Eczema is distinguished according to various subtypes. Discoid, dry and exudative eczema, pompholyx and papular eczema are common examples of the types of eczema affecting both children and adults. Eczema is also known as dermatitis. The disease can be classified according to the underlying causes of eczema.
Acquired, External Causes of Eczema
Causes of eczema from acquired sources are due to external environmental factors. For example, dry weather or low temperatures can cause the skin barrier function to worsen, such as in temperate, winter climates. In addition, using excessively astringent products, such as those containing high levels of lauryl sulfates, or other types of detergents can strip your skin barrier and cause it to become dry. This is what we call exogenous eczema, or acquired eczema.
Dr. Teo Wan Lin, dermatologist at TWL Specialist Skin & Laser Centre says “some individuals actually develop acquired eczema after allergic reactions. For example, nickel sensitization can occur throughout one’s lifetime due to exposure to costume jewelry, even if they do not have a history of nickel allergy. Most individuals develop nickel allergy in their mid life owing to chronic exposure of nickel present in costume jewelry.
This occurs most frequently in earrings as well as what is worn on the body including metal belts. That itself can constitute important causes of eczema, with a type known as allergic contact dermatitis. This is why we recommend wearing specifically medical grade surgical steel, 316L grade rather than just stainless steel, jewelry, as this eliminates the risk of nickel sensitization”.
External factors which are causes of eczema can also include cleansing methods. “Excessive handwashing, for example causes irritant contact dermatitis, a type of eczema that is caused by excessive irritation off the skin barrier causing it to lose its natural moisturizing properties as a result as increased water loss due to the environment, a phenomenon known as transepidermal water loss.”
Is My Eczema Genetic?
According to accredited Singapore dermatologist Dr. Teo Wan Lin, “Dermatologists generally regard eczema-prone individuals as having a certain genetic tendency to develop skin barrier dysfunction. In fact, there is a very specific sign that dermatologists look out for to determine if the causes of eczema are indeed genetic. Genetic testing is usually not performed outside of clinical studies for the treatment and diagnosis of eczema. The important sign of a genetic cause of eczema is known as Ichthyosis Vulgaris.”
Ichthyosis Vulgaris is a genetic type of eczema that one can detect from early childhood. It is a form of eczema or atopic dermatitis that presents itself as fish-scale like skin, commonly found over the front part of the lower legs.
If you have noticed that on your skin, you are at high risk of developing moderate to severe eczema. Another form of eczema, known as asteatotic eczema or “eczema cracquele” can look similar, and both reflect moderate to severe disease which requires treatment by a dermatologist.
Ichthyosis Vulgaris is a genetic condition caused by a deficiency in a gene known as filaggrin, which results in faulty production of ceramide. Ceramide is a fat molecule that joins skin cells together. It is essential for healthy skin barrier functioning. The stratum corneum is best envisioned as a brick and mortar model, where the skin consists of skin cells joined together by mortar.
Why ceramide-containing moisturisers are important for eczema treatment
Ceramide is produced by the body to protect itself against the external environment. This can be due to triggers such as pollen, dust, environmental pollutants. It can also be caused by contact with harsh soaps or astringents. The latter is part of common causes of eczema that results in irritant contact dermatitis.
How to know if you are prone to genetic causes of eczema
If you have a history of sensitive nose or airways which are respectively known as allergic rhinitis and asthma, then you may be at risk of developing atopic dermatitis.
This is a form of eczema that presents as a dry itchy skin condition affecting any part of the body. However, they can localise to areas prone to friction, such as the neck (collar area), underarms, elbows and knees, as well as under the breast in women. For these types of eczema, switching to a friction-free garment can help, on top of medical therapy that includes Ceramide-dominant moisturisers and prescription steroids. Prescription creams will be discussed with your dermatologist and adjusted according to the dose, strength and frequency of application.
What if I have the dry skin symptoms?
Theform of eczema known as Ichthyosis Vulgaris is significant because it is considered a marker for more severe eczema. If you have observed your skin having these symptoms from childhood, it’s very likely you have inherited it as a form of genetic dry skin.
“Ichthyosis Vulgaris is transmitted through generations. Have a look if your parents or siblings also have the same fish-scale like skin on their legs. While one may not always develop itchy, dry skin symptoms in childhood, with age, eczema symptoms may start manifesting,” says Dr. Teo.
Treatment of Genetic Eczema in Singapore
Now what to do if you have Ichthyosis Vulgaris?
Firstly, if you currently do not have symptoms, it is wise to invest in a moisturizer that is formulated as a prescription emollient device (PED).
“The PED type of moisturiser is actually the gold standard for eczema moisturizer therapy currently. It contains the ideal lipid ratio that mimics the skin’s natural composition of ceramides. Such a moisturiser formula also contains potent antioxidants that are formulated to reduce reliance on topical steroids. This is because it helps to reduce skin inflammation. Usually when the barrier is deficient, external allergens can trigger off an inflammatory cycle and this is when the skin starts getting red, itchy and may even develop pus and infection,” says Singapore dermatologist Dr. Teo Wan Lin.
Dermatologist Recommended Eczema Moisturisers
An example of an excellent ceramide-dominant PED formula moisturiser is the Multi-CERAM cream by Dr.TWL Dermaceuticals, formulated for treatment and prevention of eczema. For those with genetic causes of eczema, this moisturiser is both comfortable, safe and effective to treat and prevent flare-ups. Use of this moisturiser can also improve the appearance of skin, especially if you don’t suffer from other symptoms such as flaking, redness or itching, this moisturiser alone is sufficient.
The moisturiser has been formulated to mimic the skin’s natural barrier and also be fully absorbed without leaving a sticky feeling on skin. In addition, it can also help to reduce skin inflammation and treat the underlying causes of eczema because it contains potent botanicals that have additional anti-inflammatory properties.
Sudden appearance of Eczema on legs
Now if you have suddenly developed Ichthyosis Vulgarisas an adult, it is important that you visit an accredited dermatologist. The reason is because, in a small subset of cases that develop in adulthood is actually related to underlying malignancies, which can be dangerous if left undetected. This form of Ichthyosis Vulgarisis known as secondary Ichthyosis Vulgaris.
You may consult Dr Teo Wan Lin, accredited dermatologist of TWL Specialist Skin & Laser Center in Singapore where telemedicine consultations are offered for conditions such as acne, eczema , as well as other forms of facial skin conditions and body rashes. For more skincare tips, you may listen to her podcast Dermatologist Talks: Science of Beauty.
Slugging is a term coined by K beauty and recently popularized on the social media platform Tiktok. This skincare trend refers to the process of sealing your skin with an occlusive agent – Vaseline, white soft paraffin, or petrolatum. It is touted to keep your skin moisturized and prevent transepidermal water loss.
While this technique has been recently popularized again, dermatologists have been recommending this as the last step in the treatment of severe eczema, sealing in moisturizer and helping to trap in moisture. However, this is not commonly recommended for the facial skin, especially in humid climates like Singapore. Because, the face is usually greasier due to the distribution of oil glands. Applying an occlusive substance like Vaseline if you produce quite a bit of oil or if you have acne, is not a good idea.
The science behind slugging
Petrolatum, the ingredient found in Vaseline, Aquaphor and other topical creams, acts as an occlusive and a skin protectant – which means it prevents transepidermal water loss or evaporation of moisture from the skin.
“The trend of skincare slugging is essentially borne out of moisturising in layers. For example, what dermatologists usually recommend for individuals who suffer from severe body eczema is applying first a ceramide dominant moisturiser, one that is formulated correctly with the lipid ratio, then as a final layer, petroleum jelly. This is to increase the occlusive effect on the skin’s microenvironment and this can actually help to maintain moisture in the topmost layer of the skin.
The Multi-CERAM Cream is a new generation “Smart Moisturiser” formulated as a Prescription Emollient Device. It is formulated with an optimal skin lipid mixture, containing a mixture of plant-derived phytoceramides and synthetic ceramide. Antioxidants that fight skin inflammation are incorporated for optimal treatment of eczema.
However, slugging should be applied with other moisturizers for the best effects. The use of ceramides in moisturisers is crucial in preventing and repairing skin barrier dysfunction. When paired with the process of slugging, it can help to increase absorption of the moisturizer and speed up healing of the skin barrier,” accredited dermatologist, Dr. Teo Wan Lin.
Eczema and dry skin
Eczema is primarily due to a defect in the skin barrier and quite frequently presents as itchy and dry skin. The condition is genetically determined and can be made worse by skin irritants, allergies, environment and stress. In my practice, only ceramide-based moisturisers which focus on restoring the skin barrier are prescribed. Ceramides are lipids that occur naturally on the epidermis and are integral to locking in moisture to the skin and regulating healthy skin barrier function.
In layman terms, you may think of the skin as a protective brick wall, and ceramide being the cement that holds the bricks together and prevents water from seeping through, in order to perform an effective barrier function. Intensive moisturising with ceramide is often recommended through the course of an eczema treatment so as to restore healthy barrier function to the skin. In cases of more severe eczema, wet-wrap therapy, which enhances absorption of topical medications by the skin, may be employed over the topicals and moisturiser applied on to the skin as part of treatment.
Slugging is often recommended as the last step in order to seal in ceramide-based moisturizers for increased absorption and enhanced healing.
Is Vaseline safe to use on skin?
Mineral oils in petroleum jelly or Vaseline are completely safe for skin. As long as it’s approved for cosmetic use, the origins of this mineral oil component is not going to cause any damage to your skin. In fact it’s an effective skin smoothener and can help to prevent water loss to the environment.
Is slugging for everyone?
If you do have oily acne prone skin or active acne we don’t recommend applying a petroleum jelly on your skin. Using occlusives on an acne-prone individual can cause a form of occlusion-type comedogenic acne. Instead, opt for a moisturiser that is either cream, serum or lotion based to hydrate and protect the skin barrier.
In humid, tropical climates like Singapore, skincare slugging can increase the occlusiveness of any product that is applied to the skin. This holds truer still with the wearing of the face mask. Sealing on a layer of Vaseline will increase the comedogenicity of any moisturiser that is potentially applied on your face when it’s applied under occlusion.
Additionally, while it does act as a barrier to trap in moisture from leaving the skin, if applied on unwashed skin, it can also trap in any bad bacteria, dirt and grime – leading to breakouts.
How to do skincare slugging the right way?
Apply a ceramide-based moisturizer on dry, flaky, eczema-prone skin on the body.
Seal the products in with a thick layer of white soft paraffin, Vaseline, or a petrolatum based ointment.
Reactive skin is a term that has been used to describe sensitivity to external stimuli. This external stimuli can be in the form of physical type of manifestations, such as changes in temperature heat, cold, or even the presence of wind on the skin, or it can be chemically induced wherever whereby the skin reacts to topically applied skincare and all these factors. Subsequently, lead to inflammation in the skin. The key here is most individuals are able to tolerate environmental changes. However, in a certain group of individuals who has sensitive skin, they actually have an impaired skin barrier function which means that these external stimuli tend to cause skin reactions.
Causes of Reactive Skin
Reactive skin can be due to multiple different dermatological diagnosis, whereas sensitive skin in general, is used to refer to individuals with a form of eczema. These individuals have dry skin and have inherited a deficient molecule that leads to barrier dysfunction. Reactive skin can be due to a condition known as hives, also known as urticaria. There is a Cholinergic type of urticaria which is a type of hives that reacts to heat. And also, even to water in a type of urticaria known as Aquagenic urticaria for individuals who develop hives in response to water. After being exposed to wind or air conditioning, they most likely have a form of physical urticaria.
If you’re familiar with images of individuals who seem to have writing on their skin. This is actually a phenomenon known as Dermatographia and is part of this constellation of diagnosis that fit under the reactive skin umbrella. Individuals with urticaria can have concomitant eczema sensitive dry skin. They could also have a normal skin barrier, and only react specifically to the stimuli. It is very common to have both diagnosis together.
In addition, one may also have a condition such as rosacea whereby the skin reacts to extremes of temperature, in particular heat, as well as UV radiation. This sort of reactivity actually causes long term skin damage because of persistent inflammation. The excess blood flow can cause skin thickening over a period of time, leading to the appearance of enlarged pores and irregular skin texture.
Reactive Skin vs Sensitive Skin
It is important to differentiate in an individual between reactive versus sensitive skin. For example, if you are just trying to treat reactive skin with moisturizers alone, you are very likely going to have a sub optimal result. In addition, another possible mistake is treating rosacea with the treatment meant for sensitive skin as a form of eczema, usually in the use of anti inflammatory topical steroids. The steroids itself is inappropriate treatment for rosacea. This can in fact lead to worsening of the rosacea because it can cause steroids induced rosacea flare ups.
Furthermore, it is critical to appreciate the underlying pathophysiological processes that cause reactive and sensitive skin. Sensitive skin itself may be synonymous with dermatitis or eczema, dry skin conditions, and is primarily due to barrier dysfunction. Reactive skin, on the other hand, is a lot more complex because, in and of itself, reactive skin is not used as a medical term. This includes also the term sensitive skin, as both of these terms were coined by laypersons to describe certain symptoms of the general population.
Role of Probiotics
Some advances in our understanding of skin sensitivity and reactivity have been in the form of topical probiotics, in particular, by bifidobacterium longum extract, which was proven in a clinical trial and published in the Journal of Experimental Dermatology, to improve sensitive skin. Specifically, the results of this study demonstrate that this bacterial extract has a beneficial effect on reactive skin, and that new approaches based on bacterial lysate could be developed for treatment and/or prevention of symptoms related to sensitive skin.
Let’s talk a little bit more about what probiotics. Probiotics can be in the form of fermented or non fermented food products. They are actually part of our intestinal microflora and have a beneficial outcome by exerting an anti-inflammatory biologic effect. This is the reason why doctors tend to prescribe them as a part of functional food diets. It is interesting that live probiotics, not just regulate the intestinal health, but can also have beneficial immunomodulatory effects on skin. This has been evidenced in a study, which has also showed that an ingested probiotic was able to reduce skin sensitivity in patients who have eczema.
Have a reactive skin concern? Book a TeleConsultation, with MOH accredited dermatologist, Dr. Teo Wan Lin, to have your condition addressed. Click on bottom left button to contact us or simply click here to book an appointment now.
Eczema is the most common skin condition in children we see in our clinic. The persistent itching can result in a disruption of daily activities, and understandably, can cause distress to both the child and the parent.
A dermatologist is a qualified skin specialist who has undergone board certification for diagnosis and treatment of all skin, hair and nail conditions. Pediatric dermatology is the diagnosis and management of common dermatological conditions that occur in childhood.
What are some of the common dermatological conditions that can affect children? In this article, we’re going to focus on the treatment and diagnosis of eczema in children by a pediatric dermatologist.
1. Know the Location and Type of Eczema
First of all, how does a pediatric dermatologist diagnose eczema? The clinical pattern of eczema, is as follows. The commonest type of eczema, is a “dry” type of eczema. It occurs generally over the flexures or the extensors of the elbows and the knees. It can also occur on areas which are a bit more sensitive to friction such as the neck and the back of the ears.
Some individuals may have a form of the disease that occurs around the mouth, known as perioral dermatitis. In children who suffer from facial eczema, it is important to rule out if there is an element of irritant contact dermatitis. Very young children who drool may develop facial eczema due to salivary enzymes that cause skin irritation on contact.
The ‘wet’ type of eczema is also known as exudative or discoid eczema. Discoid refers to “coin-like” referring to the round, well-demarcated lesions of discoid eczema. The diagnosis is sometimes confused with other types of skin diseases, such as skin infections i.e. impetigo is a secondary skin infection of the skin can occur together with eczema, causing pus and yellowish discharge. Discoid eczema is a wet type of eczema that is particularly stubborn and may need treatment with oral steroids together with potent topical steroids.
2. Understand Triggers for Eczema
During your consultation with your pediatric dermatologist, it is important to identify triggers for eczema flares. Some of the common triggers would include dust mite allergies, pet fur, carpets and environmental pollution. Stress can also affect eczema flare ups. A HEPA filter may help remove allergens. Stuffed animals can be washed at high heat, sunned or removed to reduce exposure to house dust mites, a known trigger for eczema.
3. Distinguishing Irritant Contact Dermatitis from Allergic Contact Dermatitis
There are two main types of dermatitis. The first is known as irritant contact dermatitis and the second type is allergic contact dermatitis. The two categories are different, because of the way the skin reacts to environmental exposures. In an individual with irritant contact dermatitis, it is a result of accumulated exposure to a substance that breaks down the skin barrier over time. In an individual with allergic contact dermatitis, the key difference is that it is not due to the accumulated damage on skin due to a caustic substance for example, in soaps, or disinfectants.
Rather because of the individual’s true innate allergy to the substance. This means it doesn’t matter if you’ve used the product once or if it’s your 100th time using it—you will still develop an allergic reaction. In fact each allergic contact dermatitis reaction may become more severe. Is it possible to develop allergic contact dermatitis even if you have previously tolerated the product? The answer is yes.
This is due to a process known as skin sensitization. Over time your body’s immune cells build up a memory to these substances that trigger off an allergic reaction in your skin. Common examples of allergic contact dermatitis would be that induced by metals in the environment. Nickel contact dermatitis is due to the presence of the environmental contaminant nickel, in a lot of metal alloys, for example in costume jewelry. Children can become sensitized to the presence of nickel, if they wear costume jewelry from an early age.
The types of irritant contact dermatitis that we encounter in a dermatologist practice are commonly due to cleansing agents, the use of harsh soaps in individuals who have to do a lot of wet work. Working in the kitchen or doing housework, such as laundry or dishwashing without gloves, predisposes to developing irritant contact dermatitis.
The location of the dermatitis will give us a clue as to the cause of it.
Sodium lauryl sulfate, or SLS for short, when it is present in high concentrations without moisturizers in the cleansing formulation, is a major risk factor for the development of irritant contact dermatitis. Irritant dermatitis can occur on the hand and body parts that come into contact with the irritating substance.
Atopic dermatitis is a type of genetically inherited eczema, these individuals have what we termed the atopic triad, which refers to allergic rhinitis, asthma and eczema. A positive family or personal history of any one of these three conditions is a risk factor for the disease. Individuals who have atopic eczema have a genetic predisposition to defective ceramide production, due to a genetic mutation in the gene known as filaggrin.
4. Pathogenesis of Eczema including bacterial infection
The pathogenesis of eczema is best understood via the brick and mortar module of the skin wall. The bricks represent the individual keratinocytes, which form the barrier against the external environment, and the mortar would be the “cement” that holds the keratinocytes together, providing an effective protective barrier against the environment. Now, this cement, is actually the ceramide that “glues” skin cells together in individuals with atopic eczema. The defect in ceramide production leads to a “leaky” wall, which means that if you are exposed to dust, pet fur or other environmental triggers, your skin is more likely to mount an immune reaction trying to fight off these external triggers.
This immune reaction then causes skin inflammation, which leads to the signs of eczema. Signs that your dermatologist would look out for would include symptoms such as flaking, skin swelling and redness. In discoid eczema, pus formation and skin infection, which manifests with yellow crusts.
The role of bacteria in atopic eczema
Bacteria is usually present in healthy forms on a normal person’s skin. In an individual with atopic eczema or other types of acquired forms of the disease such as irritant contact dermatitis, allergic contact dermatitis, there is a disruption in the skin microbiome.
Microbiome dysbiosis refers to a disruption in the healthy balance of the skin bacteria in eczema patients. What dermatologists know is that there is an increase in the bacteria known as Staphylococcus aureus, which is otherwise harmless on normal person’s skin. However, in diseased patients, this causes a superantigen effect, meaning that on its own, the bacteria drives inflammation.
For this reason, skin infection occurs together with eczema and must be treated with all antibiotics in acute flare-ups of the disease.
General measures that can prevent worsening of skin infection in an individual with dermatitis include gentle effective cleansers, such as the Miel Honey Cleanser with medical grade honey with natural anti-bacterial effects. This helps to restore the skin microbiome.
Patients can consider bleach baths, or in the local Singapore context, the dermatologist usually advises patients to go for a weekly swim, as the chlorine present in pool water can reset the skin bacteria.
The role of food allergy in eczema
Food allergy in adults is extremely uncommon, and especially so as a trigger for eczema. However, in a child under the age of four years old, there are cases where foods can trigger off eczema. In this case, your dermatologist will advise you to keep a food diary, which helps to record the intake of specific foods and find a pattern of what may be causing the disease.
True food allergy, presents with the following symptoms. Eye and lip swelling, difficulty breathing and diarrhea, which occurs within four hours of exposure to the suspected food. It is important to manage this with appropriate appropriate dermatological care.
Investigations for Suspected Food Allergy
Skin prick tests can be performed in suspected cases of food allergy.
Other types of tests that will be useful include the RAST test for food allergy to detect specific serum IgE concentrations. A food challenge, can also be performed to determine if an individual should have a specific allergy to food.
5. Management of Eczema
Your dermatologist will first establish a diagnosis based on the clinical features, the pattern of involvement and determine if there are any environmental factors that are constantly triggering off the eczema.
A strong family history is indicative of a genetic mutation. This means the condition is likely lifelong. However, most patients do not display signs or symptoms of eczema if the condition is well controlled and treated. This is especially true for children under the age of 12, it is very important to get the disease diagnosed and treated. This is because by the time they reach adolescence, oil production begins, they have a good chance of outgrowing their eczema.
Lifestyle Measures to Prevent Eczema
Additionally, lifestyle measures to reduce the environmental triggers can be helpful. The application of moisturizers is important – the gold standard of moisturizer therapy is known as Prescription Emollient Devices (PED). PEDs are not normal moisturizers. The Multi-CERAM cream is a type of PED, the best moisturiser effective for eczema treatment. It has been formulated with the optimal lipid ratio that replicates the natural lipid barrier of the healthy skin. The moisturiser also contains antioxidants anti inflammatory ingredients that help to reduce the inflammation in skin.
The Multi-CERAM moisturiser is formulated as a Prescription Emollient Device (PED), the gold standard in eczema management. Dermatologist formulated to treat eczema, dry sensitive skin and to prevent skin ageing. Botanically derived anti-oxidants to improve the appearance of cellulite. Suitable for face and body.
Steroid Therapy for Eczema
An important point to consider is the use of medications. It is very critical to understand that eczema must be treated with prescription creams i.e. topical steroid creams. These must be used under medical supervision.
Steroid Withdrawal and Steroid Phobia
The phenomenon of steroid withdrawal and steroid phobia are commonly reported in the internet because of a poor understanding of how topical steroids work. Using steroid creams without the supervision of an accredited dermatologist can be dangerous. Inappropriate use of steroid creams can cause skin thinning, ulcers, prolonged redness and broken blood vessels. It can cause tachyphylaxis, whereby the individual develops “resistance” to steroid treatment. This is dangerous because there are a limited number of steroid classes available.
Equally, having steroid phobia, where an individual suffering from the disease refuses treatment with medicated creams such as steroids, can be dangerous. It is important to know that there are steroid-sparing alternatives such as calcineurin inhibitors, tacrolimus (trade name Protopic) or pimecrolimus which do not have steroid thinning side effects but can be more costly. These treatments can also cause burning and irritation of the skin. Consult with your dermatologist to determine if this is the best treatment for your eczema.
Steroid phobia or steroid withdrawal in an individual with eczema can lead to extreme inflammation. Worst cases end up as generalized exfoliative dermatitis, a form of Erythroderma that is potentially life threatening. It is a form of skin failure, which can lead to loss of electrolytes, dysregulation of body temperatures and overall organ failure in extreme cases.
Proactive Management of Eczema
Your dermatologist will advise you how best to control your eczema using a prescribed prescription steroid cream. A common method for long term maintenance is known as proactive management. Proactive management of the disease involves a program whereby the dermatologist instructs you how to cut down the topical steroid strength and frequency of application, in order to prevent flare ups of your condition. Gold standard moisturiser therapy with PEDs, wet occlusion therapy with double pajamas and antihistamines are also essential for management of eczema.
Dr. Teo Wan Lin is an accredited adult and pediatric dermatologist in Singapore who specialises in the diagnosis and treatment of eczema, moles and birthmarks, allergies, and skin infections in children. She is also the founder of cosmeceutical skincare line Dr.TWL Dermaceuticals, which develops evidence-based cosmeceutical actives for the adjunct treatment of eczema. She is also the author of Skincare Bible: Dermatologist’s Tips for Cosmeceutical Skincare.
Sensitive skin is typically characterized by dryness, flaking, sensations of stinging and itching associated with skin redness. It is actually a form of dermatitis otherwise known as eczema. I see a large number of patients who come in with complaints of persistent sensitive skin. What they often do not realise is that it is a form of eczema. Eczema can be caused by genetic factors and also external factors such as a change in environment and climate, presence of pollen, animal fur and dust. In this article, I shall share a few tips that I usually expound on with my patients and hopefully shed some light on this condition.
Dr. Teo Wan Lin is an accredited dermatologist and an expert on cosmeceutical skincare research and development. She is the author of “Skincare Bible – Dermatologist’s Tips for Cosmeceutical Skincare” which was published July 2019 by leading bookstores Barnes & Noble, Baker & Taylor and Apple Books and available in bookstores islandwide from January 2020. She heads up Dr.TWL Dermaceuticals, a specialist cosmeceutical skincare line with evidence-based active ingredients for anti-ageing and skin health. Its subsidiaries, the Pi- Cosmeceutical Custom Makeup Lab and the Conscious Mask Bar are part of the Conscious Concept Pharmacy launched in December featuring environmentally sustainable makeup and skincare materials. In this series “Dermatologist Talks” she shares her top tips on common skincare topics. In this article, she tells us the science behind sensitive skin – a form of eczema.
What causes eczema?
Eczema is due to a defect in the skin barrier. The skin is best characterized by a brick and mortar model whereby the bricks of the skin cells are joined together by this cement which holds the skin cells together. People who have sensitive skin or eczema actually have defective ceramide which is the cement of the brick wall which is the skin. This is genetically determined and people who develop eczema in the later part of their lives can also have their condition triggered off by environmental factors such as differences in humidity from dry to humid weather and vice versa. The use of harsh cleansers can also cause eczema to develop over one’s lifetime.
Does ageing cause eczema?
With regards to the development of sensitive skin with age, the same concept of our body’s organ degenerating with age, our skin also degenerates. The main thing is the quality and quantity of ceramide which is produced throughout one’s lifetime decreases with age. On that note, skin can become more sensitive with age.
What should I look out for in sensitive skin products?
The ingredients that are essential for sensitive skin would be a moisturizer and a gentle cleanser. A gentle cleanser such as one that is formulated with minimal laureate sulfate content, which is the foaming component of a cleanser, would be beneficial for a patient who suffers from skin sensitivity. In addition, the use of a ceramide-containing moisturizer is essential. Traditional moisturizers contain humectants such as glycerine which trap water under the skin. Increasing research in dermatology shows that one should be replacing the defective and deficient ceramide content in the skin barrier by applying ceramide rich moisturizers. More information on using Dr.TWL’s Multi-CERAM Moisturizer for eczema treatment can be found here.
Dr.TWL Multi-CERAM Moisturizer is an ultra intensive skin moisturiser for total skin barrier repair with pharmaceutical grade ingredients. It contains phytoceramides which aids in skin barrier repair and multi-ceramide which aids in skin lipid restoration.
Dr.TWL Honey Cleanser is a blend of nature-derived emulsifiers. It is anti-flaking and supples skin. It is also recommended for all skin types as it is a gentle cleanser.
Where is ceramide from?
Sources of ceramide can be plant-derived, synthetic or from animals. Bovine ceramide is the typical source of ceramide used in moisturizers. Plant-derived ceramides which are phytoceramides is what I use in my practice. It contains these lipids which are extracted from plant seed oils.
Dr.TWL Radiance Fluide Hydrating Emulsion contains LARECEA™ Extract for regeneration and skin brightening ingredients for a dewy glow. It is specially formulated for a light-weight feel to impart a radiant glow without make-up. It also contains ceramide and grape seed oil, perfect for individuals with eczema and sensitive skin.
What ingredients should I avoid if I have sensitive skin?
The ingredients that one should avoid when you have sensitive skin will be things like astringents, so any alcohol-based gel, toners or lotions should be avoided because these tend to dry up the skin further. In addition, irritating ingredients such as alpha hydroxy acids and salicylic acids are commonly used for the treatment of acne as well as for skin exfoliation, these will definitely trigger off skin sensitivity.
In patients with Eczema, there is an inherent defect of the epidermal barrier of the skin. When this barrier is compromised, bacteria and allergens are able to enter and thus there is an increased risk of secondary infections, which, in turn, can lead to aggravation of eczematous symptoms. It is believed that the best way to manage eczema is to repair the skin barrier or prevent its dysfunction, in which ceramide moisturisers play a critical role.
According to accredited dermatologistDr Teo Wan Lin who is an expert on sensitive skin and eczema, “I formulated the Dr Twl Dermaceuticals Multi-CERAM™ Moisturiserafter years of prescribing other brands of ceramide moisturisers which I found did not meet the underground clinical needs of patients, at a competitive price point. The high cost of manufacturing ceramide moisturisers lies in its reliance on synthetic sources of ceramide as well as bovine (cow derived) ceramide.”
“In the Dr Twl Dermaceuticals Multi-CERAM™ Moisturiser, which is very competitively priced with a high ceramide content, the novel focus and dermatological concept is on using multiple sources of ceramide for total skin lipid restoration, rather than just relying solely on the expensive synthetic and animal derived ceramide which results in low concentrations of ceramide being used in other ceramide moisturisers, or high price point which is prohibitive.
In the Multi-CERAM™ Moisturiser, phytoceramides are used — these are plant seed oil derived sources of ceramide that directly repair the skin barrier. This is in addition to containing plant anti-oxidants which incidentally combat cellulite, large amounts of glycerin which functions as a humectant, preventing trans-epidermal water loss, as well as Sodium Hyaluronate (Hyaluronic acid), a natural component of the skin, for dermal hydration,” Dr. Teo says.
What are Ceramides?
Ceramides are lipids that are naturally found in the intercellular “mortar” within the outer layer of s the statue corneum. They make up 40-50% of the lipid component of the lamellar lipids and are integral to the function of the epidermal barrier.
In patients with psoriasis, eczema and other dry skin conditions, reduced levels of Ceramides are observed.
The stratum corneum is comprised of corneocytes compressed within a lipid bilayer, which is made up of 40-45% Ceramides, 25% Cholesterol & 10-15% Free Fatty Acids. If incorporated in the wrong ratio, barrier repair may be impeded. These 3 major components of the stratum corneum bind the protein-rich corneocytes into a water impermeable protective barrier. A deficiency in Ceramides results in excessive transepidermal water loss, dry skin and increased permeability to environmental irritants, allergens and microorganisms. Thus, reduced levels of Ceramides is associated with dermatological disorders such as atopic dermatitis.
Studies show that if topical ceramides is applied in the correct ratio with cholesterol and free fatty acids, it can help to improve the epidermal barrier in people with Atopic Dermatitis (AD), thereby reinforcing barrier function. Therefore, ceramide moisturisers and cleansers have been proven to provide substantial relief from the symptoms of eczema.
Ceramide Dominant PED for Eczema
In order for ceramide-containing products to have a positive effect on the skin barrier function, ceramides should be present abundantly in an optimal ratio with other barrier repair ingredients. Our Multi-CERAM Moisturiser is uniquely formulated to ensure the delivery of an optimal ceramide, cholesterol and free fatty acid ratio. In fact, this moisturiser is formulated as a Prescription Emollient Device (PED), the gold standard in eczema management – Eichenfield et al. (2014) [on PubMed], and also the optimal moisturer for barrier protection against maskne – Teo (2020) [on PubMed].
By restoring healthy barrier function, the Dr. TWL Dermaceuticals Multi-CERAM Moisturiser helps to support ceramide synthesis and further augmenting skin barrier repair and skin health in general.
The Multi-CERAM™ Ceramide Moisturiser is uniquely formulated treat Eczema using:
Ceramide 1 (EOP) which is significantly deficient in eczema patients and Ceramide 3 (NP) which is linked to the transepidermal water loss experienced in eczema patients.
Phytoceramides which aids the repair of skin barrier
Sodium Hyaluronate for skin hydration
Ceramide complex (ceramides, cholesterol & FFA) which delivers ceramides topically in optimal ratios to aid in the reinforcement of the recovery of the skin barrier.
Management for patients with Eczema
A daily maintenance routine is vital. One of the main changes in eczema is a disruption and reduction in the layers of corneocytes in the stratum corneum. When the stratum corneum is well hydrated, it swells, allowing increased permeability of topical formulations. The key to managing eczema is through the regular use of a ceramide moisturiser with high ceramide content after showering or washing hands.
Successful management requires a holistic approach:
1. Avoid triggering factors 2. Maintain skin care through regular use of a moisturiser and a moisturising cleanser 3. Pharmacotherapy during acute exacerbations 4. Compliance of skin care products suggested by a dermatologist
Eczema is one of the most common skin disorders in infants and children. Apart from dealing with the medical aspect of the disease, affected patients may experience significant psychosocial effects. As such, any eczema treatment needs to be comprehensively managed and best by an accredited dermatologist
Also termed as atopic dermatitis, it is very common in children but may occur at any age.
How does Eczema arise?
Atopic dermatitis or eczema is caused by a complex interaction of genetic and environmental factors including:
Most patients with eczema have a lower amount of filaggrin in the epidermal skin layer., due to mutations in the filaggrin gene. Filaggrin is a structural protein that plays a vital role in normal barrier structure and function. A lack of filaggrin contributes to the development of eczema in several ways.
Filaggrin breaks down into amino acids and protein derivative to form natural moisturizing factors (NMFs) in the outer skin layers. NMFs provide moisture retention, maintain the acidic pH and buffering capacity of the skin barrier and prevent an overgrowth of bacteria.
Inadequate filaggrin would mean a reduced ability to maintain hydration, which can cause xerosis (dry skin), pruritus (itching) and subsequently, eczema. A dysfunction in skin barrier may also allow entry of allergens, leading to an inflammatory response thus causing eczema.
Having an impaired barrier function also causes colonisation of a bacterium called Staphylococcus aureus. Scratching disrupts the skin barrier, thus also leads to the bacteria adhering to the outer skin layers.
The extent of bacterial colonization is associated with the severity of eczema.
Apart from genetic factors, defects in immune pathways are usually observed in patients with eczema. They tend to have high levels Th-2 cells, which contribute to a defective skin barrier. Th-2 cells play an important role in the immune system. A poor skin barrier may mean water is lost from the skin and also allows the penetration of irritants (soap, dirt, detergent) and allergens (pollens, microbes, dust-mites).
There is also an overproduction of cytokines in the body. Cytokines are cell signalling molecules that aid in cell to cell communication. It regulates the movement of cells towards sites of inflammation and infection.
The excessive release of cytokines initiates new responses that eventually leads to inflammation, causing the red, itchy and painful symptoms common in eczema.
Patients also have high levels of an antibody called immunoglobulin E (IgE), which puts them at disposition for hypersensitivity to environmental allergens. Hypersensitivity is when the immune system produces undesirable or detrimental reactions, such as attacking the body’s own cells or tissues instead of protecting them. With elevated IgE levels, it would mean exposure to a certain allergen can causes the immune system to attack the body’s own tissues and therefore skin inflammation that may be observed with eczema patients.
When it comes to eczema treatment, there are 3 main components that target a specific manifestation of the disease. As a chronic, relapsing condition that may flare up at variable intervals, a comprehensive home treatment plan is important for successful management.
Repair & Maintain Healthy Skin Barrier:
Lubrication of the skin is required to maintain skin hydration, commonly known as moisturisation. This helps to alleviate the discomfort that xerosis (dry skin) may bring about.
Patients with eczema should use moisturizers that are fragrance-free and least amount of preservatives, as these are potential irritants.
Topical corticosteroids are the most effective and common form of eczema treatment. Corticosteroids are drugs that mimic cortisol, a hormone found in the body. They work by diminishing inflammation, itching and bacteria colonisation.
This medication can be classified according to its potency, ranging from class VII (low potency) to class I (super potent). Great care must be taken to balance the potency of drug needed for results so as to minimise potential side effects.
Side effects include:
Atrophy (decrease in size or wasting away of a body part/tissue)
Adrenal suppression (body produces lower levels of cortisol)
For moderate to severe eczema conditions, wet wrap therapy can be used with topical steroids and dermatologist-approved moisturisers. After the medication is applied to the affected area, it is wrapped with a few layers of wet gauze, followed by dry gauze. Such therapy reduces itching and inflammation by preventing scratching and improves penetration of corticosteroids.
Topical inhibitors of calcineurin – protein phosphatase associated with activation of the immune system, are newer forms of eczema treatment, which are considered on areas unsuitable for topical steroids (e.g. eyelids) or if other eczema treatment options do not yield results. For example, Pimecrolimus cream and Tacrolimus ointment are calcineurin inhibitors that have demonstrated good efficacy for eczema treatments and do not cause side effects that corticosteroids bring, but have other considerations of use that should be managed with an accredited dermatologist.
Antihistamines are commonly used to treat itching. Even without a significant rash, itching can be present. Oral antihistamines help to reduce the sensation of itching, ideally to decrease scratching and trauma to the skin.
Antibiotic or antifungal medicines are used to treat the infected rash, to reduce the amount of bacterium Staphylococcus aureus. Topical mupirocin is often prescribed to prevent further infection.
Taking care of the skin
Avoid dry skin. Asian skin is more susceptible to being dry. Dry skin can cause itching and scratching. Tips to avoid dry skin:
Moisturize, especially after a bath as evaporation can cause excessive drying. A ceramide-based moisturizer that is suitable for sensitive skin and face could be Radiance Fluide™ Hydrating Emulsionwhich is also infused with skin rejuvenation properties. For intensive replenishment of ceramides (which are naturally found in healthy skin barrier but deficient in diseased skin), a dermatologist-tested moisturiser such as the Multi-CERAM may also be considered.
Bathe with lukewarm water for 10-15 minutes.
Use neutral or weakly acidic pH soap. Consider a mild cleanser that soothes the skin like Le Lait™ Milk Cleanser.
Avoid high ambient temperatures.
Avoid irritants that can cause or aggravate a rash, such as perfumes, scratchy clothing or bedding and sweating.
Formerly known as Besnier prurigo, Eczema — also known as atopic dermatitis — is the most common form of dermatitis. It is categorised as a chronic, itchy skin condition. Eczema is less common in adults and more commonly affects 15–20% of children. It is almost impossible to predict whether the condition of one’s eczema will improve by itself or not in an individual.
Sensitive skin is a condition that persists life-long. In a meta-analysis of over 110,000 subjects, it was found that children who developed atopic dermatitis before the age of 2 had a much lower risk of persistent disease than those who developed eczema later in childhood or during adolescence. 20% of children with eczema still had persistent disease 8 years later. Fewer than 5% had persistent disease 20 years later.
Genetics in Atopic Dermatitis
Since ‘atopic tendency’ such as eczema, asthma and hay fever can be passed down through the family, knowing one’s own family history of asthma, eczema or hay fever is very useful in diagnosing atopic dermatitis in infants. The complex interaction between genetic and environmental factors causes and triggers atopic dermatitis. Defects in skin barrier function make the skin more susceptible to irritation by contact irritants such as soap, the weather, temperature and non-specific triggers.
The appearance of eczema varies from person to person. In acute eczema flares, inflamed, red, sometimes blistered and weepy patches are common. In between such eczema flares, the skin may appear normal or suffer from chronic eczema with dry, thickened and itchy areas. The appearance and feel of eczema varies from one’s ethnic origin, age, types of creams applies, the presence of infection or an additional skin condition. However, there are some general patterns to where the eczema is found on the body according to the age of the affected person.
Atopic Dermatitis Changes with Age
Although eczema can manifest itself in older people for the first time, the onset of eczema is usually seen before a child turns two. It is widely distributed amongst infants less than one-year-old. It is unusual for an infant to be affected with atopic dermatitis before the age of four months. However, they may suffer from infantile seborrhoeic dermatitis or other rashes prior to this.
As infant’s tend to scratch at their itchy skin with their sharp baby nails, the appearance of eczema in infants tend to be usually scaly, dry, and red. The signs of eczema are physically first apparent on cheeks of infants. Due to the moisture retention of nappies, the appearance of eczema in the napkin area is frequently spared. However, just like other babies, if wet or soiled nappies are left on too long, they can develop irritant napkin dermatitis. Although, eczema is often worst between the ages of two and four it usually improves after four and it may clear altogether by the time one enters into teenhood.
As toddlers tend to scratch vigorously at their itchy skins, the appearance of their atopic dermatitis may look very raw and uncomfortable. As they start to move around, the dermatitis tends to become more thickened and localised. Body parts and areas such as the extensor aspects of joints, specifically the elbows, wrists, knees and ankles and even genitals are most commonly affected in this age group. This changes as the child grow older. The pattern frequently shifts from extensor aspects of the joints to the flexor surfaces of the same joints, such as creases. This is when the affected skin often becomes lichenified; thickened and dry from constant rubbing and scratching.
However, the extensor pattern of eczema persists into later childhood in some children. Older school-age children tend to develop a flexural pattern of eczema which commonly affects the elbow and knee creases and other susceptible areas such as the scalp, eyelids, earlobes, and neck. It is possible for school-age children to develop recurrent acute itchy blisters on their palms, fingers and sometimes on the feet, medically known as pompholyx or vesicular hand/foot atopic dermatitis
Many children in this age group tend to develop a ‘nummular’ pattern of atopic dermatitis. This refers to the appearance of small coin-like areas of eczema scattered over the body. Commonly mistaken for a fungal infection such as a ringworm, the appearance of these round patches of eczema are usually red, dry and itchy. Most of the eczema tends to improve during school years and it may completely clear up by the time they reach their teenage years. However it is important to note that the barrier function of the skin is never entirely normal.
The presence of atopic dermatitis in adults are varied in many ways. Despite having a possibility to have a diffused pattern of eczema, eczema in adults is usually more dry and lichenified compared to eczema in children. Eczema is adults are commonly persistent, localised, and possibly confined to the eyelids, nipples, flexure, and hands or all of these areas. Hand dermatitis in adult atopic tends to appear thickened, dry but may also be blistered at the same time. Infections such as staphylococcal infections are both recurrent and a prominent possibility. Occupational irritant contact dermatitis can trigger eczema. This most often affects hands that are regularly exposed to water, detergents and /or solvents.
As eczema can be triggered by physical, environmental and cosmetic factors, particular occupations such as hairdressing, farming, domestic duties, domestic and industrial cleaning and caregiving tend to expose the skin to various irritants and, sometimes, allergens, aggravating eczema. As it is easier to choose a more suitable occupation from the outset than to change it later, tt is wise to bear this in mind when considering career options. Having atopic dermatitis does not exclude contact allergic dermatitis (confirmed by patch tests in children and adults).
It could take many months to years to treat eczema and treatments plans often includes: – Intermittent topical steroids – Reduction of exposure to trigger factors – Ceramide based moisturisers (such as the Multi-CERAM which helps restore healthy skin barrier function) – In some cases, management may also include one of more of the following: – Antibiotics – Antihistamines – Crisabarole ointment – Phototherapy – Topical calcineurin inhibitors, such as pimecrolimus cream or tacrolimus ointment – Oral corticosteroids – Longstanding and severe eczema may be treated with an immunosuppressive agent. – Azathioprine – Ciclosporin – Methotrexate
Clinical trials of biologics such as Dupilumab are promising cures for eczema.
Do you suffer from symptoms such as skin redness, flaking, itch or stinging pain? Did you have eczema, asthma or sensitive nose when you were young, or have a family history of eczema or sensitive skin? Does your skin get red and itchy when you use makeup or skincare products, or when you are exposed to a dusty or sweaty environment? Does your skin act up when travelling to a cold or dry climate?
Dermatologists diagnose true “sensitive skin”, with a medical condition known as eczema, where common exposures to the environment or skincare and make up can trigger off flare-ups.
2. What Is Defined As Sensitive Skin Then?
People with sensitive skin are likely to have atopic dermatitis, which is a genetically determined condition where the skin is deficient in certain fats. The skin acts as a barrier to the environment and, without a proper functioning skin barrier, any dust, climate change, pet fur, or even emotional stress can trigger off a flare-up.
If you have never had any of these symptoms and suddenly experience “sensitivity”, especially soon after using a new skincare or makeup product, it might actually be a form of allergic contact dermatitis to an applied substance. This would be best reviewed by a dermatologist who might suggest a patch test and also receive appropriate medical treatment.
Undiagnosed and untreated skin sensitivity can become chronic and may result in scarring such as post-inflammatory hyperpigmentation which results in dark marks on one’s face.
Your dermatologist will prescribe you anti-inflammatory creams such as topical steroids of the appropriate strength and ceramide-rich emollients that replenish the skin barrier. In the case of any infection, oral antibiotics to clear the skin infection would also be prescribed. Oral steroids may also be required for severe eczema.
Here are three of the best skincare tips for people with sensitive skin:
1) Look for “dermatologically tested and formulated” labels that are produced in certified laboratories and that work with dermatologists rather than cosmetic brands.
2) Get your dermatologist to recommend a gentle cleanser formulated for effective cleansing of eczema-prone skin.
3) Get your sensitive skin treated first before using anti-ageing products Many anti-ageing products contain stimulating ingredients which may worsen sensitive skin. If you do use them, look for a product that’s recommended by your dermatologist.
Meet with Dr. Teo Wan Lin, founder and Specialist Consultant Dermatologist of TWL Specialist Skin & Laser Centre, an accredited dermatologist specialising in medical and aesthetic dermatology. She integrates her artistic sensibility with her research background and specialist dermatologist training, by means of customised, evidence-based aesthetic treatments using state-of the-art machines, injectables (fillers and toxins) which work synergistically with her proprietary line of specialist dermatologist grade cosmeceuticals Dr.TWL Dermaceuticals.
To book an appointment with Dr. Teo, call us at +65 6355 0522, or email email@example.com. Alternatively, you may fill up our contact form here.
Definitely. If one or more parents suffer from eczema, the child is also more likely to develop the condition.
3. What should parents look for when trying to detect the onset of eczema in children?
Eczema typically starts as an itchy, dry skin condition in the first year of life or later. Parents may notice red, scaly patches occurring on areas such as scalp, face, chin, body, arms, legs or knees. Children may rub themselves against bedding to relieve themselves of the itch. This could be severe because it will interrupt children’s sleep at night.
4. Are food and allergies always linked for eczema in children?
Food does not cause eczema. However, some studies show that children below the age of 4 may find that certain foods worsen the condition of eczema. It is important to consult with your child’s dermatologist before excluding food from your child’s diet as children need a balanced diet . Only children with established food allergies will find that certain food can aggravate their eczema condition.
5. What should children with eczema refrain from doing?
Eczema in children can be especially hard to manage if good habits are not inculcated early on. Instead of scratching, children should be taught to pat their skin. At the same time, they should also keep the skin properly moisturised, keep their fingernails clipped and wear cotton gloves to bed. They should also wear clothing of light, breathable material such as cotton to sleep.
6. How should parents shower their child with eczema?
It’s best to use soap-free cleansers or bath oils. Try to avoid soaps containing sodium laureth sulphate as it contains a lathering agent that can irritate and dry the skin even more. Parents should also avoid abrasive materials such as loofahs or wash clothes.
The shower is preferably kept short, using lukewarm rather than hot water. After the shower, pat the skin dry with a towel and use moisturiser liberally when the skin is slightly damp.
After showering, diligent moisturising with a ceramide-based moisturiser such as the Multi-CERAM is also an important part of eczema management. The skin barrier may be thought of as a brick wall and ceramide, the cement that is sealing in between the bricks that confers a strong barrier function to the wall to prevent water penetration. Diseased eczema skin is often deficient in ceramides, resulting in poor skin barrier function and allowing rapid trans epidermal water loss. Hence, one may see the appearance of dry scaly patches around the diseased areas.
Diligent moisturising with a ceramide moisuriser – i.e. using a thick visible white layer on affected areas several times a day initially, is imperative in any eczema treatment. This is in order to replenish ceramides naturally found in the skin and support restoration of healthy skin barrier function. Healthy skin will in turn kickstart its own production of ceramide which will help to sustain the benefits of intensive ceramide moisturisation initially.
7. When do parents need to bring their child to a dermatologist?
Eczema in children and at any age needs to be treated, ideally by a dermatologist. In the situation when eczema gets out of control, such as when the itch significantly affects the child’s daily activities. If the skin is infected — red with pus oozing out or if the child is unwell — then it will be necessary to seek medical attention.
8. I heard eczema cannot be cured, is that true?
The root cause of eczema in children or adults is in the genetics, which cannot be changed. With better understanding of eczema these days, it can be fully treated and controlled by a dermatologist. Topical steroids are of paramount importance when reducing inflammation caused by eczema.
9. Are there any side effects of steroid treatments?
If steroids they are used inappropriately, they can cause skin thinning, which is cosmetically disfiguring. There is also a phenomenon called tachyphylaxis, which is when normal steroids lose their effects, and stronger steroids are required instead.
However, if you are getting your eczema treated by a qualified medical professional, the correct dose, potency, duration and class of steroid will be given — appropriate to your child’s eczema depending on the location, age group and severity of eczema.
Dr. Teo is an accredited dermatologist at TWL Specialist Skin & Laser Centre who is well-versed with childhood eczema. She has been interviewed on the topic by Singapore magazine, Motherhood, and Singapore news channel, Channel NewsAsia.
To book an appointment with Dr. Teo regarding your child’s eczema problem, call us at+65 6355 0522, oremail firstname.lastname@example.org. Alternatively, you may fill up our contact form here.