By Henry Ehrlich
The latest dinner lecture at the New York Allergy and Asthma Society was a real winner. You would think that the topic would be second nature to a roomful of allergists, but the speaker in this case was a pediatric dermatologist, Dr. James Treat of the Perelman Medical School at the University of Pennsylvania. Among his credentials, Treat is the head of the fellowship program at Penn, and has received many awards for his teaching. In a fluent and witty lecture, he showed why. (By the way, the term eczema was used as an umbrella term because it was broadly descriptive and easier to say all the time than switching back and forth with atopic dermatitis.)
The importance of a dual-disciplinary approach to AD can be described simply in the distinction that Treat made about bathing. Allergists recommend frequent bathing, which is important for removing environmental allergens from the skin; dermatologists recommend less frequent baths so as to allow the skin to recoup its barrier function. (Of course they’re both right!) Regardless, whether junior is bathed every day or only a couple of times a week, the bath should be followed by immediate moisturizing and wrapping. He cited research that compared bathing with immediate moisturizing, moisturizing only, and bathing followed by moisturizing at an interval of ten minutes. The third contingency was actually worse for the patient than no bathing at all. It stands to reason that if the barrier function of the skin is based in great part on its ability to retain water, evaporation is going to undo any hydration from the bath water.
Treat has an exceptional appreciation not only for the function of healthy skin as the frontline in protecting us from outside invaders, but in the role that the delicate ecology of the skin plays. Staph aureus may cause infection if your child scratches it deep into his skin because of his eczema, but when it stays on the skin where it belongs it is part of the solution, not part of the problem. Dr. Treat is no friend of anti-bacterial hand sanitizers and wipes!
One big takeaway: don’t use washcloths! Washing with a bare hand is much better. Apart from abrasion even from soft cotton, we have a tendency to hang cloths up between baths where they become excellent growing media for bacteria and molds, which are then reintroduced to the patient’s vulnerable skin. A parent’s hands, by contrast, also have health microbes that can be reintroduced to the child’s skin as part of the microbiome.
Like most of these lectures, which are given while we eat, this one was accompanied by a series of unappetizing slides featuring just about every inch of skin, including lots of rear ends. Heartbreaking though some of them were, however, they were all madly instructive.
Among the highlights: the pattern of inflammation is one of the great tools for diagnosis. For example, if there are no lesions on the nose or the “diaper area” it is very likely eczema because the nose is very oily and its barrier function is therefore likely to remain intact while other tissue is more permeable. The diaper area, being swaddled all the time, remains moist. After diapers are outgrown it may become open season on this tissue, too.
Another was redness emanating from the corners of the mouth, which can sometimes lead parents and allergists on a wild goose chase. Food allergy awareness being what it is, when this shows up in the wake of a feeding, even breast feeding, parents will start to embark on their own program of elimination, or go to a pediatrician or allergist for testing, and withhold foods based on marginal sensitivity. This sometimes results in failure to thrive. The reality often turns out to be much more mundane—the child is reacting to the enzymes in his own drool. A little gentle wiping with plain water will remove the offending substance.
Dr. Treat pointed out that the imperfect barrier of eczematous skin makes your child vulnerable to all manner of opportunistic infections. One slide made this point particularly: the lesions around a child’s mouth were perfectly round. “If they look as though they were made by pressing a pencil eraser into the skin,” he said, “they are probably herpes.” How do they get there? Many doting parents and grandparents have cold sores and kiss the kids, transmitting the virus to the child’s nerve endings.
Another alarming point: While many of us are steroid averse, sometimes to a fault, eczema brings out the opposite tendency. To wit, if it works people will continue to use the medicine too long. There’s a hierarchy of steroids and while it may be advisable to use a very strong one to gain control, the treating physician should closely monitor progress, and the dosages should be stepped down. Dr. Treat said this is a particular problem for teenage girls who want to avoid having their health supervised and will use what works to keep their skin clear until their immune systems are dangerously compromised. Dr. Treat recommended never giving more than one refill for any strong steroid and that they should be part of an action plan comparable to those for asthma and food allergies, which should include stepping down the strength of the steroids.
Like many fine lecturers, Dr. Treat is quite a card even in his choice of slides. Having made the point that herpes makes perfectly round lesions and that a clear diaper area is indicative of atopic dermatitis and not something else—he showed us a little butt that had perfectly round red sores. Then he showed us a photo of a diaper with multi-colored circles of various sizes designed, I suppose, to look like balloons. The blue circles happened to align perfectly with those sores. In their efforts to stay ahead of the competition, Pampers or Luvs, or whatever, had managed to come up with a blue dye that is allergic to some kids. “Kids show up with Cookie Monster or Grover on their butts, but not Big Bird,” he observed.
This brings me to a larger point about the cat-and-mouse game played by mass manufacturing and our children’s dermal health. Last year’s rust-retardant in paint for the hulls of commercial ships is next year’s sunscreen.
Every year the American Contact Dermatitis Society announces an allergen of the year to draw attention tothe potential of chemicals for causing skin distress. Two that stood out were Bacitracin and neomycin (Neosporin) for the fact that they are used to kill germs in skin that has already been injured physically. Add to the physical damage the allergic tendencies of an atopic child and you’ve got the potential for another allergen. For first aid, Dr. Treat has a recommendation: soap free of any of these industrial toxins and water. The rest of names on the list are mostly staples of jewelry, cosmetics, and sunscreens. On a further chemistry note, he also said that topical steroids in ointment form are always preferable to creams for the simple fact that they contain fewer “unpronounceable” ingredients with the potential for developing a new sensitivity. Finally, if you use spray-on sunblock on your kids, smear the stuff around the skin; photographs of what happens to selectively protected skin are painful to see.
The evening ended with Dr. Treat taking questions from the floor. The most interesting one was from a woman who had trained and practiced in the Soviet Union who remarked how much more atopic Americans are than kids were in the old country, although there was plenty of asthma and allergies there, too. Dr. Treat expressed great belief in what I call the “epidemic of progress” – climate change, the overuse of antibiotics, excessive resort to cesarean birth, and industrial food and chemistry. All in all, an informative evening that was a lot more entertaining than we had any right to expect.