Yes, classifying different subtypes of eczema DOES help with diagnosis and treatment.
Published On: Jun 19, 2017
Last Updated On: Jul 13, 2021
In 2008, Dr. Richard Aron, an established pediatric dermatologist in London and Cape Town, South Africa, hung out his electronic shingle, offering his own topical treatment for people living with eczema all over the world. He developed it years ago to treat pediatric eczema cases at his local office. But demand for the “Aron Regimen” kept growing, and at a certain point, that demand went viral.
“Families come to me when they’re at the end of their tether,” Aron said. “When parents can’t find help for their child—when every other treatment has failed—they look for answers online.”
Many of them find their way to Aron’s website or his discussion group on Facebook, which has more than 22,000 members. Via email, they describe their child’s symptoms and treatment history, send photographs and engage in a detailed back-and-forth with the physician himself.
So how can a simple topical treatment transform severe eczema from unbearable to tolerable or even barely noticeable, as many of Aron’s patients are claiming? The answer to that question, according to Aron, lies in the past.
Fifty years ago, when Aron was a resident, he learned the art of compounding: mixing two or more ingredients by hand to create personalized remedies for patients with a variety of skin conditions.
“Back in 1967, I’d take a bit of steroid and a little antiseptic and mix them with an emulsifying agent,” he said. “Later, as more refined products became available, I fine-tuned the mixture, and my results started becoming more predictable.”
Aron decided to include an antiseptic component because of his belief that “the single-most important factor in severe eczema is the presence of bacterial infection. A staph infection may not be the original cause of the disease, but in moderate to severe cases, it often becomes the major driver of inflammation.”
Here’s how the Aron Regimen is thought to work. The steroid component reduces the inflammation. The antiseptic ingredient eliminates the bacterial infection. And the moisturizer dilutes the steroid. “The diluting effect allows for uninterrupted, long-term therapy, which is essential for preventing relapse,” Aron explained.
Conventional treatment involves the use of more potent steroids in short-term bursts followed by steroid “holidays”—an approach that can sometimes result in eczema rebound if maintenance therapy is not included. By contrast, Aron’s compounded treatment is designed to be used long term, starting with three to four applications per day and steadily tapering off until the symptoms subside.
Aron describes the application routine as flexible. “If I specify four applications of the compound per day, parents can space these to fit their child’s schedule,” he said “If it’s convenient, the late-day dose can be applied after a bath.”
Perhaps surprisingly, he doesn’t advocate the use of additional moisturizer in the early stages of treatment, when the skin is still inflamed. “Extra moisturizing can actually create a medium for bacteria to flourish,” he said. “However, once the inflammation is brought under control, parents should go ahead and apply moisturizer—ideally, the same one I use in the compound, which is readily available in most countries. This moisturizing application should be done at a time separate from the compound applications.”
The tapering process—critical to the success of the Aron Regimen—depends on the patient’s age, disease severity and response to treatment. Patients who respond quickly and dramatically to therapy can be tapered rapidly, while those with more persistent symptoms will be able to taper, but at a slower rate.
The anecdotal evidence in support of the Aron Regimen continues to mount in the form of online testimonials, parent-authored blogs and the sheer numbers of patients, parents and caregivers who flock to the doctor’s website and Facebook group.
His treatment is said to reduce itch, often within five to seven days. For many patients with severe eczema, the treatment “reduces the need for oral antibiotics, light therapy, wet wrapping, immunosuppressive drugs and hospital admissions,” Aron claims on his website.
Despite its popularity among patients, it hasn’t exactly been embraced with open arms by the medical community. That could take time, he conceded. “For one, doctors today aren’t trained in compounding, plus the process can be expensive and time consuming,” Aron said. “Also, new approaches are often met with resistance from those who prefer to stick with the tried and true—the established protocols for treating a disease.”
Doctors try to rely on scientific evidence to support their treatment plans. To date, there has been no randomized, controlled trial on the safety or efficacy of the Aron regimen.
The most serious objection to Aron’s remedy has to do with antibiotic resistance, a major concern for the public and the medical profession alike. When an antibiotic is overused or misused, bacteria can become “resistant,” meaning they continue to multiply, even in the presence of an antibiotic designed to eliminate them.
With the emergence of “superbugs” such as methicillin-resistant staphylococcus aureus (MRSA) and clostridium difficile—aggressive, resistant bacteria that tend to breed in hospitals—physicians are prescribing antibiotics more conservatively and selectively than they used to. The question is when to use them, in what quantities and according to which criteria.
“There’s understandable concern about the risk of resistance, but I believe that risk is low, especially when an antimicrobial is used in small, controlled quantities and in the context of severe disease,” Aron said. “Risk should also be weighed against the benefits of the treatment.”
His view is starting to garner support among clinical researchers who have begun to test his paired hypotheses: that bacterial infection is the main culprit in the uncontrolled inflammation seen in severe eczema, and that treating the infection holds the key to managing this disease for the long term.
Clinical researchers in Chicago, Illinois, and Brown University in Providence, Rhode Island, recently evaluated a compounded topical formulation based on the Aron Regimen, and their results appear to line up with the anecdotal evidence.
“Compounded antibacterial, steroid and moisturizer (CASM) appears to be effective in the management of atopic dermatitis (eczema) and may offer additional benefit for patients who have plateaued with standard therapies,” wrote senior author Dr. Peter Lio. The findings were published in the May 2017 issue of Pediatric Dermatology.
Lio acknowledged that the medical community is divided on the issue of antibiotic use in eczema. The American Academy of Dermatology discourages it, while the Joint Task Force on Practice Parameters sees it as potentially helpful.
“I entered a skeptic,” said Lio “and left pretty convinced that it is helpful, and I think more helpful than steroids alone for some patients at least. It’s not a ‘miracle’ perhaps, but it really does seem to help and might be a good secondary option when things are getting tough.”
Earlier studies published in the British Journal of Dermatology have also shown an antibiotic-steroid combination to be more effective than steroid alone in alleviating the symptoms of severe eczema, and that resistance to the antibiotic used in the compound (mupirocin) was relatively low in study participants (4 percent).
For these reasons, along with his own team’s promising results, Lio believes the CASM regimen merits further testing in larger studies.
Hoping that the medical mainstream will recognize and even adopt his unique treatment for severe eczema, Aron will continue to swim against the current until the day the current shifts in his direction.
In the meantime, parents worldwide continue to find their way to Aron when all other treatments have failed to help their children. With no randomized, controlled studies available to provide evidence, it is imperative that patients review the risks (antibiotic resistance, systemic absorption of steroids from regular use) and the potential benefits with their health care provider.
Corticosteroids, including topical corticosteroids (TCS), are associated with a potentially serious condition called Topical Steroid Withdrawal (TSW). TSW is thought to be rare but can be debilitating for some patients. It may not be recognized by all health professionals as clear diagnostic criteria do not yet exist. Learn more about TSW and appropriate use of TCS.