Lawrence Eichenfield, MD: At this point, we’re going to take a broader perspective on atopic dermatitis [AD]. We’ve set up this section as available standard of care for atopic dermatitis, but we’re going to go back to where we’re at with the disease and how we manage it, and then also incorporating how we think our newer agents might fit in.
I’m going to task Peter with a big question because he’s an expert in aspects of this. Why don’t we discuss the nonpharmacological approaches to the treatment of atopic dermatitis? What potential lifestyle modifications can be made by patients to manage AD symptoms with flares? Peter, you don’t have an hour and a half, which I’m sure you could do wonderfully, but please start us off with that.
Peter Lio, MD: Thank you, Larry. Yes, you know I can go on and on about this topic because this is interesting stuff. It often gets relegated to baseline stuff or pushed to the side because it’s not as glamorous, powerful, or as reliable as the big guns we’re talking about. But it often can be the difference between somebody who needs systemic therapy and somebody who doesn’t. We can harness and leverage some of our nonpharmacological approaches to get people a little better. Sometimes that’s all I need, so I love this.
It depends on how you define it, because it can be a little slippery. Let’s start at the very basics. Of course, we have the simplest things, like avoiding known triggers, right? That’s something that’s obvious. It’s at the base of every guideline document. But sometimes we don’t spend much time on it, especially in dermatology. Our allergy colleagues are much more proactive about this.
But if you know certain things irritate or bother you, or if you’re truly allergic to something, we want to make sure we’re avoiding those things. That can mean situations that make it worse, like super high heat or lots of sweating. Not bathing after you exercise can sometimes be trouble because sweat can be a trigger for many patients. Extreme cold temperature, not putting on the proper clothing when you’re going outside in the cold—a cold Chicago winter can irritate the skin and dry it out. Those are basic.
Then we have good moisturization. That’s generally nonpharmacological, though admittedly, some of the newer moisturizers are incorporating bioactive ingredients and sound more like medicines. But the basic concept of protecting that skin barrier, strengthening it, and hopefully adding some of the natural lipids to help get it stronger are going to be helpful.
Good bathing practices are highly controversial. There’s still a lot of debate, but there’s enough consensus on the fact that daily bathing is probably better than doing it every couple of weeks, as we’ve heard. Some people have a dry approach where they say, “Don’t bathe much at all.” We think daily bathing, or more frequently, is better, especially when we use gentle products, like a synthetic detergent. I’m obsessed with oil-based cleansers that are ultra-mild that are totally nonsoap. We know that with the true soaps, rendered fat is very alkaline and very damaging to the skin and strips it. As Leon mentioned, even pure water can be stripping. It’s going to pull off some of the lipids. It’s a little alkaline, so it will help if we can buffer that a little and then moisturize right after. That soak-and-smear or soak-and-seal concept is powerful. These are some basic things.
The next level is, what about diet? We can spend a weekend workshop talking about that. It’s a big mess. The take-home point, the highest-level point, is that food allergies are extremely common in our patients with atopic dermatitis. That relationship is linear. The more severe the AD, the more likely they are to have food allergies. Generally speaking, this is not causative. The food is not driving the atopic dermatitis for the vast majority of patients. I can’t be dogmatic and say it never is the case. But for the cases we see, they have real food allergies. If anything, we think those were caused by leaky skin. They’ve sensitized at least some of these through their skin, so they’re avoiding that.
If you’re anaphylactic to peanuts, I know you’re not cheating. You’re not sneaking a peanut M&M every now and then. It’s not happening. Therefore, that’s clearly not driving your disease. What dietary things? Usually I put that at the bottom. I try to avoid the discussion of major dietary changes outside the true clear known food allergens.
Then we can even go further to lifestyle things, like certain textiles. We think that cotton clothing is very good. There’s even a literature on silk clothing. Sometimes for babies, I’ll have folks get a silk pillowcase for the baby to lie on. That has been shown to be helpful, at least in some small studies. Silk seems to be a little anti-inflammatory and is probably naturally antibacterial. We could go on, but there are all these other little pearls that come up that are very fun to talk about.
Lawrence Eichenfield, MD: This is a big avenue of concern and intervention. When I’m lecturing, the question will come up about immunogenic foods. I’m very positive about how interesting it will be for us to research to figure out how the gut access and skin access may be associated. On the other hand, when I have a family come in and say, “Let’s talk about immunogenic foods,” I’m like, ‘”Ah!”—my head is going to explode because we don’t have the data necessarily to help know if there’s any influence once you have established atopic dermatitis.
But food allergies are different. One of the things I’ve recognized is that there’s so much energy spent being concerned about foods, especially in the first few years of life associated with atopic dermatitis. There was a study that Jon Hanifin did years ago that I loved. It was like a nihilist study. He basically showed that when you get patients on a good regimen that controls their disease, they become less concerned about food allergies. It has a nihilist thing about it, because if there are true food allergies, we obviously want to know.
We have a multidisciplinary atopic dermatitis program in San Diego where I see patients with difficult eczema. We see them together. The clinical pharmacist, an allergist, and a dermatologist see them, and then we have a team-based approach. I’ve learned that the holistic approach toward environmental and food allergies helps the patient, even if they’re not triggers for their atopic dermatitis. It helps to show that we’re caring about that aspect of their lives. But Peter already relayed that we have so little time when we’re counseling patients in our normal clinics that we try to figure out what materials we can lead them to as well as themes that we go to in terms of nonpharmacological approaches to help them manage the disease.
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Transcript edited for clarity.