March 19, 2009
Doc talk
Bane of childhood
By Dr Jean Ho
It is easy to withstand pain but difficult to withstand itch, so goes an ancient Chinese saying.
Indeed, tell a child with eczema not to scratch and all he will hear is the last word: Scratch.
Any eczema sufferer will swear that its itch is mind-numbing, sleep-depriving and dedicated to compel non-stop scratching. 'Relief' comes only when the skin has been scratched off and the sensation of pain overtakes the itch.
L, a bright 10-year-old girl who aces her exams every year, has found it harder to concentrate in school. She has had eczema since pre-school but her parents had resisted medical treatment.
They had heard that medication like steroids were bad and, instead, turned to alternative therapy and traditional healing. The skin over her neck and body darkened over the years because of recurrent eczema. Countless scars remained on her arms and legs where once there were sores and open wounds.
When she became my patient, she was still suffering from repeated and unexpected bouts of red itchy rashes. She would think twice about wearing her favourite skirt or taking part in social activities with friends. Her eyes were downcast as we spoke.
Atopic eczema, in recent years, has seen an exponential rise in numbers and severity. One in five children in Singapore suffers from this condition.
The cause of atopic eczema is largely determined by the genes. More than half of the children with eczema will have a close family member with the same condition. Recently, research studies have identified a particular gene that causes an inherited form of dry skin. This same gene also causes up to half of the atopic eczema cases in children.
Dry skin is an 'impaired' skin barrier, more vulnerable to, say, soaps, detergents, germs and various allergens. Hence, the mainstay in eczema treatment is adequate and frequent moisturising. This should be carried out at least twice a day, or more often if necessary, after a bath with mild gentle cleansers.
Emotional stress makes eczema worse. Occasionally, certain types of food may aggravate the condition. Heat and sweat are also common triggers.
The condition is usually managed with a combination of steroid and steroid-free cream and oral medication called anti-histamines to reduce the itch. Antibiotics are sometimes prescribed if there are signs of skin infection.
Steroid cream is a first line treatment because it is effective in reducing itch and redness caused by eczema. It is considered safe if used under a doctor's supervision.
Side effects, such as thinning of the skin and stretch marks, can result from the unregulated use of a steroid cream which is too strong.
Eczema appears during the formative childhood years. Frequently chronic and relapsing, it can badly affect the child's emotional and physical health. Yet it is not incurable. If affected children are treated early and properly, results can be gratifying.
M, aged four years, was an unhappy boy. 'He has been scratching the whole night and we have not slept a wink for the past two weeks,' complained his mother wearily. She then showed me a video taken at 2am to prove her point.
The boy's skin was red and flaking all over. Following medical treatment, his condition improved immediately.
For some families, eczema is mild, posing negligible hindrance to life; for others, it can be physically and emotionally crippling. The suffering from severe eczema can be worse than that of other chronic illnesses like asthma or diabetes.
Patient C, an 18-year-old boy, had to endure eczema for as long as he could remember. Whenever he perspired, the condition would flare up. On hot and humid days, he would feel as uncomfortable as a fish out of water. Air-conditioning became a necessity. He had to miss school for days on end when his eczema flared up. He was permanently excused from physical education lessons.
Treatment did not seem to work and his parents were close to despair. The family then moved to another country with a temperate climate where he completed his schooling. His condition improved and he later returned to Singapore.
Now a young man, he knows how to manage his skin problem better. Unfortunately, this kind of 'treatment' is one which very few of us can afford.
One-fifth of children will recover by age 12, the remaining will experience fluctuating disease into their teenage years. Of the latter group, about two-thirds will eventually grow out of their disease.
If it is not well controlled by this stage, these kids will most likely continue to have relapses of the disease into adulthood. The sooner the eczema is treated, the better. Early and effective treatment ensures minimal disruption to the child's life and learning.
Dr Jean Ho is a consultant dermatologist specialising in paediatric dermatology. She was principal investigator of a research study on the genes causing atopic eczema and is in private practice.
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