ECZEMA AND DERMATITIS
What is dermatitis?
Dermatitis refers to a group of inflammatory conditions. It affects the outer layer of the skin, the epidermis.
Dermatitis affects about one in every five people at some time in their lives. It results from a variety of different causes and has various patterns.
The terms dermatitis and eczema are often used interchangeably. Dermatitis can be acute or chronic or both.
- Acute eczema (or dermatitis) refers to a rapidly evolving red rash which may be blistered and swollen.
- Chronic eczema (or dermatitis) refers to a longstanding irritable area. It is often darker than the surrounding skin, thickened and much scratched.
Some types of dermatitis
- Atopic dermatitis is particularly prevalent in children; inherited factors seem important, as there is nearly always a family history of dermatitis or asthma. The skin becomes extremely itchy and inflamed, causing redness, swelling, cracking, weeping, crusting, and scaling. In most commonly effects infants and young children, but it can continue into adulthood or show up later in life. Many children with atopic dermatitis enter into a permanent remission of the disease when they get older, although their skin often remains dry and easily irritated
- Irritant contact dermatitis is provoked by handling water, detergents, solvents or harsh chemicals, and by friction. Irritants cause more trouble in those who have a tendency to atopic dermatitis.
- Allergic contact dermatitis is due to skin contact with substances that most people don’t react to, most commonly nickel, perfume, rubber, hair dye or preservatives. A dermatologist my identify the responsible agent by patch testing.
- Dry skin: especially on the lower legs, may cause asteatotic dermatitis, also called eczema craquele.
- Seborrhoeic dermatitis and dandruff are due to irritation from toxic substances produced by malassezia yeasts that live on the scalp, face and sometimes elsewhere.
- Infective dermatitis seems to be provoked by impetigo (bacterial infection) or fungal infection.
- Otitis externa – dermatitis affecting the external ear canal
Environmental and internal factors can activate symptoms of atopic dermatitis at any time in the lives of individuals who were born with atopic
Causes of dermatitis
- The cause of atopic dermatitis is unknown, but the disease seems to result from a combination of genetic (hereditary) and environmental factors.
- Heat, certain foods, dust mites, chlorine, pets, soaps, stress can all cause a flare
- Clients born with eczema or atopic dermatitis are born with a filaggrin deficiency. Filaggrin is a structural protein found in the upper layers of the epidermis. It gives our skin strength and allows us to retain moisture. Without filaggrin, the skin barrier defence is down and open to irritants and constantly on high alert. Dermaviduals products contain urea and urea will support the formation of filaggrin
Treatment of dermatitis
An important aspect of treatment is to identify and tackle any contributing factors.
- Diagnosis: It is important to diagnose the type of eczema or dermatitis, how long the client has been suffering for, the triggers and topical applications used to treat the condition so far. Remember to look at diet, stress levels, occupation, work/ play habits and other factors that could work against your treatment plan.
- Supplements: Remember the skins overall health is very dependent on the availability of EFA’S through the diet. The skin is the last place that receives EFA’S from our food so it is crutial for clients to eat a diet high and BALANCED in Omega 3, 6 and 9. THE WESTERN DIET IS HIGH IN OMEGA 6- This can cause a pro-inflammatory response. Liquid Fish oil is the best way to get a good dose of all your Omegas (Nordic naturals is a good one to try) Shot 10mls in the morning before breakfast
- Bathing-Reduce how often you bath or shower, using lukewarm water. Showers are better. Replace standard soap with a substitute Total Cleansing cream, Cleansing Milk or Tenfione
- ClothingWear soft smooth cool clothes; coarse fibres (wool or synthetic) are best avoided
- IrritantsProtect skin from dust, water, solvents, detergents, injury.
- Avoid perfumed products Eliminate products that contain emulsifiers that are washing the oil and water from the barrier begin on a simple barrier building protocol at home whilst the clients barrier adjusts from over the counter products onto dermaviduals.
- Topical steroidsIf applying use sparingly and for no longer then 14 days
- Antihistaminetablets may help reduce the irritation and are particularly useful at night.
One of the best ways to address eczema, is to keep the skin moisturized and hydrated so that the skin protective barrier, the stratum corneum, can heal. Cracks in the stratum corneum lead to water loss from the skin and this can trigger an inflammatory response, which then makes the skin condition progressively worse.
There are several treatments used for treating dermatitis conditions and we will review just a few. Common remedies include corticosteroid creams and ointments, antihistamines, systemic corticosteroids (prednisone), antibiotics and other anti-inflammatory substances. Bases in certain brands may become irritating and also can cause thinning of the skin.10 Cortisone has an anti-inflammatory effect and urea reduces the itching effect as well as hydrates. Unfortunately, cortisone can cause skin atrophy after long-term use. Consequently, there is an increased susceptibility towards substances with allergenic potential. When the symptoms are so severe, the treatment program may not be effective enough to alleviate the condition. Continued use of these remedial substances may produce increased sensitivity towards external influences including the potential for infection. 10
More severe cases of atopic dermatitis may be treated with immune modulators, Tacrolimus (Protopic), cyclosporine A, interferon-ϒ, and pimecrolimus (Elidel) ointments.10 They are very powerful drugs. The FDA has placed special warning on immune modulator drugs due to cancer and other immune-system suppression issues.10
Phototherapy treatments with UVA or UVB wavelengths have been used for mild to moderate dermatitis in children over 12 years of age and in adults.
Eczema from a dermaviduals® point of view
Dehydrated skin with a high TEWL is very characteristic of eczematic skin. Seasonal weather changes can also play havoc with this skin condition. The result is a barrier disorder that leaves the skin in a more vulnerable state with an increased susceptibility for penetration of external substances such as microorganisms (fungi, bacteria and viruses).10 The stratum corneum exhibits a deficiency in ceramide-1 (linoleic acid), a main barrier component of the skin.10 Understanding the synthesis pathway for essential fatty acids, the presence of dermatitis serves as an indicator of an enzyme defect that inhibits the transformation of linoleic acid into gamma-linoleic acid (refer to our article on “Essential Fatty Acids”).10 Given that dermatitis attacks are cycling, using the intermittent times when flare-up is minimal is an ideal time to use preventative measures in order to mitigate continuous deterioration of the skin barrier. Moreover, when correct corneotherapy actives are used, they may help support the skin by increasing its barrier function. The good news is that this could easily reduce the requirement for more drug intervention.
The choice of skin care is imperative to supporting dry and scaly skin conditions. Most products contain a host of ingredients to stabilise their components as well colourants and fragrance that add to the marketing appeal of the product. Some, however, are counter-indicated for dry skin and for individuals suffering from dermatitis and/or other allergy conditions. Mineral oils and other petrolatum substances, silicones, and ceresin wax slow down the self-regenerating capability of the skin.2
Emulsifiers are used in most modern skin care products. They combine fat and water substances into a cream preventing separation of oil and water. Unfortunately, they have a wash out affect in the skin, dissolving ingredients of creams along with the natural skin lipids out of the skin.2 With each cleansing more of the natural skin lipids end up being removed. Eventually and with continuous application of the skin care cream, the barrier (NMF) actually becomes impaired and unable to self-correct. The skin begins to feel dry with increased TEWL. The tendency is to continue to re-apply more cream to correct the dry skin condition. This senseless cycle eventually places the skin in a cycle of imbalance.
Following the guidelines of corneotherapy, correcting dry skin conditions requires application of emulsifier free products to reduce and balance TEWL. Linoleic acid containing ceramide 1 is very important for the skin layers and must be readily available to the cell membranes and bilayers of the skin. When there is a reduction in ceramide 1, there is a propensity for dry and scaly skin.
Emulsifying agents can be replaced with liposomes and nanoparticles for penetrating actives. To soothe the itching in irritated skin, urea has positive effects. These specialised delivery spheres increase the permeability of the skin for the delivery of actives. They should be followed by an application of derma membrane cream (DMS®) whose chemical composition mimics the natural skin barrier. They are ideal for dermatitis conditions since they do not contain water and are free of preservatives. Dermatitis clients tend to tolerate pure vegetable oils and waxes, i.e., olive and jojoba oil in skin care that is free of water and preservative systems. Vegetable oils, lipids and waxes are able to integrate into the stratum corneum and begin to support barrier repair are generally well received in these skins.
A primary goal of introducing corneotherapy products onto eczematic skin is to reduce the amount of drugs that may further break down an already compromised barrier. Cleansers should contain very mild surfactants. Sodium lauryl sulfate type surfactants have been shown to be an irritant. They denature proteins and have hemolytic effects (destruction of cell membranes of red blood cells). 4 Cleansing milks contain membrane substances and increased oil content and avoid the washout of the natural barrier substances. These recommendations are not only for the face but also for the rest of the body. Water pH should remain neutral.
Cosmetic ingredients can be effective toward inhibiting inflammatory reactions. Sensitive skin should be protected against direct sunlight as it can degrade the active affects of a formula. Inflammatory conditions from eczema, dermatoses, and dermatitis respond well to Evening Primrose Oil, Linseed Oil, Boswellia, D-panthenol, phosphatidylcholine (nanodispersions), and Echinacea Extracts, as well as Lotion N and Novrithen.
In conclusion, treatment choice for irritated skin types requires careful analysis of the individual skin type. The goal is to rebuild the barrier as much as possible
Topical steroids and withdrawal
A topical steroid is an anti-inflammatory preparation used to control eczema/dermatitis and many other skin conditions. Topical steroids are available in creams, ointments, solutions and other vehicles.
Topical steroids are also called topical corticosteroids, glucocorticosteroids, and cortisone.
How does a topical steroid work?
The effects of topical steroid on various cells in the skin are:
Steroid is absorbed at different rates depending on skin thickness.
- The greatest absorption occurs through thin skin of eyelids, genitals, skin creases, when potent topical steroid is best avoided.
- The least absorption occurs through the thick skin of palms and soles, where mild topical steroid is ineffective.
Absorption also depends on the vehicle in which the topical steroid is delivered and is greatly enhanced by occlusion.
- They block the chemical reactions that cause inflammation. Steroids are naturally occurring hormones that are released into the bloodstream whenever the body experiences stress, disease, or trauma. When released, the steroid molecules interact with DNA in a cell’s nuclei to produce proteins called lipocortin. These proteins block the production of a chemical central to the inflammatory response called arachidonic acid. By doing so, the body experiences far less inflammation.
- They change how immune cells work The immune system fights infection with an array of defensive cells meant to neutralise foreign substances like viruses or bacteria. When this happens, the immune cells release toxins into the body which add to the inflammation. Steroids work by tempering this action and preventing tissue damage that excessive inflammation can cause.
- They constrict blood vessels. Inflammation is typified by the dilation of blood vessels around the site of trauma or infection. (This is why wounded skin is usually red, warm, and swollen.) Topical steroids work by constricting capillaries and reducing localized swelling and pain.
Local side effects may arise when a potent topical steroid is applied daily for long periods of time (months). Most reports of side effects describe prolonged use of unnecessarily potent topical steroid for inappropriate indications.
- Skin thinning (atrophy)
- Stretch marks (striae) in armpits or groin
- Easy bruising (senile/solar purpura) and tearing of the skin
- Enlarged blood vessels (telangiectasia)
- Localised increased hair thickness and length (hypertrichosis)
Topical steroid can cause, aggravate or mask skin infections.
Potent topical steroid applied for weeks to months or longer can lead to:
- Periorificial dermatitis (common); this can occur in children
- Steroid rosacea
- Symptoms due to topical corticosteroid withdrawal
- Pustular psoriasis.
Stinging frequently occurs when a topical steroid is first applied, due to underlying inflammation and broken skin. Contact allergy to steroid molecule, preservative or vehicle is uncommon, but may occur after the first application of the product or after many years of its use.
Topical steroid withdrawal syndrome
What is it?
Topical corticosteroids withdrawal (sometimes called “topical steroid addiction” or “Red Skin Syndrome”) appears to be a clinical adverse effect that can occur when topical corticosteroids are inappropriately used or overused, then stopped. It can result from prolonged, frequent, and inappropriate use of moderate to high potency topical corticosteroids, especially on the face.
What to look for?
Burning, stinging, and bright red skin are the typical features of topical steroid overuse and withdrawal. The signs and symptoms occur within days to weeks after discontinuation.
Patients going through withdrawal may experience swelling, redness, burning, and skin sensitivity usually within 1-2 weeks of stopping the steroid. Some may notice the presence of papules (pimple-like bumps), nodules (deeper bumps), pustules, redness, and–less frequently– swelling, burning, and stinging.
Based on systematic review of research to date, both types primarily affect the face of adult females and are mostly associated with inappropriately using mid- to high-potency topical corticosteroids daily for more than 12 months.
What to do?
Consult a reputable healthcare provider they will need to rule out other conditions such as allergic contact dermatitis, a skin infection or, most importantly, a true eczema flare.
Once a diagnosis of steroid addiction or overuse is made, the goal should be to discontinue the inappropriate use of topical steroids and provide supportive care. Do not take the client off steroids cold turkey if they have been using them for a long time. Take gradual steps, as this could be detrimental to their health and psychological state. Set up a programme ie: first week use once daily, second week use every second day
Natural and alternative treatments can sometimes be used in addition to or rather than conventional treatments. However, they also may have associated risks. Discuss any natural or alternative treatments with your doctor so that, together, you can devise the safest, most effective personalized treatment plan.
Importantly, there are risks to not treating your eczema effectively. Along with the profound effect on family life, eczema can negatively impact your clients quality of life, causing mood and behavioural changes, poor performance, bacterial infections, and poor sleep. Embarrassment from eczema can cause social isolation and impacts the daily life activities, such as clothing choices, holidays, interaction with friends, owning pets, swimming, and the ability to play sports or go to school or work.
Thanks to dermaviduals Australasia for this blog!