Atopic dermatitis, more usually called eczema, is a skin disease that is becoming more common in developing countries. Not only is it unsightly, it carries physical discomfort that can cause great psychological distress.
Dr Khadija Aljefri is an experienced consultant dermatologist, trained in the UK but currently working at DermaMed Clinic in Dubai. Here she explains what eczema is and how treatment of the condition has advanced.
What is atopic dermatitis and how prevalent is it in the region?
It’s very common. Five to 10 percent of adults have it and one in five children who come to my clinic have it. In fact, the incidence of eczema has increased two to threefold. We don’t really know why. It may be due to increased urbanization, or other reasons that we haven’t figured out yet, but it is a very common skin condition that can affect anyone and occur anywhere on the skin.
With eczema, the skin barrier doesn’t work very well, so the skin is very dry with patches of redness, which can be scaly and rough. It occurs mainly on the face in children but in adults it’s mainly in the skin folds — that is, in the crook of the elbow or behind the knees or in the folds of the neck.
In severe cases, people can have it all over the body, which fortunately is not that common but it is possible to have eczema from head to toe.
What are the symptoms of atopic dermatitis?
Eczema is an itch that rashes and not a rash the itches. The skin might crack or weep and 20 percent of suffered will have bleeding if they scratch too much. The main symptoms are basically red, rough, dry skin. Even if someone has eczema in only one or two patches, that person will have dry skin everywhere on their body, so all their skin will be dry and sensitive.
The itching can be debilitating and the discomfort it causes will affect other aspects of a person’s life. One of the main issues is sleep disorders. Kids with eczema don’t sleep well, which affects their performance at school. They have low self-esteem, so they don’t play as much as other kids and they have issues with making eye contact. They are not happy children.
The painful skin and the sleep disorders are just the tip of the iceberg. Eczema is more than skin deep. The skin is what you can see but eczema can cause lots of other problems. We had one patient who would not wear clothes that didn’t have a high neck and long sleeves, even when she was going to the beach, because she didn’t want anyone to see her skin.
We call eczema a type 2 inflammation. People with eczema are more prone to asthma, hay fever, allergies and so on.
Is eczema easy to diagnose?
It’s quite easy to diagnose but there are misconceptions about it even among doctors and health professionals, the main one is that it’s related to allergies. Atopic dermatitis is an entity in itself and it comes from within, and the reason people have it is multifactorial.
First, there’s the genetic issue. It runs in families.
Secondly, the immune system factor: having eczema doesn’t mean your immune system is weak, but it does mean there are immunological changes that predispose you to eczema.
Thirdly, there are environmental triggers. A lot of patients — and doctors, too — link eczema to food allergies and indeed, the incidence of food allergies in people with eczema is higher than in the general public. You’re up to 20 percent more likely to have a food allergy if you have eczema. But food allergy is not a direct cause of eczema. It’s a shame when parents deny their kids certain foods, such as milk, because the majority of these kids don’t have food allergies.
Is eczema linked to any autoimmune disorders?
It’s only recently that we have started looking at eczema differently and since the past two years, eczema is considered as a systemic disorder, because inflammation in the skin can affect other parts of the body, making patients prone to other issues. Recently, patients with eczema have been linked to a higher risk of cardiovascular disease. MRI scanning of the lining of their blood vessels showed some type of inflammation.
Are there any other common misconceptions?
Aside from food allergies, a big misconception among the general public is that eczema is contagious, so you shouldn’t touch someone who has it. It’s particularly hurtful for children and it comes down to a general lack of awareness.
Describe a patient’s journey after diagnosis
Most patients are diagnosed quickly and they have the hope that it will go away once we fix the barrier function of their skin by moisturizing all the time. Doctor and patient need to have a discussion from the outset so that expectations are realistic.
A study from 2018 showed that around 20 percent of patients will see more than 10 doctors before they’re settled and know what to do. Around 40 percent will see two to five doctors.
The basic treatment for everyone should involve moisturizing a lot and knowing what the triggers are for them. It could be too many chemicals or perfumed products or wearing clothes that aren’t comfortable, all of which will trigger sensitive skin.
Those with very little eczema that comes and goes can be treated with steroid creams. There is a lot of steroid phobia around, so treatment must be under a doctor’s supervision, because some strong steroids can have permanent side effects and can change your skin. But for eczema patients, steroids are your friend and when used properly, they are the mainstay of treatment.
If the eczema is moderate or severe, the treatment has to be systemic — injections every month or two weeks or tablets taken daily. These are targeted therapies and have very low or no side effects because they go to a specific molecule and switch it on or off. It’s a game-changer.
Is eczema a life long condition or can you grow out of it?
You can. We used to say that 60 percent of children will grow out it. We now know that’s not 100 percent true but many will grow out of it on their own — something happens to their immune profiling that switches it off.
There are around 40 percent who will have it all their lives. But lifelong treatment doesn’t mean taking tablets or using creams or having injections all your life — it means guidance on how to integrate it into your life. It’s sad to see people with severe eczema not being treated, because there are treatments now. It’s a chronic disease but you can control it so well that you have as normal a life as possible.
You mentioned urbanization as a possible reason for the increase in eczema’s prevalence…
We don’t really know, but there is the hygiene hypothesis. This might be the wrong time to say this when we’re in a pandemic, but we live cleaner lives now and maybe we are not as exposed to allergens when we’re young which means we react differently to them when we’re older.
Let me say, though, that we understand eczema much, much better now that we did 10 years ago or than we ever did before. There are now treatments and targeted therapy. We still don’t fully understand them but we never had them before.
You were recently part of the first patient advisory board on atopic dermatitis in the Middle East. What’s the objective?
As doctors we have advisory boards to discuss new medications and advances in science, but this was the first time we invited patients who live with the problem, so we could hear from them about how they got diagnosed and what their unmet needs are.
For me, it was a real eye-opener to see how much it affects their quality of life, their work, their self-esteem, their relationships with partners and friends, how they viewed themselves and how they had to adjust their behavior. For some of them, that adjustment dictates what job they take or what they do at university.
What I took from it was that eczema cannot be treated just by dermatologists. There has to be a multi-disciplinary approach. Psychologists have to be involved. Eczema can affect the eyes so those specialists need to be involved.
What is the level of awareness of eczema in the region?
The big message is that there needs to be more awareness and more education. From the doctor’s point of view, that means better medication with fewer side effects. That is in-process. In the last year, I’ve been in meetings talking about it every few months.
From the public point of view, we need more education and we need to hear from patients exactly what they need from us and other support groups, so that the school nurse knowns more about eczema and has creams available and understands that if a child is sleepy during the day it’s because they’re not sleeping well. If their top is a bit dirty with some blood on, it’s not necessarily because of neglect but because their eczema is not controlled.
When you know more about a condition you not only treat it better as a doctor but the public knows more too.
In your view, can social media improve awareness and education?
It’s a wonderful tool. It’s the easiest way to absorb information, because a piece of information is related to a person. That said, a lot of information on social media is unreliable, so you need to sift through it and always look for reliable sources and remember that what works for one patients might not work for another.
But my hope is that people will be interested in talking about it and about health issues in general and as long as the information is supported by reliable platforms like Livehealthy, social media can really improve understanding.
Dr Khadija Aljefri is a guest on the Livehealthy podcast on July 7, 2021. This podcast was the result of a partnership between Live Healthy and Pfizer to raise awareness about atopic dermatitis.
Anna Pukas has reported from all over the world as a foreign correspondent for British media. She is now an editor based in Abu Dhabi.