Dr. Sib mentions something interesting in her first post. Although she is now a doctor, when she first developed eczema around the age of 19 she waited a long time to consult a doctor. (Who then confirmed her doubts about the medical profession by prescribing an antifungal cream.)
She isn't alone in this. Many people suffer from eczema without ever having it diagnosed by a doctor. In Jon Hanifin and colleagues' 2007 survey of eczema prevalence in the U.S., the authors estimate that there are 31.6 million people in the United States with some form of eczema. How did they know these people had eczema? They surveyed 116,202 people and extrapolated to the entire population; they asked, first, whether each subject had experienced symptoms that would add up to eczema; and then, whether the subject had been diagnosed with eczema by a doctor. Of the group designated as "symptomatic," i.e. suffering from eczema, only 37.1% had been officially diagnosed.
So there could be as many as 20 million people in the U.S. who have eczema and don't even know they could try to relieve it with steroids, emollients, restricted diet, or whatever therapy you might choose. Instead, they're doing nothing, or treating it as ringworm.
Let me take this opportunity to applaud, first, the NIH's PubMed catalog of medical papers, and second, open-access scientific publishing. In the U.S., the vast majority of science research is paid for by taxpayers via the NIH. And yet, the best papers end up in Science or Nature or Cell, or other journals that you have to pay to read. (Actually, Science makes papers open-access after one year.) In my day job, I have access to a lot of journals, but as soon as I come home, I'm locked out of almost the entire scientific literature. At least PubMed is free, so I can search for papers and see what has been published (you can often write to authors and they'll send you copies, as Jon Hanifin did for me); and there is a family of quite highly ranked open-access journals called Public Library of Science (PLoS). Check 'em out. It's all free! The problem is that I haven't yet found any interesting eczema research in PLoS Medicine. We should ask prominent researchers to publish their work in the PLoS family of journals. If we funded them, they're morally obliged to try!
Tuesday, November 9, 2010
Monday, November 8, 2010
Maybe your kid CAN eat more foods
I'm back from my weekend trip to New Haven for the science writers' conference. A smashing idea, getting about 500 of us in the same place and giving us drink tickets. The hubbub of eager networking (freelance writers have to network nonstop if they want to eat) at times almost drowned out the science-themed standup comedians and a cappella groups.
My trip was a success not only professionally, but because twice in the space of two days I got up at 4:30 am, endured the stress of making a flight, sat for 7 hours in the dry, recirculated, funky air of a Boeing 737, ate at McDonald's (Hartford airport is no food paradise), and downed my share of beer and wine-- and here I am at the end of it with dry skin, yes, but no eczema to speak of. Score!
I'm going to continue the food allergy thread today. There's a recent study out of National Jewish Health Center in Denver that found that many children with eczema are unnecessarily leaving foods out of their diets, for fear of food allergies that don't exist. The main issue the authors are making is that the proof of most food allergies is in the eating. Blood test results for IgE allergies are not believable unless they show you are positive for cow's milk, hen egg, fish, peanut, or tree nuts.
If a test shows your kid IS allergic to one of those five things, you definitely shouldn't eat it. But David Fleischer and colleagues (including Donald Leung, leader of the Atopic Dermatitis Research Network, who appears to be the heavyweight author) took 125 children who had been on restrictive diets based on IgE tests, and, in a controlled fashion, let the kids eat food that they had previously avoided. The result: "Depending on the reason for food avoidance, 84 to 93 percent of foods being avoided were restored to their diets."
This matters because your young child needs a balanced diet to develop properly, and also because substitute foods (goat milk, almond butter) are expensive.
I find the study personally interesting because Voov (18 month daughter) has been on an extremely restricted diet for many months. Skin prick tests showed allergies to a number of things and the allergist recommended, at first, some ridiculous diet--seriously, like "she can only eat sweet potato, broccoli, and chicken." Completely unreasonable, and after Hidden B protested, and we got advice from a nutritionist, the allergist relented a bit and permitted these items:
Fleischer et al. don't say whether skin prick tests are as useless as most IgE blood tests. But I sure would like to expand Voov's diet, so she can experience some new tastes. Wouldn't it be great if she could just eat the same things we do!
My trip was a success not only professionally, but because twice in the space of two days I got up at 4:30 am, endured the stress of making a flight, sat for 7 hours in the dry, recirculated, funky air of a Boeing 737, ate at McDonald's (Hartford airport is no food paradise), and downed my share of beer and wine-- and here I am at the end of it with dry skin, yes, but no eczema to speak of. Score!
I'm going to continue the food allergy thread today. There's a recent study out of National Jewish Health Center in Denver that found that many children with eczema are unnecessarily leaving foods out of their diets, for fear of food allergies that don't exist. The main issue the authors are making is that the proof of most food allergies is in the eating. Blood test results for IgE allergies are not believable unless they show you are positive for cow's milk, hen egg, fish, peanut, or tree nuts.
If a test shows your kid IS allergic to one of those five things, you definitely shouldn't eat it. But David Fleischer and colleagues (including Donald Leung, leader of the Atopic Dermatitis Research Network, who appears to be the heavyweight author) took 125 children who had been on restrictive diets based on IgE tests, and, in a controlled fashion, let the kids eat food that they had previously avoided. The result: "Depending on the reason for food avoidance, 84 to 93 percent of foods being avoided were restored to their diets."
This matters because your young child needs a balanced diet to develop properly, and also because substitute foods (goat milk, almond butter) are expensive.
I find the study personally interesting because Voov (18 month daughter) has been on an extremely restricted diet for many months. Skin prick tests showed allergies to a number of things and the allergist recommended, at first, some ridiculous diet--seriously, like "she can only eat sweet potato, broccoli, and chicken." Completely unreasonable, and after Hidden B protested, and we got advice from a nutritionist, the allergist relented a bit and permitted these items:
- zucchini
- broccoli
- asparagus
- sweet potato
- pears
- bananas
- chicken
- turkey
- rice
- soy
Fleischer et al. don't say whether skin prick tests are as useless as most IgE blood tests. But I sure would like to expand Voov's diet, so she can experience some new tastes. Wouldn't it be great if she could just eat the same things we do!
Saturday, November 6, 2010
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.
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.
Thursday, November 4, 2010
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.
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.
Wednesday, November 3, 2010
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:
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.
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.
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