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.