00;00;08;26 – 00;00;25;10

Dr. Mona

Welcome to this week’s episode. I am so excited to welcome Doctor Shivani Patel. She is a board certified pediatric dermatologist and she’s on Instagram as pedes derm doc. And she’s joining me today to talk about eczema. Thank you so much for joining us, Shivani.

 

00;00;25;12 – 00;00;27;09

Dr. Shivani Patel

Thank you so much for having me.

 

00;00;27;11 – 00;00;48;04

Dr. Mona

I’m so excited. I connected with you on Instagram, and I remember when you joined social media, I was like, yes, a pediatric dermatologist. Everyone’s always asking me about skin stuff. And as a pediatrician, obviously I have my own expertise, but I love hearing from the specialist, you know, because obviously in real life I utilize my pediatric dermatologist greatly.

 

00;00;48;09 – 00;00;52;13

Dr. Mona

So I’m just so happy we could connect on social media and that we could connect on here.

 

00;00;52;16 – 00;01;03;04

Dr. Shivani Patel

Me too. I’m so glad we’re doing this and sort of putting more information out there about eczema, because it’s such a common skin condition that parents have so many questions about. So hopefully we can get some of that answered today.

 

00;01;03;06 – 00;01;08;03

Dr. Mona

And tell me more about yourself. And what drove you to go into pediatric dermatology?

 

00;01;08;05 – 00;01;38;18

Dr. Shivani Patel

Yeah. So, I am a board certified pediatric dermatologist, and a lot of people aren’t really aware of what a pediatric dermatologist is, but we are a pretty rare group of dermatologists who spend an extra year after residency training to really learn more about hair, skin, and nails in babies, kids, teenagers and adolescents. And I was really drawn to it when I was in residency, actually, because I enjoyed kind of talking to the whole family unit, being able to be involved with the care of a child and discussing that with each of the parents.

 

00;01;38;29 – 00;01;57;12

Dr. Shivani Patel

I the skin is so visual, and I think there’s so many kids out there that have skin conditions that are very rare or genetic syndromes that I found very fascinating to be able to treat and improve quality of life. And, you know, giving families that support that they need it was initially what sort of drew me to it, and it’s something that I really enjoy doing every day.

 

00;01;57;14 – 00;02;18;02

Dr. Mona

Oh that’s great. And like you said, there’s so much well, there’s so much in pediatric dermatology. Rashes is one of my favorite things like and it always, you know, things can just present so differently even if it’s the same diagnosis or there’s just such rarities too. So I have utilized my colleagues at Pediatric dermatology, like I said, and it’s just so helpful the team approach that we have too.

 

00;02;18;08 – 00;02;19;16

Dr. Shivani Patel

Yeah, absolutely.

 

00;02;19;19 – 00;02;43;16

Dr. Mona

And we chose to talk about eczema. We wanted to choose a topic that was heavily requested from my followers. And obviously Doctor Patel gets questions about eczema all the time in her practice. And then, of course, we’ll have her come on again to talk about other topics, but let’s talk about eczema. And how can it differ in infancy and childhood in terms of appearance, the time that it can set on what’s the differences there?

 

00;02;43;18 – 00;03;06;08

Dr. Shivani Patel

Yeah. So eczema another name for it is also atopic dermatitis. It’s what we call the rash that itches. So it is a rash that can be very red and oozy. Has scaling open source. And the hallmark is really the itch then it’s incredibly common in children and it’s reported and up to 25% of all kids and 90% of them will present by age five.

 

00;03;06;08 – 00;03;23;22

Dr. Shivani Patel

So I have a lot of families who come to me and ask if their child is going to get eczema and their children are a little bit older, you know, let’s say 7 or 8. And it’s unlikely at that age if you haven’t had any eczema develop that you will at that point. But it can look incredibly different between infancy into childhood and into adulthood.

 

00;03;23;22 – 00;03;40;12

Dr. Shivani Patel

And so it’s different for every single person. And that’s why it’s good to kind of know what the features are. So you know, what to sort of look out for. In infants and toddlers it tends to appear on the face and the scalp and the cheeks are kind of the key area. So the cheeks can get very oozy.

 

00;03;40;12 – 00;03;58;06

Dr. Shivani Patel

They get red, they start to get a little bit weepy, and then it can sort of extend down into the neck area. In babies, it tends to not occur in the diaper area. And that is because there’s a lot of moisture there that tends to protect the area from being involved, but it is an area that it can eventually migrate into later on in life.

 

00;03;58;12 – 00;04;14;27

Dr. Shivani Patel

When you start to get into childhood, usually around age eight or so, it starts to go onto the elbows, the knees, the wrists and even into the hands. And what parents will notice is that the face starts to clear. So the face will get better, but then it’ll sort of start to move around into the folds of the skin.

 

00;04;14;27 – 00;04;36;28

Dr. Shivani Patel

So very commonly behind the knees or again on the elbows. And this tends to also carry over into teenagers and then into adults as well. And then particularly hand eczema or, you know, really bad scaling and itching and cracking of the hands tends to be something we see a little bit later in the teenage years and then again into adulthood as well.

 

00;04;37;01 – 00;04;46;17

Dr. Mona

And are there any signs in the infancy or childhood phase that would kind of tell you that maybe the child will outgrow their eczema, or it’s really hard to say.

 

00;04;46;19 – 00;05;05;08

Dr. Shivani Patel

It’s hard to say. But most of the time, what we’ve seen in studies and even just in practice is if it’s a very mild case, it tends to be something that the child will eventually outgrow. The majority of babies with mild eczema eventually outgrow it. And again, usually by age five or so. Another marker is looking at the family as well.

 

00;05;05;08 – 00;05;15;05

Dr. Shivani Patel

So if you have a parent who was told by their parent that they had eczema, that they outgrew it, it’s also more likely that then their child will probably outgrow it as well.

 

00;05;15;07 – 00;05;31;18

Dr. Mona

And I think the million dollar question that a lot of families have, if their child has eczema is do we know why it happened? You know, what is the, I guess, the pathophysiological like the on the cellular level, skin level, what is happening that causes these children to get this eczema?

 

00;05;31;20 – 00;05;51;28

Dr. Shivani Patel

Yeah. This is really, truly is the million dollar question. Like you said, this is what I get asked on a daily basis is parents want to know why. So they really want a reason as to why it’s happening. And again, both like you said on the cellular level, but also just sort of risk factors as well. So the way that eczema happens is you have altered skin barrier.

 

00;05;51;28 – 00;06;17;00

Dr. Shivani Patel

And what that means is the uppermost layer of the skin. This is an area that protects us from bacterial infections. It keeps allergens away from our body. It helps lock moisture in. That barrier gets broken when kids have eczema. And when that happens, you can allow bacteria to get into the skin, allergens to get into the skin. And it can also lead to what’s called trans epidermal water loss, which means you start to lose water from the surface of the skin.

 

00;06;17;00 – 00;06;42;15

Dr. Shivani Patel

And that’s how you get very dry. When all of this happens, our immune system also becomes hyper aware and it starts to get revved up and it starts to cause this cascade of more inflammation and more reaction that just drives the skin to get even worse and worse. So it’s really a cycle where the skin sort of has these microscopic breaks that then gets cracked, allows substances or allergens or bacteria to get in, allows our immune system to sort of hyper rev up.

 

00;06;42;15 – 00;07;00;18

Dr. Shivani Patel

And then it sort of creates this cycle over and over again. And so when I explain this to families, they’ll often say, why? Why did my child get this right? Why is my child barrier broken when you know mine isn’t or somebody else’s isn’t? And the main thing to know is that it is what is called a multifactorial disease.

 

00;07;00;21 – 00;07;18;21

Dr. Shivani Patel

So there’s not really a true one cause. So I can’t ever tell a family member, you know, X is the reason. And if we took X away, your child would be eczema free because it tends to be so many different reasons, kind of compounded onto themselves as to why your child gets eczema. And one of the main things is genetics.

 

00;07;18;21 – 00;07;38;28

Dr. Shivani Patel

So usually families ask me if they have eczema. It tends to be that one of them probably had it as well, or a grandparent or a sibling. Or if they didn’t have eczema, they had either seasonal allergies or asthma or something else that’s related, because having one parent with eczema does increase your child’s risk three times. So it’s pretty drastic.

 

00;07;38;28 – 00;07;55;00

Dr. Shivani Patel

If one parent has a history of eczema that it’s able to be passed down to your child. And the important thing, as well as a lot of family members don’t even know they had eczema, right? The mom or the dog? Because if you outgrow it by age five, they might not have even been aware that they had it as a child.

 

00;07;55;00 – 00;08;18;16

Dr. Shivani Patel

So they often tell me, well, I’ve never had it. You know, no one in my family’s had it. But there are other signs that you can look for on the skin, and people who are predisposed or have an inclination or a propensity to form eczema. And those are things like having an extra eyelid crease underneath the eye, or having what are called hyper linear palms, where your palms have more lines than somebody else.

 

00;08;18;27 – 00;08;42;22

Dr. Shivani Patel

A condition called keratosis pilaris, where you get rough bumps on the upper arms or having fish scale on your legs. So ichthyosis or really dry skin on the legs. These are not true eczema, but they are markers of people who actually have a genetic component of dry skin. So I’ll often be able to even tell just by looking at that parent that they do have the, you know, propensity to have eczema, even if they don’t just buy these other features.

 

00;08;42;22 – 00;09;02;23

Dr. Shivani Patel

And so that’s something that I’ll often show them or explain to them that, you know, you have these other signs of dry skin, so you may not have eczema, but that genetic component got passed down likely to your child. And then a couple other factors sort of came into play and sort of created this reaction. And so a few other things that can sort of make it worse are climate.

 

00;09;02;23 – 00;09;23;23

Dr. Shivani Patel

So do I a lot of kids do better in the summertime, and then they tend to do a little bit worse in the winter when the air is dry and it’s very cold, you know, dog dander, pollen, mold, dust mites, those things can also flare it. And then stress can play a big role. So you know, a lot of times if you have a stressful event in your life, you’ll find that the skin flares with any skin disease and especially eczema.

 

00;09;23;23 – 00;09;40;11

Dr. Shivani Patel

So when they ask me sort of why it’s happening, I tend to have to, you know, explain that these are all of this sort of reasons. And so it’s not just one cause or one issue. It’s sort of, you know, a combination of things that that created this and then, you know, has led your child to have eczema.

 

00;09;40;13 – 00;09;59;11

Dr. Mona

And that’s a great point. Like knowing that it’s not just one thing and it could be, you know, multifactorial. And you mentioned something like potential allergens in your opinion. I know you are a pediatric dermatologist, but when do you recommend, say, you know, they go see a dermatologist for their eczema versus a pediatric, you know, allergy immunologist?

 

00;09;59;13 – 00;10;20;18

Dr. Shivani Patel

Yeah. So this is something that’s actually been studied heavily in both fields right now because there is definitely a link between eczema and food allergies. But in most cases, food allergies don’t cause eczema. And eczema doesn’t cause food allergies. So they’re not caused by each other. They’re just related. But I think a lot of times, again, families and parents want that answer, right.

 

00;10;20;18 – 00;10;40;06

Dr. Shivani Patel

They’re looking for one cause or one reason. And so a lot of children do get worked up for food allergies that don’t necessarily need that workup. And so they end up getting sort of these food restrictions or even causing a food allergy to develop when they never really had one before. And this happens a lot when we over test kids with very mild eczema.

 

00;10;40;06 – 00;11;16;24

Dr. Shivani Patel

So most cases when your child has very mild eczema, it tends to be something that usually the dermatologist can manage alone and doesn’t necessarily need, you know, the input of an allergist or a food allergy workup or anything like that. Where it gets tricky is when kids start to have more moderate to severe eczema. And in these cases, both the American Academy of Dermatology and the American Academy of Allergy Immunology do recommend food allergy testing, especially in children with severe eczema, who may also have poor weight gain or bloody diarrhea or feeding issues, or even a sensitivity to having, like an egg allergy, for example.

 

00;11;16;24 – 00;11;51;15

Dr. Shivani Patel

Those are the all reasons that I tend to work with my allergist and co-manage, because in those cases, when it’s severe, if you do find a true food allergy, eliminating that food can actually help the eczema. It usually won’t clear 100%, but can make it a lot better. But again, it has to usually be a severe case. And I think that’s the important distinction because a lot of families company and if their child has severe eczema or they feel like it’s really bad, but they are actually in the mild category, and so they’ll come thinking, you know, my child has really bad eczema or it’s really severe when they have just a few spots here

 

00;11;51;15 – 00;12;08;20

Dr. Shivani Patel

or there, you know, maybe a spot on the face, a spot on the chest. And that’s actually more what we call mild eczema. Severe eczema is babies who have, you know, basically covered head to toe where their entire body is red, their entire body is scaly or the majority of their body. And so these are very rare cases.

 

00;12;08;22 – 00;12;32;07

Dr. Shivani Patel

Most kids, again, are very mild. And testing at this point can lead to what we call false positives, where they get an allergy that’s shown, but it’s not really a positive reaction. And so we tend to want to reserve it for kids who are more in the severe cases when we know a true allergy can be found, and when that is confirmed with a food challenge by an allergist and eliminated from the diet can help their eczema too.

 

00;12;32;09 – 00;12;58;08

Dr. Mona

And I had a allergist on my podcast. So for anyone who wants the opinion and what you know, obviously Shivani saying about eczema from the dermatology standpoint really aligns as to what the allergy immunologist said about eczema. That is on episode seven and then episode 22 is on food allergies. So if you want more information about that and all the testing and why, we don’t recommend over testing, which she also said to and I agree.

 

00;12;58;19 – 00;13;04;24

Dr. Mona

Please listen to that. I think all three of these episodes, this one, episode seven and 22, would be super helpful.

 

00;13;04;27 – 00;13;27;15

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00;13;27;17 – 00;13;51;03

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00;13;51;08 – 00;14;01;10

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00;14;01;13 – 00;14;18;11

Dr. Mona

I also now want to talk about the management. Right. And this is not medical advice. Everyone you know, I know the most important thing is that you talk to your child’s doctor, get a referral if you want to see a dermatologist, but we’re just going to go over basic philosophies for skin care management. Some questions I get asked.

 

00;14;18;11 – 00;14;25;15

Dr. Mona

Okay. So Shivani, what are your favorite basic skincare regimen for children with eczema?

 

00;14;25;17 – 00;14;44;03

Dr. Shivani Patel

Yeah. So, I think this is actually the most important step in eczema management. There’s lots of treatments for eczema, a lot of prescriptions. But ultimately the skincare regimen is the part that is really, really important. And without it, the rest of it usually doesn’t work. So, we call it an eczema management plan, and that’s usually how I frame it to parents.

 

00;14;44;03 – 00;15;02;11

Dr. Shivani Patel

And it’s several steps that parents can use to help maintain clearance in the skin and prevent new flares. And it usually starts first with bathing. So that’s always a question I get is how often should I be bathing my child? And it really doesn’t make a difference. There’s really not a lot of data that shows one way or the other.

 

00;15;02;11 – 00;15;22;15

Dr. Shivani Patel

If you want to bathe every day, usually I’m fine with that, or even daily it’s during. Bathing is where it actually, you know, matters what you do. So what you want to do is stick to gentle, fragrance free cleansers. You want to avoid harsh antibacterial soaps, avoid bubble baths, and very heavily fragranced soap that can irritate the skin.

 

00;15;22;18 – 00;15;38;17

Dr. Shivani Patel

And you only want to use lukewarm water and make sure you’re really only bathing your child for up to ten minutes. And so that’s more important to me than actually the frequency of bathing. It’s what goes on while your child is bathing. And as soon as they’re out of the bath, you want to avoid vigorously rubbing the skin dry.

 

00;15;38;17 – 00;15;57;25

Dr. Shivani Patel

So a lot of parents will try to rub that skin really hard, get all that moisture out. But in kids with eczema, remember their barrier is dysfunctional. So you want to trap as much moisture as we can. And so instead of vigorously rubbing the skin, we want to try to pad the skin very gently, leave some of that moisture on there, and immediately apply the moisturizer.

 

00;15;57;25 – 00;16;15;14

Dr. Shivani Patel

Right after that point. And what that’s going to do is sort of seal that moisture in, lock it in and keep the skin hydrated. And so that sort of gets into the point about moisturizers and which types to use and things like that. And there’s so much out there on the market now that I tend to not really get picky over the brands and the types.

 

00;16;15;14 – 00;16;35;03

Dr. Shivani Patel

I go over a little bit of this in my Instagram post as well, but I think the key point is the type of moisturizer you use and the brand. So there are three main types of moisturizers. You have ointment, creams, and lotions. And I tend to prefer ointments in kids that can handle them because they contain about 80% oil and very little water.

 

00;16;35;03 – 00;16;50;07

Dr. Shivani Patel

So when you put it on your child’s skin, it’s not going to evaporate off very quickly. A lot of it is going to stay on and it’s going to seal that moisture in. And so those are ones that are incredibly thick. They’re very greasy, and they work really well in babies because they tend to be okay with it.

 

00;16;50;07 – 00;17;15;20

Dr. Shivani Patel

Now in older kids and in teenagers, they don’t want to feel greasy during school or and things like that. So we tend to shift to creams. Those contain about 50% water. So it’s not as thick as an ointment, but it’s still better than a lotion because a lotion contains even more water. So lotions, those are the ones that I have the hardest time with because they tend to just not be enough for kids with eczema and normal people who don’t have any eczema, it’s a great option.

 

00;17;15;20 – 00;17;33;14

Dr. Shivani Patel

But when you already have increased water loss, we want to try to keep as much of that in. And so a lotion for the majority of the time, they really don’t work well. And so a lot of families wonder, well which type do I have at home. And so I always ask them in clinic, I’ll say, does your moisturizer come in a pump bottle or a jar?

 

00;17;33;14 – 00;17;46;14

Dr. Shivani Patel

And I think that’s the best way to figure it out. If it’s in a pump bottle, it’s going to be a lotion because creams and ointments, they’re too thick, they won’t come out of the pump. And if it’s an hour, it’s a cream or anointment. So as soon as they say jar, I say, great, you know, it doesn’t really matter.

 

00;17;46;14 – 00;18;04;12

Dr. Shivani Patel

Again, which brand? Usually as long as it’s it’s in a jar and it’s getting onto the skin. That’s the most important part. So usually if it’s in a pump bottle, I’ll explain to them, you know, why this is more preferred, and try to have them switch to one of them because they do work a little bit better. And you want to try to moisturize at least 2 to 3 times a day.

 

00;18;04;17 – 00;18;27;14

Dr. Shivani Patel

In babies with severe eczema, it can actually be beneficial to do with every diaper change, which is a lot, but they are losing that much moisture that quickly. That trapping it in as much as you can can really help. So that is sort of the whole eczema management plan. We sort of start with gentle bathing, you know, the skin dry, lock that moisture back in and then use that moisturizer at least a few times a day.

 

00;18;27;17 – 00;18;42;01

Dr. Mona

Well, I’m so happy you said, you know, using it frequently like 2 to 3 times a day. Every diaper change for severe eczema. There’s a common misconception that I hear in my office, and I have to correct it, mean we should talk about it, that, oh well, if I use it too much, then my baby’s skin will get used to the moisturizer.

 

00;18;42;01 – 00;18;51;14

Dr. Mona

And I’m like, no, no, no, we want to. If your child has eczema, we want to protect your child’s skin and moisturize. So correct. Right. Like you’re not ruining them by over moisturizing?

 

00;18;51;17 – 00;19;08;09

Dr. Shivani Patel

Absolutely not. No. I hear this a lot too, where we’re parents who say, well, this moisturizer worked initially and now it doesn’t anymore. Yeah. And I tend to sort of remind them that it’s not really the moisturizer that’s not working. It’s the eczema that’s having its cycles. It’s having a good day, a bad day. And so timing that can be very tricky for people.

 

00;19;08;09 – 00;19;24;26

Dr. Shivani Patel

And oftentimes, you know, people want to associate it with the moisturizer. But moisturizer is going to work no matter what. And it’s not something that our skin gets used to. Our bodies get used to. As long as it’s on there, it’s at least doing the job it’s supposed to. Sometimes you’re still going to have breakthroughs and flares, no matter if you do it with every diaper change or 2 to 3 times a day.

 

00;19;24;26 – 00;19;32;16

Dr. Shivani Patel

But it’s still doing what it needs to do, and it would probably have been even worse of a flare had you not had that moisturizer on.

 

00;19;32;19 – 00;19;46;28

Dr. Mona

Oh, this is so good. I love how you break it down with the ointments, cream, and lotions because it does make a huge difference. I am an ointment fan, even for myself and you know, I know we’re talking about eczema skin, but I don’t have eczema. But I just have had a preference for that ointment feeling. I don’t know.

 

00;19;46;28 – 00;20;04;24

Dr. Mona

I just like it. I know it’s a little greasier, but I just feel like it moisturizes so much better for me, even for non eczema skin. But it really matters for, children with eczema and people with eczema. I want to talk about something called bleach baths. This is something that is common and I wanted to know from a dermatology perspective, this is something that’s still recommended.

 

00;20;04;24 – 00;20;09;10

Dr. Mona

And if so, when is this recommended to do and explain what it is. Yeah. Yeah.

 

00;20;09;10 – 00;20;28;19

Dr. Shivani Patel

So a bleach bath is where you basically for a bath tub with water and you put a quarter cup of bleach and usually allow your towel to sort of soak in there for about 10 to 15 minutes. And what that bleach is supposed to do is actually decrease the bacterial load on the skin, eczema, skin. And studies have shown to have more staph aureus bacteria.

 

00;20;28;22 – 00;20;53;00

Dr. Shivani Patel

And in some kids it just kind of colonizes the skin, which means it’s not doing much, but just sitting there. But in some kids, it can actually lead to an infection where they can either get an infection in the skin or even in the bloodstream if it enters the bloodstream. And so that was the whole point of bleach baths, was to try to decrease that bacterial load and in theory, hope to minimize infections or even the inflammation that infection could cause or that bacteria could cause on the skin.

 

00;20;53;03 – 00;21;20;11

Dr. Shivani Patel

And a lot of people have studied this recently to kind of figure out, is it really helpful or not in the data right now, it’s still pretty conflicting. There’s some studies that show really good improvement, and then there’s some that just say it makes no difference. I think I’ve seen good results in some kids, but I tend to reserve it for kids who have more sort of, bacterial infections where they’re constantly getting these recurrent sort of yellow, crusty skin, and you can tell that they’re sort of colonized with that bacteria.

 

00;21;20;14 – 00;21;38;15

Dr. Shivani Patel

And so I do recommend it once a week for these families. But in most kids, again, with very mild eczema, it can be overkill. And it it tends to not have much benefit. And in those kids I tend to recommend just more of that gentle bathing and the whole eczema management plan. But a nice alternative to bleach baths is actually swimming pools.

 

00;21;38;15 – 00;22;01;22

Dr. Shivani Patel

And it has the same effect. And so parents always ask me, are pools okay? Can I take my child to the pool and absolutely. I love pools for eczema skin. That chlorine can serve that same purpose. Even getting a little bit of sunlight can help the eczema, of course, being sun protected. And so I do encourage pools in the summer and fall, and it’s another way to sort of get that same benefit without having to do the bleach baths.

 

00;22;01;25 – 00;22;10;08

Dr. Mona

And then if they do go to the pool, do you recommend like moisturizing after or not? You can just get them home and give them a bath and do your moisturizer as you would have.

 

00;22;10;10 – 00;22;26;09

Dr. Shivani Patel

Yeah. So is there, more severe eczema cases? I usually want them sort of out of the pool and then immediately put that moisturizer on them, take it with them. But again, if it’s very mild cases or if you feel like your child is even outgrowing it, it’s okay to usually wait, get home, you know, get the chlorine off and then again moisturize.

 

00;22;26;11 – 00;22;46;22

Dr. Mona

Awesome. Great tip. I’m in Florida, so any of my listeners who are year round around pools and summer, you know, would love that tip. So that’s great. Now another question I get asked a lot, a lot of families on social media in my office are, you know, have a fear of steroids. You know, you hear steroid and you think, oh my gosh, I don’t want my child to be on a steroid, whether it’s by mouth or eczema.

 

00;22;46;22 – 00;22;55;28

Dr. Mona

Obviously, it’s heavily used for flare ups. So what roles do steroids play? Is there a benefit? Is it harmful? Is that other question that I get asked a lot?

 

00;22;56;00 – 00;23;18;01

Dr. Shivani Patel

Yeah. This is a really important piece of the whole, sort of eczema management plan. Steroids are really first line treatment. They work, they’re effective, and they help get the rash under control. So there is absolutely a role for them. And I usually have all of my eczema families have two steroids, one that’s usually for the body and one that’s for the face and the armpits in the groin.

 

00;23;18;16 – 00;23;35;22

Dr. Shivani Patel

The face armpits and groin area or diaper area tends to be thinner skin. And so we want to use a milder steroid in those areas. And we can use a thicker one on the body. And something that I do see a lot is this steroid phobia. They’ve actually seen that about 72% of parents have a fear of using steroids.

 

00;23;36;01 – 00;23;57;29

Dr. Shivani Patel

But when they are used as they are directed, they are incredibly safe. A lot of this fear, I think, is out there sort of on the internet and, lots of different sort of articles that people read and they get scared of it, but ultimately they’ve shown it in so many studies that if it’s used exactly as it’s directed by your doctor is a very minimal risk of it causing any sort of side effect on the skin.

 

00;23;58;02 – 00;24;15;19

Dr. Shivani Patel

And the side effects that I think people are worried about is the skin thinning and skin discoloration that you can get. If you used a steroid for months and months and months without ever taking a break, which absolutely can happen and should not be used that way. And that’s why I usually have families take what’s called a steroid free break or a steroid holiday.

 

00;24;15;19 – 00;24;35;01

Dr. Shivani Patel

So you use the steroid when the eczema is very active, when it’s very inflamed. But then you take that steroid holiday for about a week to two weeks, give the skin time to sort of be away from the steroid and then restart it if you need to. And doing it that way is incredibly safe, and there is almost no risk of getting those long term steroid side effects.

 

00;24;35;03 – 00;25;02;06

Dr. Shivani Patel

You know, one thing I think that parents do get sort of confused about, though, is eczema can leave lighter spots on the skin just because that’s what it does. And it’s a condition called post inflammatory hyperpigmentation, where after the inflammation leaves the skin, it leaves a lighter spot. And it’s not a permanent spot in there because the skin was so inflamed by the eczema that the pigment cells in the skin could not produce pigment, it got sort of pushed to the side.

 

00;25;02;09 – 00;25;21;23

Dr. Shivani Patel

And so the skin got a little bit lighter. And once that inflammation goes away, the skin has time to sort of heal again and that pigment comes back. But what I think a lot of parents get scared about is they put that steroid on and it actually works very quickly and the eczema goes away. But now they have this light spot and they’re scared that the steroid did it, so they’ll stop using it.

 

00;25;22;04 – 00;25;42;21

Dr. Shivani Patel

Until I have to explain to them pretty frequently that it was the eczema that actually created that. And the steroid was the right call to do, because had it gone on even longer, or had that inflammation been there longer, that color could have been even lighter or could have been permanent. So that is something that I think is why a lot of patients get scared because they see those side effects and then they see it happen on the skin.

 

00;25;42;26 – 00;25;50;02

Dr. Shivani Patel

And of course, you know, it’s hard to know what caused it. And so they assume it’s the steroid when it’s reality. It’s the inflammation itself that did it.

 

00;25;50;05 – 00;26;06;08

Dr. Mona

I’m so happy you said that. You almost read my mind because I was like, yeah, I was just going to ask you. I was about to interrupt you. And I was like, but doesn’t the eczema shelf cause the hyperpigmentation? So totally a great point. And I see this, you know, in gen kids all the time, and parents are exactly fearful or even not.

 

00;26;06;08 – 00;26;21;27

Dr. Mona

I just see parents come in and the child had any rash like even rashes that are not eczema. I see a child had like a, you know, an inflammatory rash of some kind. And then I look at it and I’m like, oh yeah, it’s just the hyperpigmentation. They’re like, oh, well, is it going to come back? And yes, it will even out.

 

00;26;22;11 – 00;26;32;10

Dr. Mona

I usually and I wonder what you say, I usually say like, you know, give it some time, do your normal moisturizer, wear sunscreen, you know, when you’re outside so it doesn’t become more obvious and it’ll all even out with time eventually?

 

00;26;32;10 – 00;26;52;11

Dr. Shivani Patel

Absolutely. Yeah, that’s exactly what I say to it. Will even out. And usually the summer months can be more contrasting because the rest of the skin will start to tan and that skin won’t. But then by the winter time at all evens back out. And the way to actually prevent that discoloration is to use the steroid immediately when you see the eczema, because the faster you can treat it, as soon as it comes on the skin.

 

00;26;52;13 – 00;27;01;14

Dr. Shivani Patel

Number one, the less of it that you need. So if you’re a little bit fearful, you’ll need less of it. And also you have a less chance that it’s going to be around long enough to cause that color change.

 

00;27;01;16 – 00;27;17;27

Dr. Mona

Oh, this is such great tips. See, this is why I’m so glad that we’re connecting, because this is such good information. Stuff that I love to talk about, but it’s so much better when it’s with a specialist. So again, we’re like almost through all of the main questions I have, but already I’m like gushing with all of the awesome education.

 

00;27;17;27 – 00;27;36;01

Dr. Mona

So thank you again. Now we obviously talked about steroids, but there are some other medicines on the market that parents often ask me about. And I would love to hear your opinion. Something called you, Chris. Pro topic, how long can these ointments or, medicines be used and when is it recommended versus a steroid.

 

00;27;36;03 – 00;27;51;13

Dr. Shivani Patel

Yeah. So I think this is a great question. I get asked a lot to, you know, there’s a lot of ads out as well. So parents are becoming a little more aware of these options. And I think they are really good options for kids with eczema. But there are some age restrictions. So you, Krysta, is approved for babies three months and older.

 

00;27;51;16 – 00;28;11;16

Dr. Shivani Patel

And then pro topic and a similar one called Lydell are approved for kids aged two and up. So we can’t really use those until they’re a little bit older. In larger data sets per topic, still has the best efficacy and I tend to lean towards that one because it does work very well. But again, I usually have to wait till the child is two years or older.

 

00;28;11;18 – 00;28;34;12

Dr. Shivani Patel

They don’t work as well as a steroid medicine though, so when the skin is still very heavily inflamed, I’ll have families use that steroid medicine to get it clear. And then I like these more for what we call maintenance. So it’s keeping the skin clear and getting them off the steroids. So once that skin is clear and you feel it’s back to sort of smooth texture, you start one of these medicines to prevent the eczema from recurring again.

 

00;28;34;21 – 00;28;55;23

Dr. Shivani Patel

And so this is also what I use during those steroid free holidays as well. A lot of families who have severe eczema, they can’t come off the steroid as easily. So when they have those little steroid free breaks, I don’t want them without any treatment. So I’ll give them one of these options and that will help at least keep the skin from either not flaring as bad or not flaring at all, and then they can go back to the steroid if they need it.

 

00;28;55;23 – 00;28;58;12

Dr. Shivani Patel

If it does start to sort of come back again.

 

00;28;58;14 – 00;29;17;19

Dr. Mona

Oh, that is great. And I think, you know, we talk about so much of this, like all the steroids in the you Chris, and we talked about the bleach baths and infection risk. You know, if children are prone to it. But one of the big things is the itching component. And obviously if a child itches it more, that can potentially open up infection risk.

 

00;29;17;19 – 00;29;38;22

Dr. Mona

So what can parents do about itching? This is honestly one of the hardest things I think for eczema is that itch scratch cycle, you know, and we can talk about that. But it just is really hard for me also as a pediatrician to, you know, when we’re going over management, we’re talking about everything and they’re just like, oh my gosh, my poor child, baby, toddler.

 

00;29;38;22 – 00;29;45;25

Dr. Mona

I mean, when they start to recognize that they can scratch, what can we do? And how can we help these little kiddos, that suffer from eczema?

 

00;29;45;28 – 00;30;04;26

Dr. Shivani Patel

Yeah. I agree, this is, I think, the most important step in the management and why we even treat eczema. Because the itch can be so devastating and not only for the child, but for the family as well. There’s lots of missed workdays, school days, sleep decline and sleep decline. And call your life associated with itch. And it can be a very devastating disease.

 

00;30;04;26 – 00;30;22;00

Dr. Shivani Patel

And they’ve shown even in other studies that it’s more impactful on quality of life than even something like diabetes or high blood pressure. Because it’s so unbearable. When it gets to be really bad, it can just ruin quality of life. So this is really why we treat eczema. It’s the itch. The itch is the part that keeps everybody up at night.

 

00;30;22;00 – 00;30;46;19

Dr. Shivani Patel

You know, makes people feel miserable and keeps people away from work. So one of the main things that I see being prescribed or recommended are antihistamines. So there are ones that are non sedating which means they’re not drowsy such as you know Zyrtec, Claritin, Allegra. Those are some common names that you can find over the counter. And I often have three kids on these medications, but they actually don’t really work for the itch of eczema because these are what are called antihistamines.

 

00;30;46;19 – 00;31;05;00

Dr. Shivani Patel

So they block histamine in the body. But the itch of eczema is not a histamine derived process. And so it’s not really blocking the itch. And so I see this a lot where, you know, families will say, well, they’re on, you know, these antihistamines and it’s not really working well. And that’s because it’s not really targeting the right pathway.

 

00;31;05;03 – 00;31;23;28

Dr. Shivani Patel

Now, sedating antihistamines like Benadryl or Adderall or hydrocortisone, they’re also not targeting the pathway, but they do make the child drowsy. And so it helps you fall asleep. And that can help you from not scratching. But it’s not really treating the edge. It’s just sort of making you very sleepy. So you kind of fall asleep and then forget about the itch.

 

00;31;24;08 – 00;31;43;16

Dr. Shivani Patel

And so I don’t usually use the non sedating antihistamines that often unless they have something else like seasonal allergies that they’re using it for. But the sedating and histamines can be a nice option to at least get sleep at night. But there is, another natural ingredient that I like a little bit better called melatonin. And it’s found over the counter.

 

00;31;43;22 – 00;32;02;12

Dr. Shivani Patel

And it’s a natural substance our bodies make, and it helps with our circadian rhythm and sleep cycle. And they have shown that kids with eczema do have less melatonin. And studies and supplementing this can help them fall asleep faster and also stay asleep throughout the night. So this is a safer option. It’s one that sort of naturally produced.

 

00;32;02;12 – 00;32;18;29

Dr. Shivani Patel

So families who are looking for those sorts of options, I think this is a really good one and it tends to work pretty well. And it can be given in a wide range of doses based on, you know, your child’s weight and their age. And so you can sort of titrate it at home based on how much you think your child needs and sort of play around with that a little bit.

 

00;32;18;29 – 00;32;38;08

Dr. Shivani Patel

And I think parents tend to like that, too. And then there’s a couple other tips and tricks that help a lot with the itching. One of them are colloidal oatmeal baths. And these can be, very successful and sort of calming the skin, sort of getting some of that redness and inflammation to sort of subside, and usually for about ten minutes once or twice a week can help.

 

00;32;38;11 – 00;32;56;00

Dr. Shivani Patel

And then the other option is something called wet pajama therapy or wet wrap therapy. And this is one of my favorites. I think this works incredibly well for itching. And it’s easy and it’s just available at home, so what that means is a wet pajama therapy. What you do is you take, you know, two pairs of cotton pajamas.

 

00;32;56;02 – 00;33;12;00

Dr. Shivani Patel

One of them you put under, lukewarm water or sort of wring it dry, make it damp. But not soaking wet. And you’ll first put on your child’s moisturizer and their steroid before it if they have one. And then you put on that wet pair of pajamas, and then you actually put on that second pair, that’s dry on top.

 

00;33;12;04 – 00;33;33;11

Dr. Shivani Patel

And what this does is allow that moisturizer or the steroid medicine to soak into the skin more effectively. And that cool feeling helps with the itching as well. And this rehydrate skin and calm the skin. And if you have what are called hot spots or areas of eczema that are not all over the body, so you don’t really need that full wet wrap, but let’s say it’s just on the wrist or just on an ankle.

 

00;33;33;14 – 00;33;49;03

Dr. Shivani Patel

You don’t have to do that full part. You can actually use it with the glove instead, you know, do two pairs of gloves, or you can use it with saran wrap where you put the moisturizer on, you know, and then put like a damp piece of gauze and then Saran wrap it so you don’t have to necessarily do a whole part every night.

 

00;33;49;03 – 00;34;05;28

Dr. Shivani Patel

But you can sort of treat focal areas that you feel like aren’t clearing well. And this helps a lot with itch. And it can also increase penetration of your topical steroid up to 100 times in studies. And so it can really, really get the steroid where it needs to go. So again, you use less of it and it works faster.

 

00;34;06;00 – 00;34;26;11

Dr. Mona

That is such great information. And it’s really uncanny because I literally am writing like okay, I want to ask her about wet wrap therapy. So this is awesome. You literally like are reading my mind and that’s so cool. This is awesome. I really again, I, I nerd out talking to specialist on my podcast because I like when we can just connect on things that really will help so many families.

 

00;34;26;11 – 00;34;49;01

Dr. Mona

And even though we are not the doctors for the listeners, you know, some of our listeners, maybe our patients, but I’m sure they’ll get just so much basic information that they can take to their pediatrician or they’re a pediatric dermatologist. Which brings me to one of my last questions, in your opinion, I talked about when to see like an allergist versus a derm, but when do you think a child who’s seeing their pediatrician should now see a dermatologist?

 

00;34;49;01 – 00;34;55;26

Dr. Mona

Is there certain kind of indicators if the family wants it? What are some concerning things that you think it’s time?

 

00;34;55;28 – 00;35;14;26

Dr. Shivani Patel

Yeah. So, I do think it depends on the comfort level of the pediatrician as well and how comfortable they feel managing the eczema. A lot of pediatricians, they’ll try a few very mild steroids and a few of the tips that we talked about. But when it gets a little bit more complex, they usually prefer us to be co-managing, which I think is very reasonable.

 

00;35;15;02 – 00;35;34;11

Dr. Shivani Patel

And a lot of families will ask for that as well. There are some steroid medicines that I use that are very strong, but I do them because I do them under very guided, follow ups and, you know, see the kids back very routinely. And so those are things that sometimes are out of the comfort zone. And so pediatricians will send them to me or family medicine doctors and say, you know, can we try this medicine?

 

00;35;34;11 – 00;35;53;28

Dr. Shivani Patel

It’s not something I’m familiar with, but I think maybe could work in this case. And so oftentimes we’ll get referrals that way. And then there are actually a few treatments for eczema that are either by mouth or an injection. And those tend to be ones where they’ll get referred to us first because they do have some side effects and some lab monitoring and some other things that have to go into it.

 

00;35;53;28 – 00;36;02;06

Dr. Shivani Patel

And so oftentimes they’ll want us to help manage and sort of get them on that treatment. If we feel like the topical treatments aren’t working.

 

00;36;02;08 – 00;36;27;10

Dr. Mona

This is so great, Shivani. I’m so glad that we were able to do this. And you know what would be your final message for everyone listening? You know, I know eczema, like you said, was one of the itch factors you can affect really quality of life. And I see this all the time, and I know a lot of our listeners may have a child with eczema, or they themselves have had eczema, and they can attest to that, that it really can cause a lot of stress for families.

 

00;36;27;15 – 00;36;30;02

Dr. Mona

So what would be your final message for everyone listening?

 

00;36;30;04 – 00;36;51;07

Dr. Shivani Patel

Yeah, it’s such a good message to sort of show that it is one of the most challenging diagnosis that we treat. And like you said, it really can take a toll on the whole family. And one thing I want parents to know is that the eczema management plan, you know, doing that moisturizer multiple times a day, doing those that it is hard to do and you just do your best and not to be so hard on yourself, you know, you’re going to have days where you miss something or it just doesn’t get done right.

 

00;36;51;07 – 00;37;10;01

Dr. Shivani Patel

And that’s okay. You know? That’s life, right? And so don’t beat yourself up about it. I have a lot of parents who come in. They feel guilty that, you know, they’ve missed a couple things, but we’re all doing the best that we can. And some days are going to be better than others. No matter what you do, you know, you’ll have eczema that flares up and you’ve done all the right things, and then you’ll have days that are great and you’ve, you know, missed part of the plan.

 

00;37;10;01 – 00;37;31;10

Dr. Shivani Patel

So I usually like to reassure families that 70% of kids, again, do outgrow their eczema, usually by age five. So even though it may be something that requires a lot of intensive care, for the most part, most kids, as they get older, it will get better with time. So kind of giving them that reassurance. And if it doesn’t get better, we have so many incredible therapies.

 

00;37;31;10 – 00;37;47;10

Dr. Shivani Patel

Beyond the topical treatments. We talked about that are safe and they’re effective and work really well. So even if you feel like you can’t get it under control, we have other options. So, never feel like there’s nothing else that we can do or that there’s nothing else that’s going to work because there’s a lot out there.

 

00;37;47;12 – 00;37;51;20

Dr. Mona

And, Doctor Shivani Patel, where can people find you again on Instagram?

 

00;37;51;22 – 00;38;05;03

Dr. Shivani Patel

So my Instagram is derm doc and I share a lot of tips and management options for all sorts of skin diseases and children. And so, families can find me there and shoot me a message. If there’s anything you’re interested in having me talk about or any questions that you have.

 

00;38;05;05 – 00;38;18;29

Dr. Mona

And I am attaching her handle on my show notes page because she’s definitely a must follow. Like I said, when she joined social media or when I found her on social media, I immediately DM to I’m like, Welcome to Instagram. By the way, do you want to come on my podcast? It was like there was no chill at all.

 

00;38;18;29 – 00;38;30;09

Dr. Mona

So thank you again for joining me. I am sure I’ll have you on for, you know, updates on eczema, but other topics as well in regards to pediatric skin. So thank you again.

 

00;38;30;11 – 00;38;32;06

Dr. Shivani Patel

Absolutely. Thanks for having me again.

 

00;38;32;08 – 00;38;48;00

Dr. Mona

Thank you for tuning in for this week’s episode. As always, please leave a review. Share this episode with a friend. Share it on your social media. Make sure to follow me at PedsDocTalk on Instagram and subscribe to my YouTube channel, PedsDocTalk TV. We’ll talk to you soon.