NEA Seal of Acceptance

The National Eczema Association has created the NEA Seal of Acceptance to identify products designed for patients with eczema. To receive the seal, products must not contain known irritants. The NEA also looks at testing data on "sensitivity, safety, and toxicity." The NEA grants seals in four categories: personal care products, household products, fabrics, and devices. This list of products that have received the seal is online here.

Bleach Baths

Diluted bleach baths, or what some prefer to call "swimming pool baths," have been shown to help children with eczema and they may help adults, too. Most instructions suggest mixing a quarter cup of bleach in a bathtub full of water and soaking for 5 to 10 minutes twice a week. Of course, check with your dermatologist before treating yourself.

Eczema suffers have more staph on their skin than other people. For severe cases, the staph can cause skin infections, such as folliculitis. The diluted bleach baths kill the bacteria, reducing infections. Staph can exacerbate the eczema, so killing it off can improve rashes and itching. Doctors also prefer to try and use bleach baths as a first line of defense since there is growing concern about the increasing incidence of antibiotic resistant staph.

I recently tried bleach baths and found them to be helpful. Having previously had a staph infection on my skin requiring oral antibiotics, I was in no mood for a repeat experience. When I started experiencing what appeared to be symptoms, I went to my dermatologist immediately. She suggested the bleach baths as a first step to see if it would clear up the infection before it got so bad it required antibiotics. Sure enough, it worked! I was concerned the bleach might actually inflame my sensitive skin, but it is so dilute that it does not. Thinking of it as akin to a swimming pool is helpful. You smell mildly like a pool when you get out of the bath, even after rinsing off, but the smell quickly fades. Just remember to put on lots of lotion when you get out because the baths can be quite drying, which can make eczema worse.

Watch out for aqueous cream!

Apparently, many GPs--at least in the UK--are prescribing cream that could be making eczema even worse for their patients. Aqueous cream was developed as an alternative to soap and some doctors are giving it to patients to use as a moisturizer, as reported here. Unfortunately, the cream does not contain much to moisturize the skin and also contains sodium lauryl sulphate, which can irritate sensitive skin. Eczema patients should educate themselves about which products are helpful and seek out the advice of a dermatologist.

Comparing Lotions

With the dry air of winter all around, I thought it might be useful to compare lotions on the market. Which are best for dry, itchy skin?

My personal favorite is Lubriderm's Sensitive Skin Therapy. This is great for anyone prone to flare-ups or skin reactions. It is moisturizing, not sticky, and causes no irritation. Great to use several times a day.

An alternative is Aveeno Daily Moisturizing Lotion. This also is not likely to irritate, but it is a bit lighter and I feel doesn't offer quite as much moisture as the Lubriderm lotion. Others may prefer this lightness.

For heavier lotions, I have used Eucerin's Calming Creme. This is thicker, but not as thick as Vaseline, and feels particularly nice on very dry, winter days. I have not found this to be irritating to my skin, either.

Finally, I sometimes use CeraVe Moisturizing Creme. This is more expensive (although none of these lotions are cheap!) but it claims to have ceramides to help those with eczema. While it has never seemed to cure a flare-up, it does moisturize well and gives me some psychological benefit to think that it may actually be improving my eczematious skin.

More on Acupuncture and Eczema

In an earlier post, I recounted my experience trying acupuncture to reduce eczema symptoms. Reuters has just reported on a study done by German researchers, which found that acupuncture can reduce itchiness if done immediately after exposure to an allergen and that exposure after acupuncture results in a less intense reaction. The researchers compared results when using true acupuncture points to both no treatment and the use of "placebo points," or acupuncture points that are not true points used in Chinese acupuncture. After being exposed to an allergen, those getting the "true points" treatment reported lower levels of itch. The abstract of the study, published in the journal Allergy, is online here.

For those interested in seeing if acupressure on the points would work, the two points used in the study are LI11 and SP10. The former is on the outer side of the elbow crease and the later is roughly above the knee and towards the inside of the leg.

Book Review: The Eczema Solution

The Eczema Solution, by Sue Armstrong-Brown, outlines a program to stop scratching and thus heal the skin of chronic atopic eczema sufferers. The approach was developed at the Chelsea and Westminster Hospital. The underlying principle is that if patients can stop scratching, they can reduce their itching, as discussed in an earlier post, and reduce the rash, since this is triggered by the scratch. Severe eczema patients can tell you that even though a good scratch is satisfying in the moment, it simply leads to even more intense itching and much more severe rashing and inflammation of the skin. While this is known in theory, the trick is being able to actually keep your nails off your skin in the face of intense itching.

That's where this book comes in. The author notes that chronic eczema suffers have developed a habit of scratching, even when when they are completely unconscious of the behaivor. This continuous scratching is very damaging to the skin and prevents healing, exacerbating the condition. Each chapter in the book presents exercises that the reader does before moving on to the next chapter. The exercises are designed to break the habit of scratching. At the same time, you continue to use emollients and steroids to treat flare-ups (indeed, the author argues for using steroids for some period even after the skin looks healed.)

Breaking the habit of scratching begins with logging every time you scratch with a hand tally counter. This sounds a bit crazy--and it is. For weeks, I walked around with a little clicker that I had to press each time my hands moved to my skin. This is a truly eye-opening experience. I was scratching hundreds of times a day. The counting exercise really did make me aware of all the unconscious scratching. Once aware of it, you can being to slowly reduce the amount you scratch using some habit-changing exercises presented in the book.

The book is written by someone who has suffered from atopic eczema her entire life: she has coped with the itching, been hopitalized for her eczema more than once, and tried every treatment available. It is comforting to read a book about severe eczema that is written by someone who completely gets it. The one downside is that I personally found that the book over-promises the level of relief to expect from the program. This may be because I had already learned not to scratch hard at the itchy spots or else I'd have to face worse symptoms and devastatingly ugly flare-ups! I think this book could be more profound for those who are not yet able to stop scratching at any level. Learning to control the scratch reflex can improve the look of your skin (and therefore reduce anxiety) and does, to some extent, reduce itching. It does not, however, "cure" the eczema or completely eliminate itching and sleepless nights, as the author promised. But it does help some and is worth a try, at the very least for the awareness it brings about your own unconscious habits.

Some uncommon but potentially useful treatments?

Common treatments for eczema include moisturizers/emollients, steroids, calcineurin inhibitors (Elidel and Protopic), UV treatment, and antihistimines.

Some patients have found some less common treatments and approaches that improve their eczema. Some of these are mentioned by Adnana Nasis in his book, Eczema Free for Life. He cautions that there is not conclusive research on any of these (see his book for more information). Still, when you feel discouraged by traditional approaches try one of these:

• evening primrose oil supplements
• eliminating dust mites
• Chinese medicine
• massage with lotions and emollients that are known not to cause flare-ups
• biofeedback
• Ranitidine (antihistimine)
• salt baths
• oolong tea
• Gloves in a Bottle
  

Can Acupuncture Cure Eczema?

After Western medicine failed to provide sufficient relief for endless itching and sleepless nights, I decided to try acupuncture. I did not know anyone in my city that had tried acupuncture before, so I went on Yelp and read reviews. I found an acupuncturist whose patients all said good things about him and who also had an MD, which made me feel more comfortable. I called his office. Before scheduling an appointment, he asked about what was bothering me. I described the itch and the eczema, and he thought he might be able to help. At his suggestion during the first consultation, I started with appointments twice a week for two weeks, then decreased to once a week for a few weeks, and then spaced it out to between 10 days and 2 weeks between appointments. He also gave me Chinese herbs, but they made me nervous and I ultimately did not take them.

First, the experience of acupuncture.
When I was called to a room, I would lie down on my back on a table that was like a massage table. I had to roll up any sleeves and roll up my pants to my knees so he could access certain points for the needles. My acupuncturist would put needles at my ankles, on the side of my shin just below my knees, right above my knees, in the crease between my thumb and second finger, at my wrist, to the side of the bend in my arm at my elbow, and then sometimes on top of my head and/or on my forehead. Inserting the needles never hurt, maybe just an occasional prick. After all the needles were in, however, he would manipulate them slightly. This could cause a range of sensations from tingling to slight pain - mostly at the site of the needles, but occasionally it would induce a shock of sorts up my arm or leg. He would then leave me lying on the table for 20 to 30 minutes. I would try to relax while I stayed very still. The needles could lead to a variety of sensations. Sometimes the site of the needles would tingle, sometimes it would burn, sometimes I would feel a dull ache. Most times I felt calm when the needles were in and tried to meditate or clear my mind. A couple times, the needles made me feel like I had nervous energy and those times I was more than ready when the doctor came back to take out the needles.

Did it help?
While the needles were in and I was lying on the table I experienced no itching (except, every so often, on the side of my nose). This was absolutely astonishing and marvelous. I think it is the only time in my life where I have been perfectly still, focusing on my skin, and actually NOT itched (even when I was on strong oral steroids my dermatologist claimed would get rid of the itch, they did no such thing). I loved going just for these few minutes of relief. After the needles came out, though, the results were more mixed. I think in general it probably did relive my itching somewhat, in the days after the treatment, but it certainly did not eliminate it. After the first two sessions I was still having trouble sleeping because the itch was so bad. I mentioned this to him and he added 3 new points to the treatment, 2 sort-of below and to the side of my ears that he did on both sides and one on my stomach. The first time after this, I was immediately very tired. I was glad it was an end-of-day session! The next few times did not have such a drastic effect, and I started going in the morning, but my sleep did noticeably improve.

The End Result
If acupuncture was free and acupuncturists made house calls, I'd have it done every night before sleep. It relieved the itching during the treatment and then left me relaxed (and actually tired when certain points were used). But, the treatments aren't free and my insurance did not cover them so it was a large out-of-pocket expense every month and when I had them in the morning, the effect was much reduced by the end of the day. So I have stopped going. But I am still very glad I tried it and I know it is there if I ever want to resume. There is also a physiological benefit to knowing that there is something that does relieve itch, even it costs $100 for 30 minutes and requires lying totally still with needles in you!

Ceramides: A New Treatment?

I've recently tried a new product: CeraVe. It is a cream that contains ceramides. Ceramides are a type of lipid that are present in the top layer of the skin. People with eczema have less ceramides in their skin. They also have less cholesterol and free fatty acids. All three are essential to maintain the barrier function of the outermost layer of the skin by maintaining moisture.

I like CeraVe and I do think it has helped my skin a little, but not dramatically. That said, I have not used it consistently for an extended period of time. A study discussed on the American Academy of dermatology website found that use of creams with lipids twice daily for 4 weeks resulted in improvements in skin lesions, itching, and sleep.

Good Skin Care Routines

• Use lotions and emollients -- lots of them!
• Avoid hot showers. They feel good while you're in them, but then dry your skin out, making the eczema worse.
• But do shower off dirt, sweat, and irritants that can cause flare-ups.
  
• Avoid rubbing you skin with washcloths and avoid excess use of soap.
• Avoid very alkaline soaps. I use Dove Sensitive Skin, which seems to be okay.
• If you can avoid soap, and use a cleanser, such as Cetaphil,
  
• Put lotion on immediately after showering, bathing, or swimming.
• Lukewarm baths may be better on your skin than showers.
• Oatmeal baths help soothe itching for some patients.
• Do not use lotions with artificial dyes or perfumes. Many also contain alcohol, which is drying. I have Lubriderm Sensitive Skin works for me.
• Wear loose, cotton clothing.
• Avoid triggers.
• Run a humidifier in the winter.

DIY UV therapy?

The New York Times last week cautioned eczema sufferers against trying to do UV therapy yourself at a tanning salon instead of under the care of a doctor since tanning beds carry with them a risk of cancer. Apparently, the UV rays administered by a doctor are UVB and those in most tanning beds are UVA, which are thought to be more dangerous.

Unfortunately, phototherapy from a doctor may not be covered by insurance and/or getting to a hospital or doctor's office as frequently as needed may be inconvienent or just not possible. So many eczema patients turn to tanning beds.

I have tried doctor-administered phototherapy myself during the winter, when it is difficult to get UV rays the old-fashioned way by sitting outside. While it didn't eliminate my symptoms, it may have reduced them slightly. In the end, I decided the co-pays and constant shuttling to the hospital were not worth it. That said, in late spring and early fall and some summer days, when it is possible to soak up some sun but also not get very sweaty (which aggrevates my eczema), I can feel the improvement in the itch and the rash. But I have learned the hard way to be very careful about sun exposure. I got burned on my back a couple months ago and not only was it a bit painful, it triggered a bad flare-up as my skin peeled and new skin came in. Not helpful!

New York Times Interview with Dr. Gil Yosipovitch

The New York Times has an interview with Dr. Gil Yosipovitch, a dermatologist at Wake Forest University who studies itch.

He is very understanding of the chronic itch associated with eczema, which is comforting for anyone who suffers from pruritus (techincal word for intense itching). Interestingly, he notes that the number one cause of itching is eczema. But he says that only 10% of eczema patients have severe itch. This may explain why I've seen several dermatologists who are very dismissive of the persistant itch and how disruptive to you life it can be. It is nice to see someone who understands how terrible it is!

He discusses how scratching can make the itch worse, leading to terrible itch-scratch cycle:
"So, now we can understand that brain-wise, it could feel like scratching helps for a couple of hours. But in chronic eczema the more you scratch, the more you damage the upper layers of the skin barrier, the protective layer. And the more you damage it, the nerve fibers are — I would call them wacky, they are not functioning as they are supposed to. They become overactivated, so that scratching actually intensifies the perception of itch, causing more itch. So that can explain why we have that itch-scratch cycle."

On treatments, he notes that the use of steriods can be essential for eczema patients and that anti-histimines at night can have a sedating effect to help patients sleep. He mentions new reasearch they may lead to anti-itch medications but they appear many years off still -- sadly for those of us suffering now.

Staph Infections

Eczema patients have been found to suffer from staph (staphylococcal bacteria) infections on the skin more than others.

Eczema patients do not make enough antibacterial proteins called magainins. These proteins kill bacteria in the skin but those of us with eczema are in short supply. Staph infections will usually manifest themselves as pustules. One type of staph infection that I had several years ago was folliculitis. This is a staph infection in which red pimple-looking bumps appear around the hair follicles. I had them all up and down my legs. I know, gross.

Treatment: If you have a staph infection go to your doctor immediately for antibiotics. Oral antibiotics cleared up my folliculitis in a couple days (for more of folliculitis from the Mayo clinic, click here). Oral antibiotics, though, are only given for severe infections since they can also build up resistence. The doctor also told me to wash with an antibacterial soap in the shower. Usually, eczema patients are told to avoid harsh soaps since they can be very drying, but when staph is getting out of control, it is best to use them. For less severe outbreaks, topical antibiotics can be used. One that my doctor has given me is a cream called Mupirocin. When I get a postule that appears to be infected, I just put some of this on right away.

Prevention: Since eczema patients have more staph on them than others, when an eczema patient gets a cut or scrape, it is best to wash with soapy water quickly to prevent the spread of staph. And keep cleaning it regularly. Also, use emollients often because staph likes dry skin better than well-moisturized skin.

More on Your Skin

Nasir's book Eczema-Free For Life provides some insight on how the skin of eczema patients is different from those who do not suffer from the itch that rashes.

Your skin is made up of three layers: epidermis (this is what itches and flares), the dermis (where blood vessels, glands, and hair follicles are), and the subcutis (fat layer with blood vessels).

New cells in the epidermis push older ones out and off. This is an ongoing cycle. When the older cells are pushed to the top of the skin, they form a layer called the cornified envelope. As Nasir notes, in eczema patients, this layer does not have as many lipids as in non-eczema people. This lack of lipids leads the the epidermis to dry out and crack. Irritants can enter the skin through the cracks, causing flare-ups. Essentially, the barrier function of the skin has broken down.

This is why emollients like Vaseline are great for those with eczema. The Vaseline provides needed moisture and also acts as a barrier over the cracks to prevent irritants from entering the skin.

Sleepless Nights

The persistent itching from eczema can lead to many sleepless nights. Sometimes the itch seems worse at night than during the day. This could be because the mind has nothing else to occupy itself with while lying in bed and focuses on the itch. Research has found, though, that cortisol levels are lowest while sleeping and that low cortisol levels is associated with more inflammation. So there might be more to nighttime itching than just a mind focused on the discomfort.

I remember reading somewhere that eczema patients often get an hour to two less sleep a night due to inability to fall asleep and waking up in the night from the itching. Lack of sleep can make you irritable and lead to frustration and anxiety -- I know, I've been there. And lack of sleep can make the itching and the flare-ups even worse. So finding ways to get a good night's sleep are especially important for eczema patients.

I've found the best way to try and get sleep is to take an anti-histamine before bed. I haven't found the anti-histamine to do anything for the itch, but some make me really drowsy - enough to fall asleep despite the itch. I used to take over-the-counter benadryl but often the itch would outmatch any drowsiness induced by the benadryl. My doctor then prescribed hydroxyzine HCL in 25 mg tablets. One tablet can put me to sleep on most nights despite chronic itch. It does make me groggy in the morning, but I much prefer grogginess and 8 hours of sleep to tossing and turning and scratching all night.

Eczema on your eyes?

A couple years ago, I had trouble with eye irritation. My eyes would itch. When it was very severe, they would feel like there was something in my eye that would not come out. It could get so bad that I would have to lie down with a cold washcloth on my eyes for long stretches at a time. After weeks of suffering with these symptoms, I went to see an eye doctor. He was certain it was not an infection and gave me antihistamine drops. We tried two types of antihistamine drops that did little good. Then he prescribed me Alocril - that solved the problem. They are bright yellow drops. A couple in each eye twice and day and symptoms went away.

I learned later from Nasir's book that eczema can inflame the conjunctiva. The conjunctiva is tissue covering the eyeball. When inflamed, it feels like there is something in your eye. This could be what I was experiencing. If it happens to you, ask for Alocril.

Treatment: Ointment

Ointments -- my husband fondly calls them goop -- are an eczema patient's best friend. I just use Vaseline and apply it liberally morning, noon, and night.

Some patients may dislike ointments because they leave you feeling sticky. They can then also get on sheets, clothes, or furniture. Ointments do wash off in the laundry but will stand out on fabrics as discoloration until they are washed. I find that applying them liberally and then putting on cotton pants and a long sleeve cotton shirt for protection is very helpful for my skin. Doing this as a bedtime routine can be a good alternative for those who do not want to be sticky during the day.

Why are ointments good?
Patients with eczema get tiny cracks in their skin. These cracks let irritants into the skin and moisture out. Nasir, author of Eczema-Free for Life, calls this "leaky skin." Ointments are doubly good because they keep moisture in and keep irritants out. Use them often!