This article could have been no more than a simple table of triggering factors and how they might be prevented, but in that case the tone would have been dry and academic, and indifferent to the reasons for writing it. Because the very existence of this article is the result of a question heard in a hospital corridor:
Why bother to try and find the triggering factor when you have to treat the problem anyway?
So let’s imagine the following scene: your house is on fire – what do you do?
• I’d put out the fire,
• OK, but two weeks later there’s another fire, what do you do?
• I’d put it out again,
• OK, but there’s another one, what do you do?
• I’d call the fire-brigade,
• OK, but it happens again,
• I’d move house,
• OK, but then it happens again...
• I’d start wondering why it keeps happening.
That was a little snapshot of what might happen in a therapeutic education session on atopic dermatitis, where patients get to move away from the immediate question of managing the flare-up to that of why the flare-up occurred.
There are several advantages in finding the cause:
1. It brings back rational thinking and soothes anxiety. Not knowing what has caused the flare-up just seems to exacerbate the feelings of powerlessness and guilt experienced by patients. And that just adds stress to existing stress and therefore to the disease
2. If the causes of the crisis can be identified then we can start thinking about possible means of prevention. If the most critical period is winter, would it make sense not to wash so often?
3. If a crisis can be foreseen then behaviours can be changed and treatment can be increased in anticipation of a probable flare-up: if partying results in increased itching, the patient can choose to either not party or to increase their treatment around party time…
4. The idea is to “unglue” patients from their experience – the itching – and create a space for thinking, in between their own ideas and those of their healthcare providers, that goes beyond “eczema is hell and all doctors do, is to prescribe cortisone”.
Why has this research been neglected?
There are a number of non-exclusive, non-exhaustive hypotheses underlying the question expressed by our young colleague:
1. He doesn’t know the factors that trigger flare-ups
2. He is echoing a societal mentality that has nothing to do with the medical world. You can just buy a solution to problems rather than trying to find what causes them. A little sample of modern-day consumer thinking!
3. He is under the illusion that treatments are 100% successful
4. He hasn’t been persuaded that prevention is better than cure
5. He is still under the illusion that a good doctor makes symptoms go away, although when the issue is one of chronic disease he really should be asking himself a few questions…
What are the factors that trigger flare-ups?
So let’s take a look at the triggering factors, still using the house-fire metaphor as our example. When fire breaks out, one or more boxes of matches must be involved. But which ones?
The first triggering factor is to do with hygiene
There are a number of traps awaiting us here
• Words don’t always mean the same thing to doctors and their patients: for example, does washing mean washing in general, or just having a shower, or just washing one’s hands and/or face? It needs to be made very clear: tell me what you do in the morning, in the evening...when patients start their sentence with “I” and follow it with a verb in the present tense, we know that they are taking us through the scene, describing exactly what they really do, their usual habits and everyday actions. For example: a 14-year-old girl seeks treatment for chronic lip eczema that she has had for 3 years, in an atopic context. None of the treatments prescribed work and allergy tests have not revealed any allergies. Tell me what you do! This young girl had 14 different cosmetic products – acne, make-up, atopy, morning, evening…5 products were negotiated and the eczema went away of its own accord.
• Everything to do with hygiene is hugely associated with underlying values that must be detected and discussed if failure and non-compliance are to be avoided. Resistance to change can be deeply rooted in habits, fears and needs. Deodorant use can hide an obsession with smells, which to the patient mean laxity, poverty, rejection. Personal hygiene gel use can hide the need to control sexually transmitted microbes, involving all the stigma linked to sexuality, and the use of cosmetics can hide the need to comply with the criteria that define attractiveness in the eyes of our consumer society. Healthcare providers must not be afraid, therefore, to broach the personal reasons that make patients choose such and such a product, so that they feel that they are understood and are able recognise the mistake they are making.
• The other trap concerns dry skin management: When you ask the question: what do you do about dry skin? The patient replies: I moisturise. Very few reply: first of all I’m careful never to strip it of its natural oils and secondly I moisturise. Not everyone understands that cleansing treatments can worsen the condition of the skin. A good example to use here is that of doing the washing-up, everyone knows that hot water removes grease from dirty dishes, so this helps patients to understand that hot water removes natural oils from the skin. Not everyone understands what is meant by a product stripping the skin, so it’s a good idea to use the example of a loofah and explain that many cosmetics are about as soft as a loofah! Lastly, the idea that you don’t have to wash every day, and that you don’t have to wash with a special shower product every day, is often extremely hard for people to believe, as most patients are convinced that they are doing the right thing, and following the latest hygiene rules by washing every day. Again, patients won’t change their minds or depart from positions they have held for a long time, unless another idea comes along to break these habits. It is not unusual for patients to discuss things amongst themselves during therapeutic education sessions, and if any of them have already taken the plunge and stopped washing every day, they will be able to tell the others about their experiences, and the strategies exchanged will be all the more credible in that they all suffer from the same disease
• Some patients’ skin causes them so much suffering that their only respite is to have a steaming hot shower. Of course it does bring instant relief – but it doesn’t last. Only with treatment will they be able to stop resorting to this desperate – and extremely harmful – measure. It is vital that they are not made to feel guilty for needing to do it – on the contrary, it is important to recognise that it is a habit born of great suffering. This recognition will be useful to the doctor-patient relationship.
• The importance of this stage follows on from the previous stage, when the patient was asked to guess how their skin works. For if a patient has not really got to the bottom of their skin’s basic problem, they cannot begin to understand the advice about washing. So it all starts with finding out about atopic skin, through one question after another: what does ‘dry’ mean? Lack of water! Yes, so does that mean you have to drink lots of water? Take two glasses of water, one of which has a layer of oil on top, and ask the patient what will happen to the glasses of water if they are left on top of the radiator. This helps patients to see for themselves that dry skin is the consequence of a lack of oil. At this point, tools are often needed: a drawing of the glasses of water and a drawing of a wall whose cement is of poor quality owing to a lack of the necessary fatty substances. A box with holes in the lid can also be useful for patients who need to touch things to understand how they work.
• So then comes the nitty gritty: how can we repair this skin, when it’s so full of holes it’s like a sponge? Our patients know very well that the answer is to apply an emollient cream, but the trick is to explain that in 2017 science has yet to invent a miracle pill that will sort everything out in 5 minutes, thereby destroying their as yet unexpressed illusion.
• Once all these misunderstandings have been cleared up, you can then quickly run through the list of boxes of matches in terms of hygiene: a shower that’s too hot, too many showers, showers that are too long, shower gels that strip the surface of the skin, using soap, forgetting to moisturise, only moisturising when you have a shower, not counting the time spent washing your hair or shaving when you count how long you spend in the shower, using make-up remover as well as a cleanser, a serum, a toner, an exfoliating scrub, a deodorant, an anti-dark circles cream, etc., thinking that moisturiser is all you need to treat a patch of eczema, using one moisturiser for the patch of eczema and another for the rest of the skin, etc.
The second triggering factor concerns ambient air
The second box of matches is the direct consequence of the previous one: if the skin is like a sponge, it will absorb everything that’s floating around in the ambient air. This amply explains flare-ups during pollution peaks, the pollen season, when the council is carrying out road works in the district, when the patient’s son has been clearing out his room, etc. Apart from not hanging the washing outside during the pollen season and giving the skin a good rinse as soon as possible after a country walk, unfortunately there isn’t much they can do as far as prevention is concerned. Nevertheless, we must not forget that it is absolutely crucial to explain what causes the flare-ups, so that patients can stop seeing themselves as eternal victims
The third triggering factor concerns skin flora ( biotope)
The third box of matches involves the permanent imbalance affecting the skin biotope in atopic dermatitis, which favours staphylococcus across the majority of the skin’s surface and pytirosporum, or mallassezia, in the head area.
To find out if a patient is particularly affected by this hypothesis, just ask them if they itch more when they perspire.
This is because sweat is a salty medium that promotes the proliferation of staphylococcus. Another way of finding out whether staphylococcus is involved is to see how the patches are distributed. As another feature of staphylococcus is its tendency to hide away in the hair bulb, any patches on parts of the body where hair grows indicate staphylococcus involvement.
The proliferation of staphylococcus is significantly under-estimated, despite the fact that all recent studies prove that this bacterium can exacerbate the skin’s porosity, thus instigating a vicious circle. This has three, not insignificant, practical consequences:
Any gentle antiseptic (e.g. Dalibour water) contained either in cleansing products or emollient creams, will complement the patient’s usual treatment products. The usual alcohol-based antiseptics should not be used on skin that is already under attack from the atopic dermatitis itself. There was a time when bathing the skin with Septivon was recommended, and the Canadian atopic dermatitis website advocates bathing in bleach.
Micro-nutrition, i.e. taking oral dietary supplements, can sometimes prove useful – particularly as regards zinc, a cofactor of dermcidin, one of the skin’s antimicrobial peptides, which is secreted by the sweat glands, and vitamin D, which has been shown to be deficient in atopic patients and is needed for the secretion of cathelicidin, another of the skin’s antimicrobial peptides.
Lastly, a balanced diet is crucial: as excess salt or fast sugar promotes the proliferation of staphylococcus, it is relatively easy to advise patients to reduce their consumption of industrial food products, fizzy drinks and sweets, etc.
As regards the head area, imbalance in the biotope favours a yeast which generally appears in excess in patients presenting with dandruff or persistent patches of dermatitis on the face. Some cases may even be caused by genuine sensitisation. So it isn’t hard to prescribe one of the three anti-fungal shampoos that are available on the French national health service as an annual repeat prescription, if the patient finds it helps.
The fourth triggering factor concerns the digestive system
The fourth box of matches involves the intestinal biotope.
Although the role played by the intestinal biotope is not entirely clear as yet, nothing prevents us from thinking about common situations that either improve or impair this microbial universe.
It can be improved with probiotics – impairment depends on the patient’s diet and whether or not they are frequent users of oral antibiotics.
We now know about the connections between food and intestinal biotope quality, and, once again, eating too many processed food products, bad fats, salts and fast sugars should be avoided.
As for antibiotics, we have known for a long time that they promote digestive candidiasis, and recent studies support the long-standing idea that candidiasis and atopic dermatitis are connected.
So will simply prescribing probiotics fix everything?
Let’s use another metaphor to get the message across: if you want to plant a fir tree in your garden, what do you do?
• you buy a fir tree, which shows that you can tell the difference between a fir tree and an apple tree,
• you dig a hole in your garden,
• you check that the soil and climate are suitable for growing a fir tree.
Because, if you buy a fir tree, and you dig a hole in your garden but you live in the Sahara Desert, there’s no way your fir tree is going to survive. So to ensure that the intestinal flora is optimally improved by taking probiotics, it is important to
• know which strain to take: lactobacilles rhamnosus GG
• dig a hole: take an oral anti-fungal agent for the digestive tract,
• have suitable soil and climate conditions: improve the diet.
The reason it has taken such a long time for medical studies to prove that probiotics are useful in treating atopic dermatitis, is because they only looked at 1 of the 4 criteria and ignored the others. At this point it is important to define what is part of the medical evidence base and what isn’t: the use of probiotics is still left up to individuals and oral anti-fungal treatments tend to be used by so-called alternative practitioners, who use grapefruit seed essential oils or oregano. My premise here is that it is always interesting to understand how people think and find the underlying scientific logic.
So prevention means promoting a balanced diet, and micronutrition also has a role to play if we are to avoid the need for patients to take oral antibiotics. At this point it is worth returning to our conversation with a patient: “Do you often take antibiotics? No, not at all. When was the last time you took some? Last winter, and how many times a year do you take them, oh just once or twice”. People are so used to taking them that for most patients, taking two courses of antibiotics twice a year does not seem excessive. Prevention entails bringing this number down to zero. No antibiotics at all! To achieve this, micronutrition recommends taking iron, manganese, copper, and vitamins – in small quantities, all winter long.
The fifth triggering factor concerns stress
The fifth box of matches involves stress. Because stress is a patient’s most visible triggering factor, it has the disadvantage of being singled out as the only such factor, which serves to exacerbate the “Eczema is all in the mind”, mental dictatorship, which some patients even legitimise with the cliché “anyway, I have a nervous disposition”. The connection between stress and atopic dermatitis is such a richly fascinating subject that it merits an article all to itself.
In fact it is that particular idea that is the main reason for the feelings of guilt experienced by parents, who don’t understand why their child has eczema and cannot see the point of treating it because they have fallen for the line that their child’s problem is psychosomatic... It is vital we don’t bring up the subject of stress – i.e. the emotions – straightaway. Our patient is far too vulnerable, and has been for far too long. First we have to restore their trust – both in their treatment and in their healthcare providers – so that one day they can begin to trust themselves again. Because the fundamental issue with atopic dermatitis, for both children, teenagers and adults, is that these patients are so very vulnerable on the inside, making them hypersensitive to any kind of stress, which in turn sets up a vicious circle between their skin and their emotional system. The subject of stress should only be introduced once the skin is better and the patients can manage it themselves.
Summary: If we compare atopic dermatitis to a fire, the triggering factors comprise 5 boxes of matches:
• dry skin,
• the ambient air,
• the skin biotope
• the intestinal biotope
It’s like a jigsaw puzzle. Patients need to know how to use it, so they no longer find themselves saying: “I’ve had another flare-up and I don’t know why”.
Thus the dermatologist becomes Sherlock Holmes’ Doctor Watson, creating a team to investigate and understand flare-ups and following every last little clue to find their cause.
The consequences of such practice offer a number of advantages:
• Patients no longer see their doctor as a blind provider of prescriptions who takes no interest in their fate
• Patients can foresee what might happen and find their own ways of avoiding their triggering factors
• They understand that they are unique – what works for one doesn’t always work for another
• They can gradually begin to become independent again and regain the thing that is most lacking when it comes to getting their lives back on track – trust. Trust in their treatment and trust in their healthcare provider – with the ultimate aim being to regain trust in themselves.
• The key to compliance is trust