miscellaneous, the eczema body, treatments

could physical therapists treat eczema?

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Back in my physical therapy student life, we had guest speaker Pamela Unger come in to talk to use about the role of wound care in PT. Much of what we talked about I applied (in my head) to eczema and ways to help treat it for myself. I’ll share some of my thoughts below meshed in in italics with things I learned from Pamela, but note: these are ideas I came up with and are in no way necessarily endorsed or supported by research.

To begin, we need to know that wound healing normally has 3 phases: inflammation, proliferation, and remodeling. During all 3 phases there is vasodilation (aka the blood flow increases to help close up the wound).

The inflammation phase: As we with eczema have constant inflammation, this made me think maybe we are having trouble with this phase of wound healing in particularDuring this phase, the wound works to regain balance of its cells, and also fights to prevent infection, the latter which interested me because people with eczema are generally more susceptible to staph and other skin infections. Is it because our systems start attacking our own good cells and not just the infectious bacteria? Cellularly during this phase, inflammatory mediators are released (so do people with eczema lack these mediators?) and various cells like macrophages/neutrophils consume the bacteria, but presumably less successfully if patients with eczema get staph frequently. The intended results of this phase are that the bacteria and other foreign materials are cleaned out of the wound, and that inflammation is controlled.

During the proliferation phase, the wound starts to fill in and close. Cells called fibroblasts start making collagen (collagen is an important building block for skin cells), the extracellular matrix (a molecular substance that supports the structure of cells) is made, and there is new development of blood vessels (called angiogenesis). The intended results of this phase are that new blood vessels are made, the template for new cells is made (call the scaffold), and re-epithelialization occurs (which means epithelial cells move to form a barrier between the environment and the wound).

During the remodeling phase, the scar is developing and maturing. Cellularly, the collagen fibers start to line up and the skin becomes stronger especially to tensile stress (being pulled/stretched). The intended result of this phase is that the collagen fibers cross over one another adding strength to the wound. The only aspect of this phase that I think ties to eczema is when individuals have healed eczema scars that itch more than open or unhealed areas, but that would mean something chemical is happening and I don’t know why scar tissue would itch more than the other parts of the skin. Though I suppose it could also be assumed that if during a topical steroid withdrawal, the skin becomes excessively wrinkly, it could be a problem with collagen production? 

 

Now that we have the basics, we can talk about a chronic wound. I loosely decided that eczema is a chronic wound by this definition: a skin injury that fails to heal through the normal phases, in a normal amount of time.
A chronic wound can have one of two thickness classifications (usually applied to specific types of ulcers). The first is partial thickness, meaning the epidermis (or outer layer of skin) is broken, but the next layer (the dermis) may not be. A full thickness means the dermis is also broken as well as the fascia, and there may be a breakdown into the muscle/tendon/bone level. I believe generally eczema wounds are partial thickness, though I am sure there are some exceptions/particularly bad wounds that occur.

Generally wound healing can be stalled because of 4 main things:
1. a bacterial infection,
2. inadequate electrical potential (for we are beings of electricity! More on this and the idea of E-stim for eczema management in another post),
3. not having enough microcirculation (aka circulation of blood in the smallest vessels), or
4. too much pressure from interstitial edema (or swelling in between cell layers).

Other factors like age, nutrition, and topical/oral steroids also can slow healing. With nutrition, the biochemical aspects doctors check for wound care would be albumin, pre-albumin, hemoglobin, and hematocrit. They would also want to check that a person has enough protein, calories, and fluid in their diet. We know that when you have eczema, it is especially important to drink lots of fluid and have a balanced diet, but I am unsure if the four other biochemical factors have a correlation with eczema sufferers, though I would assume people with eczema would have decreased levels of albumin (because it’s a protein).

 

So how does one really maintain their skin health? Pamela’s big takeaways were to:
1. keep the skin clean and dry (a big reason we need to clean out the wound is because a biofilm (of bacteria) easily grows in a wound and blocks healing by messing up the chemicals needed to heal),
2. use warm water (not hot) on the skin (because hot water can cause us to have more water evaporation from our skin),
3. use daily hygiene techniques, and
4. MOISTURIZE.

For wound control, Dr. Unger broke it down to 4 steps.
1. Protect the wound surface. Think using gauze, bandaids, wet wraps, cotton clothing, etc. Wet wraps would also help keep in moisture. If excessive moisture, collagen can be useful for absorption (maybe that is why I was able to use a collagen night cream to heal my facial eczema when it was raw).
2. Control bacteria. She mentioned silver ions and slow-release iodine. I believe new eczema products are trying silver so another overlap may be indicated.
3. Control odor. Unclear if this is as application to eczema but she mentioned activated charcoal and I believe there are some eczema products that have charcoal (though I could be wrong).
4. Affect cells. She mentioned using collagen (though how it would apply to eczema wounds specifically, like if it should be orally taken or topically applied, I am not sure).

The last things Pamela mentioned in her wound care lecture that I thought tied well to eczema management were:
1. massage (it has been documented that massage can help eczema, though aggressive massage around a wound may impede blood flow and slow healing, rather than help. So if a person suffering from eczema has lots of open wounds, massage may be more detrimental than useful),
2. avoiding excessive pressure (as excessive pressure or friction can cause wounds, it stands to reason that slumping in a seat, or staying in one position for too long doesn’t help the skin of people with eczema. Getting up and moving seems to have more importance than just general health, mood boosts, and circulation!), and
3. keeping the eczema wounds moist rather than letting them dry out (in the past people believed wounds needed to air out and be dry, but Pamela explained this makes it harder for the wound to heal because it needs a level of fluid movement. I believe dermatologists would support this as I have heard /read about them saying that dry skin leads to itching, and scratching the itch is what causes the rashes).

So could a physical therapist treat eczema? Like the answer I got through most of my physical therapy graduate classes: it depends.

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here’s the skin-y

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Who am I: I’m a woman with eczema. I love reading, gardening (mostly indoors lately, as I live up north), writing, playing music (though I am a bit out of practice for both viola and piano), daydreaming, sunshine and warm weather, exploring areas by foot, watching horror movies with my husband and constantly talking through them, engaging in random bursts of physical activity, being ridiculous, and spending time with family and friends, and of course, storytelling.

My eczema history: I’m one of the people who was born with eczema where it initially only bothered me on the crooks of my elbows and knees, but as I grew up it progressed. Winter 2012 I had my worst flare and a Staphylococcus aureus infection (as discovered by a fluid sample from a lymph node in my neck). I believe that was the first time I went on both oral steroids and antibiotics. Since then I have had intermittent periods of flares of varying lengths of time and degrees of severity. I have been suffering from multiple occurrences of topical steroid withdrawal periods (the longest being out 13 months) and had tried various dietary modifications (avoiding gluten, avoiding legumes, avoiding dairy, eliminating added sugars). Currently I am only doing one dietary change- reducing added sugars. Throughout my eczema journey, I’ve underwent many of the traditional routes to managing the flares, corticosteroid creams/ointments, oatmeal/bleach/epsom/essential oil baths, vaseline/eucerin lotioning, repetitive lotioning, phototherapy, antibiotics, prednisone, gluten-free/dairy-free/sugar-free/legume-free diets, seeing a naturopath, taking supplements/herbal medicines, the list goes on and on. Though I’m sure some of those solutions work for others to help manage their skin issues, the long-term result is that I still have flares and that I need to learn to control said flares in new ways, because unfortunately there really are no individual guidelines when it comes to eczema. As I was briefly a graduate student in a physical therapy doctorate program, I have been using what I learned to try to apply the concepts to my own life in regards to eczema management. I have been wondering about a few other alternatives to do to help my skin during a flare, inspired by things I’ve learned while still in PT school, and I’ll post about them over time.

Other related health stuff: I have allergies, some I was born with (food ones) and some that I developed over time (animal). The foods I am allergic to are peanuts, pistachios, and cashews; environmental factors are mold, dust, grass; animals are cats, rabbits, some types of dogs. I also have a history of asthma, though I’ve been fortunate enough to have mostly outgrown it, and haven’t had to use an inhaler since I was 8.

Impact of eczema on my life: How has eczema has affected my life? I am a person that has eczema over my entire body (at least since 2012). It changes which areas are the worst, but in general, all my skin gets impacted when I flare. This has altered my exercise habits (sweating during a flare can be intolerable), how I can sit/relax (certain materials or positions cause my skin to heat up and rash more), whether or not I can sleep through the night (my skin heats up at night and my core temperature drops so I end up feeling cold while my skin feels hot, damp, and rashy ), and what my daily life habits are (I tend to itch worse when waking up, after a shower, after applying lotion, when sitting for a while, in cold rooms). The largest change I took was deciding to leave my physical therapy doctorate in 2017 program because I wasn’t sleeping, couldn’t handle manual manipulations due to necessary skin contact at times, and because I was more prone to infection from contact with healthy skinned-people who carry Staph.

What I am doing now: I have since switched into a Masters of Health Studies and am building my program as I go along. Professionally, I’ve started thinking about how to build my own company of providing information assistance to health-related businesses, nonprofits, etc. Currently, I am an intern with Eradicate Childhood Obesity Foundation, where I do anything from grant writing, to outreach, to basic website design, blog writing and editing.

Dreams: One day I think I’d like to start my own nonprofit related to addressing health disparities in communities and increasing health literacy. I’ve also had a long term dream of becoming a librarian (but more so a feral librarian, meaning a librarian that isn’t formerly schooled in a librarian sciences education) to use the opportunity to expand what people think libraries do to showcase the real potential for community outreach and modern change that libraries can hold. Bridging the two dreams, maybe I could create a nonprofit health library that offered services such as the ability to “check-out” doctors and health providers for general consultations/patron questions, as well as rental spaces and exercise equipments to host fitness and activity classes, and education seminars on various important health topics and new research.

Weird unrelated hobbies: I enjoy setting up for parties by lightly theming a room, and then leaving it like that indefinitely. Some favorite inspirations for decorating are Harry Potter and Alice in Wonderland.

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