This is a continuation of my series on eczema…for the rest of the Skin-ny, see also:
and:
So what can an Allergist-Immunologist do for you? Well we start with the basics, so review Part I and Part IIa. Those are the foundations of care. Then we address hydration and pick any testing and treatment…
Hydrate to improve the skin barrier
Skin hydration is the foundation of eczema care; some patient’s symptoms can be controlled with skin hydration alone. It is estimated that with hydration techniques alone, the rate of increase of allergies in eczema patients is reduced by 50%.
Hydration creates, protects, and increases the elasticity of the skin barrier. This reduces water loss and minimizes the penetration of inflammatory allergens that could trigger the allergy cells underneath the skin. Both dehydration and intrusion of allergens escalate the damage.
Recommended: four levels of hydration
There are four levels of hydration, the first being the most basic for all patients with eczema; the second is intended for easily controlled eczema; the third for moderate-to-severe eczema, and the fourth for flares of eczema.
1. Daily hydration for all patients with atopic dermatitis:
Use an ultra-gentle hydrating wash with ceramides, pat skin dry (don’t rub), and apply a moisturizing cream formulated for eczema.
2. Hydration for mild, persistent eczema:
- To bathe, use an ultra-gentle hydrating wash with ceramides on moist skin. Pat dry, do not rub dry.
- Apply a thin layer of extra-virgin olive A drop is all that is frequently necessary. Your child does not need to look like a salad.
- Apply a thin layer of moisturizing cream with ceramides.
- Apply a thin layer of petroleum
- Wrap affected extremities with cotton gauze. When severely affected, consider wrapping with plastic wrap (not for a small child).
- Cover with “hydrating pajamas” (see instructions on page X 133) or leave gauze or plastic wrap in place, if adult or older
- Leave on for 20
- Wipe off
- When rash subsides, use only moisturizing cream with ceramides in areas typically
3. Bleach bath instructions for patients with moderate to severe persistent eczema:
As intimidating as a bleach bath may sound, it’s equivalent to swimming in a chlorinated pool, except you control the amount of chlorination. I assure you (from experience), when performed properly, it is safe and effective. As much work as it is, it can provide a lot of relief (although I have to admit, I am glad that we only have to perform step 1 now, and only as needed at that).
- Fill a tub for a normal bath (about 40 gallons) with lukewarm water. Never use or contact skin with undiluted bleach.
- Place 1/4 to 1/2 cup of common liquid bleach into the bath water. Before using bleach, read the label to check that the concentration of bleach (sodium hypochlorite 6% should be listed on the contents label without any other chemicals).
- Mix the bleach in the water. Just to reassure you, this is just a little stronger than appropriately chlorinated pool water.
- Test that the bleach water is thoroughly mixed.
- Soak in the chlorinated water for about 10-20 minutes.
- Thoroughly rinse the skin clear with clean, lukewarm water.
- Pat dry gently, do not rub.
- Apply prescribed moisturizing cream or medication as soon as possible.
- This may be repeated 2-3 times per week, but if used more frequently may dry the skin. Be careful about using bleach baths if there are many breaks in the skin, as it may be irritating or even painful. Monitor results because if it is too drying, it is advisable to use less frequent bleach baths.
Note: Always be cautious around bleach and a tub of water and your child. Maintain control of the bleach bottle. Make sure the bleach is only sodium hypochlorite at 6%. Add 1/4-1/2 cup bleach to the tub of water, mix thoroughly, then place bleach container in a safe area away from your child. As drownings can happen in an inch of water and accidents like slipping and falling can occur, it is imperative to be present during this entire process from the time the tub is being filled with water until the tub is completely drained after the bath.
Figure 4 Below are instructions for each step of the wet to dry wrap treatment.
4. Wet to dry wrap for severe eczema and eczema flares:
This treatment works best after bathing or moisturizing and medicating. It should only be performed under the supervision of your child’s Allergist-Immunologist.
- Soak a roll of clean cotton gauze briefly in lukewarm water.
- Wring out the roll of gauze as hard as possible so it is barely damp.
- Apply prescription topical steroid to your child’s skin as recommended by your child’s Allergist-Immunologist.
- Wrap affected areas with the damp gauze.
- Wrap the dry areas with dry gauze. Put on cotton gloves and socks, if desired. Then put on a snug layer of dry, nighttime clothing over both wet and dry wraps so they remain undisturbed and in place overnight.
As an alternative for younger children, a snugger set of pajamas with a long-sleeved shirt and long pants can be used for the wet layer and a looser set that can fit over the wet layer can be used for the dry layer.
Test to identify allergic triggers
Allergy testing for food and environmental allergies and patch testing for chemical allergy are the two quickest, easiest, and most accurate tests when performed by a board-certified Allergist-Immunologist. To briefly recap allergy skin testing, a small amount of food, pollen, pet dander, mold, or insect extract is placed just underneath the skin in the layer above that containing the master allergic cells. If recognized, the allergic cell releases histamine, which causes leakage and dilation of the blood vessel(s) under the skin to form a hive. No reaction occurs in areas that are not recognized by the allergy cells. This type of testing is used for allergies that cause an immediate reaction.
To summarize, in the patch testing process, chemicals in various dilutions are placed in contact with the skin for a prolonged time and then the irritation or allergic inflammation is read and interpreted. This testing is best for delayed-type allergy, or that which takes time to develop.
Eliminate the itch
Allergists nickname eczema “the itch that rashes” and call the flares by the trauma of itching the “itch-scratch cycle”. The frail skin is damaged by this usually minor trauma in patients with eczema. Itching also has a huge effect on sleep and stress for eczema patients, worsening the already-compromised quality of life.
The solution is to avoid food, environmental, and chemical triggers; start allergy shots for environmental allergies that are unavoidable. Any leftover itch should be treated with antihistamines and anti-leukotrienes that block the two major allergic chemicals that are released from allergic cells, histamine and leukotriene.
Reduce inflammation
Depending on the severity and acuity, atopic dermatitis is treated with topical steroids, antibiotics, phototherapy, biologics, and immunosuppressants to control inflammation that cannot be managed in other ways.
Topical steroids have been the mainstay of treatment until recently. These should be used under an Allergist-Immunologist’s supervision, as they have many side effects, including thinned skin and infections. One significant advantage of topical steroids is they tend to be fast-acting. Sensitive areas such as the eyelids, face, and genitals should be avoided.
Steroids are available in multiple strengths. Stronger steroids are used for a shorter period of time during flares and on thicker areas of skin. Once controlled, the strength is reduced.
Because regular use can result in “steroid flare” –a condition in which withdrawal of a steroid results in a great worsening of the eczema rash—it is advised that once the steroid strength is reduced and the rash controlled, it is recommended that the medication be tapered rather than stopped abruptly.
For example, if the steroid triamcinolone was used twice daily for two weeks and the rash is gone, the triamcinolone should then be used once daily for one week, every other day for one week and twice weekly for one week. If at any time the rash becomes worse, return to the last application schedule in which control was achieved and slow or stop the taper
Topical calcineurin inhibitors, such as tacrolimus (Protopic) and pimecrolimus (Elidel) help control eczema and are particularly helpful for sensitive areas like the face. They may require a month or more to take effect and need to be used regularly to work completely.
Crisaborole (Eucrisa) is a topical phosphodiesterase-4 (an enzyme that increases inflammation) inhibitor that controls activation of immune cells and the resulting inflammation in the skin. It may require a month or more to take effect and needs to be used regularly to be effective.
Dupilumab (Dupixent) is the first biologic agent to be FDA-approved for atopic dermatitis. Dupixent targets the immune system cells that create the inflammation of eczema. Regular use reduces inflammation, itch, redness, and rash. Dupixent is a prescribed drug for use in patients six years old and older that have moderate to severe atopic dermatitis.
In extremely difficult eczema cases, drugs that suppress the immune system such as methotrexate, mycophenolate, and cyclosporine are used. These drugs are not FDA-approved for this purpose (they are FDA approved for other conditions) but have been used successfully before we found adequate treatment for atopic dermatitis. Many side effects are possible and therefore, they must be prescribed by physicians and carefully monitored.
| Medications | Method of Action | Side Effects | Age of use |
| Elidel (pimecrolis) 1% cream | Controls inflammation | Headache, cold, nasal congestion, sore throat, cough, influenza, fever, viral infection, allergic reaction, burning or feeling of warmth | For mild to moderate eczema in patients >2 yo |
| Protopic (Tacrolimus) .03%, 0.1% | Same | Same | For mild to moderate eczema in patients 0.03% >2 yo
0.1% >16 yo |
| Crisaborole (Eucrisa)
2% ointment; twice daily |
Decrease inflammation | Allergic reaction, skin irritation, hives, swelling, redness, burning or stinging; application site pain | >3 months
Avoid eyes, mouth, vagina |
| Dupilumab (Dupixent)
Dose every 2-4 weeks based on weight and age |
Decreased inflammation | Allergic reaction, eye inflammation, increase in allergic white cells, worsening of asthma, risks of decreasing steroids, joint aches, infections; injection site reactions, conjunctivitis, blepharitis, oral herpes, keratitis, eye pruritus, other herpes simplex virus infection, dry eye, and eosinophilia, hand-foot-and-mouth disease and skin papilloma |
>6 months Moderate to severe |
| Ruxolitinib (Opzelura)
1.5% |
Inhibits inflammation | Allergic reaction, serious infections, higher all-cause mortality, including sudden cardiac death, lymphoma and other malignancies, myocardial infarction, stroke, thrombosis (including deep vein thrombosis, pulmonary embolism, and arterial thrombosis), non-melanoma skin cancers, blood abnormalities; nasopharyngitis, diarrhea, bronchitis, ear infection, eosinophil count increased, urticaria, folliculitis, tonsillitis, and rhinorrhea; avoid live viral vaccines | Mild to moderate atopic dermatitis pateitns > 12 yo |
| Abrocitinib (Cibinqo)
100 mg by mouth daily (200 mg if not responding) |
Inhbits inflammation | Allergic reaction, increased risk of serious infection, higher all-cause mortality, including sudden cardiac death, lymphoma and other malignancies, myocardial infarction, stroke, thrombosis (including deep vein thrombosis, pulmonary embolism; avoid liv viral vaccines; nasopharyngitis, nausea, headache, herpes simplex, increased blood creatinine phosphokinase, dizziness, urinary tract infection, fatigue, acne, vomiting, oropharyngeal pain, influenza, gastroenteritis, impetigo, hypertension, contact dermatitis, upper abdominal pain, abdominal discomfort, herpes zoster, and thrombocytopenia | Adults with moderate-to-severe eczema that did not respond to other treatments |
Barrier Maintenance
The first step to barrier maintenance is over-the-counter creams and emollients with ceramides. If these products are not helpful, your child’s Allergist-Immunologist may try prescription creams. These creams supply the lipids and ceramides from fats, oils, and waxes that eczema patients typically lack.
Recommendation to minimize stress
Patients with chronic eczema have among the highest rates of anxiety and depression when compared with patients with other severe and chronic illnesses. Yet the immune system does not work properly when under stress so it is my recommendation that stress be addressed as well.
Here are some suggestions to decrease stress:
- Make sleep a priority.
- Eat healthy meals regularly.
- Distract your child with activities he/she enjoys and that require concentration, like puzzles.
- Be gentle on yourself and your child: this is not your fault nor is it his/hers.
- Try relaxation techniques like yoga, meditation, and prayer.
- This releases hormones that protect us, relax us, and make us feel better. The release of “feel good” hormones during exercise is known as “runner’s high”.
- Comedy shows, funny movies and funny people are great stress relievers.
- Have your child call a friend and connect with others. It is widely believed that as a society, we have lost so much connection with other people, and this is an incredible source of anxiety, depression, depersonalization, and dehumanization.
- Journal: have your child write about his/her feelings.
- Be creative: try having your child draw, color, paint, play music, listen to relaxing music.
- Let your child take time for himself/herself.
- Try (and this is hard) not to dwell on the negative and don’t let your child dwell. Teach your child to recognize what he/she are doing, try to change thoughts or journal about how he/she could change. Understand that it is natural to “go negative” as this is a survival mechanism. After all, the lamb that thought the lion would treat her well probably did not last as long as the one that was wary and anxious in his presence.
- Be positive and try to encourage positivity in your child. Challenge your child to name three good events of the day. Have them write them in a journal and reread them from time to time; this will reinforce positive thinking.
- Ask your child to give someone a compliment. This not only makes the person they complement feel good, it increases positive feelings toward your child.
- Show your child how to help others. Working at a charitable event for a good cause is known to increase the “feel good” hormones. This response has been called “helper’s high”.
- Find a support group. Bring your child and encourage them to talk it out with people that understand what he/she is going through.
- Get professional help to cope with excess worry or negative thinking, especially if his/her thoughts are extreme or involve self-harm or harming others.
Call 480-500-1902 or request an appointment at https://relieveallergyaz.com/contact now! Begin your allergy testing journey with Dr. Wendt at Relieve Allergy in Scottsdale, Arizona—It’s time to take care of yourself!
Learn more about Dr. Wendt and Relieve Allergy Asthma & Hives at www.relieveallergyaz.com or connect with us: https://www.facebook.com/RelieveAllergy/, https://www.linkedin.com/in/julie-wendt/, https://x.com/RelieveAllergy, https://www.instagram.com/relieve_allergy/ or https://www.youtube.com/@JulieWendt-qx7jm. Did you know? Dr. Wendt wrote the book on allergies. Buy it at: https://geni.us/WhatsEatingOurKids
Relieve Allergy Asthma & Hives is located near Kierland Commons, 21803 N. Scottsdale Road Ste. 200, and has convenient evening and morning hours to accommodate your schedule. Dr. Wendt is also available for telemedicine appointments as appropriate. Most insurance plans are accepted.
DISCLAIMER: This blog is not meant to substitute for medical care by an Allergist-Immunologist nor is it intended to provide medical advice or imply a Physician-Patient relationship with its readers or their family. It is intended to provide guidance, direction, and moral support from someone experienced in testing and treating allergies. This is also not meant to be a “do-it-yourself” manual or a “how to” overcome your allergies. Some of the issues mentioned, whether allergic or look-a-like, can be dangerous or if left unchecked, deadly. Please develop a relationship with a Physician you trust to help you with diagnosis, advice, questions, and treatment regarding your and your family’s medical conditions.
