Managing eczema on your scalp

Scalp eczema doesn’t get much press, but a lot of us live with the problem every day. Me, for example: I own virtually no dark-colored tops, because a snow of skin flakes shows up within seconds. I comb my hair, or what’s left of it (hey, I’m a 40-year-old man) not to straighten tangles, but to clear up any rogue scabs. And I’ve had to develop my own regimen for scalp care because nobody ever handed me a pamphlet.

Eczema on your scalp is the same as it is everywhere else, except for two complications.

1. most people have hair on their heads, which makes it difficult and unsightly to apply thick creams and ointments
2. it’s right out in the open where everyone can see. You can hide it only with long hair, and long hair makes it difficult to treat the scalp.

So how should we treat it? Pretty much as we do “normal” eczema. You have to clear up infection with antiseptics; reduce the inflammation; and moisturize as much as possible. And any concerns about how your hair looks are secondary. You’re not Fabio or Catherine Zeta-Jones, so get over it.

I keep my hair very short. I use a #2 buzzer on my head. I can get away with this because I’m a man in a job where hairstyle doesn’t matter. The #2 keeps my hair short enough that I can apply steroid creams or ointments but long enough that other people can’t see my sores or scabs easily.

Steroid ointments (say, fluocinonide 0.05%, my “strong” option) come with warnings about folliculitis. You’d think this would be a problem on the scalp, but I haven’t found it to be. I try to use it sparingly, though.

Many shampoos and conditioners brag about their moisturizing properties, but they refer to what they do for your hair, not your scalp. In my experience, both shampoos and conditioners have detergents that dry out my scalp to a painful degree, and fragrances that irritate it. What to do?

Go fragrance-free, for a start. Or as fragrance-free as you can; medicated shampoos seem all to come with masking fragrances to hide their smell. Options that I’m aware of are coal tar (say, T-Gel, Zetar, Polytar); zinc pyrithione (e.g. Head and Shoulders, Selsun Blue); and iodine (Betadine). I spent several years in the UK where Betadine is available as a shampoo. I haven’t seen it as a shampoo in North America, but Hidden B, who’s a veterinarian, has a bottle of it that she uses on dogs.

Let’s tackle these one at a time, and ignore any qualms about weird smells.

Zinc pyrithione (http://en.wikipedia.org/wiki/Zinc_pyrithione) is an antimicrobial that kills bacteria and fungi. It doesn’t work for me. This is probably because my primary problem is in the skin barrier, not a secondary infection. I may also have infections that it does or doesn’t clear up.

I remember Betadine being relatively pleasant, and leaving terrible brown stains on everything. I think it worked well because it didn’t have a very strong detergent component, and was much more a medical than a cosmetic product. I’m all in favor of this. Hey, maybe I should borrow some from Hidden B. Again, the active ingredient in Betadine is iodine, because it’s a broad-spectrum antimicrobial.

Coal tar works for me, but only in the strongest formulation. I use T-Gel Extra Strength and Polytar. In the past these have been difficult to find where I live in California, and I have bought them online from a Canadian source, but recently I’ve seen tar shampoos on the shelf in pharmacies here.

Coal tar’s a bit of an oddity. It is not a pure substance that can be easily quantified. It is a mixture of apparently up to 20,000 organic compounds, and it’s a traditional treatment for scaling skin diseases that reduces inflammation and itch and kills microbes. Which of the 20,000 compounds are doing what is anyone’s guess, and there have occasionally been claims that coal tar causes cancer. I don’t take these seriously because there has never been a conclusive study and if there were a large risk we’d know about it by now. (See a recent study here.) I think that it matters very much which brand of coal tar you use, because different brands are probably from different sources and contain different stuff.

What I DO take seriously is the increased sensitivity to UV that comes with using tar shampoo. The days I use it, I often find I get lightly sunburned on my face. Sunburn = cancer risk. So if I were going to spend a day outside, I’d be careful not to use tar shampoo that morning.

The more I learn about eczema, though, the more I understand that we might not want to use a strong antiseptic on our head too much. We probably have a flora of beneficial bacteria and fungi living on our scalps, and we ought to keep them healthy while killing off the S. aureus etc. that cause us so much grief.

Lastly, for moisturizing: every morning, and after I shower (which I do not do every day), I rub jojoba oil into my scalp. Jojoba’s a very light oil, and it doesn’t make my head too greasy. I think grapeseed or walnut oil would also do the job, but olive oil would be too heavy. Sometimes, when I have really dry skin, I have resorted to rubbing Eucerin into my scalp, but this is a bit gross.

What are your solutions to cooling itch and moisturizing on your scalp? I’d be interested to hear them.

Gil Yosipovitch on alternative therapies for itch

The basic problem with treating chronic itch is that there is no cure for most conditions, including eczema. But several approaches reduce the severity by a significant amount. Some of these approaches are “Western” medicine, which I take to mean they are based on refined drugs manufactured by a pharma company. Some are “alternative,” which includes acupuncture, probiotics, “Chinese medicine” (that is, herbs that probably contain active ingredients that have not been isolated and refined into “Western” drugs), and others. Gil Yosipovitch, a world expert on itch, combines both in his approach, without overt prejudice--as long as the alternative component is not patently ridiculous.

Psychology plays a large part in Y’s method. “There are a lot of issues involved in the suffering that are beyond dermatology,” he says. “We use a lot of meds that come from psychology.”

He works with an acupuncturist. He collaborates with a practitioner of healing touch.

Here’s an aside: my own mother practices healing touch, and in past years I have mocked her for it, because there is no way that waving your hands over someone’s body is going to cause physiological changes through the medium of some imaginary “energy field” that has no connection with the laws of physics. But here’s the rub: if the patient believes there is such a connection, then I acknowledge that it is possible that undergoing healing touch could relax the patient and, via psychological paths, relieve itch or pain. Won’t work for me, though; I don’t believe in it!

“I’m a physician--I’m OK with the placebo effect,” Y says. Y doesn’t care, as long as the patient feels better. He found out that his acupuncturist has expertise in itch, and his patients who undergo acupuncture see their symptoms relieved by 20-30%. That’s better than he sees with most drugs. “Why should I prescribe drugs with side effects?” he asks. “We don’t know everything.” One of his patients was taking “enough meds for an elephant,” but they didn’t do much, and it was healing touch that appeared to improve his condition.

This holds, he says, only for chronic itch. Acute itch, that is caused by something like poison ivy or insect bite, likely has a well-defined treatment. And in any case, why worry about acute itch? It will go away. (That’s my opinion, not his.)

Probiotics: he’s not super-keen on them, but he sees a lot of people asking about them. “We have to address the issue,” he says. Again, if it works, it works, so why not try eating yogurt if it seems like a good idea.

But sometimes he sees ads for less legitimate treatments such as garlic pills or suppositories. “That’s not what I want my patients to try,” he says.

I’m confused. It seems hard to draw any sort of boundary between valid and invalid therapies, if you’re OK with healing touch. Perhaps with healing touch, or yoga, if you are “treated” or practice it regularly, there is a rhythmic relaxation effect, whereas garlic pills or their ilk are unlikely to produce anything but a weak, transitory placebo effect. However, Y knows what he sees, and he sees that healing touch has a practical, beneficial outcome.

Also, it could be that genuine caring human contact reduces anxiety. A theory occurs to me: maybe the apparent increase in incidence of eczema in developed countries is partly related to social alienation in modern life. We spend so much time dealing with machines instead of people, and so much time with strangers instead of friends and family. Can we improve our eczema symptoms by spending more time with family?

I doubt it, unfortunately. Ask any mother of a young child with eczema. It’s not that the mother doesn’t care, or isn’t doing her best to try to calm her child.

In this blog I intend mostly to pursue Western therapy as a means of treating eczema or relieving itch. I’m open-minded, though, and I hope not to bad-mouth any therapies without good reason. So, within reason, I’ll try anything myself and see if it works. That includes vitamin D. In the near future I will try a course of 4000 IU vitamin D per day, and we’ll see what happens.

With itch medicine, Y says, “large studies are a problem” because itch has so many potential causes and pathways that it’s hard to find a large identical test population. “You can’t give just one antibody for itch. That’s a simplistic approach.” And so personalized medicine, a customized approach for each of us, is our future. The responsibility lies with us. But we already knew that.

Thinking about a comeback

Hey all.

I have been thinking about returning to this blog--I miss keeping up with the latest research, and sharing ideas with people.

But as you might have read below, I am struggling with some neck and back trouble probably caused by computer use or poor ergonomics. My job involves sitting in front of a computer, and it doesn't feel good toward the end of the day, and I sure don't feel like aggravating it with more computer time after I get home and help feed the kids and put them to bed and do my prescribed physiotherapy. Plus I don't have much spare time anyway.

So bear with me--maybe I can write shorter posts during the odd lunch time; maybe I can do some video posts.

At least I feel like I owe you the second half of my interview with Gil Yosipovitch.

One new thing for now: did anyone notice this link, part of the NIH's campaign for public accountability? It's a list of all the NIH's research expenditures--I think their annual budget is $20 billion, but I haven't taken the time to add up the totals. The list shows money spent per disease, and there are a lot of diseases in the list. But there's one that seems to be missing: eczema. Is it really not there? Not under atopic dermatitis or some other name? Apparently not. Maybe it comes under psoriasis? Does anybody know?

Surely they can't not be funding eczema research. (I KNOW they are at least funding Donald Leung's multisite project.)

Yosipovitch on itch clinics

Last Thursday I spoke to Gil Yosipovitch, an eminent dermatologist and itch expert at Wake Forest University. I called him because Martin Steinhoff said Yosipovitch ran the only itch clinic in the United States, and I wanted to learn how such a clinic operates.

The only problem: Yosipovitch does not run an itch clinic. There are NO itch clinics in the United States. "I very much believe it's the future and there should be many of them," he says. He's happy that Steinhoff is establishing one. The centers in Germany are the model; apparently a colleague is also starting one in Singapore.

Y believes there are a couple barriers to itch clinics getting started in the US. The major one is insurance companies and the current system for reimbursement; doctors have much more incentive to do basic treatment like wart removal than they do to care for patients with chronic conditions who require regular monitoring. Also, he says, to establish a clinic, a department chair (at a hospital or university) has to put money into it. That means leadership, and no-one except for Steinhoff has shown that leadership.

Y says that he likes Steinhoff's plan of directing a clinic with a number of resident doctors and a nurse practitioner who keeps in touch with patients through an online forum. In fact, Y himself once ran such a forum, called "Living with Itch" (if I understand correctly, it got folded into the International Forum for the Study of Itch website, but I can't find a link to old postings). The problem was that the site, on which patients shared their "anguish, frustration, and practical ideas," was quickly "hacked," in Y's words--possibly not hacked, but overwhelmed with spam from quacks advertising miracle cures like some garlic diet. So the forum became useless and was abandoned. Y thinks an online patient forum could work if someone was dedicated to the web technology side, and ensuring that only authorized patients could use it. (Also, there are "HIPAA," or medical privacy, issues, he says; presumably his former site managed to solve them.)

A point Y insisted on making was that itch should be treated as a disease, not a symptom. It's a major issue. He sees many parallels between itch and pain; itch is now where chronic pain was thirty years ago.

Y also thinks that eczema patients should look to psoriasis as a disease whose patients have been successful in setting up support groups and activism for funding. "But [itch clinics] needsencouragement from the upper levels," he says, meaning the NIH and legislators who have the power to make insurance companies change the incentive model.

Y is a fan of the National Eczema Association. "They're providing a lot of support to atopics," he says. He was able to leverage a small NEA grant into a large NIH one (that's how science funding works--a granting agency will only give you money if someone else has already given you money). I suppose I should be happy that he likes the NEA. He said he only decided to talk to me because I was raising money for them.

In my next post I'll talk about Y's position on alternative medicine. My next post, by the way, may be my last for some time. I need to resolve this trouble I've been having with my neck, and the less time I spend at a computer the better, for the moment.

Up next, Gil Yosipovitch

Today I spoke with Gil Yosipovitch on the phone--he was at his home in North Carolina. It was a good conversation and I learned quite a bit that I will share with you in the near future. I'll be considering it in two parts: one about traditional Western medicine and one about Gil's opinion of alternative methods, which might surprise you. He is concerned that I not misrepresent his views on that subject so I'll be running his quotes by him first.

I wish I could write more today but recently I have been short of time. (My physiotherapist has given me home exercises to do that take the time I'd set aside for blogging.) Best regards to all.