Welcome to the Don't Be Rash Pediatric Dermatology Podcast, the owner's manual for your kid's skin.
I'm your host, Dr. K, board certified pediatric dermatologist and father of two boys.
I'm here to chat with you to promote dermatological education and improve skin health in our children everywhere.
Let's get started.
Welcome to Don't Be Rash, the pediatric dermatology show coming to you from historic Bethlehem, Pennsylvania.
I'm your host and board certified pediatric dermatologist, Dr. Andrew Krakowski.
On today's show, we're going to dedicate a full power hour to scratching the surface of eczema.
More specifically, in the first half of the show, we'll discuss the clinical look and feel of the specific condition called atopic dermatitis
and discuss some of the underlying reasons why your child might get it.
Then in the second half, we'll discuss management and treatment approaches, including when you as a parent should really be seeking specialty care from a pediatric dermatologist.
Joining me again as co-host is our very special guest, Dr. Alicia Walty, chief medical officer for Star Community Health.
Welcome, Dr. Walty. Thanks for joining me again today.
Of course. Thank you for having me.
When we mention the word "eczema," what comes to mind as a community pediatrician?
Itchy, itchy. I see these poor kids that come in and they're just literally squirming and itching in their kind of in their own clothes and on the exam table.
And you just kind of want to make their itch go away as soon as you possibly can.
So itchy, Itchy and Scratchy, not just cartoons from The Simpsons.
No, definitely not. Definitely not.
These poor kids have torn themselves up and they're literally fidgeting often in their seats because they're just so uncomfortable.
Would you say it's a pretty common reason for people to come in to see you as a pediatrician?
Absolutely. It's really part of bread and butter pediatrics.
We see it very, very commonly.
I would say a good portion of the number of times when we see kids come in and the complaint is just rash or marks on body or something like that.
It's often it turns out to be atopic dermatitis or a form of atopic dermatitis or a flare up of atopic dermatitis.
So often that's what we're seeing.
So it's like I said, bread and butter pediatrics. This is something that we see very, very commonly.
Well, I like the fact that you use the phrase the form of because in our world eczema is actually from the Greek to boil over.
And it's it's really what we would consider sort of an umbrella term in the sense that it includes very on purpose a number of specific diagnoses.
It's not necessarily referring to a specific subset of diagnoses within that category.
I guess for purposes of shows like this and when you're reading in a textbook, when we use the word "eczema," we're using and usually referring to a specific condition called "atopic dermatitis,"
which absolutely is, as you just pointed out, has to be by definition has to be characterized by itchy skin, inflamed skin.
So red, rough, textured. And it has to very importantly come and go.
And that's really a key factor that most parents is at least when they come to see me, haven't really grasped that, hey, this is not something that is with a silver bullet or on its own going to show up one time and then just never be seen again.
By definition, this is something that's going to come and go.
Even if it was my kids with all the eczema expertise I've got with all the access to topical medicine that I've got.
If my son has eczema, I should expect that it is going to come and go, flare and be there at different times throughout his life.
I think that's something that we try to talk to a lot of the parents about is that it's not going to a look alike in every single kid.
It's not going to show up the same way. It's not going to manifest itself the same way.
But to your point, I kind of identifying as much as possible.
Sometimes we can't, but identifying what causes some of those flares, if at all possible to try to identify what are those flares, minimizing those flares.
And we'll talk about that a lot with the treatment, but seeing what we can do so that even though it's still there and those triggers are going to still occur, what we can do to kind of temporize that and make it happen as few times as possible and really minimize the need for the medication as much as possible.
Yeah, I totally agree. And as far as it relates to our practice in the world of pediatric dermatology, I would say one out of every four, just off the top of my head, maybe one out of five patients that come through our door are coming in for something very specifically related to what we would call "atopic dermatitis/eczema."
And, you know, as a general dermatologist, we see it not just in children. We see it in adults as well. But for kids in this country, we know it can be as prevalent as up to 25% of kids in this country can have atopic dermatitis.
In Japan, other countries, it might even be a little higher than that. In some places it's lower than that. But in the United States, it's around 25%.
And for most of the kids, we happen to see them show up. I would say looking at my panel of patients, it's not uncommon to see a kid under five years of age showing up with the parents' concern for something like eczema.
While a lot of kids do grow out of it, a lot of them don't, or maybe it sort of morphs into something else. Like a lot of times we now know that eczema on the body in a young child might eventually sort of evolve (or devolve, depending on your perspective) to hand eczema in an adult.
And about 25% of patients do develop atopic dermatitis as adults. So it's not an uncommon thing in the world of dermatology for sure.
I would say that, and I'm painting with very broad strokes, it certainly isn't any rule, but a lot of times the younger that we see the kids, the more severely affected they are.
And the parents are sort of very anxiety-ridden and very anxious that there's something wrong. This can't just be regular eczema. What's going on? You know, this is really, we've already tried kind of these basic things.
And in a lot of those kids we do end up kind of moving that evaluation and that treatment up a little bit more aggressively.
But to your point, we also do see a lot of kids who have more aggressive disease, more aggressive flares, more frequent flares when they're younger.
And they do sort of, and you can't see me obviously, but air quote, grow out of it a little bit.
And they do tend to have fewer flares, less consistent flares, and whether or not that's because whatever was causing those flares is just not as active and is not severe,
or because they've really kind of self-identified some of those flares and avoid those things as they get older. In any case, they do sort of grow out of it a little bit.
Well, speaking of painting in broad strokes, paint a picture of when we're talking about eczema as a clinical condition, what are you typically looking at, like visually? What are you seeing on the kid's skin?
So if we're going kind of with our typical toddler approach, these are kids that are coming in and their parents are saying their cheeks are always really red, kind of itchy scaly, and they won't stop itching.
And what we most commonly see is this redness, this very itchy, thick, kind of flaky skin, and it's in the insides of their elbows and behind their knees.
That's the most common place that we're seeing it. And these kids are scratching, scratching, scratching, and the kid is, the skin is very red and it's very irritated.
And no matter what they're trying to do to get the kid to stop scratching, those kids are scratching. You cannot stop them from getting at it.
A lot of times by the time they come to us, sometimes that skin is also infected because kids are dirty little creatures.
We love them, but they are gross, dirty little creatures. And so kids are just unfortunately not known for washing their hands and having spectacular hygiene.
So a lot of times by the time they come to us, there is some element of infection or they've made it a little bit worse accidentally.
And so the goal at that point is to treat either the infection or to just try to kind of calm it down a little bit.
So I think that's kind of our classic patient that comes in.
I don't necessarily want to say boys more than girls because that's also sort of age dependent on when we're seeing them.
I will often say what we tend to classically see is the parents say, oh, all my other kids had this.
I kind of know what it is or I already used my other kid's medication on this or I already tried this particular steroid cream or this over the counter cream.
A lot of times people think that they've already tried a number of things that they thought would be helpful that were not or actually even maybe made it worse.
So a lot of times, again, very typical kids, it's going to be your elbows, it's going to be your knees and it's going to be there's like a strong family history.
So they kind of already had their flares up for it. They're looking for it.
Yeah. And I love when you pointed out the aspect of bacterial infection or sometimes viral infection on the skin.
You can absolutely get what we would refer to as sort of a honey colored, crusting, oozing this scale that can be really thick and cruddy looking on the skin as a sign that it might be infected.
But we can also see that in another condition called allergic contact dermatitis.
Poison ivy will present like that and have absolutely no real bacterial component to it.
So you have to know what you're talking about. I think one key physical exam finding, if you will, in a baby, especially in a child that's in diapers, is that you typically will not see eczema in the diaper area.
It's a moist environment. It's sort of an eczema protected environment, if you will.
If you're seeing rashes in that area, you got to think of some other diagnoses very commonly candidiasis from yeast, psoriasis in a diaper area is very common when it presents in babies, allergic contact again, and then cradle cap on the skin, seborrheic dermatitis.
That also can show up there sometimes. So that's a real clue.
And that's a tricky one for infants because people will often confuse that for younger kids kind of with that redness on the face and on the forehead. A lot of times parents will come in saying, oh, it's eczema, it's eczema, and it's not.
Often that seborrheic kind of dermatitis is really what we're looking at, especially on the forehead, sometimes the cheeks. But they're kind of convinced that it's eczema and it's a little tricky to talk them out of that sometimes.
Oh, sure. And the cheeks specifically, I find more often than being caused by eczema per se or atopic dermatitis per se, especially in a kid who's teething.
There is a real thing called drool dermatitis. It is an irritation from your saliva. I always tell my patients like, look, your lips are designed to get wet and dry out, get wet and dry out.
That's what they do all day. And even they will get chapped sometimes, especially in a winter like here in Pennsylvania. Your cheeks are NOT designed to get wet and dry out, wet and dry out.
And look what this kid's doing in the course of just sitting here for two minutes in front of us, right? The kid's slobbering all over himself.
So either either a cheek could be covered or sometimes you'll see just one. Why is that? Because the kid sleeps on that side and gravity is pulling it that way.
That's an actual irritation. That's not an allergy. That's not true atopic dermatitis. That's saliva acting as an irritation to the cheek.
And that can be usually cured when the kid stops teething, but easily treated or maybe not easily treated, but but effectively treated by preventing the saliva from getting to the skin, usually with a thick layer of sort of like frosting a cake kind of barrier cream or barrier ointment.
But yeah, I totally agree. Parents will come in. Kids got eczema. I'm so worried. Well, actually, just give it give it four more teeth and you're going to be fine.
Four more. It's very precise. Four more is extremely precise. Just four. Don't come back to me until there's four more teeth.
Now in older kids, I don't know if you see also the presentation of atopic dermatitis showing up in older kids or kids who have had this long standing.
They get what sort of this thickening of the skin that we call "lichenification." Yes, very, very commonly. Yeah.
And I would say also one of the things I get most of the families coming in anxious about is the fact that in areas where there was atopic dermatitis, either because it went away on its own out of good luck or they went to the Jersey Shore and the sun acted as a phototherapy agent and kind of reduced the eczema in that area.
Or they effectively treated it with our prescriptions. And now the rash is gone. And now you're what you see in the area where there used to be red rough itchy skin.
There's smooth but sort of pale or even hypo-pigmented on the white side of things. And oh, this, you know, I usually hear from parents. Oh, this must have been the steroid.
This must have been something bad that that we did to the skin. Nope. It's just where the kid had eczema. Now that area, that patch of skin, it just isn't making tan as well. And it can take up to a year for that to come back.
But it can scare you a little bit if you're a family member, a parent who sees that your kid covered in sort of leopard spots, you know, especially if they're darker skinned families.
And they tend to be more bothered by the fact that there are these pale spots on their kids and nobody wants to hear you. Yeah, there's nothing we can really do. It's going to take a year. So people are frustrated with that.
I think the other thing that it's harder for people to kind of understand is that they don't they kind of associate that red kind of irritated look with being more severe when in fact with lichenification is often harder to treat because that skin is just it's done for.
It's not. That's what we said when I worked in Kentucky. It's done for. It's done. It is. It's not. It's harder to treat. It's harder to absorb. It's not readily accepting a lot of the topical medication.
So you have to use higher potency, more strength, more. So it's the lichenfification generally is going to require a little bit more aggressive treatment to even kind of break through to that skin patch.
So I think it but again, it doesn't look as angry. So I think it's a little bit confusing in that aspect. I agree. And when you I guess if you're going to look for a positive of having lichenification, which nobody wants. But if you had that, I do find some comfort in being able to tell the families look.
And we'll talk about treatment towards the second half of this show. But one of the side effects that you do have to watch out for when you're using topical steroids, usually inappropriately and for a longer period of time than you're being prescribed.
But the risk would be that you would thin the skin. Well, little Johnny or little Mary's already starting out with thickened super thick. Yep. Yeah. So this is not really going to be an issue for you.
I will also throw out a lot of times we will see lichenification in the groin area, especially in females. If they if they have had eczema, we'll see lichenification there and the parents will come in really anxious about that and about the the appearance of it.
And the fact that these kids are really kind of scratching at their groin. There's got to be something kind of going on in their privates and their genitals. But it's not an uncommon spot to see that lichenification just from the aggressive kind of scratching.
So don't panic out of proportion. It's OK. We can treat that. Well, you mentioned in darkly pigmented skin that sometimes it'll show up a little differently. But atopic dermatitis. I find it to be I mean, I was fortunate to have trained as a pediatrician in Baltimore where there is a large population of darkly pigmented skin patients.
But it's a tricky thing to walk into a room and sometimes see without the parents actually showing you exactly where they're seeing the redness, the erythema on brown skin or darker brown skin. Sometimes that redness will look just a different shade of brown or even sort of a purple issue.
So you got to look really closely. And a lot of times in darker pigmented skin, eczema will take what's called a follicular pattern. It's a little bit more around where the hair follicles are coming out and you get these more sort of like scattered bumps rather than real big thick plaques.
So that can make it a little confusing. Anybody can get a different kind of pattern called nummular eczema. Yeah, nummular, which is usually tough to treat. Maybe that's a tricky. It's tricky.
The clue is it looks like a coin. It's coin-shaped is what nummular means. So that's different than "annular." Annular in our world, if you mention a scaly red annular rash, you're usually talking about ringworm.
And that annular part refers to the fact that the center of the of the skin lesion is sort of void or downplayed. Nummular doesn't imply that at all. It just means that the shape of the eczema lesion is a round coin-shaped object.
I tend to see nummular in younger kids. I don't know if that's actually a thing or if that's just been my experience, but I tend to see that in more year toddlerish kind of kids.
Yeah, I've been inclined to agree with that. I don't see it in adults for sure as much as I see it in kids. So there's probably some truth to that. When you're looking at a kid with eczema, do you have any physical clues that maybe, geez, this kid almost slam dunk has atopic dermatitis specifically?
So I think a lot of it is in the history. How long it's been there. Did this come about abruptly? Has this kind of come about and worsened? When do you notice that they're kind of itching, scratching? Is it, to your point, kind of coming, going more evanescent? So is it getting worse, getting better, getting worse, getting better? What have you already tried?
So a lot of times they'll say, I tried some over the counter steroid or I tried my cousin's steroid or I tried something else and it got a little better, but then I stopped and now it got worse again. Or, yeah, I tried my hot pink lotion that I got that's peppermint fragranced for Christmas and it got worse or something to that effect.
It might be Pepto-Bismol. It could just be Pepto-Bismol they rubbed on their kid. And that's fine too. I don't judge. But so a lot of it is the history. A lot of it is the family history. You know, when you've got this is your third kid and they all have eczema and the parents have eczema or other histories of being what we call atopic. So kind of just allergic kids in general. So this kid already has two food allergies or the parents have food allergies or things like that. Then you kind of are shoved in that direction, at least initially until you can prove it.
And then I think on the physical exam, it's really that location. So again, they're kind of, I don't want to say like golden highlight spots, but yeah, so you're looking at your antecubital areas, which is the inside of your elbows. You're looking popliteal, so behind your knees. In some kids, older kids, generally you're going to look at the hands. You're going to look at the creasing of the hands. In the winter, that's generally where you're going to find a lot of problems in hands and older kids that can wash their hands. In the winter, you're going to see a lot more on the face. So you're, I'm talking, I'm touching my face. I'm sorry.
That's why Dr. Krakowski is laughing because nobody in the radio world can actually see that. But so I think a lot of it really depends on lining up the history with that clinical exam. I think some of it kind of comes from experience as well. These are generally not bumpy rashes. These are not what we call papular. So these don't look like little blisters. These don't look like little, they're not papular. They're not vesicular. They're not blisters. They are not filled with pus. If they're not infected, generally they're not filled with pus. So these are not, they're not filled with pus.
So generally there's no liquid involved in them. So this is nothing that you can kind of pop. This isn't something that you can generally squeeze. This is, you know, it's red, irritated, kind of flaky skin. A lot of times there's blood at the kids scratching.
A lot of times with kids whose nails aren't necessarily cut short, you can actually see, especially younger kids that just really just aren't able to kind of control themselves and have that discipline. You'll see scratch marks all locally around where those areas are.
You'll see where the area of eczema is, but then you'll also see just these red scratch marks that are super angry looking around those areas. On younger babies that aren't even really mobile, like they really can't sit themselves up and move around, will actually see a lot of times marks on the back from where they kind of fidget and try to actually soothe themselves.
And they'll try to kind of be like moving around and actually fidget on their backs a little bit to cause themselves a little bit of relief. So I don't want to say that it's easy for a general pediatrician to diagnose atopic dermatitis or eczema in any kind of its forms.
But again, it's really bread and butter and there's definitely other things that you need to rule out. But in most forms, it's not a super complicated thing. Once it gets infected, once it's more or the less common forms, once you've got eczema herpeticum, which I think we're going to talk about a little bit later.
So once you've got another virus or a bacteria, once it's more severe, if it's trying to identify kind of the trigger, like once you kind of get into the nitty gritty, it's significantly more complicated. But just that initial, ooh, that kid's got this. That's generally not the challenge. It's everything that comes after that.
Well, you made me think literally yesterday I took care of a teenager who came in in a school uniform. And geez, I noticed two things pretty much immediately when I came in the room. One was she had scratched, I guess before I entered the room, she had scratched so badly on her
lateral thighs that she had actually bled onto our exam table. And her mom was mortified. Oh my goodness. I'm so I'm sorry. I'm listening. Don't worry about that. We can clean that up. But like, maybe we should be working a little bit more aggressively on her eczema. The other thing, same kid.
You know, you wonder how you get infections into your skin when you have a condition like eczema. Well, we looked as part of the physical exam, we looked at her fingernails, I can't even describe they were like Wolverine claws, she had she had them so sharp.
Those are very in style now I just want you to know you're dating yourself. Maybe it's the the movies that are out now but that's that's what came to mind and she you could look under her fingernails and you would see a combination of like dirt and crud and skin cells, I mean she had ripped the skin off of her and so she really needed to do some resetting on her but that is not an uncommon thing.
Most of what you say in terms of bread and butter easy to diagnose 100% is my experience as well, except when there's this sort of overlap phenomenon where geez I've been fooled, saying, I think this is psoriasis or I think this is seborrheic dermatitis, and it turns out to be eczema or any combination there.
Yeah, or vice versa. Sometimes it just there is an inverse psoriasis there is an atypical presentation of whatever so you never are 100% sure but I've got a couple sort of telltale signs that I look for in a kid in a baby diapers we're talking about diaper age kid, many times and again I'm touching my face now, Dr.
Walti but you can't see it but there's sort of like a little triangle in the center of their face, close to where their nasal creases are and sort of around their mouth, where that will be paler and almost spared versus some of the rash that's around the face.
That can be a clue that you're talking about eczema, I think probably the most prevalent clue that I see and actually use it as an educational tool is something called keratosis pilaris, which I'm sure you picked up on yeah thousand something but this is that sort of chicken skin that you get on
most adults will have it on the triceps the back of their arms and but when you're a child you'll typically get it on the cheeks and lateral thighs is not uncommon to have it. Also in the winter associated with keratosis pilaris you'll get what we call sort of like fish like scale or
ichthyosis vulgaris on the shins, real itchy shins and that those two conditions plus you'll get lucky sometimes looking at a kid's hands, you'll just notice that the lines in their hands are more prominent than like yours or mine and okay those those can all be clues that you're
dealing with someone with atopic dermatitis. I think one of the more powerful findings is when I'm trying to convince the family that it is eczema or that this is related to something called atopy which is the combination of eczema, allergic rhinitis or allergies, hay fever and asthma and I say listen,
before I ask any questions about eczema I want to ask does your child rub his or her eyes a lot? Yeah how'd you know that? Well I'm looking at them and they have what are called allergic shiners where you can get sort of these little bags under their eyes, they're too young to have been working into the night so it's not because they've been staying up late on their calculus exam and then if you look closely they usually have a couple extra folds in their eyes as well and those are called Dennie-Morgan lines and that's from the
eyes, that's just from swelling locally around the eyes from rubbing and you can also get lucky sometimes they'll have what's called the "nasal salute." Yep that's my favorite because it's something that's so easily demonstrable to patients. I'm like come here, come here, come here, look at this thing and I can show it, I love stuff like that because I can show it to parents because it's like a trick because I'm like look there's this thing and it's from this and so it's an easy thing to show people and to demonstrate and be like look I promise I actually know what this thing is. They're not, you know, I'm not making things up. Instant credibility. I swear.
Instant credibility. Yes it's like when the strep test is positive before you walk in the room and you walk in looking like a genius. I know what this is. Yes I know. What is your approach when parents ask about you know do I need blood work, do I need biopsies, what are you telling them in the clinics?
So it depends on the initial presentation and how severe it is. Very very kind of run of the mill normal kids that have what presents to me is something that's not infected, not severe, not affecting you know any kind of their activities of life, not holding them back at all.
Well appearing kids no. I usually say this is pretty routine we're going to just start off with some basic education, we're going to start off with some basic treatments.
I do like them to at least keep an eye out and I always say I just need you to be open minded and kind of consider what could be causing some of these flares. So if you notice and especially in younger kids and toddlers that are expanding their palette, if you notice that every time you give your kid
citrus fruits, every time you give your kid you know whatever X, Y, and Z food this is what happens or every time you know your son or daughter is outside and it's cold this is what happens or whatever it is. Just try to you know everybody has iPhones now or smartphones.
Mark a note of it, just open a note, open a file on your phone and just write it down and be like oh this happened today, this happened today, that kind of thing. If you notice that there's a food association or a stress association.
If you notice that a lot of times in girls it's when you get your period things like that.
If they're of that age if they're in puberty. So just try to see if you can notice what some of those flares are and then I usually will start them kind of on just basic education and supportive care and mild treatment.
And if that's not enough to kind of come back. There's no starter blood work that I that I would do unless there were complications later. I will say the patients that I've had that have had the most severe disease unfortunately often will come in after years of not coming in and they kind of come into the office and I'm stunned by how severely they're affected and how they've just kind of accommodated it and I think that's partly because A there's usually a strong family history everybody in their family looks that way acts that way,
has the same problems. There were not several options for treatment up until fairly recently. I want to say maybe the last 10 years there's there's a lot more option available to patients.
So a lot of these people are you know 40 50 60 years old that have suffered their whole lives and so kind of their kids and their kids kids are like okay well there's nothing I can do about it.
So sometimes these kids will present after again not sure you know we saw you four years ago with eczema why didn't you come back and tell me and these poor kids are really severely affected and you know it hurts me to say why didn't you come back why didn't you tell me I could have done something about this.
These kids are troopers man they they look different which is really really hard socially just from the general pediatrician aspect they they often have some kind of mental health trauma as a result of knowing that they look different they're trying to kind of hide it they're trying to accommodate you know being itchy all the time and they really they kind of have settled in and have taken this approach of like well this is just kind of how it is this is this is my skin I don't I don't need anything and where I'm like oh my God yes you do I can.
Do something about this let me help you and like I said it's almost this generational well we've all got this and this is just kind of how it is whereas I think now there are a lot more options available for some of those kids that are really severely I totally agree we're seeing people come out of the woodwork and because you know we have finally something that works and offer and we can offer them some real real change and you can't go six minutes without seeing commercial TV, so now everybody knows.
Well at one point I will make though sometimes I'll have families come in and say well you know I want you to do a biopsy on my son or daughter and because that's because that's what you did or or another dermatologist or specialist did for my friends kid with eczema and I'll explain my approach most of the time we know in kids with atopic dermatitis that in terms of blood work almost all of those kids like up to 80% of those patients are going out
and they're going to have something that we call increased serum Immunoglobulin E levels - IgE for short - serum IgE levels and they'll often have an eosinophilia portion of their sort of the blood panel that's revved up with an associate with allergies so finding that or looking for it more importantly I guess as goes for this discussion is not helping me right so I'm really part of my job as a pediatric dermatologist is to try to not hurt your kid any more than we have to sort of be invasive right.
And if I can avoid a blood work stick or something like that then then that's my job so proving that something's high when I already know it is high is going to be of little interest to me and it often can be a little contentious with the family because I'm telling them that this is not something that I need to do or want to do and they're asking me to do it.
Sometimes we'll see IgE get tested there's a condition called hyper-IgE syndrome now just as an interesting tangent here you would think in a condition where the name of it is called "hyper" or increased or more IgE that the levels of your serum Immunoglobulin E levels would be so high that nothing would compete with them many times many times - and this is a little clinical pearl that my mentor, Larry Eichenfield, out in San Diego taught me - many times with a severe atopic dermatitis
patient their IgE levels are actually higher than the kid with hyper-IgE syndrome. So again it just frames how little that really can help you in terms of helping make that specific diagnosis and I think to kind of go along with that often those same kids also have severe kind of allergic rhinitis and their noses are running and they have that kind of persistent cough and post nasal drip and they want testing for that as well.
And we kind of have to talk them off the ledge as well about testing for specific allergens and triggers because again it's not going to change my approach. If you're allergic to a tree you're not going to avoid the tree if you know this is going to come back and tell me you're allergic to dust and six types of grass.
You're not going to do anything differently about your life. There's absolutely no difference in the treatment that we're going to give you so there's no added value to me at this point in our evaluation I'm going to put you on the same medication we're going to advise the exact same thing.
And this falls in line is often the same patients to be honest. There's nothing different that we're going to do. So let's start this first phase of medication let's start this first phase of treatment and then should that not be successful we can kind of dig a little bit deeper.
But me telling you that your child is allergic to dust and oak trees is probably not going to help you avoid oak trees any more than you may already do it.
Well I don't know if you're specifically referring to something that's called IgE RAST testing, which is blood work that that is the bane of my existence because yeah I met all of it.
So for our allergy friends, right, when they do skin prick testing it's very helpful. I mean that part yes. But allergists - good allergists - will tell you that IgE blood - IgE RAST testing - in the setting of a kid with known eczema is somewhat useless.
I mean and especially, there's a guy out at Children's Hospital Philadelphia Dr. Spergel who's built part of his career around this very topic. I've heard him lecture about it and he very - I think eloquently - sums it up and I'm paraphrasing here but here's the concept right.
So if you know you have a condition like atopic dermatitis where in that condition the total serum Immunoglobulin E levels are going to be high, the blood IgE levels are going to be high - so testing for any sub-component - tree dog cat dust mite...
You're going to probably get a high level back because the whole bucket is high to begin with. Those individual things...you're not necessarily allergic to your. Your best friend - your dog - right? You don't have to get rid of the puppy.
Geez, no that's not the point. In fact the only thing that I used IgE RAST testing for because many times the patients will come in with the the tome that's been printed out for them is where those tests say you are "zero" - where you are not allergic to your dog; you're not allergic to peanuts; you're not...
you could be pretty confident that you are not allergic to those things. So in that sense it's very helpful because sometimes we get asked about, "Hey is it the dog or is it the cat?" Just as a side note, there's been, there was at least one good study where dogs seem to be
protective against atopic dermatitis. Cats - maybe a little bit more associated with eczema. So if you're a cat lover out there I apologize but.
Oh my you can't say that on a pod. Well I'm a dog person too but I also I also actually I actually say that to my patients is unless you're willing like if I'm going to order this test and you're going to get rid of your dog or cat like are you going to get rid of your dog or cat if this comes back positive and they're like oh my gosh no and I said well then I'm not ordering it because what are you going to do with the results of it like that's just silly.
Some other tests that I always get asked about at some point is the value of a skin biopsy. We do do skin biopsies on some patients when as we referred to earlier there's a concern for hey do I actually have the right diagnosis or there's just an atypical presentation but certainly we do not do skin biopsies on most kids with eczema that would be cruel and unusual.
So you might see us do a little what we call a fungal scraping where we'll where we'll scrape you with with the side of a glass slide or something else and capture a little bit of the scale and then look under the microscope to see if there's fungus there that that kind of differentiates ringworm from from eczema.
So that's what we call a fungal scraping where we look at the body as a whole and then I would say not uncommonly I do refer patients out especially when they show up with an eczema that is what we call "bilateral and symmetric" meaning it's on the exact same part of the body on both sides of the body.
To the outside of the body like that not much those rashes when there's something on both sides of the body equally cut off at the exact same spot that's usually what we call an "outside job" that's usually associated with something like an allergy.
So we do do something called skin patch testing - allergy skin patch testing - where you wear these little panels on your back. You put them on usually on a Monday. You get them taken off on a Wednesday, and then they read the results on a Friday, and can be very helpful for telling you hey your skin does show an allergy to X, Y, and Z.
But that's not everybody. And then finally like very super rarely, we will send some patients for genetic testing. That's where I was going to go with the biopsy. Yeah, there is some value like there's a pretty serious
condition, a genetic syndrome called Netherton syndrome. That's okay that's not where I was going to go. Okay, well, it's out there. I mean, it's, I believe you.
I have to Google it. Don't, don't tell anybody. Well, it's unfortunately is one of a few that that do exist. I mean, these are super super rare but if the point here is is if everything is not responding like you would expect with atopic dermatitis, but it looks like that
okay then you have to think about these sort of "zebras," zebras being a medical term where we say it's like, if you hear hoofbeats, it's usually a horse in Pennsylvania, but hey sometimes it could be a zebra. So think about that, right, the rare thing.
Why is it just a horse in Pennsylvania. And that's not, that's not just Pennsylvania. That's everywhere.
Tennessee, more horses there I would say. There's still horse. Oh my gracious. I, other than Netherton which I'm going to fully and wholly agree with, I think it's a very rare thing.
I fully and wholeheartedly admit that I don't know what that is and I'm board certified, but still don't know what that is.
We will sometimes send you to genetics for who often will do the biopsy for you so it kind of just depends on who we can get you in sooner genetics will sometimes do a skin biopsy or punch biopsy, Derm can do it.
A lot of times it just depends on scheduling at that point because we want to get the results back.
If we are not 100% convinced that it is eczema and we are seeing other issues with your child, especially in infancy so we are concerned about immunodeficiencies we are concerned about anemia as we are concerned about anything that could be kind of causing those issues.
In addition to skin findings and maybe we've chalked it up to eczema but now we're not so convinced because we're seeing other things that are going wrong.
In those cases we will often send you to genetics or to Derm to potentially get a biopsy but again it's I think I've maybe done that a handful of times in my career so it's not common to Dr. Krakowski's point.
It is certainly not common so it's not something to worry about at all.
Great. Well that's a good segue into what are some of the perceived or known at this point causes of atopic dermatitis. This has been a moving target since I got into medicine let alone dermatology.
It used to be that this was entirely an immune system problem then that shifted to what we call the barrier, the skin barrier was where it's at.
That was the bee's knees for many many years and now it's I think kind of settled more into where at least it makes sense for me that this is a truly a multifactorial many problems coming together sort of condition where you have an element of skin barrier dysfunction.
You've got an element of dysregulated immune system in the skin. You've got the environmental allergy triggers that are driving some of this and I use the analogy of a "seesaw" - a "teeter-totter,"
where things from inside the body are teeter totter. See if you like it. If you like it you can keep it. It's the inside the body stuff being married and reconciling with the outside the body stuff and you're going back and forth different directions.
Does that work? Does that work for you? I like the teeter totter. I was still kind of caught up with the bee's knees but now I'm up to the teeter totter.
Well the bee's knees was a different episode. That's why I threw you for a loop. We did stings.
But I agree. I think again when I trained it was something different and then everything was blamed on food. To your point, yes, everything is really kind of changed. I can't overstate enough though that family history for us is a huge driver.
I can't tell you how often I've repeated like this isn't something you're doing. This isn't something you are not doing. You are doing the right things. It is okay.
You are handling this appropriately. You are following the advice. You are doing everything correctly. This is going to be a thing. This is just a thing and I am sorry that this is your thing.
But this is a better thing than other things and we can manage this thing and it will come and go. But this isn't your fault. This is just something that's kind of in those genes and this is just something that unfortunately just like all the good things that get passed down, this is something that is in there.
And we have more tools to control it but it is there. Well you hit the nail on the head, right? So why is family history so important? It's because we know there are things like mutations in what's known as the filaggrin gene or filaggrin depending on where you're from.
That is a mutation that is passed. It's associated with the keratosis pilaris that we discussed earlier, the hyperlinear palms, the ichthyosis vulgaris, the scaly shins.
And this is not a cause of eczema per se directly but we know that because of how that mutation in that filaggrin gene works that the skin barrier, the stratum corneum which is your first line of defense against the outside environment, that is impaired more in a condition where you have defective filaggrin or filaggrin.
That now your stratum corneum, that outer layer skin, you're losing water more easily to the outside environment. You've got stuff more easily coming in: bacteria, viruses, allergens. That's going to further screw up the barrier.
It drives pro-inflammatory cytokines that are now forcing the immune system into the area and driving a whole cascade of more and more inflammation. So that-
That's two things I have to Google now. Two things. I'm making a list.
filaggrin?
Well I don't know. I mean I've heard of it but now I have to look up all these things.
Oh no. So I hope I'm getting it right but Dr. Alan Irvine out in Ireland, pediatric dermatologist out there, he was I think the first gentleman to characterize it, Found it in an Irish population. Doesn't mean it's specific to Irish patients.
I've got this mutation myself and now we know that each little ethnic enclave has their own sort of variation of the mutation. And it's kind of worked out genetically if one, if both parents have the mutation, then every child that they have together will also have the mutation.
So everybody will have keratosis pilaris. If only one parent has it, then each child has a 50-50 chance. It's autosomal dominant. So it's very powerful. Now it doesn't mean you will have eczema. Plenty of people have keratosis pilaris and don't develop eczema.
But having it is certainly a risk factor. And that's the family component.
I know. I'm learning so much. This is good. This is like I should get CME first. I should get continuing medical education for spending time.
I don't think we could afford to get that certified for CME. But okay, something to think about down the line.
Now, immune dysregulation, where I trained in dermatology was out at University of California San Diego. Our chair out there, Richard Gallo, is a very famous dermatological researcher, very much focused on what was called the innate immunity.
The immune system that lives resides permanently, always on, always working in your skin. Specifically, he was looking at antimicrobial peptides and their role in atopic dermatitis as well as psoriasis and rosacea.
We know that both the innate immune system, what's built into your skin, as well as the part of our immune system that sort of learns from previous encounters, right?
That's the adaptive immune system. Both of them are also involved in what is known as Type 2 inflammation, which is the kind of inflammation that drives atopic dermatitis and is involved with that sort of dysregulated immune system.
But when that is awry, when that's not working correctly, we know many of the specific cytokines now, thankfully, like you said, in the last 10 years, this has kind of really come to light.
IL-4, IL-13, IL-31, IL-22, that can actually drive further disruption of the barrier. So this is all intertwined. You can't really just look at it as one thing without considering the other.
And I think it's, again, I think the point needs to be made that it's not necessarily the same for every patient. So some kids are going to be more driven by one.
Some kids are going to be more driven by another. So it really is that mix and trying to find whatever treatment is going to work for that child in that moment or adult.
Absolutely. I will say my medical assistants and residents who work with me know that I am probably responsible for single-handedly depleting the bacterial swab population in the United States.
It's been you. It's your fault.
It is literally. I apologize. I'm sure that's not good for the environment. But when I walk into a room of a kid with eczema and I see pink all over, their eczema might not even be that bad.
Again, the rough red itchy parts of their skin, but they're just pink all over or they have a fine scale. I know that that is Staph bacteria or strep very unlike, but one of those two almost always.
And I will do a skin swab, simple bacterial culture. You pop it in for we send it for what's called wound culture and gram stain. But bacterial swab is basically is.
We will almost always in those cases find the presence of Staph aureus and sometimes MRSA (methicillin resistant staph aureus) on that kid's skin.
And we know if I take Staph aureus and put it on your healthy skin, Dr. Walty, where you don't have eczema, if I put enough of it on there for a long enough time, I can almost guaranteed elicit a response that looks like eczema in that area.
It's driving part of that response. The other crazy. Please don't. I won't. I like you. I would never do that to you. Thank you. Plus we do not have IRB approval for that study.
No, no. And I would challenge you to find it. So there you go. But the flip side of that is we're supposed to have normal bacteria, normal in quotes, the air quotes that we can't see, but you can feel.
So normal bacteria is supposed to be on our skin, and it's probably there to protect us from the Staph and Strep, the pathogenic bacteria, from getting on and taking a hold.
And when you're missing those normal bacteria, now Staph has a better chance of getting on there, taking over and running wild. So it's just an amazing thing how everything kind of works together.
It's the teeter -totter. It's the teeter-totter. Teeter-totter. But no, 100%. I will tell you, I definitely do less cultures than I think you do.
The only time I really will end up probably by an exponential amount. The only time I really will do the cultures is if I do think that there's a super infection that I need to treat and that's really more to guide treatment.
Although honestly, even now, I do it rarely because it's not often going to change my treatment. I will do some fungal scrapes, like you mentioned earlier.
So I will sometimes do that, especially with the numular eczema, if I'm just not sure 100%. But I definitely don't do the cultures as much as I maybe should, or I just don't think it changes my treatment as much.
Whereas I think for you, it probably guides a little bit more of the treatment.
Well, yes, I find it to be very helpful. And I'm very aggressive with treating that as well. When I get Staph aureus back, unless it's just "in the broth."
But if there's true Staph aureus growing on a kid's skin, and I do now one of two things. I will tend to treat it aggressively, but I also sort of expand my physical exam.
Now I will have the families bring back some of the products that the kids are using. What I have found...
Contamination.
Exactly. We actually did that study here at St. Luke's. We sampled, it was a pilot study, but we sampled directly the most used products, skincare products, and that includes prescription medications, on the 20 or so patients with pediatric atopic dermatitis.
And what we found was an alarming amount of bacteria were growing in those products. And strangely...
In-in?
What's that?
How in? Like on the surface of? Or in?
We did our swabs from the inside of the containers and sometimes from the product itself. Then what was unique in that study, we actually looked also at the nares colonization of the patients, that's the nostrils, and compared those two culture results back to the bacteria that was found to be growing on the skin of these children.
And surprisingly, we found a definite correlation between both the nares and the skin, but also the skincare products and the skin. We actually just a couple days ago, in order to improve the power, in order to find out if this is a real thing, we actually reactivated the study.
So we'll be revisiting that and trying to get a bunch more patients through the door to see if that's a real thing or not. I definitely do consider that a possibility that, hey, this patient's using...
Yeah.
...recolonizing themselves over and over.
Well, sure. I mean, one of the other things we learned in that brief little pilot study was people will...we refer to it as a sunken cost bias. If I'm buying 60, 70, 80 dollars worth of skincare products, I'm going to use those products until they're gone. Not necessarily until the expiration date hits, right?
So we were somewhat surprised, but somewhat not surprised, that a lot of the products that were contaminated were after their expiration date. What that means, we don't really know, but geez, it probably is a thing. So we're looking into that.
I have more questions for you about that. I also need to go clean out my closet at home now that I'm scared, but I'll ask you another time. That's okay.
Fair enough.
I'm so fascinated now. I really am anxious about my own products. So now I'm completely distracted. So there you go. Good job. Well done, teeter-totter.
I appreciate that. That's the skin effect, I guess.
Yes, very much so.
I'd like to thank Dr. Walty for coming back and talking to us today about the first part of atopic dermatitis. We went over a little bit of the reasons you might have it, some of the risk factors for why you might have it, the way it shows up in kids. We haven't really delved into treatment yet, and we'll do that on our next show coming right up.
Thanks for tuning in to this episode of the Don't Be Rash Pediatric Dermatology Podcast. I'm your host, Dr. Andrew Krakowski.
Don't forget to subscribe to our show on your favorite podcast platform and check out DontBeRash.org for more information. A special thank you to our nonprofit sponsor, the St. Luke's University Health Network, for making this episode possible. Until next time, remember: Keep calm and Don't Be Rash!