Posts Tagged ‘eczema sufferers’

Elimination diet
An elimination diet is a method of diagnosing idiopathic food intolerance (see p. 74) and certain other

forms of food sensitivity where indirect tests, such as skin tests, are unhelpful. The principle of the

elimination diet is very simple. It begins by removing from the body every food that could possibly

cause a reaction, and seeing if this produces a symptom-free state. If it does, the elimination diet

then presents the body with different foods, each in its pure form, to see which ones cause symptoms.
While the principle is simple, the practicalities of the elimination diet can be much more complex, and

it is vital to understand the details fully before you start. There is absolutely no room for

‘cheating’ with this diet – one mouthful of cake is enough to ruin the whole thing. You need forward

planning and a lot of self-discipline, backed up by a good stock of the permitted foods for moments

when hunger overcomes you. Some cooked foods, stored in the freezer in individual portions for quick

defrosting, are a great help.
Doing an elimination diet incorrectly is not just a waste of time. Some people acquire new

sensitivities during the diet, which may make it very much more difficult to do a second elimination

diet. So plan ahead and get it right first time.
The planning stage
First of all, start an accurate symptom diary. This will give you a precise picture of how bad things

are now, before you try any dietary measures. A detailed daily symptom record, covering a period of

about two weeks, can be very useful, whether or not you actually do an elimination diet. It can serve
as a baseline against which to judge the effects of any future treatment.
Before you begin an elimination diet, you must see your doctor and ask if it is safe for you to do the

diet. Read through the next four pages first – the more you know about elimination diets, before

talking to your doctor, the better.
There are some conditions where, although an elimination diet can be very helpful, it should not be

attempted without full medical supervision. Two main causes for concern exist:
•    For people who are undernourished to start with, the elimination diet may be too demanding – it

is difficult to eat enough calories during the first few weeks of the diet, unless an elemental diet is

used as a supplement (see box on p. 196). If you are underweight, or have rheumatoid arthritis or

Crohn’s disease, the possible use of elemental diets is something you should discuss with your doctor.
•    With certain diseases (see list that follows), the testing stage may induce severe symptoms.

Sometimes these can be life-threatening and need immediate medical attention.
Medical supervision during food testing is recommended for anyone with these conditions:
•    Crohn’s disease – testing can bring on a prolonged relapse. Very small amounts of food should

be tested initially, and the quantity slowly increased.
•    Brittle asthma – after a period of avoidance, a culprit food can bring on a severe and possibly

life-threatening asthma attack.
•    Atopic eczema – the risk of reactions is higher if skin tests are positive (see p. 198).
•    Chronic urticaria – occasionally there is an immediate reaction to an offending food. It is

advisable to test foods in very small portions oust a mouthful) at first. If there is no reaction

whatever after four hours, a normal portion can be tested.
Note that an elimination diet is not suitable for anyone with true food allergy (see p. 62). If you

have ever had an immediate reaction to any food, or any symptoms in the lips or mouth, testing foods

can be dangerous. Caution is also necessary if you have ever reacted to a food with violent vomiting

and/or diarrhoea some hours after eating. This could be due to an infection, of course, but such

symptoms can also, very rarely, result from true food allergy (see p. 64). Finally, if you have ever

suffered anaphylaxis from any cause – not just food –the testing phase of an elimination diet might be

risky. Ask your doctor’s advice.
Once you have your doctor’s permission to try the diet, work out how the stages of the diet will fit in

with your life over the weeks or months ahead. Until it is over, eating food made by other people is

virtually out of the question. When eating away from home, you must either take prepared food with you,

or just eat very simple foods – such as permitted fruits or nuts. Think about the practicalities of

carrying food for meals away from home.
Finally, devise the diet you will follow during the exclusion phase (see right), locate shops that sell

the more unusual foods, and stock up on everything required.
You will continue to eat a lot of these foods for the first few weeks of the testing stage, so you may

want to buy extra stocks and refrigerate them for
longer storage, especially if the sources of supply are some distance from your home.
Note that food ingredients in medication could interfere with the results of the elimination diet. For

example, if you are very sensitive to maize (corn), the cornflour that is added to many antihistamines

and other drugs could create much confusion. Food-free medicines are available – talk to your

pharmacist about this initially, then to your doctor if you need a different prescription.
The exclusion phase
During the first part of an elimination diet, you exclude all the foods that you normally eat, plus any

closely related foods. For example, if you normally eat oranges, you should avoid all other citrus

fruits, including lemon, limes and grapefruit, even though you do not normally eat these. If you

normally eat plenty of broccoli, you should omit all its relatives, such as cabbage, kale, spring

greens and cress.
The best way to conduct the exclusion phase is not to follow a set menu, such as the well-known

‘Iamb-and-pears’ diet, but to draw up your own list of permitted foods. This can include foods that you

have never eaten before, and those you eat rarely.
The list should run to at least ten items. One problem with an exclusion phase that consists of only

two foods (as in the ‘Iamb-and-pears’ diet) is that you are bound to eat a huge amount of these foods.

This is asking for trouble if you have a tendency to food intolerance, because you can quite quickly

become sensitive to new foods if eating them in large amounts.
Your list of permitted foods should include:
Some starchy items. These are essential for keeping hunger at bay: try some of the more exotic root

crops, such as sweet potatoes, yams, dasheen and cassava. These are available in large supermarkets and

in small shops catering to Indian, African, Chinese and Caribbean communities. (Cook them as you would

potatoes. In the case of cassava, it must be boiled, not baked.) You can also eat parsnips, turnips,

chestnuts and pumpkin. Tapioca, sago, buckwheat, millet, quinoa and sorghum are other possibilities: a

health-food shop is a good source of some of these. Use rice if it is not normally part of your diet.

Do not include sweetcorn or maize meal, even though you do not normally eat these –corn products are

very widely used in packaged food, and sensitivity to corn is not uncommon.
Several fruits and vegetables that you don’t normally eat. Exotic produce such as mangoes and okra can

help a lot in keeping the diet tasty. Avocados, which are very rich and nutritious, can be included if

you don’t eat them often.
Some protein items. For carnivores, this is the easy part – any meat that you don’t normally eat is

suitable. Consider turkey, rabbit, pigeon or game, for example. (Soak rabbit meat in salt water

overnight to get rid of the strong taste, if you dislike this.) Strict vegetarians have more problems

here, since goat’s milk, sheep’s milk and all birds’ eggs are disallowed – their proteins are much too

similar to those of normal milk and eggs. Soya products such as tofu should definitely be avoided, as

should other pulses initially, because sensitivity to these is a possibility among vegetarians. Quorn,

or mycoprotein, could affect anyone sensitised to yeast, and should not be included. Fortunately the

exclusion phase is fairly brief, so a low intake of protein will not be disastrous. Including some nuts

on your list of permitted foods will help, as these contain protein. If nuts are part of your normal

diet, you may have to resort to rarely eaten kinds such as macadamias, cashews or pistachios.
Elemental diets
An elemental diet is a powder that contains all the nutrients the human body needs but is free from the

substances in food that provoke allergic and intolerance reactions. It is mixed with water to create a

complete substitute for food. Originally designed for space travel, this totally synthetic form of

sustenance is also known as ‘the astronaut’s diet’.
Used alone during the exclusion phase, elemental diets are the basis for the ultimate – and

theoretically foolproof – elimination diet. They sustain you through the exclusion phase, and continue

to provide your basic diet during the testing phase.
For anyone with multiple food sensitivity, using an elemental diet circumvents the problem of finding

ten or more safe foods with which the elimination diet can begin.
Those who are underweight can also benefit from using an elemental diet, simply as a calorie-boosting

supplement during the exclusion phase and testing phase.
Unfortunately, elemental diets taste fairly unpleasant and are quite expensive. You
may need a prescription, so talk to your doctor. Ideally you should get an elemental diet that does not

contain sucrose (sugar).
Some items that make good snacks. Nuts, pumpkin seeds, sunflower seeds, fresh fruit and dried fruit are

all useful for times when you are away from home, or feel hungry between meals. At the outset of the

diet, use only unsulphured dried fruit –available from health-food shops. At a later stage, you can

test ordinary dried fruit (all of which is treated with sulphur preservatives – see box on p. 207).
A cooking oil, preferably one that you have not used much in the past. Use this fairly liberally, to

keep the calorie content of your diet at a reasonable level
Note that this is a very plain diet – you eat the permitted foods and absolutely nothing else. You

cannot use spices, herbs or other flavourings. Salt is allowed, but sugar is out, as are tea, coffee,

alcohol and all soft drinks. You must drink only mineral water and pure juices from permitted fruits.
Don’t use canned or packaged versions of the permitted foods. Buy raw food and cook it yourself. The

idea is to avoid food additives and other contaminants, such as those from the linings of cans.
Throughout this phase, and the next, you must be very careful not to eat too much of any one food.

Never eat any food every day, and stay away from any food that you begin to develop a real passion for

– this is always a bad sign in people with food intolerance. It is better to go a little hungry

(assuming you are not underweight to start with) rather than binge on any of the permitted foods.

Acquiring new sensitivities is all too easy.
Assuming you do have food intolerance, and you have excluded all the foods that affect you, there

should be a complete clearance of symptoms within 7-10 days. The response is usually unmistakable. A

partial or slight response is probably just a coincidence, and should be discounted, except for those

with rheumatoid arthritis (see below).
Be warned that you may feel a great deal worse before you get better. For those who do have idiopathic

food intolerance, the first 5-6 days of the diet can be very unpleasant – usually they suffer the same

symptoms as before the diet, but far more severe.
Some conditions, such as Crohn’s disease and rheumatoid arthritis, may require a longer exclusion

phase, but there is no point in continuing beyond three weeks. Bear in mind that long-term structural

damage to arthritic joints may prevent a complete recovery. A partial but sustained improvement in the

joints, accompanied by a distinct improvement in general health, suggests that food could well be

playing a part in causing the disease, and that it is worth going on to the testing phase.
Symptoms that are only intermittent, such as chronic urticaria or migraine, pose a special problem. You

need to decide, before starting the diet, how long the exclusion phase should continue in order to give

you a clear sign that your state of health is improved. A symptom diary is vital here. If, for example,

your symptom diary shows that you sometimes have a week that is symptom-free but you never get through

two weeks without an attack, then your exclusion phase should continue for two weeks.
You should only go on to the testing phase if you improve during the exclusion phase. If you do not

improve, you have excluded the possibility of food intolerance, and can give up the diet.
The testing phase
This part of the diet, which is sometimes called the reintroduction phase, takes about eight weeks. It

requires careful observation of your symptoms, and constant self-discipline about everything you eat.

You should not stop or delay the testing unless you are ill – it is vitally important to complete it as

quickly as possible.
Foods have to be reintroduced one at a time, with a space between in which symptoms can be observed. It

sounds simple, but this is where errors can easily occur.
During this phase, as well as noting your symptoms daily, you should also record absolutely everything

you eat.
For the first 2-3 weeks you should test foods that are unlikely to cause symptoms. Start by testing

fruits, vegetables and meats that you do not eat very often normally, but which you do like. If they

pass the test, you can use them to vary your diet. This will make life much easier and reduce the risk

of developing new sensitivities.
Next test foods that you do eat reasonably often, but not every day. Leave the most likely culprits –

the foods you eat very regularly, such as wheat and milk products – until you have established a safe

diet that contains at least 25 different foods. This safe and relatively varied diet should be the

backdrop against which you test staple foods.
The testing procedure changes over time, because your sensitivity may decline as the diet progresses.

During the first eight weeks, you should test one food each day, eating a normal-sized portion for

lunch or supper. A reaction to the food might occur quite soon after the meal, or some hours later. Any

symptoms that occur within the following 24 hours should be provisionally attributed to that food.
Unfortunately, bowel symptoms can sometimes take longer to develop – up to 48 hours. This can confuse

things when a new food is being tested every day.
There may also be uncertainty about intermittent conditions such as chronic urticaria. You may not be

absolutely sure that the problem really responded to the exclusion phase. If so, when the symptoms

recur during the testing phase, this may be due to a food, or it may just be coincidence.
Should there be any doubt about which food caused a particular set of symptoms, cut out all the suspect

foods for now, and retest them after a couple of weeks, using a three-day testing procedure (see

below).
When a reaction does occur to a food, stop all testing and go back to the safe diet until you feel

completely better. But don’t wait too long before resuming testing. You need to get through most of the

testing within eight weeks because, for some people, intolerance to the foods begins to fade after

that.
This does not mean that the intolerance has been ‘cured’, unfortunately. A period of eating the food

regularly will soon bring the problem back.
If you are still testing foods after eight weeks, you must change to three-day testing – eat a normal

portion of the food every day for three days, stopping only if you get symptoms. Should you have no

reaction to the food by the end of the fourth day, you can consider it safe. (But leave it out of your

diet for at least another four days.)
There are some special procedures for testing certain foods:
•    When you test wheat, even if it is quite early on, use the three-day test procedure (see

above). Reactions to wheat can be very slow. (If you have rheumatoid arthritis, you should spend a full

five days testing wheat, and eat it at least twice a day.) Don’t use bread to test wheat because this

also contains yeast and other ingredients. Use a pure wheat cereal such as Shredded Wheat – moisten it

with fruit juice if you cannot have milk. Note that some people who react to whole-wheat are sensitive

to the wheat germ, and can tolerate refined wheat, as in white bread and flour. For others only white

flour is a problem – they are usually reacting to additives in the white flour. Careful testing will

sort out these issues.
•    Test milk before cheese and butter. You may react to one but not the others. If you react to

fresh milk, wait a few weeks, then test evaporated milk. Later, you can test goat’s milk and then

sheep’s milk. Some people can tolerate these, but must be very careful not to consume too much of them.
•    You can test yeast using Marmite or yeast-based B-vitamin tablets. Do this before you test

mushrooms, •    At some point, test a canned food. This is to check for reactions to the lining

material used on cans. Choose something that contains no other ingredients or additives, such as

carrots. Test it first in a frozen or fresh form, so that you are sure you don’t have a reaction to the

food itself.
•    Throughout the testing period, continue with cooking all your own food from scratch. At a

fairly late stage in the testing, when you have tested most foods, spend three days eating packaged

food. The idea is to eat a wide range of different food additives all at once. Read the labels

carefully (see p. 172) to check that all the food ingredients are ones which you have already tested

and found safe. You are unlikely to react to these packaged foods, but if you do, you should then

conduct tests with all the individual food additives. You may need some help from a dietitian for this

(see p. 201).
Testing becomes more and more uncertain after 12 weeks. If you
have not completed it by then, reintroduce all the untested foods.
Should your symptoms come back, cut out all those foods again,
then test them individually.
What next?
For anyone who recovers during an elimination diet, and successfully identifies their problem foods, a

period of complete abstinence from those foods follows. After about a year, it is worth testing the

foods again, as the sensitivity may have subsided. (Don’t do this if you have rheumatoid arthritis –

see p. 23.)
If, after a year or two, you find that a food no longer makes you ill, don’t go back to your old ways –

remember that you must only eat the food occasionally. Once every three or four bays is a good rule of

thumb for a food to which you were previously intolerant. You might get away with having it slightly

more often than this, but never go back to eating it daily. If it starts to become your ‘favourite

food’ again – the thing you fancy more often than anything else – watch out.
Good nutrition is an important issue for anyone avoiding certain key foods. If you have cut out all

milk products, for example, you should probably be taking a calcium supplement, unless you eat a lot of

other calcium-rich foods. Ask your doctor to refer you to a dietician or nutritionist if you feel you

need help.
An elimination diet for children with eczema
Before putting your child on any kind of restrictive diet, it is vital that you talk to your doctor.

The risks of malnutrition are far higher for children, and there can be serious long-term consequences,

such as stunted growth or impaired intelligence. You must therefore have medical consent and

supervision for an elimination diet.
For young children with atopic eczema, there is rarely any need for a stringent elimination diet, such

as that described on pp. 194-7. Children are usually sensitised to only one or two commonly eaten

foods.
In the case of recently weaned infants, it is enough to simply cut out individual foods, one at a time.

Avoid each food for two weeks, while observing symptoms carefully.
For older children a simple elimination diet, with an exclusion phase which avoids just the most likely

culprits, works well. The foods that you should exclude at the outset are:
•    any food which has given a positive skin-prick test (see p. 69)
•    any food which you think may have caused digestive symptoms, such as diarrhoea, either now or

in the past
•    eggs, milk and all milk products
•    beef and chicken
•    citrus fruits (oranges, lemons etc.)
•    food additives.
If the child’s skin is no better after a week of this diet, cut out the following foods as well:
•    peanuts and other nuts
•    soya
•    fish
•    wheat and maize (corn)
•    tomatoes
•    lamb.
If there is no response after another week, food is unlikely to be contributing to the eczema.
For the testing phase, use three-day testing, as described on p. 197, if you have fewer than ten foods

to test. Use one-day testing if you have more than ten foods to test.
You should begin by testing a very small amount of the food. Wait ten minutes for any symptoms (not

just skin symptoms – the mouth or stomach may also be affected) then give a little more if nothing has

happened. Build up gradually to testing a normal portion of the food.
A more cautious approach is required for children who give positive skin-prick tests to foods, or have

a history of symptoms in the mouth or digestive tract. They are more likely to suffer severe symptoms

in the lips, mouth and throat – the type of reaction associated with food allergy. Emergency medical

treatment may be needed. You can see if there is any likelihood of a severe immediate reaction to foods

by starting with a test on the face, and then the outer lip (see box on p. 23). If nothing happens, it

is probably safe to go on to the next stage – giving the child a very small amount of the food to eat.

However, you should have medical supervision for Rare reactions
Very occasionally, atopic eczema sufferers on milk-avoidance diets develop a sensitivity reaction to

calcium supplements. There is no scientific explanation for this, but it has been very well documented

in two children. Should you encounter this problem, the answer may be some alternative natural source

of calcium: sardines or other small fish, eaten whole, are one possibility, assuming your child will

eat fish. A dietician can advise on how much is needed per day.
There has also been one well-documented report of a child reacting to mineral water. When the water she

usually drank was changed to another brand, her eczema cleared up. This is very unlikely to be a common

problem.
this procedure in the case of foods that gave positive skin tests. If your child has both severe eczema

and additional symptoms (such as nettle rash, or symptoms in the mouth or digestive tract) it may be

advisable to have medical supervision when testing all foods.
Bear in mind that atopic eczema naturally fluctuates a great deal. To observe the effects of trying out

a food, you need the child’s skin to be in a steady state. That means being absolutely consistent about

applying steroids and moisturisers, avoiding (for the period of testing) any stressful situations that

could provoke a flare-up, not exposing the skin to sudden doses of irritants or airborne allergens, and

keeping scratching under control. Be aware of other factors that could muddy the waters by provoking a

flare-up of eczema – such as teething, or a cold (see p. 44).
If certain foods are identified as provoking eczema symptoms, and you decide to cut the food from your

child’s diet, a nutritional supplement may well be needed. Ask your doctor to refer you to a

nutritionist or dietician.
Other diagnostic diets
These diets are not used by (or even known to) the majority of doctors. While some, such as the

low-nickel diet, have been subjected to rigorous scientific testing and have shown their worth, others

have not been tested scientifically. The evidence in favour of them is purely anecdotal – in other

words, doctors have used these treatments repeatedly and observed good results with some of their

patients. That is not hard science, but it is how innovations in medicine often begin.
There are few risks with any of these diets – the number of foods to be avoided is small, and you are

most unlikely to become malnourished. Your doctor should not object to you trying any of these diets,

however sceptical he or she may be about its possible benefits.
Low-nickel diet
This diet is sometimes of benefit to adults with eczema. There are various pointers which indicate that

the diet may help, as described on pp. 55-6.
Make sure that you have absolutely no contact with any nickel (e.g. in jewellery, jeans studs, watches

or hair clips) throughout this diet, and for at least two weeks before starting it.
Ideally you should also stop treatment with steroids or antihistamines a week or so before starting the

diet. This allows any improvement to be easily observed. Obviously you should get your doctor’s

permission to do this.
The diet could take anything from six weeks to six months to take full effect. Some people have a

complete clearance of their eczema, while for others there is a partial but distinct improvement.
The foods with a high nickel content, which should be avoided as far as possible, are:
•    shellfish
•    green beans and peas
•    beansprouts and lucerne sprouts
•    dry beans and lentils (pulses) of all kinds; soya protein and products containing it (e.g.

vegetarian sausages and burgers)
•    spinach and kale
•    lettuce, leeks
•    wheat bran (avoid bran cereals and other products; replace wholemeal bread with white bread, or

eat it in moderation only – you can get plenty of fibre from fruits and vegetables; do not eat

multi-grain breads at all)
•    oatmeal, millet and buckwheat
•    raspberries, prunes, pineapple, figs
•    chocolate and cocoa
•    tea from drinks dispensers (restrict intake of other tea and coffee, and don’t make them too

strong)
•    peanuts, hazelnuts, almonds and marzipan
•    liquorice
•    sunflower seeds, linseed
•    baking powder, in large amounts
•    vitamin or mineral preparations that contain nickel (check the label carefully), Nickel is also

found in drinking water, and absorbed from certain cooking utensils, so:
•    Do not use items plated with nickel (e.g. tea balls, some tea strainers, egg beaters). The

extremely shiny appearance of nickel makes these easy to recognise.
•    Do not cook acid fruits in stainless steel pans, since the acid leaches some nickel out of the

stainless steel. An enamel cooking pot is safe.
•    Minimise the amount of tinned food that you eat.
•    In the morning, run off the first litre of water from the tap, as this may contain nickel

released from the tap itself.
Several other foods and drinks seem to aggravate the skin of nickel-sensitive people, even though the

foods are not rich in nickel. These foods and drinks should also be avoided:
•    beer, wine
•    herring, mackerel, tuna
•tomatoes, carrots, onions, apples; oranges and other citrus fruits, including their juices.
Low-chromium and low-cobalt diets
Skin sensitivity to chromium or cobalt can, very occasionally, result in a tendency to react to these

same metals when consumed in food or drink (see pp. 56).
Unfortunately, both chromium and cobalt are essential for good nutrition, so avoiding them is fraught

with problems. You would need the help of a really good dietician, or a doctor with a particular

interest in nutritional problems, to guide you through a diet of this kind.
The only measure you can safely take at home is to cut down on excessive consumption of these metals,

for three weeks only, to see if this produces any improvement in your symptoms. If it does, that should

encourage you to seek expert help for a more thorough avoidance diet.
In the case of cobalt sensitivity avoid:
•    all canned and bottled beer.
In the case of chromium sensitivity avoid:
•    beer, wine and cider
•    yeast extract and yeast tablets
•    black pepper
•    calf’s liver
•    wheatgerm and wholemeal bread
•    cheese.
If you also have nickel sensitivity, avoid nickel-rich foods (see p. 199) at the same time.
Low-histamine diet
Histamine in food is mostly produced by bacterial action. The majority of people can break down any

histamine they eat, as long as the amount is not excessive (see box on p. 67).
Temporary susceptibility to histamine may accompany viral hepatitis or other liver conditions.
A permanently impaired ability to detoxify histamine is relatively unusual. When it does occur it can

result in symptoms such as chronic urticaria, migraine or recurrent headaches. A low-histamine diet may

help in these cases. All of the following should be avoided:
Very high histamine content:
•    red wine, champagne
•    tuna, sardines
•    Emmenthal and Camembert cheeses.
High histamine content:
•    beer, white wine
•    anchovies
•    Gouda, Roquefort, Stilton and all other well-matured cheeses
•    salami and other well-matured sausages, Westphalian ham
•    sauerkraut
•    spinach
•    tomato ketchup.
If you improve only partially on this diet, this may indicate that you are on the right track

(histamine is indeed the problem) but that the bacteria in your gut are undermining your efforts with

the additional histamine which they generate. You can investigate this possibility by trying a

low-carbohydrate diet, as described on p. 53.
Low-amine diet
Naturally occurring substances called amines, found in many different foods, can have a drug-like

effect on the blood vessels, making them open up a little and so increasing the blood flow. The effect

is usually small, but some people are more susceptible than others. A low-amine diet is worth trying if

you have chronic urticaria or migraines, and have not improved with other treatments. A low-amine diet

can also be useful in atopic eczema: amines in food are not a basic cause of eczema, but they can

aggravate the rash by increasing blood flow to the skin. To begin with, cut out all foods listed below:
Very high amine content:
•    all cheeses except cottage cheese
•    dark or plain chocolate
•    yeast extract (Marmite etc.), miso, tempeh, tomato paste, tandoori spice mix, stock cubes,

ready-made sauces •    cola drinks, orange juice, tomato juice
•    any dried, pickled or smoked fish
•    sausages, pies and smoked meats, beef liver, chicken skin
•    broad beans, spinach
•    sauerkraut
•    almonds.
High or moderate amine content:
•    milk chocolate
•    soy sauce
•    beer, wine and cider
•    pork, including bacon and ham, salami, chicken liver, offal
•    all fresh or tinned fish, except white fish
•    all nuts except chestnuts and cashews
•    sesame seeds, sunflower seeds
•    avocados, aubergines, mushrooms, tomatoes, broccoli, cauliflower
•    olives and olive oil
•    oranges, lemons and other citrus fruits
•    pineapples, bananas, raspberries, strawberries, pineapples, plums, grapes, dates, figs, kiwi

fruit, passion fruit.
Continue for at least three weeks, and longer if your symptoms are normally intermittent. if you

improve, you can then experiment with reintroducing small portions of foods from the second list, three

or four times a week. Gradually build up to a higher intake, but cut back if your symptoms return.
Organic diet
The objective here is to avoid pesticides, i.e. chemical sprays applied to kill fungi and insect pests.

This may be helpful for people with chemical intolerance (see p. 84).
`Chemical-free’ or ‘unsprayed’ food (crops grown without pesticides) will do just as well as 100%

organic food (which is grown without either pesticides or artificial fertilisers).
The highest intake of pesticides is from fresh fruit and vegetables, so if your budget is tight,

concentrate on buying organic or chemical-free versions of these. If you have a garden, growing some of

your own food will reduce the cost.
You can also reduce the pesticide content of ordinary fruits and vegetables by:
•    Storing them for as long as possible before using them, because the pesticides break down quite

quickly
•    Always peeling them. With difficult-to-peel items such as peaches and tomatoes, pour boiling

water over them and leave them to stand for a few minutes first, as this loosens the skin. Rinse in

cold water, then peel.
•    If peeling is not possible, washing them very well with soap or detergent, then rinsing them

thoroughly
•    Cooking them, as this drives off some of the pesticides; avoid inhaling the steam and ventilate

the kitchen well while doing this.
You should drink mineral water from a reputable source, or use a very high-quality water filter (not a

jug filter).
Additive-free diet
Food additives are occasionally the culprit in chronic urticaria (see p. 53). At the same time as

avoiding additives, people with chronic urticaria should cut out other potential culprits – alcohol,

spices and all aspirin-like drugs (see box on p. 151).
An additive-free diet may also be of value for some people with chemical intolerance (see p. 84).
In the case of children with Attention Deficit Disorder (ADD), also called Hyperkinetic Syndrome, the

role of additive-free diets is a contentious issue (see p. 81).
An additive-free diet is very healthy but quite hard work. It means making all your own food from 100%

fresh, unmodified produce (you cannot have bacon or ham, and even things like cooked chicken and

ready-to-eat salad can contain some additives; so does most restaurant food). Note that wines, beers

and other alcoholic drinks can contain many additives without declaring them on the label. (German

bottled beer is an exception here.) Baked goods sold unwrapped can also contain many additives without

declaring them.
Stop using toothpaste unless it is an additive-free brand. You can buy such toothpaste from a

health-food shop – or use sodium bicarbonate powder instead. Drink mineral water or filtered water (you

need a good-quality filter for this, not a jug filter).
Medicinal drugs can contain colourings and other additives, so you should try to get additive-free

versions. Talk to your pharmacist about this initially.
Assuming the symptoms clear up, testing can begin, but you will probably need medical help to work out

exactly which additives are at fault. It is difficult to organise these tests at home, because most

foods contain such a mixture of additives.
With chronic urticaria, there is the possibility of quite severe reactions on testing, so medical

supervision is desirable. You can undertake cautious testing with small amounts of tap water, spices

and alcohol at home, but make sure you are in a position to get emergency medical help if you need it.

Aspirin or aspirin-like drugs should not be tested at home. Life-threatening reactions are common in

sensitive individuals, and temporary avoidance can heighten your reaction.

‘I get ill if I do a long coach journey - six or seven hours say. I usually feel sick by the end of the journey, and have a headache. The funny thing is, if I’m walking along

the street and I happen to see a coach of the kind that I do long trips on, I feel a bit sick then too, just for a short while. It seems crazy, but I get ill just from seeing

the coach.’
What Jake is observing is the powerful effect of the mind on the body, in the reaction known as conditioning. Some people are more susceptible to it than others, but no one is

completely immune.
The Russian scientist Ivan Petrovich Pavlov first demonstrated conditioning in 1889, with his famous dog-and-dinner-bell experiment. Pavlov rang a bell every time he fed the

dog, and eventually the dog would salivate each time it heard the bell, whether dinner was being served or not. Its stomach would also begin to secrete acid, in anticipation of

the meal, simply on hearing the bell.
Modern-day experiments have shown that conditioning works with immune reactions too. For example, rats can be conditioned by repeatedly giving them an immunosuppressive drug and

always adding saccharin to their drinking water on the day the drug is given. Subsequently, just the taste of saccharin in the water is enough to- suppress their immune

responses.
This surprising discovery is partially explained by the finding that there are nerves running to the lymph nodes – key areas where the immune responses are coordinated. In other

words, the immune system and the nervous system, once thought of as completely separate domains, are in conversation with each other. In fact this is a three-way discussion,

because the hormones are also involved. The study of these complex interactions,
which we are only just beginning to understand, is known as psychoneuroimmunology.
Even before Pavlov carried out his classic experiment, Dr John MacKenzie of Baltimore had discovered that an artificial rose, in the vase on his desk, would bring on an attack

of rhinitis and asthma in one of his patients who believed that she was allergic to roses. (In fact such an allergy is unlikely –see box on p. 127. It is usually the strong

scent that triggers symptoms, the allergy being to something else, often grass pollen, which is in the air when roses flower.)
Much more recently, something similar happened – this time unintentionally – when a boy with severe hayfever and pollen asthma was undergoing hypnosis aimed at helping him

relax. Part of the hypnotist’s standard technique was to describe an idyllic scene in an alpine meadow, and ask the subject to imagine being there. For this boy, it worked all

too well – the thought of the grass pollen in the meadow brought on a severe asthma attack. The hypnotist, with great presence of mind, asked him to imagine a helicopter

suddenly appearing in the sky and rescuing him from the meadow – and the asthma attack subsided. How allergies affect the mind
In studying the psychological aspects of allergy, researchers have discovered that some patients frequently have thoughts that catastrophise the situation. In the case of atopic

eczema, these thoughts might go along the lines of ‘this terrible itching will never end’ or ‘none of the treatment really makes much difference’.
Such thoughts may be just below the surface of the conscious mind most of the time, and it is only by developing the ability to notice what is going on internally that the

allergy sufferer can become aware of them.
Researchers have also found that, when negative thoughts such as these arise, eczema sufferers are far more likely to scratch their skin and so make the eczema worse. Thus the

thought becomes a reality – a self-fulfilling prophecy.
The tendency to catastrophise difficult situations is something that most people develop (or acquire from others) at a very young age, and it may take some effort to even become

aware of this mental habit, let alone change it. Yet it is possible to start thinking about illness, and about life in general, in a different way – for example, as a difficult

challenge but one that can usually be overcome.
Allergies are in no sense unique. Any long-term disease that causes intense discomfort, makes life unpredictable or limits your activities, is bound to have profound effects on

the personality. However strong a person you are, it affects your life, and influences you in a very deep way – shaping you as a thinking and feeling individual. This is

especially true if illness begins at an early age, becoming part of your formative interactions with your parents (see box on p. 233) or marking you out as different from other

children.
This shaping can have both positive and negative aspects, and it is important to recognise that there is a choice about which aspect you emphasise. It is never too late to try

to change the emphasis. Counselling or psychotherapy (see p. 225) may help with this, especially if the counter-productive attitudes to the illness are deeply rooted in family

experiences.
The role of the mind in asthma
The diagnosis of intrinsic asthma has long since been abandoned. This diagnosis, which was commonplace in the 1950s and 1960s, technically meant ‘asthma with no external cause’.

But the widespread assumption was that the cause was psychological. As older asthmatics will tell you, this made their lives particularly miserable, because they were held

responsible for their disease. Families were often ashamed of having an asthmatic child.
The injustice of this sweeping assumption is clear today. Modern research shows that an external stimulus which initiated the asthma, such as an allergen, can usually be found.

Among asthmatic children, an allergic cause exists in 80-90% of cases. Even where no specific stimulus can be found, there is still a clear-cut state of inflammation in the

airways. No one with any knowledge of asthma would now claim that it is an entirely psychosomatic disease, nor even that it is predominantly psychosomatic.
Nevertheless, once asthma has begun, the mind may play an important role in bringing on attacks, or making them worse, as many asthmatics know from their own experience. This is

entirely understandable when you think how closely breathing is tied up with our emotional lives – fear, sadness, excitement and anger all alter the usual breathing pattern in

different ways, and any of these reactions may trigger an asthma attack.
The interactions between the mind and the airways are complex in the extreme, and vary from one person to another. Anxiety and tension can make asthma a great deal worse for

some people, while others only suffer an asthma attack when the stress is over. A few people actually have less trouble with their asthma when under stress and, oddly enough,

this is the reaction that is easiest to explain. Stress activates the sympathetic nervous system (see box on p.235), which produces adrenaline, and the adrenaline opens up the

airways.
For stress to make asthma worse, as it frequently does, there must be some other reaction going on which overrides the effect of the adrenaline. Doctors don’t know exactly what

this is, but asthmatics who get worse when stressed could be hyperventilating (see p. 226) just a little – not enough for it to be obvious, but enough to make their airway

muscles contract.
Breathing through the mouth, rather than the nose, can also occur under intense stress, and this is bad for the airways because the air they receive tends to be drier, dustier

and possibly colder, for not having passed through the nose first. This raw air may irritate the sensitive airway linings of an asthmatic, and so make the airway muscles

tighten. Small local nerves, that run directly from the airway linings to the airway muscles, could cause this reaction.
Scientific tests, carried out in a laboratory, back up these casual observations. For example, many people who are allergic to grass pollen will suffer an asthma attack if the

experimenter says they are inhaling grass pollen through a mouthpiece – even though they are actually inhaling fresh air.
It can work the other way as well. Telling the same asthmatics that they are now inhaling a reliever drug will stop the attack, even though they are still breathing the same air

as before. This is the basis of placebo effect, the benefit that tends to occur with any treatment, even a dummy pill, as long as patients believe that the treatment will work.
Note that it is not necessarily the immune system producing all these reactions. There are also direct effects of the mind on the skin, in atopic eczema, on the airway muscles,

in the case of asthma, and on the nose, in rhinitis. Some of these are due to the autonomic nervous system (see box on p. 235) while others are much less well understood.
The findings described above should be reassuring for anyone who has noticed that their allergy or asthma symptoms are sometimes affected by their thoughts and feelings. There

is no need to feel bad about this, and it certainly doesn’t mean that your allergies are ‘all in the mind’. Conditioning, and other psychological responses, are an entirely

natural reaction to a very real illness.
However, if you suspect that psychological reactions are making a big contribution to your symptoms, you could try to address the problem directly. Hypnotherapy (see p. 223) can

be particularly useful in this regard, because those who are most susceptible to conditioning are also very responsive to hypnotic suggestion – which can counteract the

conditioning messages. Hypnotherapy can also help those asthmatics who
become psychologically dependent on their inhalers – something that happens quite often, especially in people with severe asthma. In the words of one asthmatic ‘If I found that

I’d left my Ventolin at home, that would sometimes start me off wheezing straight away. I was so afraid of being without it.’ Of course, it is important to carry your reliever

inhaler with you at all times, but this kind of excessive psychological dependence is distinctly unhealthy. At worst, it can lead you to over-use your reliever inhaler, which

can increase your risk of a life-threatening asthma attack (see pp. 153-4).
Sometimes the psychological effects involved in allergies and asthma are far more complex and deep-rooted than this, not just a matter of simple conditioning. It is not uncommon

for asthma attacks, in particular, to be provoked by family tensions and anxieties, or by suppressed memories from childhood. This can occur even though the asthma also has a

clear-cut physical cause, such as an allergy to house-dust mite. Some people find that their asthma always gets worse when they are in a certain place, with a certain person, or

in a particular situation. These problems are usually helped by psychotherapy (see p. 225).
While hypnotherapy and psychological treatments can sometimes be valuable, it is vital to remember that the mental factors in allergic reactions are always operating in

combination with purely physical responses – such as the triggering of mast cells by allergens (see box on p.12). Using psychological treatments alone is as much of a mistake as

ignoring the mental and emotional dimension of ill-health completely. The two aspects of treatment – physical and psychological – should always go hand in hand. Be very wary of

alternative therapists who overemphasise the psychological aspects (see p. 209).
Under the skin
To see a baby with severe eczema is heart-breaking for any parent – tormented by something it cannot understand, the child often experiences touch, not as a comforting and

pleasurable contact, but as a further irritation. According to some psychologists who have studied eczema in depth, suffering from severely itchy skin in the early years of life

may create long-lasting psychological problems. They believe that the discomfort associated with the skin, and especially with being touched, interferes with normal processes of

relating to the world and developing loving relationships with others. That is why it is so important to get the skin symptoms under control, with the proper use of steroid

creams, skin care, dietary changes if appropriate, and an anti-scratching programme (see p. 47).
Psychological symptoms from sensitivity reactions
‘People thought that because the hospital couldn’t find anything wrong with me, and because I wasn’t terminally ill, there was nothing wrong with me at all. No one could

understand how I was feeling, or even believed me. My friends and family lost patience with me. I overheard one member of my family saying they thought I was just

attention-seeking. This hurt me so much. I hated being ill all the time. I wanted to go out and enjoy myself and do the things I’d always done, but I couldn’t because I felt so

bad.’
Josey, who is now 27, was ill in this way for seven years, and her symptoms were so incapacitating that she had to give up work and abandon any sort of social life. Now, as she

puts it, ‘I have my life back again.’
The cause of her symptoms – dizziness, confusion, panic attacks, depression, shortness of breath, and a conviction that she was dying – turned out to be a sensitivity to

caffeine which was inducing hyperventilation (see p. 226). Giving up tea, coffee
and cola drinks restored her to normality very promptly, and she has not relapsed since, except on one occasion, when she unwittingly took a headache remedy that contained

caffeine.
What is clear from Josey’s story is how much the disbelief of those around her added to her problems. She felt trapped by her symptoms, which she could not overcome, while

everyone around her assumed that the whole problem was in her head, and that she could ’snap out of it’ if she chose to.
The suffering of patients like Josey could easily be avoided if more GPs knew how to recognise hyperventilation. This is one of those conditions that is well described in the

medical literature, but does not always get onto the curriculum in medical schools. As a result, many hyperventilating patients go through a lot of expensive and time-wasting

investigations, and may not get a proper diagnosis even then. This is especially sad when hyperventilation is so easy to diagnose and treat (see p. 228).
While the symptoms of hyperventilation are easy to spot, once you know what to look for, this is certainly not true of all
The autonomic nervous system
The autonomic nervous system is a kind of ‘auto-pilot’ – a set of controls that generally keeps you well adjusted to your external circumstances without you having to think

consciously about the situation at all.
The autonomic nervous system controls all the involuntary muscles – those in the heart, around the digestive system, and around the airways. It also controls the state of the

blood vessels, including those in the skin. The autonomic nervous system does its work by issuing two different sets of signals – one set that gears the body up for action and

one set that calms the body down.
Two completely separate nerve networks, the sympathetic nervous system and the parasympathetic nervous system, issue these different signals. The target organs – the airways,

heart, skin, and so on – all receive input from both networks.
The ‘get active’ signals are issued by the sympathetic nervous system, which comes into play at times of stress, excitement, fear or anger. When you can hear your heart pounding

or feel your pulse race, that is your sympathetic nervous system at work. It also makes your nasal passages and airways open up, because extra oxygen is needed for intense

physical activity, and it tightens the muscles around the blood vessels, which raises your blood pressure.
‘Chill out’ messages are delivered by the parasympathetic nervous system. This network comes on-stream when you know you can afford to relax. It slows down the heart, lowers the

blood pressure, encourages the digestive system to do its work, and makes the airways grow narrower because less air is needed when you are less active.
Adrenaline (epinephrine) is the messenger substance released by the sympathetic nervous system. Its action in tightening the muscles around the blood vessels allows adrenaline

to be employed as a drug, which saves the lives of people affected by anaphylaxis (see p. 150). During anaphylaxis, there is a massive fall in blood pressure produced by

histamine (see box on p. 12), but an injection of adrenaline can reverse this.
Both adrenaline and its derivatives, the beta-2 relievers such as Ventolin (see p. 152), also help in asthma attacks. They do this by making the muscles around the airways

relax.
The messenger substance of the parasympathetic nervous system is acetylcholine. Drugs which oppose its action – the
anti-cholinergics – can also help relieve an asthma attack (see p. 156) by blocking the airway-narrowing action of the parasympathetic.
One of the ways in which acupuncture appears to work is by adjusting the activity of the autonomic nervous system. When
acupuncture is used to deal with the immediate symptoms of an asthma attack, this is probably how it makes the airways open up.
sensitivity reactions. Food sensitivity can occasionally cause some unexpected psychological symptoms, such as bouts of hysterical crying (see p. 80) that no conventional doctor

would ever associate with food.
Inevitably, patients with sensitivity problems such as these will initially be diagnosed as having a psychological illness rather than a physical one. It may be a very long time

before the correct diagnosis is established.
Even if the patient works out the link between eating the food and experiencing the psychological response, the doctor may well remain unconvinced. What complicates matters for

doctors is that quite a few people with genuine psychological problems would prefer to think that these have a non-psychological cause, such as a sensitivity to food. (In the

opinion of most doctors, patients of this kind are far more common than patients with psychological problems that are genuinely caused by food or chemical intolerance.) For such

patients, accepting that their problems have a psychological cause means thinking about what that cause might be – and it is often something deeply distressing which the person

would rather forget.
Unfortunately, for people who get into this situation, the phoney explanation doesn’t actually help at all, though it can provide a temporary distraction. Ignoring unpleasant

hidden memories is not the answer – the problem does not go away, it just festers. Facing up to the real underlying problem is the only way to get rid of the distress (see p.

225).
If you have psychological symptoms of any kind, bear in mind that psychological causes are by far the most likely. Such causes can include difficult life circumstances, damaging

experiences during childhood, loss of close relationships, or extremely traumatic incidents in the more recent past. Where there are longstanding problems, neurological factors

(damage to the nerves or brain) or metabolic factors (something affecting the balance of chemicals in the brain), might also play a part, or sometimes be the sole cause.
For a busy doctor, without much time to spare, it is immensely difficult to distinguish patients who really do have psychological symptoms due to food or chemical intolerance,

from patients with psychological problems that they have mistakenly attributed to an intolerance reaction.
What adds to the difficulty is that, with time, psychological causes can sometimes be grafted onto a straightforward intolerance problem. This occurs because illness of any kind

can produce some psychological problems of its own, especially if the person affected cannot lead a normal life. The psychological effects of the illness invariably get worse if

the person concerned has been treated with disbelief by doctors, family or friends – as
is frequently the case when a person has indefinite long-term symptoms that are due to food or chemical intolerance. Separating the secondary psychological reactions to the

illness (or to the scepticism of others) from the primary psychological symptoms that are genuinely produced by the intolerance reactions is far from easy.
Hyperventilation and chemical intolerance
Hyperventilation (see pp. 226-9) and chemical intolerance (see p. 84) often go hand in hand. A person who is sensitive to airborne items which they cannot avoid inhaling, such

as perfume or petrol fumes, may well feel apprehensive when they catch a whiff of these, and unconsciously alter their breathing in response. They may hyperventilate.
If they do, this can both aggravate the sensitivity symptoms, and increase their anxious feelings – because one key symptom of hyperventilation is anxiety (see p. 227). In this

way the problem begins to feed upon itself, and can spiral out of control.
Hyperventilation, pure and simple, may also masquerade as chemical intolerance. In these cases, a deep underlying anxiety probably exists in the person concerned, and one way in

which this expresses itself is as a fear of synthetic chemicals. The person’s fear triggers hyperventilation, which is the initial cause of symptoms. That is not how the person

interprets those symptoms however – because the person was anticipating a reaction to synthetic chemicals, the symptoms seem to confirm that a reaction has occurred. Again, a

vicious circle has been started which is hard to break.
Another possible scenario is that someone with a few sensitivity reactions – for example, a reaction to perfume and cigarette smoke – starts to feel concerned about other

chemical sub-
‘ and to suspect that these might also cause problems. If an anxious reaction to the presence of these substances develops into hyperventilation, symptoms will ensue from the

hyperventilation. These symptoms will appear to confirm the person’s fears about yet more sensitivity reactions. In this way, people with relatively mild chemical intolerance

can begin to believe that their chemical intolerance reactions are far more extensive and disabling than they actually are.
Where the symptoms of hyperventilation are all tangled up with symptoms due to genuine chemical intolerance, opinions tend to split. Some doctors will interpret all the symptoms

as psychological, while other doctors will attribute them all to the intolerance. Both are over-simplifying the problem, and missing a crucial ingredient – hyperventilation.

Recognising and treating hyperventilation (see p. 228) can help a great deal to alleviate the illness.
The psychologisation of illness
‘From the moment Joanna was born, she was never hungry’ Sandra recalls. ‘It took all day to force an ounce of milk down, and she seemed to have terrible stomach pains. At six

months old, after countless trips to the doctor, she was admitted to hospital. The hospital doctors couldn’t work out what was wrong, and in the end they said that she was just

very independent and that she wouldn’t eat until she could feed herself. I couldn’t believe my ears – what a thing to say about a six-month-old baby!’ But as far as the doctors

were concerned, that was that.
As Joanna got older, the symptoms got worse. She developed severe constipation, opening her bowels only once every four weeks. Because her over-full bowel put so much pressure

on her bladder, she wet herself several times a day.
‘She hated school, because the other children teased her, saying she smelled. And she had such awful stomach pains that she couldn’t bend down to tie her shoelaces. When she was

six she was admitted to hospital for a second time.
‘Again they said there was nothing physically wrong with her and it was all in her head, and this time they decided that it must be because something traumatic had happened at

home. They wanted her to see a psychiatrist. It was terrible. I knew nothing like that had happened to her at home, but it was impossible to convince them.’ There was talk of

Joanna being taken away from her parents, because of suspicions about child abuse.
Two weeks before seeing the psychiatrist, something happened to change Joanna’s life. Sandra saw an item on television about a book on food allergies. She bought the book and,

remembering how fiercely Joanna had rejected milk as a baby, she hazarded a guess that milk was the problem. She immediately took all dairy products out of Joanna’s diet.
The effect was astonishing. ‘Within 12 hours her tummy ache had gone, and after six weeks she began opening her bowels almost every day. She stopped wetting herself, and was so

much happier and healthier.’ In fact, all of Joanna’s symptoms went away. and she has remained well on a milk-free diet.
Psychologisation is most frequently encountered by patients %vith medical problems that are unrecognised by conventional medicine – Joanna is a typical example of such a

patient. Occasionally, however, those with true allergies find themselves in the same situation. Take, for example, someone who has collapsed after being stung by a wasp but

gives a negative skin-test result to wasp venom. In the case of insect-sting allergy, skin-tests are supposed to give very few false negatives – so the doctor may be sceptical

about the patient’s observation of what happened. A PAST test (see p. 92) may be ordered, but sometimes this too gives a false negative.
Doctors are – not unreasonably – more inclined to believe that the patient is an unreliable witness (there was never any insect involved), or that the patient has a

psychological problem that has led to this consultation, than that both these tests gave a false-negative result. A patient in this position may need to be quite persistent to

get proper treatment. The same goes for anyone else with unusual allergic reactions that are initially labelled ‘psychological’ by their doctor. In such cases, good

communication is everything.
Good communication with your doctor
Given the intense pressure under which they work, doctors often react badly to symptoms that don’t fit into a neat diagnostic pigeonhole, or don’t respond to standard treatment.

They simply do not have the time for unravelling complex problems and there is a common tendency to ‘psychologise’ such symptoms automatically. This often does great damage to

the patients concerned, boxing them into a corner from which it is impossible to escape – the more they try to convince the doctor their symptoms are genuine, and request

further tests or treatment, the more the doctor views them as difficult, demanding patients with psychological problems. Unfortunately, it is part of the dogma about

psychosomatic illness that patients affected by it will object vehemently to such a diagnosis. So the more you insist that the symptoms are not psychological, the more this

confirms the diagnosis as far as many doctors are concerned.
The psychologisation of illness becomes a real nightmare where the patient is a child, and parents are accused of actually causing the symptoms in some way (see Joanna’s story,

left). This has happened more than once to children with unusual sensitivity reactions.
Good communication skills may stop you from sliding into this situation with your doctor. Firstly, whatever else you do, stay very very calm. Getting emotional, agitated or

angry always causes doctors to suspect a psychological cause for your symptoms.
Secondly, be very open with the doctor, and don’t conceal anything. Be clear about describing symptoms, and accurate about times, the intensity of the reaction and any other

details. Never, ever exaggerate. If you are given to describing things quite colourfully in everyday life, tone it down as much as possible for your doctor’s benefit.
Thirdly, don’t make your own diagnosis – doctors are taught to believe that patients who diagnose themselves may well be suffering from hypochondria. Present any medical

knowledge you have acquired from books or the Internet as tactfully as possible. Finally, it will probably help a lot to use the appropriate words to describe your illness when

talking with the doctor.

Skin-prick tests
This is an indirect method of detecting true allergic reactions. It is one of a family of skin tests that use a similar approach. The three different tests in this family are known as: skin-prick tests or prick tests, puncture tests, and scratch tests.
For the skin-prick test - the technique used in Britain - a small drop of liquid containing an allergen, such as grass pollen, is placed on the arm. The doctor makes a small prick in the skin, under the drop of liquid, allowing a minuscule amount of the allergen to get into the skin. A positive reaction is recorded if a red bump develops soon afterwards. For accuracy, the bump must be compared to positive and negative controls (see below).
The puncture method is very similar to the skin-prick test but uses a slightly different technique for breaking the skin. The term prick-puncture test covers both techniques.
With the scratch method, the skin is scratched lightly, and the allergen solution is then applied over the scratch. This method gives less consistent results than prick-puncture testing.
It is important to include a negative control in the test - a skin-prick test with plain salt water (saline). This should not produce much of a bump - if it does, the skin is clearly over-reactive and the tests more difficult to assess. The doctor should also include a positive control - a skin-prick test with histamine, the substance that plays a central role in allergic reactions. This should always produce a bump. If it does not, the skin is decidedly under-reactive, and the tests are invalid.
Taking antihistamines will make the skin under-reactive, and you should stop taking them before the testing, for a period ranging from a day to several weeks - it varies depending on the particular antihistamine. Ask your doctor for specific instructions about stopping these and other drugs before testing.
Skin tends to be over-reactive to testing in people with dermatographism (see p. 52). Blood tests for specific IgE,
such as RASTs (see p. 92), are needed for anyone who has this condition. Eczema sufferers with a rash over large areas of the body may also require blood tests, if there is too little clear skin for testing.
Skin-prick tests can produce both false positives and false negatives (see box below). Some allergic diseases will give a lot of false negatives and relatively few false positives, while for others the reverse is true. The allergen itself influences the rates of misleading reactions: for example, tests for soya allergy are notoriously unreliable, whereas those for peanut are far more accurate. The age of the person being tested also makes a difference. With all these influences at work, interpreting the test responses is a real art, and the doctor’s experience counts for a lot.
All sorts of people offer skin-prick tests, including alternative practitioners. Get them done by a qualified doctor, preferably by an allergist, who will know how to make sense of the reactions.
Note that the purpose of these tests, and of blood tests for specific IgE, is to identify the allergens that are bringing on your symptoms, not to predict how strongly you will react to those allergens. The tests may give some indication of the intensity of your reaction, but they cannot be regarded as a good guide to how you will respond to the allergen in the future.
The safety record of skin-prick tests is very good. Occasionally a systemic reaction (anaphylaxis) occurs with these tests, but there are no records of any deaths. Nevertheless, if you suffer from severe asthma or have experienced anaphylactic shock in the past, it is advisable for the doctor to have adrenaline and resuscitation equipment available. Those with strong allergic reactions to latex may also react badly if they are tested with an allergen that cross-reacts with latex (e.g. cypress pollen), not just when tested with latex itself. Taking beta-Mockers (see box on p. 150) increases the risk of a life-threatening reaction for anyone in these higher-risk categories.
False positives and false negatives
Apart from challenge tests, none of the tests used for allergy works with 100% accuracy. Most give both false positives and false negatives.
A false positive means that there is a positive test but no actual reaction when the allergen is encountered (e.g. eaten or inhaled). A false negative means that there is a negative test result despite a genuine reaction (as shown by a challenge test, for example).
A test that gives relatively few false positives has good positive predictive value - in other words, if it suggests you are allergic to something, you probably are.
A test that gives relatively few false negatives has good negative predictive value. If it comes up negative, you are probably not allergic to that allergen.
Some tests for allergic reactions show good positive predictive value but poor negative predictive value, while for other tests the reverse is true.
Fresh is best
The fruit and vegetable allergens that provoke Oral Allergy Syndrome (see p. 63) are chemically unstable, so commercially produced extracts for skin-prick testing quickly lose their potency and give false-negative results. Most allergists now favour using a drop of fresh juice from the fruit or vegetable concerned.
Intradermal tests
These tests (also called ‘intracutaneous tests’) put allergen more deeply into the skin than prick-puncture tests. The skin tends to react more when penetrated to this depth, so there are more false positives. There is also a greater risk of a serious reaction which may require emergency resuscitation. Don’t undergo these tests if you are taking beta-Mockers (see box on p. 150).
Blood tests for IgE
There are blood tests that look at the total amount of IgE (the allergy antibody), which is sometimes useful in diagnosis. But more important are blood tests for specific IgE – against egg or grass pollen or latex, for example. There are different ways of measuring the IgE in the blood, the most commonly used being a radio-allergosorbent test or RAST.
Research shows that RASTs are no more accurate than skin-prick tests in confirming real-life allergic reactions. However, they are useful for patients who can’t discontinue their antihistamines without developing severe symptoms, and for those with dermatographism or very severe eczema (see p. 91).
Patch tests
These tests, used primarily for contact dermatitis, are similar to straightforward challenge tests, because the suspect substances are applied directly to the skin.
The test substances are placed on the skin – usually on your back – in small chambers. They are held in place with sticky tape, and left there for several days. Ideally, the reaction of the skin should be checked three times: after two days, again the next day, and again the day after that. It really is worth going back for all these separate visits, because the accuracy of the test increases greatly with repeated checking.
The substances chosen for testing are a standard set of antigens that most commonly cause contact dermatitis. This standard set will pick up 60-80% of all sensitivity reactions in contact dermatitis. If you have substances that you suspect may be causing symptoms, such as cosmetics, the doctor can usually test for these too.
You should not be tested while you still have a rash, as the testing will probably make the existing rash flare up, even though the test patches are applied well away from the rash.
Use of steroid creams and any light treatments (including exposure of the test area to ordinary sunlight) must stop at least a week before testing starts, or the results will not be accurate.
Interpreting patch tests requires a huge amount of skill, plus extensive knowledge of the finicky details of the different test substances. You need a dermatologist with considerable experience in this area.
False positives (see box on p. 91) can occur, especially if you react very strongly to one of the substances tested – some people develop what dermatologists call an ‘angry back’, and this generates false positives to various other substances being tested at the same time. Should you be told that you are sensitive to a great many different things, you may want to query this reading of the test. Ernest N. Charlesworth, an allergist and dermatologist at the University of Texas, describes patients who ‘develop into environmental cripples’ after being told that they are definitely sensitive to multiple antigens, on the basis of misinterpreted false-positive patch tests.
False negatives (see box on p. 91) are also possible, even with very careful testing. Should this occur, a type of challenge test known as a ROAT (Repeat Open Application Test) is possible. The suspect substance is applied to the inner fold of the elbow twice a day for a week. Get your doctor’s agreement before trying this test.
Endoscopy and biopsy
Miniaturised cameras and sophisticated fibre-optics have allowed modern doctors to do something that their predecessors could never have imagined possible – look right inside the human body. This procedure is called endoscopy, and it has a useful role in a few sensitivity reactions.
Looking inside the sinus cavities can assist in understanding exactly what is going wrong in chronic sinusitis. Inspecting the digestive tract can be valuable in several of the non-IgE immune reactions to food, such as coeliac disease (see p. 70) and eosinophilic gastroenteritis (see p. 72).
A biopsy is often carried out at the same time as endoscopy.
s involves taking a small sample from the affected area, such as
I ning of the gut, and studying it in detail under a microscope.
One purpose of a gut biopsy is to look for characteristic :goes of damage to the lining of the gut – such as the distinctive charges produced by untreated coeliac disease. A biopsy can also reveal what kind of immune cells are present. Abnormal numbers of certain immune cells, for example, eosinophils (see p 19), may suggest a particular diagnosis.
Another way of looking at what kind of immune reactions are going on, used for lung diseases, is a bronchoalveolar lavage – iterally a ‘washing out’ of the airways and lungs, allowing immune cells to be collected and studied. This diagnostic technique is lased for Heiner’s Syndrome (see p. 72).
Tests for food intolerance
The only really effective way of testing for food intolerance is an el ruination diet (see pp. 194-7). This is the gold standard. However, it is neither easy nor quick – which has led to a constant search for alternative tests.
The proposed alternatives are all indirect tests, that is to say, non-dietary. The results of the tests are used as a basis for an avoidance diet. In other words, the foods that give a positive test result are avoided.
Some of these tests use samples of hair or blood, others use pulse testing, pendulums, or muscle strength tests (’applied kinesiology’). A few of these tests do show some promise. Pulse tests, and a blood test called the ‘lymphocyte transformation test’. for example, can give a general indication of sensitivity reactions – sometimes. However, even in the most expert hands, these do not give a result that is accurate enough to be useful.
Of the other tests that are available, most have not been evaluated at all objectively.
Many of them are advertised directly to the public, and one of the problems with this approach is that the testing company starts by assuming that food is the problem. The same is usually true of ‘dietary therapists’ and others in the alternative health field offering tests of this kind.
Almost everyone who undertakes such tests is given a fairly long list of foods which have come up positive in the tests. This does not fit with the evidence from medical trials in which a group of people with irritable bowel or migraine (typical food intolerance symptoms) undertake an elimination diet. A significant proportion of them always find that they do not have food intolerance. Of the rest. many find that they react to one or two foods only. The long lists of foods produced by the commercial tests are, to put it mildly, implausible.
With tests that require a sample of blood, sending off two blood samples from the same person, under different names, is a simple way of assessing the tests’ validity. This exercise has been tried several times with different testing companies, and every time two completely different lists of foods have been sent back.
Covert studies of this kind have also shown that the tests overlook genuine reactions. In one alarming case, a woman with a true allergy to peanuts was assured by a ‘dietary therapist’ that she really could eat peanuts safely.
Many people with food intolerance will tell you that they did well after following a diet based on such tests – and they may well have done. Given that common foods such as wheat and milk are regular offenders in food intolerance, and that these foods very frequently feature on the lists of positive test results generated by commercial testing companies, quite a few people should do well. The problem is that these people may also be avoiding many other foods quite unnecessarily.
Furthermore, if people have sensitivities to some other foods that are not on the list, they will be missing out. They could enjoy a far better level of health if all the foods causing symptoms were Identified and removed from their diet.
In the end, an elimination diet is both cheaper and far more likely to give the right answers.
Testing for IgG antibodies
In diagnosing food intolerance, a few doctors offer tests for a type of antibody called IgG. This antibody is formed to any food molecules that get Into the bloodstream after a meal – and some do, even in entirely healthy people. So finding IgG antibodies to food molecules is not indicative of any disease at all. It occurs in everyone and is perfectly normal.
Nevertheless, some doctors feel that by measuring the level of IgG antibodies to foods, they can get a general idea of the permeability of the gut wall (which might possibly be true) and of particular foods that could be causing intolerance reactions (very doubtful – the tests just tell you what you eat most, and you know that already).
This test does measure something real, unlike some of the alternative tests for food intolerance. But the relevance of what it measures to the health of the individual concerned is partial and indefinite. A recent study of IgG testing for irritable bowel syndrome has confirmed this view.
In short, blood tests for IgG antibodies to food molecules seem like very poor value for money, and potentially misleading, whereas an elimination diet is a far more precise way of pinpointing food intolerances.

Various other things can irritate the skin and make atopic eczema flare up:
• cold weather
• dry air
• long car journeys
• sweating heavily; clothes or shoes that trap sweat may also cause problems
• dust mites, which can act as an irritant, even if not an allergen
• tobacco smoke
• solvents and other chemicals encountered at work
• skin contact with fruit (especially citrus), vegetables, and sometimes other foods. The spray generated by peeling potatoes can even produce eczema on the face.
Anything which increases blood flow through the skin makes the itching worse:
• heat, especially a hot bath or being too hot in bed
• anger or embarassment
• hot drinks of any kind
• coffee, tea and alcohol because of the drug-like substances they contain
• vinegar and spicy foods
• chocolate, soy sauce, yeast extract, orange juice, tomatoes and other foods that are rich in amines (see p. 200).
Various changes in the body can make the eczema worse:
• teething, in babies
• colds and other viral infections
• in women, certain phases of the menstrual cycle.
Many eczema sufferers are aware that their skin gets worse when they are upset, stressed or anxious Oust before examinations, for example). Like other allergic diseases, atopic eczema is not primarily psychological but, once it has begun, psychological factors can play quite a big part.
The good news…
…for children and teenagers, is that if you have eczema as a child, your chances of developing acne during your teens are greatly reduced.
Contact dermatitis too?
People with atopic eczema can develop contact dermatitis (see p. 54) in addition to their existing rash. There is always this risk with regularly applying creams to your skin, especially anything containing fragrance or lanolin. Antihistamine and antibiotic creams also carry this risk.
Even the ingredients in the creams prescribed for eczema – such as moisturisers and steroids – can sometimes provoke contact dermatitis. Creams are more likely to contain sensitising ingredients than ointments. Very occasionally, the sensitivity is to a preservative or emulsifier that is widely used in different ointments and creams, which means that switching brands yields no improvement. Steroid suspended in petrolatum (white paraffin jelly) is the least likely to cause reactions.
The rash produced by contact dermatitis looks no different from atopic eczema, so this sensitivity will be far from obvious. It will just seem as though the atopic eczema is not getting better.
Talk to your doctor if you think there may be a problem of this kind. He or she can check by using the suspect cream on one side of the body, and a different-but-equivalent product on the other side. Patch tests (see p. 92) may also help to identify contact sensitivity.
Diagnosis
There are five separate aspects to diagnosis:
1 Is this really atopic eczema? There are no clear-cut tests for atopic eczema. Instead the diagnosis is based on a ‘points system’ – how many of the typical features of atopic eczema are present? The doctor adds them up, and if there are enough, then it’s atopic eczema. Sometimes all the typical features are there and this is obviously the right diagnosis, but in other cases there may be room for doubt. The doctor should rule out the possibility of contact
dermatitis (see p. 54), especially if you have eczema only, or mainly, on the hands.
2 What avoidable irritants are making the skin worse?
3 Is the eczematous skin infected? The signs of infection are usually clear, but not always, especially with fungal infections. Steroid creams can sometimes mask the overt signs of infections: if atopic eczema is not responding to treatment this possibility should be investigated.
4 Are there any allergic reactions to those infections? Or to the normally harmless microbes that live naturally on the skin (see p. 17)? Skin-prick tests or blood tests can reveal such allergic reactions where fungi are concerned. Adults with persistent atopic, eczema which is getting worse rather than better are the most likely candidates.
5 Are there allergic reactions (or other sensitivity reactions) to food, or to allergens such as house-dust mite?
This fifth aspect of diagnosis is where controversy is rife. Many dermatologists feel that atopic eczema is treated quite adequately with moisturisers (emollients) and steroid creams. The search for allergic/sensitivity reactions – in other words, for basic causes – seems unnecessary for most patients, or more trouble than it is worth. Indeed, some dermatologists believe that looking for such sensitivity reactions is actually mistaken because they are not basic causes (see p. 42).
Other specialists disagree, and feel that allergic/sensitivity reactions are a basic causative factor in atopic eczema. They concede that there are many false positives, but in their opinion, there are enough true positives in the skin-prick test results to make it worth sorting them out from the false positives. Except for patients with very mild eczema, such doctors prefer to identify and eliminate the root causes, if possible.
Patch tests are now used by some of these doctors (see p. 69) – yet another contentious issue! The time-honoured use for patch tests is in contact dermatitis, and there is a lot of resistance to using them for atopic eczema. Traditionally, the immune reactions involved in atopic eczema and contact dermatitis are seen as entirely different – the former involving IgE and being a quick reaction (identified by skin-prick tests), the latter involving other players and
Sweaty sock dermatitis
More correctly known as ‘juvenile plantar dermatitis’, this rash on the feet affects an awful lot of atopic children. It is frequently misdiagnosed as athlete’s foot, and treated with anti-fungal drugs. The important clue can be found by looking between the toes: if there’s no rash there, then it is not athlete’s foot.
being much slower (identified by patch tests). New research into atopic eczema shows this view to be overly simple (see pp. 18-19) – and it provides a rational basis for using patch tests.
If, as a patient or a parent, you are keen to search for fundamental causes, remember that this should never displace treatments to quell infection or moisturise the skin and restore its protective structure. When these treatments are neglected the whole problem can get far worse, because of the vicious circles that sustain atopic eczema.
Treatment
Treatment for atopic eczema has five possible angles:
1 calming the inflammation
2 avoidance of scratching and rubbing
3 caring for the skin and restoring its normal structure
4 treating infections
5 avoiding allergens.
One or more of these aspects may be neglected, depending on what kind of specialist you are seeing.
Calming the inflammation
Steroid creams are the mainstay of atopic eczema treatment because they calm the inflammation in the skin. The creams do carry a risk of side effects, but are safe when used correctly (see p. 147). An over-fearful attitude to steroids creams can mean that the eczema never gets under control, and this can mean using more steroids in the long run. When treating an outbreak of atopic eczema with steroid cream, it is vital to continue applying the cream until the ‘hidden healing’ has occurred (see p. 146) – don’t stop as soon as the skin looks better.
Promising alternatives to steroid creams now exist: these are tacrolimus and pimecrolimus ointments (see p. 147). Unfortunately they are much more expensive, and your doctor will probably prescribe them only if there is some pressing reason.
Tar-based ointments have a much milder anti-inflammatory effect, and can be helpful for areas of thickened skin. They were once widely used for atopic eczema, but are used less now, in part because they stain fabrics and smell unpleasant. Sometimes they irritate the skin, too, and there are concerns about safety: they contain carcinogens, and significant amounts are absorbed into the bloodstream. However no evidence has been found that these cause cancer, despite intensive searching.
Antihistamine tablets are sometimes used and while they
may not help the eczema much, some evidence suggests that
they could reduce the risk of asthma developing later (see p. 249).
Powerful drugs such as cyclosporin are sometimes used in
severe cases of atopic eczema, to damp down the immune
response. They are taken by mouth, and can affect other parts of the body, not just the skin. Very careful monitoring is needed.
Sunlight is often beneficial, because it suppresses the inflammatory processes in the skin. However, not everyone improves with sun exposure – some get worse. Careful experimentation is the only way to find out: build up the length of sun exposure very gradually, starting with less than an hour a day.
Medical treatment with UV (ultraviolet) light can produce the same effect as sunshine and suppress inflammation. This treatment may be prescribed, but you should not try it for yourself with a sun-lamp. In PUVA treatment, a plant-derived substance called psoralen is given by mouth, or applied to the skin, to enhance the response to UV light.
Kicking the scratching habit
Scratching is a substantial part of the problem in long-standing atopic eczema. Experiments with healthy people and mechanical ’scratching machines’ show that perfectly normal skin will erupt into eczema if it is scratched intensively.
There is no steroid cream powerful enough to counteract the effects of scratching. But if scratching stops, then the skin can –with the help of medication – heal up.
Note that ’scratching’, in this case, includes rubbing the itch (directly or through clothes; using a hand, wrist, chin, leg, foot, or any other part of the body), touching or picking at the skin, rubbing against sheets, furniture or another person, or using a towel, flannel or hairbrush to rub the skin. All these activities can be habitual and quite unconscious, if atopic eczema has been present for more than a few months – you just don’t realise you’re doing it most of the time.
For many with atopic eczema, another problem creeps in –scratching without itching. This may be just habit, a response to boredom, stress or anxiety, or even part of the family dynamics, in which scratching has become a form of emotional expression. Scratching alone can set off itching, and a scratch-itch-scratch cycle ensues.
The first step in combating scratching (for an adult or older child) is simply to notice how often scratching occurs. Doctors at the Chelsea and Westminster Hospital in London issue their patients with little hand-held counting devices (tally-counters), and ask them to press the button on the device every time they scratch or rub. Over a period of days, patients discover – usually to their own amazement – just how often they do scratch. The point of the exercise is simply to become conscious of the scratching impulse, and to notice the situations which typically provoke scratching. You could use a small pocket-sized notebook and pencil to achieve the same end.
Once this awareness has been gained, then you are in a position to break the scratching habit. The methods involved –called ‘habit reversal’ – were first developed by a Swedish dermatologist, Peter Noren. It takes about 2-4 weeks for most people, but the change is long-lasting. Most eczema sufferers find that they recoup their time investment rapidly, once they are free from the chore of dealing with chronic eczema.
When you notice that you are about to start scratching, and before the urge to scratch overwhelms you, take control and do something deliberate with your hands – for example, clench your fists, while breathing deeply and slowly. Think cool non-itchy thoughts. The urge to scratch may pass. If it doesn’t, then you can allay the itch by pinching the itchy area gently, or pressing your fingernail into it, or lightly applying a little moisturiser.
In the bath or shower, don’t use flannels, and never rub or scrub the skin. Dry off by gently patting with a soft towel.
The aim is to get scratching episodes down to fewer than ten per day. In achieving this goal, relaxation exercises, stress management techniques, hypnotherapy or autogenic training (see p. 222) can also be very helpful, especially if you sometimes scratch in tense situations.
With small children, the parents have to do the noticing. Most are unaware just how much their child scratches or rubs the eczema – babies often rub against the side of the cot.
Once the awareness is there, a child over four can usually be taught the habit-reversal technique described above. With a younger child, the parents must distract the child when scratching is imminent, by talking or playing. If the child is scratching while asleep, parents should pick the child up and, very gently, hold the child’s hands away from the body. Situations and activities which commonly provoke scratching should be avoided, or planned for. Give the child something to hold while dressing and undressing, for example – keep the hands busy. But never say ‘Don’t scratch’ – it usually has the opposite effect in the long run.
For the first four days and nights, while you are trying to break the scratching habit, the child should never be alone, even for a minute – someone who is able to distract the child from scratching should always be there, and awake. Fortunately, children lose the habit far more quickly than adults.
Keep a child’s fingernails very short, and smooth them with an emery board too, so that if any scratching does occur the effects are minimised. (Soft cotton mittens, to be worn at night, are often recommended, but the cotton itself can be used to rub the skin – observe your child carefully! The same is true of all-over cotton suits.)
For this anti-scratching programme to be effective in healing the skin, there must be a determined effort with drug treatment at
Will it clear up?
Small children with eczema generally grow out of it by the age of two. Those who have eczema after this age tend to show a big improvement at puberty. Sometimes, however, the eczema can disappear at puberty, only to reappear later: so continue to be careful with your skin.
Atopic eczema is frequently the first sign of a tendency to allergies (see p. 22). Given this early warning sign, parents should take steps to avoid allergies developing, or at least reduce their severity (see pp. 244-9). One small piece of good cheer: atopic eczema and life-threatening food allergies are very rarely found together.
People with both asthma and atopic eczema frequently notice that when one improves the other seems to get worse. There is no explanation for this as yet.
Moisturisers - how to use them
Moisturisers (emollients) do two things: they increase the amount of water in the skin, and they lubricate the skin, making it less brittle.
A moisturiser is designed to leave an oily layer on the surface of the skin which stops the skin’s natural moisture from escaping. The most effective preparations, from this point of view, are ointments made from white paraffin, such as Vaseline, which form an uninterrupted waterproof layer: these are sometimes called occlusives. They contain no water, unlike creams. Although a cream forms a less formidable barrier to the escape of moisture from the skin, it does provide some moisture itself, which can soak into the skin.
The most important thing is to have something that you like using, so that you apply it regularly. There are lots of moisturisers available, so ask the doctor for different ones to try.
Applying moisturiser well is crucial:
• Apply moisturiser before your skin gets dry, as a preventive treatment.
• There’s no need to rub in your moisturiser (this can be a form of scratching). Just apply it very lightly.
• A thin layer is all that’s needed. A thick layer keeps in heat which aggravates the skin.
• Always apply within three minutes of a bath or shower.
• In addition, apply every 3-4 hours during the day. Carrying moisturiser around with you is helpful – get a small tube of moisturiser for this purpose.
• Ask the doctor to prescribe moisturiser in large quantities, to make sure you have enough. But beware of infecting big pots with Staphylococcus bacteria and then reinfecting your skin. Pump-action dispensers are safer.
Moisturiser can also be smeared onto bandages which are then wound around the affected areas at night to reduce the itch – or you can use ready-made ‘wet-wraps’ (ask your doctor about these). As long as the bandages/wraps are immovable, they will reduce nocturnal rubbing and scratching.
Avoid lotions, and any non-prescribed creams, as they could be irritating to the skin. Choose bath oils with care – some contain alcohol which is an irritant.
the same time. You should be using a steroid cream of sufficient strength, twice a day, and plenty of moisturising treatment.
By taking this ‘Combined Approach’, as Dr Christopher Bridgett and his colleages at the Chelsea and Westminster Hospital call it, you should be able to clear the eczema completely, even if you have had it for years and have tried innumerable different treatments. Once this has been achieved, you can maintain an eczema-free state by watching carefully for any outbreaks of itching, redness or roughness, and treating them immediately with a short course of steroid cream (see p. 146).
Skin care
Firstly, avoid all the irritants which you think may affect your skin. Give clothes an extra rinse cycle in the washing machine, to remove all detergent. or use a non-detergent system such as Eco-balls or Aquaballs. Wash all new clothes before wearing them, to remove chemicals such as formaldehyde. Wear soft cotton or silk next to the skin.
Where eczema affects the hands, special care is needed (see p. 57).
Water can be both good and bad for eczema. When you soak in a bath, water is absorbed by the skin cells, which helps correct the dryness of the skin. But when you get out of the bath, and the skin dries, the outermost layer shrinks and develops microscopic cracks, making it even less waterproof than it was before. The way around this is to apply a moisturiser immediately after a bath or shower –gently pat the skin until partially dry, and apply the moisturiser immediately to trap the water in the skin.
For anyone with a severe flare of eczema, current recommendations are:
• soak in lukewarm water for 20 minutes, twice a day
• pat dry
• quickly apply steroid cream to the eczematous areas, then moisturiser over the top, and to all other dry-skin areas
• make sure the moisturiser goes on within 3 minutes of emerging from the water.
This works well for some people, but not all. For a few eczema sufferers, the effect of taking natural oils out of the skin (which soaking does, to some extent) may outweigh the benefits of putting water in. Or they could be sensitive to something in the tap water – the chlorine, perhaps, or pollutants. It may not be obvious that this routine treatment is not helping. As Dr Michael Tettenborn, a British paediatrician with long experience of atopic eczema, observes: ‘By the time they’re referred to me, children are usually on the standard regimen of two-soaks-a-day. One of the first things I do, as an experiment, is tell the parents to just bathe them once a week and use a moisturiser and tissues to keep them clean the rest of the time. Some children do a lot better after that.