Dermatology Physicians Residents - Perspectives on Eczema
We first learned about atopic dermatitis while studying medicine at Harvard Medical School. It was introduced to us during dermatology lectures where photos of mostly young children where shown with uncomfortable and itchy appearing rashes. At that time, this was another disease that we had to learn and memorize the symptoms and the diagnostic criteria for our exams.
This all changed a few years ago after we started residency and rotated through pediatric dermatology at Children’s Hospital Boston when we actually got to see and interact with the patients and family members of those suffering from this chronic disease. The stories that follow are our own personal experiences with patients with eczema.
On the first week of my pediatric dermatology rotation, I walked into a room where a new patient was waiting for me in the arms of her mother. The baby was a nine-month old healthy girl with no major medical problems except eczema. As I introduced myself and started learning the history about the little baby girl, I could not help but notice that she was very uncomfortable. She was restless and kept turning her body trying to scratch her skin against the exam table. She was pinching her skin with her hands to relieve the itch and crying from the inability to do so.
At first, I thought that this would be an easy case for me, as I know the diagnosis based on the distribution and clinical appearance of the rash. Also, I thought I knew how to treat eczema. But as I started taking history I soon realized that this baby had already tried every single agent that I was thinking of recommending. Her mother reported that she was using mild soaps and moisturizer. Her mother had tried many different topical steroids with no success. She was on antihistamines already but still very itchy. They had even tried bleach baths which also did not help. I finished my exam and stepped out to present the case to our supervising dermatologist. When it came time to propose the treatment plan I said: “Dr. M, this family has tried every treatment modality that I had in mind, but nothing has worked. I’m not sure how we are going to help this family?”
“Don’t worry Lilit,” Dr. M replied. “I am sure we can find a way to help this child. Let’s go find out more about how they used each treatment and for how long?” Our attending dermatology physician made it clear to me that when it comes to treating chronic diseases such as eczema or atopic dermatitis, patient education is the key to success.
We went back to the room and found out that the baby girl uses moisturizers only once daily or every other day because it has not helped her rash. Her mother has only used topical steroids for 2 days at a time, as she was worried about side effects. The bleach baths were also only used few times and then stopped. The patient was only taking Benadryl syrup for itch, which was not doing anything for the rash at all. I could feel the frustration from the family as they were talking about this. They wanted to know why their child had this disease and how to get rid of it. When Dr. M questioned them further about eczema, it turned out that they had not understood the chronic nature of the disease and the multiple causes that result in eczema. This is when I realized that my attending was correct.
This little girl and her family had tried multiple treatments, had seen many other doctors and had been dealing with this disease for months, but no one had sat down to talk to the family about the course of the disease and linked education of the disease to the importance of treatment therapies. This led to inconsistent treatment of the eczema.
We spent 45 minutes in the room talking about eczema with the family. We explained to them that eczema is a common disease that affects about 10-20% of children. It is a chronic disease and thus far there is no cure for eczema. The treatment options available control the symptoms of eczema, and patients with eczema have to practice good skin care throughout their lifetime.
The family was very grateful for the in-depth discussion of the disease and treatment modalities. There was still some skepticism in their eyes but given the amount of time and education, they were willing to give our recommendations a try. Hand written detailed instructions were given to the mother in case she had any questions.
Two weeks later, when I saw this baby girl in follow up visit, she was a different person. She was no longer itchy, and her rash had improved by 90% and she appeared much more comfortable and happy. Her skin was also very well moisturized, soft and smooth. It was very satisfying to see that all the effort put in to educating the family about the disease pathogenesis and teaching them to treat all aspects of the disease process together at once had led to significant symptomatic relief for the patient and for the family. Educating this family is what made our recommended treatment a success. It is important for healthcare providers to educate patients about how to tailor therapy to target all components that drive the eczema disease process.
The science behind eczema and rationale for targeting the four triggers of eczema:
The four major triggers which cause and propagate eczema are itching, dryness, inflammation and infection. Furthermore, at the molecular level, there is a protein within our skin called filaggrin that plays an important function in forming a strong barrier between our body and the environment. Most kids with eczema have low levels of this protein in their skin. Without normal levels of this protein the barrier function of the skin is compromised thus this skin is unable to retain water and hydration, so it becomes dry and itchy. Without the strong barrier the skin is also unable to keep irritants and bacteria away from penetrating our skin and causing more irritation and infection. Any treatment of eczema has to address all four skin problems at once: dryness, itchiness, inflammation and infection. It is important to treat them all together because each untreated individual problem can restart the disease process and lead to treatment failure if not addressed.
In our next post we will discuss why patient education is the key to successful treatment.