Anna Pugh talks to DrB about atopic eczema during pregnancy
The Combined Approach to atopic eczema in pregnancy
Anna Pugh was referred to our clinic with chronic atopic eczema in 1991 during her first pregnancy. Having always had an interest in the relationship between food and health, she now works as a nutritionist. She regularly contributes as an “expert patient” on the reality of living with skin conditions on the post-graduate dermatology course at the UK University of Hertfordshire.
DrB: You came to our clinic during your first pregnancy?
AP: Yes, I was 6 months pregnant. Newly married, I had become pregnant straight away. I had had eczema since childhood, but pregnancy seemed to make my skin more sensitive. My eczema was exacerbated. My skin was irritable, very dry, hot and tight and it would weep constantly. It was a good time to get fresh advice. With my first pregnancy I became aware of my body in a way I hadn't been before. I also wanted to be as well as possible for my baby.
DrB: Did you go to antenatal classes?
AP: Yes, but because my skin was difficult to look after I felt very different from the other pregnant mothers. I felt isolated. They would be discussing what happened if their waters broke in the supermarket and I was wondering how I'd be able to maintain my skin care - 2 hours every morning of bathing/creaming/calming skin down - before I could start the day and how would I be able to look after a baby if it took so much time to look after myself?
DrB: And, looking back, what do you remember was your overall impression then of The Combined Approach?
AP: With the programme I understood for the first time in my life exactly what emollients and steroids were for and how to use them. I had never considered before that I had to work on my skin being an effective barrier against water loss. Achieving “hidden healing” through using topical steroids for long enough made total sense to me - I now use those two words often in my work as a nutritionist. I see a lightbulb switch on in people's eyes. I wish I'd seen those diagrams and cartoons at the age of 10. With The Combined Approach I took responsibility for the first time, because for the first time I had the tools and knowledge to look after myself.
DrB: How about habit reversal?
AP: Previously I had believed that it was impossible to stop scratching in response to itch. Challenging that belief was a key to recovery. Asking why I was scratching was a difficult! Now I do it whenever I scratch. I know it's rarely in response to itch! For the first time in life I felt hope in response to my eczema. I don't mean I wasn't positive and energetic as a person before, but I never believed I would ever get on top of my skin. I was “the girl with eczema”. I had always lived without the hope of being free from having eczema. The Combined Approach tapped into my deep desire to be hopeful. It was akin to giving me the keys to freedom!
DrB: You discovered things could change?
AP: Yes. After treatment the texture came back and the weeping disappeared and the scars began to slowly heal. It would break down occasionally but I watched it like a hawk and treated every eruption. I would just allow myself half an hour to get up, jump in a oatmeal bath, assess my skin in the bath and work out my strategy on how much cream to use, how much steroid, then get out of bath and enact my strategy. The bath became a psychological half-way house between waking and getting on with my life, what to do and how I was and how I felt and how my eczema was. My confidence grew gradually as I began to wear different clothes and enjoy being a little more normal.
For me habit reversal worked as a disruption: there's potentially great value in disruption. It was a time to disrupt normal habits and learn new ones. With hindsight, using habit reversal I was good at resisting scratching, but perhaps I didn't take on board the importance of developing displacement activities and new habits. I kind of stopped in order to become more still. And I imposed a calm and stillness on life which was at odds with the way I felt inside. It sort of straight-jacketed me! My desperation to have good skin meant that I had to change the way I had been living before. The message is that maximising your skin care means that you have to put more time and effort into looking after yourself. Then one's life will undoubtedly adapt and change.
DrB: How did things go after the delivery?
AP: Breast feeding was a MAJOR problem as the eczema on my nipples was very bad. To begin with the paediatrician arranged soya feed for my baby. But after 24 hours I decided to lift off the scars on my nipples and breast feed. With all messages that “breast is best” I couldn't bear not being able to breast feed. I kept it up for 6 weeks, but then I was in hospital for a week with liver problems, and was forced to stop. Breast feeding and rubbing milk on my nipples helped with my eczema. Breast feeding for mothers with eczema is very important because everywhere you read that it is best for the baby, particularly if you are atopic. I managed to breast feed my second child for 8 weeks, until my eczema got infected in hospital after an inguinal hernia operation. But I managed to feed my third child for 7 months, which was a total joy.
DrB: How was your eczema in your next two pregnancies?
AP: The next two pregnancies were far better and I remember really enjoying them, I enjoyed being pregnant. My skin was in good condition so there was not need to use the level of steroids I had during my first pregnancy. It was still a preoccupation but I was dealing with it well and remember being happy. My deliveries were straight forward which was lucky. I was less fearful about my skin and about my ability to look after children. I didn’t have to go back to work though and wonder how I would have coped if I had. Life would have been very difficult.
I wish someone had explained that with each child the experience is so different. And none of my 3 children have eczema, which is interesting. I am blessed. I definitely treated them as if they did - no chemicals on their skin or in the bath, used water and cotton wool instead of wipes, wet dusted everything, no pets. I have no idea whether those strategies helped them - probably more likely we got the gene mix right when we married: my husband was a very healthy specimen!
DrB: So, pregnancy and The Combined Approach was a success for you! Do you have any general tips for coping in pregnancy with atopic eczema?
AP: I do remember thinking that I can't have eczema like this and be overweight. I was probably over careful with food during pregnancy and that may have been an extra stress. Later I became a nutritional therapist. This was the result of noting the association between diet and health all my life - and I wish that diet was more of a culprit regarding eczema than it actually is! At least my experience of The Combined Approach has put that idea in its place. But now I do advise pregnant mothers to take a mixed-strain probiotic, and to ensure sufficient intake of omega 3 essential fatty acids - and I generally suggest ways to maximise their health through nutrition.
DrB: Your children are now grown up. Your youngest has just started University. How is your eczema now? If members who have read this want to ask you about your experience, is that OK?
AP: Now all is good. No one would say I had eczema! I would say I am normal and energetic. With The Combined Approach I have learnt to live without eczema! And, yes indeed, I am happy to answer more questions! Ask away!
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See also... Atopic eczema in pregnancy