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Rash medicine

MagazineMay 1994 (Vol. 5 Issue 2)Rash medicine

Poor diagnosis and the overuse of steroids have caused a rash of severe side effects, leading to malpractice suits

Poor diagnosis and the overuse of steroids have caused a rash of severe side effects, leading to malpractice suits.

Doctors like to call it "dermatitis". You won't find a clear cut definition of the word, but eczema is essentially inflammation of the skin and can afflict up to one fifth of all children younger than 11 (J Am Acad Derm, 1994; 30: 35-39). Diagnosing a particular type of eczema is difficult. The disease can take on many guises and an accurate diagnosis depends on the doctor's experience.

Unfortunately, doctors get it wrong. They completely misread the symptoms, rarely understand the cause, and either prescribe the wrong drug or underappreciate the dangers of the drugs they use. Severe side effects of the treatment are common; sometimes patients die.

Five hundred British GPs are now being threatened with legal action by their patients for alleged negligence when prescribing steroids for eczema, among other diseases. Around 700 sufferers say they've put on weight, their skin has become paper thin and some claim to have suffered osteoporosis, mainly from the use of systemic and topical steroids, although a few cases also involve the use of inhaled steroids.

By the time the first case comes to court in the summer of 1994, a further 200 GPs will have received a letter from London law firm Evill and Coleman asking them to disclose patient records and show, among other things, whether or not they warned their patients about the long term risk of steroid treatment and adequately monitored its use. Legal aid has been granted to the firm's 700 or so eczema (plus rheumatoid arthritis and asthma) sufferers, so they can pursue individual claims for alleged negligence by hospital doctors and steroid manufacturers.

However, most claims relate to the behaviour of GPs and specialist prescribers, some of whose patients were kept on repeat prescriptions for so long, they seemed to be prescribing for themselves.

Doctors regard eczema as a non infective skin rash and, rather than seeking the cause, often treat it with some form of agent to suppress the inflammation either a steroid (corticosteroid) or, more recently, cyclosporin, a powerful immunosuppressant originally used in transplant surgery, so that the body won't reject the new organ, or even oral psoralen photochemotherapy (oral PUVA), one treatment option for psoriasis.

Some doctors will tell you that one of the reasons why eczema gets worse and won't respond to treatment is because it's infected. For this reason, doctors prefer to adopt an approach akin to pinning the tail on the donkey by prescribing a mixture of steroid (to fight the eczema) and antibiotic (to fight the infection) which often causes a candida albicans overgrowth (the thrush germ; see WDDTY vol 2, nos 5 and 11), usually making the eczema worse.

Although a doctor may well be prescribing this mixture of drugs because he thinks the eczema isn't responding to treatment, this can also be taken as a sign that your doctor can't make a precise diagnosis of the condition and is hoping that by throwing a mixture of drugs at the problem it will go away.

Most sufferers are given topical steroids, although severe cases are often treated with combined oral and and even inhaled steroids (beclomethasone diproprionate, the drug of choice for asthma).

Topological steroids have long been touted as the safe alternative to systemic steroids, but there's little evidence to back this up. Although the first cases of allergic contact dermatitis due to topical corticosteroids date back to 1959, recent reports suggest that they can cause an eczema like allergic reaction, thus perpetuating the disease they are supposed to treat (J of the Amer Acad of Derm, Apr 1993; Br J of Derm July 1989; Archives of Der, Mar 1993; Contact Dermatitis, Aug 1991). Some sufferers have been shown to be allergic to hydrocortisone cream (The Lancet, 30 Mar 1991). Indeed, one of the side effects of long term inhaled steroid use is mouth and throat candida albicans overgrowth, which can manifest itself as eczema. Antihistamines are sometimes used to relieve itching and can be used as a sedative to help people with eczema to get a good night's sleep. However, they too can create a condition akin to the one they are trying to cure.

More worrisome than allergies is the long term damage of topical steroids, which increasingly are shown to be every bit as dangerous as their orally delivered cousins. Indeed, researchers at New York University throw topical and systemic steroids into the same pot, warning that "their use is not without potential complications" (Dermatological Clinics, July 1992).

Topical corticosteroids can produce an array of serious skin problems (American Family Physician, July 1993; J of Derm, Aug 1991). They've been shown to damage organs, and cause permanent adrenal suppression (Zeitschrift fur Hautkrankheiten Apr 1988).

Children with asthma and eczema in particular often the most likely to be subjected to drug treatment are prone to the side effects of steroids (Arch of Disease in Childhood, 62, 1987), such as stunted growth and adrenal disease (The Lancet, 14 Dec 1991). One child covered with eczema from head to food from 18 months was treated once a day from age six with a layer of betamethasone ointment over his entire body; by age 13, he was 24 cm (about nine and a half inches) smaller than average. Although he enjoyed some catch up growth once steroids were discontinued, he never recovered what was estimated to be his likely size. "Every effort should be made to search for an alternative mode of treatment", concluded Dr Hans Henning Bode (J of Am Med Assoc, 22/29 Aug 1980).

In other instances topical steroids have also been implicated in Cushing's syndrome (moon face) in children, as soon as a month after treatment (Arch Dis Child, 1982; 57: 204-7). The authors concluded that topical steroids may impair pituitary adrenal responses, requiring systemic steroids during illness or trauma.

Even the supposedly mild hydrocortisone cream, which is even prescribed for babies, is known to have a myriad of side effects including thinning of the skin, especially the face, stretch marks, delayed healing or ulceration of wounds, suppression of adrenals, sugar in the urine and eye damage, such as glaucoma and cataracts (see WDDTYvol 1, no 11).

In fact, increasing evidence is emerging to suggest that topical and inhaled steroids can cause the eye damage cataracts and glaucoma ordinarily only associated with oral steroids (The Lancet, 20 November 1993, New Eng J of Med, 9 Dec 1993). Cases of psychotic episodes with inhaled steroids, ordinarily only associated with systemic use, are also coming to light (Ann Int Med, 15 Oct 1988).

Patients using systemic steroids who haven't had chickenpox can also be placed in great danger, as the well reported case of nine year old Lexie McConnell proved so tragically when she died of chickenpox after doctors failed to warn her parents of the side effects and dangers of a routine course of treatment (see WDDTY vol 4 no 8). Steroids suppressed her immune system and therefore made her more susceptible to serious infection.

About 30 people die each year from chickenpox, a third of whose deaths are associated with immunosuppression (Curr Probs in Pharm, Feb 1994). Indeed, in 1992, following reports of such deaths, the US Food and Drug Administration has asked manufacturers of oral and inhaled steroids to add a warning to their product labelling that children on immunosuppressant drugs are more susceptible to deaths from measles and chickenpox than healthy children (J Am Med Assoc, 15 January 1992).

The recent Evill and Coleman litigation highlights the threat of osteoporosis, one of the more serious side effects from taking steroids over a long period.

As for cyclosporin, this powerful immunosuppressant brings with it a whole host of dangerous side effects such as skin cancer and other types of malignancies (see WDDTY vol 4, no 6). It's also associated with liver and kidney damage.

The reason that conventional treatments fare so poorly in anything other than suppressing symptoms of eczema is a fundamental lack of understanding of its various causes. A child's allergic reaction to a vaccination, or bottle feeding with cow's milk can trigger it off, as can introducing solid foods too early (Monitor Weekly 7 July 1993). The culprit can be one of a number of airborne substances (such as pollen, mould or dustmites) or food allergies (such as wheat). Eczema can also run in the family with a history of allergies; indeed, eczema and asthma frequently sit side by side in the same person.

Our panellist Dr John Mansfield says that in his allergy specialist practice 60 per cent of cases of eczema are caused by food allergies (such as dairy produce), 20-25 per cent by dust, mite and mould allergies, a small percentage by chemical sensitivities and nearly 20 per cent by systemic candidiasis. According to panel member Dr Jean Monro, seborrheic eczema is often hormonally related or caused by pollutants.

In Superimmunity for Kids (Bloomsbury 1989), Dr Leo Galland says that in 1931 American pediatrician Arild Hansen discovered that children with eczema had abnormal level of omega-6 EFAs in their blood. He explains that people with eczema (as well as asthma and hayfever) lack a key enzyme which converts EFAs into prostaglandins. Fifty years later, British dermatologists were able to reproduce Hansen's results, says Galland, and found that evening primrose oil was effective in relieving a group of patients with severe symptoms (The Lancet 1982; 2:1120-2). Another good source of omega-6 fatty acids is blackcurrant seed oil.

Perhaps predictably, conventional medicine gives evening primrose oil short shrift, although there is some evidence that trials were not conducted as well as they should have been (Drugs and Therapeuticals Monthly 1990; 28: 69-70; The Lancet, 26 May 1990).In one trial, the EPO group were 20 per cent more effected with eczema than the controls (The Lancet 26 May 1990).

Another alternative eczema treatment given a good deal of press is Chinese herbal medicine (CHM), or traditional Chinese herbal therapy (TCHT), as it's called, which boasts excellent results in treating eczema and psoriasis. Chinese herbal medicine often prescribes a mixture of herbs which are chosen for the individual then added to water and boiled to form a liquid "decoction". Dr David Atherton, a dermatologist at Great Ormond Street Hospital, was amazed when some of his eczema patients, who hadn't responded to conventional treatment, improved dramatically after receiving Chinese herbal medicine prescribed from Dr Ding-Hui Luo, who practises in Soho. He decided to have these herbs standardized and test them on children and later adults (see WDDTY vol 4, no 5).

The Sheehan-Atherton studies certainly showed promise. Among 37 children randomly given placebo or the herb mixture, all the treated children responded to treatment (Br J of Derm, 1992; 126: 179-84). A year later, 40 adults with long standing eczema given either the herbs or a placebo reported seeing about a five fold improvement in their condition over two months (The Lancet, 4 July 1992). In longer term trials 12 out of 21 adults and 12 of 20 chidren remained clear of symptoms after a year.

Not surprisingly, the medical establishment has pounced on every last case of toxicity as proof that this therapy is more dangerous than steroids. The main side effects reported by patients taking the decoction have been generally mild and reversible. They included headache, nausea, bloated stomach and loose bowels. There was no evidence of blood liver or kidney toxicity in the short term study of children, but two cases of reversible liver function abnormalities in the longer studies.

However, cases of hepatitis, from drinking herbal tea, have been reported (The Lancet, 12 Sept 1992). One 28 year old woman recovered, but a few months later took herbs for another three weeks and developed liver failure. She was given an emergency liver transplant, but still died.

A large number of clinics in this country offer traditional Chinese herbal therapy. Some are run by Chinese doctors with extensive training in traditional Chinese herbal medicine. Others are run by people with no medical training whatsoever. Although the Chinese community in Britain may well be able to distinguish reputable practitioners from the more dubious, Westerners remain vulnerable to exploitation. A Register of Chinese Herbal Medicine does exist, but it's estimated that only 120 or so of the 600 clinics in Britain are registered.

Some Chinese creams or ointments have been found to be amplified with (often impure) steroids like prednisolone. In spite of these reports, the exact risk level associated with traditional Chinese Herbal Therapy is not known,although it's well to balance these isolated cases against the known damage caused by everything that conventional medicine has on offer.

Writing in The Lancet (12 Sept 1992) Malcolm Rustin and David Atherton say: "TCHT seems to be much less toxic than drugs such as cyclosporin and any other treatments for severe atopic eczema, including oral corticosteroids, oral photochemotherapy and azathioprine. No hematological or biochemical abnormalities have been detected so far in any adults with atopic eczema under our care who have received a formulation of TCHT that has been prepared with careful attention to high quality control standards."

!AClive Couldwell

Clive Couldwell writes regularly for the London Times and the Daily Telegraph on a variety of subjects.


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