In this episode of DermView, Adelaide Hebert, MD, explains the clinical manifestations of eczema, how the chronic the condition is, and the benefits of using ceramide cream for management.
Adelaide Hebert, MD, chief of pediatric dermatology at the McGovern Medical School at UTHealth Houston, Texas highlights the clinical aspects of eczema and how to provide optimal care to pediatric patients.
To listen to what she had to say, watch the video below.
Morgan Petronelli, Associate Editor: Well thank you so much for joining me today. My name is Morgan Petrelli, Associate Editor with dermatology times and today I'm joined by Dr. Adelaide Hebert, Dr. Hebert if you want to introduce yourself and any of the research that you're currently conducting.
Adelaide Hebert, MD: I'm Dr. Adelaide Hebert. I work at the University of Texas Medical School in Houston, Texas. I've been chief of pediatric dermatology here for 37 years, and have been actively engaged in clinical research for the past 36 years. The research interests that I have include atopic dermatitis, psoriasis, hyperhydrosis, acne, rosacea, skin, soft tissue infections, and diaper dermatitis. We really will study almost anything that deals with skin in both pediatric and adult realms. I don't typically do IV antibiotics studies, but we're very interested in biologic therapy and the new Janus kinase (JAK) inhibitors. We do the full scope we feel of research within the adult and pediatric realm.
Petronelli: What are the clinical manifestations of eczema?
Hebert: Well one of the things we noticed that's different in the age spectrums is the areas of the body that are affected with atopic dermatitis in the youngest children, they can have virtually total body involvement with a lot of facial involvement. As children get a little bit older, we tend to see head/neck involvement, antecubital public heel, wrist, and ankle involvement.
[It is] very common locations for spongiotic dermatitis and often as our patients get a bit older, let's say go through puberty or age, they may have had neck involvement, but classic eczema affects the antecubital and popliteal fossa, [and also] sometimes the wrist and the hands.
As patients get into the adult realm and they have less of the more available or obvious spongiotic dermatitis. They may still have head neck involvement, but they often have hand involvement... We know that as many as 50% of patients who have childhood eczema may have more focal involvement as they [age].
Petronelli: Can you describe the chronic relapsing clinical course of eczema?
Hebert: One of the diagnostic features of eczema is that it comes and goes. This is a great challenge because parents don't know why it tends to relapse over time. They're often very frustrated. Let's say they've seen their primary care physician received a topical steroid, the skin gets much clearer and then again, the relapse occurs, and they cannot believe that they're dealing with this all over again.
So a part of the fundamental education we give to every patient [and] every parent comes in with atopic dermatitis is "Yes, the disease often reoccur with many of the currently available therapies." We have to deal with that. We have to educate them to treat the acute disease in one way and often the maintenance part of the regimen in a different way. That's a hard thing for a parent to understand when they come in for the first is because they really like to know that their child has something that's treatable, controllable, [and] it's not always as easy as that. Many small children, of course, can't have some of the more advanced therapies because they're not yet FDA approved in that age realm.
Petronelli: What is the greatest approach for optimal management of eczema?
Hebert: I've seen the single most important component to successful outcomes in eczema management is education. I say this because if you walk into the physician's office and you get a prescription, but you don't really get disease state understanding, if you don't recognize the chronic relapsing course, you don't understand there's an acute management strategy that we employ, and then chronic maintenance therapy that we want the patient to undertake, we don't often get very good successful outcomes.
I think, again, dealing with the patient apparent disappointment that this will not be something that we can cure currently, that has to be dealt with. Recognition of skin infections, and getting appropriate therapy in a timely fashion is absolutely essential. But in the scope of managing the skin, they really have to have a skincare regimen that calms the skin [and] protects the skin [so it] allows restoration of the defective [skin] barrier in order to really maintain a successful control state within the atopic realm.
It's not always possible to get every patient perfectly controlled. But I have seen in my own practice that if we provide that education, the parents leave with a much better understanding and a better coping strategy that they can often undertake. [Also,] to look carefully at our colleagues literature within the nursing relam. The [dermatology] nurses have had a huge role in providing education, and often reassuring the parents.
I know that there's an older article in the blue journal where John Hanifin taught us that providing that education [decreased] the parents concerned that this condition was due to allergies, particularly food allergies, [and instead] teaching them a great skin regimen decreased their concern about finding a focal allergy that they could eliminate and think that the eczema would go away by just being taught appropriate skincare regimens in atopic dermatitis management.
Petronelli: Absolutely and what of the nonpharmacologic interventions for maintaining skin hydration?
Hebert: Well, I think we're very fortunate to have a wide choice range for topical regimens. moisturization, of course, is really essential. And if you look at all of the guidelines, both the American guidelines for atopic dermatitis management, the European guidelines, and even the guidelines provided in [other countries] moisturization twice daily is really a cornerstone of therapy. Why do we need this?
This skin barrier is defective even when the skin looks normal even between flares, it is essential to actually restore and repair that barrier on an ongoing basis. This helps keep the eczema flares in check. It often makes the child a lot more comfortable. It reduces itching. We have less risk overall of skin infections because the barrier is repaired. So all these things come into play.
One of the key ingredients that we like to recommend is a ceramide containing cream because we know that the ceramides are deficient in atopic dermatitis and restoring or replacing those ceramides is essential for good barrier repair. When parents come in and they want to find that 1 thing or 26 things that they could take away their child won't have eczema, they're often discouraged by the fact I say it's very hard to find that.
I often cite the literature where physician scientists around the world tried to find elimination processes, including elimination diets to eradicate eczema. Despite 150 clinical trials, no one could find a means currently to eradicate a component and have the child have an eczema free path going forward. So I cite that literature, but instead of talking to parents about what they can take away I'll often talk to them about what they can give.
Since the child's skin is lacking in ceramides, here's an opportunity for them with over the counter products, to put that ceramide back and this can restore the barrier [with] having a much more comfortable child. [It also] does also avoid steroids which parents often wish to not use.
Even though used correctly, [steroids are] extremely safe agents. They've been around a long time they're on most health care insurance plans. So we do use topical steroids particularly in in acute flares, but giving these parents this reassurance and education, again, are cornerstones of success in getting a good outcome for patients and parents managing atopic dermatitis.