Commentary: Low self-esteem, depression and frequent flare-ups plague growing numbers of eczema sufferers
As a society, we must overcome the shameful stigma that those who suffer from eczema bear, says dermatologist Dr Joyce Lim.
SINGAPORE: I met Jamie* when she was 35. She stopped work after the debilitating rashes from her eczema became unbearable.
Monthly flares left a red scaly rash all over her body and threw her into episodes of intense itches.
In between flares, she suffered from a constant itch and need to scratch, on top of the pain, bleeding and already intense damage to her skin from frequent scratching.
At work she struggled to complete her work assignments, having to stop working every 10 to 20 minutes to scratch. She also could not concentrate, exhausted from the bouts of waking up at night to an overwhelming itch. She took medical leave almost every fortnight.
Then there was 13-year-old Samuel*. Red, scaly rashes that covered his arms and legs affected his confidence. He entered my clinic with his head down, avoiding eye contact throughout the appointment. He had no friends as he avoided socialising at school.
Those who suffer from this medical scourge have inflamed patches of skin that are itchy, red, cracked, and rough, and blisters sometimes occur. Eczema is particularly common in children but can develop at any age.
Eczema can be crippling for families with young children. Heart-broken parents helplessly watch their children in pain, while exhausted siblings are drained from being woken up at night when their brother or sister wakes to episodes of intense itch, crying, crushed by a condition they have little control over.
Primary school children suffer greatly from the condition. Stress during examination periods can cause more frequent flare-ups. The anxious child - sleep deprived and irritable by morning - may not perform as well as hoped, through no fault of their own.
Apart from frequent sleep disturbances and anxiety, eczema leave many sufferers with low self-esteem and even depression.
During their teenage years, several eczema sufferers end up victims of marginalisation or bullying, as their visible skin condition confers them an inescapable social stigma. Recreational activities are limited, as many tend to avoid sports and outdoor activities, to avoid perspiring and worsening their condition.
In adults, frequent flare-ups can impair concentration, fuel frequent absenteeism and affect performance at work.
A patient once said to me:
Eczema is not just a skin problem, it scarred my life, inside and out. I wouldn't wish it on even my worst enemy.
ECZEMA IN SINGAPORE
The occurrence of eczema in Singapore is one of the highest in the world. It is the most common skin condition in Singapore. Yet the occurrence in Primary One children has grown over the past five years.
This is surprisingly common in advanced Asian nations, including Japan where three in 10 infants suffer from the condition.
A combination of genetics, abnormal immune system functionality, environmental factors and defects in the skin barrier, contribute to its development.
Research suggests that too clean a living environment may deprive the body of the beneficial bacteria essential for building a strong immune system. When our environment is too clean, the immune system just does not develop the cells needed to fight infections from allergens.
With air-conditioned environments commonplace, the increased amount of time children spend in air-conditioned settings correlates with an increase in occurrence of eczema. Air-conditioners makes a room dry, sucking up moisture from the skin, precipitating eczema symptoms, and drawing air and allergens from the outside environment into the room.
Conversely, studies have also shown that children exposed to nature, whether through living in the countryside, or by having a pet dog at home, have stronger immune systems and are less likely to suffer from eczema.
Most patients seek help only when their eczema worsens but treatments can prevent new outbreaks apart from relieving certain symptoms.
A reactive treatment applies emollients with anti-inflammatory topical therapy daily to eczema lesions, stopping only after the lesions subsided or cleared completely. A proactive treatment involves a long-term, intermittent application of anti-inflammatory emollients to previously affected areas and unaffected skin.
A proactive treatment is equally, if not more important, as it can reduce the occurrence of flares by almost eight times, according to studies. And as intervals between flares get longer, there is a greater chance of a child outgrowing the eczema.
I cannot emphasise how important it is for parents and children to be educated on good skin care and to treat eczema early. Not realising that areas of normal looking skin does not mean full recovery has been achieved, many discontinue treatment and hope to revert to their pre-eczema routine.
But caring daily for your skin must be a new way of life, including taking extra care to use fragrance-free and dermatologically-tested moisturisers, on top of continuing with proactive treatment.
Generally, patients who use appropriate moisturisers find that their skin becomes less irritable. Small doses of antihistamines also help the itch.
Controlling the environment, ensuing that there is circulation of natural air for instance, or that humidifiers and filters to control external allergens, can also help.
The good news is eczema can usually be outgrown, as the condition goes into remission when the child grows and their immune system matures, generally 50 to 60 per cent of those who have had childhood eczema outgrow their condition.
However, the more severe the condition in childhood, the higher the risk of the disease continuing into adulthood.
WHAT MORE CAN BE DONE?
As a society, we must overcome the shameful stigma that those who suffer from this condition bear. Eczema patients deserve to live a healthy and productive life free from discrimination.
Some help to alleviate the condition can move the needle. Avoiding activities that involve sand, grass and heavily chlorinated water that can exacerbate the condition will help pre-schoolers with eczema.
In primary school and above, children with eczema should be seated under fans or near windows for fresh, circulating air. Giving them options to wear loose, cotton clothing (for example, Physical Education attire) would also go a long way in reducing discomfort, as many school uniforms are made out of synthetic fibers that can trap heat.
Education is also key where the condition is often seen as “contagious" or a result of someone being “dirty”.
A 2-year-old patient of mine, goes to childcare on a daily basis. Initially, the teachers were unsure of how to help. However, her mother taught the teachers how to alleviate the child’s condition by applying moisturisers after showers, keeping her cool and having her stay away from sand pits.
The teachers eventually learnt that eczema was not contagious and could be managed. They taught the same to the rest of the patient’s classmates. Soon after, the other toddlers socialised and played together. The patient now enjoys going to school in spite of her condition.
Primary school health education needs to include basic education on skin diseases – since it is most apparent in children at this age.
As the above example showed, parents and teachers themselves need to be equipped with knowledge on the misconceptions about the condition, the facts, and how they can help young children in their care perform tasks required of them.
In the workplace, having an understanding of the condition can go a long way in helping an eczema suffering employee feel supported and remain productive despite the ailments the condition brings.
Flexible hours or work from home options allow patients to create a comfortable work environment that helps manage the condition, for instance. Removing dust and allergen traps like heavy curtains and carpets, and regular air-conditioner maintenance are effective ways to keep the work environment conducive.
When Jamie understood the pathogenesis of eczema, she learnt how to cope with the flare ups, maintain her skin’s moisture and improve her overall condition. Happily, Jamie has since returned to work.
One thing both Jamie and Samuel had in common was the mindset that they have no choice but with this condition for the rest of their lives. They are not the only ones, as many eczema-sufferers are so used to seeing their skin in rashes they give up all hope of normalcy.
But there is optimism for those who suffer from eczema. With treatment, public education and support from those around them, these patients can lead a healthy, productive and stigma-free life.
*Pseudonyms have been used.
Dr Joyce Lim Teng Ee is a dermatologist in private practice at Joyce Lim Skin and Laser Clinic. She recently spoke at the inaugural Asia Derma conference held in Singapore in December 2018.