Proteque Newsletter Special Edition
Parent Education for Children with Skin Problems – Eczema or Dermatitis
Questions & Answers by Dr. Carol S. Stern, Dermatologist
Carol S. Stern, M.D. is a Dermatologist in Seattle WA. She graduated from New York UNIV SCHOOL OF MEDICINE, NEW YORK NY. and did her residencies at NY UNIV MED CTR , DERMATOLOGY and KINGS COUNTY HOSP CTR, INTERNAL MEDICINE. Dr. Stern has dedicated her 30+ year career to helping families live a better quality life. She has offered to answer questions or comments from Protèque’s Newsletter readers – physicians, nurses, adults and children around the world. Submit them to email@example.com or call 800-953-9250. Website: www.proteque.com
1. What are some of the patient health problems that you have seen with long-term use of corticosteroid creams prescribed by physicians?
Dr. Stern: Problems I have encountered following physician decisions have been localized to the areas of use. The inappropriate choice of steroid strength for the body site or for the patient age (not duration of therapy alone) has been the main factor.
I have seen telangiectases (dilated capillaries) on the face; for example, a patient being treated for seborrheic dermatitis (a red, scaly condition) with a fluorinated steroid mistakes the continuing redness in the eyebrows and hairline to be uncontrolled rash. So, the patient uses the product more often as the redness progresses.
It doesn't take very long to trigger a flare of perioral (usually around the mouth) dermatitis, then get into the trap of continued steroid use to control the redness, acne like bumps and scaling. Weaning a patient off fluorinated steroids and talking them through the inevitable flare, which precedes improvement of perioral dermatitis, is never easy.
Striae (stretch marks) in the underarms, groin and various body folds (such as the abdominal Apron) secondary to potent steroid use are too common. I also have seen striae with older, less potent products on the arms and legs when used under occlusion with plastic wrap. Striae frequency can be limited if both the patient and physician are alert to early atrophic (thinning) and still reversible changes.
For both children and adults my training was to limit the potency and duration of topical steroids on the eyelids and to keep the product off the lid margins. When it was available I used Decadron ophthalmic ointment on adult eyelids.
I have, on rare occasion, seen striae and other side effects when all was done correctly and briefly. There are patients who are exquisitely sensitive to steroids, as there are those who have no problems with significant abuse.
In babies, I have seen nodules in the diaper area and on the extremities and facial acne-like pimples presumed secondary to too potent steroid use, as well as the more common issues of stretch marks and atrophy (thinning of the skin).
As with any topical, allergic contact dermatitis (inflammation of the skin) can develop -- usually to a preservative, but occasionally to the synthetic steroid itself.
2. For parents with children having allergies, eczema, diaper dermatitis or atopic dermatitis -- what do you recommend as safe effective approaches for management of the itching, irritation, redness, chapping?
Dr. Stern: Rashes in children might include atopic dermatitis, contact dermatitis -- allergic or irritant, or infectious, or a combination of any or all. So, I start with a history.
Let’s start with atopic dermatitis, an inherited skin hypersensitivity. I find that for most kids with atopic dermatitis there is a family history of hay fever or asthma or hives or of atopic dermatitis -- or if not fully developed atopic dermatitis, there is a history of skin sensitivity. I find that history taking helps the parent to see family patterns and, in the case of a parent with sensitive skin, be more understanding of their child's discomfort. I dread seeing any child punished for scratching.
I explain that people with atopic dermatitis are special; our skin is different from others in several ways.
a) We make less oil than others do; moreover, some body areas make less oil than others and oil production varies over a lifetime. Since we make less oil, we have to preserve what we produce because we need our oil to seal in body moisture. I disagree with some physicians who recommend 20+ min. baths twice daily followed by emollient (moisturizer) application. It may work, but I know very few with the time or inclination to do so. I carefully review those things that remove oil, such as cleansers and hot water and make an analogy to dishwashing -- you need soap and hot water to clean a dish that held pork chops, but a quick cool rinse is sufficient to remove dirt from a lettuce leaf. Atopics are like fragile lettuce, so decrease the time and temperature and frequency of bathing and limit soap to the areas of need. The bottom line is don't remove your skin oil faster than your body can replace it.
b) As a group we sweat less than others do, but where we sweat we get irritated. The sweat acts like a degreaser, then puts salt in the open wounds. So, it is necessary to rinse off sweat- quickly and coolly, and avoid clothing that traps sweat, such as pantyhose or polyester.
c) Our skin itches more easily than others do. We are the people who love to get our backs scratched and hate to wear wool (the fibers tickle our skin -- not true wool or lanolin allergy). A clothing label, a loose nylon thread or a wrinkle in our sock can annoy us. We are more sensitive.
3. How effective are the most common moisturizers or barrier creams to "protect the skin against irritants?" Are they all the same regardless of price?
I've found that the choice of moisturizers for atopics is a very personal one -- with great variation in what feels good. Moreover, the choice may vary with season, age and body site. For myself, I can't tolerate any product for general body use that feels like it is trapping sweat. For kids who want to apply their own medicine, fragrance free hypoallergenic moisturizing cream serves well. For general moisturizers, I don't think it's a matter of cost. For blisters and itching, compresses help too. Domeboro dries larger blisters. Normal saline works for smaller ones, half milk and half ice water soothes the genitals and face. Atopic dermatitis, on the other hand, may be more generalized or symmetric and may take on different, but recognized, patterns as the patient ages.
There exists immediate as well as delayed allergic contact dermatitis. Either allergic or irritant reactions may itch and/or burn. There may be spread beyond the original pattern of contact. Underlying skin reactivity may alter the symptoms and appearance and severity. Medication reactions, either allergic or irritant, can be added to the initial problem. Over time, skin response to scratching and rubbing may develop including eczematous patches (itchy, dry, red and scaly) and lichen simplex chronicus (thickened itchy scaly and red skin). Of course, secondary infection is also a possibility.
4. What do the dermatologists know about eczema or dermatitis that most pediatricians or GP/FPs do not know -- e.g. diagnosis, treatment, prevention, post treatment tips on approaches and risks?
Dr. Stern: Before I recommend treatment, I start with an evaluation of the diagnosis. Even though the same medications may be used, the education and program for prevention of future outbreaks will vary. Using terms such as eczema or dermatitis without modifiers such as atopic or allergic may only confuse treatment.
I don't think any practitioner, regardless of specialty, can adequately treat (and diagnose) eczematous dermatoses without taking time for history and educating the patient.
Down the line, patch testing may have a role. Some favorite patterns that suggest contact dermatitis are irregular linear, not following anatomic lines, as when being brushed by poison oak or ivy plants or splash patterns, such as those created by spilling Margaritas while drinking aboard ship in the sunshine.
5. What about Contact Dermatitis?
Dr. Stern: Contact dermatitis may be allergic or irritant. Typically, allergic contact dermatitis develops after a delay of 6-96 hours, lasts 2-3 weeks, itches and may cause blistering; irritant contact dermatitis develops rapidly, lasts up to a week, and usually burns. By definition, contact dermatitis of either type forms in the areas and patterns of contact.
6. What are some kernels of wisdom that you would like to share with other physicians and consumers about “skincare”?
· Healthcare practitioners should educate the patients (and parents) before giving them medications. In the case of steroids, talk about the right steroid for a body area or condition, the potential ill-effects, the correct method of application, the appropriate duration and the proper way to taper off treatment.
· On the issue of skin management for atopics, to improve all of the symptoms and side effects I have cited treat special skin specially -- follow the dry skin care rules and dress comfortably in smooth, loose, breathable clothing with the labels removed.
· When there is itching keep cool mentally and physically. Apply a cool compress to an itchy trigger site. (Both scratching and rubbing set off changes that worsen eczematous patches and increase itching.)
· Obviously, some kids need a systemic antihistamine to break the itch-scratch cycle and/or to allow a good nights sleep. Age and site appropriate topical steroids, correctly applied, bring relief to all concerned and a measure of faith in trying suggested life-style changes.
· For atopics and others with hand dermatitis, use tools not hands. For practitioners, the most involved hand is usually the dominant hand for wet tasks.
· The best remedy for contact dermatitis is avoidance: don't pour kerosene on your hands and don't drink Margaritas on a rocking boat.
Editor’s comments: Protèque is a new non-steroid complementary approach to the treatment and management of eczema and dermatitis. Consult your physician for a proper diagnosis and appropriate use of Protèque. If your doctor is not familiar with Protèque, have your physician call for educational information and samples.– Patty Brachman, RN.
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