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on breastfeeding, breastmilk, and NPR

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Photo by Daria Shevtsova on Pexels.com

I’m combining all my other blogs’ content to this site. Please bear with me as I post older content.  🙂

A while back I took a class on breastfeeding at the hospital where I planned to deliver (North Shore Medical Center Salem Hospital). Below I’ve outlined some of the notes I took as they pertain to women’s health, as well as my own thoughts.

As many people are saying, “breast is best”, it’s interesting to look into why. Studies have shown breast feeding can help women lose some of the pregnancy weight faster as you are expelling energy to produce milk. It can also help reduce your risks of ovarian cancer, breast cancer, heart disease, and type 2 diabetes, as well as it releases hormones to calm you down.

But what’s actually going on in the body when it produces milk? The glands that produce milk (alveoli) send the milk to ducts which lead to the nipple opening. The baby draws the milk out when sucking, and the more the baby drinks, the more our breasts produce. At first we only produce colostrum, which is this fatty liquid that has all kinds of goodies like antibodies and beta carotene for our babies newly-developing immune system and gut. Then the real milk comes in after about 3-5 days. When a baby started nursing each time, first (s)he will get the foremilk which is mostly composed of water, and after feeding for a few minutes (up to 10 minutes) the hindmilk (which is a lot fattier) follows. The Letdown Reflex happens each time the baby feeds and it is when the baby has latched and the breasts transition from letting out foremilk to hindmilk. Some women can feel the letdown reflex happening (described as pins and needles or some localized tightness) but many women feel nothing.

But how does breastfeeding feel? Well, apparently it is a very novel sensation to most when the baby first latches (it definitely was in my experience) and for many it is difficult to get a good latch and takes some practice! The biggest worry is that a baby who has latched poorly and is just hooked onto your nipple and so (s)he will cause the mom pain. The way to avoid this is to make sure the baby gets more of the areola in its mouth rather than just the nipple. To detach a baby from your nipple if they are incorrectly latched, you definitely don’t want to just pull them off (ouch), but instead you should insert a clean finger into their mouth to break the suction, by running your finger along their gum line.

Also leaking is normal, especially at the beginning of breastfeeding, but it usually does slow down and stop as you continue breastfeeding and your baby gets used to it. You can use nursing pads and also press your nipple/cross your arms when you feel like you are leaking to help to try and stop it.

What about your diet; how does it affect the breastmilk? What can you eat? From this class I was told you can eat and drink anything, it’s just a matter of seeing what your baby’s reaction is (if they get gassy, fussy, hiccup-y, etc after a meal, check back to see what you last eat). Obviously some things to consider are making sure things like alcohol and caffeine are out of your system before you breastfeed (I think the advice was if you have an alcoholic drink, you don’t want to feel tipsy, and you want to wait about 2 hours before you breastfeed… but don’t quote me on those hours). Also for babies that have occult blood (invisible blood in the baby’s stool), the first things a doctor may advise you to avoid are probably dairy and soy, because they are the most common culprits that irritate the babies developing gastro-intestinal system (this is what occurred in my experience). The Kelly Mom blog has a post that goes into food sensitivities in more detail.

For pumping, the advice was not to start until 3-4 weeks unless needed and to make sure you get a pump with a suction cup that is sized correctly to your breast; you don’t want your nipple squished on the sides. The other advice was to pump in the morning, or after a baby’s feeding (I believe about 30 minutes after is the recommendation).

For general nipple care, the advice was to try using your own breast milk around the inflamed area first. Then you can try lansinoh or coconut oil on tender area, and then if it’s really bad, use manuka honey (here’s a cream made with it), but wash it off before feeding the baby.

Other painful aspects about breastfeeding include:

  • Engorgement: this occurs when you don’t breastfeed enough so your breasts become swollen and hard. Regularly nursing helps prevent this, but if you need to you can also remove milk by hand (or what’s called expressing milk) you can use a pump. Just express until your breasts are no longer hard. Cold compresses can also be used after feeding to help bring down the swelling. To express, massage the breast tissue and then grab above and below the breast with your thumb and forefinger and press back towards your chest wall, then gently squeeze, moving your hand all around to help drain multiple areas.
  • Mastitis: this is the most common problem, and it is when your breast gets infected with bacteria, causing pain. You will probably have a fever or other flu-like symptoms as well. This can occur from blocked ducts, nipple injuries, or problems with breastfeeding. You want to call the doctor if you feel this has occurred. Also also make sure to wash your hands frequently to reduce infection risk.
  • Blocked ducts: this is caused by not relieving the breasts. A blocked duct will feel sore and tender. Try taking a warm shower and apply moist heat, and/or gently massage before breast feeding. Also try expressing after feedings if you still feel engorged.
  • Yeast infection: this will cause your nipples to be shiny, red, and painful. Yeast (also called thrush) can also grow in your baby’s mouth so look for cottage cheese looking stuff in their cheeks.

Who can you call for help? Nowadays you can call your doctor, your baby’s pediatrician, and/or some hospitals also have lactation support groups (sometimes free), or lactation consultants (usually not free) that you can call to get one-on-one help.

A little more about breastmilk. In lieu of my own little own having some kind of sickness, I’ve been looking more into breastmilk’s functions. This searching led me to this internet viral photo showing how a mom’s breastmilk changed when her infant got sick. The 2013 study mentioned in that post talks about breastmilk’s immunological function and explains how when the mom or baby get sick, the number of leukocytes (aka white blood cells) in the breastmilk drastically increases to help protect them, because leukocytes help fight disease. I find that to be such a cool example of symbiosis. I personally have also noticed that breastfeeding seems to keep both me and the baby from getting some of the sicknesses that were going around (my mom, mother-in-law, and husband each got sick after the baby was born while the two moms were visiting!).

Lastly, I also read an article by NPR addressing the breastfeeding versus formula debate for poor countries.  The major points that this article made were that formula is not a godsend for impoverished countries for the following reasons:

  • formula requires water to make it, of which clean sources are not always available
  • formula causes increased risks of diarrhea and respiratory infections, and
  • formula can cost up to 30% of a families income, and subsequently families made dilute the formula to make it last longer, which reduces the amount of nutrients the baby gets per serving.

The article also talked about how it’s weird that we are constantly trying to research the benefits of breastfeeding when it’s as natural as “breathing, chewing, hearing, passing stool”. It also went on to explain that even an underfed mom can make excellent quality milk, and as for quantity, it is also enough except in the case of severe malnutrition. The latter point is interesting to me because I hear a lot of moms, including myself with babies labeled as “failure to thrive”, which essentially means our babies aren’t gaining weight at a rate that the medical professional expects. In my case, the doctor assumed I wasn’t producing enough milk and told me to supplement with formula. It turned out that my baby drank the same amount of formula as I was producing of milk, so I wasn’t the common denominator and rather my baby just drank only tiny amounts per feed. I’m curious as to why there are many medical professionals that believe many moms can’t produce enough milk when studies may be showing the contrary.

Anyway, the article ended by saying that it is up to the mom on how they want to provide for their child, however, it is important that they have accurate information to make informed decisions. This means that we would need to reform the system so doctors are never paid to handout formula samples, and on in which moms are not incentivized by free samples to use formula.

 

 

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prepared childbirth: the skin plan

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Photo by Pixabay on Pexels.com

I’m combining all my other blogs’ content to this site. Please bear with me as I post older content. 🙂

In April of 2018, my husband and I attended a 6-hour class on childbirth preparation. I’ll go into a few details about specifics we learned, though it is important to keep in mind, different hospitals and different OBs may have different practices than what we were told.

The whole view around labor now, is that modern medicine is more than capable of helping pregnant folk with the pain. The thing they can’t fix is if we get fatigued. Fatigue is the biggest predictor of if there will be a need for an unplanned Cesarian section because if we laboring women wear ourselves out before we are in the pushing stage, we won’t be able to physically get the baby out into the world. This becomes even more important to note when the pregnant mama-to-be is already battling eczema and it’s host of fatigue-induced symptoms like sleep deprivation.

The first topic the educator went into were ways to conserve energy, aka ways to relax. Physiologically and mentally, giving birth is draining. Mentally, there is pain, so she explained the options our specific hospital has to allow women to cope.

  • Analgesics – I can’t remember the specific names of the two that are put into the IVs but essentially, all of the analgesic options help take the edge off. They don’t make the pain of contractions disappear, but they chemically help to relax the muscles, which allows for us to perceive less pain. How it works is that it helps us waste less energy reacting to pain, decreasing how much we stiffen up from feeling pain or how we can’t relax between contractions. The two analgesics mentioned in the class do cross the placenta, and thus can affect the baby, so the educator advised that if we want these ones to request them before we are 9cm dilated so that there is more of a chance of it getting out of the baby’s system before the baby is born. Otherwise the baby will also get some of that chemical relaxation affect and may then score poorly on the APGAR test (because they will be unfocused and floppy). The third type of analgesic mentioned was nitrous oxide (aka NO, or that’s right, laughing gas!). It does not cross the placenta nor affect the baby but its catch is that only the mom herself can administer this drug. She has to be able to hold the mask to her own face and breathe and then remove it on her own (for legal reasons). Now how do these chemicals affect the skin of someone with eczema?
  • Epidurals – There are two types used: the local or the full. The local (which has gotten the misleading name of “the walking epidural”) numbs the woman’s body from basically her chest to her groin. Though theoretically her legs would still have feeling, if you can’t feel your abdominals or other stabilizing core muscles, you really can’t walk. The full epidural numbs all the way down to the feet, and it is administered when you have to go into an unplanned C-section. When you get a local epidural you have to go in to the C-position on the bed (or that position we see women giving birth in in movies all the time), and you will have to be cued of when to push because the epidural numbs you from feeling any pain of the contractions at all. Supposedly you will still feel something, but most often it is described as a distant pressure.

The rub with all these options for medical pain killers (analgesics and epidurals) is that they can have the unintended consequence of slowing down the labor. If they cause you to be too relaxed, particularly your uterus, you run the risk of the doctor then needing to give you something to “get you back on track”. What this means is that they will add pitocin (a manmade version of oxytocin) to stimulate stronger contractions. The catch-22 of pitocin is that, unlike oxytocin which is made naturally by your body and will gradually increase your contractions to some extent, pitocin is more of a 0-to-60-in-no-time kind of drug, and often times women report that it makes contractions much more painful. It definitely did in my case.

If you have a scheduled C-section, you will be given a spinal tap, which is when the medication is administered so it goes into your spinal fluid. You will then lay down and a tarp will cover you from the chest down (though you can request a see-through one if you want to watch the procedure) and your arms will be tied in a T shape so that one can have constantly blood pressure monitoring, and the other can have the IV in place. Afterwards, depending on the hospital, you may be able to have the baby wrapped up against your body after they have taken the baby for cleaning and screenings, or you can have your partner do skin-to-skin contact if you are too tired/out of it.

Which brings me back to mentioning induction. A hospital can have a few reasons to induce, and I think it can vary by hospital/practice. One reason is if your baby may be late. Apparently, it is common to induce around week 39 now because it allows for an extra week in utero so that if the due date was off by 7 days, you are at least on week 38 (week 38-42 is deemed the safe range for a baby to be born and be totally developed but also still get enough nutrients from the placenta).

Fun fact: did you know they figure out the age of the baby, and whether they were right or not at their predictions, by the placenta? Apparently, it ages and you can figure out when it formed by its coloration!).

Back to induction; so what normally causes labor to start? Scientists and doctors have no idea what triggers the chemical to be released at that specific time, but they do know that prostaglandin is the chemical that sets it all in motion. This is because prostaglandin cause the cervix to soften. Many women when seeing a OB/GYN probably learned that the cervix feels like “the cartilage at the tip of your nose” or something like that. Well when we are going into labor, we want it to soften so that it can then efface (or thin out) and make way for the baby. So first, if you need to be induced, they will add prostaglandin to you (either via an IV or through a suppository inserted in your vagina that has to dissolve). If that works and your cervix softens, then you are given pitocin to make the uterus contract. Then if all goes well, you’ll quickly ramp up in contractions and soon progress to the pushing stage.

So what happens during this first stage, the contractions? Well, like I mentioned before, the focus is on controlling pain so that you don’t tire yourself out. That’s really it. As your body works on the contractions and starts to dilate your cervix to 10 cm, you aren’t really an active participant, so you just have to find ways to bear the pain/discomfort without wasting your energy staying balled up or tiring yourself out. Unmedicated suggestions they mention are (and again this depends on the hospital you are at) using a hospital bath/whirlpool to relax the muscles, sitting on a PT ball, moving around and changing position (if you didn’t get an epidural), taking deep breathing (always need to keep breathing and never hold your breathe- it makes you tight/wastes energy), visualizing something calming, etc. The educator also mentioned how if you are “stalling” or your contractions aren’t going at the speed the doctor thinks they should, and he/she feels they may need to give you pitocin, that you should request an extra 30 minutes and do everything from listen to music, 6th grade slow dancing with your partner, cuddle, kiss, or get up and move around (if you didn’t have an epidural). This is because all these actions can help release more oxytocin, which helps force those contractions to continue.

Then when you’ve finally reached 10 cm dilation, the pushing stage can begin. There are many ways one can go about the breathing during the pushing stage, but the advice was that you want to push when having a contraction (more force) and that at that point you generally tuck your chin to your chest to help exert more downward pressure. If the contractions are going for 60 seconds, you want to take 2 deep breaths right before it starts and then breathe out while pushing, take a smaller breath in (you don’t want to take a deep breathe in because the baby is kind of yo-yoing inside of you and you want to make sure you are pushing it down faster during the contractions), and then breathe out while you squeeze out. After the contraction, relax. If the doctor tells you not to push during a contraction, bring your chin up high and try to resist the urge. A reason a doctor might tell you not to push is to adjust the cord around your baby.

The doctor will give you updates about the baby’s location relative to your pelvis. If they are lined up with the ischial tuberosities, they are at ground 0 and you will see the head soon. If they are not there yet and are still higher up, you’ll get a positive number (of centimeters), and if their head is already visible, you will get a negative number and will probably be seeing that baby very soon.

Then we have to talk about episiotomies. So at my hospital the rate is very low (under 2%), and they will only do it if they think the vaginal tissue is going to rip towards the urethra, in which case they will cut the perineum down a little bit (in the direction towards the rectum). If it doesn’t seem like the vaginal tissue is going to rip in that upward direction (which is determined if the tissue turns white, indicating it has stretched to its max and there is no more blood flowing through it), then instead they will apply a warm compress to the rectal area to help try to warm those muscles and tissues up to get them to relax and stretch a bit more. If they do need to cut you, they will give you a local anesthesia and then do a quick incision.

Also another thing to keep in mind if you are going to a hospital is what are the state laws. In my state, it is mandatory that the baby get antibiotic drops in their eyes, and I think the TB shot before they leave. They also will prick the baby’s foot to take blood for genetic screenings. It’s important to understand what procedures are required like that, so that way you don’t find yourself fighting a state law after you’ve given birth. Also, my hospital will put antibiotics in our IV’s during labor if the mom was positive for group strep B culture during a vaginal/rectal swap between week 35-37. Other than that, if a mom comes in dehydrated, she will also automatically be given an IV for her labor.

A big emphasis that the educator couldn’t say enough was that when you have your new baby, you really want to do skin-to-skin contact. It helps warm the baby up but also is an amazing bonding experience and helps calm both the mom and the baby down. Obviously this can be challenging as a mom with eczema. I found personally that I could hold my baby skin to skin right after the birth (but also note I had been on antibiotics during the birth), and then later when home would struggle with skin to skin, where as soon as my baby was asleep and I’d put her down for a nap, I’d need to scratch like crazy.

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how to handle a baby when you have eczema

white bed spread near a human foot during night time
Photo by Pixabay on Pexels.com

For the first few days after having my little one, I was on such a high of nerves and adrenaline that I felt great!  I had been on antibiotics while in the hospital, and after getting home my skin started to feel really dry. I started taking some probiotics and focusing on drinking lots of water (I knew getting enough sleep was a lost cause), and keeping my stress down.

Initially, my skin was calm enough that I had no problem doing skin-to-skin contact with baby Fi, but around week 4 or so I started to experience more flare symptoms- sweating, itching, redness- whenever I had the baby lay on me for too long. I started to have to wear long sleeves when holding her to not get overheated. I’m not exactly sure when this happened, but it may have also correlated when the humidity increased, and the temperature with it.

I’m not sure if it was due to the antibiotics, the temperature, the lack of sleep, the terrible diet I had in the hospital (think chicken fingers and ice cream for multiple meals in a day), or the hormone fluctuations but my skin definitely became more sensitive post-pregnancy. Though estrogen has been considered one of the reasons women can flare-up worse during pregnancy (see my post about pregnancy and eczema), after pregnancy the estrogen drops so it’s unclear what would be provoking my symptoms (besides the above mentioned items).

Either way I’ve had to be more creative about adjusting to life with a newborn. The biggest aspect I’ve had to cultivate is endless patience mixed with quick stress-reduction habits. My lackadaisical approach to getting house and life stuff done has been somewhat of a saving grace because my little one has wreaked havoc on my schedule. I’m exhausted in the afternoons, I have no idea what it feels like to sleep more than 3 hours at a time anymore, I tend to eat a bit worse now (mostly eating too many carbs and too much) because I lack the self control to stay as dietarily balanced when I’m sleep deprived. It’s something I’ll have to work on in the coming months.

I find ways to not focus on my skin when it’s getting all sweaty from holding her and I have learned to wear light layers or wrap a small blanket between her and myself when breastfeeding to avoid irritating the more sensitive skin areas like my stomach.

There are some inherently awesome aspects to having a newborn when you have eczema (at least in my experience). For one, I tend not to think about myself as much so I am not as aware when I am itchy. She keeps me busy to such an extent that even when I’m immersing my hands in water (which is traditionally a huge irritant) to give her a bath, I barely notice. Also, lately my core temperature seems to be evening out even as my skin fluctuates (which means that the hot, sweaty skin nights and cold shivers have been decreasing). I actually enjoy the cold temperature more than I used to, and I don’t enjoy basking in the sun for quite as long.

And overall I do think that my skin has been able to consistently heal slowly but surely. I feel as though I look more or less human again, what with the redness decreasing.  I think the hormones from breastfeeding are helping my skin heal to some extent; I know my hair has gotten shinier, which is an awesome boon.

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where’s my glow? (pregnancy with eczema)

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Today I decided to dig a bit more into the world of eczema for us pregnant folk.

I started by watching a podcast done by Abby Lai (of Prime Physique Nutrition) in which she talked with Dr. Peter Lio (he’s done a few National Eczema Association webinars). Link to Abby’s podcast is here.

The major points were:

  • It’s not really understood why but about 1/2 of pregnant women have worsened symptoms and 1/2 have bettered symptoms. Dr. Lio likened it to how some women get nausea during pregnancy.
  • You can have a flare in one pregnancy, but not in the next. Also you can have changes in skin between trimesters.
  • Dr. Lio mentioned a few itching conditions that can occur during pregnancy such as cholestasis (when liver and gall bladder slow down their bile flow which causes a terrible itch), atopic eruption of pregnancy, PUPPP (or pruritic urticarial papules and plaques of pregnancy which usually occurs during the 3rd trimester).

He and Abby then talked about treatments used during pregnancy including such as:

  • how topical steroids are okay but not most potent ones. The goal is to keep body surface area that you apply the topical steroids to relatively low (so not WHOLE body), because topical steroids go in blood if they are used long enough or over large surface areas.
  • light/phototherapy
  • Benadryl and other anti-histamines
  • wet wraps, icing, moisturizers (see my post on products I’ve tried here)
  • anti-itch creams in small amounts (such as camphor and menthol)
  • natural oils like coconut and sunflower seed oil (if not allergic)
  • dilute bleach baths (he also mentioned a recent paper shows it’s anti-inflammatory and anti-itch directly, as well as being antibacterial)
  • topical vitamin B 12 (water soluble) – pink magic

The takeaway advice he gave was don’t be afraid to use medicine so long as you have a doctor helping you.

I was having trouble finding full access studies but I did stumble across a PDF from the National Eczema Association about getting pregnancy, skin tips during pregnancy, and after pregnancy advice. It also talked about the likelihood of the baby getting eczema and things to hopefully prevent it. The same PDF also mentioned that avoiding soap can also help decrease the disruption to the skin barrier (which is not something I’ve heard said often; normally it was just to not use antibacterial soap specifically because the bacteria can adapt over time and we’ll be stuck with pathogens that can’t be killed as easily).

In regards to when the mothers are postpartum, such as how there can be challenges with breastfeeding if the mother develops eczema around the area. In that case, the study said low to moderate potency topical steroids can be used so long as they are washed off before the next breastfeeding.

Updated: The National Eczema Association posted a new article May 2018 called Oh baby! Eczema from pregnancy to menopause that goes into more detail about why women may experience more incidences of eczema during pregnancy. It mentions how a researcher at the University of California-San Francisco (Dr. Jenny Murase) found that when a woman is pregnant, her body shifts from Th1-dominant to Th2-dominant immunity in order to protect the fetus (because Th1 attacks foreign material that get into our cells, aka it would attack the fetus since they have half of the father’s cells). Th2-dominant immunity means the mom’s body attacks allergens and whatnot that are flowing around outside her cells, protecting the fetus, but not helping when it comes to eczema. The blog post said that the shift from Th1 to Th2 is driven by the surge of estrogen. Perhaps that is also why women generally have higher rates of eczema than men? Unfortunately I couldn’t find the study that the NEA article cited so I can’t follow up with more, though I did find an abstract from Dr. Murase et al, that mentioned how psoriasis tends to improve during pregnancy correlating with those higher estrogen levels… so maybe one of the immunity-linked causes of eczema and psoriasis are opposite in origin?

My personal experience with being pregnant while having eczema has been that I have to be more mindful about how I treat my eczema relative to general lifestyle changes too. For example, no longer can I go and drink tons of kombucha (due to varying alcohol content and the light risk of bacteria), enjoy whatever random herbs I feel will help me heal, go jump into a hot yoga class unprepared (because getting dizzy affects another being besides myself), eat whatever fish I want whenever (I am a tuna fan and enjoy sushi when not pregnant), run and jump into a hot springs all willy nilly, etc. I have to be more mindful about sharing my body and not just jumping into whatever new protocol or thing I want to try out to help my skin. I can’t decide to just go on a particularly aggressive dietary change that involves caloric restrictions or drastic nutritional adjustments.

That being said, being pregnant has also had a lot of changes that might be helping my skin. In my first trimester I was very sugar and meat adverse, so I ended up eating a lot more veggies. When I wrote this piece in my third trimester I tended to crave veggies as a way to keep my guts feeling good, and to keep indigestion at bay. I also ate smaller meals more frequently, and didn’t really accidentally binge eat big meals mindlessly, which was great because it meant that my body wasn’t overtaxed in digestion (which meant more time to heal the skin!). Pregnancy had me feeling a bit more tired (and much like with a flare, also avoiding high intensity activities), so I tended to stick to lower impact, longer duration activities like going for walks for miles or remembering to get in 100 modified push-ups a day.

Anyway, I’ll stop there and leave you with a current photo of me when I wrote this post. I was about 31 weeks pregnant now and you can see my arms and hands in particular were especially topically-challenged.

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REFERENCES

Crane, Margaret W. Oh, baby! Eczema from pregnancy to menopause. National Eczema Association, https://nationaleczema.org/oh-baby-eczema/. Accessed 30 Apr 2018.

Lawton, Sandra. “Pregnancy and eczema”. Exchange, https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=20&ved=0ahUKEwj3hO2D-9jaAhWmc98KHRNhAusQFgjGATAT&url=http%3A%2F%2Fwww.eczema.org%2Fdocuments%2F711&usg=AOvVaw2fS6lrX7fvyosOV1imHE4p. Accessed 30 Apr 2018.

Murase JE, Chan KK, Garite TJ, Cooper DM, Weinstein GD. Hormonal effect on psoriasis in pregnancy and post partum. Arch Dermatol. 2015 May;141(5):601-606.

Silverberg JI, Hanifin JM. Adult eczema prevalence and associations with asthma and other health demographic factors: a US population-based study. J Allergy Clin Immunol. 2013 Nov;132(5):1132-1138.

 

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why do i have wrinkles on my knees?!

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My skin is going through what I believe to be another topical steroid withdrawal. My reasoning? I have excessive wrinkling on the extensor surfaces of my skin (I call this stage of skin my “elephant” phase, and I’m not alone; see the study here), and I was on a moderately potent steroid ointment for most of my body and a lower potent one for my face/crooks of elbows and knees when I found out I was pregnant. What finding out I was pregnant meant for my skin was that, because the more potent one was not necessarily safe for a growing baby, I was taken off of it earlier than planned and told to use just the lower potency one all over my body instead. Unfortunately my thicker skin areas were used to the higher one so the response was less than ideal and I ended up still flaring a lot as I did my low potency taper. I gradually phased out using the lower one despite some discomfort because having to use topical steroids over such a large surface area of skin does increase the risk of it being absorbed into the bloodstream, making it more likely to affect my baby.

So in a nutshell I had a fairly quick taper and now am cold turkey off all topical steroids again. The result has been interesting. This winter has dragged on which means I have been starved for vitamin D, more sluggish from being trapped indoors, and cold. Whenever I have a withdrawal, my skin is hotter to the touch because it is acting as an impaired barrier and letting my core temperature heat go. The result? I am a grouchy popsicle of a human.

Luckily, we have finally seen a break in the northeast chill, and I was able to enjoy the weekend basking in the sun and walking for miles. Hopefully getting outside and playing more will help me get my skin back to its old equilibrium before the baby comes.

Nighttime presents its own problems. Though I am less stressed about losing sleep nowadays (having a remote job helps), I do find that physically sleeping is still a trigger. The last few days I have had hives that appear on my back when I am in bed (but not in the same part of my back each day which would have made me think it was my sheets or  lotion). I also tend to get heat rash-like symptoms on whatever side of my body I am laying on, or even if I roll over to lay on my back for a bit. I haven’t figured out why that is, but it’s extremely irritating and usually affects my IT band area on my legs the most. And naturally since I am awake weird hours, I notice how my skin dries out as the night goes on (but I am usually too tired to actually get up and re-apply another coat of lotion/moisturizer).

My methods of combatting this withdrawal flare are the following:

  1. keeping calm. I have been extraordinarily unfazed by my skin this time round. I am not worried it will never heal, and I am not worried when I miss sleep (I just try to take more cat naps later on or go to bed the next day at crazily early times like 5pm).
  2. diluted bleach baths. I tend to take one many once every one or two weeks just to make sure I keep the potential infections at bay. I usually know when I have had bad scratching bouts or see signs of what I think may be early infections, and I decide when to do these baths by those feelings.
  3. sugar reduction. Yes, despite being a sugar-lover, I am trying to cut down on added sugars. I don’t even put sugar in my oatmeal anymore (instead I cut up a fresh green apple into it or add berries if I have them). I let myself have one treat on Saturday and Sunday, but I make it so I have to work for it (like walk 2 miles to get the treat, then walk back).
  4. finding a good product for the skin presentation. Lately I’m hooked on Exederm’s daily care moisturizer. It doesn’t stop me from still drying out and flaking but it also usually doesn’t burn or cause excessive itching (except sometimes at night, but my skin is an unpredictable animal at night).
  5. living the “motion is lotion” motto. I have been trying to increase my NEAT (non-exercise activity thermogenesis) meaning I have been trying to reduce the time I am a sedentary lump. The warming weather is helping (I will happily walk anywhere in my town even if it is a 1-3 mile walk one way), and I have been doing a 100 push-up challenge every night before bed (I do modified pushups as my belly has been getting bigger!). I also started incorporating more hip workouts and squats/lunges to keep my legs in shape as this baby grows. All in all, “I like to move it, move it”.
  6. showers first thing. When I get up from bed (which sometimes is a struggle in itself), I get into the shower to start my day. One, I find it therapeutic, the feeling of water. Two, it helps me soften the skin and wash off some of the dead skin so that the lotion/moisturizer can be better absorbed. Three, it bases me in a routine.

All in all I feel like I am handling this withdrawal much better than previous ones. My skin has more or less remained skin-colored this time (instead of reddening everywhere). I’ll give updates if it starts to subside or if it gets worse in time.

Oh and here is a photo of what I mean when I say I have elephant skin (this is my right knee):

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REFERENCES

Sheary B. Steroid Withdrawal Effects Following Long-term Topical Corticosteroid Use. Dermatitis. 2018 Jul;29(4):213-218.

all posts, community, eczema

how to find dr. right (dermatology edition)

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As one of many people who sees a dermatologist for some kind of reoccurring eczema or atopic dermatitis (AD) and as someone who has cycled through the what feels like all options for treatment (often never finding that perfect product, the lifestyle management, or that patient-doctor connection), and as someone always searching to get to my dream skin, I am always hunting for ways to build a relationship with my future Dr. Right.

The most important part of having a good working relationship with your dermatologist is being able to speak your concerns. I have gotten to a point in my life where, when meeting a new dermatologist, I throw out my entire skin background in a verbal paragraph; the goal being to test the waters of this new budding relationship. Here are some examples below for personal context:

  • I have had topical steroid withdrawal (TSW) before because of my excessive use of steroidal topical ointments in my earlier years, and I am somewhat hesistant to use them now. I am also not entirely interested in oral steroids again, because of their shopping list of side effects. It is important to speak your fears of strong medications, so your derm knows what you need to discuss.
  • I have been using coconut oil on my skin and have had no problems with it except that it didn’t prevent a flare. This bit of information is shared because it’s true (and you never know when new research will come out saying that coconut oil is not as good as we thought it was… e.g. what happened with olive oil) but it also can be used to get the derm’s opinion on natural products/non-dermatologically created alternatives.
  • I have been avoiding gluten and soy (because they are common allergens and because I have other legume allergies) for a while and worry that me starting to eat them again this summer may be part of the reason for my flare. This is brought up to bridge into the field of nutrition to figure out my new derm’s opinions on diet in regards to its effect on eczema and management.
  • I know about the current new drugs on the market (Dupixent) and wonder about its effect on pre/peri/post natal women. It’s crucial to remember to bring up reproduction-related information if you are going to start a drug that hasn’t been tested on men or women for reproductive side effects, if you are interested in having children one day.
  • What is the plan for me and what will my management entail going forward? After all, I want to know she isn’t just going to prescribe me a crap ton of drugs and wish me the best with my life… continuity of care is extremely important for preventative care and management.

In the case with AD, I was hesitant about both topical and oral steroids as the major component of my management, and my derm was receptive to my initial hesitation. However, she also argued with the need for inflammation management, because in an untreated state, chronic inflammation will damage other organs and systems in time. So she walked me through the details about what she was thinking for both types of steroids- the dosages planned and how long she planned to keep me on them. If you are confused about what the drugs do or their safety, it doesn’t hurt to inquire more (for example 60mg of prednisone is on the high end of how much doctors will prescribe).

My derm told me of her roadmap for my management (an important thing you want your dermatologist to bring up!)- how long she’d want me on the oral steroids, which topical steroid was for my face versus which for the rest of my body, how we’d cycle through a 2-week steroidal/1-week non-steroidal topical cycle, and the need for more frequent bleach baths to prevent staph infections from other healthy-skinned people (because everyone carries some level of staph on their skin).

When I asked her my big question — what can I do to prevent these flares from coming back aggressively again, she also brought up diet changes, as well planning future appointments to monitor how the preventative measurements were going. All in all I left with a sense of her being committed to making sure things worked, not just prescribing me all the meds I could carry and hoping I didn’t ever need to come back.

The big takeaway from being a frequent flyer of the dermatology world is that it is okay to need to find a dermatologist who fits with you. You want someone you feel comfortable with, who you can talk to openly and feel like they both have the time to listen and are receptive to your ideas and where you are in your health literacy (i.e. do you like written or oral directions, how familiar are you with the drugs/treatments/interventions, how much you feel you understand or care to understand about the condition as a whole, how it works genetically, immunologically, neurologically, etc).

You should feel like you are leaving with enough information to get you by AND also with your questions answered, but also that you know what to expect and when to reconnect with the derm in the event that something isn’t working just right. You don’t want to feel like you’ve heard it all before, or that there is something the derm just isn’t getting about you. The relationship needs to be out on the table and the communication level high. If you have persistent remaining questions- ask them! If you are frustrated by something, voice it!

With any chronic disease, management relies on the ability to be able to communicate your feelings and symptoms, and on the ability of the provider to be able to give you the support and care contingency to make sure that you don’t falls through the cracks in the system. So when working to develop a fruitful and useful relationship with your dermatologist, don’t be afraid to be a bit selective and work through difficult questions to see if you have found your Dr. Right.

 

Here’s a photo of my own hands October 2016 (left) and March 2017 (right):

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