dermatitis

Topical steroids (part 2 of 2)

In this 2 part series we are investigating topical steroids, as well as topical steroid withdrawal. In our previous article, Part 1, we discussed what it is, how it works, in what forms it is available, what it is used for and how to use it. In this article, Part 2, we will discuss the dangers of overuse. TSW – Topical Steroid Withdrawal The term “topical steroid withdrawal” (also referred to as topical steroid addiction, steroid withdrawal syndrome or red skin syndrome) refers to a constellation of symptoms that may emerge in the days and weeks after a person stops the use of topical corticosteroids. Due to a lack of research and no clear diagnostic criteria, it’s not yet known what amount of steroid use causes TSW, how many people have the condition and what percentage of people using topical steroids may develop it. However, according to a systematic review of topical corticosteroid withdrawal published in the Journal of the American Academy of Dermatology and initiated by National Eczema Association (NEA): “TSW is more commonly seen in adult women who apply mid- or high potency topical corticosteroids to the face or genital region. The condition seems to be associated with more prolonged use of daily topical steroids, topical corticosteroids to more sensitive areas or use of topical steroids without tapering or periodic breaks.” The first description of the condition occurred in 1979. A systematic review (meta-analysis) in accordance with evidence-based medicine frameworks and current research standards for clinical decision-making was performed in 2016 and was republished with updates in 2020. What is topical corticosteroid withdrawal? Topical corticosteroid withdrawal refers to a rare adverse reaction relating to the use of a topical steroid after it has been discontinued. It can occur after prolonged, inappropriate, and/or frequent use/abuse of moderate- to high-potency topical corticosteroids. Most reports of side effects follow the prolonged use of an unnecessarily potent topical steroid for conditions not warranting such strong treatments. There are two distinct clinical presentations of topical steroid withdrawal: How does TSW develop? Topical steroid withdrawal, also known as red burning skin and steroid dermatitis, has been reported in people who apply topical steroids daily for 2 weeks or longer and then discontinue use. Symptoms affect the skin and include redness, a burning sensation, and itchiness, which may then be followed by peeling. It appears to be a specific adverse effect of topical corticosteroid use. People with atopic dermatitis are most at risk. First signs of over-use Topical steroid addiction (TSA) is characterised by uncontrollable, spreading dermatitis and worsening skin inflammation, which requires a stronger topical steroid to get the same result as the first prescription. This cycle is known as steroid addiction syndrome. When topical steroid medication is stopped, the skin experiences redness, burning, a deep and uncontrollable itch, scabs, hot skin, swelling, hives and/or oozing for a length of time. After the withdrawal period is over, the atopic dermatitis can cease or is less severe than it was before. Topical steroid addiction has also been reported in the male scrotum area. Other symptoms include nerve pain, insomnia, excessive sweating, anxiety, severe depression, fatigue, eye problems, and frequent infections. Signs include the following: Although it may even be prescribed for these conditions, a topical steroid can cause, aggravate or mask skin infections such as impetigo, tinea, herpes simplex, malassezia folliculitis and molluscum contagiosum. When used correctly, in appropriate doses and potency, for short periods of time, along with preventative treatment measures, topical steroids remains the first-line treatment for infected eczema. When is it dangerous Stinging frequently occurs when a topical steroid is first applied, due to underlying inflammation and broken skin. Contact allergy to the steroid molecule, preservative or vehicle is uncommon, but it may occur after the first application of the product or even after many years of regular or intermittent use. To prevent tachyphylaxis, a topical steroid is often prescribed to be used on a week on, week off routine. Some recommend using the topical steroid for 3 consecutive days on, followed by 4 consecutive days off. However, even with the break in use, long-term use of topical steroids can lead to secondary infection with fungus or bacteria (see tinea incognito), skin atrophy, telangiectasia (prominent blood vessels), skin bruising and fragility. More serious side effects Hypothalamic–pituitary–adrenal axis (HPA) suppression Cushing’s syndrome Ocular effects: Topical steroid drops are frequently used after eye surgery but can also raise intraocular pressure (IOP) and increase the risk of glaucoma, cataract, retinopathy as well as systemic adverse effects. Tachyphylaxis: The acute development of tolerance to the action of a drug after repeated doses. Significant tachyphylaxis can occur by day 4 of therapy. Recovery usually occurs after 3 to 4 days’ rest. This has led to therapies such as 3 days on, 4 days off; or one week on therapy, and one week off therapy. Other local adverse effects: These include facial hypertrichosis, folliculitis, miliaria, genital ulcers, and granuloma gluteale infantum. Long-term use has resulted in Norwegian scabies, Kaposi’s sarcoma, and other unusual dermatosis. What are the clinical features of topical corticosteroid withdrawal? One of the difficulties is determining whether the skin reaction observed is due to the stopping of topical corticosteroids, or is simply a worsening of the underlying skin disease for which the topical steroids had been prescribed. Complications of topical corticosteroid withdrawal Patients with red burning skin after topical corticosteroid withdrawal may be distressed by the intensity of itch, lack of sleep, and difficulty in treatment. They may also develop secondary infection. How is topical corticosteroid withdrawal diagnosed? The definition of topical corticosteroid withdrawal requires the following features to be present: Skin biopsy is generally unhelpful to distinguish from a flare of the underlying skin disorder as the histopathology overlaps. Patch testing may identify some cases of contact allergy to the topical agents being applied to the skin, eg topical corticosteroid or other topical medications, moisturisers, cosmetics.   What is the treatment for topical corticosteroid withdrawal? There is no agreed treatment for topical corticosteroid withdrawal, apart from ceasing the topical corticosteroid. However whether this should be tapered or abrupt has not been determined. Japanese reports suggest there is minimal difference in the outcome, so the recommendation is immediate cessation. A tapering course of oral steroids is helpful, as the addiction appears to relate only to the use of topical corticosteroids. Oral tetracyclines and low-dose isotretinoin have been used in steroid rosacea and perioral/periorificial dermatitis. Supportive measures such as cold compresses and psychological support are often recommended. Prevention or treatment of secondary infection may require oral antibiotics. Our Eczema Skin Restoring Cream

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Topical steroids (part 1 of 2)

In this 2 part series we are investigating topical steroids. In our previous article, Part 1, we discussed what it is, how it works, in what forms it is available, what it is used for and how to use it. In this article, Part 2, we will discuss the dangers of overuse. What is it Corticosteroid hormones are naturally occurring hormones produced by the adrenal glands within the body. Topical corticosteroids are synthetic (man-made), and it is a type of anti-inflammatory drug, that suppresses the immune response and are classified based on their skin vasoconstrictive abilities. Topical steroids are the topical forms of corticosteroids. It is also called glucocorticosteroids, and cortisone. Corticosteroids were first made available for general use around 1950. Topical steroids are the most commonly prescribed topical medications for the treatment of rash, eczema, and dermatitis. It is used based on the potency, area of the body where it will be applied, and type of skin condition being treated. This medication is available in creams, ointments, solutions and various other forms. How does it work? Topical corticosteroids work through different mechanisms: Forms of the medication: Creams are better for skin that is moist and weepy. Ointments are thicker and greasier, and are better for dry or flaky areas of skin. The strength of the products range from 0.1% (1mg of hydrocortisone in each gram) to 2.5% (25mg of hydrocortisone in each gram). Pharmacies sell hydrocortisone skin cream up to a maximum 1% strength. There is a stronger hydrocortisone cream called hydrocortisone butyrate. However, this is only available with a prescription. Sometimes hydrocortisone is mixed with antimicrobials (chemicals that kill germs). This is used to treat skin problems caused by bacterial or fungal infections. As a general rule, the weakest possible steroid that will do the job, whould be used. Sometimes, It is appropriate to use a potent preparation for a short time to ensure the skin condition clears completely.  What is it used for Corticosteroids is used to treat a variety of skin conditions: insect bites, poison oak/ivy, eczema, dermatitis, allergies, rash, itching of the outer female genitals, anal itching. However, it can make some skin problems worse like impetigo, rosacea and acne. Hydrocortisone skin treatments should only be used on children under 10 years old if a doctor recommends it. Creams you can buy are not supposed to be used on the eyes, around the bottom or genitals, or on broken or infected skin. How to use it Unless instructed otherwise by your doctor, follow the directions on the patient information leaflet that comes with the medicine. This will give details of how much to apply and how often. The use of the finger tip unit may be helpful in guiding how much topical steroid is required to cover different areas of the body. Topical steroid is applied once daily (usually at night) to inflamed skin.  Most people only need to use the medicine once or twice a day for 1 to 2 weeks. Occasionally a doctor may suggest using it less frequently over a longer period of time, after that, it is usually stopped, or the strength or frequency of application is reduced. The medicine should only be applied to affected areas of skin by gently applying a smooth, thin layer onto your skin in the direction the hair grows. If you’re using both topical corticosteroids and emollients, you should apply the emollient first. Then wait about 30 minutes before applying the topical corticosteroid. Infection may need additional treatment. Topical steroids should not be used for longer periods than prescribed by your doctor or indicated on the leaflet. Overuse can lead to the development of serious medical conditions. In our next article, we will discuss the dangers of overuse of topical steroids. References:

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Eczema – the truth (Part 2 of 2)

Eczema is a common chronic or recurrent inflammatory skin disease and affects 15-20% of children and 1-3% of adults worldwide. Although common, it is often misunderstood. In this 2-part article, we will give you all the information you need to understand and treat eczema a little better. In Part 1 we will discuss: In Part 2 we will discuss: Part 2 Types of Eczema Atopic dermatitis is the most common form of eczema. It usually starts in childhood, and often gets milder or goes away by adulthood. Atopic dermatitis is part of what healthcare professionals call the atopic triad. “Triad” means three. The other two diseases in the triad are asthma and hay fever. Many people with atopic dermatitis have all three conditions.  Symptoms Causes Atopic dermatitis happens when your skin’s natural barrier against the elements is weakened. This means your skin is less able to protect you from irritants and allergens. Atopic dermatitis is likely caused by a combination of factors, such as: 2. Contact dermatitis If you have red, irritated skin, thick scaly region that’s caused by a reaction to substances you touch, you may have contact dermatitis. It comes in two types: Allergic contact dermatitis is an immune system reaction to an irritant, like latex or metal. Irritant contact dermatitis starts when a chemical or other substance irritates your skin. Symptoms Causes Contact dermatitis happens when you touch a substance that irritates your skin or causes an allergic reaction. The most common causes are: 3. Dyshidrotic eczema Dyshidrotic eczema causes small blisters to form on your hands and feet. It’s more common in women than men. Symptoms Causes 4. Hand eczema Eczema that only affects your hands is called hand eczema. You may get this type if you work a job, like hairdressing or cleaning, where you regularly use chemicals that irritate the skin. Symptoms Causes Hand eczema is triggered by exposure to chemicals. People are more likely to get this form if they work in jobs that expose them to irritants, such as: 5. Neurodermatitis Neurodermatitis is similar to atopic dermatitis. It causes thick, scaly patches to appear on your skin. Symptoms Causes Neurodermatitis usually starts in people who have other types of eczema or psoriasis. Doctors don’t know exactly what causes it, but stress can be a trigger. 6. Nummular eczema This type of eczema causes round, coin-shaped spots to form on your skin. The word “nummular” means coin in Latin. Nummular eczema looks very different from other types of eczema, and it can itch a lot. Symptoms Causes Nummular eczema can be triggered by a reaction to an insect bite or an allergic reaction to metals or chemicals. Dry skin can also cause it. You’re more likely to get this form if you have another type of eczema, such as atopic dermatitis. 7. Stasis dermatitis Stasis dermatitis happens when fluid leaks out of weakened veins into your skin. This fluid causes: Symptoms Causes Stasis dermatitis happens in people who have blood flow problems in their lower legs. If the valves that normally push blood up through your legs toward your heart malfunction, blood can pool in your legs. Your legs can swell up and varicose veins can form.  Identifying which one you or your loved one suffers from, can be difficult, time-consuming and costly at times. If the eczema is severe, painful, affecting your ability to do daily tasks, or leaves the skin broken and not healing, I suggest a visit to a professional (doctor, dermatologist) immediately. Triggers & aggravators Although it isn’t always easy to completely avoid these triggers or aggravators, it will go a long way in helping to lessen the severity or frequency of outbreaks. Although glycerin is truly a wonderful moisturizer, with amazing properties, it should be avoided in the treatment of eczema. Basically all the articles advocate for the use of glycerin in treating eczema, but our experience have been that once it is eliminated, the skin reacts better and heals quicker. Any exposure to products that contain glycerin, aggravates the eczema again. Treatments There is no cure for eczema.  But it can be managed. Everyday solutions Treatment of atopic dermatitis may start with regular moisturizing and other self-care habits:  If these don’t help, your health care provider might suggest medicated creams that control itching and help repair skin. These are sometimes combined with other treatments. Atopic dermatitis can be persistent. You may need to try various treatments over months or years to control it. And even if treatment is successful, symptoms may return (flare). Our Skin Restoring Eczema Cream is designed as an effective daily moisturizer, that also helps to relieve and ease the symptoms of eczema. Medications Wet a cloth with water and plain bath oil (example chux or rediwipe). Apply to wet cloth to itchy areas for 5 -10 minutes, then apply a moisturiser post compressing. These are also the wet dressing for the face, and are best applied while awake and when feeding. Another option is using a thermal water spray to the itchy area. Age dependant the children should be encouraged to learn this technique rather than scratching.  Treatments for severe eczema.  Therapies Baby eczema Treatment for eczema in babies (infantile eczema) includes: Infected eczema Secondary infection of eczema is a common complication as the skin is not intact and thus more vulnerable to infection. Infection can make eczema worse and more difficult to treat. A common causative bacterium is Staphylococcus aureus which is commonly found on eczema skin.  Infection should be suspected if there is crusting, weeping, erythema, cracks, frank pus or multiple excoriations and increased soreness and itching which may suggest bacterial infection.  Secondary viral infection caused by herpes simplex virus (HSV) is characterized by a sudden onset of grouped, small white or clear fluid filled vesicles, satellite or “punch out” lesions, pustules, and erosions. It is often tender, painful and itchy. Other viruses that may cause the eczema to flare are molluscum contagiosum and coxsackie A6 virus (hand foot and mouth disease). Secondary infection should be treated by a doctor. Do not try to treat it

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Eczema – the truth (Part 1 of 2)

Eczema is a common chronic or recurrent inflammatory skin disease and affects 15-20% of children and 1-3% of adults worldwide. Although common, it is often misunderstood. In this 2-part article, we will give you all the information you need to understand and treat eczema a little better. In Part 1 we will discuss: In Part 2 we will discuss: Part 1 What is eczema? Atopic dermatitis (eczema) is one of several types of dermatitis. Other common types are contact dermatitis and seborrheic dermatitis (dandruff). Dermatitis isn’t contagious, but infections are possible. It often begins before age 5 and may continue into the teen and adult years. For some people, it flares and then clears up for a time, even for several years. In some people, atopic dermatitis is related to a gene variation that affects the skin’s ability to provide protection. With a weak barrier function, the skin is less able to retain moisture and protect against bacteria, irritants, allergens and environmental factors — such as tobacco smoke. In other people, atopic dermatitis is caused by too much of the bacteria Staphylococcus aureus on the skin. This displaces helpful bacteria and disrupts the skin’s barrier function. A weak skin barrier function might also trigger an immune system response that causes the inflamed skin and other symptoms. General symptoms Atopic dermatitis (eczema) symptoms can appear anywhere on the body and vary widely from person to person. They may include: Complications Complications of atopic dermatitis (eczema) may include: Asthma and hay fever. Many people with atopic dermatitis develop asthma and hay fever. This can happen before or after developing atopic dermatitis. Food allergies. People with atopic dermatitis often develop food allergies. One of the main symptoms of this condition is hives (urticaria). Chronic itchy, scaly skin. A skin condition called neurodermatitis (lichen simplex chronicus) starts with a patch of itchy skin. You scratch the area, which provides only temporary relief. Scratching actually makes the skin itchier because it activates the nerve fibers in your skin. Over time, you may scratch out of habit. This condition can cause the affected skin to become discolored, thick and leathery. Patches of skin that’s darker or lighter than the surrounding area. This complication after the rash has healed is called post-inflammatory hyperpigmentation or hypopigmentation. It’s more common in people with brown or Black skin. It might take several months for the discoloration to fade. Skin infections. Repeated scratching that breaks the skin can cause open sores and cracks. These increase the risk of infection from bacteria and viruses. These skin infections can spread and become life-threatening. Irritant hand dermatitis. This especially affects people whose hands are often wet and exposed to harsh soaps, detergents and disinfectant at work. Allergic contact dermatitis. This condition is common in people with atopic dermatitis. Allergic contact dermatitis is an itchy rash caused by touching substances you’re allergic to. The color of the rash varies depending on your skin color. Sleep problems. The itchiness of atopic dermatitis can interfere with sleep. Mental health conditions. Atopic dermatitis is associated with depression and anxiety. This may be related to the constant itching and sleep problems common among people with atopic dermatitis. References:

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