WEBVTT

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Welcome to the Don't Be Rash Pediatric Dermatology

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Podcast, the owner's manual for your kid's skin.

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I'm your host, Dr. K, board-certified pediatric

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dermatologist and father of two boys. I'm here

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to chat with you to promote dermatological education

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and improve skin health in our children everywhere.

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Let's get started. Welcome to Don't Be Rash,

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the pediatric dermatology show, coming to you

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from beautiful, historic Bethlehem, Pennsylvania.

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I'm your host and board-certified pediatric

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dermatologist, Dr. Andrew Krakowski. On today's

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show, we're going to continue to scratch the

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surface of eczema. In Part One, we discussed

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the clinical look and feel of atopic dermatitis,

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eczema, and explored some of the underlying reasons

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why your child might be prone to developing it.

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Today, we're going to devote our energies to discussing

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the science-based approach to management and

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treatment of this chronic condition.

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Joining me again as co-host is our very special

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guest, Dr. Alicia Walty, Chief Medical Officer

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for Star Community Health. Welcome back, Dr.

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Walty. Thanks for joining today. Anytime. I'm

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happy to be here. Since we last spoke, how many

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eczema patients have you seen since we did part

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one of the show? Definitely a handful. I will

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say that. It's not just one or two, so probably

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a few. I've done quite a few med refills since

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then. Thank you. Yeah, I think it's been on my

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radar as well. Man, I'm feeling like maybe every

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three or four kids coming into clinic with this

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dry weather has eczema or we discover it on him

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or her. So pretty relevant to the times. Absolutely.

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Yeah. And definitely in some babies too. Everything

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we talked about is definitely timely. Well, I

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guess we'll jump right in. Usually for the first

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thing that I'm doing when I'm thinking about

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developing a management plan around a chronic

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condition like eczema, and what do I mean by

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that? The definition, just to remind everyone,

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to have eczema, you have to have an itchy rash

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that comes and goes. And that means even someone

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like Dr. Walty or someone like myself with all

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of the resources that we have as physicians,

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all of the prescriptions and access to great

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medicines that we've got, even our own children,

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if they had eczema, if they have a diagnosis

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of eczema, we would expect that the rash is going

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to come and go. There's nothing that we can do

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about it in the sense that you can't cure it.

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There's no magic bullet. What I try to instill

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in my patients is that there's two equally important

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goals when you're managing eczema. The first

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is when you have a flare. And just to remind

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everyone what a flare is, that's when you have

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red, rough, itchy skin. You want to decrease

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the amount of time, days, hours, whatever you

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want to use as your time period. But let's say

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days. You want to decrease the number of days

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that a flare is present on the child. Equally

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just as important is the second goal of... managing

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eczema which is increasing the days between a

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flare. Now again you can't cure it but you can

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with really good skin hygiene, great moisturizer

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use, proper cleanser selection and all the other

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stuff we'll talk about as well as prescriptions.

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you can increase those days in between the flares

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such that you might get a flare only seasonally

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or once or twice a couple times a year. You know,

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that's kind of what my goal is. Do you have different

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goals when you approach this with your families?

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No, that's really exactly what I tell them is

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that it is probably going to come back based

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on age. They are going to definitely see the

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flares. We talked in the last episode about trying

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to identify what some of those triggers could

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be for those flares, which sometimes we can find,

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sometimes we can't. But I try to really, again,

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say, almost exactly the same thing you do. Fewer

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days on medication, the better. The most that

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we can manage with just kind of over -the -counter

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products, moisturizers, creams, things like that,

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and make the baby or make the child less itchy,

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less uncomfortable. We kind of look at days that

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they'd have to leave school, days that they are

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complaining of being itchy, days that they'd

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need other medication just for itching or scratching

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or things like that. And then as they get older,

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goals kind of switch a little bit to more social

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goals. So are they comfortable with how they're

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looking? Are they not being uncomfortable going

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out or wearing... and clothes, things like that.

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Yeah, and for me, I mean, I get a... sort of

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a pulse check. As soon as I walk in the room,

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I can many times just tell what I'm dealing with

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in terms of the severity, clinical severity of

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these patients. But I think you tapped on a really

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just as important point, the psychosocial impact,

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not only on the patient, but also on the family,

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the people who are taking care of the patient

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directly or indirectly, right? So you can see

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what it's doing to school performance, or at

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least you can hear it if you ask, if you take

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the time to ask. But then really where you're

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like, When you're doing eczema really well on

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an expert level and you're part of a specialty

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clinic, you start diving in and getting past

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the. should I say embarrassment of asking the

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mom or dad or both, if they happen to be there,

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how, how is eczema as a condition impacting your

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life? And you hear, geez, you know, I can't,

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I'm not getting a good night's sleep. Maybe it's

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that my, my child needs to co -sleep with me

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in bed and they're scratching. So now I'm up

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all night and that's messing me up. I'm, I'm

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at, I'm up for a promotion, but geez, it's, I

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don't think it's going to go well because I'm,

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I look like I haven't slept in 40 hours cause

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I haven't, you know, or. You hear from a family

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that a mom and dad or whomever, hey, this is

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affecting marital relations. Who has time for

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anything when the lights turn off? We're trying

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our hardest to deal with what we've got in front

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of us, and it's already draining all of the energy

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that we've got. So it's kind of a real flog in

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terms of how it hits home. But I start with clinical

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severity, and I kind of just... instinctively

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use, in my mind, the easy grade of, is the kid

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clear or does he or she have mild, moderate,

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or severe eczema? And that kind of frames what

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we're talking about in terms of how I approach

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it. Any differences from your end? Nope, exactly

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the same. Same thing. And then again, really

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taking into consideration the age of the patient.

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So there's a few different branches that you

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could take if it's a baby versus an older child.

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Is the patient going to be applying the medicine

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or is a parent applying the medicine? And then

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obviously payer. Some of these medications can

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be expensive. So that kind of always plays in

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the back of our mind. What can we do without

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kind of breaching that arena first? What can

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we try before hitting that if it's possible?

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Sometimes it's not. Sometimes that's just not

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something that's going to be feasible. But yeah,

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those are exactly the same things that kind of...

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of run into our mind. Yeah, financial costs are

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certainly a burden also to consider in this condition.

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But for me, a lot of times, and I guess I should

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say for the audience's sake, we're mostly going

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to be talking about mild to moderate eczema today.

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You could devote an entire four shows to moderate

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to severe and severe eczema and all the medications

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that exist for that and sort of the intricacies

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of managing those conditions. But do know that

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everything we say today for mild to moderate,

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atopic dermatitis would apply to your moderate

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and severe patients as well. One of the things

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that I've really tried to stress to the people

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that I train in clinic to become the next generation

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dermatologist is to look for pink. That's the

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redness, the erythema that is a part of a flare,

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atopic dermatitis, but then it's that special

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red that tells me, geez, this kid might be colonized

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by bacteria. There might be some Staph aureus

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or strep bacteria that has gotten into the sort

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of nooks and crannies of this child's eczematous

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skin and has taken hold. And now I know that

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if I don't treat that colonization of the bacteria

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on the skin, that that can lead to a true infection

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like impetigo or even worse like cellulitis.

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And I'm also looking for that dreaded, I think

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you mentioned it in the last show, that dreaded

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eczema herpeticum. The virus, herpes virus that

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gets into the skin, spreads like wildfire across

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open flaring eczema and has a morbidity associated

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with it. I mean, let's not pull any punches here.

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People have died from overwhelming infections

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from those conditions. Yeah, we've definitely

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seen kids hospitalized for secondary problems

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due to their eczema. And it's sad because most

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of the time. It is preventable. I don't want

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to go out and say that the parents were aware

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of that. I think, again, most of the time people

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are not aware of the different treatments that

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are available to them. But we've definitely had

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some hospitalizations over the years. I've been

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lucky. I haven't seen anything super serious.

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You know, these kids are admitted. They are missing

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school. They do have IVs. They do have treatments.

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They do have significant secondary markings and

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scarring and things like that. And a lot of that

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really is preventable. So it's something that

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we can work on. bacterial swabs and HSV cultures

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on these kids? Or is that something that you

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kind of let us do? Or what's your approach? I

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do now since our last podcast. Oh, really? Since

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you schooled me on it. I would say that I usually

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have not, unless I really suspect that there's

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something a little bit different going on. Typically,

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the antibiotics that most general pediatricians

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would use for a co-infection kind of cover.

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fairly well, your Staph bacteria and your Strep

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bacteria. So most of those antibiotics that we

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would use do cover those more common bacteria.

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If we think it's not working or if we think there

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could be resistance, obviously MRSA (methicillin-resistant Staph aureus), which is

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a bacteria that is a bit more resistant to some

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of those antibiotics, then we would use a different

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antibiotic. Some of us actually tend to go to

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the standard medication used for MRSA anyway.

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So some of us use those medications kind of more

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routinely. The culture isn't necessarily getting

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us a whole lot of frontline treatment. Some of

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us will only use the culture if we've noticed

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that what we've tried and prescribed isn't working

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necessarily. I will say for eczema herpeticum,

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I send out those HSV (Herpes Simplex Virus) cultures or a PCR, depending

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on what the preferred lab is, wherever you're

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working. I definitely send those because I don't

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want to either A, miss that and overlook it,

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especially if it's on the face, because there's

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some additional risks, or genitals. And I generally

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tend to do that as well, just to make sure that

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I'm not missing a bacterial infection that could...

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could present more in a bullous faction, like kind

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of with those blisters. And I'm thinking it's

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eczema herpeticum, but maybe it's not. Maybe

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it's like a Staph aureus, something like that.

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Just to kind of validate myself, I will order

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those cultures. No, and I think that's quite

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prudent. It's usually hard to miss a kid with

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eczema herpeticum. Again, that's herpes-super

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infected eczema, because these kids don't look

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healthy. They look sick. They look unwell. They

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tend to have fevers. They tend to have swollen

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lymph nodes. I think it's very helpful when you

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stop and look at the rash that is associated

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with eczema herpeticum, you can get a lot of

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information just from that. If you remember those

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old school hole punchers that you used to hold

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by hand, not the three ring binder punchers,

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but the single use little kind of looks like

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a stapler, but it's got a puncher. If you can

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imagine you were holding one of those in your

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hand and you were clicking the skin and punching

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out little holes, that's exactly what uh herpeticum

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looks like and it's got this distinctive look

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we call it "monomorphic erosions" right so that

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they all look the same and they're all little

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erosions that's a real clue that you're dealing

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with herpeticum and now this is super uncommon

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in normal kids. It's not uncommon in eczema patients,

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but most eczema patients don't get eczema herpeticum

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just for the audience's sake here. But when they

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have it, you have to treat it and you have to

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treat it seriously. And that does usually lead

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to at least a 10 -day course of either a medicine

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called acyclovir or valcyclovir. And usually

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when I'm worried that someone has eczema herpeticum,

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I'm also, to your point, treating on top for

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staph or strep super infection, because that's

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not uncommon. Even if you came into the office

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without having staph, or strep. Eventually, when

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you have eczema or pedicum, that bacteria can

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get in there as well. So you might as well cover

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for both. And that's a real bummer when the kid

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gets that. But also, to your point, the importance

00:12:11.789 --> 00:12:15.610
of doing a PCR or viral culture to specifically

00:12:15.610 --> 00:12:17.809
figure out the culprit. There's another entity,

00:12:17.909 --> 00:12:20.629
which we didn't mention, called eczema coxacium,

00:12:20.789 --> 00:12:23.350
which is actually hand -foot -mouth virus, very

00:12:23.350 --> 00:12:26.559
common in kids. but can do exactly the same thing

00:12:26.559 --> 00:12:28.879
as the herpes virus on top of eczema skin. It

00:12:28.879 --> 00:12:31.799
can get in there and spread like wildfire. Totally

00:12:31.799 --> 00:12:35.919
not herpes virus, and usually just something

00:12:35.919 --> 00:12:38.700
that the kid kind of gets through to the other

00:12:38.700 --> 00:12:41.799
side and is fine with. But differentiating those

00:12:41.799 --> 00:12:45.139
sometimes does make a difference. But to your

00:12:45.139 --> 00:12:47.139
point, if you're considering eczema herpeticum,

00:12:47.220 --> 00:12:49.620
usually you would cover for the herpes virus

00:12:49.620 --> 00:12:53.309
anyway, and then you're kind of safe. We're not

00:12:53.309 --> 00:12:56.190
really talking about those patients in general

00:12:56.190 --> 00:12:59.909
today. But for most kids, where do you start

00:12:59.909 --> 00:13:03.090
in terms of your approach to managing eczema?

00:13:03.149 --> 00:13:05.750
What's important to you? So just definitely...

00:13:06.250 --> 00:13:08.169
daily care so the things that they're going to

00:13:08.169 --> 00:13:10.590
need to do regardless of if there's flares if

00:13:10.590 --> 00:13:12.110
there aren't flares if they're well if they're

00:13:12.110 --> 00:13:14.789
sick kind of the vitamins for of their skin so

00:13:14.789 --> 00:13:16.870
what are they using for moisturizer how often

00:13:16.870 --> 00:13:18.970
are they bathing or showering how quickly are

00:13:18.970 --> 00:13:21.529
they putting the moisturizer on after that what

00:13:21.529 --> 00:13:23.730
kind of things are they using to wash their clothes

00:13:23.730 --> 00:13:27.090
and the bed sheets so the really daily skin exposures

00:13:27.090 --> 00:13:29.370
that they're seeing what can we do to kind of

00:13:29.370 --> 00:13:31.590
toughen up the skin a little bit make sure that

00:13:31.590 --> 00:13:34.549
the skin is healthy is not having any kind of

00:13:34.549 --> 00:13:36.820
extra exposures to any triggers, really kind

00:13:36.820 --> 00:13:39.139
of get the skin as primed and ready as we can

00:13:39.139 --> 00:13:41.620
to be healthy. So almost more preventive measures

00:13:41.620 --> 00:13:43.620
than it really is treatment. And I think that's

00:13:43.620 --> 00:13:45.460
really key for the parents to understand is even

00:13:45.460 --> 00:13:47.820
when those flares go away, you have to keep this

00:13:47.820 --> 00:13:50.019
up. This is every day. This is you've still got

00:13:50.019 --> 00:13:52.720
to grease up that baby every single day. Otherwise

00:13:52.720 --> 00:13:54.440
you're going to fall back into that pattern again.

00:13:54.480 --> 00:13:56.879
So I think even just looking at that preventative.

00:13:57.419 --> 00:13:59.120
approach is something that we tend to really

00:13:59.120 --> 00:14:01.440
harp on as pediatricians. Yeah, I think what

00:14:01.440 --> 00:14:04.419
I'm hearing from you is, first off, that's not

00:14:04.419 --> 00:14:06.320
a short visit, right? I mean, to have all that

00:14:06.320 --> 00:14:08.980
explained correctly, this is a 20 to 30 minute

00:14:08.980 --> 00:14:11.840
discussion, if you're lucky, sometimes longer

00:14:11.840 --> 00:14:13.399
than that with all the questions that people

00:14:13.399 --> 00:14:16.879
rightfully have. But for me, it's "education is

00:14:16.879 --> 00:14:18.899
an intervention!" - right? So that's something I

00:14:18.899 --> 00:14:22.059
try to stress in practice, whenever I'm talking

00:14:22.059 --> 00:14:26.019
about eczema, education as itself is an intervention.

00:14:26.700 --> 00:14:30.000
And it starts with getting correct resources,

00:14:30.200 --> 00:14:34.120
trusted resources from trusted people. I personally,

00:14:34.240 --> 00:14:36.039
I love it when I have a well-informed patient

00:14:36.039 --> 00:14:40.139
who comes in who's pushing me to better explain.

00:14:40.809 --> 00:14:43.129
True science, you know, instead of the person

00:14:43.129 --> 00:14:45.210
who watched a TikTok video and says, geez, you

00:14:45.210 --> 00:14:47.509
know, now I know that I know everything that

00:14:47.509 --> 00:14:49.289
you do about eczema. And you're like, oh, okay,

00:14:49.350 --> 00:14:52.529
well, that's great to know. Beef tallow is the

00:14:52.529 --> 00:14:54.950
bane of my existence right now. I'm hearing about

00:14:54.950 --> 00:14:57.129
this everywhere I look. That's disgusting. And

00:14:57.129 --> 00:15:00.730
then, you know, to have 20 to 30 minutes is really

00:15:00.730 --> 00:15:04.070
hard to do. Sometimes you have to bring the patient

00:15:04.070 --> 00:15:06.769
back in just to make sure that, A, they got the

00:15:06.769 --> 00:15:09.580
message. from the first meeting, and then B,

00:15:09.840 --> 00:15:12.120
that they don't have follow-up questions that

00:15:12.120 --> 00:15:15.639
you need to really go through with them. So that

00:15:15.639 --> 00:15:18.799
to me is where I kind of start. And I like what

00:15:18.799 --> 00:15:22.019
you said, prevention is really what you're focusing

00:15:22.019 --> 00:15:24.320
on, but you're trying to give them the resources

00:15:24.320 --> 00:15:26.860
for when they have an acute flare in the short

00:15:26.860 --> 00:15:28.679
term, what to do. So I don't know about you,

00:15:28.720 --> 00:15:31.100
but I get asked a ton of questions about food

00:15:31.100 --> 00:15:34.379
allergens. Do you have any sort of go-to spiel

00:15:34.379 --> 00:15:37.230
about? the role these food allergens may or may

00:15:37.230 --> 00:15:40.429
not play. Only in very young babies where I'm

00:15:40.429 --> 00:15:42.649
seeing more severe eczema and I'm seeing other

00:15:42.649 --> 00:15:45.850
signs as well of food allergies. So babies that

00:15:45.850 --> 00:15:47.909
are having milk protein allergy signs, so blood

00:15:47.909 --> 00:15:49.990
in the stools, not growing as well as they should,

00:15:50.009 --> 00:15:52.730
very fussy, colicky babies that in addition to

00:15:52.730 --> 00:15:54.450
the fussiness and the colicky look like they're

00:15:54.450 --> 00:15:57.250
having additional severe problems with eczema,

00:15:57.269 --> 00:16:00.710
things like that. As they get older, I don't

00:16:00.710 --> 00:16:03.669
tend to see that. But we do, obviously, if we

00:16:03.669 --> 00:16:05.710
suspect that that's a part of it, we'll evaluate

00:16:05.710 --> 00:16:08.250
for them. We'll refer out for further evaluation.

00:16:08.409 --> 00:16:11.929
But it doesn't tend to change the treatment.

00:16:12.070 --> 00:16:15.389
If you're still having a fairly infrequent breakout,

00:16:15.649 --> 00:16:17.429
it doesn't tend to change the treatment for that.

00:16:17.529 --> 00:16:19.370
Those are for the kids that are more moderate

00:16:19.370 --> 00:16:21.830
to severe. We're not able to get them medication

00:16:21.830 --> 00:16:23.789
-free. We're not able to get them to a point

00:16:23.789 --> 00:16:25.429
that they're not flaring. They're kind of constantly.

00:16:26.399 --> 00:16:29.539
having these more severe outbreaks, that's definitely

00:16:29.539 --> 00:16:31.580
something we look at to see because there's constant

00:16:31.580 --> 00:16:33.820
exposure to it. If we're having periods of being

00:16:33.820 --> 00:16:35.720
clear in between, that tends not to be something

00:16:35.720 --> 00:16:39.519
that rises. Yeah, I totally agree. For me, both

00:16:39.519 --> 00:16:42.539
through 20 years of doing this, as well as the

00:16:42.539 --> 00:16:44.820
way I was trained, some really good people within

00:16:44.820 --> 00:16:47.159
the world of atopic dermatitis, as well as allergies

00:16:47.159 --> 00:16:50.399
and asthma and gastroenteritis and eosinophilic

00:16:50.399 --> 00:16:53.740
esophagitis, the concept that food allergens

00:16:53.740 --> 00:16:56.679
would would be the primary cause. It certainly

00:16:56.679 --> 00:16:59.000
is an appealing thought because geez, if you

00:16:59.000 --> 00:17:01.840
just avoided those foods, you would have no eczema.

00:17:01.919 --> 00:17:06.990
And we know that just by far most. atopic dermatitis

00:17:06.990 --> 00:17:10.210
patients are not experiencing these exacerbations

00:17:10.210 --> 00:17:12.690
because of something they're eating. And it would

00:17:12.690 --> 00:17:15.630
be nice to say, geez, yes, avoid cow's milk or

00:17:15.630 --> 00:17:19.009
egg or weed or peanut or whatever. But for most

00:17:19.009 --> 00:17:21.349
kids, that's not doing anything. It's irrelevant

00:17:21.349 --> 00:17:24.049
to the course of their atopic dermatitis. And,

00:17:24.069 --> 00:17:26.410
you know, I for one just don't recommend dietary

00:17:26.410 --> 00:17:28.569
interventions or elimination diets or anything

00:17:28.569 --> 00:17:33.190
like that, except in a very, very small subset

00:17:33.190 --> 00:17:36.210
of the most severe eczema patients, right? This

00:17:36.210 --> 00:17:39.049
is not the normal off-the-street eczema patient

00:17:39.049 --> 00:17:41.769
that you see. Clearly, there is a correlation

00:17:41.769 --> 00:17:43.869
between what they're eating. And, geez, they're

00:17:43.869 --> 00:17:46.089
having an anaphylactic reaction when they're

00:17:46.089 --> 00:17:47.890
having some of these foods. And those are the

00:17:47.890 --> 00:17:49.470
patients you have to manage with allergy and

00:17:49.470 --> 00:17:52.390
immunology together. But 98% of my patient population

00:17:52.390 --> 00:17:55.710
truly, I think, would be unaffected by a specific

00:17:55.710 --> 00:17:58.190
food that they might be eating. The only time

00:17:58.190 --> 00:18:00.769
I think I've really actually advised, again,

00:18:00.849 --> 00:18:03.029
without the collection, of an allergist a dietary

00:18:03.029 --> 00:18:06.450
change for skin reasons would be if I'm if it's

00:18:06.450 --> 00:18:08.970
a younger baby and I'm putting them on a hypoallergenic

00:18:08.970 --> 00:18:12.190
or hydros like one of those formulas and and

00:18:12.190 --> 00:18:13.950
that's the only food the baby's eating at the

00:18:13.950 --> 00:18:17.880
time so once kids are eating foods It's not something

00:18:17.880 --> 00:18:19.799
that I would be doing without any kind of confirmatory

00:18:19.799 --> 00:18:21.420
testing. And we don't do that in a vacuum. We

00:18:21.420 --> 00:18:23.380
do that with, again, the dermatologist and the

00:18:23.380 --> 00:18:26.019
allergist and things like that. What's your approach

00:18:26.019 --> 00:18:28.140
to bathing? That's always a question. Do you

00:18:28.140 --> 00:18:31.039
not bathe? Do you bathe? We bathe our kids way

00:18:31.039 --> 00:18:34.119
too much in this country. I think generally,

00:18:34.339 --> 00:18:38.019
what I usually tell, especially for newborns

00:18:38.019 --> 00:18:41.470
and babies, is... you're wiping that baby already

00:18:41.470 --> 00:18:43.990
and you're wiping the dirty areas of your non

00:18:43.990 --> 00:18:46.869
-mobile infant already almost every time that

00:18:46.869 --> 00:18:49.130
you are changing the diaper, if not every time

00:18:49.130 --> 00:18:50.930
they're changing the diaper. So you do not need

00:18:50.930 --> 00:18:53.440
to give that baby a bath. every single day or

00:18:53.440 --> 00:18:55.519
twice a day. It's just not something that's necessary.

00:18:55.700 --> 00:18:57.380
And in kids that have eczema, it can be even

00:18:57.380 --> 00:19:00.240
less frequently. So I usually tell them every

00:19:00.240 --> 00:19:02.460
other day. It can be really every two days. That's

00:19:02.460 --> 00:19:03.819
fine. Obviously, if they're dirty, if you're

00:19:03.819 --> 00:19:05.500
outside, if they're playing, you know, once they

00:19:05.500 --> 00:19:07.420
hit toddler stage and they're filthy little munchkins,

00:19:07.579 --> 00:19:09.259
then they're going to need to, you know, they're

00:19:09.259 --> 00:19:10.960
going to need to bathe more. But when these are

00:19:10.960 --> 00:19:13.140
tiny babies, when these are younger kids, when

00:19:13.140 --> 00:19:15.440
these are toddlers that are, you know, it's winter,

00:19:15.519 --> 00:19:17.519
they're not outside, they're not playing. We

00:19:17.519 --> 00:19:19.619
don't need to bathe them as much as we generally

00:19:19.619 --> 00:19:21.859
tend to think that we do. Unfortunately, kids

00:19:21.960 --> 00:19:23.740
love the bath and they love sitting in the bath

00:19:23.740 --> 00:19:25.359
and they love playing in the bath and they love

00:19:25.359 --> 00:19:27.660
playing with their bath toys. And for kids that

00:19:27.660 --> 00:19:29.680
have eczema, that's just not ideal. Unfortunately,

00:19:29.940 --> 00:19:31.579
you kind of want to get them in, get them clean,

00:19:31.759 --> 00:19:33.579
get them out, dry them off and grease them up

00:19:33.579 --> 00:19:35.740
as quickly as you can with whatever moisturizer

00:19:35.740 --> 00:19:39.039
they're using. So less frequently, less long,

00:19:39.220 --> 00:19:41.380
less pruned up and shriveled, and then really

00:19:41.380 --> 00:19:43.220
as much as you can just to make sure that you're

00:19:43.220 --> 00:19:45.000
moisturizing as soon as you can get them out

00:19:45.000 --> 00:19:48.720
of the bath or the shower. Now, 17-year-old

00:19:48.720 --> 00:19:50.759
boys should get a shower every day. Seven times

00:19:50.759 --> 00:19:55.380
a day and for 30 minutes each time, Yes.  Perfect.

00:19:55.759 --> 00:19:58.299
And then after an hour goes by, you should take

00:19:58.299 --> 00:20:00.700
another shower just to make sure the first one's

00:20:00.700 --> 00:20:02.960
stuck. Yeah, you might have missed a spot. Yes,

00:20:03.059 --> 00:20:05.099
and there should be deodorant in every room of

00:20:05.099 --> 00:20:07.440
the house. And if you pass it by, put it on.

00:20:07.640 --> 00:20:10.220
Don't think about it. Just put it on. Just do

00:20:10.220 --> 00:20:13.880
it. Just do it. Yes, that's very similar to my

00:20:13.880 --> 00:20:18.569
approach for the young kids. I think right around

00:20:18.569 --> 00:20:22.470
toddler, I do, I'm advocating for a short bath

00:20:22.470 --> 00:20:26.089
once a day. There's really a lot of controversy

00:20:26.089 --> 00:20:29.349
and inconsistency in the peds derm world of what

00:20:29.349 --> 00:20:31.730
to do for bathing. Some people will say once

00:20:31.730 --> 00:20:35.130
a week, some people will say once a day, Once

00:20:35.130 --> 00:20:37.130
a week?. I mean, yes, there's some extremes. If

00:20:37.130 --> 00:20:40.549
you're doing the bath, do you soak for long periods,

00:20:40.630 --> 00:20:42.269
like you had mentioned, turn yourself into a

00:20:42.269 --> 00:20:46.029
prune or raisin on purpose? My approach is short

00:20:46.029 --> 00:20:49.839
bath, Five to 10 minutes max, lukewarm water.

00:20:50.079 --> 00:20:53.740
Why?  Real hot showers tend to take off more of

00:20:53.740 --> 00:20:55.599
the natural oils you're supposed to have on your

00:20:55.599 --> 00:20:58.079
skin. You're trying not to lose those as much

00:20:58.079 --> 00:21:01.200
as possible. But then really from that, that's

00:21:01.200 --> 00:21:04.279
my own personal take on showering or bathing.

00:21:05.390 --> 00:21:07.950
What I tell families is I don't really care as

00:21:07.950 --> 00:21:11.170
long as, right, as long as you are lubing up

00:21:11.170 --> 00:21:13.730
with a solid moisturizer, which we'll talk in

00:21:13.730 --> 00:21:16.190
a second, at least three times a day. And that's

00:21:16.190 --> 00:21:17.769
the problem. Nobody ever really does that three

00:21:17.769 --> 00:21:20.210
times a day. But geez, it almost doesn't matter.

00:21:21.680 --> 00:21:23.279
Two, and I don't think they listen to me. So

00:21:23.279 --> 00:21:25.799
no one's listening to you, Dr. Krakowski. Well,

00:21:25.859 --> 00:21:27.720
we should say 10 and hope that they do it two

00:21:27.720 --> 00:21:29.259
or three. I mean, that's really kind of what

00:21:29.259 --> 00:21:31.720
we're going for. And I want to throw in super

00:21:31.720 --> 00:21:34.240
quickly, it doesn't matter how often you bathe

00:21:34.240 --> 00:21:36.019
your kid if you don't cut their nails short.

00:21:36.220 --> 00:21:39.680
This is a huge thing for us is to always make

00:21:39.680 --> 00:21:41.400
sure we're telling them, please keep the kids'

00:21:41.519 --> 00:21:43.940
nails short because if they're even just a little

00:21:43.940 --> 00:21:46.460
bit long. when they do that scratching that they

00:21:46.460 --> 00:21:48.299
can't help themselves because they're so so itchy

00:21:48.299 --> 00:21:50.700
that's what sets them up for risk and that really

00:21:50.700 --> 00:21:52.660
makes it worse and that really lichenifies the

00:21:52.660 --> 00:21:54.400
skin and thickens it so it's that scratching

00:21:54.400 --> 00:21:57.319
with those nails if you can in the winter if

00:21:57.319 --> 00:21:59.200
you can cover up the areas or in the summer if

00:21:59.200 --> 00:22:00.640
it's on their ankles if you can get them to wear

00:22:00.640 --> 00:22:02.279
pants or behind their knees if you can get them

00:22:02.279 --> 00:22:04.299
to wear pants anything you can do to kind of

00:22:04.299 --> 00:22:07.220
protect the area from the kids clawing at it

00:22:07.220 --> 00:22:09.740
is going to be helpful. But we see these kids

00:22:09.740 --> 00:22:11.400
that come in that are super, super, super clean,

00:22:11.500 --> 00:22:13.859
but their nails are long and it's really, really

00:22:13.859 --> 00:22:15.779
hard because that's what's going to cause the

00:22:15.779 --> 00:22:17.839
problem. You're scratching, you're excoriating

00:22:17.839 --> 00:22:20.539
the skin. Now the bacteria or the virus can get

00:22:20.539 --> 00:22:22.660
into the skin more easily. So that's a great

00:22:22.660 --> 00:22:25.319
question about bathing. Do you utilize bleach

00:22:25.319 --> 00:22:27.579
baths at all for your population or is that something

00:22:27.579 --> 00:22:30.160
you leave to us? So I leave that to you. The

00:22:30.160 --> 00:22:32.220
only times that I would really recommend bleach

00:22:32.220 --> 00:22:34.539
baths or that I have recommended bleach baths

00:22:34.539 --> 00:22:36.420
is if we've had kids. that have had recurrent

00:22:36.420 --> 00:22:41.079
either pustules or abscesses from MRSA. Otherwise,

00:22:41.220 --> 00:22:43.980
I wouldn't. I have not done that, but maybe I

00:22:43.980 --> 00:22:45.599
should be culturing more, like you said, and

00:22:45.599 --> 00:22:47.440
then maybe I should be treating more, like you

00:22:47.440 --> 00:22:52.119
said. Well, no, I mean, I think it's all patient

00:22:52.119 --> 00:22:55.339
dependent. But for us, we use bleach baths probably

00:22:55.339 --> 00:22:58.500
maybe four to five times a week. I'll recommend

00:22:58.500 --> 00:23:02.009
that. seeing you know over 30 or 40 eczema patients

00:23:02.009 --> 00:23:04.589
a week so it's not everybody who's walking out

00:23:04.589 --> 00:23:06.869
the door gets a recommendation for bleach baths

00:23:06.869 --> 00:23:08.710
by the way what are bleach baths for the for

00:23:08.710 --> 00:23:10.809
the listening audience basically you are making

00:23:10.809 --> 00:23:13.549
a swimming pool in your bathtub so a you have

00:23:13.549 --> 00:23:16.029
to have a bathtub in your house that's uh that's

00:23:16.029 --> 00:23:17.849
one thing that not everybody has so you have

00:23:17.849 --> 00:23:20.210
to be aware of that there are some third -party

00:23:20.210 --> 00:23:23.269
products that basically sell "swimming pool in

00:23:23.269 --> 00:23:24.849
a bottle" that you can then put on your skin,

00:23:24.970 --> 00:23:27.309
but they tend to be expensive and a bottle of

00:23:27.309 --> 00:23:29.650
chlorine bleach - which is what we're talking about

00:23:29.650 --> 00:23:32.809
here - is less than ten dollars at least since last time I've

00:23:32.809 --> 00:23:35.609
been in the supermarket So it's way less expensive

00:23:35.609 --> 00:23:39.609
to do it the bulk method for making a bleach

00:23:39.609 --> 00:23:41.880
bath in your bathtub than it is to buy these

00:23:41.880 --> 00:23:44.519
other products. But anyway, it's a careful mixture

00:23:44.519 --> 00:23:47.299
of about a quarter cup to a half a cup of chlorine

00:23:47.299 --> 00:23:50.480
bleach, regular strength Clorox, and you mix

00:23:50.480 --> 00:23:53.660
that with a full tub of water and you swish it

00:23:53.660 --> 00:23:55.740
around, make sure it's stirred evenly, not too

00:23:55.740 --> 00:23:58.180
warm, not too cold. Lukewarm is what you're going

00:23:58.180 --> 00:24:01.420
for. The kid sits in there for five minutes.

00:24:01.889 --> 00:24:04.690
10 minutes tops. You can throw toys in there

00:24:04.690 --> 00:24:06.910
too. They'll just get clean. It's literally like

00:24:06.910 --> 00:24:09.309
swimming in a swimming pool. But the really important

00:24:09.309 --> 00:24:13.509
part is one, you can overdo it. So I usually

00:24:13.509 --> 00:24:15.829
tell my patients no more than three times a week,

00:24:15.910 --> 00:24:18.369
Monday, Wednesday, Friday. Of course, if you

00:24:18.369 --> 00:24:20.369
also have a patient that's swimming in a pool,

00:24:20.490 --> 00:24:23.230
like winter swims going on right now in our house,

00:24:23.269 --> 00:24:26.069
well, that counts. You're going to get extra

00:24:26.069 --> 00:24:29.339
dry if you also come home after doing winter

00:24:29.339 --> 00:24:31.220
swim for two hours and then get in your bleach

00:24:31.220 --> 00:24:33.240
bath. So you have to kind of take that into account.

00:24:33.359 --> 00:24:35.420
But the most important thing I have my patients

00:24:35.420 --> 00:24:38.220
do after a bleach bath is rinse off with FRESH

00:24:38.220 --> 00:24:41.680
water. And then they have to either medicate

00:24:41.680 --> 00:24:44.039
if it's time to put the medications on the skin.

00:24:44.650 --> 00:24:47.890
and or they have to moisturize immediately after

00:24:47.890 --> 00:24:50.029
they do the bleach bath, after they've rinsed

00:24:50.029 --> 00:24:52.970
off that chlorine. But I find that to be a useful

00:24:52.970 --> 00:24:56.529
alternative adjunct, if you will, to knocking

00:24:56.529 --> 00:24:59.150
down some of that bacterial colonization on the

00:24:59.150 --> 00:25:01.670
skin. And I do find that it does keep down true

00:25:01.670 --> 00:25:04.430
skin infections and keeps kids off of oral antibiotics

00:25:04.430 --> 00:25:07.470
as much as you can. Do you recommend that for

00:25:07.470 --> 00:25:10.619
patients that have sort of... Excoriated lesions,

00:25:10.619 --> 00:25:12.779
lesions that they've already scratched or like

00:25:12.779 --> 00:25:14.539
kind of, I don't want to say open lesions, but

00:25:14.539 --> 00:25:16.099
do you recommend that for kids whose skin is

00:25:16.099 --> 00:25:18.799
pretty actively inflamed or not so much? But

00:25:18.799 --> 00:25:20.839
yeah, no, it really depends on how open you are.

00:25:20.960 --> 00:25:24.720
So if you're concerned about that, then instead

00:25:24.720 --> 00:25:26.660
of doing the half cup of bleach, which would

00:25:26.660 --> 00:25:29.779
be the stronger recipe, I would do maybe an eighth

00:25:29.779 --> 00:25:32.220
of a cup or a quarter of a cup and really just

00:25:32.220 --> 00:25:34.359
do it less, really. That's as simple as that.

00:25:34.400 --> 00:25:36.859
And then two or three days. doing the bleach

00:25:36.859 --> 00:25:39.039
baths, you're going to find that you're going

00:25:39.039 --> 00:25:41.019
to not be as excoriated. Some of those wounds

00:25:41.019 --> 00:25:42.660
are going to have healed up because you're also

00:25:42.660 --> 00:25:45.680
hopefully doing the topical steroids, the topical

00:25:45.680 --> 00:25:48.140
moisturizers that you want. Now you can go in

00:25:48.140 --> 00:25:50.579
and do the full strength ones. So that's a perfect

00:25:50.579 --> 00:25:53.160
segue into what you look for in terms of a moisturizer.

00:25:53.299 --> 00:25:56.099
I was about to say, but Dr. Krakowski, what moisturizer

00:25:56.099 --> 00:25:58.599
should I use? Well, I mean, it's simple for me.

00:25:58.680 --> 00:26:00.920
I get a lot of complicated questions about eczema,

00:26:01.019 --> 00:26:03.640
drilling down on tiny things that may or may

00:26:03.640 --> 00:26:05.519
not be that important. But at the end of the

00:26:05.519 --> 00:26:09.200
day, for me, the foundation of good eczema care,

00:26:09.380 --> 00:26:11.839
it comes down to the moisturizer and how many

00:26:11.839 --> 00:26:14.519
times you're putting on a good moisturizer and

00:26:14.519 --> 00:26:16.799
cream. I'll be very specific. Why am I making

00:26:16.799 --> 00:26:18.940
a distinction between different products? And

00:26:18.940 --> 00:26:20.640
some people don't even know that there is a difference.

00:26:20.740 --> 00:26:23.539
There are different what we call "vehicles" in

00:26:23.539 --> 00:26:26.200
dermatology. That is, the same ingredients might

00:26:26.200 --> 00:26:29.880
be put into the same bottle, but how those ingredients

00:26:29.880 --> 00:26:33.039
get delivered to the skin is the vehicle. And

00:26:33.039 --> 00:26:35.700
you can have a vehicle. that it might be a foam,

00:26:35.880 --> 00:26:38.680
it might be a gel. Typically, a gel is alcohol

00:26:38.680 --> 00:26:41.400
-based. That tends to be drying. That would not

00:26:41.400 --> 00:26:44.900
be a good product for eczema. And if I had to

00:26:44.900 --> 00:26:46.839
think about it, I couldn't even name a gel -based

00:26:46.839 --> 00:26:49.700
eczema product right now off the top of my head.

00:26:49.779 --> 00:26:53.920
But you get into the larger, more sort of consumer

00:26:53.920 --> 00:26:57.000
-based approach to "moisturizers"

00:26:57.000 --> 00:26:58.740
and you're quickly hit in the head with having

00:26:58.740 --> 00:27:02.329
to make a decision between the big three:  Lotions,

00:27:02.329 --> 00:27:04.730
Ointments, and Moisturizing Creams. And some

00:27:04.730 --> 00:27:06.150
people would say, "Well, there is no difference.

00:27:06.289 --> 00:27:08.410
It's the same thing, right?" No, big difference.

00:27:08.650 --> 00:27:12.869
So a lotion, from the perspective of a dermatologist,

00:27:12.990 --> 00:27:15.369
typically implies, and there's variations, but

00:27:15.369 --> 00:27:18.470
the gist of it is you make a lotion similar to

00:27:18.470 --> 00:27:20.650
how you might make Crystal Light or Kool-Aid,

00:27:20.710 --> 00:27:22.450
the drink that you might enjoy in the spring

00:27:22.450 --> 00:27:25.470
and summer. It's a powder mixed with water, just

00:27:25.470 --> 00:27:28.099
a lot of powder. is what gives the lotion its

00:27:28.099 --> 00:27:30.799
thicker consistency. And I try to impress on

00:27:30.799 --> 00:27:33.019
my patients that everybody, no matter where you

00:27:33.019 --> 00:27:35.339
live in the United States, you know if you're

00:27:35.339 --> 00:27:37.579
in the middle of the summer and you take a glass

00:27:37.579 --> 00:27:39.380
of water and you throw it out on the sidewalk

00:27:39.380 --> 00:27:41.880
and you come back two to three hours later, no

00:27:41.880 --> 00:27:44.720
matter where you live, that water has evaporated

00:27:44.720 --> 00:27:47.319
into the atmosphere. It's gone. And that same

00:27:47.319 --> 00:27:49.700
process happens when you put a lotion or any

00:27:49.700 --> 00:27:52.440
product onto your skin. Just lotion, because

00:27:52.440 --> 00:27:55.000
it's mostly water and powder, that's where it

00:27:55.000 --> 00:27:57.880
clinically matters. Why? Well, the water portion

00:27:57.880 --> 00:27:59.720
is going to evaporate off. And what are you left

00:27:59.720 --> 00:28:02.339
with? The powder portion. So in dermatology,

00:28:02.480 --> 00:28:04.720
if you had a weeping, oozing wound, which is

00:28:04.720 --> 00:28:06.599
gross to think about, but if you did, we can

00:28:06.599 --> 00:28:10.400
actually use a lotion to dry or to help dry out

00:28:10.400 --> 00:28:13.390
that wound. because we take advantage of the

00:28:13.390 --> 00:28:15.769
fact that the water component is going to evaporate

00:28:15.769 --> 00:28:17.750
off and that powder will sit on your skin and

00:28:17.750 --> 00:28:20.670
do the drying for us. So the trick with a lotion,

00:28:20.890 --> 00:28:23.730
and the layperson just wouldn't know this, is

00:28:23.730 --> 00:28:27.769
unless you are somehow thwarting the evaporation

00:28:27.769 --> 00:28:31.220
process, a lotion might... actually be counterproductive

00:28:31.220 --> 00:28:33.960
to your moisturizing efforts. How would you thwart

00:28:33.960 --> 00:28:36.539
evaporation? Well, you'd have to put the lotion

00:28:36.539 --> 00:28:39.119
on 24 hours a day, seven days a week. You'd just

00:28:39.119 --> 00:28:41.460
have to constantly be swimming in lotion.

00:28:41.599 --> 00:28:43.680
That would be one way. The other way would be

00:28:43.680 --> 00:28:46.059
to put it on and then wrap yourself in Saran

00:28:46.059 --> 00:28:48.779
wrap and keep the moisture in. But it's practically

00:28:48.779 --> 00:28:52.559
impossible. Well, and not recommended in pediatrics.

00:28:52.559 --> 00:28:54.579
You should not wrap your children in Saran wrap.

00:28:55.320 --> 00:28:58.759
No, for a lot of reasons. So, yeah, lotions,

00:28:58.759 --> 00:29:01.180
you have to look. In general, if you can pump

00:29:01.180 --> 00:29:03.920
the product, you might want to look at it again

00:29:03.920 --> 00:29:05.460
closely and make sure it's not a lotion because

00:29:05.460 --> 00:29:07.960
you're missing out on – if you're doing the work,

00:29:08.119 --> 00:29:09.799
you might as well get the benefit. You're missing

00:29:09.799 --> 00:29:12.880
out on some of the benefit from a lotion. I've

00:29:12.880 --> 00:29:14.680
been doing the right thing for all these years

00:29:14.680 --> 00:29:16.660
and I didn't know it. I always tell people if

00:29:16.660 --> 00:29:19.819
you can get it in a tub and it's boring, that's

00:29:19.819 --> 00:29:21.440
probably the best thing to put on your skin.

00:29:21.599 --> 00:29:23.319
Like if it has no scent, no smell, and it comes

00:29:23.319 --> 00:29:26.109
in a big tub, then – i'm happy for you well i

00:29:26.109 --> 00:29:28.589
like no smell we'll talk about the tubs i think

00:29:28.589 --> 00:29:31.130
the tubs are more common in the second second

00:29:31.130 --> 00:29:33.069
vehicle we'll discuss a little bit more in detail

00:29:33.069 --> 00:29:35.990
called ointments that's your you know big tub

00:29:35.990 --> 00:29:39.190
of vaseline or a product like Aquaphor, which

00:29:39.190 --> 00:29:42.109
is a great product.  These are wonderful.

00:29:42.109 --> 00:29:45.710
I call them skin protectants right so you put

00:29:45.710 --> 00:29:48.819
them on and they form a thick obvious barrier

00:29:48.819 --> 00:29:52.279
between the outside world and the skin. That's

00:29:52.279 --> 00:29:55.299
very useful. I've got no problem calling Aquaphor

00:29:55.299 --> 00:29:58.319
out as being a great product. We use it for surgical

00:29:58.319 --> 00:30:00.619
wounds in our clinic all the time. Same with

00:30:00.619 --> 00:30:02.420
Vaseline. It's just cheaper. By the way, what's

00:30:02.420 --> 00:30:03.759
the difference between Aquaphor and Vaseline?

00:30:03.920 --> 00:30:07.119
Both are petrolatum-based, so they're petroleum

00:30:07.119 --> 00:30:10.859
-based. Aquaphor does, I guess, literally and

00:30:10.859 --> 00:30:13.039
figuratively rub some people the wrong way because

00:30:13.039 --> 00:30:16.480
it contains lanolin, which is sheep's wool. And

00:30:16.480 --> 00:30:19.240
that can be irritating to some people. But in

00:30:19.240 --> 00:30:21.779
general, we have great success using those products

00:30:21.779 --> 00:30:25.400
on top of, for example, like a stitch, a sutured

00:30:25.400 --> 00:30:27.599
wound that we create in the clinic. It helps

00:30:27.599 --> 00:30:30.180
protect the skin, keeps the dirt out, keeps the

00:30:30.180 --> 00:30:32.420
environmental allergens out, and seals everything

00:30:32.420 --> 00:30:35.519
off pretty nicely. The problem with it is, you

00:30:35.519 --> 00:30:38.259
know from basic science class, oil and water

00:30:38.259 --> 00:30:42.259
don't mix, right? So putting an oil-based product

00:30:42.259 --> 00:30:44.819
onto your skin and hoping that somehow magically...

00:30:45.500 --> 00:30:48.000
opposite to any true chemistry or law of physics,

00:30:48.099 --> 00:30:50.539
how would you get moisture to come out of that

00:30:50.539 --> 00:30:54.109
oil and into your skin? That's kind of the rub,

00:30:54.190 --> 00:30:55.950
right? That was the most long-winded way of

00:30:55.950 --> 00:30:57.630
saying, Walty, you've been doing it wrong that

00:30:57.630 --> 00:31:00.789
I've ever heard. It was very nice. You even said

00:31:00.789 --> 00:31:03.369
you know this from basic science class. That's

00:31:03.369 --> 00:31:05.190
how far down you, that was how deep you dug.

00:31:05.329 --> 00:31:07.970
But I appreciate the kindness and patience that

00:31:07.970 --> 00:31:10.410
you just demonstrated. So thank you. Well, listen,

00:31:10.589 --> 00:31:13.950
I mean, who would ever talk to somebody about

00:31:13.950 --> 00:31:17.450
this stuff, right? It's kind of nuts. This is

00:31:17.450 --> 00:31:19.369
good. I'm getting schooled and I appreciate it.

00:31:19.430 --> 00:31:21.250
So this is very good. So the good news is you

00:31:21.250 --> 00:31:23.630
don't have to be a scientist. science whiz. If

00:31:23.630 --> 00:31:25.789
you're out there shopping in CVS or Rite Aid

00:31:25.789 --> 00:31:27.569
and you're trying to find a good moisturizer,

00:31:27.910 --> 00:31:30.869
the word moisturizer is in the thing I want everybody

00:31:30.869 --> 00:31:34.910
to buy. Moisturizing Cream. This is usually a

00:31:34.910 --> 00:31:38.309
concoction of water mixed with oil. It's developed

00:31:38.309 --> 00:31:42.410
and formulated so that moisture will actually

00:31:42.410 --> 00:31:45.339
be put into the skin, as well as getting some

00:31:45.339 --> 00:31:47.819
of the effect of the oil on the skin as the barrier.

00:31:48.000 --> 00:31:51.539
So it's a good compromise. I tend to also like

00:31:51.539 --> 00:31:54.579
it because it blends in eventually. It doesn't

00:31:54.579 --> 00:31:56.500
sit up on the skin like an ointment does. That

00:31:56.500 --> 00:31:58.559
drives people crazy if it's coming through your

00:31:58.559 --> 00:32:01.180
clothing or getting on your couch or your car

00:32:01.180 --> 00:32:03.779
upholstery or whatever. Moisturizing creams usually

00:32:03.779 --> 00:32:07.279
do blend in. But 100% agree with you. Avoid

00:32:07.279 --> 00:32:09.759
fragrance, right? You really want something where

00:32:09.759 --> 00:32:12.500
it's fragrance-free. Thank you for throwing

00:32:12.500 --> 00:32:14.359
me that bone. That's kind of you. Thank you.

00:32:14.440 --> 00:32:17.339
Yeah, and do you remember "unscented" versus "fragrance

00:32:17.339 --> 00:32:19.380
-free?" I looked at a product and see the word

00:32:19.380 --> 00:32:22.599
"unscented." Yeah, it's like "no sugar added." It's

00:32:22.599 --> 00:32:24.339
like no sugar added, but the juice still has

00:32:24.339 --> 00:32:26.920
a lot of sugar in it. Well, so "fragrance-free"

00:32:26.920 --> 00:32:28.700
is kind of like the "no sugar added." So "fragrance

00:32:28.700 --> 00:32:31.039
-free," when you go to buy a product, if it says

00:32:31.039 --> 00:32:34.710
"fragrance-free," what that means is that however

00:32:34.710 --> 00:32:37.390
the ingredients were combined into that bottle

00:32:37.390 --> 00:32:40.410
or tube or tub is the combination, and however

00:32:40.410 --> 00:32:43.609
it smells is what you get as the consumer, okay?

00:32:43.930 --> 00:32:46.150
"Fragrance-free" means someone did not then take

00:32:46.150 --> 00:32:50.589
an extra step to add menthol or, you know, what's

00:32:50.589 --> 00:32:53.130
another? Cinnamon or honey flavoring or scent,

00:32:53.289 --> 00:32:55.069
right? Some rose or whatever it might be. You

00:32:55.069 --> 00:32:57.349
always have to do the foods. You had to do the

00:32:57.349 --> 00:32:59.309
cinnamon. Well, how about leather? I don't know.

00:32:59.309 --> 00:33:01.150
Pick a smell that you like. I don't know, but

00:33:01.150 --> 00:33:02.609
you just brought up cinnamon, and now I'm...

00:33:03.250 --> 00:33:06.970
Not a cinnamon fan? Not at the moment, no. Oh,

00:33:06.970 --> 00:33:08.809
okay. We're talking about rubbing things into

00:33:08.809 --> 00:33:11.509
wounds. Cinnamon would not be good. No, that

00:33:11.509 --> 00:33:14.630
would hurt. But a fragrance, you could add a

00:33:14.630 --> 00:33:17.150
fragrance to the combination of ingredients.

00:33:17.369 --> 00:33:18.930
Then you can't call it fragrance-free, but you

00:33:18.930 --> 00:33:20.970
would change the way it smells. "Fragrance-free"...

00:33:21.029 --> 00:33:23.710
it is what it is. It smells the way it was cooked

00:33:23.710 --> 00:33:26.890
up in the lab. It can smell very medicinal, and

00:33:26.890 --> 00:33:30.009
that is sometimes a knock for people. "Unscented".

00:33:30.599 --> 00:33:33.000
is another trick that's been played on human beings.

00:33:33.160 --> 00:33:36.039
How would you ever know this? "Unscented" means

00:33:36.039 --> 00:33:39.099
someone cooked up the batch of ingredients that

00:33:39.099 --> 00:33:41.660
they want in the product. It has whatever smell

00:33:41.660 --> 00:33:44.380
is at the end. But then instead of putting a

00:33:44.380 --> 00:33:46.819
fragrance into the product to make it smell like

00:33:46.819 --> 00:33:49.279
the fragrance, there's a combination usually

00:33:49.279 --> 00:33:53.200
of fragrances that inactivate the base smell

00:33:53.200 --> 00:33:56.640
of the ingredients in. their entirety, in their

00:33:56.640 --> 00:33:59.220
aggregate. So it's actually usually an unscented

00:33:59.220 --> 00:34:03.200
product has more fragrance added than sometimes

00:34:03.200 --> 00:34:06.700
even a fragranced product because you have to

00:34:06.700 --> 00:34:09.099
add three or four things as a fragrance to an

00:34:09.099 --> 00:34:12.179
unscented product to neutralize the odor of the

00:34:12.179 --> 00:34:14.380
base ingredients. Does that make sense? Totally.

00:34:14.519 --> 00:34:17.460
A hundred percent. It's crazy. I'm taking notes.

00:34:17.820 --> 00:34:19.780
It makes sense to me. I'm taking notes and I

00:34:19.780 --> 00:34:21.840
was, I will fully admit when I was wrong, but

00:34:21.840 --> 00:34:23.780
I was like a little close to being right. Yeah.

00:34:23.800 --> 00:34:26.789
Very close. Sort of. how would it how would a

00:34:26.789 --> 00:34:29.429
normal human being walking into a pharmacy know

00:34:29.429 --> 00:34:31.510
that you know it sounds like you're doing something

00:34:31.510 --> 00:34:33.329
great for your kids that you're going to give

00:34:33.329 --> 00:34:35.010
them this unscented product and you're walking

00:34:35.010 --> 00:34:37.130
out with something that actually could have more

00:34:37.130 --> 00:34:39.329
fragrance than than the fragrance free product

00:34:39.329 --> 00:34:42.190
so who knows i also do look for moisturizers

00:34:42.190 --> 00:34:46.369
that do not have Potential sensitizers, I just

00:34:46.369 --> 00:34:48.289
kind of lose my patience with people that tell

00:34:48.289 --> 00:34:51.849
me tea tree oil and lavender and ylang-ylang

00:34:51.849 --> 00:34:54.250
solves the world's problems. Like, no, you don't

00:34:54.250 --> 00:34:55.469
need that in these products. I don't know what

00:34:55.469 --> 00:34:57.599
that is, but... Don't say it again because it

00:34:57.599 --> 00:34:59.000
was kind of funny. I won't say it ever again.

00:34:59.019 --> 00:35:01.519
I promise you. It was very funny. I have heard

00:35:01.519 --> 00:35:03.179
the tea tree oil. That I've definitely heard,

00:35:03.239 --> 00:35:05.340
and I've told people to kind of avoid that because

00:35:05.340 --> 00:35:08.219
it's not helping anything. In this particular

00:35:08.219 --> 00:35:10.460
instance, I'm not discussing its use for other

00:35:10.460 --> 00:35:12.159
things, but for this particular instance, it's

00:35:12.159 --> 00:35:14.619
definitely not helping. Right. I mean, the other

00:35:14.619 --> 00:35:17.219
one I get a lot is coconut oil. Is that a useful

00:35:17.219 --> 00:35:19.599
moisturizer? You know, it's a tree nut. There

00:35:19.599 --> 00:35:23.219
is a potential to sensitize there. That's probably

00:35:23.219 --> 00:35:25.960
not a huge, huge risk. But I guess the point

00:35:25.960 --> 00:35:29.260
is there's better moisturizers. Why are you dedicating

00:35:29.260 --> 00:35:31.480
yourself and effort? If you're going to put on...

00:35:31.920 --> 00:35:33.679
If you're going to put on coconut oil three times

00:35:33.679 --> 00:35:35.559
a day, if you just switch to a moisturizing cream,

00:35:35.739 --> 00:35:37.960
you'd be getting so much better results and you'd

00:35:37.960 --> 00:35:39.659
be sitting there going, geez, I didn't need this

00:35:39.659 --> 00:35:42.000
expensive coconut oil in the first place, you

00:35:42.000 --> 00:35:43.860
know? Perfect. The other caution that I would

00:35:43.860 --> 00:35:46.860
say is just because something has the label "hypoallergenic,"

00:35:46.860 --> 00:35:50.139
which suggests that somehow it's less allergy

00:35:50.139 --> 00:35:52.420
causing, doesn't mean it can't cause an allergy.

00:35:52.559 --> 00:35:55.739
I can put anything on a person enough and

00:35:55.739 --> 00:35:58.760
in the right person, it will cause an allergy.

00:35:59.800 --> 00:36:02.800
You know, the best example is poison ivy. I don't

00:36:02.800 --> 00:36:04.219
know if you've ever heard somebody who tells

00:36:04.219 --> 00:36:06.380
you that they're not allergic to poison ivy.

00:36:06.380 --> 00:36:08.920
Well, they might not yet have been sensitized

00:36:08.920 --> 00:36:11.599
to poison ivy. Most of us as human beings, if

00:36:11.599 --> 00:36:14.820
we encounter poison ivy one time, we're sensitized

00:36:14.820 --> 00:36:17.519
enough that we will get a rash of poison ivy

00:36:17.519 --> 00:36:19.800
the next time we see it. Some people have encountered

00:36:19.800 --> 00:36:22.110
it. or thought they've encountered it and have

00:36:22.110 --> 00:36:23.630
not gotten the rash, so they're 

00:36:23.630 --> 00:36:26.570
"immune." Not true. I can take that poison ivy.

00:36:26.570 --> 00:36:29.030
I put it on enough of you, enough times and enough

00:36:29.030 --> 00:36:31.329
volume, you're going to get a rash eventually

00:36:31.329 --> 00:36:34.550
from poison ivy. Things that I look for in a

00:36:34.550 --> 00:36:38.210
moisturizing cream that matter to me, I actually

00:36:38.210 --> 00:36:41.110
like the families and the patients specifically,

00:36:41.210 --> 00:36:42.769
if they're old enough to say what they like,

00:36:42.849 --> 00:36:45.550
to pick a consistency. Because even within the

00:36:45.719 --> 00:36:47.880
realm of moisturizing creams there are different

00:36:47.880 --> 00:36:50.260
thicknesses, different consistencies viscosities

00:36:50.809 --> 00:36:52.829
Pick one that you like. Pick one that you're

00:36:52.829 --> 00:36:54.570
going to use. You know, there's an old saying

00:36:54.570 --> 00:36:56.489
in dermatology. It's if I can get it right. "The

00:36:56.489 --> 00:36:59.650
moisturizer that you use is better than the expensive

00:36:59.650 --> 00:37:01.670
one that sits up in your medicine cabinet." Something

00:37:01.670 --> 00:37:04.670
to that effect, you know? So find one that you

00:37:04.670 --> 00:37:08.329
like. I do typically look for a fragrance-free

00:37:08.329 --> 00:37:10.469
marketed product. That's the least amount of

00:37:10.469 --> 00:37:12.889
fragrance. And keeping with the American Academy

00:37:12.889 --> 00:37:14.829
of Dermatology and the American Academy of Pediatric

00:37:14.829 --> 00:37:17.190
recommendations, I'm looking for a product that

00:37:17.190 --> 00:37:21.269
does include ceramides. That's been recommended. Still

00:37:21.269 --> 00:37:23.969
unclear if it's actually. really useful in terms

00:37:23.969 --> 00:37:26.730
of, like, does it actually supplement at the level

00:37:26.730 --> 00:37:28.869
of the stratum corneum? But the recommendations

00:37:28.869 --> 00:37:31.829
are there. And I feel like that's usually the

00:37:31.829 --> 00:37:34.429
products that have the ceramides in it are formulated

00:37:34.429 --> 00:37:37.670
well around the ceramides such that they're safe

00:37:37.670 --> 00:37:40.170
and effective for a condition like eczema. No,

00:37:40.230 --> 00:37:42.969
I have no particular opinions on ceramides. No.

00:37:43.010 --> 00:37:44.809
And for most of my patients, it's going to be

00:37:44.809 --> 00:37:47.489
whatever is cost effective. So it's whatever

00:37:47.489 --> 00:37:49.730
they can get in a bulkier volume that's going

00:37:49.730 --> 00:37:52.119
to last, that's thicker, that... they're not

00:37:52.119 --> 00:37:53.820
going to have to run through as many times a

00:37:53.820 --> 00:37:55.880
day. So to your point, that viscosity is important

00:37:55.880 --> 00:37:57.760
to a lot of the families because then maybe they

00:37:57.760 --> 00:37:59.820
don't have to continue to reapply it, reapply

00:37:59.820 --> 00:38:02.340
it, reapply it. So yeah, I would say all of those

00:38:02.340 --> 00:38:04.619
things that you mentioned in cost. The one thing

00:38:04.619 --> 00:38:07.039
I will say I do mention to them is that they

00:38:07.039 --> 00:38:08.820
don't have to get brand name for a lot of these

00:38:08.820 --> 00:38:11.340
things. So if they wanted to use, and I'm making,

00:38:11.480 --> 00:38:13.260
you know, these are hypotheticals, if they wanted

00:38:13.260 --> 00:38:15.980
to use Eucerin or Aquaphor, they can use Walmart-aphor

00:38:15.980 --> 00:38:19.199
and they can use, Walgreen-acin. It doesn't

00:38:19.199 --> 00:38:21.460
make any difference whatsoever. no difference

00:38:21.460 --> 00:38:23.380
between the generic and the brand name. And there's

00:38:23.380 --> 00:38:25.500
a huge cost difference for some of those. So

00:38:25.500 --> 00:38:28.599
I do always tell them that that's the same. They

00:38:28.599 --> 00:38:31.679
don't need to get the more expensive, costly,

00:38:31.900 --> 00:38:35.380
you know, organic name brand type products. They

00:38:35.380 --> 00:38:37.719
can use the ones that are a little bit less expensive.

00:38:38.000 --> 00:38:40.219
I totally agree with you on that. I mean, I try

00:38:40.219 --> 00:38:41.679
to actually stay away from the 

00:38:41.679 --> 00:38:44.550
"organic". label products. That's just adding a

00:38:44.550 --> 00:38:48.570
zero to the cost without any real benefit. The

00:38:48.570 --> 00:38:50.710
other thing I'm sort of embarrassed to say, a

00:38:50.710 --> 00:38:52.730
lot of products carry the seal of approval from

00:38:52.730 --> 00:38:54.789
the National Eczema Association, which sounds

00:38:54.789 --> 00:38:57.329
like, geez, that would be really important. But

00:38:57.329 --> 00:39:00.909
without going into it, you can basically get

00:39:00.909 --> 00:39:03.130
that seal of approval without doing much. Let's

00:39:03.130 --> 00:39:05.980
just leave it there. So I feel like that's more

00:39:05.980 --> 00:39:08.159
of a marketing gimmick than anything else. And

00:39:08.159 --> 00:39:10.960
it's not just that because that seal of approval is

00:39:10.960 --> 00:39:12.860
on your product doesn't necessarily mean you're

00:39:12.860 --> 00:39:14.940
using the best product. It's kind of crazy to

00:39:14.940 --> 00:39:18.940
think about. But I do try to steer my patients

00:39:18.940 --> 00:39:21.840
to something that they can afford, will use three

00:39:21.840 --> 00:39:25.039
times a day, every day until they go to college

00:39:25.039 --> 00:39:27.159
or make their own decisions, whatever it is.

00:39:27.679 --> 00:39:30.340
You mentioned tubs. That is one thing that I

00:39:30.340 --> 00:39:32.840
have changed. I usually, or I should say I used

00:39:32.840 --> 00:39:35.849
to recommend getting the pound (1 lb) tubs wherever

00:39:35.849 --> 00:39:38.510
you could because it's just more economical than

00:39:38.510 --> 00:39:41.550
than an individual tube so like a pound tub but

00:39:41.550 --> 00:39:42.889
here's where you're going to tell me it's going

00:39:42.889 --> 00:39:44.869
to grow bacteria and you're going to grow horns

00:39:44.869 --> 00:39:47.110
this is i know where we're going with this because

00:39:47.110 --> 00:39:49.869
i paid attention during the last one see so that's

00:39:49.869 --> 00:39:51.989
that's how that's one thing i've changed i do

00:39:51.989 --> 00:39:55.219
go i recommend that they get individual tubes

00:39:55.219 --> 00:39:58.119
that they can clean off with rubbing alcohol

00:39:58.119 --> 00:40:02.280
around the flip top lid if it has one or whatever.

00:40:02.559 --> 00:40:05.019
And I've also found, honestly, that let's say

00:40:05.019 --> 00:40:08.739
you're trying to match a pound tub, that's what,

00:40:08.780 --> 00:40:13.639
16 ounces, right? So that's four, four ounce

00:40:13.639 --> 00:40:16.079
tubes or something close to three, six ounce

00:40:16.079 --> 00:40:19.579
tubes. having those extra tubes i've found can

00:40:19.579 --> 00:40:22.079
be very helpful for a number of reasons a you're

00:40:22.079 --> 00:40:24.340
still getting the same amount of medicine it

00:40:24.340 --> 00:40:26.920
is a little bit more expensive per tube but let's

00:40:26.920 --> 00:40:29.179
say it's a split household with where the child

00:40:29.179 --> 00:40:31.920
lives with mom during the work week and dad on

00:40:31.920 --> 00:40:34.079
the weekend or whatever combination. Well you

00:40:34.079 --> 00:40:37.340
know having Johnny or Mary's moisturizing cream

00:40:37.920 --> 00:40:39.880
split up a little bit is nice because if you

00:40:39.880 --> 00:40:42.099
forget one, at least you got two others spread

00:40:42.099 --> 00:40:44.039
somewhere else. Having one at school, if you

00:40:44.039 --> 00:40:45.880
can sneak it into the kid's locker and get him

00:40:45.880 --> 00:40:48.300
or her to use it during school, that's great.

00:40:48.320 --> 00:40:50.719
Or give it to the nurse if you have a nurse that's

00:40:50.719 --> 00:40:52.739
willing to do that. Not all are, but they should

00:40:52.739 --> 00:40:56.699
be. So, you know, I like to push the tubes now.

00:40:56.860 --> 00:40:58.039
I don't know. What do you think about that? I

00:40:58.039 --> 00:40:59.840
agree. And I think that actually makes perfect

00:40:59.840 --> 00:41:01.800
sense. And I wanted to also just kind of harp

00:41:01.800 --> 00:41:04.199
on your point about like split custody families

00:41:04.199 --> 00:41:06.000
or where there's more than one environment that

00:41:06.000 --> 00:41:07.329
they're living. They're always, you know. at

00:41:07.329 --> 00:41:10.170
one person's house for care during the day. They

00:41:10.170 --> 00:41:11.789
go to someone else's house for care during the

00:41:11.789 --> 00:41:13.469
night. The collaboration between the caregivers

00:41:13.469 --> 00:41:15.389
and the fact that they're both online and doing

00:41:15.389 --> 00:41:17.610
the same page for eczema is really, really important.

00:41:17.809 --> 00:41:20.389
I mean, it is for any chronic disease, anything

00:41:20.389 --> 00:41:22.170
where you're looking at prevention as part of

00:41:22.170 --> 00:41:24.349
the cure. But if you're always doing one thing,

00:41:24.409 --> 00:41:26.150
but maybe grandma's doing something a little

00:41:26.150 --> 00:41:28.070
bit different or isn't really on board, or maybe

00:41:28.070 --> 00:41:30.190
dad's not doing the same thing, or dad's doing

00:41:30.190 --> 00:41:32.889
one thing and mom's doing another, or vice versa,

00:41:32.969 --> 00:41:35.489
however it is, and the child's really only getting

00:41:35.489 --> 00:41:37.289
the appropriate treatment, for half the time

00:41:37.289 --> 00:41:39.469
or is getting bathed every day, you know, for

00:41:39.469 --> 00:41:41.429
four days of the week and then not getting bathed

00:41:41.429 --> 00:41:44.190
for three days, it's not going to work. And so

00:41:44.190 --> 00:41:45.889
we always try to encourage that everybody comes

00:41:45.889 --> 00:41:47.829
to the appointment or there's really good, clear

00:41:47.829 --> 00:41:50.050
communication for this purpose or we'll write

00:41:50.050 --> 00:41:52.030
out instructions, we'll write out, we'll give

00:41:52.030 --> 00:41:53.929
out education and try to make sure that everybody's

00:41:53.929 --> 00:41:56.309
on the same page. Because again, if there's any

00:41:56.309 --> 00:41:58.469
kind of, you know, different people are doing

00:41:58.469 --> 00:42:00.650
things in a different fashion, any kind of different

00:42:00.650 --> 00:42:03.449
caregiver, that's going to just go out the window

00:42:03.449 --> 00:42:05.250
right away. And all of your good efforts just

00:42:05.250 --> 00:42:07.800
kind of. get wasted. So it's very common and

00:42:07.800 --> 00:42:09.760
we see that a lot in our kids. And so it's something

00:42:09.760 --> 00:42:11.260
that could be really helpful to keep in the back

00:42:11.260 --> 00:42:13.380
of your mind. So up until now, we've kind of

00:42:13.380 --> 00:42:14.840
been talking about the stuff that you need to

00:42:14.840 --> 00:42:18.079
do every day, no matter what, for as long as

00:42:18.079 --> 00:42:20.460
you have eczema or I guess as long as you care

00:42:20.460 --> 00:42:22.880
about it. Let's switch gears just slightly and

00:42:22.880 --> 00:42:25.500
kind of wrap up this session with a discussion

00:42:25.500 --> 00:42:27.840
around some of the prescriptions that we have

00:42:27.840 --> 00:42:30.579
available for helping out specifically with flares

00:42:30.579 --> 00:42:33.420
and also for helping to prevent flares. For me,

00:42:33.460 --> 00:42:36.019
that's topical corticosteroids. at the top of

00:42:36.019 --> 00:42:40.039
my armamentarium. It's still the mainstay of

00:42:40.039 --> 00:42:42.239
therapy for mild to moderate atopic dermatitis

00:42:42.239 --> 00:42:45.599
for me. How about your approach? Yep, absolutely.

00:42:45.880 --> 00:42:48.639
Over-the-counter hydrocortisone 1%. Sometimes we'll go to

00:42:48.639 --> 00:42:50.519
the 2 .5%, which you need a prescription for.

00:42:50.699 --> 00:42:53.599
And then, yeah, absolutely. That's the first

00:42:53.599 --> 00:42:55.420
thing. That's go-to. That's what we refill.

00:42:55.659 --> 00:42:58.019
That's what we usually say. Generally, you don't

00:42:58.019 --> 00:42:59.699
even need to come in to see us if this is what's

00:42:59.699 --> 00:43:02.599
going on. Are you comfortable prescribing? more

00:43:02.599 --> 00:43:06.360
potent steroids than hydrocortisone 2 .5%? I

00:43:06.360 --> 00:43:08.199
will, yeah, especially if we know it's a reliable

00:43:08.199 --> 00:43:11.039
caregiver. We know there's going to be good feedback.

00:43:11.159 --> 00:43:12.460
We know that they're going to either send us

00:43:12.460 --> 00:43:14.320
pictures through our medical record system or

00:43:14.320 --> 00:43:15.559
they're going to come in if there's a problem.

00:43:15.639 --> 00:43:19.739
Yeah, I do. So I'll use some a little bit stronger

00:43:19.739 --> 00:43:21.960
steroids. So I'll use the triamcinolone. I'll

00:43:21.960 --> 00:43:24.400
use fluocinonide, you know, depending on the case

00:43:24.400 --> 00:43:26.940
and the situation, Stuff like that. Past that,

00:43:27.800 --> 00:43:30.179
That's your territory, sir. That's where I start

00:43:30.179 --> 00:43:32.739
to really send it to you. No, I think that's

00:43:32.739 --> 00:43:35.579
great. Oh, and then we will often use certain

00:43:35.579 --> 00:43:37.340
other medications. I'm trying to avoid using

00:43:37.340 --> 00:43:38.880
brand names, but I'm going to end up using Singular.

00:43:39.219 --> 00:43:42.320
So, Montelukast or an antihistamine of some sort

00:43:42.320 --> 00:43:44.119
as well in conjunction to help with some of the

00:43:44.119 --> 00:43:46.380
itching, some of the other kind of atopy and

00:43:46.380 --> 00:43:48.099
allergy symptoms that we think could possibly

00:43:48.099 --> 00:43:50.360
be causing some issues with the kids. So we try

00:43:50.360 --> 00:43:52.820
to kind of maximize out as much as we can before

00:43:52.820 --> 00:43:54.579
we send them to you, just because sometimes it's

00:43:54.579 --> 00:43:56.679
hard to find you. And so therefore, we try to

00:43:56.679 --> 00:43:58.210
do as much as we can. we can and then we send

00:43:58.210 --> 00:44:00.090
them off to you. We wrap them up as best we can.

00:44:00.599 --> 00:44:03.480
No, I think that's wonderful. And here, so we

00:44:03.480 --> 00:44:05.619
just talked about the differences between lotions,

00:44:05.619 --> 00:44:07.539
moisturizing creams, and ointments. You have

00:44:07.539 --> 00:44:09.940
the same vehicle selection available to you,

00:44:10.019 --> 00:44:12.440
but here's where I do actually favor an ointment.

00:44:12.519 --> 00:44:16.280
It does tend to penetrate the skin and allow

00:44:16.280 --> 00:44:18.519
the medicine to get delivered into the skin a

00:44:18.519 --> 00:44:20.920
little bit more potently than some of the other

00:44:20.920 --> 00:44:23.639
vehicles. It also tends to have less preservatives

00:44:23.639 --> 00:44:25.599
in it. So if you're going to use something like

00:44:25.599 --> 00:44:29.480
Triamcinolone, I think Triamcinolone 0 .1% ointment,

00:44:29.500 --> 00:44:32.619
that's medium strength steroid, you could use

00:44:32.619 --> 00:44:35.000
that medicine safely on really, I mean, unless

00:44:35.000 --> 00:44:37.179
you're talking about the smallest preemie, you

00:44:37.179 --> 00:44:39.880
could use that safely on a kid's arms, legs,

00:44:40.019 --> 00:44:44.309
chest, back twice a day. For no more than two

00:44:44.309 --> 00:44:46.190
weeks straight, you would have zero problems

00:44:46.190 --> 00:44:48.769
doing that. Up on the face, I really wouldn't

00:44:48.769 --> 00:44:50.889
use triamcinolone more than maybe three to five

00:44:50.889 --> 00:44:54.409
days without somebody knowing about it, especially

00:44:54.409 --> 00:44:56.750
not around the eyes. You don't want to get that

00:44:56.750 --> 00:44:58.550
steroid up around the eyes because it can...

00:44:58.550 --> 00:45:01.170
One of the ways it works is it's a vasoconstrictor,

00:45:01.170 --> 00:45:03.170
so it tightens the blood vessels, and that can

00:45:03.170 --> 00:45:06.210
lead to some damage. Specifically up in the eye,

00:45:06.250 --> 00:45:09.170
it can cause something called glaucoma or cataracts

00:45:09.170 --> 00:45:12.800
with the... is another side effect. But it's

00:45:12.800 --> 00:45:14.820
super rare. You would have to really use that

00:45:14.820 --> 00:45:17.400
medicine a lot longer than what I just detailed.

00:45:17.559 --> 00:45:19.659
The ointments, because they don't have as many

00:45:19.659 --> 00:45:21.900
of the preservatives that some of the cream formulations

00:45:21.900 --> 00:45:24.559
do, they also sting less when you put it on open

00:45:24.559 --> 00:45:26.960
skin. So you should very much be comfortable

00:45:26.960 --> 00:45:30.480
using something like Triam 0 .1% ointment. And

00:45:30.480 --> 00:45:32.159
then I think you mentioned Fluocinonide. That's

00:45:32.159 --> 00:45:34.079
even stronger than Triam. That's about the second

00:45:34.079 --> 00:45:37.860
from the top. And that's like my, if I'm using

00:45:37.860 --> 00:45:39.860
Lidex ointment, that's the brand name for Fluocinonide.

00:45:39.980 --> 00:45:43.119
If I'm using fluocinonide, then that kid needs

00:45:43.119 --> 00:45:47.360
some quick acute relief, but I'm very, very comfortable

00:45:47.360 --> 00:45:49.760
using that medicine. It's great. Those are usually

00:45:49.760 --> 00:45:52.579
the kids for that that I see that have, like

00:45:52.579 --> 00:45:54.059
I said, we talked a little bit last week about

00:45:54.059 --> 00:45:55.800
some of that really thicker lichenified skin,

00:45:56.039 --> 00:45:58.940
really thicker. They're generally older kids.

00:45:59.039 --> 00:46:00.880
I really haven't had to use that on younger kids,

00:46:00.980 --> 00:46:03.480
but to your point, more acute. I need to kind

00:46:03.480 --> 00:46:05.039
of get in there a little bit faster. I really

00:46:05.039 --> 00:46:07.239
write for that much, much less, but it does tend

00:46:07.239 --> 00:46:09.610
to be much. more effective more quickly. Now,

00:46:09.610 --> 00:46:11.030
here's another chance for you to tell me I'm

00:46:11.030 --> 00:46:12.889
doing something wrong. I always tell my patients

00:46:12.889 --> 00:46:14.989
to put that medicine on first and then cover

00:46:14.989 --> 00:46:17.510
it with a moisturizer cream. I like the putting

00:46:17.510 --> 00:46:22.030
it on first. We used to absolutely teach that

00:46:22.030 --> 00:46:24.210
and believe that, geez, if you did it the wrong

00:46:24.210 --> 00:46:26.210
way, it would screw something up. Somebody did

00:46:26.210 --> 00:46:27.989
a study, I forget who or else I'd give them credit

00:46:27.989 --> 00:46:30.170
for, where it turns out it didn't really make

00:46:30.170 --> 00:46:32.510
much of a difference if I'm being academic about

00:46:32.510 --> 00:46:35.530
it. But I think it... From a practical perspective,

00:46:35.769 --> 00:46:37.949
you're delivering the flare-reducing medication

00:46:37.949 --> 00:46:41.030
directly to the flare, and then you are moisturizing

00:46:41.030 --> 00:46:43.489
over the top of that. That's exactly how I do

00:46:43.489 --> 00:46:47.429
it. I like the medicine first and then the moisturizer.

00:46:47.630 --> 00:46:49.769
So you're cool on that. Look, I'm like two for

00:46:49.769 --> 00:46:51.670
27 at this point. That's exciting. Well, here,

00:46:51.690 --> 00:46:53.710
let me see if I catch you on this one. No, please.

00:46:54.329 --> 00:46:57.550
Well, most people don't give – there's two camps.

00:46:57.730 --> 00:47:00.570
There's the people who are steroid-phobic, and

00:47:00.570 --> 00:47:03.309
there's people who overuse it. I probably overuse

00:47:03.309 --> 00:47:05.679
it. Keep going. I want to hear the question.

00:47:05.980 --> 00:47:08.579
Well, again, if you're doing it under two weeks,

00:47:08.800 --> 00:47:12.119
you're probably safe. And that includes like,

00:47:12.219 --> 00:47:14.579
okay, remember, you're not swimming in this.

00:47:14.659 --> 00:47:18.340
And if little Johnny has eczema on his antecubital

00:47:18.340 --> 00:47:21.199
fossa - the crooks of his arms - you're not bathing

00:47:21.199 --> 00:47:23.860
him entirely in triamcinolone. You're just putting

00:47:23.860 --> 00:47:26.340
it on the areas where he's flaring, right? So

00:47:26.340 --> 00:47:28.659
if you did that for up to two weeks, and what

00:47:28.659 --> 00:47:31.079
I actually tell my patients is "Do it until the

00:47:31.079 --> 00:47:34.510
red, itchy, rough skin goes away. plus two days,"

00:47:34.750 --> 00:47:36.550
Right? Because there's always a little micro-

00:47:36.550 --> 00:47:38.750
inflammation that you can't see. But if you're

00:47:38.750 --> 00:47:41.070
doing that and you're under two weeks, you are

00:47:41.070 --> 00:47:43.849
reasonable to do that. That's easy. And then

00:47:43.849 --> 00:47:46.250
if you really want to be safe, give me a week.

00:47:46.639 --> 00:47:50.260
before you use it in that SAME spot. But if eczema

00:47:50.260 --> 00:47:52.940
pops up on the leg, treat that as if it's never

00:47:52.940 --> 00:47:55.519
been treated before, up to two weeks. And a lot

00:47:55.519 --> 00:47:57.320
of people don't get that, Not the clinicians

00:47:57.320 --> 00:47:59.460
so much, but the patients say, "Well, you told

00:47:59.460 --> 00:48:01.619
me not to use it after two weeks!" No, no, You

00:48:01.619 --> 00:48:04.340
can use it again, just maybe not in the same

00:48:04.340 --> 00:48:06.699
spot, Give a little break, and then use it certainly

00:48:06.699 --> 00:48:08.960
in a new spot that pops up. Do you ever run into

00:48:08.960 --> 00:48:12.460
that problem? So I usually do a week. I usually

00:48:12.460 --> 00:48:15.510
tell the patients a week. twice a day for a week

00:48:15.510 --> 00:48:17.889
underneath the moisturizer and then just continue

00:48:17.889 --> 00:48:19.789
the moisturizer, stop the medication, use the

00:48:19.789 --> 00:48:21.769
moisturizer. But I do tell them that if it does

00:48:21.769 --> 00:48:23.650
come back and they have to do it again, restart

00:48:23.650 --> 00:48:26.289
the whole process for a week. So it's similar.

00:48:26.530 --> 00:48:28.449
We're in line. Yeah, very reasonable. Three out

00:48:28.449 --> 00:48:32.389
of 27. I got through medical school with those

00:48:32.389 --> 00:48:36.070
grades. Yeah. One other thing that the sort of

00:48:36.070 --> 00:48:38.389
the other. flip side of the people who might

00:48:38.389 --> 00:48:40.829
be using it too much are the people who are afraid

00:48:40.829 --> 00:48:44.289
of the product. And I've figured out, actually

00:48:44.289 --> 00:48:46.849
to give credit to my mentor, a guy named Larry

00:48:46.849 --> 00:48:49.329
Eichenfield, MD out at Children's San Diego, he stressed

00:48:49.329 --> 00:48:52.630
when he was teaching us, make them show you,

00:48:52.690 --> 00:48:56.030
i .e. bring in the product, make them show you

00:48:56.030 --> 00:48:59.289
how much of the steroid they've used. We know

00:48:59.289 --> 00:49:02.820
it takes about 30 grams. like minimum to cover

00:49:02.820 --> 00:49:05.579
an average adult in terms of body surface, right?

00:49:05.579 --> 00:49:07.460
So now you're not doing that - i just made the

00:49:07.460 --> 00:49:08.980
point that you're not covering the entire body -

00:49:08.980 --> 00:49:11.719
but just to frame it like a 30 gram tube you'd

00:49:11.719 --> 00:49:13.320
have to throw that in the garbage if you really

00:49:13.320 --> 00:49:14.900
were going to cover somebody from head to toe

00:49:14.900 --> 00:49:17.239
so if you give someone a 30 gram tube of triamcinolone

00:49:17.239 --> 00:49:19.239
ointment for like let's say a six-year-old

00:49:19.239 --> 00:49:21.800
and said i'll see you back in nine months you're

00:49:21.800 --> 00:49:25.000
not going to just need one 30 gram tube, so you

00:49:25.000 --> 00:49:28.099
give some refills.  Okay you now have no idea how

00:49:28.099 --> 00:49:31.050
many refills the family have have gone.  So you

00:49:31.050 --> 00:49:32.809
have to ask that and you have to look at the

00:49:32.809 --> 00:49:35.750
cream or the tube, I should say. You look at

00:49:35.750 --> 00:49:37.250
the tube and you say, okay, how much of that

00:49:37.250 --> 00:49:39.750
would you use in a day? And they might say the

00:49:39.750 --> 00:49:41.570
whole tube or they might say, oh, just a little

00:49:41.570 --> 00:49:43.889
smidgen. No, you know, you got to actually divide

00:49:43.889 --> 00:49:46.429
it out for them and show them, geez, in a normal

00:49:46.429 --> 00:49:48.530
amount of time, this is how much of that medicine

00:49:48.530 --> 00:49:50.849
you should go through. And to me, that totally

00:49:50.849 --> 00:49:54.449
resets their expectations and safety profile

00:49:54.449 --> 00:49:57.449
as they approach the question, "Is this safe for

00:49:57.449 --> 00:50:02.739
my kids?"  Ever use oral steroids for eczema? if

00:50:02.739 --> 00:50:05.280
you are doling out oral steroids in this day

00:50:05.280 --> 00:50:09.039
and age and I'm talking mostly like in an urgent

00:50:09.039 --> 00:50:13.239
care facility, in the ER. You're doing that with,

00:50:13.320 --> 00:50:15.480
I think, good intent. You want to help the patients.

00:50:15.659 --> 00:50:18.099
You want to help them quickly. But what you don't

00:50:18.099 --> 00:50:21.139
see is that two or three days after those steroids

00:50:21.139 --> 00:50:23.420
have worn out, there is a phenomenon called "rebound"

00:50:23.420 --> 00:50:27.739
where it will come raging back. Sometimes, often times

00:50:27.739 --> 00:50:31.159
worse than what it was originally. Now, on top

00:50:31.159 --> 00:50:33.699
of that, if you have any concern of a topical

00:50:33.699 --> 00:50:35.630
steroid, which I'm going to hopefully... the

00:50:35.630 --> 00:50:38.170
education part of this show is to get you to

00:50:38.170 --> 00:50:40.289
not be so scared of a topical steroid. If you're

00:50:40.289 --> 00:50:43.289
using it correctly, Oral steroids on the, on

00:50:43.289 --> 00:50:46.710
the flip side have a tremendous number of side

00:50:46.710 --> 00:50:49.869
effects. I mean, very quickly in a long, if you

00:50:49.869 --> 00:50:51.889
were doing like a six week course of oral steroids

00:50:51.889 --> 00:50:53.869
for something like poison Ivy, you do have to

00:50:53.869 --> 00:50:56.900
think about osteo. well, not osteoporosis, but

00:50:56.900 --> 00:50:59.300
there is some bone absorption that's happening

00:50:59.300 --> 00:51:01.599
from those steroids in the first two to three

00:51:01.599 --> 00:51:06.039
weeks of oral use. There is a true risk of Cushing's.

00:51:06.119 --> 00:51:09.880
There is a true risk of thinning the skin, eye

00:51:09.880 --> 00:51:12.159
changes like the glaucoma and cataract we talked

00:51:12.159 --> 00:51:14.500
about. And there are behavioral changes in those

00:51:14.500 --> 00:51:16.960
kids during the use. So those kids are hungry

00:51:16.960 --> 00:51:19.039
and they are cranky and they are mad and they're

00:51:19.039 --> 00:51:21.659
not learning things in school and they're unpleasant.

00:51:22.679 --> 00:51:25.059
They're generally unpleasant children when that

00:51:25.059 --> 00:51:28.239
happens. So I really do try to avoid oral steroids.

00:51:28.320 --> 00:51:30.900
I mean, I don't think I've ever done an oral

00:51:30.900 --> 00:51:33.539
steroid for an eczema kid. I've done oral steroids

00:51:33.539 --> 00:51:36.380
plenty of times in dermatology, but I think over

00:51:36.380 --> 00:51:38.500
20 years, I don't think I've done an oral steroid

00:51:38.500 --> 00:51:41.760
for a kid. There are other answers to acute.

00:51:42.590 --> 00:51:46.349
quick fixes that we've got now, especially in

00:51:46.349 --> 00:51:48.989
the last couple of years. So please, if you have

00:51:48.989 --> 00:51:52.050
the ability to NOT do an oral steroid, either

00:51:52.050 --> 00:51:54.409
by the fact that you're the clinician that could

00:51:54.409 --> 00:51:56.969
prescribe it, resist that, what am I trying to

00:51:56.969 --> 00:52:00.000
say? Don't scratch the itch. Thank you. Don't

00:52:00.000 --> 00:52:02.420
scratch the itch. I love it. And if you're a

00:52:02.420 --> 00:52:04.179
patient - That's like four out of 27 for me.

00:52:04.219 --> 00:52:06.820
We need to stop right now. I'm done now. We have

00:52:06.820 --> 00:52:08.780
to stop recording. And we're finished while I'm

00:52:08.780 --> 00:52:10.760
ahead. All right. So that was a great way to

00:52:10.760 --> 00:52:12.679
end, I think. You know, talking about - I win.

00:52:12.860 --> 00:52:15.579
We are starting. Yeah, you did. Let's end on

00:52:15.579 --> 00:52:17.300
a winning note. I mean, I guess I'll throw in

00:52:17.300 --> 00:52:19.699
a plug. There are some ways to extend those days

00:52:19.699 --> 00:52:21.719
where you're not flaring. You mentioned Elidel.

00:52:21.860 --> 00:52:25.019
Elidel is pimecrolimus. There's another generic

00:52:25.019 --> 00:52:26.920
called tacrolimus, which is sold under the brand

00:52:26.920 --> 00:52:30.050
name Protopic. These are topical calcineurin inhibitors.

00:52:30.110 --> 00:52:33.639
Your pediatrician or dermatologist or pediatric

00:52:33.639 --> 00:52:35.739
dermatologist might prescribe these. They have

00:52:35.739 --> 00:52:38.980
been deemed safe. And originally, they were a

00:52:38.980 --> 00:52:40.460
little scary because they came with what's called

00:52:40.460 --> 00:52:42.679
a "black box" warning, which, geez, could these

00:52:42.679 --> 00:52:45.599
things cause skin cancers? Well, that warning

00:52:45.599 --> 00:52:49.280
was removed in Canada in 2021. It's been now

00:52:49.280 --> 00:52:51.719
approved down to kids three months or older in

00:52:51.719 --> 00:52:54.800
Canada. In the United States, it's still pimecrolimus

00:52:54.800 --> 00:52:57.760
is greater than two years of age. And tacrolimus

00:52:57.760 --> 00:53:01.960
is - It depends on what strength. For 0.03%, it's

00:53:01.960 --> 00:53:04.900
greater than two years of age. And for the 0.1%,

00:53:04.900 --> 00:53:09.039
the stronger, it's 16 or older. But we know

00:53:09.039 --> 00:53:10.739
that this medicine, which has been studied in

00:53:10.739 --> 00:53:13.519
many registries over the years, this is a safe

00:53:13.519 --> 00:53:15.980
alternative to putting steroid on every day.

00:53:16.019 --> 00:53:17.780
And you should really embrace that as a way to

00:53:17.780 --> 00:53:20.219
decrease some of the flares that you got. But

00:53:20.219 --> 00:53:22.559
with that, I think we'll take the opportunity

00:53:22.559 --> 00:53:24.920
to wrap this up and maybe do a little further

00:53:24.920 --> 00:53:27.639
education on some of the... big hitter medications

00:53:27.639 --> 00:53:30.539
down the line. But thank you, Dr. Walty, for

00:53:30.539 --> 00:53:33.320
joining us and adding to the discussion that

00:53:33.320 --> 00:53:35.840
we had previously. I think, you know, for anyone

00:53:35.840 --> 00:53:38.300
who was unfamiliar with eczema coming in, they

00:53:38.300 --> 00:53:42.239
probably got an earful. Maybe too much. But no,

00:53:42.300 --> 00:53:44.579
I appreciate the invitation. I learned some things.

00:53:44.619 --> 00:53:46.940
So that was good. Well, as always, it's a pleasure

00:53:46.940 --> 00:53:49.519
working with you. And thank you for joining us.

00:53:53.159 --> 00:53:55.539
Thanks for tuning in to this episode of the Don't

00:53:55.539 --> 00:53:58.280
Be Rash Pediatric Dermatology Podcast. I'm your

00:53:58.280 --> 00:54:00.739
host, Dr. Andrew Krakowski. Don't forget to subscribe

00:54:00.739 --> 00:54:02.960
to our show on your favorite podcast platform

00:54:02.960 --> 00:54:06.760
and check out dontberash.org for more information.

00:54:06.960 --> 00:54:09.260
A special thank you to our nonprofit sponsor,

00:54:09.519 --> 00:54:11.960
the St. Luke's University Health Network, for

00:54:11.960 --> 00:54:14.360
making this episode possible. Until next time,

00:54:14.400 --> 00:54:17.059
remember:  :Keep calm and don't be rash!"