Disclaimer: This podcast is for informational purposes only and is not intended to be used as personalized medical advice.

Melanie Cole, MS (Host): Welcome to Be Well with Skagit Regional Health. I'm Melanie Cole. Today, we're talking about dry skin and eczema with Dr. Amy Hopkins. She's a dermatologist with Skagit Regional Health. Dr. Hopkins, thank you so much for joining us today. Start by explaining a little bit about what eczema is, how it's related to dry skin. What is it really?

Dr. Amy Hopkins: Eczema is, in general terms, a breakdown in the barrier of the skin. It's related to dry skin in a number of ways. The most kind of simple way to explain it is that there's a decrease in barrier proteins in the skin when you have eczema. So, that kind of means that the tightness of the barrier protecting you from the outside elements is leaky. So in that way, things can get in and water can get out.

And so, as opposed to a nice seal that you might have in healthy skin, eczema skin doesn't hold onto water as well. And therefore, you get dryness. So, that can be flaking, it can be cracking, there can be fissures in the skin. And that can be also very uncomfortable because inflammation can happen, particularly if there's allergens or irritants that get into the skin.

Melanie Cole, MS: Dr. Hopkins, is eczema considered a dermatologic condition or is it autoimmune? Is it something deeper?

Dr. Amy Hopkins: So, eczema is kind of this umbrella term, and it encompasses a number of different things. So, eczema can be considered both an irritant contact dermatitis, for example. So, that's something where anyone could get eczema from an irritant on this skin, because it can kind of start breaking down that barrier.

When we start talking about autoimmunity or autoinflammatory, you know, we think about our genetics and the underlying mutations or changes in our genetic code that we might all have. And there are some known genetic changes that are linked to eczema such as a defect in a protein called Filaggrin, and it's actually a common defect. And so, some people who have this Filaggrin defect for example, don't make as much of the proteins that kind of seal in the barrier for eczema. And they are more prone to having that breakdown, more prone to having inflammation in general that can kind of fuel an eczema flare.

Melanie Cole, MS: So then, how is it different from rashes, allergy skin, irritants, from any number of things that we might get?

Dr. Amy Hopkins: So, the process of eczema, what's going on under this skin kind of is the same regardless of whether or not it's an irritant or an allergy in a lot of ways. So when we're talking about skin allergies, oftentimes we use the term allergic contact dermatitis. And what's happening there is that there's something getting on the skin. Usually, a small molecule chemical that the body's immune system in the skin recognizes as an allergy. And then, there's an inflammatory response that happens. This is the same thing that happens, for example, with poison ivy. It's called a delayed type IV hypersensitivity reaction where that oil from poison ivy gets on your skin.

A T-cell from your immune system recognizes it, and then causes one heck of a rash about hour to days later. So, not everyone is sensitive to poison ivy, for example. But those who are, you know, know what I'm talking about. And it's not just poison ivy, but it can be a number of different metals or preservatives or fragrances, for example, that can cause this allergic contact dermatitis, eczema in people with sensitive skin. So, that's very different than an irritant. However, what's going on under the skin can be very similar and can give you that same eczema type, dry, itchy, burning, red, sometimes rash.

Melanie Cole, MS: Yeah. I know that some people you could just rub against something. And then, before you know it, there's some kind of dermatitis or a little rash irritant going on there. So, that's really common now. Eczema is pretty common. Dr. Hopkins, who's most likely to experience it? You mentioned genetics earlier. Is this something that is hereditary? Is it something that just happens? I know my daughter has it and had it as a little kid. So, tell us a little bit about who's most at risk.

Dr. Amy Hopkins: Yeah. I kind of like to talk about that in two main groups. Again, kind of those who are more at risk of getting it from childhood. For example, if you have a genetic underpinning like that Filaggrin defect, then, yeah, you might get eczema from the beginning as a baby. And those patients, you know, some studies have shown that, again, that Filaggrin mutation is pretty common, especially in the Caucasian population.

And so, we see, in general, kids there's been estimated to be 20-25% of children under five are at risk of eczema in the United States. And so, oftentimes, those kids will have some improvement over time and, by adolescents, grow out of their eczema. But then, with some of them, persisting through adulthood.

So, genetics is definitely one risk factor. And so if you have a family history, for example, of severe eczema, then that would definitely increase your risk. Eczema, we also talk about as one of the three main atopic conditions. And so, atopy or atopic, atopic dermatitis is another name for that intrinsic eczema. And other atopic conditions are things like asthma as well as environmental allergies. And anyone with a personal or family history of asthma and allergic rhinitis or environmental allergies would also have an increased risk of eczema.

That second group I was kind of talking about would be more in that irritant category. So, someone who might get eczema as an adult and risk factors. There are more have to do with environment. So, that's coming into contact with things like pollution. So if people who live in urban areas are at more increased risk of getting eczema just from the air quality or people who live in an environment that might have more, wildfires, for example. And then, people who live in a more dry environment. So, we know that there's also an increased risk if the environment has low humidity or it's not as humid, you are at increased risk as well. So, there's kind of those two main categories for risk factors.

Melanie Cole, MS: Now, let's talk about diagnosis. How do we know that that's what's going on? And it's not just some simple come and go rash. We go to a dermatologist, we spot these things on our kids, or our cells on our hands. You know, where does it most likely show itself and how do you determine that's what we have?

Dr. Amy Hopkins: Yeah. It's something that we ask ourselves every day in clinic. So again, eczema is kind of this umbrella term and there's many different types. So if we're talking about that intrinsic atopic dermatitis, it's starting as a child. The classic locations also depends on age. And so, in infants, we are often seeing it on the cheeks, for example, around the mouth, especially in a kiddo who's just starting to eat or they're drooling more, right? So, those irritants are influencing that skin.

As they get a little bit older, you might notice it in the creases of the elbows and the knees. So, we call that the flexural areas where they're bending, as well as the wrists from starting when they start washing their hands, a lot of soap contact in that area. Soap can be an irritant as well. And so, those are kind of classic areas in childhood, atopic dermatitis that we see eczema coming up in.

Other types of eczema. So when we're talking about allergic contact dermatitis or an eczema from an allergy, that really depends on how it's getting on your skin. And so, for example, if you were allergic to something in your shampoo, you might have quite an outbreak on your scalp or dripping down your back, the upper back area where that's been contacted.

Another example might be a photo allergy. So, a photo allergic contact dermatitis from a sunscreen chemical such as oxybenzone. And so, those patients, you know, anywhere they put sunscreen actually, they might break out when the sun touches their skin in those areas. And so, you can have different patterns. And it's depending on the type of eczema we're talking about. And there's many other types that, you know, kind of we don't have time to get into today.

Melanie Cole, MS: Well, then, let's talk about treatments. Do we start with home treatments? Do we start with topicals, Aquaphor, Vaseline, these things? Do we use something specifically prescribed? Because there's a lot of things over-the-counter. I mean, it could be dizzying. The amount of things that you can see, these hydrocortisone and Benadryls and all these things. What do we do, Dr. Hopkins?

Dr. Amy Hopkins: Absolutely. And some of this depends on your risk factors. So if you're someone with a family history with a strong prevalence of eczema, then you're probably going to want to start using a moisturizer or emollient from day one, you know? And that looks like anytime your skin is in water or after coming into contact with an irritant. A thick emollient is what you want to use, and that's something like Vaseline or Aquaphor or something that has petroleum jelly in it. Something that is thick enough that you have to scoop out of a jar as opposed to a pump or a liquid or a lotion.

Those thick emollients are really what's going to seal in that broken skin barrier so that you can have that protection, that you don't naturally have if you're missing, for example, that Filaggrin gene. And then, when it comes to treatment, when you have an active eczema outbreak, that's really when we're talking in the office about prescriptions to decrease the inflammation.

Oftentimes, we're using things like topical steroids or other nonsteroidal anti-inflammatory creams, that don't have any allergens in them. That's an important point. You want to make sure if you're allergic to any preservatives in those creams, that we stay away from that. And those you want to use twice a day for two weeks is kind of a general treatment to get that eczema to go down. And some people with intrinsic atopic dermatitis are needing more long-term treatment. For example, twice a week of some of those prescriptions of their trouble spots to keep them from flaring up.

Another thing I would point out is eczema can become infected. So, you know, because that barrier is broken down, our skin is designed to keep us protected from things like bacteria and viruses and infections. So in an active eczema outbreak, you're also at risk of getting infected. So if there's any yellow crusting or drainage, oftentimes we're culturing for bacteria or infection to see if you need an antibiotic. And often, treating the infection will also help treat the eczema.

Melanie Cole, MS: I remember those days of putting that thick stuff on and sometimes even gloves over my daughter's hands, and she would sleep with them on the outside of the blanket because they got so raw and so dry on the knuckles and the top of the hands that it was painful. Really painful. Now, what about systemic treatments? When does it become something that where you're like, "Okay, we're going to look at some of these oral medications or other treatments"?

Dr. Amy Hopkins: So, number one is making sure you avoid all the triggers. So, you know, if you're getting rid of those irritants, you're doing the best you can to have, for example, a humidifier if your environment is too dry. And staying away from any allergens and you still have eczema just because it's an intrinsic condition going on, then yeah, we often do turn to systemic medications. And thankfully, we have quite a few options now more than we did five, 10 years ago.

That target, the specific inflammatory pathway, for example, the itch pathway, that's leading to all the discomfort that has to do with eczema. And so, these are things that are either pills or injections that we talk about in the office a lot that, thankfully, they're pretty specific for eczema. So, they don't often knock down the other arms of the immune system. They really just work on that itch pathway. And some of them are a pill once a day with pretty minimal side effects. And then, others are a shot, once every other week, for example, that you can give yourself at home that really help to bring that down.

The inflammatory reaction of eczema is a little bit slow, meaning some of these treatments, even the oral ones take one to three months to really start working. So, we're often using the topicals in combination with the systemics in order to reach that goal where everybody's happy. And then, once we're there, kind of keeping you on the medications for six to 12 months before seeing if we can eventually peel them back.

Melanie Cole, MS: Dr. Hopkins, you've given us such great information. What have we missed? What would you like people to know? Lifestyle habits that can maybe help prevent these flares, healthy skin in general, especially for people that are predisposed to really dry skin. Give us your best advice here from a dermatologist on what we can do for this really dry skin and specifically eczema.

Dr. Amy Hopkins: I would say some lasting tips, include bathing. So, a lot of people have questions about how often to bathe. Is it bad to bathe if you have eczema? And lots of studies have been done about it. And really, it's okay to bathe. We want you to bathe so that we're preventing infection, of course.

The most important thing is right after bathing or washing hands is to put that emollient on. So, the best way to do that is to kind of pat dry, but leave a little bit of water on the skin so that when you use that greasy Vaseline that nobody really likes the texture of, it rubs in a little bit better when there is a little water on the skin. So, that's one tip that I like to give people.

I also like to give people the tip, especially for hand dermatitis, keep something with you always. So if that's little travel size jars, just get it on there as much as you can, because you really can't overdo it with hand dermatitis, since we use our hands so much. There's so much opportunity to trigger eczema. So, you want to be kind of constantly in prevention mode.

Other than that, I would say in terms of eczema and skin allergies, less is more. So, go for the products that have less ingredients. A lot of people like plant-based products, for example. But I like to remind them that poison ivy is a plant, and it's a hundred percent natural, but it can give you a heck of a rash. And so, a lot of those plant-based products, for a lot of people, they'll be fine. But for some, they can be allergenic. And so, kind of going for less products overall if you can. And then, for the products, you choose just less ingredients.

And I just want to mention also that, you know, eczema is often something that gets better with age. And so, particularly, if it's something that you have as a child, there's a good chance you're going to grow out of it with age.

Melanie Cole, MS: That's very good news. Thank you so much, Dr. Hopkins, for joining us and sharing your incredible expertise for us today. And for more information, you can visit our website at skagitregionalhealth.org. That concludes this episode of Be Well With Skagit Regional Health. Thank you so much for joining us. I'm Melanie Cole