On the biological underpinnings of the atopic march, also called the atopic triad, and what people with eczema need to know.
Published On: Jan 8, 2017
Last Updated On: Jul 15, 2021
Peter Lio, M.D., is a practicing dermatologist in Chicago. This article was excerpted from a presentation at the National Eczema Association annual patient conference.
A lot of eczema research has focused on ﬁlaggrin, which is a protein that keeps skin cells tightly bound together. When this protein breaks down naturally over time, it also has a whole second life; it is incredibly hygroscopic (absorbs water from the air).
We know that if you’re missing this protein, if your gene for ﬁlaggrin is not functioning correctly, then you don’t have the same strength between cells, water leaks out, and bad stuff gets in.
For a small group of eczema patients, maybe 10 to 20 percent, the underlying problem, the root cause of their eczema, is this genetic defect. But even if you have the normal gene, its presence decreases in the presence of inﬂammation. Your body stops making ﬁlaggrin for some reason.
The take-home point is that no matter what the cause of your eczema, protecting the skin barrier is incredibly important — and that means moisturizing. Moisturizers keep the water in and the bad stuff (like allergens and irritants) out.
We tried to quantify how much water different moisturizers (ointments, creams, lotions, gels, foams, etc.) help us to retain. We found a way to spin them each down with water to see how much water they hold onto. On one side of the spectrum there is motor oil, which just sits on top of the water. On the other side, there are the more lotion-y mixtures, which hold onto a lot of water.
In the old days, the greasy moisturizers tended to be the best, and I think by and large that’s still true. But we don’t have to be married to the greasy stuff now.
Some innovations allow us to use moisturizers that are not so greasy, that don’t stain clothes and ruin washing machines. The ceramides, or lipid molecules, in some of the new moisturizing barrier creams are really exciting. I think they’re very promising, particularly as one part of a regimen. Some people might do well using a moisturizer with ceramides during the day and then something heavy and greasy at night.
How are we going to ﬁgure out what is best for each person with eczema trial and error because one size, one product, does not ﬁt all.
Now perhaps more exciting than just plain old moisturizers are the moisturizing creams that claim to restore the skin barrier. These include products like EpiCeram, Atopiclair, MimyX and Biaﬁne.
Some of these manufacturers make drug-like claims, but they are not drugs and they don’t really go through the rigors of drug testing. Instead, they go through device testing, which is the same process to test crutches or the material used to make casts.
I’ve seen some really amazing results with some of the barrier devices, but we have to think about cost effectiveness. Because they’re marketed as prescription treatments, even though they’re not a drug, they are priced like a drug.
There was a rather scathing study, where the researchers did a fancy analysis of moisturizers, basically looking at how much better you get per nickel spent. What they found was that it was really much more efficient to use the old-fashioned over-the-counter moisturizers that contain mostly petroleum. But that doesn’t mean the moisturizing barrier creams are bad. I think it’s worth understanding them more.
In all, the old adage holds true: the best moisturizer is the one you use. If you ﬁnd one that you like and you use it daily, that is the right moisturizer for you.
Topical steroids are the mainstay of anti-inﬂammatory treatment. I wish they weren’t. I’m a searcher and I want to ﬁnd other things that are better and safer. But topical steroids are incredibly powerful, and when used correctly, they do a great job and are relatively safe.
I tell patients who are worried about using topical steroids that, in a way, they’re a natural product. Our bodies make cortisol every morning, so the steroid molecule is something every cell in the body knows about and knows what to do with.
In contrast, from your body’s standpoint, some of the plant materials we use, like tea tree oil, are very foreign and that can get in the way. Steroids are a natural product and we know what they do. Like any good medicine, when used properly, steroids can be helpful. When used improperly, they can cause a lot of trouble.
So what about topical calcineurin inhibitors like Protopic and Elidel? I think they can be put to great use and can make a difference.
Where do they do best? I think they shine as maintenance therapy. They’re actually fairly crummy for an acute ﬂare-up. I think it is to best to get ﬂare-ups under control with a cortisone, using it for just a few days at best, or for a week or two if the ﬂare-up is really bad. Get things looking good, then use a topical calcineurin inhibitor to help maintain that.
Otherwise, when you stop the cortisone, the patient can ﬂare up and then we’re right back where we started and we have all this cortisone addiction, which is terrible. We don’t want that, so we put the patient on a calcineurin inhibitor. At ﬁrst maybe they only go a few days and they ﬂare up and we need to use steroids again. But if we keep doing it, the maintenance period gets longer and longer and the ﬂares get smaller and smaller, and then people get to something like a remission state, which is the goal. That is when we high-ﬁve and celebrate in the clinic!
Researchers are looking at topical calcineurin inhibitors as a proactive treatment. They had people use tacrolimus on trouble spots on the weekends even when they didn’t have a ﬂare-up. By putting it on proactively, they had many fewer ﬂares. People stayed in remission longer, they needed less medicine, and they did better overall.
Other studies show a similar effect with pimecrolimus and even with low-potency topical steroids. We hope we can encourage people to use these medications proactively so they need less of the stronger medicines.
Dr. Lio is an Assistant Professor of Clinical Dermatology and Pediatrics at Northwestern University’s Feinberg School of Medicine and the Director of the Northwestern University Eczema Care and Education Center. His clinical practice is at Dermatology & Aesthetics of Wicker Park in Chicago. His special interests are atopic dermatitis and alternative medicine, and he has publications and several active projects in these areas. Dr. Lio was appointed to the National Eczema Association Scientific Advisory Committee in 2011.