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Sensitive conversations

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Sensitive conversations

It’s been a long, hot summer and while good news for most, for some the weather will have exacerbated their eczema. Kathy Oxtoby explores the best advice you can give to support patients with this distressing condition.

Eczema is a common skin condition that can affect any age group, from babies to people in their 90s – in fact one in five children and one in 12 adults have eczema, according to the National Eczema Society.

People with eczema usually have a rash with dry, flaky, and often itchy skin. Those with severe forms of eczema – the most common being atopic dermatitis (AD), which is a chronic condition – will present with cracked, thickened, inflamed, and weepy skin.

Eczema tends to appear on the face, and in the creases of skin such as in the elbows, behind around the knees, at the back of the neck, or under the arms, but it can appear anywhere on the body.

There are several reasons why people develop eczema, explains consultant dermatologist Dr Anton Alexandroff, a spokesperson for the British Skin Foundation and for the British Association of Dermatologists.

"The causes are usually from inside of the body and so are genetic. Other causes could be allergic contact dermatitis where patients develop allergies to particular chemicals such as nickel, perfumes, or preservatives in household products, or irritant contact dermatitis due to repeated exposure to irritant substances like soap,” he says.

Lila Thakerar, superintendent pharmacist, Shaftesbury Pharmacy, Harrow, says eczema can be linked to asthma. It may be related to seasonal allergies, such as hay fever. It could be caused by pollution, and can be exacerbated by stress. Whatever the cause, she stresses people should be aware that eczema is not contagious. “I come across patients who are very conscious that other people around them don’t want to touch them.

“It’s a superficial outlook when people are judged by how they look and not, say, by their intelligence. We need to make people aware that eczema is not contagious and to be more sympathetic about the condition.”

Psychological impact

People with eczema are not only affected by its physical impact – it has a psychological impact too. A UK survey of people with moderate-to-severe atopic dermatitis (AD)1 conducted by Sanofi and published in May 2018, found that the disease can impact on every aspect of an individual’s life. Difficulty sleeping emerged as a significant problem, affecting 75% of those surveyed; the constant itching and pain when trying to sleep, left people feeling tired and restless in the day.1

Some 80% of survey participants reported that atopic dermatitis has a direct impact
on their mood. In interviews, participants reported feeling anxious, especially in public and social settings, and feeling that they were being looked at and judged by others. Over 55% admitted they feel depressed because of their skin, with some taking antidepressants to try and help the situation. And 60% of male participants and 55% of female participants noted that their self-esteem and self-confidence is frequently impacted due to their skin condition.

Stefanie Holman, head of communications for Sanofi Genzyme, UK/Ireland, said the survey revealed some “heartbreaking situations” about patient experiences, including how one woman was unable to sleep in the same bed with her husband because her itching and scratching shook the bed every night so much her husband could not sleep.

Lack of sleep associated with AD can lead to mental health disorders, and is linked to absenteeism both at school and at work, and an impaired quality of life, Holman explained.

In her pharmacy, Lila Thakerar has witnessed the ongoing impact of eczema on individual’s
lives first hand. “I have seen a lot of patients with eczema, including very young children. “One patient I’ve known since birth. They were born with eczema and their mother suffers from it too. The poor child suffered at school – they were picked on – and even now at university has not grown out of it. It’s difficult to realise what that child has gone through personally, and the isolation at all stages of their life. Eczema has an impact on self-esteem and confidence without a doubt,” she says.

Community pharmacist Terry Maguire of Maguire Pharmacy, Belfast, says pharmacy’s role in supporting patients with eczema is to make sure they get the information they need to optimise treatment outcomes, such as the vital importance of moisturising infected skin two to three times a day to stop chafing, and reduce scalyness. “But effective management of eczema requires time, effort and commitment, so pharmacists need to talk about the importance of compliance and give information and advice about treatments to patients, including children’s parents,” he says.

In August, the first new drug treatment for atopic eczema in many years was approved by the National Institute for Health and Care Excellence (NICE). Sanofi’s new treatment Dupixent (dupilumab) is recommended for routine use on the NHS and eligible patients should be able to access the drug within 30 days of NICE’s recommendation. Dupilumab is a recombinant human monoclonal antibody that inhibits interleukin-4 and interleukin-13 signaling; these cytokines are involved in atopic eczema.

OTC treatments

There have been no recent innovations in eczema skincare OTC products, but those in demand offer a variety of approaches to relieve symptoms and treat mild to moderate eczema. Popular products include the E45 range, such as bath gels and creams, Aveeno, Balneum, and Perrigo’s Dermalex eczema treatment range.

While available on prescription, these first line eczema treatments are also available to buy in the pharmacy, which is becoming more common practice now that clinical commissioning groups are discouraging GPs to prescribe them in order to make savings, Lily Thakerar suggests. “These products aren’t cheap – it can cost patients £30 a month to purchase emollients if their GP won’t prescribe them”, and if patients can’t afford them “their condition will worsen,” she warns.

For severe eczema, steroids such as Eumovate Cream can be provided OTC under strict guidelines – which include that it should not be used on the face, for young children, or on open skin. Terry Maguire believes some pharmacists tend not to be confident in addressing eczema flare-ups which low steroid treatments can address.

“Colleagues are often reserved about dealing with this, but they should be able to support people to self-treat. If someone needs short-term management for their eczema there’s no reason why pharmacists shouldn’t supply an OTC steroid, and then give advice and information about the use of emollients,” he maintains.

Pharmacists can also support people with eczema in their day-to-day lives to help them maintain their overall health. Farah Ali, general manager at Perrigo’s centre of excellence, Warman-Freed pharmacy, said: “A well-balanced diet should provide all essential  supplements. However, if someone is lacking in any of the supplements because of dietary, medical or other factors then adding skin- specific supplements to the diet can help.”

These include vitamins A, C, E, B2 (riboflavin), B3 (niacin), B7 (biotin), zinc and iodine. Fish and omega oils are also often taken to support healthy skin. “All these supplements could help the atopic eczema sufferer,” she says.

Pharmacists can also recommend patients keep a food diary to identify what may make their eczema worse, such as certain foods, or dairy products, Lily Thakerar advises.

And, as Terry Maguire says, knowing the stigma associated with the condition, and the distress it can cause, gives pharmacists “even more reason to make sure individuals get the right treatment and know how to use it”.

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