Sunday, May 14, 2017

Eczema...Undergoing a Treatment Renaissance.

If you or a family member suffer from severe eczema (atopic dermatitis), you may feel like you have been living in the Dark Ages.  Every time you go to the doctor, you hope for some new therapy, but it has always been the same answers for the last 10 years with a variety of creams, foams, and gels that more or less left you scratching your itchy skin.

It is now the dawn of a new era in eczema therapy.  Molecular targets have been identified as targets of new drugs.  In other words, the immune system of people with eczema is overly active in certain ways, and medicines have been developed that hone in on those particular elements of the immune system that are too active. One medicine that has just been approved is dupilumab, a target of two interleukins involved in stimulating eczema.  The medicine has been approved for adults, and phase III clinical trials for children are underway.  The study looked at adults who started out with severe eczema, i.e., some of the toughest cases out there.  36-38% of them were "clear or almost clear" at the end of 16 weeks.   The studies also measured something called the EASI score, which stands for Eczema Area and Severity Index.  Around 50% of patients saw a 75% improvement in their EASI score.  These results left me pretty impressed.  If even half of my severe eczema patients can feel and look 75% better, that's a treatment victory. 

Dupilumab is an injectable medication that the patient can self-administer at home.  If that sounds intimidating or scary, don't worry too much.  A nurse educator can train you on how to give yourself the shots.  That temporary prick of the needle may be well worth it in the long run if your eczema is better controlled. 

The side effect profile of dupilumab was not too alarming.  The most common side effect was pain and redness at the injection site, but no one dropped out of the trial due to this side effect.  The second most common side effect was conjunctivitis, or eye redness and irritation.  There was also increased incidence of herpes virus infections.  We are still learning more about how to manage the side effects, but it will be important to mention to your doctor if you have a history of cold sores or genital herpes.  Your doctor may want to prescribe an antiviral medication for you.

Not everyone's immune system is the same, and there will be other molecular targets that can be targeted too.  Several other agents are in phase III clinical trials now for FDA approval targeting other molecules involved in triggering eczema. 

There was also a new topical medicine that was approved for eczema this year, crisaborole.  It is a boron-based medication that inhibits an enzyme called phosphodiesterase that can trigger inflammation.  As opposed to topical steroids, it won't thin the skin over time.  I generally will plan to use this medication in addition to topical steroids so that there can be days when steroid creams are not used but the eczema is still being actively treated. 

Treatment of Staph infection or even carriage of this bacteria in the nose is another point I want to reiterate.  Many patients have benefitted from a regimen that includes a dilute bleach bath just a little stronger than swimming pool water once or twice a week.  The Staph bacteria seem to really love to colonize the impaired skin barrier of eczema patients.  In turn, this stimulates the immune system and the eczema gets worse, and that is why decreasing the numbers of Staph bacteria on the skin is so important.

Finally, don't throw away all of your topical steroid creams yet.  Topical steroid creams for flares and regular use of emollient creams will continue to be the standard for treating eczema.  Not everyone will be a candidate for dupilumab or other molecular targeted therapies.  However, it may be a great time to review your current therapy with your dermatologist to make sure you are receiving the most appropriate regimen for your skin. 

For further reference:
Simpson EL, Bieber T, Guttman-Yassky E, et al.  SOLO 1 and SOLO 2 Investigators.  Two phase 3 trials of dupilumab versus placebo in atopic dermatitis.  N Engl J Med. 2016; 375: 2335-2348.

Wednesday, May 3, 2017

Don't Let the Bedbugs Bite





I had once thought that bedbugs were mere mythical creatures spoken only in folklore by people of my grandparents’ generation. It hasn’t been until recent years that I have discovered in fact the nasty little varmint known as the bedbug really does exist in a place other than my worst nightmare. Apparently, the bed bug has long existed but has only been more recently wreaking havoc in a bedroom near you. And unfortunately their presence has been on the rise and reaching epidemic proportions. I have personally seen an increasing number of patients present with mysterious itchy skin lesions only to find out they have an unwelcomed bedmate. In case you aren’t creeped out already, here are some facts about bedbugs.

What are bedbugs?

Also known as Cimex lectularis, the bedbug is a small insect that feeds on human hosts (yuck!). Their nickname comes from the fact that they tend to set up house in your bedroom, along your bedroom furniture and mattress and wait until you are fast asleep to make their way to you to feed, sometimes traveling several feet during the night to get there!

What do they look like?

Bedbugs are reddish-brown wingless insects that are about the size of an apple seed. So you can see them with your naked eye, but as you can imagine they can be easily overlooked, especially if there are only a few. The nymphs (baby bedbugs) can be even smaller and whitish in color.

How do I get bedbugs?

Bedbugs are the modern day hobo. They hitchhike from place to place as people travel. They may have arrived when your Aunt Sally came to visit after her most recent trip to the orient, or you may have picked them up on your last trip to the beach. And it's not just from the Roach Motel. These guys have caused problems in even the nicest of 5-star hotels, dorm rooms, and apartment complexes. They have even been known to travel down the street from house to house. I have had patients who unfortunately got them from their brand new mattress!


(photo bedbugtreatmentsite.com)

What are the signs of a bedbug infestation?

Patients frequently present to my office with a history of large, itchy red nodules that can persist for several days to a couple of weeks. These are often in clusters of three that we refer to as the "breakfast, lunch, and dinner" sign. This is because the bug feeds, rests, travels a few millimeters, feeds again, and so on.

"I share a bed with my husband, and I am the only one that has bites. It can't be bedbugs!"

Unfortunately, I have seen this many times. One spouse is covered in bites while the other is blissfully itch-free. We are not sure why this happens, but it does. Perhaps it depends on where the bedbugs are coming from each night and who they get to first. But, I like to tell my patients that they just must be sweeter than their spouse. :)

Where do I look for the bedbugs?

Bedbugs will hide in the seams of your mattress, bedframe, headboard, dresser crevices, inside/around your electrical outlets, between curtains/cushions, and at the junction of where the wall and ceiling meet. Look for them at night. Bedbugs are nocturnal, and you won't see them out during the day. The search usually requires a flashlight and some help to lift mattresses and furniture.

You may notice other signs of them besides the bug itself. Rust-colored stains on the bedding or mattress from bedbugs being crushed. They may also leave pinpoint dark spots that bleed like a marker would.

"I looked for the bedbugs and couldn't find them, but I'm still getting new spots. What now?"

Since the bedbugs can be hard to detect, especially with a small infestation, this frequently happens. If there is still a high suspicion, I have patients sleep in another bedroom or on their couch for at least a week to see if any new spots occur. If the spots decrease in production or stop completely with sleeping elsewhere, there is a high probability that you have some friends joining you in your bedroom.

How do I get rid of them?

Calling a pest control specialist is almost always necessary as they are very difficult to get rid of with home remedies. There are various methods that can be used from pesticides to heating the home.

How can I protect myself from getting bedbugs?

Read hotel reviews before booking. When traveling, keep your belongings stowed and bags closed. There have been reports of bedbug infestations even on airplanes! Keep your suitcase zipped up. Try to avoid putting your clothes in the dressers and hang everything that can be hung in the closet. Do a quick inspection of your hotel room when you arrive. Check the furniture around the bed and the dressers for any signs of bedbugs.