Integrative Medicine for Atopic Dermatitis: Q&A With Vivian Shi, MD, Part 2

In part 2, Vivian Shi, MD, assistant professor of dermatology in the Department of Medicine at the University of Arizona and Banner University Medical Center and director of the Eczema and Skin Barrier Clinic and Follicular Disorder Clinic in Tucson, Arizona, discusses which products and ingredients patients should avoid, the Eczema Action Plan, and the top questions she receives most from her patients. Part 1 covered the nonpharmacologic treatment options she discusses with her patients, such as acupuncture, and how she approaches integrative medicine.

Q. What products or ingredients do you advise your patients to avoid?

A. I live in Tucson, Arizona, where patients tend to gravitate and are open to complementary and alternative medicine (CAM) therapies, so it offers great opportunities for me to incorporate integrative approaches to their skin care and treatment. AD is the poster child for integrative dermatology, however, sometimes people rub topical compounds and products on their skin that may be irritating and may even flare their AD. While many “natural” topical compounds are great moisturizers, we have to be cautious when selecting them. For example, poison ivy is natural but we would not rub that on our skin.

One of the products patients with AD should avoid is essential oils. Essential oils are very different from the natural oil in nuts or seeds. Natural nut- or seed-based oils are made by pressing the nut/seed under high pressure without adding any chemicals or ingredients. Essential oils, however, are extracted from the aromatic parts of the plant, such as a flower or leaf. The oils typically are extracted by a process called steam circulation, where the components of the plant are added to heat and chemicals are added to extract the fragrance, as well as aromatic compounds, and sometimes a carrier oil. The whole process often adds and creates irritating compounds such as terpenes and terpenoids, as well as irritating fatty acids.

I tell patients to avoid using essential oils as a moisturizer, but most commonly people use it in aromatherapy. I also recommend against using essential oils for aromatherapy because they can develop airborne contact allergy that may flare AD. In addition, I work closely with my patients to learn about ingredient selection in their moisturizers, especially to avoid drying agents, which includes products containing alcohol, retinols, or vitamin A. Sometimes a product will say anti-aging or retinol formula and these products will have alpha-hydroxy-acid or retinoid, which is good for skin aging and acne but can be irritating to the dry and sensitive skin of people with AD. Other ingredients are synthetic dyes and certain preservatives, as well as any known allergen. For example, if a patient is allergic to peanuts, they should make sure the product does not have peanut oil.

For moisturizers, the FDA has limited regulations for what can be labeled for sensitive skin or AD-prone skin. Even if a product is labeled for sensitive skin or AD skin, it may still contain risky ingredients such as allergens, fragrance, and synthetic dyes. It’s also important to keep in mind that what is an allergen to one person may not be an allergen to another person. These are some of the general considerations for selecting topical products for AD patients.

Q. What are some of the top questions patients ask about skin care?

A. In addition to the bathing question, another topic that is frequently mentioned is “I read that individuals with AD are more prone to infection.” In that case, the patient wants to try to get rid of the infection and will lather over-the-counter antibiotic cream, such as neomycin, polymyxins, and sometimes they will actually use a loofa to scrub their skin or bathe more often because they think this will decolonize their skin. I highly recommend against using over-the-counter antibiotic because they are relatively common allergens to our skin. I also advise patients not to scrub the skin because AD skin already has a very defective skin barrier and using a loofa or scrub is essentially like scratching your skin. It breaks the skin barrier allowing more allergens, irritants, and microbes to enter causing more inflammation.

Probiotics are frequently brought up as well. The microbiome are the microorganisms that live on the skin and other organs in the body that are exposed to an external environment, with the highest variation in the intestines and the skin because both have the most exposure to an external environment. In AD, instead of a balanced speciation in the skin and gut there are too few beneficial bacteria and there is overgrowth of the pathogenic bacteria. What we try to do is restore this balance because having too much pathogenic bacteria and frequent antibiotics use can disrupt the microbial balance and this is associated with damage to the skin and lining of the intestines. However, this is a controversial topic.

The first probiotic article came out this May in the Journal of Clinical Investigations Insight,³ which showed that topical probiotics can improve AD severity. The overarching goal is that patients can take oral probiotics that are beneficial, which include Lactobacillus laminosus and acidophilus or bifidobacterium longum, or any brevis or lactis species. Prebiotics, indigestible fructo- or lacto-oligosaccharides, are the food source for probiotics. A meta-analysis published in JAMA Pediatric in 2016⁴ showed that a combination of prebiotics and probiotics, called synbiotics, are effective for treating AD in children, and synbiotics are more beneficial than probiotics alone, and the mixed ranged probiotics is better than single strained probiotics. However, there is currently no head to head trial comparing synbiotics to probiotics.

Another study on the topical microbiome in AD that came out of Heidi Kong’s group⁵ in 2015 showed that S. aureus load or overload, along with decreases in microbial diversity on the skin surface is 1 of the triggers for an AD flare. In fact, these 2 things actually occur before clinically apparent flares appear. The opposite occurs when AD improves. There is a decrease in S. aureus on the skin and restoration of the diversity of the microbial colony. This leads to questions on skin microbiome transplant—can this restore the microbiome balance and improve AD? In fact, the paper published in Journal of Clinical Investigations Insight³ showed that topical Roseomonas mucosa, a topical probiotic lysate applied to the skin of individuals with AD, can improve AD severity as early as 6 weeks with near resolution in 10 weeks.

Q. What resources are useful for patients and dermatologists when developing a skin care regimen?

A. The Eczema Action Plan, which was originally derived over a decade ago from the Asthma Action Plan, is a traffic light signal scheme where patients work with a dermatologist to develop a treatment plan based on the traffic signals. If they are red that means they have flared and I write out the steps they need to do to improve, and if they are yellow then there is improvement but with active lesions, and I write the steps they need to follow for resolution. If a patient is green, it means they are clear or almost clear and need to follow other steps to avoid relapses. AD is a chronic, remitting, relapsing condition so there is not a single regimen that will work forever. We have to tailor the regimen dynamically to match the patient’s disease state and that is how we can get maximum efficacy without the adverse effects from chronic steroid use.

I refer my patients to the National Eczema Association website, which is probably one of the best reading resources for patients that covers regimens and has other helpful materials. The other resource for patients who are more interested in integrative treatment for AD is a website called Dermveda. It is the only integrative educational source for the general public and has very helpful resources and evidence-based writing for integrative approaches to treating AD. The website has 3 free ebooks that cover everything related to AD, written by experts who have dedicated their career to treating this disease. The ebooks can be downloaded from the Dermveda website (https://www.dermveda.com/ebooks). These are helpful resources that can help patients get familiarized with the triggers and treatments of eczema.  Finally, we should all be humbled that eczema is an ever-changing condition, and in my opinion, it’s best treated through an integrative approach. The ultimate goal is to improve the quality of life of my patients and their families.

Reference

1. Maarouf M, Shi VY. Bleach for atopic dermatitis: beyond antimicrobials [published online before print April 3, 2018]. Dermatitis. doi:10.1097/DER.0000000000000358

2. Lee KC, Keyes A, Hensley JR, et al. Effectiveness of acupressure on pruritus and lichenification associated with atopic dermatitis: a pilot trial. Acupunt Med. 2012;30(1):8-11. doi:10.1136/acupmed-2011-010088

3. Myles IA, Earland NJ, Anderson ED, et al. First-in-human topical microbiome transplantation with Roseomonas mucosa for atopic dermatitis [published online May 3, 2018]. JCI Insight. https://doi.org/10.1172/jci.insight.120608

4. Chang Y, Trivedi MK, Jha A, Lin Y, Dimaano L, García-Romero MT. Synbiotics for prevention and treatment of atopic dermatitis: a meta-analysis of randomized clinical trials. JAMA Pediatr. 2016;170(3):236–242. doi:10.1001/jamapediatrics.2015.3943

5. Byrd AL, Deming C, Cassidy SKB. Staphylococcus aureus and Staphylococcus epidermidis strain diversity underlying pediatric atopic dermatitis. Sci Transl Med. 2017;9(397): eaal4651.
doi:10.1126/scitranslmed.aal4651