September 23, 2024 • 26 mins
Do you have eczema-prone skin? Tune in to this episode to hear Dr George Moncrieff and Dr Roger Henderson discuss three important areas of eczema management; the treatments, the lifestyle changes and how to prevent flare-ups.
Your two dermatology experts will also cover:
- How to wash your eczema-prone skin
- What to do if your eczema is infected
- How you can keep track of your eczema flare-ups in a way that will give doctors the information they need to tailor your treatment to your skin
Thank you to our kind sponsor AproDerm, who provide a range of emollients designed for the management of dry skin conditions, including eczema, psoriasis and ichthyosis.
Everyone’s skin is unique and what works for one person, may not work for another. That’s why AproDerm has developed the AproDerm Emollient Starter Pack. This pack contains all four of their emollients varying in their formulation, consistency and hydration, giving you the choice to find a routine which suits you.
Find out more here.
IG: https://www.instagram.com/aproderm/
FB: https://www.facebook.com/AproDerm
We hope you find this podcast interesting and helpful. Please leave us a review or email info@aproderm.com with any feedback on this episode or suggestions on skin-related topics that you would like to hear about in future podcasts.
The views expressed in this podcast are of Dr George Moncrieff and Dr Roger Henderson. Fontus Health has not influenced, participated, or been involved in the programme, materials, or delivery of educational content.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:10):
Hello and welcome to this latest Skin Deeppodcast, where we look at skin-related
issues, conditions and treatments,in an interesting and informed way.
I'm Dr Roger Henderson, and I'm aGP with a long-standing interest
in this particular area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I'venow retired from my practice.
(00:33):
I'm also the past Chair of theDermatology Council for England.
This is the second of a two-partpodcast on eczema, and today we're
looking at how eczema is treated,including self-help tips, and how
to prevent the condition flaringup, along with some skin treatment.
If you were with us last time,you'll know that George and I talked
about the basics of atopic eczema.
(01:00):
So George, let's start with thebasic principles of management
today, and I suppose, first ofall, we should be trying to avoid
anything that's irritating the skin.
It's fairly basic, but it isthe perfect starting place if
we talk about eczema, isn't it?
What I actually say to my patientsis, "Tell me, how do you wash?"
(01:24):
And they often look quiteastonished at that question.
So I sit back and say, "Well okay, doyou have a bath or do you have a shower?
And how long are youin the bath or shower?
How hot is the water?
How often do you have a shower or a bath?
And what are you washing with?
Are you washing with shower gel and soaps?
Are you washing your hair withshampoo, that you're allowing
(01:47):
to rinse all over your skin?
Do you ever use a foam bubble bath?"
Because, I say, "Your eczema willnever settle, unless you stop
all detergents, all soaps, showergels, shampoos on your skin.
With that, it will be an ongoing problem."
(02:08):
And it's a Catch-22 in some ways, becausewith advertising, we are bombarded
these days with, you know, the perfectsoaps, the perfect shampoos, you
should be using this for skin health.
And for someone with eczema, it'sthe worst thing they can be doing.
So, I can understand why they thinkthey're doing the right thing, if
(02:29):
they're using a pH neutral soap or amild skin soap, a soap that cares for
your skin, all the phrases that we hear,but actually it's still absolutely the
wrong thing they can be doing, isn't it?
Well, it's less bad.
Certainly, normal soap, normalshower gels have a very high pH.
They're alkaline, and that'svery abnormal for the skin, and
(02:51):
so it causes a lot of damage.
Also, soaps and detergents, they'redesigned to degrease the skin, and the
grease is there to help, to protect theskin from losing water, to preserve water.
So, by degreasing, you'remaking things worse.
Certainly, the synthetic detergents,the much gentler ones, the so-called
'syndets', have a much more acidicpH and they're less degreasing,
(03:17):
so they're a lot less damaging.
But if you've got bad eczema, Iwould say stop those two and use
an emollient as a soap substitute.
Emollients are pH balanced to maintainthat acid environment on the skin, and
emollients will regrease your skin, ratherthan detergents, which degrease the skin.
(03:37):
They will actually soften the skin andmake things better, whereas, even syndets
in my experience, can make eczema worse.
The other tip, I have to say,is that, yeah, people, you
know, they do want to wash.
I wash every day, but Iwash with an emollient.
If you're fortunate enough to havehair, and neither Roger and I have a
big issue there, but yes, if you'vegot hair, that hair needs washing.
(03:59):
And so, by all means, washyour hair with a shampoo.
If you've got bad hand eczema,you probably ought to use gloves
or get somebody else to help you.
But don't let that shampoo get ontoyour scalp, if you can help it.
Don't let it go over your body.
So ideally, put your head back overthe back of a sink and get somebody
to help you, but, if you must washit in the shower, the very least,
(04:21):
just wash the hair, trying notto get too much on the scalp, and
then rinse it off very thoroughlyoff your body, not onto your body.
Now what about what we wear, George?
I'm thinking things like, woolcompared to things like silk or cotton.
Can what we wear, certainlydirectly onto our skin, impact
on the state of someone's eczema?
(04:44):
I don't think wearing things wouldactually cause eczema but certainly
if you're wearing, woollen thingsagainst rough dry skin, they will
snag and catch and feel uncomfortable.
So many patients have discovered thatusing cotton, or even better perhaps, silk
pyjamas is very much more comfortable.
Another thing is avoid getting too hot.
If the skin is hot that makes it moreitchy so don't wear too many thick layers.
(05:08):
But well-fitting, comfortable, modernclothes tending towards cotton, and
maybe silk, if you can afford it asyour pyjamas, a lot more sensible
than having wool against the skin.
So, yeah, keep the wool away.
People worry that lanolin cancause allergies and things.
Lanolin is an oil presentin wools, sheep wools.
Lanolin allergy is much, much morerare than is generally believed.
(05:31):
Yes.
It went through a phase, some years agowhere a lot of people thought there was
a lanolin link and we found that therewasn't. People listening to our podcast
will hear us talk about emollients, timeand time and time again, won't they?
And these are absolutely crucialwith the treatment of eczema.
Emollients, moisturisers in another name.
(05:55):
The three E's, which doctors oftentalk about with treating eczema, are
emollients, emollients, and emollients.
Now I know we've talked about thisat length, but it's just worth
mentioning again, how importantthese are just to hydrate our skin.
Without emollients, we're reallygoing to struggle to control eczema.
Indeed, that is exactly the problem.
(06:16):
So we should be using anemollient as a soap substitute.
That can be a fairly cheap,non-sophisticated emollient, because
it's going to go down the drain, andyou're using it as something that's
going to just generally help to regreasethe skin and maintain that surface pH.
But do be careful because thatemollient will make the shower
tray or a bath quite slippery.
(06:37):
For yourself, and for the next person, andit could, over time, clog up the drain.
So the drains may need attention as well.
A soap substitute is really a verysensible first thing to change.
So when you come out of thebath or the shower, it's a great
time to apply a sophisticatedemollient over all your skin.
Your skin is nice and moist.
(06:57):
You can trap that moisture in the skin.
It's nice and warm.
So just stand on a towel and just strokeemollient all over your whole body.
The whole skin isabnormal in atopic eczema.
The whole skin has anabnormal skin microbiome.
The whole skin is drier than normal.
And the whole skin hasa higher pH than normal.
So putting an emollient on willhelp to address all of those.
(07:19):
And of course, the best emollientis the one that you like.
So, do make sure that you areprescribed an emollient, in
adequate quantities, to do that.
And I'm talking about, half a greatbig tub per week for a child, or
a whole tub for an adult per week.
So you need four of those a month,if you're going to be using it
(07:39):
appropriately, if you're covering yourwhole body with that after washing.
And that, in my experience, can makea dramatic difference to how your
skin feels, how severe your eczemabecomes, and to prevent flares.
It's a really important part of themanagement, as Roger was saying.
Amongst the emollients we've got,I have to say I really do like the
(08:00):
AproDerm® range, and that is why I wasvery pleased when they were prepared to
sponsor and support this podcast series.
They've got AproDerm® EmollientCream, which is perfect as a
leave-on if you want, but it canalso be used as a soap substitute.
It mixes beautifully with water,as does the AproDerm® Gel which,
although it's called a gel, it doesn'tlook like a sort of clear jelly,
(08:23):
it's actually much more of a cream.
And then they've got the very nice,sophisticated AproDerm® Colloidal
Oat Cream, which containing colloidaloat is really lovely and soothing
on itchy, dry skin conditions.
But also the colloidal oat extendsthe TEWL, the transepidermal water
loss time, the amount of time ittakes before water starts to leave the
(08:45):
skin again after you've applied it.
And by extending that, it's really usefulbecause patients haven't got to apply it
so often and makes it also more economic.
So it's a really lovely product there.
But if you want to, see which ofthose you prefer, they're the only
company to produce a patient starterpack, which can be prescribed.
And then you can take those away andtry them out and see which one you like.
(09:08):
I've used those and I'vefound them excellent.
And as someone with no hair, either on hisface or indeed on his head, I find them
an excellent moisturiser, that preventsme running into problems with dry skin.
You mentioned, the prescribing ofemollients, by doctors there, George.
Also, some people listening willhave had topical steroid creams and
(09:30):
ointments prescribed by their doctor.
And I think it's probably worthjust mentioning these, in passing.
Some people can be slightly concernedjust by hearing the word steroids,
but they do have their place withthe treatment of eczema, don't they?
And I've used them for decades quitehappily, but they are not something
(09:52):
that we should just be using allthe time, constantly, and slapping
them on without a second thought.
They're not licensed forlong-term use in that way, at all.
I think I couldn't manage skin diseasewithout the use of topical steroids.
They're wonderful.
They're clean, they don'tsmell and they work.
They are really excellentfrom that point of view.
(10:14):
So when I do prescribe them, I wouldprefer to prescribe them as ointments.
Now I'd ask your doctor to prescribethem as an ointment, not as a cream.
I'm sure when you put a cream on, it soaksin, it's nicer to use, and an ointment
feels sticky and tacky for longer.
But you're going to end up using theseon and off, for a long, long time, almost
inevitably, and creams have a high watercontent, so they need preservatives
(10:36):
to stop bacteria growing in them.
You can become sensitised tothe preservatives in them.
So an ointment, having a lowwater content, doesn't need that.
Also, an ointment gives much betterskin barrier protection and it
also stays where you want it to be.
It is less likely to spread everywhere.
So nearly always, an ointmentis the right thing to use.
(10:57):
You only need to put yoursteroid on, at most, once a day.
And so putting a sticky ointment onat bedtime is less of a problem than
having to use things during the daywhen you perhaps need to use your hands,
and other parts of your body, and theointment will be too sticky and tacky.
But they are only intended for quiteshort courses, like a couple of weeks.
(11:19):
And if I do prescribe them, I like touse a strength that is going to work.
So I tend to start strong, with anointment, once a day, and if that is
used, it will normally get things undercontrol within a couple of weeks, at most.
Then you can drop down to a maintenancedose where you use it just for
two consecutive nights a week.
(11:39):
So, for example, a Saturdayand a Sunday night.
We call that weekend therapy, and dothat for a further couple of weekends.
So that you don't just suddenly withdrawand then things rebound and get bad again.
But patients, rightly I think,are concerned about putting
steroids on their skin and weshouldn't be using them long-term.
They're not designed for flareprevention or for maintenance.
(12:03):
And I think their concerns arelegitimate and I think it's professional.
We haven't listened to thoseconcerns carefully enough.
Just blamed our patients, thatthey're not using them, they're not
adhering to our treatment, and that'swhy their eczema is not getting
better, rather than acknowledgingthat their concerns are justified.
Because steroids aren't thatgreat for a number of reasons.
They do raise the pH, and I'vebeen talking a lot about pH.
(12:27):
They make the skin thinner.
They reduce the support proteinsin the deeper parts of the skin.
They interfere with the ability ofthe skin to make a skin barrier.
And they give very broadimmune suppression.
So, if there's any infectionthere, they can actually cause
that infection to go a bit deeper.
So, there are problemswith topical steroids.
And we have got alternatives,which we'll come on to.
(12:50):
So, yes, they're great forgetting things under control.
Hit it hard, get it undercontrol, and drop the dose down.
But don't just blunder on with themfor long-term, and if you're anxious
about using them, discuss that withyour doctor and see whether they
can talk to you about other things.
But don't forget the emollients!
They're important all the way through.
Absolutely.
(13:10):
I'm often asked by patients "Doctor,which should I put on first?
Should I put my steroid onfirst, or my emollient on
first, or the other way around?"
And I tend to say to them, "Itdoesn't really matter too much,
but try and give it, half an houror so between putting them on."
Perhaps put the emollient on first,is perhaps the one I tend to favour.
(13:31):
You know, it helps to get that skinnicely hydrated, and perhaps more
receptive to putting the steroidon, sort of, 30 minutes later.
Is that the sort of generaladvice that you'd give?
Exactly that, yes.
Cover the whole skin with theemollient because that's what you
want to be doing, treating the wholeskin, and then you can target the
worst areas with the topical steroid.
But the critical message, as yousaid, is have about a half an hour
(13:54):
interval if you can, between the two.
So, emollient first, generally, andthen last thing before you get into
bed, just pop the topical steroidonto the areas where you want to
get things under better control.
Yeah, nice and simple.
Now we both have seen many patients,and sometimes it's the reason why
patients with eczema actually presentto us, is with infected eczema.
(14:16):
Which is obviously a big risk ofsomeone with, all stages of eczema,
but obviously the more severe theeczema, the more likely, perhaps,
it is that it can become infected.
And as a general rule, I thinkI've learnt that, don't treat
the infection per se, unless thatpatient is actually really ill.
(14:37):
Treat the eczema, and usually ifyou treat the eczema correctly,
the infection will start to settle.
Having said that, as I say, if thepatient is unwell, then we should be
looking to treat them with antibiotics.
I think that's somethingthat we would both concur on.
Do you agree?
Yes.
If the eczema is managed, and the skinbarrier is covered by treating the eczema,
(14:59):
the body will deal with the infection.
So I reserve antibiotics, and Idon't use topical antibiotics,
for eczema really at all.
I know many dermatologists do, but Iprefer to avoid topical antibiotics.
I treat the patient who's ill, and Itreat them with a systemic antibiotic.
And I'm not treating the eczema there,I'm treating the illness of the patient.
(15:20):
So, yeah, I think with antibiotics, you'remessing up their microbiome, for a start.
All flares will be infected.
So, you may want to use somethingantiseptic, that's perhaps reasonable,
particularly, if someone's gettingrepeated flares, one flare after
another, just keep bouncing back.
But then you may want to use anantiseptic to try and sort of knock
that back, but even that will damagethe microbiome quite disastrously.
(15:43):
Yeah.
So again, we come back to, keep theeczema as well controlled as we can,
and by doing that, you're reducingthe chances of flares occurring.
There's been a vogue recently,for bleach baths and, and...
Oh yes, we both, I think, I suspect, havegot the same views about bleach baths.
They're not, we're goingto say, don't use bleach.
(16:04):
It's a Milton® bath, but Milton® issodium hypochlorite, I believe, and that
is a very, very, very potent alkali.
And so even when you dilute it, onepart to a thousand, which is what you're
probably going to do in a bath, you'vestill got an alkaline solution there.
It's so alkaline.
So it needs very little of that towreak havoc on the skin barrier.
(16:27):
But it's also an incrediblypotent antiseptic and it will
just blast everything to pieces.
So I think that if you use a bleachbath, I can only imagine one or two
circumstances in my career, when I mighthave felt that it could have been useful
for the patient, who's going from onecatastrophic, badly infected flare to
(16:48):
another, just to knock things back.
But, I personally, would not want tonapalm the skin with bleach at all.
There are a lot ofdermatologists who swear by them.
They're, you know, some exceptionallyimpressive dermatologists.
But for me, bleach baths are notpart of my armamentarium, at all.
No, I think those of us of a certainage, listening, may still shudder
(17:12):
at the memories of their mum puttingDettol in the bath when they'd come
in off the football or rugby pitch.
I'm sure my skin hasn't quite recovered.
It will never recover.
[Laughing] So we touched, as well, onantibiotics and they can, obviously,
(17:32):
have a place, but because antibioticsdo impact on the makeup of the skin,
what we call the skin biome, again, wehave to be slightly careful about using
antibiotics in eczema, although manypeople will have had experience of being
prescribed antibiotics for their eczema,but it's just, use with care, isn't it?
(17:55):
Yes.
Absolutely.
So, people listening with eczema,they may know how their eczema goes,
they may be comfortable with how theytreat it, they may be less clear about
when they should be speaking withtheir doctor about, when to see them,
(18:16):
or discuss their eczema with them.
What are the sort of things, thatpeople listening, with eczema, should
be looking out for, as to when to,perhaps just, at least pick up the
phone, or speak with their healthcareprofessional about their eczema?
Well, the most obvious is, when the skinis getting out of control, and they're
having a bad flare which is impactingon their ability to lead a normal life.
(18:40):
So, that's when patients generallytrot along and come and see us.
But, I think, we as a profession, havebeen very bad about inviting the patient
to come back once the flare is undercontrol, to discuss how to keep their skin
healthy and to prevent the next flare.
I don't think we've givenenough time and attention to
(19:00):
thinking about flare prevention.
And there's more to flare preventionthan just not using soaps and detergents
and things we've been talking about.
So, yes, a large part of that is usingemollients optimally, but there are other
things that your doctor can talk to youabout and prescribe, including topical
immunomodulators, which are designed tobe used long-term, and to prevent flares.
(19:24):
So I think that, if you've been havinga problem with repeated flares, not a
bad idea, perhaps, to consider goingalong to see a doctor and say, "Look,
what can we do to prevent these flares?"
So I think that would be oneof the first things I'd say.
Yeah.
The second is, there's awonderful app, produced by Fontus
Health, called mySkinHealth App.
mySkinHealth, all one word.
(19:46):
It's a free app, you can download,and on that you can record all the
treatments you're using on your skin.
All the treatments that are available.
But it also includes an objectivemeasure of how bad your eczema is.
It's called the POEM.
P-O-E-M, which stands for Patient-OrientedEczema Measure, and it asks you to score
(20:08):
how bad your eczema has been in thelast week, against about 10 different
stem questions, like, how itchy is it?
And how much has it disturbed your sleep?
And so on.
So you can score it and it recordsthat and it will remind you
every week to do another POEM.
So how have things beenover the last week?
And if you can see that your POEM scoreis getting progressively worse, then you
(20:30):
might be heading towards a flare, andyou might be able to nip it in the bud by
contacting a doctor and discussing things.
Do you need to step up your steroid,for example, briefly, for a week or so?
Or could you use something else?
And, what else is goingon that's driving this?
So, that's another situation, whereI'd say seeing a doctor would be good.
I think, in this modern ageof, digital technology, video
(20:52):
consultation, sending photographsto your GP, they can be useful.
I know that George and I have had thesame experience with this, which is that
the quality of the image that you sendto your doctor is absolutely crucial.
So it's only as good as thetechnology that you've taken your
(21:12):
picture on, and it's only as goodas technology at the doctor's end.
So if you are going to send apicture to your doctor, which as
I say, can be very helpful, makesure you do it in very good light.
Ideally, get someone else to takethe picture for you, get the picture
as sharply in focus as you can.
(21:33):
It's very frustrating if someone'staken all the effort to send a photo
to you, but it's slightly out of focus,because that really isn't any use.
So, don't be afraid to send a photographto your, your GP, provided you can
get it as crisp as it can look, aswell-lit as it can be, and in the
highest quality that you can get it.
(21:54):
That's really what we're afterand I think George and I have
probably had both experience ofbeing frustrated with poor quality
photographs through no one's fault.
It's so critical that, it really is,and what's quite nice, is to have a view
from a slight distance so you can orientyourself, which part of the body it is
and then a close-up, and the close-upis the one that's often out of focus.
(22:16):
So, by tapping on your smartphone screen,that often brings it into focus at the
point where you tap it on the image.
So, a nice orientating image froma distance, or, if it's just a
close-up, then make sure you tellus which part of the body this rash
or this change is, where it is.
Good information in, you'llget good advice back.
That's such an important message, and I'mtrying to try to advise when you've got
(22:39):
an image that's completely out of focus.
I've occasionally said, "Is this a pictureof a human being, or is it the wall?"
You can't be sure sometimes.
[Laughing] So the messages fromthe wayside pulpit, I suppose,
that we've covered today, George.
Avoid irritants, especiallythings like detergents.
(23:02):
Look at whether you're wearing harshclothing directly onto your skin,
making sure that you're using enoughemollients, moisturisers, and quantity
is really important, and usingthem regularly is absolutely vital.
Don't be afraid of using topicalsteroids appropriately and correctly,
(23:24):
but not constantly in the long-term.
If we can treat our eczema properlyin the first place, we'd reduce the
risk and likelihood of it becominginfected, but occasionally, if you
do have infected eczema, it mayneed treating with antibiotics,
but again, not for the long-term.
And if you're thinking about scoring youreczema, making sure that it's as good as
(23:49):
it can be, or if you're concerned thatit may be getting away from you, the
mySkinHealth app is a really nice placeto go, to just keep an eye on it, to see
if it's getting better or getting worse.
And I think those, really, are the keypoints we've made, aren't they, George?
Absolutely, those are the key points.
Just a couple of other quick ones.
(24:09):
I would urge you probably notto rely on antihistamines.
Histamine does not mediatethe itch in eczema.
And the old-fashioned sedating ones canmake you sleepy, which might be quite
nice, but that drowsiness can lastwell into the next day and interfere
with your functioning the next day.
So, even those I'd probably avoid.
(24:30):
So, antihistamines are not consideredappropriate any longer for atopic
eczema, but watch this space.
We're going to have alternativesfor helping itch in the
foreseeable future, hopefully.
And the other, just a quick messageis, I think all patients with atopic
eczema should be on vitamin D.
I think vitamin D is the panacea forso many things, and I take vitamin D,
(24:50):
but I would say, is to take it orally,even children and in adults, I think
a little of sensible, non-burningsunlight could do some good for eczema.
We use ultraviolet light to treatsevere eczema, for example, but
definitely consider taking vitamin D.
It's very hard to overdose on vitamin D.
You have to take industrial doses.
So, take some sensible vitamin D.
(25:11):
One, two, or three thousand unitsa day would be very reasonable.
And that has been shown to be helpful.
I think that's a really good place towrap this particular podcast up, George.
It's recommendations I giveto my patients, and in fact,
I take vitamin D as well.
So I hope that everyone listening to ustoday has found this podcast helpful,
and interesting, and if you do haveeczema, that you've come away with tips
(25:35):
that will help to improve your skin,both in the short and the long-term.
Roger and I look forward to you joiningus again in two weeks time when we'll be
talking about more skin-related topics.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Skin Deep podcasts together.
So, until the next time,it's goodbye from George.
Goodbye.
(25:56):
And it's goodbye from me.
Goodbye.
Hello and welcome to this latest Skin Deeppodcast, where we look at skin-related
issues, conditions and treatments,in an interesting and informed way.
I'm Dr Roger Henderson, and I'm aGP with a long-standing interest
in this particular area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I'venow retired from my practice.
(00:33):
I'm also the past Chair of theDermatology Council for England.
This is the second of a two-partpodcast on eczema, and today we're
looking at how eczema is treated,including self-help tips, and how
to prevent the condition flaringup, along with some skin treatment.
If you were with us last time,you'll know that George and I talked
about the basics of atopic eczema.
(01:00):
So George, let's start with thebasic principles of management
today, and I suppose, first ofall, we should be trying to avoid
anything that's irritating the skin.
It's fairly basic, but it isthe perfect starting place if
we talk about eczema, isn't it?
What I actually say to my patientsis, "Tell me, how do you wash?"
(01:24):
And they often look quiteastonished at that question.
So I sit back and say, "Well okay, doyou have a bath or do you have a shower?
And how long are youin the bath or shower?
How hot is the water?
How often do you have a shower or a bath?
And what are you washing with?
Are you washing with shower gel and soaps?
Are you washing your hair withshampoo, that you're allowing
(01:47):
to rinse all over your skin?
Do you ever use a foam bubble bath?"
Because, I say, "Your eczema willnever settle, unless you stop
all detergents, all soaps, showergels, shampoos on your skin.
With that, it will be an ongoing problem."
(02:08):
And it's a Catch-22 in some ways, becausewith advertising, we are bombarded
these days with, you know, the perfectsoaps, the perfect shampoos, you
should be using this for skin health.
And for someone with eczema, it'sthe worst thing they can be doing.
So, I can understand why they thinkthey're doing the right thing, if
(02:29):
they're using a pH neutral soap or amild skin soap, a soap that cares for
your skin, all the phrases that we hear,but actually it's still absolutely the
wrong thing they can be doing, isn't it?
Well, it's less bad.
Certainly, normal soap, normalshower gels have a very high pH.
They're alkaline, and that'svery abnormal for the skin, and
(02:51):
so it causes a lot of damage.
Also, soaps and detergents, they'redesigned to degrease the skin, and the
grease is there to help, to protect theskin from losing water, to preserve water.
So, by degreasing, you'remaking things worse.
Certainly, the synthetic detergents,the much gentler ones, the so-called
'syndets', have a much more acidicpH and they're less degreasing,
(03:17):
so they're a lot less damaging.
But if you've got bad eczema, Iwould say stop those two and use
an emollient as a soap substitute.
Emollients are pH balanced to maintainthat acid environment on the skin, and
emollients will regrease your skin, ratherthan detergents, which degrease the skin.
(03:37):
They will actually soften the skin andmake things better, whereas, even syndets
in my experience, can make eczema worse.
The other tip, I have to say,is that, yeah, people, you
know, they do want to wash.
I wash every day, but Iwash with an emollient.
If you're fortunate enough to havehair, and neither Roger and I have a
big issue there, but yes, if you'vegot hair, that hair needs washing.
(03:59):
And so, by all means, washyour hair with a shampoo.
If you've got bad hand eczema,you probably ought to use gloves
or get somebody else to help you.
But don't let that shampoo get ontoyour scalp, if you can help it.
Don't let it go over your body.
So ideally, put your head back overthe back of a sink and get somebody
to help you, but, if you must washit in the shower, the very least,
(04:21):
just wash the hair, trying notto get too much on the scalp, and
then rinse it off very thoroughlyoff your body, not onto your body.
Now what about what we wear, George?
I'm thinking things like, woolcompared to things like silk or cotton.
Can what we wear, certainlydirectly onto our skin, impact
on the state of someone's eczema?
(04:44):
I don't think wearing things wouldactually cause eczema but certainly
if you're wearing, woollen thingsagainst rough dry skin, they will
snag and catch and feel uncomfortable.
So many patients have discovered thatusing cotton, or even better perhaps, silk
pyjamas is very much more comfortable.
Another thing is avoid getting too hot.
If the skin is hot that makes it moreitchy so don't wear too many thick layers.
(05:08):
But well-fitting, comfortable, modernclothes tending towards cotton, and
maybe silk, if you can afford it asyour pyjamas, a lot more sensible
than having wool against the skin.
So, yeah, keep the wool away.
People worry that lanolin cancause allergies and things.
Lanolin is an oil presentin wools, sheep wools.
Lanolin allergy is much, much morerare than is generally believed.
(05:31):
Yes.
It went through a phase, some years agowhere a lot of people thought there was
a lanolin link and we found that therewasn't. People listening to our podcast
will hear us talk about emollients, timeand time and time again, won't they?
And these are absolutely crucialwith the treatment of eczema.
Emollients, moisturisers in another name.
(05:55):
The three E's, which doctors oftentalk about with treating eczema, are
emollients, emollients, and emollients.
Now I know we've talked about thisat length, but it's just worth
mentioning again, how importantthese are just to hydrate our skin.
Without emollients, we're reallygoing to struggle to control eczema.
Indeed, that is exactly the problem.
(06:16):
So we should be using anemollient as a soap substitute.
That can be a fairly cheap,non-sophisticated emollient, because
it's going to go down the drain, andyou're using it as something that's
going to just generally help to regreasethe skin and maintain that surface pH.
But do be careful because thatemollient will make the shower
tray or a bath quite slippery.
(06:37):
For yourself, and for the next person, andit could, over time, clog up the drain.
So the drains may need attention as well.
A soap substitute is really a verysensible first thing to change.
So when you come out of thebath or the shower, it's a great
time to apply a sophisticatedemollient over all your skin.
Your skin is nice and moist.
(06:57):
You can trap that moisture in the skin.
It's nice and warm.
So just stand on a towel and just strokeemollient all over your whole body.
The whole skin isabnormal in atopic eczema.
The whole skin has anabnormal skin microbiome.
The whole skin is drier than normal.
And the whole skin hasa higher pH than normal.
So putting an emollient on willhelp to address all of those.
(07:19):
And of course, the best emollientis the one that you like.
So, do make sure that you areprescribed an emollient, in
adequate quantities, to do that.
And I'm talking about, half a greatbig tub per week for a child, or
a whole tub for an adult per week.
So you need four of those a month,if you're going to be using it
(07:39):
appropriately, if you're covering yourwhole body with that after washing.
And that, in my experience, can makea dramatic difference to how your
skin feels, how severe your eczemabecomes, and to prevent flares.
It's a really important part of themanagement, as Roger was saying.
Amongst the emollients we've got,I have to say I really do like the
(08:00):
AproDerm® range, and that is why I wasvery pleased when they were prepared to
sponsor and support this podcast series.
They've got AproDerm® EmollientCream, which is perfect as a
leave-on if you want, but it canalso be used as a soap substitute.
It mixes beautifully with water,as does the AproDerm® Gel which,
although it's called a gel, it doesn'tlook like a sort of clear jelly,
(08:23):
it's actually much more of a cream.
And then they've got the very nice,sophisticated AproDerm® Colloidal
Oat Cream, which containing colloidaloat is really lovely and soothing
on itchy, dry skin conditions.
But also the colloidal oat extendsthe TEWL, the transepidermal water
loss time, the amount of time ittakes before water starts to leave the
(08:45):
skin again after you've applied it.
And by extending that, it's really usefulbecause patients haven't got to apply it
so often and makes it also more economic.
So it's a really lovely product there.
But if you want to, see which ofthose you prefer, they're the only
company to produce a patient starterpack, which can be prescribed.
And then you can take those away andtry them out and see which one you like.
(09:08):
I've used those and I'vefound them excellent.
And as someone with no hair, either on hisface or indeed on his head, I find them
an excellent moisturiser, that preventsme running into problems with dry skin.
You mentioned, the prescribing ofemollients, by doctors there, George.
Also, some people listening willhave had topical steroid creams and
(09:30):
ointments prescribed by their doctor.
And I think it's probably worthjust mentioning these, in passing.
Some people can be slightly concernedjust by hearing the word steroids,
but they do have their place withthe treatment of eczema, don't they?
And I've used them for decades quitehappily, but they are not something
(09:52):
that we should just be using allthe time, constantly, and slapping
them on without a second thought.
They're not licensed forlong-term use in that way, at all.
I think I couldn't manage skin diseasewithout the use of topical steroids.
They're wonderful.
They're clean, they don'tsmell and they work.
They are really excellentfrom that point of view.
(10:14):
So when I do prescribe them, I wouldprefer to prescribe them as ointments.
Now I'd ask your doctor to prescribethem as an ointment, not as a cream.
I'm sure when you put a cream on, it soaksin, it's nicer to use, and an ointment
feels sticky and tacky for longer.
But you're going to end up using theseon and off, for a long, long time, almost
inevitably, and creams have a high watercontent, so they need preservatives
(10:36):
to stop bacteria growing in them.
You can become sensitised tothe preservatives in them.
So an ointment, having a lowwater content, doesn't need that.
Also, an ointment gives much betterskin barrier protection and it
also stays where you want it to be.
It is less likely to spread everywhere.
So nearly always, an ointmentis the right thing to use.
(10:57):
You only need to put yoursteroid on, at most, once a day.
And so putting a sticky ointment onat bedtime is less of a problem than
having to use things during the daywhen you perhaps need to use your hands,
and other parts of your body, and theointment will be too sticky and tacky.
But they are only intended for quiteshort courses, like a couple of weeks.
(11:19):
And if I do prescribe them, I like touse a strength that is going to work.
So I tend to start strong, with anointment, once a day, and if that is
used, it will normally get things undercontrol within a couple of weeks, at most.
Then you can drop down to a maintenancedose where you use it just for
two consecutive nights a week.
(11:39):
So, for example, a Saturdayand a Sunday night.
We call that weekend therapy, and dothat for a further couple of weekends.
So that you don't just suddenly withdrawand then things rebound and get bad again.
But patients, rightly I think,are concerned about putting
steroids on their skin and weshouldn't be using them long-term.
They're not designed for flareprevention or for maintenance.
(12:03):
And I think their concerns arelegitimate and I think it's professional.
We haven't listened to thoseconcerns carefully enough.
Just blamed our patients, thatthey're not using them, they're not
adhering to our treatment, and that'swhy their eczema is not getting
better, rather than acknowledgingthat their concerns are justified.
Because steroids aren't thatgreat for a number of reasons.
They do raise the pH, and I'vebeen talking a lot about pH.
(12:27):
They make the skin thinner.
They reduce the support proteinsin the deeper parts of the skin.
They interfere with the ability ofthe skin to make a skin barrier.
And they give very broadimmune suppression.
So, if there's any infectionthere, they can actually cause
that infection to go a bit deeper.
So, there are problemswith topical steroids.
And we have got alternatives,which we'll come on to.
(12:50):
So, yes, they're great forgetting things under control.
Hit it hard, get it undercontrol, and drop the dose down.
But don't just blunder on with themfor long-term, and if you're anxious
about using them, discuss that withyour doctor and see whether they
can talk to you about other things.
But don't forget the emollients!
They're important all the way through.
Absolutely.
(13:10):
I'm often asked by patients "Doctor,which should I put on first?
Should I put my steroid onfirst, or my emollient on
first, or the other way around?"
And I tend to say to them, "Itdoesn't really matter too much,
but try and give it, half an houror so between putting them on."
Perhaps put the emollient on first,is perhaps the one I tend to favour.
(13:31):
You know, it helps to get that skinnicely hydrated, and perhaps more
receptive to putting the steroidon, sort of, 30 minutes later.
Is that the sort of generaladvice that you'd give?
Exactly that, yes.
Cover the whole skin with theemollient because that's what you
want to be doing, treating the wholeskin, and then you can target the
worst areas with the topical steroid.
But the critical message, as yousaid, is have about a half an hour
(13:54):
interval if you can, between the two.
So, emollient first, generally, andthen last thing before you get into
bed, just pop the topical steroidonto the areas where you want to
get things under better control.
Yeah, nice and simple.
Now we both have seen many patients,and sometimes it's the reason why
patients with eczema actually presentto us, is with infected eczema.
(14:16):
Which is obviously a big risk ofsomeone with, all stages of eczema,
but obviously the more severe theeczema, the more likely, perhaps,
it is that it can become infected.
And as a general rule, I thinkI've learnt that, don't treat
the infection per se, unless thatpatient is actually really ill.
(14:37):
Treat the eczema, and usually ifyou treat the eczema correctly,
the infection will start to settle.
Having said that, as I say, if thepatient is unwell, then we should be
looking to treat them with antibiotics.
I think that's somethingthat we would both concur on.
Do you agree?
Yes.
If the eczema is managed, and the skinbarrier is covered by treating the eczema,
(14:59):
the body will deal with the infection.
So I reserve antibiotics, and Idon't use topical antibiotics,
for eczema really at all.
I know many dermatologists do, but Iprefer to avoid topical antibiotics.
I treat the patient who's ill, and Itreat them with a systemic antibiotic.
And I'm not treating the eczema there,I'm treating the illness of the patient.
(15:20):
So, yeah, I think with antibiotics, you'remessing up their microbiome, for a start.
All flares will be infected.
So, you may want to use somethingantiseptic, that's perhaps reasonable,
particularly, if someone's gettingrepeated flares, one flare after
another, just keep bouncing back.
But then you may want to use anantiseptic to try and sort of knock
that back, but even that will damagethe microbiome quite disastrously.
(15:43):
Yeah.
So again, we come back to, keep theeczema as well controlled as we can,
and by doing that, you're reducingthe chances of flares occurring.
There's been a vogue recently,for bleach baths and, and...
Oh yes, we both, I think, I suspect, havegot the same views about bleach baths.
They're not, we're goingto say, don't use bleach.
(16:04):
It's a Milton® bath, but Milton® issodium hypochlorite, I believe, and that
is a very, very, very potent alkali.
And so even when you dilute it, onepart to a thousand, which is what you're
probably going to do in a bath, you'vestill got an alkaline solution there.
It's so alkaline.
So it needs very little of that towreak havoc on the skin barrier.
(16:27):
But it's also an incrediblypotent antiseptic and it will
just blast everything to pieces.
So I think that if you use a bleachbath, I can only imagine one or two
circumstances in my career, when I mighthave felt that it could have been useful
for the patient, who's going from onecatastrophic, badly infected flare to
(16:48):
another, just to knock things back.
But, I personally, would not want tonapalm the skin with bleach at all.
There are a lot ofdermatologists who swear by them.
They're, you know, some exceptionallyimpressive dermatologists.
But for me, bleach baths are notpart of my armamentarium, at all.
No, I think those of us of a certainage, listening, may still shudder
(17:12):
at the memories of their mum puttingDettol in the bath when they'd come
in off the football or rugby pitch.
I'm sure my skin hasn't quite recovered.
It will never recover.
[Laughing] So we touched, as well, onantibiotics and they can, obviously,
(17:32):
have a place, but because antibioticsdo impact on the makeup of the skin,
what we call the skin biome, again, wehave to be slightly careful about using
antibiotics in eczema, although manypeople will have had experience of being
prescribed antibiotics for their eczema,but it's just, use with care, isn't it?
(17:55):
Yes.
Absolutely.
So, people listening with eczema,they may know how their eczema goes,
they may be comfortable with how theytreat it, they may be less clear about
when they should be speaking withtheir doctor about, when to see them,
(18:16):
or discuss their eczema with them.
What are the sort of things, thatpeople listening, with eczema, should
be looking out for, as to when to,perhaps just, at least pick up the
phone, or speak with their healthcareprofessional about their eczema?
Well, the most obvious is, when the skinis getting out of control, and they're
having a bad flare which is impactingon their ability to lead a normal life.
(18:40):
So, that's when patients generallytrot along and come and see us.
But, I think, we as a profession, havebeen very bad about inviting the patient
to come back once the flare is undercontrol, to discuss how to keep their skin
healthy and to prevent the next flare.
I don't think we've givenenough time and attention to
(19:00):
thinking about flare prevention.
And there's more to flare preventionthan just not using soaps and detergents
and things we've been talking about.
So, yes, a large part of that is usingemollients optimally, but there are other
things that your doctor can talk to youabout and prescribe, including topical
immunomodulators, which are designed tobe used long-term, and to prevent flares.
(19:24):
So I think that, if you've been havinga problem with repeated flares, not a
bad idea, perhaps, to consider goingalong to see a doctor and say, "Look,
what can we do to prevent these flares?"
So I think that would be oneof the first things I'd say.
Yeah.
The second is, there's awonderful app, produced by Fontus
Health, called mySkinHealth App.
mySkinHealth, all one word.
(19:46):
It's a free app, you can download,and on that you can record all the
treatments you're using on your skin.
All the treatments that are available.
But it also includes an objectivemeasure of how bad your eczema is.
It's called the POEM.
P-O-E-M, which stands for Patient-OrientedEczema Measure, and it asks you to score
(20:08):
how bad your eczema has been in thelast week, against about 10 different
stem questions, like, how itchy is it?
And how much has it disturbed your sleep?
And so on.
So you can score it and it recordsthat and it will remind you
every week to do another POEM.
So how have things beenover the last week?
And if you can see that your POEM scoreis getting progressively worse, then you
(20:30):
might be heading towards a flare, andyou might be able to nip it in the bud by
contacting a doctor and discussing things.
Do you need to step up your steroid,for example, briefly, for a week or so?
Or could you use something else?
And, what else is goingon that's driving this?
So, that's another situation, whereI'd say seeing a doctor would be good.
I think, in this modern ageof, digital technology, video
(20:52):
consultation, sending photographsto your GP, they can be useful.
I know that George and I have had thesame experience with this, which is that
the quality of the image that you sendto your doctor is absolutely crucial.
So it's only as good as thetechnology that you've taken your
(21:12):
picture on, and it's only as goodas technology at the doctor's end.
So if you are going to send apicture to your doctor, which as
I say, can be very helpful, makesure you do it in very good light.
Ideally, get someone else to takethe picture for you, get the picture
as sharply in focus as you can.
(21:33):
It's very frustrating if someone'staken all the effort to send a photo
to you, but it's slightly out of focus,because that really isn't any use.
So, don't be afraid to send a photographto your, your GP, provided you can
get it as crisp as it can look, aswell-lit as it can be, and in the
highest quality that you can get it.
(21:54):
That's really what we're afterand I think George and I have
probably had both experience ofbeing frustrated with poor quality
photographs through no one's fault.
It's so critical that, it really is,and what's quite nice, is to have a view
from a slight distance so you can orientyourself, which part of the body it is
and then a close-up, and the close-upis the one that's often out of focus.
(22:16):
So, by tapping on your smartphone screen,that often brings it into focus at the
point where you tap it on the image.
So, a nice orientating image froma distance, or, if it's just a
close-up, then make sure you tellus which part of the body this rash
or this change is, where it is.
Good information in, you'llget good advice back.
That's such an important message, and I'mtrying to try to advise when you've got
(22:39):
an image that's completely out of focus.
I've occasionally said, "Is this a pictureof a human being, or is it the wall?"
You can't be sure sometimes.
[Laughing] So the messages fromthe wayside pulpit, I suppose,
that we've covered today, George.
Avoid irritants, especiallythings like detergents.
(23:02):
Look at whether you're wearing harshclothing directly onto your skin,
making sure that you're using enoughemollients, moisturisers, and quantity
is really important, and usingthem regularly is absolutely vital.
Don't be afraid of using topicalsteroids appropriately and correctly,
(23:24):
but not constantly in the long-term.
If we can treat our eczema properlyin the first place, we'd reduce the
risk and likelihood of it becominginfected, but occasionally, if you
do have infected eczema, it mayneed treating with antibiotics,
but again, not for the long-term.
And if you're thinking about scoring youreczema, making sure that it's as good as
(23:49):
it can be, or if you're concerned thatit may be getting away from you, the
mySkinHealth app is a really nice placeto go, to just keep an eye on it, to see
if it's getting better or getting worse.
And I think those, really, are the keypoints we've made, aren't they, George?
Absolutely, those are the key points.
Just a couple of other quick ones.
(24:09):
I would urge you probably notto rely on antihistamines.
Histamine does not mediatethe itch in eczema.
And the old-fashioned sedating ones canmake you sleepy, which might be quite
nice, but that drowsiness can lastwell into the next day and interfere
with your functioning the next day.
So, even those I'd probably avoid.
(24:30):
So, antihistamines are not consideredappropriate any longer for atopic
eczema, but watch this space.
We're going to have alternativesfor helping itch in the
foreseeable future, hopefully.
And the other, just a quick messageis, I think all patients with atopic
eczema should be on vitamin D.
I think vitamin D is the panacea forso many things, and I take vitamin D,
(24:50):
but I would say, is to take it orally,even children and in adults, I think
a little of sensible, non-burningsunlight could do some good for eczema.
We use ultraviolet light to treatsevere eczema, for example, but
definitely consider taking vitamin D.
It's very hard to overdose on vitamin D.
You have to take industrial doses.
So, take some sensible vitamin D.
(25:11):
One, two, or three thousand unitsa day would be very reasonable.
And that has been shown to be helpful.
I think that's a really good place towrap this particular podcast up, George.
It's recommendations I giveto my patients, and in fact,
I take vitamin D as well.
So I hope that everyone listening to ustoday has found this podcast helpful,
and interesting, and if you do haveeczema, that you've come away with tips
(25:35):
that will help to improve your skin,both in the short and the long-term.
Roger and I look forward to you joiningus again in two weeks time when we'll be
talking about more skin-related topics.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Skin Deep podcasts together.
So, until the next time,it's goodbye from George.
Goodbye.
(25:56):
And it's goodbye from me.
Goodbye.
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