| ECZEMA REPORT | |
For PDF file of full report including Appendices 3.0 FINDINGS FROM THE ENVIRONMENTAL SCAN 3.2 Topic Areas 3.2.1 Epidemiology The term atopic dermatitis is a general reference to many different types of skin disorders whereas ‘atopic’ refers to the preponderance to develop allergic sensitizations. Specifically, eczema presents as eruptions of the skin that are red, inflamed areas with or without scaling. As the eruption continues, it may progress into a thick grooved patch that can blister or crack. The most rampant symptom of eczema is itching that can be very severe. A common form of eczema is atopic eczema that affects the entire body especially creases or folds in the skin and is frequently found on the face, behind the ears, front of the elbows, hands, back of the knees and trunk area of the body. When a child is initially afflicted with eczema as an infant, eczema often appears between 2 and 4 months of age and frequently occurs on the facial area. As the child grows older, other areas of the body become affected such as the arms and legs, particularly behind the knees, in elbow creases and in the hand and wrist area. A rash begins and the most irritating and frequent symptom is itching. The itch-scratch cycle then breaks the skin, inflaming and irritating the skin even further and importantly allowing the penetration of foreign substances into the body through the broken skin barrier. Commonly, a child who is going to develop eczema will show symptoms by the age of 2 years. Furthermore, approximately 70% of children who suffer from eczema are expected to out-grow the condition by age 11 and show no permanent scarring (6) but this is not the case for all children and some individuals will continue to have the disease into adulthood (See Appendix F: ‘Types of Atopic Dermatitis’ for a list of common types). Worldwide, approximately 12-25% of children between the ages of 6 months and 5 years are afflicted with eczema (4;8). Studies have demonstrated that approximately 50-75% of children are symptomatic before the age of 6 months and up to 90% by the age of 5 years. Furthermore, 60% of those children will have eczema after puberty and nearly 15% will continue to remain afflicted with eczema into adulthood. Alarmingly, the prevalence of childhood eczema has almost tripled since the early 1970's (9). Additionally, the past 10 years have seen rapid increases in the prevalence of eczema, which researchers now suggest are likely impacted by environmental factors (10). The largest epidemiological study ever completed in child health is the International Study of Asthma and Allergies in Childhood (ISAAC), lead by Professor Williams at The University of Nottingham. The purpose of the study was to examine allergic disease through the analyses of information derived from survey data between 1991 and 2001 of over 450,000 children in 55 countries. The children were 6-7 and 13-14 years of age at the time of data collection. Results showed a less rapid increase in the number of children ages 13 and 14 who have eczema along with a decrease in some previously high geographical areas such as the United Kingdom and New Zealand. However, across developing countries and among younger children ages 6 and 7, the prevalence of eczema continues to increase. In concluding the results of the ISAAC study, Professor Williams stated that the cause of eczema, although not fully understood is a multi-factorial issue and attention to both genetic and environmental factors are necessary. Additionally, he stressed the possibility of eczema being a preventable disease with better understanding and that effective management strategies are known thus, it is important to remain vigilant in the evaluation of eczema components globally in order to illuminate how patients, clinicians and researchers may successful understand, cope and manage eczema. 3.2.2 Causes and Triggers of Childhood Eczema 3.2.2.1 Personal Hygiene Among eczema research it is now well understood that an individual's use of soap and other bathing products (shower gels, bubble baths) along with baby wipes are all linked to both the development and flare ups associated with eczema. Simple breakdown in the skin's barriers leave cracks and the ability for irritates to penetrate the protective barrier of the skin, which can result in the development of lesions. Estimates suggest 1 in 5 children develops eczema because of the increase in using such products. 3.2.2.2 Pharmacology Regarding the use of acetaminophen (paracetamol), a recent study (the ISSAC programme) found that among children who were 6-7 years old, the use of acetaminophen in the first year of life was associated with both an increase in the likelihood of eczema and asthma. In addition, the researchers stated that children with eczema, asthma and nasal allergies were more likely to use acetaminophen thus, research into pharmacology is still necessary and on-going and further investigation into the relationship between acetaminophen and possible increases in the likelihood of asthma is warranted (11) (12). 3.2.2.3 Hygienic Hypothesis Dr. Sami Baha, the chief of Allergy and Immunology at Louisiana State University Health Sciences Centre and other leading clinicians suggests the 'hygienic hypothesis' is responsible for impacting the current increasing prevalence trends of childhood eczema. The hypothesis is based on the fact that many children, especially those living in the West have immune systems that are deficient in normal processes of identifying and attacking ‘invaders’ of the body. When children are increasingly exposed to sterile environments from birth, their immune systems do not develop normally by being challenged by various pathogens. Factors such as the use antibiotics and vaccinations, along with an emphasis on antibacterial soaps, creams and cleaners produce an environment whereby the immune system does not receive adequate exposure to develop normally and fight infection. As a result the overall system can become hyperactive (13;14). Specifically concerning vaccines, some researchers have focused on possible links between vaccinations and the incidence of both eczema and asthma. A study published in the UK in 2004, examined vaccinations for diphtheria, polio, whooping cough, measles, mumps and tetanus and found that there were no significant risk factors for either eczema or asthma (15). Similarly, Bernsen reported a lower risk of atopic disorders in the whole-cell pertussis vaccine when comparing results with children who did not have the immunization (16) However, it is widely understood that individuals with eczema should not receive the smallpox vaccine. A U.S. study noted the importance of knowing an individual’s dermatological history with respect to atopic dermatitis and specifically eczema before receiving the smallpox vaccine as individuals with eczema may develop eczema vaccinatum when either they themselves or someone who is in close contact receives the vaccine (17). 3.2.2.4 Genetics Although the definitive cause of childhood eczema remains complicated and unclear, research during the past 25 years has led to many hypotheses including genetic factors, environmental triggers, allergic origins and stress conditions (8). Family history is widely accepted as the strongest predictor of whether or not a child will develop eczema. Genetic predisposition, such as whether the child has a parent or sibling who has eczema, asthma or hayfever is associated with a higher risk of developing the disease. Specifically, estimates suggest that if either parents (or a sibling) are afflicted with eczema, hayfever or asthma, their child has a 50% chance of also having eczema. Similarly, if only one parent has any of the former conditions and older siblings are not afflicted, the child's risk falls to 25% (18). Specifically, research in the area of the association between genetics and the development of eczema has identified particular variants in the fillagrin (FLG) gene as factor in the predisposition to eczema and has been replicated in numerous studies (19-21). A mutation in the fillagrin gene impairs a barrier within the skin that results in penetration of allergens and irritants. Additionally, the variant is also believed to be associated with food allergies. Importantly, research out of Ireland had noted that when an individual has two specific mutations of the fillagrin gene together they are very susceptible to atopic conditions, which increases their risk of eczema and specifically may be associated with a form that begins in infancy and continues through to adulthood (21). The variant in the FLG gene alone however does not explain the development of eczema. Under normal conditions, fillagrin is found in the skin and performs the function of a protective barrier protein. For individuals with the variant, researchers believe a catalyst, such as an exposure to allergen triggers eczema and then the variant in the gene prevents the immune system from working effectively. Additionally, genetic research has also uncovered the gene associated with itching or the 'itch-sensation' as the GRPR (gastrin-releasing peptide receptor). The hope in this area of research is to develop treatment options that will effectively impair the messaging of the itch in the body and bring relief to those who suffer chronic itching symptoms such as eczema patients (22). The exact association between genetic factors and eczema are not well understood; however, there is consensus among researchers and clinicians that having a genetic predisposition can make a child more susceptible to developing eczema but genetic factors may not be sufficient on their own to cause the disease (9). 3.2.2.5 Allergies A substantial trigger associated with eczema is allergies. Numerous agents causing allergic reactions are thought to have an association with eczema including environmental allergens such as house dust, dust mites, cockroach allergens, outdoor air pollen and pet dander; however, the true relationship between atopic sensitizations and allergic disease is poorly understood (23). A particularly difficult situation surrounds dust and dust mites as they are near impossible to avoid. When an individual already has eczema and the skin is damaged, the exposure to an allergen further impairs the protective layer of the skin to heal thus leading to more severe symptoms. It is well known that pet dander causes an allergic reaction for many individuals and that an exposure to animals for people suffering with eczema and asthma can be a very serious reaction. Research out of the University of Manchester and Copenhagen has specifically examined the link between cats and eczema. Importantly, researchers have found that in children who are predisposed genetically to eczema and who are also exposed within the first year of life to cats increased the risk of developing eczema to that 4 times greater than for children who are not exposed. The exposure to dogs had no effect. Other research has suggested exposure to not only cats but other animals in fact provides a protective effect against eczema by exposing children to various allergens and bacteria early in life to stimulate a healthy immune responses (to contradict the effects of the hygienic hypothesis discussed above). Conversely, additional studies focused on pets have suggested that having a bird in the home may reduce eczema. The hypothesis is that when children are exposed at a young age to the bird feathers, which contain toxins their immune system responds and during early development this exposure may prevent allergies. Finally, another body of investigations in the area of the correlation between allergies and the severity of eczema showed that only those children who were considered severely afflicted with eczema and who may also report difficulties in responding to treatments are likely to be further adversely affected by allergens such as grass and domestic animals (24). Another extremely difficult issue to manage in the area of childhood eczema and allergies is the area of food sensitization. In 2008, the CDC reported that 27% of children who had food allergies also reported either eczema or a skin allergy (25). Any child with a food allergy is estimated to have 2 to 4 times a higher risk of having eczema, asthma or other allergies. Data briefs out of the CDC state between 1997 and 2007 the diagnosed cases of food allergies in children in the United States rose 18%, which translates into approximately 3 million children or 4 in every 100. Similarly, in 2008, Dr. Hanifin speaking at a dermatology conference in the US estimated that up to 40% of children, who experience eczema as infants and young children will go on to develop food allergies. He emphasized that public education must include dispelling the common myth that food allergies cause eczema and that in fact the sequence of events is the other way around. Similarly, research in Australia has reported that the earlier a child develops eczema in their life and the greater the severity of their condition are both markers for increased prevalence of food sensitivities (26) Notably, parents experience, on a daily basis the impact food their child has eaten and associations with eczema albeit do not necessarily know which food is causing a specific reaction. It is extremely frustrating and difficult for parents to manage this issue of their child’s disease. Clinicians state that the skin is highly susceptible to the food we ingest and that a person's skin is a reflection of not only their overall health but of the specific state of the bodies’ hormone balance and immune system. It is understood that certain foods are known to have a clear association with eczema and 90% of all food allergies are attributed to 8 foods: milk, eggs, peanuts, soybeans, fish, shellfish, wheat and tree nuts (25); however, the specific mechanisms by which the reactions take place are elusive. Importantly, some food allergic reactions are not restricted to having to ingest the allergen. For example, some children may be so sensitive to certain food items that simply having their skin come in contact with such a trigger can cause anything from a flare up of hives and/or an outburst of eczema all the way to a life threatening anaphylactic shock reaction. Furthermore, not all food allergens are confined to edible items. Some elements can be found in other areas of their environment such as cosmetics, making the avoidance of certain allergens very difficult as the overriding concern is the severity or sensitivity of food allergies that continues to rise. 3.2.3 Co-Morbid Conditions: Asthma and Rhinitis Both asthma and rhinitis are well known co-morbid conditions of eczema (27;28). A great deal of attention has focused on children with eczema and further development later in life of asthma and other allergies or the ‘allergen sensitization’. Although a difficult issue to untangle and to clinically understand, findings from numerous clinical studies have shown the direct association between childhood eczema and the onset of asthma even into later adult years; childhood eczema is not simply a child disease but may have serious life consequences later in life (27). In Australia cited results that show the risk for people developing asthma, who were sufferers of childhood eczema was double that of their peers who did not suffer with the skin disease. Furthermore the Journal of Allergy and Clinical Immunology recently reported that 46% of children who have eczema also develop asthma and in 2007, 29% of children in the United States with food allergies also suffered with asthma (25). Work done on the Childhood Asthma Prevention Study showed definitively that eczema as opposed to childhood wheezing or rhinitis may be largely responsible for allergen sensitization when the child become older, such findings support the position that early clinical management of eczema is important in impacting later life allergy development (29) Rhinitis, which is best known as a runny nose is the clinical reference to nasal membranes that are irritated or inflamed caused by irritants such as bacteria or allergens (30). Common types of rhinitis include non-allergic (vasomotor), allergic and hayfever. The importance of asthma, rhinitis and eczema are the common occurring allergic associations and the need to manage and treat all manifestations of atopic disease holistically. Thus, research must also include a comprehensive approach in investigating childhood eczema, asthma, and rhinitis and acknowledge the interplay of all components to effectively help children and their families dealing with atopic disease and subsequent allergic sensitivity. 3.2.4 Environmental Factors Much attention has focused on the environment and its association to eczema. In particular, factors and patterns of the environment from both the outdoor environment and the indoor microclimate have shed light on how the environment impacts individuals with eczema. Within the home, humidity levels and the level of ventilation can worsen eczema conditions. McNally and associates reported a statistically significant association between eczema in children and increased humidity in the home and excessive heat and dryness specifically in the child's bedroom (31). Not only are air quality issues a concern in the fight against eczema but a whole host of chemicals and toxins throughout the environment, both known and unknown are believed to play a role in the development of eczema and exacerbation of symptoms. For example, in July, 2008 the Eczema Natural Treatment website posted an information piece describing the use of dimethyl fumarate in furniture production (used to prevent mold). This highly sensitive agent is known to cause serious harm among individuals who are exposed thus, the use of dimethyl furmarate in manufacturing poses a serious risk at large and specifically for individuals who already have eczema. This is only one example of the numerous chemicals found in our everyday environments that not only affect overall health but may be particularly devastating to individuals with certain sensitizations. Concerning the outdoor environment, for example actual weather patterns, can affect people suffering with eczema. Various seasons can impact eczema such as the cold in winter causing skin to become drier and increasingly itchy whereas, warmer temperatures and sunny conditions have promoted the remission of eczema for many. However, in very humid and hot environments sweat can increase suffering. An increase in symptoms of eczema in the spring and summer climates is likely an indication of seasonal allergies where reactions to pollen are influencing symptoms. See Appendix G: ‘Environmental Triggers’ for a list of more common environmental triggers of eczema. In Germany, researchers specifically examined the influence of daily temperatures, humidity, radiation and pollen levels in the air. Their findings showed seasonal variations are very different among children and no one pattern is applicable to all. Some children showed worse symptoms as the air temperature dropped and others were highly influenced by pollen, which made their itch symptoms much worse. Overall, the results of the study highlighted the need to more fully examine not only seasonal variations of symptoms among children with eczema but also include detailed work surrounding the relationship among climate factors and specific types of eczema to better understand the impact of different seasons (32). There are sparse epidemiologic studies that specifically examine air pollution (outside) and climatic factors and their association with eczema. The ISSAC programme has shown an increased likelihood between air pollution and the prevalence of eczema in children (33). Similarly, very recent work completed in Taiwan supports the hypothesis that air pollution and climatic factors may impact the development and severity of eczema. Lee and associates looked at data from air monitoring stations and the prevalence of eczema among 300,000 plus school age children. Results showed eczema was associated with air pollution from traffic (the nitrogen oxides and carbon monoxide). Additionally, the relative humidity levels were also associated with eczema. Overall, their work does show an association between air pollution elements and climatic factors with respect to eczema (34).Clinicians and individuals with eczema are well aware of how eczema flare-ups and symptoms are influenced by particular seasons; however, there is little scientific research that has investigated how specifically this happens. Another aspect of the environment under investigation is the Urban versus Rural question. Research out of New Zealand, Greece and Germany has all focused on possible exposure characteristics between living in a rural versus urban population and the development of eczema in children. As may be expected, long term exposure in the urban environment is associated with hayfever (35) and air pollution as discussed above. Conversely, there was a protective affect found when examining the prevalence of eczema in those children who had long term exposures in the rural environment where they were found to develop eczema less often. Over 1,300 children born to mothers who lived on a farm during their pregnancy had a 50% lower risk of developing eczema and hayfever along with a reduction in asthma. Results of this study render further support for the hygienic hypothesis (see Section 3.2.2) by suggesting that children who are exposed to bacteria and animals may have their immune system challenged at the fetal stage of life; however, the protective effect may only continue if the child continues exposure after birth (36). Conversely, work out of Germany has shown there is a link between the development of child allergies and environmental pollution. Allergies such as eczema, hayfever and asthma were 50% higher in children who resided near major roads. Various factors such as climatic zones, altitude, humidity levels, pollutions levels, ground level ozone and outdoor pollen are areas where researchers are interested in continuing their investigations to uncover factors associated with the symptomology of eczema among all age groups (37). 3.2.5 Psychosocial Factors The area of psychosocial factors regarding eczema is extremely important. Specifically, childhood eczema is known to have a dramatic impact on children from infancy through to teenage years. Although many children will outgrow eczema by the age of 11, the years leading up to this are crucial for personal and social development. The stigma associated with visible outbreaks of eczema is difficult to manage and for young children and teenagers, their self-esteem at particularly crucial times of development is affected. In addition, social interactions and participation in social activities are hindered. It is well documented that all skin diseases negatively impact quality of life and often individuals with eczema have low(er) self-esteem thus, emotional support in the form of support groups or other social organizations like a child's camp can help close the gap on a child feeling isolated and provide a comfortable opportunity for social interaction with other people who share similar experiences (38;39). The stigma attached to having a condition that requires constant management, alienates the child from social situations and that severely impacts their family unit are all concerns that lay beyond the clinical understanding and management of how to diagnose, treat and manage the disease over the life course. For parents of a child suffering with eczema, the discomfort and severe itching interrupts both the child and parental sleep cycles thereby worsening the entire families’ ability to cope and manage the eczema. In addition, pharmacological treatment such as antihistamines may also leave the child lethargic and irritable in the morning. Parents and children become sleep deprived and a parent's ability to perform day-to-day activities is hampered whereas children may display behavioral issues due to a lack of proper and restful sleep. Similarly, throughout the life cycle scholastic, work and professional activities are affected by eczema through lost participation rates, illness days and the psychological factors such as avoidance of social situations associated with having the disease or caring for someone who is afflicted. Emotional stress affects both the child and parent and for the child their stress can affect the severity of the disease. For example, at the height of the summer season when a child is unable to wear comfortable clothing for weather conditions such as shorts and t-shirts either because exposing their skin may worsen the condition or they are self-consciousness in exposing skin that is flaring with an eruption affects both the child and the parent. Similarly, stress itself can worsen an individual’s eczema, which is particularly important in cases of childhood eczema that continue through the teen years. Specifically, research has investigated the relationship among stress reactions such as frustration and anger and the 'itch-scratch' cycle. However, among researchers it is acknowledged that the association between immune reactions and stress remain elusive and requires further research. In their systematic review of the literature regarding the impact of childhood eczema and stress, Hawkins summarized several different studies that showed children with more severe eczema also had an increased risk of certain psychological problems such as somatic complaints including stomach problems and excessive worrying. In addition, some research has uncovered conduct problems and children experiencing bullying at school (39;40). Support and programs aimed at reducing anxiety and depression is paramount for children in order to reduce the overriding burden of illness suffered by these children and subsequently their parents (39) For a parent of a child with eczema the emotional stress can be overwhelming and the grief of what their child must endure is very real. Parents often feel guilty and have a difficult time watching their child suffer in pain and discomfort along with feelings of helplessness in not being able to either bring relief or eradicate the disease all together. Similarly, parents may become overwhelmed by severe sadness at what their child is missing in their young life. There are feelings of anger to others who stare, tease or are simply ignorant to their child's suffering. Importantly for the family unit, the culmination of exhaustion, stress and emotional roller coaster for parents affects relationships and the marriage just as any chronic on-going stressful situation would for any family. Research published in the Archives of Disease and Childhood states that mothers of children with eczema showed stress levels that were on par and equivalent to mothers whose children had severe developmental and physical problems (4;40). This is an important finding for parents whose child (ren) are afflicted with eczema and requires further public education to help ease the burden of illness for families. 3.2.6 Conventional Treatment Obtaining the right diagnosis and treatment for eczema is complex and is often difficult for parents and clinicians to find the right combination of therapies that work and that continue to work over time. Optimally, it is best to keep the skin healthy and attempt to heal the skin as promptly as possible when flare ups do occur. Conventional treatment for eczema includes the use of skin hydration products designed to moisturizes the skin and steroid topical preparations which reduce the inflammation associated with eczema flare ups (41) although not without some serious side effect for certain individuals. An exacerbating symptom for sufferers of eczema is itching, which is often treated with antihistamines. Additionally, secondary infections can occur from the scratching and when are treated with various antibiotics. See Appendix H: ‘Treatments’ for a list of common prescription and non-prescription treatments for eczema. A relatively new class of treatments are available known as topical calcineurin inhibitors (TIMs) (42). The hope for this particular class of agents is that they are steroid-free. TIMs work with the immune imbalance in the skin. In particular, they work by suppressing the immune response, which for many patients improves their eczema significantly. More research in the area of TIMs is required; however, at this time they do offer a steroid free option of treatment (1). However, given TIM's are relatively new and no long-term studies have been completed, the risks of use over time remains unknown. Finally, light therapy and/or the use of light therapy in conjunction with other approaches are becoming more common. Within the past 10 years, research has focused on ways the diet can improve conditions associated with eczema. Several studies published in the medical journal the Lancet between 2001 and 2003 discussed the advantage of children ingesting good bacteria such as probiotics and other forms found in foods such as yogurt or milk enriched with acidophilus. It was found that babies, who suffered from severe eczema, had higher levels of E coli and bacteroids in their stool samples. Additional research conducted in the Netherlands has also identified that the gut microbiota make up of infants that contained both E. Coli and Clostridium difficile were at an increased risk of developing eczema, recurrent wheeze and allergic sensitization (13). Furthermore, review of the literature suggested there are beneficial aspects of ingesting probiotics whereby, probiotics have shown to mediate the immune system and have a positive effect on both the treatment and prevention of food allergies (43). The majority of research conducted in the area of probiotics has taken place in Europe and Australia. Children who had probiotics as part of their diet over time were both less likely to develop eczema and for those who showed symptoms, their eczema improved (44). Dr. Abrahamsson of Sweden showed that expectant mothers who took probiotic supplements late in their pregnancy and continued to give their child such during their first year reduced the incidence of IgE associated eczema and notably had less sensitivity to the skin-prick test. To date, no conclusive evidence of the benefits of probiotics exists and one underlying methodological problem in the research is that each study is often testing a different combination or formulation of probiotics thus it is difficult to produce conclusive statements. Researchers agree the more work needs done in this area and replication studies may provide the evidence based information required to show that probiotics are effective in treating eczema. A Swedish study published in the Archives of Disease in Childhood by Bernt and McMahan has shown that infants who began eating fish (regardless of what type) prior to 9 months of age were 25% less likely to develop eczema. The study looked at various types of fish in the diet, namely white fish, mackerel and tuna and the particular type of fish did not appear to be a factor. This finding contradicts nearly 10 years of previous recommendations, including those from the American Academy of Pediatrics, where introducing fish before the age of 3 years old could in fact lead to allergic responses and possibly to the development of eczema. These former dietary recommendations for children were revised in 2008. Similarly, a German study found improvements in eczema symptoms when patients took daily supplements of Omega-3 (5.7g/day) compared to those who took the placebo. By measuring symptoms on the SSAD (Severity Scoring of Atopic Dermatitis), researchers were able to show an 18% decrease in symptoms of patients who took the Omega-3 supplements (March, 2008). Other foods that remain high in antioxidants such as certain types of grapes and blueberries and items that are full of Vitamin C and A such as oranges, carrots and broccoli are all considered good for skin health. Naturopathic doctors and nutritionist stress the importance of hydrating the skin and recommend 8-10 glasses of water each day along with dietary choices that include omega 3 to aid in keeping the skin supple and aid in the prevention of eczema outbreaks. However, many children suffer from food allergies and getting the right nutrients and avoiding others that tend to cause problems for those suffering with eczema can be extremely challenging. Overall conventional treatments of behavior modification in conjunction with some form of topical application have shown to provide the best outcomes for patients with eczema. This treatment approach uses the traditional topical therapies in combination with teaching the patient to learn, modify and ultimately control their behavior such as reducing the amount they scratch their skin. By combining therapies, the topical treatment reduces inflammation and the behavior modification reduces the amount of scratching, which together allows the skin to heal, reduces flare-ups and prevents secondary infections. Furthermore, other added benefits of the behavior modification are an increase in the patient's understanding of how to use skin moisturizers effectively along with understanding the importance of adhering to their treatment plans. This approach is widely used in the UK and has proven effective. When treating eczema it is imperative to understand that there is no one treatment modality that works and most people with eczema use several types of treatments in combination with each other. Furthermore, it is very common for a treatment to work at times and then the patient will suddenly find the chosen treatment does not bring relief thus, a new option must be started. An extremely difficult challenge for children and parents is their adherence to the treatment regime, which if not followed diligently can lead to a worsening of symptoms, more frequent outbreaks and secondary infections. It can be difficult to find out exactly what to do in treating eczema and then following the treatment course. Patient education and in the case of childhood eczema the education of parents in the process and management of eczema is vitally important to finding the best combinations of effective treatments in order to successful treat eczema (42;45). Additionally, research into the understanding of stress and the effect on eczema flare-ups continues and we do know that dealing with stress through biotherapy, certain massage techniques using essential oils, muscle relaxation exercises and meditation are showing positive preliminary successes in dealing with eczema, although more research is required, it is likely we will see the addition of stress reduction incorporated into treatment plans for people with eczema. Finally, Chang and colleagues point out that a large challenge in developing new treatments in the area of childhood eczema is attributed to the “failure in translating basic science information in clinical application” (46). Moreover, the key informants interviewed as part of this project repeatedly raised the concern of having scientific information translated to both front-line clinicians such as primary care physicians and pediatricians along with having the same information made available in lay terms to the public is of paramount importance. Our key informants stressed the need for better communication between parents and their clinical care-givers as well as information being made available to educators, daycares and anywhere else children spend time in an educational or social setting (40;47;48) 3.2.6.1 Primary Care Treatment and Eczema: The Health Care Team The importance of parents and health care providers working together in the treatment of childhood eczema cannot be overemphasized. It is pertinent to remember that many of the funding models for primary health care, where physicians and nurses are often front line workers for patients and particularly parents whose children have eczema often do not allow for optimum patient education, primarily because consultation times are in high demand and restricted. (49). Importantly, primary care providers should be aware of the difference in patterns of presentation of eczema along age and gender characteristics to provide the best diagnosis and treatment along with understanding predisposition characteristics not only to eczema but asthma as well (17;50;51). Research out of Australia demonstrates the importance of the transdisciplinary nature of the health-care team in treating patients with eczema. Children with mild to moderate eczema who were treated by nursing staff showed considerably better treatment outcomes compared to children who were treated with by either a dermatologists or pediatricians. Conclusions of the study suggested that the amount of time spent with the children by the nurses compared to other clinicians (90 versus 40 minutes respectively), the consistency of bathing, application of emollients and management of wet dressing all led to improved patient outcomes. The findings illustrate the importance of the patient centered model of care and the role allied health care professionals have in providing better quality of care for patients beyond the sole primary care physician and pediatrician (49). 3.2.7 Alternative Therapies A plethora of natural and herbal or alternative therapies in print and electronic information pertaining to eczema is available. There exist large discrepancies in both the academic and gray literature surrounding the effectiveness of alternatives therapies such as homeopathic treatments. Although much work remains in scientifically examining the effectiveness of alternative therapies, a study published in 2008 which was a comparator investigation of the effectiveness of homeopathic treatment versus conventional approaches demonstrated that both treatment approaches were effective in improving the symptoms of eczema and the quality of life as reported by the patients and/or parents in the study (52). Particular herbs, teas and food supplements state claims of relieving eczema symptoms even curing the condition all together. It is beyond the scope of this report to either back any claims of such alternative items or refute the possible role they may play in managing and treating eczema. However, the following discussion will outline the more common or popular natural/herbal approaches in eczema care along with highlighting certain other alternative therapies such as Chinese medicine. For sufferers of eczema and their caregivers, one of the most important points to consider is that any product that is labeled 'natural' or 'herbal' may cause serious side effects if taken even when the product relieves eczema symptoms. Such effects can include liver toxicity and kidney damage. Furthermore, reactions are not isolated to items that are ingested, topic applications; especially those that contain corticosteroids have long term adverse effects. The use of chamomile tea remains poorly understood and has shown severe allergic reactions in some individuals. Many people prefer chamomile tea to oolong, green or black tea as they contain caffeine, which can intensify feelings of sleeplessness and anxiety that may already be heightened among eczema sufferers. Conversely, the benefits of oolong tea had been reported in Japan without implications to date and improvements in eczema of those who participated were seen as early as 2 weeks. Overall, there is sparse research in this area. Much discourse in the area of cleansing the body through diet surrounds the treatment of eczema. Depending on the age of the person with eczema cleansing diets such as eating only fruit for a period of time is recommended to 'cleanse' the body of toxins and restore homeostasis. Furthermore, the use of enemas for the same purpose is thought to cleanse the bowels of any matter which may produce a toxic effect leading to an eczema break-out. Similarly, taking wheatgrass juice clears the blood of particular toxins and improves the alkalinity of the blood. The opposing condition, acidity in the body is not only thought to predispose the body to certain eczema symptoms but is associated with a host of poor health outcomes. Finally, wheatgrass is also known to contain vital enzymes that assist in optimal functioning of the immune system. It is quite feasible that as more and more research focuses on diet and food allergies, the connection between what we ingest and skin disorders will become evident and many people have already found success in adhering to cleansing regimes and identifying foods that both hinder and assist in managing their eczema. Other natural topical approaches include: hydrotherapy; hot mud, chickweed and sand baths; calendula, wild pansy, jewelweed and witch hazel applications; benzion, geranium and hyssop oils and Dead Sea bathing salts. Particularly interesting is the long-term decline in sensitivity some people experience with the use of the Dead Sea salt bathing. The DMZ Clinic at the Dead Sea provided climatotherapy and of the patient population at the clinic, approximately 21% have eczema. Encouragingly, a recent study done at the clinic showed that 95% of both adults and children who attended the clinic for climatotherapy for a minimum of 4 weeks had dramatic improvements. Additionally, since there are no medications thus no side-effects along with a successful treatment outcome, Dead Sea climatotherapy is deemed a highly effective treatment (53) Chinese medicine has shown very promising in treating eczema and often in very stubborn and difficult cases to treat using conventional approaches. Commonly, a tea is prepared for the patient and tailored specifically to meet their needs. Usually this would contain approximately 10 different Chinese herbs. All the elements used are listed in the Chinese pharmacopoeia and considered within the accepted practice of Chinese medicine. The elements work by affecting the immune response, providing anti-inflammatory properties along with a sedative effect. Of the studies completed that examined the benefits of Chinese medicine, many have shown a decrease in eczema symptoms and flare-ups. Treatments were found to be temporary lasting on average for 12 months and patients also often relapsed after discontinuing the approach. Importantly, the issues of toxicity, such as liver and kidney problems were identified. Recommendations out of the UK suggest that the use of Chinese medicine may have a place, especially among cases of severe eczema where all other forms of treatment are unsuccessful but in all cases, anyone undergoing Chinese medical treatment should seek medical supervision from both a trained Chinese medicine doctor in conjunction with their primary care provider. The amount of information can prove overwhelming in this area. Understandably the longer an individual has suffered with eczema or a parent has endured their child's suffering, the more appealing alternative methods may become. And, it is possible that some element of natural and herbal remedies will work, likely as part of a holistic treatment plan. However, it is imperative that the use of such therapies be in consultation with a health care provider and under the supervision of a trained caregiver as serious even life-threatening side effects can and do happen. Moreover, the added emotional and financial stress of constantly searching for a cure, often without positive outcomes may be further detrimental rather than providing beneficial outcome for managing and treating eczema. |
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