Eczema Management - Dr. CHAN Chun Yin, Johnny

Q1. I think I have eczema. How is it diagnosed?
Eczema is also known as atopic dermatitis. It is caused by the interaction of congenital and acquired factors. The former are hereditary. It can be diagnosed with a detailed medical history and thorough clinical examination including one’s allergy history and that of the family members, e.g. allergic rhinitis, asthma, etc. Acquired factors are allergens in food and environment. With different tests like skin prick tests or new blood tests nearly 100 allergens can be identified for avoidance.

In case of persistent patches, some of them are mistaken for eczema and may be caused by other conditions such as psoriasis or autoimmune diseases like systemic lupus erythematosus, even skin cancer, etc. They all have similar presentations. After discussion with doctor, skin tissues may be extracted by surgery for examination to confirm the diagnosis of eczema.

Q2. Is eczema curable? Will there be any severe side effects if steroid is used for treatment?
Eczema is also known as atopic dermatitis. In over 80% of eczema patients, the onset age is before 5 years old. People need not worry too much if eczema is curable or not as data show that over half of the patients recover in adulthood, thanks to a mature immune system. Significant improvement is also noted in the remaining cases. To cure eczema, especially in its early stage, proactive treatment is recommended when patients are still young or are in mild condition. If eczema gets out of control, or skin inflammation keeps recurring, the epidermis may become less capable to retain moisture, making eczema less likely to be cured. Therefore proactive treatment is very important.

Some people may also worry about the side effects of steroids used during treatment. Your doctor knows about the topical or systemic side effects. For use over a large area, diluted or lower-strength steroids are prescribed for use in a large area or over a long period of time. Stronger steroids are only prescribed for topical use if severe. They are used for no longer than a few days or a week as it is safer to limit the use of steroids.

Q3. Is there any non-steroid treatment for eczema?
You can get started with changes in lifestyles without using ointments. Discuss with your doctor and test for allergens. Try to avoid them in food and environment as it helps improve the condition. Skin creams are also important. Skin creams have 3 major functions: to keep the skin moisturised, as the creams are added with moisture, to reduce water loss as a barrier. These functions are common in most skin creams. New skin creams have moisturising factors. In recent years, the epidermis is known to be able to lock up moisture in the medical world due to a natural moisturising factor called ceramide. Some skin creams also contain ceramide to provide relief to eczema sufferers. Steroid ointments are used more often in conventional treatment but thanks to the recent medical advance new ointments are now available for daily use. Unlike skin creams, these ointments are medicinal but contain no steroids. New ointments like TCI or PDE4 inhibitors have been put on the market in recent years. They are effective in controlling eczema and can reduce the use of steroids.

Q4. I have severe eczema. What can I do to put it under control and improve the quality of life?
For treatment of atopic dermatitis, doctor will first make a detailed assessment and classify the condition as mild, moderate or severe based on 4 objective criteria, i.e. the percentage of affected skin, extent of redness, thickness of affected skin and skin loss in the affected area. Based on these 4 criteria, the condition is categorised as mild, moderate or severe. Patients with mild eczema
are advised to make some lifestyle changes, take good care of the skin and use ointments which may contain steroids or not. Doing these 3 things is good enough for mild eczema patients. For moderate or severe eczema patients, these 3 recommendations do not suffice for putting eczema completely under control. They may need advanced treatments to improve the quality of life.

There are 3 treatment options, including light therapy, also known as phototherapy which uses ultraviolet light, especially UV-B light. UVB is absorbed in the skin to suppress the overactive T lymphocytes and stop them from attacking the skin, leading to improvement in skin condition. Conventional immune system inhibitors are now less used. The use of immunomodulatory agents can suppress the overactive immune system and improve the skin condition. But oral medications may compromise the immune system and are likely to affect liver and renal functions.  

To enhance treatment safety, your doctor will arrange regular blood tests. The latest treatment option is biologics. Like agents for targeted therapy, biologics are injectable. They focus on neutralising eczema-related inflammatory factors leading to significant improvement. Also they do not affect our own white blood cells or other immune systems. They are safer and more effective than conventional inhibitors. These treatments can provide relief to patients with mild or severe atopic dermatitis and greatly improve the quality of life.  

Q5. What are the latest developments of eczema treatment? What are biologics?
As medicine advances, doctors are learning more and more about atopic dermatitis. We can probably identify the gene that triggers atopic dermatitis and affects the immune system. There is a type of abnormal white blood cells called “T lymphocytes”. One of its major subtypes is Th2 cells, which for genetic reasons promote inflammation with an inflammatory factor called “interleukin”. The newly developed biologics focus on neutralising eczema-related inflammatory factors like interleukin thereby resulting in significant improvement in atopic dermatitis. And more importantly, biologics do not affect the functions of our T lymphocytes and other immune systems.

They are safer than conventional immune system inhibitors. By focusing on neutralising the inflammatory factors of eczema biologics have by far the highest efficacy and can now be administered by injection and orally. Besides interleukin, thanks to medical advance, we also know about different factors that trigger pro-inflammatory signals. One of the signals is JAK in white blood cells. It is closely associated with inflammation. Some new oral biologics can terminate the JAK signals. It can greatly reduce pro-inflammatory signals and improve atopic dermatitis. These new oral biologics are a godsend for eczema patients.

For more information of HKSH Healthcare Dermatology Centre, please click here.

Check out YouTube videos from HKSH Medical Group for more health information.