June 19, 2025 • 51 mins
Is it time to rethink how we treat atopic dermatitis?
Atopic dermatitis is more than skin deep—and naturopath and award-winning clinician Rebecca Hughes is here to prove it. In this practical and insightful episode, Rebecca shares her integrative, root-cause approach to eczema that goes far beyond suppressing symptoms with topical steroids.
Drawing from extensive clinical experience, Rebecca highlights the importance of accurate diagnosis, noting that conditions such as psoriasis, seborrheic dermatitis, and lupus are often misidentified as eczema—leading to ineffective treatment. She walks practitioners through key investigations, from food intolerance and intestinal permeability testing to genetic susceptibilities, that help identify true inflammatory drivers.
Rebecca also outlines her foundational nutrient protocol, including zinc, vitamin D, vitamin A, quercetin, and glutamine, and discusses how these work synergistically to modulate immune response, stabilise mast cells, and repair gut integrity. She also addresses overlooked environmental triggers like mould and water-damaged buildings, as well as the clinical importance of emotional support, sleep hygiene, and managing the psychological toll of visible skin conditions.
Clinicians will find practical strategies for supporting patients through topical steroid withdrawal, tips on using bleach baths safely for Staphylococcus aureus overgrowth, and why children with eczema require particularly vigilant care.
With a soon-to-be-released practitioner course on atopic dermatitis, Rebecca equips healthcare professionals with the tools they need to treat this complex condition confidently and holistically.
Connect with Rebecca: Home - Rebecca Hughes Naturopath
Explore Rebecca's Managing Atopic Dermatitis Course: Use code SAVE30 for a 30% discount. More information on the course can be found here: Managing Atopic Dermatitis | Natural Skin Medicine Courses
Shownotes and references are available on the Designs for Health website
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:13):
This is Wellness by Designs, and I'm your host, amy
Skilton, and joining us today isRebecca Hughes, a naturopath
who practices functionalmedicine in Melbourne and as
well on telehealth online, andRebecca has a special interest
and brings us a wealth ofclinical experience in several
areas, including skin acne,eczema and psoriasis.
(00:38):
She also won the 2020 BEMAClinical Excellence Award as
recognition from our professionof her outstanding skills as a
practitioner.
Rebecca's contribution tonatural medicine extends well
beyond the clinical setting,though, and she has also
lectured in nutrition andnaturopathic degree programs,
(00:58):
regulated complementarymedicines at the TGA,
coordinated mental healthguidance for the National Health
and Medical Research Counciland contributed to a national
reference text on herbs andnatural supplements, and we are
so lucky to be hearing from hertoday on the topic of atopic
dermatitis, more commonly calledeczema.
(01:20):
So welcome to the podcast,rebecca.
Speaker 2 (01:23):
Thank you.
I'm really excited to betalking about atopic dermatitis.
It's a big passion of mine.
Speaker 1 (01:29):
Yes, eczema is such a tricky beast for children and
adults and it certainly bringswith it a rather large degree of
suffering at times.
And I think one of the thingsI'm really excited to talk about
today is, you know, with eczema, conventionally speaking, the
(01:49):
approach tends to be prettybasic, external things that are
not without challenges.
You know corticosteroids, toname the big one, and I think
the conversation we're going tohave today we're going to touch
on steroid withdrawal, actuallya little bit, but what we're
really going to dive into is anaturopathic approach to
(02:12):
actually clearing atopicdermatitis from the inside out,
as well as providing reliefwhere we can and I think we've
got I don't even really knowwhere to start I think maybe we
might open this conversationwith ensuring that you have the
diagnosis right, and I say thisboth as a practitioner and also
(02:37):
as a patient.
If you are a patient and you'veassumed that you've got eczema,
please get it checked outprofessionally, because we can
get all kinds of strange rashesand skin irritations that may
actually be something a bitdifferent.
That would change and informthe approach and, as
practitioners, making sure thatit is indeed eczema that you're
(02:58):
dealing with is certainly thefirst step.
So, rebecca, do you want totake us through?
You know where you've seen thisfall over and what you
recommend doing about it.
Speaker 2 (03:10):
Well, I always question the diagnosis when
someone's come to see me, and Iencourage other practitioners to
do the same, because it's veryeasy to think that, because a
patient has been to see their GPand in some cases even several
dermatologists, to assume thatthe diagnosis is accurate.
However, I have seen patientsthat have come to me and they're
(03:33):
convinced that they have atopicdermatitis, but when I look at
their health history and thepattern of the disease and the
character and the anatomicallocations, from my perspective
what I'm actually treating issomething different, and that
might be I'm treating psoriasisor in fact I'm treating atopic
dermatitis sorry, seborrheicdermatitis or acne, rosacea or
(03:57):
lupus, or there are many, manydifferent diagnostic patterns
that you can go through, andjust because many of them are
treated with the same drug indermatological settings doesn't
mean that they're the samedisease.
And from the perspective of anaturopath or, you know,
(04:18):
functional medicine practitioner, we do bring a different lens
to each of those differentdiagnoses.
Speaker 1 (04:24):
We don't use the same strategies and the same
medicines, and I think that'sprobably where the departure
lies, is that we're looking atthe condition through a
different set of eyes, yes, amore holistic way of viewing
where it's coming from, which Ithink makes a huge difference,
particularly as it informs thetreatment.
(04:46):
Actually, before I continue topick your brains on atopic
dermatitis, I'd love to know howdid your interest in skin
things start Like?
What your trajectory inpractice has been like, that's
led you to having a particularpassion for skin things?
Speaker 2 (05:03):
Well, I think that I started to.
I mean, as sometimes happens inpractices, that you sometimes
see a number of differentpatients in a row but they all
sort of have the same thing andthat started with acne, common
acne vulgaris, and I havepersonal experience with that as
well.
When I was a young woman, sortof transitioning from high
(05:25):
school into my 20s, I suddenlygot acne, which was a bit of a
surprise to me, and I rememberthat pathway, which was a very
conventional medical pathwaybecause I wasn't yet a
naturopath and there justweren't a lot of choice.
There wasn't a lot of choice,there weren't options presented
(05:47):
to me.
It was just simply that this iswhat you do and in fact it's
exactly the same treatmentthat's offered now to the same
patients.
There's nothing really new inthe area of acne vulgaris, with
treatment, and that also thepsychological distress that goes
along with having a skincondition is.
(06:08):
I guess I have a lot of empathyfor these patients because I've
experienced it myself and Iknow that it's not just dealing
with.
Well, firstly you're dealingwith maybe pain, irritation,
inflammation, but then you alsohave to manage yourself.
You have to manage youremotions and psychology around
having the condition, becauseit's public Almost.
(06:31):
You know people can see it.
It's not something, it's notlike your fatty liver disease
that's living inside your body.
No one can see that you know.
So it's got, I guess, thatdegree of complexity to it.
So I think that's why I'vecontinued to want to um take
ground in this area and toprovide people with options,
(06:51):
because I feel like there aren'tthat many out there currently.
Speaker 1 (06:57):
I would agree.
I have a very similar story toyou where I had acne as a
teenager and I went straight onthe pill at 16.
And then, when I startedstudying naturopathy, I realized
it wasn't treating theunderlying cause.
And you're so right.
Like 25 years later, you knowit's still the same.
It's antibiotics, oralcontraceptive or Roaccutane or a
(07:20):
combination of those, none ofwhich actually treat the root
causes or provide sustainableresults, and that's
disappointing, regardless ofwhat condition you know that may
pertain to.
But, as you said, a skincondition is uniquely
distressing in that it's visibleto everybody else.
(07:41):
You know it's not like anyonewith high cholesterol or high
blood pressure, it's.
I was walking around embarrassedof how that looks on your body
because you can't tell,certainly with acne or eczema or
psoriasis or seborrheicdermatitis or any of those other
skin conditions there, there isand unfortunately, because of
that, bi-directionalrelationship with the nervous
(08:03):
system and the gut and the skin,or I suppose it's a
tri-directional relationshipwith the nervous system and the
gut and the skin, or I supposeit's a tri-directional
relationship.
What then becomes further, Iguess, complicating, is that
impact of distress about thecondition actually contributes
to the persistence of it as well.
So, yeah, so there's certainlya lot of moving parts as far as
(08:28):
you know, assessing someone andsupporting someone.
I guess, when we're thinkingabout diagnostics of atopic
dermatitis and the differentialsbetween that and other things
that present very similarly,there's obviously external
assessments that you can do, butI'm also really interested in
hearing about the kinds of teststhat you also run in terms of
(08:52):
blood tests or GI map or anyother types of functional
testing, when you're actuallyassessing someone who's
presenting to you with atopicdermatitis.
Speaker 2 (09:03):
I don't think there's any one specific diagnostic
test, unfortunately, and I thinkthat's the that's probably one
of the difficulties indermatology in general is that
you're often making like aclinical diagnosis with some
supportive evidence, you know,with pathology findings, and so
I tend to rely on some generalblood work, like some basic
(09:28):
blood work that that even thatdoctors use, so we might look at
something like a full bloodcount and see if, um, if that's
normal or are they elevated.
You know, isonophils, basophils, uh, perhaps serum, igg, total
serum IgG, sorry, ige,immunoglobulin E, and then if
there is any tests run forspecific allergies so
(09:54):
environmental allergies orordering those, you can order
total blood histamine and thereis some value in it.
But I guess, because itfluctuates so much from day to
day to moment to moment that youknow anyone can have elevated
blood histamine if they've beenexposed to a trigger.
(10:16):
So I'm not sure that that's andit's kind of a no-brainer.
If you've got a rash that'sitchy, you're very likely to
have elevated histamine.
It's not necessarily going toguide treatment unless you're
looking, I guess, at factorsthat contribute to that, so
perhaps histaminosis driven byum, estrogen or dysbiosis.
(10:39):
Then it's, it's again, it'smore supportive materials and it
.
It may help encourage treatmentwith the patient and you might
like to use it as a benchmarkthroughout the treatment and
look at blood histamine levelscoming down, serum IgE coming
down.
So sometimes pathology isn'tjust used for diagnosis.
(11:00):
It's also used for tracking theefficacy of your treatment and
for encouraging patients as wellthat they tracking the efficacy
of your treatment and forencouraging patients as well
that they're doing all the rightthings and that they're making
progress.
From a functional medicineperspective.
I look at food intolerance andallergy testing.
I do I like to do both together.
I feel like more and morepatients arrive in front of me
(11:23):
having very little investigationdone around any kind of food
reactions whatsoever.
It's a very typical message fromdermatologists, unfortunately,
that food has nothing to do withatopic dermatitis.
I'm fully aware that it's notthe only driver, but given that
our gut is a barrier between usand food and that we can have
(11:49):
responses to it, I think it'suseful to investigate it and see
if it is making a differencefor that person.
And then I might look at thingslike intestinal permeability
again because of that interfacewith food, um so intestinal
permeability markers such asfecal zonulin and and also, if I
(12:11):
am unsure about what's going onand there are some other
co-occurring diagnosis with apatient, then things like cal,
fecal calprotectin.
It can be really useful, likeif you're not sure and then you
see fecal calprotectin, thatwill lead you as a practitioner
down another pathway, not justexploring atopy, like starting
to look at is there anautoimmune involvement in this
(12:33):
patient's presentation?
Secretory IgA, like when it'stoo low, then there's
insufficient gut-related mucosalimmunity.
If it's too elevated, it'sanother indicator of
inflammation.
It's not so specific like itcould be atopic, it could be
autoimmune, but it shouldcertainly be highlighted if it
(12:54):
is elevated and then in bloodand fecal samples you can also
look for the evidence of celiacdisease or gluten enteropathies,
and you can do that in bloodwith immunoglobulins, faecal
immunoglobulins.
You can also measure the orlook at the genetic
(13:15):
susceptibility, which I think isalso very helpful, and I often
test for that in patients whereit's never been investigated and
particularly if they have afamily history of autoimmunity.
So that's just some of thetests that I might run up front.
Speaker 1 (13:33):
Yes, great foundations and such a lovely
place to start.
And I'm really glad youmentioned genetic susceptibility
to celiac, because I think,know, the development of celiac
disease is something that occursover actually quite an
extensive period of time and bythe time there are antibodies
found in the blood first of all,it's too late to turn the ship
(13:57):
around and you've alreadydeveloped one autoimmune disease
, putting you at risk of anotherone by an increased 30%,
putting you at risk of anotherone by an increased 30%.
And what I've personally foundin clinic is finding fecal
antigens is kind of like one ofthose early warning signs and
usually the blood sort of comeslater than that.
(14:17):
But even further upstream,looking at the genetic
susceptibility allows you toidentify that this dietary
antigen is going to be a problem.
If anything else has succumbed,you know is less than optimal.
And when you already have thepresentation of a skin disorder,
knowing the connection betweenthe skin and the gut, you can
already tick that box, meaningto continue to eat gluten in the
(14:40):
face of having a geneticsusceptibility to celiac disease
, you're just asking for moreinflammation and trouble and
contributing to to the problem.
Um, so I think you know, I knowthere's a lot of conversation
around whether removing glutenis necessary and there's a lot
of arguments for and against,but ultimately, if you are
(15:03):
finding genetic susceptibility,then every other conversation
becomes redundant in that case.
So, yeah, thank you for sharingthat with us.
And so, having done anassessment with a client and
identifying that, yes, theydefinitely have atopic
dermatitis, and you've picked upwhat you've picked up on the
(15:24):
markers, where do you begin interms of triaging the steps for
a protocol?
Because I know, you know,probably many of us clinicians
have got this laundry list andthe whole map of everything
mapped out for our client, butsharing a hundred things to
start with for a client doesn'ttend to go the way that we want.
(15:44):
So what do you try andprioritize with clients, knowing
that it's very individual?
Of course, some, you know somefor diet, it might be the more
obvious place but do you have ageneral order in which you
tackle things?
Speaker 2 (16:01):
Yeah, I do to the phases of that.
But I guess what I wanted topre-frame is pre-framing
actually, which is meetingclient, creating actually the
client's expectations or thepatient's expectations, both for
them and for yourself.
Because most patients have beenif they have, are an adult with
(16:23):
atopic dermatitis.
This has been a long time inthe making.
They might have had atopicdermatitis since they're an
infant and it's very common forfor patients to have that.
And so I and it sounds a bitstrange, but I sort of say to
them right at the beginning ofthe treatment program I say that
what's likely is that you'regoing to go through, you're
(16:47):
going to continue to go throughflare and remission cycles of
your atopic dermatitis, evenwhilst you're being treated by
me.
Because what we're about to gothrough is we're about to
discover what are all the thingsthat aggravate and drive your
atopic dermatitis.
And that's like pulling on,it's like having a ball of
thread and pulling on all of the, the strings that that sort of
(17:11):
stick out.
You don't really know whichone's going to completely
unravel the ball of wool and andusually it's not just one
single thing.
It's rarely that, particularlyonce someone has had a disease
for decades the disease itself,the chronic inflammation itself
becomes part of the genesis ofthe disease.
(17:32):
So there's many differentfactors to consider.
So basically I say that to themup front, that this is what's
going to happen and that it'snot going to be a clean, linear
process.
And then I look atfundamentally, first of all
trying to make them comfortableas quickly as possible.
So, whilst because when youorder tests you know it takes a
(17:54):
while for those test results tocome back, so I sort of combine
all of I try and get the initialtesting done as quickly as
possible, try and do as muchtesting and gather as much
objective data as fast as I can,and whilst I'm waiting for all
those samples to be processed,then what I'm focusing on is
their comfort and usuallystarting to work on soothing the
(18:17):
barrier, because in most casesthe barrier is excoriatedated,
it's erythrodermic, it's youknow it's it's in poor shape,
and because the skin is anotherorgan of sensitization, just
like your lungs and just andyour gut, then covering up any
broken skin it's as basic asthat.
(18:39):
Covering it up is a very goodstart, like if you're, if you
can stop allergens fromsensitizing the immune system
through the skin, that's areally, really good start whilst
you're doing all the additionalwork in the background.
So initially it might look likejust doing um.
Nutrients and substances thatstabilize mast cells, key
(19:00):
nutrients that modulate theimmune system.
We know that vitamin D is areally potent immune modulator
and we also know that theevidence shows that people with
chronic atopic dermatitis oftenhave genetic mutations on one or
more SNPs that relate tovitamin D.
It might be conversion receptorexpression.
(19:20):
Zinc, also a potent immunemodulator, as well as skin
barrier and gut barrier repairer, and vitamin A for its benefits
with skin repair, and I prettymuch just this is another thing
I wanted to highlight.
I start with nutrients because Idon't yet know what this
(19:43):
person's immune system is goingto do.
If they're a new patient, Idon't know what they're going to
react to.
So that's how I start out andthen, once I get that objective
data back, the test resultsstart coming in.
Then I can tailor, I can startto tailor the treatment toward
(20:05):
that patient.
So you know, do they need to doa food elimination?
What kind?
For how long?
Do the intestinal permeabilityresults show that they've got a
really leaky gut, in which caseyou know that you're going to be
on a three-month program ofjust gut repair at the same time
as doing food elimination do,and then that's probably once
you've got those things in place, then what can we now work on?
(20:27):
Environmentally, emotionally,how can we support, you know,
all the other factors that arecontributing to the atopic
dermatitis?
Does that provide enough of aguide?
Speaker 1 (20:42):
yes, I think that makes really good sense,
starting with the nutrients,because those are things that
are essential, regardless oftheir sensitivities and, as you
said, you know, with with atopicdermatitis patients.
Um, the bulk of them are zincdeficient, the bulk of them are
vitamin d deficient.
Many of them have issues withvitamin a, either because
(21:04):
they're not consuming enough inits you know, active form, or
there's an issue with conversionfrom beta carotene and all of
those things just compound, andI think you know your approach
allows to the steadying of theship, so to speak, which also
calms the immune system down alittle bit, which gives you more
(21:26):
bandwidth to play with as faras treatment protocols go, if
you want to introduce herbs andand things like that down the
track.
Yeah, brilliant.
I think that's such a wonderfulapproach and such a considered
one when it can be very tempting, when it comes to relieving
someone's suffering, just tojust throw everything,
everything in um.
(21:47):
So you mentioned, obviously,initially you're looking at
nutrients and then you mightstart eliminating foods and and,
of course, at this stage youwill have likely received some
test results back.
You mentioned a little bitearlier about allergy testing
and I know you're a big fan ofutilising that.
Is there a theme with whatcomes up more commonly with
(22:10):
those who are struggling withatopic dermatitis, or is it just
a bit of a mixed bag of lollies?
Speaker 2 (22:17):
I'd say environmentally.
A lot of patients haveallergies to dust mites and
animal danders, often pollens aswell.
But I guess we have to consideralso that that is the general
battery of tests that's doneunder the Medicare item number
in Australia.
So they're really only up front.
(22:38):
They test for pollens, danders,dust mites, maybe sometimes
cockroaches, things like that.
So a lot of patients will comeback with those and sometimes
what's not separated out iswhich pollens which danders, and
that's really usefulinformation.
I mean, obviously there'sthings that can't be controlled.
You can't control the pollencount, but you can control to a
(23:02):
degree your environmentinternally, like when you're in
your office or in your home.
You can use air filtrationsystems to try and reduce the
pollen count indoors.
But it would be also useful forsome patients to be able to
anticipate if there are certainpollens that they know they're
highly reactive to and that timeof year is coming around, then
(23:26):
they can fortify themselves, youknow, to know that that's
coming.
And with danders, I find thisan interesting area because
there's so many people thatdon't get tested, or they, or
this is even more alarming to meis that they know that they're
(23:46):
allergic to dogs and yet theystill have a dog and they try
and convince me that their dogis hypoallergenic and I'm like,
yeah, but that doesn't mean it'snon-allergenic.
That just means that what weknow is that certain breeds of
dogs are less antigenic to somepeople.
But we don't know that you andthat dog are a match made in
(24:09):
heaven.
You know, we don't.
We don't really know.
Now, of course I don't expectpeople to get rid of their pets,
but um, but then there'sstrategies that you can take
around.
It called you know, maybe thedog doesn't sleep on the soft
furnishings in the home, becausethen the fur and the dander is
being transferred all over theplace and it has its own area
and maybe you're not patting thedog as much.
(24:31):
Or you know there's strategiesthat can be put in place for
those types of situations.
But it does surprise me howrarely that's now tested,
especially in general practice,general medical care.
Those just basic, routine bloodtests don't appear to be done.
(24:52):
And ultimately it's just well,here's some cortisone and good
luck cortisone and good luck.
Speaker 1 (25:05):
Yes, that's so disappointing and I can
understand from one perspective,that perhaps the testing has
been dropped because, if theonly route you're going is
allopathic, it doesn't informany change in the treatment,
does it Because?
you're just going to be gettingsteroids, but from a functional
medicine perspective and lookingfor the root cause, these
things can be the differencebetween you actually needing
(25:26):
steroids, the dose that yourequire, how long you're going
to require them for use.
I mean just thinking out loud,environmentally speaking, with
dust mites.
Of course, your home is not theonly place you could be exposed
, but if you're being exposed todust mites, that's indicative
that the space, a space you'reinhabiting, maybe multiple
spaces we look at your homefirst is experiencing elevated
(25:47):
moisture levels and the relativehumidity is over 60% and that's
why dust mites areproliferating.
And therefore, if you controlthe moisture, you can get rid of
the dust mites and then theallergy to them will dissipate.
You know if you're looking for,you know, getting to the root
cause and really solving theproblem, actually understanding
the nuances of this allergytesting can give you tools that
(26:11):
you otherwise wouldn't haveaccess to.
It's what I'm hearing you saythat's right, yeah, yeah, yeah,
brilliant and mold, you knowwhen we talk about humidity also
.
Speaker 2 (26:23):
Mold spores uh, even if it's not chronic inflammatory
response syndrome, I meanthere's two, as you know that
there's two potential reactions.
You could have a frank allergyto the mold spores or you could
be in the the realm more of likethe chronic inflammatory
response syndrome, where it'sthe mycotoxins that are
affecting the immune dysfunctionyes, exactly.
Speaker 1 (26:45):
And mycotoxins, even if you don't have a genetic
susceptibility to SIRS, they're.
They all destroy the gut flora,they destroy barrier integrity,
which then not has a knock-oneffect to nutrient absorptions,
and can vitamin a that then hasa knock-on effect to nutrient
absorption, zinc and vitamin Athat then has a knock-on effect
to the skin.
And, of course, the body'salways going to respond in an
inflammatory way to persistenttoxins.
(27:08):
And indeed, just touching onwater-damaged buildings and
eczema, we know that an elevatedERMI score and an ERMI is a
test that you can run in a homeor an office to determine its
overall moldiness as well asit's almost like a microbiome
test for the space that you'retesting and you can see the
(27:30):
distribution amongst species ofnormal fungal ecology versus
water damaged buildings.
And an elevated ERMI, meaning amoldier home, particularly
during infancy, is actually apredictor of asthma and eczema
at seven years of age.
And we know that in bothchildren and adults, the
(27:52):
severity of eczema is directlycorrelated to the degree of
water damage in the buildingsthat are inhabited.
And again, giving steroids islike trying to put out a
bushfire with a garden hose ifyou are living in a water
damaged building and you'reconstantly exposing yourself to
these things.
(28:12):
You're just really.
It's an uphill battle and onethat you're not going to get
very far, and it actually iskind of ridiculous when you
think about such a powerfuldriver of that disease being
completely ignored.
And I suppose you know ifpeople are doing more extensive
allergy tests they might spotsomething in terms of mold, if
(28:34):
there has been IgE testing there.
There are, of course, otherways to do it, but I always
think if someone has really badeczema or it's really
unresponsive to things or theyhave odd reactions to
supplements and herbs, to methat's almost always a red flag
of a water damage building andcertainly if and this is for
(28:58):
most people most people aren'tmonitoring the humidity at home
and therefore could potentiallyhave elevated moisture levels
and aspergillus and penicillium.
So certainly there's lots ofthings to keep in mind with the
root cause and I am going totalk to you a little bit more
about your treatment approach ina moment.
But I just wanted to touch onsomething you mentioned before
(29:20):
which I think is really such anessential element that I think
can be overlooked.
And I can say this as apractitioner too I can get very
focused on treating the cause,fixing the nutrient deficiencies
using herbal medicines.
And it can be easy when you'rein all of that to actually
forget the emotional toll thathealth conditions can take on
(29:42):
people, especially when it'ssomething that's so publicly,
externally.
What do you do?
How do you approach that?
Do you have a referral network?
Do you have tools In terms ofthe emotional support of
patients?
How do you approach that?
Speaker 2 (30:00):
Well, firstly, make I check in about their sleep, and
this is another.
It's it's really unfortunatefor people with eczema that
their symptoms as they you know,as their own natural cortisol
declines throughout the day,like for all of us.
Our symptoms tend to get worsein the afternoon and the evening
, and so then their sleep isdisrupted, and they may have had
(30:21):
chronically disrupted sleep foryears or decades, and so of
course that makes any one of usless resilient when we don't get
adequate or deep quality sleep.
So I'll attend to that as muchas I can in the treatment
program If they like.
Let's say, if it's an adult andthey're not responding to the
(30:43):
treatment that I give them forsleep, then I'll refer them back
to their GP for whatever'sneeded to be prescribed and I
honestly am not.
I'm a very middle of the roadpractitioner and I am that
whatever works works, you know,and particularly around sleep,
because it's such a foundationalpart of health that if you
(31:04):
can't sleep you can't heal, andand so I address a lot around
sleep hygiene and practices andyou know the environment.
But ultimately, if all ofthat's, if they're attending to
all of that and they're stillnot improving with their sleep,
then I'll refer back to theirdoctor or maybe a sleep
psychologist, because if the, ifthe sleep pattern's been
(31:25):
disturbed for a really long time, sometimes there are mental
barriers towards sleeping thathave appeared over time.
Um, and then, yeah, in terms ofreferral network around, uh,
their mindset and psychology,sometimes it's necessary to see
a psychologist, or sometimes itsimply is teaching, giving them
(31:47):
tools to gradually developmindfulness around their
thoughts and, you know, givingjust basic CBT tools.
I'm obviously not apsychologist, but I can
encourage them to use journalingtechniques or mindfulness
breathing techniques.
I'm lucky enough to work withcoaches.
(32:08):
I work with health coaches, somy patients have additional
support with health coaching andthen distraction techniques as
well because of the itching witheczema.
Then you know it's useful forpatients to learn how to
distract themselves withsomething else instead of
itching, and bringingmindfulness to itching actually
(32:32):
is a really important thing todo.
It's not so useful for children.
Children don't have thecognitive awareness yet to know
when they're being habitualversus reactive.
But adults, adults know andthey know that, and what I've
seen is a cycle where they'renot even physically or
physiologically itchy, but theyget stressed about something and
(32:54):
start scratching, and soscratching has become
inadvertently, has become sortof a self-soothing mechanism for
other things that are going onin their life, and so that's a
really great tool that patientscan bring to their own habitual
(33:14):
scratching, because it doesbecome habitual.
Sometimes there's not evenanything there to itch anymore.
Speaker 1 (33:23):
Yes, I think that's such a good point, and I have
heard that referred to as thescratch that itches, and it
becomes this feedback systemwhere they actually create an
itch from the irritation.
So, yeah, that's some reallypowerful recommendations there
in terms of supporting people,especially adults, obviously,
who have the wherewithal to beable to apply that, who have the
(33:47):
the wherewithal to be able toapply that um.
I want to ask you a couple morethings about your preferred
ingredients that you rely on,and you know we've sort of
talked about zinc and vitamin dum, but I know there are other
ones that you like to to drawupon.
What are, what are your sort offavorite handful of things that
you go to for atopic dermatitis?
Speaker 2 (34:08):
uh, I like quercetin and and other bioflavonoids um
to stabilize mast cells.
I like quercetin because it'salso you know it's it's not a
whole plant yet you know I'm notready generally to prescribe
whole plants, but quercetinbecause it's you know, it's
extracted, so that's reallyuseful.
And glutamine for gut repair.
(34:32):
I'd say in most cases withatopic dermatitis there is
significant leaky gut.
It's very, very unusual that Idon't find a patient who has
leaky gut.
Just as a side note, though,it's interesting that when I
test patients with psoriasisthat they don't.
I haven't yet uncovered whythat is yet, but it's becoming
(34:53):
more of a pattern.
So, yeah, leaky gut.
So then you need glutamine andyou need zinc, you know, to heal
leaky gut, in addition to someprobiotics that we know do a
great job with leaky gut, likelgg and uh saccharomyces
boulardii.
So those tend to getincorporated into treatment
plans as well because they'revery easy and low reactive.
(35:17):
Uh, oh, I'm um nac andglutathione.
I use use those because of theoxidative stress that's caused
by chronic inflammation and Ithink that sometimes we forget
about that again with atopicdermatitis, that because it's
(35:40):
regarded as this superficialthing, like it's superficial,
it's on the outside, it's not achronic disease, but it is.
You know it is a chronicdisease and so and you can't
with acute inflammation you canuse anti-inflammatory substances
, herbs, topicals but whensomething has a really chronic
nature to it, I think it worksbetter to also add in the
(36:06):
antioxidants to help interruptthat entire cycle, because we
know that, you know, chronicinflammation even alters the
cycle of inflammation, soNF-kappa B expression and then
the inflammatory cytokines thatarise from that.
So zinc is also really greatfor that.
So zinc's, in my opinion, likean absolute hero nutrient when
(36:30):
it comes to treating atopicdermatitis, because it has so
many useful actions and it'squite well tolerated, you know.
And obviously you need to doseaccording to weight, especially
in children, um, and you don'tneed to.
Really, I don't think you needto do even really heroic doses
with it, though I think you canstick to somewhere between 15
(36:50):
and 20 milligrams or if you wantto do higher doses, do it every
second day, but still getreally beneficial effects from
prescribing zinc.
And often, you know, in thosevery, very highly reactive
patients, sometimes I don't havemuch choice at the start about
what I can prescribe, and so Imight just be starting with two
(37:11):
products, two things, twonutrients and I'll make sure
that they're single ingredientformulations and I'll introduce
each of them one at a time aswell, so that I know what might
be.
If they get a reaction, then Iknow what's causing it, so that
I know what might be if they geta reaction, then I know what's
causing it, and I'm often I'mreally surprised at how quickly
(37:32):
zinc makes a difference.
Speaker 1 (37:33):
That's so brilliant, and it's nice to know that it
can actually be kind of simpleas well.
You don't necessarily need touse a whole lot of things and a
really you know coordinatedeffort to shift things.
Sometimes it's just a couple ofinstrumental nutrients to see a
really big, big shift.
Um, is there any value do youfind in using collagen to
(37:56):
support the skin, or is thatsomething that you would maybe
park?
Yeah, how do you approach that?
Speaker 2 (38:04):
I'll use collagen.
I'll usually use it after I'vedone food intolerance and
allergy testing, because I haveseen some patients that do have
reactivities to beef as well asbovine.
Yeah, you know, they'll havereactions to casein whey and
beef as well, and so, in whichcase, you need to be mindful
(38:27):
about which collagen you choose.
But if they don't have that asa sensitivity, then yeah, I will
use beef collagen, and thereare also marine-derived
collagens.
On the market.
But I think it's great becausethen you're providing the
building blocks for making thenew skin, and we all know that
that takes time.
You know making the new skinand, yes, we all know that that
takes time.
You know, making the new skinand I forgot to actually mention
(38:49):
that at the start is thatthat's another thing I tell my
patients.
It's like, well, you know, ittakes a while for that, that,
that one new skin cell that'smade and to float to the top.
You know of the epidermis andand then you think of how many
millions of skin cells you needto make to replace all of that
broken skin yeah, it's huge.
Speaker 1 (39:12):
I mean, even if the turnover is, you know, four to
six weekly, you've got toconsider that underlying
inflammation is still affectingthe basal layer.
So you can see quite quickly.
But also, if you're dealingwith major systemic things, it
might take a little bit longer,longer too.
There's just a couple of littlethings I'd love to ask you as
(39:34):
well before we wrap up today,and one of those we have talked
about off air and that was theadvice around bleach baths.
And I know it's a bit of acontentious topic in the sense
that, naturopathically speaking,at first glance it appears to
(39:55):
be a really wrong thing to do,and of course there's a time and
a place for everything andthere's a reason why it became
part of allopathicrecommendations.
So I'd love to hear yourperspective on where you think
they're appropriate and perhapswhere they're not, but
(40:16):
ultimately, their intendedpurpose and place in atopic
dermatitis protocols.
Speaker 2 (40:23):
Yeah, I find that bleach baths are recommended
more for children and primarilywhy they're recommended is to
control staphylococcus aureuspopulations.
And we know that in patients,from the microbiome samples that
are taken from patients whohave atopic dermatitis, that
they appear to have highercolony numbers of staph aureus
(40:47):
and that Staph aureus becomesagain over time involved in the
disease cycle of atopicdermatitis.
So it's important to controlthe Staph aureus numbers, also
because the Staph aureusinterferes with the lipid layer,
it starts to interfere withceramide production and then if
you don't have good ceramidesthen of course your lipid
(41:09):
bilayer and your skin getscompromised.
So there's a really good reasonfor doing bleach baths and it's
probably easier, when you thinkabout it, than applying
antiseptic to your entire body,that you can immerse yourself
into something that and you knowit sounds scary bleach baths,
but they're talking about a fewmils.
(41:32):
It's a controlled amount in avery large volume of water.
It's a controlled amount in avery large volume of water.
Probably what practitionersdon't hear about is that after
bleach baths the protocol is toapply emollients after the
bleach bath moisturisers andemollients because the bleach
(41:54):
will, because, being alkaline,it will increase permeability
and drynessness.
You know there will be what wecall trans-epidermal water loss,
like there is with any dry skin.
But I, um, I think it'sinteresting I was, I was reading
something about this the otherday, about the um sort of you
(42:15):
know, all the marketing aroundproducts that talk about, oh,
but it's pH neutral or it's pHacidic, so it's more appropriate
for people with damaged skin,but no one's ever talking about
the fact that water isn't alwayspH neutral, especially tap
water it's not, and so whenyou're, it's usually a little
(42:42):
bit alkaline and so you thinkabout adding bleach to something
that's already alkaline anyway.
I mean, how much more it's,it's, it's not going to change
the ph that much.
Equally, I think I'm going togo a bit off topic, I won't talk
about that yet but those, themarketing around eczema products
sometimes really bugs mebecause they I think they scare
people into using products thatthey don't necessarily need.
(43:03):
Um, but yeah, bleach baths aregood and and they're good for
the job that they're doing,which is controlling staph
aureus, and they're notrecommended forever.
They're just a control andinfection at that time.
And and I just want to touch ontreating children, because they
are prescribed more for childrenand, um, I think it's really
(43:24):
important because children can.
They're a more vulnerablepopulation.
They can become, theircondition can become unstable
quickly and that if a childstarts having really red oozing
skin they might not even have araised temperature yet but
they'll quickly get a raisedtemperature that they should be
(43:46):
taken very quickly to theirdoctor or an ED and whatever the
prescription is for that I sayfollow it.
Like if the doctor or the EDphysician says that the child
needs antibiotics to control theinfection, then I think it's
always best to err on the sideof caution with that and you can
clean up the mess of theantibiotics later.
(44:06):
But you don't want thecondition to turn into something
that is serious, you know, likecellulitis or something like
that.
That can happen and I don'tthink we sort of I don't think
that always gets explained topatients either around the
primary care of their child'seczema?
Speaker 1 (44:27):
Yeah, very important point, especially with how
quickly kids can deteriorate andtaking quick action if there's
any initial signs of that.
And the very last thing Iwanted to just get your thoughts
on is something I'm sure you'reseeing, unfortunately, more
frequently than you'd like, andthat is the topic of steroid
withdrawal, because certainly inyou know parents who are
(44:51):
treating kids with steroids oradults that are being prescribed
steroids for their eczema.
I haven't really met too manypeople who are like, oh, I
really love that I'm usingsteroids to control my symptoms.
Most of them will say I'm nothappy being on this and I want
to get off it.
But I know, in terms of comingoff steroids, it must be done
(45:14):
really carefully in order toavoid steroid withdrawal, and I
think you've borne witness manya time to when things have gone
wrong there.
Do you want to just highlightthat issue for us and how you
approach that also?
Speaker 2 (45:26):
Yeah, it's a message that I started getting at the
beginning of a treatment program.
I'll really reinforce with mypatients that just because I'm
overseeing your care doesn'tmean you can stop using steroids
, and please don't stop usingthem until you're more stable.
And we've had a conversationand we've got a strategy for
(45:48):
this.
And people still takethemselves off their steroids
and then they end up in a flare,but it's okay, we can clean
that up.
But it is really an important Ithink what's not explained to
patients is how powerful thosemedications are.
Those medications aresuppressing an immune response
(46:09):
and and if you've been using itfor years, it's been suppressing
it for years, and so that theissue with steroids it doesn't
matter whether they're oral ortopical is that everyone
experiences steroid rebound.
When they stop using or takinga steroid, usually there'll be a
transient flare in theirinflammation and that might be
(46:32):
followed by remission afterwards.
If it's been like a short-livedsituation that they've had to
take the medication for and thatwill, that will just
self-resolve.
But when steroids have beenused for months and years, they
have completely disturbed theimmune response and the hpa axis
.
So that's your body's ownability to produce its own
(46:55):
cortisol, and cortisone has nowbeen downregulated because we
all have that ability to produceour own natural
anti-inflammatory.
Cortisol or cortisone is anatural anti-inflammatory and
it's made from cortisol.
So there's a dose, you know,that's circulating around in the
body.
We know that people absorb umsteroids that they apply
(47:19):
topically.
That affects the hpa axis.
Then you know the hypothalamuspituitary regulates then how
much the adrenals create.
Your own adrenals create andthat's probably a lot less.
Now if you've been using it foryears and years and years, then
you're not making as much asyour own cortisol.
So you take that drug away andthen there's nothing left.
(47:40):
There's no safety net.
That's what the topical steroidwithdrawal syndrome is all
about.
It's that patients haven'tallowed and this is not their
fault.
It's not explained to how thedrug affects their body.
But that, sorry, what was Isaying?
So you withdraw the drug.
But body, but, uh, that, um,sorry, what was I saying?
So you withdraw the drug.
But that actually needs to bedone slowly so that the whole
(48:04):
physiology can catch up with thechange that there's this.
So if you withdraw the druggradually, there's less of it
available.
Then that feedback mechanismthrough the hypothalamus
pituitary adrenal axis can startto catch up and it'll be latent
, just like every um endocrineaxis.
There'll be a lag and then theamount of cortisol and cortisone
(48:26):
that your body's making willstart to slowly increase.
But we don't know how longthat's going to take and it's
going to be different for everypatient.
It's going to be dose dependent, how the duration of the
cortisone management, the, thepotencies of cortisone that
they've been using, thefrequency you know it's, and
(48:48):
also how permeable their skin is, because that's the other thing
is like the more permeable andbroken your skin is, the more
cortisone cortisol you're goingto absorb.
So when you've got a damagedbarrier, your absorption of the
cortisone and cortisol topicallythe cortisone topically is
going to be higher anyway so I'musually doing all of that work
(49:09):
with my patients, that thatpre-work that I talked about and
then I have a conversationabout now.
Let's try and step down thecortisone use, and so that might
be like probably reducingfrequency first, like keeping
the dose and the type of thecream or ointment exactly the
same and then reducing thefrequency.
(49:30):
So if they're using it threetimes a day, then we go down to
reducing it twice a day and thento once a day and then every
other day, but all the while Imean it's your patient, right.
So you've got to be workingtogether to figure out what is
the tolerable dose that they canreduce their steroids without
feeling uncomfortable.
Or, if there is discomfort,it's a manageable amount of
(49:53):
discomfort.
And that's really the realityof it is that it's going to be
walking the line of manageablediscomfort while the patient is
reducing the steroid, as well aswhatever other topical
supportive management thatyou're doing.
Speaker 1 (50:11):
That's such a comprehensive and intentional
approach in terms of taperingcadence, making sure that you've
actually got support underneathand you've addressed some of
those root causes before youbother, and then managing it as
you go through.
Gosh, this whole conversationhas just been full of so much
practical, clinically applicableinformation, rebecca.
(50:34):
So thank you so much for yourtime and for taking us through
everything you know about atopicdermatitis.
Speaker 2 (50:42):
Yeah, you're welcome and you know for I think we
talked about it off air thatpractical advice is what I like
to impart to my patients and toother practitioners who
sometimes approach me formentoring, and because of that
I'm soon be releasing a coursethat's to support practitioners
(51:02):
in treating atopic dermatitisconfidently.
Speaker 1 (51:07):
That's going to be so powerful, and we will make sure
we put a link in the show notesso that you can connect with
Rebecca and hear about that assoon as it's available.
So thanks again, rebecca.
That's so wonderful to haveyour brains accessible to the
rest of us who want to divedeeper into this, and thank you
for joining us today.
(51:27):
Remember, you can findeverything we talked about in
the show notes or on the Designsfor Health website.
I'm Amy Skilton and this isWellness by Designs.
This is Wellness by Designs, and I'm your host, amy
Skilton, and joining us today isRebecca Hughes, a naturopath
who practices functionalmedicine in Melbourne and as
well on telehealth online, andRebecca has a special interest
and brings us a wealth ofclinical experience in several
areas, including skin acne,eczema and psoriasis.
(00:38):
She also won the 2020 BEMAClinical Excellence Award as
recognition from our professionof her outstanding skills as a
practitioner.
Rebecca's contribution tonatural medicine extends well
beyond the clinical setting,though, and she has also
lectured in nutrition andnaturopathic degree programs,
(00:58):
regulated complementarymedicines at the TGA,
coordinated mental healthguidance for the National Health
and Medical Research Counciland contributed to a national
reference text on herbs andnatural supplements, and we are
so lucky to be hearing from hertoday on the topic of atopic
dermatitis, more commonly calledeczema.
(01:20):
So welcome to the podcast,rebecca.
Speaker 2 (01:23):
Thank you.
I'm really excited to betalking about atopic dermatitis.
It's a big passion of mine.
Speaker 1 (01:29):
Yes, eczema is such a tricky beast for children and
adults and it certainly bringswith it a rather large degree of
suffering at times.
And I think one of the thingsI'm really excited to talk about
today is, you know, with eczema, conventionally speaking, the
(01:49):
approach tends to be prettybasic, external things that are
not without challenges.
You know corticosteroids, toname the big one, and I think
the conversation we're going tohave today we're going to touch
on steroid withdrawal, actuallya little bit, but what we're
really going to dive into is anaturopathic approach to
(02:12):
actually clearing atopicdermatitis from the inside out,
as well as providing reliefwhere we can and I think we've
got I don't even really knowwhere to start I think maybe we
might open this conversationwith ensuring that you have the
diagnosis right, and I say thisboth as a practitioner and also
(02:37):
as a patient.
If you are a patient and you'veassumed that you've got eczema,
please get it checked outprofessionally, because we can
get all kinds of strange rashesand skin irritations that may
actually be something a bitdifferent.
That would change and informthe approach and, as
practitioners, making sure thatit is indeed eczema that you're
(02:58):
dealing with is certainly thefirst step.
So, rebecca, do you want totake us through?
You know where you've seen thisfall over and what you
recommend doing about it.
Speaker 2 (03:10):
Well, I always question the diagnosis when
someone's come to see me, and Iencourage other practitioners to
do the same, because it's veryeasy to think that, because a
patient has been to see their GPand in some cases even several
dermatologists, to assume thatthe diagnosis is accurate.
However, I have seen patientsthat have come to me and they're
(03:33):
convinced that they have atopicdermatitis, but when I look at
their health history and thepattern of the disease and the
character and the anatomicallocations, from my perspective
what I'm actually treating issomething different, and that
might be I'm treating psoriasisor in fact I'm treating atopic
dermatitis sorry, seborrheicdermatitis or acne, rosacea or
(03:57):
lupus, or there are many, manydifferent diagnostic patterns
that you can go through, andjust because many of them are
treated with the same drug indermatological settings doesn't
mean that they're the samedisease.
And from the perspective of anaturopath or, you know,
(04:18):
functional medicine practitioner, we do bring a different lens
to each of those differentdiagnoses.
Speaker 1 (04:24):
We don't use the same strategies and the same
medicines, and I think that'sprobably where the departure
lies, is that we're looking atthe condition through a
different set of eyes, yes, amore holistic way of viewing
where it's coming from, which Ithink makes a huge difference,
particularly as it informs thetreatment.
(04:46):
Actually, before I continue topick your brains on atopic
dermatitis, I'd love to know howdid your interest in skin
things start Like?
What your trajectory inpractice has been like, that's
led you to having a particularpassion for skin things?
Speaker 2 (05:03):
Well, I think that I started to.
I mean, as sometimes happens inpractices, that you sometimes
see a number of differentpatients in a row but they all
sort of have the same thing andthat started with acne, common
acne vulgaris, and I havepersonal experience with that as
well.
When I was a young woman, sortof transitioning from high
(05:25):
school into my 20s, I suddenlygot acne, which was a bit of a
surprise to me, and I rememberthat pathway, which was a very
conventional medical pathwaybecause I wasn't yet a
naturopath and there justweren't a lot of choice.
There wasn't a lot of choice,there weren't options presented
(05:47):
to me.
It was just simply that this iswhat you do and in fact it's
exactly the same treatmentthat's offered now to the same
patients.
There's nothing really new inthe area of acne vulgaris, with
treatment, and that also thepsychological distress that goes
along with having a skincondition is.
(06:08):
I guess I have a lot of empathyfor these patients because I've
experienced it myself and Iknow that it's not just dealing
with.
Well, firstly you're dealingwith maybe pain, irritation,
inflammation, but then you alsohave to manage yourself.
You have to manage youremotions and psychology around
having the condition, becauseit's public Almost.
(06:31):
You know people can see it.
It's not something, it's notlike your fatty liver disease
that's living inside your body.
No one can see that you know.
So it's got, I guess, thatdegree of complexity to it.
So I think that's why I'vecontinued to want to um take
ground in this area and toprovide people with options,
(06:51):
because I feel like there aren'tthat many out there currently.
Speaker 1 (06:57):
I would agree.
I have a very similar story toyou where I had acne as a
teenager and I went straight onthe pill at 16.
And then, when I startedstudying naturopathy, I realized
it wasn't treating theunderlying cause.
And you're so right.
Like 25 years later, you knowit's still the same.
It's antibiotics, oralcontraceptive or Roaccutane or a
(07:20):
combination of those, none ofwhich actually treat the root
causes or provide sustainableresults, and that's
disappointing, regardless ofwhat condition you know that may
pertain to.
But, as you said, a skincondition is uniquely
distressing in that it's visibleto everybody else.
(07:41):
You know it's not like anyonewith high cholesterol or high
blood pressure, it's.
I was walking around embarrassedof how that looks on your body
because you can't tell,certainly with acne or eczema or
psoriasis or seborrheicdermatitis or any of those other
skin conditions there, there isand unfortunately, because of
that, bi-directionalrelationship with the nervous
(08:03):
system and the gut and the skin,or I suppose it's a
tri-directional relationshipwith the nervous system and the
gut and the skin, or I supposeit's a tri-directional
relationship.
What then becomes further, Iguess, complicating, is that
impact of distress about thecondition actually contributes
to the persistence of it as well.
So, yeah, so there's certainlya lot of moving parts as far as
(08:28):
you know, assessing someone andsupporting someone.
I guess, when we're thinkingabout diagnostics of atopic
dermatitis and the differentialsbetween that and other things
that present very similarly,there's obviously external
assessments that you can do, butI'm also really interested in
hearing about the kinds of teststhat you also run in terms of
(08:52):
blood tests or GI map or anyother types of functional
testing, when you're actuallyassessing someone who's
presenting to you with atopicdermatitis.
Speaker 2 (09:03):
I don't think there's any one specific diagnostic
test, unfortunately, and I thinkthat's the that's probably one
of the difficulties indermatology in general is that
you're often making like aclinical diagnosis with some
supportive evidence, you know,with pathology findings, and so
I tend to rely on some generalblood work, like some basic
(09:28):
blood work that that even thatdoctors use, so we might look at
something like a full bloodcount and see if, um, if that's
normal or are they elevated.
You know, isonophils, basophils, uh, perhaps serum, igg, total
serum IgG, sorry, ige,immunoglobulin E, and then if
there is any tests run forspecific allergies so
(09:54):
environmental allergies orordering those, you can order
total blood histamine and thereis some value in it.
But I guess, because itfluctuates so much from day to
day to moment to moment that youknow anyone can have elevated
blood histamine if they've beenexposed to a trigger.
(10:16):
So I'm not sure that that's andit's kind of a no-brainer.
If you've got a rash that'sitchy, you're very likely to
have elevated histamine.
It's not necessarily going toguide treatment unless you're
looking, I guess, at factorsthat contribute to that, so
perhaps histaminosis driven byum, estrogen or dysbiosis.
(10:39):
Then it's, it's again, it'smore supportive materials and it
.
It may help encourage treatmentwith the patient and you might
like to use it as a benchmarkthroughout the treatment and
look at blood histamine levelscoming down, serum IgE coming
down.
So sometimes pathology isn'tjust used for diagnosis.
(11:00):
It's also used for tracking theefficacy of your treatment and
for encouraging patients as wellthat they tracking the efficacy
of your treatment and forencouraging patients as well
that they're doing all the rightthings and that they're making
progress.
From a functional medicineperspective.
I look at food intolerance andallergy testing.
I do I like to do both together.
I feel like more and morepatients arrive in front of me
(11:23):
having very little investigationdone around any kind of food
reactions whatsoever.
It's a very typical message fromdermatologists, unfortunately,
that food has nothing to do withatopic dermatitis.
I'm fully aware that it's notthe only driver, but given that
our gut is a barrier between usand food and that we can have
(11:49):
responses to it, I think it'suseful to investigate it and see
if it is making a differencefor that person.
And then I might look at thingslike intestinal permeability
again because of that interfacewith food, um so intestinal
permeability markers such asfecal zonulin and and also, if I
(12:11):
am unsure about what's going onand there are some other
co-occurring diagnosis with apatient, then things like cal,
fecal calprotectin.
It can be really useful, likeif you're not sure and then you
see fecal calprotectin, thatwill lead you as a practitioner
down another pathway, not justexploring atopy, like starting
to look at is there anautoimmune involvement in this
(12:33):
patient's presentation?
Secretory IgA, like when it'stoo low, then there's
insufficient gut-related mucosalimmunity.
If it's too elevated, it'sanother indicator of
inflammation.
It's not so specific like itcould be atopic, it could be
autoimmune, but it shouldcertainly be highlighted if it
(12:54):
is elevated and then in bloodand fecal samples you can also
look for the evidence of celiacdisease or gluten enteropathies,
and you can do that in bloodwith immunoglobulins, faecal
immunoglobulins.
You can also measure the orlook at the genetic
(13:15):
susceptibility, which I think isalso very helpful, and I often
test for that in patients whereit's never been investigated and
particularly if they have afamily history of autoimmunity.
So that's just some of thetests that I might run up front.
Speaker 1 (13:33):
Yes, great foundations and such a lovely
place to start.
And I'm really glad youmentioned genetic susceptibility
to celiac, because I think,know, the development of celiac
disease is something that occursover actually quite an
extensive period of time and bythe time there are antibodies
found in the blood first of all,it's too late to turn the ship
(13:57):
around and you've alreadydeveloped one autoimmune disease
, putting you at risk of anotherone by an increased 30%,
putting you at risk of anotherone by an increased 30%.
And what I've personally foundin clinic is finding fecal
antigens is kind of like one ofthose early warning signs and
usually the blood sort of comeslater than that.
(14:17):
But even further upstream,looking at the genetic
susceptibility allows you toidentify that this dietary
antigen is going to be a problem.
If anything else has succumbed,you know is less than optimal.
And when you already have thepresentation of a skin disorder,
knowing the connection betweenthe skin and the gut, you can
already tick that box, meaningto continue to eat gluten in the
(14:40):
face of having a geneticsusceptibility to celiac disease
, you're just asking for moreinflammation and trouble and
contributing to to the problem.
Um, so I think you know, I knowthere's a lot of conversation
around whether removing glutenis necessary and there's a lot
of arguments for and against,but ultimately, if you are
(15:03):
finding genetic susceptibility,then every other conversation
becomes redundant in that case.
So, yeah, thank you for sharingthat with us.
And so, having done anassessment with a client and
identifying that, yes, theydefinitely have atopic
dermatitis, and you've picked upwhat you've picked up on the
(15:24):
markers, where do you begin interms of triaging the steps for
a protocol?
Because I know, you know,probably many of us clinicians
have got this laundry list andthe whole map of everything
mapped out for our client, butsharing a hundred things to
start with for a client doesn'ttend to go the way that we want.
(15:44):
So what do you try andprioritize with clients, knowing
that it's very individual?
Of course, some, you know somefor diet, it might be the more
obvious place but do you have ageneral order in which you
tackle things?
Speaker 2 (16:01):
Yeah, I do to the phases of that.
But I guess what I wanted topre-frame is pre-framing
actually, which is meetingclient, creating actually the
client's expectations or thepatient's expectations, both for
them and for yourself.
Because most patients have beenif they have, are an adult with
(16:23):
atopic dermatitis.
This has been a long time inthe making.
They might have had atopicdermatitis since they're an
infant and it's very common forfor patients to have that.
And so I and it sounds a bitstrange, but I sort of say to
them right at the beginning ofthe treatment program I say that
what's likely is that you'regoing to go through, you're
(16:47):
going to continue to go throughflare and remission cycles of
your atopic dermatitis, evenwhilst you're being treated by
me.
Because what we're about to gothrough is we're about to
discover what are all the thingsthat aggravate and drive your
atopic dermatitis.
And that's like pulling on,it's like having a ball of
thread and pulling on all of the, the strings that that sort of
(17:11):
stick out.
You don't really know whichone's going to completely
unravel the ball of wool and andusually it's not just one
single thing.
It's rarely that, particularlyonce someone has had a disease
for decades the disease itself,the chronic inflammation itself
becomes part of the genesis ofthe disease.
(17:32):
So there's many differentfactors to consider.
So basically I say that to themup front, that this is what's
going to happen and that it'snot going to be a clean, linear
process.
And then I look atfundamentally, first of all
trying to make them comfortableas quickly as possible.
So, whilst because when youorder tests you know it takes a
(17:54):
while for those test results tocome back, so I sort of combine
all of I try and get the initialtesting done as quickly as
possible, try and do as muchtesting and gather as much
objective data as fast as I can,and whilst I'm waiting for all
those samples to be processed,then what I'm focusing on is
their comfort and usuallystarting to work on soothing the
(18:17):
barrier, because in most casesthe barrier is excoriatedated,
it's erythrodermic, it's youknow it's it's in poor shape,
and because the skin is anotherorgan of sensitization, just
like your lungs and just andyour gut, then covering up any
broken skin it's as basic asthat.
(18:39):
Covering it up is a very goodstart, like if you're, if you
can stop allergens fromsensitizing the immune system
through the skin, that's areally, really good start whilst
you're doing all the additionalwork in the background.
So initially it might look likejust doing um.
Nutrients and substances thatstabilize mast cells, key
(19:00):
nutrients that modulate theimmune system.
We know that vitamin D is areally potent immune modulator
and we also know that theevidence shows that people with
chronic atopic dermatitis oftenhave genetic mutations on one or
more SNPs that relate tovitamin D.
It might be conversion receptorexpression.
(19:20):
Zinc, also a potent immunemodulator, as well as skin
barrier and gut barrier repairer, and vitamin A for its benefits
with skin repair, and I prettymuch just this is another thing
I wanted to highlight.
I start with nutrients because Idon't yet know what this
(19:43):
person's immune system is goingto do.
If they're a new patient, Idon't know what they're going to
react to.
So that's how I start out andthen, once I get that objective
data back, the test resultsstart coming in.
Then I can tailor, I can startto tailor the treatment toward
(20:05):
that patient.
So you know, do they need to doa food elimination?
What kind?
For how long?
Do the intestinal permeabilityresults show that they've got a
really leaky gut, in which caseyou know that you're going to be
on a three-month program ofjust gut repair at the same time
as doing food elimination do,and then that's probably once
you've got those things in place, then what can we now work on?
(20:27):
Environmentally, emotionally,how can we support, you know,
all the other factors that arecontributing to the atopic
dermatitis?
Does that provide enough of aguide?
Speaker 1 (20:42):
yes, I think that makes really good sense,
starting with the nutrients,because those are things that
are essential, regardless oftheir sensitivities and, as you
said, you know, with with atopicdermatitis patients.
Um, the bulk of them are zincdeficient, the bulk of them are
vitamin d deficient.
Many of them have issues withvitamin a, either because
(21:04):
they're not consuming enough inits you know, active form, or
there's an issue with conversionfrom beta carotene and all of
those things just compound, andI think you know your approach
allows to the steadying of theship, so to speak, which also
calms the immune system down alittle bit, which gives you more
(21:26):
bandwidth to play with as faras treatment protocols go, if
you want to introduce herbs andand things like that down the
track.
Yeah, brilliant.
I think that's such a wonderfulapproach and such a considered
one when it can be very tempting, when it comes to relieving
someone's suffering, just tojust throw everything,
everything in um.
(21:47):
So you mentioned, obviously,initially you're looking at
nutrients and then you mightstart eliminating foods and and,
of course, at this stage youwill have likely received some
test results back.
You mentioned a little bitearlier about allergy testing
and I know you're a big fan ofutilising that.
Is there a theme with whatcomes up more commonly with
(22:10):
those who are struggling withatopic dermatitis, or is it just
a bit of a mixed bag of lollies?
Speaker 2 (22:17):
I'd say environmentally.
A lot of patients haveallergies to dust mites and
animal danders, often pollens aswell.
But I guess we have to consideralso that that is the general
battery of tests that's doneunder the Medicare item number
in Australia.
So they're really only up front.
(22:38):
They test for pollens, danders,dust mites, maybe sometimes
cockroaches, things like that.
So a lot of patients will comeback with those and sometimes
what's not separated out iswhich pollens which danders, and
that's really usefulinformation.
I mean, obviously there'sthings that can't be controlled.
You can't control the pollencount, but you can control to a
(23:02):
degree your environmentinternally, like when you're in
your office or in your home.
You can use air filtrationsystems to try and reduce the
pollen count indoors.
But it would be also useful forsome patients to be able to
anticipate if there are certainpollens that they know they're
highly reactive to and that timeof year is coming around, then
(23:26):
they can fortify themselves, youknow, to know that that's
coming.
And with danders, I find thisan interesting area because
there's so many people thatdon't get tested, or they, or
this is even more alarming to meis that they know that they're
(23:46):
allergic to dogs and yet theystill have a dog and they try
and convince me that their dogis hypoallergenic and I'm like,
yeah, but that doesn't mean it'snon-allergenic.
That just means that what weknow is that certain breeds of
dogs are less antigenic to somepeople.
But we don't know that you andthat dog are a match made in
(24:09):
heaven.
You know, we don't.
We don't really know.
Now, of course I don't expectpeople to get rid of their pets,
but um, but then there'sstrategies that you can take
around.
It called you know, maybe thedog doesn't sleep on the soft
furnishings in the home, becausethen the fur and the dander is
being transferred all over theplace and it has its own area
and maybe you're not patting thedog as much.
(24:31):
Or you know there's strategiesthat can be put in place for
those types of situations.
But it does surprise me howrarely that's now tested,
especially in general practice,general medical care.
Those just basic, routine bloodtests don't appear to be done.
(24:52):
And ultimately it's just well,here's some cortisone and good
luck cortisone and good luck.
Speaker 1 (25:05):
Yes, that's so disappointing and I can
understand from one perspective,that perhaps the testing has
been dropped because, if theonly route you're going is
allopathic, it doesn't informany change in the treatment,
does it Because?
you're just going to be gettingsteroids, but from a functional
medicine perspective and lookingfor the root cause, these
things can be the differencebetween you actually needing
(25:26):
steroids, the dose that yourequire, how long you're going
to require them for use.
I mean just thinking out loud,environmentally speaking, with
dust mites.
Of course, your home is not theonly place you could be exposed
, but if you're being exposed todust mites, that's indicative
that the space, a space you'reinhabiting, maybe multiple
spaces we look at your homefirst is experiencing elevated
(25:47):
moisture levels and the relativehumidity is over 60% and that's
why dust mites areproliferating.
And therefore, if you controlthe moisture, you can get rid of
the dust mites and then theallergy to them will dissipate.
You know if you're looking for,you know, getting to the root
cause and really solving theproblem, actually understanding
the nuances of this allergytesting can give you tools that
(26:11):
you otherwise wouldn't haveaccess to.
It's what I'm hearing you saythat's right, yeah, yeah, yeah,
brilliant and mold, you knowwhen we talk about humidity also
.
Speaker 2 (26:23):
Mold spores uh, even if it's not chronic inflammatory
response syndrome, I meanthere's two, as you know that
there's two potential reactions.
You could have a frank allergyto the mold spores or you could
be in the the realm more of likethe chronic inflammatory
response syndrome, where it'sthe mycotoxins that are
affecting the immune dysfunctionyes, exactly.
Speaker 1 (26:45):
And mycotoxins, even if you don't have a genetic
susceptibility to SIRS, they're.
They all destroy the gut flora,they destroy barrier integrity,
which then not has a knock-oneffect to nutrient absorptions,
and can vitamin a that then hasa knock-on effect to nutrient
absorption, zinc and vitamin Athat then has a knock-on effect
to the skin.
And, of course, the body'salways going to respond in an
inflammatory way to persistenttoxins.
(27:08):
And indeed, just touching onwater-damaged buildings and
eczema, we know that an elevatedERMI score and an ERMI is a
test that you can run in a homeor an office to determine its
overall moldiness as well asit's almost like a microbiome
test for the space that you'retesting and you can see the
(27:30):
distribution amongst species ofnormal fungal ecology versus
water damaged buildings.
And an elevated ERMI, meaning amoldier home, particularly
during infancy, is actually apredictor of asthma and eczema
at seven years of age.
And we know that in bothchildren and adults, the
(27:52):
severity of eczema is directlycorrelated to the degree of
water damage in the buildingsthat are inhabited.
And again, giving steroids islike trying to put out a
bushfire with a garden hose ifyou are living in a water
damaged building and you'reconstantly exposing yourself to
these things.
(28:12):
You're just really.
It's an uphill battle and onethat you're not going to get
very far, and it actually iskind of ridiculous when you
think about such a powerfuldriver of that disease being
completely ignored.
And I suppose you know ifpeople are doing more extensive
allergy tests they might spotsomething in terms of mold, if
(28:34):
there has been IgE testing there.
There are, of course, otherways to do it, but I always
think if someone has really badeczema or it's really
unresponsive to things or theyhave odd reactions to
supplements and herbs, to methat's almost always a red flag
of a water damage building andcertainly if and this is for
(28:58):
most people most people aren'tmonitoring the humidity at home
and therefore could potentiallyhave elevated moisture levels
and aspergillus and penicillium.
So certainly there's lots ofthings to keep in mind with the
root cause and I am going totalk to you a little bit more
about your treatment approach ina moment.
But I just wanted to touch onsomething you mentioned before
(29:20):
which I think is really such anessential element that I think
can be overlooked.
And I can say this as apractitioner too I can get very
focused on treating the cause,fixing the nutrient deficiencies
using herbal medicines.
And it can be easy when you'rein all of that to actually
forget the emotional toll thathealth conditions can take on
(29:42):
people, especially when it'ssomething that's so publicly,
externally.
What do you do?
How do you approach that?
Do you have a referral network?
Do you have tools In terms ofthe emotional support of
patients?
How do you approach that?
Speaker 2 (30:00):
Well, firstly, make I check in about their sleep, and
this is another.
It's it's really unfortunatefor people with eczema that
their symptoms as they you know,as their own natural cortisol
declines throughout the day,like for all of us.
Our symptoms tend to get worsein the afternoon and the evening
, and so then their sleep isdisrupted, and they may have had
(30:21):
chronically disrupted sleep foryears or decades, and so of
course that makes any one of usless resilient when we don't get
adequate or deep quality sleep.
So I'll attend to that as muchas I can in the treatment
program If they like.
Let's say, if it's an adult andthey're not responding to the
(30:43):
treatment that I give them forsleep, then I'll refer them back
to their GP for whatever'sneeded to be prescribed and I
honestly am not.
I'm a very middle of the roadpractitioner and I am that
whatever works works, you know,and particularly around sleep,
because it's such a foundationalpart of health that if you
(31:04):
can't sleep you can't heal, andand so I address a lot around
sleep hygiene and practices andyou know the environment.
But ultimately, if all ofthat's, if they're attending to
all of that and they're stillnot improving with their sleep,
then I'll refer back to theirdoctor or maybe a sleep
psychologist, because if the, ifthe sleep pattern's been
(31:25):
disturbed for a really long time, sometimes there are mental
barriers towards sleeping thathave appeared over time.
Um, and then, yeah, in terms ofreferral network around, uh,
their mindset and psychology,sometimes it's necessary to see
a psychologist, or sometimes itsimply is teaching, giving them
(31:47):
tools to gradually developmindfulness around their
thoughts and, you know, givingjust basic CBT tools.
I'm obviously not apsychologist, but I can
encourage them to use journalingtechniques or mindfulness
breathing techniques.
I'm lucky enough to work withcoaches.
(32:08):
I work with health coaches, somy patients have additional
support with health coaching andthen distraction techniques as
well because of the itching witheczema.
Then you know it's useful forpatients to learn how to
distract themselves withsomething else instead of
itching, and bringingmindfulness to itching actually
(32:32):
is a really important thing todo.
It's not so useful for children.
Children don't have thecognitive awareness yet to know
when they're being habitualversus reactive.
But adults, adults know andthey know that, and what I've
seen is a cycle where they'renot even physically or
physiologically itchy, but theyget stressed about something and
(32:54):
start scratching, and soscratching has become
inadvertently, has become sortof a self-soothing mechanism for
other things that are going onin their life, and so that's a
really great tool that patientscan bring to their own habitual
(33:14):
scratching, because it doesbecome habitual.
Sometimes there's not evenanything there to itch anymore.
Speaker 1 (33:23):
Yes, I think that's such a good point, and I have
heard that referred to as thescratch that itches, and it
becomes this feedback systemwhere they actually create an
itch from the irritation.
So, yeah, that's some reallypowerful recommendations there
in terms of supporting people,especially adults, obviously,
who have the wherewithal to beable to apply that, who have the
(33:47):
the wherewithal to be able toapply that um.
I want to ask you a couple morethings about your preferred
ingredients that you rely on,and you know we've sort of
talked about zinc and vitamin dum, but I know there are other
ones that you like to to drawupon.
What are, what are your sort offavorite handful of things that
you go to for atopic dermatitis?
Speaker 2 (34:08):
uh, I like quercetin and and other bioflavonoids um
to stabilize mast cells.
I like quercetin because it'salso you know it's it's not a
whole plant yet you know I'm notready generally to prescribe
whole plants, but quercetinbecause it's you know, it's
extracted, so that's reallyuseful.
And glutamine for gut repair.
(34:32):
I'd say in most cases withatopic dermatitis there is
significant leaky gut.
It's very, very unusual that Idon't find a patient who has
leaky gut.
Just as a side note, though,it's interesting that when I
test patients with psoriasisthat they don't.
I haven't yet uncovered whythat is yet, but it's becoming
(34:53):
more of a pattern.
So, yeah, leaky gut.
So then you need glutamine andyou need zinc, you know, to heal
leaky gut, in addition to someprobiotics that we know do a
great job with leaky gut, likelgg and uh saccharomyces
boulardii.
So those tend to getincorporated into treatment
plans as well because they'revery easy and low reactive.
(35:17):
Uh, oh, I'm um nac andglutathione.
I use use those because of theoxidative stress that's caused
by chronic inflammation and Ithink that sometimes we forget
about that again with atopicdermatitis, that because it's
(35:40):
regarded as this superficialthing, like it's superficial,
it's on the outside, it's not achronic disease, but it is.
You know it is a chronicdisease and so and you can't
with acute inflammation you canuse anti-inflammatory substances
, herbs, topicals but whensomething has a really chronic
nature to it, I think it worksbetter to also add in the
(36:06):
antioxidants to help interruptthat entire cycle, because we
know that, you know, chronicinflammation even alters the
cycle of inflammation, soNF-kappa B expression and then
the inflammatory cytokines thatarise from that.
So zinc is also really greatfor that.
So zinc's, in my opinion, likean absolute hero nutrient when
(36:30):
it comes to treating atopicdermatitis, because it has so
many useful actions and it'squite well tolerated, you know.
And obviously you need to doseaccording to weight, especially
in children, um, and you don'tneed to.
Really, I don't think you needto do even really heroic doses
with it, though I think you canstick to somewhere between 15
(36:50):
and 20 milligrams or if you wantto do higher doses, do it every
second day, but still getreally beneficial effects from
prescribing zinc.
And often, you know, in thosevery, very highly reactive
patients, sometimes I don't havemuch choice at the start about
what I can prescribe, and so Imight just be starting with two
(37:11):
products, two things, twonutrients and I'll make sure
that they're single ingredientformulations and I'll introduce
each of them one at a time aswell, so that I know what might
be.
If they get a reaction, then Iknow what's causing it, so that
I know what might be if they geta reaction, then I know what's
causing it, and I'm often I'mreally surprised at how quickly
(37:32):
zinc makes a difference.
Speaker 1 (37:33):
That's so brilliant, and it's nice to know that it
can actually be kind of simpleas well.
You don't necessarily need touse a whole lot of things and a
really you know coordinatedeffort to shift things.
Sometimes it's just a couple ofinstrumental nutrients to see a
really big, big shift.
Um, is there any value do youfind in using collagen to
(37:56):
support the skin, or is thatsomething that you would maybe
park?
Yeah, how do you approach that?
Speaker 2 (38:04):
I'll use collagen.
I'll usually use it after I'vedone food intolerance and
allergy testing, because I haveseen some patients that do have
reactivities to beef as well asbovine.
Yeah, you know, they'll havereactions to casein whey and
beef as well, and so, in whichcase, you need to be mindful
(38:27):
about which collagen you choose.
But if they don't have that asa sensitivity, then yeah, I will
use beef collagen, and thereare also marine-derived
collagens.
On the market.
But I think it's great becausethen you're providing the
building blocks for making thenew skin, and we all know that
that takes time.
You know making the new skinand, yes, we all know that that
takes time.
You know, making the new skinand I forgot to actually mention
(38:49):
that at the start is thatthat's another thing I tell my
patients.
It's like, well, you know, ittakes a while for that, that,
that one new skin cell that'smade and to float to the top.
You know of the epidermis andand then you think of how many
millions of skin cells you needto make to replace all of that
broken skin yeah, it's huge.
Speaker 1 (39:12):
I mean, even if the turnover is, you know, four to
six weekly, you've got toconsider that underlying
inflammation is still affectingthe basal layer.
So you can see quite quickly.
But also, if you're dealingwith major systemic things, it
might take a little bit longer,longer too.
There's just a couple of littlethings I'd love to ask you as
(39:34):
well before we wrap up today,and one of those we have talked
about off air and that was theadvice around bleach baths.
And I know it's a bit of acontentious topic in the sense
that, naturopathically speaking,at first glance it appears to
(39:55):
be a really wrong thing to do,and of course there's a time and
a place for everything andthere's a reason why it became
part of allopathicrecommendations.
So I'd love to hear yourperspective on where you think
they're appropriate and perhapswhere they're not, but
(40:16):
ultimately, their intendedpurpose and place in atopic
dermatitis protocols.
Speaker 2 (40:23):
Yeah, I find that bleach baths are recommended
more for children and primarilywhy they're recommended is to
control staphylococcus aureuspopulations.
And we know that in patients,from the microbiome samples that
are taken from patients whohave atopic dermatitis, that
they appear to have highercolony numbers of staph aureus
(40:47):
and that Staph aureus becomesagain over time involved in the
disease cycle of atopicdermatitis.
So it's important to controlthe Staph aureus numbers, also
because the Staph aureusinterferes with the lipid layer,
it starts to interfere withceramide production and then if
you don't have good ceramidesthen of course your lipid
(41:09):
bilayer and your skin getscompromised.
So there's a really good reasonfor doing bleach baths and it's
probably easier, when you thinkabout it, than applying
antiseptic to your entire body,that you can immerse yourself
into something that and you knowit sounds scary bleach baths,
but they're talking about a fewmils.
(41:32):
It's a controlled amount in avery large volume of water.
It's a controlled amount in avery large volume of water.
Probably what practitionersdon't hear about is that after
bleach baths the protocol is toapply emollients after the
bleach bath moisturisers andemollients because the bleach
(41:54):
will, because, being alkaline,it will increase permeability
and drynessness.
You know there will be what wecall trans-epidermal water loss,
like there is with any dry skin.
But I, um, I think it'sinteresting I was, I was reading
something about this the otherday, about the um sort of you
(42:15):
know, all the marketing aroundproducts that talk about, oh,
but it's pH neutral or it's pHacidic, so it's more appropriate
for people with damaged skin,but no one's ever talking about
the fact that water isn't alwayspH neutral, especially tap
water it's not, and so whenyou're, it's usually a little
(42:42):
bit alkaline and so you thinkabout adding bleach to something
that's already alkaline anyway.
I mean, how much more it's,it's, it's not going to change
the ph that much.
Equally, I think I'm going togo a bit off topic, I won't talk
about that yet but those, themarketing around eczema products
sometimes really bugs mebecause they I think they scare
people into using products thatthey don't necessarily need.
(43:03):
Um, but yeah, bleach baths aregood and and they're good for
the job that they're doing,which is controlling staph
aureus, and they're notrecommended forever.
They're just a control andinfection at that time.
And and I just want to touch ontreating children, because they
are prescribed more for childrenand, um, I think it's really
(43:24):
important because children can.
They're a more vulnerablepopulation.
They can become, theircondition can become unstable
quickly and that if a childstarts having really red oozing
skin they might not even have araised temperature yet but
they'll quickly get a raisedtemperature that they should be
(43:46):
taken very quickly to theirdoctor or an ED and whatever the
prescription is for that I sayfollow it.
Like if the doctor or the EDphysician says that the child
needs antibiotics to control theinfection, then I think it's
always best to err on the sideof caution with that and you can
clean up the mess of theantibiotics later.
(44:06):
But you don't want thecondition to turn into something
that is serious, you know, likecellulitis or something like
that.
That can happen and I don'tthink we sort of I don't think
that always gets explained topatients either around the
primary care of their child'seczema?
Speaker 1 (44:27):
Yeah, very important point, especially with how
quickly kids can deteriorate andtaking quick action if there's
any initial signs of that.
And the very last thing Iwanted to just get your thoughts
on is something I'm sure you'reseeing, unfortunately, more
frequently than you'd like, andthat is the topic of steroid
withdrawal, because certainly inyou know parents who are
(44:51):
treating kids with steroids oradults that are being prescribed
steroids for their eczema.
I haven't really met too manypeople who are like, oh, I
really love that I'm usingsteroids to control my symptoms.
Most of them will say I'm nothappy being on this and I want
to get off it.
But I know, in terms of comingoff steroids, it must be done
(45:14):
really carefully in order toavoid steroid withdrawal, and I
think you've borne witness manya time to when things have gone
wrong there.
Do you want to just highlightthat issue for us and how you
approach that also?
Speaker 2 (45:26):
Yeah, it's a message that I started getting at the
beginning of a treatment program.
I'll really reinforce with mypatients that just because I'm
overseeing your care doesn'tmean you can stop using steroids
, and please don't stop usingthem until you're more stable.
And we've had a conversationand we've got a strategy for
(45:48):
this.
And people still takethemselves off their steroids
and then they end up in a flare,but it's okay, we can clean
that up.
But it is really an important Ithink what's not explained to
patients is how powerful thosemedications are.
Those medications aresuppressing an immune response
(46:09):
and and if you've been using itfor years, it's been suppressing
it for years, and so that theissue with steroids it doesn't
matter whether they're oral ortopical is that everyone
experiences steroid rebound.
When they stop using or takinga steroid, usually there'll be a
transient flare in theirinflammation and that might be
(46:32):
followed by remission afterwards.
If it's been like a short-livedsituation that they've had to
take the medication for and thatwill, that will just
self-resolve.
But when steroids have beenused for months and years, they
have completely disturbed theimmune response and the hpa axis
.
So that's your body's ownability to produce its own
(46:55):
cortisol, and cortisone has nowbeen downregulated because we
all have that ability to produceour own natural
anti-inflammatory.
Cortisol or cortisone is anatural anti-inflammatory and
it's made from cortisol.
So there's a dose, you know,that's circulating around in the
body.
We know that people absorb umsteroids that they apply
(47:19):
topically.
That affects the hpa axis.
Then you know the hypothalamuspituitary regulates then how
much the adrenals create.
Your own adrenals create andthat's probably a lot less.
Now if you've been using it foryears and years and years, then
you're not making as much asyour own cortisol.
So you take that drug away andthen there's nothing left.
(47:40):
There's no safety net.
That's what the topical steroidwithdrawal syndrome is all
about.
It's that patients haven'tallowed and this is not their
fault.
It's not explained to how thedrug affects their body.
But that, sorry, what was Isaying?
So you withdraw the drug.
But body, but, uh, that, um,sorry, what was I saying?
So you withdraw the drug.
But that actually needs to bedone slowly so that the whole
(48:04):
physiology can catch up with thechange that there's this.
So if you withdraw the druggradually, there's less of it
available.
Then that feedback mechanismthrough the hypothalamus
pituitary adrenal axis can startto catch up and it'll be latent
, just like every um endocrineaxis.
There'll be a lag and then theamount of cortisol and cortisone
(48:26):
that your body's making willstart to slowly increase.
But we don't know how longthat's going to take and it's
going to be different for everypatient.
It's going to be dose dependent, how the duration of the
cortisone management, the, thepotencies of cortisone that
they've been using, thefrequency you know it's, and
(48:48):
also how permeable their skin is, because that's the other thing
is like the more permeable andbroken your skin is, the more
cortisone cortisol you're goingto absorb.
So when you've got a damagedbarrier, your absorption of the
cortisone and cortisol topicallythe cortisone topically is
going to be higher anyway so I'musually doing all of that work
(49:09):
with my patients, that thatpre-work that I talked about and
then I have a conversationabout now.
Let's try and step down thecortisone use, and so that might
be like probably reducingfrequency first, like keeping
the dose and the type of thecream or ointment exactly the
same and then reducing thefrequency.
(49:30):
So if they're using it threetimes a day, then we go down to
reducing it twice a day and thento once a day and then every
other day, but all the while Imean it's your patient, right.
So you've got to be workingtogether to figure out what is
the tolerable dose that they canreduce their steroids without
feeling uncomfortable.
Or, if there is discomfort,it's a manageable amount of
(49:53):
discomfort.
And that's really the realityof it is that it's going to be
walking the line of manageablediscomfort while the patient is
reducing the steroid, as well aswhatever other topical
supportive management thatyou're doing.
Speaker 1 (50:11):
That's such a comprehensive and intentional
approach in terms of taperingcadence, making sure that you've
actually got support underneathand you've addressed some of
those root causes before youbother, and then managing it as
you go through.
Gosh, this whole conversationhas just been full of so much
practical, clinically applicableinformation, rebecca.
(50:34):
So thank you so much for yourtime and for taking us through
everything you know about atopicdermatitis.
Speaker 2 (50:42):
Yeah, you're welcome and you know for I think we
talked about it off air thatpractical advice is what I like
to impart to my patients and toother practitioners who
sometimes approach me formentoring, and because of that
I'm soon be releasing a coursethat's to support practitioners
(51:02):
in treating atopic dermatitisconfidently.
Speaker 1 (51:07):
That's going to be so powerful, and we will make sure
we put a link in the show notesso that you can connect with
Rebecca and hear about that assoon as it's available.
So thanks again, rebecca.
That's so wonderful to haveyour brains accessible to the
rest of us who want to divedeeper into this, and thank you
for joining us today.
(51:27):
Remember, you can findeverything we talked about in
the show notes or on the Designsfor Health website.
I'm Amy Skilton and this isWellness by Designs.
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