Welcome to the fourth episode of our podcast series, “Atopic Dermatitis In Skin of Color.” The podcast series examines the importance of diagnosing, managing and treating atopic dermatitis (also called eczema) in people of all skin colors.
This episode addresses “Medications for Treating Atopic Dermatitis” – everything from topical and oral steroids to more advanced treatments such as JAK inhibitors and biologics.
The podcast is a joint collaboration between Allergy & Asthma Network and The Itch Podcast led by co-hosts Kortney Kwong Hing and allergist/immunologist Payel Gupta, MD. Kortney and Dr. Gupta once again speak with special guest and social media influencer Shiv Sewlal, who lives with severe eczema.
You can also listen to or download the podcast on ItchPodcast.com for listening anytime, anywhere. The podcast can be downloaded at:
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In this Episode…
- 1:25 – Topical treatments for eczema
- 2:32 – Topical treatments and skin of color
- 3:00 – Alleviating fear of topical steroids
- 5:10 – A look at topical steroid withdrawal
- 9:35 – Other topical treatments: calcineurin inhibitors, PDE4, JAK inhibitors
- 13:10 – Use of oral steroids for atopic dermatitis
- 16:20 – Antibiotics and eczema: For infections only
- 19:12 – Are antihistamines helpful for atopic dermatitis?
- 20:10 – A pill for AD: JAK inhibitors
- 21:30 – Biologics for AD: dupilumab and tralokinumab
- 23:15 – Side effects for biologics
- 25:04 – Shiv Sewlal on taking steroids, wet wrap therapy and antibiotics
- 28:15 – How light therapy works for eczema
Transcript
Kortney Kwong Hing: You’re listening to The Itch, a podcast exploring all things allergy, asthma and immunology. I’m your co-host Kortney, a real-life allergy, asthma and eczema girl.
Payel Gupta, MD: And I’m your second co-host, Dr. Payel Gupta, a board-certified allergy, asthma and immunology doctor. Kortney and I hope to balance each other out so that we get you all the information that you want and need about allergies, asthma and immunology.
Kortney: Finally, we are talking about how to treat atopic dermatitis in all skin colors, but with extra tips for those with skin of color. If you have been following this current “Atopic Dermatitis in Skin of Color” series in partnership with Allergy & Asthma Network, you know we have talked about what atopic derm is, how it is diagnosed, and strategies to help keep your skin as healthy as possible.
If you are just tuning in, you may want to jump and listen to our other episodes for a base understanding of AD in skin of color, as we have a huge amount of information to try and cover in the next 30 minutes. I know that there are a ton of different therapies available that we will be discussing, like topicals, oral medication, and injections.
So, Dr. G, where do you think we should start?
Payel: Let’s start with topical treatments for eczema. The most commonly used treatments for eczema are topical steroids. Steroids help because they reduce inflammation and help the skin heal. We use topical steroids specifically when the skin is experiencing a flare and we need to get rid of inflammation and irritation.
There are different strengths, or potencies, of steroids, and your doctor will help you choose the potency based on how severe the eczema is. So our general rule of thumb is that for areas such as the face, neck, armpits, groin, and sensitive areas where the skin is thinner, we will choose a lower potency steroid. The rest of the body can handle a higher potency if necessary.
Kortney: What I’m hearing is that topical steroids treat inflammation and why that’s important, which is what we discussed in our first episode, is that inflammation is what causes those long-term skin issues, such as hyper- and hypopigmentation and thicker skin – which you said is more common in skin of color.
Payel: Yes, let’s just recap this because it is a really important point for patients with skin of color. Discoloration is more common in skin of color and essentially the earlier we treat eczema with the appropriate medications, the less we should see these negative consequences.
Kortney: Early treatment is really important in all skin colors, but especially skin of color. If I am honest with you, I knew that I needed to seek treatment in the past and did not because I felt like I could deal with it, until I couldn’t. One reason was this irrational fear of steroids and becoming dependent on them. I have heard from others – they are also nervous about steroids. Can you unpack for us where this fear of steroids may be coming from?
Payel: Yes, I understand the fear that people have with steroid medications but there is a difference between topical and oral steroids and I think that people group them together – which causes that fear and anxiety. Oral steroids can have systemic side effects which can be very dangerous and we will review those later in the episode.
But with topical steroids, if you put them only over the skin where the eczema flares are, and no more than twice a day and only for a short amount of time – the side effects should be minimal. And that’s really our goal with therapy.
Most of the time, the skin will improve markedly within a couple days just with bathing, steroids and ointments, but sometimes you need to slowly taper the frequency of the steroids to prevent the skin from flaring again. There is a risk of skin thinning, a change in the color of the skin or an acne type reaction with topical steroids, but we generally see that if you aren’t using the steroids as prescribed. If you see these side effects it is best to stop the medication and talk to your doctor. Most of these things will resolve over time after you discontinue use of the medications.
In addition, most of these side effects will present in more sensitive areas like the eyelids and face in general, and then the genitals. It is important to monitor the side effects from any medication used and for patients to talk to their doctor to request a change in therapy, if needed, earlier rather than later.
Kortney: So the bottom line is we shouldn’t really be scared to use it. I can speak from personal experience that using a topical steroid gave me the first few itch-free days in years! What about topical steroid withdrawal? This has been popping up on my social media feeds a ton and I think it is also contributing to a fear of using any form of medication to treat AD.
Payel: Withdrawal of topical corticosteroids after using steroids for a prolonged period of time, which is considered 2 weeks or more – it sometimes occurs after less than 2 weeks of use, but it is generally seen in patients who use topical steroids daily for two months or more.
We see a varying constellation of signs and symptoms including erythema, burning or stinging sensation, pruritus (itching), pain, and facial hot flashes. These symptoms occur days to weeks after steroid discontinuation and are more likely to occur on the face or genitals.
The duration of acute topical corticosteroid withdrawal is variable; the skin can take months to years to return to its original condition. The duration of steroid use may influence the recovery factor time, with the patients who used steroids for the longest time reporting the slowest recovery.
Kortney: Is there any way to know if this may happen to you? What about tapering your topical steroid use?
Payel: There is no way to tell if you will get the withdrawal symptoms unfortunately. I think that the rule of thumb is that it is best to use topical steroids for a short period of time in only the necessary areas.
Sometimes what happens is that a patient comes in after using the steroid for a long time and that is when I will try and have them taper off of it to hopefully prevent the occurrence of withdrawal.
Kortney: Thank you for explaining that. Before we get into more on oral steroids, what about things that are over the counter like hydrocortisone cream? What should someone consider when using it?
Payel: Over-the-counter hydrocortisone is a mild strength topical steroid but is still a topical steroid so the same rules should be followed.
Kortney: To recap, topical steroids come in many potencies and your doctor will help determine the one you will need based on your specific case. We don’t want to use topical steroids for a prolonged time and they should be used only on the areas where you have your eczema. Finally, we should not be afraid to use them because the earlier you treat your inflammation the less likely you will have long-term effects like discoloration.
I know there are a lot of different options for topical treatments. What about other topicals that can be used and that are available by prescription?
Payel: So in the last 20 years or so, we actually have a lot more medications that we can use for atopic dermatitis, including three classes of medications that do not contain steroids.
One is called calcineurin inhibitors – you may have heard of tacrolimus (or Protopic) and elidel (or pimecrolimus). The other is called a phosphodiesterase 4 inhibitor, crisaborole (or Eucrisa). And lastly, the newest on the block, there are topical JAK inhibitors. These medications are great because they can help patients keep their skin healthy so that we don’t need to use topical or oral steroids. If you haven’t been offered these medications, it is important to ask your doctor or consult with a specialist.
Kortney: Since these are not using steroids, what should people know about them? Like are they also only supposed to be used for a short period of time? What are the side effects? Can I bucket them all here or should you break each one down?
Payel: We can quickly talk about each of these categories but they are all different medications.
For the tacrolimus and pimecrolimus – these medications can be used intermittently like steroids but can also be used in what we call an intermittent long-term way. This means that we use them once a week in areas that are usually problematic for patients. The most common side effects are transient burning, redness and itching. They have also been linked to cancer – but these concerns haven’t completely been validated and I have never seen it in my practice. Limiting use to only select areas and for short periods of time or using them once a week to keep the skin under control are usually my recommendations. Again, the risk of cancer really hasn’t been completely established. I use it on myself and recommend it all the time – but with anything, limited use is best.
For Eucrisa – this is more of a daily ointment that can be used to improve the skin barrier. It is applied twice a day to areas that are affected by atopic dermatitis. It doesn’t have too many side effects. Some people have burning with it and cannot tolerate it, but it isn’t associated with any other scary side effects.
And lastly there are new JAK inhibitor medications that help tamp down your overactive immune system. Topical JAK inhibitors are used like tacrolimus and pimecrolimus for short-term or long-term intermittent use. Like any other topical agent, some people don’t respond as well to these medications as others do, but in general they are well tolerated. And I feel that in patients with skin of color it is important to add in these alternative medications in between and during flares so that we prevent the disease from getting to the point of a severe flare, which leads to the skin discoloration and thickening we discussed previously.
Kortney: That was a lot of information. Did we cover all types of topical medications?
Payel: Yes, so we can move onto the oral medications that patients may be prescribed. Let’s first discuss oral steroids. Oral steroids should be reserved as a last resort in general but unfortunately patients get them prescribed often by the ER or their primary care physician and that leads to patients over-relying on these therapies. As we know oral steroids have a lot of risks associated with them. We can use them for severe exacerbations and absolutely need to at times – but they should be reserved for very short-term use and not prolonged use and ideally not more than once a year if even that.
Kortney: It sounds like you should try to avoid going to the ER as much as possible because they may only be giving you oral steroids when really you need to be most likely using a topical treatment?
Payel: Yes, so the ER and urgent care centers out there are really for emergencies – these doctors are really good at helping save people when they are about to die but they are not trained in how to keep conditions under control. Each doctor has a different type of training and we have to remember that. So, yes – they will go to oral steroids because that is the medication that they know will help quickly. They also don’t know how many times you might have used oral steroids in the past year, and the side effects, and all of those things need to be considered when we are managing chronic conditions like eczema. This is also very true for asthma.
Kortney: I don’t think we need to go into much more detail about oral steroids, because as you mentioned, they are a last line of defense. Another medicine that I have heard other people getting prescribed for AD are antibiotics. Can you tell us why this would be?
Payel: Yes. So antibiotics should also rarely be used in patients with atopic dermatitis but they might be needed when the skin gets to the point of infection. With the itch, scratch and rash cycle – we need to remember that our nails are dirty and that can cause the skin to get infected, when the skin barrier is broken by scratching.
Kortney: Ah yes, I have heard of people getting staph infections, so this may be why.
Payel: Yes, staph is a common cause of these infections. We all naturally have bacteria in our skin, sometimes we scratch so much that we can introduce bad bacteria into an area where the skin is open. You can get things like cellulitis with inflammation, redness, swelling, and sometimes even a fever or an infection. And that can even lead into an infection in your bloodstream, which can be very scary. Impetigo can also happen, which is when the skin looks like honey-crusted sores. We treat all infections with antibiotics – both topical and oral. Sometimes doing a dilute bleach bath once or twice a week may decrease the need for antibiotics and reduce the incidence of these infections.
Kortney: Oh yeah, I have heard that bleach baths work to eliminate the bad bacteria on your skin. I was always worried it would bleach my hair.
Payel: Yes, it would make sense that people might worry that it would discolor their hair or skin even. But I want to calm everyone’s fears. It won’t do anything like that. In all skin types, bleach baths are safe to use and don’t cause discoloration. We don’t put direct bleach on our skin.
Kortney: That makes a lot of sense. Thanks for clarifying that. So, I have actually been prescribed antihistamines for my AD. Selfishly asking, is this a normal part of an eczema management plan?
Payel: Antihistamines don’t have a lot of good backing in atopic dermatitis, but the first-generation antihistamines – meaning the older antihistamines like Benadryl and hydroxyzine, the ones that cause more sedation – are thought to help more. And I think that’s mostly because they put you to sleep and you don’t get bothered by the itching as much. Since antihistamines are relatively safe to use, I always give them a try to see if they will help people with their symptoms. But it’s not a surefire way of getting rid of eczema.
Kortney: Are there any other oral medications that can be prescribed for AD?
Payel: Yes, there is an oral pill, the new kid on the block – JAK inhibitors. We spoke about them earlier in the topical medications section. They help tamp down your immune system. The oral therapies just came out this year and are used for moderate to severe eczema where other treatment options haven’t worked. They are taken once a day orally. We need to monitor blood work when you are on them. They have potential side effects related to infection, heart issues and liver issues, which your doctor will review with you prior to starting this medication.
Kortney: It sounds like this is really something that you would consider if nothing else has worked. Just to be clear, are the side effects the same for the topical JAK inhibitors?
Payel: No, the side effects for oral JAK inhibitors are more systemic where the topical JAK inhibitors are associated with less side effects.
Kortney: Now that we have hit upon all the oral medications, one treatment that I am very excited about are biologics. Can we dive into those now?
Payel: Yes. So, first what are biologics? They are medications that are unlike traditional drugs, which are made from chemical compounds. Biologics for eczema are made from living organisms. These injectable medications affect a specific immune response to help reduce the inflammation that causes eczema symptoms.
We have two different options for biologic treatment for patients with moderate to severe eczema. The first one out is dupilumab, or Dupixent. And recently we have tralokinumab, or Adbry.
Dupilumab has recently been approved now for children as young as 6 months of age and older. And Tralokinumab is only approved for adults who are 18 years and older.
Both are given every two weeks in adults and Dupilumab is given every month for infants and kids. Both can be given to yourself at home, but if you don’t feel comfortable you can sometimes have the option to get it in the office – but this can sometimes depend on your insurance.
Right now, we use these medications ongoing. They are not a cure. So technically when you stop them, your symptoms may recur. Sometimes patients want to see if they can tolerate waiting three weeks or four weeks as adults to get the medication and see if their symptoms are still controlled and I am always open to trying that – because less medication is always the best.
Kortney: Are there side effects that we should know about?
Payel: For any medication, you can have a reaction to the medication like anaphylaxis – but this is rare.
What’s interesting is that with dupilumab and atopic eczema, patients can experience really severe dry eye – a side effect that doesn’t appear in patients who are being treated for their asthma with dupilumab. And also with tralokinumab we find a similar conjunctivitis is possible.
Kortney: That’s good to know. I know that we discussed biologics with Shiv Sewlal, who has been contributing this to the podcast, so I wanted to mention that it is not always an option for people due to its high cost and insurance. Let’s hear from Shiv and then we will jump into some treatments she does that are more affordable.
Shiv Sewlal: So I’ve been on topical steroids since I was a baby. And I’ve only ever been – I try to avoid oral steroids as much as possible and I use them only if I’m having very severe asthma or going to oral steroids where the asthma pump is not working and you take something a lot stronger. But a lot of the time the eczema treatments are very expensive, so my allergist recommends wet wrapping to me. It’s the most affordable treatment I’ve ever done. You start by applying a thick layer of emollient and I prefer using creams to lotions, and then you use a wet bandage or tight piece of clothing that will cover the specific area. You use another bandage but this one will be dry and you place it on top of the wet layer. I love this treatment because I was a broke student who saved up enough money to see a specialist but I didn’t have enough for expensive treatment. So she helped me find a way to still try to manage my eczema as well as keep it affordable.
Payel: So you have been on topical steroids and sometimes you get oral steroids for your asthma which also helps your eczema. And then you said you have the wheeping type of eczema, so have you been on a lot of antibiotics and been getting infections frequently?
Shiv: I have not had infections very frequently. The most recent was when I was 18. I have a lot of scalp eczema. And I scratch it a lot and I get a lot of symptoms all around my scalp. So I go to the doctor a lot and when I was scratching my scalp a lot it got infected and I had to go on antibiotics for that. And that’s the most recent one. Other than that, I have not had any infections.
Payel: This is an important thing that doctors have to juggle on a daily basis. Thinking about which therapies work and also which are covered by insurance and affordable is a big part of therapy for all conditions and it is true also for atopic dermatitis.
I really do love wet-wrap therapy but you have to be motivated like Shiv to use it. I also wanted to mention that we don’t recommend doing wet wraps when you use calcineurin inhibitors or PDE4 inhibitors, but it is safe to be used with a low-dose topical steroid or an emollient.
Kortney: What about other things that I see on the internet like light therapy?
Payel: Yes, there are studies to show that the use of phototherapy can help with adults – we don’t use this for babies or kids. It’s a treatment that is done with the doctor, with what we call narrow band UVB, so it’s a specific light that is different from the sun. The sun is made up of UVA and UVB rays, so this isn’t the same thing as what you get when you get phototherapy.
It’s designed to reduce inflammation, lessen itch and boost the body’s bacteria-fighting ability in hard-to-control eczema. Also important to note that it is cumbersome because you have to go in usually three times a week for it to be effective and length of time is determined by the dermatologist and sometimes is not covered by insurance. I don’t do this in my practice and it’s normally done with a dermatologist just because you need the special equipment and allergists don’t tend to have that equipment since we don’t see other conditions that would require the use of the machine.
Lastly, light therapy may cause hyperpigmentation (darkening of the skin) in some people of color, so it’s important for people to know that when they are considering this option.
Kortney: Got it. So light therapy is not as easy as going to the tanning salon and something you need to discuss with your doctor.
Payel: Yes, a tanning salon is definitely not the same thing as doing light therapy for eczema. A totally different machine and different lights. That being said, I know there are a lot of machines out there that are being advertised – I am not sure about the scientific evidence behind them and would make sure to do a lot of research before spending a lot of money on these machines. As I said, I don’t do this treatment in my office because of the cost of these machines.
Kortney: Yeah, I see a lot of different machines being advertised. Again this is something you should discuss with your doctor. On that note, in our final episode, we will be talking about Shared Decision-Making and how to work with your medical team. So you can take what you have learned today into your next appointment and feel more empowered in managing your AD.
Dr. Gupta: Thank you for listening to today’s episode. Remember that all information you hear today is for informational purposes only and are not intended to serve as a substitute for the consultation, diagnosis, and or medical treatment of a qualified physician or healthcare provider.
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