Making People Better
Managing Eczema: Expert Tips on Skin Health and Topical Steroid Usage
Unlock the secrets to managing chronic skin conditions in our latest episode featuring Sophia Brown, lead dermatology nurse, and Dr. Toby Nelson, a consultant dermatologist and Mohs micrographic surgeon. Have you ever wondered why eczema has become more prevalent, especially during the pandemic? We dive deep into the factors contributing to this rise, from lifestyle and diet to the overuse of soaps and shifts in our skin biome. You'll gain invaluable insights into quick fixes and available treatments that can help you navigate this common yet challenging condition.
Join us as we explore the complexities of using topical steroids effectively. Learn about the "steroid ladder" and the importance of proper dosing with the "fingertip unit" method. We'll also address how to break the itch-scratch cycle in young children with practical nighttime tips. Toward the end of our episode, Sophia and Dr. Nelson share their expertise on the latest advancements in dermatology and stress the critical role of early detection in skin cancer. This episode is a comprehensive guide to better skin health and well-being, packed with expert advice and practical strategies. Don't miss out on this enlightening conversation!
Unlock the secrets to managing chronic skin conditions in our latest episode featuring Sophia Brown, lead dermatology nurse, and Dr. Toby Nelson, a consultant dermatologist and Mohs micrographic surgeon. Have you ever wondered why eczema has become more prevalent, especially during the pandemic? We dive deep into the factors contributing to this rise, from lifestyle and diet to the overuse of soaps and shifts in our skin biome. You'll gain invaluable insights into quick fixes and available treatments that can help you navigate this common yet challenging condition.
Join us as we explore the complexities of using topical steroids effectively. Learn about the "steroid ladder" and the importance of proper dosing with the "fingertip unit" method. We'll also address how to break the itch-scratch cycle in young children with practical nighttime tips. Toward the end of our episode, Sophia and Dr. Nelson share their expertise on the latest advancements in dermatology and stress the critical role of early detection in skin cancer. This episode is a comprehensive guide to better skin health and well-being, packed with expert advice and practical strategies. Don't miss out on this enlightening conversation!
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Speaker 2:Yes, hello and welcome. I'm Glenn Tomsett. Yes, it's time for another of the Making People Better podcasts with Visa Health Group. This continuing series explores the challenges of everyday life, with a special focus on mental and physical health and well-being. We hope very much that you've been enjoying the series. We've got a whole back catalogue of material with some invaluable advice, so please do check out previous episodes. And I'm joined on each podcast by various experts in their chosen field, today joined by Sophia Brown. Sophia is a lead dermatology nurse at Vita and we also welcome Dr Toby Nelson, a consultant dermatologist and Mohs micrographic surgeon. Sophia, first of all, welcome along to you and nice to have you back on the podcast. How are you doing? How's things?
Speaker 3:Great. Thank you, Glenn. Thank you for having me back.
Speaker 2:Lovely to see you because we can see each other on this particular session of the podcast, and we're also welcoming Dr Toby Nelson as well. We'll have a chat with Toby very shortly, but this particular episode is taking on a slightly different sound and a feel, because I know very much you want to lead the session today, sophia. So I know very much you want to lead the session today, sophia, so I know you're very keen to grill Toby with some of your questioning. So yeah, tell us firstly a bit about yourself, sophia. What do you do exactly?
Speaker 3:Thank you, glenn. I'm the lead nurse for Vita Health Group, so focusing on the NHS contracts, lots of babies, paediatrics, adult services and lots of patients with skin problems, glenn.
Speaker 2:Okay, and Toby, let's find out about yourself.
Speaker 4:Yes, I'm a consultant down in Devon and Cornwall and I am the Clinical Director for Dermatology for Vita, supporting Sophia in delivering the pathways, providing second opinion to the GPs and the nurses for any challenging cases, as well as keeping up to date and informing the team of any new changes in practice which might need to implement for our patients. And I'm guessing you keep very busy as well, always busy, always busy. There's no shortage of work for dermatologists, that's for sure. Okay.
Speaker 3:Never any shortages.
Speaker 2:Absolutely Well, Sophia, what I'm going to do is you very much want to lead the session today. I'm going to throw it over to you to have a chat with Toby and Grilliam on a number of various points that you're keen to learn more about. So what I'm going to do is just sit back and throw my slippers off and enjoy the conversation. So away you go.
Speaker 3:Thank you, Glenn. Get a cup of coffee while you're at it.
Speaker 2:I will.
Speaker 3:So my guest today is Toby Nelson. Thank you, Toby, for joining. So you're a consultant dermatologist specialising in Mohs surgery, also director of Map my Mole, which is a patient self-surveillance initiative for patients to check their moles in the comfort of their own home. Can you talk us through some of the common chronic skin conditions that we see at Vita?
Speaker 4:Lovely to speak with you, sophia. So the skin. Obviously there's thousands, thousands of diagnoses, and if you ever pick up a textbook to do with dermatology, it's usually three textbooks and you'll see these tens of thousands of weird and wonderful diagnoses. But common things being common, the majority of our patients will suffer from one of only a handful conditions, and these are things like eczema, psoriasis, acne, itchy skin not always with a rash, sometimes just a sense of itch, hair disorders, nail disorders and obviously skin lesions, which account for probably half, if not more, of the referrals at any dermatology services people worried about a new or changing mole just homing in on eczema.
Speaker 3:When I think of eczema, lots of my friends have babies that are born with eczema. How common is it and how many people does it affect?
Speaker 4:Yeah, gosh, that's a good question. It's increasingly common. How many people does it affect? I don't know the exact figure, but I think it affects something like one in 20 of the population and at some point in anyone's lives, especially if those work in healthcare or certain occupations, you may get an element of eczema, for instance, on the hands. But yeah, it's an increasingly common problem. Why is that?
Speaker 4:There's lots of theories. Is it to do with our lifestyles? Probably Diet changes, maybe Overwashing, exposure to soaps, detergents Bearing in mind that people didn't used to wash that much and now they wash a lot. Some people wash multiple times a day and then there's also a change in the skin biome. So that's the bacteria and yeast that live on our skin that may have been affected through exposure to medicines, antibiotics, previous infections, covid all these things can trigger or give someone an outbreak of eczema, but usually in the majority of people it's not as simple as one would like. It's a very common question is why have I got this? I would like a test. What am I allergic to? I'm afraid eczema is not as simple as that, as you know. So people can have eczema for lots of different reasons a bit of bad luck, a bit of environment, a bit of genetics, usually what leads to people developing eczema.
Speaker 3:Yeah, it's a good point. I'm just thinking back to the pandemic and we would have staff that would just run into the clinic and say can you help me with my hands please? I'm washing my hands in Covid and you know they're all falling apart and they're bleeding. And we saw this massive surge of healthcare professionals just running into dermatology like can you give us some quick fixes? So what kind of quick fixes are out there for treatment for eczema? Toby?
Speaker 4:If we take all eczema. So obviously the most common type let's take a step back is atopic eczema. Well, that's the one you're most likely to get. Just inbuilt, you'd be like that's the one we might see. Some people call that atopic dermatitis, atopic eczema, those interchangeable terminology names. Then you've got your describe, which is more of an irritant eczema. So if I was to wash my hands all day long, which healthcare extends to do you're entitled to get eczema on your hands. That's because your hands are being damaged for exposure to known irritants not allergy, not allergens, irritants. So soap bleach. If we all stuck our hands in bleach all day long, all of us would have a problem with skin on our hands. So that's irritant. There is an allergy eczema, or what we call allergic contact dermatitis, and that might be something you're exposed to in your home, your work environment or daily skincare products that when it's in contact with your skin, it then brings out an allergy and you could be using the same fragrance, for instance, for life, and then suddenly you become sensitive or allergic to it. So that's the third type of like and there are a few others, but those are them in the main.
Speaker 4:Now to answer your question, simple, easy steps. Well, the first thing all these things have in common is it's a dry skin condition, the skin barrier is broken, it's dry, it's chapped and it's cracked. So hydrating the skin is really important. So that's applying a moisturizer, what we might call anient, of which there are lots, and it's about finding one that you like and one you're willing to apply and sits on the skin, doesn't sting too much, doesn't smell. So we tend to allow patients to sort of self-direct in that respect. But the simpler the better. Try and find one that is medicated, as opposed to one that's full of fragrances, because any product you apply to eczema skin, you may then induce a contact allergy to it. So we tend to go with old-fashioned things that are petroleum-based, like paraffin-based, what we call an emollient things like cocoa butter.
Speaker 3:They've got fragrance in, so they would be no good, would they sort of the good old cocoa butter, sheer butter?
Speaker 4:it's the sort of things we don't tend to recommend, but there are plenty of people who probably use them and get on just fine with them. You just have to bear in mind that if you pick it up and it smells nice, it's going to have a fragrance in. Everything has a preservative in. These things need to last more than a few days to a few weeks or they'll go off. So by applying an emollient, if it's not causing the rash to get worse, it's probably fine to use, but the thicker better. So the terminology ointment, cream and lotion is worth bearing in mind.
Speaker 4:An ointment is a screw top lid. Then there's a cream these tend to come in the pumps and they tend to be easier to apply, rub in but don't last as long and there's a lotion. Lotions tend to be what you wouldn't have as a medical treatment. It might be what you apply to your face as a daily moisture to your face. I personally tend to go with an ointment, but there's so many on the market. It is about finding one that you're willing to use and stick with.
Speaker 3:And that's it. There is so many on the market you don't know what to use sometimes. But how many times should we be applying these in a day, toby?
Speaker 4:If you've got eczema all over or on your hands, for instance, often is good. I would tend to say, you know, once or twice a day and then, if you've washed your hands, maybe have a little pot available. So if you're a kid at school and mum and dad have sent you in, you've got eczema, you might want to pop a little bit on when you can, would you remember? But it's hard for patients to apply these creams if it's all over their body and you can't really be taking all your clothes off at work two or three times a day. So maybe morning and night would make sense. After you've had a shower, dried yourself off, you could apply it. There are some once daily applications. You can get that some people like.
Speaker 3:But yeah, as often as you can, more the merrier when the skin feels dry or itchy okay, so not getting too hung up if they can't do it six or seven times a day, but trying to get those additives in the bath and as many applications as possible exactly, exactly.
Speaker 4:You've got to be realistic. People have got a job. They can't be um putting their moisturizer onto their back while they're at work, or for kids at school taking off their shirt and tie every time they need to put a put a big cream on. So as often as is feasible, but bearing in mind that's just the one thing that we have to do for eczema is the application of the moisturizer.
Speaker 3:It's not the only thing that you need to do so I'm thinking of things like steroid creams, and I know a lot of parents get quite misinformation about steroid cream. Is it something we need to be mindful of?
Speaker 4:that it can thin the skin this is a really talkative point at the moment. So steroid topical steroids have been around for a very long time. They've got the most evidence behind them to be effective and they are incredibly safe. You just need to know how to use them, how much, for how long, where to apply and understand the principle of potency. So different strength steroids, where and where you should not apply them.
Speaker 4:The fear that is sometimes given to patients and carers by mistake from healthcare workers is often a large part of what I do is unpicking that exact anxiety of. I've been told this will thin my skin. I've been told. If I use this for more than five days it will make my eczema worse. I'll get a rebound, I'll get addicted to it. That's a reasonably new but increasingly common anxiety. Will it absorb into my bloodstream All these kind of fears that people have? So it's our job to provide an impartial but informed explanation behind them, based on evidence and experience, and usually you can convince patients and carers to use these creams sensibly and, end of the day, if they see it working, they'll appreciate the benefits of them and they have to bear in mind if they're not working, it's not the only treatment, but we do need to trust in long-standing treatments such as corticosteroids in the management of eczema.
Speaker 3:Excellent. So fingertip measurements, fingertip units, how would you describe that to patients?
Speaker 4:If I was to go through my very common you know almost daily consultation is when someone has eczema and we've talked about the use of moisturizers and then we're talking about topical steroids. The two things I'll go through. One is what you refer to as the fingertip unit and that's how you dose one, and the other is the concept of a steroid ladder which we can maybe cover off at the same time. So when you are prescribed topical steroid and they are very different in their potency, you can buy topical steroids. Hydrocortisone it's very weak. It's one of the weakest creams. It's probably no stronger than the steroid our skin produces anyway At the top of the steroid ladder. So if you had a ladder up the wall and you climbed to the very top rung, you might have a steroid called clobetazole that's, in theory, maybe several hundred times more powerful than hydrocortisone. So applying more hydrocortisone will never get to the same endpoint as going to the top of the ladder and applying a little bit of clobetazole. By using a more potent steroid you're going to get a better response to the steroid and then you can come down the ladder and sometimes off the ladder. So patients need to understand. They're different potencies but they all look the same. So when they say I've already had a topical steroid, it's not the same. You have to think of it as a completely different new treatment. Now, when you get the box, often the pharmacist, more out of ignorance, will say use sparingly for no more than five days or use once or twice a day. This, in my experience, is not correct. It's usually only once a day in eczema that you need to apply a corticosteroid and using the fingertip unit, and this is the dosing of how you dose topical steroid. It's freely available online, so I use the analogy a bit like a toothbrush and a toothpaste. So if this is my finger, here's a line at the end. I'm going to run my steroid along from that line to the very end. That is a fingertip unit and that should only be applied to an area of skin the size of two palms. If I'm doing my own leg, I might put one fingertip unit on the upper thigh, another one on the lower thigh, so on and so forth. So I've covered my whole leg, chest or back. That way you're applying the correct amount to the right surface area.
Speaker 4:Sometimes you find patients try and spread a p size amount, tiny amount, over a big area. It's a bit like if I gave them a tablet and said take one tablet a day and all they did was they licked it for four or five seconds and then threw the tablet in the bin. They're clearly not going to get the dose that's required. So that's how you make sure you're getting the right dose, and that's really important to do, because when we see patients back, if they're not responding to the treatment, we know they've done everything they can, they've maximized their topical therapy, and that will allow us to guide them through the second therapy line or third therapy. But if we've not done everything we can at the beginning of the journey to do it properly, safely, then we may end up pushing these patients through to stronger, know stronger, potentially more dangerous medicines without having first ticked off everything we can do at the beginning.
Speaker 4:So that's your fingertip unit, the concept of steroid ladder, and then you need to know how long to use it for now this is where people get worried about skin thinning. Skin thinning will happen if you use a very, very strong steroid for many, many weeks on end, especially in folded skin. So skin flex's the armpit around the neck. What we tend to see with long-term steroid use on the face is acne. You give yourself spots. We don't like strong steroids around the eyes because it could absorb through the thin skin of the eye into the eyeball and cause glaucoma or put the pressure up, so we wouldn't see skin thinning.
Speaker 4:If you apply your steroid every day, I might tend to tell my patients to put it on once a day, utilizing the, the fingertip unit, for two weeks, and I say don't stop.
Speaker 4:Then you then go to every other day for another two weeks and then I say you've got to get to what's called the maintenance phase and that's a twice weekly application of topical steroid to all your usual stubborn sites.
Speaker 4:And if we can get our patients to the maintenance phase and the eczema is all melted away and they're all happy, then we can come down that steroid ladder and potentially off it and just back to moisturizers. But on the other side of the coin, if they come back at their follow-up and they say well, doctor, I've done all the things, absolutely said fingertip unit weaned along the ladder come down every day, as soon as I'm coming down to every other day, my eczema flares back up. That's telling us that their eczema is declared it's too stubborn, too strong that they can't just sit tight on topical steroids and we will then progress them onto a second-line agent. But until they've done that it's very hard to know who will and who will not benefit from corticosteroids in the mainstay of their treatment longer term. But probably three out of four more than that will probably be able to manage their eczema for the rest of their lives just with that simple bit of education understanding how to apply topical steroids, having them prescribed appropriately.
Speaker 3:Great education toby there. So how do we break the?
Speaker 4:itch scratch cycle, because eczema is very itchy. That's a really tough one. So obviously the topical steroids and the moisturizers come into play, trying to break this cycle and it's also about trying to stop people getting to their skin, especially in their sleep. In young children this is going to be quite challenging because the more they itch, the more they scratch, the worse it gets. So you can put their creams on before they go to bed. It doesn't matter which one you apply first. Maybe allow half an hour between the two so you could wash the babe, dry the babe off, apply the moisturizer, have a cuddle story and then put a bit of steroid on half an hour later and then put baby into a onesie. Hands and feet are enclosed, sew on some hands and feet so they can't scratch their skin at night. Slightly older child, a bit more compliant. You might do the same, and then you could use some bandages.
Speaker 4:There's different bandages out there. I tend to like the ones with zinc. Zinc's been around since Roman times. It's really good at settling inflammation. A mum, dad or, if it's yourself, you can bandage your limbs. This is obviously just for limbs. You can't go put this around your children's head very easily, but if they've got itchy ankles and wrists, put the creams on and then the bandage can be wrapped around, hold that in place with a bit of comfy, fast or tuby grip and they can leave that in place for several days. They can just roll it down, reapply the steroids the next day and roll those bandages back into place and over the course of usually the first week or two, you can break that itch, scratch, rub cycle. And I use those bandages and that technique in most of my patients who's got bad limb eczema. We just want to try and break that cycle of scratching and itching, especially at night when they might be doing it in their sleep.
Speaker 3:Super Toby, so you talked about different lines of treatment for eczema. So we're looking at Narrovan UVB light therapy as another option, and also there's these medications on the market that are meant to be one injection, then it cures your eczema. What can you tell us about that?
Speaker 4:So Narrovan UVB light therapy. It's a really nice treatment. It's very safe. Downside is time.
Speaker 4:You have to come in and out of the hospital two, sometimes three times a week, where you basically take your clothes off and go inside a medical grade sunbed if you like, but that's not to condone using sunbeds on the high street. These are very different machines and that will settle down the inflammation in your skin. When we find patients who can't come for that, or they've had it and it's failing, then you might look at some medication calms your immune system down. This might be a medication like cyclosporine or methotrexate and these can be used long term. They do need blood test monitoring and they obviously do have side effects, hence why we use very low doses in eczema. But we can use these in children, adults right through to old age.
Speaker 4:The newer class of medicines that have become available wouldn't be available to someone until they've at least tried all those first few steps, and these can be injections or tablets. And they are at least tried all those first few steps, and these can be injections or tablets, and they are transforming lives. They're very, very good, but they are new. So we don't have the long-term safety profile that we do have with all the other treatments. They're hugely expensive. Hence why there's very strict licensing about who can and can't have them. And again, they do. Some of them do need some ongoing requirement and monitoring to check for side effects. But you know, in summary, people with ecz, there's a lot of options out there for them. They mustn't forget the basics moisturizers, corticosteroids, breaking the itch-cratch-rub cycle. These are all as important for everyone, not just those patients who've got very severe resistant eczema.
Speaker 3:Great Toby. So so there's no cure, but it's all about management and getting patients to a point that it's stable and that it's not affecting their day-to-day living because it can have a psychological impact, can't it, on their mental well-being.
Speaker 4:You mustn't ever dismiss people with eczema. It can have a huge impact, not just on them but their family Sleep. If a child doesn't sleep, mum and dad don't sleep. That can have impact on on their relationship and their jobs. If you can't sleep, you're drowsy. You know it's going to have a bad impact on the rest of your health. So, yeah, it's really important to try and provide that education, direct them towards the appropriate management of eczema, dismiss any kind of myths or fears that they might have, and then make sure they're informed and they can move forward and look after their skin themselves.
Speaker 3:They don't need to be having their hand held moving forward with regards to the management of eczema in the majority of patients. Yeah, and I'm even thinking like going to the gym sweating. Surely, if your skin's quite sore, that would be quite sore for the patient, wouldn't it? Activities of going to the gym, just your day-to-day regular stuff, that would be affected if you had this severe flare-up of eczema, wouldn't it?
Speaker 4:all these things. It's a very debilitating condition. So anything we can do to calm it down, give patients the education and the word or how to look after it then they can move on and enjoy their life.
Speaker 3:That's great, Toby. Thank you for joining us today and your expertise. Just to wrap up the podcast for today. If anyone's got any further queries, please join our Vita Health Group website where we will post all the up-to-date information, and please do go to your GP and get a referral to dermatology if this needs further management.
Speaker 4:Patients. Information is widely available. I'd recommend patients go to a reliable source such as the British Association of Dermatologists website. There's patient information leaflets there on eczema hand, eczema steroid, steroid use. There's the NHS website and, obviously, vita will be providing informed and free access to education. I'd avoid trying to get your information from other sources. Sometimes you can go down a rabbit warren, especially around products for sale. As a closing comment, I would just say there's a lot of people out there trying to sell you something who've never treated a single person with eczema in their life. But they will tell you, based on their own experience, that there's only one way to solve and that's to buy something. Do not buy anything for your eczema until you've had a consultation with someone who has looked after the patients with eczema for a long time and knows how it's done.
Speaker 3:Thank you, Toby.
Speaker 4:Pleasure. Thanks guys.
Speaker 2:Sophia, thank you so much for those fascinating questions and also to you, toby, for answering those questions as well. One quick one from me. I always cast my mind back to my dear old nan, whose handle is no longer with us. She had the nicest, loveliest skin and all she did was wash her face in cold water every morning and every night she went to bed she just did a quick slush over with cold water. I'm guessing that's not for everybody, but everybody said to my nan you've got such wonderful skin, how do you keep it looking so young? And she said I just wash it with cold water.
Speaker 3:That's great If you get to the point and all you need to do is wash it with cold water. That's marvellous.
Speaker 4:She must have had some very good genes to keep herself looking. I mean mean, the thing that ages you most, glenn, is sunshine and smoking. You want to stay younger for longer, don't?
Speaker 2:forget your sunscreen and don't start smoking. Yeah, sounds like you're gonna age well. A fascinating podcast. Thank you so much for that. Today, uh, sophia brown, lead dermatology nurse at vita, and also dr toby nelson, a consultant dermatologist and mo's micrographic surgeon. If anybody wants details, head over to that website Details coming up in just a moment. But both of you, thank you so much for your contribution today. Fascinating stuff.
Speaker 1:Thank you. Thank you for listening to this Making People Better podcast, part of the Wellbeing series from Vita Health Group. Improving your lives, physically and mentally, drives everything we do, and getting you back to doing what you love is our priority.