Peter A. Lio, MD, is a big user of the "big guns" for his patients with atopic dermatitis — biologics, conventional immunosuppressants, and JAK inhibitors. But he also has a big menu of treatments — from oral hempseed oil and black tea compresses to probiotics and acupressure — that he encourages patients to try as they use the big guns, or as they attempt to wean off of them or avoid their use altogether.
During a presentation at the annual Integrative Dermatology Symposium, Lio said that he uses "5 pillars" to guide his integrative treatment plans: The skin barrier, the psyche, the microbiome, inflammation, and itch. "I try to flag approaches that predominantly address the categories that I think need the most help," he said. "And I tell patients [which pillar or pillars] each treatment is addressing."
Most commonly, the greatest challenge with AD — and the "single biggest weakness of conventional Western medicine" — lies not with getting patients clear in the first place, but in keeping them clear safely, he said. "I don't think that using immunosuppressive [medications] is okay for the long-term unless there is no other choice," said Lio, who cofounded the Chicago Integrative Eczema Center about 6 years ago and is clinical assistant professor of dermatology and pediatrics at Northwestern University, Chicago. Oftentimes, he said, complementary approaches, including dietary changes, can also serve as supportive adjunctive therapy to biologics and JAK inhibitors.
He has three main criteria, or "filters," for evaluating these treatments before recommending them to patients: At least some clinical evidence for efficacy (preferably randomized trials but not necessarily), safety, and practicality. The "only way we're going to move things forward [for AD and other conditions] is to try out less tested treatments...to open up to them," Lio said in an interview after the meeting. And in doing so, he said, dermatologists "can connect with a lot of patients whom naysayers can't connect with."
An Integrative Menu
Lio individualizes plans, suggesting treatments after "listening to patients' stories" and considering their age, history, symptoms and skin presentation, and other factors. He said he "goes little by little," telling a patient, for instance, "I'd love for us to try adding a little hemp oil to your diet."
If patients aren't pleased with or are tired of treatments, he said in the interview, "we move on and try something else."
At the meeting, he described some of the treatments on his menu and the supporting evidence for those treatments:
Oral hempseed oil. A randomized crossover study of 20 adult patients with AD found that daily consumption of 2 tablespoons of hempseed oil decreased skin dryness, itchiness, and use of topical medications compared with consumption of olive oil. "It was statistically significant and seemed clinically meaningful," likely resulting from the high concentration of polyunsaturated fatty acids in the oil, Lio said.
Topical vitamin B12. In a phase 3 randomized controlled trial of topical B12 applied twice a day for 8 weeks, patients experienced significant improvements in the extent and severity of AD compared with placebo. Another study in children with AD aged 6 months to 18 years found significant improvement in as early as 2 weeks of use. "It really does help, and is very gentle in babies," Lio said.
Black tea compresses. "It's absolutely my favorite kind of compress," he said. "It was studied on the face and eyelids but I use it all over the body for adults and kids." A German study of 22 patients with AD or contact facial dermatitis showed significant improvements in facial dermatitis within the first 3 days of treatment with application of black tea dressings plus an emollient cream, with significant reductions in four disease activity scores (the Facial Eczema Area and Severity Index, visual analog scale for pruritus, Investigator's Global Assessment score, and Patient's Self-Assessment Score) that continued through day 6.
Oolong tea. In a 2001 study, after 1 month of drinking oolong tea after each meal, 64% of patients with recalcitrant AD who continued with their regular treatment showed marked to moderate improvements in AD, with a beneficial effect first noticed after 1-2 weeks. At 6 months, 54% still had a good response to treatment. "It's super cheap and accessible," Lio said.
Coconut oil. One of the greatest benefits of coconut oil is on the microbiome and the dysbiosis that can result from a disrupted, or "leaky," skin barrier — especially overgrowth of Staphylococcus aureus, which "drives AD," Lio said. In a study of adults with AD from the Philippines, topically applied coconut oil decreased S. aureus colonization by 95% when applied twice daily for 4 weeks, compared with a 50% decrease in an olive oil control group. Other research has shown coconut oil to be superior to mineral oil as a moisturizer, he said at the meeting.
Acupressure. After a pilot study conducted by Lio and colleagues showed greater decreases in itch (per the visual analogue scale) in adults with AD who applied an acupressure bead at the LI11 point (near the elbow) for 3 minutes three times a week for 4 weeks, than among those who did not use the acupressure tool, Lio began trying it with some of his patients. "Now I use it broadly," he added in the interview. "Kids over 10 can figure out how to use it and teenagers love it [to relief itch]. Some don't use the beads anymore, they just use their fingertips."
Advice on Diet, Vitamin D, and Probiotics
AD severity is "powerfully" correlated with IgE food allergy, but Lio said at the meeting that he currently takes a cautious approach toward strict elimination diets.
There is a growing school of thought among allergists, he said, that positive IgE tests without evidence of acute reactions may not indicate true allergy, but rather sensitivity — and may not warrant food eliminations. And as has been shown with peanuts, there can be a serious downside to elimination, as food avoidance can lead to serious allergy later on, he said.
"More and more people are thinking that if you can tolerate [a food], continue it," he added in the interview. In the absence of clear reactions, the only way to really know if a food is making eczema worse is to do a double-blind, placebo-controlled food challenge test, he noted.
Patients often come to see him believing that food is the "root cause" of their eczema and feeling frustrated, even anxious, about strict dietary restrictions they've implemented. But for many of these patients, the right question "would be to ask, why is my eczema causing my food allergy?" he said at the meeting, referring to the epithelial barrier hypothesis, which posits that skin barrier dysfunction can lead to asthma, allergic rhinitis, and food allergy.
Lio often recommends the Autoimmune Protocol (AIP) diet, a "close cousin" of the paleo diet for patients with AD, as general guidance to be followed "holistically" and often without the strict eliminations it prescribes. Minimizing processed foods and dairy and grains, which "can be inflammatory in some people," and focusing on whole, nutrient-rich foods — all in keeping with the AIP principles — should have positive effects on the microbiome, overall health, and likely AD as well, he said.
Across the board, Lio recommends vitamin D (at nationally recommended dosages) and probiotics. Vitamin D has been shown to significantly help a small percentage of patients with eczema, he said, so he advises patients that it's worth a trial. "I tell patients that I don't know how to pick that small group out, so let's try for a few months and see," he said. "Inevitably, a percentage of patients come back and say it makes a huge difference."
Lio's understanding and use of probiotics has been "dynamic" over the years. "The best, most reliable evidence" that probiotics can improve AD symptoms comes with the use of multiple probiotic strains together, he said. Based on limited but growing literature, he ensures that recommended formulations for babies include Lactobacillus rhamnosus, and that formulations for adults include Lactobacillus salivarius.
Lio works closely with dietitians, hypnotherapists, and psychologists — and will occasionally refer interested patients with AD to a Chinese medicine practitioner who personalizes the use of herbal formulations.
Lio reported no relevant disclosures.
This article originally appeared on MDedge.com, part of the Medscape Professional Network.
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Image 1: Dr. Peter Lio
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Cite this: An Integrative Approach to Atopic Dermatitis Features a Long List of Options - Medscape - Nov 03, 2022.