Q I would like your advice for the son of a friend of mine. James, 22, had eczema as a child. His passion in life is motorcycles and, thus, he comes into contact with cleaning chemicals as well as oil, grease and the like.
He has now been diagnosed with contact dermatitis, and the steroid cream has made the skin on his hands very thin, which prevents him working with his hands (even with gloves). James is now unable to find a job, which is making him more and more depressed. I hope you can help him.- DVE, Haywards Heath, West Sussex
A Contact dermatitis is a catch-all phrase which basically means a skin inflammation caused by being 'in contact' with something that triggers an irritation or allergic reaction. There are two types of contact dermatitis: primary irritant contact dermatitis refers to a condition caused by contact with a substance that is irritating or harsh; allergic contact dermatitis is an allergic reaction to a substance.
The body part involved is almost always a clue to the offending substance. Dermatitis of the hands usually means a detergent, an oil, tar or rubber compound, latex, chemical soap or something else he was handling.
As James had eczema, it sounds as though he has a predilection to allergy and the chemicals he is coming into contact with are now the final straw - pushing his body into toxic overload.
It's impossible to know exactly what James is allergic to, but with machinery, it could be the grease or oil, the chemicals, or even the hand cleansers and detergents to clean them off.
Many of those whose occupation involves extensive cleaning and soaping of the skin develop dehydration or shrivelling of the keratin layers of the skin of the hands, which can lead to the primary irritant type of contact dermatitis.
Fair-skinned people working in lots of water can often develop dermatitis, as skin is acidic and water is alkaline, particularly 'hard' water containing high concentrations of calcium and magnesium.
When skin is continuously exposed to soaps and detergents, this can impair the skin's alkaline neutralisation process, causing drying and fissuring of the keratin layer, thus allowing increased permeability and then allergy to even ordinarily well-tolerated substances. So what began as a primary irritant contact dermatitis may sensitise an individual, triggering off a chronic allergy to an increasing array of substances.
According to the Dermatology Society, even hand soaps, which contain tiny particles of talc, borax, cornmeal or pumice to make them more effective, can be irritating and sensitising. Other triggers include fabric finishes, dyes, cosmetics, perfume, wood resins, insecticides, plastics, paints, glue, metals, polishes and fibreglass. Yet other culprits are the solvents found in many cleaning solutions.
Another common sensitiser is paraphenylenediamine, a chemical used in hair dyes. Women can also be sensitised by eyeliner, nail polish, contact lens wetting solutions, lipsticks, perfumes, sunscreen preparations containing PABA and toothpaste.
To make matters worse, all these chemicals can interact with other chemicals. Methyleneparaphenylenediamine, for example, crossreacts with sulphonamides and thiazides, PABA in sunscreens, the oral antidiabetics tolbutamide and chlorpropamide, and even the artificial sweetener saccharin.
It is likely that the chemicals James has worked with have triggered this type of progressive sensitisation, making an already allergic individual hypersensitive to a variety of substances (see our article on multiple chemical sensitivity, WDDTY, vol 8 no 8).
MCS creates a vicious cycle of ever- increasing allergy. If left uncorrected and exposure to the offending product continues, a hypersensitivity to other allergens can result, often due to over-treatment with medicine. According to the Dermatology Society, drugs themselves can act as sensitisers. The worst offenders include the 'caine' anaesthetics (such as lignocaine), antihistamines like tripelennamine, antibiotics like neomycin and nitrofurazone, penicillin and sulpha drugs. Neomycin is often mixed with corticosteroids in topical products. If you become sensitised, you could absorb too much steroid through your inflamed skin.
The typical medical approach to eczema and dermatitis is topical corticosteroids, which suppress symptoms without getting to the root of the problem. This class of drugs comes with a plethora of side-effects (see WDDTY, vol 7 no 2), and there is no doubt that the steroid cream James has been given has caused the thinned skin with easy bruising.
This cream could also be worsening his problem as most ointments, creams and lotions contain petrolatum, waxes, paraffin, propylene glycol or mineral oil. As it's easy to develop tolerance to topical steroids, requiring higher doses for the same anti-inflammatory effects, he could be increasing his exposure to the offending substances.
The cream could also be contributing to his depression. According to a recent study, certain corticosteroids (dexamethasone) enhance emotional arousal and negative feelings, such as anger or sadness (Psychoneuroendocrinology, 1996; 21: 515-23).
It seems to us imperative that James be weaned off steroids, which are not in fact dealing with the problem.
The best alternative treatment is for him to consult a clinical ecologist, who can examine the effects of a patient's entire environment - his diet, stress levels, toxin exposure - on his health. Through a number of tests and perhaps an exclusion diet, this kind of 'environmental doctor' will determine the total toxic load that James is exposed to, including any food, chemical or airborne allergies.
He will also take James off steroids by 'stepping down' to a lower-potency agent, then on to less frequent applications, before cutting out the drugs altogether. Needless to say, James should not stop the steroids suddenly or he may precipitate an adrenal crisis.
James' health and tolerance to allergens can best improve through careful nutrition and supplementation, and possibly a course of desensitisation.
The provocation/neutralisation test, or the 'Miller technique', works by injecting test substances under the skin until a wheal appears at the injection site. Higher and lower doses are then given serially until the wheal disappears. This is considered the 'neutralising' dose. After several months, it will turn off all symptoms, often permanently. (For a list of practitioners, contact the British Society for Allergy, Environmental and Nutritional Medicine, tel: 01547 550 378.)
Although James requires a custom-tailored diet, all chemically sensitive individuals should avoid a high intake of sugar and carbohydrates, which makes their sensitivity worse. He should also supplement with calcium, magnesium, zinc, and vitamins B6, C and D, as steroids interfere with their absorption. The clinical ecologist will determine if he needs any other supplements.
Most drug manufacturers claim that skin atrophy may be reversible at two months after stopping steroids. It's likely that his skin texture and strength will improve with the right nutritional supplement programme, although stretch marks are usually permanent.