Dermatology nurse practitioner Emma Coleman shares her holistic approach to eczema management and presents a patient case study
Approximately 15 million people in the UK are living with eczema.1 Also known as atopic dermatitis (AD) it is estimated that in 2015, GPs in England wrote 27 million prescriptions for topical AD treatments at a cost of approximately £169 million to the NHS.2 I have found that 4% of my entire patient base have eczema. The British Association of Dermatologists (BAD) acknowledges that the dermatology sector was under-provisioned in 2013,3 and in 2012, the BAD established the Psychodermatology Working Party to support this situation.4 The association also stated that 17% of dermatology patients need psychological support and 14% have a psychological condition exacerbating their skin disease.4
An integrated, holistic care approach to dermatology patients at the Royal London Hospital in 2015, led to 86% of dermatology subjects being discharged after one follow-up appointment, meaning the department had extra time for new referrals and the projected NHS cost savings were estimated at around £19,370 per year – up to £52,200 at five years.5
These figures suggest a need for change in approaches to eczema treatment in the UK, and here I present areas of research, both supporting and refuting unorthodox pathways. In my own clinic, I have observed that giving eczema patients and their families time, education and autonomy over the disease has a profound effect on disease attitudes. It should be noted that I don’t always charge for my time – treatment outcome is a priority for me.
AD may be associated with altered gut microbiata6 and three small scale trials provided evidence that mixed-strain bacterial supplement therapy (synbiotics), significantly improves the SCORAD Index in child subjects after eight weeks, possibly inducing immunological changes (n=39, 60 and 40 respectively).7-9 On the other hand, another trial (n=41), reported that there is no significant impact on SCORAD scoring with synbiotics, and cannot be viewed as effective therapy in AD cases.10
Several studies have linked development of fatty, oversized liver in non-obese AD sufferers of all ages, thought to be due to abnormal lipid metabolism, possibly involving the enzyme delta-6-desaturase.11,12 It is thought that AD sufferers have a reduced rate of conversion of dietary linoleic acid into its metabolites, and impairment of incorporation of essential fatty acids (EFAs) into phospholipids, leading to elevated hepatic and reduced serum fatty acids.13 Additionally, an Italian study suggested that reduced foetal polyunsaturated fat (PUFA) blood levels may predict eczema development.14
As it appears that epidermal linoleic acid is depleted in AD sufferers, it follows that therapeutic fatty acid supplementation such as gamma linolenic acid (GLA), an omega 6 source, should improve symptoms.13 One double-blind trial demonstrated that taking oral evening primrose oil (EPO) reduces inflammation, dryness, scaling and severity compared to controls, with no adverse side effects.15 Another study provided evidence that when taken over a 12-week period, oral EPO significantly reduces the need to use topical steroids three-fold in adults and children compared to placebo.16 One study suggested that 6g of orally-administered EPO produced a rise of up to 46% in the epidermal dihomo-γ-linolenic acid (DGLA) levels, compared to a control group.17
Statistical support for using topical EPO is limited, with only one small-scale trial showing positive outcome when using this therapy with eczema patients.18
In all cases, study sizes are small and steroids are often used alongside EPO; one study refutes the benefits of EPO in AD, highlighting a need for further trials.20
There is evidence to suggest supplementation with 10g of sea buckthorn pulp over four months led to reduced AD symptoms, improved skin condition and elevated serum high density lipoprotein cholesterol levels (n=49).19
We often associate stress as a cause of inflammatory disease flares; this has been extensively studied with AD cases and some findings are interesting. One investigation found no significant elevation of basal serum cortisol or adrenocorticotropic hormone (ACTH) levels in eczema patients compared to a non-AD population.21 Eczema patients appear to have sparse numbers of adrenergic β-adrenergic receptors compared to non-AD patients, causing a blunted hypothalamic-pituitary-axis (HPA) response.22 Animals that fail to generate a sufficient glucocorticoid response to pharmacological or psychological stimuli are highly vulnerable to inflammatory processes.23,24 In one study, 20% of eczema patients report anxiety and 14% depression, which tend to increase in correlation with symptom severity.25
Use of complementary and alternative medicine (CAM) and psychological interventions in alleviating eczema and its symptoms remains controversial at present. Several studies highlight a positive correlation between CAM, stress relief and improved quality of life in eczema sufferers.26-31 However, trials have often been identified as haphazard in their randomisation methods and outcome measurement, and too small scale to warrant real value.32
One study combined therapeutic autogenic training and cognitive behavioural therapy in eczema patients, which led to reduced topical steroid use and skin condition improvement.27 Whilst there is evidence to suggest that combining group and relaxation therapies reduced scratching in 100% of AD subjects (n=10),26 application of ayurvedic herb Nigella sativa was comparable to betamethasone in its reduction of hand eczema over a four-week period, leading to significant Dermatology Life Quality Index (DLQI) score reduction.29
Elevated epinephrine and norepinephrine concentrations in eczema patients were significantly reduced by four weeks of treatment with EPO compared to control in a German study.31 There is evidence to suggest that autogenic training, cognitive behavioural therapy, combined dermatological education and cognitive-behavioural therapy, as well as habit reversal behavioural therapy, significantly reduce itch and scratching intensity.27,33,34 In summary, the evidence is promising but needs wider attention.
My first step in creating an eczema patient plan is usually referral for blood and/or allergy testing. Dietary recommendations should be specific, given only in diagnosed individual food allergy,35 and dietary intervention remains controversial in this patient group.
One study looked purely at dietary habits in AD and non-AD patients, and although vitamin D intake was lower in the AD group, there were no significant dietary differences between refined sugar or fruit and vegetable consumption, and no links between dietary habits and clinical status were highlighted.36 Another longitudinal study (n=1,265) conducted over 10 years found that infants weaned onto solid food by the age of four months were approximately 1.6 times more likely to develop childhood eczema, particularly in cases with family history of the disease.37 Fast foods, butter, margarine and pasta intake three or more times weekly may impact eczema incidence in children and adolescents according to one global, large scale study (n=500,827). Fruit, vegetables, eggs and milk consumption were inversely associated with severe current eczema and therefore labelled as protective. In the same study, there was no association identified between obesity and eczema.38 One individual case report provided strong evidence that eczema was lactose-induced in a male patient, where milk withdrawal led to complete resolution.39
A 21-one-year old man presented to me on December 2 2019 with poorly demarcated redness to the face with frequent itching and visible excoriation. He had a history of itching, inflamed rash to the face and sometimes the upper arms for the past two years, with prior history of flare ups since early childhood, (from the age of approximately one year). The patient had known allergies to erythromycin and penicillin, hay fever, and was using Dermol cream and Betamethasone Valerate 0.1% from the GP at his initial consultation. I diagnosed moderate eczema based on a Patient-Orientated Eczema Measure (POEM) score of 14.40 I also performed my Five Pillars Consultation, assessing lifestyle and psychological status. In addition, I identified that the patient also has acne vulgaris (mild) over his lateral lower face.
In the consultation he explained that the eczema was disturbing his sleep and impacting his social life due to feelings of self-consciousness. He works for his dad at a transportation company operating at management level, which he finds stressful. He feels the impact of stress in his stomach, experiencing nausea at times. He lives with his parents, smokes an average of 10 cigarettes daily and drinks beer at weekends. He is a grazer, snacking on fizzy drinks, crisps and sandwiches during the day; his mum prepares his evening meals – usually meat, potatoes or pasta and vegetables, rarely fish. In this case, the two-way relationship between AD, mental and physical health was clear.
I explained my plan to calm the eczema flare then treat the acne, because the former was causing the most discomfort and topical acne treatments are designed to aggressively dry out affected skin. My initial plan was to commence synbiotic and EPO therapy, and refer the patient to his GP for full blood count and allergy testing; as stated in the NICE guidelines, impaired barrier function may lead to increased allergen susceptibility.41 The patient remarked that he was unlikely to stop smoking, but said that he would reduce alcohol and sugar intake. I advised a breathing/meditation app for use at moments of stress, as well as the use of anti-histamines, which are known to alleviate itching in some eczema cases,42 emollients and a seven-day course of topical tacrolimus to calm the flare, as advised in the NICE guidelines stepped approach.42 I arranged for a follow-up and diet plan one week later. On December 9, the patient had not visited his GP about allergy testing. He explained he had been too busy with work, but when pushed he said he doesn’t like needles. I reiterated the importance of this and suggested his mum go with him to the appointment. Patient compliance is a common issue that I encounter and is difficult to manage at times, which is why frequent contact is essential. Although, the patient’s redness, itching and excoriation had significantly calmed and his POEM score had reduced to from 14 to 9 (moderate eczema). He had purchased and started taking the supplements – synbiotics three times daily and EPO once daily – which take an average of eight weeks to start working, in my experience.
The patient had undertaken short mediation sessions three times over the last week via an app called ‘Head Space’ and his mood seemed elevated. I asked why this was and he said, “I feel positive that I’m trying a different approach.” I commenced him on a course of 1% topical hydrocortisone and provided him with dietary recipes, involving reduced sugar and saturated fat options, daily celery juices and increased fruit and vegetables. We arranged for a phone call follow up at two weeks, and another face-to-face consultation at four weeks.
We had the phone call on December 23, and I advised him to stop using 1% topical hydrocortisone, based on his reporting of further improvement to his skin condition including reduced redness and itching. This part of the treatment was stopped to prevent risk of skin atrophy, and to allow the other lifestyle changes to do their part in preventing the eczema. This was explained to the patient. On January 8, the patient came back to clinic for his scheduled face-to-face consultation. He still had not visited his GP regarding general blood and allergy tests, reporting he needed to arrange a date with his mum. I explained the importance of this again, suggesting that all his hard work would be in vein if he doesn’t have the tests. I provided details of a private clinic in London, which he may prefer. The patient has continued to comply with the supplements and meditation; his mum has agreed to prepare the types of meals I have recommended for him to eat. On assessment, his POEM score was 0, however the patient was very agitated about his acne and we turned our attention to treatment of this aspect, for which I was able to prescribe Skinoren (azelaic acid) and create a new holistic plan, with which we have had some success. There is never a quick fix for healing skin conditions like eczema, and I am committed to exploring triggers with patients to get to the root cause. I feel the success of this eczema management case was partly attributed to regular patient contact, including emotional support and encouragement, alongside the holistic treatment programme itself.
I see eczema treatment as three-fold – symptom control, education and prevention – and each patient is an individual and should be managed as such. There is a gap between eczema patient demand, dermatological resource and provision, and although evidence for taking a more holistic approach seems promising, and could be of value in long term management, future research including large scale studies is imperative.
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