JOHN WHYTE: Welcome, everyone.
I'm Dr. John Whyte, the Chief
Medical Officer at WebMD.
Many patients present
with rashes.
It's actually a very common
condition that patients present
to the doctor.
So how do you figure out what it
is?
Is it something serious?
Is it something that can be
treated?
What about atopic dermatitis?
What exactly is it and how does
it present?
So to help answer
these questions, I've asked two
experts.
Dr. Peter Lio.
He is the Clinical Professor
of Dermatology and Pediatrics
at Northwestern University
Feinberg School of Medicine,
and Dr. Emma Guttman.
She's the Waldman professor
and system chair of Dermatology
and Immunology
at the Icahn School of Medicine
at Mount Sinai.
Doctors, thanks for joining me.
PETER LIO: Thank you for having
us.
EMMA GUTTMAN: Thank you
for having me.
JOHN WHYTE: Absolutely.
Let's start off with this issue
of atopic dermatitis.
Sometimes people will refer
to it as eczema, but that's not
exactly accurate.
So Dr. Guttman, how would you
describe the atopic dermatitis
and where does it fit in when
we're also talking about eczema?
EMMA GUTTMAN: Sure.
So the public knows it is
eczema.
And when patients come to me,
I always explain that what they
know is eczema, many times it
is atopic dermatitis.
Because eczema has
multiple flavors.
It can also
be
allergic and atopic dermatitis,
I explain to them,
that it's from inside the body,
rather than being
an outside job, an allergy
to something.
And the disease causes
erythematosus rashes.
I think the hallmark
of these rashes
are that they itch like crazy.
So it will keep you up at night.
Of course, it's a matter
of how much of your body
is involved.
If you have only two patches,
you'll be fine.
But if you have
extensive involvement of eczema,
it really will interfere
with all your functioning.
JOHN WHYTE: Dr. Lio, I wanted
to ask you, what do we know
in terms of the causes
of atopic dermatitis?
There's a belief out there
and some data to support
that there is
a genetic component to it.
But there's also some risk
factors.
So can you describe our latest
understanding of the etiology
of atopic dermatitis?
PETER LIO: Definitely.
And I often lament the fact
that most of the easy diseases,
if you will,
the things that sort of have
a very simple, straightforward
cause, they've already been
figured out.
We kind of know them.
We kind of cross them off.
But atopic dermatitis really has
been pretty elusive.
And it seems like it's
because it's not just one thing.
There are multiple factors
driving into this.
Genetically, if you have a skin
barrier defect, and mind you,
this only describes
a certain group of patients,
so that's something going on.
We also know the immune system
is intimately involved
and its dysregulated.
It's going crazy for reasons
we don't understand completely.
But some of it
seems to be the fact
that once abnormal allergens
and irritants and pathogens
get through that impaired skin
barrier, the immune system is
actually not acting so crazy.
It's like, oh, the reason it's
acting so wild is because it's
being exposed to things that
is not supposed to be.
We add on top
of that disorganization
of the microbiome.
So the microbiota,
the healthy bacteria,
viruses and fungi on the skin,
they actually become disordered
as well.
And we also know that there is
the itch component, and even
a behavioral component.
All these pieces are playing
a role.
And the deeper question though,
why?
What's driving it?
We don't fully understand.
Some people blame hygiene.
Modern hygiene, that we're
so clean,
has changed the ability
of the immune system
to develop, perhaps,
in a normal way.
We know that pollutants play
a role.
JOHN WHYTE: Is there a greater
risk in women, a greater risk
in people of color?
What do we know
about the epidemiology?
PETER LIO: The epidemiology
is fascinating.
One thing that we feel pretty
confident is that it seems
like it's more
common in developed countries,
rather than countries that are
developing or more rural areas.
In fact, growing up on a farm
seems to be somewhat protective.
Growing up with a dog
seems to be somewhat protective.
I do think there is a signature
in the literature
that in skin of color,
particularly Black patients,
there's a higher incidence
of atopic dermatitis,
and it may be worse
in certain groups as well.
EMMA GUTTMAN: We also see that
in African-Americans
have much more thick lesions,
that are much more
difficult to reverse
with treatment.
They may need higher doses,
longer treatment,
to get to the same effect.
And we've seen that
with several treatments.
And we also saw that when you
look under the microscope,
the phenotype
of African-Americans
is different than the phenotype
of European-Americans.
JOHN WHYTE: But Dr. Lio, it's
a clinical diagnosis, correct,
in terms of there's
no lab test that diagnosis it.
We don't biopsy the plaques
or lesions.
Is that correct?
PETER LIO: That's right.
Sometimes patients are kind of
disappointed.
They really want a test.
They want a sheet of paper that
explains exactly what they have.
But really, it's still
a clinical diagnosis,
and there's only three things
we need to make that diagnosis,
for better or for worse.
It has to be itchy,
and we've already said that
a few times.
It has to be eczematous
morphology.
And we can talk certainly, more
about that.
It's a little bit nuanced
because there's
a huge heterogeneous
presentation of the morphologies
across individuals
and different groups,
but also in the same individual
over time.
There's sort
of an infantile pattern,
there's a childhood pattern,
then there's
an adolescent and adult pattern.
So it's a little bit more
nuanced, but they have to have
that sort of basic morphology.
And then it has to be
either chronic or relapsing.
JOHN WHYTE: Dr. Guttman, what
is the current treatment
algorithm for patients who
present with atopic dermatitis?
Patient comes in to see you,
they're seeing
the dermatologist, as you
suggest.
What's that algorithm you use
to determine treatment?
EMMA GUTTMAN: So the moment
the patient comes to see me,
I really look
at the entire body.
I believe that the first time
when we see a patient,
you really need to undress
the patient to understand how
much of the body is involved.
Then I'll usually give
a topical treatment.
I may bring them back
after, let's say, a month to two
months,
to see if the topical treatment
worked.
If it did not work,
I may go
to phototherapy, light
treatment.
And there are now
other medications, that target
specifically,
some immune molecules,
such as monoclonal antibodies,
that we can offer patients.
We have oral medications that
are in clinical trials.
We also have
some oral medications that are
approved for other indications.
So the idea in eczema,
you want to go specific,
because then you do not have
the side effects.
If you go
with immunosuppressants,
then there is a baggage
and we are trying to avoid
that baggage.
JOHN WHYTE: And Dr. Lio, what's
the strategy that you use?
PETER LIO: Usually we're going
to start out
with topical corticosteroids
for a reactive approach.
So a patient, let's just imagine
a mild patient,
they have a few areas that are
involved.
They flare up every now
and then.
It's very
reasonable in the first line
in almost all guidelines
universally,
for a reactive approach.
Go ahead and put a little bit
of a mild to moderate strength,
a mid potency
topical corticosteroid on there,
twice a day for a little bit,
ideally less than a couple
of weeks.
Cool things down and then take
a break.
The next level up, though,
is one of two things has
happened.
Either they come back and say,
doc, the prescription you gave
me, it didn't clear me.
Like it didn't even help enough.
Like maybe it helped a little,
but I'm still pretty miserable.
So failure to clear.
Number two, much more commonly,
is they say, I used it and I got
better.
I used that and it got better.
But then you said don't use it
all the time.
But as soon as I stopped,
it flared right back up.
So now you have this inability
to keep them
clear in a safe manner.
So now we have to step up
to the next round.
Here we start to bring
in our non-steroidal medicine.
So we have our calcineurin
inhibitors, tacrolimus,
and pimecrolimus, and then we
have crisaborole,
a phosphodiesterase 4 inhibitor.
Those then can sometimes
be brought in to sort of be
steroid alternative.
Should that fail, then we can
kind of go up
to the next levels, where Dr.
Guttman talked about using
things like wet wrap therapy,
phototherapy, or one
of the systemic agents.
JOHN WHYTE: Dr. Guttman, I want
to ask you, can we ever
say atopic dermatitis can be
cured?
EMMA GUTTMAN: That's
an excellent question.
So I have to say, right now
we have treatments,
either approved
or in development, that
primarily are,
they want to treat the patients
in a safe manner,
but they need to be given all
the time, chronically.
But the good news, there is
a lot of work being done now
by my lab, by other people,
and by pharma,
to develop these new treatments
that potentially you will need
to give them much
less frequently,
let's say every eight weeks,
every 12 weeks,
similar to some psoriasis
medications that we see.
And even there is a thinking,
but it's far away,
but I'm sure that we'll see it
in our lifetime, of treatments
that potentially switch it.
Meaning that at some point,
you will stop taking it,
and then you'll not have
the disease back.
JOHN WHYTE: What are
the long term complications
of atopic dermatitis?
People might be thinking,
you know what, it's just a rash.
I'll put a lot of cream on it.
But is there a concern
that, if left untreated,
it can cause other issues?
EMMA GUTTMAN: Absolutely.
So first of all,
atopic dermatitis,
as we discussed, it involves
systemic inflammation,
particularly when you have
multiple parts of the body
involved.
And now there are more and more
publications showing
that systemic inflammation
over time can cause potentially
cardiovascular disease later
on in life.
And we are talking
about young people
because atopic dermatitis,
remember, you start as a baby
many times.
So if you have inflammation
for 30 years, sometimes you have
that inflammation in the body,
that left untreated,
we did a study in which we found
that patients
with atopic dermatitis,
they did not know that they have
heart disease.
But they did have inflammation
in the aorta, the carotids.
So it's very important to treat
that systemic inflammation,
particularly when it's severe,
with systemic treatment.
JOHN WHYTE: Dr. Lio, I wanted
to go back to this issue
of flare ups,
and how we can help patients
prevent flare ups.
PETER LIO: Yes, and that's one
of the interesting puzzles we
have to solve,
with every patient we see.
Because there often are
some very individualized
triggers for them.
So we got to kind of explore
a bit.
For example, wool fabric,
and any kind of itchy,
kind of starchy fabrics,
those can be unpleasant.
Temperature extremes, for sure.
So getting really,
really hot and sweaty,
but also getting freezing
cold and super dry skin
in the winter.
So many of my patients
have flare ups at each extreme,
they'll see that.
Poor sleep actually seems
to have some very
direct and measurable changes,
both on the immune system,
and on the skin barrier.
So really it can fuel this fire.
People are using heavily
fragrance products, things you
can be allergic to.
So we really try to get a very
bland set of cleansers
and moisturizers
that go on the skin.
We try to recommend cotton
clothes.
But then people get into food.
And food is one
of those big topics we could
spend a long time talking about.
But my advice to my patients
for food
is, I try to let that be
the last thing we tackle.
JOHN WHYTE: And we may need more
data on the issue
of the relationship
a food and atopic dermatitis
flares.
Would that be accurate?
PETER LIO: Absolutely.
We're at the tip of the iceberg.
One of the most exciting things
we found in this couple of years
is the fact that we probably
have a lot of this backwards.
For years, people have said, OK,
well, maybe there's some food
and diet that's driving this.
But now we're beginning
to understand that the reason
people are getting
allergic to foods, at least
for some foods, like peanut,
we think is it's
because the skin barrier is not
doing its job.
And things like peanut protein
and other food allergens
can get into the skin
and inside the skin,
epicutaneously,
or inside the body,
transcutaneously.
EMMA GUTTMAN: Yeah, no, that's
very important.
Because I think early on
in babies and infants,
you really can prevent
the other manifestations
that Peter so nicely elaborated
on.
So you treat the eczema early.
Eczema is kind of the window
to the entire atopic march.
And if you treat it early,
you may prevent asthma, hay
fever, and other manifestations.
So it's actually very important
that parents are aware of that
and treat it early
because otherwise, I so much
agree with this.
You can force this entire fire.
JOHN WHYTE: Well, Dr. Lio,
Dr. Guttman, I want to thank you
for taking the time today
to talk about how we diagnose
and treat atopic dermatitis.
And for those persons that may
be experiencing
a red, itchy rash,
you need to be seen.
You need to go into your doctor,
you need to see a dermatologist.
Because as you both point out,
this
is an inflammatory condition,
for which early diagnosis
and treatment is going to result
in a better outcome.
Thank you both doctors.
EMMA GUTTMAN: Thank you.
PETER LIO: Thank you.
JOHN WHYTE: And thank you
for watching.