My Dance with Eczema: And 80 Lessons for the Patient and the Doctor

By Derrick Chen-Wee Aw

A senior dermatologist opens up about his lifelong struggle with eczema. Through a blow by blow account of how eczema affected and changed his life, eczema sufferers around the world will connect with him while doctors treating eczema patients can become more empathetic and adopt a more thoughtful approach in their management. Dr Aw will also explain what causes eczema, how to differentiate eczema from lookalikes, and how to manage eczema holistically. Myths, misconceptions and beliefs about the condition and its various treatments available will be clarified

• Language: English
• Publisher: Partridge Publishing Singapore
• Release date: May 10, 2021
• ISBN: 9781543764123

Book preview

Copyright © 2021 Derrick Chen-Wee Aw. All rights reserved.

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ISBN

978-1-5437-6411-6 (sc)

978-1-5437-6437-6 (hc)

978-1-5437-6412-3 (e)

Library of Congress Control Number: 2021908216

05/10/2021

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Contents

Prologue

Acknowledgments

Part 1: Living with Eczema

Childhood and Teenage Times

Army Times

Medical School Times

Training Times

Working Times

Part 2: Understanding Eczema

What Is Atopic Eczema?

What Is NOT Atopic Eczema

How Atopic Eczema Can Get Messy

Part 3: Knowing Your Options

Topical Corticosteroid

Other Topical Immunosuppressants

Moisturizing Therapy

Systemic Therapy

Part 4: Other Concerns about Eczema

Personal Factors

Lifestyle Modifications

Complementary and Alternative Medicine

Epilogue

Prologue

M any years ago, I was invited to give a lecture on acne and skin care to a class at a local technical institute, the course of which was Beauty and Wellness. To my astonishment, each and every student’s face looked virtually flawless! At that moment, I wondered to myself, How many dermatologists have clear, symptomless, eczema-free skin? How many of my patients would know that my scrubs was hiding a skin with itchy rashes that keep coming and going, forever and ever?

One of the top skin conditions almost all dermatologists encounter in their clinics is eczema. I say almost all because some of us have joined the dark side—cosmetic work being their bread and butter. Which begs the next question: Why am I still in institutional practice?

Well, I’ve always liked to teach. In the public institution, not only do I practice clinical medicine as a physician and dermatologist, I also get to devote a sizeable fraction of my time mentoring, teaching, and supervising students and residents. My work life is exciting, invigorating, and fun!

And that’s what this book is about: me sharing my personal experiences with suffering from eczema for more than half my life, my take on a wide range of questions and myths about eczema and its management, and my practical and therapeutic pearls with both sufferers of eczema and their doctors too. The takeaway pointers at the end of each chapter are color-coded, like traffic lights, for your ease of reference: red is meant for patients, amber is meant for patients and doctors, and green is meant for doctors.

Throughout the book are numerous examples of commercial products. These are not my personal endorsements. I have attempted to showcase a wide spectrum of products essentially for illustrative purposes.

This book was written from front to back. Hence it is best to read it likewise. As the story unfolds and your learning progresses, additional information and insights will piggyback on stuff that had been covered in preceding chapters.

I hope my story resonates with patients and their caregivers (mostly parents, I’d imagine), and that I give everyone a satisfactory perspective on most stuff concerning this common condition. As for my colleagues reading this book, I hope it helps you to empathize more with your patients and also gives you some insight on how you can manage patients with eczema a little more thoughtfully.

Acknowledgments

T ruth be told, the inspiration for this book popped up after my hospital chief executive officer, Professor Christopher Cheng, published a book, I Thought I Knew: A Professor Turned Patient , and gave me a complimentary copy. In it, he reminisced about his encounters and edification after discovering he suffered the very condition in which he was an expert—prostate cancer. I thought it’s time I shared my story too.

I also want to thank my head of department, Associate Professor Melvin Chua, and hospital chairman medical board, Associate Professor Ong Biauw Chi, for supporting me in this endeavor. I had originally planned to co-edit my sixth academic book with Melvin but put it on hold (sorry, pal) because of this project. Thank you, Biauw Chi, for always being so supportive and encouraging in everything I do.

Right outside my door are two incredibly helpful and resourceful secretaries, Siti Badariah and Juwisaswirza, who both uncomplainingly helped me with some photographs as well as numerous administrative matters. Thank you both for putting up with my fussiness.

I would like to record my appreciation to the numerous pharmaceutical companies and distributors who kindly gave permission to use their product images, as well as all the reps and managers who helped facilitate that. I think I accomplished what I told you—a fair and measured assessment of your products.

Buddies on whom I tapped for quotes and information, sometimes surreptitiously, are Associate Professor Mark Koh Jean Ann from Kandang Kerbau Women’s and Children’s Hospital, Dr. Yew Yik Weng from National Skin Centre, Associate Professor Samuel Tay Sam Wah from Department of Anatomy of Yong Loo Lin School of Medicine, National University of Singapore, Sister Lee Siew Hui from Alex Campus of National University Health System and Mr. Loh Peng Keong from the fragrance industry. Thanks and hugs for sharing, guys.

I must also thank Dr. (TCM) Colin Chan from Ideal TCM Clinic, previously my teacher and now friend, who kindly corrected my insights of TCM concepts in eczema.

Also I must give lots of thanks to my talented nephew, Macsen, and my cousin-in-law Ching-Tzu, who kindly contributed graphics depicting six emotional states of ECZEMA (Exasperated, Crushed, Zoned-out, Embittered, Mad, Anxious) for my book. Thank you for your patience and support!

And the most important people to thank, are of course, my patients and their parents. Thank you for trusting me to manage your (or your kids’) eczema. Because of you, I have learned so much more about this nasty condition, much more than I would have known as a dermatologist and a lifelong sufferer myself. You, and your experiences, complete my book.

Part 1:

Living with Eczema

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Childhood and Teenage Times

M y memory is foggy on when exactly I manifested symptoms of eczema. I remember scratching a great deal at night, to wake up in the morning with streaks of dried blood and skin flakes on my bedsheets. My mother used to joke that I was shedding skin like a snake. I think I was too young to feel embarrassed or affected by it.

As I grew older, I became very bothered by itch and pain predominantly affecting my feet. The skin there was always dry and thickened. It often cracked spontaneously over the heels. Cracks were painful, especially when walking (let alone running!). They were painful even in the shower, but that’s still okay as I was alone in my own world. In front of other people, it was embarrassing to walk or run in a way that avoided exerting excessive pressure over the cracks, so I forced myself to walk and run as normally as it could look. This caused old cracks to widen and new cracks to form. So the best way to minimize pain from the cracks and also the pain of embarrassment was simply to avoid physical activities.

You probably can imagine how fearful I was of the yearly compulsory Individual Physical Proficiency Test (IPPT) in school. The standing board jump, the 4x10-meter shuttle run, and worst of all, the 2.4-kilometer run all caused me intense anxiety. The odds of performing properly (I wasn’t even hoping for superiorly) were heavily stacked against me: My heart was unfit due to lack of regular exercise, and I was physically compromised from that pair of rotten feet.

The good thing about youth is that the healing abilities are strong. It was only a matter of time that cracks healed. The frustrating thing was that the rest of the package didn’t: dryness, redness, thickening, and itch.

The instant remedy of an itch is a scratch. Every human would have experienced itch at some point in life. The differences in the experience lie within the nature and cause of that itch. Say, one has itch from a mosquito bite—you scratch to relive that sensation, the bite reaction typically subsides in a day or two, bringing that itch sensation into oblivion, and you forget that uncomfortable feeling in no time. Let’s stretch it a bit more. Say one gets itch from hives, which often looks exactly like many mosquito bites but are really due to a release of a chemical called histamine from mast cells in the skin. This release can be triggered by many factors, but let’s just say a reaction to a medication. Indeed, you may be scratching like mad but after you stop taking that culprit medication and consume some antihistamines, the condition subsides, hopefully forever, as long as you don’t encounter that medication again, and you also merrily forget that itchy episode. With eczema, you have a whole new level of itch!

The itch of eczema is like a psychological leech—it sucks the senses out of you. It tempts you when the skin is broken, or inflamed, or scaly, or dry, or wet, or even when it looks innocently normal. A scratch typically acts to remove the noxious stimulus (as in above, a mosquito bite or hives), but in eczema, that scratch brings forth a flood of ecstasy. It’s almost orgasmic. The perverse effect is that despite knowing that scratching is going to cause further damage to the skin, that urge for an instant gratification overwhelms all logical thinking. We are not stupid: we know fully well that the skin damage may appear in the form of bleeding, discharging, swelling, crusting, blistering, and cracking. In fact, there were occasions when I became attached to these symptoms—I needed to experience the eczema worsening. I wanted to challenge myself to see how bad it could get. I became so attached to my eczema, that I actually missed it when it cleared!

Sometimes I told myself that I deserved to have a pair of normal-looking feet, and in these moments of resolute I kept reminding myself to resist the urge to scratch. But when night came, my ankles gently touched each other in bed and the tingle of itch immediately crept up. I initially resisted from scratching with my hands, but my feet would rub against each other to simulate the act of scratching. The pleasure from rubbing would build to a climax, and in a final frenzied act of desperation while chanting the same mantra just this one last time, my fingers would reach for the feet.

This is precisely what happened to Audrey, a dermatologist colleague of mine. She related to me that when she was young, her parents once strapped her down onto the bed by tying her four hands and feet to the corners of the bed. I believed the parents must have been desperate to stop their daughter from maiming her skin. It didn’t help, of course, since she constantly rubbed her limbs against the ties and the bed itself, leaving a bloody mess. Probably it was less bloody than without the ties, but still . . .

Scratching (with nails) is what causes the skin to split, while rubbing (with a blunt surface such as the heels of our feet) provides a small bit of relief, but which is cumulative when repeated long enough.

Once during a trip in China, my mother spent half a thousand Singapore dollars (probably also succumbed to sales tactics) on a pure silk quilt cover set for me as a birthday gift. The sensation of my skin against the silk was pure heaven—when I got up in the morning I was craving for night to come. However, the rough skin and flakes on my feet insidiously tore at the delicate silk every night. After two washes, the linen felt as rough as my feet, and sadly I had to stop using it. I now use the second best—Egyptian cotton—which is most kind to my skin and doesn’t tear easily.

At this point, I wish to clarify that my feet eczema with cracked heels is not the same as cracked heels in normal people without eczema. Some people develop thickened skin over the heels either due to genetic factors (skin is inherently drier) or excessive pressure (from being overweight or prolonged standing and walking). That dry thickened skin then cracks naturally. Filing of the excessively thickened skin, regular moisturizing with strong ointments, coupled with elimination of the physical factors that aggravate the pressure will usually help ameliorate the condition. In eczema, there is underlying inflammation, which is characterized by redness, swelling, and itch. The redness and swelling may be absent or subtle, but itch is invariably present.

I know I wrote a fair bit about my feet, but actually I too had another itchy problem on my wrists. I found that whenever I wore a watch, the skin beneath it would itch and turn red. I also observed that not wearing a watch for a few days would inevitably resolve that itch and redness. My initial suspicion was an allergy to the metal or the leather strap. Over the next several years I continued to experiment with different watches, hoping for one that would not cause inflammation. I have worn watches with goat leather, crocodile leather, deerskin, snake skin, and nickel and chromium casings, and all caused a recurrence of symptoms.

I now have a large collection of gifts of watches, which I am unable to use. One of those is a Hamilton watch from the army as a farewell gift before I ended my service. I can’t eBay it because my name is engraved on the casing. My last watch was a fully plastic Swatch watch, which I bought to use during my advanced skin surgery training in London—no prizes for guessing that it too caused a rash.

The real problem for me is not the material of the watch at all. Essentially, sweat accumulates beneath the casing or strap, and that sweat was the culprit. But in the days before mobile phones, we needed some way to keep track of time. I resorted to using pocket watches.

If you are thinking of using these archaic devices, perhaps as a novelty, think thrice. These sturdy-looking oyster cases are not as tough as they appear to be—they break down easily. The contraption for opening and locking the cover loosens after a couple of flips. Not only is the pocket watch hard to come by, nothing else can comfortably share that same space once you have it in your pocket. I have, since, not used a watch in the past fifteen years.

In secondary school, I joined the judo club under the influence of my cousin (he was one year my senior in the same school) but also because I secretly desired to learn a martial art. In judo, we trained on bare feet. You see, although eczema is always there in the background, it can be really mild at times. And those times I truly treasured the minutes. Whenever my feet cracked, I felt disgusted and ashamed. But as I was committed to this club, I had to drag my feet to attend training even when the eczema flared. I remembered fidgeting discreetly while observing the sparring demonstrations, shuffling between sitting cross-legged and kneeling because the friction against the mat kept irritating the cracks of my feet. In order to blend in, I pretended to walk and run normally while enduring the pain during eczema flares. After six months, I couldn’t keep up with the discomfort and pretense anymore and quit the club. In retrospect, I think I was lucky I never caught a bacterial infection throughout that period of walking barefooted in the school gymnasium! Skin cracks are portals where bacteria can potentially enter the skin and cause a deep-seated infection.

Around this time my paternal grandfather passed away. In traditional Taoist proceedings, everyone had to wear mourning garb throughout the week of wake and funeral. The problem for me was the thin white socks. And my feet chose this time to flare and crack. We had to ambulate en masse along a rocky and gravel road from my grandparents’ kampong house, slowly (to match the speed of the coffin-bearers), toward the main road of Mount Pleasant. No amount of pretense or bravery could hide my anguish, but I didn’t have a choice to escape from the activity. That journey, which seemed like an eternity, was entirely reminiscent of the judo club experience, and definitely worse. Probably the worst experience ever, because there had been a sight rain so the roads were somewhat damp, and that dampness soaked right into the cracks of my feet!

My mother initially brought me to see an old general practitioner (GP) downstairs my maternal grandmother’s flat, but he didn’t seem to have anything to help. She then brought me to the emergency department (ED) of the hospital where she worked as a medical social work assistant then. The doctor smirked and told me that this was not an emergency that warranted a presentation at the ED. Well, the doctor is right, but obviously we were desperate, ignorant, and not resourceful. At that time, our regular GP couldn’t help, and polyclinics were not established yet. Anyway, the little bit of cream prescribed didn’t work. Finally, my mother got wind of a popular specialist in Chinatown, and I started seeing him since.

It turned out that Dr. Tan Ngak Jiang (now retired) who ran the Kreta Ayer Clinic in Chinatown was an established and highly sought-after dermatologist. An hour before his clinic opened, a queue snaking all the way from the entrance to the staircase lobby (that’s about fifty meters) would have formed. About fifteen minutes before he stepped in, the receptionist would have started doing the registrations. Even as you are waiting for your turn, some skimpily dressed females in stilettos would intermittently pop into an adjacent consultation room (apparently they didn’t need a queue number), and they exited within a few minutes. Later, I would come to learn that these were commercial sex workers who attended for mandatory screenings for sexually transmitted infections.

Dr. Tan greatly impressed my mother and me on our first visit with his gentle approach, listening ear, and patient explanations. He even demonstrated on my skin how a steroid cream should be applied. He became my first role model dermatologist. For my feet eczema, he only prescribed one steroid ointment, and to me it worked like magic. However, the container was so small I had to return to his clinic almost every month for a refill. Thanks to him, I was excused from physical education and swimming lessons (the chlorine irritated the skin) whenever my eczema flared badly. About the time of my National Service enlistment, he wrote a letter recommending a less intense physical training regime as my feet condition had become very brittle. As a result of that, I was accorded Physical Employment Status (PES) C in the army.

Key Takeaway Pointers:

• Suspect your child has eczema if he frequently scratches himself particularly at night.

• Instead of admonishing your child for scratching (which really isn’t going to help much), how about suggesting your child apply a moisturizer instead?

23706.png If you identify friction and sweat as important triggers of the eczema, refrain from wearing wristwatches!

23706.png Eczema is a chronic dynamic disease. Its activity waxes and wanes. What totally annoys and frustrates people is the unpredictability of the flares.

➢ Onset in childhood is a universal criterion for the diagnosis of atopic eczema. It is very frequently present, but not mandatory for diagnosis.

➢ Instructing the eczema patient not to scratch oneself is an extremely unempathetic request—I never do it. Unless or until you have experienced the itch of eczema, a word of kindness endears you more to the patient.

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Army Times

I was not proud of my PES status. It made me feel like a loser. The fact that the training intensities of PES A (medically completely fit) and C (medical misfits but not severe enough to be let off regular physical training) were not that different merely magnified that feeling. To rub that in, companies were named in alphabetical order and ours was called the Marines (an allusion to the United States Marine Corps, an elite fighting force specializing in amphibious operations), with full cognizance that upon completion of basic military training (BMT), PES C privates would be vocationalized to relatively cushy jobs such as clerks, store-men, and drivers.

Incredibly, my skin condition settled to a most quiescent stage (the medical term is in remission) since I entered BMT, even without regular treatment! To many male patients with eczema in the army, the perspiration from physical training and the dusty living environments are common provocative factors of eczema flares.

In other words, I trudged through my entire BMT training as a normal but a physically disadvantaged one. My eczema had earlier prevented me from undergoing regular physical exercises, but now that my physical fitness is called for, my old friend has mysteriously slipped

Reviews for My Dance with Eczema

[Beatrice Yeoh · Rating: 5 out of 5 stars]

Dr Derrick was my Dermatologist when he was at NUH. I sought him out when I saw he is also an acupuncturist as at that time I was looking for alternate treatment.
Unfortunately his time at NUH was towards the end.
I was surprised that he could be accessed via email at NUH and I could reach him when I panicked at new flares and reach him I did!

This book is a must read for all acute eczema patients as well as dermatologists. As an acute eczema sufferer of more than 10 years, so glad to know that there is a doctor who truly empathise with the anxiety of this scourge of a disease. I like it especially that he understands our “need to scratch” which many doctors do not and the admonishments from both doctors and families send us up the wall.

BC Yeoh