Eczema: To Bathe Or Not To Bathe

duckEczema is a common skin problem, affecting 10-20% of children. Dry, scaly patches and intense itching result in unhappy children and parents. Complications include bacterial infections, viral infections, bleeding and most importantly, sleep disturbance. Often allergic eczema (atopic dermatitis, AD) is the precursor to several allergic conditions; food allergy, asthma and allergic rhinitis.

Before getting wet let’s look at the causes of eczema. Genetic mutations and environmental factors combine to produce a skin-barrier defect. This ‘leaky’ skin barrier allows for excessive water loss. Additionally, local immune dysfunction, allergy and infection produce inflammation of the skin. Inflammation leads  to itching. Itching leads to scratching. Scratching leads to further inflammation. Treatment must restore health to the skin and break the itch-scratch-cycle.

There are a staggering number of treatment choices; oils, lotions, creams, soaps and ointments. Some are natural and some contain potent steroids. An effective treatment regimen should include a combination of medicines, specific for the individual patient. Rehydrating the skin is essential for healing the skin and preventing recurrence. Doctors advise frequent moisturizer use and bathing on a regular schedule.  Recommendations range from bathing twice daily to twice weekly. The frequency is likely based on physician training and experience.  There is little consensus and even less evidence which is best.

It is commonly accepted that bathing dries out the skin. Water not only washes away dirt but also natural oils. Use of soap and harsh detergents, such as sodium lauryl sufate (SLS), has been shown to remove protective skin lipids and natural moisturizing factors. Bar soaps are often highly alkaline and can result in further drying. They may have chemical additives (i.e. perfumes) that can act as irritants or allergens causing inflammation. Hot and very hot water contribute to inflammation as well. The problems don’t end when the bath is over. Aggressive drying creates friction and skin damage.

On the other hand, bathing has important benefits. Soaking in water may help to rehydrate skin cells. Cleaning bacteria from the skin reduces the risk of infection. The intermittent addition of bleach is effective in lowering the amount of bacteria living on the skin.

My conclusion, bathing can dry out the skin UNLESS done properly. Here are some tips for effective bathing and hydration:

• Keep water at a lukewarm temperature.

• The bath should last approximately 15-20 minutes.

• Avoid harsh soaps, bubble bath and hand washes. Instead use emollient washing products.

• Be gentle. Try not to rub your body too strongly with your towel.

• Apply moisturizer to slightly damp skin within three minutes of getting out.

• Intermittent use of antiseptic bath oils and dilute bleach can reduce flares.

• Other additives may be helpful, for example magnesium salts and natural colloidal oatmeal.

• Use LOTS of moisturizer following the bath and throughout the day. Emollients (moisturizers) and steroids should be applied in a 10:1 ratio.

Application should be separated by 30 minutes, 1 hour for tacrolimus. Remember not to insert hands or fingers directly into emollients, in order to avoid microbial contamination of the contents.

Can Diet Cure Chronic Hives?

Food dish

Food dishFat, Sick and Nearly Dead is a 2010 documentary which follows the journey of Australian Joe Cross (http://www.fatsickandnearlydead.com). Joe traveled the country during a 60 day juice fast. Nothing but liquid nutrition. His purpose; cure disease, reduce dependence on medications and lose weight. Joe has chronic hives (urticaria). He relies on multiple medications, including oral steroids, to control symptoms. Throughout the trip he undergoes a miraculous transformation. The number of pills and pounds continue to drop.

Should everyone expect these results? Probably not. A documentary film is not sound medical evidence. In this film, there is only one subject. There is no comparison group. Most importantly, hives frequently come and go on their own without reason.

A German study published in 2010 investigated diet manipulation for the treatment of chronic hives. Patients eliminated all processed foods, artificial substances, food additives, dyes, antibiotics, preservatives, phenols and natural foods rich in aromatic compounds such as tomatoes. What is most interesting, patients avoided the majority of Joe’s diet – NO fruit. The results were mixed; 34% benefited from the diet and 24% deteriorated while on the diet. Responders took on average 3 or more weeks to respond.

These doctors believe that artificial preservatives and dyes in modern processed foods (and aromatic compounds in some natural foods) act as pseudoallergens, substances causing allergy symptoms via non-allergic mechanisms. These foods trigger the release of histamine and subsequent hives without an allergic immune response. This suggests another possible link, those foods with high levels of histamine (http://chronichives.com/useful-information/histamine-restricted-diet).

An Italian group put patients on an oligo-antigenic and histamine-free diet for 21 days. They excluded foods with artificial coloring (esp. tartrazine), fermented foods, benzoates, Butylated hydroxyanisole (BHA) and butylated hydoxytoluene (BHT). Patients in this study had a significant improvement in symptoms. However, there were only 10 patients. Additionally, patients in a similar study out of Canada showed less substantial improvement.

Other foods under investigation for chronic urticaria include; MSG, parabens and aspartame. Alcohol and spices both can cause vasodilation (widening of the blood vessels) and hives in  patients with chronic urticaria. Unfortunately, hives continue to occur after elimination.

Overall, there is little scientific evidence to support elimination diets for the treatment of hives. We do not routinely advise patients to adopt a pseudoallergen free diet. However, there are patients who do not respond well to medications, who require multiple medications or are experiencing significant side effects. For this group, there is little risk in trying an elimination diet. Patients should be motivated. Patients should eliminate a large group of foods; although foods can be added one at a time (after hives have resolved), it is unlikely to help if they are removed one at a time. Most important, prolonged diet changes require the supervision of a doctor or nutritionist.