THE PROBLEM WITH ECZEMA AND HOW TO TREAT IT: Doctors like to call it "dermatitis". You won't find a clear-cut definition of the word but eczema is essentially inflammation of the skin. Diagnosing a particular type of eczema is difficult. The disease can take on many guises and an accurate diagnosis depends on the doctor's experience.
Unfortunately, doctors get it wrong. They completely misread the symptoms and incorrectly prescribe a drug. Severe side effects are common; sometimes patients die.
However, change is in the air. Five hundred GPs now being threatened with legal action by their patients for alleged negligence when prescribing steroids for eczema shows that sufferers have put up with the side effects of these drugs for long enough. Around 700 sufferers say they've put on weight, their skin has become paper thin and some claim to have suffered osteoporosis from the use of systemic and topical steroids, although a few cases involve the use of just inhaled steroids.
By the time the first case comes to court, a further 200 GPs will have received a letter from London law firm Evill and Coleman asking them to disclose patient records and show, among other things, whether or not they warned their patients about the long-term risk of steroid treatment and adequately monitored its use. Legal aid has been granted to the firm's 700 or so ezcema (rheumatoid arthritis and asthma) sufferers, so they can pursue individual claims for alleged negligence by hospital doctors and steroid manufacturers.
However, the majority of claims relate to the behaviour of GPs and specialist prescribers, some of whose patients were kept on repeat prescriptions for so long, they seemed to be prescribing for themselves.
Doctors regard eczema as a non-infective skin rash and often treat it with some form of steroid (corticosteroid) which suppresses the inflammation. Of course, proper treatment depends upon an effective diagnosis which in turn depends upon the experience of the doctor. Some doctors will tell you that one of the reasons why eczema gets worse and won't respond to treatment is because it's infected. But recognising the skin is infected can't be guaranteed. Although weeping, encrusted skin is a common outward sign of infection, to the inexperienced eye infection can just as easily remain hidden.
For this reason, doctors prefer to adopt an approach akin to pinning the tail-on-the-donkey by prescribing a mixture of steriod (to fight the eczema) and antibiotic (to fight the infection) which often causes a candida albicans overgrowth (the thrush germ), making the eczema worse.
Although, a doctor may well be prescribing this mixture of drugs because he thinks the eczema isn't responding to treatment, this can also be taken as a sign that your doctor can't make a precise diagnosis of the condition and is hoping that by throwing a mixture of drugs at the problem it will go away.
SIDE EFFECTS: Reaction to steroids depends on the strength of the prescription, the severity of the eczema, and the duration of the treatment. Topological steroids are now being touted as the safe alternative to systemic steroids but there's little evidence to back this up. Unfortunately, the skin can react to the base of the steroid cream which usually contains a preservative. For example, some sufferers are allergic to hydrocortisone cream (The Lancet, 23 Nov, 1991) which has a myriad of side effects.
Although the first cases of allergic contact dermatitis due to topical corticosteroids date back to 1959, recent reports suggest that topical steroids — thought to be less severe than their orally-delivered cousins — can also cause the same allergic reaction (J of the American Academy of Der, Apr 1993; Br J of Derm Jul 1989; Archives of Der, Mar 1993; Contact Dermatitis, Aug 1991) and damage organs, such as the kidneys (Zeitschrift fur Hautkrankheiten, Apr 1988). Indeed, researchers at New York University throw topical and systemic steroids into the same pot, warning "their use is not without potential complications" and even suggest that topical steroids may be associated with glaucoma (Dermatological Clinics, Jul 1992; Scottish Med J, Jun 1990). Excessive use of topical corticosteroids can also produce an array of serious skin problems (American Family Physician, Jul 1993; J of Derm, Aug 1991).
Some children with asthma and eczema are being kept away from steroids because of the fear of side effects (Arch of Disease in Childhood, 62, 1987) such as stunted growth and kidney disease (The Lancet, 14 Dec, 1991).
Patients using systemic corticosteroids who haven't had chickenpox can also be placed in great danger, as the well-reported case of nine-year-old Lexie McConnell proved so tragically when she died of chickenpox after doctors failed to warn her parents of the side effects and dangers of a routine course of treatment. Corticosteroids suppressed her immune system and therefore made her more susceptible to serious infection. About 30 people die each year from chickenpox, a third of which are associated with immunosuppression (Curr Probs in Pharm, Feb 1994).
The recent Evill and Coleman litigation brings out the threat of osteoporosis, one of the more serious side effects from taking corticosteroids over a long period. Unfortunately, clinical trials conducted over periods of weeks pass the drugs as safe, but don't take into account their effects on people who may be using them year in year out.
Even Dr Hans Bode, writing in the BMA Journal (22/29 Aug 1980) says: "The beneficial effects of prolonged therapy with topical glucocorticoids are outweighed by detrimental side effects, such as adrenal suppression, dermal atrophy, axillary and inguinal striae, hyperglycemia, and even multiple gastric ulcers." Bode also says the treatment can stunt growth.
There are also numerous reports of allergic reactions to systemic and antibacterial drugs (administered when the skin becomes infected), the most common being allergic contact dermatitis induced by topical antibacterials. However, other antibacterial drugs known to cause contact dermatitis include:
Aminoglycosides Amoxycillin Ampicillin Antituberculosis drugs Bacitracin Cephalosporins Erythromycin Gentamycin Lincomycin Rifamycin Sodium fusidate.
BETTER WAY TO TREAT ECZEMA: Unfortunately, neither conventional nor complementary medicines cure eczema. Although, it's certainly important to remember that not everyone benefits from every treatment available, there are a number of things you can try to make the skin more comfortable.
Initially, doctors say you should bathe using a non-perfumed soap. Moisturisers (emollients) used frequently — and also added to the bath water — can prevent the skin from becoming too dry.
Emulsifying ointment can also be used, but watch out for products which contain lanolin (wool fat), or hydrocarbons (paraffin). These usually trigger allergic reactions and cause symptoms indistinguishable from the condition they're supposed to be treating.
Tar-based preparations are an old form of treatment favoured by homeopaths. Sulphur applications act as strong suppresants.
Evening Primrose oil (the name given to the oil which naturally occurs in the seeds of the evening primrose plant) has been used for years to reduce the symptoms of eczema and other skin conditions, because it is rich in fatty acids (linoleic and gamolenic acids) which are believed to be able to modify the chemicals which cause inflammatory skin disease.
However, perhaps predictably, conventional medicine gives it short shrift saying "it is best regarded as an optional addition to more conventional (ie.steroid) treatment and as a dietary supplement rather than as a drug for eczema" (The Lancet, Vol 336, 621) and suggesting it makes a slight, but not marked, difference to eczema suffers, certainly not enough of a difference to convince doctors that primrose oil is what they would term a proper (ie. orthodox) cure (The Lancet, Vol 335, 1283).
But this is a fatuous argument. For many years, taking Evening Primrose oil has been accepted as an alternative therapy for eczema sufferers, but it isn't a quick worker. It takes from six to 12 weeks before you see any improvement. Although previously available from healthfood shops, after extensive testing to check its safety and supposedly long term effects, it was only until Evening Primrose oil became available on prescription in 1988, under the trade name Epogam that the conventional medicine lobby was spurred into action by debating whether or not Evening Primrose oil should have been allowed on prescription at all. The important thing to remember here is that eczema sufferers obviously find relief from taking it, and for that reason alone it's worth trying although you should continue with other creams or medicines that have already been prescribed. Good skin care is a long term treatment anyway, so it shouldn't stop. Keep on applying moisturisers to the skin even when it's better.
Another alternative eczema treatment worth trying is Chinese herbal medicine (CHM), or traditional Chinese herbal therapy (TCHT), as it's called, which boasts excellent results in treating eczema, atopic dermatitis (the most common form of eczema) and psoriasis. Dr David Atherton, a dermatologist at Great Ormond Street Hospital, was amazed when some of his eczema patients, who hadn't responded to conventional treatment, improved dramatically after receiving Chinese herbal medicine prescribed from Dr Ding-Hui Luo, who practises in Soho.
However, you must remember that Chinese herbal medicine often prescribes a mixture of herbs which are then added to water and boiled to form a liquid "decoction" (plants used in traditional Chinese herbal medicine are known as medicinal plant therapies or remedies, herbal therapies, or plant decoctions). The type and amount of herbs used will depend on the patient and their symptoms. A group of patients with atopic eczema, for example, would probably all receive different mixtures of herbs.
Since herbs are often looked upon as a "natural" remedy, people think they are safe to take. They may not be. Some herbs are poisonous and many have side effects if taken wrongly. The main side effects reported by patients taking the decoction have been generally mild and reversible. They included headache, nausea, bloated stomach and loose bowels. However, such studies (only carried out over a short period, long term effects are not known) refered to a fixed prescription of herbs, rather than the individual mixture usually given, and made specifically to suit people with severe, widespread atopic eczema whose skin was very dry, free of infection, and not weeping.
Practitioners of Chinese herbal medicine, will tell you that patients get worse before they feel the treatment is working. They often say this is because impurities are leaving, or moving down through, the body.
However, the fact that you're assessed as an individual and treated as such means that potentially, you should have a far better chance of receiving the appropriate "cure".
There are a large number of clinics in this country which offer traditional Chinese herbal therapy. Some are run by Chinese doctors with extensive training in traditional Chinese herbal medicine. Others are run by people with no medical training whatsoever.
No one treatment will be effective on its own but most forms of eczema will respond to a combination of medical products and self-help (watching your intake and avoiding other potential sources of irritation such as wool, synthetic fabrics, washing powder, etc).
Of course, making sure you manage your food intake properly can be the most difficult to get right; the correct balance will be trial and error. It is a good idea to avoid red meat which is high in arachidonic acid and has inflammatory properties; milk — infants especially weaned from their mother's milk can be susceptible to allergies from cow's milk; fermented foods, such as vinegar, soya sauce and alcohol; and also stay clear of cheese, eggs, chocolate, caffeine and wheat.
CHINESE VERSUS STEROIDS AND CYCLOSPORENS: Although the Chinese community in Britain may well be able to distinguish reputable practitioners from the more dubious, Westerners remain vulnerable to exploitation. A Register of Chinese Herbal Medicine does exist, but it's estimated that only 120 or so of the 600 clinics in Britain are registered.
Some practitioners may tell you their creams, ointments, or impregnated dressings (for atopic eczema) are safe, but some have been found to contain potent steroids which are impure. Doctors strongly recommend any cream shouldn't be used unless the product is properly labelled with a full list of ingredients (eg. see "Chinese herbs for eczema", The Lancet, Vol 336, 177). It is illegal for anyone to prescribe creams containing potent steroids unless they are medically qualified.
Zemaphyte (trademarked by Phytopharm), a product of the Great Ormond Street and Royal Free hospital trials (and based on formulae brought to the UK in 1981 by Dr Ding-Hui-Luo from Guangzhuo — Canton), should only be taken under the direct guidance of a dermatologist by those with severe, widespread, atopic eczema, whose skin is especially dry and not infected. It's not a cure.
Further studies are being carried out to find out more about the safety and long term effects of taking it. Phytopharm says doctors should check liver and kidney function every one or two months.
Great care needs to be taken with herb remedies. Because treatment depends very much on the individual make-up of the patient, reports of side effects appear to be isolated.
After six weeks of drinking his brew one person's chest, back and scalp became covered in bumps. Eventually his face swelled up like a football, sealing both his eyes shut. Ironically, only a high dose of steroids managed to reduce the swelling. Had it spread to his throat, it could have been fatal.
Cases of hepatitis, from drinking herbal tea, have also been reported (The Lancet, Vol 340, 12 Sept 1992). One 28-year-old woman recovered, but a few months later took herbs for another three weeks and developed liver failure. She was given an emergency liver transplant, but still died.
However, in spite of these reports, the exact risk level associated with traditional Chinese Herbal Therapy is not known. Writing in The Lancet (Vol 340, 12 Sept 1992) Malcolm Rustin and David Atherton say: "TCHT seems to be much less toxic than drugs such as cyclosporin and any other treatments for severe atopic eczema, including oral corticosteroids, oral photochemotherapy and azathioprine. No haematological or biochemical abnormalities have been detected so far in any adults with atopic eczema under our care who have received a formulation of TCHT that has been prepared with careful attention to high-quality control standards."
CORTICOSTEROIDS: Side effects from these span from serious skin problems, kidney disease, stunted growth and glaucoma, to osteoporosis and extreme vulnerability to infection. One woman said her husband took corticosteroids (orally) for 20 years and became severely depressed, although a series of mood swings also produced symptoms of schizophrenia.
Mildly potent: Alcomethasone Fluocinoline 1:10 (0.0025%) Hydrocortisone Methylprednisolone
Moderately potent: Clobetasone Desoxymethasone 0.05% Fluocinoline 1:4 (0.00625%) Fluocortolone Flurandrenalone
Potent: Beclomethasone Betamethasone Budesonide Desoxymethasone 0.25% Diflucortolone Fluclorolone Fluocinolone 0.025% Fluocinonide Hydrocortisone 17-butyrate Triamcinolone
Very Potent: Clobetasol Diflucortolone 0.3% Halcinonide
Cyclosporin Originally used in transplant surgery, so that the body wouldn't reject the new organ, Cyclosporin is a powerful immunosuppressant being used to treat other, unrelated conditions, such as psoriasis. Unfortunately, Cyclosporin brings with it a whole host of dangerous side effects such as skin cancer, and other types of malignancies including lymphoma. It's also associated with liver and kidney damage.
The potentially good news is that the pharmacologists are refining the drug to improve its effectiveness and reduce its dangers.