all posts, treatments

my addicted (skin) life

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As the science of skin (dermatology) progressed, more information was understood about what this large organ is made of, how it works, and how to keep it healthy.

I won’t go into the skin anatomy today but one thing that was more or less universally accepted was: dry skin = bad skin. So in practice this meant that doctors prescribed patients to take baths and let our skin absorb lots of water and then get out, lightly pat dry, and apply the topical medication. An NEA webinar mentioned you need to get the topical medication on within 3 minutes of getting out of the water, which for a full grown adult with eczema over the entire body, proves to be a bit of a challenge.

So now let’s go more into the specifics about topical medications, let’s start with steroids. Topical steroids come in 7 classes: from Super Potent to Least Potent. A high potency topical steroid is one we’d put on our hands/feet/wrist/ankles or the areas that are more likely to have excessive thickening. A mid-strength topical steroid may be safer for the whole body but only for a 3–5 days for thin skin areas (around the eyes, mouth, genital areas). A low potency topical steroid includes the things you can get over the counter like hydrocortisone (1%).

A useful fact to keep in mind is you should know the name of the steroid you will/are using as well as the concentration (listed as a percentage). When in doubt, it doesn’t hurt to google up your specific steroid to see what strength it is if you are not sure, or ask your doctor.

Now for the more recent developments in the eczema world: the non-steroidal anti-inflammatory medications (like Protopic and Elidel). Both are types of topical calcineurin-inhibitors (TCIs), which is a big term that just means they block T cells and stop the too much cytosine (a protein that can cause redness, inflammation, and itching) from being released. TCIs are great because they help the skin without decreasing the amount of healthy cells, and without going as deeply into the skin layers (unlike topical steroids, which cause thinning of the skin if used for a long time).

Protopic is usually stronger than Elidel, but both are often seen as medications to be used after you’ve finished the course of a mid-strength topical steroid, the reason being is that the TCIs can be used for longer periods of time. They are said to be safe to use around those thin-skinned areas, but that they generally don’t work on lichenified (or thickened) skin.

An even newer development was Eucrisa. This is a non-steroidal topical ointment that works by blocking an enzyme called phosphodiesterase (which is increased in immune cells of people with eczema), which then also blocks out the production of excessive cytokines. More research is still to come, but Eucrisa seems to be another promising non-steroidal option.

Lastly, let’s talk about topical corticosteroid (TCS) withdrawal (also known as topical steroid withdrawal or TSW). The health community is still hotly torn on this issue. On the one hand, in 2015 it was stated that the TCS withdrawal is a potential adverse effect of prolonged use of topical steroids, though it was said to be a rare occurrence with not a lot of evidence backing it, and that it was probably caused by topical steroids being used incorrectly. To be honest though, it seems it would be difficult not to have misused topical steroids in the past as the research behind how much to use and how often has changed over the years.

On the other side, there are organizations like the International Topical Steroid Addiction Network (ITSAN) or individuals like Dr. Rapaport that argue that the Red Skin Syndrome (RSS) is directly because of the topical steroid use/overuse/abuse in societies.

An interesting blog post I came across talked about how much cortisol a healthy body can normally produce, and how the commonly prescribed topical corticosteroids measure up. His analysis was that the potency of prescription steroids are often so much higher than what our bodies could naturally produce, which might explain why it seems so much more common to hear about people’s skins getting addicted. He was testing out how using very low potencies and/or low doses to mirror how much cortisol our bodies could normally produce, and see if that helped him maintain his skin throughout the winter.

Also food for thought, we know that studies are incredibly expensive to fund, and so to get a lot of evidence backing up TCS withdrawal or RSS, there would need to be big companies supporting the research. However, if these studies could then have results that jeopardize major supporters (like a pharmaceutical company), it becomes less likely any such companies will want to fund said studies. I’d bet it will be a while before we get a lot of evidence around more specifics of TCS withdrawal/RSS.

 

REFERENCES

Carr WW. Topical Calcineurin Inhibitors for Atopic Dermatitis: Review and Treatment Recommendations. Pediatr Drugs. 2013 Aug;15(4):303-310.

Hajar T, Leshem YA, Hanifin JM, Nedorost ST, Lio PA, Paller AS, Block J, Simpson EL. A systematic review of topical corticosteroid withdrawal (“steroid addiction”) in patients with atopic dermatitis and other dermatoses. JAAD. 2015 Mar;72(3):543-549.e2.

Paller AS, Tom WL, Lebwohl MG, Blumenthal RL, Boguniewicz M, Call RS, Eichenfield LF, Forsha DW, Rees WC, Simpson EL, Spellman MC, Stein Gold LF, Zaenglein AL, Hughes MH, Zane LT, Hebert AA. Efficacy and safety of crisaborole ointment, a novel, nonsteroidal phosphodiesterase 4 (PDE4) inhibitor for the topical treatment of atopic dermatitis (AD) in children and adults. J Am Acad Dermatol. 2016 Sep;75(3):494-503.e6.

 

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all posts, miscellaneous

let’s get creative! (aka freeform fiction writing)

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As I child I always loved reading and subsequently writing as I developed my own worlds in my mind. I have a story I started when I was about 12 years old that I have since molded to reflect various stages in my life over the last 14 years or so. Recently, inspired by my current eczema flare, I decided to personify the flare as a new section of that story. Below is an excerpt. At some point perhaps I’ll continue it.


Another goddamn visit from a Flare. This time it’s the more benign cousin of the usual suspects. She comes only with her mild temper, and only the occasional and light irritation under my skin. Though she does confuse me as to how to get rid of her- and she is particularly chiding to my cheeks and around my neck like an ever present wind that buries under my scarves.
Still, she, who I’ll call M as she is far down the crisis scale, is a mystery. She is particularly nary after I shower and irritates the fuck out of me, but then within 10 minutes or so she leaves me be more or less, minus the occasional heated moment. She tends to be a bit of a blowhard at night, especially when I am trying to get comfortable and sleep, but minus waking me up intermittently until I toss onto my other side, she mostly lets me get my rest. I much prefer her to some of her relatives, though I do wonder how I can slow some of her persistence. Perhaps she’ll leave me alone if I go and soak in the bath for a while. Though I don’t think she comes in barring infections, you never know with these unwanted guests.

“Well boys. It looks as though we’ve got another one,” the detective mused, adjusting his increasingly baggy pants waistline with one hand while he scanned the note held by tweezers in his other. His men picked themselves up from various places in the crime scene and ambled over towards him, hankering to see over his shoulder at the note’s contents.
“Another Flare has been through town. What is the point of the mayor’s extensively expensive Flare-reduction policies, if he can’t keep a- a ‘benign cousin’ from rolling through and wreaking havoc!”

His men grumbled ascension sounds in response. One officer, looking back over the crime scene absent-mindedly, almost unconsciously piqued “But sir, what if this is a worser Flare than we think? It’s possible the hostage was under duress and just using some of those techniques the good head doc has been lecturing. You know ‘mindfulness practices’ and whatnot. Or maybe the hostage has been tormented by so many Flares already, she barely knows when she’s in a bad situation anymore. Couldn’t we have a situation like that at hand here? Until we have the biopsies, we won’t know which Flare we were actually dealing with.”

The detective swiveled around to turn to look at the officer. Swiveling was getting easier now that he’d finally taken up his wife’s request and stopped indulging Sweets.

Officer McCormick. He was a newer recruit, coming from a larger town. Before working in the Eczema Dept he had worked in Staph A. and it was rumored though he was good, the stress got to him so management reassigned him to Eczema to give him some time to find his bearings. He still seemed a bit strung out though.

“Now son,” the detective started gently. “We’ve been dealing with Flares in this town since the town was first declared, and none of them has been higher than a crisis scale of H. And even then it was the result of a consumables gang-mix up triggering some interest on the low grade Flares radars. I know you must have seen a lot coming from where you did, but here in ChroniCity we don’t jump to conclusions until the evidence points us that way. Red will collect the samples for the biopsy and we’ll know who we are dealing with soon.”
“But what if it is more serious! Shouldn’t we alert Anti-Bac and Court’roids just in case we’ll need them here quickly-”
“McCormick! This small town doesn’t have the budget to be dragging out higher-ups on every whim. Like I said before, our ChroniCity is usually pretty peaceful so we will proceed as usual unless we find evidence to the contrary. Got it?”
“Understood, sir.” McCormick responded, feeling unjustly chastised. The other men shuffled about uncomfortably, all unused to hearing the detective bark out.