The epidemic of eczema, which affects one fifth of children, may be the fallout from our obsessive concern with keeping our children free of germs.
Eczema is now a worldwide epidemic. In the UK, up to one fifth of school age children and one in 12 adults suffer from it. It is itchy, painful, reduces the quality of life and has no cure.
Also known as atopic dermatitis, eczema forms part of the 'atopic triad', a group of disorders including allergies and asthma all of which are becoming increasingly common. Each of these conditions is thought to be a different manifestation of the same internal chaos, and they commonly appear in the same person all together at the same time or serially.
Some argue that without a clear understanding of the cause of a disease, it is impossible to provide effective treatment eczema appears to be a good argument in favour of this idea. Treatment, usually with ointments and creams, topical steroids, antibiotics and antiinflammatories, can be hamfisted or hit and miss. Most of these treatments are poorly researched (Health Tech Assess, 2000; 4: 1-191), not suitable for long term use and certainly not safe for children. Often, they will appear to work for a short time before the disease flares up again even worse than before.
Just how poor most eczema treatments are was illustrated last year at a meeting of the American Academy of Dermatology. There, Dr Amy S. Paler, professor of dermatology at Northwestern Medical School, revealed the results of a study on patient satisfaction with conventional eczema medications.
In a study which surveyed the parents of 429 paediatric eczema patients, one third of parents considered the medications prescribed for their children ineffective (Skin Allergy News, 2000; 31: 29). According to Dr Paler's results, prescription medications such as the topical corticosteriods betamethasone dipropionate, clobetasol propionate, hydrocortisone and mometasone furoate were considered not effective (32 per cent), somewhat effective (26 per cent) and fairly effective (23 per cent). Only 19 per cent of parents felt that the medications were very effective for their children. This held true even when the medications were considered to be moderate to high potency.
Non prescription remedies did not fare much better. Asked to judge agents containing hydrocortisone, 36 per cent of parents rated them as not effective, 57 per cent said they were somewhat effective or fairly effective, and only 7 per cent found them to be very effective.
Apart from being ineffective, topical steroids bring other problems, such as allergic skin reactions (J Dermatol, 1991; 18: 454-64; Skin Pharmacol, 1992; 5: 77-80), bone and organ damage (Dermatol Clin, 1992; 10: 505-12; Lancet, 1995; 345: 330), permanent adrenal suppression (Zeitschr Hautkrankh, 1988; 63: 302-8), eye damage (Br Dermatol, 1989; 120: 427-3; Eye, 1993; 7: 664-6) and damage to vital organs such as liver and kidneys. While it behooves us to find safer alternatives, no such initiative has yet taken place (see box, page 4 ).
The hygiene hypothesis
The causes of eczema are many and varied. It is thought that the tendency towards atopy is inherited, and that it involves an excessive immune reaction to allergens in the environment. The link between eczema and food allergies is well established in the literature, yet few physicians use restrictive diet or test for allergies as a first line treatment. But if the link between food and atopy is rarely acted upon, the link between childhood drug use and atopy is positively ignored.