skindoc. is an online dermatology service whereby patients can be seen by a consultant dermatologist without leaving home. Assessment, diagnosis and treatment are all done via live digital consultation.
skindoc. partnered with Phlo Connect to help them provide a digital end-to-end seamless healthcare experience to their patients. Once a skindoc. patient has had an initial virtual dermatology consultation, Phlo Connects technology allows their patients to easily order and schedule their medication delivery through the app at a time and place that suits them. We take care of the electronic prescribing, dispensing, patient updates and pricing information and delivery to the patients preferred address.
Dr Sreedhar Krishna, NHS Consultant Dermatologist and co-founder of skindoc., answers some common questions about the skin condition eczema. He tells us more about the causes and progression of the condition as well as some of the advanced treatment options available.
Sure! I became a doctor in 2010 and really enjoyed the insight into people’s lives that medicine gives you. Along the way, I had a placement in dermatology where I saw how important the clinical skill of the doctor is. In contrast to doctors who specialise in hearts and lungs, we don’t use many tests to diagnose what is wrong with people. We use our ears to listen to the problem and our eyes to look at the problem - it is pure clinical medicine, and something that I enjoy doing every day.
I became interested in wanting to know how skin problems arise at the cellular level and so decided to undertake a fellowship in skin pathology. The aim is that patients can come to see me, have a biopsy if needed at the same time, and get an ultra-quick diagnosis as I could look at the tissue myself - all in pursuit of getting patients the best care, as quickly as possible.
Eczema is an umbrella term that is used to describe a range of conditions in which the skin becomes dry, red and itchy. It is a very common condition that affects around 1 in 5 of us. The most common form of eczema is called atopic eczema and is caused by inherited factors as well as certain factors in our environment. People who inherit the condition often have an overactive immune system that results in the skin attacking itself for no reason. There are things in our environment which make eczema worse. These include washing with soaps (these dry out your skin), dusty environments, and especially stress. (If only I could prescribe holidays to Barbados…)
Really good question! This is a hot topic that is being actively researched. The prevalence of eczema varies hugely across the globe - from 0.9% of people in India to 22.5% in Ecuador. We don’t really understand why this is, but we do know that there are multiple risk factors which influence the risk of developing eczema. These include living in urban environments, high levels of fast food consumption, obesity and exposure to pollution. We know that children who grow up with dogs or on farms have a lower risk of developing eczema. This is because immune systems which are exposed to bugs at a young age are better at learning not to overreact to irritants in the outside world.
Both can manifest as red, dry, scaly patches but there are crucial differences between the two conditions. Eczema is far more common in children than psoriasis (but up to 1% of children can develop psoriasis). Eczema is by definition very itchy, while the degree of itch in psoriasis is variable, but when present, is usually mild. Eczema tends to like skin folds (e.g. the crook of the arm, or the back of the knees) while psoriasis tends to like the opposite areas (i.e. the front of the knees and the elbows). Crucially, 1 in 3 people who have psoriasis can also have arthritis which damages the joints. In contrast to garden-variety arthritis that is caused by overuse, the arthritis caused by psoriasis can be controlled very effectively using tablet medication - so it pays to be aware of joint aches if you have psoriasis.
Eczema is a condition in which the skin barrier is damaged. You can think of this as being like a brick wall, in which the cement is not sealing the bricks nicely. This can mean that bad stuff can get in (e.g. leading to infections) and good stuff can leak out.
We need to protect the skin barrier by using good moisturisers. This helps augment the skin barrier function. We also need to reduce the inflammation on the skin. This can be achieved by the use of steroid creams, as well as newer non-steroidal creams such as calcineurin inhibitors. These are effective and can reduce the amount of steroid cream that you need to use.
There are a whole host of good facial cleansers for eczema-prone skin available on the market today. The best products contain ingredients that nourish and rejuvenate the skin, and are not overly exfoliative. I also tend to advise staying away from alcohol-based products which can dry out the skin further.
My personal favourite is CeraVe’s Hydrating cleanser for normal-to-dry skin. The product contains three natural ceramides which help protect the skin barrier function, while hyaluronic acid helps lock in moisture.
There is a huge amount of research going on in this arena. There are already injectable biologic drugs which target the root cause of eczema and can largely switch off the redness and itch that can be so debilitating. It is personally hugely satisfying to be able to prescribe these agents to people who have spent their whole lives suffering. The moment when they come into the clinic smiling is a feeling that I wish I could just bottle up!
The good news is that there are even more agents coming onto the market which can modify the effect of eczema. These include tablet medications called JAK inhibitors which block specific parts of the immune pathway and are incredibly effective at controlling eczema.
Another great question. The issue of diet and eczema is so intertwined that it is difficult to separate the two threads!
It sounds old hat to say this, but a healthy diet and lifestyle pays dividends in the long run. In terms of diet, avoiding junk foods and high sugar snacks helps reduce inflammation within the body. As we know, eczema is, in part, driven by inflammation so a poor diet only adds fuel to the fire.
Sleep is when our body goes to work, repairing all the damage accumulated during the day. Good sleep also helps reduce our stress hormone level which can help balance mood and concentration, enabling us to better manage the tendency to scratch. While it may be tempting to burn the candle at both ends, it is not worth it in the long run.
An outdoor, active lifestyle that helps get our pulse going (with sensible sun exposure), can help reduce inflammation and control eczema.
Prevention is better than cure. I’d suggest keeping a good line of dialogue with your GP or dermatologist. I’d strongly suggest having a set skincare routine to help maintain the condition of your skin. This being said, there will be ups and downs, and so it is important that you have sufficient quantities of steroid creams in your cupboard for when they’re needed - rather than needing to chase your doctor when your skin is already in a crisis! At skindoc., we keep open lines of communication with our patients (between appointments) so we are able to squash an eczema flare before it has a chance to go wild!
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