Eczema or atopic dermatitis can be frustrating to manage for both patient and practitioner alike. Unravelling the underlying complexities for each individual's presentation can take patience and some systematic trial and error.
Today we're joined by Rebecca Hughes, who has a gift for clinical success in skin conditions. Rebecca shares with us how she approaches eczema and atopic dermatitis cases and what therapeutics she employs to achieve long-lasting relief for her patients.
Covered in this episode
[00:38] Welcoming back Rebecca Hughes
[01:30] Today’s topic: Atopic dermatitis
[03:54] Differential diagnosis
[08:02] Standard medical approaches
[14:32] The gut-skin relationship
[23:18] Vitamin D for skin repair
[25:07] Vitamin A, zinc and prebiotics
[28:17] Amino acids and Herbs
[31:39] Rotation-elimination and gut restoration
[34:04] Homeopathic remedies and fish oil
[39:08] Bioflavonoids and herbal medicines
[43:14] Manuka honey
[44:56] Cautions, caveats or red flags?
Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line again today is Rebecca Hughes. A Naturopath and Herbalist who's been involved in the natural health profession for over 15 years since completing a Bachelor of naturopathy in 2003, at Southern Cross Uni. In addition to private practice, Rebecca has previously acted as a regulator of complementary medicines at the Therapeutic Goods Administration and helped develop a clinical practice guideline for the National Health and Medical Research Council.
Rebecca has also lectured, conducted research, and has been a peer reviewer for naturopathic academic texts and authored chapters for Braun and Cohen's Herbs and Natural Supplements: An Evidence-Based Guide.
Welcome back to FX Medicine, Rebecca, how are you going?
Rebecca: Thank you. I'm really well. Thanks for inviting me back again.
Andrew: Look, it's our pleasure. Now, we're going to be talking about a really confounding condition today for many clinicians, that's Atopic dermatitis. How did you get involved in treating this majorly in your clinic?
Rebecca: So sometimes I'll call it also Atopic dermatitis and sometimes I'll simply call it eczema just for ease of discussion.
Andrew: Yep. Because Australians will shorten things.
Rebecca: And it's kind of what people are familiar with, you know? It's mostly called eczema by patients and I guess I started treating a lot of it because I treat a lot of children and the incidence of eczema is much, much higher in children, you know? I mean, depending on which reviews you read, and which countries, you know, it's up to sort of 20% now of children experience eczema at some point in their development. So, because I was treating lots of children, I ended up treating lots of eczema. Yeah, that's how.
Andrew: Now, you said now here? And this is something that concerns me with allergies and atopy, is the incidence and the prevalence increasing?
Rebecca: Yeah, it is increasing. For anyone who wants to read it, there's a really great article called The Atopic March by Bantz and Zheng published 2014 and it's called The Atopic March: Progression from Atopic Dermatitis to Allergic Rhinitis and Asthma. And basically the whole part of...the central conversation in this article is about the incidence of atopic dermatitis but also the risk for developing other atopic disease later in life.
And so, you know, they talk about worldwide statistics and that, you know, there's varying reports from, you know like I said, from 0.3% to 20% across the countries. But in under six months of age, it's up to 17%.
Rebecca: So it's quite high, and IgE-mediated food allergy, as we all know, has also, you know, gone through the roof really in the last few years. And so they think that that's estimated now at about 35%.
Rebecca: Well, mostly it's characterised by itching, inflamed skin. Now, there are different types of eczema because there's one very specific and distinct type is discoid eczema. Where they look like the size of a coin and they're much more discreet over the different parts of the body. But typically, I would say it's a rash, it's red, it's raised, not necessarily scaling like psoriasis, and not a weal like urticaria. But a rough red rash, that's usually not well circumscribed.
Rebecca: Now, textbook wise of course, when you learn about eczema at university, they say it's always in the folds, you know, it's in the popliteal fossa and antecubital fossa, and the maybe in the folds of the neck or something like that. But, yeah, I mean, certainly, it's more typical there. But now that I've treated a lot of eczema over the years, I can safely say that eczema can just about appear anywhere. And typically on infants actually, it's on their face.
Rebecca: It's on their cheeks.
Rebecca: Parents often notice it first on their face versus on parts of their body. So, I don't think how we learned about eczema at university is necessarily how it, you know, always shows up. And some people have more broken skin, so the eczema will be...
Andrew: They’ll weep.
Rebecca: And then some people actually experience, and this would be very painful, is splitting of the eczema. They've got...the character that splits more than...and it still weeps but it's sort of these deep fissures that...
Andrew: Weeping from a cut, yeah.
Rebecca: Yeah. So, that's what it looks like.
Andrew: Yeah. So, it's almost like it's trying to heal but splitting open. And the memory, for me, and I don't have eczema. But the memory for me is like when you smile and you might have dry lips and you crack a lip, you know? And it just hurts. So, if you can imagine that, you know, in several places on your body, and just this continual crack and heal, crack and heal, it's really, really uncomfortable for these patients.
Rebecca: Yeah, absolutely. And also the constant irritation of itch.
Rebecca: Because certainly, anyone who has eczema knows what feeling incredibly itchy feels like. And if you've ever been incredibly itchy even from something else, like if you, I don't know, went travelling or went camping and got, you know, more than 10 mosquito bites, you'll know what being incredibly itchy feels like.
Andrew: Oh, yeah.
Rebecca: But imagine feeling like that all the time? All day, all night whilst you sleep, scratching at yourself.
Rebecca: I think it's entirely underestimated actually, the impact that it has on people's mood.
Andrew: I mean, there's been incidences of suicide from itch. I don't know about from eczema, but from...
Rebecca: Oh, dermatitis herpetiformis?
Andrew: Herpetiformis. Thank you. There's been cases of suicide from that.
Andrew: You know, if you just don't dry yourself properly and you have an itchy skin after getting out of the shower, or something, or being at the beach, it's just, you have to find a pole. And we laugh at it because we can get relief, but imagine not being able to get relief, you know, ever?
Andrew: It would drive people insane.
Rebecca: And I noticed this particularly because I see a lot of young patients. And the parent will report the rash, and then the next thing they'll say is, "She or he is unbearable. They are so..."
Rebecca: "...their behaviour is so bad, they won't sleep, all these tantrums." And I think, "Well, I'd be like that too if I itched all the time." I'd have massive tantrums if I was constantly itchy!
Andrew: I mean, this must be so frustrating for patients who are undergoing their current medical therapy. So, let's talk about that. What are the current medical therapies and how effective do you find them? Indeed, what stories do your patients' report?
Rebecca: Well, the medical therapy probably up until recently has been pretty limited. Primarily, most of my patients say exactly the same thing. Which is, "My child got the rash, or I got the rash, so I went to the pharmacist and I got some over-the-counter cortisone cream. And that didn't work. So, I went to see my doctor, who prescribed a higher percentage cortisone cream. And that worked for a short time, but then it came back. So, then my doctor referred me to a dermatologist who prescribed an even higher percentage cortisone cream."
And that pretty much has been the roundabout of medication for most people, topically.
Rebecca: And then occasionally, if things are really, really bad, of course, they might get prescribed antihistamines or short periods of oral...
Rebecca: ...steroids. But of course, no doctor wants to prescribe long term oral steroids because of the risk associated with them. So, even I think, you know, to a degree, I think even the doctors experience frustration with being able to manage this condition.
But, you know, even in the wider medical literature, it is now being acknowledged that in fact atopic dermatitis is a systemic disease.
Rebecca: You know, that it isn't simply a rash on your skin, which is great, it's great that that's being acknowledged. The part that I suppose frightens me a little bit though then, is the new class of medications that are being prescribed which are immune suppressants or immune modulators, you know? So now...
Andrew: Yep. So this includes the monoclonal antibodies, yeah?
Rebecca: Yeah, and cyclosporine and things like that. So, that's the new line of treatment. And I even saw a...I've seen one child also who's been prescribed that by a specialist. And that concerns me. Because there are some pretty decent long...not so much immediate side effects associated with those medications, although of course there are. You know, if you're messing around with your immune response, but there's the long-term effects of them that concern me as well.
Rebecca: I'd say more often than not, I typically see them once they've been down that pathway that I described, of pharmacists, general practitioners, specialist. And then they might have experienced periods of relief, but that are not long-lasting. And so, then they come to see me because they feel like they're not really given, I suppose, any real answers as to why this keeps occurring. And what they want to be is empowered.
Rebecca: Like they want to know why this is happening, and what they can personally do about it besides applying a cream that may or may not work.
Andrew: So, do you find though that these patients have been given remedial advice like for instance, cold showers, whether it be coal tar or oatmeal, you know, shower gels and baths, and things like emollients, and clothing?
Rebecca: Sometimes, not all the time. I mean, sometimes they're told, yeah about different...well, usually more from pharmacists, about additional topical washes and emollients and creams that they could use to help relieve symptoms.
If they are very young patients and they've been to say the Children's Hospital, they will have been given some more detailed advice about the importance of clothing and temperature. But of course, also the gold standard of bleach baths is also prescribed by the Children's Hospital and wet wraps. Some people know about wet wrapping…
Andrew: Yep, yep.
Rebecca: For their children, but some people don't. I'd say most people don't, it's usually only if they've gone as far as specialised childhood care that they know about those types of interventions for their kids.
Andrew: So this is the Royal Melbourne Children's Hospital. They have a great handout on how to do bleach baths properly. But, can you please take us through why they're used and indeed how to use them responsibly?
Rebecca: Bleach baths are used to reduce the occurrence of secondary infections primarily by staph aureus or Staphylococcus aureus.
Rebecca: Because patients who have, you know, when you've got broken skin, so you've compromised what's called their epithelial barrier function, then there's a much higher risk that pathogens, microbes, etc will colonise that area. Just like any other area of broken skin. But, in particular, there's been quite a bit of research done around atopic dermatitis and Staphylococcus aureus, and these patients seem to have a much higher risk than other people of getting staph aureus overgrowth in their skin.
And so much so that they're even described in the literature as staph aureus positive or staph aureus negative patients.
Andrew: Oh, right.
Rebecca: Now, I'm not quite sure what testing and swapping etc that the Royal Children's Hospital does if they make those determinations about patients. But I think it's really based on, you know, the presentation of the child and how severe and recurrent the eczema is.
So, what they recommend is bleach baths to control the staph aureus colonisation. And like you said, it's a very, very, very, very dilute amount. So, it's 12mLs of 4% bleach per 10 liters of water. So that's 0.012%. And you have to measure it.
Andrew: Oh yeah.
Rebecca: You have to measure the water and you have to measure the bleach, you can't guesstimate what that's going to be. And also if you think about bleach, being a volatile substance, you would have to put that in fairly lukewarm water, not hot water as well.
Rebecca: Because otherwise then you'll start to burn the eyes and the mucous membranes potentially with the vapour.
Andrew: Yeah, and it makes sense from a temperature point of view anyway, you know, cooler water is going to be more soothing to the skin than warm.
Andrew: So, when you're talking about this subset of patients, so do you find different subsets or is it just sort of the infectious versus non-infectious? You mentioned the nummular, the discoid eczema before. So are there other subsets that you work with or do you just...Is there a basic, like a general treatment, for dermatitis with natural medicines?
Rebecca: In terms of subsets like I think there certainly are those patients that I see that tend to always get some kind of secondary infection on top of their eczema.
Now, the research points to the, you know, some studies say like, up to 90% of patients have staph aureus colonisation, they might, that may be the case, but I'm pretty sure we all have staph aureus in our skin microbiome. So, I don't think that's necessarily a predictor of disease progression. But, for me, as a clinician, I would say that the patients that I see who get secondary infections are actually, for me, quite a small subset of those patients.
Mostly what I'm dealing with is the skin irritation. So, the intense inflammation, itching and the compromised, what I call compromised, barrier function. And what I mean by that is that the skin is broken. And because the child, or the person, is in that scratch itch cycle where they can't stop themselves from itching, then the barrier function is ongoingly compromised.
So, I guess with respect to treatment aims, what I'm looking at is exploring, well, what's causing the inflammation and irritation? Is it environmental? Is it food? Is it some other type of inflammation that's already existing in the body that might be maintaining it?
Andrew: There's even cases of, you know, parasites causing dermatitis. So, I mean, even looking down that line, in the patient interview, if you like, looking for these other particularly say, abdominal symptoms or something like that.
Rebecca: I think it's pretty intensive patient subsets. I would say almost all of my patients who have eczema have some kind of digestive dysfunction occurring at the same time. And more often than not, it's slow transit time or constipation, that's what I see a lot of.
Rebecca: Occasionally you may see the complete opposite, which is frequent loose bowel motions that's associated with their eczema. But I think in both...and both of them though, to some degree, can indicate a food sensitisation or intolerance. That's what I see a lot of in practice.
Or it may simply be that, you know, they're dehydrated and they don't drink enough water. And that, you know, once you actually manage the systems of elimination, and that they're having daily soft bowel motions that are easy to pass, that in fact, their skin starts to resolve as well. But they're a pretty rare group. They're the easy to treat ones.
Andrew: Yeah, they're the ones you want that you don't get.
Rebecca: You just want...sometimes it's like, oh the common cold in practice, wow.
So, there's looking at barrier function, reducing inflammation so that you reduce the itching. And then improving gastrointestinal integrity. Integrity of, you know, the lining of the lumen plus also motility and making sure that actually, you know, the contents are being evacuated as they should be.
Rebecca: So, they are the areas that I look at in terms of the mainstays of my practice and...
Andrew: Can we discuss that. The poster child of therapies for Atopic dermatitis in the probiotic arena would be Lactobacillus rhamnosus GG. Glows in some studies…
Andrew: 48% success rate in one study, and then of course, bring it to Australia, fail. So, there may be issues here with things like timing dose, whether you use it pre-natally as opposed to just in post-natally giving it to the child. So, the actual initiation of therapy compared to birth and priming of the immune system. So, all these factors coming in, what's your take on it, what do you find works?
Rebecca: Well, I think certainly the research points to that...I think, supplementation of LGG in the third trimester, for those patients that are at risk, and they determine risk by family risk and family history, that it does reduce the risk of atopy in childhood and later on in life. That's the research that I read about it. And certainly, the Murdoch Institute have done some great studies with reducing allergy sensitisation. So IgE-mediated reactions and LGG. And I think that's quite compelling data that they have.
Andrew: Yeah, so...
Rebecca: There's also other research around T regulatory cells and atopy and autoimmunity. Whereas, because, you know, before, we really thought back in, I suppose, the '90s that it was all about, you know, Th2 dominance and, you know, if you just dampened that then everything would be okay. And to a degree, that worked, you know? In some but not all patients. But in the majority of patients that conceptual framework was okay.
But, you know, there's always those patients that...because the thing about the Th1, Th2 model is that one side of the seesaw was more associated with autoimmunity and the other side with atopy. However, that's not always how patients present, and it...
Andrew: Explain coeliac disease then.
Rebecca: Exactly. And then also explain why when you take someone's family history, that there's a strong incidence of both in their family history as well.
Rebecca: And I have seen patients who have atopy in childhood autoimmunity later in life. So, they're certainly not unrelated, and a lot of the research around just, you know, immunotherapy is now pointing to that. That it's a dysregulation of the immune system. It's not necessarily about, you know, which T helper cells population are more dominant than the other. But what it does suggest is that there's a loss of function of T regulatory cells.
Rebecca: And then, you know, building on from that then we know that there's a lot of natural substances that help with T regulatory cells and one of those is probiotics. And, you know, there's a lot more research being done around multi-strain formulas, and their influence on T regulatory cells via different interleukin populations, etc.
So, there's certainly more research I've noticed going down that pathway, looking at multi-strand formulas and how that can exert a particular effect on immune function.
Andrew: Yeah, we'll certainly put some of this research up on the FX Medicine website so that people can look at it.
Rebecca: Yeah. And vitamin D. You know, in immune regulation and used effectively in both Atopy and autoimmunity.
So, I think, you know, it really does point to the importance of regulation of the immune system…
Rebecca: In the treatment of atopy. Which is why in standard medicine, they are going down that path of using immunosuppressants and immunomodulating medications because they recognise that it's a problem with immune dysregulation, and that's their answer to it. Whereas we just have a different answer.
Andrew: I'm really interested in vitamin D because I remember talking to a professor of immunology, basically saying they knew it worked, they just wanted to do the trial in using vitamin D in kids with eczema. What's interesting to me though is, vitamin D is free from the sun, and yet the sun is hot, and you try to avoid the sun when you get vitamin D...you try to avoid the heat when you've got eczema.
Andrew: So there's this issue where you've got the free sun, making you the best form of vitamin D. And it's certainly the best way to get vitamin D, as long as it's ‘safe sun exposure’. And yet, there's the issue of the heat sort of thing. So maybe these people are at risk of vitamin D deficiency? But certainly this, you know, vitamin D was just this...I was really impressed by the way she said, "We know it works, we just want to write it up."
Rebecca: Yes. And, you know, I think there is some mixed evidence out there about effectiveness of vitamin D.
Rebecca: However, I was just reading something the other day about vitamin D being maybe the reason...one of the reasons why it works is because it's involved with creating filaggrin. Which is, you know, filaggrin is a protein that's in the stratum corneum, that is like, it's a bit like the tight junctions in the gut. It's like it's responsible for the integrity of the barrier.
Rebecca: So, vitamin D is involved in the process of making filaggrin along with glutamine, interestingly. So, maybe it's not just immune modulation with vitamin D? Maybe it actually is involved with the physical process of repairing the skin?
Rebecca: Well, I use vitamin A and zinc. Both in...as in, I prescribe it internally, so, orally. But the action is for repairing both the insides and the outside. So, zinc and vitamin A are required for, you know, rebuilding epithelium. And of course, we have epithelium in both places.
Rebecca: So, I use that, and it's both dependent on whether I'm looking at a child or an adult. And in terms of, again, treating gut integrity, I do prescribe glutamine as well. And what else? Oh, and I forgot to mention, I suppose, prebiotics.
Andrew: Ahh, yes.
Rebecca: So if there is constipation, I certainly am using, you know, I might be using gum arabic, or PHGG, or simply, you know, certainly there are prebiotic foods. But if there really is a problem with constipation, you do need to address it fairly quickly because things aren't going to improve if the patient is constipated.
So, there's also lactulose I use as a prebiotic because of, you know, it really does build up lactobaccili populations. And then there's FOS and GOS as well. Fructooligosaccharide and Galactooligosaccharides that can all be, they're all various different probiotics that can be...prebiotics, sorry, that can be used for gut health.
Andrew: Now, PHGG, the partially hydrolysed guar gum, this was really horrendously expensive years ago, not the story now though, right?
Rebecca: No, it's not.
Rebecca: It's actually a really affordable treatment for patients. And it's not high dose. I certainly don't start with a high dose with any prebiotic generally because we don't quite know what's going to happen.
Rebecca: It may produce a lot of gas by prescribing prebiotics and that can be pretty uncomfortable for people. So, I generally start lower, and the same with lactulose, you know, I'll start on a lower dose and then build up to a higher dose.
Andrew: The thing about prebiotics though that interesting to me, and, you know, people don't like to fart because it's culturally unacceptable, right?
Andrew: But I think in the privacy of one's home, one of the, I don't know, call me a little bit boorish or gung-ho. But I find that the worst thing to do is to piddle around for weeks finding the dose that works.
Andrew: So I sort of tend to be a little bit heroic and say, look, try the moderate dose. But if you get a bad reaction, don't blame me, it's your body getting accustomed to it. The worst thing is to happen, is nothing.
Rebecca: And also the timing of the dose. So if you are going to play around with higher doses, do it at bedtime.
Andrew: Yes. Yep.
Rebecca: So that you experience whatever the effect is going to be in the morning before you go to work before you go to school, etc, not whilst you're at school or work.
Rebecca: So, yeah, I always prescribe...If I'm looking at increasing doses of prebiotics, I say, it's at bedtime, that's when you do that.
Rebecca: Oh, just two more nutrients I wanted to mention…
Rebecca: Are glycine and cysteine. Because of their involvement in liver transformation. And, oh, yes, cysteine in the form of N-acetylcysteine and glycine.
Rebecca: And I particularly use those where, because I haven't talked about this much, but food intolerance is suspected. And either food intolerance is like salicylates, amines, glutamates. So, that class of food intolerances. Or IgG-mediated food intolerances. And of course, one set you can test for, and one set you can't test for, you simply...but in both situations, I do a full elimination and reintroduction. However, whilst I'm doing the reintroduction, I like to support it with nutrients like glycine and cysteine which are going to help the liver just deal with those antigens essentially.
And how I determine whether it is...you know, we summarise them as SAGS; salicylates, amines, glutamates.
Rebecca: Or IgG is through case history. And you can do that simply by just identifying high salicylate-containing...like, have a set of high salicylate-containing foods that you ask about, a set of high amine foods that you can ask about, and a set of glutamate foods that you can ask about.
But generally what I find particularly with patients, because those types of food intolerances tend to show up more in children than I would say, adults. But the patients will almost always tell you. They'll say, "Every time she eats strawberries, her lips swell up."
Andrew: Yes, yep.
Rebecca: Or, "Every time she eats oranges and she gets the juice on her, her skin gets all itchy." But they're just some simple questions that you can...you just have a little cheat sheet of like, ask about these foods. And if it looks like it's SAGs, then I might do that first. Like do an elimination, which is very challenging. Like it's very challenging to do that kind of elimination. And you need to provide a lot of information like lots of food charts, and try that and see if the symptoms improve. And of course, if the symptoms don't improve, there's no real point in putting someone through the re-challenge process if there's been no real change after elimination. And then, if there is no change, then I'll look at testing for IgG food intolerances and I do that a lot. I have to say I do that a lot in clinical practice. And when I get the results back, I'll do like a two to three-month elimination. And whilst I'm doing the elimination I'm doing the restorative work with the digestive system.
So, the glutamine, zinc, vitamin A, anti-inflammatory herbs. This is where I get to herbs as well. And it's not just anti-inflammatory herbs on the outside, it's looking at things like Chamomile, Boswellia, curcumin, things like that internally as well.
Andrew: Yep, yep.
Rebecca: So that you can reduce systemic inflammation, not just external inflammation.
Andrew: Absolutely. I'm so glad you said the word reintroduce. Because too often I find people are being taken off foods, and then they have the concept that these foods are bad forever. Rather than bad for now. And there may be some that are bad forever. But, you know, I think the big job, if you like, is to restore integrity, you know, what was lost…
Andrew: And so that they can then handle, in a normal way, most of the foods, including some of those which they previously reacted to. I just think it's such an important thing that we leave behind.
Andrew: I'm so glad you say it, that's great.
Rebecca: And also, it's also about quality of life, you can't expect people to take those foods out, it's not realistic, for starters. And it's too limiting.
And it's entirely possible, I had a 29-year-old woman come to see me and she had some of the most severe facial eczema I've ever seen. And she's had eczema since she was an infant. It didn't start on her face, it started on her arm and you could see that really, you know, that really leathery patch where the eczema had been there for so long that it had depigmented and changed the whole architecture of the skin.
Andrew: Oh, gosh. Yep.
Rebecca: But the eczema on her face it almost looked like a mask on one side because it was so severe. And she was really impacted by it. I mean, as you would be, but she's also a speech pathologist.
Rebecca: And she would... feel compelled to say to her patients, “It's okay I'm not contagious.”
Andrew: Yep, yeah.
Rebecca: It's how concerned she was about this. And I thought, wow, like, you know, there's some cases that walk through the door and you do wonder, you're like, I'm not sure. I'm not sure if I can do something about this.
And we did food intolerance testing with her. She was intolerant to the holy trifecta, of eggs, gluten, and dairy, which is difficult for anyone to deal with. But she did a stellar job, really, of eliminating those foods. She was a great patient, we did all the right things. And she has successfully reintroduced every single one of those foods, even though she had a very, very, like high reaction in the test results. But all of that work that we did the elimination, the restoring of gut integrity, worked a treat. And she has no eczema now.
Rebecca: Oh, well, I haven't talked about homeopathics, I know that that can be a bit controversial. But I do use them in practice. And I use them more so in children, than adults, because sometimes treating children can be very challenging.
Rebecca: You know, palatability is a very, very big deal. And certain children will not take anything, they just won't.
Andrew: And yet, you find they respond?
Rebecca: They do respond, yes, they respond very well.
Rebecca: Now, also in fish...I haven't talked about fish oils, but I think that's kind of...I think everybody knows about the benefits of fish oils.
But, fortunately, on the market, there are a lot of deodorised and flavoured fish oils now.
Rebecca: So, I can prescribe fish oils and have them be taken by children. So, thank goodness to all those companies that have done that. So, they work, and also because now you can also get the same thing with cod liver oil. So, cod liver oil is a great way of getting both essential fatty acids and vitamin A into children.
Rebecca: And you can get zinc in liquid forms. So I've had to really get versatile about the way I treat children. So there's lots of nutrients you can get in liquids and powders. But still, children are very fussy about taste, so if they don't like the flavouring blend that's been used in the medicine, it's very unlikely that you'll be able to get them to take it. And it will just become world war III in their house with their parents every single day and that's not nice for anyone.
Rebecca: So homeopathics can be a really great solution to that because they don't taste of anything. And I know, traditionally you put homeopathics in, you know, a certain percentage of alcohol and then mostly water. In kids I don't do that, I just put the homeopathic drops into purified water and I deliver it as drops and that's all I do. I know it's the smallest amount of alcohol, but I just still don't like...I try not to give alcohol to children.
Andrew: Yeah, sure.
Rebecca: So I might use symptomatic treatment in lower doses, so, with things like graphites for that splitting eczema. Graphites is also particularly great for, and specific for eczema on the eyelids and eczema on the fingers. And then I might use things like Rhus tox just because it's good for that kind of pruritic presentation. And nettle as well.
Maybe occasionally I might use Apis, like, if it's really hot and swollen. And then I might do more constitutional treatment which is sort of deeper treatment. And also, one of the remedies that's very, very, very, very well indicated for eczema is sulphur. But sulphur is a very reactive remedy. So, sometimes you can give sulphur to a patient and it causes an aggravation. Which is never really what eczema patients want to experience is an aggravation of their symptoms.
Rebecca: So sometimes what we do is I work from very, very low potencies of sulphur and work up to the higher potencies. And that is something that can actually take several months to accomplish. And it's where you give a certain potency until you only see improvement without aggravation. And then you move on to the next potency.
But the great thing about that particular approach, and I have to acknowledge my colleague Keonie Moore for letting me in on that one. Is that you can see resolution by getting to really higher doses of sulphur.
Rebecca: You can start to see complete resolution of a very entrenched eczema.
Now, I've done that more, probably in adults, actually. When...because, you know, with children, they're strong, they're vital, their cell turnover is ridiculous. You know, they respond so well to treatment. They're the best patients in the world. I love treating kids. But the thing with adults, if they've got a chronic condition, you know, it's...
Andrew: They're worn out?
Rebecca: ...it's not as easy, they're worn out, they're sick of it, their body isn't as strong as it used to be, it isn't as responsive as it used to be. So sometimes I find homeopathics also in adults can be just the thing that really gets in and underneath what's going on.
Now, I know that none of us can explain how homeopathics work and I can't even explain it as I'm talking to you about why it works. But I know that it works, that's what I know.
Andrew: Yeah. Look, homeopathy isn't my bag. However, I do find it curious that when we had homestay students from Argentina, they were very well versed in homeopathy. Because it's a system of medicine that's actually accepted over there.
Rebecca: It's the same in India, India is very accepting of homeopathy, has some of the biggest homeopathic hospitals in the world.
Rebecca: I use bioflavonoids.
Rebecca: They're really as well in terms of a preparation type, they're usually in powders. So, easier to administer to children. And adults don't mind them either and they generally taste quite good. And, you know, they have that brilliant effect on stabilising mast cells. So, you're reducing the amount of histamine that's released into the system. Which is fantastic for breaking that scratch-itch-cycle.
And inhibits IgE antibody formation. So, quercetin and bioflavonoids; wonderful. So that's another nutrient.
But in terms of herbal medicine, again, you know, looking at...you have to, I suppose, look at the different inflammatory pathways that are at play. So mast cells are some of the, you know, the most common white blood cells that are being activated during that process.
So, Albizia is a herb that stabilises mast cells. Baical skullcap as well has an anti-allergic, anti-histamine sort of action. I think it also acts on, even though it's not necessarily exactly related, but it acts on COX-2 and lipoxygenase, etc. So you've got those two herbs.
Then you can also look at immunomodulation. So, we have plenty of herbs in our dispensary that modulate the immune system. So, herbs like Echinacea, Astragalus. You might even look at therapeutic mushrooms, for example.
Andrew: Yes! Yep.
Rebecca: When I look at prescribing of herbs, I'm looking at what are the different actions, what are the different, you know, pathways that could be being activated. So, looking at, you know, anti... things that stabilise mast cells and reduce histamine, that's really looking at a symptomatic management, but then also looking at systemic management. So looking at immune modulation as well.
And Licorice, of course, you know, our old friend Licorice. Which is potently anti-inflammatory and beautiful for the gut as well, you know. You get all the beautiful demulcent characteristics of Licorice internally and then you get, you know, the anti-inflammatory benefits externally. I don't mean apply it externally, I mean you get the benefits externally.
And certainly topically, I mean, there's a huge raft of herbs in the dispensary from the tradition of Western herbal medicine, like Chickweed, Calendula, even Comfrey. You know once the skin isn't broken anymore, but you want to increase the integrity of the barrier you could use Comfrey externally.
Some studies have used vitamin D and vitamin E topically as well with benefit. That show improvements in the scoring around all the symptoms. And Chamomile…
Andrew: Good old chamomile.
Rebecca: You can use externally.
Rebecca: Internally and externally, because of the beautiful essential oil content of it.
Andrew: Now, do you use the actual concentrated essential oils and maybe mix that up into a cream or do you tend to use the fluid extract and mix that into a cream?
Rebecca: I tend to use the fluid extract because it's what's here in my dispensary.
Andrew: Got you.
Rebecca: But I would… I have recommended to patients to get some chamomile oil and use it at home as well. They can mix it into a carrier oil, for example, you could mix it into sunflower seed oil, or maybe you want to use coconut oil, or even jojoba oil. Whilst Jojoba oil is quite expensive, it's also...they say that the profile of it is the most similar to human sebum. So, it's why it is used I think in a lot of beauty products. But you could use Jojoba oil as well.
Rebecca: So, those are some of the things that I use topically. And then you might want to look at, if you're concerned about staph aureus infections or any kind of secondary infection, looking at things that can interrupt that as well.
Rebecca: So, in fact, what we use a lot of in this clinic is Manuka honey.
Andrew: Now, there's a treatment that's underutilised, certainly in infections.
Rebecca: Yeah. And it's beautiful because you can also combine it with wet wraps. So, you can put the Manuka honey on, then put the dampened cloth, then put the dry dressing and the dry clothes over that. So, you're getting the antimicrobial action plus the repair of the...and the protection of the epithelial barrier.
Andrew: Do you use just Manuka honey as in just the normal eating one or do you use the UMF types, the unique Manuka factor?
Rebecca: We use a therapeutic one, you know, that's sterile and, you know, those things. You probably could, I mean, if you want to just use Manuka honey, you could use that as well. It's just sometimes a bit messy.
Andrew: Yeah, I think you raise an important point about the UMF, though, about you using...you're using it as a medicine, not as a food.
Andrew: And if you want a sort of controlled effect, then you need to use something that's got a defined parameter, at least to some degree.
Rebecca: Yeah, it's got a percentage of therapeutic ingredient. It's been manufactured under sterile conditions, because if you're concerned about infection, then you probably want to be putting something that isn't going to, you know, introduce any other kind of cross-contamination.
Rebecca: Well I think there’s… one thing that I think is being overlooked more and more in clinical practice is coeliac disease.
Rebecca: That's one thing that I would say is that not enough patients are screened for, including paediatric patients. And of course that involves a referral to a general practitioner. And I think that's really important. And you'd probably make that assessment in a child based on their family history. And I don't just ask about mum’s and dad’s and brother’s and sister’s as well. I often ask about first, particularly if they don't come from a very large family unit, I will ask about first cousins as well. And I find I often get some pretty useful information about first cousins.
Andrew: Got you.
Rebecca: So, I will do that and refer for that.
And also, I don't think drug reactions can be underestimated.
Rebecca: And it's something that I missed recently, actually, in a patient of mine who had, you know, I've been treating her for a long time, and as far as I knew, her medications from her cardiologist had remained the same for a very long time. And they had, except that I hadn't put two and two together. Because her eczema started a number of months after the medication was changed by the cardiologist.
But when I read about drug reactions, there is often a delay between the change in drug and the emergence of the drug reaction.
Rebecca: So it can be up to three months later that the drug reaction happens. And her eczema was quite diffuse. So, I wouldn't actually call it eczema now. I would say that she had a drug reaction and she had some type of dermatosis that was uniformly all over her arms, and to a degree on her lower legs as well. And it wasn't patchy, it was actually this uniform rash.
Rebecca: And it didn't start out that way, it started out patchy and then it just increasingly became worse and sort of ubiquitous. So, I think that's certainly something to...
Andrew: That's a good little red flag.
Andrew: Yeah. What about the dose of vitamin A that you use in kids in your practice, Rebecca?
Rebecca: Well in kids, I dose depend on...with everything with children I dose dependent on weight. And I know the weight of all of my patients because everybody gets weighed. And so with children, all nutrient dosing is weight dependent. So, I guess in adults, for example, I will prescribe up to 10,000 unit IU of vitamin A per day for the short term, and so I can dose down from there depending on weight.
But probably in children about the average might be 3,000 international units per day, and that will probably be limited to a couple of months. Like that type of dosing, because it's all aimed at skin and gut repair and I don't really need to use it after that.
Andrew: Got you.
Rebecca: Like once I've done the restoration, that's it.
Andrew: Was that 3000 IU or retinol equivalence?
Andrew: IU, so that's 750 retinol equivalence, is that right? Something like that?
Rebecca: I think it's 900 micrograms of retinol equivalent.
Andrew: Nine hundred, got you. Okay, great. Yeah.
So I think that's a pertinent thing to say. There's a lot of paranoia about vitamin A, which it's really taken out of context.
Andrew: There is quite a lot of research on toxicity. And we'll put these papers up on the fxmedicine.com.au website so that practitioners can learn from them and have the truth behind vitamin A in kids, in adults, and indeed, in pregnancy. I'll put them all up there.
Rebecca: Exactly. I mean, as you can imagine, I treat primarily skin conditions, so I use a lot of vitamin A in practice, and having used it now for years in practice, I don't have those kinds of concerns.
Andrew: And that speaks volumes for your experience that you've accumulated over years of treating patients.
Rebecca, thank you so much for taking us through these relevant aspects of responsible care for dermatitis in both adults and kids, which I think is really important. And I mean that word care. Obviously they've found a great advocate for their health by finding you.
Thanks so much for joining us on FX Medicine.
Rebecca: You're welcome. Thank you.
Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.
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