Exploring the Allergy Roots of Eczema Leads to New Treatment Options

Eczema is a chronic condition that is often associated with allergies. The sharp provider can offer patients several treatment options.

The cold winter months may offer respite for patients with pure pollen allergy, but they are no friend to patients suffering with eczema. Eczema, also known as Atopic Dermatitis, is the classic allergic skin rash. It’s known as “the itch that rashes,” meaning that it is typical for a patient to experience the symptom of itching first and clinical rash next. Atopic dermatitis patients usually have elevated total IgE, which explains why they frequently have comorbid conditions of allergic rhinitis and asthma. The simple treatment for the eczema patient’s symptoms is a prescription for a topical cortisone cream. Cortisone may give the patient temporary relief, but a more comprehensive plan is needed to provide the fundamental disease control that they deserve.

We sometimes forget that the skin is the largest organ in the body.  It covers our entire outer surface. In order to adequately protect that organ, we must provide an emollient that can serve as a barrier to the harsh environment. The good news is these are easy to acquire and they aren’t very expensive. My professor of allergy and dermatology at Columbia Presbyterian Medical Center extolled the benefits of baby oil. Yes, good old fashioned baby oil just after a shower, when the skin pores are wide open, can provide a nice general coating for the skin. In areas of severe dryness or broken skin resulting from the eczema, plain Vaseline or Aquaphor lotion is helpful. Vaseline may be sticky and messy but it’s effective. When we had patients on the dermatology ward with severe rashes, the nurses coated them with Vaseline — it was very soothing and therapeutic.

Cortisone creams are an important element in the treatment regimen, but they should be targeted to the affected areas. It is very important to show the patient how to apply the cream; they must see how to massage it in coin size amounts to the local areas of redness. If they just lightly smear tons of cream over the body, absorption — and therefore effectiveness — is limited. I usually find that a mid-potency steroid cream, such as Mometasone is effective. However, you should use only low potency hydrocortisone (1 or 2.5%) on the face due to the risk of atrophy with the mid-potency preparations. The other important ointment in the treatment spectrum is Muciprin, which contains an antibacterial agent that helps reduce the growth of Staph.aureus on the affected skin areas. Muciprin should be applied to broken skin areas that are oozing with fluid.

The above steps are familiar to most doctors. Now, comes the expert territory. Even dermatologists are a bit lax when pursuing the underlying cause of eczema. Numerous studies show that atopic dermatitis is worse in children with food or environmental allergies — especially to dust mites. It’s important to take a thorough history on these patients and perform an allergy test to see if an allergen exacerbates the condition. Dr. Hugh Sampson, when he was at Johns Hopkins, demonstrated that 50% of children with eczema had food allergies. The studies further showed that eliminating these foods from the children’s diet caused improvement of the eczema. This was ground-breaking information in the late 1990s — now it’s recognized as a standard of care. The AllerVision allergy skin test panel of standard foods is a good place to start your evaluation. AllerVision also offers an additional food panel that allows you to test for 40 individual foods; it’s an excellent way to augment your program.

Exciting new areas of research into eczema treatment indicate that enhancing immunity may provide significant benefit to the patient. The latest studies from Harvard suggest that supplementing with Vitamin D3 can help control patients’ eczema and decrease reliance on topical corticosteroids. As a result, I have recommended supplementation with Vitamin D3 in the ranges of 1,000- 3,000 units daily for all of my eczema patients. I prefer the liquid Vitamin D3 over pills, as the pills can be difficult to swallow. Following your patients’ D3 level along the course of eczema treatment can provide interesting information regarding management.

Finally, it’s worth noting that studies substantiate the value of sublingual allergy immunotherapy (allergy drops) for patients with mild to moderate atopic dermatitis. Specifically data has shown that dust mite allergy, which is associated with aggravating atopic dermatitis, can be treated effectively with sublingual allergy immunotherapy. The same has not been demonstrated with subcutaneous injection immunotherapy.

Once you determine — though medical history and allergy testing — the root of the eczema, you can determine which of these treatments can take the itch out of your patient’s lives.

– Dr. Dean Mitchell

The Keys to Successful Allergy Treatment in ’14: Compliance, Compliance, Compliance

A provider explains the benefits of allergy drops to to a patient and demonstrates their use.

The new year is beginning and with it comes resolutions. I want to put this challenge out there — 2014 will be the year that doctors who treat allergies make a promise of clinical improvement for their patients… and inspire patients to do their own part in fulfilling that promise! The common ground required for this achievement: compliance.

Compliance is an important building block in the success of almost any endeavor. In medicine, it’s the key to reaching maximum therapeutic results. With allergy treatment specifically, patients must be disciplined because their symptoms are sometimes periodic, but to attain the highest level of success possible, allergy immunotherapy requires year ’round application. The struggles here are similar to those with hypertension meds where the overall wellness of the patient depends on their adherence to medication protocols even in the absence of symptoms. Studies show that compliance for allergy injection therapy is in the low 30% in most situations. Allergy drops compliance has been reported to be as high as 90% or as low as 20%. II have been fortunate in my medical practice to attain closer to 90% compliance with my immunotherapy programs and I’ll share what I’ve learned to make this possible for your clinic.

The key to compliance with allergy immunotherapy is motivation. Of course it may be easier to motivate patients at the beginning of treatment if they are diagnosed when the misery of allergies is clear in their mind. The hard part is inspiring them when they are asymptomatic, and then maintaining the course when they are feeling good. I’ve found that there are two important “up-front” times to motivate a patient: 1) At the visit when test results show their specific allergies, whether they be to pollen, dust mites, mold or animal dander. 2) At the point of informed consent. You will clearly have the patient’s attention when they are able to visually confront the allergens that have been causing them to sneeze, wheeze and itch. But to parlay that into successful treatment takes effort by both the patient and your practice. If the patient has positive allergy tests that correlate with clinical symptoms and immunotherapy is being discussed, the informed consent process is a vital opportunity to discuss the keys to successful outcome and motivate my patients to invest their time for long-term success.

Informed consent can be accomplished many ways in medicine. It is possible to unknowingly scare a patient out of a treatment with extensive lists of possible adverse events, but if you emphasize the positives in comparison to the potential negatives then you have an interested patient. Fortunately with allergy drops, the advantages far outweigh the few negatives. As always, the goal is to make the patient an equal partner in the decision-making process.

In discussing informed consent for immunotherapy, I start off with the many advantages. First, immunotherapy is a program that’s directed at the patient’s specific allergens (not a generic mix that all patients get). Second, the goal is to not only decrease their allergy symptoms, but to reverse the disease. Third, I explain that the allergens used are not drugs but elements from the environment (such as pollens) designed to train their bodies to accept their normal surroundings. Fourth, I let my patients know that studies indicate that immunotherapy is safe and effective. I also explain that the process of desensitization to allergies is similar to working out with weights: “in your workouts, it’s best to start at a low weight and gradually build up. Of course, everyone wants to see immediate results, but with time you will — you just have to visualize yourself on the road to getting there.” The final clincher with the allergy drops is convenience. When the patient realizes what they are taking is good for them and easy to use, they feel the responsibility to be an active participant.

I always ask  patients, “Do you brush your teeth everyday?” They look at me like I’m crazy; they swear they wouldn’t leave the house or go to sleep without brushing their teeth. Well, I tell them, leave your allergy drops by your toothbrush and you’ll never forget to take them either! My patients who regularly take their allergy drops see significant improvement when pollen seasons hit or when they visit a friend’s home with cats and dogs that they couldn’t tolerate in the past.

In the long term, the true key to successful compliance is the relationship between doctor and patient. Studies show that physicians can significantly increase adherence to treatment protocols through consistent follow-up visits. As much as patients know in the back of their minds that they should stay the course, nothing replaces the impact of checking in with their providers for a reminder that they have a partner in their quest for wellness.

Remember, in Latin, doctor stands for teacher. I take it another step further: as doctors we are our patient’s coaches and need to encourage them in the right direction. My best days in practice are when I see my patient at a follow-up visit during a high pollen day and I ask them what’s bothering them and they answer “Nothing!” We both celebrate!

-Dr. Dean Mitchell