Derm-It Trotter! Don't Swear About Skincare.
Feeling frustrated or overwhelmed with everything skin? Does the skinformation overload make you want to swear about skincare? Join Dr. Shannon C. Trotter, board certified dermatologist, as she talks with fellow dermatologists and colleagues in skincare to help separate fact from fiction and simplify the world of skin. After listening, you won’t swear about skincare anymore!
Derm-It Trotter! Don't Swear About Skincare.
Atopic Dermatitis Secrets Part 2
Discover how stress can take a toll on your skin with insights from our esteemed guest, Dr. Matt Zirwas, who has spent over two decades unraveling the mysteries of eczema. You’ll gain a new understanding of the powerful connection between stress and atopic dermatitis and why managing stress is crucial for skin health.
We also learn that the foods we eat can impact eczema by altering our gut microbiome. This episode challenges conventional wisdom, suggesting that the key might not be avoiding certain foods but rather nurturing a healthy gut with probiotics. From dietary considerations to cutting-edge treatment strategies you'll hear several ways eczema may be managed.
Welcome to Dermot Trotter Don't Swear About Skin Care where host Dr Shannon C Trotter, a board certified dermatologist, sits down with fellow dermatologists and skincare experts to separate fact from fiction and simplify skincare. Let's get started.
Speaker 2:Welcome to the Dermot Trotter, Don't Swear About Skin Care podcast. We've got another podcast that's going to surely excite you today as we talk a little bit more about atopic dermatitis and some things you probably didn't know about how stress impacts it and, of course, treatment. I've got with me Dr Matt Zyrus. You know well he's focused on eczema for the last 20 years of his career, written a textbook, led sure to thousands of dermatologists, over 200 peer-reviewed published articles. So we've got an expert in the house to talk with us about this topic. So welcome to the show, Dr Zyrus. Thank you, Dr Trotter. So I know one thing that we all complain about in today's world we're all stressed, you know, we're pulling our hair out, we've overscheduled, overworked and we all see it impact our health.
Speaker 3:And a lot of people know how does this really affect the skin, especially in regards to atopic dermatitis? Yep, so this is a really interesting question. So we first let me just say we don't have fantastic experimental data on this, but we've got more than you would think. So I'm going to be extrapolating a little bit from data looking at skin barrier function in stress. But first let's go back for a second and talk for a minute about stress.
Speaker 3:So when we talk about stress from a medical perspective and I know you know this, but for the listeners, really a stress state primarily is a hormonal and neurological state. So whenever you're under stress, you're releasing more hormones like cortisol, norepinephrine, epinephrine, things like that, and then you also have increased autonomic nerve stimulation, and so the physiologically Right stimulation, and so the physiologically right. So the first thing is, whenever we talk about stress affecting atopic derm, it is absolutely nothing like oh, it's in your head or you think you feel itchier because you're anxious or something. No, that is not it at all. It is the stress that significantly affects your body physiologically. The analogy that I always give people to really hammer home the idea that this isn't like in your head is I often talk about Pavlov's dogs, but in the human sense. So I say, look so, think about it like this when you smell, if you're hungry and you smell food, that is your favorite food. When your mouth starts to water, that's all in your head, right, because you smell the food, your brain knows that that's going to relieve your hunger, so it's getting ready to eat and your mouth starts to water. Okay, great, now that you know that it's in your head, you should be able to fix it right. So next time you smell, you're hungry and you smell something really delicious, just fill your mouth water. No, you can't do that Right. You cannot overcome your body's autonomic nervous system and so it's not all in people's heads.
Speaker 3:So now to get into really what the data is. So this has been looked at in both what you would call subacute stress and chronic stress. And so for subacute stress, they looked at college students and looked at skin barrier function how well your skin protects you from the environment, which we know is the fundamental problem in eczema. How was your skin protect you from eczema? They looked at that kind of right whenever they got back from a new, from a break. So they were very, you know, college students unstressed, not relaxed, how their skin barrier function was. Then they looked at skin barrier function during finals week. So subacute stress, dramatic changes in skin barrier function, reduced lipid production, probably related to steroids, to the cortisol that your body makes naturally. And then they also looked at chronic stress by looking through people going through contentious divorces, and again showed that stress dramatically affects you know skin barrier function and skin physiology.
Speaker 3:Now also, I'm a firm believer. So we know for sure, for example, that sweat makes atopic dermatitis worse and autonomic nervous function causes increased sweating, and so we know it's more than just the physiologic effects on the skin. So now the problem becomes okay, if you're somebody who has atopic dermatitis, you already know well, if I get stressed it makes me worse. Ok, great, right. So can I help? Can I? Is there something we can do?
Speaker 3:Probably the only things that I would suggest and there are no data to really back this up, but you know the both non-pharmacologic and pharmacologic approaches should be helpful. So there is some data showing that hypnosis can be helpful in atopic dermatitis. If hypnosis is helpful, then we also know that. Probably we should know that meditation would be helpful. I would imagine that pharmacologic approaches, so things like antidepressants and SSRIs may be helpful, although I haven't seen any real data about that.
Speaker 3:The one thing that we do have good solid, pretty rock-solid data on is melatonin, and so we know that stress affects circadian rhythms, can affect sleep, and when they've looked at melatonin as a sleep aid, as a replacement for, say, benadryl or hydroxyzine, actually found that sleep improved and atopic dermatitis improved. And so you know, getting good sleep uh seems to be an important thing as well. But, right, if you're itchy it's pretty darn hard to sleep. So, uh, but those would be. I don't have a great answer for like. So, if something stressful is going on, do this, uh, but we definitely know for sure that stress makes atopic dermatitis worse via direct effects on barrier function, probably has direct effects on immune function as well Not even probably. We know stress affects your immune function, but may push it in a TH2 direction and then through activating your autonomic nervous system as well no-transcript.
Speaker 2:The role of melatonin. You know people want alternate solutions to manage their skin. What are some of the complimentary alternate therapies that you like to recommend to patients and what's the evidence that says it really makes a difference?
Speaker 3:So fantastic question. And let me tell you I am a really strong believer in the effectiveness of what we would call non-traditional therapies. But the challenge becomes there are so many non-traditional therapies available. How do you determine what are you going to recommend? And then it's not just okay if it works, but it costs an exorbitant amount $400 a month in supplements or something, or some really expensive blood testing or stool testing. We know for sure that it's really, really going to be helpful. It's hard for me to recommend that, so I stick to things that number one we have really good evidence for and number two, that are cheap, and so we actually have several of those things.
Speaker 3:So first I mentioned melatonin. We've got randomized double-blind placebo-controlled trials showing that melatonin helps. I don't recommend it very frequently, but it does help, and that's because I'm typically taking care of people with severe eczema who really need aggressive pharmacological therapy, and that's going to get them so much better that they don't need something like melatonin. But for somebody with mild to moderate atopic dermatitis, I think melatonin can make a big difference. I recommend five milligrams QHA at night. If it's a kid, I recommend one milligrams QHA at night. If it's a kid, I recommend one or three milligrams at night, and again, we have randomized, double-blind, placebo-controlled trials to support that.
Speaker 3:Other things that I recommend to just Now. The next two things I recommend to everybody. So the first is an oral ceramide supplement. So ceramides are the special, key component of your skin barrier that helps seal water in and keep irritants out, things that might trigger eczema. And, believe it or not, we have much better data that taking them by mouth helps your skin barrier function Much better data for that than we do for putting them on topically, and so we have randomized, multiple randomized, double-blind, placebo-controlled trials showing that taking ceramides by mouth improves barrier function.
Speaker 3:The one in particular that I recommend is from a company called Life Extension. You get it on Amazon. It's about 16, 17 bucks a month. It's from a company called Life Extension. I have no connection with them, I don't make anything from this, but it is called Life Extension Skin Restoring Ceramides. It's one small pill a day and I tell people give it about three months to see if it's going to make a big difference and the way that I describe how that's working.
Speaker 3:I tell people your skin is supposed to look like this and nothing can get in or out. Well, if you've got atopic derm, either genetically or from long-term damage, from environmental chemicals. Your skin looks like this and has these gaps in it. They're letting things in to irritate you and letting water out. So your skin gets dry, so the ceramide acts as a. Water out, so your skin gets dry, so the ceramide acts as a. It fills these gaps in and people get that idea.
Speaker 3:So ceramides, then the next one after that, and then I recommend everybody is a probiotic and we have multiple studies showing that particular probiotics definitely help, while as other probiotics definitely do not help. So there are certain strains that we need to get. There are four in particular. I can never remember the names of the four, but the probiotic that I recommend is called NOW N-O-W. Can you get it on Amazon? This one's about eight bucks a month. Now N-O-W is the brand Probiotic 10, meaning it has 10 strains of bacteria in it and then they make different strengths. I recommend the 25 billion. It's the most cost effective. It costs about eight bucks a month.
Speaker 3:And what that one is doing. We know that a big reason for the atopic dermatitis epidemic over the last 50 years has been the American diet and in particular, the American diet upsets the natural healthy microbiome, and a natural healthy microbiome is supposed to be making substances that help calm your immune system and keep it regulated, and so we need to replace those natural healthy bacteria with this probiotic. And really, where you go with this one is if the patient says that diet, you know I have to avoid certain things, or I flare. What should I be avoiding? What should I not be avoiding? It's not. There's nothing they're going to be able to figure out long-term. That is a avoid this. What really is happening? There are certain foods that are going to cause relatively acute changes in the microbiome, uh, and that then makes people flare, and so you in which foods it is going to change over time. So instead of of telling people to go see an allergist or avoid certain foods, you're trying elimination diet. You put them on a probiotic, and that is helping to calm down and regulate their immune system. And then and again now probiotic, and that is helping to calm down and regulate their immune system. And then and again now probiotic. 10, 25 billion.
Speaker 3:And then the third supplement or the fourth. So right, we got melatonin ceramides, probiotic. Then the fourth one that we have randomized double-blind placebo-controlled trials for is high omega-3 fish oil. And there again we know the American diet. You have way too much omega-6, which is pro-inflammatory, and not enough omega-3, which is anti-inflammatory. And so we have people we have randomized double-blown super controlled trials it's at least 500 milligrams a day of omega-3. And really any. Again I recommend from Life Extension. They make a super omega-3. That's what I take personally. Uh, I take actually all of these uh things personally, even though I don't. I don't take the ceramides, but I take the probiotic and the fish oil. Uh. So the the life extension, uh, super omega-3. And again we've got randomized double black placebo controlled trials supporting that.
Speaker 3:Now I don't recommend the fish oil to everybody and that is because the ceramide is one small capsule a day, the probiotic is one small capsule a day and if you can't take a capsule you can open it and pour it on food. But the fish oil is four big pills a day, so it can end up becoming a lot for the fish oil in terms of how much you have to take. But those are the supplements that I recommend. I don't recommend any topicals. So you know, some people talk about even primrose oil, sunflower seed oil, things like that. Never seen any real data that anything topically really makes a difference. But those are the oral supplements that I recommend for people with atopic derm. So and again, the fish oil. It's an anti-inflammatory, the probiotic is to regulate the immune system and the ceramides are to help restore barrier function. And all things together I would say that those supplements get people 10 to 20 percent better. Now it's actually more.
Speaker 3:What I would say is it reduces the severity of eczema by one to two steps. So if we put eczema on a 10 point scale zero, you're perfect. Ten is the worst you could possibly imagine being. If you're an eight, I think it takes you to a six or seven. So it's not like, oh, if you've got bad eczema takes you to a six or a seven. So it's not like, ooh, it's, if you've got bad eczema, you can get better with the supplement. No, but if you're a two or a three and I can take you to. Or if you're a one, two or three and I can take you to a zero or one by getting you one or two points better. I have a lot of patients who don't need to use any topicals as long as they are using the oral supplements. So they do make a difference. They all have randomized, double-blind, super controlled trials, and those are the three that I know for sure have some benefit.
Speaker 2:And if somebody wants to take those, as you mentioned, better part of a more complete treatment regimen, which we'll talk about another broadcast, but you mentioned, you know a little bit of a concern which I think is important to bring up. You know the food connection. So when you have somebody come in it's like oh, this food is definitely making me break out. I need you to send me to an allergist. How do you handle that? Like what do you tell patients? Like the real role, potential food allergies and their atopic dermatitis, because I think people think it's much more of a true cause than what it really is. So, trying to dispel that myth and how we work with allergists, but really it's more of a complimentary approach.
Speaker 3:So I will talk about two different things here. So I do think that there's a role for allergists in treating some cases of atopic dermatitis with allergy shots. We have some data to back that up. But first to talk about how do we talk about food allergy? So the first thing we've got data that tells us that about two out of three patients with eczema, food is a triggering factor for them. So it's not, you know I don't talk to because 10 years ago, even five, three, probably three to five years ago I was still telling patients it's probably a coincidence, I know it seems like every time you eat that food you get worse, but really it's just that eczema kind of gets better or worse on its own. It's probably coincidental. Patients hated that answer and, to be honest, I think that answer was wrong answer and, to be honest, I think that answer was wrong. So once I understood more about the microbiome, now I will proactively bring diet up, because it seems so that from the patient perspective, if they bring diet up and then I give them the answer I'm about to give, they often take it as like I'm making something up just to placate them, whereas if I bring it up proactively, then they feel like, oh, this guy knows what he's talking about. He brought up food. Most doctors tell me food's not an issue, so I will proactively often bring up hey.
Speaker 3:So about two-thirds of my patients with eczema tell me that food is a major trigger for them, but they usually can never pin it down to just one or two foods. Does it a trigger for you? And if they say no, then I'll still be like, well, it might become a trigger, so we're going to, and if they say yes, then it's much easier though. So if they say yes, then I say okay. Now it's a really interesting thing, because we know that food allergy never makes eczema worse. So now, food is definitely causing your eczema to flare, but it's not a food allergy. Food allergies show up as stomach aches, abdominal pain, maybe hives, like you know, if you ever know somebody who's allergic to peanuts, like if they eat a peanut, they die immediately. That's what food allergy is. Food allergy is never my eczema gets worse, so, but food is definitely. Food is definitely making my eczema gets worse, but food is definitely making your eczema worse.
Speaker 3:It's not an allergy. It's that food is really processed in your stomach and in your intestines by the natural healthy bacteria that are supposed to be there, and we know that the American diet things like food additives, food preservatives, emulsifiers, antibiotics, hormones you know all of those things in food are upsetting the natural healthy bacteria. Then, once that happens, certain foods and which foods it is will change over time, because the bacteria are always changing will make that worse and make those bacteria even more unhappy and then so that can make your eczema worse. And so the key isn't to figure out which foods to avoid, because it's changing all the time. You're going to you will notice sometimes you know, for a few months, anytime I eat tomatoes I get worse, and then suddenly you can eat tomatoes just fine, but now anytime you eat corn you get worse. It's, it changes over time. So it's not about finding the foods to avoid, it's about getting that natural bacteria healthy again, and we're going to fix that by having to start to take this probiotic Now. Patients really appreciate that.
Speaker 3:Now to talk about the role of allergen immunotherapy, so particularly for dust mites.
Speaker 3:So we've got fairly good evidence that doing immunotherapy for dust mites for people who are highly allergic to dust mites does seem or not. Even people will often get severe reactions from the shot, either locally or they could get a systemic reaction where their airway starts to close off. They're like in the allergy office it's an emergency. But if you've really got somebody, that you're somebody who's really stuck and nothing's working for their eczema, it can be very reasonable, especially for dustbite to get tested and then, if you are allergic to dustbite, to get treated for dustbite allergy. But again, it is not easy treatment and then even if you are able to get through the initial few shots, which is where you see most of those side effects, then you've got to be going into the allergy office like once a week, you know, for a year essentially to get shots, and so it could be a real challenge. But in tough cases it can be helpful. But that's about the only place that I've really seen data or clinically experienced that allergy shots really helped.
Speaker 2:Well, that's great information. I think that clarifies you know a little bit of where patients you know want to jump the allergy train quickly, which we know. A lot of people with eczema just happen to have seasonal allergies as well or allergies to other things. But the relevance to the eczema or atopic dermatitis is part of what the question is and where we can work with allergy to figure that out if it's worthwhile. So we got some really good secrets and tips from you here today and we're going to wrap up the podcast because next time we'll have you on to talk a little bit more about the pharmaceutical therapeutics that are variable, you know, available for patients. Which one works, which one is better, which one do you think is the right time for a patient to start on? So we'll dive into that a little bit deeper on our next episode. But I want to thank you, dr Zyrus, for all the information today. They got people thinking twice and they stop in that supplement aisle or maybe look online that they have alternatives to help with their atopic dermatitis.
Speaker 3:And and the big thing with the uh, with the supplements, I always tell people give it about three months. Uh, you know, get on all three of them. You know, if you're going to, if you're going to do it, at least the two, the ceramides and the probiotics, uh, and give those at least three months. And I'll even tell people give it six because we know they're good for you in general. It's really just a matter of is it worth spending the $25 a month to be on them, and I think you can figure that out in three to six months.
Speaker 2:Great tip. Great tip. And for those of our listeners that want to find you, where can they find you? Online, available or everywhere?
Speaker 3:I stay under the radar. They can find me on the Dermot Trotter podcast. I do no social media or anything else of my own, and so I'm really not out there anywhere.
Speaker 2:All right, we'll find him here on the Dermot Trotter podcast and maybe we'll be able to get him into one of our future parodies or TikTok or Instagram videos. We'll try, we'll try. We'll introduce him. I would love it. Great Thanks, thanks again.
Speaker 1:Thanks for listening to Dermot Trotter. For more about skincare, visit Dermot Trottercom. Don't forget to subscribe, leave a review and share this podcast with anyone who needs a little skincare sanity. Until next time, stay skin smart.
