New medications for eczema – an update from the American Academy of Dermatology annual conference 2018

 

Dr Georgina Lyons - Hope Dermatology

 

 

Dr Georgina Lyons talks all new things in eczema.

Reporting from the AAD meeting San Diego 

 

“I have just returned from sunny San Diego, where the American Academy of Dermatology held their annual scientific meeting this year. As the largest dermatology conference in the world the AAD meeting is always a wonderful opportunity to hear from the best dermatologists in America and catch up on all the latest advances in dermatology (many of which are released in the U.S. first before making their way to Australia).

This year there were several exciting developments in terms of new treatments available for eczema, including the biologic Dupilimumab for widespread recalcitrant eczema and the new non-steroid topical cream Crisaborole. Whilst not yet on the PBS these medications were approved for use in Australia by the TGA earlier in the year, and will hopefully soon be government subsidised for treatment of eczema in Australia.

Also, it turns out that vinegar doesn’t just go well with fish and chips – vinegar baths for eczema were discussed as a simple and effective alternative or adjunct to bleach baths in treating flares and preventing secondary infection. I am looking forward to trying this out with some of my patients!”

Eczema in babies

 

 

And just like that in the blink of an eye my youngest is nearly 8 months. Trawling through old videos and photos, I came across this video that was shot when I was pregnant with him. I am talking about eczema in the video and little did I know that he would also have infantile eczema, like his older sister (eczema tends to run in families). And little did I know I would have many a sleepless night with him scratching and irritable!

Today I was asked about suggestions for eczema management for a medical colleague’s baby. She was having trouble managing her 4 month old’s eczema. Here is the conversation, almost verbatim….

{Sleepless mum of 4-monther}  Eczema runs in my family. Bub has eczema and dribble rash and also heat rash on the trunk. He is scratching at night and I really want to help him. I have been putting on greasy moisturiser on the dribble rash and barrier cream containing zinc but I think this has made it worse. I have been applying bath oils in the bath, moisturising creams and 1% hydrocortisone cream for the body rash but am getting no where and no one in my house in getting sleep. HELP!

{Me} Don’t bother with 1% hydrocortisone on the body. This over-the-counter cream is really only for the mildest of eczema rashes. It does have its place but when the eczema is severe enough that no one in the family is getting any sleep, you need to bring in the medium/strong potency topical steroids for the body eczema. I would suggest topical steroids such as methylprednisolone aceponate 0.1% daily for about 2-3 weeks until the rash settles considerably and then downgrade to the 1% hydrocortisone for maintenance.

{Sleepless mum of 4-monther} But the 0.1% cream you’ve suggested must be weaker than the 1% hydrocortisone that I have been using.

{Me} This is a common misconception. The percentage that is displayed on the topical steroid cream does not in any way correlate with potency strength. It is a bit confusing but as dermatologists we are used to figuring out which potency strength patients are going to need to sort out their rashes. A lot of people ask me about steroid atrophy (thinning of the skin)  but if you apply the steroid cream only to the rash areas and not on normal skin, and apply for short periods of time to control the rash, you would rarely get skin thinning. You should go with your gut and if bub is unhappy and itching away, then he needs active cream treatments.

{Sleepless mum of 4-monther} What about his heat rash? I’m doing all the right things; avoiding overheating; using lukewarm baths…

{Me} Here are some additional things that you might want to make sure you are doing for the heat rash/eczema….If you have a mattress protector, consider ditching it for the short while until the rash resolves. Most mattress protectors will be quite “plasticky” and trap heat. As you have a young 4 monther that is not yet able to roll over, he might get too hot in the cot but he won’t be able to roll over or get himself in a more comfortable position. I have found with my 8 monther, once he was rolling and sitting up by himself, a lot of his eczema settled down as he is able to “air himself” out more. If bub co-sleeps in bed with you, he may also be overheated. Also if he uses a sleeping bag, try and opt for a light cotton one rather than a heavy duty style. Try and use 100% cotton sheets in bedding rather than poly/cotton blend to keep him cool, avoid any clothes that might irritate his skin – wool, clothes with irritating zips and tags (consider cutting off tags even!), ribbed singlets..

{Sleepless mum of 4-monther} **SMS’ me a picture of the heat rash**

{Me} ….bub’s skin does look irritated in the pic. I would also steer clear of occlusive ointments. So if you are using topical steroids, go for the cream preparation rather than the greasy ointment as ointments can be too “sticky” and make the heat rash worse. Get bub reviewed if the above don’t help. Sometimes eczema can become secondarily infected and then there might be a need for topical or oral antibiotics or anti-septic washes. Good luck! Most kids will grow out of eczema but hopefully by doing all of the above, you can make the transition easier….and hopefully get some more zzzzzz in the meantime.

 

Light at the end of the tunnel for alopecia areata sufferers

We talk alopecia areata

Alopecia areata is an autoimmune disease with a complex genetic basis. There may be a pattern in the family of this type of hair loss but often it can appear in patients where there is no history of hair loss at all! It typically presents with patchy hair loss and can progress to total baldness. Hair loss can extend to other areas of the body such as the eyebrows, eyelashes and body hair. It can have a big impact on patients’ well-being. Treatment is often challenging but can include creams/lotions and injections if the hair loss areas are mild. If the area of hair loss is a bit more substantial, then consideration of oral medications and even immunosuppressive drugs may be needed. 

Trials on the use of medications called JAK inhibitors such as astofacitinib and ruxolinitib are on their way with early encouraging results. These medications have been used in other autoimmune diseases such as rheumatoid arthritis and trials are also on their way for psoriasis. Their safer profile and tolerability is much better when compared with currently used systemic therapies. A quick response may occur within 4 weeks which makes a world of difference to our patients. More than 75% of patients responded with at least 50% hair regrowth by week 12. But patients may need to continue therapy long term due to likely relapse if the treatment is discontinued.” 

Get the glow; just not the red glow…..

We often hear from our patients that they want their skin to glow! But not the RED kind of glow!

If you’re plagued with skin that glows red for hours after any physical exertion, at the thought of public speaking or you just wake up red and rosy you could probably benefit from our vascular laser!  There are a number of skin conditions that can cause excessive redness in the skin. Rosacea is a common one that we see as dermatologists and laser bridges the gap between a medical approach (prescription creams, medicine) and a cosmetic approach to shut down the telangiectasia (blood vessels) caused by flare-ups. Many of our patients present with generalised sun damage caused by accumulated UV exposure, causing dilation of the superficial vessels and making them visible or obvious. Surprisingly, many people are not aware that WE CAN TREAT THIS…. With laser.

Laser has been available in Australia since the early 80’s and these days the technology has been refined to give us great results, safely, with as little downtime as possible.  In saying this… laser is NOT a walk-in, walk-out treatment in most cases! Expect some downtime in most instances. HINT: swelling++.

So if redness, red spots or large vessels are getting you down, pick up your biggest pair of Hollywood sunglasses to hide behind and book yourself in for some laser at our clinic!

My approach to acne

This is such a common problem. As dermatologists, we see a LOT of acne! I’m writing this post with my wriggly 7 month old boy on my lap and even he has acne….infantile acne that is! Acne is one of those conditions that truly can affect a wide cross section of people. I’ve treated babies, teens and the middle aged! It is one of the pesky conditions that just won’t behave when you want it to!

Treatments for acne can range from creams and lotions, to oral tablets and adjunct cosmetic treatments such as good skin care (with ingredients such as AHAs, niacinamide, vitamin A), laser, skin needling and peels etc. Each patient with acne will have a different treatment regime as not all acne is the same. There may be different triggers of acne for different people including stress, diet, environment, hormones and genetics and often taking a detailed history is essential to try and minimise any external triggers for acne. Topical treatments may include antiseptic washes, antibiotic lotions and vitamin A creams. Each of these topicals has a different mechanism of action on acne. Similarly, oral tablets include oral antibiotics, hormonal therapies and vitamin A tablets (isotretinoin is dermatologist-only prescribed in Australia).

Any acne treatment typically takes about 1 – 2 months for patients to really start seeing the difference. Our approach is get patients with acne into our clinic quickly, initiate treatment and to promptly alter acne treatment regimes if there is minimal or no response as we want to get acne under control FAST to minimise the risk of scarring.

Hope this helps clarify the overall approach to acne in our clinic!