Eczema Questions & Answers

We have been given special permission by the publishers to reproduce questions and answers from the excellent

'Eczema and Your Child - A Parent's Guide' see below

'Food Allergies - enjoying life with a severe food allergy' see below

National Eczema Society - - Frequently Asked Questions and Answers

Eczema and Your Child - A Parent's Guide. Dr Tim Mitchell, Dr David Paige, Karen Spowart. Listed below are some questions and answers from this book

What Happens In The Skin Of People With Eczema?

To explain what happens you need to understand the structure of the skin as seen down a microscope. The skin consists of three layers.

The outer layer is called the epidermis. This contains a 'brick wall' of skin cells (keratinocytes) that are held together by a 'cement' mostly made up of fats or lipids. The skin cells constantly reproduce to replace the daily shedding of dead cells from the surface. The lipid cement acts as a barrier against the environment. It prevents the skin losing too much water and prevents noxious (poisonous) substances getting in.

The middle layer of skin is called the dermis. This consists of tough structural fibres called collagen and elastin, which provide strength and elasticity to the skin. It also contains blood vessels that supply nutrients and oxygen to both the dermis and the epidermis.

The deepest layer of skin is called the subcutaneous layer and is made up predominantly of an insulating layer of fat.

In eczema it is the dermis and epidermis that are affected The epidermis shows the most marked changes. The inflammation leads to leaky blood vessels and fluid collects between the keratinocytes, causing them to separate The brick wall takes on a sponge-like appearance. The constant rubbing/scratching with eczema causes the epidermis to regenerate more quickly, and so it becomes thickened Finally, eczema causes changes in the upper part of the dermis. This region becomes flooded with white blood cells, which are part of the body's immune system or defences. They leak out of the vessels and even pass up into the epidermis. Current evidence suggests that it is these cells that drive the whole process of inflammation in the skin.

Why Does My Son's Skin Weep Fluid and Feel Wet?

If you think of the epidermis changing to look like a sponge you can imagine the fluid leaking out and causing blisters that break easily to give a wet weeping area.

Why Is The Skin With Eczema So Susceptible To Irritants?

As fluid accumulates in the epidermis, the 'bricks' separate and the 'cement' becomes disrupted. This makes the skin barrier less effective, allowing the irritants through to the more sensitive dermis. Some irritants such as soaps, work by dissolving the lipid 'cement', leading to further breakdown of the skin's barrier function.

What Do Steroids Do?

Steroids are essentially hormones and there are many different types with quite different actions. The human body makes it own steroids in the adrenal gland and these are vital for the body's normal function. Different types of synthetic steroids have been developed for use in medicine. There is a group called anabolic steroids, which some athletes take (illegally!) to help build up muscle mass, and these should not be confused with the steroids used in eczema. The other group is called catabolic steroids or glucocorticoids e.g. prednisolone); they are used as an oral medicine for a variety of different diseases because of their anti-inflammatory and immunosuppressive properties. This means that they act by damping down the activity of various immune cells that cause inflammation. Catabolic steroids have proved a very useful medicine, even lifesaving, in some medical conditions such as severe asthma or rheumatoid arthritis. The down side of this group of steroids is that if they are used at a high dose for a prolonged period they have many side-effects such as weight gain, bone thinning, decreased growth in children, high blood pressure and loss of muscle mass. Because of this, doctors try to use these at the lowest possible dose for short periods. This type of steroid is occasionally used in the treatment of a very severe flare-up of eczema. However, for the reasons already mentioned, they would normally be used for only a few weeks, starting at a high dose and then slowly decreasing. This method should prevent or minimise any serious side-effects. Fortunately, these anti-inflammatory steroids can also be made into creams for topical application - directly onto the skin. They act in a way like that of their oral counterpart, as they have been developed to try to produce the same anti-inflammatory properties without all the general ('systemic') side-effccts on the rest of the body, even after long-term use. This approach has been very successful and the topical steroids provide one of the main components in eczema treatment.

I'm confused because my neighbour says that steroids will harm my child but the doctor says that hydrocortisone is very safe to use, even on a baby. Why is there so much conflicting information about steroids and their safety?

This is an extremely common question and concern of parents. We are not entirely sure why so much misinformation has been generated about topical steroids but people do seem to have extremely strong views about their safety. The anxiety about the use of topical steroids has led to significant under-use of a very valuable form of therapy. This has caused much unnecessary suffering for children. If you talk to doctors who looked after children before the 1950s, when topical steroids were developed, you will realise what an enormous advance they have been in managing eczema. The following points may in part explain why some of the myths have developed. Originally some of the earliest topical steroids developed were very strong, Group 1, steroids (Table 3). These will readily cause skin thinning if used on any skin other than palms and soles. For this reason they are almost never used in eczema. Unfortunately, when this side-effect was first noticed, all topical steroids got a bad name because people then thought mistakenly (and some still do) that the side-effect occurred even with the very weak ones. Remember that topical steroids vary enormously in strength. Steroids taken by mouth have many side-effects. Many people assume that topical steroids have them as well. This isn't true. Topical steroids were developed specifically to try to prevent the problems of oral steroids. There are different types of steroids: they act differently and have different side-effects. It is easy, though, to assume that all steroids are the same and thus misunderstand the side-effect risks. For example, anabolic steroids can cause an increase in muscle size and liver damage, but this does not occur with the topical steroids used in eczema - which are from the glucocorticoid (catabolic) group. Many people have become disillusioned with conventional medicine. There has been a social trend to assume that Western medicines are dangerous and that herbal remedies or natural products are safe and preferable. The word 'steroid' has become almost synonymous with all that is had about conventional medical treatments. Steroids do not cure eczema, so it often recurs after using them. You may have expected a cure - partly because the media loves reporting on 'miracle cures' - and might be reluctant to use them again.

Does This Mean That Steroids Are Completely Safe?

We would not claim that any conventional therapy is 100% safe but then neither are less conventional treatments. Risks have to be assessed for any form of therapy. If topical steroids are used appropriately, they are an extremely valuable, safe and effective part of eczema therapy. Table 3 gives some of the different types and strengths. The following list should act as a guideline to the safe use of topical steroids. Use steroids only if the eczema is not controlled by moisturisers and bath oils, and use them for only as long as is needed. Use steroids only if the eczema is red, itchy and inflamed. Do not use in place of a moisturiser on dry skin. Steroids should not be used more than twice daily. Some of the newer steroids are designed for once-daily use. ln all children, always use weak Group 4 steroids on the face, where the skin is thinner. In older children, Group 3 or 4 steroids may be used on the body. Group 2b steroids may be used for flare-ups. In older children with very severe eczema Group 2 steroids are occasionally used on the body. They can thin the skin so they must be used for only a few days. Group I and 2 steroids are occasionally used for eczema on the palms and soles, where the skin is very thick. They should not be used on the back of the hands or the top of the feet.

Table 3 Topical steroids classified by strength

Group/Strength Chemical Name (Trade Name)
1/Very strong 0.05% clobetasol propionate (Dermovate)
0.3% diflucortolone valerate (Nerisone forte)
2a/Strong 0.1% betamethasone valerate (Betnovate)
0.025% fluocinolone acetonide (Synalar)
0.1% mometasone furoate (Elocon)*
0.05% fluticasone propionate (Cutivate)*
2b/Moderately Strong 0.025% betamethasone valerate (Betnovate RD)
0.00625% fluocinolone acetonide (1/4 Synalar)
3/Moderate 0.05% clobetasone butyrate (Eumovate)
0.05% aclometasone dipropionate (Modrasone)
4/Mild 0.5% hydrocortisone (generic)
1.0% hydrocortisone (generic)

*once-daily use only
('generic' means the chemical name or ordinary name of the steroid rather than the manufacturer's name of its own brand)

My son's skin is lighter in the areas where he has had eczema -is this because of the steroid?

No, it is more likely that the eczema itself has caused a change in pigmentation of the skin. It can either decrease, as in your son, or increase the pigmentation. This problem can occur in anybody with eczema but is much more common in racial groups with pre-existing pigmented skin, such as Asians or African/Caribbeans. This problem is not just confined to eczema. Any inflammatory skin condition (e.g. psoriasis or even acne) can cause pigment disturbance. If the eczema is controlled, and kept that way, the pigmentation will go back to normal, but this takes a number of months.

People tell me that steroids will thin my daughter's skin. What does that mean?

If very strong topical steroids are used on the skin for more than a few weeks, they can certainly thin the skin, sometimes called skin atrophy. Topical steroids may be classified into five groups depending on their strength (see Table 3). The strongest, Groups 1 and 2, are most likely to cause skin thinning. If this happens, the skin looks thin, prematurely aged and may wrinkle. These changes are often reversible in the early stages. With continued application of strong topical steroids, the blood vessels of the skin may become abnormally widened, or dilated, giving an appearance of stretch marks; this tends to be irreversible. Of course, stretch marks may appear for other reasons, such as the rapid growth of puberty or in pregnancy. The weaker topical steroids are used in the treatment of eczema, to avoid thinning especially on the face where it is more likely. If stronger steroids are used, it is normally only for a few days, such as during a flare-up of eczema. Your doctor should give you accurate instructions about which steroid to use where, and for how long. Provided these are adhered to, topical steroids can be used quite safely, and skin thinning is not a significant problem.

What should I do to prevent the steroid side-effects affecting my child?

The most important advice here is to stick to the instructions from your doctor about which steroid cream to use where and for how long. Steroids are the active treatment for your child's eczema and should only be needed in the short term. If they aren't working, you should consult your doctor again and your child may need a different or stronger treatment.

Can steroids be used on broken skin?

'Do not use on broken skin' is often written on the packaging of topical steroid creams. This is not very helpful and indeed is rather alarmist. It could be said that all children with eczema will have evidence of broken skin by the very nature of the condition. We suspect that pharmaceutical companies are being over-cautious but there is some evidence to suggest that, if very large areas of broken skin are treated, increased absorption of the steroid can occur. However, we feel that topical steroids can still be used safely, provided they are used sparingly on any patch of eczema even if it is infected -although in that case an antibiotic will be needed as well. Where the skin really is 'broken' (e.g. after a graze), steroids should not be used, because they can slow down healing.

The eczema around my daughter's eyes is very painful but I am worried about using a steroid in this area. What do you suggest?

If the eczema around her eyes has become painful, this suggests that it is quite severe, uncontrolled and may be infected with bacteria. Infection normally manifests as weeping or crusted skin. There is also a risk of eczema herpeticum, as it commonly affects this site. We would advise you to consult your doctor in this situation. If the eczema is infected, you will need treatment with an antibiotic - as either a cream or tablets, depending on the extent of the infection. Once the infection is being treated, you will also need to treat the eczema. Topical steroids are quite safe in this area provided your daughter keeps to the weaker ones (Group 4). They need to he applied carefully to prevent direct contact with the eyes. The Group 4 steroids will not cause any side-effects; after a few days the eczema should settle down and you may be able to withdraw the steroid. It is unfortunate that most steroids say 'Do not use on the face' on their packaging. This is unnecessarily alarmist. You should also use a moisturiser regularly around her eyes.

What Is Allergy?

An allergy is an inappropriate and harmful response of the body's defence mechanisms to substances that are normally harmless. Allergic reactions involve the immune system, which protects us from infections by viruses, bacteria and parasites. When a potentially harmful attacker, such as the measles virus or a staphylococcus bacterium, invades our body, the many different parts of the immune system work together, signalling to one another using chemical rnessengers, to surround and kill the attacker before serious damage is done. The first time the body encounters a new type of germ, it will be several days before the infection is overcome. However, the immune system retains a memory of the attacker, so that future infections are dealt with promptly and efficiently. This memory is in trio form of antibodies, which are small proteins that are tailor-made for each attacker. There are several different types of antibody, and the main ones involved in fighting infections are immunoglobulin A (IgA), immunoglobulin M (IgM) and immunoglobulin E (IgE). In people who develop allergies, the immune system works perfectly well against infectious organisms. In addition, though, it has a tendency to react to normally harmless substances as if they were attackers. When this happens, the immune system becomes sensitised to the substance - it mistakenly identifies the substance as a hostile factor and, by producing antibodies against it, programmes the body to react whenever it is encountered. Whenever the body encounters this substance again an allerqic reaction results. Substances that cause this reaction are known as allergens, which are almost always protein molecules. When the body encounters an allergen, even in tiny amounts, large quantities of allergy antibodies (immunoglobulin E. or IgE) are made, which react with the allergen to set off a series of events called the allergic reaction. This process involves many different parts of the immune system, co-ordinated by chemical messengers released by the white blood cells. Most of the damage to the body's tissues that occurs during an allergic reaction is a result of the release of the chemicals from a type of cell called the mast cell. Mast cells are one of the cells that make up the immune system and are found in many different tissues of the body. (They are particularly common in the airways of the lung, in the bowel wall, and in the eyes, nose and throat). These chemicals are stored inside the mast cell in tiny packages, or granules. When an allergen reacts with the IgE antibodies on the surface of the mast cell, these granules are released. The chemicals in them have a number of effects, including the enlargement of small blood vessels, increased leakiness of the blood vessel walls, the contraction of the muscle in the bowel wall and lung airways, and the increased secretion of mucus. These changes lead to the redness, tenderness and swelling commonly known as inflammation. This allergic inflammation has different effects in different parts of the body. In the lungs it causes coughing and wheezing - the symptoms of asthma. In the nose it causes runniness and blockage -the symptoms of rhinitis or hay-fever. In the bowel it causes colicky pain and diarrhoea, or, in the mouth, itching and tingling - the symptoms of food allergy. Sometimes the allergic reaction involves the skin, leading to itching and skin rashes.

Adverse Reactions To Food?

There are many different ways in which our bodies can react adversely to foodstuffs. Some of these are predictable and will occur in everybody to a greater or lesser extent. They include the effects of foodstuffs such as those containing caffeine or alcohol, and the results of eating food contaminated with micro-organisms such as salmonella, which causes food poisoning. All other adverse reactions to food are abnormal in that they do not occur in everyone, just in certain individuals. These reactions include food aversion, a psychological reaction that occurs only when the person knows that they have eaten a particular food, and food intolerance, when there is a genuine and repeatable reaction to a particular food. There are two main types of food intolerance. In metabolic defects individuals have abnormally low levels of the enzymes that digest certain foods, and so they are unable to tolerate those foods (e.g. lactose intolerance). The other main form of food intolernace is food allergy, which occurs when an individual's immune system has become sensitised to a particular allergen, which then subsequently causes allergic reactions - for example, hives (urticaria) or swelling of the face, lips and tongue (angio-oedema).

The Dietitian's Role?

If you wish to see a dietitian for dietary advice, you need a referral from either your GP or a hospital consultant. Any hospital consultant and many GPs can refer a patient to the dietitian but it is usually by a dermatologist, chest physician or allergy specialist because they are the specialists who see the people with allergies.

Even if you decide to see a dietitian privately, you still need a referral. This is to protect you from dietary advice that might adversely affect an ongoing medical condition or treatment. After your appointment it is usual for the dietitian to send a letter to the referring doctor to inform them of the nutritional advice you have been given. The doctor then files this information in your medical notes for future reference Unfortunately, some people choose to see a 'nutritionist', 'nutrititional therapist' or similar person who may have only very limited or no medical qualifications. In addition, they are not state registered and are therefore not bound by any national regulations. You do not need a doctor's referral to see them, and their treatment may be damaging if they do not know your full medical history. The other drawback is that follow-up care may not be given after you are placed on a restricted diet, which is dangerous.

Latin Names?

This can cause a problem when common ingredients are not recognised. An example of this is arachis oil', which is the International Nomenclature of Cosmetic Ingredients (INCI) name for peanut oil. The only answer is for you to have a list with the Latin names of the ingredients that you must avoid and refer to this whenever buying products.
Ingredient (INCI Name)
Avocado (Persea gratissima)
Bitter Almond (Prunus amara)
Brazil Nut (Bertholletia excelsa)
Coconut (Cocos nucifera)
Cod Liver Oil (Gadi iecur)
Egg (Ovum)
Hazel Nut (Corylus rostrata/americana/avellana)
Macadamia Nut (Macademia ternifolia)
Melo (Cucumis melo)
Milk (Lac)
Mixed Fish Oil (Piscum iecur)
Pea (Pisum sativum)
Peanut Oil (Arachis oil)
Sesame (Sesamum indicum)
Soya (Glycine soja)
Sweet Almond/Almond Oil (Prunus dulcis)
Walnut (Juglans regia/nigra)

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