DPM DERM BLOG #2
Hi, ladies of DPM! Welcome back for the second installment of our dermatology blog. The main topic of this blog is dry skin (specifically eczema and seborrheic dermatitis). I will give you a short basic science background on both diseases, and as always, our (Sheila’s and my) favorite recommendations for products.
ATOPIC DERMATITIS
Atopic dermatitis is a chronic relapsing, and often very itchy rash, which can affect infants to adults. In many cases, it is associated with a personal or family history of atopy (seasonal rhinitis, asthma, or eczema). Skin involvement can range from acute weeping crusted areas to papules (small bumps) to lichenified (thickened) plaques. While most cases of eczema acutely worsen in the winter time (attributable to cold dry air), a small percentage of cases worsen in the summer.
SK: Yes, there are definitely subsets of cases, particularly in children who sweat a lot, who will worsen in warm weather. This is why there is sometimes a predilection for the folds of the skin in children where there is sweat accumulation and friction. For these children, keeping the areas free of moisture can be important ie patting dry after play etc. I do NOT mean keeping it free of moisturizer. Cream moisturizers may be better in these cases over thicker ointments.
Appropriate therapy for eczema involves proper instructions regarding bathing, skin hydration, avoidance of disease triggers, topical or systemic treatments, and stress reduction.
- Avoid triggers: sweating, detergents/solvents, infection, contact allergens, environmental aero-allergens
- In very young children, food allergy may be linked to recalcitrant eczema therapy (although the American Academy of Pediatrics is now recommending early introduction of common food allergens, which is a new consensus guideline).
- This only occurs in about 10% of children below the age of 2 years old, and foods most commonly implicated are eggs, milk, wheat, peanuts, soy
- Bathing habits: short lukewarm showers < 5 minutes long or baths with lukewarm water < 5 minutes long.
- THE KEY IS TO MOISTURIZE RIGHT AFTER GETTING OUT OF SHOWER OR BATH (within 5-10 seconds of emerging!)
- Favorite soaps: Vanicream bar soap, Aveeno Eczema Therapy, Cerave*, Cetaphil Restoraderm*
- *Many washes now contain CERAMIDES, which are the type of fatty acid we know is genetically lacking in those with atopic dermatitis
- Replenishing the ceramides in the course of washing the skin can dramatically improve the skin
- Favorite moisturizers: Vanicream, Aveeno Eczema Therapy Itch Relief Balm (specifically the one that comes in a tub, as it lacks propylene glycol, a common allergen), Cetaphil Restoraderm, Cerave, Vaseline or Aquaphor
SK: I swear by Vanicream (and it’s cousins Vaniply and Vanicream Lite lotion) for moisturizer, sunscreen, and soap. It’s a great brand and has yet to let me down in even my most sensitive patients. I also thick Aveeno eczema balm in the tub is probably the most perfect blend of a cream and ointment that I have yet found.
- The thicker the emollient, the better barrier and protection it will provide
- As a mom of TWO kids that suffered from eczema, they were bathed daily and massaged with Aquaphor immediately afterward and put into long-sleeved shirts and pants (or onesie pajamas)—which is a modified wet wrap and heals the skin incredibly well
- SK: I am also a mom of an eczematous kid. I have found that being early and appropriately aggressive therapy (steroids and non-steroids) has been most important to avoid worsening of the disease and control flares.
- Topical prescriptions
- The most commonly used topicals in the acute flare of eczema are topical steroids—and they remain the cornerstone of therapy for inflammation and itching
- One of my favorites to Rx in squirmy little kids who don’t like to stay still is DERMA SMOOTHE OIL (generic: fluocinolone) as it can be immediately applied after bath. However, the oil does evaporate quickly and should be sealed with a moisturizer (any as noted above).
- SK: For those of you with peanut allergic kids, you might worry that the oil in Derma-Smoothe is peanut based. It has been shown that this peanut base does NOT trigger peanut allergies.
- Another workhorse is triamcinolone ointment—I prefer ointments in the dry skin because of the thicker emollient effect they have on dry skin
- *DISCLAIMER: while I am mentioning Rx treatment options, I would advise against treating yourself or your own child and rather seeking the opinion of a board-certified dermatologist locally.
- For chronic use on the face, I prefer Elidel or Protopic, as they are steroid-sparing agents and do not cause thinning of the skin like the chronic use of steroids can
- Systemic therapies can range from light therapy to oral steroids to azathioprine to cyclosporine to methotrexate to the newest biologic Dupixent
- I am not going to explore this topic further because if the eczema is severe enough, you are not going to be reading this blog, but seeking an appointment with a dermatologist!
- SK: AGREE!
- Parting words of advice for eczema on the face: it is often confused with seborrheic dermatitis, which I will touch on next
- But you want to be careful with which emollients you use on your face if you are prone to acne
- I like marula oil (Amazon has a nice brand ACURE marula oil) and argon oil as moisturizers in very dry sensitive skin
- I also like Clinique moisture surge or any hyaluronic acid containing moisturizer (Neutrogena Hydro Gel)
- SK: Last subset of dry skin to discuss — pityriasis alba is low-grade eczema that affects the face of children. It presents as hypopigmented patches sometimes with a bit of scale. It is exceedingly common in ethnic children with some pigment in the skin. The treatments are similar to those listed above. Notably, we often introduce non-steroid creams earlier due to the need to use on the face and to avoid further hypopigmentation.
- A subset of eczema that can affect adults is chronic hand dermatitis
- Favorite moisturizers: Neutrogena Norwegian Formula Hand cream, Gloves in a Bottle, Cerave Healing Ointment
- Key is to wash hands right before bed, pat dry, apply one of the creams above, and sleep overnight with cotton liner gloves
- And for those of you with incredibly dry feet:
- Try the BABY FOOT Exfoliant Foot peel!!
- It is life changing—you cannot just do it once and expect your feet to look perfect forever. But it is a great start and will leave you with baby soft feet.
- Then for maintenance, wash your feet right before bedtime and apply a thin layer of AMLACTIN foot cream + a thin layer of Vaseline or Aquaphor and cover your feet with socks!
- Favorite moisturizers: Neutrogena Norwegian Formula Hand cream, Gloves in a Bottle, Cerave Healing Ointment
- But you want to be careful with which emollients you use on your face if you are prone to acne
Lastly, I cannot emphasize enough that eczema is a chronic condition. The importance of proper and gentle skin care is paramount to preventing flares.
SEBORRHEIC DERMATITIS
Seborrheic dermatitis is often mistaken for eczema. It manifests as dry, burning, often itchy red rash in a typical distribution pattern affecting the scalp, nasolabial folds, eyebrows, ears, neck, and chest. It can also affect infants (cradle cap). It is also a chronic relapsing condition.
- There are two schools of thought as to what contributes to seborrhea: overgrowth of yeast and/or inflammation
- The face is often dry and flaky, so avoidance of harsh soaps can be helpful
- Believe it or not, I often recommend my patients use Selsun Blue or Head and Shoulders shampoo to wash the affected areas carefully—allow the suds of shampoo to sit for a couple of minutes before washing
- Topical antifungal therapy can also be helpful, particularly ketoconazole shampoo, cream, or gel
- Topical steroids and immunomodulators are often helpful again, but I ask my patients to limit their use to only times they are flaring
- Favorite gentle washes to recommend: Cerave, Cetaphil, Purpose, Aquanil, Epionce Gentle Foaming Cleanser
- Favorite moisturizers: same as noted above for eczema, making special note of marula and argon oil for those who have a tendency to break out
Recalcitrant scalp disease can be very difficult to treat. I often have my patients dampen their scalp before bedtime, apply a mixture of equal parts coconut oil and sunflower seed oil to their scalp, and sleep overnight. The next morning, take a soft bristle toothbrush to gently wash out sa cale. Alternate shampoos with Neutrogena T-gel (to help soften scale) and Neutrogena T-sal (to help shed scale). Often times, immediate application of a high potency steroid right after emerging from the shower can provide relief. Repeating this regimen daily for 2-3 nights will often give rapid relief.
SK: I also use P and S scalp solution to help loosen scales. I am also a fan of tea tree oil as it has a mild antiseptic effect. I DO NOT recommend olive oil — I learned this the hard way with scalp seborrhea. As it turns out, olive oil is the lab medium for growth of the yeast implicated in seborrhea. So, no olive oil.
I echo Sheila’s sentiments about olive oil—and love tea tree oil as well! Tea tree oil comes as a concentrate OR as a shampoo, and I recommend both several times a day!
And that’s our recommendations for dry skin care! Cheers until next time!
