Answering Patient Questions About Eczema
Eczema is a common condition, affecting more than 31 million people in the United States.1 Dermatologists are often asked questions about eczema, from patients with new diagnoses, those who have attained control or remission, and parents of children with the disease. We asked our trusted key opinion leaders how they usually respond to patient questions. Their responses may help you answer questions from your patients as well.
What Caused My Eczema?
When eczema is diagnosed, patients are likely to ask what caused it. This question can be difficult to answer because there are many contributing factors, including the environment, genetics, and triggers such as stress.2 “Although we wish we had the answer to that question for every patient, the truth is we almost never know exactly what caused an individual’s eczema. Certainly, there are genetic risk factors such as a mutation in the gene that codes for filaggrin, which can lead to a weakened skin barrier and allow allergens, irritants, pollutants, and bacteria to enter the skin in an abnormal way and cause trouble,” said Peter A. Lio, MD, clinical assistant professor of dermatology and pediatrics at Northwestern University Feinberg School of Medicine in Chicago, IL. He continued, “For at least a sizable group of people, the root cause of eczema might be a weakened skin barrier. For others, however, it may be an overactive immune system. For others still, it may be exposure to an allergen or irritant that starts a reaction, leading to the itch-scratch cycle where things get very troublesome. It really does seem that eczema is not all one thing, and different individuals likely have different subtypes, which in turn have different root causes. Part of the problem we face is that once established, so many things can trigger a flare. From hot weather to cold weather, sweat to certain types of fabric, and even stress—all of these can cause a flare.”
Patients may be surprised to learn about the role their immune system may be playing in their eczema flares.2 “For most patients, I explain that eczema is a hypersensitivity of the skin to the environment, the same way that asthma is a hypersensitivity of the airway. I also point out that the immune system tends to be overactive in the skin. For a patient who wants more detail, I might describe how certain signaling molecules in the immune system are being produced at a higher rate than normal and that we can target these signaling molecules to bring the immune system back into balance,” stated Steven R. Feldman, MD, PhD, board-certified dermatologist and dermatopathologist at Wake Forest University School of Medicine in Winston-Salem, NC.
Will My Child Outgrow Their Eczema?
Understandably, parents of children with eczema have numerous concerns, including how potential comorbidities, such as asthma and food allergy, sleep disturbance, and the burden of itch, will affect their child.1 In the United States, more than 9 million children younger than 18 years of age have atopic dermatitis, with one-third experiencing moderate to severe disease.1 “It used to be thought that almost all children outgrew eczema in time. It turns out that this is not true anymore and might not ever have been true, but we just did not have enough information,” Dr Lio remarked. For many pediatric patients, their eczema started at younger than 2 years of age, and 80% of individuals with atopic dermatitis will experience onset of symptoms before 6 years of age.1 Lawrence Green, MD, clinical professor of dermatology at George Washington University School of Medicine in Washington, DC, added, “Most children outgrow their atopic dermatitis, and their skin becomes less sensitive to the environment around them. However, after adolescence, up to 20% of young adults will still have atopic dermatitis into adulthood.”
If a child’s eczema is persistent and severe, they are at greater risk for prolonged disease, which is why early treatment is necessary.1 Dr Lio concluded, “Some individuals continue to have eczema into adulthood, whereas others may get better for some time but then develop it again years later. It seems that a significant group of patients will not outgrow their disease, especially in the more severe cases. This is important because sometimes parents ask me if we can just ‘wait it out.’ I emphasize that eczema can sometimes continue into adulthood and because we cannot really predict if that will happen, we would be remiss to just wait. Moreover, I truly believe that early treatment can help break the cycle of this disease and may actually increase the chances of a longer-term remission.”
Once My Eczema Is Better, Can I Stop Using My Therapies?
When discussing the management of flares, patients may ask whether they will be able to stop using their topical, oral, and/or biologic medication in the future if their skin is clear. “I would say the answer is a qualified ‘yes!’ Unlike some chronic conditions such as hypertension, for example, eczema is a disease of vicious cycles. When things are bad, they often keep getting worse and spiral out of control. Poor sleep leads to more stress, which leads to more skin barrier damage and scratching, which leads to a damaged microbiome, which contributes to more inflammation. However, once good control has been achieved, I have seen many patients drastically reduce or even totally stop many medications, including systemic ones,” stated Dr Lio. He continued, “Although I would never promise being medication free, it is part of my long-term treatment goal for patients to get good control and maintain it as safely as possible.”
Although many patients attain control or remission, those with moderate to severe eczema will most likely need to continue oral and/or biologic therapy. Dr Feldman said, “For most people with eczema, the condition is rather mild, gets better with topical corticosteroids, and then can stay gone a long time before the rash comes back and a little more topical corticosteroid is needed. For some patients with severe eczema, the disease requires continued therapy with oral or injection treatment to maintain control. It may be okay even in these patients to try cutting back slowly and see how little treatment is needed to maintain control of the skin rash.” Dr Green added, “Usually, people with mild atopic dermatitis can stop using their topical medications and continue to control their atopic dermatitis by using moisturizers alone. But people with moderate to severe atopic dermatitis often have their disease recur if they stop using their oral or injectable medications despite using moisturizers. We usually recommend that people with moderate to severe atopic dermatitis remain on their oral/biologic therapy unless their disease stays in complete remission for a long time.”
I’m Concerned About the Black Box Warning for the Topical and Oral Janus Kinase (JAK) Inhibitors. What Is My Risk for These Adverse Effects?
Patients may be nervous about black box warnings and potential adverse reactions, which can make them hesitant to try JAK inhibitors. Dr Lio explained, “This is a very good question and, to be totally honest, we do not really know. We do have a very good sense that, when used correctly and under close guidance, these agents seem relatively safe.3 We also understand that certain pre-existing risk factors, such as being a smoker or having other cardiovascular risk factors, come into play. At the end of the day, it is important to discuss with patients the individual risk factors and review the plan for safety monitoring. With the topical JAK inhibitors, no laboratory monitoring is required, and we feel that, as long as they are not being used on more than about 20% of the body, the risks are quite minimal.” Dr Green agreed, “The risk of a systemic adverse event would go up if a patient is using a topical medication on a large portion of their body surface. That is why we do not recommend putting a topical medication on a large part of your skin every day.”
Dr Feldman added, “The topical JAK inhibitor probably has little to no systemic effects. I suspect the black box warnings were related to the blood levels in patients putting it on large parts of their body for an extended period, and even then, the risks were theoretical and not something where adverse effects were actually observed.” He continued, “The oral JAK inhibitors may have some risk. The black box warning risks are largely based on the experience of patients who have been treated with other JAK inhibitors for rheumatoid arthritis.4 So far, JAK inhibitors seem very safe when used by otherwise healthy people with eczema. The most common risk in these patients was acne-like rashes.” Future research will further our understanding of the similarities and differences between individuals with rheumatoid arthritis taking JAK inhibitors and those taking JAK inhibitors as a treatment for eczema.4
What Are Some Practical Ways to Manage the Itch of Eczema?
“I think the single most important thing is getting the inflammation under control. We find that if we just try to treat the itch, it tends to push back unless we cool the underlying inflammation,” said Dr Lio.Because chronic itch can lead to pain, poor sleep, and mental health issues,5 Dr Feldman recommended, “The best thing to do is to clear up the eczema. This can be done with a topical medication. Another excellent treatment for eczema and its itch is UV light exposure, either in the office, from the sun, or possibly even from a tanning bed. If the eczema is severe, systemic treatment may be helpful.”
Although this may be difficult, advise patients not to excessively scratch to avoid damaging their skin and triggering the itch-scratch cycle.5 “Try to discover what is triggering the itch. For some people, overly dry and sensitive skin is the trigger. These patients respond best to cream- or petrolatum-based moisturizers used several times per day. For some individuals, their sweat irritates their skin and causes atopic dermatitis to flare. For these patients, it is important to wash off sweat and then moisturize the skin,” suggested Dr Green. If patients do get caught in the itch-scratch cycle, they can develop neurodermatitis in which the irritated nerve endings in the skin cause it to become even itchier.5 Dr Lio advised, “Gentle topical products that contain ingredients such as pramoxine can be used to calm the nerve sensation of itch. Patients can consider old-fashioned cool compresses with dilute black tea, calamine lotion, and even some of the newer products that use things like strontium for itch.”
Conclusion
Effectively answering your patients’ questions about eczema allows you to not only improve the care they receive, but also their quality of life. Cutting-edge medications and emerging research will help achieve this mission as new clinical experience is gained with each patient.
References
1. Eczema stats. National Eczema Association. Accessed April 19, 2022. https://nationaleczema.org/research/eczema-facts
2. Eczema causes and triggers. National Eczema Association. Accessed April 19, 2022. https://nationaleczema.org/eczema/causes-and-triggers-of-eczema
3. JAK inhibitors are coming and they are the biggest eczema development in years. News release. National Eczema Association. January 4, 2021. Updated March 15, 2022. Accessed April 19, 2022. https://nationaleczema.org/jak-inhibitors-research
4. What does a black box warning mean for eczema treatments? News release. National Eczema Association. February 28, 2022. Updated March 29, 2022. Accessed April 19, 2022. https://nationaleczema.org/black-box-warning-eczema
5. Managing itch. National Eczema Association. Accessed April 19, 2022. https://nationaleczema.org/eczema/itchy-skin
