Episode 82 - Eczema Basics

Episode 82: Eczema Basics. By Lam Chau, MS3, Ross University School of Medicine; and Brandy Truong, MS4, Ross University School of Medicine. Edited and moderated by Hector Arreaza, MD. Brandy and Lam discuss the basics of pathophysiology, presentation, and general treatment of eczema.   This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. Atopic dermatitis (eczema). A common skin disorder among children is atopic dermatitis, commonly known as eczema. At least 1 in 10 children have eczema; however, it affects many adults as well. About 31.6 million people, which is 10% in the U.S., have some form of eczema. Some other statistics worth noting are that children born outside of the U.S. have a 50% lower risk of developing eczema. The risk increases after living in the U.S. for 10 years. Also, 80% of individuals with eczema experience the onset at younger than 6 years old, and at least 80% will outgrow it by adolescence or adulthood.  Pathophysiology.  Eczema is caused by a disruption of the skin barrier. The outer layer of the skin contains a protein called “filaggrin” which helps form a barrier between the skin and environment. If a person has less of this protein, it’s harder for the skin to retain water and lock in that moisture. Genetics and environment play a role and it often runs in families. People with eczema often have other allergic conditions such as asthma, seasonal allergies, and/or food allergies. Presentation. Eczema rashes can present differently for each person. It can be all over the body or just a few spots and people go through exacerbations or flare ups where the rash worsens and then gets better, which we call remission.  In babies, eczema tends to start on the scalp and face. You’ll sometimes see red, dry rashes on the cheeks, forehead, and around the mouth.  For young children, rashes can occur in the elbow creases, on the back of the knees, the neck, and around the eyes. Sometimes the rash will ooze and crust.  There’s different severities in eczema which helps guide treatment. Mild: some mild areas of dry skin, mild itching (with or without small areas of redness), little or no impact on everyday activities, sleep, and psychosocial well-being.Moderate: moderate areas of dry skin, pruritus becomes more frequent, redness is moderate, moderate impact on everyday activities and psychosocial well-being, and frequently disturbed sleep.Severe: widespread areas of dry skin, continuous itching, redness, bleeding, oozing, cracking, severe limitation of everyday activities and psychosocial functioning, and loss of sleep each night. Exacerbating factors. Factors that exacerbate eczema include excessive bathing without moisturizing, low humidity environments, stress, overheating, and exposure to solvents and detergents. Management. Explaining in detail the management of eczema would take a long time, but we will give you some of the basic principles of treatment. Patient follow up is key to succeed in the management of eczema. You may need to see these patients every 2-4 weeks in some cases and escalate treatment depending on severity. Eczema can be very frustrating for parents and patients. The management requires a multi approach including - eliminating factors that exacerbate eczema, restoring the skin barrier, treating infection, hydrating the skin, patient education, and oral medications. In terms of patient education, a study was done where it showed a 6-week education program that had 2-hour weekly sessions that talked about medical, nutritional, and psychological issues associated with eczema. It resulted in an overall decrease in severity after one year. Moisturizing cannot be overstressed. It is the mainstay of the treatment. Use as much creams as you can. The best moisturizers have a high content of oil, and they are recommended instead of lotions, which contain a percentage of alcohol. So, use emollients or thick creams liberally. Emollients should be applied two times daily and after bathing or handwashing. Some common moisturizers that can be found at common drug stores include Lubriderm, Aveeno, Aquaphor, Cetaphil, and CeraVe.  Keeping the skin hydrated and moisturized will also help with the itching. Itching can be very disrupting in the patients’ lives and it can worsen symptoms if left untreated. Itching can result in lichenification, infection, bleeding, crusting, oozing, and cause permanent scars.   Topical steroids is another basic treatment for mild to moderate cases of eczema. Steroids can be used intermittently to prevent and treat exacerbations. For prevention, for example, topical steroids can be used two days a week (weekends) for 16 weeks. To treat exacerbations, prescribe twice a day topical steroid for 2-4 weeks.  When using topical corticosteroids, there should be caution using a high potency on areas like the face and skin folds since those are areas at risk for atrophy. However, a brief use of a higher potency can provide a quick response then patients can be switched to a lower potency. In the US, topical steroids are classified in 7 groups, going from group 1 “super-high potency” to group 7 “least potent”. As a primary care provider, you can memorize at least one formulation from each category and prescribe it as needed.  An example of low potency topical steroid would be hydrocortisone 2.5% (least potent, group 7) and triamcinolone 0.1% (Kenalog®), low potency, group 6.  A high potency topical corticosteroid would be Betamethasone dipropionate 0.05% cream (Diproline®) or mometasone furoate 0.1% cream (Elocon®). Those two creams are in the group 2 or high potency. There are other treatments we did not talk about, including calcineurin inhibitors, crisaborole, a phosphodiesterase 4 inhibitor (Eucrisa®), antibiotics, and oral medications. We invite you to keep learning about eczema. As we conclude this episode, we’d like to recommend you take a look at the National Eczema Association website. It contains a lot of helpful information material for patients. Invite your patients to consult that website as well.  Conclusion: Now we conclude our episode number 82 “Eczema Basics.” Our medical students have become excellent teachers. Today they explained very well the basics of eczema. Remind your patients to moisturize, moisturize and moisturize their skin with emollients. Topical steroids can be used for the treatment and prevention of exacerbations. Other treatments such as antibiotics, medications and even biologicals are not always needed but they may be used depending on severity. Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email at [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Brandy Truong, and Lam Chau. Audio edition: Suraj Amrutia. See you next week! _____________________References:“Eczema Prevalence, Quality of Life and Economic Impact.” National Eczema Association, 8 Sept. 2021, https://nationaleczema.org/research/eczema-facts/.  Howe, William. Treatment of atopic dermatitis (eczema). Up to Date, last updated: December 08, 2021. https://www.uptodate.com/contents/treatment-of-atopic-dermatitis-eczema?search=eczema&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1 . Sarah, Stein. “Eczema in Babies and Children.” HealthyChildren.org, American Academy of Pediatrics, 13 Mar. 2020, www.healthychildren.org/English/health-issues/conditions/skin/Pages/Eczema.aspx#:~:text=At%20least%20one%20in%2010,sensitive%20skin%20than%20other%20people.   Watson, Stephanie. “Eczema Support Group: Local, How to Find, and More.” Healthline, Healthline Media, 27 May 2021, www.healthline.com/health/eczema/eczema-support-group#takeaway.  Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!