eczema treatment singapore

eczema treatment singapore

What is Eczema?

Atopic Eczema (atopic dermatitis) refers to a chronic inflammatory condition of the skin characterized by a defective skin barrier. It is a very common skin condition, mostly appearing in childhood and may be associated with asthma or allergic rhinitis (sensitive nose) in two thirds of cases. As itching tends to be chronic, it can cause profound sleep disturbance and interfere with social, behavioural and educational development. Eczema is a complex disease, influenced by immune, genetic and environmental factors.

How Common is Eczema?

Atopic eczema or dermatitis often starts from childhood. It is reported that about 70% of individuals first develop eczema during the first 5 years of life. About 20% of school going children (aged 7-16 years) in Singapore have eczema. Adult onset eczema is not uncommon either, representing about 10-15% of the cases. The prevalence of atopic eczema appears to have increased over the last few decades. Although it appears to be more common in affluent countries, there is an increasing trend worldwide. Although eczema does gets better in about two thirds of cases during the adolescent period, there may be occasional flares during adulthood.

what-is-eczema

What Conditions Are Associated With Atopic Eczema?

Atopic eczema is considered an atopic disease. Atopic diseases are those where there is a heightened response of the immune system to allergens. Asthma, Allergic rhinitis (sensitive nose) and allergic conjunctivitis (sensitive eyes) are examples of atopic conditions. There is a 60-70% chance of developing either asthma or allergic rhinitis if you have existing atopic eczema.

What Causes Eczema?

Although atopic eczema is a common condition, the underlying mechanism is complex and involves an interplay between genetics, immune system, skin barrier dysfunction and the environment. A mutation of the epidermal protein known as Filaggrin has been shown to be the strongest genetic factor in atopic eczema. However, not everyone with filaggrin gene mutation will develop eczema. Skin barrier dysfunction is also attributed to deficiency in ceramides and protease inhibitors in the skin. Intriguingly, studies have shown that individuals who migrate to a urban region from a rural one will increase their risk of atopic related diseases.

How Is Atopic Eczema Diagnosed?

Most cases of atopic eczema are diagnosed from the clinical history and clinical examination. Although common, there is no specific blood or imaging tests to diagnose the condition. 

A diagnostic criteria by the UK Working Party states that a patient with Atopic Eczema must have a history of itchy skin with 3 or more of the following:

  • History of rash in the skin creases, including the cheeks of children less than 10 years of age
  • personal history of asthma, hay fever or history of atopic diseases in first degree relatives in children < 4 years old
  • Onset less than 2 years of age
  • Dry skin within the last year
  • Visible flexural eczema e.g. neck, front of elbow, back of knees, ankles.

What Can Trigger Eczema?

Factors that may worsen eczema should be identified and minimised wherever possible. Different individuals may have different triggering factors, which may change seasonally, according to weather and geography. Common factors include stress, sweating, heat, dust mites and infections. External factors such as harsh soaps, detergents, latex and food allergens are possible factors.

How Eczema Impacts Your Health

In many individuals, atopic eczema that is not well controlled can cause sleep disturbances, poor school or work performance and low self-esteem. This may subsequently affect recreational activities, and cause significant psychological and financial stress for the individual and their families at large. 

Eczema Treatment Singapore

Eczema treatment options depends on the severity of your condition. For mild to moderate cases of Atopic Eczema, the focus is on repairing the skin barrier with regular moisturizers and topical steroids or topical calcineurin inhibitors to reduce inflammation and itchiness. For severe cases of Atopic eczema, treatment options include phototherapy, systemic therapy (e.g. ciclosporin, methotrexate) and biological therapy (e.g. Dupilumab).

Moisturizers for Eczema

Moisturizers are integral at reducing the transpeidermal water loss and reducing the skin barrier defect. Moisturizers are fundamental for eczema care and management. From studies, early use and regular use of moisturizers have been found to reduce eczema flares and incidences.

There are 3 main classes of moisturizers. Emollient moisturizers act by softening the skin and covering the skin with a protective film. Humectant moisturizers retains the moisture within the skin by pulling water to the upper layers of the skin. Lastly, occlusive moisturizers contain ingredients, typically lipid that protects the skin against too much transepidermal water loss.

  • Emollients e.g. Ceramide, Shea butter, Palmitoyl-ethanolamine
  • Humectants e.g. Glycerin, Urea, Hyaluronic acid
  • Occlusives e.g. Paraffin, Petrolatum, Olive oil, Coconut oil

Topical Steroids for Eczema

Topical steroids work by reducing the inflammatory component of an eczema flare. They have proven to be effective, reduce itchiness, redness and improve sleep quality. Many patients who may have unfounded phobias about the use of topical steroids will unfortunately hamper the management of their eczema care. However, with judicious use, it is a safe and effective treatment.

Topical steroids come in different potencies and formulations. The type of topical steroid prescribed will depend on the affected area, age of the individual and severity of the condition. Generally, topical steroids are applied once or twice a day, no longer than 2 weeks at a time. Abuse or inappropriate use of topical steroids can lead to skin thinning (atrophy), visible blood vessels, folliculitis, acne and perioral dermatitis.

Topical Calcineurin Inhibitors for Eczema

Topical calcineurin inhibitors work by modulating the immune response of the skin to eczema. They are perhaps best known for their steroid sparing effects. Topical calcineurin inhibitors such as Pimecrolimus cream and Tacrolimus ointment are FDA-approved for use in moderate to severe eczema in individuals who are more than 2 years of age.

Recent studies have allayed fears on the risk of malignancy associated with topical calcineurin inhibitor use.

Due its steroid sparing effects, topical calcineurin inhibitors are useful in sensitive areas such as the eyelids, face, neck and skin creases. They play an important role in maintenance therapy to reduce eczema flare ups. When first starting topical calcineurin inhibitors, you may first notice redness and a burning sensation, but this resolves after continued use.

Although atopic eczema is a common chronic skin condition that may affect your quality of life, a tailored approach to finding a balance between maintaining your skin barrier and reducing flare ups will lead to good results. The best eczema treatment hinges on avoiding trigger factors, protecting the skin barrier and maintenance therapy.

Atopic eczema is considered a chronic inflammatory condition. Although there is no cure for eczema, effective treatments help to reduce symptom, improve sleep quality and overall quality of life.

Wet wrap therapy is suitable for children with severe eczema to help restore the skin barrier and to reduce itchiness. A first moist layer of pyjamas or bandage is used followed by a second dry layer. When topical steroids are used, treatment is limited to once a day for up to a week.

Non-soap cleansers that have neutral or low pH and are hypoallergenic are recommended. Avoid soaps associated with fragrances and with high pH levels.

Although anti-histamines as monotherapy do not control the itchiness associated with eczema, they may play a role to improve sleep. However, they should be used cautiously in children due to the effects on cognition.

Intermittent use of mild to moderate topical steroids for short duration is safe for pregnant women.

Generally, for older children and adults, food allergens are quite unlikely to worsen atopic dermatitis. A food dairy and selected allergen testing may be beneficial in the proper context.

Food allergy may be suspected in younger children, less than 3 years of age with widespread and stubborn eczema. Common allergens include cow’s milk, eggs, wheat, nuts and soy. An evaluation by an allergist may be necessary if dietary intervention is to be considered.

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References:
  1. Eichenfield LF, Tom WL, Chamlin SL, Feldman SR, Hanifin JM, Simpson EL, et al. Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol. 2014 Feb. 70(2):338-51.
  2. Leung DY, Bieber T. Atopic dermatitis. Lancet. 2003 Jan 11. 361(9352):151-60.
  3. Sidbury R, Tom WL, Bergman JN, Cooper KD, Silverman RA, Berger TG, et al. Guidelines of care for the management of atopic dermatitis: Section 4. Prevention of disease flares and use of adjunctive therapies and approaches. J Am Acad Dermatol. 2014 Sep 25.
  4. Tay YK, Chan YC, Chandran NS, Ho MS, Koh MJ, Lim YL, Tang MB, Thirumoorthy T. Guidelines for the management of atopic dermatitis in Singapore. Ann Acad Med Singap. 2016 Oct 1;45(10):439-50.