Friday, October 20, 2017

Eczema/updated treatment options

Eczema/updated treatment options



Kids get a lot of rashes, but the most common diagnosis is probably eczema. The term eczema is broadly applied to a range of persistent skin conditions.

New options for treatment come along regularly.


Some babies have buttery soft skin. Others are not so lucky. The very dry skin is prone to all sorts of rashes. This is one of those topics that we routinely get calls about year round. It doesn’t have a season. Understanding some basic facts about the skin can help you understand what is going on and how to deal with it.


Eczema actually comes from the Greek word for “eruption”. You may also hear it referred to as Atopic Dermatitis. The top layer of the skin is called the epidermis and the top layer of the epidermis is called the stratum corneum (SC). The SC is incredibly thin but it is the main barrier of the skin. It keeps chemicals that come in contact with the skin from being absorbed into the body, and it keeps fluid inside the skin from leaching out. The SC contains 3 types of lipids that have different chemical compositions and functions; ceramides, cholesterol and free fatty acids. But it gets even more complicated. There are nine different types of ceramides in the SC, conveniently named ceramide 1 through ceramide 9, and they account for 40-50% of the lipids in this outermost layer. Scientists are doing a lot of research on the important function that ceramides play. What they are now discovering is that people with eczema have significantly fewer ceramides in the SC than folks with healthy skin. (Don’t worry there won’t be a test on this.)



The obvious focus is to try to re balance and add back some of those deficient ceramides. Thus, the key to treating basic eczema is moisturizing! There are some very good products that can make a big difference. Dr Lawrence Cheung is my go to dermatologist who sees a lot of our patients. He lists the following products as some of his favorites:


Aveeno Eczema Therapy

Cetaphil Restoraderm

Cerave Hydrating Cleanser and Moisturizing Cream


Eucerin and Vaniply are a few other good brands. Read the labels and make sure that ceramides are on the list of ingredients.


If you like home remedies, my sister-in-law Barbara swears by coconut oil mixed with a bit of tea tree oil.


Well lubricated skin does not get as itchy and doesn’t break down as easily. It is important to moisturize at least once a day, but there is no downside to greasing up your kid more often than that. It is really important to break that itch cycle. Aside from causing misery, scratching can tear the skin, and an infection can occur.


There does seem to be a hereditary component to this condition so it is pretty common for eczema to run in families. My patients with this diagnosis generally have fairly dry skin with rough patches. These kids (and adults) seem to be much more sensitive to various foods and other environmental factors. Something that is making the skin reactive is referred to as a trigger. Triggers can range from changes in temperature, a new detergent, teething or a new food. Acidic foods seem to be a big culprit for some kids.


Every year when it is “easy peel” tangerine season, I start getting loads of calls about patients whose eczema is flaring up like crazy. Other kids seem to react to dairy. My daughter Lauren got horrible eczema when she first switched to cow's milk. I stopped it for a while; when we retried it several months later she was fine with it. Sometimes you just need to do some trial and error experiments.


When food sensitivity is to blame you will often see chapped cheeks and a red ring around the anal area.


People used to recommend infrequent bathing, but it turns out that this is a myth. If your child likes their bath, you can give one as often as you like. Baths are fine, but sitting in soapy water for extended periods is not such a good idea. Let them do their “fun in the tub” session for most of the bath first and then do the actual washing and rinsing with gentle soap and shampoo right before getting out. Bubble baths and harsh soaps are pretty high on my list of suspects when I am sleuthing around for the cause of a rash.


Some folks find that adding a splash of apple cider vinegar to the bath water (about ¼-½ cup for a big tub) is soothing and may even prevent some rashes. If the eczema is severe, believe it or not, a bleach bath is often recommended by many dermatologists.


Here are important steps for giving a bleach bath:


1.     Use regular strength – 6 percent – bleach for the bath. Do not use concentrated bleach. And use plain bleach; avoid those with various scents added.


2.     Use a measuring cup or measuring spoon to add the bleach to the bath. Adding too much bleach to the bath can irritate your children’s skin. Adding too little bleach may not help.


3.     Measure the amount of bleach before adding it to the bath water. For a full bathtub of water, use a half cup of bleach. For a half-full tub of water, add a quarter cup of bleach. For a baby or toddler bathtub, add one teaspoon of bleach per gallon of water. Obviously these are approximate measurements since baths will have varying amounts of water.


4.     Never apply bleach directly to your child’s eczema. While the tub is filling, pour the bleach into the water. Be sure to wait until the bath is fully drawn and bleach is poured before your child enters the tub.


5.     Talk with your dermatologist about how long your child should soak in the tub. Most dermatologists recommend a five- to 10-minute soak.


All baths should be followed up immediately with some lotion!!!


One pediatrician that I used to work with advocated the “greased pajama” method. Put the jammies on right after applying the moisturizer. The pajamas will be a little greasy. As long as they stay clean otherwise, wear those for several nights in a row.


As I already mentioned, we want to minimize itching. If your child is doing a lot of scratching we may end up recommending an antihistamine. Zyrtec (cetirizine) and Benadryl (diphenhydramine) are the two main brands that we tend to use. Benadryl is shorter acting. Most of the time it makes the kids sleepy, but once in a while it has the opposite effect (not something you want to find out at night.) Zyrtec is longer lasting and doesn’t tend to cause either the sleepiness or the jitters.


Although the label will warn you to check with your MD if your child is under 2 years, most pediatricians have no hesitation giving the Zyrtec as young as 6 months if necessary. It comes in a liquid form. I would start with ½ teaspoon at bedtime.


Hydro-cortisone creams or ointments can also be used to spot treat especially itchy areas. Start with the weaker over-the-counter strength. If that isn’t helping, it would be a good idea to have a doctor take a look. There are several options of different prescription strength ointments, creams and oils that can be tried.. Most of the time simple eczema can be handled by your pediatrician's office. Once in a while complicated cases that are not responding to treatment may end up at the dermatologist.



If the eczema is mild to moderate and not responding to simple moisturizing and OTC hydrocortisone, there are prescription medications available that range from topical to injection options. Other patients get relief from photo-therapy.


If you like to think out of the box, I have seen some patients have a big improvement in their skin from some treatments from the folks at Advanced Allergy solutions. They are not the magic wand for everyone, but have been very helpful for many of my patients.


In summary


  • Keep your child moisturized daily with one of the recommended lotions or creams

  • Make sure your kids nails are kept short. Infants can have little mittens on their hands at night if they are doing a lot of scratching.

  • See if you can figure out what the triggers are and avoid them. Sometimes it is simply cutting out berries.

  • Zyrtec and Benadryl are fine for itching but don’t treat the underlying cause.


Talk to your doctor about taking advantage of  new treatment options if the basic home treatment isn’t doing the trick.

Friday, October 13, 2017

Fires/smoke and air quality alerts

The Bay Area Air Quality Management District ( has issued a Health Advisory and Spare the Air Alert this week. Very unhealthy air quality from the wildfires in the North Bay is causing unprecedented levels of air pollution throughout the Bay Area. Due to active wildfires and changing wind patterns, air quality could be impacted for many days to come. Outside of the active fire areas, air quality will be variable and unpredictable. Air quality may improve at times or get worse, very quickly.

For those of you who are reading this and are not in the Bay Area, go outside and take a deep breath of fresh air. Now take another one and savor it. We tend to take so much for granted, Including breathable air, until we are faced with situations like this.

Sunday evening in the middle of the night I woke up and thought I smelled smoke. I crept down to my kitchen to make sure that I hadn’t left on an appliance. There was nothing obvious. I poked my sleeping husband, “do you smell something?” He grunted “mmmph” which I took as a NO, so l went back to sleep. It turns out that many of the people I know had done some vestige of the middle-of-the- night sniffing around. Some had gone outside to make sure there was nothing burning in the immediate vicinity. When I turned on the news on Monday morning we had an answer. The news about the fire up in the north bay was devastating. So many homes, schools, and businesses are gone, including the home of one of my very best friends, where I was lucky enough to spend countless weekends in their little patch of heaven. It is heartbreaking.

An acquaintance of mine who is a reporter reached out and I got my 30 seconds of fame later that morning

Understandably the phones and emails have been nonstop for parents worried about the impact of the smoke.

It is not surprising that many people are experiencing some degree of irritation from the smoke. For those of you who are not local, we are talking about serious smoke. Here in SF we are almost 70 miles away from the actual flames but we are still impacted. There is ash on the cars. Have you ever been to a bonfire or campfire? You know how your clothes reek of smoke? That is how the air smells. The beautiful panoramic views that we get from our hilltops are clouded by a gray haze. Scratchy throat, stingy eyes, irritated sinuses, headaches are prevalent.

The most basic suggestion is common sense. Pay attention to local air quality reports. The link will give you information about how the air is improving or worsening:

Stay indoors and keep your indoor air as clean as possible. Keep windows and doors closed. Luckily it isn’t too hot this week, but if it gets warmer, run an air conditioner if you have one, ( most folks in SF don’t actually own one.) If you do have one, keep the fresh-air intake closed and the filter clean to prevent outdoor smoke from getting inside.

Do not add to indoor pollution. Don’t use anything that burns, such as candles or incense. Don’t vacuum unless you have a really good filtered machine. Normal vacuums stir up particles that are already inside your home. Don’t smoke tobacco or other products; the air is already polluted enough!!

Avoid any strenuous activity outside. It is fine to get to where you need to go. I just wouldn’t do any extra outdoor playing until things improve. I don’t think the bounce house birthday party in the park is a good idea this weekend.

Use an air filter
If you have a HEPA filter, use it. My patients reported that the local stores were completely out of the machines today. I would suggest that you take advantage of online shopping. It is probably not a bad investment even if the air is improved by the time you get it.
I am by no means an expert on Hepa filters and there is a lot of information online. I feel like consumers reports is a pretty good guide, so I am including that:

Keep in mind that the ionic filters that create ozone are not recommended and will not remove the particles that we are concerned about.

Do not rely on dust masks for protection. The only masks that will be at all protective are labeled N95 o N100. They don’t seal well on a young child, so your best bet is staying indoors.

In San Francisco with our blessed fog that comes and clears things out on a regular basis, we are accustomed to better than average air quality. It is important to keep in mind that there are populations around the world where the norm is very unhealthy air all of the time. For most healthy folks, a week or so of terrible air won’t have a lasting impact.

If you have a child with sensitive lungs absolutely keep an eye on them. Wheezing, shortness of breath, chest pain and/ or rapid heartbeat would be reason to get seen by the physician. If your child has a prescription for inhaled steroids, it might be a good idea to get those out and start using them at the first sign of any issues. Remember that if an inhaler hasn’t been used in over 2 weeks, it may need to be primed.

At this time, there has been no medical directive issued to leave the area . It is hard to say how long the fires and bad air will be an issue, and more information may be forthcoming from the Air Quality District in the next few days. There seems to be no good answer at this point as to when to go and how far folks would need to travel to be safe as there are wildfires all over southern California as well. Do what you feel is best for you and your family.

Your local municipalities should be able to provide you with information regarding air quality, safety precautions, evacuation and recommendations for local facilities that have filtered air.

A friend of mine who lives in Santa Barbara and has been through this a number of times, posted a very good list that is worth sharing:

Home Evacuation Checklist – How to Prepare for Evacuation:

Inside the House
  • Shut all windows and doors, leaving them unlocked.
  • Remove flammable window shades, curtains and close metal shutters.
  • Remove lightweight curtains.
  • Move flammable furniture to the center of the room, away from windows and doors.
  • Shut off gas at the meter; turn off pilot lights.
  • Leave your lights on so firefighters can see your house under smoky conditions.
  • Shut off the air conditioning

  • Gather up flammable items from the exterior of the house and bring them inside (patio furniture, children’s toys, door mats, trash cans, etc.) or place them in your pool.
  • Turn off propane tanks.
  • Move propane BBQ appliances away from structures.
  • Connect garden hoses to outside water valves or spigots for use by firefighters. Fill water buckets and place them around the house.
  • Don’t leave sprinklers on or water running, they can affect critical water pressure.
  • Leave exterior lights on so your home is visible to firefighters in the smoke or darkness of night.
  • Put your Emergency Supply Kit in your vehicle.
  • Back your car into the driveway with vehicle loaded and all doors and windows closed. Carry your car keys with you.
  • Have a ladder available and place it at the corner of the house for firefighters to quickly access your roof.
  • Seal attic and ground vents with pre-cut plywood or commercial seals.
  • Patrol your property and monitor the fire situation. Don’t wait for an evacuation order if you feel threatened.
  • Check on neighbors and make sure they are preparing to leave.

I also want to share some wisdom from Heather, a local mom who started a group called

As many of you know well, we have neighbors in need. 22 fires, many out of control, continue to rage in our backyard counties. In San Francisco, many miles away from the wildfires, we wake up daily to a visible, dense layer of smog and keep our stir-crazy kids and pets inside so they won’t breathe in what has become pretty horrible air quality. In the towns directly affected by this horrific and overnight destruction, hundreds of people have lost everything they have with thousands more forced to evacuate their homes, waiting in the wings to see what happens next. Some have lost or missing family members including precious animals. I cannot imagine what the air quality is closer to the destruction and active fire zone, nor how long it will take for kids to even be able to go back to school, much less what it will take to rebuild homes and businesses after the damage is done.

Because many of you, like me, feel lost in how to help, I have asked my friends directly affected by this tragedy what we can do from afar. There are many resources available out there; here are a few I found to be noteworthy:

1.   Donate to a credible monetary fund in the area who is directly helping victims in Napa. This is a good and relatively easy one to do remotely; the fund will use the money however it is best needed on a day by day basis:

2.   Help feed and nourish Santa Rosa and the Sonoma County community by providing healthy and nutritious meals to those in need; SAGmonkey is run by a friend and long-time resident of Sonoma County who is generously giving his time and energies to help to rebuild our community.

Your donations will go directly to the purchase of food and supplies to prepare and distribute fully cooked meals over the course of the next three months. By utilizing the resources of the Redwood Empire Food Bank and other local food pantries we will prepare and distribute meals for those in need. We want to make a difference in the lives of our neighbors and friends by providing this service. We have a commercial mobile kitchen trailer that is fully licensed by the State of California and the County of Sonoma.

3.   Consider volunteering to staff a shelter, donating food and other needed items, and helping pets:

Donation drop off points listed here for SF and East Bay residents to avoid tying up roads:

4.   If you know anyone who can host people or animals in need,the travel site HipCamp is connecting evacuees who cannot return to their homes with people who have available space to host them at ranches and rural properties, bed and breakfasts, and even RVs. Anyone who wants to be added to the list can contact HipCamp

5.   ADOPT-A-FAMILY! We were lucky enough to be able to take in dear friends who had to evacuate their home this week. We’re trying to turn a tragedy into a “Fun sleepover” for kids, dogs and adults. Since our friends who live in an affected area know many people affected directly, they recommend this as something folks really need right now. This is a difficult task if you don’t know anyone there but worth the ask as you check in with friends, colleagues and local businesses etc. who may have been affected.
Hoping the wind and weather helps us all see some relief soon…
In love and light,

Friday, October 6, 2017

Lead exposure and prevention 2017

  Please see the updated post July 2019
Unfortunately in our current world, many of us live in environments where our kids not completely safe from getting some lead exposure. Lead does not break down or fade away with time. It remains in the environment and we are stuck dealing with bad habits past and current.

Knowledge is power. It is worth getting your child tested. In our office we usually suggest a blood test at either the 9 month, 12 month or 15 month exam depending on the circumstances (if there are obvious hazards we test on the earlier side.) I suggest coupling the lead test with a routine CBC (complete blood count) that also tests the iron level.

Once in awhile things can get sidetracked at some of the the well child exams. There are so many things to talk about and sometime the kids are kicking up a bit of a ruckus towards the end of the visit. If the doctor doesn't bring up the subject of getting a blood test, feel free to remind them. You should find out which laboratories are preferred by your specific insurance plan. Although they are not always in network, the hospital labs facilities are often more adept and drawing blood from our younger patients.

When we get the lead results, the best news is <2 or undetectable. In past years the public health department lead prevention program would get involved if the level was over 10 but as of 2016 the standards have changed. Now, NO measurable level is considered okay. If there is some lead showing up, they want to figure out where it is coming from and keep that level from getting higher. If your child in San Francisco has any elevated lead level the city will send out a public health nurse to help you explore your environment and see if they can figure out the source. The lab is legally required to report all positive tests for environmental and communicable issues.

For reference a level over 45 is an urgent situation that needs treatment.

This link gives a full description of what the different levels signify:

Young children are much more likely to be exposed to lead hazards by touching lead-contaminated surfaces and then putting their hands in their mouths. In addition, children's bodies absorb more lead than adult bodies do because they are still growing; but lead is a problem for all of us. Pregnant women need to be especially careful because any exposure can harm their unborn babies.

Lead in the water is always a concern. The following links are terrific resources:

According to the very helpful Childhood Lead Prevention Program here in SF, new brass fixtures can actually be more of a problem than the old pipes. Even if the new fixtures claim to be lead free, it is possible for some lead to get into the water. Only use cold water for cooking, drinking or making baby formula because hot water is more likely to contain higher lead levels. If you haven't used a faucet in the last six hours, flush it out for one to two minutes before drinking or cooking with it. The longer water has been sitting in the pipes, the more lead it can absorb. You can use the initial water for watering plants.

If you want to go the extra mile and get your water tested, in San Francisco, it is free for anyone on the WIC program. Contact the lead program for a voucher. For everyone else it is $25/tap. Click the link for directions :

There are also some products for testing water available from Amazon, but as is the case with most things, they have mixed reviews.

If you are not lucky enough to live in a place with safe water, consider getting a filter that is tested to remove contaminants. Boiling water will NOT remove lead. Make sure that if your child is getting only filtered water that they are getting necessary fluoride.

Pipes and water are only one of the many ways in which kids can get exposed. Most of the lead gets into your child from the hand to mouth route. They either chew on something directly, or put hands that have been in contact with lead dust into their mouths.

Common Sources can include:

  • paint chips.

  • keys (don't let your child chew on them)

  • Brightly painted pottery or toys

Beware of things imported from different countries The brighter the color, the more apt they are to have lead. It's hard to be absolutely sure if a toy has lead in it or not. Start by to see if a specific toy has been recalled.

Be wary of cheaper toys -- like those from vending machines or street fairs -- and especially plastic jewelry. If you notice that your child is putting a toy in her mouth frequently and you're not absolutely sure it's lead-free, take it away. To lower the risks of poisoning, make sure that your child is playing with age-appropriate toys that he's not at risk of swallowing.

  • Antique furniture varnish

  • Varnish on bathtubs

  • Some lipstick brands

  • Some candies imported from other countries

  • some computer cables (of course chewing on cables is not a good idea no matter what)

  • Dirt and sand that get tracked in from outdoors

  • urban gardening (increases contact with possibly contaminated soil)

  • Ayurvedic medicine

  • Imported beads or necklaces

  • Potentially eating a lot of bone broth. I wasn’t able to find any definitive studies, but it makes sense that lead is stored in the bones, and if the animals were exposed to lead in the soil, the broth from the bones could be an issue\

  • Pre 1997 imported vinyl blinds

Prevention is the best defense!

A nutritious diet is VERY important. Iron, calcium and vitamin C compete with lead for absorption. Healthy eating should be considered a first line of defense.

Consider having a 'shoes off' policy to avoid tracking lead dust inside. This is especially important if someone in the household has routine lead exposure during their job; make sure they clean off well before having close contact with other family members.

Make sure your kids get in the habit of frequent hand washing, especially before meals and snacks

Do the best you can to make sure there are no obvious lead sources inside your home. Any home built prior to 1979 is at greater risk. If you have an older house with any peeling paint, make sure that cribs and high chairs are moved away from walls.

There are some home testing kits that check paint for lead, but they are often misused. The easiest paint to test is that on wood or varnish. In order to get an accurate result, you need to scratch the surface and mix the test liquid with more powdery paint. I don't have a favorite brand.

If you have any concerns about your home, regardless of whether or not your child has been tested for lead, call the SF lead program to arrange a public health nurse visit or speak with the Public Health nurse.