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Covid-19 Infection and Skin Problems

Covid-19 infection is a multi-system disorder where skin involvement is common. Interestingly, data from a UK Covid-19 symptoms study with 11544 respondents reveals that:

• 17% of Covid-19 positive patients reported skin rashes as the FIRST presentation of symptoms;
• 21% reported skin rashes as the ONLY clinical problem of Covid-19.

Similarly, Covid skin issues have also been reported in 20.4% of Italian patients, 7.25% in Indians and 0.2% in Chinese.

What Are the Common Skin Problems Caused by Covid-19?

A Spanish study published in April 2020 with 375 cases shows the following as the most common skin problems:

• Pseudo-chilblain/Covid toes (where the toes are swollen and inflamed)
• Vesicular (small blisters / bubbles)
• Urticarial (hives)
• Maculo-papular (red rash)
• Livedo necrotic (this is the most severe problem when the blood supply to the skin is compromised)

Our Singapore General Hospital has also published their review and reported similar observation as the above Spanish study.

Skin Problems Related to Personal Protective Equipment (PPE)

What started off in early 2020 as a flu like illness with serious pneumonia risk has gotten dermatologists very busy as well. Skin problems, especially those triggered by Covid-19 PPE measures and mRNA vaccination are what we see most often now.

Facemasks

Dermatologists are seeing increased “mask related facial rash” like:

• Acne / Maskne
• Seborrheic eczema
• Contact dermatitis
• Atopic eczema
• Rosacea

These skin rashes could be a brand new problem with no previous history or a flare up of pre-existing problems. The mask-induced occlusion, increase friction and increase moisture led to:

• Skin barrier damage
• Changes in bacterial population on the skin
• Increase in skin hydration and pH level
• Increase sebum production (both on the covered and uncovered skin) and
• Skin temperature changes

Hand Washing and Hand Sanitizers

Skin Specialist also see increased number of patients with hand eczema because of the need to use hand sanitizers and to wash hand regularly. During the Covid-19 outbreak in China, 66.1% of healthcare workers washed their hands more than 10 times per day. BUT only 22.1% applied moisturizers after hand washing. Lack of hand care and discipline to use hand moisturizes trigger and aggravate hand eczema.

Skin Problems Related to Covid-19 Vaccination

Covid-19 Vaccine and Common Skin Side Effects

In a Spanish study with 405 cases, skin rash that occurred within 21 days after any dose of Covid-19 vaccine were regarded as a vaccine side effects. These side effects after Covid-19 vaccination vary from local reaction to widespread skin eruption:

• Covid arm. A delayed large local site reaction with redness, soreness and swelling is the most common. Covid arm is more frequent in mRNA vaccine and in women. It usually resolved in 2-5 days, and it may relapse after the 2nd dose, usually less severe.
• Rash that looks like active Covid 19 infection e.g., chilblains, hives etc.
• Flare or initiation of skin disorders e.g., eczema, psoriasis, rosacea, cold sores, and chickenpox infection. Less common reactions like cosmetic filler reactions were also reported.
• Globally, allergic reaction is rare, occurring in 0.2% after first dose and 0.4% after 2nd dose. Out of 9,209,201 doses of the Pfizer and Moderna mRNA vaccines that have been administered in Singapore (as of 30 September 2021), 12,589 suspected side effect reports (0.14% of administered doses) were received. The most common skin allergic reactions include itchy rash, hives and swelling of eyelids, face and lips and these allergic reactions tend to occur early, soon after or within 1-2 days of vaccine administration.
• Moderna vaccine causes more skin reaction (61-83%) than Pfizer does (17%). Most Skin reactions are not severe and should not prevent the administration of 2nd or booster dose.

Who Should Visit a Dermatologist Before/After Vaccination?

• Patients who are concerned whether they are suitable for vaccination if they have pre-existing skin problems. e.g., eczema, psoriasis, drug allergy. The common question is whether the vaccination will worsen their existing skin problems.
• Patients who develop post-vaccination itchy rashes or aggravation of existing eczema.
• Patients who request for vaccine allergy test before they proceed with the vaccination. Some patients want to know for certain that they will not develop allergy reaction before they go for the vaccination. They need counseling and reassurance from Skin Specialist.

How Can a Dermatologist Help?

A Dermatologist can do the following:

• Allay their concerns and anxiety over vaccination with proper medical counselling. I will advise them to proceed with vaccination to minimize the risk of serious infection from Covid-19 / Covid-19 death.
• Advise them the likelihood of true allergic reaction is very low, and most will do well without any issues.
• Do not skip vaccination because of anxiety over potential skin related issues. We will deal with the skin problem accordingly when it occurs.
• Explain to them that a rash does not always equate allergy.
• Advise them whether they are suitable for vaccination with their existing skin problems.
• Direct them to appropriate authority for further testing and allergy confirmation if truly needed.

Covid has come and stay, and the latest variant is Omicron. Patients need to deal with their skin problems caused by Covid-19 infection, Covid-19 PPE measures as well as Covid vaccination.

As a Dermatologist, I read up and keep myself as current as possible to attend to my patient’s needs. There are many hearsays online and my duty as a dermatologist is to share with them the medical truth and to alleviate their fears of Covid-19 and the vaccine side effects. I treat my patient’s skin problem, I give relevant medical advice on skin care, hand care and mask care so that my patients are equipped with proper medical knowledge how to live and manage with the side effects and issues brought along with Covid-19 and vaccinations issues. I adhere “to cure sometimes, to relieve often, to comfort always” in this ever evolving and disruptive pandemic era.

Some Fast Facts About Eczema

According to the National Skin Centre (NSC), at least 1 out of 10 people (10%) in Singapore will be affected by eczema at some point in their life. Here are some facts you should know about the skin disease:

• It results in dry, inflamed and scaly skin
• It is one of the most commonly treated skin diseases at the NSC
• There is no proven cause of eczema, but research points to a combination of hereditary factors and external triggers
• The incidence of eczema in Singapore is among the highest in the world
• The condition is not contagious
• There is no cure, but the symptoms can be effectively managed

Eczema is also called atopic dermatitis, and is one of many types of dermatitis. The terms ‘eczema’ and ‘dermatitis’ are sometimes used interchangeably but both refer to the inflammation of the skin.

Although most often seen in children, the condition may persist into adolescence and adulthood. Some adults continue to have symptoms on and off for the rest of their life.

Eczema may result in reduced self-confidence, sleep disturbance, inability to concentrate at school or work, depression, as well as social isolation. It is important for you to seek treatment early to prevent the condition from worsening, especially if the chronic itch causes great physical discomfort and affects your quality of life.

Symptoms Of Eczema

The symptoms of eczema will look different for everyone as it is a highly individual condition that comes in many different forms. In mild cases, your skin could simply be dry, inflamed and itchy. But in more severe cases, your skin may experience oozing, crusting, or even bleeding.

Eczema patients will usually experience a period of time when their symptoms flare up, followed by a period of time when their symptoms abate due to medical treatment.

Children with eczema typically develop the condition before turning five. However, most of them will see their symptoms subside when they grow up. The symptoms in adults, children, and infants may be different.

Signs and symptoms of eczema in adults may include:

• Dry and sensitive skin
• Chronic itching that may intensify at night
• Red to brown patches, especially on your hands, feet, ankles, wrists, neck, upper chest, eyelids, inside the bend of your knees and elbows
• Small, raised bumps, which may leak fluid and form crusts when scratched
• Thickened, cracked, and scaly skin

For children aged two and above, the symptoms may include:

• Bumpy rashes
• Rashes accompanied by a discolouration
• Rashes that form behind the creases of elbows and knees
• Rashes that appear on the neck, wrists, ankles, and the creases between the buttocks and legs
• Lichenification (thickening of the skin)

For infants under the age of two, the symptoms may include:

• Rashes on the scalp and cheeks
• Rashes that bubble up before leaking fluid
• Rashes that can cause extreme itchiness and disturbed sleep

If you have suffered from eczema as a child but no longer experience the condition as an adult, you may still be prone to dry or sensitive skin that is easily irritated.

The physical appearance of your skin will depend on how much you scratch it and whether or not your skin is infected. Scratching the affected areas will only further irritate the skin, increase inflammation, and exacerbate the condition.

Types Of Eczema

There are seven different types of eczema:

• Atopic dermatitis
• Contact dermatitis
• Neurodermatitis
• Dyshidrotic eczema
• Nummular eczema
• Seborrheic dermatitis
• Stasis dermatitis

It is possible for you to have more than one type of eczema present on your body at the same time. Each form of eczema has its own separate set of triggers and requires different treatment methods. For this reason, it is crucial that you consult a dermatologist who specialises in treating these skin conditions.

What Causes Eczema

Doctors and healthcare practitioners do not know what the exact causes of eczema are. However, research strongly suggests that it is likely caused by a combination of things which may include:

• Genetics: Having relatives with eczema is a major risk factor.
• Autoimmune system problems: Your body’s reaction to triggers is what causes inflammation, and having an immune system that overreacts to irritants or allergens can cause eczema.
• Environment
• Lifestyle
• Stress

As eczema is not contagious, you cannot get it from, or give it to, another person by bodily contact.

Eczema Triggers And How To Avoid Them

In order to manage your eczema, it is helpful to have a good skincare routine best suited for keeping the condition under control. You should also identify and avoid certain trigger factors which cause flare-ups.

Food Allergens

An allergic reaction is an immune response to a specific substance you may be sensitive to.

Some patients with eczema have an accompanying food allergy which triggers their symptoms. While the skin condition is not caused by the allergic reaction itself, flare-ups will usually occur if patients eat certain foods. For example, foods such as simple sugars, refined carbohydrates, gluten, red meat, and dairy tend to cause bodily inflammation. These might cause your eczema to flare up.

You should speak with your dermatologist about allergy testing to detect the foods you may be allergic to. Alternatively, you may also consider an elimination diet by removing certain foods from your diet and reintroducing them after some time to identify which are responsible for worsening your symptoms. In future, this allows you to avoid them and minimise your likelihood of flare-ups.

Irritants

You may also experience eczema flare-ups due to certain irritants that serve as trigger factors. These may include:

• Friction between your skin and certain clothing fabrics
• Artificial fragrance, such as scented body products
• Cleaning products such as sprays, detergent or washing powder

These irritants can interfere with your skin barrier by removing natural oils and moisture. As a result, itching and scratching may ensue. For example, many people with eczema find that wool and synthetic materials trigger itching. Body products and cleaning products can also contain chemicals that cause skin dryness or irritation.

You may consider avoiding these irritants and opt for lifestyle alternatives where necessary. Clothing materials that are eczema-friendly such as cotton, bamboo, and silk are less harsh on the skin. Similarly, you should opt for hypoallergenic and scent and chemical-free body and cleaning products. Household alternatives such as white vinegar as a glass cleaner and baking soda as a kitchen cleaner are better alternatives as these agents do not contain any added chemicals.

Water

Another triggering factor for eczema is prolonged exposure to moisture. This is because water can dry out your skin, which results in persistent itching. Frequent showering, bathing, swimming, and washing of your hands can make eczema outbreaks more likely.

You should apply moisturiser to your skin after swimming or bathing, and shower with warm water to prevent excessive drying out of your skin.

Stress levels

Mental and emotional stress does not directly cause eczema but can stir up your symptoms. When your body is placed under stress, your adrenal glands secrete the hormone cortisol into your bloodstream. This hormone increases inflammation throughout your body as part of its ‘flight or fight” response, which can cause flare-ups.

To minimise stress levels, you should consider making time for rest and relaxation during the day. It also helps to engage in stress-relieving activities such as walking, reading, or meditating. If you are having trouble with depressive thoughts, you should seek help from a mental health professional.

Air temperature

Hot weather is known to irritate the skin, and is capable of worsening your itch. Heavy perspiration will also cause flare-ups in some cases. This is especially so in Singapore’s hot and humid weather, whereby excessive sweating can affect the skin’s barrier function.

You should try to keep your body temperature cool and limit sweating as much as possible. It is also good to stay hydrated and avoid being out in the hot sun.

On the other hand, cold weather can also cause your eczema to flare up. This is because cold air is usually accompanied by dry air which strips away your skin’s natural moisture. When you travel to cold countries, you may experience increased itching due to the dryness, which then leads to scratching and inflammation.

You should bring a skin moisturiser that helps to protect your skin. If you are residing in a cold country for an extended period of time, you may consider using a humidifier in your home to reduce the likelihood of skin dryness.

Hormonal changes

There is some evidence from medical research which suggests that sex hormones can influence the incidence of eczema.

The male hormone testosterone has a negative effect on your skin barrier function, making it more sensitive and vulnerable to drying out. Similarly, a drop in the female sex hormone estrogen right before a menstrual cycle can cause your skin to lose water, affecting its ability to maintain moisture. This leads to dryness and exacerbates your eczema symptoms.

It is not possible to avoid hormonal changes but you can mitigate the condition through the use of topical steroids. For females, you could also try marking out dates in your calendar when you’re likely to flare up such as during your period. If that is the case, you can take extra steps to avoid irritants that trigger your symptoms.

Microbes

Certain bacteria, viruses, and fungi are responsible for the outbreak of some types of infection in eczema. Some of them may include:

• Staphylococcus aureus: This bacteria is the leading cause of skin and soft tissue infections. Scratching your skin allows it to get into your skin’s deeper layers, causing infection.
• Malassezia: This kind of yeast infection can cause both dandruff and an itchy, flaky rash where your natural oils are present.
• Herpes: The herpes simplex virus can affect large areas of your skin, giving rise to a certain type of eczema known as eczema herpeticum.

To avoid the outbreak of eczema infection, you should observe proper hygiene habits and avoid scratching your skin as much as possible.

Exercise

Vigorous exercise or strenuous physical activity will lead to heavy sweating, which can exacerbate your eczema symptoms.

If you tend to have flare-ups after strenuous exercise, you should consider opting for less intense forms of activity or select a cooler time of the day to work out.

Eczema Treatments, What’s Your Best Option?

If you suffer from eczema, you know just how frustrating flare-ups can be. For most people, it can take some measure of trial-and-error to find the best way to reduce symptoms. Sometimes, little adjustments can help. Dermatologists recommend warm showers and over-the-counter moisturising products that hydrate the skin.

However, when these home remedies and self-care steps fail, you will need medical treatment. There are a range of medications which your dermatologist can prescribe to help alleviate your symptoms. These will also help your skin to heal and reduce discomfort.

Topical steroids

This form of treatment is most commonly prescribed as the main treatment for patients with eczema. Topical steroids will help to reduce skin inflammation and do not have any significant risks if used appropriately. The strength of the steroid cream will depend on your age, as well as the severity of your condition. However, some possible long-term side effects include thinning of the skin layer, easy bruising, and stretch marks

Steroid-free topical medications

Steroid-free topical medications have also been developed for use in the treatment of eczema. These new ointments, tacrolimus and pimecrolimus, are called TCI creams (topical calcineurin inhibitors) and treatment will depend on your suitability. Your dermatologist will assess your condition to determine if this treatment is appropriate for you.

Oral treatments

Oral medication for eczema is used in the form of antibiotics to counter skin infections. Additionally, antihistamines are prescribed to reduce flare-ups and prevent excessive scratching from the ensuing itch. But they are not recommended for daily use.

Other treatments

Wet-wrap therapy is another form of treatment to deal with severe eczema. This involves wrapping the affected area with wet bandages to re-introduce moisture into the skin layers and soothe your itch.

In some cases, your dermatologist may discuss the prospect of other treatment alternatives such as phototherapy, oral immunosuppressants and biologic injection treatment.

A Note From Dr Wong Soon Tee (Senior Consultant Dermatologist In Singapore)

If you are suffering from eczema, you’re not alone. Eczema is a very common skin condition that is treatable and can be kept under control.

Although eczema can be chronic and persistent throughout your life, early diagnosis and medical intervention will help to mitigate your symptoms effectively. It is important that you consult a dermatologist who is experienced in treating eczema in order to improve your quality of life.

Why do I develop an allergy?

• Immune tolerance is essential for our body to harmoniously handle and have peaceful coexistence with many food proteins and external antigens on a daily basis.
• Allergic reaction develops e.g. allergic rhinitis, asthma, atopic dermatitis, food or drug allergy, when our body becomes intolerant to the external antigens.

Do I need to do any food allergy test? Is there any food that I need to avoid?

• The vast majority of patients do not require a food allergy test. Dr Wong does not order any food allergy test routinely unless in special situation.
• Keeping a food allergy journal is more useful. Discussing with your dermatologist over your observation of the association of eczema outbreak and certain food is more relevant than doing test blindly.

Why do doctors continue to use steroid cream as the first line of treatment for eczema despite so many known side effects?

• Common side effects of steroid creams include skin thinning, stretch marks, easy bruising, enlarged blood vessels, and localised increase in hair.
• Steroid cream is still used as first line treatment most of the time because it is effective and affordable.
• When a patient wants to save the cost of a consultation and starts buying steroid cream on his / her own, that is when the problem starts.
• Side effects occur when a patient self-medicates, often with the most potent steroid cream, or is not under the supervisory care of just one primary doctor.
• Not all steroid creams are of the same potency. Some creams are a lot more potent than others.
• Dermatologists are trained to supervise, manage and minimize the side effect impact of steroid treatments. They will advise the patients when to reduce the cream or switch to gentler steroid creams over the course of treatment.
• Dermatologists will also administer holistic skin care to reduce the side effects of steroid cream e.g. anti-bacterial treatment, regular moisturization and steroid sparing cream or oral medicine.

In what circumstances are oral steroids or oral immuno-suppressants recommended?

• Since there is immune over-activity in the skin of patients with eczema, oral steroids and immuno suppressant drugs are very useful and important in the treatment of eczema.
• Oral steroids and immuno-suppressants are used when patients have very severe eczema that is not responding to topical treatments, when their sleep or quality of life is severely affected.
• Common side effects of oral steroids include thinning of the bone, weight gain, increased chance of infection, increase in blood pressure and blood sugar, increased risk of developing glaucoma, cataract and stomach ulcers, muscle weakness and mood changes. Side effects of oral immunosuppressants include increased blood pressure, liver or kidney impairment.
• For many patients, the benefits of these oral treatments usually outweigh the risk of the side effects. A short course of oral steroids e.g. 1-2 weeks usually cause no side effects.
• Many patients have benefitted from such treatments as their inflamed skin is finally controlled. They can sleep better and live as normal a life as possible.

FDA-approved drugs such as Elidel cream and Protopic ointment claim to have no side effects apart from “Black Box” warning of increased risk of cancer. How concerned should I be?

• Topical immunosuppressant drugs like Elidel and especially Protopic ointment are very useful because they reduce the use and reliance of steroid creams. Dermatologists all over the world are using them, especially in situations where there are concerns over the use of steroids.
• It is especially useful on the face, around the eyes, neck and groin area.
• We share with patients that the FDA “Black Box “ warning of increased skin cancer is only observed in the animals during the trials.
• Dermatologists have been monitoring very carefully with regard to the occurrence of skin cancer and the use of Elidel and Protopic over many years and are not alarmed so far. The likelihood of cancers occurring in real life patients is very low.
• Despite the controversy, most patients accept our recommendation.

When will you recommend the use of Dupixent, the latest drug in the fight of eczema?

• When a patient has moderate to severe eczema that is not responding to topical treatments, when their sleep or quality of life is severely affected, I would consider offering Dupixent.
• The cons with Dupixent are the high cost of treatment and the reluctance of insurance companies to reimburse the cost of treatment.
• The pros of Dupixent are that it is free from serious organ side effects and the need for any frequent monitoring blood tests.