A tale of two itches

As SK is cavorting across the continent, I will take the opportunity to introduce myself as a guest blogger on End Eczema. You can call me Dr Sib.

As mentioned in previous posts, I share in approximately half of SK's genetic pool, being his sister. Unfortunately for me, our genetic overlap appears to include a faulty filaggrin gene that has been the root cause of much unhappy scratching by us both. And, while I've certainly spent my fair share of time shredding my own skin with my 10 digits, I have to confess that this particular organ is fairly intact at the moment, my atopy manifesting itself more at the asthma end of the allergy spectrum.

I attribute this happy state of affairs, based on a sample size of 1 (myself), in part to my geographic locale. My eczema has never been as flared as it was for the 12 months I spent on Vancouver Island on Canada's western coast. There, I spent the entire time bleeding into my sheets at night, tossing and turning with the torment, and avoiding showers because the chlorine in the water burned too much to bear on a daily basis. No dietary measure had any effect. Nor did the usual routine of steroids and emollients that I had come to rely on in the past.

Musing back, I realize (quite ironically for reasons that will become clear in a moment) that I never consulted a physician during this time, nor did it even occur to me to do so. Essentially, anything I had learned about managing my eczema up to this point had been from personal experience and the advice of fellow sufferers. It was well known amongst this same cohort, that our family doctors had proven to be pretty useless when it came to treating our dysfunctional skin. At the same time, I had never been referred to a dermatologist, so I assumed I was stuck with things as they were, bad as they were.

Now, as a first year resident in family medicine, what do I do with this memory? I admit I do feel it reveals a certain incompetence on the part of the family doctors I've had in the past in managing atopic dermatitis. The time I've spent with dermatologists thus far in my training has suggested that family doctors have a tendency to be far too cautious when it comes to the use of topical steroids, particularly in children and adolescents. I seek to rectify the problem in myself by taking a special interest in the dermatological complaints of my patients. And, I hope I have a well-developed capacity to empathize fully with the impact a symptom as 'harmless' as ITCH can have on an individual's life. Finally, I feel the drive to be competent in diagnosing, counseling, and managing this problem in my own patients. For me, this will mean an extra rotation in dermatology during my residency training.

My story brightened when I moved back east, first to central Canada (Ontario), and then to the Maritimes. My skin healed of its own accord. While I used to attribute my temporary misery to some quality of the water to which I was exposed, I've come around to assuming there must have been an environmental allergen triggering me, be it mould in the basement apartment I was inhabiting, or some type of noxious pollen circulating in the botanical breezes of the west coast. Either way, I'm left a number of habits/superstitions that I use to ward off a recurrence: I never miss a full-body moisturizing after a shower/bath. I don't expose my skin to long, hot soaks. And, I'm aware that every coffee, every alcoholic beverage, and every spicy meal exacts a toll that may tip me over the edge into a flare.

A shared resource for immunotherapy

I'm off tomorrow to New Haven for the annual meeting of the National Association of Science Writers. A junket that will see me absent at the kids' bedtime not once, but twice, as Hidden B pointed out, using this as a cudgel to get me to change a particularly stinky diaper. So the blog will resume on Monday.

I'm pressed for time tonight, too. Have to go get some cash, pick up an organics CSA box that is contending for the status of all-time most inconvenient birthday present, make dinner, and pack. Flying into the fair city of Hartford, departing Oakland at 07:35. You may recall an earlier post in which I awarded a Mark Twain Steel Trap Award to the gentlemen responsible for the FAA's no-moisturizer-in-carryons law. Messrs. Ali, Sarwar, et al. were on my mind the other day as I purchased a small, but filthy expensive, tube of Eucerin that will see me through the next two-and-a-half days.

The eczema news of the day is a little tangential. A few posts ago, I wrote about sublingual immunotherapy. The idea in this technique is that if your eczema arises predominantly from an allergy to one thing, you try to induce your immune system to become tolerant to that thing, thereby reducing your eczema symptoms. In the past, immunotherapy doctors have injected allergens. Now, for the wimpy, there is the (slightly less effective) droplet-under-the-tongue, or "sublingual," technique. The doctor gives you a small bottle of drops and you take one or a few a day; the allergens get taken up by dendritic cells in your mucosal linings, and presented to T cells, and thus (the hope is), your body learns that the allergen is no big deal and shouldn't induce an eczema reaction.

For scientists in the realm of immunotherapy research--the study of techniques to induce tolerance in autoimmune and allergic diseases--there is now a new resource at the University of California, San Francisco. UCSF's BioShare, a bank of over 100,000 specimens from a ten-year federal project to catalog biomarkers of various diseases, is now offering its samples openly to qualified researchers. The samples were taken from patients with thoroughly diagnosed conditions, at well-defined points in the progression of the diseases. So now you can analyze the samples to see how much of this or that protein or hormone or whatever the body is producing at each point-- and how the body alters its output when immunotherapy is given. It's a way to measure whether the immunotherapy is working or not.

Have a good weekend.

Boring yourself to sleep may be the best tactic

Yesterday I wrote about discovering by happy luck an editorial by Jon Hanifin on the topic of sleep and itch. Hanifin's an eminent dermatologist at Oregon Health Sciences University in Portland and the author of, among gazillions of papers I'm sure, "A Population-Based Survey of Eczema Prevalence in the United States." This is one of very few major surveys to explore how many people have eczema in this country.

The problem: the study appears in Dermatitis, a journal that my institution doesn't subscribe to. I wrote to Hanifin to ask whether he could send me a copy of the paper, and he very graciously agreed; so now I have that valuable source of data to explore.

Eczema is no rare disease. It affects a lot of people in the U.S., and by extension, worldwide. I'm interested in the U.S. because I live here and because I have some understanding of how science funding works. We might be able to increase funding for eczema research--and, in particular, "translational medicine" leading to a cure--by applying pressure on Congress. Although there's not much evidence that Congress makes decisions based on facts, it won't hurt us to quote some facts when we write our representatives.

Hanifin's editorial led an issue of the journal Sleep Medicine Reviews, and introduced two papers in the issue devoted to the topic of sleep and itch. I read the first of the two papers. According to the authors, eczema is one of several skin diseases for which itch and sleep disturbance is a problem. But there's not much research out there on how to manage sleep problems for patients with eczema. I didn't get too much out of the paper, to be honest. Here's what I learned:

• The itch of eczema causes sleep disturbance that has effects similar to insomnia; but the eczema is the cause, and if you can manage your eczema, the itch will recede, and your sleep will improve, which will improve your skin in a positive feedback cycle.
• Doctors prescribe antihistamines for eczema patients almost solely based on the drowsiness they induce. But the authors say there is no study that uses sleep as an objective measure and shows that antihistamines improve sleep.
• The only sedative that patients reported to improve sleep was nitrazepam (not an antihistamine). However, nitrazepam also induces amnesia, so it's possible the patients just forgot they had a terrible night's sleep.

Not particularly encouraging, hey? In theory, the authors say, doctors should prescribe "hypnotic" drugs like Ambien for short periods only, so that patients can get a few good nights' sleep and break the itch/wake cycle. I've tried Ambien myself, during a period of insomnia a few years back. It didn't knock me out, it just turned me into a zombie the next day. I'd recommend reading something boring-- for me, John McPhee's recent New Yorker article about golf would do the trick.

Good night, sweet prince

You may have noticed there's some sort of election going on. I am doing my best to ignore it-- having, though, voted this morning-- because it'll only increase my stress level. I don't know exactly why, but politics is one of those things that triggers instant stress. Whichever side you're on. I'm on one side, and the things that get said by the extreme members of the other side seem so ridiculous you'd laugh them off, if these people hadn't shown themselves capable in the past of doing what they propose.

So, please, let me not look at the electoral results until tomorrow morning. Then the night won't be so bad.

If you're like me-- that is, you have eczema-- you wake up some morning wondering what the hell happened while you were asleep. The skin on your hands, or your scalp, will be torn, and your sheets will be speckled with blood. Because of what you ate the day before, or because you're stressed about exams, or a relationship, or modern life, your body decided to have a scratching fit while on autopilot.

This behavior is well-documented in sleep and itch research. By chance today I came across an editorial written on the topic by Robert Sack and Jon Hanifin at Oregon Health and Sciences University. I think the piece might become open-access at some point. The neat thing-- two review papers in the journal issue cover the topic of skin disorders and sleep problems. I can't wait to read them. It's twisted, but I get off on learning that researchers are out there studying stuff that has happened to me personally.

For one: the itch of eczema--rather, the scratching--has, at times, severely affected my sleep. There have been periods when I have to have a good scratch before I can get to sleep, and then once I'm asleep, I partially wake up some time later, scratching the hell out of some body part, dreaming that by doing so I'm solving a vital problem. I used to do this a lot in college and grad school while I was taking physics or math courses. At the end of the night, you may have spent eight hours in bed, but only five of them in anything resembling restful sleep.

One of the reviews in this journal discusses how night-time scratching might, in kids, lead to ADHD.

The editorial also drops two nuggets of information. One: that it's well-known that at night, the blood vessels in your skin dilate (get bigger) in order to radiate more heat away, so you can lower your core body temperature. As I mentioned in my previous post, I find that alcohol, hot peppers, and exercise, all of which dilate your blood vessels, cause me to itch. So, every night, my body may be doing the same thing to itself.

Two: that although doctors regularly prescribe antihistamines for kids and adults with eczema, possibly in the hope that they'll reduce histamine levels and inflammation, there's no evidence that antihistamines reduce itch. They do, however, make you feel a bit drowsy, so they might help you go to sleep. I've found antihistamines to be of no use for anything, myself.

I'll read those reviews and see what I can learn. I'll be interested particularly in what Gil Yosipovitch at Wake Forest University is doing-- I read something in the NY Times a couple years ago about his International Forum for the Study of Itch, and they had some videos showing sleeping people scratching themselves silly. The reader was supposed to be aghast, but I just thought: "That could be me on camera!"

Mr. Peanut need not apply

Eczema Mom recently posted about her experience being on a plane with her kid, who's been diagnosed with severe peanut allergy-- some guy opened a bag of peanuts in the row ahead of them, and the smell drifted back, and she could do nothing but wait and see whether her kid would have a reaction. (On a plane! What are you going to do if he DOES have a reaction?)

Peanuts-- I love to eat peanut butter, and Snickers, but I'm learning that a lot of people have severe allergies to them. In fact, Voov was diagnosed with a peanut reaction on her skin prick test-- Hidden B will know all the details. Hidden B is breastfeeding Voov (who's been on solid food for a while now, being 18 months old) and has had to avoid peanut butter herself. I get in trouble for eating the sunflower and almond butter-- which somehow seem more exotic and tasty than my peanut butter.

Peanuts are in the news at the moment. There's a study out in the Journal of Allergy and Clinical Immunology by a group at the Mount Sinai School of Medicine in NYC, indicating that pregnant women ought not to eat peanuts if they can help it. The specifics-- seems only to apply to kids who are suspected of being allergic to milk or eggs, or have eczema and allergies to milk or eggs. (An odd study group, that-- but I can't see the details because my institution doesn't have access to the paper itself.)

Kids with eczema really have it tough-- the itch, the rash, the food reactions, and then they're at higher risk of developing a life-threatening peanut allergy. Life's a bitch.

I had a short email today from a reader, Jon, letting me know that his partner, who's had eczema for a long time, had recently seen a dramatic improvement after cutting out dairy products. That's awesome and I encourage anyone who has eczema and who has never tried an elimination diet to do the same thing. Cut out, one at a time and for two weeks or more, milk, soy, peanuts, wheat, and eggs. (And fish, if you eat it regularly-- Hidden B hates fish, so I never cook it.)

Here's my personal take: I draw a distinction between food ALLERGIES and food (or drink) that causes REACTIONS. I might have a food allergy; I don't know for sure. But I do know I have reactions to alcohol and hot peppers, which both dilate the blood vessels in the skin. I get itchy after drinking booze or eating a hot curry in the same way I do after I exercise. I'm guessing the heat or blood flow somehow stimulates itch nerve fibers. And then, I also have reactions (oh, so vicious) to aged cheese like real Parmesan, and to preserved foods that are high in histamine. These just have to be triggering inflammation systemically.

Does this mean I never have a drink, or enjoy a fine double Gloucester? Hell no. You have to live. But I often regret it the day afterward.