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.
2
:I'm here with Corey Kapoza, founder
of GPAR, and today we are discussing
3
:the new American Academy of Allergy,
Asthma, and Immunology Guidelines
4
:for Optimal Management of Eczema.
5
:These evidence based guidelines
were written in consultation
6
:with patients and caregivers
7
:.
Joining us are the co authors of the guidelines.
8
:Dr.
9
:Linda Schneider is the Director of
the Atopic Dermatitis Center, as
10
:well as a Professor of Pediatrics
at Harvard Medical School.
11
:And Dr.
12
:Derek Chu is Assistant Professor
in Allergy and Clinical Immunology.
13
:At McMaster University, Canada,
his research focus is on using
14
:the best evidence and patient
partnership to achieve optimal
15
:outcomes in allergy and eczema care.
16
:Dr.
17
:Schneider and Dr.
18
:Chu, welcome to the podcast.
19
:Dr. Schneider: thank you
very much for having us.
20
:audioDerekChu11036064286: Thanks so much.
21
:Really excited to be here today.
22
:Lynita: And Corey, I'll kick
it over to you to start us off.
23
:Korey: I'm super excited to have
you both on the podcasts both as
24
:leaders on this important guideline
work and as really, I think,
25
:advocates for patients and families.
26
:Sometimes, you start talking
about guidelines and people's
27
:eyes kind of glaze over.
28
:But they're a really big deal.
29
:And it's so important that these
guidelines include patients and
30
:families, which is, , something that
we've been a strong advocate on and
31
:worked with you on, but why should
people care about these guidelines?
32
:, I mean, how do they impact
patients and families?
33
:audioDerekChu11036064286: I I think
It's a crucial and fundamental
34
:piece of information that bring
everything together, summarize
35
:everything, and put it at point of care
36
:guidelines . make sure that evidence
is provided to everyone that's
37
:critical to making decisions when a
clinician and a patient have to interact
38
:to make those decisions tailored to
that individual patients scenario.
39
:Korey: Yeah, so . ultimately, when a
patient, when a caregiver is sitting
40
:down with a physician, these type
of guidelines should be influencing
41
:what they hear in that office visit.
42
:And likewise, like you said, it
can also be used by patients and
43
:caregivers as a tool to guide their own
decision making or something they can
44
:bring to the office visit themselves
and say, , let's talk about this.
45
:So it's huge.
46
:Why are we updating these guidelines now?
47
:Dr. Schneider: So
48
:We last had practice parameters
for atopic dermatitis.
49
:In 2012.
50
:So really the last 10 years , there's been
a lot of progress in atopic dermatitis.
51
:There's been many new therapies.
52
:And so that was really a big
reason why the joint task force
53
:wanted to update the guidelines.
54
:Korey: Yeah, and one thing that I
love about these guidelines is that
55
:they really look at some of these new
treatments and the evidence for them
56
:and weigh them in the context of other
treatments, but they also answer some
57
:old questions that have been kicking
around for a long time, like bleach
58
:baths that haven't been really looked
at carefully before and really using a
59
:very systematic evidence based approach.
60
:Dr. Schneider: yeah, I think,
61
:we had a very strict process, you
know, starting with both patients
62
:and clinicians including nurses,
psychologists family medicine, doctor
63
:pediatrician, and really thinking about
what are the things that are important.
64
:In looking at treatments for
a topic dermatitis and ranking
65
:how important they were.
66
:And going from there, Derek's team
collected all of the evidence.
67
:And , research all those
topics very thoroughly.
68
:audioDerekChu11036064286: Yeah.
69
:And
70
:how much of a change is actually
important and how does that weigh
71
:against the burden of using a new tree
or the harms that one might experience,
72
:Korey: exactly.
73
:Should we talk a little bit about what's
in the guidelines Lenita and I wanted
74
:to start off talking about some of
the more surprising recommendations.
75
:And so, , let's talk 1st about
76
:immunotherapy because I
don't think a lot of.
77
:Patients hear about it as
a treatment or adjunctive
78
:treatment for atopic dermatitis.
79
:What is the recommendation
and who is it for?
80
:Dr. Schneider: Immunotherapy
is a process by which you start
81
:with a very small amount of the
substance, which you're allergic.
82
:And you gradually increase the amount
over time to desensitize the patient.
83
:So this is allergy shots.
84
:And In the last several years.
85
:There's become available.
86
:. immunotherapy, where you have a
tablet that's under your tongue
87
:that can also desensitize.
88
:It's a very slow process.
89
:So, you're not going to really see
much of an effect for about a year.
90
:allergy shots do require a lot of time
and effort on the part of the patients
91
:and families because you do need
to come weekly for several months.
92
:advantage to allergy shots is that
you can do multiple allergens at once.
93
:so, you could have like dust
mites and pollens Whereas with the
94
:sublingual immunotherapy, , you're
only doing 1 allergen at a time.
95
:But the sublingual immunotherapy is
easier because you have to come in for
96
:your 1st dose and then going forward,
you can just take it yourself at home
97
:Lynita: And are they equally as
effective, versus the subcutaneous?
98
:audioDerekChu11036064286: Yes, among
the trials, they seemed similarly
99
:effective in reducing eczema severity
and improving quality of life.
100
:Lynita: And it takes a year
for a result to be seen.
101
:You take it for a year and then
you're done for life or keep going?
102
:Dr. Schneider: So, it's really
like, kind of a 3 to 5 year process.
103
:So you know, it is a long term process
to really enable the desensitization.
104
:And, you know, usually once you finish,
patients will have good protection against
105
:the allergens for a few years after.
106
:Lynita: ask because, , if you have a
little child and you're hoping that
107
:they're going to grow out of Eczema.
108
:You might think in five years it
might be gone, so do I really want to
109
:embark on something that might not be
a problem for me in two years anyway?
110
:audioDerekChu11036064286: Yeah, and
that's why we said although it seems
111
:to be quite effective across every
severity we can find, it may not
112
:make the most sense to use this on
every case of atopic dermatitis.
113
:. And some of the conditions to consider
in there are about multi morbidity.
114
:So if someone has very bad
asthma or very bad, , allergic
115
:rhinitis, this might tip them over.
116
:And so , those are some of the
considerations that need to be
117
:individualized where the clinician will
sign posts to them, this might make
118
:sense for you, because it could treat
two birds with one stone, . These are the
119
:implications, let's have a discussion.
120
:What do you think?
121
:Does this make sense to you, or do
you want to talk about something else?
122
:Lynita: kids that travel down the atopic
march my son is one of them , I wish I'd
123
:tried immunotherapy many years ago for
him and it might be helping with some
124
:of these other conditions he's now got.
125
:Korey: I think when we were reading
the recommendation, both Anita and
126
:I were like, how do we get this?
127
:audioDerekChu11036064286: it's accessible.
128
:It's all FDA approved
129
:Dr. Schneider: Yeah,
130
:audioDerekChu11036064286: Sublingual
is a little bit more popular in
131
:Canada compared to the states.
132
:In Europe.
133
:It is much more popular
134
:Dr. Schneider: Grass and
ragweed are approved in the
135
:United States for 6 and older.
136
:, and then house dust might is for 12
years and older and the US and Canada.
137
:And that is a common allergen and children
and adults with atopic dermatitis.
138
:So I think maybe we can get it back down
to 6 you might see a little more usage.
139
:audioDerekChu11036064286: And
that approval might be on the way.
140
:So.
141
:Korey: Looking at it for dustmites
in kids with 80 makes a ton of
142
:sense because we know does my.
143
:Allergy is such a problem.
144
:The other thing is that when we're
talking about kids with moderate to
145
:severe eczema, at this point in the U.
146
:S.
147
:so many are on dupilumab and
they're already getting injection.
148
:So the last thing they want is more
injections in a doctor's office.
149
:So I think looking at a therapy
where they don't have to do that.
150
:But it might still confer a
benefit is super important.
151
:audioDerekChu11036064286: Yeah.
152
:Korey: I want to now move to
maybe the most controversial
153
:topic which is elimination diet.
154
:Patients and parents.
155
:Often use elimination diets because
there is an association between foods
156
:that their child is eating and eczema.
157
:But When we talked about the guidelines
on our social media channels,
158
:it didn't sit well with people.
159
:audioDerekChu11036064286: Yeah , it's
very prominent for folks to experience
160
:food reactions when they eat.
161
:But The critical question that people
are actually asking is if I remove
162
:it, will the eczema get better?
163
:And I think distinguishing those two
things is a very important nuance.
164
:And the effect that they have is there.
165
:But , that effect was
very, very, very small.
166
:So can be done, , but then what's
the downside to avoiding these
167
:foods , especially in young infants.
168
:We now know
169
:if one avoids foods for a prolonged period
of time, it's going to increase the risk
170
:of developing a true food allergy to it.
171
:, one that could be potentially lifelong,
172
:and could be life threatening.
173
:What's that trade off like?
174
:. So we talked to our caregivers directly.
175
:What do you guys think?
176
:And they said, this is not something
that we would want and so we actually
177
:made a conditional recommendation
against using elimination diets.
178
:But there was a lot of conditions.
179
:And, we suggest, if you're really
serious about trying, despite those
180
:potential harms, we provide a guide,
and then you finally analyze your own
181
:data, and see, is there a clear pattern
that you actually massively improved?
182
:Most folks that I personally have used
it on have not found any association.
183
:And find that it's not worth their time.
184
:Korey: Yeah, I think that's helpful.
185
:So, and I did want to reiterate when
you start really restricting diets
186
:. You run the risk of setting up your
child for serious food allergies.
187
:So that's what we want to be careful of.
188
:Lynita: I love that if you really do want
to go down the track of eliminating diet
189
:you've got a guideline for how to do it.
190
:, I read the numbers that said
it's probably not going to help.
191
:But when I'm looking at my
suffering child, even a 1 percent
192
:chance that it might help is
something that I'm going to try.
193
:So, thank you for including a, a how
to do it if you're going to do it.
194
:audioDerekChu11036064286: Thanks.
195
:The feedback we got from many patients
was often them feeling dismissed and
196
:we want to make sure we change that
narrative to be that there is clear
197
:guidance that while the evidence may still
suggest that there's very little effect
198
:and that there are significant harms
that we communicate that appropriately
199
:to our patients and if they're still
quite adamant, we still support them.
200
:Thank you.
201
:Is there a way to test which food
allergies cause eczema to flare?
202
:audioDerekChu11036064286: Some
people suspect that they should
203
:eliminate things based off of a skin
test, like an allergy skin test.
204
:We found this is not helpful.
205
:And in fact, we now know allergy skin
testing, especially in patients with
206
:eczema, has a very high rate of false
positives, like 80 percent plus.
207
:And so we do not suggest at all to
do any kind of allergy skin testing
208
:for foods to guide what to eliminate
because can be highly misleading.
209
:I don't know.
210
:Linda, what do you think?
211
:Dr. Schneider: Yeah,
agree with you, Derek.
212
:should just note that there are some
patients who have immediate allergic
213
:reactions to the foods . So if you
have hives and vomiting and wheezing
214
:and you have an allergic reaction,
you definitely want to avoid the food.
215
:But part of the thing with atopic
dermatitis is that sometimes
216
:the kids are already flared.
217
:So it's very hard to sort out if the
food is really causing a problem.
218
:because you already have.
219
:Flared eczema.
220
:In a retrospective paper that
looked at all their patients.
221
:They only found a couple percent
where they really thought that
222
:there was true food induced eczema.
223
:Korey: Right
224
:Well, moving on I want to talk a
little bit about topical steroids.
225
:I'm sure you heard a lot from your
patients on this one, but can you talk
226
:about the recommendation and , for
whom, for how long, et cetera.
227
:Dr. Schneider: We recommended
getting under control and then
228
:particularly in patients with
moderate to severe disease, going to
229
:a maintenance or proactive regimen.
230
:We did, recommend not using topical
stories for more than 4 weeks at a time.
231
:And to avoid the high
potency topical steroids.
232
:For prolonged periods of times, and
in very sensitive areas, like the
233
:face and the folds and the groin.
234
:So in general, though, there's been
a lot of use of topical steroids.
235
:They're really very safe.
236
:You know, when you use them correctly
for limited periods of time,
237
:Korey: They never really get
the eczema under control.
238
:And so it's very common for people to
use it well, beyond that period of time.
239
:I personally never had my son's eczema
under control using a topical steroid.
240
:So.
241
:That's where I think , when we
are prescribing, especially higher
242
:potency steroids to especially young
children, there needs to be tighter
243
:clinical management or help from
a nurse practitioner or something.
244
:Cause it's challenging with more serious
eczema to control it through a topical.
245
:Dr. Schneider: When you have really
moderate to severe disease, Corey's right
246
:you need to be seen pretty frequently.
247
:So, when we see a new patient in our
atopic dermatitis center, we always
248
:try to bring them back within a month.
249
:And by having these shorter visits, then
you're, better able to control, like, the
250
:amount of topical steroid that's used.
251
:audioDerekChu11036064286: So topical
steroids have benefits and harms.
252
:They are highly effective, and
when used typically there are
253
:little to no adverse effects.
254
:Now this is very different from
what can happen with, patients
255
:if they use chronic high dose.
256
:high potency steroids for a long
time You want to try to limit them
257
:to less than four weeks continuous
258
:.
Lynita: How long should you have a break from it ? Because I know in
259
:that break time, , my son's skin
is just going to go out of control.
260
:So how long do I make him suffer
before I start after my break.
261
:Dr. Schneider: you know, , if you
have moderate to severe disease, you
262
:want to go from, 2 weeks of topical
steroids to a maintenance regimen.
263
:And that can be like, 3 days a week of a
medium policy topical steward or a topical
264
:counselor and inhibitor at twice a day.
265
:So, I think the topical counselor
inhibitors can very helpful
266
:in and then, over the last
many years, we have had other.
267
:Non steroidal treatments,
so , you can look to other
268
:things that are steroid sparing
269
:then, if you really are.
270
:failing maintenance as well, then
you need to step up to a biologic.
271
:, , we're lucky now we have biologics that
are approved down to six months of age.
272
:Lynita: thank you.
273
:Korey: I think that you're
left as a parent, like, I don't
274
:know, is this controlled enough?
275
:Do I keep going?
276
:, but I appreciate the recommendation.
277
:Dr. Schneider: yeah, I agree.
278
:I mean, always call who's
prescribed the medication for you.
279
:Call them back.
280
: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,
282
:like these new Jack inhibitors,
like new topicals and some of your.
283
:, recommendations were for those
patients who cannot get control
284
:with the topical uh, a biologic like
Dupilumab, like Trelokinumab, maybe
285
:something to consider and in those
patients who can't get control with
286
:a biologic, then you can start to
consider something like a DAC inhibitor.
287
:Is that basically the summary, would
you say of what you recommended?
288
:Dr. Schneider: Yes,
289
:audioDerekChu11036064286: Yeah,
in essence, there are many factors
290
:to consider if people want to
go on a Jack inhibitor, there's
291
:a lot of shared decision making
that does have to take place.
292
:Before that step, if people refractor
at least two topical treatments despite,
293
:you know, all the fundamentals of good
skin care and avoiding triggers and,
294
:and moisturization, , then yes, there
was a strong recommendation for one
295
:of the biologics like Dupilumab or
Trilokinumab, that has a very strong
296
:role for efficacy and safety that level.
297
:And then we can consider these other ones.
298
:Korey: Yeah, and so wonderful that
we have super treatments now, sorry.
299
:I know we're at time.
300
:Just really too quick.
301
:Questions from parents.
302
:I think that Lenita wanted
to ask 1 really quickly.
303
:Lynita: I have one question from
a parent who asks about bathing
304
:because this is something we can do.
305
:And the question is about how
frequently should we bath?
306
:What temperature should it be?
307
:What about putting other things
in the bath like loyal oatmeal or
308
:coconut oil, that sort of thing.
309
:audioDerekChu11036064286: there
was not a very large difference
310
:between frequent bathing like
daily versus twice a week ish.
311
:That being said, I don't believe there's
many trials that have assessed that.
312
:So the certainty of the evidence
might be ultimately low.
313
:But I think more important would
be the fundamentals of skin care.
314
:If you're going to be washing, it's going
to make you vulnerable to drying out.
315
:Higher temperatures generally promote.
316
:Dehydration right after so you might
be cautious about that and same thing
317
:with additives such as detergents and
so you want to make sure you moisturize,
318
:moisturize, moisturize soon that you
are able to use your topical treatments.
319
:And then I believe.
320
: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.
326
:Korey: Well, great and I think maybe
as we close, I'll just mention that
327
:one of the other things I thought
really distinguished your guidelines
328
:is that you talked about the importance
investigating triggers because parents
329
: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.
332
:What could be triggering
the eczema in the 1st place?
333
:So, with that I wanted to thank you
both for this excellent work and for
334
: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
336
:through these really excellent guidelines.
337
:Lynita: it's been a wonderful chat
and I hope that we've answered
338
:some questions that parents have.
339
:audioDerekChu11036064286: What's
the pleasure of being here today?
340
:And again, this wouldn't have
been possible without the support
341
:of the joint task force without
support directly of the patients.
342
:In the guideline and so many so many
people to help bring this together.
343
:And really appreciate all that you do
344
:Korey: awesome.
345
:Thank you.
346
:thank you very much.