have a ton of patients come in to see me using Ivory. Why? It’s 99 point whatever, 97% pure but look at its pH. Its pH is 9.5. That’s a very alkaline soap and it can be very irritating to sensitive skin.
In terms of moisturizers, thicker is better and it’s often a battle with folks to get them to use those thicker, greasier ointments, but it’s a battle worth fighting. Now one of the problems at least here in Missouri that we deal with is sometimes in the summertime those greasy ointments like Vaseline or thick creams even like Eucerin can sometimes be too occlusive. If the child is active or likes to play outside a lot and you grease him up and then send him out into this 100-degree heat that we’ve been having lately, you can get a secondary flare dermatitis because it’s overly occlusive. I’ve had some patients report to me that water softeners have been helpful and certainly during the wintertime, humidified air seems to help.
I like bleach baths. Some folks add salt to the bath. Soaps for irritated skin areas can be incredibly helpful and one of the ones that you’ll see a lot is Burrow’s solution. Burrow’s solution can be very helpful for weeping areas
Even though we’ve got a child who’s got very recalcitrant eczema that’s been difficult to treat, we’ve taken care of the skin care issues and the moisturization issues but we’re still working from ways to topically treat them. Things that you can do at home that don’t require systemic medications because that’s always our goal, to use as little medication as necessary and so I find these soaks to be helpful even for children that are having pretty severe flares.
Sometimes you alter your therapy depending on the time of the year. Kids that come in in the middle of summer flared up very aggressively are often being triggered by the heat and the sweat and dirt and other allergens like that. I sometimes modify my treatment strategies to address that. I like for kids to be able to do whatever they want to do. If they want to be outside playing and they can handle that, I want them to do it, but if they’re getting hot, getting sweaty, getting dirty and that’s triggering their eczema to flare, then as soon as they’re done I have the parents bring them in, give them a quick rinse off and moisturize their skin, rinsing off the sweat, the dirt, the allergens that they picked up while outside and yet still working on keeping that barrier intact. I find that’s at least somewhat helpful. Winter, we all know about that. The air dries out because of the forced air heating that we all have and that’s where being much more aggressive about your skin moisturization and certainly here in Missouri going to very greasy ointment-based emollients can be very helpful.
The role of diet is controversial. I’m unclear about the role of diet and allergies in a lot of my patients. If a child has a clear food allergy you bet, avoid it. If they eat peanuts and they swell up or their skin flares and that’s something that happens every time they have peanuts then they should not have peanuts, that simple. But for a lot of my atopic patients, it’s a much blurrier picture than that and I certainly have had several children who’ve been on such restrictive diets because of the food allergies they’ve tested positive to that their growth curves have dropped off. And that always makes me very nervous because their skin was still bad, they just weren’t growing very well.
There’s this issue of probiotics in the literature, the studies that were done with lactobacillus, sort of the yogurt-type bacteria that seemed to indicate that that may help some patients with eczema. I think the jury’s still out on some of that but it’s an interesting idea.
What about other topical therapies that you can do? Wet wraps are one of the things that I’m sure a lot of you have experience with either personally or for a family member and it’s one of my particular favorite things to do. It’s a way that you can do either full skin or spot intensive therapy again without having to go on systemic medications and it works sort of on that tropical zone principle. For a lot of you, I’m sure you’ve noticed for at least those of you with children with atopic dermatitis, kids very rarely have a rash in their diaper area. We call that the tropical zone, it’s warm and it’s moist and the skin stays happy down there. We’re trying to generalize that to these other more inflamed areas. You’re trying to get sort of an intensive moisturization exposure for the skin. Most protocols involve hydrating the skin in the bath sometimes with mineral oil or baby oil, something like that added to the bath water. Remember, I tell everybody when you’re doing that, just watch out, that tub gets slippery and that’s a real concern. And then you come out of the bath, you pat dry, you put on your moisturizer or your medication and then you wrap the affected areas of the skin with wet bandages, bandages that have been soaked in warm water or moisturizer and then you overlay those with a dry one and then the individual goes to bed and sleeps in that. That is incredibly time consuming as I’m sure any of you that have done that know and so I try and modify that a little bit. I think that that’s helpful for spot therapy, but for some kids where either they’re not going to leave on the wet wraps, they pull them off, or where it’s going to be incredibly time consuming to do, sometimes what we’ll do is rather than doing the damp dressings, we do just a pair of wet PJs or wet sweats and then pull a dry layer of sweats over that and you can often achieve the same affect. In a way it’s a lot like the sauna suits that are out there which work on the same principle. You can modify this based on location.
If you’ve got chronic hand eczema, you can do what’s called moist vinyl glove occlusion where you soap the hands, you put on your medicine or your moisturizer, then a layer of wet cotton gloves and then a layer of vinyl gloves and go to bed in that. That is aggressive hydration for the skin. It drives the medicine in, it’s soothing, it hydrates and it can often flip around these very recalcitrant eczema lesions.
What do you have to watch for? The biggest thing is if kids are too small, you can over chill them. Obviously if you’ve got this very wet fabric that’s evaporating and this has certainly happened to at least one of my patients and one of the reasons we don’t do this in very young infants. And it dramatically increases the penetration of your topical medication so this is not something to be doing for months on end.
Topical corticosteroids are various ways to make those work better. Those are the mainstay of medical therapy for all eczema in my book and I still use them for most of my patients. The other topical immunomodulators, the Tacrolimus and Pimecrolimus are also still very widely used. There is this recent black box controversy but it really hasn’t changed a lot of the prescribing habits. The biggest problem I have is just getting the Tacrolimus for patients but otherwise those are still very helpful agents.
I’ve been asked already about ultraviolet light. This is something that at least for my pediatric patients I consider a second tier therapy but I do consider it a helpful therapy. There are various types of ultraviolet light and it’s important to understand the differences between what a patient may be exposed to. What we have in our office is something called narrow band ultraviolet B light. It’s the most restricted spectrum of ultraviolet light that you can give. It seems to be more effective and we hope safer than the older light boxes which delivered a much broader wavelength of ultraviolet light. Remember we worry about exposure to ultraviolet light. You hear dermatologists all the time saying stay out of the sun yet in our offices we have these sun boxes that we stick our patients in. It’s kind of hypocritical, right? But we hope that that focused application of light coming from these light boxes can be helpful in these inflammatory skin diseases. It certainly can help turn off eczema or other chronic skin diseases where if we’re having trouble getting them under control with other topical agents. The biggest hassle is getting the patient to the light because it’s harder to get the light to the patient. There are home boxes that are available. I think ultraviolet light is the reason a lot of kids better in the summertime. They’re outdoors more, they’re swimming and they’re getting a lot of sun and sun helps.
There are systemic medicines. Antihistamines are sort of anti-scratch medicines, they’re not really anti-itch medicines as much. They help itch a little but what they really do is sedate us or our children or both and eliminate the scratching a little bit. Antibiotics are a mainstay in my treatment book for difficult atopic dermatitis patients. Lately the biggest problem has been this community-acquired methacylin resistant staphylococcus bacteria. I’ve been seeing a lot of that in my practice and when I’ve had atopics that have flared up more often and that I can’t get under control, more often than not the thing that I find is that resistant bacteria. If I get that bacteria under control, their skin clears. There are other anti-inflammatory medicines. The issues of systemic corticosteroids is one of those very controversial areas. They work, there is no doubt that they work. But all they do is sort of temporarily fix things. You have to take them away. You don’t want to leave somebody on them for long periods of time and when you do, the eczema comes right back so one of the things I always stress to my patients is this is why I work so hard to try and manage things topically. Cyclosporine has been used now for quite a while and can be very effective for atopic dermatitis but it also has systemic side effects. It’s the medicine you get if you get a new kidney or organ transplant and it’s not something that we like to have patients on for a very long period of time. Now there’s a medicine that’s being used more frequently now called CellCept, that long name mycophenolate mofetil. That has worked well for patients with some more severe forms recalcitrant atopic dermatitis.
I’ve had patients that have done absolutely wonderfully on it. I’ve also had patients that it doesn’t seem to help. I don’t know what the difference is there but when it helps, for an immunosuppressive medication it seems to be very well tolerated and so it’s one that’s being used more often. Gamma interferon is not one that I personally have used just because we didn’t do it in my training, but some pediatric dermatologists believe that it’s helpful. The problem with that one is it’s a shot. There are other medications if you start reading about it that people have tried. In the United Kingdom azathioprine has been used. I don’t use that one for various reasons. There’s data on even using antifungal medications and then of course there’s the lesser explored but I think very intriguing issues of biofeedback behavior modification, the massage therapy and things like that that I think actually could have enormous benefits but are actually in some ways more difficult to research.
I actually found hospitalization to be very helpful at times. I’ve had children that for whatever reason we cannot get clear and we’ve battled with their eczema for months and months. We bring them into the hospital and after a couple of days, they look 90% better. I don’t know what that is, but I think that process allows everybody to take a break. Kids get break from parents, parents get break from kids, somebody else takes over the burden of all this care, oftentimes they’re getting I.V. medications rather than having to take it by mouth. All of those things I think play a role. I don’t do this as much now simply because of the resistant bacteria that are out there either in the hospitals or on my patients that they might bring into the hospital and I’ve been able to manage.