Loading summary
Transcript125 lines
- [00:01]
A
Welcome to season two of Derms on Drugs, a video podcast brought to you by Scholars in Medicine. The best educational platform in dermatology and provided a no cost to medical providers. Derms on Drugs is we're cutting edge germ meets. Yeah, hit or miss comedy. I'm Matt Zyrus from Doc's Dermatology and each week I'm joined by my residency buddies, Dr. Laura Faris from the University of North Carolina, Dr. Tim Patton from the University of Pittsburgh. And we use our 60 years of combined derm experience to discuss, debate and dissect the hottest topics in dermatology. It is everything you need to know to be on the cutting edge of derp and you'll actually have some fun listening. New episodes drop every Friday on Scholars in Medicine, Apple Podcasts, Spotify and other major podcast platforms. And a reminder that the video, the podcast does have a video component that has the key figures and tables from the articles we talk about. And today's episode is supported by Lilly, a medicine company. This week we have a guest that we are so excited about. We've got Dr. Peter Leo from Medical Dermatology Associates of Chicago joining us this week. Dr. Leo, how you doing?
- [01:03]
B
I'm doing great. Thank you so much for having me. I am a longtime listener and first time caller and it is really a thrill to be here.
- [01:10]
A
You know what, that phrase, I bet to 2/3 of our listeners, they don't know, they probably never listened to AM talk radio, right?
- [01:19]
B
It's true.
- [01:20]
A
Long time listener, first time caller. Right on.
- [01:23]
C
People in their 50s love us. That's why I get the references.
- [01:27]
A
Exactly. Well, let's, let's go ahead and get started. So let's see here. Why don't we start with Dr. Ferris? Dr. Ferris, what do you got?
- [01:36]
C
All right, so I have a paper that is the skin, immune, neurogastro, endocrine or singe system lighting the fire on Atopic Dermatitis research. This is by Paz and Dr. Leo and this was published in Dermatology Practical and Conceptual, I think is the name of the journal. And so, so I thought this would be great to be able. I love having a paper and then being able to talk about it with the author. So this is really thinking about atopic dermatitis, you know, not just as a skin disease but as sort of a multi, multi organ system disease. So singe, skin, immune, neurogastro, endocrine. And so, you know, I think we've thought about atopic dermatitis as being skin and immune system, but this really brings in sort of the neurogastro and endocrine as aspect of it. So I thought it was an interesting paper. So let's start with. We'll go through it alphabetically. S skin. So we know, you know, we've, we've all learned the FLAG mutation is important in atopic derm. Tight junctions are important. So what they really emphasize is yes, the epithelial barrier matters but they also talk about like the role of impaired keratinocytes. So the keratinocytes being important in sort of being cells that are involved in the pathogenesis of AD and the itch scratch and barrier dysfunction and sort of how that interacts with the rest of the immune system. So emphasizing yes, emollients barrier protection. All of that is like, is really, you should think of it as upstream disease modification.
- [03:24]
A
That's below. So it's. We'll talk about it more. I'll let you get.
- [03:28]
C
We'll talk about it more. I immune access axis. So we know that there's you know, Th2 cytokines, Il4,5,13,31. We know we've got biologics that target those. But that in chronic disease you also get th1 and th2 responses and that there's a skin associated lymphoid tissue that is sort of driving the whole process and that that involves also the keratinocytes and longer Hans cells sort of beyond mast cells, eosinophils, beyond just the T cells. So you know, that's why we know that, you know, we know the immune system is involved. We know that this is why most of the drugs that we have that work for this actually target different arms of the im. Um, and you know, they also point out that, you know, not every drug works well for every patient or equally well for every patient. So you know, we ought to think about more precision precision medicine. Like you know, there's probably different endotypes within AD and you know, we can maybe try to find biomarkers of response to particular drug types. We can talk a little bit about what's maybe out there are coming N is neuro. So you know, the itch is what drives the disease. It's an important concept. But then they also mentioned that, you know, we need to think about neuropeptides, substance P cgrp. So mentioning that you know, these are involved in driving the immune response but they're also potential future targets. So pointing out things like substance P is overexpressed in AD drives things like mast cell degranulation fuels the itch. So you Know, we could think about, you know, novel sort of novel therapies that might be ba based on this. G. So this is gastro or gut. So this is I think the thing that is really different. So I think, you know, I used to kind of think, oh, patients always are like, is this related to my leaky gut? And I kind of thought that was a bunch of bs but the point here is that, you know, there is actually a connection to. To the gut and the skin. And I like one of my favorite papers of last year was this story that showed that a paper that showed in mice, if you have cutaneous damage and then you get sensitized to it or you get exposed to an antigen through the gut, you actually will be more likely to make an alert to develop an allergy to that. So there really is this like skin gut access. So, you know, there's the microbiome and they talk about, you know, specifically Bifidobacterium and Lactobacillus are sort of good and protective for the skin versus C. Diff and E. Coli are worse and can make disease worse. So probably related to short chain fatty acids like butyrate, acetate and propionate that modulate T cell function. So, you know, what does that mean? You know, focusing on things like, you know, asking about GI symptoms or thinking about diet. Diets that maybe we can talk with Dr. Leo about what are the diets that you would recommend, but things that sort of promote a healthy microbiome. We've also in this podcast talked about pre. About WhatsApp.
- [06:45]
A
Eat whatever you want.
- [06:47]
D
Eat whatever you want.
- [06:48]
C
You. You actually presented a paper on using one of the. What the probiotics. Probiotics that's associated with. With improved disease.
- [07:02]
A
So that's right to eat whatever you want. All the junk food, processed foods, all of it. Just take a probiotic and you'll be fine.
- [07:09]
C
Okay, well, we'll see.
- [07:11]
B
We'll see.
- [07:13]
C
And then E is endocrine. So stress activates the central HPA axis. So cr, acth, cortisol. The skin actually has its own local HPA like system. And that cortisol can signaling which you would think, all right, steroids make atopic dermatitis better. That should be protective. But that it's actually those are that topical steroids and probably even like endogenous steroids are contributing to barrier dysfunction. So we ought to A rethink the topical steroid model. But B also think about how, you know, endogenous steroid production through stress might be making this worse. So you know, so where does it leave us? That kind of gives us a more integrative approach to think about the skin barrier, the. The immune system, the neuro access, the gut skin access, and then stress. So I thought it was a nice summary. I would encourage people, we can put this there, the link that there's, you know, a couple nice figures that sort of show how these all interact with each other.
- [08:15]
A
So Ferris, all right, that, the Leo guy, he likes to publish all this weird Stu. No clinical relevance at all. So was Ferris, was there any waste, Is there any clinical takeaway from this of like, oh, so we should do this, right?
- [08:32]
C
Yeah, I mean, and that's what I want to ask. And maybe since he's on, we'll just ask him. Like, for Dr. Leo, I thought this was really, you know, I thought it was an interesting way to put it all into a framework. I guess, to Matt's point, I think what. What do you practically tell people to do? So do you give people. So think it. Starting with, like, the gut, do you recommend a certain diet and do you recommend certain probiotics?
- [09:00]
B
No, thank you. And that was beautifully, beautifully presented. I think on one hand, if you step back, you could look at this and be like, well, duh. This is just saying that, like, eczema is not just skin deep. Like, yes, it affects every organ. The body is connected. Like, it sort of seems ridiculous and, and maybe overly reductive. But on the other hand, I think it is kind of magical to start, you know, with a deep dive on the skin and really look at that separately, but then say, wait a minute, you're right, this is very much connected. I always show my patients, I'm like, when you think about it, it's skin, skin, skin, skin. And as you round the corner of your lips, it's gut. You go to your own gut, epithelium, right, that's your gut. They're part of the same tube inside and outside, and we think about how deeply connected they are. And I love that you alluded to that leaky gut thing, because I started in the same place. I thought it was sort of a metaphor or some way of thinking about it, but it turns out there, like, legitimately is a way to measure gut leakiness. Like it's a thing and it correlates with AD severity. So I love just looking at all these different connections. Now, the hard part is, what does it mean for us as clinicians? Can we act on this? And the truth is, I don't think we can act easily on all of these Factors, at least equilaterally. Right. And that's why I say also to my patients. I say, yes, your gut is part of the story, but I can't reach your gut. Like, what I can reach is your antecubital fossa where you're scratching right now. I can put something there. We can change that environment. We can fix behavioral pieces, too. We can use things like everything from habit reversal therapy, this kind of quantity, quirky thing where you give a replacement behavior to stop that sort of itch scratch cycle, to acupuncture to help with some of the nerve aspects. So we have these little pieces of the puzzle we can do. And I think when you. When you explain it this way, it's sort of. I think it puts the patients at rest. It's like, okay, this clinician is really thinking about me broadly. They're not just talking about the skin, but they're also being practical in that you can't necessarily do much with the endocrine part of this at this point in time. And that's maybe going to be something that's downstream.
- [10:46]
A
So Patton's habit reversal therapy is. Is drinking beer. So that's the. Every time he wants to scratch, he just drinks. But the. The thing that I think is my.
- [10:57]
D
Liver is starting to fail, and I'm much more itchy. So this is really not working as I plan.
- [11:03]
A
So one of the things that I find super clinically relevant here is the. The idea that the gut is playing a major role in the disease, and where that changes it is. Right. What's one of the questions that y'?
- [11:19]
B
All.
- [11:19]
A
We all hate, right? So what food should I avo? Three months ago, I ate a tomato, and I flared. So I've been avoiding red, and I was good. But then I ate, you know, a banana, and I was okay. But then when I ate a tomato and a banana together, I didn't flare. So I think maybe orange foods are the prop. Like, and you're just like, shut up. Go see an allergist. Right?
- [11:39]
D
Which.
- [11:40]
A
But right. Historically, what we told people is you're not allergic to any foods. Food allergy is not driving your ad. And I think that if that's where we stop, the patient then leaves our office, calls their mom, says, mom, that dermatologist. Doctors never listened to you. They didn't think that tomatoes were playing a role. They don't know what they're talking about. Remember whenever I ate that tomato, I'm going to go see a naturopath, and I'm not going to use that Medication, they told me I want to. But now we can really say, you know what? Absolutely. Your gut is playing a huge role in this. And the things that you eat absolutely are playing a big role in your eczema. But we don't know. It's. It's not an allergy. It's more the overall, you know, what are all those healthy bacteria in your intestines doing? Some foods are gonna, you know, make them better, some foods are gonna make them worse.
- [12:27]
B
It's gonna.
- [12:28]
A
They're always changing. So it might be a. Tomatoes a problem this week, and two months from now it might not be a problem. So you can't really, you know, there's not gonna be a magic bullet. Stop eating this. If you eat a healthier diet and if you take a probiotic, that might help over time. And then that person feels listened to. Right? They feel like you really. You didn't say, no, it's not food. Like you. You gave them a. Food is playing a role.
- [12:52]
B
Right?
- [12:53]
A
That's the, you know, Peter, what's your spiel? Whenever a patient says, what food should I avoid? You know, have you.
- [13:00]
B
Exactly. As in so many things, you and I converge almost in exactly the same place. I mean. Yeah, that's exactly how I say it. I wish it were one food. I'm like, it would be so much easier. You and I wouldn't even have to be here today. We could be out golfing or something. Like, it'd be simple. But it's not. You've already. And you've already tried it. You told me you went gluten free free. And you cut dairy and you cut tomatoes and nightshades and all this stuff. It's like, so we know it's not that. Like, that can't be the root cause. So what is the root cause? I'm like, well, I don't know. But it's probably not just food. And we understand that food is playing a number of different roles. Your glycemic index and just pro inflammatory foods. And there's a contact dermatitis from foods. Little babies, they're eating stuff and their skin gets all irritated on their face. And the mom's like, maybe he's allergic. It's like, well, or maybe eating citrus is really irritating. Like, I don't think that's an allergy, but it's just irritation. So we can put a barrier to help with that. So we have all these pieces. And I said, part of the problem is there's a threshold effect when your skin is a mess and the system is in a bad spiral. It is really tough to know anything because there's so much variability. Let's get you better first and then we're going to have a much better insight into that baseline and what could be making things worse. And most of the time, and I'm very honestly, most of the time, you know what my family say to me, I guess it wasn't food after all because now we're kind of eating everything. And I really like that, that let them come to that conclusion because I'm not trying to tell them what to do, but I want them to feel heard and I really want them to know that we're not just saying it because it's a shortcut. We're saying it because it really doesn't seem to give.
- [14:18]
A
It's right on. So let's, let's. In this vein, let's go on to Dr. Patton's article and for anybody who's watching the video component, Dr. Patton's middle name is literally Luddite. So he, he, I think is using a Commodore 64 and it, it broke down today. So he's.
- [14:35]
D
It's a Texas. It's a Texas instrument.
- [14:39]
A
Texas instrument. So he's like, he's on his own.
- [14:42]
D
Yeah, it's pronounced Ludete. It's Italian. All right. So, yeah, along that vein. November deep dive, November 2025 edition of Nutrition and is titled can Food Choices be Associated with Nutritional Status and Atopic Dermatitis Severity in Children and Adolescents. It's by Bekele et al. So, right. AAD published guidelines in 2014. Pretty unenthusiastic about the idea that diet affects AD. In 2023, both the American Academy and the College of Allergy, Asthma Immunology, if you like. If you. Is it harder to get into the college or the academy or is it. Are you in either? I don't know.
- [15:23]
A
You gotta be an analogist. They just like they can't be in the aad, but they. So yeah, they've got like the quad AI and I think the quad AI is bigger than the college. Right. There's the American Academy of blah blah blah, and then the American College of Blah blah blah. I think the academy is bigger than the college.
- [15:41]
D
It sounds like it's fancier. Yeah, yeah. All right. Anyways, they published an atopic dermatitis guideline. And regarding elimination diets, they determined that, quote, most individuals pursuing a diet elimination strategy would most likely experience little to no benefit and that it actually may be harmful, leaky gut making, like potential food Allergies worse by leaving it out and not exposing your gut to those allergens earlier. So not a ringing endorsement for the idea that the D and atopic derm severity are related at all. Ian Miles, we had him earlier on. He published this in the jad, as Matt likes to say, international, which listed, and I kid you not, 42 different environmental and behavioral strategies to mitigate AD symptoms and includes the line quote, no specific dietary plan or avoidance is recommended. So it seems to me patients ask their eczemas relative diet. I'm not on the same page with you guys. I am. Like, no, experts have determined conclus. Like, get out of my office if you keep bringing that up. Like I, people get better on doopie and they don't change their diet at all. Like, I'm not engaging you on this at all. Maybe that's why press Gaines are like.
- [16:57]
A
In the negative numbers. You're, you're making our point for us. The point is you tell them, yes, diet is involved, but changing your diet is not going to help because if you say your diet's not involved, they're not going to take the dupixent.
- [17:12]
B
So.
- [17:12]
D
So I don't care.
- [17:13]
C
So diet and elimination diet are two different things though. So. Right. So healthy diet that encourages a healthier microbiome and more short chain fatty acids is not an elimination. I mean, it's like an elimination of Twinkies. Okay, but other than that, like, it's not like, oh, I don't eat nightshades.
- [17:34]
D
No, I get that.
- [17:35]
A
But go ahead, Pat, we'll give you.
- [17:37]
D
You put somebody on Dupixent. You put somebody on Dupixent and they get better. And you didn't counsel them at all about diet. Like, it's not the diet. But I digress. Let's move along. So, so this, did this study even need to be done? It was done by nutritionists. So a different perspective maybe. And the authors actually they hypo, they went against the grain. They hypothesized food choices can be associated with AD severity. That was their hypothesis going in. So 104 patients between 1 and 18 years of age recruited from a few dermatology offices in Brazil. They underwent nutritional and AD assessments and completed questionnaires related to diet, medication use, supplements, blah, blah, basic takeaway. There was not an association between diet and AD severity. It's kind of a weird study. It was like a one time thing. So like, I don't know how you say, oh, diet's not helping this person. Like, you don't know what they were previously. It was a, it's like a one time visit and they're like, what do you eat? How bad is your eczema? Okay, your eczema is really not that bad and you eat terribly. So therefore there's no association. There wasn't really a table or figure that presented the data. It was more narrative. In the results section, authors state, quote, foods classified as ultra processed by the NOVA classification were grouped and submitted to correlation analysis regarding AD severity. There was no correlation between the food consumption of the ultra processed food group and participants scorad. At the end of the same paragraph, they state that none of the other foods in the questionnaire were associated with disease severity. So, you know, what were the patients doing? About 30% of patients were on an elimination diet. Table 4 lists the foods that were restricted. Topping the list, lactose, eggs, dyes, cow's milk. Table 4 also lists the reasons for following it. 75% said that eliminated food that seemed to worsen the dermatitis. So that's why I eliminated it. 30% of patients said they adopted the diet on their own. The rest of the patients said that the diet was adopted following advice from a healthcare provider, most often a pediatrician. But 17% of patients said it was a dermatologist that Rebecca did that recommended the dietary change.
- [19:41]
A
So that's a, that's, let's be clear. It was a, a Brazilian dermatologist, not an American dermatologist.
- [19:49]
D
Stop it. Brazilian dermatologists. You know, I had a Brazilian resident who told me how to say stop it. And I didn't write it down. So I don't know how to do that. But Brazilian dermatologists stopped doing that because this is not like 17 had that conversation about, well, I don't know, they were like, hey, you should cut out eggs, right? I mean that's, that seems too high to me. 70% of. But no, 77.4% of patients confirmed that there, there was a decrease in symptoms by following the diet. So it didn't help with patient perception at all. So we're fighting an uphill battle, that's all. That's almost 80% of patients that were like, you know what? I did cut out oatmeal and my skin is way better. So that's all, it didn't really add a whole lot. It was a weird way to do that, that sort of study. But I think when their hypothesis, which was, we're gonna find, you know, junk food diets and that's going to be with the worst eczema and healthy, healthy diets is going to be with the mildest eczema. And that was not the case. So just adds more fuel to the fire of diet. Doesn't make a difference.
- [20:59]
B
Yeah.
- [20:59]
A
So two, two quick thoughts. Number one, I think it's useful in the sense that it gives us a. Yeah. There were this group of nutritionists who really thought that eczema was driven by diet. And they did this big study. It asked people all about their diet. And the takeaway was that it often seems like your diet is playing a big role or eliminating something helps, blah, blah, blah. The other point though, that is super useful. So Eric Simpson published a great article maybe 2 years ago now where they looked at like 70 some patients, old people who had eczematous drug eruptions, and they looked at drug discontinuation trials and I think 70% of them initially got better. Right. So we're meaning the normal waxing and waning, but not a single person had a long term improvement. Like it got a little better and then it came back despite still being off the drug. I think there's, that's the, what we're fighting against is the, the natural waxing and waning of the disease. You're like, oh, two weeks ago I started avoiding tomatoes and now I'm getting better. It must have taken that long to work its way out of my system. No, it's just, you know. Yeah, beside, that's what I, I thought this was reassuring. Gave us more ammunition.
- [22:20]
B
I don't know, I was gonna just add there's a great quote from Ruchi Gupta. She's a pediatrician in Chicago and she's focused on food allergy. And it's, it really kind of summarizes what we've brought up a little bit too about the dangers of avoiding foods.
- [22:35]
A
Right.
- [22:35]
B
We know that, that of course, part of the reason we think people get, get sensitized to foods is through their skin, broken skin. So we want to heal the barrier. And the other piece is that if they're not eating those foods, as we learned with the, the leap study from Gideon Lack and his group, that if you don't expose it, then you don't become tolerant. So her little mnemonic, the little poem, and I say this to patients all the time, is through the skin, allergies begin through the diet. They stay quiet. And I love that. So that tells them, you know, we don't want to just start cutting stuff out because we know. And Annmarie Singh is a great allergist up in Wisconsin she did this beautiful study show that a proportion, I think it was almost 20% of patients who cut a food because they thought the food was driving their eczema. When they cut the food, they degree that, okay, it wasn't this food, this wasn't the cause of it. When they added it back, 1 out of 5 then actually became allergic to it. They actually got either hives or angioedema or even anaphylaxis for some of these patients. So that's a real risk. The only other thing I'll say just disclaimer because I just want to be careful because when we and I'm with you guys 100% that I agree that for the vast majority of patients this is not the right path for most people. But I agree haters are going to hate people are going to bring it up. Are there people for whom a food or foods is really a major driver of disease? Yes, it's true. I think there are a few patients. The problem is those patients become kind of evangelists for this idea and sort of poison everybody and say, well, I found it for me, so it must be the case for everybody. And I think our pushback is just that in general for the vast majority of patients, for at least 95%, it seems like it's not going to be the major piece that doesn't preclude the fact that there are some people out there and many blessings to them. They're so lucky. They don't need to. I would even argue that if your eczema was solely driven by a food, you didn't have eczema, you did not have atopic dermatitis, you had a food driven eczema disruption. That's something different. But good for you. Now please go do other things and quit torturing our patients about this. Right?
- [24:22]
A
That is exactly so. Susan Netterost, who was at Case Western for a long time, is now one of my partners. She and I have this conversation. A lot of like systemic contact derm and particularly nickel in Balsam of Peru, but potentially lots of other things as well can drive something that's essentially indistinguishable from atopic derm. Other than you avoid it and you get better. And I always make so what her and I's argument is like, look, if I was the patient, I would rather just give me a shot and do Pixit once every two weeks and I'll eat whatever the hell I want. And she's like, oh, we need to avoid these, you know, drugs can have side effects that we don't know. And I'm like, yeah, I know they can. I know they can. But I, you know, I'm more of a. If, if food, if dietary changes were an effective way to manage disease, we wouldn't need statins or blood pressure meds or diabetes meds, right, everybody? Because Those are diseases 100%. Your. Your diet is completely causing your disease. No, they can't get better without the meds. Right? It's. It's an interesting thing, but it's not.
- [25:27]
C
An all or nothing, Matt. So you could say obesity is not at all related to diet, because if I put you on high enough dose of tirzepatide, you will not be obese. Therefore, it's not related to diet. But it is. You're just overcoming something that is dietary related.
- [25:46]
D
Yeah.
- [25:47]
A
My point is more that even if it is diet related, telling people to change their diet rarely works. Right. Because if it, if it. People. It's hard. It's really hard. Like the time that it takes to, to make the healthy foods and the, you know, this and the that and the other. Like, it's. It's hard even if it's. It takes a lot of effort to. For dietary changes to do anything.
- [26:14]
C
Yes. I actually think we should teach people how to cook. I think that is, like, probably one of the most important things we can do is to teach people how to actually cook real food. I think that's probably one of the biggest drivers of poor health in our country. But that's an aside.
- [26:29]
A
I agree. I agree. Patton, did you have something you wanted to say?
- [26:34]
D
No, I. I did want to say. I don't. I don't. I'm not harsh with patients like that. I do kind of go along and be like, yeah, well, maybe it could be. But you know what? It's probably a different food for every different patient. And so that's just impossible to counsel against. And hey, if. If dill. If dill flavored potato chips flare your eczema but the old bay ones don't, then yes, makes sense to avoid dill. That's been reported. I mean, I'm making that up. I don't know if that's true, but whatever. So I do do that. I'm not as harsh as I say, but, man, I really want to be like, no, no, stop. We're going to be wasting time. Not only like, could it be harmful? That's totally stressful. Like, you know what? Yes, here's this diet and avoid it. And then they're like, okay, well, I'm going to read this package and, oh, my gosh, I think this had this in it. And like, who. Why live your life that way? Like, you. You're going to be a freer, happier person because you're not going to be stressing about every little thing that goes into your mouth.
- [27:36]
A
Oh, I. I had a patient who, like, can't remember what it was that they got allergy tested and they came back positive to something. And then it was like, well, okay, this particular ingredient can be derived from, like, corn or from some other vegetable. And if it's derived from corn, then it can have this in it. So they were contacting companies to be like, where do you get your. What do you make your something from? And it's like the.
- [28:08]
C
So can I ask, though? So, probiotics, right? We've read. We've read some papers on probiotics. So we're not going to make everyone change their diet. That's fine. But, Peter, do you recommend a probiotic? And what do you tell patients about them? Because I'm sure they ask you about them.
- [28:24]
B
I do. And. And I'm a big fan of them. I think that, you know, I kind of tell the story. I say there's pretty good evidence that if you give expectant moms and then newborn babies lactobacillus rhamnosis gg, that actually seems to prevent some atopic derma or at least delay the onset. But by the time they're seeing me, they already have it. And there's pretty convincing data that the lactobacillus rhamnosis GG doesn't do much at all for existing eczema. They. They've looked at that over and over. But I think the most compelling data are for some of the mixed strains in particular. Like, there's Lactobacillus, paracaseae, salivarius, There are a few like that. So there are a number of different companies that make them. Now, there's a general caveat, and this is one of the hardest things about any kind of supplement. It's like, first of all, does the actual ingredient do what we think? And here it's not even proven. It's like, it seems like maybe these strains are more helpful. We hope, we think, okay, then, does the actual supplement contain what they say it contains? You hope. Does it have it in the level they're saying it is? And is it consistent? And is it safe? You know, is the background, you know, gonna be something like heavy metals or some other bad stuff? But I do think there are some relatively affordable probiotic Combinations. The one I'm, I've switched over the years to different ones. There's one now on Amazon that comes as a powder which is really nice. It seems like it's, it's pretty good company. They have independent verification by batch and I like it because it's really cheap. It's like 17 for a one month supply for an adult. But for kids, for like adolescents I'll have them do half a sachet and then for the babies I'll have them do a quarter sachet and it's really great.
- [29:54]
A
What's it called? What's the brand? What's the.
- [29:56]
B
Let me pull it. Have it in my. I keep it actually I have a printout at work but then I keep it in my Amazon cart for when I'm doing telemedicine medicine because I, I.
- [30:04]
A
Have one that is, it might be the same one. The one that I recommend is from a company called Now Probiotic 10. It's got 10 strains but four of them are the, are the mix that is known to be good.
- [30:17]
B
Basically. Yeah. So this one, the one I've picked, it's called the company Zabora. Z E B O R A. I have no conflict of interest. Probiotics super nutritional powder. 50 billion organisms. 13 probiotic strains. Really inexpensive. $16.99 for a one month supply for adults. But that would be multiple months for kids and really long, like you know, four months for babies.
- [30:37]
A
Spell it again.
- [30:37]
B
Z Z is in zebra E B O R A. So it looks like almost like Zebra Zabora.
- [30:44]
A
Okay.
- [30:44]
B
Probiotic super nutritional powder.
- [30:46]
A
And as a. This was in a relatively obscure journal, you probably have heard of it. There's this, there was a study recently out of Italy, this probiotic called Visbiome that had this unbelievable like it. But it's like 120 bucks a month. It's like expensive. It's very expensive. And so it's. Even though the results were phenomenal, I'm still like, oh, that's a pretty darn pricey probiotic. But it just confirmed for me again that there are probiotics that work. The other thing that is an interesting thing about talking to patients about probiotics is the idea that the probiotics, I mean there's pretty good evidence for this now that it's not that toxins are leaking out of your gut into your circulation, it's that the healthy bacteria are making good stuff, right? They're making the short chain fatty acids that are anti inflammatory. They're making these indole metabolites that activate the arrowhydrocarbon receptor pathway. So the same thing that Fatama does just systemically, like it's, it's really, like it's, it's really cool. Like it's really cool. And it's, and it fits well into the idea that there's gotta be a reason that eczema dermatitis in general has gotten so much more common than it was, you know, 50 years ago. And food is one of the, is one of the easy things. It's kind of a low hanging fruit. All right now, so for our last deep dive paper, I want to jump over to one that, that I picked. And this was a. Out of Denmark. And so it's not terribly relevant because it, anything that is socioeconomic that comes out of Denmark you can't really like listen to because it, their socioeconomic situation is so different than ours. But the title of this was New Insights into the Burden of Atopic Dermatitis. How Holistic Care. And also consider socioeconomics. Main takeaway of this one was in Denmark, even if you were born with eczema, your life outcomes were basically the same as everybody else. They did a pretty good sibling study where they were like, okay, you know, if you come out of the same family, so presumably similar parents and upbringing and everything else, your outcomes are pretty much identical long term. Okay, great. What I find much more interesting about this is when I hear people talk about, you know, the expense of the drugs that we now have for ad, whether we're talking topical or systemic. All I'm thinking when we talk about that, we're talking about society and I'm always thinking about the patient in front of me. And the truth is if I can give somebody one of these expensive drugs, whether it's a topical or systemic, and it really works, not just the better sleep and the, you know, you're not itchy and you're more productive at work and you do better at school, but also you're going to spend less time and money on moisturizers and on, you know, doing things like you become a normal person. And it, it's, it's one of the reasons I kind of went over at the beginning when Laura was talking about, you know, the cutaneous and the barrier and the moisturizers. Like one of my goals whenever I put somebody on Dupy or absolute Vertama or Zuri or Rinvoak or whatever is so that they don't have to put moisturizer on anymore because it's, it's if they want to, great I'm not like, don't. But I'm like, my goal is that it becomes something that you can do, not something that you have to do. Right. Is it so that from moisturizer?
- [34:29]
C
Wait, so what you're doing, you're saving the world from moisturizer?
- [34:32]
A
That's exactly right. These people could spend hundreds of dollars a year on. On Cerave and Aveeno and all of that stuff. So I'm saving society money with the 60,000.
- [34:43]
C
All right, I'm not buying this. This is a load of bs.
- [34:47]
D
No. Okay, so I think one of the analogies I had was it's like, if you had a lion, like, locked in your basement, like, you could say, there's a line locked in my basement, but he's locked in the basement. It's fine. But you would think about that constantly. You'd be like, oh, my gosh, is the lock up? Did we update it? Is it rusting through? Going to bed at night? Like, is the line gonna stay locked as opposed to getting rid of the lion? And then it's not a constant part of your life? And eczema is the lion in the basement. I'm coining that. Take it to the Beck that.
- [35:23]
A
Love that pretty patent. That's good stuff. Usually I'm like. When you. When we talk about, like, what you say to patients, I'm usually like, my God, like, they're really desperate for derms in Pittsburgh. That one's really good.
- [35:38]
D
Yeah. Yeah.
- [35:39]
A
That one's really, really good. All right, so be.
- [35:41]
D
Yeah.
- [35:42]
A
Me.
- [35:44]
C
We don't have basements, so we don't worry about this stuff.
- [35:47]
A
We still have to moisturize in your attic crawl space. You can have a lion in there. All right, so we've covered our article just. Peter, before we sign off, what do you think is going to be. So the last few years in atopic derm have been unbelievable, right? The last 10 years, the new drugs, the new understanding of kind of some of this dietary stuff, some of the air pollution and environmental stuff. This. The bearer hypothesis, what do you think is because. Right. You publish a lot, and you publish a lot on stuff that most people have never heard of, right? Because whenever I look up, when I look up, Peter, Leo, what's he published in the last six months? I'm like, shit, I've never heard, like, what do you think is going to be the big atopic dermatitis stories in 2026?
- [36:37]
B
The reason you haven't heard of it is because it's obscure, crazy stuff. That's. That's the only reason it's not anything useful or mainstream, of course. But no, I think a couple things. I love the fact that we are finally distilling it down. We actually can say something relatively intelligent about why the environmental story, and I give so much credit to Ian Miles for that. He really pushed that forward. The staph bacteria story, I mean that really Heidi Kong at National Institutes of Health, she turned that completely around. I mean that, that to me was a revelation. When I first read that paper in 2012 where staff was a driver of disease, I was like, like, oh my goodness, this, this changes everything. So now we're, we're finally seeing the ramifications of that. And I always call it the virtuous cycle of drug development that we get some new treatments that help. But then more importantly than they being just helpful, they teach us more about the disease and we build on them and build on that so we're finally in that cycle. Which I think psoriasis has got about a 10 year head start over atopic derm. I also think the microbiome, both the, you know, we talked about oral probiotics, but also on the skin. We have some amazing stuff in the pipeline looking at topical probiotics and other ways to manipulate that microbio biome. We finally have opened the door to really interacting with itch and the nerves themselves. I think the IL31 is the beginning of a new, a whole new frontier. So I think we're going to get to the point where we're going to. I love the way you put it, like this idea of freedom from eczema but keeping getting rid of the line instead of just worrying about it being locked up. But that freedom from disease, it's a big deal. And I know, I guess if you're really, if you're pessimistic, you'd say, well, you guys are just trying to spend the healthcare dollars. You can do fine with a moisturizer. And we're not arguing that for sure. If you can, by all means. But for these patients who are really struggling and we see the impact to be able to take that equation and change it fundamentally, I think it's unbelievable. It's a miracle.
- [38:18]
C
Can I ask a couple of questions? One, I want to. Do you tell patients to moisturize their skin or do you say do?
- [38:24]
B
Yes, I'm a moisturizer fanatic. In fact, my, my little signature move is I get a lot of patients with like sensory issues. They hate all moisturizers or super sensitive skin. And I'll come In with, like, a palette of different moisturizers. And I'll be like, try this one, try this one. And we do it together. I'm like, I take 10 minutes. I'm like, I want you to show me. And the best is. Usually it's little kids, but they'll put one on and be like, oh, I like this one. One. I'm like, all right, that's your moisturizer. Here's a whole bunch more. Here's where you can get it. This is the one you're going to use. I love that moment because I feel like there's. It's also here. Right. That's very psychological. They like the feel. I want that. That enthusiasm about it, because then we know it's going to work.
- [38:56]
C
Okay, that's cool. That's super helpful. That's so helpful that I forgot what my second question was.
- [39:02]
D
Is it like a painter's palette? Like, you come in with a palette and there's little smudges of moisturizer, or.
- [39:08]
A
You'Ve got a fork.
- [39:08]
D
That would be awesome.
- [39:10]
C
And do you have a beret?
- [39:11]
B
I like both of those. Big handful.
- [39:15]
D
I was gonna say that you wear a little. A beret at a jaunty angle.
- [39:19]
A
Jaunty, I like that. So, Laura, did you have something else you wanted to ask before? I, I. There's. I want to talk a little bit more about staff, but was there something else you wanted to ask before?
- [39:30]
C
No, no. That's good. That's good. Go on, talk about staff.
- [39:33]
A
So, Peter, I. I may. And I'm. I'm actually not familiar with the name of the woman who you mentioned from the NIH from 2012. I think of Staph as driving ad by producing super antigens that can penetrate through the impaired barrier. Right. Normal people don't have an impaired barrier. So the super antigens can't penetrate. Is that kind of. What is she the person who sort of figured that out?
- [39:57]
B
She's done so much work. But I think her major paper in 2012, the one that I always cite, was the one that has the. That cool graph where she was able to show that you see staph aureus become dominant, and then you see diversity of the microbiome drop, and then you see a flare up so that the temporal. You know, because I think we were all trained, it's like, yeah, you have a broken skin barrier. People are scratching, they have grubby hands. There's staff all over the place. And staff is an opportunist. It sees an opportunity. It goes in it makes a mess and they can get infected. But Heidi made the point where, no, actually the staff was there first and it's driving this change. Presumably it's in its favor. Right. And all these, these different factors like alpha toxin and delta toxin and the V8 protease, like, they're driving this whole process to make it perfect so that it can essentially improve its colonization and drive the disease. And of course, it's not for everybody. We know the majority of patients have this, not all. And we know that just killing the staff isn't enough either. Like, this is a more complex system. And that's why it's. It's so exciting to me to think about how else can we manipulate the microbiome? Can we change the environment, can we change the ph? Can we add probiotics to help put the good guys there? Can we do things to stop this? You know, they have these, these quorum sensing genes. Can we turn them off? And like in the pipeline we have all of these things. It's like, holy guacamole.
- [41:11]
A
So right now, do you do anything? So rarely, I will. There are some moisturizers out there that actually hand sanitizers that are lotions that have benzalkonium chloride in them. Rarely. I will recommend those. There's a hand sanitizer called Zuno that is this weird stuff that it has 24 hour efficacy, but you really can only use it on your hands because you can't get enough of it. But is there any. I rarely do either of those. Is there anything that you do if you're looking at somebody thinking, I think staff is playing a big role in this person, or is there anything you do in particular in general or for people that you think staff is more likely to be playing a role?
- [41:53]
B
I think a couple big things for me. One of them is the hypochlorous acid sprays. And I think they are fundamentally different than a dilute bleach bath. Oh, yeah. Dr. Gallo pointed out that's probably not the same level of strength. But the stabilized gels, I think are more bactericidal, so they're important. I really, I'm a huge fan, I know it's controversial, but of the Dr. Aaron compound, and that is purely that.
- [42:15]
A
You'Re telling people to put it on eight times a day. If I can get people to put anything on eight times a day, they will get better.
- [42:20]
B
I cannot rule out that possibility, I promise, but it does seem to help in those patients particularly well. And then I really do think that coconut oil there was a couple of great studies where they showed that you were able to decrease colonization by using virgin coconut oil. So I'll have patients do that. Not to replace anything, it's just part of the regimen. So I'll say you take your shower at night, you put your coconut oil on, then your medicine, then your moisturizer because it's not sufficient by itself. But wow, does that make a big difference? And again, it may be multifactorial. The, the adding an extra layer of oil is just great. It enhances everything. Maybe by telling them to stay on it, they, they're much more likely to be adherent, et cetera. But I love that and I feel like that can make a big difference.
- [42:54]
C
What, what's your favorite hypochlorous acid? What, what's your favorite one? Is it that CLN or what do you recommend?
- [43:02]
B
The one I recommend the most. And again, I have no conflict, but it's actually the cheapest one on Amazon. It's called Skin Smart. It comes in a big, a big sprayer. It's great, it's really economical. And I love that one. I know Tower 28 makes one and the founder of that is a, she's a board member for National Eczema association and then she's a big, a big, you know, advocate for eczema. So I respect that too. It's just a bit more pricey. But I love the Skin Smart from Amazon.
- [43:25]
A
I do the Skin Smart as well. To two quick thoughts. So the Aaron regimen for anybody doesn't know, it's basically, if you look it up, you'll be able to find it. But it's basically mixing together moisturizer, beta methazone and some mupirocin in a particular ratio. Both Dr. Leo and Lisa Swanson, so the two best pediatric dermatologists in the world as far as I'm concerned, believe that this stuff is amazing. I say it's baloney, so you should believe me, not the pediatric dermatologists who actually know what they're talking about. So obviously that's tongue in cheek and it tells me that this stuff does actually work. And then I have one other thing, but now I've totally forgotten about. What? Oh, the coconut oil. Here's my favorite thing with the coconut oil. Whenever they say, oh, I've already tried coconut oil, well, it has to be virgin, cold pressed, unrefined coconut oil. Is that what you tried? Oh, no, yeah, that's. And it's true, it does have to be that because it's the medium Chain triglycerides, which get out of it as soon as you do anything to it.
- [44:28]
B
Yeah, I love it. I love it.
- [44:30]
C
This is great. We've got, like, totally practical stuff here of a spray you can get on Amazon, a probiotic you can get on Amazon, probably coconut oil you can get on Amazon. And patients. This is like gold for patients, right? They love this kind of stuff. We should. If we are allowed, we'll pet. We'll post the links to all these so people can have an easy thing to recommend.
- [44:53]
A
Sounds good.
- [44:53]
C
All right, got some trivia for us.
- [44:56]
A
Let's go, Patton. Let's go to trivia.
- [45:00]
D
All right, it's. It's root causes. That's the category.
- [45:04]
A
All right. And Peter, you know. You know the rules. You got to wait till Patton finishes reading the question and then shout it out, whatever you think it is.
- [45:15]
D
All right, so the word root is going to be in the question or the answer. All right, number one, the Bible, verse 1 Timothy 6, 10 states that what is the root of many evils?
- [45:28]
C
Money.
- [45:28]
A
The. No, it's the love of money.
- [45:33]
D
Dr. Cyrus is right. A lot of people, the quote is often misquoted. It's not money. It is the love of money. So, yeah, I don't love money. I just like it a whole lot. All right, number two, what American rock band saw their 1994 song Send Me On My Way gained renewed popularity about a decade later when it was featured in the animated movie Ice Age?
- [46:02]
C
Rusted root.
- [46:04]
D
It is rusted root.
- [46:06]
A
That's a Pittsburgh band.
- [46:07]
D
Yeah, that's a Pittsburgh band. So definite advantage for the podcast team on that one. All right, number three, original recipes for root beer use primarily the root from which treats willow. Sassafras was like the main one. Sarsaparilla was used a lot, but it was sassafras bark root. That was one of the main things. Apparently, in 1960, the FDA banned the use of Saffrol, and that's the compound that's in sassafras. So it was felt to be carcinogenic. Showing once again how the government ruins everything. So now it's all artificial flavored sassafras. Yeah.
- [46:50]
A
Pat, this is something you might know that I wonder all the time, what is the definition of beer and ale? Because, like, why is root beer a beer and why is ginger ale an ale whenever neither one of them has any alcohol in them? Do you know?
- [47:05]
D
I have no idea. The original root beer actually did. It was made from molasses, and then it was flavored with these things and it was fermented to give it a little bubbles, but it was really low. It was like 2% alcohol. Okay.
- [47:18]
A
So it's a little like when they.
- [47:19]
D
Originally made it, they did market it as a beer because technically speaking, it was a little bit alcoholic and I have no idea why ginger ale is an ale and root beer is a beer. Okay, good question. Maybe something for the next episode.
- [47:32]
A
All right. Well, Peter, I want to thank you for coming on. This has been such a fun, fun, fun episode. And I want to thank all of our listeners for joining us this week. We hope you learned a few things. We hope you laughed once or twice. And you but mostly we're hoping you're planning to join us next week. And until then, I'm Matt Zyrus.
- [47:50]
D
I'm Tim Patton.
- [47:51]
C
I'm Laura Farris. And we are Derms on Drugs.