Paige Mills is just like any other 21-year-old who loves travelling, playing sport, spending time with her boyfriend and posting photos of her adventures.
Except she has eczema.
The Sydney university student delights in exploring the world but when she travels she avoids being photographed, embarrassed by the angry red rashes covering her face.
She plays basketball but even in 30C heat wears long sleeves and leggings to hide her irritated skin, knowing the extra layers will only make her hotter.
She adored her dog but had to give him up after discovering an allergy that was aggravating her condition.
And while she loves staying at her boyfriend's house, his dog means she must keep the bedroom door closed and take antihistamines to avoid another flare-up.
Much of Paige's money goes on moisturisers, zinc creams, allergy treatments and air purifiers, while her days revolve around managing a condition that has robbed her of sleep, confidence and an entire semester of university.
Now, with another Australian summer approaching – predicted by some to shatter heat records thanks to a so-called super El Nino – she is bracing for heat that can turn her skin red raw and unbearably itchy.
When even showering becomes an ordeal
"I am dreading the heat," she tells AAP.
For someone who has had eczema since infancy, the condition was relatively manageable until she turned 19.
Then, amid the stress of finishing school and a bout of the stomach infection H. pylori, her skin deteriorated dramatically.
Severe rashes spread across her face and body, leaving her scratching through the night and exhausted during the day.
At its worst, even showering became an ordeal.
"The lukewarm water would irritate it and then I'd have to moisturise with Vaseline and a lot more emollients again," she says.
During the worst flare-ups, Paige was showering just once a week, covering herself in moisturiser and wet cloths, trying bleach baths, antihistamines and dietary changes in a desperate search for relief.
Nothing seemed to work.
"I was not sleeping. I was itching all night," she says.
Eventually, she stopped attending university for an entire semester.
Her symptoms have since improved considerably with fortnightly Dupixent injections, although she still experiences heat rashes and worries about what might happen if she stops treatment.
She also uses MooGoo creams, the Vaseline and zinc oxide products to soothe flare-ups.
But the mental burden remains.
"What's going to fix this? What can I do? You need to be very on-the-ball with it. Very mentally draining," she says.
One of her greatest comforts is swimming in the ocean, where she finds the saltwater helps calm her skin.
But getting to the beach is not always possible and even air conditioning can dry out her skin.
Still only in October, she recently managed just half an hour sitting in the sun before needing to cool down with a cold shower.
With forecasts pointing to unusually hot summer conditions, she fears another difficult few months.
Heat make eczema 'redder and angrier'
Sydney dermatologist and UNSW Conjoint Associate Professor Dr Deshan Sebaratnam says heat can aggravate eczema by increasing blood flow to already inflamed skin.
"And so the eczema will be redder and angrier," he tells AAP.
Sweating can also irritate the damaged skin barrier, with salt in perspiration aggravating existing inflammation.
The relationship between sunlight and eczema is complicated, with some patients actually experiencing an improvement during summer.
But for those whose symptoms worsen, the consequences can extend far beyond uncomfortable skin.
Severe eczema can disrupt sleep, education, relationships and employment, while badly damaged skin can become infected and, in rare cases, lead to life-threatening complications.
"Eczema isn't just itchy skin," MooGoo chief executive Melody Livingstone says.
"For some families, it means children scratching until they bleed, parents up half the night and painful flare-ups that can take the fun out of summer.
"Heat, sweat and dry air are well-known triggers, and once that itch-scratch cycle starts, it can be incredibly difficult to break."
The condition affects an estimated one-in-10 Australians, yet accessing specialist treatment can be difficult.
Australia has just 686 dermatologists for a population of about 28 million, equivalent to roughly one specialist for every 41,000 people, according to the Australasian College of Dermatologists.
Graduate doctor spends more time watching Titanic than studying ezcema
Sebaratnam says the shortage reflects a longstanding failure to invest in specialist training positions, despite the enormous burden of skin disease.
"If the hospitals can hire another surgeon or another cardiologist, they'll do that rather than hiring a dermatologist or a dermatology trainee," he says.
"So there's a sort of disconnect between what society needs."
About one-in-five Australian children and one-in-10 adults have eczema while acne affects most people at some point, Sebaratnam says, and two-thirds of Australians are expected to develop skin cancer by retirement age.
Yet dermatology remains a neglected specialty in hospitals and medical schools.
Sebaratnam recalls receiving just two hours of dermatology education during his medical degree.
"So I graduated as a doctor having spent more hours watching Titanic," he says.
He believes governments and hospitals must invest in more training positions, while medical schools should give skin conditions greater attention.
A long journey to a chance of hope
For Paige Mills, finding the right specialist has been a long journey involving three dermatologists, extensive allergy testing and countless treatments.
She hopes the stress of recent years – including her illness and the heartbreak of surrendering her dog – contributed to the severity of her symptoms and that life will eventually become more manageable.
But she also knows there might not be a simple solution.
"I don't want eczema to decide what I can and can't do with my life," she says.
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