A routine of having a good soak in the bath for 15 minutes (the best way of rehydrating the skin is to wet it) using a bath oil and washing with an emollient (avoiding soap as much as possible) then covering the skin with a moisturiser may keep mild eczema under good control.
Q. There seems to be a lot more interest in the role of skin bacteria these days - why is this, and what can be practically be done to help?
A. Bacterial infection of eczema is very common. In the most common form of eczema, atopic eczema, the bacterium Staphylococcus aureus, is almost always present. Scratching the skin leads to a breakdown of the normal barrier function of the skin and this makes skin infection more likely. The problem with infection with Staphylococcus aureus is that the bacterium produces specific chemicals, called superantigens, which non-specifically stimulate the immune system and this will lead to a worsening of the eczema. The major cause of a flare up of eczema is infection. This may not be very obvious: the skin may just look more red or it may become weepy. If the infection is not cleared, the eczema will not settle.
These days, there are a number of bath oils that contain antimicrobials that will help keep infection rates down. Avoid scratching as this damage to the skin precipitates the infection. If you do have a flare of eczema, think about infection and see you doctor for topical or oral antibiotics.
Q. What percentage of people with eczema are likely to respond to Evening Primrose Oil and related supplements? And how long do they need to be taken for to assess any benefits?
A. This is difficult to predict. People with very dry skin do better on Evening Primrose oil than those with fairly normal feeling skin. The oil works by boosting natural oil production in the skin and reducing the inflammation the skin can produce. It is important to take the correct dose - this is 320mg in a young child going up to 480mg in an adult. You need to be patient with it and I usually use it for at least 3 months before deciding that it has not worked.
Q. Are there any significant side effects associated with using 1% hydrocortisone cream in either children or adults?
A. No. The potential side effects of topical steroids are local, with skin thinning, and systemic with inhibition of normal steroid production in the body , stretch marks, increased susceptibility to infections and stunting of growth in children. These may be seen with strong steroid creams but not with hydrocortisone, which is the weakest steroid available. It can be used without problems on the face and over the entire body in infants. If very large quantities are used - more than 30 grams per week in a child under 1 year of age, there may be sufficient absorption to cause some problems. In practice this level is never used and it is thus safe in all ages. It is more important to use the hydrocortisone to control the eczema than to worry about hypothetical side effects.
Q. What's your opinion of treating mild eczema on an ad hoc basis ie dibbing and dabbing a bit of cream here and there for a day or two as required? Does it make more sense to either leave well alone or treat more aggressively for a long period?
A. Eczema in all age groups tends to have periods when it is quiet and times when it is active. Patients should always use emollients and moisturisers as a daily routine, which will help to keep the eczema quiet but should have a steroid cream ready to use if the eczema becomes active. Always use the steroid cream regularly if there is any evidence of eczema - itching, redness, scratch marks, thickening of the skin or scaling. Only stop when the skin is normal again. Remember that in some patients the eczema will cause darkening of the skin - the darkness does not mean active eczema and will take a long time to settle down.
Q. Just how likely is it that eczema in children is related to some sort of food sensitivity and what's the best way of investigating such a link?
A. The association of eczema with food allergy is grossly overstated. Always try treating eczema conventionally with emollients, moisturisers and topical steroids with antibiotics when needed. If the eczema fails to respond think about a possible food allergy but never start a diet of any form without referral to a dietitian. In children over 1 year of age the possibility of a food allergy is very low.
If you think your child has a food allergy, try putting them on a diet of boiled rice, boiled or fried lamb and pears. This will give them all the nutrients they need but these foods are very low in allergens. If the diet makes no difference after 1 week, diet is not important and put them on a normal diet.
Q. Do you use any complementary therapies - if so what is the evidence behind them, and if not, why not?
A. No, I personally do not use complimentary therapies. Chinese herbal medicines are probably the best investigated and the most successful of the alternative remedies. Chinese herbal medicines are, however, not regulated, we have no idea what is in them and just because they are herbal does not mean they are safe. Liver abnormalities have been identified in children using there medicines and it is recommended that children should have their liver functions monitored regularly while on them. A word of warning - a study where Chinese herbal creams were analysed showed that may of them contained very strong topical steroids, which could harm the skin of a child.
Other forms of treatment such as homeopathy have been tried and because the practitioner spends a lot of time with the patients and the family, this can help from at least a psychological viewpoint.
Q. How important are dust mite allergies and can practical measures to reduce dust mite numbers make a significant difference?
A. Dust mites live off dead human skin which accumulates in carpets, soft toys and bedding. There is a good correlation between house dust mite and severity of eczema. Removing carpets, use of plastic pillow case covers and mattress covers and frequent hovering with wet dusting does help.
Q. Can you explain the genetics behind most cases of childhood eczema and what fraction of children will eventually "grow out" of their problems?
A. The commonest childhood eczema is atopic eczema which is eczema associated with asthma and hayfever in the same individual or other family members. 70% of patients give a family history of atopic disease which is strongest in siblings. There is probably not a single gene that controls atopic eczema but multiple genes and environmental influences are very important in the expression of the disease.
50% of children will go into spontaneous remission by the age of 13 years. Up to 80% will clear by 20 years of age. The incidence of atopic eczema at 30 years of age is low, but we are seeing more patients who reactivate their eczema later in life - often related to work. Work in which the skin is abused ie nursing, hairdressing, car mechanics, bar staff - is more likely to cause a recurrence of atopic eczema.
Q. Are there any exciting new developments in the pipeline?
A. Topical steroids have been the mainstay of treatment of eczema for the last few decades. The realisation that infection plays such a key role in eczema has seen a shift in our treatment to address this with more widespread use of topical antibiotics and antibacterials. A new class of topical drugs, derived from ascomycin or macrolide antibiotics, have now been shown to be effective in the treatment of eczema and to have fewer potential side effects than topical steroids. These drugs are in clinical trials but should be in use in the next few years.
We are indebited to the National Eczema Society for their help in compiling this section.
