Dr Ruth: Our skin is our ultimate boundary, and for me when I'm quite angry, I notice that my skin gets worse. It kind of tells me that maybe my boundaries are being pushed a little bit. You know, getting out if you've been in your office all day, it actually, it physically cools my skin down. So, yeah, especially when my skin was really bad, my daily walk was a vital part of how I was managing my skin.
Dr Rupy: Welcome to the Doctor's Kitchen podcast. The show about food, lifestyle, medicine and how to improve your health today. I'm Dr Rupy, your host. I'm a medical doctor, I study nutrition, and I'm a firm believer in the power of food and lifestyle as medicine. Join me and my expert guests where we discuss the multiple determinants of what allows you to lead your best life. Eczema is the topic of today's conversation with Dr Ruth Kamish, an NHS GP, a GP trainer, and the regional director for the British Society of Lifestyle Medicine in Manchester. She's been a GP for 13 years, mostly working in a deprived inner city area, and her own experiences as a patient with severe eczema has highlighted how holistic care is a vital part of any long-term condition, especially chronic skin diseases. You'll also hear about how Dr Ruth suffered with severe eczema her whole life, ending up on ciclosporin and immunosuppressant medication and discovering topical steroid withdrawal. As a practice, Dr Ruth and her colleagues have been awarded a CQC outstanding rating twice based on their approach to their patient population, which includes group consultations and an exercise class for COPD patients and their work for vulnerable patients. And I can totally imagine that after speaking with Dr Ruth today, you can really tell that her and her colleagues have created a wonderful practice. On today's podcast, you'll hear about what eczema is and who it affects, the link with food intolerance and allergy, topical steroid withdrawal and how that occurs, the mechanisms behind eczema as a disease, environmental triggers like temperature, pollen, pollution and dust, household irritants like skin care products, beauty care, clothing, laundry and detergents, stress and why it triggers the immune system, plus, obviously, diet, gut health, nature therapy, and also we talk about supplements and skin too. Dr Ruth can be found on Instagram at Dr Ruth Skin Journey, and I really hope you enjoy the show. Please do listen right to the end for my top tips for eczema and do rate and review, it really helps spread the message. Ruth, thank you so much for coming on the podcast. We've been talking about this for a while, and our diaries obviously need to match up, but it's a pleasure to have you on. I've been following you on Instagram for a little while now, so thank you so much for making the time.
Dr Ruth: Yeah, thank you for inviting me. I've loved your podcast for years, so I'm really excited to be here and it's lovely to speak to a GP as well who's so interested in the kind of ways that I like to look at patient care. So, thank you so much for having me.
Dr Rupy: Oh, thank you. It's it's funny. I've I've had a string of GP chats over the last couple of weeks, actually. I had Dr Gemeron recently, and Dr A I speak to regularly anyway, but it's it's nice to have like a community of like-minded GPs who are not afraid to talk about subjects perhaps slightly outside of the norm. So, the pleasure's mine. So, tell us a bit about yourself and where abouts you work within the NHS.
Dr Ruth: So, I am a GP in Central Manchester. I've been a GP for about 12 or 13 years. I'm a GP trainer as well, which is a part of my job that I love. Really passionate about education of GPs. I have mainly worked in Manchester, I trained in Sheffield. I've been in the same practice for most of that time. So, work in a pretty deprived part of not kind of the outer inner city of Manchester. So, an area that is pretty deprived, has a lot of chronic conditions. But that's the kind of medicine I love. I love really challenging consultations. I love that a lot of my patients have health conditions, obviously, and a lot of pathology, a lot of disease where I work. But also they have a lot of social issues as well. There's a huge amount of unemployment, addiction issues, domestic violence, drug use, and I don't know, I really love that my job is about disease and illness, but also about factoring in what's going on in that person's life as well and how that impacts on their experience of their kind of disease as well. So, yeah, I feel really lucky to work in a challenging practice. Not always easy, but it definitely keeps me on my toes.
Dr Rupy: It's incredible, isn't it? That you know, despite the challenges of general practice, we still see it as a privilege. And I know we're we're here to talk about skin, in particular your skin journey and eczema. But I wonder if we can digress a bit because I don't think a lot of people and perhaps a lot of people listening really understand the complexity and the breadth of us as GPs have to deal with on a daily basis. Like you mentioned a few things there, like addiction, social issues, housing problems, domestic violence. These can all come in at the same time as your typical worried parent who perhaps, you know, has got a a first or a second child with a cold and or or something else perhaps even more sinister. It's it's amazing. And I always want to ask GPs how they deal with that complexity on an eight minute by eight minute basis.
Dr Ruth: And and and I think that's what keeps for me, I think that's what's going to keep me in general practice for a long time is that everyone who walks through your door, even if you have three patients with diabetes in a row, they will all have an individual response to that disease, which is their illness. So their their experience of their disease, which is their illness, will differ so massively. And therefore what I love about that is the solutions that you help them find are different between every single patient. And I think people can sometimes think general practice is or don't look at general practice as a speciality, but there are so many skills that you need in a consultation to draw out the patient's perspective, how that disease impacts their life, their family, their work, their caring responsibilities. And so I really try to get my GP trainees really curious about the person in front of them. And that's why I think it's such a privilege to be a GP. And we don't get it right all the time, but I think if you can always keep that in mind that the person in front of you has something to teach you, something, something that makes them individual, then you're always going to have that passion for general practice. It's never dull if you look at everyone as a complete individual.
Dr Rupy: Yeah, it's really not dull at all, actually. It's it's amazing just how many people we can get through the door. And I you know, just just to stick on this subject for a matter for a small amount of time. One of the pushbacks I get, I think, as a GP from my own sort of colleagues is, you know, well, how on earth do you start addressing the wider aspects of disease like nutrition, like lifestyle? It's almost got like a bit of an elitism attached to it. Like, well, this is for, you know, people who, you know, don't really need the drugs, but we need need something else. You know, how do you deal with that, particularly with your diverse patient group?
Dr Ruth: I think it all it doesn't all happen in one consultation. And again, that's why I love being a GP is you see patients, you know, often over the course of, you know, hopefully for me in my practice, 10, 20, 30 years. I met with my old senior partner over lunch today and he was at our practice for 35 years. And the stories he had about patients and their families and he would see babies born and then he might look after them as teenagers and then as mothers themselves. And you know, we have a lifetime or a long amount of time with our patients to get to know them better. So, no, in one consultation, that's really difficult to get out, but continuity, seeing the same patient again, if possible, that's when you can start to draw out some of the hints that people give you about how their illness is affecting them.
Dr Rupy: Immediately, Ruth, you you strike me as just such a lovely GP. They're probably people probably listening to this and like, oh man, I wish she was my GP. She just sounds like so lovely. I just talk to her about everything.
Dr Ruth: But you know, but then don't I think we bring the energy that we want, you know, to our jobs, don't we? And you know, I'm not I'm not perfect every day at all. But I you know, I do I I've been lucky to be trained really well. I had some really a really amazing GP trainer who always, you know, always dealt with her patients with real kindness. And I did work in a deprived practice as a GP Reg as well. And and she always said to me that you might be the only person to have been kind to that patient today or to have listened to that patient today. And there's such therapeutic value in listening to somebody and really hearing them. And when we get to talk about my skin, that's maybe not the experience I necessarily had. And in a lot of ways, it's made me even more passionate as a GP that we need to aim to hear everyone because that even that in a consultation, you know, people don't always need medications. You know, actually just the value of that 10 minutes with their GP and feeling understood can be enough, especially with mental health, for somebody to be on the right path to feeling better.
Dr Rupy: Absolutely. And this is why like, you know, I think a lot of us would like to define medicine as the prescription of pills or the interventions of a more sinister severe nature like surgery. But actually it's talking, it's demonstrating compassion. It's all the other wider aspects of lifestyle medicine that can be medicine as well. And I wonder, you know, because a lot of us in this field have had that personal experience and I wanted to come to your own journey because on on social media, you're refreshingly authentic and and and you really demonstrate perhaps not ease at showing vulnerability, but but certainly courage and bravery to demonstrate that amount of vulnerability online as well. Um I I wonder if this is sort of permeated into your empathetic nature as being a practitioner.
Dr Ruth: Well, yeah, thank you. That's really kind. I I have found that social media for me through my difficult time with my skin, it has been a it in a lot of ways, it's been one of the worst things that's ever happened to me. You know, and I think health, you know, health, when your health isn't there, it's a massive part of your life at that time. But the beautiful thing about life is it often leads you to places that you wouldn't think. So, looking at my own skin holistically, introduced me to lifestyle medicine. You know, I'm now the British Society of Lifestyle Medicine director for Manchester. I've done my diploma in lifestyle medicine. So my own experiences with my health have led me to be a better GP. So, every experience that we have can have a positive. I mean, I wish that I hadn't had to have gone through it, you know, but um I'm kind of glad that it did. It's led me to opportunities like this. I know a lot of the people that following me on Instagram, it's helped them find their triggers for their skin. Um so we need people to be vulnerable and share what's going on with them because I think there's a huge amount of learning that we can have from each other's experiences.
Dr Rupy: Yeah, absolutely. I mean, it was certainly my own experience of ill health that led me down the path of exploring other avenues around lifestyle medicine and certainly made me a lot more um empathetic, I would say, uh to to patients being a patient myself. But it's it's it's funny. It reminds me of a conversation I had with a a psychiatrist colleague of mine who said there's a stat about one in four people have mental health. And he says, I hate that stat because in reality, four in four people have mental health. We all have mental health. In the same way, we're we are all patients as well as physicians. Um so, I I I just think it's it it's it's great to have that perspective and I think it makes us a lot more compassionate as a as a specialty too. Well, let's dive into your your skin journey. So, so tell us a bit about when that started and and and what your journey has has been.
Dr Ruth: Yeah, so I have had eczema my whole life. Started with eczema as a child. Um and unfortunately was um one of the children with eczema that didn't grow out of it. So, you know, eczema is a hugely common condition, like up to one in five children will have it at some point. And the majority of kids grow out of it. So two-thirds of children will, but a third of um adults will still have eczema um into adulthood. And unfortunately, those are generally the people who have it more severely as a child. Um so my eczema has always been um kind of quite well controllable. It was always worse with animals and dust, etc. Um but it got quite bad in my teens and then again in my 30s, so my mid 30s. Um and I noticed that it was usually at points of stress that it got a lot worse. But it got to the point in my mid 30s that it was having a significant effect on me. I was under dermatology because it was so bad. Um and I was increasingly using a lot of potent topical steroids to get it under control. And about five years ago, I was stuck in a really bad cycle of, you know, topical steroids would keep it under control for a couple of weeks and then it would just come straight back. And the hard thing with skin is, you know, the skin is what we greet the world with. And especially if you're a doctor and people are looking at you and and your face is so important in the way that you communicate. Um and I think it was really damaging my self-esteem and confidence. And as a human, I wanted it to go away. So I would use my topical steroids for long periods of time. Um they were kind of like, I'd use them like rescue meds. I'd just quickly put them on, maybe get a couple of good days off them, but then I was finding that I was using them again and again and again for prolonged periods of time. And after a couple of years, I had noticed that my eczema was starting to not look, it was not looking the same as it usually did. It was spreading to different areas and I was never quite getting on top of it. And that was actually when um I found out about the condition called topical steroid addiction and topical steroid withdrawal. And although social media can get a bashing in terms of medicine and misinformation, um I I don't think I would I wouldn't be where I am now with pretty great skin if I hadn't have had that discovery because of Instagram. Um and as a doctor, I'd never heard about this condition, but when I saw pictures of mainly women, because women are more affected than men, I felt like I was looking at hundreds of women with exactly the same pattern of skin disease as me. And that was both frightening and fantastic because I suddenly felt like I had an answer to what was happening. Um and that reality was my skin had become tolerant to the potent topical steroids that I was using. And in order for me to improve my skin, I would have to go through a withdrawal period, which is what I did. And that has dominated in a lot of ways my life for the last two to three years. But I'm at the end of it and I've been free of topical steroids for about three, four years now and my skin has been great for um over 12 months or about 12 months now.
Dr Rupy: So you've you've completely off topical steroids?
Dr Ruth: Yep.
Dr Rupy: Wow.
Dr Ruth: So I now manage my eczema holistically and by um recognizing my triggers, um with my gut health and also with um managing my skin barrier better. I think it's important to say at this point that I'm not anti-topical steroids at all. I think steroids have been used since the 70s for a whole host of inflammatory skin conditions. But there are a subset of people who use steroids who unfortunately with prolonged steroid use will get to the point when it's not eczema anymore, it's this condition called topical steroid addiction and then topical steroid withdrawal.
Dr Rupy: Right. I mean, I'm glad we're talking about this because I think it's particularly right now very easy to label social media, particularly the discussion of medical subjects on social media as dangerous and, you know, potentially misinforming, which of course, it definitely has that impact and we've we've witnessed a lot of that during the pandemic as well. However, I think what you've highlighted there is this um potential for community and almost uh a socially motivated way of sharing information that if is conducted in a considered way is actually really beneficial. So, you know, it strikes me as as amazing that even yourself as a as a doctor, someone with years of experience, hadn't come across this before and actually led to you improving your skin condition to that extent. And the reason why I'm saying for the listeners, the reason why I'm saying wow is because I've seen so many patients with topical steroid use who are almost in that similar pattern to you, like, well, there's not really much else that we can do apart from trying to limit steroid use, know your triggers and, you know, all the other things like barrier and and things that we'll we'll get on to in a second. Um but yeah, no, that that's that's really, really interesting to know.
Dr Ruth: And you know, there's been over the past four months. So in in January, um the National Eczema Society and the British Association of Dermatologists for the first time, they released a statement um acknowledging topical steroid addiction and withdrawal for the first time. And that's huge. And it's huge and was very emotional as a sufferer to get to the point where dermatology had taken notice of this growing number of people on social media who had this condition. But for me as a doctor, why it's important is for this condition to be understood, it needs to be researched. And for the management kind of options to be there, it has to be acknowledged in the first place because the community is amazing, the topical steroid withdrawal community, but everyone is just sharing their experiences. And misdiagnosis because not all red skin in the the pattern that happens in topical steroid withdrawal is topical steroid withdrawal. And and therefore there might be people who are mistreating their skin condition, but but before this statement, they weren't able to go to dermatology and say, this is what I think I'm experiencing. So we were just as a community just stuck in a really difficult place. So, um, Itzan who are um an American society who actually were the first people I found that were talking about topical steroid withdrawal and an organization called Scratch That in the UK who have some brilliant information about um topical steroid withdrawal. They've been massive for campaigning for this. But on a personal level, it just feels so great to be able to say, yeah, this is what I've got and I got through it with really, as a doctor, no real support from my dermatology, my dermatologist. Um so, yeah, it it it was an amazing statement.
Dr Rupy: I mean, it's it's pretty incredible, isn't it? To feel validated. And I don't know if this was your experience, but certainly the community perhaps would have felt quite dismissed by colleagues and professional people, particularly if it wasn't a recognized condition at that point. Um and I think this is all an exercise in listening to the patient. They're telling you something and so often, and I'm not, you know, being dismissive of dermatologists or or other doctors for that matter, but you know, sometimes it is quite easy to fall into a pattern of just symptom and diagnosis recognition. And if it doesn't fit a nice bucket, it's probably nothing. It's probably, you know, maybe psychological or maybe something like a nocebo or, you know, whatever. But it's it's something I've recognized in a lot of different fields beyond dermatology as well.
Dr Ruth: I absolutely agree. And and and science changes. You know, think about the stuff that we learned at medical school that actually management, kind of diagnosis that is just not relevant now. You know, maybe even five years ago, things, guidelines have changed, our, if you look at COVID as an example, think about over this year, how much more we know about possible treatments and long COVID, we're going to know so much more over the next few years. So, as doctors, we have a responsibility, as you say, to listen, but also to be open to the idea that we don't know everything.
Dr Rupy: Yeah, yeah, absolutely. I think, you know, again, on the subject of vulnerability, putting yourself in that position is perhaps not really taught that well at medical school. Um we we're sort of like, you know, we're taught that that game of spot the diagnosis and you're expected to know. And if you don't know, it's pretty belittling. Um so, I I think, yeah, in the spirit of like being a lot more authentic with people and and being vulnerable, we have to get used to the words I don't know because it's not it's it's just a fact that we can't know everything.
Dr Ruth: Absolutely. And you know, a quite eminent dermatologist in the UK who works for the National Eczema Society said at the time of the statement that he felt we were letting people down, that there were a group of people that were not being supported appropriately in this country. So, yeah, it's great. And and also to say that because the condition wasn't recognized, it then was turning into a very kind of anti-steroid place because I prescribe steroids for eczema. I actually feel really passionate, especially with, you know, children with eczema, their risk of food developing food allergies is so much higher if their eczema is poorly managed when they're little. Um but until we know who develops topical steroid addiction, how long it takes, you know, social media in the community is always full of someone who developed it after two weeks of using steroids. Well, I used topical steroids on and off for 30 years. Until you know who gets it, you're not able to safely reassure parents and patients about what is safe use.
Dr Rupy: Yeah, yeah. I know we've we you've mentioned a bit about the statistics of the number of people who suffer with eczema and those who go into adulthood with eczema as well, which is a persistent problem. Um perhaps we should rewind and just talk about the mechanisms behind eczema and what we know about eczema as a condition. And then we can um just zoom in on um the topical steroid addiction as it's defined currently and what we know and what we don't know about it.
Dr Ruth: Yeah, brilliant. So, you know, eczema is a a very common inflammatory skin condition. I'm sure you see a lot of it in your practice. Um the cause is multifactorial. Um there's a genetic um element of it. Um but generally, there's two main parts, which is a defective skin barrier. So a lot of people with eczema lack a protein called filaggrin, um which is kind of like the cement that keeps the skin cells together. So without that cement, the skin barrier itself is quite gappy. So it loses moisture easily, leading to dryness, but also importantly, allergens like dust, pollen, pollution, if the skin has these gaps in it, it goes through the skin and causes an inflammatory response, redness, dryness, which is eczema. But also people with eczema have an elevated immune response, so an allergic immune response. So I will react to things like lilies, um and somebody without eczema will not um respond in the same way. So, um that kind of overzealous immune response is a really important part of eczema. And all and that's not something we can necessarily change. We might be able to help it. Um there is no cure for eczema because of those reasons, but it is definitely a condition that can be managed well so that people can function well and not be too debilitated by flares in their skin.
Dr Rupy: And you alluded to something earlier about the link between poorly controlled eczema and uh childhood food allergies as well. There there's a mechanism behind that, right?
Dr Ruth: Yeah, so my understanding is the mechanism is about sensitization. So that um uh allergens including food, um pass through the skin barrier to the skin and cause sensitization. Um because even 10 years ago, we thought that kids with a strong family history of allergies or eczema, we should avoid certain foods. Um but the LEAP study in terms of peanuts, um and what we know now is actually a really diverse diet early is important to reduce the risk of food allergies. But also that children with a high risk of eczema or have severe eczema um when they're newborn, actually might need to be weaned earlier as well. So weaned at four to five months rather than six to stop that um that kind of atopic march and that kind of development of food allergies. So another example of how much we've learned over a short period of time.
Dr Rupy: Exactly. Yeah.
Dr Ruth: Um so, yeah, so, you know, eczema, um yeah, really common. Um people can be mildly affected or severely affected. Um and most people are managed through their GPs generally, very few children need to go to dermatologist. So I'm sure you've got a lot of experience of seeing children with eczema. What what's your experience of um the kind of issues that parents or patients bring to your consultation room?
Dr Rupy: It's usually they usually fit criteria. So, um I see a lot of children from ethnic backgrounds, um diverse ethnic backgrounds that tend to be more likely to have eczema, which is something I wanted to ask you about in in terms of your experience. Um certainly runs in families. And uh I I always talk to them about getting on top of it quite early. So, like you, I'm definitely not anti-steroid use, I'm definitely not anti-topicals, and I think with rigorous use of those early and identification of triggers, potential food issues as well, um and uh uh looking at um their their hygiene measures and making sure, you know, we're taking things out that could be potentially irritant to the skin. And a lot of children are irritant irritated by by quite a few household products. Um that's usually the strategy. And like you said, a lot of it is um dealt with at a GP level rather than going to dermatology. And I only quite infrequently would I send someone to see a dermatologist. And it's usually in that moderate to severe category where we've used a number of different agents, we're not getting on top of it and we want to get them seen as soon as possible.
Dr Ruth: I think that is music to my ears. What a what a brilliant GP consultation. And um I'm not surprised at all that you manage it like that. I I fear that that's not the experience that most patients or parents get. Um I mean, you know that the level of dermatology training in medical school is pretty low. I feel like I've learned all of mine on the job whilst I've been a GP. And and we see so many dermatological conditions in primary care. I would love to see that change. Um because I think the NHS is brilliant at acute care. If you break your leg, you know, it it's fantastic, free at the point of care, amazing. I think the areas that we really need to work on is how we manage chronic conditions and long-term conditions because 10 minutes to go through triggers, to go through skin barrier management, oh, that's a huge ask, isn't it? In in a consultation. Um and I think the NHS is really trying to get there, but I think we really need to turn around how we deal with with chronic conditions.
Dr Rupy: Definitely. And this is why I think social media has or or just, you know, um good resources on the internet can be very useful for a time poor general practitioner who has to deal with a number of different things in the office. Um so, yeah, I I I think like, you know, putting out good content, um putting out really good resources so that people can actually action themselves is a is a great way of scaling up that sort of information because it can't be on the on the shoulders of GPs across the country. It's just near impossible.
Dr Ruth: Absolutely. And one of the things that we've done in our practice and and I suppose this is a a key area in in lifestyle medicine in general is this idea of group consultations. So, we in our practice, we've done them for hypertension and type two diabetes.
Dr Rupy: Wow.
Dr Ruth: And and I suppose for for your listeners that, you know, most patients with diabetes get two sessions, two appointments with a diabetic nurse or a GP every year for their annual checkup. Um and so that nurse is telling the same information to, you know, we have 400 diabetic patients within our 7,000 patients um in our practice. And and so one thing is that's not massively time efficient. And and so one of the purposes of um group consultations is about getting a group of people together to support each other, but to deliver kind of information giving in a different way because those kind of informal networks of patients that are formed through group consultations are so powerful. You know, patients who start kind of meeting up on a Tuesday to walk to Tesco together to do their shopping. You know, in an area of deprivation like ours, for somebody to know somebody else who's got diabetes, the kind of work that they can do together on that chat as they walk to Tesco every week is probably more than two appointments with our practice nurse. You know, and you're right, it empowers patients to self-care, you know, it it gives them correct information. And I would love to see that for dermatological conditions, for parents, for patients, to go somewhere where you know you're going to get the right information, but that you can share your experiences of it together and help each other by the things that have maybe helped you, um or, you know, we like stories, don't we, as people? We kind of identify with the stories of others. And and I think that that will help us shift from a paternalistic way of dealing with health, do this because it'll make your blood test better or your blood pressure better, to actually, um, yeah, empowering communities of people with the same condition to get well together.
Dr Rupy: Yeah, absolutely. Like those small subtle nudges that social groups can um create cycles around it is really, really interesting. And I think it's something that particularly as community practitioners, we need to capitalize on. And the other thing that sprung to mind whilst you were talking there is this whole concept of um the Ulysses contract. I don't know whether this is a a particular analogy that's directly relevant, but the Ulysses contract is um where you make a contract with yourself for doing something in the future and it's heightened if that's tied into a social bond. So if I was to say to you, Ruth, on Saturday at 9:00 a.m., we're going to go to the gym. I'm tied into that contract with you. If it was just me, I might be inclined to break that contract because I'm just breaking it with myself, but it's tied to you and your emotional connection such that it will heighten the likelihood that I will keep that bond with you. And I think, you know, that that can happen when you when you create um communities around um a shared experience and ever more so than when it's with a a condition as well.
Dr Ruth: That that's amazing. That's that accountability. And and also then that positive, you know, when you both go to the gym and you've done it, you know, actually that you've had a positive shared experience together. And I know I've found that with my informal community on Instagram that when people are getting better, it feels like a win for you. You know, like I I when I was in the depths of topical steroid withdrawal, I needed to see people who were getting better. You know, at some points it was the only thing that dragged me through. Um and I think that can work for a lot of different conditions.
Dr Rupy: So yeah, you know, lifestyle medicine feels like the right way to go. Um and, you know, I'm proud that our practice have taken that on board and are trying to innovate um differently.
Dr Rupy: Definitely. I mean, your your practice sounds amazing and I love how you're, you know, jumping on that um that concept of group consultations because you're right, it's just inefficient to see individual patients like that. And when there are so many knock-on benefits of having uh formed those groups, I I think it's brilliant. Um I I want to talk about your experience of withdrawal now in terms of how how that works. What what we know about topical withdrawal um eczema and and and what that process was like for you as well.
Dr Ruth: So, topical steroids work by constricting blood vessels. So, um they reduce inflammation in the skin by reducing blood flow. So when you've used steroids for a long amount of time, your blood vessels don't really know how to dilate and then constrict again. So, one of the first things when you stop using steroids is your blood vessels are in fixed vasodilation. So the blood vessels are big, lots of blood flow to the skin, and you get this fixed redness. Um and it affects very different areas from eczema. So, the common signs of it, um I mean, basically it looked like I'd been hung up upside down and dipped in a pot of acid. You know, the distribution of it is chest up and then something called red sleeves, which you never see in eczema, which is it kind of spares the palm of your hand, but from the the whole all of my skin was like a red, a red angry sleeve. You know, I've had eczema for 35 years, it never looked like that. So that's quite pathognomonic for topical steroid withdrawal. And then because the skin barrier is pretty thin because of the years of steroid use, it's very friable. It's um there's a lot of oozing that happens. So as long along with that redness, um temperature, you know, you can't control your own temperature because of that um so temperature regulation becomes difficult, but also your skin just oozes. So it becomes very wet and the chance of infection is really high at that point. Um you also get what's called elephant skin, which is although the skin is really thin, it becomes quite thickened in areas as well. Um so it it looks super wrinkly like an elephant. Um so those are the common things that that people notice. On a psychological level, um it's extremely painful because of the effect on because your skin is so thin, you get a lot of nerve pains. It's incredibly itchy. Um people get a lot of, yeah, neuropathic pains with it. It feels like your skin is on fire. Um and it's deeply unpleasant. And unfortunately, there aren't a lot of treatment options apart from symptomatic relief. So, I used a lot of ice packs when it was bad. I needed antibiotics at some point when it was infected. But actually, it got to the point where I couldn't work because of how it was. Um so, after about six months of withdrawal, um because I was under dermatology at that time, I actually made the decision to go on an immunosuppressant for 12 months, which is quite a controversial area in the TSW community because again, we don't have we don't have research that tells us what works. But for me, I needed a break. I you know, I needed to live, I needed to go to work. It had huge implications and psychological implications as well. It was a very dark time. Um and so I went on ciclosporin for a year under dermatology. And then when I stopped it after 12 months, which is the usual course, um I went into withdrawal again, which I knew I probably would, but because my skin barrier was in such a better state because I'd spent a lot of time over that year researching, looking at my triggers, I was able to have a much shortened second withdrawal, which was about six to seven months.
Dr Rupy: Seven months.
Dr Ruth: Yeah. So, I I had to have some more time off work over that time because it got pretty bad again. And to go through that a second time when you know what what you've gone through before was tough, but I think I knew that it would be shorter. I had a lot more faith that it would get better because the first time I was kind of just guessing. I hoped that it would get better, but I wasn't sure. My dermatologist didn't recognize it as a, you know, a condition, so was treating me for severe eczema. Um and for the majority of people, it takes between six months and a few years to go through that withdrawal process.
Dr Rupy: Wow. Wow. And just to rewind a second, what was the distribution of your eczema prior to that? Where where was it uh affecting you majorly?
Dr Ruth: So it'd always affected my neck and my cheeks, um uh my um like flexor surfaces behind my knees, behind my elbows. Those were the typical areas for me. So, yeah, just completely not not that. It it looked totally different.
Dr Rupy: Yeah, wow. Wow. And so just for the listeners, I mean, like going on ciclosporin for a year, there's no uh light undertaking for anyone.
Dr Ruth: Yeah, and but I knew it was going to give me a break from what I was going through and it was well monitored by dermatology. I didn't have some very, very mild side effects, but generally, yeah, it just gave me my life back for 12 months.
Dr Rupy: Yeah.
Dr Ruth: So it was it was a it was a blessing. I I I could not have I I really don't think I think that break for me just helped my skin get into just a better uh a better state to go through it again for the second time.
Dr Rupy: Yeah, definitely. And from our limited knowledge of this, I mean, how many people do we think might be suffering from this condition?
Dr Ruth: I think there's been one Japanese study that's maybe um kind of looked at prevalence of adults with eczema and how many might be going through that. And I think from memory, it's around 10%.
Dr Rupy: Oh, wow.
Dr Ruth: So quite high.
Dr Rupy: That's high. Yeah.
Dr Ruth: But that was a it was a small study. Um Itzan, the American Association that I talked about, have been um data collecting at the end of 2020 um to get more of an idea. I suppose the hard thing is, um when does severe eczema become topical steroid addiction?
Dr Rupy: Exactly. Yeah, yeah. I mean, what when is the cutoff? You know, is it is it a few years? Is it when you have those pathognomonic symptoms? You know, there's so many unknowns here.
Dr Ruth: And and also, you know, I was tested appropriately for contact dermatitis. So, eczema that appears on the face and neck is commonly a reaction to things like products that you're using. And all those tests were negative for me. But just because your face is red, doesn't mean it's topical steroid withdrawal. It it could be another important diagnosis as well. Um so we don't know.
Dr Rupy: Yeah, yeah, yeah. Well, I mean, it's incredible what you've been able to achieve with that. And I think, you know, having the social media community has been, you know, an example of just how positive it is, it can be.
Dr Ruth: Yeah, it can be. It it definitely has been. Although it is actually quite hard when you're better to see people going through the same thing and obviously I can't give medical advice on social media, but people are desperate because people need people need a management plan. Um and I really, really hope that dermatology in the UK are able to give us that in time. Um and that's why the statement was so important because hopefully research will follow.
Dr Rupy: Yeah, absolutely. Well, I mean, it's an incredible journey. Why don't we talk about how you're managing it currently and also how that sort of marries with people trying to look after their own eczema and perhaps, you know, much further along, sorry, not further along, much uh before they they get to a point where they're they're become reliant potentially on on steroid use.
Dr Ruth: Yeah, and and and my passion now in terms of how I use my Instagram page is thinking, how can we um holistically manage eczema so that although steroids might be part of that management, they're not the first line for it. Um so, um the first thing that I think is important is understanding your triggers. So, and that can be really tough because when you're in the mire with your skin, trying to find what feels like a needle in the haystack for your triggers can be difficult, but it's so satisfying when you eventually find them. Um for me, it's often a perfect storm. So, there's that idea of that cumulative effect of triggers. So for example, tree pollen in early spring is is is my worst trigger. I know that because I track my symptoms and they're always worse in April and May, particularly with very swollen eyelids. Not necessarily eyelid eczema, it's not dry. My eyes are just very, very swollen. And that is often an indicator of an airborne trigger. So whether that's fragrance at home, whether that's dust, dust mites, or whether that's pollen. So, if I've looked after my skin barrier well that month and I've slept well and I haven't had much eye makeup on, I can probably get away with it not flaring. But if I haven't, I haven't removed my eye makeup or I'm stressed, I'm not sleeping, then I will notice a flare. So, it's never just about one thing for me. It it's usually a couple of things that collide to lead to um a flare of my skin.
Dr Rupy: Gotcha. How do you how do you track your symptoms? Do you have like a like a regimented scoring measure that you use or you ask people to?
Dr Ruth: I mean, I don't anymore because I just know them, but I think the the best thing to do is when people start is to write a diary. So, um to think about um, you know, what they've eaten that day, how their stress levels are, to think about their environment. So are they at home? That's a more predictable environment for us all. Have they used any new laundry products, perfume, um makeup, um different um skin products as well, looking environmentally at the weather. So, pollen, obviously, dust, um but also about um the temperature outside. So obviously when it's cold, we lose more moisture from our skin and our skin barrier becomes more compromised, which is why winter and especially early winter when it's very dry, like the humidity is low, that can often be a time where eczema flares as well. So, in reality, people need to probably track their symptoms for a few months to start getting some of those. I also found that um my um menstrual period was um a real trigger for my eczema because our histamine, our histamine rises and falls with our estrogen levels. So the week before my period is when my eczema is always a little bit worse. And I know a lot of other women um have found that that is the case or postmenopausally, because skin becomes a lot drier as estrogen drops, is a really common time for people to develop more dermatitis and also more contact dermatitis because of that drop in the estrogen levels.
Dr Rupy: I don't think I've consciously asked about um to female patients about the fluctuations in eczema according to the time of their period because I didn't know about the um the association with histamine, but that is that's very interesting. I'm I'm writing notes on these different things I'm picking up. That's great. I mean, for for me, so I I I suffer from dry skin and and have done since I was a child. And I think you're right, you need to sort of find an intuitive way of tracking your own symptoms. So, for me, I um do it by um limb. So, you know, if I've got uh itchy patches, this is probably TMI for the audience, but itchy patches on which limb, on which, you know, arms and stuff, how many there are. Um I usually because mine's not that bad, I usually use just the the concept of a 50 pence piece and how many there there are just to see what the the flare is. And I I I know what my triggers are for sure. And it's a whole bunch that you've you've just talked about there, poor sleep, um poor hydration. If I've had uh alcohol the night before, that's tends to dry my skin and then I get a flare up and temperature definitely. During the winter, my my um uh legs definitely flare up. Um and and I think, you know, there's so many uh individual triggers as well that certain people are a little bit more prone toward. Um but that that, you know, that's fascinating.
Dr Ruth: And it's so um kind of rewarding when you get to that point. You know, I always say on my Instagram, like be your own detective. You know, like take and maybe like 10, 15 years ago, I did just want my skin to be better. I I wasn't in that mindset at that time for like, right, I really want to look after myself better and understand that. So I think that comes to different people at different points in their life. Two two other big ones for me is is stress. So obviously cortisol, our stress hormone is really um pro-inflammatory. You know, it directly affects our immune system, um and how effectively it can deal with inflammation. But also for me, stress and itching is really linked. So, if I'm on a difficult phone consultation at work, I I I don't notice till I'm five seconds into that itch. Um and that's not because my skin is flared, it's because for me, it's an emotional trigger. Um so that is really important to think about. Um and secondly, about if you think about our clothes, our towels, our bedding, we're in contact with so many fabrics during the day. And so what you actually wash your um clothes in is really important. So I have never used fragrance. You know, my mom, we use a certain kind of laundry product. She's used it since the 90s. Um you know, because fragrance, if I go away for the weekend, stay in a hotel, I take my own pillowcase, washed in my laundry powder, because my face is my really sensitive area. So, you know, even when I went traveling around South America, I took a couple of my pillowcases, like washed in my laundry product, but that's because I know it's that that is a massive trigger for me. So, thinking about where what your skin is in contact with is really it is really important.
Dr Rupy: Are there particular um ingredients or recipients within laundry products that are troublesome for eczema sufferers?
Dr Ruth: So fragrance is one and everyone's different um with that. So it is often trial and error. But there's um SLS, so um sodium laurel sulfate, which in cleaning products, it's um it works on breaking down oil. So it's often used in laundry products and um in anything that's kind of cleansing, so a lot of um maybe kitchen products, etc. And those of us with a skin barrier, we need the oils in our skin. So if we're in contact with a substance that breaks down oil, it's likely to lead to dryness and irritation. So a lot of people try SLS free products um because a lot of people have contact allergies to SLS.
Dr Rupy: Yeah. And there's quite a few skin products um on the shelves these days that have removal of SLS and parabens, um phthalates, perfumes. Um it's great to have the choice, I guess, for people who want to experiment with less things in them. And I think if they don't really have that much of an impact on the quality of the product, bar preservatives, um I I guess it's something to to trial. Is is that your opinion or?
Dr Ruth: So do you mean in terms of emollients or or just general?
Dr Rupy: Yeah, emollients or or general household products, general skin care products like um cleansers, shampoos, body gels, you know, all the things that we come into contact with on a daily basis, we don't really consciously think about.
Dr Ruth: And and I think the hard thing is those reactions, like true contact dermatitis, like you wear a belt and you've got a nickel allergy and you get, you know, those are rarer, but contact irritants where something you use over, you know, a matter of weeks or months that causes just some low-level inflammation, you're only really going to find that out from trial and error. So, I was lucky that I had patch testing. I know the waiting times were bad pre-COVID. I think they're going to be really, really long in reality. I knew that I didn't have any contact dermatitis to products, which helped, but I do know that there are just certain things that I can't use. I can't use shower gel. It's too drying. I can't use soap. I can't use things in my bath. But but that has been trial and error.
Dr Rupy: Yeah, yeah. There there is this sort of um perspective these days that we do over clean just in general. So regardless of whether you have an eczema uh condition or any sort of dermatitis, inflammatory skin condition, we are using harsh products on our skin on a daily basis that could rid ourselves of that protective barrier. And we're going to get on to the the microbiota skin connection. Um but uh what what is your opinion on that? Should should we be um a little bit, it's hard to talk about this in the middle of a pandemic where we're constantly washing our hands. And I'm not suggesting that we shouldn't be washing our hands with antibacterial soaps. But our bodies, is that something that you think we're we're over cleansing?
Dr Ruth: Yeah, I think there's generally, we, you know, I think probably the, you know, it's it's men and women, isn't it? But I'd imagine the the average woman in the bathroom has, you know, 20, 30 kind of products that they use, skin, shower, hair, and is that necessary? I think I think that's unclear. You know, the the balance that we have on our skin is very delicate. And for most people, that's fine. But in reality, if you are somebody with eczema or sensitive skin, you probably do need to be a bit more careful with that delicate balance. And I think one of the key things for me is about staph aureus. So, staph aureus is a bacteria that lives on our skin very happily. It's part of um the usual bugs that live on our skin. It's fine. But in eczema, um it can drive flare-ups. Um and when they've swabbed a lot of people as they're having flares, they have high levels of staph aureus. So actually, yeah, if you're stripping all the natural oils and bacteria from your skin, the bad bacteria might be able to multiply and then make you more likely to have inflammatory flares on your skin. So my experience has been when I flare, I have a few products that I know don't irritate me. Um and I just strip everything back. I have the same shampoos, the same few emollients, and I don't really um steer away from that because that's what works for me. But it's probably taken a good 20 years to understand what those products are.
Dr Rupy: Yeah, definitely. It's it's interesting, isn't it? There's the one element which is just the genuine nature of being in a natural environment with the greenery and the calm sounds and the birds and everything else. And then there's the sort of geeky mechanistic idea about how the phytoncides that are imbued in the air from the uh the leaves and the plants have a genuine immunomodulatory effect. Uh and whether that has an impact uh in addition, maybe it's synergistic, who knows? But uh I always find looking at that aspect quite uh quite interesting too.
Dr Ruth: And and I think there's something there about simplification, isn't there? And getting back to what feels right for us as humans. You know, actually we live in a very over-paced, kind of fast lifestyle. And although this comes from a obviously a a place of privilege, I think, you know, my journey with my skin has taken me back to some of those basics about how I want to live my life and how I want to be. And my skin will definitely tell me when I'm pushing it. So, actually part of my journey to understand my skin better has helped me understand myself better and what makes me tick, what works for me. My diary being less busy is always good for my eczema as well. So, I wonder if we sometimes lose that ability to tune into our emotional health as well as our physical health. And I think if you if you're somebody who's trying to manage your skin differently, taking that time to understand those elements, it's always going to it's always going to help you manage your skin better.
Dr Rupy: Ruth, this has been such a lovely conversation. I've just loved chatting to you, listening to you talk. You know, I can just imagine you in general practice with your patients. They must absolutely love you and adore you and and your trainees as well. Um thank you. I just want to say thank you so much for for joining me today and uh discussing your skin journey and and I can't wait to help promote whatever you're doing in the future with uh on social media. It's it's it's brilliant what you're doing.
Dr Ruth: Thank you so much. I just hope that this gives everyone a little bit of a flavour for like that holistic approach to skin and come and find me on Instagram. You know, my mission is about to get people to think in this way. So a lot of my posts on my grid go into this way of thinking. Um and yeah, I'd love people to kind of find me there um and kind of join this, you know, inclusive eczema and topical steroid withdrawal community that we have as well.
Dr Rupy: I really hope you enjoyed today's podcast. We talked about a whole bunch of things to do with eczema. I think my top tips would be three. Look at your diet and as Dr Ruth says, including even if it's just one thing at every meal time, similar to my TEDx talk, whether it's a portion of fruit, vegetables, nuts or seeds at every meal time, that food in its whole form contains a collection of micronutrients, phytonutrients, which benefit a multiple aspects of your health beyond just skin as well. And there's a whole skin chapter in my second book, Eat to Beat Illness too. When it comes to the other triggers of skin disease, particularly dermatitis and eczema, household triggers like uh skin care products, beauty care products, clothing, um the type of materials that we use in our laundry, they can have quite severe effects on irritating our skin. So it's definitely something to look into, read the ingredients and look for uh elements or other products that have more sensitive ingredients in them. And the other thing I think which is a big uh factor for me is stress. Finding a stress relieving activity, whether it be walking, whether it be meditation, whether it be breath work. And I find breathing in and out through my nose, 10 minutes twice a day is fantastic at modulating your parasympathetic, sympathetic pathways such that it induces calm and you'll be surprised at the impact it can have on multiple aspects of your healthcare beyond skin care as well. So do think about getting a regular meditation regime. I really hope you enjoyed today's podcast and I will see you here next time.
