Saturday, September 30, 2006

Really Bad Eczema

Remember the old TV ad with the sonorous voice-over that said “Eczema…seborrhea…the heartbreak of psoriasis…” ? I don’t remember now what product the ad was selling, I just remember the phrase. Many Yupik Eskimos of southwest Alaska could be posterchildren for that ad. I have never seen such severe atopic skin disease as I have encountered here.

Recently I spoke with one of the pediatricians on the medical staff of our hospital who has a special interest in the “triple A triad”: atopy, allergy and asthma. He considers our pediatric population to be “hyperreactive”—they have more hives, more rashes, more rhinitis, more wheezing than non-Native children in the lower 48 or in Alaska.
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Eczema is an extremely common problem among the children here, and it is often severe. Occasionally I see a child in whom it is limited to wrists or elbow creases, or perhaps around the ears; more commonly it is far more wide spread, sometimes involving the entire body.

The child in these photos is Joshua, a 4-year-old boy from one of the villages. His photos are used with his mother’s permission. His hospital record contains his entire medical history from birth on. He had no skin problems at all until the age of 2, when he was noted on Well Child Exam to have small areas of eczema at the elbow creases. His mom was given hydrocortisone cream for the rash.

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Over the next year he was found to have ever-increasing areas of eczema, more dry skin, more itching misery. Mom was given diphenhydramine suspension (Benedryl) to help with his itching and moisturizers to treat his dry skin. It is unclear how regularly these have been used; often, months have gone by with no refills being obtained.

At this point, his entire body is covered in a severe case of eczema, with constant itching, flaking and peeling skin, and frequent skin infections (impetigo) from the open sores he has scratched into being. He has gone from a laughing, happy boy at age 2 to a somewhat grumpy and petulant child with a scowl much of the time. And with good reason; how miserable can it be to have skin like this? It breaks my heart to see what he lives with every day.
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He is periodically treated with oral steroids when the eczema is at its worst. He is regularly given topical steroids: mid-potency creams like triamcinolone for the body and low-potency creams like hydrocortisone for the face. And lots of moisturizers such as Aqua-Phor and Eucerin for constant treatment of his dry skin.

I always wonder about medication compliance; Joshua has five siblings, and two of them have similar, though less severe problems. His mom tries her best with all of them, but Joshua’s skin care may be somewhat sporatic.

Joshua’s case is one of the more severe, but it is by no means rare. Nearly every village has a child or two with eczema this bad, and many children with less severe conditions. They often improve significantly by age 6 or 7 and may have minimal problem with it after that.



Fortunately, Joshua has not had the co-existing problems with asthma, allergies, and ear infections that many atopic children do. The ones who get all three of the Triple A Triad have a huge ration of misery to deal with in childhood. I wonder to what degree that experience affects their outlook as adults. Are they generally more cranky and/or whiney? More pessimistic? More complaining? More dissatisfied with life? I would think that possibility would be there, but I don’t see it in my adult patients who tell me they had “bad eczema as a child.”

I am optimistic that Joshua’s personality will not be molded by his skin’s discomfort. Despite his constant itching, he plays with other children, has outbursts of joy, and is sometimes quite charming. I hope he is one of the lucky ones whose skin will clear in the next few years and allow him some peace.


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18 Comments:

Anonymous wolfbaby said...

I had all of those problems as a child and seemed to have passed them on to my children.. thankfully none of us have had that severe a case of eczema. That poor child. We have had to use some cream on my girls for that and thankfully i have a very good doc who moniters them very closly and understands my fears of antibiotics because of my own severe allergies to them. I hope his eczema does clear up as he gets older!!!

Saturday, September 30, 2006 10:22:00 PM  
Anonymous Leah said...

I'm over in Fbks and the local Derm told me that he sees a LOT of this plus psoriasis too; especially in Native kids. I have to wonder if there's not an something lacking in our western diets that traditionally, Natives had? Some fatty acid? My own kids (btw Native) require LOTS of lotion and "baby lube" from the start or they start getting scaly itchy and spotty. Half of them end up getting a script for troublesome spots.

Tuesday, October 03, 2006 10:16:00 AM  
Blogger tk said...

I worked with Native American children in my previous job and regularly saw several children like this. One in particular would come in with huge weeping patches of secondary infection. Compliance on the part the parents is a big issue. They often don't understand that eczema a chronic condition that requires daily care.

Tuesday, October 03, 2006 5:13:00 PM  
Blogger medstudentitis said...

I feel so sorry for that kid. I have a recurring dime sized patch of contact derm on my face and I grouchy about that. I can't imagine having full body eczema. Poor kiddo.

Tuesday, October 03, 2006 5:38:00 PM  
Blogger Paul Auerbach, M.D. said...

Nicely presented. I look forward to reading more of your posts on wilderness-related medical situations.

Medicine for the Outdoors blog

Wednesday, October 04, 2006 1:43:00 PM  
Anonymous Anonymous said...

I wonder if little Joshua doesn't have a food sensitivity. After all, babies start eating as children right about then. Wheat? Soy? Corn? I had terrible allergies as a child, with atopic skin, and didn't learn until I was an adult that I shouldn't eat wheat. Once I cut that out of my diet, my allergies finally became tame. I really wish someone had suggested it to my parents when I was little; I would have been saved a lot of suffering. So look at Josh's diet, OK?

Wednesday, October 04, 2006 5:20:00 PM  
Blogger Morenna said...

Ok, I'll stop whining about the poison ivy I got on my arms a couple of weeks ago. At least that is going away. That kid must feel horrible. Any chance you and your colleagues will study the prevalence of eczema in the pediatric population and try to figure out what's going on?

Wednesday, October 04, 2006 5:37:00 PM  
Blogger TheTundraPA said...

Thanks for all the great comments! Joshua's case does kind of put things into perspective when I have some tiny little itchy patch. Compliance is definitely an issue; whether it is lack of understanding (despite my efforts at education) or lack of time/energy, I am reasonably sure that Joshua doesn't get the daily skin care attention that he needs.

Anonymous--good thought about the food sensitivities. Joshua is being evaluated for that with immunoassay.

Friday, October 06, 2006 8:06:00 AM  
Blogger TheTundraPA said...

Hey Dr. Paul! Thanks for stopping by, and for commenting. If you haven't browsed back through the archives, check out the post on Eskimo Home Remedies. You might find it amusing...

Friday, October 06, 2006 8:08:00 AM  
Blogger Mother Jones RN said...

I had eczema on my feet when I was a kid. It was really bad, so bad in fact that the doctors wanted to
amputate my toes. Then my parents took me to another doctor who thought I was drinking too much milk. I stopped drinking milk, and within 3 months everything cleared up.

Just something to think about.

Saturday, October 07, 2006 3:34:00 PM  
Anonymous AKBessy said...

One of my children had (and still has at the age of 20) a bad case of eczema - but not as bad as the poor baby in the pictures. All kinds of lotions and "grease" have occupied my shelves throughout the years in efforts to keep my child comfortable. Do children that consume a lot of seal oil have problems with eczema?

Sunday, October 08, 2006 9:41:00 AM  
Blogger Alison Cummins said...

While I never had whole-body eczema, starting from the age of four I did have it on my ankles, wrists, knee and elbow creases, eyelids and hands. My hands were the worst, and all through high school they were swollen, blistered, puffy, itchy and weepy. I had painful grooves and cracks where other people had fingerprints. When I consulted for it, doctors prescribed hydrocortisone for me but told me not to use it more than six days. (I'm not sure what a six-day treatment for a chronic condition is supposed to do, but that's what I got.)

Once I saw a doctor who prescribed an oral antimycotic. My eczema disappeared for the duration of the course of medication, then came back.

Finally, in my early twenties, I was referred to a dermatologist who explained how to manage it. I should keep my skin clean by soaking in Alpha-keri bath oil to remove irritants. I should moisturise with plain old Vaseline petroleum jelly. And if I absolutely couldn't stand something I could use a hydrocortisone cream, but no longer than three days because cortisone would thin my skin and make it more sensitive to irritation. (I have found Vaseline petroleum jelly to be far superior to any other cream or ointment, including Eucerin. I've tried a lot of them.)

I was careful about the detergents I used and stopped using fabric softener.

From the day of that appointment my eczema calmed down to the point that I haven't used a hydrocortisone cream since. It disappeared for all intents and purposes when I bought my own washer and dryer and didn't have to try my clothes in a machine coated with someone else's Bounce.

If the advice this kid's family is getting is to use steroids and moisturise and his skin isn't improving, then maybe a different regimen could be tried? Like avoiding irritants and discontinuing the steroids?

Monday, October 09, 2006 11:35:00 AM  
Anonymous Anonymous said...

im 14 and i have eczema. not as bad, thankfully, but i have it. at one point i couldnt go to school because i was in so much pain and my derm told me to sit in the tub with luke warm water for 10 minutes, dont try off, apply triancinolome, pat dry then apply eucerin. ive been clear since last year but its starting to get cold out so lets knock on wood. but see if that works

Thursday, October 12, 2006 3:51:00 PM  
Blogger TheTundraPA said...

Lots of good suggestions! Thanks, everyone, for commenting. I have asked Joshua's mother to completely remove dairy products from his diet for 3 months; I hope she will manage that. Many Yupiks are lactose-intolerant, and it may be a factor. I'll post an update when I have more info.

Sunday, October 15, 2006 10:58:00 AM  
Anonymous Anonymous said...

Eczema can be a serious impediment to self confidence as people deal with the physical appearance of the disease. Eczema treatments generally help, but don't eliminate this issue.

Monday, January 08, 2007 6:27:00 AM  
Blogger Time Freedom Fighter said...

A number of home remedies for eczema usually focus on limiting dry skin and skin irritations that trigger the condition. Many people with atopic eczema are somewhere in between the extremes of the condition and learn to live with the condition by adjusting to the affliction.

Wednesday, January 10, 2007 6:55:00 AM  
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Sunday, October 21, 2012 2:04:00 AM  
Blogger shoolaroon said...

I'm an eczema sufferer too so I feel for that kid. As many of the cases seem to improve as the kids get older, I'm wondering if MILK might be a culprit as we're always urged to drink milk as kids as Native Americans can't digest it. Always hated milk myself. Got to be some kind of dietary problem behind it.

Thursday, August 28, 2014 3:09:00 PM  

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