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Dr. Tarbox: Hello, and welcome to "Skincast," the podcast that teaches you how to take the very best care of the skin you're in. My name is Michelle Tarbox, and I am an associate professor of dermatology and dermatopathology at Texas Tech Ï㽶ÊÓƵ Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hello.

Dr. Tarbox: So today, we're going to follow up our previous podcast episode that talked about eczema, what causes it, what might trigger it, what it might do over the course of a patient's life. And today, we're going to talk about how you treat it.

Dr. Johnson: The medical term for eczema is atopic dermatitis. So if you've heard that term, that's what we're talking about. And in our last episode, we talked about how one of the primary issues that causes, or at least helps to perpetuate, eczema is what I like to call leaky skin. So your skin is supposed to be a nice firm barrier against the outside world. For people with eczema, it's leaky.

Again, you can listen to that episode if you want to hear me say the word leaky more often with more detail.

But because of that concern, one way we treat eczema is by repairing the skin barrier, which we do with moisturizers.

Dr. Tarbox: So, Luke, what is in your leaky cauldron of products that you like to use on skin that has become leaky?

Dr. Johnson: Well, most people, I think, know that moisturizers can be helpful for eczema and dry skin. Dermatologists are super nerds, and so we draw a distinction between lotions, and creams, and ointments, and humectants, and emollients, and all kinds of stuff that a lot of people just call lotions. And that's fine. Most people aren't dermatologists, so they don't have to worry about all this stuff, but we do.

And the most effective moisturizer you can use to repair your skin is the thickest and greasiest thing that you or your child will not feel terrible about putting on your skin.

So I tell people, "I want you to use something you kind of like, because I don't want you to be cursing my name every time you put this stuff on your skin. But the thickest and greasiest thing is best."

So the thickest and greasiest thing out there is just petroleum jelly. Vaseline, for example, is the original. But Vaseline is a company that makes a number of different products now. But just petroleum jelly, also called petrolatum. You can buy the generic brand. It's thick, it's greasy, nobody gets allergic to it. It's kind of messy, though.

Dr. Tarbox: There are a couple of other products that are somewhat similar. There's one called Waxelene that's actually made from beeswax if people are averse to using petrolatum products. And there are other products available as well that are replacements for petroleum jelly.

Dr. Johnson: So other nice options are shea butter and coconut oil. So shea butter and coconut oil are both thick and greasy and they don't have a lot of ingredients that can cause people to develop allergies in their skin to them. Coconut oil, in particular, has some medical studies that say it's especially good for the skin.

Other oils are also all right, especially sunflower and safflower oil. Again, those have specific studies that say they're especially good for the skin.

But don't use olive oil. For some reason, that disrupts your natural oils. But other oils, baby oil, oil, mineral oil, other food oils, those would be okay.

And if those are still not your cup of tea or your cup of oil, then anything that's nice and thick that you have to scoop out of a jar or squeeze out of a tube that's called a cream or ointment, those would be good choices. The lotions, which are lighter and can pump out of a pump bottle, can be fine if you just have dry skin, but I don't think they're going to do the job if you or your child has eczema.

Dr. Tarbox: I sometimes tell my patients a lotion is like a potion. It's mostly liquid. And that liquid can sometimes evaporate if a person's barrier doesn't work. It actually evaporates and takes more water with it. So it can actually make things worse.

If you are petroleum-averse and you want to try something that's a little bit different, there's another product I also sometimes recommend called Alba Botanica Un-Petroleum. So it's not petroleum. It's un-petroleum, which is another kind of plant-based product that is very soothing, and very gentle, and not terribly expensive.

Dr. Johnson: Though, remember, petroleum was once a prehistoric plant, so in a way it's plant-based.

Dr. Tarbox: Oh, Luke.

Dr. Johnson: I think it's helpful to know that after the skin is inflamed . . . So if you've got eczema and you're pink and itchy, or your child is, the moisturizers aren't going to do much. They're much better at restoring the skin barrier and preventing the rash from showing up than at treating the rash in the first place.

They're, of course, better than nothing, because if you're putting moisturizer on the rash, then it's not going to be getting worse while the body heals itself. But it can take a while.

But as long as you mentioned that moisturizers can sometimes evaporate and make the problem worse, I want to talk about bathing techniques. So, people with eczema have skin that's more easily irritated than people without eczema. And so all kinds of stuff can be more drying or irritating to the skin, including various soaps and shampoos and so on.

And it turns out that the human body doesn't necessarily need soap, except in the problem areas. You can't see me pointing because this is a podcast, but the problem areas are the armpits and the groin and places like that that get smelly. But we don't really develop problem areas until we become stinky teenagers.

So especially for babies and little kids, I recommend just plain water baths. No soap, no shampoo, no bubble bath, nothing except water and toys. Toys are fine. Let them hang out for about 10 minutes. At the end of that time, you can shampoo their little heads if you want, but then get them right out so they're not sitting in the shampoo-y water. And don't dry them off.

So as you pointed out, Michelle, if something that's water or water-based gets on the skin, once that water leaves the skin, whether it evaporates or it's towel-dried or whatever, it takes more water away with it.

So any time water gets on your skin, it's going to dry you out. So the solution is to seal in the moisture that's seeped into the skin during the bath.

So if your kid is sitting in a bathtub for 10 minutes, that water is going to seep into the top layer of the skin and hydrate it. You take them out and then while they're still dripping wet, you grease them up with Vaseline. That water that's seeped into their skin cannot evaporate away. And if you do it that way, giving your kid a bath is a good way to restore the skin barrier.

If they do what I think most people do, which is soap up a lot and get out and towel off, that's fine if you don't have eczema, but if you do, I think it's going to make the problem worse.

Dr. Tarbox: Yeah, sitting in soap is pretty much a recipe for disaster for little kids with eczema. So I think that you do have to be careful about that. I think other water exposures, too. You have to think about pools or sponge baths, or even kids playing with water-based things.

Dr. Johnson: Yeah, what we call wet-dry cycles are really tough on the skin if you've got eczema or your child does. So sponge baths will really dry the heck out of your child. For adults and teenagers who have eczema and prefer to take a shower to a bath, I often recommend that they keep their moisturizer and their medicines in the shower with them. So you turn off the water, you grab your Vaseline, and you rub it all over yourself.

By the way, I know we've used a few brand-name products, so it's probably important to point out that we are not sponsored by anybody. So we're not getting kickbacks from Vaseline for better or worse.

Dr. Tarbox: So what else can you do to help treat it, Luke? What is one of your favorite go-tos?

Dr. Johnson: Well, if we're going to use medicines, which we should use if you have an itchy red rash, then ointments are better than creams, just like ointment-based moisturizers are better than other types of moisturizers. The medicines work better. Plus, they moisturize the skin and repair the skin barrier at the same time.

So we use a lot of topical steroids. So remember, topical means something you put on the skin. You put "on top" of it, if you will. And hydrocortisone is the steroid that's available over the counter. So hydrocortisone 1% ointment is a pretty decent option if you want to start treating your own or your child's eczema at home. And what I normally recommend is that you do it twice a day.

Frequently, I recommend develop a routine where twice a day, you put medicine on rash and moisturizer everywhere else. Moisturizer doesn't need to go over the top of the medicine, remember, because the medicine that you're using is already a nice gloopy ointment. It's already like a medicated moisturizer, so you don't need to put it over the top. And if you do, that would dilute the medicine. So just medicine on rash, moisturizer everywhere else, twice a day. And that works for a lot of people.

Dr. Tarbox: I think also minimizing irritants like we talked about, staying away from irritating soaps, heavy fragrances, and dyes. One of the things that I always find people kind of forget about is the detergent that's in the clothing. So I actually think that that's a very important step that people can take.

The one that I prefer is the All Free Clear. I'm personally actually quite sensitive to Tide. And if you are sensitive to Tide, you're sensitive to the detergent itself, not to the fragrance or dye. So even the Tide Free and Clear is still going to be pretty irritating in a patient population that's sensitive.

Dr. Johnson: Costco also makes their own version, a Costco version that's like All Free and Clear. So, because the skin is more easily irritated, fragrances and dyes and stuff can irritate it. So I think that makes sense. Avoid dryer sheets as well for similar reasons. And then . . .

Dr. Tarbox: I like those balls, those little dryer balls. I think they do very well.

Dr. Johnson: I don't actually know what you're talking about.

Dr. Tarbox: Oh, there are little dryer balls that can either be little plastic things that are spiky that are sort of coronavirus reminiscent. But they help kind of fluff up the laundry. Or you can use wool dryer balls if you don't have a sensitivity to that. And it helps to kind of take the static cling out of the clothes and replace the fabric softener.

Dr. Johnson: How about that? Coronavirus dryer balls. . .

Dr. Tarbox: So what about bleach baths, Luke? What do you think about those?

Dr. Johnson: So a lot of my patients and parents have heard about bleach baths, and when you first hear it, it sounds crazy. "I'm not going to give my child a bath in bleach!" And that would be crazy. But a bleach bath is actually just putting a little bit of bleach into the bathtub.

Bleach is sodium hypochlorite. That's its chemical name. And so basically, you're putting chlorine and calcium sometimes into the water. And that kind of makes it like a swimming pool. So like a swimming pool is chlorinated, you can sort of chlorinate your bathtub by putting a little bit of bleach in there.

You don't put in very much. If it's a baby bathtub because you have a baby, then you do a little cap full of bleach. And the cap on a bleach tub is very small. So it's not a lot. And for a full adult size bathtub, it's like a quarter to a half a cup. So it's not very much. And then otherwise, you take the bath as normal.

To be honest, I think the medical data to support bleach baths is kind of wishy-washy.

Dr. Tarbox: Ha-ha.

Dr. Johnson: Thanks. But there are pediatric dermatologists who really swear by them. So I think they at least work sometimes for some people.

I don't feel strongly, and taking care of eczema is already a lot of work, so if people are already doing it and they think it works, I think it's fine to keep doing it.

If people aren't already doing it, I usually don't recommend it to begin with just because there's a lot of other stuff. Twice-a-day medicine to rash, moisturizer everywhere else is already kind of a lot of work, plus all these other bathing techniques, that layering on bleach baths as well seems like a lot. But I think they can help some people, and they're pretty safe as long as you don't put in too much bleach.

One complication, though, is that a lot of "bleach" that's sold these days is not just pure bleach. It's got other stuff in it. So if it says it's splashless or it's color-safe, for example, it'll have other ingredients in it that can be irritating to the skin. So you really need to find something that's just plain old, industrial bleach that probably comes in a scary-looking bottle. And oftentimes, you can't even find these at big stores like Walmart and Target anymore. You might have to find them online.

Dr. Tarbox: One of the reasons people think that at is because it decreases the bacterial colonization of the skin. And some patients with atopic dermatitis or eczema do struggle with recurrent bacterial infections. In that patient population, I think it can be helpful, partially because we actually have something in our own what's called innate immune system, which is our fast sort of primitive immune system, called hypochlorous acid, which is very similar to the active ingredient in bleach.

Now, if using bleach in the tub is kind of not appealing to you or if you're a person that takes showers instead of baths, there's a product line called CLN, which is actually based off of that skin-safe hypochlorous acid, and that can be used even in small children with their gentle wash.

Dr. Johnson: Some people use vinegar instead of bleach as well. It probably can potentially have similar effects, though I don't think that the medical data is as strong. I just don't think there have been as many medical studies on it. But it also is potentially useful and can make you smell like an egg.

Dr. Tarbox: So rinse off.

Dr. Johnson: I want to talk a little bit about natural sunlight. So, there's a particular wavelength of light that's helpful for inflammation in the skin, and dermatologists have machines that produce that particular wavelength of light. But that wavelength of light is also present in natural sunlight. So are a bunch of other wavelengths, including wavelengths we don't like that can cause sunburn and increase your risk of skin cancer later on in life and so on. But natural sunlight, since it does carry that wavelength, can be helpful for inflammation of the skin with something like eczema.

So if you wanted to try that, you would want to stand outside in the sunlight for 10 to 20 minutes per day. The 10 to 20 minutes is sort of based on the season and your latitude, and you want to wear as little clothing as is comfortable and convenient for you. And just do that every day.

If you're going to be out or your kid is going to be out for longer than 10 or 20 minutes, you want to do the whole sunscreen and hats and long sleeves and everything that dermatologists usually recommend. But a little bit of sunlight can actually be helpful for eczema.

Dr. Tarbox: You do have to be careful about areas of the skin that are very sensitive to the sun. Of course, we want to protect the areas that aren't involved with the eczema. So if you have non-fatal eczema, maybe protecting the face would be appropriate.

So what kind of medical treatments are available as a prescription, Luke?

Dr. Johnson: So, if you or your child has eczema and you've done over-the-counter hydrocortisone ointments, and you've used some good moisturizers, and maybe you've even tried bleach baths or natural sunlight, and things still aren't very good, well, you're in good company for starters because those are not strong treatments and they'll work if you have really mild eczema, but not if you have anything worse than that. And that's where dermatologists can really help you. We've got lots of things we can do for eczema. There's no reason to suffer with it. We can reduce it to an inconvenience.

We can't cure it. I'm sorry, we can't. Maybe one day we will. But we can at least reduce it to an inconvenience as opposed to something that dominates your life or your family's life.

Usually, we use stronger topical steroids than hydrocortisone. Some people are a little bit worried about topical steroids and potential side effects, but dermatologists, part of our training is to learn which ones are safe to use in which age groups and which part of the body.

And then we can use this special wavelength of light that I talked about potentially and use one of our machines to deliver that.

And then if that still isn't working and you or your child has really bad eczema, there are medicines that we call systemic medications that are given either via a shot or taken by mouth that can affect the whole body. We usually only use those for really bad eczema, but I think it's important to know that those are out there.

So if you or your child does have really bad eczema, there are some pretty good options these days to make it better.

Dr. Tarbox: And there are new medicines coming down the pipeline that are alternatives to steroids. They're still in studies, but we have new medicines that we're developing every day to help patients with these conditions.

So, Luke, what about what doesn't work?

Dr. Johnson: Since eczema is so common, I think that there have been a lot of misperceptions about what could or couldn't work. And one of those reasons is because eczema just gets better, gets worse, gets better, gets worse on its own. And there's a tendency to think that when it gets better, it's something we did, or when it gets worse, it's something we did.

But antibiotics, for example, don't particularly work for eczema. Now, because the skin is leaky and has little holes in it, it's easier for bacteria to get in the skin of eczema than to other skin. So it's actually fairly common for eczema to get a bacterial infection in it. We call that impetigo, or we say that the eczema is impetiginized. And in that case, antibiotics can help. So your dermatologist, for example, might prescribe a short course of antibiotics to get rid of that.

But otherwise, just antibiotics aren't going to help, especially topical antibiotics that you might buy over the counter, like Neosporin. Dermatologists are very suspicious of Neosporin because of the surprising number of people develop an allergy to it. The reason it seems to work for a lot of things, I think, is just because it's a nice gloopy ointment like petroleum jelly. So petroleum jelly, please. Neosporin, no.

Dr. Tarbox: At least about 10% of people are allergic to Neosporin. That's a fairly significant percentage. And that can make the eczema that's already bad act even worse.

Dr. Johnson: Sometimes people get systemic steroids. So they have names like prednisone or prednisolone or dexamethasone. Those can be given by mouth or as a shot, especially if somebody's eczema is so bad that they go to the emergency room, for example.

Those can help in the short run. They make the eczema better while you're taking them or using them. But then the eczema often will get worse afterward, and we worry that they kind of make it worse overall in the long run. So you want to avoid those if you can.

Now, if you or your child needs steroids for other reasons like an asthma attack, definitely take them even if they have eczema. But I don't like them if they're just used for eczema.

Dr. Tarbox: What about changing the diet?

Dr. Johnson: So again, this goes back to the idea that we want to be able to control it because it gets better, gets worse, gets better, gets worse on its own. Maybe it was the eggs we gave him the other day. Well, there's been a lot of research into this, and in the vast majority of cases, the diet does not affect eczema. So you don't need to change your diet. Your child doesn't need to change their diet. A breastfeeding mother of a child with eczema doesn't need to change their diet.

Kids with eczema do get more food allergies than other kids. That's true. But they tend not to be related to eczema.

There are probably a few people out there where this is not the case. So maybe like 1 in 200 kids, for example. Especially if you've seen a dermatologist and they've prescribed stuff and you've done it all the way you're supposed to and the eczema still just isn't getting better or seems to obviously flare whenever they get a certain food. Then that might be worth exploring, but it's quite uncommon.

Dr. Tarbox: So I think that there are lots of different ways you can go after eczema. But the most important thing to know is that there are ways that we can help even severe cases. So if you can't get it better at home with gentle measures, such as moisturization, changing bathing habits, and watching what you're putting on or near the skin, then it's very appropriate to seek help from a medical doctor.

Dr. Johnson: Thanks for listening to us chat about eczema today, guys. That's all we've got. I want to thank our institutions, of course. Thanks to the Ï㽶ÊÓƵ of Utah Department of Dermatology for supporting the podcast and employing me. And thanks to Texas Tech for lending us Michelle.

If you are a total dermatology nerd like Michelle and I, you might be interested to know that we have another podcast. It's called "Dermasphere," and is really intended for other dermatologists and similar folks. But if that sounds cool to you, check it out, Dermasphere.

Otherwise, hope your eczema gets better soon, and we'll see you next time.