Podcast Summary: Derms on Drugs – "Outside the Box for Atopic Dermatitis"

Date: February 6, 2026
Hosts: Matt Zirwas, Laura Ferris, Tim Patton
Guest: Dr. Peter Leo (Medical Dermatology Associates of Chicago)

Episode Overview

In this lively and educational episode, the Derms on Drugs crew welcomes special guest Dr. Peter Leo to explore atopic dermatitis (AD) "outside the box." Together, they dissect the evolving understanding of AD as a complex, multi-system disease, discuss the latest research on diet, microbiome, and environmental factors, and share practical strategies and memorable clinical pearls for managing patients. The tone is equal parts evidence-based dermatology and playful banter.

Key Discussion Points and Insights

1. Rethinking Atopic Dermatitis: The SIN-GE Framework

[01:36–08:15]

• Laura Ferris introduces a recent paper by Dr. Leo and colleagues that proposes the “SIN-GE” framework for AD:
  • Skin (barrier dysfunction, keratinocytes)
  • Immune (classic and chronic cytokine involvement, Th2 and Th1)
  • Neuro (role of itch, neuropeptides like substance P, potential future drug targets)
  • Gastro/Gut (gut-skin axis, microbiome influence, diet, probiotics)
  • Endocrine (HPA axis, stress, local and systemic cortisol, need to rethink topical steroid use).

“This is really thinking about atopic dermatitis not just as a skin disease, but as sort of a multi-organ system disease.”
— Laura Ferris, [01:36]

• Dr. Leo emphasizes how interconnected these systems are:

  “…it sort of seems ridiculous and maybe overly reductive. But on the other hand, I think it is kind of magical to start…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.”
  — Dr. Leo, [08:59]

Clinical Pearl:
While the complexity of AD is evident, actionable guidance is often limited, especially regarding "gut" and "endocrine" axes. Dr. Leo highlights focusing practical efforts on what can be changed—like the skin environment and behavioral strategies.

2. Diet, Food, and Atopic Dermatitis – Separating Fact from Fiction

[08:15–27:35]

• The group dissects patient questions about food triggers for eczema.

• Matt Zirwas reframes the typical dismissive approach:

  “Historically, what we told people is you’re not allergic to any foods. Food allergy is not driving your AD. ... 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...there’s not gonna be a magic bullet.”
  — Matt Zirwas, [11:18]

• Dr. Leo’s patient spiel:

  “I wish it were one food. ... You told me you went gluten free…and you cut dairy and you cut tomatoes and nightshades and all this stuff. ... So what is the root cause? ... It’s probably not just food.”
  — Dr. Leo, [13:00]

Key Study Discussion:

• Tim Patton presents a Brazilian study (Bekele et al., Nov 2025) on food choices and AD severity in children/teens:

  • No strong association between specific diets and disease severity.
  • Many patients self-implement elimination diets.
  • 80% believed their symptoms improved after elimination, likely reflecting the waxing/waning nature of AD, not cause-and-effect.
  • Dangers discussed: unnecessary elimination can foster food allergies.

• Dr. Leo shares Ruchi Gupta’s quote:

  “Through the skin, allergies begin; through the diet, they stay quiet.”
  — Dr. Leo, [22:34]

Clinical Pearl:
For most patients, dietary elimination is not beneficial, can be harmful, and is not supported by robust evidence. However, clinicians should validate patient concerns and explain the complex, variable nature of dietary influence.

3. Probiotics and the Microbiome

[28:08–34:28]

• Discussion shifts to practical use of probiotics for AD:
  • Early use in infants/expectant mothers may delay or prevent AD, but little effect once disease is established.
  • Mixed strains (e.g., L. paracaseae, salivarius) have strongest evidence.
  • Brand Recommendations: “Zabora Probiotic Super Nutritional Powder” and “Now Probiotic 10” (Amazon, affordable, batch-verified).

“There are probiotics that work...the healthy bacteria are making good stuff, right? They’re making the short chain fatty acids that are anti-inflammatory...”
— Matt Zirwas, [34:11]

• The team underscores "the gut-skin axis"—the idea that gut health influences skin inflammation via the microbiome and its metabolic byproducts.

4. Socioeconomics, Treatment, and Quality of Life

[34:29–36:33]

• They briefly review a Danish sibling study showing equal adult outcomes for those with and without childhood AD in a society with universal access to care.
• Zirwas points out the true value of advanced AD therapies: not just improving symptoms, but freeing patients from the burden of constant skin care and the psychological weight of disease.
• Patton’s memorable analogy:

  “It’s like, if you had a lion, like, locked in your basement...eczema is the lion in the basement.”
  — Tim Patton, [34:47]

5. Looking Forward: Future of Atopic Dermatitis

[36:36–38:17]

• Dr. Leo’s Predictions:
  • Integrating environmental, microbial, and neural insights into care ("the virtuous cycle of drug development").
  • Topical and oral microbiome-targeting therapies.
  • Emerging therapies for itch (e.g., IL-31 pathway).
  • Societal shifts with access to advanced therapies leading to “freedom from eczema”.

“We’re finally in that cycle…which I think psoriasis has got about a 10-year head start over atopic derm.”
— Dr. Leo, [36:57]

6. Rapid-Fire Practical Tips

[38:17–44:52]

• Moisturizers:

  • Dr. Leo is a proponent, even brings a "palette" of samples for sensory-challenged children to choose their favorite.
  • Preference and sensory experience influence adherence.

• Staph Management:

  • Hypochlorous acid sprays (e.g., Skin Smart on Amazon) recommended for barrier and antimicrobial support.
  • Coconut oil (virgin, cold-pressed) can reduce staph colonization, serve as a barrier adjunct.

• Dr. Aaron Regimen:

  • Mixed opinions, but Dr. Leo and other pediatric derms see real-world benefit (moisturizer + betamethasone + mupirocin).

“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. ... This is like gold for patients…”
— Laura Ferris, [44:29]

Notable Quotes & Memorable Moments

• On connecting with patients about food triggers:

  “If you eat a healthier diet and if you take a probiotic, that might help over time. And then that person feels listened to.”
  — Matt Zirwas, [12:27]

• On the evangelists for dietary eczema cures:

  “If your eczema was solely driven by a food, you didn’t have eczema...you had a food-driven eczema disruption.”
  — Dr. Leo, [24:18]

• On the moisturizing “palette” clinic experience:

  “I want that enthusiasm about it, because then we know it’s going to work.”
  — Dr. Leo, [38:55]

Timestamps for Key Segments

• SIN-GE Framework Overview: [01:36–08:15]
• Clinical Relevance of Holistic Model: [08:15–10:46]
• Diet/Food Triggers Debunked: [10:46–27:35]
• Probiotics & Microbiome: [28:08–34:28]
• Socioeconomics & Big Picture: [34:29–36:33]
• Future Directions in AD: [36:36–38:17]
• Practical Patient Tips (moisturizer, staph, coconut oil): [38:17–44:52]

Final Thoughts

The episode expertly balances cutting-edge science and practical wisdom—challenging the reductionist view of atopic dermatitis, validating patient experiences, and offering actionable advice that listeners can deploy in clinic. The ongoing evolution of treatments, understanding of the microbiome, and patient-centered communication are front and center in this insightful, entertaining discussion.

For additional information, resources, and article links, visit scholarsinmedicine.com.