Thursday, May 31, 2012

Hormone works in tandem with vitamin D to fight skin infections

A certain hormone works in tandem with vitamin D to control how skin cells produce a natural microbe-fighting agent, and can compensate for a lack of vitamin D, scientists have found.

The new results help explain something that has confused researchers for a long time: although it is known that vitamin D plays a role in the immune defense, there are very few clinical trials that show that taking supplemental vitamin D helps prevent infection.

The work was led by Richard Gallo, a professor of medicine and pediatrics and chief of the Division of Dermatology at the University of California, San Diego. It was published this week in the journal Science Translational Medicine.

The skin makes natural antimicrobial compounds (protein fragments called peptides) to kill unwanted bacteria, fungi, and viruses. Eczema patients produce these compounds at lower levels than normal; psoriasis patients, at higher levels. Vitamin D initiates production of cathelicidin, a broad-spectrum antimicrobial.

Gallo and colleagues showed that human skin cells produce parathyroid hormone (PTH) when treated with a bacterial compound known to trigger the immune system. The same cells, stimulated with vitamin D, manufactured copies of the receptor for PTH. And the skin cells produce far more cathelicidin when they are treated with parathyroid hormone and vitamin D than with either compound alone.

The results suggest a model in which, in humans, vitamin D can stimulate cathelicidin production by itself—but PTH is doing so by a parallel pathway, which vitamin D can amplify.

The scientists also showed that PTH helps reduce the severity and extent of Streptococcus skin infections in mice—but it does so much more strongly in normal mice, compared to mice genetically engineered to be unable to convert vitamin D to its active form. (Apparently it is very difficult to make a mouse deficient in vitamin D.)

What this means for eczema patients is not clear yet. The research gets us further toward understanding how vitamin D and other factors participate in the skin’s immune response. If I were a doctor, it would make me hesitant to recommend that patients with normal vitamin D levels should take supplements.

Wednesday, May 30, 2012

The three-year allergy test: a comedy of error and opinion

It’s a schizophrenic experience to write a blog covering research on a medical condition while at the same time being a patient and a parent of a child with that disease. Some days I’m writing about what’s possible at the cutting edge. Other days I’m dealing with the imperfections of medicine when it’s applied by real people.

Yesterday it was the latter. My daughter Voov had her 3-year allergy checkup at Kaiser Permanente. First time around, we saw an allergist who barely spoke English. She administered a skin prick test that showed Voov reacting to virtually every food allergen. She advised us to feed her nothing but three things (rice, broccoli, and bananas) for two years.

Can you believe that? Where did this allergist learn about nutrition? Fortunately we, as Voov’s parents, had heard of fat and protein and the idea of a balanced diet. We negotiated a list of ten or so items—including meat—and the possibility of trying a few others.

Voov eats boring food, but she doesn’t care. Her absolute favorite is potato chips. She can go through a party bowl of chips like a school of piranhas through a pig.

Two years later, Voov has her second allergy test—again, a battery of skin-prick tests—with a different allergist, because we weren’t going to put up with the first one again. Voov squirms as the pricks are made and writhes as the itch sets in. She appears to register positive only to dairy. Hooray!

But wait. After consultation it appears that Voov is not allergic to dust mites, which virtually every eczema patient reacts to. Is she really not allergic to dust mites? Let’s look at her back again. Oops—there’s a big red wheal about where the dust mite allergen was applied. Or is it?

It turns out that the tech who read the results didn’t do so in a rigorous manner. She just noted the few spots that showed positive reactions, rather than going through every spot to verify the negative locations. And immediately after reading in this shortcut fashion, she erased all the pen markings on Voov’s back with alcohol.

The allergist is left advising us that Voov is probably allergic to dust mites and dairy. But, she adds, the results of skin prick tests don’t bear much relation to what foods people really react to. Just feed the kid stuff and see if she reacts, the allergist says—and no need to wait the usual two weeks; three days is enough.

I like this idea—let’s just get on with trying foods and seeing if there’s a problem. But it’s unnerving to run into medical professionals who have different opinions—not to mention the odd opinion that is clearly wrong. I’d like to think there was something close to truth out there regarding food allergies and eczema. Unfortunately, while scientists can agree that barrier problems with eczema somehow predispose kids to develop food triggers, the best practice in the clinic seems to be to leave it up to the parents to figure out what’s causing the problem.

Tuesday, May 22, 2012

People with eczema more anxious in relationships than others--but just as satisfied

People who have eczema feel less secure in romantic relationships than those who do not, a new study says; but when they are in a relationship, they find it just as satisfying as anyone else.

Jan Dieris-Hirche and colleagues at the University of Giessen in Germany report their findings in a paper released online ahead of publication in the journal Acta Dermato-Venereologica.

Their initial assumption was that "the presence and severity of AD affects partnership satisfaction, since the negotiation of intimacy and tenderness seemed to be complicated" by psychic issues connected to poor self-image.

The authors compared attitudes of two age-and-sex-matched 62-person groups: one of eczema patients, the other of "normal" controls.The average age of the subjects was 29, and two-thirds were women.
Answering questionnaires, eczema patients said they felt less close to their partners, trusted them less, and felt more anxious about being left than the control group did.

(The authors point out that, although the severity of symptoms was correlated to the degree of insecurity, it isn't clear which causes which.)

However, eczema patients felt just as satisfied in relationships by three measures--fighting, intimacy, and communication--as the control group.

The authors did not address the question of whether people with eczema are more or less likely than others to form romantic relationships.

Saturday, May 19, 2012

Which alternative therapies for eczema are worth considering?

The recent issue of The Advocate, the newsletter of the National Eczema Association, features two positive articles on alternative therapies for eczema--an account of an acupressure study conducted by Peter Lio of Northwestern University in Chicago, and a review of alternative, complementary, and integrative medicine that Lio seems to have had a hand in editing.

The review is well done, and mentions a new center set up at the NIH to study these therapies, but my initial reaction was one of dismay. There is nothing physical that operates outside the rules of Western science. I'm 100% for evidence-based medicine and I think most alternative treatments offer nothing more than a placebo effect.

But I like to treat people fairly, so I had a look at the Wikipedia page for traditional Chinese medicine. My opinion was reinforced. The theories--what a load of hogwash. It's like going back to medieval days, when doctors believed illnesses were caused by an imbalance in the four Hippocratic humours--blood, phlegm, black bile and yellow bile--and treated nearly everything with leeches.

But, as I keep reminding myself that this blog has a POSITIVE outlook on eczema research and therapies, and that the point is not to get caught up in criticizing quack medicine or poor studies, as much fun as that may be, I decided to map out for myself whether I could get enthusiastic about any alternative therapies at all.

I drew a plot of where common alternative therapies for eczema lie on two axes: how probable it is that they will do what the people promoting them say they will, and how probable it is that they could cause harm to a patient in some way. Here's my plot. For comparison, I included two standard treatments for eczema: straight-up moisturizing, with something like Eucerin or Aveeno; and low-potency steroids such as 1% hydrocortisone.

I found it illuminating to do this. Let me elaborate my thoughts:
  • Homeopathy, the practice of ultra-diluting reagents, has zero chance of working. You're just drinking water.
  • NAET, in which practitioners claim to diagnose allergies by "applied kinesiology," not only has zero chance of working, but could actually harm patients if they take the practitioner's word that they aren't allergic to a substance that they really are.
  • Acupressure and acupuncture might counteract the itch stimulus with pressure or pain. But based on the mediocre results from small-group studies I've read, I don't really think they do anything. And with acupuncture you are poking holes in your skin, which is never a good idea.
  • Vitamin D is a fad, but it seems true that many people have levels below the recommended 30 ng/ml. Taking vitamin D to boost your levels to normal makes sense. Taking more does not. You could poison yourself if you took too much.
  • Probiotics--consuming foods that contain live, benign microbes to normalize your gut flora--make a lot of sense (especially since more links between gut flora and systemic inflammation are emerging) but I haven't seen any knock-'em-dead studies that really show they significantly relieve eczema.
  • Herbal Chinese medicine does hold promise for eczema therapies. (Tiger penis and rhino horn, not so much.) There are real drugs hiding in there. Artemisinin, for example, is a scientifically verified antimalarial isolated from a traditional Chinese herb. But I won't believe in the efficacy or safety of any Chinese therapy until it has been verified by the full spectrum of clinical trials. In short--when it's not alternative anymore, but mainstream. And if a drug works, it is going to have side effects and interactions with other medications. So there's definitely the potential for Chinese herbs to produce some good therapies in the future--the pharma company Glaxo Smith Kline now has a traditional Chinese medicine division. There are also other storeholds of incredible biodiversity, such as marine compounds from the Malaysian coastline. But it could be decades before we see any drugs hit the market from these sources.
My plot is too simple to make clear that I think it's possible that some drugs isolated from Chinese herbs might be more effective than low-potency steroids such as hydrocortisone. They could be better. But on average I'd be surprised if they were. And if it's true (according to Wikipedia) that a typical herbal treatment from a traditional Chinese practitioner is decocted from 9-18 herbs, I have to wonder what exactly the active ingredients are and how sure the practitioner is of the dose and proportions.

I also worry that we just don't know what some of these herbal compounds are doing. What are the side effects? And where were the herbs harvested? Do they contain arsenic and heavy metals? China's not famous for its environmental policies.

The Chinese multi-component treatment does have a parallel with Western pharma approaches such as the "triple cocktail" antiretroviral for HIV, or combination chemotherapy. The Chinese herbal compounds just haven't been rigorously identified, categorized, and tested in the way that they need to be.
I clearly find Chinese herbal medicine intriguing. You can expect me to investigate Chinese herbal eczema therapies in this blog. I'll also consider vitamin D and probiotics, although from what I've seen, they do not promise anything but slight improvement for the average patient.

Wednesday, May 16, 2012

Voov makes it to three--and eczema, food reactions continue

Looks like my daughter, Voov, is stuck with eczema for life. She recently turned three and had her annual checkup. The pediatrician told us what we already knew, which is that children whose eczema persists past the age of two usually carry it into adulthood.

But at least her affliction isn't severe. It's not nearly as bad as what I've dealt with myself and what I see discussed on forums and in the National Eczema Association newsletter.

We're also still waiting to see what will happen with her asthma. She takes medication twice a day through an inhaler, but only because when she gets sick, as she is now, she wheezes. She hasn't had an asthma attack.

Food allergies/reactions are another issue. God, she's been eating the same stuff for years. Let me see: chicken, turkey, soy. Rice and oatmeal. Carrots, peas, sweet potato, corn. Apple, pear, banana. That's it! How boring. We've also given her tomato, potato, orange, green beans, and pork, and she refuses to eat any of them, although she doesn't have a reaction.

Two weeks ago, my wife, Hidden B, gave her cow's milk instead of soy milk by mistake, and Voov announced she felt ill and then threw up all over the kitchen floor.


I like to cook, and I keep hoping that someday I'll be able to make one meal for the whole family. At the moment I cook food for Voov and then food for everyone else. We have to tell her over and over again that she can't eat what we and other people eat, because she's special. I wonder how long that fiction will hold up.

The weird thing is that she's hardly ever had an eczema flareup that we could connect to a food we've tried. Voov seems to have allergies or intolerances that aren't directly connected to eczema.

In a few weeks she's going to have a skin prick allergy test for all the same things she was tested for two years ago. We're hoping we'll find that she's grown out of some of her allergies. I myself would like to just give her foods and see whether she reacts, but Hidden B has overruled me. Probably wise, if Voov's reaction to milk is any indication.

Friday, May 11, 2012

Scientists claim electroacupuncture relieves itch

"Electroacupuncture" is more effective than a common antihistamine pill for relieving allergic itch, researchers report in a small-scale study published recently in Allergy, the European Journal of Allergy and Clinical Immunology.

In electroacupuncture, two needles are inserted at classical acupuncture points, and a signal generator sends a low-frequency electrical current from one needle to the other. Whether electroacupuncture works is controversial.

The researchers, mostly Germans, led by Florian Pfab, a visiting professor at Harvard Medical School, compared electroacupuncture with the antihistamine cetirizine, and with placebo acupuncture and antihistamine, in a group of 20 patients. The patients had tested positive for type 1 hypersensitivity itch reaction to various allergens--and it was these allergens that the patients were skin-pricked with before the treatments. The scientists then asked the patients to rate how itchy they felt. The conclusion was that true  acupuncture applied during an itchy period was the most effective method. (They also tested acupuncture as a preventive measure before allergen prick--the effect was much weaker.)

Let's consider various aspects of the paper.

The very small group size. There were actually seven different subgroups out of 19 patients (one was dropped because he/she didn't feel itchy) so the subgroups were only two or three people apiece. That's way too small to produce definitive results.

Electroacupuncture is kinda weird. Were the researchers even performing it properly? I can't tell from the paper. They say they were using this device. It appears to have four separate channels--is that four separate pairs of electrodes? I used to be an electrical engineer [geek warning], and the way you set up a circuit is that one lead is the ground, and the other one is the signal. If you have four channels do you have one ground and three signals? Or four grounds and four signals? It would seem pretty dumb to connect more than one ground or signal to the body at the same time. Then you'd have current flowing all over your skin in an unpredictable pattern. I was once working in a lab where people were measuring the electrical activity of bird brains, and one of the postdoctoral researchers didn't even know what voltage was. So I'm not convinced these guys know what they're doing.

They're only treating allergic itch applied by a skin prick. If you're allergic to dust mites, you breathe it in and then you're itchy all over. You don't get chronic eczema from pinpoint contact with these allergens.

Beating antihistamine as an itch treatment for eczema doesn't mean much. In my experience antihistamines don't do anything to relieve itch.

So here's the killer: say they do know what they're doing, and the results are good. Is this a practical treatment method? I'd say no. It would only relieve the itch while the electroacupuncture was being done. The paper itself says so. Anyone with chronic eczema knows that you get it all over your body and you get it all the time. You can't just run off to the acupuncturist when the itch on your feet is driving you nuts, because ten minutes after the appointment, your scalp or the backs of your hands will be flaring up. You might as well pinch your skin, creating pain to dull the itch.

OK, I've been critical enough. It is interesting to see that acupuncture is being taken seriously, but scarce research funding should go to more useful projects.

Wednesday, May 9, 2012

Diversity of food eaten in first year linked to less eczema afterward

Feeding your child a variety of foods, especially yogurt, in the first year of life appears to reduce the chances he or she will develop eczema later on, a group of European scientists reported recently in the Journal of Allergy and Clinical Immunology.

The group, led by Caroline Roduit of Children's Hospital at the University of Zurich, had considerable overlap with the researchers who reported two years ago that the mother's exposure to farm animals before birth reduced the incidence of eczema. Both studies were based on data from the Protection against Allergy--Study in Rural Environments (PASTURE) project.

The authors say that, in the existing scientific literature, there is no consistent evidence that avoiding food allergens during pregnancy or infancy prevents allergies later. Because they conducted this study, it would seem they believe the opposite: that exposing kids to allergens could lead to tolerance and therefore fewer allergies. And eczema often has an allergic component, although it's sometimes difficult to classify the precise type of reaction that a patient has to a food.

The authors considered data from 1041 children, seeking to correlate the variety of foods fed eaten with whether the children developed eczema (not whether they developed food allergies). They reported an inverse correlation: the more foods eaten, the less eczema in the children. Here's Figure 2, the key graphic.

Looks to me like the first two foods make the most difference. After that, the curve is essentially flat.

Four interesting features stand out in the paper:

1) the authors observe that it is very hard to study the connection between food and eczema before a child is one year old, because if a child has symptoms of eczema early, or if one or both of the parents has allergies, the child tends to be given very few foods in addition to breast milk. So a naive researcher might immediately conclude that giving a kid only one or two foods leads to eczema. To be rigorous, the authors restricted their study to children who developed eczema after the first year.

2) yogurt, according to this data, is a special case. If a child eats yogurt, and very few other foods, it appears to reduce the odds of developing eczema to 40% of what they were to begin with. That may be because the yogurt bacteria somehow provide a probiotic effect in the gut.

3) the six major food groups that the authors consider as independent are vegetables and fruits; cereals; meat; bread; yogurt; and cake. (Cake is a separate food group in Europe?) I find this odd, given that bread and cake are made from cereals and the three groups must contain very similar allergens.

4) Europeans apparently give their children very few soy-based foods. North Americans must have been influenced by Asian cuisine and include tofu and soy sauce in their diets more than they used to. Or maybe it just looks that way because I live in the Pacific Rim.

I wouldn't make any radical changes to my kids' diet based on this paper, but you can't do any harm feeding them yogurt.

Monday, May 7, 2012

Eczema and the perfect crime

I'm a fan of "Cold Case Files," that low-budget true-crime show that features slow-pan narrated black-and-white photos of old blood spatters, bad re-enactments of decades-old events, and interviews with neighbors who were always uneasy about Jim Bob's collection of garage-sale Barbies with missing limbs.

I don't follow the show, but I used to watch it when I was on the stationary bike alone in the office exercise room in the basement. I found it added a certain frisson. And so that's how I came to know a few things about the perfect crime: own a property way off in the boonies, dispose of the body in acid, and never leave any traces of either the victim's DNA or your own. They always get you through the DNA.

For those of us with eczema, that poses a challenge. We're always scratching and leaving clouds of DNA-containing skin cells behind us on our clothing, the furniture, and anyone we come in physical contact with. If a cold case officer knows what to look for, I'm toast. That's assuming I'm the perp.

But what if I'm the victim? Then, not that it's going to do me any good personally, but the cops are going to be able to follow my trail or deduce that I was once an unwilling passenger in Jim Bob's trunk.

And there's a third angle to this--if I had any ambition to be a cold-case investigator myself, I'd be a poor choice for the guy collecting evidence. I'd be leaving microscopic fragments of skin all over everything and contaminating the samples. No joke--it's there in Interpol's Handbook on DNA Data Exchange and Practice. People with eczema have to wear special suits if we're tapped for that job--and what detective is going to want to run the risk we'd screw it up?

But that does suggest there are special suits available that I might want to wear if I were, say, considering the perfect crime. I'll just file that trivia away.

Thursday, May 3, 2012

Building social bonds to fight eczema: guest post by Eczema Outreach Scotland

A lot has been said about medical treatment of eczema, as opposed to a social approach. Even this blog, End Eczema, suggests that finding a cure for the skin condition, eradicating its tragic effects of which we are all well aware, is only a matter of time. Since eczema is thought to be a part genetic and part environmental issue, it is a very ambitious task. But then again, scientists’ achievements in medical genetics, arguably due to a technical advancement too, have been astonishing.

We at Eczema Outreach Scotland obviously do support the research which is being done with an aim of implementing a successful treatment for eczema. However, we have chosen to follow a different path, of a social character. This is not to suggest that we should drop professional medical advice, quite the opposite.

Eczema Outreach Scotland concentrates on building strong social bonds between eczema sufferers. This approach is well built in our services. We support families by creating connections between them and giving information. Our social outings aim at increasing confidence and self-esteem of children with eczema. Reduction of stigma, which is another Eczema Outreach Scotland goal, is again directly connected to the social relations that we build around us.

The need for strengthening these relations can be well observed in children’s words. Five-year old G said: ‘Before I met K, I used to think I was the only scratchy girl in the world. She is my new friend. She wears bandages too. We had a lot of fun together today and our mummies said we’d keep in touch.’ This is food for thought, and not only for people from outside the eczema world, but also all those with an interest in the cause.

Eczema Outreach Scotland gives room for children and parents to socialise. Our free outings organised in Scotland are an excellent example of this approach. Few weeks ago, for instance, we organised one in Edinburgh. It included allergy-free cookery demonstration and talk hosted by Children and Young Peoples Allergy Network Scotland as well as drama and art workshops. There were lots of opportunities for children to start and nurture new friendships, build self-esteem and enjoy a positive experience connected to their condition. Now we are planning new outings in Elgin and Cumbernauld.

Every family affected by childhood eczema in Scotland is encouraged to join our free membership and we count on each reader of this blog to spread the word!

Wednesday, May 2, 2012

Lymph node immunotherapy may be simpler, safer

A new, improved method of immunotherapy is emerging: injection of modified allergen, directly to the lymph node--which promises to prevent allergy to specific triggers with only a few treatments and minimal risk.

A group of Swiss, German, and Swedish scientists reports in the latest issue of the Journal of Allergy and Clinical Immunology that they reduced nasal tolerance of cat dander, a major trigger for atopic allergy, by a factor of 74 in a group of 20 subjects, using only three injections over two months. That means it took 74 times as much dander to cause the same amount of allergic reaction--the scientists used the flow of liquid from the nose as their measure--in a treated person as in a subject given placebo.

[This article featured in JACI's Journal Club.]

Immunotherapy for specific allergens currently requires 30 to 80 injections over three to five years and includes a risk of anaphylactic reaction. It is not popular. The new method, if confirmed, looks much more practical.

The researchers, Gabriela Senti of University Hospital Zurich and colleagues, were basically repeating an earlier, successful study that they had done with grass pollen. (I consider cat allergy avoidable but grass pollen is a big deal--you can't get away from it, unless you're in Antarctica.)

But the new study came with a twist--the researchers modified the cat dander allergen with two molecular changes. The first added a short chain of amino acids that helped the allergen enter the cell membrane--essentially, the membrane of B and T cells, since it was injected into the lymph nodes. This seems to have prevented other white blood cells, such as macrophages and mast cells, from encountering the allergen and provoking inflammation.

The second modification ensured that the allergen didn't get immediately destroyed inside the cells, but instead got chopped up and presented on the surface of antigen-presenting cells, which are a key element of the antibody arm of the immune system. Thus, by a process I don't really understand, your immune system becomes "tolerant" to that allergen.

Treatment with the modified cat allergen did not increase IgE antibody levels, or induce any "adverse events" in the treated group, which, it has to be said, numbered only 12. It's possible that in a larger test group some problems might reveal themselves.

If an environmental allergy is a big problem for your eczema, and you can stand nurses injecting things into your lymph nodes, this looks like good news. I don't know how long it might be until the FDA approves this treatment in the US though.