The question above is one of the most frequently asked by patients and their loved ones when their skin condition does not heal completely within the duration hoped for. It is most often asked by those with chronic skin conditions, such as eczema, during a consultation at a skin specialist (dermatologist) clinic or government health clinic. These complaints and worries stem from a lack of understanding of the skin condition that they have.
It bears reminding that skin diseases come and go. Usually they cannot be cured completely within the patient’s expected time frame. This is because the root cause of the disease is the relationship between internal and external factors; not a simple reason like a bacterial infection that can be cured with antibiotics.
Atopic dermatitis, better known as eczema, is related to genetic factors and underlying allergies. It is a skin rash that causes severe itchiness and can disrupt sleep or negatively impact one’s quality of life. It usually appears in children below the age of two and shows symptoms in “high and low tides” – sometimes it is under control (remission) and other times it gets worse (exacerbation). However, in severe cases, patients may experience long term itchiness and non-resolving rashes.
Signs of atopic dermatitis include red, dry and scaly skin which worsens with repeated scratching. Prolonged scratching allows the damaged skin to become susceptible to deep bacterial infections which exacerbate the eczema, resulting in a vicious cycle. In addition, scarring may occur, which hardens the skin.
The skin areas affected depend on the patient’s age. Generally, babies develop atopic dermatitis on the face, trunk, knee caps, behind the elbows and extensor surfaces (outside of joints). In older children and adults, it usually occurs around the eyes, at the next region and flexor surfaces (inside of joints) like the area behind the knees, in front of elbows and the front part of ankles.
Importance of patient education
The most important treatment for eczema begins with proper education regarding the condition. Patients and their loved ones must understand that eczema is a chronic disease that cannot be fully cured but can be controlled. They need to know they may suffer from the condition for a long time. Although some patients outgrow the disease, not all experience the same outcome. They are strongly encouraged to persevere in applying the topical treatments prescribed. “Doctor shopping” and changing medications often will only slow down healing and are usually a waste of time and money. Also, the condition may worsen as a side effect to the different kinds of medication taken. Patients must dentify triggering factors and avoid them as much as possible. Some suggestions include wearing clothes made of cotton that allow air circulation and using air-conditioning to maintain a comfortable temperature at night to prevent sweating.
Avoid triggering factors
Patients with atopic eczema, as well as their relatives, often have underlying allergic conditions like allergic rhinitis, asthma and allergic conjunctivitis. These conditions become exacerbated when patients are exposed to substances that trigger the allergies and cause inflammation. Examples of common triggers are seafood, hot and dry weather, dust, mites, infections, psychological stress and depression. Some ingredients in face and body wash products can also cause allergic reactions among patients with eczema.
Take care of your skin
A good skincare regime is vital, so patients are advised to maintain good hygiene, Avoid long exposure to hot and sunny conditions. Moisturising products in shower gels and creams can be very helpful. Creams can be applied anytime the skin feels dry. Patients are advised to discuss with their treating doctor if they’d like to use any commercial products in addition to the creams prescribed.
A note about steroid creams
Steroid cream, when used properly in the correct strength, can be helpful when treating skin that shows signs of irritation such as redness, hardening, thickening or scaling. The strength of the steroid used is dependent on the level of skin irritation present. High concentration steroid creams should not be used for more than 2 weeks and by prescription only. Medium and high strength steroid creams should be generally avoided in children and on areas where the skin is soft and thin, for example at the private parts. Only a small amount of steroid cream is needed – approximately the size of the tip of a finger – and is applied in a thin, even layer in a circular motion over the affected area. This is usually done only once or twice a day. Patients must understand that steroid creams act as an anti-irritant and not a moisturiser. For best results, apply steroid creams within 30 minutes of applying moisturising creams.
Other considerations
Other treatments include anti-histamine medications to control itching. These drugs can also be given to patients who have problems sleeping due to excessive itchiness. Therefore the drowsy side effect of anti-histamines actually goes a long way to help eczema sufferers sleep better. However, non-sleepy medications like loratidine should be prioritised for children under two years old. Antibiotics, both oral and in cream form, may also be required if there is a bacterial skin infection and are usually prescribed for seven to ten days.
It is best for patients experiencing severe skin problems to consult a dermatologist. This is because larger volume of creams, up to 500g, can only be obtained from specialist clinics. Government health clinics only provide topical treatment in small amounts, lasting between one to two weeks. This is usually insufficient for patients who need the creams regularly.
Based on the above, the appropriate response to the question “Doctor, do I need any other topical medications for my skin?” is “None, because what you really need is to understand your skin condition, be persistent in applying the prescribed medications, be patient, and give time a chance. There is no magic cream!”
This article was written by Dr Shaiful Ehsan.
Dr Shaiful Ehsan is currently a Family Health Specialis trainet and is a lecturer at the International Islamic University Malaysia. This article is translated from the original at https://www.mmgazette.com/doktor-tak-ada-ubat-sapuan-lain-untuk-kulit-saya-dr-mohd-shaiful-ehsan/ by Nur Nadhirah.
References:
- Atlas of Paediatric Diseases – Dermatitis & Psoriasis 2014
- Uptodate – Atopic dermatitis
- American Family Physician – Atopic eczema
- Clinical Medicine – Kumar & Clark
- Malaysia Paediatric Protocol 3rd edition
[This article belongs to The Malaysian Medical Gazette. Any republication (online or offline) without written permission from The Malaysian Medical Gazette is prohibited.]