Dermatologist Tim Berger, MD, draws on decades of experience to illuminate the range of conditions called eczema, providing diagnostic criteria for different types, a pruritus rating scale to use with patients, and effective treatment strategies. Includes tips on moisturizers, topical steroids, bathing practices and when to worry about staph infection.
So we're gonna We're gonna talk about eczema in adults, eczema and Children is almost all a topic dermatitis. And the management is slightly different because, um, in little kids, you does things a little bit differently. They have different causes for their eczema s. We're gonna talk about adult eczema. Most of these things would be applicable for Children above the age of six. Uh, where eczema becomes more of an adult pattern disease. Okay, so this is the outline of what we're gonna cover. How to determine how bad the eczema is? What are the different kinds of xmas that we see in adults and then some basis basics of treatment. Um, this is gonna be a patient centered approach. So you have to individualize your treatment to your patient and their various needs, uh, their socioeconomic situation, uh, often their cultural background and understandings that they have about disease. Okay, so what about a topic dermatitis? Well, a topic. Dermatitis and adults. It's not the most common cause of eczema. And many of the patients who are referred to us as having adult a topic dermatitis have something else, but about 1 to 3% of adults worldwide have a topic dermatitis. So that's a lot of people and a topic. Dermatitis is increasing in Children, and some percent of those will go on to be adults. So over your practice time, more and more adults with a topic dermatitis air gonna present to adult clinics in order to make the diagnosis of adult a topic dermatitis. You should meet these criteria so it should have an onset in childhood, usually before the age of 21. There's often other a topic. Diseases like asthma, hay fever, allergic rhinitis. The morphology should be pretty difficult, like Ken ified or thinking itchy areas in the flex shires of the elbows and knees, and 90% of patients facial dermatitis and then hand Exuma nipple eczema and eyelid eczema. These three regional Exumas are highly characteristic of on a topic diagnosis, and if you see a patient with xom located on the hands, nipples or eyelid, a topic dermatitis should behind your differential. The place where it begins should be classic, usually on the Fletchers but in adults also in the hands, and you should have these features. If you're going to say that the patient has adult a topic dermatitis. Yeah, So what about eczema, eczema or a whole group of inflammatory skin diseases? And their characterized by the following features Number one, They itch. And if a patient presents with some kind of skin inflammation and they say it's not itchy, and Exuma should be further down on your list, the word eczema means using or weeping. And so weeping is a feature of eczema in the acute phase. In the chronic phase, there's thickened skin from rubbing and scratching. Uh, if that severe, there's going to be erosions and then they'll be readiness around and within the lesions era theme, a sign of inflammation. So those air the features you should see when you examine the patient, and we'll illustrate this by looking at a Siris of pictures of ne Mueller dermatitis. So when I see a patient who has unexamined is dermatitis and I wanna figure out how to treat them, do they have mild moderate to severe disease? I'm asking myself, Well, how bad is it? And that's partly what I can see. So in other words, what body surface area is covered by the dermatitis? This is situation, really, which you really have toe. See the whole patient? Uh, you can't do sort of a peekaboo exam because the distribution of the inflammation and the dermatitis is gonna give you a clue to the diagnosis. And then the problem for the patient is not how much rash they have usually, but how much itching they have. And it's the itching that impairs their quality of life. And so you have to be able to quantify the itch. The as you see adults, especially as you see older adults, you have to think about other health conditions that they may have medical co morbidity, ease and the medications they're on. And we'll talk about that. And based on all that information, you're gonna make a specific diagnosis of the type of exam a you think the patient has. Okay, so first of all, how do we score itch? So this is gonna be important because the FDA about five years ago decided that the pharmaceutical industry could make drugs for each. So just like they have drugs for pain, we are developing drugs for which, and in orderto decide how to measure how well these drugs work, they had to have a scale that was easily reproducible, and that scale became the numerical rating scale, or NRS. It's very similar to the pain scale, so zero is no itch, and 10 is the worst that you can imagine, and you have to use those exact words. This has been tested in numerous languages. It's used internationally, and it's the scoring system that is used to validate that drugs are effective. When you ask the patient how bad they're itching is, you'll get some number. And in order to validate that number, you need toe sort of have a next colonel marker. So if the patient says that this itch awakes them from sleep, that usually means it's greater than seven or eight. We call that severe rich. That's where quality of life's impacted. And if the patient says the itch intrudes in their mind or distracts them from tasks like reading the paper, that's usually greater than a five. So with a couple of quick questions, you can get this. It's score, which you then can write in the shark. Um, and as we mentioned, the quality of life impact is related to the itch severity. So we now regularly score this in our charts on def. You get consults from us, you'll see that we have written. There's an NRS of a certain amount. Thea FDA requires an n rs reduction of four for there to be proof of adequacy of efficacy against itching. So ah, four point reduction in each score is considered inactive drug. Okay, so what are the adult Exumas that air? Not a topic Dermatitis, wells, erotic Exuma or dry skin x tema. And we'll talk about how to make these diagnoses. Most patients who are older and it probably do not have dry skin, eczema, everything you read in the literature will say that that's the case. But it turns out you can't prove that, Um, and at UCSF, we're doing some studies now. Actually show that dry skin is not the cause of itching and most adults. But if people overuse soaps and get their skin dried out, they can itch. Stasis Dermatitis is gonna be on the lower leg worse on the left and the right, usually on the medial compartment. Uh, in a patient who has some people oedema and maybe varicose veins. Allergic contact dermatitis is becoming more and more common as more and more allergens or added to our products. So people now are allergic not only the nickel but the disinfectants, especially things used in wipes on. Now with co vid, we're seeing more and more patients with allergies to these preservatives and D contaminants. Photo dermatitis of, uh, dermatitis that's in sun exposed areas. Hispanics and African Americans have often the hereditary gene that predisposes to photo dermatitis. HIV infected patients get photo dermatitis. So this is one of those diagnoses where stepping back and looking where the rashes helps you. And then, lastly, here, no Mueller dermatitis you can get is Emma's from drugs. But that's actually quite rare. Drugs are not usually the cause. If you biopsy and eczema, the pathologist will tell you it could be a drug eruption. But in fact, most drug eruptions don't show exam on biopsy. The one family that's an exception is calcium channel blockers. Calcium channel blockers, air, a common cause of examiners, dermatitis in the elderly. You can be on the calcium channel blocker for 14 years and then get the rash, and it takes one year off the calcium channel blocker Thio for the rash to resolve. But up to 25% of otherwise not classifiable examine its eruptions in the elderly are due thio calcium channel blocker. So if you have a patient who's got an exam in its ration is on a calcium channel blocker, start looking for a new drug to manage their blood pressure. The problem with this differential diagnosis here is that if you biopsy it, you're gonna get a report back, says spongy attic dermatitis, sub acute sponge attic dermatitis. These all look the same under the microscope, and so are most useful procedure, which is a biopsy is not very helpful. In this case, irritation or errant and dermatitis gets all kinds of Exumas worse. And so when the patient begins to get a rash, they often think that they have an infection. They begin toe overwash. They may get harsher products to wash with, um and all that just makes the rash much worse. So that just flares the eczema. So, as a part of the initial evaluation, you have to check in. What are you doing? What are you washing with all that stuff and take away all these irritants? Not only does the irritant dermatitis make the rash worse But once you induce an irritant dermatitis, now your likelihood to become allergic to the stuff you're putting on your skin increases the most common scenario in which this occurs. His hand dermatitis, where often begins with an irritant component and then develops on allergic component. So take a good history of how are you taking care of your skin? How often are you bathing? Often? Because patients get some transient relief from bathing. They begin bathing multiple times a day, and that only dries out their skin. Okay, the way I think about eczema and adults is that they're in two buckets. One is exogenous. So that's Exumas that have an external cause. And I'm looking for outside problems that air, causing that because I can treat those outside problems and get the patient better. I don't have to treat the eczema itself right. Okay, so drug eruptions. We talked about calcium channel blockers and interesting enough TNF inhibitors when they're used to treat psoriasis, can trigger eczema and you stick in a mob. Another psoriasis medication, also used for employment. Three. Bowel disease also can trigger unexamined dermatitis, and the reason is that both TNF blockers and Mr Kinney mob block th won immunity, and that enhances th two immunity. So this is called a site, a kind imbalance syndrome. And by seeing something you think it's psoriasis treating it for psoriasis, you can actually induce Exuma. It's erotic dermatitis. The strike skin eczema, photo dermatitis, allergic contact dermatitis and states dissed Irma Titus. So distribution is the key to the diagnosis. When you talk to the patient, if they say when I get in the water, my itching disappears right away and it stays away for some period. And now that I'm bathing more regularly, it stays away less long. Then I asked, You have it in your armpits, your groin on your scalp And they say no. So those air moist areas that air spared So those air my clues that there is a component of cirrhosis and that I really need to moisturize that patient Stasis dermatitis starts on the legs worse on the legs left greater than right. And there you have to address the Venus insufficiency. And that may include referral, uh, to the vascular lab toe. Have Venus studies done because sometimes correcting the Venus reflux well actually lead to improvement of the dermatitis and the Stasis. Dermatitis can often be the harbinger to a leg ulcer, and so you want to intervene. While there's just dermatitis and before the patient ulcer rates allergic contact dermatitis. So some component of something that's touching the patient's skin is driving. Their rash is usually going to be a symmetrical. It'll have a pattern of application on. Then there'll be a history of exposure. So say, I'm worried the patient has a dermatitis do to their hot tub. I'll ask him whether they have a hot tub. I'm asking about now a lot about these wipes and things that people are doing toe keep themselves covitz safe because many of those chemicals are potent allergens. Of course, we have poison oak, uh, here. And remember that patients who are poison oak sensitive are also mango sensitive, uh, and break out from the mango skin. So I had a patient who was sent on, uh, Monday as an emergency who had severe poison oak 20 years before and then had a mango that he peeled and had rash on his face from touching the mango. So always asked about mangoes and lastly photo dermatitis, you need to ask where the rash started. First photo dermatitis is gonna be on the side of the neck. It's gonna be on the back of the hands and the forearms. It's gonna be more on the extensive surface than the flecks of surface is gonna spare. Doubly covered areas. Uh and so this is where you need to step back and see the whole patient and see the distribution. And you have to be aware of the patients. Ethnicity. A za risk photo Dermatitis can be induced by many medications. The biggest family is cellphone areas. So that's so from the doctors will try method crime or CETRA Hydrochlorothiazide Lasix, self honoria, anti diabetic medicine. So that's a big class of medications. Um, that's a trigger for photo dermatitis and then other medications can also cause photo sensitivity. But most of it comes in that family doxycycline that we all use a fair amount. Eyes. A Putin is a possible photo sensitizing, but not as bad as the other drugs we mentioned. Okay, what about endogenous examined? So we talked about a topic dermatitis, and now we're gonna talk about Nanula dermatitis. A non militant dermatitis is a very specific kind of exam on it illustrates the perfect exam elements of eczema. So it begins as a solitary lesion, usually on the leg but not far distal, usually on the calf. Not right over the medium. A Leela's and it could be on the hand. And then this one patch sort of sits there for a while. Maybe weeks, maybe months, sometimes over drying skin can trigger this thing. It occurs more and men than women and men, usually in middle age, so twenties thio fifties, but not elderly. So it's more in the middle aged males and my experience associated with alcohol consumption. The lesion morphology is very characteristic. It's weepy, it's crusted, and the lesions air fairly well. Margin ated. So at first glance it can look like psoriasis. And then what happens is the lesions begin to increase, each one spreading and then multiplying. Uh, and initially, they get a new lesion every week, and then they start to get new lesions every day. Okay, so here's a prototypical picture oven. Examiners dermatitis read, crusty, bumpy, weepy, itchy. So those are all the things, and this is an early lesion of ne Mueller dermatitis, and you can see at the periphery. There's these little dots that have also been excoriated. And that's the mini lesion of this lesion. And it turns out an area of about 10 to 20 centimeters is the size of one each nerve family, and that's the area that this spot is affecting. Here's a single lesion on the hand. Now this patients know Mueller dermatitis is accelerating, so the border is less clear. They're getting Maura cute. Examine this. Spots at the periphery of the lesion and their lesions have begun to multiply. This patient will complain of a lot of itchy. Now, these patients also have crust and some prevalence. When you culture these, you often will grow staff, and we're gonna talk later on about whether staff is a colonizer. In other words, he just lives on this skin or whether it's an actual pathogen. But whence we see pustules around this, or if the there's kind of Lakes of Puss, then we're gonna culture that probably treat for staff. Here's a little bit more advanced leaves a little bit larger right here on the leg, and now this patient has begun toe have generalized lesions so you could see small lesions and large lesions. But each of them maintains that sort of coin shaped or ne Mueller morphology, and this patient would be incredibly itchy. They will tell you that they think they spread the rash around because they will have scratched the spot and scratched another area on their skin, and a lesion will come up in that area. And that's a normal way that dermatitis response. And that's because the whole skin is affected. Even though the plaques are limited. This patient up in his right shoulder also illustrates ah, complication of managing the Mueller dermatitis and that this patient has steroid acne, so you can see these pustules over the shoulders and look acne, a form that's because he's been given systemic steroids and topical steroids to try to control his Exuma. And it's resulted in acne, so sometimes the patient will come in. You look around, you'll do a biopsy, have a red spot and you get back a report. Fully colitis. Well, this is not follicular itis, but the acne from the treatment is the filic. You'll itis, so you have to be aware of that as a pitfall. Once nebula dermatitis is widespread the whole skin is involved, and it will spread to areas where the patient scratches. Um, and this condition is called conditioned hyper irritability. Nebula dermatitis is worsened by alcohol, so I have patients try to cut back on their alcohol consumption, and the Mueller dermatitis is really hard to treat Onda. We often need you systemic steroids or even other immuno suppressive. And this is a patient who has. Now you can see really rip roaring. No Mueller dermatitis. That's widespread. Um, and when I was in Korea for a year and I Onley sent to patients back from Korea to the United States to be managed, one had leishmaniasis, which I couldn't treat. You did antimony, and this was the second patient. There was nothing I could do to getting better, and he went to Bethesda. You know, the hospital where the president's go? They couldn't get him better either, so they sent him home to his parents farm, and he just hung out there for a year, and it all went away. Andi, that's the natural history of Ne Mueller dermatitis that it lasts about a year or a year and a half, and then it disappears So your goal is toe. Identify it, treat the patient and then keep them controlled for that year to year and a half. And then usually you could taper off their treatment and they'll be fine. So it's actually a self limited disease. No one knows the cause of this. About a quarter of the patients also have contact dermatitis. Okay, Okay. We're gonna talk some about the basic principles of treating Exumas. Uh, and I think you'll hear a few things here that are a little bit different than what you may have read or have been told. Andi, these come from new ideas about, uh, these skin eruptions and also from experience so moisturized. So we talked about this. That is Emma's. Weep the skin where there's Exuma can't hold water, it dries out. And moisturizing is critical moisturizing. I have ahead of Medicaid, so you're gonna wanna use an appropriate strength of a topical medication, and we'll go over that in general when we see patients, the strength of medication we would use for the eczema is going to be greater than what the referring healthcare provider would have used. So we like to use big guns for a short time, get the patient better go down to lower strength, the idea of using lower strength steroids and then sort of escalating your therapy kind of leads to tacky Phil axis. So you get a little bit of a responsive patient breaks through, you go up to the next class, the patient break and you just kind of chase your tail. So we go right to the top, knock the Exuma down, and, uh, then back off. If we think the patient has secondary infection with staff, we treat that. And then we also measure and treat the itch because sometimes the rashes and what bothers the patient, it's the itching. Okay, so what about moisturizing in general? Examine. The skin is super sensitive. So a lot of things they're gonna be irritating. So we want to use non irritating things, but we want to use things that holding water because examiners skin loses water, it's essentially for my skin. And the thing that holds water in your skin is called natural moisturizing factor. And you can measure that in examine a skin and it's markedly reduced. So what inherently holds water into the skin is lost so we have to seal the skin in order to replace that and prevent that water loss. The other principle is that in that patient with no Mueller dermatitis and in other patients with eczema, if they're getting worse, they already have sub clinically involved areas. And if we measure water loss in those areas, it's already accelerated. So before the eczema shows up, the water loss shows up. So when you treat a patient who has Exuma, you wanna moisturize them all over, even in areas where they don't itch except in the moist skin areas, so they don't need to put it in their armpits. They don't need to put in their growing, uh, usually not on their scalp or face, but the patient who has trunk aligned, scattered leg dermatitis. We're having them put their moisturizer all over, so we're huge moisturizer fans. We like the moisturize after bathing, and we'll talk about why, and we'll talk about what moisturizers makes sense to use. So if you go to the store, these air, all the kinds of moisturizers you can see, there's Vaseline. There's Vanna Cream, There's Aqua for, and it's cousin use sarin. There's Sarabi and then here we have said it, Phil, and there's many more. These are nice because they all come in big £1 jars and there's different technologies for different moisturizers. And, uh, it's good to know that. So these moisturizers are in different classes. There's moisturizers that work just like a barrier they hold in water. So that's use sarin. That's aqua for that's Vaseline. That's sort of Greece, and it holds it in. If the skin is dry, we can use Yuria as a you mech tint. It pulls water into the skin. This is great for sort of dry peel the skin, especially in older patients who don't bathe very frequently. And they may not like the fact that their skin sort of piles up a little bit. And putting a thin film of Yuria on sort of softens the skin up. It works great for thinking souls, Um, where around the hell where the skin gets stick so we will use you re at times, uh, 5 to 10%. The oil that's critical to the skin sting moist is ah, family of chemicals called ceremony IEDs and the industry in the, uh, Kozmus. Ooh, tickle industry latched onto this and began to make Serra meid containing moisturizers. And Sarah V is one of those. It's the most economical. There's others like episode serum, which is prescription and pretty expensive. But you will see lipid enriched moisturizers. And that's actually not Krockey that's enriched with these Serra minds. And they could be nice to use during the day because they're cream like they're not so greasy that they do moisturize. So you rub Serra V into your skin and you get in the shower. The water will beat up, even though your skin doesn't feel greasy. We like things that help the itch so we might mix camper and menthol in there so that Sarna or we may mix Prum ocs ng in there. And that's prob practice or sarna for sensitive skin. So if you have a patient who has needs to use a daytime moisturizer, and they have a lot of itching, these air safe to apply multiple times a day, and if it gives the patient a few hours of relief, that's great. And then they can use a heavier moisturizer at night bath oils. The Mayo Clinic and I have a big disagreement about this. The Mayo Clinic loves bath oils. I don't like bath oils so much, and the major reason is I see a lot of geriatric patients, and I'm concerned about them slipping on falling, and it is really a mess. It's already slippery in the shower, and then to put a bunch of oil in there makes it even more tricky. And I don't know how much the oil is retained, so we like to rub the oil in. Lastly, if the patient has allergies to preservatives, you can use VANOC cream. Savannah cream is the vanishing cream base that was developed at the Mayo Clinic, and so it's preservative free on DWI. Use it in our patients, where we're concerned that they have an allergen. So if you see a patient and you think they may have an element of allergic contact dermatitis thio to some product they used to a preservative to a fragrance you can give them vanna cream to use. And, uh, you can avoid some of those allergens. The pharmaceutical industry has also used mild anti inflammatories and oatmeal that's in a vino. Products actually is a mild anti inflammatory do thio. These different chemicals that are in the oatmeal in general, when a patient goes looking for a moisturizer, what I tell them is if you pick the bottle up and the first ingredient is water, get something else. It either should be mineral oil or petrol. Autumn, but it should be something a little heavier and not water. Okay, what about bathing? So we used to do the Schultz regimen for eczema. In other words, you had eczema. You didn't get any water on your skin. And the people, You at University of Pennsylvania sort of disagreed with that and developed a different strategy. And the basis of this is if you bathe and you don't moisturize, your skin will get dried out. So if you get wet and then you let the water evaporate, it actually drives your skin out. So that's how you could do cool compresses for week. The Exuma. Right. But if you soak your skin, get it hydrated, and then within three minutes you put on a moisturizer and seal that skin in. You actually moisturize your skin, so it helps. So we have switched from the dry approach to the wet approached, so we like soaking and ceiling. And that's our approach. And it's this three minute rule that you need to remember. So your patient gets out of the shower. The tub pats try has their moisturizer or medication right there. And they put it on within three minutes of getting out of the water. Okay, so that's how to use them aliens. And what kind of, um, aliens we have. Okay, we're gonna talk about anti inflammatories that we can apply topically topical steroids as a workhorse topical call Sonoran inhibitors. That's pro topic, which is topical tackle LIMAs and l adult, which is topical. Pamuk, rely mus and then a p d e four inhibitor, which is called you Krisha. A prima last, which is an aural medicine, is in this same family. Andi, it is this. It was found that of these possible digest a races of their which they're 1 to 10. PD four was markedly elevated in eczema. And so they elected to make a specific inhibitor of that PDE. So that's why number four was chosen. Okay, you can think of the stories and one of two ways by potency, either low, mid and high in general, you should know one medication in each class. Unfortunately, with the insurers, uh, renegotiating prices, it's hard to know exactly which medications they're gonna be covered. But in general, we have low potency. That's the hydrocortisone class. Mid potency triumphs in alone or debate a Method Zones and then Super High Potency Club is all a more sophisticated sort of look at. It would be toe have five classes. So Class Juan, the strongest super potent club, is all. And although club is all may not be on many formularies, beta methadone die appropriate, which is Dipper. Lien is covered by many plans. It's generic. Andi, that's our go to super potent steroid Class two is flu. Listen denied. That's high potency. That's light X on dishonesty. Meta Zone is also in that class. Mid potency. Try and sit alone. That's our workhorse. Uh, Destiny died is class, for that's the mid low potency. So something a little bit stronger, but not Floren ated, so you can put it on the face. And that's now not on a lot of pharmacy plans. But Alcala Meta Zone, which is equivalent, is on those plans and clo Durham. So if that's the night, it's not covered. I just right for up on that. His own for like, separate dermatitis of the face or mild exam. And then, lastly, is high records in class, you can become allergic to the cortisone is themselves. And if you had eczema for a long time and you've been putting cortisone is on your skin, you can develop cortisone allergy in order to approach that, you have to use cortisone. Is that air structurally different? And so in the middle of potency? That's clo Durham, and that's dis oxy medicine. So the patient who has steroid allergy, what they'll tell you is that they rub the medicine on and it gets better. But then when they start rubbing it, unless it gets worse, Um, sometimes I'll have a flair if they take a course of systemic steroids. Um, and we've seen that as well. So we diagnosed three or four patients a year with topical steroid allergy on its seen, most characteristically, in patients who have used steroids for a long time. But we have some good alternatives here. Okay, the steroid is one thing. The vehicle is another. So we have appointments, their greasy, but we like them because they moisturize and they're more effective creams, Robin. But old creams like light X The formulation is not so good. So it leaves kind of a white film. And the patients don't like that. They have solutions and lotions, phones and sprays. These air all ah, bit more expensive. But they're good for Harry areas. Andi even, uh, steroids put in tow peanut oil that you can rub through Harry skin. So for people who have ah, lot of hair, you wanna use these lighter vehicles. Okay, So what about using these topical steroids? They're effective and they're safe. If you use them correctly, you wanna use the adequate amount you need and rub it in. Well, you wanna put it on wet skin. There's no evidence that using things twice a day is any better than using them. Once a day on British Health Service actually commissioned a study to see what the national policy in the United Kingdom would be around the use of topical steroids. And there was no evidence that twice a day was any better. The companies that develop these medicines test them as is higher frequency is they can get compliance because they think they'll get a better result, and then when they get approved, they get approved at that frequency. But, um, I often have patients use it just once a day, especially patients who have to have someone else put their medicine on. So once a day with steroid and once a day with the moisturizer. An important way Thio treat your patient adequately is to know that you can dilute destroyed with three parts of moisturizer without affecting the advocacy. So if you try to give the patient enough steroid to treat their skin, and we said you may have to treat wide areas, So if you're going to treat their chest and back in their arms and legs, that's, you know, 18, 18, 18, 18 and two nines. You add that up. You need that percent times 30 g 30 g to cover your body. One time you're talking about pounds of steroids that you need, so what I do is I'll have the patient by their pound of moisturizer. I'll give them two ounces of their topical steroid, and then they go home and they take that pound and they cut it in half. Put it in a container and put their two ounces of topical steroids in that eight ounces of moisturizer mixed that up. Keep it in the refrigerator to keep it cool, and that's their medicine that they put on after they bathe once a day. So that will stretch out your topical steroid and reduce topical steroid side effects and also cost. If you cover steroids up so occlusion you put the steroid on the moist skin and then you cover it. The penetration steroid goes up tenfold. So we do this regularly when we admit patients with Osama, which we rarely do now or when we send them home and we use either wet wraps, which is, the patient takes a pair of moist of pajamas and makes them moist, puts them on, and then, as a dry pair of pajamas, they pull over the top. So ah, wet layer and then a dry layer you can buy vinyl suits had Big five. The wrestlers use it to lose weight, but that will seal the skin. They're sold. Also, Biderman a logic cos you can use Saran wrap. We regularly use trash bags, just cut a top out in a couple of arms and pull that over on, and that can then seal the steroid in. So we're gonna soak the skin to get it wet. We're gonna smear on the steroid, and then we're gonna seal it, soak, smear and seal. So we call this soaking smear. This is like giving hydrochloric thighs side for mild blood pressure. This is like every day basic Exuma management. So if you remember one thing from this lecture, soak, smear seal, that's that's the ticket to success. Okay, in general, of the patients having a severe flare, we're gonna soak and smear them aggressively. And I will tell the patients, okay, you gotta commit to me for three days. Here's your stuff. I have a mix it up and I say you're going to take a bath for 20 minutes, you're gonna get out, you're gonna smear. You're gonna cover yourself with your raps. You're gonna leave those on four hours and you're going to repeat that a second time during the day. So morning and night, you're going to do a four hour regimen, Soak, smear seal, and you can break a severe flare of eczema about 50% of the time just by doing that? The class of steroid you're gonna use in smaller Children is gonna be mid potency. So try, um, syndrome is gonna be your workhorse. But in adults who have really bad example, you're gonna want to use one of these higher, super potent steroids in treating that patient if they have thick, localized areas that you might need to rub the super potent steroid right on it. Uh, in infants, you can start with a much lower strength steroid because they have more, better cutaneous absorption. So you can start with hydrocortisone if the patient has relapsing areas. So in other words, they treat their eczema, everything gets better. Then when you stop, one spot keeps coming back on the leg somewhere. Then what you want to do is just use a mid potency steroid for a week, get it under control, then pick a little bit lower potency steroid. 2.5% hydrocortisone. The alkali met his own destiny and put that on twice a week for a month or two. And that prevents the relapse at that site. And we'll knock out that local regional example from the dermatologist perspective. Don't under treat if you start with lower strength steroids, our experiences bid. You end up treating longer and you end up with more local side effects. So you want to treat aggressively, uh, to knock the Exuma back. So soak, smear seal. Okay, what about these nonsteroidal anti inflammatories? We'll tackle Lima's 0.1 point three tackle. Lima's is about equivalent 2.1% in crime scene alone, so it's convenient. Tackle Lima's attack are the same. Efficacy and Pinchbeck rely Mas's sort of a little bit lower than that. Um, these products burn when you apply them to inflame skin that last for a few days. We may have to put a steroid on first and then do the topical microclimates. But we like this for facial skin and for areas that the skin congrats tria. So around the egg zilla on the breast, uh, microclimate tackle LIMAs and microclimates are self safe to use around the eyes and on the eyelids, so that avoids the concerns about glaucoma and cataracts from using topical steroids on the eyes. And I even have some patients who had constructive of involvement where the pro topic has just been directly applied to the constant Taiba. The ophthalmologist also will compound Pro Topic Azan, anti inflammatory or topical cyclosporin. It's cousin, so you can use these around the I remember re Stasis. I dropped his topical cycle sport, so that's, ah, way you can cheat Thio, get pro Topic if you're just treating around the eye, okay? And then, lastly, you. Chris uh, which is Chris Abba Role is a nice product, is elegant. It can burn. It's not very strong, so it's kind of 2.5% hydrocortisone. Maybe the micro Lima's strength. Eso is great for Mild Exuma, good for kids because it feels good when it goes on, although if it burns, that could be a problem. And but I don't find much use for it in adults because the volume is small, so it would be a one off for a localized area of dermatitis. Now there are other things we do for patients with bad eczema, least mere tar on them. We love tar, but it's a mess, so most of time we do it in our in patient treatment center, which is over on Spruce Street, and you can see our nurse smearing this patient up with terrible Exuma with tar and wrapping him in Saran wrap. So he's getting his soaking smear and he'll sit there all day and that will break his Exuma flair and keep him clear for about six months. We use light, um, which, uh, can repair the skin barrier and knocked down Exuma. We do sometimes get patients home light boxes. Andi, In the most severe cases, we will actually put patients in our day treatment unit on break their flair. The day treatment is specifically good for little kids who can go to day treatment. If they've got, like, terrible eczema and you don't wanna put him on a systemic medication, you can send them today treatment. They get treated during their school vacation for a few weeks, their skin gets much better. They could go back to school. So it's really good for school age kids. Okay, what about creating the itch? So you're gonna measure the itch, right? And then you need toe figure out what to do with that. So each in X tema is not due to histamine. So this is a non history energy kitsch thes nerves that are activated in a topic. Dermatitis are not responsive to history. So we don't use anti histamines except a sedative. So if you give a patient Benadryl or hydraulics cuisine, you're not really doing anything about the inflammatory component. And these things really are not that effective on the neural side, either. On you can give patients high doses of fexofenadine, for instance, which are great for verdict area, which is clearly history mediated, and it does nothing for Exumas. So we're not fans of anti histamines, and already dermatologists are beginning to use less and less and a histamines. Uh, based on this new understanding, the most important thing is to treat the eczema, because if you treat the eczema, you can make the itching better. Um, the medication we now start with is gabapentin or pre gavel in. If topical therapy alone is not working and we usually do an afternoon in the nighttime dose, half assed much in the afternoon is in the evening, so we might do 306 100 something like that on if patient has side effects from the gap of Penton, Um, we use pre gabble in. You have to be careful with non sedating antihistamines in the elderly increases Alzheimer's and, um, dementia risk. You have to be careful with gabapentin and pre goblin and the elderly because it increases falls. So we were always walking a fine line and our elderly patients. But we're getting them off the hydroxy scene and Benadryl and getting them on toe gabapentin pre Gavilon. We will add on drugs when the itching is really bad. Marinol, which is THC, right? Or Sina Quan, which is oxygen, which is tricyclic and it works Neural E. It also turns out to be a potent in the history. The reason we like measuring ish is in. The patient has a really bad rash. The rash may get better slower than the treatment is suggesting. So the itch may be improving. The dermatitis doesn't look so good. So we see the patient back after a couple of weeks of aggressive topical treatment, and the patient says, I don't think my rashes any better. We look at it. We think it's kind of going in the right direction. Um, and then we'll ask them, What's your ich score? You know, and then we'll go like six we got. You know, the last time you're in you told us it was nine. So you're actually getting better. And numerous times I've had this discussion with patients and we've been able to continue just doing topical therapy and the patient clear. But it gives you an external metric. And the nice thing is, it's a patient reported outcome, so the patient can relate to that. They scored their own disease, and now they're scoring it again, and they're reporting that they're better. So it kind of is a saying to the patient. We care about what you feel and we listen to what you're having to tell us that you're getting better. Okay, we're gonna talk a little bit about staff. So staph aureus colonizers and then maybe infects eczema. So if you take a whole pile of patients with eczema and you give one half of them antibiotics and you give the other half of them no antibiotics in one week, the patients who got the antibiotics are a little bit better. But at two weeks everybody is the same. And if you just put topical steroids on patches of eczema, the staff goes away, meaning the eczema allows the staff to grow. So that's kind of colonization. So we re do. We limit the term infected Exuma to where we see crusting custom URLs or the classic figuring of the ear lobes where the ear lobe attaches to the cheek and the jaw. If there's a fisher there that patients carrying staff and staff when it gets on the top of eczema makes it worse, and the way it makes it worse is it actually stops the immune cells from being responsive to the cortisone creams. So you're treating away with crime scene alone, and suddenly it's not working well. That's because staff super image and shut off the cortisone receptors on the immune cells, and now they're not responding in your topical steroid. So in the patient with Exuma, whose flaring look for staph infections so we'll cut, well, swab those lesions. And if the culture comes back, if we suspect it will treat them right away. But if the culture comes back positive, we treat them, and we treat them not just for the staff, but sometimes we also treat them for staff carriage. So, um, we do cultures that I've been through two generations of staff resistance in San Francisco. So during the HIV epidemic in the nineties, all staff in in San Francisco was resistant to sell from a doctor's ultra method from because that was used for PCP prophylaxis and so many patients in the community were on that. Now everybody is worried about M. R s A. And is using doxy as first line therapy for staph infections. And so we regularly see now Salva mailboxes all sensitive, boxy, resistant staph. So I begin by giving Seth election. And if it's M. R s a, then we re adjust. But I don't use Doxy is my first choice unless I know it's M. R s A. And then I'll treat with rampant 600 mg a day for five days to clear the characters. I also have the patient put New Pearson in their nose. Um, women carry staff in their vaginas, and revamping will clear that. So getting rid of that carriage can keep your patient with eczema, then staff free. But if you don't treat the carriage, if you just give doxy or regular antibiotic, you're not going to clear the carriage and then the patients will relapse. Pets carry staff is well, especially dogs. Um, and if you're patient has recurrent staph infections. Check for a low vitamin D because vitamin D is required for your your skin to make its own immune. Fighting protein so low Vitamin D is associated with bad eczema. Treating with vitamin D gets your patients exam a better. So we're looking at vitamin D. We're looking at staff. Were looking for contact allergy, and we're soaking, smearing and sealing our patients. Okay, we Sometimes we'll use bleach bears. Patient could just swim in a pool. Or you could put a quarter cup of household bleach in a tub of water and soak for 20 minutes. Use me Pearson in the nose. If I have a patient who has eczema and bad staph infections, I have everyone in the household using you. Pierson, uh, in Australia, they mix them your Pearson with the topical steroids. Some patients like that. Your target vitamin D level is to get above 30 and treat the whole family and the pets if you find staff. Okay, so this is what we've gone over. Measure how each year patient is and measure how bad their dermatitis is. Figure out what type of banks? Um a. They have do they have a contact dermatitis? And they have a topic. Dermatitis, ne Mueller photo Stasis that will be based on the pattern that you see on the patient's body. We're gonna soak, smear and seal these patients, uh, in some form. The simplest is we're going to use a steroid ointment, which will smear and seal by itself. We may do the whole shebang of putting the patient in the tub, soaking, smearing, putting on wet wraps to break a severe flare. Remember, don't be afraid to use high potency steroid early on. Then switch over to something not quite so strong because you'll end up with a shorter course. And remember, if there's no response, think that there's a contact dermatitis or some exogenous factor, or that their staph infection
