The conventional medical approach to treating skin conditions typically involves symptom management & immune suppression through topical & oral pharmaceutical drugs & moisturisers. It focuses on the symptoms rather than viewing the body as a whole.
Doctors will prescribe a combination of topical steroids, antibiotics, antihistamines, immune suppressants & petrochemical moisturisers & cleansers. Sometimes wet wraps & bleach baths are also recommended. Little if any attention is given to diet, lifestyle, gut health & mental health.
Specialised treatment for more severe dermatitis can involve skin prick tests & blood tests. However there is not systematic approach to removing all external contact irritants & balancing the overactive immune response internally.
It is focused on immune suppression & pharmaceutical use. It goes against the innate healing & balance of the body. The immune system is almost viewed as an enemy. Little attention is paid to the core reasons why the immune system & skin are imbalanced.
Wet wraps are fabric bandages that are soaked in water & applied to the affected skin. They are wrapped over emollients and/or topical steroid creams to areas flaring & weeping eczema. A dry layer of bandage is then placed over the wet layer.
They are designed to hinder scratching & aid the absorption of emollients & topical products. They may also help to cool the skin as water gradually evaporates from the bandage.
However, they are inconvenient, uncomfortable, increase the risk of bacterial infection & could disrupt the skin barrier due to extended wetting of the skin. They are another form of symptom management.
Typical pharmaceutical skincare products are usually based on petrochemicals like mineral oil, petroleum jelly & dimethicone. They could be in the form of gels, creams, oils, balms, lotions & sprays.
Ethoxylated ingredients (PEG's, polysorbates, anything end in 'eth') are often used as cost efficient emulsifiers as are questionable synthetic preservatives. The concern with ethoxylated ingredients is that they are almost always contaminated with 1,4 dioxane & ethylene oxide, two highly toxic & carcinogenic chemicals. It is especially concerning that ethoxylated ingredients are not banned from baby products.
As petrochemicals are inert, they are unlikely to cause skin irritation, however they can not be metabolised by the skin. Their effect is more superficial than physiologically based formulations made with skin identical lipids.
Products are often greenwashed. For example, many brands will market themselves as being natural when they contain less than a few percent of natural ingredients in a petrochemical base.
Other times, impressive claims & unique sounding ingredients will be used alongside incredible claims from self studied clinical trials & surveys. Celebrities, dermatologists & eczema associations are often used to promote products. The reality is that you can make a study show what you want through careful design.
With an ongoing & severe case of dermatitis, eventually you may be able to skin prick test & blood test. Everyone's immune system is different so each will be allergic to & irritated by different things.
In a skin prick test they will prick your skin & place different allergens on each spot then measure your irritation response.
In an immunoglobulin E (IgE) blood test measures the level of IgE, a type of antibody. Antibodies are made by the immune system to protect the body from bacteria, viruses, and allergens. IgE antibodies are normally found in small amounts in the blood, but higher amounts can be a sign that the body overreacts to allergens.
This is a useful benchmark to gain a clearer understanding of the state of your immune system. However, there is no systematic approach for removing the most common contact irritants in daily life. Nor is there a specific diet designed to balance the immune response.
Many doctors are in favour of frequent bathing (at least once a day). They believe that dry skin can be hydrated through frequent baths followed by copious amounts of moisturiser in a process known as ‘soak & smear’. They recommend lukewarm water & patting dry with a towel to minimise skin disruption.
Others believe infrequent water contact helps the skin to remain hydrated because it avoids constant evaporation of water, which can be drying. It also means less use of the soaps which can aggravate eczema.
We believe that overly frequent bathing & water contact disrupts the skin barrier in the long term & that it should be minimised. Frequent bathing will raise skin pH levels above their usual acidic balance. The re-acidification & buffering capacity of those with skin problems is already impaired, so this process can exacerbate skin imbalance.
A more alkaline skin environment is one of the conditions that allow staphylococcus aureus bacteria to proliferate. Staph is highly prevalent on those with dermatitis.
Additionally, water soluble natural moisturising factor & essential skin lipids can be washed out with overly frequent washing & cleansing. Applying copious amounts of moisturiser is superficial & can lead to the skin becoming dependent on an external source of moisture. It also impairs certain skin functions like sweating, excretion & temperature regulation.
Topical corticosteroids have been used for over 50 years to manage various inflammatory skin conditions. They are the main prescription given by doctors & dermatologists for dermatitis & most immune related skin problems. They come in various strengths, vehicles (lotions, creams and ointments) & absorb more readily into thin, sensitive areas such as the eyelids, genitals & skin folds.
They work by preventing cells from producing inflammation-causing chemicals that are released in response to a variety of triggers. They can help manage flare ups & reduce the likelihood of infection that occurs as a result of scratching & damage to the skin.
Topical steroids used sparingly & on one-off or very short term occasions can be effective especially when dealing with more contact induced dermatitis. They work quickly & are commonly prescribed. Many have seen great success in applying a diluted steroid & antibiotic in a plain petrochemical moisturiser base.
However, they have no effect on the underlying cause of skin problems & can have multiple potential adverse effects especially when used long term. It likely helps with the staph. auereus overgrowth but again unless you change the conditions that cause the skin to be susceptible to infection you are not solving the root issue. It will typically have to be used indefinitely in order to maintain clear skin so it does not fix the problem.
Their mode of action involves vasoconstriction, anti-inflammation, immune suppression & inhibition of cell proliferation. However, they are simply tools for symptom management.
Prolonged, repeated use of high-potency steroids particularly on thin epidermal regions can lead to significant long term adverse effects. Although potentially useful for isolated use, the well researched adverse effects must be acknowledged.
Adverse effects include dermal atrophy (skin thinning), erythema (redness), adrenal suppression, pigment alteration, hair loss, delayed wound healing & dependency on continually more potent steroids. It also inhibits cell proliferation & collagen synthesis in the dermis which impacts the skin's structure, mechanical strength &appearance. As a result, the skin develops tolerance to the topical corticosteroid which leads to a loss in vasoconstriction (constriction of blood vessels) by the capillaries.
When steroids are applied to large body surface areas, enough may be absorbed to inhibit the body’s own production of cortisol, a condition known as adrenal suppression. This creates a dependency on using the cortisone. When treatment is stopped, the skin is no longer artificially constricted & the body is not used to producing its own cortisol leading to prolonged flares & what the International Topical Steroid Addiction Network call ‘Topical Steroid Withdrawal’.
Topical calcineurin inhibitors are a class of immunosuppressant drugs approved by the FDA for the treatment of moderate to severe eczema (atopic dermatitis).
Tacrolimus (Protopic) was discovered in 1984 and is produced by a type of natural soil bacterium, Streptomyces tsukubaensis. Pimecrolimus (Elidel) is a closely-related compound and has a nearly-identical mechanism of action.
Topical calcineurin inhibitors work by blocking a protein called calcineurin, which is responsible for activating a type of white blood cell known as a T-cell. T-cells help instigate the immune response by stimulating the release of inflammatory compounds called cytokines. While this response is considered normal and beneficial, it can be problematic if it is too robust.
Eczema is characterized by an overactive immune response. By reducing inflammation at the source, TCIs have proven effective in relieving these symptoms. It is largely presumed that Protopic and Elidel can benefit people with psoriasis by tempering local inflammation and slowing the hyperproduction of skin cells.
Their main advantages compared with conventional topical corticosteroid therapy are that they are more selective in their mode of action, do not induce skin atrophy and are not associated with significant systemic absorption.
Before using Protopic, tell your doctor if you have skin cancer or a skin infection (including herpes or chickenpox), any genetic skin disorder (such as Netherton's syndrome), a weak immune system, kidney disease, or swelling, redness, or irritation of large areas of your skin. You should not use Protopic if you are allergic to tacrolimus.
The safety of using Protopic for extended periods is unknown.
Some people have developed skin cancer or lymphoma after using Protopic or pimecrolimus. However, it is not known if either of these medicines causes skin cancer or lymphoma. Talk to your doctor about your individual risk.
Protopic can lower the blood cells that help your body fight infections. This can make it easier for you to get sick from a virus such as chicken pox or herpes (cold sores or shingles).
The most common side effects of PROTOPIC Ointment at the skin application site are stinging, burning, or itching of the skin treated with Protopic.
These side effects are usually mild to moderate, are most common during the first few days of treatment, and usually go away as your skin heals. Other side effects include acne, swollen or infected hair follicles, headache, increased sensitivity of the skin to hot or cold temperatures, or flu-like symptoms such as the common cold and stuffy nose, skin tingling, upset stomach, muscle pain, swollen glands (enlarged lymph nodes), or skin infections including cold sores, chicken pox or shingles.
Avoid sunlight, sun lamps, tanning beds, and phototherapy treatments with UVA or UVB light. If you must be outdoors, wear loose clothing over the skin areas treated with Protopic. Do not use sunscreen on treated skin unless your doctor has told you to.
Do not use Protopic continuously for a long time. Use only on areas of your skin that have eczema. Do not use it on a child under 2 years old. Talk to your doctor if your skin condition does not improve after using Protopic for 6 weeks
Based on the serious, wide ranging potential side effects and the fact that they do not address the root cause of the issue we can not recommend using calcineurin inhibitors long term.
Many have had success with the Dr Aron treatment which involves a compounded cream mix of a topical steroid, a topical antibiotic and a pharmaceutical moisturizer. For example, Diprosone (steroid), Fucidin (antibiotic) and Diprobase (moisturiser).
He recommends using a low-potency corticosteroid but with increased frequency of application, starting with 5-6 daily applications in the first week before tapering down to 3 times, 2 times, once, then ideally off the cream completely. With conventional eczema treatments, the three cream components are separately applied and antibiotics are usually only used if there is an infection.
However some do not respond to it sufficiently, found the cream base irritating, antibiotic resistance could develop and there are concerns of using topical steroids for extended periods.
Granted that most people with eczema have an elevated level of staphylococcus aureus, have inflamed skin and often dry or infected skin you could see why many would achieve a level of success with this treatment plan. It can help to alleviate the symptoms and break the itch scratch cycle. Some people grow out of their skin problems, some only have a more contact irritant induced problem. However, this has no underlying effect on the root cause of the issue itself.
Since childhood, I had severe eczema, food allergies, asthma & mental health issues. I was using cortisones regularly until 15 years of age. I was using them sparingly in combination with the recommended moisturises, cleansers & sometimes topical antibiotics when my skin was infected.
When I was 10, I asked my dermatologist Lucinda about diet. It was never emphasised but I noticed my skin would worsen when I ate high levels of processed & fried foods. I was told verbatim 'there is no conclusive evidence that diet has a direct correlation with your eczema'. I was told by various doctors that there was no cure & that all I could do was to manage the symptoms for the rest of my life.
None of the convention treatment ever gave me long term relief. My skin was hypersensitive, my immune system was hyperactive & I kept needing more potent steroids. My skin became thinner over time & became infected far more easily. Like most other long term users of topical steroids, my skin had this pinkish grey tone, was wrinkled & elephant like & often bright red. Even when I was flare free it did not look healthy.
Whenever I started on a stronger steroid I would experience a temporary improvement. However, my skin would flare even more aggressively if I stopped using it. Over time my skin took longer to repair, bruised easily & eventually I became irritated by cortisones & had to stop using them.
The advice I was given & the products I was prescribed did not promote my long term health. It was mainly just symptom suppression. The blood tests & skin prick tests helped but without the ability to systemically target everything effecting my skin, the only tool that was at their disposal was one of immune suppression.
The side effects are downplayed or not mentioned at all which is somewhat negligent given the increasing deterioration & dependency of my skin on the steroids. There are potential conflicts of interest between academia, medical professionals & industry.
I am grateful for the extreme experience I had as I have now developed a much deeper understanding of the systemic change needed to address problem skin. To change my life & regain my will to live, I needed to take complete control of my own health.
If you have a chronic skin condition you need to target the root cause. Not just treat the inflammation & suppress the immune system. The doctors & dermatologists I saw were good, hardworking people. It just felt like their toolkit was restricted, their training was imbalanced & their incentives were not tied to the improvement of my health.