Frustrated by eczema care that ignores patient priorities? New guidelines from the medical societies for allergists and immunologists may help change that. These guidelines were informed by the views of eczema patients and caregivers and based in evidence (hallelujah!). We chat with the guideline co-authors Dr. Lynda Schneider, founder and director of the Atopic Dermatitis Center at Boston Children’s Hospital, and Dr. Derek Chu, director of  the challenge clinic for allergy diagnosis, research and treatment at McMaster University, about some of the new and surprising ideas they recommend. (And if you like our podcast, consider supporting it with a tax deductible donation). Read the transcript.

Research mentioned

Atopic dermatitis guidelines: 2023 

Is Food-Triggered Atopic Dermatitis a Form of Systemic Contact Dermatitis?

Hello.

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I'm here with Corey Kapoza, founder

of GPAR, and today we are discussing

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the new American Academy of Allergy,

Asthma, and Immunology Guidelines

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for Optimal Management of Eczema.

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These evidence based guidelines

were written in consultation

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with patients and caregivers

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.

Joining us are the co authors of the guidelines.

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Dr.

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Linda Schneider is the Director of

the Atopic Dermatitis Center, as

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well as a Professor of Pediatrics

at Harvard Medical School.

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And Dr.

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Derek Chu is Assistant Professor

in Allergy and Clinical Immunology.

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At McMaster University, Canada,

his research focus is on using

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the best evidence and patient

partnership to achieve optimal

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outcomes in allergy and eczema care.

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Dr.

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Schneider and Dr.

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Chu, welcome to the podcast.

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Dr. Schneider: thank you

very much for having us.

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audioDerekChu11036064286: Thanks so much.

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Really excited to be here today.

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Lynita: And Corey, I'll kick

it over to you to start us off.

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Korey: I'm super excited to have

you both on the podcasts both as

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leaders on this important guideline

work and as really, I think,

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advocates for patients and families.

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Sometimes, you start talking

about guidelines and people's

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eyes kind of glaze over.

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But they're a really big deal.

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And it's so important that these

guidelines include patients and

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families, which is, , something that

we've been a strong advocate on and

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worked with you on, but why should

people care about these guidelines?

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, I mean, how do they impact

patients and families?

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audioDerekChu11036064286: I I think

It's a crucial and fundamental

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piece of information that bring

everything together, summarize

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everything, and put it at point of care

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guidelines . make sure that evidence

is provided to everyone that's

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critical to making decisions when a

clinician and a patient have to interact

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to make those decisions tailored to

that individual patients scenario.

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Korey: Yeah, so . ultimately, when a

patient, when a caregiver is sitting

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down with a physician, these type

of guidelines should be influencing

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what they hear in that office visit.

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And likewise, like you said, it

can also be used by patients and

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caregivers as a tool to guide their own

decision making or something they can

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bring to the office visit themselves

and say, , let's talk about this.

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So it's huge.

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Why are we updating these guidelines now?

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Dr. Schneider: So

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We last had practice parameters

for atopic dermatitis.

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In 2012.

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So really the last 10 years , there's been

a lot of progress in atopic dermatitis.

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There's been many new therapies.

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And so that was really a big

reason why the joint task force

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wanted to update the guidelines.

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Korey: Yeah, and one thing that I

love about these guidelines is that

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they really look at some of these new

treatments and the evidence for them

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and weigh them in the context of other

treatments, but they also answer some

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old questions that have been kicking

around for a long time, like bleach

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baths that haven't been really looked

at carefully before and really using a

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very systematic evidence based approach.

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Dr. Schneider: yeah, I think,

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we had a very strict process, you

know, starting with both patients

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and clinicians including nurses,

psychologists family medicine, doctor

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pediatrician, and really thinking about

what are the things that are important.

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In looking at treatments for

a topic dermatitis and ranking

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how important they were.

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And going from there, Derek's team

collected all of the evidence.

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And , research all those

topics very thoroughly.

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audioDerekChu11036064286: Yeah.

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And

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how much of a change is actually

important and how does that weigh

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against the burden of using a new tree

or the harms that one might experience,

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Korey: exactly.

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Should we talk a little bit about what's

in the guidelines Lenita and I wanted

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to start off talking about some of

the more surprising recommendations.

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And so, , let's talk 1st about

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immunotherapy because I

don't think a lot of.

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Patients hear about it as

a treatment or adjunctive

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treatment for atopic dermatitis.

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What is the recommendation

and who is it for?

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Dr. Schneider: Immunotherapy

is a process by which you start

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with a very small amount of the

substance, which you're allergic.

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And you gradually increase the amount

over time to desensitize the patient.

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So this is allergy shots.

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And In the last several years.

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There's become available.

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. immunotherapy, where you have a

tablet that's under your tongue

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that can also desensitize.

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It's a very slow process.

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So, you're not going to really see

much of an effect for about a year.

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allergy shots do require a lot of time

and effort on the part of the patients

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and families because you do need

to come weekly for several months.

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advantage to allergy shots is that

you can do multiple allergens at once.

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so, you could have like dust

mites and pollens Whereas with the

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sublingual immunotherapy, , you're

only doing 1 allergen at a time.

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But the sublingual immunotherapy is

easier because you have to come in for

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your 1st dose and then going forward,

you can just take it yourself at home

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Lynita: And are they equally as

effective, versus the subcutaneous?

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audioDerekChu11036064286: Yes, among

the trials, they seemed similarly

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effective in reducing eczema severity

and improving quality of life.

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Lynita: And it takes a year

for a result to be seen.

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You take it for a year and then

you're done for life or keep going?

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Dr. Schneider: So, it's really

like, kind of a 3 to 5 year process.

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So you know, it is a long term process

to really enable the desensitization.

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And, you know, usually once you finish,

patients will have good protection against

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the allergens for a few years after.

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Lynita: ask because, , if you have a

little child and you're hoping that

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they're going to grow out of Eczema.

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You might think in five years it

might be gone, so do I really want to

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embark on something that might not be

a problem for me in two years anyway?

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audioDerekChu11036064286: Yeah, and

that's why we said although it seems

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to be quite effective across every

severity we can find, it may not

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make the most sense to use this on

every case of atopic dermatitis.

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. And some of the conditions to consider

in there are about multi morbidity.

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So if someone has very bad

asthma or very bad, , allergic

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rhinitis, this might tip them over.

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And so , those are some of the

considerations that need to be

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individualized where the clinician will

sign posts to them, this might make

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sense for you, because it could treat

two birds with one stone, . These are the

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implications, let's have a discussion.

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What do you think?

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Does this make sense to you, or do

you want to talk about something else?

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Lynita: kids that travel down the atopic

march my son is one of them , I wish I'd

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tried immunotherapy many years ago for

him and it might be helping with some

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of these other conditions he's now got.

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Korey: I think when we were reading

the recommendation, both Anita and

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I were like, how do we get this?

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audioDerekChu11036064286: it's accessible.

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It's all FDA approved

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Dr. Schneider: Yeah,

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audioDerekChu11036064286: Sublingual

is a little bit more popular in

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Canada compared to the states.

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In Europe.

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It is much more popular

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Dr. Schneider: Grass and

ragweed are approved in the

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United States for 6 and older.

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, and then house dust might is for 12

years and older and the US and Canada.

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And that is a common allergen and children

and adults with atopic dermatitis.

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So I think maybe we can get it back down

to 6 you might see a little more usage.

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audioDerekChu11036064286: And

that approval might be on the way.

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So.

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Korey: Looking at it for dustmites

in kids with 80 makes a ton of

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sense because we know does my.

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Allergy is such a problem.

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The other thing is that when we're

talking about kids with moderate to

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severe eczema, at this point in the U.

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S.

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so many are on dupilumab and

they're already getting injection.

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So the last thing they want is more

injections in a doctor's office.

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So I think looking at a therapy

where they don't have to do that.

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But it might still confer a

benefit is super important.

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audioDerekChu11036064286: Yeah.

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Korey: I want to now move to

maybe the most controversial

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topic which is elimination diet.

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Patients and parents.

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Often use elimination diets because

there is an association between foods

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that their child is eating and eczema.

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But When we talked about the guidelines

on our social media channels,

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it didn't sit well with people.

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audioDerekChu11036064286: Yeah , it's

very prominent for folks to experience

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food reactions when they eat.

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But The critical question that people

are actually asking is if I remove

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it, will the eczema get better?

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And I think distinguishing those two

things is a very important nuance.

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And the effect that they have is there.

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But , that effect was

very, very, very small.

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So can be done, , but then what's

the downside to avoiding these

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foods , especially in young infants.

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We now know

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if one avoids foods for a prolonged period

of time, it's going to increase the risk

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of developing a true food allergy to it.

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, one that could be potentially lifelong,

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and could be life threatening.

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What's that trade off like?

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. So we talked to our caregivers directly.

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What do you guys think?

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And they said, this is not something

that we would want and so we actually

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made a conditional recommendation

against using elimination diets.

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But there was a lot of conditions.

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And, we suggest, if you're really

serious about trying, despite those

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potential harms, we provide a guide,

and then you finally analyze your own

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data, and see, is there a clear pattern

that you actually massively improved?

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Most folks that I personally have used

it on have not found any association.

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And find that it's not worth their time.

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Korey: Yeah, I think that's helpful.

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So, and I did want to reiterate when

you start really restricting diets

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. You run the risk of setting up your

child for serious food allergies.

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So that's what we want to be careful of.

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Lynita: I love that if you really do want

to go down the track of eliminating diet

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you've got a guideline for how to do it.

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, I read the numbers that said

it's probably not going to help.

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But when I'm looking at my

suffering child, even a 1 percent

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chance that it might help is

something that I'm going to try.

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So, thank you for including a, a how

to do it if you're going to do it.

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audioDerekChu11036064286: Thanks.

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The feedback we got from many patients

was often them feeling dismissed and

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we want to make sure we change that

narrative to be that there is clear

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guidance that while the evidence may still

suggest that there's very little effect

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and that there are significant harms

that we communicate that appropriately

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to our patients and if they're still

quite adamant, we still support them.

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Thank you.

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Is there a way to test which food

allergies cause eczema to flare?

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audioDerekChu11036064286: Some

people suspect that they should

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eliminate things based off of a skin

test, like an allergy skin test.

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We found this is not helpful.

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And in fact, we now know allergy skin

testing, especially in patients with

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eczema, has a very high rate of false

positives, like 80 percent plus.

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And so we do not suggest at all to

do any kind of allergy skin testing

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for foods to guide what to eliminate

because can be highly misleading.

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I don't know.

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Linda, what do you think?

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Dr. Schneider: Yeah,

agree with you, Derek.

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should just note that there are some

patients who have immediate allergic

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reactions to the foods . So if you

have hives and vomiting and wheezing

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and you have an allergic reaction,

you definitely want to avoid the food.

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But part of the thing with atopic

dermatitis is that sometimes

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the kids are already flared.

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So it's very hard to sort out if the

food is really causing a problem.

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because you already have.

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Flared eczema.

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In a retrospective paper that

looked at all their patients.

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They only found a couple percent

where they really thought that

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there was true food induced eczema.

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Korey: Right

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Well, moving on I want to talk a

little bit about topical steroids.

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I'm sure you heard a lot from your

patients on this one, but can you talk

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about the recommendation and , for

whom, for how long, et cetera.

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Dr. Schneider: We recommended

getting under control and then

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particularly in patients with

moderate to severe disease, going to

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a maintenance or proactive regimen.

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We did, recommend not using topical

stories for more than 4 weeks at a time.

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And to avoid the high

potency topical steroids.

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For prolonged periods of times, and

in very sensitive areas, like the

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face and the folds and the groin.

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So in general, though, there's been

a lot of use of topical steroids.

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They're really very safe.

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You know, when you use them correctly

for limited periods of time,

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Korey: They never really get

the eczema under control.

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And so it's very common for people to

use it well, beyond that period of time.

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I personally never had my son's eczema

under control using a topical steroid.

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So.

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That's where I think , when we

are prescribing, especially higher

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potency steroids to especially young

children, there needs to be tighter

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clinical management or help from

a nurse practitioner or something.

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Cause it's challenging with more serious

eczema to control it through a topical.

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Dr. Schneider: When you have really

moderate to severe disease, Corey's right

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you need to be seen pretty frequently.

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So, when we see a new patient in our

atopic dermatitis center, we always

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try to bring them back within a month.

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And by having these shorter visits, then

you're, better able to control, like, the

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amount of topical steroid that's used.

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audioDerekChu11036064286: So topical

steroids have benefits and harms.

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They are highly effective, and

when used typically there are

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little to no adverse effects.

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Now this is very different from

what can happen with, patients

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if they use chronic high dose.

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high potency steroids for a long

time You want to try to limit them

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to less than four weeks continuous

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Lynita: How long should you have a break from it ? Because I know in

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that break time, , my son's skin

is just going to go out of control.

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So how long do I make him suffer

before I start after my break.

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Dr. Schneider: you know, , if you

have moderate to severe disease, you

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want to go from, 2 weeks of topical

steroids to a maintenance regimen.

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And that can be like, 3 days a week of a

medium policy topical steward or a topical

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counselor and inhibitor at twice a day.

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So, I think the topical counselor

inhibitors can very helpful

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in and then, over the last

many years, we have had other.

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Non steroidal treatments,

so , you can look to other

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things that are steroid sparing

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then, if you really are.

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failing maintenance as well, then

you need to step up to a biologic.

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, , we're lucky now we have biologics that

are approved down to six months of age.

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Lynita: thank you.

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Korey: I think that you're

left as a parent, like, I don't

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know, is this controlled enough?

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Do I keep going?

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, but I appreciate the recommendation.

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Dr. Schneider: yeah, I agree.

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I mean, always call who's

prescribed the medication for you.

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Call them back.

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Korey: Okay, now we're able to

talk about, , Linda, what you were

281

just referring to, which is that

we have options like biologics,

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like these new Jack inhibitors,

like new topicals and some of your.

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, recommendations were for those

patients who cannot get control

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with the topical uh, a biologic like

Dupilumab, like Trelokinumab, maybe

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something to consider and in those

patients who can't get control with

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a biologic, then you can start to

consider something like a DAC inhibitor.

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Is that basically the summary, would

you say of what you recommended?

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Dr. Schneider: Yes,

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audioDerekChu11036064286: Yeah,

in essence, there are many factors

290

to consider if people want to

go on a Jack inhibitor, there's

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a lot of shared decision making

that does have to take place.

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Before that step, if people refractor

at least two topical treatments despite,

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you know, all the fundamentals of good

skin care and avoiding triggers and,

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and moisturization, , then yes, there

was a strong recommendation for one

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of the biologics like Dupilumab or

Trilokinumab, that has a very strong

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role for efficacy and safety that level.

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And then we can consider these other ones.

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Korey: Yeah, and so wonderful that

we have super treatments now, sorry.

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I know we're at time.

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Just really too quick.

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Questions from parents.

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I think that Lenita wanted

to ask 1 really quickly.

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Lynita: I have one question from

a parent who asks about bathing

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because this is something we can do.

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And the question is about how

frequently should we bath?

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What temperature should it be?

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What about putting other things

in the bath like loyal oatmeal or

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coconut oil, that sort of thing.

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audioDerekChu11036064286: there

was not a very large difference

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between frequent bathing like

daily versus twice a week ish.

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That being said, I don't believe there's

many trials that have assessed that.

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So the certainty of the evidence

might be ultimately low.

313

But I think more important would

be the fundamentals of skin care.

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If you're going to be washing, it's going

to make you vulnerable to drying out.

315

Higher temperatures generally promote.

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Dehydration right after so you might

be cautious about that and same thing

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with additives such as detergents and

so you want to make sure you moisturize,

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moisturize, moisturize soon that you

are able to use your topical treatments.

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And then I believe.

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The H.

321

additive trial, , suggested

little to no difference to most B.

322

A.

323

T.

324

H.

325

additives, , for improving

X Men care overall.

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Korey: Well, great and I think maybe

as we close, I'll just mention that

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one of the other things I thought

really distinguished your guidelines

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is that you talked about the importance

investigating triggers because parents

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and patients really want to know the

why, why, what is causing the eczema?

330

And I really appreciated these guidelines

hearing that and incorporating that

331

into the recommendations about taking

that time to really understand it.

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What could be triggering

the eczema in the 1st place?

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So, with that I wanted to thank you

both for this excellent work and for

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your contributions to really, I think

advancing evidence based practice for

335

inclusion of patients and for hopefully

improving care for people in the future

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through these really excellent guidelines.

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Lynita: it's been a wonderful chat

and I hope that we've answered

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some questions that parents have.

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audioDerekChu11036064286: What's

the pleasure of being here today?

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And again, this wouldn't have

been possible without the support

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of the joint task force without

support directly of the patients.

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In the guideline and so many so many

people to help bring this together.

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And really appreciate all that you do

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Korey: awesome.

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Thank you.

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thank you very much.