An illness you can’t hide

My experience as a medical student with a skin condition

Chronic. Never-ending. No cure. These are painful words that unfortunately many patients have to hear in the doctor’s office. Having a disease is never fun. It’s painful, it’s embarrassing, and it can impact your life in unexpected ways. However, chronic conditions carry with them an additional burden. This burden is knowing that your pain and discomfort isn’t temporary. It’s a persistent problem that you have to continuously try to readjust your life to. It’s knowing at the end of the day, things might not get better. Even if you’re able to manage your symptoms with medication and adjustments, it’s a lifelong subscription to pills, pharmacy visits, and endless doctors appointments.

At a young age, I was diagnosed with atopic dermatitis, otherwise known as eczema. My parents were told it was a common condition, and were given a tube of steroid cream to use when I had a flare-up. They were told I would most likely grow out of it. As a little kid, I didn’t give this much thought. It sometimes kept me up at night itching, but other than the discomfort I was a happy kid. However, as I got older, I became more aware of what other people think of my skin. Other kids would point at it and ask what was wrong with me. ‘Ew, is that contagious?’ ‘What’s wrong with your skin?!’ ‘Try moisturizer!’ are some phrases I’ve heard. Nobody could see the hours I put into taking care of my skin, with prescription medication and endless tubes of moisturizer. People would stare when I wore short sleeve shirts. I became self-conscious and

“Ew, is that contagious?” “What’s wrong with your skin?” “Just use moisturizer!”

started wearing sweaters in the summer, only leading to sweating and worse flare ups. For many conditions, it is a hidden struggle. But for chronic skin conditions, it’s a battle that’s written all over your body. It’s an additional factor to consider as a body-conscious teenager in a world so focused on appearances. It’s missing pool parties because the chlorine burns your skin, and the thought of everyone seeing you in a bathing suit making you feel sick. It’s throwing away bath bombs, perfumed lotions, and makeup. It’s constantly thinking about and avoiding anything that might trigger your skin. Today, I’m twenty years old, and I never outgrew eczema as my doctors had hoped. While my actual skin became thinner from steroid creams and damage, my skin grew thicker against people’s comments. I’m studying Medicine, my dream field, and I have so much to be thankful for despite my eczema. I’m excited to help people in the future who feel just as frustrated and hopeless with their health as I have felt with mine. However, being a medical student with such a visible illness carries its own challenges. I overhear friends discuss the pictures of skin conditions we see in lectures and textbooks, calling them gross and nauseating. Pictures of skin that looks a lot like mine. ‘I’ll never specialize in dermatology, yuck!’. Eager, interested students look at my skin and comment what they think it is, and how I should treat it. I can’t blame them, as they mean no harm; however it’s not nice to be seen and treated as a medical case by my peers. During a particularly bad flare up in my second year, my eczema appeared on my face and neck. I had red, blotchy patches right where everyone could see. Eczema on my eyelids causes my eyes to sometimes swell shut. I stopped going to lectures and hid in my room, only leaving to get groceries. My roommates tried to get me out into the world again. As you might expect, my grades suffered a lot during this block of the semester.

Despite this, being a medical student with a skin condition is not always a bad thing. I really understand my illness now, and how my body works. I appreciate being healthy in all other aspects, as I now have an awareness of other conditions besides my own, and how they negatively impact people’s life. I’m thankful to have a working heart, lungs, and be healthy enough

to run around, travel, and use my body as I need. I think I bring a unique perspective to future consultations with patients, as I have firsthand experience with illness that gives me the ability to empathize with the struggles of others. I read publications about developments in eczema treatment, and I can now understand it. It gives me hope for a future where eczema will be less of a burden for so many people, including myself. More and more promising biological drugs for eczema are being developed and brought to the market in the upcoming years, and maybe one might arrive that finally brings the diease under control, for me and many others.

Because eczema is a common illness, we as future doctors will surely encounter it in our daily practice, no matter the speciality. However, patient satisfaction with the treatment of eczema is shockingly low; 91% of patients feel that their doctors don’t know how to treat their eczema (see image). So, how can we, as future practitioners, change this narrative? Through my experience with eczema and the treatment I have recieved, I suggest these points to keep in mind when seeing future patients.

It’s not as simple as ‘stop scratching’ This is often the first step doctors try when treating eczema. It’s definitely true that the less scratching the patient does, the better the eczema heals. However, due to the chronic and relapsing nature of the disease, scratching the itch can sometimes offer the only temporary relief a patient has after hours of irritation and inflammation. Of course the patient recognizes that scratching is not in their best interest, but it’s an unachievable goal to tell them not to. The patient likely already feels guilt, so try to skip stating the obvious and making them feel ashamed if they can’t adhere to that advice.

Stronger corticosteriods is not the answer for everyone The first-line treatment for eczema is topical corticosteroids, which reduce the inflammation and the itch. This works for a lot of patients, but often doctors see the only route of treatment as continuously upping the dosage and potency of the steroids. However, this is not without consequence. Too high dose steroids for a long period of time can cause what is now known as topical steroid withdrawal (TSW). This is when the body adjusts to the constant medication, and leads to much worse symptoms when the medication is stopped than the intial symptoms of eczema. This can take months to recover from, yet many doctors still do not practice caution when prescribing corticosteroids for long-term use. Steroids also cause local skin thinning over time, leading to the skin being more vulnerable to damage. Often, investigating possible triggers and allergies (laundry detergent, pets, foods, cosemetics, etc.) and removing them from the enviroment can prevent eczema from occuring in the first place. This is a valuable approach that many doctor’s skip over because its ‘like finding a needle in a hay stack’. However, if the triggers are uncovered it can have a major impact on the patients quality of life. There are also other, non-pharmaceutical treatment options available that should not be overlooked. Light therapy can offer significant relieve for some. A strict moisturizing regimen can also provide control. Its important to look outside the box when treating a patient, as corticosteroids are not the only element of treatment.

Listen to your patient This may come as a suprise, but eczema is one of the dieases with the highest reduction in quality of life (QOL). It can affect a patient’s relationships, self confidence, and even their career. I was told by my dermatologist that I should not consider a surgical speciality, because scrubbing in to surgery would be too rough on my hand eczema. Listening to the patient and how it affects their life is key, because then you can tailor a treatment that offers the best support for their situation.