A Factual Picture of Eczema

Eczema is characterized by a rash, dryness of skin, itching, and redness of skin (Rouse). The symptoms of eczema occur due to the overproduction of damaging inflammatory skin cells and continue to worsen as a result of certain factors in the environment. The cause of eczema can be traced to environmental factors. Foods, shampoos, soaps, laundry detergents, synthetic fabrics, stress, and temperature changes are capable of irritating already existing eczema and may even be the cause of a new eczema condition. Although eczema is a chronic skin condition, there are various forms of treatment and interventions available to help control eczema. Eczema is a hereditary condition and thus is not contagious to others. A general picture of eczema can encompass different stages. Some people may have only a small patch of affected skin while others may have larger patches all over the body. An individual may experience one mild eczema outbreak while others experience chronic severe incidences of eczema. In some cases after an eczema outbreak the skin remains more reactive than it was prior to the outbreak. The eczema-affected skin is very sensitive and the individual must be aware of the trigger factors and try to avoid them.

The Eczema - Steroid Connection

For those people who suffer from eczema, the use of topical corticosteroids is high up on their list of concerns: How should they be used? And are they safe? New research to be launched today (Monday 26 September 2005) at the British Pharmaceutical Conference in Manchester shows that pharmacists can drastically reduce patients worries about using steroids by more than 50% when they intervene to address patients' needs and concerns.
The study, undertaken by Pharmacy Alliance, the Medicines Management Division of UniChem, investigated the contribution of community pharmacists in meeting the needs of patients with atomic eczema, in collaboration with GPs. In the UK, atopic eczema affects 15% of children(1,2) and up to 10% of adults(2). Treatment is often complex and confusing, and patients' concerns about using topical corticosteroids can often prevent them from treating their condition effectively.
In this new study 48 community pharmacies recruited 370 patients diagnosed with atopic eczema, and followed them up 8 weeks later. Patients' needs and concerns were assessed using a patient questionnaire. Patients were referred to their GP when their needs could not be met in the pharmacy.
The results showed that, following help and advice from a pharmacist, or pharmacy staff:
- Steroid concerns reduced from 68% to 30%
- Poor understanding of atopic eczema fell from 43% to 6%
- The need for lifestyle advice dropped from 51% to 20%
The research also found that:
Community pharmacists identified a total of 1,597 problems. Of these:
- 20% involved steroid concerns
- 15% required lifestyle advice
- 12% of patients had unmet treatment goals
- 11% of patients had poor understanding of atopic eczema
Pharmacist Caroline Tinkler who led the study said that said that it is extremely important for patients to be appropriately educated about eczema and its treatment. "If patients are empowered they are able to make informed decisions about their eczema condition and self-management," she says.
"This study proves that many of the problems or concerns patients experience with eczema or its management, particularly around the use of topical corticosteroids, can be suitably addressed by community pharmacists."
Notes to Editors
References
1. Graham-Brown R, Bourke J. Mosby's colour atlas and text of dermatology. Pub. Mosby, London 1998: 160-169.
2. McHenry P, Williams H, Bingham E. Fortnightly review Management of atopic eczema. BMJ 1995; 311: 843-847.
The British Pharmaceutical Conference is being held Monday 26 - Wednesday 28 September 2005 at the Manchester International Convention Centre. The conference theme is A common vision for health: Linking science with practice.

The Eczema Prevention Picture: Jewelry and Nickel

Contact allergic dermatitis to nickel may develop at any age. Once this nickel allergy has occurred, it persists for many years, often life-long. Nickel allergy is more common in women, probably because they are more likely to have pierced ears than men, although this is changing. The degree of allergy varies. Some people develop dermatitis (also called eczema) from even brief contact with nickel-containing items, while others break out only after many years of skin contact with nickel.
In jewelry necklaces, necklace-clips, earrings, bracelets, watch-straps and rings may contain nickel. "Hypoallergenic", solid gold (12 carat or more) and silver jewelry should be safe. Nine carat gold and white gold both contain nickel. Plastic covers for earring studs can be obtained. Coating the stud with nail varnish is not recommended.

The Eczema Prevention Picture: Footwear

The chief cause of eczema in footwear is the thermoplastic or rubber-boxed toes, and the cements and dichromates used in tanning. Dyes, anti-mildew agents, formaldehyde and nickel eyelets or nickel in arch supports also can cause dermatitis. A waterproofing silicone spray externally applied to the shoe can also be the cause. The dermatitis usually begins on the big toe and spreads to the rest of the foot. Socks washed in Bold or bleached with a strong whitener can also cause dermatitis.
Formaldehyde is used in the tanning of white leather shoes in "elk," "white kid" and "new bucks." Tannins obtained from trees are used to tan leather (vegetable tanning) and do not cause dermatitis. However, if the shoe is made of vegetable-tanned leather, the lining should not be chrome- tanned.
Sweat leaches out chromates from the leather, so controlling perspiration is essential. Zeasorb Powder (Stiefel) and Dr. Scholl's foot granules in soap are excellent for reducing some of this.

The Eczema Prevention Picture: Soaps And Detergents

Dishwashers, housewives, laundresses and surgeons, often show dehydration or shriveling of the keratin layers, which leads to irritation (primary irritant type dermatitis). Coconut-oil-containing soap is often the worst culprit. Neutral soaps, such as Cetaphil, Lowila, Basis, Oilatum, or Dove are much less drying. Many of the stronger antibacterial soaps, such as Dial, Zest, Lifebuoy, Safeguard, Coast and Palmolive Gold, are sensitizing as well as drying, and may be photosensitizing.
Contact with clothing washed in strong soaps or detergents (for instance sheets used by bed patients) can lead to dermatitis. This is especially true if bleach or whitener is used. The laundry detergents most likely to cause a reaction include Axion, Bold, Ajax Detergent, Cold Power, Salveo Tabs, Coldwater All, Amway, Arm & Hammer, Era and Dynamo.

The Eczema Prevention Picture: Rubber

Fully finished and polymerized plastics seldom cause an allergic contact dermatitis, whereas fully "cured" rubber articles do so quite frequently. Of the antioxidants used to prolong the life of the rubber, monobenzyl ether of hydroquinone (which can depigment skin) and phenyl-beta-naphthylamine are the most common sensitizers. The accelerators, mercaptobenzothiazole, tetramethyl thiuram monosulfide and diphenyguanidine, and the peptizer, thio-beta napthal, are the chemicals causing most of the dermatitides attributable to rubber. Two other accelerators, disulfuram (Antabuse) and thiuram, will produce itching, redness and hives in those exposed who ingest alcohol. Thiuram is also used as a lawn fungicide (Tersan). Occasionally bleach will activate a rubber accelerator, zinc dibenzyl dithiocarbamated (ZDC) to become highly allergenic.
Elastic in hair nets may cause dermatitis, and ribbons or wrap-around hair nets may have to be substituted. Where an eruption is due to a rubber condom, Fourex (Schmidt) fish-skins can be substituted.
Adhesive tape can cause a miliaria-like occlusion of poral openings, although true contact dermatitis spreads beyond the margin of the contact with the tape.
Latex cements are used in the shoe and textile trade. Vulcanizing solutions come in two solutions which, when mixed, seal punctures. It takes a few hours to cure, and sensitization can occur from the various chemicals. Non-vulcanizing rubber solutions are used in the shoe industry and automobile trimmings and can cause dermatitis.
Non-rubber Adhesives. These are chiefly synthetic resin adhesives which can sensitize, although fish glues generally do not. Glues made from cotton (e.g., cellulose acetate) are not sensitizers, and neither is collodion. Vegetable gums such as karaya, acacia and tagacanth are sensitizers.

The Eczema Prevention Picture: Cosmetics

Most commonly occurs from hair dyes, nail polishes, perfumes, lipsticks and sunscreen agents. The chief site of the eruption is the eyelids area, with ears and neck next.
Eye makeup, such as mascara, eye shadow and eye pencil, seldom causes dermatitis (although eyeliner often does) whereas nail polish, while seldom causing trouble around the fingernails, affects the eyelids first. Lower eyelid dermatitis is often form wetting solutions or eye drops. Various formaldehyde resins are used in nail lacquers and nail lacquers and nail hardeners, as are sulfonamide derivatives, both of which sensitize.
Lipsticks contain waxes and fats (occasionally cocoa butter sensitizes), perfumes (occasionally sensitize), and dyes (especially tetrabromofluorescein), which may occasionally dry the lips and produce photosensitivity. Special lipsticks are available which contain neither fluorescent dyes, nor perfumes, like, such as, Almay (Texas Pharmacal) or Ar-Ex.
Sunscreen preparations containing PABA (para-aminobenzoic acid), hydroquinone or digalloy trioleate can sensitize, and in some cases, photosensitize. Bleaching creams are sensitizers too, either mercury, or hydroquinone being the culprit.
Toothpaste and mouthwashes can cause dermatitis from oils, cinnamon or other flavoring, or antiseptics. This is called peri-oral dermatitis. Using a non-tartar, non-fluoride toothpaste can often help in these cases.
Hair dyes are mostly of the permanent or "oxidation" type, containing para-phenylene diamine (PPDA), soap, ammonia and other modifiers which penetrate and color the hair when mixed with 20 volumes of peroxide. This type of dye accepts shampoos and cold waves and sensitizes most commonly. The azo and aniline dyes produce a semi-permanent coloring which is tolerated well in most PPDA-sensitive patients, but lasts through only a few washings. Metallic hair dyes (Romans used a lead comb dipped in vinegar to darken gray hair) are also referred to as hair "restorers" and are mostly still based on lead and do not sensitize. Vegetable rinses are usually made form henna, which is non-sensitizing, although some pyrogallol combinations are sensitizing. Methylene PPDA can cross-react with PABA in sunscreens, local anesthetics and sulfonamides-thiazides (Diruil), tolbutamide (Orinase), chlorpropamide (Diabinase) and saccharin.
Permanent-wave solutions, usually thioglycolates, are alkaline reducing agents which make the hair malleable; the hair is "waved" on rollers and then "fixed" with an oxidizer (hydrogen peroxide, perborate, bromates of citric acid). Thioglycolates rarely sensitize, but do occasionally cause primary irritation if not carefully mopped up, and can split and break the hair.
The adhesive used to attach toupees and false eyelashes occasionally cause dermatitis. Bleaching or freckle creams usually contain mercury or quinones, and all can sensitize; Benzoquin (Elder) is a very potent sensitizer. Face powders and rouge rarely cause dermatitis. For toupees and ileostomy stoma irritated by other rubber cements, Duo brand surgical adhesive (Johnson & Johnson) is well tolerated by many.
People should be advised to apply perfume to their clothes if possible rather than to their skin and certainly should avoid using photosensitizing perfumes (one such example is Shalimar) on their skin in bright sun.

The Eczema Prevention Picture: Cotton Clothing

Wool and some synthetic fabrics can irritate your skin. Most people with sensitive skin feel better in clothes made of cotton or a cotton blend. In clothing metal zips, bra hooks, suspender clips, hair-pins, buttons, studs, spectacle frames etc. are likely to contain nickel which can irritate eczema. Use substitutes made of plastic, coated or painted metal or some other material.
Natural fiber clothing, made from wool, cotton, linen and mohair, have never in themselves been shown to be sensitizers. Sizing and stiffening cotton with starch or rosin may produce dermatitis. Dermatitis may occur more frequently from the use of dark clothing. Heavy perspiration, especially in oily-skinned individuals, causes more bleeding of the dye (e.g., widow's dermatitis).
Fabric finishes which are used to increase durability, to soften of stiffen a fabric, or to impart waterproofing, crease resistance or other properties to the fabric. The use of formaldehyde or its resins in clothing is widespread, but the incidence of resulting dermatitis is comparatively low. These are used to make fabrics crease resistant, water-repellent and shrink resistant. Dermatitis occurs mostly in obese women who demonstrate a dermatitis starting in the axilla and later affecting the sides of the neck, the antecubitals and the inguinals. In men, it is usually in the inner thighs, gluteal folds and back of the knees.
Stoddard solvent or other dry-cleaning solutions will occasionally produce a clothing-oriented dermatitis, as will moth crystals. Airing the clothes for a few days before wearing them will usually prevent this.
Management of clothing dermatitis involves the use of Decadron spray, which contains isopropyl myristate, a film or "spray-on-shield" which suppresses sweat and may protect the fabric and acts as a deodorant. Weight loss in obese women sometimes seems to help, as well as avoidance of panty girdles. Those who are sensitive to formaldehyde must avoid wash-and-dry or wash-and-wear and drip-dry clothing.

The Eczema Prevention Picture: Wear Gloves

One thing that can help in the eczema prevention picture is to wear vinyl or plastic gloves for work that requires you to have your hands in water. Also, wear gloves when your hands will be exposed to anything that can irritate your skin. Wear cotton gloves under plastic gloves to soak up sweat from your hands. Take occasional breaks and remove your gloves to prevent a buildup of sweat inside your gloves.
Wear gloves when you go outside during the winter. Cold air and low humidity can dry your skin, and dryness can make your eczema worse.

Things That Can Irritate Eczema

Some things that may irritate your skin include household cleansers, detergents, aftershave lotions, soap, gasoline, turpentine and other solvents. Try to avoid contact with things that make you break out with eczema. Because soaps and wetness can cause skin irritation, wash your hands only when necessary, especially if you have eczema on your hands. Be sure to dry your hands completely after you wash them.

Cancer Treatment Fills The Eczema Picture

A therapy traditionally used on esophageal cancer and lung cancer is causing a buzz in dermatology circles as a way to treat precancerous skin lesions, sun damage and acne.
Called photodynamic therapy, or PDT, it is gaining popularity with claims that it's more convenient and less painful, and that it brings fewer side effects than conventional treatments.
The Food and Drug Administration has approved PDT only for the treatment of certain tumors and actinic keratoses, which are scaly or crusty bumps that form on the skin surface from too much sun. But now the procedure also is being widely used for sun damage and acne on an "off-label" basis.
"There are exciting new and improved cosmetic indications," says Dr. Ron Berne, an Elmwood Park, Ill. dermatologist who began using PDT on his patients in March.
He explained that PDT can improve sun damage such as blotchy complexion, fine lines and telangiectasia, which are dilated superficial blood vessels such as are found with rosacea. The procedure improves the entire area treated, creating a more uniform color, texture and tone, rather than just spot treating with liquid nitrogen or other techniques.
The procedure involves applying a topical solution called 5-aminolevulinic acid (Levulan Kerastick) directly to the skin, then activating it with a light source for a specific time. The solution is absorbed by the abnormal keratin in precancerous or sun-damaged cells or oil glands, depending on what is being targeted.
A variety of light sources may be used, from lasers and intense pulsed light to blue light, which refers to the light wavelength. Therapy can be repeated several times at the same site if necessary.
PDT also can dramatically improve mild to moderate inflammatory acne when used in combination with other treatments, Berne says, eliminating the need for oral antibiotics or the controversial drug Accutane. The Levulan is absorbed into the oil glands, significantly reducing them.
Accutane has a much higher risk of side effects, such as birth defects and liver problems, according to Berne.
Kim Nguyen, 32, of Chicago, Ill., is allergic to many antibiotics and benzyl peroxide, so she is limited in her choices of acne treatment. She has had two PDT treatments.
"I can see a reduction in the acne and scars, and the redness is less intense," she says.
She has two more treatments scheduled, and her health insurance has covered a portion of the cost.
A PDT treatment typically ranges from $250 to $350.
In general, patients must avoid all sunlight and even brightly lit rooms for 36 hours or risk getting a severe burn due to heightened skin sensitivity to light.
"Plan a day and a half inside in the shadows," Berne says.
Even with that drawback, Berne prefers PDT as a treatment for actinic keratoses.
The standard treatment uses liquid nitrogen to freeze off the lesions. But doctors can't treat more than a couple at a time, so return office visits are required, according to Berne.
"For multiple actinic keratoses, conventional therapy can be painful and inconvenient," he added.
PDT targets only abnormal cells, so all lesions can be treated at one time, or repeated if necessary, according to Berne.
The use of PDT in dermatology, however, isn't universally hailed, says Dr. Gregg Menaker, director of dermatologic surgery at Evanston Northwestern Healthcare and assistant professor of dermatology at the Feinberg School of Medicine at Northwestern University, Evanston, Ill.
While director of the dermatologic surgery unit at Massachusetts General Hospital (Boston), "I saw a steady parade of people from our lab to my surgical unit for lesions that didn't go away with PDT," he says.
In patients with multiple actinic keratoses, not every lesion may be an actinic keratosis, he explains. The lesion could be a squamous cell, a common skin cancer. "There are other treatments that are faster, cheaper and more effective," he says.
As for using PDT for acne, Menaker says, "Our standard acne therapies are going to end up being the preferred way to treat acne. Acne patients are mostly kids who are in school and don't want to come to the dermatologist. From a scheduling standpoint it's difficult. And there is no long-term data to support its use."
But PDT is in use at the Texas Dermatology Research Institute, where Dr. William Abramovits, a professor of dermatology at Baylor University Medical Center in Dallas employs it to treat actinic keratoses, acne and other skin diseases.
He says, however, that because low-energy light may not be able to penetrate deep enough into thick lesions, PDT may fail to destroy squamous cell cancers or thick actinic keratoses.
"Many centers, particularly in Europe, are exploring the potential of newer sensitizers, and light of wavelengths that will penetrate deep enough to destroy thicker lesions," Abramovits says. "The results are very promising.

Understanding Seborrheic Keratosis

Seborrheic keratoses are raised growths on the skin. Seborrheic means greasy and keratosis means thickening of the skin. There may be just one or clusters of dozens. They are usually start off light tan, and then may darken to dark brown or nearly black. They may be oval spots a fraction of an inch across, or form long Christmas tree like patterns on the torso inches long.

The consistent feature of seborrheic keratoses is their waxy, pasted-on or stuck-on look. The look is often compared to brown candle wax that was dropped onto the skin. They may be unsightly, especially if they begin to appear on the face.These are not contagious and do not spread. They have no relationship to skin cancer and do not pose a risk to health. They get darker after sunless tanning creams have been used. Unlike moles (Nevi), they never turn into melanoma.

As people age they may simply develop more, and some people grow more than others. Sometimes seborrheic keratoses may erupt during pregnancy, following hormone replacement therapy or as a result of other medical problems.They are mostly hereditary and not caused by sun exposure. One often inherit the pattern and favored locations they grow on.

They often are found on the trunk and where the face meets the scalp. A different type of seborrheic keratosis may grow in liver or age spots (solar lentigines), but there are usually only a few of these. Some rough, brown keratoses on the face are actually actinic keratosis from sun damage.

Clothing rubbing against can get them irritated and make them grow. Alpha-hydroxy lotions and mild topical steroid creams may help this. If they get very itchy, irritated and bleed easily they should be removed. When a seborrheic keratosis turns black it may be difficult to distinguish from a skin cancer without a biopsy.

Because the keratoses are superficial, their removal shouldn't result in much scarring. Local anesthetics can be used to make the treatment painless. There may be a little discomfort as the treated area heals. Most often liquid nitrogen (cryosurgery) is sprayed on the spots, and produces blisters that lift up the seborrheic keratosis. These form into scab-like crusts that fall off within a few weeks. Occasionally there may be a small dark or light spot or a scar. These will fade over time. Sometimes part of the growth will eventually return.Another treatment often done is scraping off with a curette (ED&C). This is more useful when only a few need to be done, and one really want them not come back. It is also used when one spot needs a biopsy, since the scrapings can be sent to a lab. Healing is slower and scarring is more common. Sometimes seborrheic keratoses are burnt off with an electric needle or laser, especially if they are small.