Beyond Dermatology: Holistic Healthcare Can Provide A Wider Range Of Treatment Options
Charnae Sanders said she wished her dermatologist knew there was more to her condition than what shows up on her medical chart. Even though the effects of my eczema can be seen physically, she said, there is emotional and mental pain I live with: its important that dermatologists are mindful of how they talk to patients and recognize that the scars we carry arent limited to what the eye can see.
I would recommend that doctors lean towards using more of a holistic approach, Charnae said. I appreciate it when my dermatologist does not just limit the conversation to better care but also discusses how to manage my stress and find support groups for people who also have eczema.
Which Skin Type Are You
Skin type is described by the Fitzpatrick classification , which determines the colour of skin by phototype, which depends on the amount of melanin pigment in the skin.
In this article we describe skin as lighter or darker.
Skin types: Fitzpatrick classification, adapted from:
Skin changes are caused either by active eczema or by scratching as a result of eczema itch. These changes can result in two types of pigmentary skin changes in eczema:
- HYPO-PIGMENTATION Loss of skin pigment or colour, usually seen as patches of skin that are lighter than overall skin tone.
- HYPER-PIGMENTATION Patches of skin becoming darker than the normal skin tone.
Hypo- and hyper-pigmentation are more visible in darker skin types but can occur in any skin type and can be concerning and distressing for anyone with eczema.
The main way of improving skin pigmentation changes is to treat the underlying eczema and inflammation. But discoloration can last for months or years, even after the eczema is treated.
How Do Dermatologists Treat Severe Ad
Each patient with severe AD receives a personalized treatment plan.
To create this plan, your dermatologist will want to know how long youve had AD, your response to past treatments, and your preferences for treating AD.
Even for severe AD, treatment often begins with the basics skin care, trigger management, and medication.
For treatment to work, its equally important to find out if you have any other medical conditions. If you have an undiagnosed medical condition, it may prevent your AD treatment from working.
Heres what you can expect if you see a board-certified dermatologist for severe AD.
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When Adults Get It
You might notice itchy patches on the hands, elbows, and in the “bending” areas of the body, such as the inside of the elbows and back of the knees. But eczema can appear anywhere, including the neck, chest, and eyelids. People who had atopic dermatitis as a child may see drier, scaly rashes as adults. The skin may be discolored or thickened.
Your Eczema May Not Disappear Completely But You Can Help Keep Your Skin Healthy
I emphasize to my patients that they shouldnt expect their symptoms to completely disappear once they start treatment. Its equally important to adopt lifestyle changes and to understand that, at baseline, most people with eczema have super dry and sensitive skin, even when the eczema isnt flaring. I want people to understand that there are things you can do every daygood days, medium days, and bad daysto keep your skin looking and feeling its best.
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In Babies: Cradle Cap
Cradle cap is seborrheic dermatitis that commonly develops in babies between 2 weeks and 12 months. You might notice red or dark, scaly or crusty yellow patches on their scalp. Or it could start in the face or diaper area and spread elsewhere. Itâs usually not serious and often goes away on its own in a few weeks. Talk to your doctor if symptoms worsen or lead to other problems like infection.
So What Causes Eczema
Basically, the cause of eczema is somewhat unknown. Some people are born with genetic tendency to develop eczema. However, it is not completely understood why some people develop a more severe form than others or when it develops, says Dr. Robinson.
Dr. Scott agrees that the cause is a combination of genetics and environment. Of course in certain seasons, if the temperatures drop where you live, dry skin will be more prevalent.
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What Are The Clinical Features Of Dermatitis
Dermatitis may be either acute or chronic, and although the mechanism by which the dermatitis develops may be the same, the appearances may be starkly different.
- Acute dermatitis will show redness or swelling, papulation, vesiculation, oozing and weeping, and even blistering.
- Chronic eczema will show skin thickening with accentuation of the skin creases, hyperkeratosis, scaling, fissuring, excoriation, and hyperpigmentation.
- Subacute dermatitis will show features of both.
Treatment And Management Methods
The treatment goals of AD remain the same regardless of skin type. The goals are to prevent and manage flares while working to repair and improve the function of the skin barrier. Studies have shown that skin barrier dysfunction is the initial step in the development of AD. Many factors impact skin barrier dysfunction, including but not limited to immune dysregulation, filaggrin mutations, deficiency of antimicrobial peptides, and skin dysbiosis.10 A compromise in skin barrier causes a loss of moisture in the skin while allowing irritants and allergens to enter the skin. Discussing proper skincare is a fundamental step in the treatment of AD, but one that is often overlooked in a busy clinical practice. Studies have shown that the number of topical corticosteroids used can be significantly reduced by proper skin hydration through regular and frequent use of unscented emollients.11
Managing exacerbations of AD depend on the severity of the flare. For mild-moderate flares, AD can often be treated with TCs, topical calcineurin inhibitors , or phosphodiesterase-4 inhibitor. It is important to note that there is low risk of adverse side effects when TCs are used appropriately. Interestingly, the harm due to undertreatment of AD is greater than the potential for adverse side effects from TCs.12
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What Type Of Moisturizer Treats Eczema
There are several options of moisturizer available to treat eczema. Choose skin care products that:
- Are hypoallergenic, fragrance- and dye-free.
- Are gentle or for sensitive skin.
- Contain petroleum jelly or mineral oil.
- Dont include preservatives or stabilizers.
- Have lipids and ceramides to improve your skins barrier.
It may take several different products through trial and error before you find one that works for you. If you need help choosing a moisturizer, talk to your healthcare provider.
Eczema Risk Factors On Darker Skin
The National Eczema Association reports that family history also plays a role in why some populations have more severe eczema. Eczema tends to run in families with a history of eczema, allergies, hay fever, asthma , and other allergic conditions.
You are also at a higher risk of getting eczema if you are diagnosed with allergies or asthma or if you have a family history of other inflammatory skin conditions.
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How Is Eczema Diagnosed
Theres no specific test that can be used to diagnose eczema. Often, a doctor can diagnose the condition by talking with you about your symptoms and examining your skin. Sometimes, a patch test might be done to help find eczema triggers.
A patch test can pinpoint certain allergens that trigger symptoms, like skin allergies associated with contact dermatitis
During a patch test, an allergen is applied to a patch thats placed on the skin. Your skin will become inflamed and irritated if the allergen is a trigger for you.
How Is Eczema Treated In Darker Skin
The treatment of eczema is similar in people of all races and ethnicities. Gentle skin care and liberal use of moisturizers is the mainstay of treatment. For some patients, topical or systemic medications may be needed.
Atopic skin tends to be dry and sensitive, so harsh and fragranced skin care products should be avoided to prevent worsening of atopic dermatitis. Increasing the moisture content of the skin is also essential. Fragrance-free emollients should be used at least once per day, ideally immediately after bathing. Thicker moisturizers, such as creams and ointments , tend to work better. Shea butter is a useful natural alternative to commercially available moisturizers.
Further, eczema patients should bathe and shower in warm water and limit the time to less than 10 minutes. Hot water can dry out the skin and trigger itching, making eczema worse. This tends to be particularly problematic in darker skinned patients who may be more prone to dry, itchy skin.
Prescription medications may also be needed to adequately control eczema. Topical corticosteroids are typically the first-line treatment but are generally used for limited periods of time. Non-steroid creams and ointments such as pimecrolimus , tacrolimus , and crisaborole may also be prescribed. These medications are highly effective and safe for use in all skin types.
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What Are The Types Of Dermatitis
Exogenous dermatitis is the result of an external factor or insult that induces skin inflammation. Common causes include:
- Allergic contact dermatitis due to immune sensitisation of an individual to an allergen, often at even low concentration, such as nickel, hair dye, rubber, or perfumes identified by patch testing.
- Irritant contact dermatitis will occur in anyone exposed to an irritant at sufficient concentration for long enough irritants include soaps, detergents, organic solvents, degreasing agents, abrasives, desiccants, dust, urine, and even water
- triggered by light or UV radiation
- Post-traumatic dermatitis due to physical injuries such as abrasions, burns, or surgery
- Dermatitis induced by local skin infections such as bacterial, fungal, and viral e.g. molluscum contagiosum and HTLV-1 disease
- Drug-induced dermatitis.
Endogenous dermatitis occurs because of often ill-understood internal factors. Common types include:
A detailed history and examination may be all that is required to make an accurate diagnosis.
The following investigations may sometimes be needed:
- Skin scraping to exclude a fungal infection mimicking a dermatitis
- Skin swab looking for bacterial or viral superadded infection
- Patch testing to identify contact allergens
- Light testing if a photosensitive dermatitis is considered
- Skin biopsy to exclude mimics of dermatitis
- Blood tests IgE , thyroid function .
Can You Prevent Eczema
Currently, theres no way to prevent developing eczema. However, if you have eczema, there are steps that you can take in your daily life to help reduce the risk of having a flare-up.
- Avoid triggers. Try to avoid the things that cause your flare-ups. These can be different for every individual but can include things like soaps, fragrances, or stress.
- Moisturize frequently. Use a fragrance-free lotion, cream, or ointment to add moisture to your skin. Good times to moisturize include right after showering and anytime your skin feels dry.
- Choose products carefully. Some soaps, detergents, and skin care products can irritate the skin and cause a flare-up. Focus on using fragrance-free products. Try to test them on a small area of skin before using them on larger areas.
- Change your shower routine. Try to limit the length of showers to about 10 to 15 minutes total, using water thats warm but not hot. When youre done showering, gently pat yourself dry with a clean towel and moisturize.
- Mind the temperature. Remember that some conditions can increase the risk of a flare-up. For example, colder temperatures can lead to drier skin that may require additional moisturizing.
- Clothe carefully. Aim to wear loose-fitting, breathable clothes while avoiding tight-fitting garments. Additionally, wash any new clothes prior to wearing them for the first time.
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Cultural Considerations In The Management Of Ad
Recognition of common cultural practices and traditional herbal remedies used for the treatment of AD is paramount. In African, Asian and Hispanic cultures, patients often use herbal remedies for skin ailments prior to seeking dermatological care, which may have significant implications on treatment outcome., While some cultural remedies have been shown to be beneficial in AD, the associated risks are largely unknown.
In Chinese, Korean and South-East Asian cultures, oral herbal preparations, bath therapy and topical treatments are commonly used for skin conditions. Interestingly, ingestion of Chinese Herbal Medicine and Japanese Kampo medicines may improve erythema and inflammation in patients with AD and may have additive benefits when combined with Western medicine.- A meta-analysis of 9 randomized controlled trials showed that a combination of CHM and Western medicine is superior to Western medicine alone, and that, when compared to placebo, CHM significantly improves erythema, surface damage, pruritus, sleep scores and quality of life. Several adverse events have been reported with the use of CHM, including liver enzyme elevations, gastrointestinal upset, rashes, dizziness and headache., Therefore, providers should thoroughly review the risk/benefit profile with any patient who uses or plans to use CHM.
Scratching Often Leads To Hyperpigmentation
Inflammation and scratching stimulate pigmentation. Simply scratching the skin, even without eczema, can cause brown patches, for example on the back. Eczema lichenificationthe thickening of the skin due to scratchingoften appears hyperpigmented on dark skin.
This hyperpigmentation is temporary and is gradually reduced with treatment.
We also observe on dark skin a particular form of lichenification comprised of, for example, isolated spots .
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Better Treatment For Black People With Eczema Requires Better Training And Representation
To treat her eczema symptoms, Ashley Hardy experienced multiple rounds of allergy testing a lengthy, painful and expensive process before recognizing her allergens and learned how to best manage her severe atopic dermatitis. People of color are not represented very well in books about health, she said. Eczema does not look the same in darker skin. And it makes me question how well a doctor can treat skin of color if it isnt a part of their education.
Reggie, in his role as vice president of a healthcare service company, made a similar comment about the medical textbooks he saw in his line work. Most of my studies, down to the pictures in our textbooks, were of white people, he said. If doctors dont have textbooks with people of color who have dark skin, how are they supposed to treat patients of color?
Other Skin Conditions That Cause Pigmentary Changes
Eczema is not the only condition that causes pigmentary changes: they can also be caused by various other skin conditions that someone may have alongside their eczema. Two other common pigmentary skin conditions are melasma and vitiligo, but there are many rarer conditions too. So, any form of pigmentary skin problems that cannot be explained by eczema should be assessed and investigated.
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Eczema & Dry Skin Treatment
Dry skin can lead to itchiness and leave skin irritated and flaky. Dry skin is often caused by a dry, cold climate. It may also be caused by steamy showers, chemicals or moisture-robbing routines like drying off right after a shower without moisturizing first or using certain soaps. Severe dry skin may also be due to another medical condition, such as thyroid disease.
Eczema, also called atopic dermatitis, is a common type of dry skin condition that causes dryness, itching and burning. Though adults and individuals of any age can develop eczema, the condition is most common during the first five years of life and baby eczema often manifests in infants less than a year old.
How Can You Treat Eczema In Black Skin
There are a few ways experts treat eczema, but it depends on the severity of the case. Moisturizers are one of the most important treatments, Dr. Scott says. We need to restore lost water and seal it in, so thick creams or ointments are the backbone to any eczema treatment and preventing flare ups. Consider over-the-counter options like Vanicream Moisturizing Cream or CeraVe Moisturizing Cream.
Vanicream Moisturizing Cream
Dr. Kagha recommends reaching for a cream thats fragrance-free, bland, and thick. Using products with added fragrances can irritate the skin even more and cause the eczema to worsen.
CeraVe Moisturizing Cream
While a heavy moisturizer can help keep moisture locked into the skin, Dr. Scott says a flare-up will often require a topical steroid. Topical steroids calm down the inflammation and help to control itch, but shouldnt be used long-term. If youre looking for a non-steroid option, talk with your dermatologist to see which option would be best for you. For severe cases that affect most of the body, one treatment option is a light-based treatment called phototherapy. Oral medications or biologic injections might be other possibilities, Dr. Scott adds.
The bottom line: Eczema may be more common on Black skin, but is often misdiagnosed. If you believe you might have eczema, schedule an appointment with a dermatologist to discuss the best next steps.
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What Causes Eczema To Start
The first signs of eczema are itchiness, dry skin and a rash. These signs indicate that you came into contact with a trigger in your environment that caused your symptoms to start or flare up. Identifying environmental triggers and avoiding them can reduce your risk of an eczema flare-up in your future.
How Different Skin Types Are Affected
The features of eczema differ depending on the persons skin type.
On paler skin, the typical pattern is inflamed, red or dark pink patches, with dry itchy skin, which in severe flares may ooze with small vesicles .
On darker skin, inflammation is more difficult to detect, as it is seen as various stages of hyper-pigmentation and is more subtle, so often redness is not seen. As a result, the severity of eczema can be underestimated.
Post-inflammatory hypo- and hyper-pigmentation are a much greater concern in people with darker skin, as it can take months for this to resolve and the discoloration can sometimes be a greater concern than the eczema itself.
Another feature of eczema, more commonly found in darker skin, is follicular prominence. This is where the eczema appears in small, itchy bumps or papules on the skin mainly on the trunk and forearms. Dry skin and scale can also be more prominent, as its white or grey colour shows up most noticeably.
A UK longitudinal study into ethnic variations in atopic eczema reported that children with darker skin were more likely to develop atopic eczema than their white counterparts and were six times more likely to develop severe eczema.
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