Dr Lim Kar Seng, Senior Consultant Dermatologist at The Dermatology Practice talks about moderate to severe eczema and how new treatments can help manage the condition.
For Life (FL): What is eczema and how prevalent is it in Singapore?
Dr Lim Kar Seng (Dr L): Eczema, or atopic dermatitis, is a chronic inflammatory disease that affects the skin, causing irritation, itch, and redness of the skin. About 20% of children and 10% of adults in Singapore suffer from eczema. It can be passed down from parent to child, and although 80% of children outgrow eczema by the time they turn eight, those who have more severe forms of eczema are likely to have symptoms that persist through adulthood.
FL: What are the different forms of eczema?
Dr L: Eczema presents as mild, moderate, or severe. Mild eczema is characterised by dryness, redness, and itching of the skin, affecting smaller areas such as the folds of the skin and hands. Moderate to severe eczema tend to spread over a larger area such as the back and legs. Patients experience a more intense itch and scratch cycle, often leading to thickened, swollen, and flaky skin. The prevalence of moderate to severe eczema among Singaporean young adults is reported at 26%.
In some severe cases, the skin becomes infected, a condition known as infected eczema. In these cases, patients will notice bleeding and oozing of pus from the sores; the skin usually becomes swollen and sore. Unfortunately, when the skin is affected by moderate to severe eczema, it becomes nearly impossible for patients to perform daily activities. For instance, taking a shower can hurt, and constant itch can prevent patients from getting sufficient sleep.
FL: What are eczema triggers and how to avoid them? How can patients manage their eczema better?
Dr L: Everyone’s triggers are different, so it’s critical to identify your eczema triggers and avoid them when possible. While we may be able to avoid triggers such as dust and gluten, stress is a part of life and almost impossible to avoid. So, I advise my patients whose eczema is triggered by stress to find ways to alleviate it, such as through exercise or meditation. Patients who suffer from eczema must moisturize regularly. Since the skin’s natural barrier is compromised in eczema patients, moisturising helps maintain the integrity of the skin’s barrier and allows the skin to fight infections.
There is a lot of misinformation circulating online about eczema, so I would advise patients to always consult a dermatologist first before embarking on any treatment.
FL: What kind of treatments can help manage moderate to severe eczema?
Dr L: There is a treatment step ladder for the management of eczema. As well as trying to avoid one’s specific triggers, using moisturisers is the mainstay of treatment. The next step is using topical steroids. Fortunately, there are non-steroidal alternatives today for patients who are not comfortable taking steroids. Mild forms of eczema can be managed with moisturising and low-dose steroid creams. If these are still not sufficient to manage the eczema, doctors then prescribe phototherapy, followed by systemic treatments which are prescription oral drugs.
We have newer treatments like biologics and JAK inhibitors, which are a newer class of drugs that has been shown to help patients manage moderate to severe eczema. I tend to prescribe these treatments in combination, for example, I may recommend applying moisturisers as well as JAK inhibitors.
FL: Please share more about JAK inhibitors.
Dr L: Janus Kinase or JAK inhibitors is an oral pill that can stop the itch-scratch cycle, allowing the skin to heal and reducing the risk of skin infections. It reduces the inflammation of the skin by disrupting the inflammation-signaling mechanisms that control inflammatory proteins in our body. Consequently, for eczema patients, the immune system is not as overactive as before, leading to better control of the symptoms.
FL: What are the benefits of JAK inhibitors you have observed in patients?
Dr L: One thing I notice in patients on JAK inhibitors is that their itch symptoms improve significantly and quickly, usually within a few days on the medication. Within two weeks, the redness and swelling substantially decreased too.
Because JAK inhibitors come as oral pills, it is easy for patients to include this medication in their daily routine. I usually prescribe them to patients who suffer intense itch-scratch cycles. Patients are recommended to take the pill daily until their eczema has stabilised.
FL: What are the concerns that patients have with regard to JAK inhibitors?
Dr L: The JAK inhibitors are generally a safe medication but as a precaution, I send my patients for a health screening and blood test before they take their first pill, and a month or two after they have been on the medication. I do not prescribe JAK inhibitors to patients who have a history of cardiovascular diseases.
Some patients have reported mild side effects such as nausea, but it is tolerable. Most of my patients are comfortable taking JAK inhibitors and I have not had any patients stop their medication due to side effects.
Photo by Dreamstime, Doctor photo courtesy of Dr Lim Kar Seng