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 focuses on a growing trend – Teledermatology.
What is teledermatology?
Telemedicine is the practice of using telecommunication technologies to transfer medical information. Information can be shared through audio, visual and data communication. Teledermatology is a subset of telemedicine involving the dermatology specialty, that incorporates healthcare management such as during consultation, diagnoses, treatment and education via an encrypted digital platform.
What are some examples of teledermatology practices?
Teledermatology can be practiced in the following ways: Store and forward (SAF) and real time or interactive teledermatology. A simple example of SAF could be sending an email inquiry with an attached digital image of a lesion to receive advice on how to treat the skin condition. For real time teledermatology, it includes a live video conference between the medical provider and the patient. TWL Specialist Skin & Laser Centre developed a stringent teledermatology protocol incorporating both store and forward as well as real time interactive technology via an encrypted platform.
How is it relevant for me?
Teledermatology has many benefits. First, it is a convenient practice as it does not require both parties to be present at the same location. Some skin conditions require follow up appointments up to two times per week. This can takes up a lot of time. As such, teledermatology can be used to drive down the time and costs required in such follow-up visits.
Teledermatology can also be used to help patients receive a second opinion on their diagnosis to improve accuracy. In the unusual healthcare situation such as that of the COVID-19 Virus currently, the availability of remote consultations will greatly assist in public healthcare needs. Teledermatology enables you to consult with a dermatologist right in the comfort of your home.
Twl Specialist Skin & Laser Centre offers accredited Teledermatology services, via virtual interactive real time technology with our dermatologist. Available as of 1st February 2020, all consultations are also integrated with online pharmacy dispensary services. Delivery to doorstep fulfilment of prescriptions available for local and international patients.
What should I expect from a teledermatology appointment?
1. Book an appointment via our online booking system or call 63550522. Key in a valid email address and phone number which will be the main form of correspondence. You will receive a confirmation of the appointment within 1 working day.
2. A Payment Link will be sent, to be completed for First Consultation/Subsequent Consultation Fees before commencement of consultation.
3. A Post-Payment Secure Process will be communicated to you via email for the subsequent steps which will involve the following:
Filling up of 3 single page forms, submission of required images at least 2 hours before scheduled consultation time with our dermatologist*, a fully encrypted video call saved on our secure patient data base will be conducted.
Subsequent fulfilment of prescription is done by our in-house pharmacy with full courier services to your home.
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 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.
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 email@example.com. Alternatively, you may fill up our contact form here.