Childhood Eczema: An Environmental Scan
Table of Contents
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)