Scalp eczema therapy: a work in progress

Last year I wrote about scalp eczema. The post is one of the most-read on this blog. Good news: I’m going to write about it again! The reason: once again, scalp eczema is a problem for me.

My scalp trouble seems to follow a yearly cycle, and it might have something to do with pollen, since I had it last spring. Or it might be just that I started swimming again a few months ago. There’s no getting around the fact that swimming is bad for my skin. (I swim, nevertheless, because it’s good for my back.)

I just get this ridiculously dry scalp that starts breaking out into itchy patches. It is extremely hard not to pick at and scratch.

It seems to be a three-part problem: inflammation, dryness, and bad habit.

To treat the inflammation I rub in steroid, which is bad because 1) it’s quite strong (fluocinonide ointment) and 2) it hardly works at all.

I also use a tar shampoo, T-Gel. I love tar shampoo—it’s got a great bite to it and knocks the itch out for a few hours. But it’s a shampoo, made from detergents, which wash oils out and leave my scalp screaming dry.

I realized that the tar shampoo was part of the problem, so now I use it only once a week.

I used to follow tar shampoo with jojoba oil. Jojoba is an expensive, fine-grade natural oil that comes from the seeds of a Mexican desert plant. It is my conclusion that jojoba is a waste of time and money. It doesn't do much besides run down behind your ears and make your neck greasy.

Now I follow my tar shampoo with Aveeno Daily Moisturizing lotion. That's right, I rub it all over my head. It dries to a shellac and makes me look like my grandfather when he used Brylcreem back in the 1950s. Aveeno is good both because it contains soothing oatmeal extract and dimethicone, a rubbery polymer that holds moisture well.

This is not a perfect solution, and a bit disgusting. But it’s better than rubbing in strong steroid ointment out of desperation, I think.

In order to use the Aveeno lotion (to get more of it on my scalp and less on my hair), I buzz my hair short. I’ve got a home barber kit for this. I use the 0.5” or 0.75” attachments. I gave myself a haircut last week, after waiting several months for my scalp eczema to go away so I could go to the barber.

I’m not super-keen on Aveeno for this though. I am going to try shea butter, which at least has the virtue of being a bona fide hair product.

I am surprised that very few commercial companies, if any, make moisturizing scalp lotion. You’d think there would be a market for it. Cosmetics companies seem to approach this as a conditioner problem, as if we’re all worried about how beautiful and manageable our hair is. Well I’m not. I’m a 41-year-old balding man and I have no use for conditioner.

Ironically, Kamedis, the Chinese herbal therapeutics company whose skin lotion I reviewed recently (and none too positively) makes scalp lotion for eczema. Maybe I should give that a shot!

* * *

Let’s not forget that my bad habit of picking at dry skin and scabs on my scalp is part of the problem too. I know that it’s possible to quit the habit to some degree by undergoing habit-reversal training.

There are two phases to habit reversal. In the first, you count how many times you touch, pick, or scratch yourself during the day. In the second, you train yourself to recognize that you're about to scratch, and to resist the urge, either by clenching your hand or digging your nails into your palm. 

Here’s the barrier that prevents me from self-training—I don’t own a simple digital counter that would enable me to keep track of how many times I am scratching. Last time I tried habit-reversal, I made pencil marks on the back of a business card. I touch my head more than 500 times a day, apparently. It's a pain to have to keep making pencil marks.

I just looked on Amazon. This is what I want. Isn’t it ridiculous that I am not able to stop picking at my scalp because I don’t have a little clicker device that costs less than $7.00? I just bought it.

Aveeno stonewalls; and introducing eosinophils, the "riflemen" in your skin

So I wrote to Aveeno the other day, asking them two very simple questions:

1. What makes the Eczema Therapy line different from any of their umpteen other moisturizers?
2. What data can they show to prove that it works?

I found out that Aveeno is owned by Johnson and Johnson, and that, despite Aveeno's friendly Facebook video, J&J is as terrible at customer relations as any giant corporation.
Answer #1:

...the Aveeno® Advanced Care™ Moisturizing  Cream is different in these ways:

Essential ACTIVE NATURALS®:
-Pure oat essence and natural colloidal oatmeal to soothe skin
-Ceramides to help enhance skin's ability to retain moisture
-Plus moisture-rich oat oil

However,  this product has since been discontinued.

Not particularly helpful, since that wasn't the product I asked about. I wrote them again, repeating my original question. We'll see what they say. The active ingredient in the Eczema Therapy lotion is 1% colloidal oatmeal. Hardly revolutionary. Is it any different from anything else Aveeno puts out? Probably not.

Answer #2:

We are very sorry, but our company policy prohibits disclosing this type of information. Most of our research, marketing and sales information is proprietary, as is information regarding our ingredient percentages and formulations of individual products.

So: none of your business.

I did call the FDA to see if there were any instances on record of an official FDA warning letter being sent to Aveeno (recall, Peter Lio told me Aveeno had come out with this line a few years ago, and got their hand slapped because they were making an unsubstantiated therapeutic claim).  I was shuttled from the cosmetics division to the drug division-- colloidal oatmeal is classed as a drug, I found out, with the magical property of "skin protectant." There are no warning letters on record. I'm guessing that perhaps there was some low-level communication from the FDA to Aveeno that resulted in them listing colloidal oatmeal as the active ingredient.

The ridiculous thing is that someone at some point had to register oatmeal as a drug, which must have involved all kinds of safety trials.

* * *

Last week, you may recall, saw the end of the annual conference of the American College of Allergy, Asthma, and Immunology. On the Saturday before last, there was this session in the afternoon called the "Great Atopic Dermatitis Raft Debate." I have now found out what this was about, or more specifically, what "raft" is doing in the title. From the conference brochure:

Premise: Experts involved in atopic dermatitis management are adrift in a life raft. There's enough food and water in the raft for only one to survive, and the surrounding waters are teeming with sharks. Each expert has exactly 15 minutes to make his case. Come and see who gets tossed to the sharks!

This explains why sharks feature so prominently in the Powerpoint of Mitchell Grayson, MD, one of the presenters. I wrote to all four professors in the debate, asking if they could send me their presentations and save me paying $350 to the ACAAI (now there's a posse of sharks) for the conference DVD. Only Grayson obliged. So I declare him, by default, the winner-- we toss Mark Boguniewicz, Donald Leung, and Lawrence Schwartz off the raft.

Grayson represented "eosinophils" in this epic tussle. Eosinophils are a type of white blood cell. My PhD topic had an immunological focus (helper T cells) but I really never heard diddly about eosinophils, so I was excited to go through his presentation. Let me share the gist:

On the battleground of eczema, eosinophils are the "riflemen," according to Grayson.

Eosinophils are, he argues, the cells most responsible for eczema. (Keep in mind that he was trying to win a 15-minute debate.)

Eosinophils, triggered through a signaling chain that begins with mast cells and goes through T cells, are the ones who "shoot" pathogens, destroying them with reactive oxygen species (e.g. peroxides) and "cytotoxic granules," aka poison. We'll ignore the fact that history usually holds the generals responsible for what the army does in war, although recent events at Gitmo show that we may not have enough perspective on that conflict yet.

Activated eosinophils are found in the middle layer of skin in patients with eczema. In normal skin, eosinophils have no business being there. Some scientists think that eosinophils contribute to skin irritation by releasing their toxic payloads. Here's a microscopic view of an eosinophil, from Grayson's Powerpoint:

You can see a cytotoxic granule highlighted. Some evidence that skin eosinophils may play an important role in eczema: urinary levels of eosinophil products are proportional to the severity of eczema; treatment of eczema with tacrolimus and pimecrolimus reduces the number of skin (but not blood) eosinophils; reduction of blood eosinophils has no effect on eczema. One experimental mouse model develops eczema only if eosinophils are present.

So there's a lot of circumstantial evidence against eosinophils. Our real question: OK, say you prove eosinophils are the key-- how can we target them to prevent eczema?

On that, Grayson has no answer. We can forgive him, though. It seems that dendritic cells and adhesion molecules are really what he specializes in.

The secret powers of oatmeal

I'd like to ask you a favor. Since the purpose of this blog is to raise $1 million for eczema research-- through a cunning plan the details of which will be revealed, and if you find out, please tell me-- I'd appreciate it if you could link to this site and share it with your friends. This will raise the blog's Google profile. At the moment if you go to blogsearch.google.com and type in "eczema blog," Google returns a lot of pretty useless sites. (Mind you, Priya Mulji's blog ranks highly--she sometimes has a good personal take on eczema, although not from a scientific angle.) To attract the attention of potential donors, I want to get this site ranked higher. I'm not asking YOU for money, unless you can write a check for $100,000. I just want to reach blue-blood philanthropists affected by eczema who may not realize they could make a difference.

About Aveeno's new "Eczema Therapy" product line, now touted on their Facebook page-- writing about it yesterday, I wondered what it was about colloidal oatmeal that makes it such a fantastic ingredient in these various powders, bars, lotions, etc. that Aveeno manufactures. I wrote to Peter Lio, MD, an associate professor of dermatology and pediatrics at Northwestern University. Lio gave a presentation at this summer's NEA Patient Conference in Chicago, and covered skin pH, cleansers, and moisturizing, so I figured he'd have an answer. And he did. Let me quote his email, since it is so readable and packed with information:

About the Eczema Therapy line:

They've actually been out for a few years, initially as Aveeno Eczema Care, then the FDA slapped their wrists for putting a disease name on a product without evidence to back it up... so they had to pull it and it was then called Aveeno Advanced Care... and now they've finally got it back up with some data, calling it Eczema Therapy.

On oatmeal:

Oatmeal is pretty interesting and does seem to have some specific anti-itch and anti-inflammatory properties of its own. "Avenanthramides" are thought to be the "active ingredient" in them (but it is probably a whole lot more complex, as with many plant products).

Aventhramides, he says, act to reduce cellular levels of NF-KB, a molecule that triggers protein production in the immune response-- so they could reduce inflammation in this way. From what I know, NF-KB seems to be involved in a lot of processes, so there must be more going on, and Lio elaborates:

Cells treated with avenanthramides showed a significant inhibition of tumor necrosis factor-alpha, a powerful inflammatory cytokine. They have also found direct anti-itch effect with these substances as well. (Reference)

He thinks Aveeno may be going too far, chasing novelty for marketing purposes: 

[The] Aveeno line...is such a complex lineup of products and they keep moving things around and changing things!  If I tell a patient about an Aveeno product, they go to CVS or Walgreens and find 2 shelves of different types of moisturizers... Active Naturals, Positively Radiant, Clear Complexion, Positively Ageless, Nourishing Refresher...I just wish they'd put their best foot forward and make the best one they can make. That's why I love CeraVe so much.

I agree. Less is more. Aveeno confuses me with their offerings. At least their shaving gel is back on the market, after a hiatus of frickin' MONTHS in which I had to shave using an Aveeno bar or whatever fragrance-free shave gel I could find at CVS. (Walgreens: still in the Stone Age, carries no fragrance free shave gel.)

Lio also has some interesting ideas about other natural emollients, which I'll share in a future post.

Remember the ACAAI meeting in Denver? (Peanuts in schools; anaphylactic shock via sex.) I did get in touch with Mitchell Grayson, one of the four pugilists in the Great Atopic Dermatitis Raft Debate. He was in the "eosinophil" corner, and he sent me his Powerpoint presentation. Now I know a lot more about eosinophils. And so will you, if you read my next post.

Eczema Haul!!!

An End Eczema first today: let's look at a video. As I've said before, this blog is going to be light on photos and such because eczema doesn't make the most attractive visuals. And video? Well, this one is an exception. It's kind of fun. The girl has decided to show us all the panoply or arsenal or whatever of the products that she uses daily to treat her eczema. She's titled her video "Eczema Haul!!!" --must be some new slang term I haven't heard of.

Easy to tell that she's American: well, first, her accent, but if you hadn't registered that, "I don't have insurance" is a dead giveaway. Let me be perfectly clear. I live in the U.S., but I think it's barbaric that this is the only first-world country without universal health insurance. Imagine having eczema and getting a staph infection and wondering whether you ought to go see a doctor because it might cost too much. For one thing, every infection that unnecessarily goes too far puts other people at risk of being infected.

Here's the video (she's disabled embedding).

A couple interesting points. She's obviously very keen on Aveeno. So am I. It's a great company with great products, and the Daily Moisturizing Lotion with dimethicone (a rubbery sealant) is almost the best I've found. The shaving gel is awesome, although a while back they were having manufacturing problems and you couldn't find it in stores, so I've been using some fragrance-free Edge. But you can't go completely Aveeno. I tried Aveeno shampoo and found it little better than ordinary shampoo,  leaving my scalp drier than the Mojave. Here's my secret: tar shampoo, rinse, and then, rubbed into the scalp, some jojoba oil.

Ironically, jojoba grows in the Mojave.

Toward the end she pulls out a bottle of vitamin E capsules and touts its benefits to people with skin diseases. "Vitamins are good for you, period, people." I am not so sure. I confess to taking a daily multivitamin (mostly for the potassium-- I get muscle cramps sometimes), but all that I read about eczema tells me that the way to a happier you is to avoid problem foods rather than take any miracle nostrums.

To quote an impeccable authority, Wikipedia:

The consensus in the medical community is that there is no good evidence to support health benefits from vitamin E supplementation, yet there is strong evidence that taking more than 400 IU of vitamin E per day for extended periods increases the risk of death.

I like to avoid death, myself. It's something that, according to the prophet Mohammed, even black cumin can't cure.

Something I forgot to relate after my trip east to the science writers' conference this past weekend: there is a new book just out on MRSA. Superbug: The Fatal Menace of MRSA. (The author, Maryn McKenna, was on a panel discussing how to publish a popular science book.) I'm not saying you should read it--even the website gives me the willies--but it sure looks like the comprehensive resource on the emergence of this medical hazard that is of concern to everyone with eczema. Perhaps Dr. Sib can give us her perspective on MRSA, what it's like to deal with it in the hospital.