A primer on immunosuppressive medications for eczema from a parent’s point of view-cyclosporine, azathioprine and methotrexate

I am really sorry for not having written anything for a really long time now. I have been busy with my Functional Medicine Health Coaching Course (from the US based Functional Medicine Coaching Academy) and my Dietetics and Nutrition course. The Health Coaching course has been an immensely enjoyable and fulfilling experience and I become a Certified Health Coach next month! I will write more on that next time. This post is about something else.

I have written quite a while back on a comparison between 2 immunosuppressive medications that my daughter has been on earlier on. In this post, I want to write about one more immunosuppressive medication that my daughter has been on since the past couple of years and it is called methotrexate.

Before I go any further though, I would like to out some things in perspective. Since these medications are very powerful and potent drugs, these medications are the last line of treatment for Atopic Dermatitis. They do not “cure” eczema, they are given to manage severe eczema which are not being managed by other lines of treatment. These are usually given for many months or years depending upon the patient’s condition. These medications are not given to any patient, child or adult, unless all other forms of treatment (moisturisers, topical steroids, narrow band UVB, wet wrapping, oral steroids) have failed to reduce suffering due to severe eczema or even bring it under control.

Also, I would like to mention that while we certainly had no choice in giving our daughter these medications, initially I did not know that there was anything other way that we could bring her very severe eczema under control. However, I am really happy to say that this is no longer the case and if you have been following my blog posts you will know what I am talking about her Functional Medicine treatment. I would also like to mention here that my daughter’s condition is much better now. We have lowered her dosage and are looking at hopefully gradually continue to lower and finally discontinuing her medication in the near future. But I will cover that in my next post.

A few things which are common to all these types of medication are as given below-

  • they need to given and monitored regularly by health professionals to monitor for adverse side effects
  • dosages and frequency are different for each drug and must be followed meticulously
  • since these medications work by suppressing the immune system, precautions must be taken to limit exposure to infections
  • usually live vaccinations are not given to patients (children) who are on these medications

Cyclosporine and our experience

Cyclosporine was our first introduction to immunosuppressive medications in 2012. Aiyana was already on oral steroids at that time to manage her very severe eczema which had escalated beyond control and she initially needed an a fast acting intervention like oral steroids. The doctors prescribed cyclosporine as the systemic drug to help manage her severe eczema.

Cyclosporine works by blocking the body’s inflammatory process which can reduce itching and rashes. After about 6 months of being on this medication in 2012, we switched to azathioprine in 2013 as recommended by another dermatologist. However, we had to come back to this medication once again in mid 2013 since azathioprine had a disastrous effect on her health. She was on cyclosporine for another year till we switched over to the third immunosuppressive medication methotrexate in late 2104.

A word of caution

However like any other such drug, the side effects of cyclosporine are many and in particular it can affect the kidney and blood pressure adversely. Hence, regular blood tests need to be carried out to determine kidney function in particular and to monitor other health parameters.

Research

Cyclosporin in the treatment of severe atopic dermatitis: a retrospective study- https://www.ncbi.nlm.nih.gov/pubmed/15175770

Azathioprine and our experience

Azathioprine was the second medication that we used to manage our daughter’s eczema. She had already been on cyclosporine for a year and a half and the doctors wanted to get her off cyclosporine since it clearly had not been very effective in managing her eczema very well.

Azathioprine is another type of immunosuppressive medication which is used for many autoimmune conditions including atopic dermatitis. It was originally developed to prevent infections due to transplanted organs like the kidneys. It takes longer than cyclosporine to take effect and is not used for acute cases of eczema due to the time taken. Since one of the main side effects of azathioprine is bone marrow suppression, a blood test measuring an enzyme called TPMT (anthiopurine methyltransferase). Those with low levels of TPMT are unable to break down azathioprine in the normal way and are at high risk of dangerous bone marrow suppression. Hence, those with very low levels of TPMT are not given this medication.

A word of caution 

However, as we realised to our dismay, just getting the TPMT levels tested and taking a decision of giving azathioprine to someone may not work out as planned at all. And we also learned a HUGE lesson in terms of how things can go terribly wrong even when all known rules and protocol are followed. Our daughter was one of the outliers who suffered from the disastrous side effects of azathioprine inspite of having completely normal and within range TPMT levels. Infact, it was this experience that led me to search extensively another form of intervention for her. I have written about this in details in my earlier blog posts- https://eczema-anindianperspective.com/2013/10/27/the-tough-get-going-part-2/. 

Azathioprine can have a host of side effects apart from the bone marrow and can also affect the liver adversely.  Tests are done regularly to ensure liver, bone marrow and other organs are working properly.  Any symptoms like hair loss, flu like symptoms and any others should be looked into immediately.

Research-

A retrospective evaluation of azathioprine in severe childhood atopic eczema- https://www.ncbi.nlm.nih.gov/pubmed/12174104

Methotrexate and our experience

Methotrexate was the third immunosuppressive medication that our daughter was prescribed in 2014 and she is still on this medication as of now. This drug has worked for her pretty well and she is now on a reduced dosage. With a very good response to the Functional Medicine treatment which is now finally showing its impact after being on this treatment for almost 2 years.

Methotrexate is actually a drug used mainly for treating psoriasis and rheumatoid arthritis. Methotrexate belongs to a class of drugs known as antimetabolites and also works by suppressing the immune system.

A word of warning

Methotrexate can also cause some serious side effects by affecting the bone marrow, liver or lungs and once again regular blood tests are a must to monitor the effects of this medication.

Research

http://www.mdedge.com/edermatologynews/article/100861/atopic-dermatitis/wcd-methotrexate-found-safer-less-effective

The other side of the story

While I have given above an account of our experiences with the various drugs, I would also like to point out the other side of the story- these drugs help save many lives. The primary objective of these medicines is to suppress the immune system. They improve the chances of a patient to successfully undergo an organ transplant by preventing the organ getting rejected by the immune system. These medications are also used in other conditions like severe eczema, rheumatoid arthritis and other conditions as well where the immune system is involved. No matter what the reason for taking these medications, these medications should be taken only if prescribed by a qualified medical professional and should be monitored regularly under his care.  

 

Just show up…

Show up

As someone once said, “sometimes the bravest and the most important thing you can do is just show up“. This is especially true when we really do not like the turn our life has taken. It is true when we want to find a better way of dealing with our problems but we do not have a choice right at that moment and so we go along with it. This is what it feels like for us when we give our daughter these medications. But I know that I am doing the right thing for her at this moment and at the same time I also know that I am doing whatever it takes to hopefully enable her to lead a healthy life without depending on any medications.

But whether I succeed in this or not, I will always know that I never shied away for showing up for whatever life has to offer us. This is what enables us to deal with eczema and its effect in our lives. This is also what makes life seem so enjoyable and memorable for all of us and is so much more than any difficult circumstances, illness and medication.

 

 

Eczema Support Group meeting for parents

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I am having the 4th Eczema Support Group meeting on the 21st of February, Saturday from 10 am till 11 am.

This is a meeting for the parents of children who are suffering from moderate to severe eczema. The objective is to provide a platform for parents to share their experiences and learnings with each other. In this meeting we will discuss various treatment options, personal experiences, skin care routine and other related topics as discussed by the members in advance. Infact parents often come up with various suggestions, information in terms of what has worked in managing and improving their child’s eczema which can benefit another child in the support group.
Also, sometimes it helps just to talk to another primary caregiver /parent who is going through a similar struggle of dealing with their child’s eczema.

Topics

  • Diet and its role in eczema/autoimmune disorders
  •  Skin care and bathing routine
  • Phototherapy treatment

Venue- Planet Godrej, Mahalaxmi, Mumbai

For further details and registration please get in touch with me via email at eczemaanindianperspective@gmail.com latest by the 18th of Wednesday.

Our journey continues….( a look at our ancient way of healing- Ayurveda and mindfulness meditation)

I am back! I am back with more stories to tell, experiences to share and hopefully some tidbits of information which might help another parent to cope with their child’s eczema along the way. Only a parent who is a first hand witness to their child’ s suffering due to this skin condition ( and any other such chronic medical conditions)  will be able to empathise with another family’s pain, exhaustion and some times negative thoughts that can arise out of dealing with sleeplessness, social and psychological impact that eczema can have on on a child. And that is what keeps me going to share what works for us ( most of the time) and what products, methods etc help in dealing with my daughter’s eczema.

Our introduction to Ayurveda

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I had recently taken my daughter, Aiyana to an ayurvedic hospital ( IAIM Healthcare centre – an Institute of Ayurveda or Integrative Medicine) in the outskirts of Bangalore (the capital city in the southern state of Karnataka). I was not looking for a quick fix solution or a cure to her eczema, but just exploring other traditional methods of Indian medicine which go back a very long way and seeks to heal from within. My hope is to see if our traditional medicine has something to offer to help my daughter to control her eczema in the long run without the help of other powerful medications like she is on currently.

A rigorous process

At IAIM Healthcare Centre, she was first put on an increasing dose of medicated ghee ( it is a type of clarified butter made by simmering the butter made from the milk so that it gets caramelised which gives it the unique taste and aroma) along with a severely restricted diet. This was done to remove all the toxins from her body prior to starting medications, since Ayurveda considers ghee to be satvik ( in the mode of goodness)  and is the main ingredient in many traditional Ayurvedic medicines. She was given this for 4 days till her body was saturated with ghee (as they could make out from her stools). All this while she was ONLY allowed a diet of fruits (non citrus) and plain khichdi (which is a preparation made from rice and pulses); she was also not allowed to go out anywhere but stay in one place in a warm environment to facilitate this process. The 5th day was the day of purging and she was given a laxative in order to prepare her for the medicines to follow from the next day. All this while she was given a daily medicinal ghee massage and a warm bath mixed with herbs.

An interesting change

One very interesting change that took place during this time was that her skin condition was the softest and the smoothest I had seen in some time. While Aiyana’s immunosuppressive medication continued at the same level with no change, her skin condition improved dramatically with all the diet restrictions (and no other medicines). However, once the medicines started the next day and her diet restrictions eased up, her skin condition slowly came back to normal in the next few weeks. I guess her extremely restrictive diet played a key role in improving her skin condition during the first week at the ayurvedic hsopital (even though it is simply not possible to continue with this kind of diet for more than a few days).

However, Ayurvedic medication demands that one follows a restricted diet since certain food types do not go well with the ayurvedic medicines. Hence, Aiyana has been asked to stay away from fermented products (inc yeast based bakery items) like yogurt, dosa, idli etc; all citrus fruits and vegetables like oranges, lemons, tomatoes; root vegetables like cauliflower, potatoes; other processed and refined foods like white rice and refined sugar; leafy green vegetables. She has also been advised to have everything cooked in ghee. As you can make out it IS a difficult way of life to follow since it does not involve only medication but also a whole lot of changes in one’s diet. In any case, she has been very cooperative and we have been able to follow most of the food restrictions so far.

Our goal

The goal of Ayurvedic medicines according to Dr Gangadharan (who is the Head of the Dept. and treating my daughter) was to strengthen her immune system from within so that over time her body was naturally able to bring the severity of her eczema within a manageable level. I will keep you posted on her progress and any changes as far as Ayurveda is concerned. We have been back in Mumbai for 3 weeks now and her skin condition has come back to normal. I will however have to continue with her Ayurvedic medication for some more time if I want to give it a chance to work. I will also be taking her for a follow-up to IAIM Healthcare Centre next month in order to assess her progress, change in medication etc.

The good, the bad and the ugly

It is always a case of a mix of good days and bad days for her even with her medications. And since there are various triggers to her flare ups, it is nearly impossible to pin point and avoid the the same completely. This leads to a  yoyo like swing in her moods making it difficult for her and all of us especially on those bad (and ugly) days and nights with her itching and inability to sleep. I have already touched upon this psychological impact (which can lead to lack of self-confidence and social skills) and I have described how I have been dealing with it in my daughter’s case in my post Beauty is not just “skin” deep- helping your child cope with eczema.

Let them sleep, for when they wake…they will move mountains

We have been grappling with sleepless nights ever since she was 1-year-old (even though her condition was mild at that time) and when you add to that the mild eczema that my 4-year-old son has as well, you can see that it leads to a lot of sleepless nights and fatigue for the entire family. It is an aspect of eczema ( and Atopic Dermatitis in particular since it affects children) that severely impacts a child’s well-being leading to lack of concentration in school and a lack of self-confidence amongst other problems. It also one issue the entire family (which has children suffering from Atopic Dermatitis) will have faced some time or the other. As a result I have been searching for a way to improve our quality of sleep (without further use of medicines) by reducing stress levels and learning relaxation techniques.

Mindfulness Meditation

mindfulness

To this end I have been reading about a form of stress reduction technique called ” Mindfulness Based Stress Reduction”  (MBSR) program developed by Dr. Jon Kabat-Zinn at the University of Massachusetts Medical Center. It is meant to work by making one more “grounded” or “aware” of the present moment and simply means paying attention in a particular way: “on purpose, in the present moment, and nonjudgmentally” as described by Dr Kabat- Zinn. In this post, I will be just touching upon this topic since we have just started following the same ourselves.

My goal in trying to incorporate it in our daily life is very simple – to help my daughter reduce her stress and frustration levels and hopefully cope with her medical condition better with time and practice. The good thing is that one does not have to be a Buddhist to practice this though it has its roots in Buddhism, Taoism and yoga. Mindfulness is the art of conscious living so that you live a life being who you are already and not try and be someone that you are not. Hence, one’s religious beliefs does not interfere with this practice.

Meditation and coping

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I am using the book and CD combination- “Planting Seeds: Practicing Mindfulness with Children which is based on Thich Nhat Hanh’s (a Zen Buddhist monk) thirty years of teaching mindfulness and compassion. They are designed to help relieve stress, increase concentration, nourish gratitude and confidence, deal with difficult emotions and improve communication.

While we have just started practising this, Aiyana has been enjoying our daily sessions of “deep relaxation” before bedtime since it is helping to calm her (and me) down quite a bit and relax. While it is too early to comment on the results of practising this, I can say that it has made a slight improvement in her sleep quality. And anytime that she wakes up feeling itchy, the music is soothing enough to lull her back to sleep most of the times. I am also planning to use another well-known book for practising mindfulness meditation with children – “Peaceful Piggy Meditation” by Kerry Lee Maclean for the same purpose.

Be happy for this moment, this moment is your life

And in the end, this is what matters. How well we lived our life, how well we loved, how we counted our blessings along the way; how we learned to accept the things we simply cannot change and faced our most difficult moments. This is the lesson I strive to teach my children, one lesson that I am myself learning every day of my life.

 

 

Moisturizers and eczema

 

Our long-term relationship with moisturizers

Moisturizing is a critical element in the treatment of eczema. They are found in the form creams, ointments and lotions.

Creams  contain a mixture of fat and water and feel light and cool to the skin. I have used them on my daughter during the hot summer months and during the day in the winter months.

Ointments are very thick and can be very greasy but they are very effective at holding water in the skin and hence are useful for very dry and thickened skin. I use these for Aiyana at night and as a soap substitute while bathing during the dry season.

Lotions contain more water and less fat than creams and can be used for moisturizing the skin in case of mild dryness.

All of the above may be suitable to be used at various points in time depending on whether a person’s eczema reacts to a specific ingredient or ingredients in an emollient, the humidity and the severity of eczema. Also for eczema (especially in case of children) such moisturizers necessarily have to be non cosmetic  and fragrance free since products containing alcohol, perfumes, lanolin, or preservatives tend to cause eczema breakouts.

Ever since we realised that Aiyana has eczema, I have been looking for the most suitable moisturizer for her. In this regard I have noticed that there is no one ideal moisturizer which has suited her at all times. I have changed her moisturizer brands over the years due to various reasons but I am always looking for a better one for her. I have used a type of cream on her earlier known as aqueous cream which is now believed to be more harmful than beneficial due to its sulphate content. In any case we noticed her skin did not get moisturized properly and I stopped using it more than a year back. (Source: http://www.eczema.org/aqueous)

Thus I have used quite a few products on my daughter, some of which are available in India and others are not. These have been recommended not only by her doctors but also by other parents across the world in their blogs and websites. Maybe you will find one here which will work better for your child as well.

HydromolOver the past few years I have used moisturizer brands like E45 cream, Exomega, Epaderm, Oilatum, Aveeno, Eucerin, California Baby, Mustela, Cetaphil, Burt’s Bees and Pure Potions at various points in  time. All these brands are not available here in India as of now. It can be very confusing to know which cream is suitable for your child and even I have learned through trial and error.

Although I have tried all the creams that I have mentioned, the ones which I found to have a creamier consistency ( these have seemed to work well with Aiyana) are the oat based ones like Aveeno and Exomega cream. I have used both of these interchangeably depending on their availability in Mumbai. But I had to shift from oat based moisturizers to others since she tested positive to the oat allergen last June in the IgE blood allergy test.

Another moisturizer which worked well for her last year is the ubiquitous coconut oil. In fact, when she had developed Erythroderma, we had used coconut oil (Parachute brand suited her better than the organic one) since her skin used to burn if we used any creams at all. It worked well as a moisturizer overall and seemed to really soothe her skin. But it was not as effective during the dry months. Also, Pure Potions amongst the ones I have mentioned has a “skin salvation” ointment which is a thick cream and supposed to have restorative properties and has helped Aiyana to some extent.

Currently I am using Hydromol cream on her(I switch to Hydromol ointment during the dry months) which seems to suit her skin and is effective in keeping her skin just moist. I had started using Hydromol Ointment on Aiyana in the dry months (December 2012 onwards) based on a UK-based doctor’s recommendation. I wanted to change her moisturizers to sulphate and paraben free creams (more on this in a separate post) and hence the change. And I have stuck to this brand ever since as it suits her skin. Amongst the other brands of creams, skincare and bath products (bath wash, shampoo, bath emollient) that have worked for her and have been highly recommended by other parents are the organic, sulphate and paraben free ones like California Baby (US), Burt’s Bees (US) and Pure Potions (UK). But these are on the expensive side as compared to the other brands and I have used these sparingly from time to time.

The other relatively less expensive mosisturizing bath products I have used in the past which I have found to be good for her are the fragrance free washes and shower/bath emollients from Aveeno, Oilatum and E45 out of which Oilatum is readily available in India. Currently I use California Baby bath products extensively for both my children since I have found them to be very gentle on their skin, especially for my daughter. ( I will elaborate on her skin care routine and her bath routine separately).  California Baby wash

Availability

  • Hydromol range is a UK based brand and is available online at amazon.co.UK through a seller-Mistry’s Pharmacy (all the sellers do not ship to India) as well as all the BOOTS pharmacies in UK.
  • Exomega range of products by Aderma, Cetaphil, Oilatum are available in big pharmacies in Mumbai like Rakhangi Medical( Worli), Asian Chemist (Bandra West) , Sterling Chemist (Pedder Road) amongst others as well as stores like Just Moms (Breach Candy), Green Bell (Juhu) and Amarsons.
  • Other brands like Mustela, Aveeno, Eucerin, California Baby, E45 and Burt’s Bees products are available in stores like Just Moms (in Breach Candy), Green Bell (Juhu) and to some extent Amarsons.
  • Pure Potions and Epaderm range are available on Amazon.co.uk as well as some other websites but may not be shipped to India.

I have tried to highlight as many options as possible keeping in mind different budgets. I have also compiled a list of the brands that we have used and their availability in Mumbai…I hope this helps incase you do decide to try any of these for your child. I would love to hear from you about what has worked for your child. Also, please feel free to ask me for any clarifications or any further information.