Category Archives: eczema

Atopic eczema: On the rise

Atopic dermatitis or eczema is a chronic inflammatory skin condition characterised by recurrent acute flares of erythematous (red) itchy skin rash with all without some oozing.

Atopic eczema (AE) usually starts in infancy (< 1 year) or during childhood. Some children outgrow the disease while for maturity it may persist into adulthood. AE can also present for the first time in adulthood

It is estimated that approximately 2.3 million people worldwide suffers from AE. The number of cases is increasing globally including in Asia. Though AE has a lower prevalence in India compared to other Asian countries, the prevalence has consistently increase over the years.

How does one develop AE?

AE is cause by numerous factors interplaying with each other.

How does Atopic eczema presents?

Itching is a hallmark feature of atopic eczema. Itching can worsen the rash or even trigger the onset of eczematous rash.

For this reason atopic eczema is rightfully termed as an “itch that rashes

Itching in atopic eczema patient can become chronic, lasting for >6 weeks. Scratching to relief the itching can set in motion a viscous itch scratch cycle.

Atopic dermatitis is more than just skin deep?

The damaged skin barrier in patients with atopic dermatitis/eczema allows various allergens (proteins able to mount an immune response in the skin, body) to penetrate the skin, thereby sensitising an individual and causing allergic immune response seen clinically as red itchy rash.

Similar process can occur in the lining of the nose, pharynx predisposing patients to be sensitised to inhaled allergens such as pollen, pollution, dust etc resulting in Allergic rhinitis and or Bronchial Asthma.

A follow up article on the treatment and skin care measures for atopic eczema will be posted in the next blog post.

Atopic eczema in skin of colour

Prevalence of atopic eczema has been reported to be higher in individuals with skin of colour. However the clinical presentation of AE in darker skin tone is different from AE in Caucasians.

Erythema (redness) is usually masked in darker skin tone individuals. Other presentation or associated features are hyperlinear palms, prurigo nodularis, peri orbital melanosis (dark circles), lichenified lesions (thickened hyperpigmented skin) etc.

Denie Morgan line

Pityriasis alba

A skin condition better known as “Khaid” in my mother tongue : Khasi.

Pityriasis alba is a common skin condition mostly seen in children & adolescents between 3-16 years of age

Pityriasis” refers to the fine scales and “Alba” refers to the pale hypo-pigmented patches.

These pale patches are mostly seen on the cheeks, arms, chest, or back.

What causes P.alba?

The aetiology is still unknown. However there are some factors that have been implicated in the development of P.alba:

How does P.alba present?

P. alba evolves through different stages:

  • First stage : Starts as areas of mildly erythematous (red) patches on the cheeks or chin, or arms. It may be itchy at this stage. This stage is commonly more noticeable in fair skin individuals and often missed in darker skin individuals.
  • Second stage : The erythematous patches subsides leaving behind pale hypo-pigmented patches with the fine scaling on the surface. This is more prominent in darker skin tones and it is usually at this stage that parents seeks medical attention for the patches.
  • Third stage: The pale patches spontaneously subsides in a few months to years leaving no scars

Variants of P.alba

Should I be worried that my child has P.alba?

No, P.alba is a benign self resolving condition. The patches subside spontaneously within a few months or years for some without any sequelae.

It is important to remember that it may take years to complete resolution of the patches of P.alba in few patients.

Why do you need to see a dermatologist?

P. alba can mimic many other skin conditions, therefore getting an expert to examine the skin lesions for a proper diagnosis is of utmost imporatance.

You dermatologist can help conduct certain bedside test on the skin to help rule out the above mentioned conditions.

Once the diagnosis of P. alba is ascertain, the dermatologist will advised on your skin care and treatment accordingly depending on the stage of the condition.

How is P. Alba treated?

What one can do to help improve the appearance of the skin lesions:

  • Avoid excessive bathing and excessive washing and scrubbing of face
  • Use moisturisers, it helps improve the appearance of the dry scaly patches
  • Always use a broad spectrum sunscreen which will help prevent further tanning and darkening of the surrounding skin, thus minimising the contrast between the pale patches and the neighbouring tanned skin.

What your dermatologist may prescibe?

  • A Short course of mild topical steroids especially during the first stage of the disease when the rash erythematous and itchy.
  • Topical calineurin inhibitors such as tacrolimus or pimecrolimus during the second stage.

Winter skin care

I recently visited my hometown, Shillong in the north eastern part on India during the last few days of November and it was already cold especially at night. The water was freezing cold as well.

The first thing I noticed was my skin felt extra dry, with visible patches of dry spots. My lips were constantly chapped and I could literally write on the skin on my legs. These skin changes were happening with everyone. My family members and I had patients from back home that all complaint that their skin felt tight.

So why does this happen in winter?

To understand this, we will have to do a deep dive into how our skin functions in an optimal environment.

As you can see the protein filaggrin plays an important role in hydrating the skin, protection against UV rays and maintaining a healthy skin barrier. Individuals with mutation in the gene encoding filaggrin protein are more predisposed to developed eczemas and other allergic conditions such as asthma. Studies have found that low humidity and low temperature causes a decrease in the amount of natural moisturising factor (NMF) in the stratum corneum and this causes decrease in skin hydration. This results in the subjective feeling of dry flaky skin during winters.

Animal studies also show that when the skin is exposed to low humidity, a reactive pathway favouring pro inflammation is activated within 24 hours. What this means clinically is that, the skin maybe more sensitive to ingredients present in skin care products during winters.

Certain skin conditions can worsen during winters. Individuals suffering from eczema, psoriasis, rosacea, cold urticaria should be careful not to be exposed to cold weather, water and to aggressively take care of the skin by moisturising and being gentle with their skincare.

Skin changes associated with using radiation heaters during winters

Homes in Shillong do not have central heating and rely on the use of radiation heaters or coal stoves to keep them warm. There are certain skin changes that can be associated from exposure to such infrared radiation.

Erythema ab igne/ Toasted skin syndrome/Fire stains

Reticulate (lacy pattern) erythema (redness) and pigmentation on the skin caused by chronic and repeated exposure to infrared radiation from heaters, wood or coal stoves. This has recently been described to be seen on the thighs of people with prolonged contact with laptops.

Though the condition is benign and resolves when the heat source is removed, the pigmentation can be permanent for some and in rare instances skin cancers such as squamous cell carcinoma or merkel cell carcinoma can develop.

Avoid sitting too close to the heat source (heater or stove)

Wear protective clothing to prevent direct exposure of the skin to the heat radiation

Remove the most heat source the moment redness develops on the skin

Seek a dermatological examination if a non-healing ulcers or wound develops over the skin where the pre-existing erythema or pigmentation was.

Worsening of Melasma

A multi centric cross-sectional study from India found a significant and positive association with the duration of heat exposure and the severity of melasma

If you suffer from melasma, avoid sitting too close to the heat source and always remember to wear a broad-spectrum sunscreen even when indoors.

Illustrations done by Alexandra Kristin Mawlong