Friday, December 31, 2010

Ciclosporin has improved my eczema quite considerably

Please allow me to introduce myself. My name is Huw, I’m 42 years old, and I work in primary healthcare. I’ve suffered from eczema for as long as I can remember, and spent several months in hospital, several times, because of it when I was younger.

Around eighteen months ago, I went to my GP to ask if my treatment could be reviewed. At that time I was using Betnovate cream for “affected areas” and aqueous cream as a moisturiser. I didn’t (and still don’t) use any specialised scalp preparations as I tend to keep my hair very short so can use my normal creams on my head. I was becoming slightly concerned about the side effects of long-term potent steroid use, and asked if there were any alternatives.

My GP, who is very pleasant, approachable and, I thought, knew what he was talking about told me that there was “nothing new under the sun” in the field of eczema treatment, and suggested I try downgrading to Betnovate RD (which is diluted to a quarter of the potency of straight Betnovate) if I was concerned about topical steroid use, to see how it went. So I did. My treatment now comprised Betnovate RD and aqueous cream, together with antihistamines that I’d buy as and when I needed them.

A few months later, after a prolonged period of poorly controlled eczema, I again went back to my GP. This time, I saw a different GP who I hadn’t seen before (and will never consult again). I asked her for a referral to a dermatologist, and when she asked me why I wanted one I told her that I hadn’t seen a dermatologist for over 20 years, and as my condition was a specialist one I’d like to have my treatment reviewed by a specialist. Her response was to tell me that my eczema wasn’t severe enough to be referred, and to continue with my treatment of Betnovate RD and aqueous cream.

I’ve never been one for an argument, so accepted her opinion and went away, even if I wasn’t happy with the outcome. Over the next week or so I talked to some medico friends and did some research, then went back to see GP number three, who had retired from the practise but still came back to help out when they were short. I asked him for a referral, explained my reasons (same as before) and he immediately agreed and arranged for me to use Choose and Book. I chose, and booked.

The next morning, while I was still asleep (I work shifts and my sleep patterns are somewhat erratic) I had a phone call from GP number 2, (the “your eczema isn’t bad enough for a referral” one) querying my reasons for coming back and asking for a referral again. In my sleep-fuddled state I simply agreed when she asked if it had got worse since she saw me. Afterwards, I wished I’d told her the real reason: that I wasn’t happy with her opinion or the way she’d spoken to me, and had gone back to see someone else and if necessary insist on a referral.

Cut to a few weeks later, and I’m at my first appointment with the dermatologist. “Typical,” I think to myself as I sit in the waiting room “I finally get to see a specialist and my skin’s better than it’s been for years. I bet they laugh me out of the clinic.” In anticipation of this, I had compiled a file of photographs of my eczema when it was bad, together with a document entitled “Why do I want to see a Dermatologist?” which listed about 15 reasons, collected over the preceding few weeks.

My name was called, and I walked in to the consulting room, sporting my near-perfect skin and dreading the derision with which I was sure to be met.

“Wow,” said the dermatologist, “that’s really extensive eczema.” I collapsed into a relieved heap on the chair next to her desk.

After a comprehensive consultation, the dermatologist suggested I try a treatment called Ciclosporin. She explained that it was a immune system suppressant, and I seem to remember her telling me that it had only been used for eczema treatment for a few years (after the theory/discovery that eczema is caused by an overactive immune system). She told me that it could have adverse side effects (high blood pressure and kidney problems), but that I would be closely monitored before and after I started using it, if I chose to try it, to make sure any ill effects were picked up quickly. I was given a sheaf of information about the treatment so that I could make an informed choice, together with another appointment at the clinic, a couple of weeks later, to see the nurse specialist.

I read, I researched, I decided. I saw the nurse specialist, was measured, weighed, sphygmomanometised and had bloods taken. I returned for my third appointment where I had a final check over by the dermatologist to confirm my suitability, then started on the treatment.

My initial dose was to be 250mg per day, split into 100mg in the morning and 150mg in the evening. I carefully read the patient information booklet that came with the Ciclosporin (which was lucky, because I had been taking St John’s Wort for some months beforehand and discovered that I had to stop it when I started the new treatment). Another common drug that can’t be taken with Ciclosporin is Ibuprofen, and I’ve also been advised to avoid sushi (not a big deal for me) and blue cheese (something of a bigger deal) due to the increased risk of listeria caused by suppressing my immune system I haven’t tested the issue, as much as I miss my Stilton.

Another thing I was warned about was the increased risk of infections, especially chest infections, for the same reason. I was told to see my GP (guess which GP I wouldn’t be consulting?) as soon as I started to feel ill.

The patient information booklet told me that most people who take Ciclosporin benefit from it, and somewhere in the literature a timescale of two to three weeks was mentioned. The booklet warns to immediately see your doctor if you develop a sore throat, any infections or begin to feel generally unwell, then lists a string of possible side effects.

Over the first few weeks after I started the treatment, my skin steadily improved until I was 95% clear of eczema, with no topical steroid use. The biggest differences I saw were on my face, scalp and forearms: my face no longer had its untreatable dry patches (they had always seemed to instantly absorb cream and return to flakiness in about 30 seconds flat), likewise my scalp (I suddenly found myself able to wear dark t-shirts for the first time) and my forearms stopped developing spontaneous and unrelievable maddeningly itchy patches that would end up as purpuric bruises after I scratched them.

My blood pressure was up, however, at about 145/98, and I had occasional bouts of suddenly feeling really ill: nauseous, abdominal cramps, just ill. I have had only four or five of these ‘attacks’ over the last seven months, and they have passed after at most an hour or two. I also had a couple of skin infections, and became quite closely acquainted with Flucloxacillin, which was prescribed by walk-in centre GPs (on both occasions at about 3am – one of the benefits of working shifts is not having to queue!). On two or three mornings I woke up with a hangover-like headache, without the more usual cause!

I discussed these issues with the nurse specialist on my first review consultation at the dermatology clinic. After referring to a dermatologist, my dose of Ciclosporin was reduced from 250mg/day to 200mg/day, and I was given Dermol, which is a moisturiser with antimicrobial properties to reduce skin infections. I was also given Dermol lotion to use as a soap/shower gel substitute. I was also referred to my GP to consider treatment for my raised blood pressure, but the GP (one of the good ones) didn’t seem particularly concerned at the levels I had reached, describing them as “not in the treatable range”, and when it was checked at the surgery it was a more respectable 120/80.

I continued on the 200mg/day until my next appointment (probably four months into the treatment). My bouts of feeling ill had stopped, but my eczema had deteriorated. It was still much better than it was before I started on the Ciclosporin (face and arms still clear), but my legs and torso were becoming sore and red again. I had had a couple more skin infections, and one episode of what I’m pretty sure was cellulitis on my ankle, which resulted in an early finish to a night shift and a visit to A&E, where the doctor agreed with my provisional diagnosis and prescribed Fucibet cream and, you guessed it, Flucloxacillin.

I had still not suffered any chest infections (touch wood), and my blood results were still coming back OK – no nasties appearing and no indication that my kidneys or liver were suffering any ill effects from the medication, so my dose was increased to 300mg/day (150mg BD).

This brings me up to now. I haven’t had any headaches for months, my skin’s still much better than it was before I started Ciclosporin, but it’s not perfect. I still get the occasional attack of nausea and abdominal cramps (most notably on Christmas day, making me miss my dinner!) but they still pass after an hour or two curled up in bed. I still haven’t had any chest infections, but seem to have a constant niggling skin infection, usually on my lower legs. I think the Dermol is keeping that under control, if not getting rid of it completely. I’m using about 10% as much topical steroid as I did pre-Ciclosporin. I’m not yet at the maximum dose of Ciclosporin for my weight, and my next appointment at the clinic is scheduled for the 1st March 2011. I’ve got a couple more blood tests between now and then.

My conclusion? Ciclosporin has improved my eczema quite considerably. It’s not a magic bullet, and my skin’s still far from perfect, but it’s a lot better than it was before the treatment. I think the side effects I have experienced are a relatively small price to pay for the improvement to my skin, but my wife doesn’t share my opinion. She doesn’t like me being on the Ciclosporin (ever read the list of possible side effects? Then again, ever read the list of possible side effects for virtually every medicine going?), but then she doesn’t know how my skin felt before I was on it, and how distressing it could be. It’s still an ongoing process, and it remains to be seen how things work out in the longer term, but I hope I can carry on with it.

My advice for anyone who’s had their eczema treated by no-one but their GP for a few years? Ask for a referral to a dermatologist, and don’t take no for an answer. You have a specialised condition that needs to be assessed and treated by a specialist, and you’re entitled to that treatment.

Tuesday, August 31, 2010

Anna's Referral Story

I'm Anna Burton and have met you [Amanda] at support group meetings when they used to be held and I went to the eczema open day last September. Both my children Daniel and Abigail are under Sandra and we are regular visitors to her.

Both children suffered with eczema from within weeks of birth but it was with Daniel who we had the referral nightmare.

We repeatedly asked our GP for a referral to a dermatologist, but they kept saying to try another moisturiser. The whole team of health visitor said we needed wet wraps and a specialist but they even seemed helpless. I would have to sit holding Daniel through the bars of his cot to stop him from scratching to try and get him into a deep sleep. This resulted in him being in our room for over a year so I could hold him through the bars while I lay in bed too. Relatives questioned why I put photographs in an album when his face looked so bad red and painful. (It was that or no photos)!! He was dry and crusty all over. His Bedding regularly had blood on it from where he rubbed and scratched in his sleep. It was heartbreaking. The strongest steroid the GP would give us was Eumovate. Then one night Daniel cried and scratched through till the early hours of the morning. We called the out of hours GP and were seen at about 3am!! We were given piriton although sheer tiredness and the car journey sent him to sleep. 1st thing on Monday morning we went to the GP and finally the doctor agreed to the referral. We were sent to our local hospital, given Epaderm and Elocon. I was stunned, I had Elocon in the house for a different condition I was suffering. This was the 1st relief to his eczema in over a year. I then started going to the meetings of NSGCCE. What a great forward thinking group prepared to fight eczema and gave me hope.

I went back to our Dermatologist with Daniel one day with bleeding hands and they just said he had eczema and what did I expect???? I cried as I took my suffering baby back to the car, 'he has eczema what do you expect' was not a comment I expected from health professionals who I was turning to for help. I had not touched a drop of alcohol or coffee while pregnant and had exclusively breastfed him, had never risked a baby wipe and carried warm water and cotton wool wherever we went. Yet I had accepted the need for steroid creams and needed help. A hard step for many mums.

Then at a NSGCCE meeting Sandra said there were many different options for us and we should be able to get control which the group all agreed to along with yourself and Colin. I do remember being pregnant and crying on all of you at some point. Sandra suggested I transfer hospital. I went straight to the GP (carefully picking a nice one) and she agreed there and then and it was that simple she sent a letter off and we were soon fighting eczema with Sandra.

We still sink, but we have fight and periods of control. Both children are suffering this week for reasons unknown but I know Sandra is not far away. She is our life line. Daniel was in a constant mess before Sandra, now we have ups and downs but there are ups not just downs as before. I'm a regular in the Talk eczema message board and have said many times from my experience that you must fight for the referral you or your child needs and if not happy then change specialist. If only we could of got to Sandra sooner his first year of life needn't of been so painful. Thankfull for Abigail we had her ready to be referred before she was born!!!

Sorry to go on, hope this is a bit of what you wanted. Eczema has gone nuts here today. Daniel is drugged up on antihistamine and colpol. He said today to cancel his 6th birthday party next week as he so itchy. What is a Mum meant to do? Eczema does not leave the energy to fight health professionals. Thank god for NSGCCE and Sandra’s team. I can truly say that as I have experienced differences in attitude between hospitals in the same NHS system.

Regards Anna x

Webmasters Note: This is again, so similar to what we went through 14 years ago with our eldest daughter! Please, if there is anyone else out there that has had the same / similar referral difficulty. Let me know what it was like for you getting a referral. Good or Bad but honest. You can contact me via the website. Thank you.

The following is the follow-on conversation between Amanda Roberts and Anna Burton. It adds a huge amount to understanding some of the hoops that Anna has to jump through to get through all this.

[Amanda] Lovely to hear from you. I wonder if the change in weather temperature has any bearing on the way the two are at the moment? Whatever the reason, it is good to hear how much more confident you feel. Is Daniel at going to playschool school yet? We want to hear from you whenever you want.

[Anna] Daniel has finished his 1st year at school, he's loving it and can read really well already!! Time flies by. He is 6 on Friday. He is very brave but we do struggle. Abigail is at pre school and loves it. Daniel has a set member of staff who applies his creams every dinner time. He has struggled with his skin through his 1st year but school have learnt with us that some of their activities are not suitable for him. He more often than not wears cotton gloves to school. He used to have spiderman red, then being a good parent I dyed some blue to blend in with school uniform, but I have just dyed the latest lot Ben 10 green!!! Who cares about school colours keeping Daniel comfortable and happy is my priority. Pre school apply Abigails creams if she needs them. I often get a call from school or pre school asking about creams, sun or an activity, I know we are lucky to have this support but it has been through a lot of hard work and pushing for meetings with staff, I actually had 2 meetings in school before Daniel even started as I knew they needed to know what was what from day one. School got right behind me when they saw a terrible flare overnight from an activity, it shocked them and they felt very responsible.

[Amanda] Bet the school felt responsible – shame it took Daniel suffering to demonstrate it to them. It does sound wearing for you though. How do you look after yourself?

[Anna] Yes school only had my word how bad things could get along with photographs I'd taken in to show them. I did not have to say anything to them, he went into school looking like his face was burnt. I'd said enough at home and Daniel repeated it to staff!!!! They approached me with an apology and stepped up his care plan.

I smiled when I read your question about how do I look after myself. I have been the bottom of the list for the last 6 years. Trying to fight up now but I get the time that is left. Many times I have cried with my children, probably wrong but sometimes cannot be helped. Eczema certainly made my return to work low priority for me and husband. Daniel said tonight will his eczema be gone when he is a teenager? No idea where that came from and even if he understands what a teenager is??

[Amanda] Crying is natural and normal – it happens even when you are not struggling against massive odds. And it can be good for us (I expect I read that in Woman’s Own or something!).

Fewer mothers of children with atopic eczema are in outside employment (Arch Dis Cild 1993 69(6) Daud, Garralda and David). More of them feel stressed in relation to their parenting and less efficient in their disciplining. 1993 might sound like a really old piece of research – but I bet it is no different now.

Not everyone “grows out” of their eczema – but a lot do find their eczema improves with age. In fact, just heard from someone today who is hoping that this may be the case with their child after a remission of 5-6 months. Travelling with hope is always a better situation than otherwise.

Posted by Anna Burton : Web Address at 9:12 AM
Edited on: Tuesday, August 31, 2010 10:59 AM
Topic(s): NSGCCE, Posts from Anna, Referral Issues, Stories

Tuesday, August 24, 2010

Are our NHS GPs failing us?

When we or our children are diagnosed with Eczema, it can almost seem like an isolated experience. When you feel that uncontrollable urge to itch and non-eczema sufferers do not seem to get why you can’t "just stop". It can also be a depressing experience not only for aesthetic reasons and your self esteem but that feeling that you have no control (many times I have woken up and found I’ve already scratched myself to death in my sleep); there is also a distinct sense of self harm to it.

At times in this isolated desperation we search the internet for that quick fix, or confide in other sufferers for the latest "this really helps" treatment, which cannot always be relied on. What we do rely on however, is that if it all gets too much and our latest moisturiser gets too sore to bear, we can always see our local GP courtesy of the NHS to get the best possible help...right? When I'm asked on forms "who is your GP?” I never have an answer, why you ask? Because I am still yet to find one GP who quite understands my condition as well as they should or seem to care for that matter.

This year I have found that my eczema has been a lot worse than usual, what I would usually define as mild eczema (apart from when I eat wheat) turned into severe and constant bouts that I could not control. My usual treatments being rendered useless and blaming it on exhaustion I stopped my usual workout routine and keeping my existence as easily as possible. Soon I developed what was diagnosed as a viral rash, which was given steroid ointments for, which became large, painful spots/lumps on my legs. Again steroid ointment for me and now some blood tests.

After no conclusions apart from my blood showing signs of inflammatories, the various GPs that I saw the rash/spot/lumps had gone so therefore, I was ok. "What about my skin now?" pointing out how eczema is consuming my body, the response "you have eczema though, don't you?". Yes I do realise what my condition has already been diagnosed but should that really be a label no matter what the changers in severity are?

After yet another trip to the doctors and the doctor not saying a word a word to me after my complaint before I requested to get referred. Luckily for me my work place supply private health insurance so was referred to a private dermatologist. Going private managed to unearth that I have developed an infection and because no treatment was given an endless cycle was occurring. Also, I had a lot more allergies than I was originally aware (NHS will only test you for 5 things and you really have to fight for that as I found out years previous).

Now I am not a medical expert, but I would have thought just a simple infection was easy to spot, all it took was a week’s worth of antibiotics to get me back to my usual self. It is hard to tell what is simply "an easy mistake" made, or the fact that as soon as someone is diagnosed with eczema it does not matter how much we try and protest that our condition is worsening....it’s just seen as eczema plain and simple.

Now I understand that our GPs are not experts of skin conditions so we cannot expect them to know everything, but surely they must understand how stressful and exhausting it is for us to just get a little help, a simple referral would do. I do also feel angered about this eczema diagnosis being an answer for all when there could be underlying problems, I do feel that some GPs should have trust in patients to be able to identify when something is different. I had to suffer for over 3 months before I got as far as going private, only now I’m beginning to get the treatment I needed months ago.

My diagnosis? If you do not feel you are getting the treatment you feel you or your child deserve, ask to be referred.

Webmasters Note: This is so similar to what I went through 14 years ago with our eldest daughter! Is there anyone else out there that has had the same / similar referral difficulty. Let me know what it was like for you getting a referral. Good or Bad but honest. You can contact me via the website. Thank you.

Posted by Louise Newman : Web Address http://www.louisenewman.co.uk/ at 10:07 AM
Edited on: Monday, August 30, 2010 11:16 PM
Topic(s): NSGCCE, Posts from Louise, Referral Issues, Stories