Welcome to the Don't Be Rash Pediatric Dermatology
Podcast, the owner's manual for your kid's skin.
I'm your host, Dr. K, board-certified pediatric
dermatologist and father of two boys. I'm here
to chat with you to promote dermatological education
and improve skin health in our children everywhere.
Let's get started. Welcome to Don't Be Rash,
the pediatric dermatology show, coming to you
from beautiful, historic Bethlehem, Pennsylvania.
I'm your host and board-certified pediatric
dermatologist, Dr. Andrew Krakowski. On today's
show, we're going to continue to scratch the
surface of eczema. In Part One, we discussed
the clinical look and feel of atopic dermatitis,
eczema, and explored some of the underlying reasons
why your child might be prone to developing it.
Today, we're going to devote our energies to discussing
the science-based approach to management and
treatment of this chronic condition.
Joining me again as co-host is our very special
guest, Dr. Alicia Walty, Chief Medical Officer
for Star Community Health. Welcome back, Dr.
Walty. Thanks for joining today. Anytime. I'm
happy to be here. Since we last spoke, how many
eczema patients have you seen since we did part
one of the show? Definitely a handful. I will
say that. It's not just one or two, so probably
a few. I've done quite a few med refills since
then. Thank you. Yeah, I think it's been on my
radar as well. Man, I'm feeling like maybe every
three or four kids coming into clinic with this
dry weather has eczema or we discover it on him
or her. So pretty relevant to the times. Absolutely.
Yeah. And definitely in some babies too. Everything
we talked about is definitely timely. Well, I
guess we'll jump right in. Usually for the first
thing that I'm doing when I'm thinking about
developing a management plan around a chronic
condition like eczema, and what do I mean by
that? The definition, just to remind everyone,
to have eczema, you have to have an itchy rash
that comes and goes. And that means even someone
like Dr. Walty or someone like myself with all
of the resources that we have as physicians,
all of the prescriptions and access to great
medicines that we've got, even our own children,
if they had eczema, if they have a diagnosis
of eczema, we would expect that the rash is going
to come and go. There's nothing that we can do
about it in the sense that you can't cure it.
There's no magic bullet. What I try to instill
in my patients is that there's two equally important
goals when you're managing eczema. The first
is when you have a flare. And just to remind
everyone what a flare is, that's when you have
red, rough, itchy skin. You want to decrease
the amount of time, days, hours, whatever you
want to use as your time period. But let's say
days. You want to decrease the number of days
that a flare is present on the child. Equally
just as important is the second goal of... managing
eczema which is increasing the days between a
flare. Now again you can't cure it but you can
with really good skin hygiene, great moisturizer
use, proper cleanser selection and all the other
stuff we'll talk about as well as prescriptions.
you can increase those days in between the flares
such that you might get a flare only seasonally
or once or twice a couple times a year. You know,
that's kind of what my goal is. Do you have different
goals when you approach this with your families?
No, that's really exactly what I tell them is
that it is probably going to come back based
on age. They are going to definitely see the
flares. We talked in the last episode about trying
to identify what some of those triggers could
be for those flares, which sometimes we can find,
sometimes we can't. But I try to really, again,
say, almost exactly the same thing you do. Fewer
days on medication, the better. The most that
we can manage with just kind of over -the -counter
products, moisturizers, creams, things like that,
and make the baby or make the child less itchy,
less uncomfortable. We kind of look at days that
they'd have to leave school, days that they are
complaining of being itchy, days that they'd
need other medication just for itching or scratching
or things like that. And then as they get older,
goals kind of switch a little bit to more social
goals. So are they comfortable with how they're
looking? Are they not being uncomfortable going
out or wearing... and clothes, things like that.
Yeah, and for me, I mean, I get a... sort of
a pulse check. As soon as I walk in the room,
I can many times just tell what I'm dealing with
in terms of the severity, clinical severity of
these patients. But I think you tapped on a really
just as important point, the psychosocial impact,
not only on the patient, but also on the family,
the people who are taking care of the patient
directly or indirectly, right? So you can see
what it's doing to school performance, or at
least you can hear it if you ask, if you take
the time to ask. But then really where you're
like, When you're doing eczema really well on
an expert level and you're part of a specialty
clinic, you start diving in and getting past
the. should I say embarrassment of asking the
mom or dad or both, if they happen to be there,
how, how is eczema as a condition impacting your
life? And you hear, geez, you know, I can't,
I'm not getting a good night's sleep. Maybe it's
that my, my child needs to co -sleep with me
in bed and they're scratching. So now I'm up
all night and that's messing me up. I'm, I'm
at, I'm up for a promotion, but geez, it's, I
don't think it's going to go well because I'm,
I look like I haven't slept in 40 hours cause
I haven't, you know, or. You hear from a family
that a mom and dad or whomever, hey, this is
affecting marital relations. Who has time for
anything when the lights turn off? We're trying
our hardest to deal with what we've got in front
of us, and it's already draining all of the energy
that we've got. So it's kind of a real flog in
terms of how it hits home. But I start with clinical
severity, and I kind of just... instinctively
use, in my mind, the easy grade of, is the kid
clear or does he or she have mild, moderate,
or severe eczema? And that kind of frames what
we're talking about in terms of how I approach
it. Any differences from your end? Nope, exactly
the same. Same thing. And then again, really
taking into consideration the age of the patient.
So there's a few different branches that you
could take if it's a baby versus an older child.
Is the patient going to be applying the medicine
or is a parent applying the medicine? And then
obviously payer. Some of these medications can
be expensive. So that kind of always plays in
the back of our mind. What can we do without
kind of breaching that arena first? What can
we try before hitting that if it's possible?
Sometimes it's not. Sometimes that's just not
something that's going to be feasible. But yeah,
those are exactly the same things that kind of...
of run into our mind. Yeah, financial costs are
certainly a burden also to consider in this condition.
But for me, a lot of times, and I guess I should
say for the audience's sake, we're mostly going
to be talking about mild to moderate eczema today.
You could devote an entire four shows to moderate
to severe and severe eczema and all the medications
that exist for that and sort of the intricacies
of managing those conditions. But do know that
everything we say today for mild to moderate,
atopic dermatitis would apply to your moderate
and severe patients as well. One of the things
that I've really tried to stress to the people
that I train in clinic to become the next generation
dermatologist is to look for pink. That's the
redness, the erythema that is a part of a flare,
atopic dermatitis, but then it's that special
red that tells me, geez, this kid might be colonized
by bacteria. There might be some Staph aureus
or strep bacteria that has gotten into the sort
of nooks and crannies of this child's eczematous
skin and has taken hold. And now I know that
if I don't treat that colonization of the bacteria
on the skin, that that can lead to a true infection
like impetigo or even worse like cellulitis.
And I'm also looking for that dreaded, I think
you mentioned it in the last show, that dreaded
eczema herpeticum. The virus, herpes virus that
gets into the skin, spreads like wildfire across
open flaring eczema and has a morbidity associated
with it. I mean, let's not pull any punches here.
People have died from overwhelming infections
from those conditions. Yeah, we've definitely
seen kids hospitalized for secondary problems
due to their eczema. And it's sad because most
of the time. It is preventable. I don't want
to go out and say that the parents were aware
of that. I think, again, most of the time people
are not aware of the different treatments that
are available to them. But we've definitely had
some hospitalizations over the years. I've been
lucky. I haven't seen anything super serious.
You know, these kids are admitted. They are missing
school. They do have IVs. They do have treatments.
They do have significant secondary markings and
scarring and things like that. And a lot of that
really is preventable. So it's something that
we can work on. bacterial swabs and HSV cultures
on these kids? Or is that something that you
kind of let us do? Or what's your approach? I
do now since our last podcast. Oh, really? Since
you schooled me on it. I would say that I usually
have not, unless I really suspect that there's
something a little bit different going on. Typically,
the antibiotics that most general pediatricians
would use for a co-infection kind of cover.
fairly well, your Staph bacteria and your Strep
bacteria. So most of those antibiotics that we
would use do cover those more common bacteria.
If we think it's not working or if we think there
could be resistance, obviously MRSA (methicillin-resistant Staph aureus), which is
a bacteria that is a bit more resistant to some
of those antibiotics, then we would use a different
antibiotic. Some of us actually tend to go to
the standard medication used for MRSA anyway.
So some of us use those medications kind of more
routinely. The culture isn't necessarily getting
us a whole lot of frontline treatment. Some of
us will only use the culture if we've noticed
that what we've tried and prescribed isn't working
necessarily. I will say for eczema herpeticum,
I send out those HSV (Herpes Simplex Virus) cultures or a PCR, depending
on what the preferred lab is, wherever you're
working. I definitely send those because I don't
want to either A, miss that and overlook it,
especially if it's on the face, because there's
some additional risks, or genitals. And I generally
tend to do that as well, just to make sure that
I'm not missing a bacterial infection that could...
could present more in a bullous faction, like kind
of with those blisters. And I'm thinking it's
eczema herpeticum, but maybe it's not. Maybe
it's like a Staph aureus, something like that.
Just to kind of validate myself, I will order
those cultures. No, and I think that's quite
prudent. It's usually hard to miss a kid with
eczema herpeticum. Again, that's herpes-super
infected eczema, because these kids don't look
healthy. They look sick. They look unwell. They
tend to have fevers. They tend to have swollen
lymph nodes. I think it's very helpful when you
stop and look at the rash that is associated
with eczema herpeticum, you can get a lot of
information just from that. If you remember those
old school hole punchers that you used to hold
by hand, not the three ring binder punchers,
but the single use little kind of looks like
a stapler, but it's got a puncher. If you can
imagine you were holding one of those in your
hand and you were clicking the skin and punching
out little holes, that's exactly what uh herpeticum
looks like and it's got this distinctive look
we call it "monomorphic erosions" right so that
they all look the same and they're all little
erosions that's a real clue that you're dealing
with herpeticum and now this is super uncommon
in normal kids. It's not uncommon in eczema patients,
but most eczema patients don't get eczema herpeticum
just for the audience's sake here. But when they
have it, you have to treat it and you have to
treat it seriously. And that does usually lead
to at least a 10 -day course of either a medicine
called acyclovir or valcyclovir. And usually
when I'm worried that someone has eczema herpeticum,
I'm also, to your point, treating on top for
staph or strep super infection, because that's
not uncommon. Even if you came into the office
without having staph, or strep. Eventually, when
you have eczema or pedicum, that bacteria can
get in there as well. So you might as well cover
for both. And that's a real bummer when the kid
gets that. But also, to your point, the importance
of doing a PCR or viral culture to specifically
figure out the culprit. There's another entity,
which we didn't mention, called eczema coxacium,
which is actually hand -foot -mouth virus, very
common in kids. but can do exactly the same thing
as the herpes virus on top of eczema skin. It
can get in there and spread like wildfire. Totally
not herpes virus, and usually just something
that the kid kind of gets through to the other
side and is fine with. But differentiating those
sometimes does make a difference. But to your
point, if you're considering eczema herpeticum,
usually you would cover for the herpes virus
anyway, and then you're kind of safe. We're not
really talking about those patients in general
today. But for most kids, where do you start
in terms of your approach to managing eczema?
What's important to you? So just definitely...
daily care so the things that they're going to
need to do regardless of if there's flares if
there aren't flares if they're well if they're
sick kind of the vitamins for of their skin so
what are they using for moisturizer how often
are they bathing or showering how quickly are
they putting the moisturizer on after that what
kind of things are they using to wash their clothes
and the bed sheets so the really daily skin exposures
that they're seeing what can we do to kind of
toughen up the skin a little bit make sure that
the skin is healthy is not having any kind of
extra exposures to any triggers, really kind
of get the skin as primed and ready as we can
to be healthy. So almost more preventive measures
than it really is treatment. And I think that's
really key for the parents to understand is even
when those flares go away, you have to keep this
up. This is every day. This is you've still got
to grease up that baby every single day. Otherwise
you're going to fall back into that pattern again.
So I think even just looking at that preventative.
approach is something that we tend to really
harp on as pediatricians. Yeah, I think what
I'm hearing from you is, first off, that's not
a short visit, right? I mean, to have all that
explained correctly, this is a 20 to 30 minute
discussion, if you're lucky, sometimes longer
than that with all the questions that people
rightfully have. But for me, it's "education is
an intervention!" - right? So that's something I
try to stress in practice, whenever I'm talking
about eczema, education as itself is an intervention.
And it starts with getting correct resources,
trusted resources from trusted people. I personally,
I love it when I have a well-informed patient
who comes in who's pushing me to better explain.
True science, you know, instead of the person
who watched a TikTok video and says, geez, you
know, now I know that I know everything that
you do about eczema. And you're like, oh, okay,
well, that's great to know. Beef tallow is the
bane of my existence right now. I'm hearing about
this everywhere I look. That's disgusting. And
then, you know, to have 20 to 30 minutes is really
hard to do. Sometimes you have to bring the patient
back in just to make sure that, A, they got the
message. from the first meeting, and then B,
that they don't have follow-up questions that
you need to really go through with them. So that
to me is where I kind of start. And I like what
you said, prevention is really what you're focusing
on, but you're trying to give them the resources
for when they have an acute flare in the short
term, what to do. So I don't know about you,
but I get asked a ton of questions about food
allergens. Do you have any sort of go-to spiel
about? the role these food allergens may or may
not play. Only in very young babies where I'm
seeing more severe eczema and I'm seeing other
signs as well of food allergies. So babies that
are having milk protein allergy signs, so blood
in the stools, not growing as well as they should,
very fussy, colicky babies that in addition to
the fussiness and the colicky look like they're
having additional severe problems with eczema,
things like that. As they get older, I don't
tend to see that. But we do, obviously, if we
suspect that that's a part of it, we'll evaluate
for them. We'll refer out for further evaluation.
But it doesn't tend to change the treatment.
If you're still having a fairly infrequent breakout,
it doesn't tend to change the treatment for that.
Those are for the kids that are more moderate
to severe. We're not able to get them medication
-free. We're not able to get them to a point
that they're not flaring. They're kind of constantly.
having these more severe outbreaks, that's definitely
something we look at to see because there's constant
exposure to it. If we're having periods of being
clear in between, that tends not to be something
that rises. Yeah, I totally agree. For me, both
through 20 years of doing this, as well as the
way I was trained, some really good people within
the world of atopic dermatitis, as well as allergies
and asthma and gastroenteritis and eosinophilic
esophagitis, the concept that food allergens
would would be the primary cause. It certainly
is an appealing thought because geez, if you
just avoided those foods, you would have no eczema.
And we know that just by far most. atopic dermatitis
patients are not experiencing these exacerbations
because of something they're eating. And it would
be nice to say, geez, yes, avoid cow's milk or
egg or weed or peanut or whatever. But for most
kids, that's not doing anything. It's irrelevant
to the course of their atopic dermatitis. And,
you know, I for one just don't recommend dietary
interventions or elimination diets or anything
like that, except in a very, very small subset
of the most severe eczema patients, right? This
is not the normal off-the-street eczema patient
that you see. Clearly, there is a correlation
between what they're eating. And, geez, they're
having an anaphylactic reaction when they're
having some of these foods. And those are the
patients you have to manage with allergy and
immunology together. But 98% of my patient population
truly, I think, would be unaffected by a specific
food that they might be eating. The only time
I think I've really actually advised, again,
without the collection, of an allergist a dietary
change for skin reasons would be if I'm if it's
a younger baby and I'm putting them on a hypoallergenic
or hydros like one of those formulas and and
that's the only food the baby's eating at the
time so once kids are eating foods It's not something
that I would be doing without any kind of confirmatory
testing. And we don't do that in a vacuum. We
do that with, again, the dermatologist and the
allergist and things like that. What's your approach
to bathing? That's always a question. Do you
not bathe? Do you bathe? We bathe our kids way
too much in this country. I think generally,
what I usually tell, especially for newborns
and babies, is... you're wiping that baby already
and you're wiping the dirty areas of your non
-mobile infant already almost every time that
you are changing the diaper, if not every time
they're changing the diaper. So you do not need
to give that baby a bath. every single day or
twice a day. It's just not something that's necessary.
And in kids that have eczema, it can be even
less frequently. So I usually tell them every
other day. It can be really every two days. That's
fine. Obviously, if they're dirty, if you're
outside, if they're playing, you know, once they
hit toddler stage and they're filthy little munchkins,
then they're going to need to, you know, they're
going to need to bathe more. But when these are
tiny babies, when these are younger kids, when
these are toddlers that are, you know, it's winter,
they're not outside, they're not playing. We
don't need to bathe them as much as we generally
tend to think that we do. Unfortunately, kids
love the bath and they love sitting in the bath
and they love playing in the bath and they love
playing with their bath toys. And for kids that
have eczema, that's just not ideal. Unfortunately,
you kind of want to get them in, get them clean,
get them out, dry them off and grease them up
as quickly as you can with whatever moisturizer
they're using. So less frequently, less long,
less pruned up and shriveled, and then really
as much as you can just to make sure that you're
moisturizing as soon as you can get them out
of the bath or the shower. Now, 17-year-old
boys should get a shower every day. Seven times
a day and for 30 minutes each time, Yes. Perfect.
And then after an hour goes by, you should take
another shower just to make sure the first one's
stuck. Yeah, you might have missed a spot. Yes,
and there should be deodorant in every room of
the house. And if you pass it by, put it on.
Don't think about it. Just put it on. Just do
it. Just do it. Yes, that's very similar to my
approach for the young kids. I think right around
toddler, I do, I'm advocating for a short bath
once a day. There's really a lot of controversy
and inconsistency in the peds derm world of what
to do for bathing. Some people will say once
a week, some people will say once a day, Once
a week?. I mean, yes, there's some extremes. If
you're doing the bath, do you soak for long periods,
like you had mentioned, turn yourself into a
prune or raisin on purpose? My approach is short
bath, Five to 10 minutes max, lukewarm water.
Why? Real hot showers tend to take off more of
the natural oils you're supposed to have on your
skin. You're trying not to lose those as much
as possible. But then really from that, that's
my own personal take on showering or bathing.
What I tell families is I don't really care as
long as, right, as long as you are lubing up
with a solid moisturizer, which we'll talk in
a second, at least three times a day. And that's
the problem. Nobody ever really does that three
times a day. But geez, it almost doesn't matter.
Two, and I don't think they listen to me. So
no one's listening to you, Dr. Krakowski. Well,
we should say 10 and hope that they do it two
or three. I mean, that's really kind of what
we're going for. And I want to throw in super
quickly, it doesn't matter how often you bathe
your kid if you don't cut their nails short.
This is a huge thing for us is to always make
sure we're telling them, please keep the kids'
nails short because if they're even just a little
bit long. when they do that scratching that they
can't help themselves because they're so so itchy
that's what sets them up for risk and that really
makes it worse and that really lichenifies the
skin and thickens it so it's that scratching
with those nails if you can in the winter if
you can cover up the areas or in the summer if
it's on their ankles if you can get them to wear
pants or behind their knees if you can get them
to wear pants anything you can do to kind of
protect the area from the kids clawing at it
is going to be helpful. But we see these kids
that come in that are super, super, super clean,
but their nails are long and it's really, really
hard because that's what's going to cause the
problem. You're scratching, you're excoriating
the skin. Now the bacteria or the virus can get
into the skin more easily. So that's a great
question about bathing. Do you utilize bleach
baths at all for your population or is that something
you leave to us? So I leave that to you. The
only times that I would really recommend bleach
baths or that I have recommended bleach baths
is if we've had kids. that have had recurrent
either pustules or abscesses from MRSA. Otherwise,
I wouldn't. I have not done that, but maybe I
should be culturing more, like you said, and
then maybe I should be treating more, like you
said. Well, no, I mean, I think it's all patient
dependent. But for us, we use bleach baths probably
maybe four to five times a week. I'll recommend
that. seeing you know over 30 or 40 eczema patients
a week so it's not everybody who's walking out
the door gets a recommendation for bleach baths
by the way what are bleach baths for the for
the listening audience basically you are making
a swimming pool in your bathtub so a you have
to have a bathtub in your house that's uh that's
one thing that not everybody has so you have
to be aware of that there are some third -party
products that basically sell "swimming pool in
a bottle" that you can then put on your skin,
but they tend to be expensive and a bottle of
chlorine bleach - which is what we're talking about
here - is less than ten dollars at least since last time I've
been in the supermarket So it's way less expensive
to do it the bulk method for making a bleach
bath in your bathtub than it is to buy these
other products. But anyway, it's a careful mixture
of about a quarter cup to a half a cup of chlorine
bleach, regular strength Clorox, and you mix
that with a full tub of water and you swish it
around, make sure it's stirred evenly, not too
warm, not too cold. Lukewarm is what you're going
for. The kid sits in there for five minutes.
10 minutes tops. You can throw toys in there
too. They'll just get clean. It's literally like
swimming in a swimming pool. But the really important
part is one, you can overdo it. So I usually
tell my patients no more than three times a week,
Monday, Wednesday, Friday. Of course, if you
also have a patient that's swimming in a pool,
like winter swims going on right now in our house,
well, that counts. You're going to get extra
dry if you also come home after doing winter
swim for two hours and then get in your bleach
bath. So you have to kind of take that into account.
But the most important thing I have my patients
do after a bleach bath is rinse off with FRESH
water. And then they have to either medicate
if it's time to put the medications on the skin.
and or they have to moisturize immediately after
they do the bleach bath, after they've rinsed
off that chlorine. But I find that to be a useful
alternative adjunct, if you will, to knocking
down some of that bacterial colonization on the
skin. And I do find that it does keep down true
skin infections and keeps kids off of oral antibiotics
as much as you can. Do you recommend that for
patients that have sort of... Excoriated lesions,
lesions that they've already scratched or like
kind of, I don't want to say open lesions, but
do you recommend that for kids whose skin is
pretty actively inflamed or not so much? But
yeah, no, it really depends on how open you are.
So if you're concerned about that, then instead
of doing the half cup of bleach, which would
be the stronger recipe, I would do maybe an eighth
of a cup or a quarter of a cup and really just
do it less, really. That's as simple as that.
And then two or three days. doing the bleach
baths, you're going to find that you're going
to not be as excoriated. Some of those wounds
are going to have healed up because you're also
hopefully doing the topical steroids, the topical
moisturizers that you want. Now you can go in
and do the full strength ones. So that's a perfect
segue into what you look for in terms of a moisturizer.
I was about to say, but Dr. Krakowski, what moisturizer
should I use? Well, I mean, it's simple for me.
I get a lot of complicated questions about eczema,
drilling down on tiny things that may or may
not be that important. But at the end of the
day, for me, the foundation of good eczema care,
it comes down to the moisturizer and how many
times you're putting on a good moisturizer and
cream. I'll be very specific. Why am I making
a distinction between different products? And
some people don't even know that there is a difference.
There are different what we call "vehicles" in
dermatology. That is, the same ingredients might
be put into the same bottle, but how those ingredients
get delivered to the skin is the vehicle. And
you can have a vehicle. that it might be a foam,
it might be a gel. Typically, a gel is alcohol
-based. That tends to be drying. That would not
be a good product for eczema. And if I had to
think about it, I couldn't even name a gel -based
eczema product right now off the top of my head.
But you get into the larger, more sort of consumer
-based approach to "moisturizers"
and you're quickly hit in the head with having
to make a decision between the big three: Lotions,
Ointments, and Moisturizing Creams. And some
people would say, "Well, there is no difference.
It's the same thing, right?" No, big difference.
So a lotion, from the perspective of a dermatologist,
typically implies, and there's variations, but
the gist of it is you make a lotion similar to
how you might make Crystal Light or Kool-Aid,
the drink that you might enjoy in the spring
and summer. It's a powder mixed with water, just
a lot of powder. is what gives the lotion its
thicker consistency. And I try to impress on
my patients that everybody, no matter where you
live in the United States, you know if you're
in the middle of the summer and you take a glass
of water and you throw it out on the sidewalk
and you come back two to three hours later, no
matter where you live, that water has evaporated
into the atmosphere. It's gone. And that same
process happens when you put a lotion or any
product onto your skin. Just lotion, because
it's mostly water and powder, that's where it
clinically matters. Why? Well, the water portion
is going to evaporate off. And what are you left
with? The powder portion. So in dermatology,
if you had a weeping, oozing wound, which is
gross to think about, but if you did, we can
actually use a lotion to dry or to help dry out
that wound. because we take advantage of the
fact that the water component is going to evaporate
off and that powder will sit on your skin and
do the drying for us. So the trick with a lotion,
and the layperson just wouldn't know this, is
unless you are somehow thwarting the evaporation
process, a lotion might... actually be counterproductive
to your moisturizing efforts. How would you thwart
evaporation? Well, you'd have to put the lotion
on 24 hours a day, seven days a week. You'd just
have to constantly be swimming in lotion.
That would be one way. The other way would be
to put it on and then wrap yourself in Saran
wrap and keep the moisture in. But it's practically
impossible. Well, and not recommended in pediatrics.
You should not wrap your children in Saran wrap.
No, for a lot of reasons. So, yeah, lotions,
you have to look. In general, if you can pump
the product, you might want to look at it again
closely and make sure it's not a lotion because
you're missing out on – if you're doing the work,
you might as well get the benefit. You're missing
out on some of the benefit from a lotion. I've
been doing the right thing for all these years
and I didn't know it. I always tell people if
you can get it in a tub and it's boring, that's
probably the best thing to put on your skin.
Like if it has no scent, no smell, and it comes
in a big tub, then – i'm happy for you well i
like no smell we'll talk about the tubs i think
the tubs are more common in the second second
vehicle we'll discuss a little bit more in detail
called ointments that's your you know big tub
of vaseline or a product like Aquaphor, which
is a great product. These are wonderful.
I call them skin protectants right so you put
them on and they form a thick obvious barrier
between the outside world and the skin. That's
very useful. I've got no problem calling Aquaphor
out as being a great product. We use it for surgical
wounds in our clinic all the time. Same with
Vaseline. It's just cheaper. By the way, what's
the difference between Aquaphor and Vaseline?
Both are petrolatum-based, so they're petroleum
-based. Aquaphor does, I guess, literally and
figuratively rub some people the wrong way because
it contains lanolin, which is sheep's wool. And
that can be irritating to some people. But in
general, we have great success using those products
on top of, for example, like a stitch, a sutured
wound that we create in the clinic. It helps
protect the skin, keeps the dirt out, keeps the
environmental allergens out, and seals everything
off pretty nicely. The problem with it is, you
know from basic science class, oil and water
don't mix, right? So putting an oil-based product
onto your skin and hoping that somehow magically...
opposite to any true chemistry or law of physics,
how would you get moisture to come out of that
oil and into your skin? That's kind of the rub,
right? That was the most long-winded way of
saying, Walty, you've been doing it wrong that
I've ever heard. It was very nice. You even said
you know this from basic science class. That's
how far down you, that was how deep you dug.
But I appreciate the kindness and patience that
you just demonstrated. So thank you. Well, listen,
I mean, who would ever talk to somebody about
this stuff, right? It's kind of nuts. This is
good. I'm getting schooled and I appreciate it.
So this is very good. So the good news is you
don't have to be a scientist. science whiz. If
you're out there shopping in CVS or Rite Aid
and you're trying to find a good moisturizer,
the word moisturizer is in the thing I want everybody
to buy. Moisturizing Cream. This is usually a
concoction of water mixed with oil. It's developed
and formulated so that moisture will actually
be put into the skin, as well as getting some
of the effect of the oil on the skin as the barrier.
So it's a good compromise. I tend to also like
it because it blends in eventually. It doesn't
sit up on the skin like an ointment does. That
drives people crazy if it's coming through your
clothing or getting on your couch or your car
upholstery or whatever. Moisturizing creams usually
do blend in. But 100% agree with you. Avoid
fragrance, right? You really want something where
it's fragrance-free. Thank you for throwing
me that bone. That's kind of you. Thank you.
Yeah, and do you remember "unscented" versus "fragrance
-free?" I looked at a product and see the word
"unscented." Yeah, it's like "no sugar added." It's
like no sugar added, but the juice still has
a lot of sugar in it. Well, so "fragrance-free"
is kind of like the "no sugar added." So "fragrance
-free," when you go to buy a product, if it says
"fragrance-free," what that means is that however
the ingredients were combined into that bottle
or tube or tub is the combination, and however
it smells is what you get as the consumer, okay?
"Fragrance-free" means someone did not then take
an extra step to add menthol or, you know, what's
another? Cinnamon or honey flavoring or scent,
right? Some rose or whatever it might be. You
always have to do the foods. You had to do the
cinnamon. Well, how about leather? I don't know.
Pick a smell that you like. I don't know, but
you just brought up cinnamon, and now I'm...
Not a cinnamon fan? Not at the moment, no. Oh,
okay. We're talking about rubbing things into
wounds. Cinnamon would not be good. No, that
would hurt. But a fragrance, you could add a
fragrance to the combination of ingredients.
Then you can't call it fragrance-free, but you
would change the way it smells. "Fragrance-free"...
it is what it is. It smells the way it was cooked
up in the lab. It can smell very medicinal, and
that is sometimes a knock for people. "Unscented".
is another trick that's been played on human beings.
How would you ever know this? "Unscented" means
someone cooked up the batch of ingredients that
they want in the product. It has whatever smell
is at the end. But then instead of putting a
fragrance into the product to make it smell like
the fragrance, there's a combination usually
of fragrances that inactivate the base smell
of the ingredients in. their entirety, in their
aggregate. So it's actually usually an unscented
product has more fragrance added than sometimes
even a fragranced product because you have to
add three or four things as a fragrance to an
unscented product to neutralize the odor of the
base ingredients. Does that make sense? Totally.
A hundred percent. It's crazy. I'm taking notes.
It makes sense to me. I'm taking notes and I
was, I will fully admit when I was wrong, but
I was like a little close to being right. Yeah.
Very close. Sort of. how would it how would a
normal human being walking into a pharmacy know
that you know it sounds like you're doing something
great for your kids that you're going to give
them this unscented product and you're walking
out with something that actually could have more
fragrance than than the fragrance free product
so who knows i also do look for moisturizers
that do not have Potential sensitizers, I just
kind of lose my patience with people that tell
me tea tree oil and lavender and ylang-ylang
solves the world's problems. Like, no, you don't
need that in these products. I don't know what
that is, but... Don't say it again because it
was kind of funny. I won't say it ever again.
I promise you. It was very funny. I have heard
the tea tree oil. That I've definitely heard,
and I've told people to kind of avoid that because
it's not helping anything. In this particular
instance, I'm not discussing its use for other
things, but for this particular instance, it's
definitely not helping. Right. I mean, the other
one I get a lot is coconut oil. Is that a useful
moisturizer? You know, it's a tree nut. There
is a potential to sensitize there. That's probably
not a huge, huge risk. But I guess the point
is there's better moisturizers. Why are you dedicating
yourself and effort? If you're going to put on...
If you're going to put on coconut oil three times
a day, if you just switch to a moisturizing cream,
you'd be getting so much better results and you'd
be sitting there going, geez, I didn't need this
expensive coconut oil in the first place, you
know? Perfect. The other caution that I would
say is just because something has the label "hypoallergenic,"
which suggests that somehow it's less allergy
causing, doesn't mean it can't cause an allergy.
I can put anything on a person enough and
in the right person, it will cause an allergy.
You know, the best example is poison ivy. I don't
know if you've ever heard somebody who tells
you that they're not allergic to poison ivy.
Well, they might not yet have been sensitized
to poison ivy. Most of us as human beings, if
we encounter poison ivy one time, we're sensitized
enough that we will get a rash of poison ivy
the next time we see it. Some people have encountered
it. or thought they've encountered it and have
not gotten the rash, so they're
"immune." Not true. I can take that poison ivy.
I put it on enough of you, enough times and enough
volume, you're going to get a rash eventually
from poison ivy. Things that I look for in a
moisturizing cream that matter to me, I actually
like the families and the patients specifically,
if they're old enough to say what they like,
to pick a consistency. Because even within the
realm of moisturizing creams there are different
thicknesses, different consistencies viscosities
Pick one that you like. Pick one that you're
going to use. You know, there's an old saying
in dermatology. It's if I can get it right. "The
moisturizer that you use is better than the expensive
one that sits up in your medicine cabinet." Something
to that effect, you know? So find one that you
like. I do typically look for a fragrance-free
marketed product. That's the least amount of
fragrance. And keeping with the American Academy
of Dermatology and the American Academy of Pediatric
recommendations, I'm looking for a product that
does include ceramides. That's been recommended. Still
unclear if it's actually. really useful in terms
of, like, does it actually supplement at the level
of the stratum corneum? But the recommendations
are there. And I feel like that's usually the
products that have the ceramides in it are formulated
well around the ceramides such that they're safe
and effective for a condition like eczema. No,
I have no particular opinions on ceramides. No.
And for most of my patients, it's going to be
whatever is cost effective. So it's whatever
they can get in a bulkier volume that's going
to last, that's thicker, that... they're not
going to have to run through as many times a
day. So to your point, that viscosity is important
to a lot of the families because then maybe they
don't have to continue to reapply it, reapply
it, reapply it. So yeah, I would say all of those
things that you mentioned in cost. The one thing
I will say I do mention to them is that they
don't have to get brand name for a lot of these
things. So if they wanted to use, and I'm making,
you know, these are hypotheticals, if they wanted
to use Eucerin or Aquaphor, they can use Walmart-aphor
and they can use, Walgreen-acin. It doesn't
make any difference whatsoever. no difference
between the generic and the brand name. And there's
a huge cost difference for some of those. So
I do always tell them that that's the same. They
don't need to get the more expensive, costly,
you know, organic name brand type products. They
can use the ones that are a little bit less expensive.
I totally agree with you on that. I mean, I try
to actually stay away from the
"organic". label products. That's just adding a
zero to the cost without any real benefit. The
other thing I'm sort of embarrassed to say, a
lot of products carry the seal of approval from
the National Eczema Association, which sounds
like, geez, that would be really important. But
without going into it, you can basically get
that seal of approval without doing much. Let's
just leave it there. So I feel like that's more
of a marketing gimmick than anything else. And
it's not just that because that seal of approval is
on your product doesn't necessarily mean you're
using the best product. It's kind of crazy to
think about. But I do try to steer my patients
to something that they can afford, will use three
times a day, every day until they go to college
or make their own decisions, whatever it is.
You mentioned tubs. That is one thing that I
have changed. I usually, or I should say I used
to recommend getting the pound (1 lb) tubs wherever
you could because it's just more economical than
than an individual tube so like a pound tub but
here's where you're going to tell me it's going
to grow bacteria and you're going to grow horns
this is i know where we're going with this because
i paid attention during the last one see so that's
that's how that's one thing i've changed i do
go i recommend that they get individual tubes
that they can clean off with rubbing alcohol
around the flip top lid if it has one or whatever.
And I've also found, honestly, that let's say
you're trying to match a pound tub, that's what,
16 ounces, right? So that's four, four ounce
tubes or something close to three, six ounce
tubes. having those extra tubes i've found can
be very helpful for a number of reasons a you're
still getting the same amount of medicine it
is a little bit more expensive per tube but let's
say it's a split household with where the child
lives with mom during the work week and dad on
the weekend or whatever combination. Well you
know having Johnny or Mary's moisturizing cream
split up a little bit is nice because if you
forget one, at least you got two others spread
somewhere else. Having one at school, if you
can sneak it into the kid's locker and get him
or her to use it during school, that's great.
Or give it to the nurse if you have a nurse that's
willing to do that. Not all are, but they should
be. So, you know, I like to push the tubes now.
I don't know. What do you think about that? I
agree. And I think that actually makes perfect
sense. And I wanted to also just kind of harp
on your point about like split custody families
or where there's more than one environment that
they're living. They're always, you know. at
one person's house for care during the day. They
go to someone else's house for care during the
night. The collaboration between the caregivers
and the fact that they're both online and doing
the same page for eczema is really, really important.
I mean, it is for any chronic disease, anything
where you're looking at prevention as part of
the cure. But if you're always doing one thing,
but maybe grandma's doing something a little
bit different or isn't really on board, or maybe
dad's not doing the same thing, or dad's doing
one thing and mom's doing another, or vice versa,
however it is, and the child's really only getting
the appropriate treatment, for half the time
or is getting bathed every day, you know, for
four days of the week and then not getting bathed
for three days, it's not going to work. And so
we always try to encourage that everybody comes
to the appointment or there's really good, clear
communication for this purpose or we'll write
out instructions, we'll write out, we'll give
out education and try to make sure that everybody's
on the same page. Because again, if there's any
kind of, you know, different people are doing
things in a different fashion, any kind of different
caregiver, that's going to just go out the window
right away. And all of your good efforts just
kind of. get wasted. So it's very common and
we see that a lot in our kids. And so it's something
that could be really helpful to keep in the back
of your mind. So up until now, we've kind of
been talking about the stuff that you need to
do every day, no matter what, for as long as
you have eczema or I guess as long as you care
about it. Let's switch gears just slightly and
kind of wrap up this session with a discussion
around some of the prescriptions that we have
available for helping out specifically with flares
and also for helping to prevent flares. For me,
that's topical corticosteroids. at the top of
my armamentarium. It's still the mainstay of
therapy for mild to moderate atopic dermatitis
for me. How about your approach? Yep, absolutely.
Over-the-counter hydrocortisone 1%. Sometimes we'll go to
the 2 .5%, which you need a prescription for.
And then, yeah, absolutely. That's the first
thing. That's go-to. That's what we refill.
That's what we usually say. Generally, you don't
even need to come in to see us if this is what's
going on. Are you comfortable prescribing? more
potent steroids than hydrocortisone 2 .5%? I
will, yeah, especially if we know it's a reliable
caregiver. We know there's going to be good feedback.
We know that they're going to either send us
pictures through our medical record system or
they're going to come in if there's a problem.
Yeah, I do. So I'll use some a little bit stronger
steroids. So I'll use the triamcinolone. I'll
use fluocinonide, you know, depending on the case
and the situation, Stuff like that. Past that,
That's your territory, sir. That's where I start
to really send it to you. No, I think that's
great. Oh, and then we will often use certain
other medications. I'm trying to avoid using
brand names, but I'm going to end up using Singular.
So, Montelukast or an antihistamine of some sort
as well in conjunction to help with some of the
itching, some of the other kind of atopy and
allergy symptoms that we think could possibly
be causing some issues with the kids. So we try
to kind of maximize out as much as we can before
we send them to you, just because sometimes it's
hard to find you. And so therefore, we try to
do as much as we can. we can and then we send
them off to you. We wrap them up as best we can.
No, I think that's wonderful. And here, so we
just talked about the differences between lotions,
moisturizing creams, and ointments. You have
the same vehicle selection available to you,
but here's where I do actually favor an ointment.
It does tend to penetrate the skin and allow
the medicine to get delivered into the skin a
little bit more potently than some of the other
vehicles. It also tends to have less preservatives
in it. So if you're going to use something like
Triamcinolone, I think Triamcinolone 0 .1% ointment,
that's medium strength steroid, you could use
that medicine safely on really, I mean, unless
you're talking about the smallest preemie, you
could use that safely on a kid's arms, legs,
chest, back twice a day. For no more than two
weeks straight, you would have zero problems
doing that. Up on the face, I really wouldn't
use triamcinolone more than maybe three to five
days without somebody knowing about it, especially
not around the eyes. You don't want to get that
steroid up around the eyes because it can...
One of the ways it works is it's a vasoconstrictor,
so it tightens the blood vessels, and that can
lead to some damage. Specifically up in the eye,
it can cause something called glaucoma or cataracts
with the... is another side effect. But it's
super rare. You would have to really use that
medicine a lot longer than what I just detailed.
The ointments, because they don't have as many
of the preservatives that some of the cream formulations
do, they also sting less when you put it on open
skin. So you should very much be comfortable
using something like Triam 0 .1% ointment. And
then I think you mentioned Fluocinonide. That's
even stronger than Triam. That's about the second
from the top. And that's like my, if I'm using
Lidex ointment, that's the brand name for Fluocinonide.
If I'm using fluocinonide, then that kid needs
some quick acute relief, but I'm very, very comfortable
using that medicine. It's great. Those are usually
the kids for that that I see that have, like
I said, we talked a little bit last week about
some of that really thicker lichenified skin,
really thicker. They're generally older kids.
I really haven't had to use that on younger kids,
but to your point, more acute. I need to kind
of get in there a little bit faster. I really
write for that much, much less, but it does tend
to be much. more effective more quickly. Now,
here's another chance for you to tell me I'm
doing something wrong. I always tell my patients
to put that medicine on first and then cover
it with a moisturizer cream. I like the putting
it on first. We used to absolutely teach that
and believe that, geez, if you did it the wrong
way, it would screw something up. Somebody did
a study, I forget who or else I'd give them credit
for, where it turns out it didn't really make
much of a difference if I'm being academic about
it. But I think it... From a practical perspective,
you're delivering the flare-reducing medication
directly to the flare, and then you are moisturizing
over the top of that. That's exactly how I do
it. I like the medicine first and then the moisturizer.
So you're cool on that. Look, I'm like two for
27 at this point. That's exciting. Well, here,
let me see if I catch you on this one. No, please.
Well, most people don't give – there's two camps.
There's the people who are steroid-phobic, and
there's people who overuse it. I probably overuse
it. Keep going. I want to hear the question.
Well, again, if you're doing it under two weeks,
you're probably safe. And that includes like,
okay, remember, you're not swimming in this.
And if little Johnny has eczema on his antecubital
fossa - the crooks of his arms - you're not bathing
him entirely in triamcinolone. You're just putting
it on the areas where he's flaring, right? So
if you did that for up to two weeks, and what
I actually tell my patients is "Do it until the
red, itchy, rough skin goes away. plus two days,"
Right? Because there's always a little micro-
inflammation that you can't see. But if you're
doing that and you're under two weeks, you are
reasonable to do that. That's easy. And then
if you really want to be safe, give me a week.
before you use it in that SAME spot. But if eczema
pops up on the leg, treat that as if it's never
been treated before, up to two weeks. And a lot
of people don't get that, Not the clinicians
so much, but the patients say, "Well, you told
me not to use it after two weeks!" No, no, You
can use it again, just maybe not in the same
spot, Give a little break, and then use it certainly
in a new spot that pops up. Do you ever run into
that problem? So I usually do a week. I usually
tell the patients a week. twice a day for a week
underneath the moisturizer and then just continue
the moisturizer, stop the medication, use the
moisturizer. But I do tell them that if it does
come back and they have to do it again, restart
the whole process for a week. So it's similar.
We're in line. Yeah, very reasonable. Three out
of 27. I got through medical school with those
grades. Yeah. One other thing that the sort of
the other. flip side of the people who might
be using it too much are the people who are afraid
of the product. And I've figured out, actually
to give credit to my mentor, a guy named Larry
Eichenfield, MD out at Children's San Diego, he stressed
when he was teaching us, make them show you,
i .e. bring in the product, make them show you
how much of the steroid they've used. We know
it takes about 30 grams. like minimum to cover
an average adult in terms of body surface, right?
So now you're not doing that - i just made the
point that you're not covering the entire body -
but just to frame it like a 30 gram tube you'd
have to throw that in the garbage if you really
were going to cover somebody from head to toe
so if you give someone a 30 gram tube of triamcinolone
ointment for like let's say a six-year-old
and said i'll see you back in nine months you're
not going to just need one 30 gram tube, so you
give some refills. Okay you now have no idea how
many refills the family have have gone. So you
have to ask that and you have to look at the
cream or the tube, I should say. You look at
the tube and you say, okay, how much of that
would you use in a day? And they might say the
whole tube or they might say, oh, just a little
smidgen. No, you know, you got to actually divide
it out for them and show them, geez, in a normal
amount of time, this is how much of that medicine
you should go through. And to me, that totally
resets their expectations and safety profile
as they approach the question, "Is this safe for
my kids?" Ever use oral steroids for eczema? if
you are doling out oral steroids in this day
and age and I'm talking mostly like in an urgent
care facility, in the ER. You're doing that with,
I think, good intent. You want to help the patients.
You want to help them quickly. But what you don't
see is that two or three days after those steroids
have worn out, there is a phenomenon called "rebound"
where it will come raging back. Sometimes, often times
worse than what it was originally. Now, on top
of that, if you have any concern of a topical
steroid, which I'm going to hopefully... the
education part of this show is to get you to
not be so scared of a topical steroid. If you're
using it correctly, Oral steroids on the, on
the flip side have a tremendous number of side
effects. I mean, very quickly in a long, if you
were doing like a six week course of oral steroids
for something like poison Ivy, you do have to
think about osteo. well, not osteoporosis, but
there is some bone absorption that's happening
from those steroids in the first two to three
weeks of oral use. There is a true risk of Cushing's.
There is a true risk of thinning the skin, eye
changes like the glaucoma and cataract we talked
about. And there are behavioral changes in those
kids during the use. So those kids are hungry
and they are cranky and they are mad and they're
not learning things in school and they're unpleasant.
They're generally unpleasant children when that
happens. So I really do try to avoid oral steroids.
I mean, I don't think I've ever done an oral
steroid for an eczema kid. I've done oral steroids
plenty of times in dermatology, but I think over
20 years, I don't think I've done an oral steroid
for a kid. There are other answers to acute.
quick fixes that we've got now, especially in
the last couple of years. So please, if you have
the ability to NOT do an oral steroid, either
by the fact that you're the clinician that could
prescribe it, resist that, what am I trying to
say? Don't scratch the itch. Thank you. Don't
scratch the itch. I love it. And if you're a
patient - That's like four out of 27 for me.
We need to stop right now. I'm done now. We have
to stop recording. And we're finished while I'm
ahead. All right. So that was a great way to
end, I think. You know, talking about - I win.
We are starting. Yeah, you did. Let's end on
a winning note. I mean, I guess I'll throw in
a plug. There are some ways to extend those days
where you're not flaring. You mentioned Elidel.
Elidel is pimecrolimus. There's another generic
called tacrolimus, which is sold under the brand
name Protopic. These are topical calcineurin inhibitors.
Your pediatrician or dermatologist or pediatric
dermatologist might prescribe these. They have
been deemed safe. And originally, they were a
little scary because they came with what's called
a "black box" warning, which, geez, could these
things cause skin cancers? Well, that warning
was removed in Canada in 2021. It's been now
approved down to kids three months or older in
Canada. In the United States, it's still pimecrolimus
is greater than two years of age. And tacrolimus
is - It depends on what strength. For 0.03%, it's
greater than two years of age. And for the 0.1%,
the stronger, it's 16 or older. But we know
that this medicine, which has been studied in
many registries over the years, this is a safe
alternative to putting steroid on every day.
And you should really embrace that as a way to
decrease some of the flares that you got. But
with that, I think we'll take the opportunity
to wrap this up and maybe do a little further
education on some of the... big hitter medications
down the line. But thank you, Dr. Walty, for
joining us and adding to the discussion that
we had previously. I think, you know, for anyone
who was unfamiliar with eczema coming in, they
probably got an earful. Maybe too much. But no,
I appreciate the invitation. I learned some things.
So that was good. Well, as always, it's a pleasure
working with you. And thank you for joining us.
Thanks for tuning in to this episode of the Don't
Be Rash Pediatric Dermatology Podcast. I'm your
host, Dr. Andrew Krakowski. Don't forget to subscribe
to our show on your favorite podcast platform
and check out dontberash.org for more information.
A special thank you to our nonprofit sponsor,
the St. Luke's University Health Network, for
making this episode possible. Until next time,
remember: :Keep calm and don't be rash!"