[Amy Risley] Total Skin Nerds is brought to you by Skinfix. We're clean, clinically active, and on a mission to help heal your skin.

Welcome to Total Skin Nerds. I'm Amy Risley, the CEO of Skinfix, and a first rate skin nerd myself. On this episode, my guest is Dr. Peter Lio, a Chicago based and Harvard trained board certified dermatologist. He's a professor of dermatology and pediatrics at Northwestern University, and co-founder and co-director of the Chicago Integrative Eczema Center. Dr. Lio's passionate area of focus is one that is also a cornerstone of Skinfix. I'm talking about eczema, painful, itchy, dry inflamed.

It's a skin condition that affects hundreds of millions of people around the world, including me. Coming up, Dr. Lio talks about his crusade to treat patients with an innovative and compassionate combination of Eastern and Western medicine, plus why he thinks we're living in the golden age of moisturization, and why our skin barriers must not be taken for granted. All that and so much more with one of the world's great eczema resources, Dr. Peter Lio. Stick with me nerds. Don't go away.

[Amy Risley] Welcome Dr. Lio to Total Skin Nerds. We are incredibly honored to have you here. You're one of the world's foremost, if not the world's foremost, experts on eczema, which is a condition that is very near and dear to our hearts here at Skin Fix. And we're just so thrilled that you would join us and talk to us.

[Dr. Peter Lio] Well, gosh, thanks for having me. It's an honor to be here.

[Amy Risley] We want to dive right in and ask you just some very basic questions for our listeners to understand what eczema is and how you treat it and then we'll dive a little deeper and talk about some specific modalities, but first and foremost, what is eczema and how do we know if we have it?

[Dr. Peter Lio]    Yeah, I think it is a great question, and sometimes I'll give one of the lectures for the medical students and I'll spend an hour up there showing pictures and diagrams and talking about science and I've beads of sweat at the end, and someone inevitably raises their hand and says, "Wait, what is it again?" Because it's slippery, right? It's a complex group of different symptoms that really come together in people a little bit differently sometimes too.

But broadly speaking, there's two pieces of eczema. There is skin barrier damage. So, the skin is supposed to keep the good stuff in and the bad stuff out. But in our eczema patients, it's broken. I often refer to it as leaky skin. Then there's immune overactivity. So, there's inflammation in the skin that's probably contributing in part to that skin barrier damage and also make some of the symptoms like itch and sometimes pain and burning in the skin.

That those two over time really constitute eczema, which is part of this broad class of other issues that can fit in this eczema umbrella, one of which a little bit more specific is one called atopic dermatitis.

[Amy Risley] Is it the broken or leaky skin barrier that causes the inflammation or does the inflammation cause the leaky skin barrier or do we really know?

[Dr. Peter Lio] The answer is yes. It's kind of both. And we think probably, and there actually are kind of two schools that have thought on this. Some people think that they call it the outside in, so that stuff from the outside world is triggering this and causing it in the first place. Then there's the inside out that people have something internal primarily, but we know, no matter where you start, both are going to be involved and they fuel each other, so it's a kind of a chicken and egg problem.

For some people, for sure, they are genetically born with damaged skin barrier. In particular, one we found that's kind of exciting about a decade ago, is a protein called filaggrin. If you make abnormal filaggrin, then your skin barrier is kind of leaky, and that really would be the closest to a first cause. It's like, the reason you have eczema, we think, is because you have this leaky skin gene, and therefore you then moved on to become sensitized and having inflammation, all these other things.

But other people seem to have pretty normal skin barrier when they're young and have an inflammatory issue first, so then that damages the barrier as a secondary. Again, the cool thing is that, no matter where you start, both are involved. So, we really need to address both, I think, to get people better.

[Amy Risley] Got it. Now, are there different populations of people that are more prone to eczema or more prone to the genetic deficiency and filaggrin?

[Dr. Peter Lio] There definitely are. When they look at different global populations, there are different mutations that we see, different subtypes. This is really an exciting area right now. We're all trying to figure out, can we find biomarkers? In other words, molecular signs that can help us know what kind of eczema somebody, has and will it help us, not only with giving them a sense of the prognosis, are you going to live with this forever? Is this going to bring with it food allergy or asthma?

Because a lot of our patients have those comorbidities or concurrent problems. Also, eventually, when we have some more on our plate, hopefully soon, we're going to be able to say, ah, because you have this deficiency or this issue, we can use this medicine and that's going to suit you the best. This is this drive towards what they call personalized or precision medicine, where we're going to be able to figure out exactly why you have what you have and hopefully treat it just right.

[Amy Risley] When you talk about skin barrier health, it seems to be really the fundamental, most important thing as a first line of defense in treating eczema, is trying to get that leaky barrier to not be as leaky. You talk a lot about moisturization and how it's one of the four treatments for eczema. I loved how you said, and something I was listening to, the best moisturizer is the one you use, meaning if you do nothing else, be compliant. Talk a little bit about how moisturizers are really helpful in treating that barrier topically and hopefully helping to mitigate eczema.

[Dr. Peter Lio] Well, yes, as you know, moisturizers super important. One of the things I like about them is that they're also not medicated, so we can potentially avoid exposing people, and largely kids, because many of the people that have eczema are kids. We don't want to put them on medicines unless we need to. So, if we can use more gentle things, more supportive treatments, we may be able to avoid that for a lot of patients, which is always our goal. Sometimes we get accused of being drug pushers, but really, I don't like drug. I try to minimize when I can and we're just trying to get people better.

The history of moisturizers is fascinating. When I was in residency in dermatology, there was a book on the shelf that was, I kid you not, like six inches thick, and it was called moisturization. It was tiny 10 point font and they were taking through the history of moisturizer research and development. Many dead ends in that history where people found stuff that actually made stuff worse, they found things that were irritating.

For example, if you put humectants on the skin without an occlusive, you can actually pull water out and cause more harm than good. But now we live in kind of a golden age. I think a lot of the forebears have done the hard work. To be very frank, you can walk into a drug store and there's shelves and shelves and moisturizers, and by and large, so long as you pick one that's reputable and ideally designed for sensitive skin, you're actually probably going to do okay.

Certainly there are some things we don't want, and there are kind of fancy fragrance-free things that have all sorts of other stuff that are more of a cosmetic. That's not what we're talking about here. Those might not be so agreeable, but many of the good brands that are available are quite nice. A big part of our problem is finding the one that people will actually use. What feels good on your skin? I get a lot of difficult patients referred to me.

Sometimes they come in and they say, "Everything burns my skin, everything feels terrible." This is really tough, especially when it's a kid, because not only will they not put moisturizer, but they might not even put on a topical medicine. My favorite trick is I go into my little back storage closet and I make a little palette of different moisturizer, and I put them on a little clean tray, and I come in with my glove on and I just put a little bit on the back of their hand.

I say, how does this one feel? The best moment is when the little kid says, "Ooh, I like that one. That one's good." And it's like, yes [crosstalk 00:08:03].

[Amy Risley] So cute.

[Dr. Peter Lio] Yes. And I'm like, and I give them a little sample like, this one I think is the good one. You can just tell them, this is the one that you liked in Dr. Lio's office. That one's going to be good. The truth is there's not ... I don't have a secret one for that, but I have a bunch of good ones in my back pocket that I can bring out. Some people, for example, and I'm of this group, I really like the heavier moisturizers. I think when the skin is cracked and damaged, heavier things that have waxes and dimethicone and petrolatum, those are great because they really protect. They seal things in.

Typically, the ointment, these heavier ones also have fewer preservatives and fewer ingredients overall so a little bit better tolerated, but some patients are like, nah, I'm not putting that on my skin, particularly when it's hot and steamy out there. I just feel like it's boiling, I can't breathe. So then we can use some of the lighter weight creams. Then even very rarely, there are a couple of newer products that are lotion and gel-like, that historically would have said no way, but now the new technology has allowed for some of these innovations where people can use some of these gel type ones, and they say, you know what? It actually is okay.

It's not stinging and burning. They're not alcohol containing gels. It's been amazing to watch the technology keep going up, and up, and up.

[Amy Risley] You talk a little bit too, in one of the National Eczema Association conferences, I was listening to your speech and you talked about the FDA. What I loved is you said the FDA is there to protect us. And they've done a lot of really great research. If they monograph or approve an ingredient, it's because there's likely hundreds or thousands of studies to back it up. And not only to back up its efficacy at treating a specific concern, but also the safety.

So, at Skinfix, we use primarily, in our eczema products, OTC monograph ingredients. We use colloidal oatmeal as a skin protectant. We use sweet almond oil, which is actually monograph by Health Canada as an antipyretic or NIH. And we use zinc oxide and also atlanto as a mild humectant and also keratolytic. But we're very, very careful about how we formulate. So, we're as natural as we can be and we use the ingredients that have been approved by the FDA, but we try to avoid a lot of ingredients that could be potentially irritating or that don't have the science to back them up.

I just wanted to get your perspective on some of these sort of natural remedies or homeopathic remedies that people use to treat eczema because they really want to avoid steroids. What do you see when patients are using some of those products that maybe don't have the science or the efficacy or the safety to back them up?

[Dr. Peter Lio]    No, it's such an interesting point. I'm very interested in that area, so I spend a lot of time thinking about botanicals and natural approaches to help people. But one of the key pieces you point out is that when something's not regulated, it also opens up the possibility that it's not what they say it is. That's one of our toughest things. For example, there's a bit of a craze right now with cannabinoids. These kind of marijuana derivatives from the cannabis plant. And they're very interesting. The science underlying them is actually quite compelling.

They may have some anti-itch properties. They may have anti-inflammatory properties. They really seem to be quite nice. But the problem is there's a disconnect between knowing what something might do scientifically and then going to the store and buying something if there's no oversight. What if it doesn't have what they say it has? What if it's not been purified correctly? We take some of these risks when we, especially when we go into new areas that are not as well regulated and when we go away from things that we know a lot about.

Now, sometimes it can be a risk that benefits people find great products all the time and say, hey, this changed my life. But the internet, of course, we know also falsely magnifies those messages. There might be a thousand people who tried it and got irritated or lost their money on it and they never post. But the one person who may or may not even gotten a free sample or gotten some kind of compensation from a company says, this is the greatest product ever. This cured me for life. So, it's really tough to fight that because people read those and they get those impressions over and over and over.

All that being said, I do think there are some amazing natural products. I mean, even, for example, the almond oil, some of the natural oils that we can bring in can be wonderful. I'm a big proponent of coconut oil. I think that can help some of our patients. Of course, like a lot of botanicals, it has a risk of becoming allergic to that. We can get allergic to plants and foods, but it is kind of neat. I also really like some of the natural sunflower oil products, because sunflower oil seems to have an anti-inflammatory effect and also kind of boosts our natural production of ceramides, those special fats in our skin.

But again, everyone's a little bit different and some people are just so sensitive. I try to pick stuff that's very limited in ingredients, and others are a little more daring and want to go outside of that.

[Amy Risley] It's probably a process of trial and error to some degree, because as you point out, somebody might be allergic to pretty much anything and you've got to find the right thing that's going to help and not hurt. What I love about you and what I love about your approach is that, in one of the things that I listened to said, I want to believe. When there's a new therapy like CBD, cannabinoid, I want to believe that it could work because I really want to find more modalities that can really help treat eczema and I'm willing to dive in and really try to find sort of the science behind it.

I love that approach. One of the things that you studied, I don't know if it was after or before medical school is acupuncture, and you talked a little bit about acupressure in one of your lectures as really being helpful in treating, I think, a patient that had serious problems with itch. Talk a little bit about some of those alternative modalities and how you might use them in your practice. And do you use acupuncture in your practice?

[Dr. Peter Lio] Yes, I do, and I am always looking for, again, non-pharmacologic, nonmedical ways to help people get better and feel better. The acupressure study was kind of fun because we knew there was a few studies looking at acupuncture. So, the puncture is when you actually use the needle. In particular, there's one spot on the arm, it's called large intestine 11. It's kind of by the crook of the elbow.

They did this study in patients that have kidney disease. If your kidneys are not working well, you actually can get incredibly itchy. We call it a metabolic type of itch, because your body's not getting rid of the toxins that it's supposed to, and it's imbalanced, and you can get terribly, terribly itchy. And they found that, in this group of really tough patients, this acupuncture with a needle worked and helped them a lot. We tried to do the same thing, but our institutional review board said, no, we don't want needles because if they have some infection on their skin, they were worried.

This is an eczema hotspot, is right where we're going to put it in, so can you just do an acupressure? And we said, okay, we'll do acupressure instead of needles, which makes it very low risk. And we had these patients massage that area, that same point called large intestine 11, just three minutes, three times a week. And it was amazing. It really did have a significant effect. Now, it was a very small study. It was just a pilot study and a very reasonable thing you could bring up to say, well, did you have a fake acupuncture point group or acupressure point group? As they call it, a sham point, we did not.

It could have all just been placebo. It could have just been keeping your hands busy, but what I countered was that's okay. It didn't cost anything. It's super duper safe. If it really was just keeping busy and that made patients feel better enough to be statistically significant, I'll take it.

[Amy Risley] Right. I mean, yeah, no one's going to be negatively impacted by rubbing a point on their elbow. That's amazing. There is a study that talks about babies, and you referenced it in one of the podcasts I was listening to, it was done by Dr. Simpson and Hannah Farr, and it's a study that we often mentioned when we're in Sephora stores training on our products, because it's quite compelling. Can you tell our listeners a little bit about that study and what the findings were?

[Dr. Peter Lio] This was the prevention study, right? We're talking about. Yes.

[Amy Risley] Yes. With babies. Yes.

[Dr. Peter Lio] Dr. Simpson, yeah, this is his amazing work where they looked, and the idea was, if leaky skin is the first step to developing eczema, that if you could compensate for that really early on, ideally within the first week or two of life, have people put a moisturizer on, could you prevent the development of atopic dermatitis? It's a wonderful question and it really takes this theory and puts it to the test in a way, doesn't it?

Actually, they found in that initial work that they did, somewhere on the order of 30% to 50% decrease in the number of kids developed eczema than what they predicted kind of given historical norms. I'm really promising that putting, especially high risk babies, these were babies that were high risk, that other family members that had other types of allergic diseases, that if we moisturize their skin, it might actually help prevent.

Now, the bad news is, or sort of bad news is that, since then, a few different studies have come out that have been a little larger and they haven't quite validated that. In fact, they show not as much of an effect, which is a little bit disappointing, but we're kind of picking them apart a little bit. They weren't all done quite the same way as Dr. Simpson's Study. We're really hoping to get this done very much like he did at a high-risk population.

Because we think, if you just take all comers and you put it on there, it might not do much. We think that you won't see it if there's not a high risk of eczema in the first place. So, we really want to get those kids who are at higher risk, and then this also may be that subtype or biomarker question. Maybe the reason that first study worked out is they got a bunch of the kids who really skin defect was their primary problem.

Later studies, since we don't know what to look for, they might've gotten sort of unlucky from our standpoint and picked kids where the immune system was the primary problem. So, putting on moisturizer in the first few months, or first year of life, it didn't do much because that wasn't the primary issue. That was a secondary problem, and it wouldn't have protected them in the first place. I'm not ready to throw out the baby with the bath water yet.

[Amy Risley] Sounds good. And is there a connection between eczema and skin sensitive ... Or sorry, diet sensitivities? I had eczema as a child and my daughter had eczema as a child, and we both went gluten-free and dairy-free, and I believe that it cleared up my eczema, both of our eczema cleared up and actually helped with our asthma quite a bit as well. Is there a connection in many cases with food allergies and eczema?

[Dr. Peter Lio] There definitely is, and it is a complex relationship, and I think you illustrate it well. A lot of patients kind of tell me a similar story. The thing I think we know for sure, I think no one would argue, this is not controversial, is just that a lot of kids and adults with eczema have food allergies. And that the more severe your skin is, the more likely you are to have food allergies. In the group that's moderate and severe, they have way more. In fact, I was looking at some data recently from a study, something like two thirds of the patients with moderate to severe atopic dermatitis had verifiable food allergies, like the real deal testing.

So, enormous number. Now, when we take it to even include things more like food sensitivities, which would be sort of maybe not being allergic to it on a test, not having hives, not swelling, but people will report, "Boy, I ate this food and I seem to get worse." It's even higher I'd imagine. Because that includes an additional group of people that sort of say, "I know the test is negative, but there's something else going on here."

Then I put there's even a third category about foods. I just think that some foods are pro-inflammatory. Again, no test would pick this up. You're not allergic to it necessarily, but that when you eat this food, it just kind of fuels inflammation. We see that in other disease states. And it's weird. Sometimes my colleagues will push back on me and they'll be like, come on, this is speculative. I'm like, we talk about this in acne all the time, and acne, I don't think that dairy causes acne, but a lot of my patients, and now there've been a number of reasonably good studies, when you cut dairy out, patients do better with acne.

I think there may be pro-inflammatory foods. They're not allergic to it, and they can tolerate it, it's just this matter, it seems to push inflammation in one direction or another. I think those are the three kind of dietary issues that we're seeing. In your case, it's hard to know. Gluten is a particularly interesting thing because a decent number of patients have true gluten sensitivity where they're actually making antibodies specifically to it. Sometimes that can be inflammatory, but other people just seem to ... It has that pro-inflammatory role in their body. So, you're not alone.

Many people find that when they clean up their diet, things get better. The other confounding issue is that gluten, of course, is in a lot of processed foods. One of the ways, when we cut gluten, it's not just like, I'm going to stop eating this beautiful, fresh, homemade bread that we make every week and everything else stays the same. Almost never. Maybe there are some cases like that, but in my experience, most families, then it's like, okay, I guess we're not having cookies, we're not having cake. We're going to cut back on the pizza. We're not going to have the burgers.

And all of a sudden you see this entire category of kind of junky processed food disappear, and people say, See, it was the gluten." And I'm like, it might've been the gluten, but holy cow, your diet is so much better now. Maybe it's that now you're eating all this other good food and you've cut out so many of the processed foods associated with gluten. Again, I don't mean that this is for everybody, but I think that's why it's so hard to parse all this out because you have all these confounders.

[Amy Risley] Interesting because those processed foods could be causing the inflammation and just happened to also carry the gluten with them. That's a really interesting point. When I was young and I used to get eczema very badly on my calves and the crux and my knees and the crux of my elbows, in the summertime, my mother, because this was the '70s, and we didn't care as much about getting too much sun exposure, she'd say, just go to the beach. Get some sun, swim in the salt water. I grew up in California. I have to say that in the summer, my eczema was really under control.

I know that you often, or you sometimes will treat eczema with phototherapy, which is a much safer way to do it than me laying out in the sun, and you talked a little bit about sort of an eye and eye saltwater as well. Is there any validity to my mom's sort of wives tale of go to the beach and your eczema will clear up?

[Dr. Peter Lio] Absolutely. You're absolutely right. The strict name, when we're thinking about phototherapy or light therapy, what you guys were doing, maybe we even call it climatotherapy because you're not only getting into light, but you're getting the saltwater in the sea. There's even an aspect of probably the emotional state too, and we're in a wonderful place. We relax, we come down, we break those different kinds of cycles that we have that are habitual.

I've actually sent some of my patients to get spa therapy in Europe. So, France in particular, but a number of European countries, it's actually part of their healthcare system, you can go and spend two weeks getting the mineral water soaks, getting some sunshine, all these kinds of things, and it's dramatic. It's so powerful. So, I think you're right on. What we do in the office is kind of a baby version of that.

We use phototherapy, which is sort of filtered UV light. It's a little safer than the sun, because unfortunately, the sun of course has a lot of UVA, which can be damaging over time, especially if we get too much of it. A little bit of sunlight is probably good, but we don't want to overdo it with the light machine we have. It's filtered in a way to be a lot less dangerous and less sort of causing skin cancer, but that can help a lot of people too. But I do think, if I had to pick, I'd rather go to the beach and hang out too, because you get all those little aspects.

[Amy Risley] Absolutely. We've seen because we sell a range of eczema products to treat eczema sort of from the head to the feet. We've seen a huge spike in sales in our eczema line during the last few months, during the pandemic, and we also have seen just a magnitude of questions come in on our customer service channels, asking about eczema and eczema products. I have to think that a lot of it may be due to our contact, our direct contact with hand sanitizers and Clorox wipes and also potentially all of the sanitized sort of particles in our environment.

But I also have to imagine that stress and the related sort of sleep deprivation that comes along with it might also be causing the spike amongst our clients and our consumers. Are you seeing the same thing? And do you see direct correlations between stress and sleep deprivation and eczema?

[Dr. Peter Lio] Absolutely. It's been crazy. I think all the things you pointed out, they prolong stress. The sleep has been really disrupted for a lot of people, and of course, the hand sanitizers and even just washing, all that is brutal. So, we're seeing tons and tons of hand dermatitis, even in people who never had it before. But in our patients with existing sensitive skin and eczema, man, they are really suffering right now.

[Amy Risley] Okay. There are lots of different ways that you can treat eczema. You talk about anti-inflammatories antibiotics, antipruritics, and moisturization as sort of this different modalities. How do you, when someone, when a patient comes to you, how do you start the approach? Does it sort of depend on what you're seeing in terms of severity and location on the body? Or do you sort of start to treat everyone the same and then kind of sort of edit as you go and iterate as you go? How do you know which patient needs which therapies?

[Dr. Peter Lio] I think, yeah, there's a bit of art to it. Part of the things I'm looking at when I meet somebody is the extent, how much is involved in their body, the severity. Somebody could come in and they might just be a little pink and dry. Other people come in and they're infected crusting, oozing, really, really in trouble. The age of the patients, and of course also matters. If they're a little baby, then that's going to change us a lot than if they're 25-years-old. So, all these pieces, and then the history.

How long has it been going on? What have they been using? One of the things that's important to me too, and part of the reason I like knowing about a lot of different modalities is because sometimes patients come in full of despair and they say, I've tried everything. I've bought every moisturizer from the drug store. I've tried them all. I have basically a drugstore in my house. Nothing you're going to give me is new. Part of what I pride myself on is being able to say, hmm, let me see if I can delight and surprise you with something you've never heard about before.

I've cultivated over many, many years and working with lots of different traditions, too, lots of tricks from my magic hat that I can pull out of. I think that matters. I don't want to say that flippantly. It's not that I'm trying to trick somebody or just surprise them. But I think, by showing them that there are other approaches, sometimes that little tiny glimmer of hope is really all that they need. When they hear something new, when they hear a different approach, different idea, sometimes that galvanizes them in the best possible way that now they're saying, "Okay, you know what? This is different. I've never heard this before. You're not just writing me [inaudible 00:25:47] in a one pound jar with 11 refills.

You actually have a different approach. So many of my patients are exhausted from that. I think that can get people on the road of getting better. It's really hard to get somebody better if they're not ready because they have to do it. They have to actually put on all this stuff and follow along with me and have to buy into it to a certain degree. But once they do that, I think we're halfway there or more.

[Amy Risley] Is eczema ultimately curable, or will it always be a chronic condition that they've got to sort of get ahead of and deal with?

[Dr. Peter Lio] I do think that for the majority of patients that I see, and mind you, I'm pretty biased. I'm only referrals so I'm seeing kind of the worst of the worst, but for the patients I see, I think it is more part of them. It is something that they're going to have to work on. That being said, we can get an awful lot of patients, even those who had given up hope, we can get them to a point where they're really not using any medicines.

So, we can put them, and I like call it a prolonged remission, where they're just like, I'm just really good. I haven't eaten anything. I'm cool. That doesn't mean they can go to bath and body works and put on a frequency thing or go to the cologne counter and put on everything. They might not be able to do that ever. But it does mean they can hopefully get back to enjoying their life and do most things. For a lot of patients who are doing restrictive diets, sometimes they say, you know what? We really thought X, Y, and Z foods were triggering this, but now we're okay and we're able to eat those again.

I know my daughter has some food allergies and there ... It's a big deal. It's hard. And it weighs on her mind a lot as she's getting older. She's always nervous about stuff and it really limits her. If I can give somebody a chance to not have to worry about, even just one thing, even if we say, you know what? Maybe the tomatoes, I know you were worried about tomatoes. The allergy test was negative though, but I know you felt like they made you worse. Let's try them again now that your skin is better. A lot of patients say, you know what? You're right.

My skin was terrible. It felt like it made it worse. But now that I'm stronger, it doesn't bother me, and I call this the threshold phenomenon. It's like, when you wake up in a bad mood, the littlest thing can set you off. Somebody accidentally bumps you, it's like, what are you doing? Why are you in the way? When you're in a good mood, somebody can check you against the wall and you're like, hey, no problem have a great day. I think our skin is like that too.

It's made our whatever, inflammatory food, whatever it may be, may really cause trouble when your skin is in the dumps. But when it's better and stronger, it's no big deal. It rolls right off.

[Amy Risley] How important is the psychological component of what you do? I mean, are people coming to see you just really down in the dumps over their skin and how they feel and the itch and the aggravation, and the way it looks? And do you find that you refer a lot of patients to psychotherapy or do you do a lot of, sort of in-office psychotherapy yourself? I mean, just to ... It's such an emotional thing, having a skin concern.

[Dr. Peter Lio] It really is. I don't know if I'd ever call it psychotherapy, but I do think that being there and expressing empathy and putting out your hand to help somebody feel like they're not alone, that is psychotherapy. That is a way to support and strengthen somebody. Yes, I do. There's a couple of groups that I refer to, and I often kind of couch it in the fact that I'm like, this is a burden for anybody, but it's a double burden when you're also suffering with physical stuff.

The physical brings out mental stuff, and so when patients really feel down or really anxious about their skin, I think they can benefit from talking to somebody. There are some really cool folks that focus on behavioral issues around skin problems. I think patients like that, I even have a hypnotherapist that I work with that can be amazing. She can help them kind of do some gentle self-hypnosis, especially when they're feeling really itchy and inflamed or having trouble sleeping.

Patients, obviously that it's not the secret cure, but they'll say, you know what? That really helps me. That helps me ... Instead of going to that terrible place where everything's falling apart, I can sometimes ramp it back down before it gets there. So, I think it's really powerful, but sometimes it is a hard sell. I don't want them to think I'm saying they're crazy. I'm just saying that this is a terrible burden on anybody and it's really important to get some help sometimes to help us get through this together.

[Amy Risley] Yeah. It's okay to not feel okay. It's all right.

[Dr. Peter Lio] Exactly.

[Amy Risley] And you have every right to not feel okay. One of the things that I really love about you is that I feel like you're on a mission. You're so dedicated and devoted to the treatment of eczema and you seem to turn over every rock, every stone. You want to find new modalities and you just are so open-minded and open-hearted in your sort of pursuit of a cure or treatments. And I love that about you. What turned you on about eczema? When you were at medical school and you decided to become a dermatologist, why this sort of focus and what brought you here?

[Dr. Peter Lio] Yeah, I think for me, the dermatology choice was really to follow some teachers that I adored and respected. When you're a medical student, you get this huge cavalcade of lectures in front of you, and some are amazing and some are sort of mediocre, but the dermatologists that spoke blew my mind. The way that they used words and ideas and the way that they understood the skin in really seemed different than any other specialty.

Then when I got a little more exposure, part of what I fell in love with is this idea that we have all of these different treatment modalities. If you're an interventional cardiologist, you can do a lot of stuff. You can go in there and you can zap stuff and you have different pills and things, but in dermatology, it's like multiple dimensions more. We can use lasers, we can use thermal devices, we can use all these topical things. We can use oral medicines, we can use lifestyle change. We have all these different ways to approach stuff. That kind of really excited me.

Then eczema drew me because it is just hard. I have to say, it was more that I was sort of selected. I didn't select it. It sort of selected me. I just kept getting these tough patient over and over and over that really needed some help and needed a way out. Because I pride myself as someone who really will keep fighting, I often say like, I'm not going to give up on you. I just need you not to give up on me. I think that sort of cultivated that reputation, and little by little got better and better at it.

That was in a time, I think, when it was less interesting. Now, I feel kind of lucky, it kind of went from zero to hero, and now a lot of companies are interested and people are more aware of it, but 15 years ago, it was sort of the backwater of dermatology.

[Amy Risley] Well, thankfully, you did throw your formidable power behind it, which has been great for eczema and great for all of your patients, for sure. What is the biggest challenge in treating eczema? What is the hardest thing to tackle and the one thing that we don't really have a reliable treatment for, in your mind?

[Dr. Peter Lio] I still think itch is really brutal and I wish we had better direct treatments for itch. Sometimes patients are just suffering so much from it and we're waiting for everything to kick in.

[Amy Risley] Yeah. You had mentioned it was the dark side of eczema mountain in one of your speeches. I know, just growing up with eczema, that itch at night was just brutal and just it's so disruptive to your quality of life. Well, Dr. Lio, would you describe for us what a sort of worst case scenario eczema patient looks like in terms of what's going on in the symptoms?

[Dr. Peter Lio] Absolutely. We know for the mildest patients, you could meet them on the street and wouldn't even know that they had any eczema. It might just be more of a dry, sensitive skin. They might only react intermittently. Those can be a little bit under the radar. For the most severe patients that I see, you're often talking much of the body, if not all of the body involved. So, sometimes their whole skin surface is bright red. There's often open oozing areas. There's often secondary bacterial infections, so crusting all over the place.

Most of the time, for these more severe patients, it's not just itch anymore. Now it's actual skin pain. Since we've learned to ask that question, I think again, a few years ago, that was even a little controversial. It would be like, wait, skin pain, who's asking that. But then once that got out, people started asking me more and more, many of my patients say, yes, it actually hurts. It feels like a burn. Some of the patients I see, they're so severe that if they're taking the bus or they're taking the subway, everyone backs away. They think they have something terrible because they look so, so horrible. They look like they've been burned.

[Amy Risley] It's terrible. I mean, as you mentioned, we're used to sort of the common eczema that might be in a certain area of the body and you wouldn't necessarily know, but when someone's dealing with an extreme case, it's really affecting all aspects of their life, I imagine.

[Dr. Peter Lio] Absolutely.

[Amy Risley] Dr. Lio, you talked about the fact that when you have eczema, you've got basically a leaky skin barrier that, that brick and mortar that forms our skin barrier, our epidermis is open, is leaky. Can that ultimately lead to other issues? Can that lead to letting sort of viruses or bacteria into the body and can that also lead to other even more severe illnesses?

[Dr. Peter Lio] Absolutely. We think it is the gateway for lots of badness. The first thing is, of course, that when the barrier is weakened or leaky, allergens can come in. One of the theories now is that the way people become allergic to, at least some foods, we don't know if this explains everything, and it may be again, multifactorial, but some foods seem to become sensitized via the skin, and we call this transcutaneous sensitization.

This is this concept that maybe if we were to protect that skin barrier early on, maybe we could even prevent food allergies, which are pretty terrible, and again, have a lot of their own issues and suffering associated with it. Lots of morbidity. The other thing of course is that we have to keep out pathogens. So, bacteria, funguses, viruses, all these bad things. Again, when the skin barrier is down, those can take advantage of it.

The most common, probably that we see all the time in my clinic is staph aureus. Staph aureus is a common pathogenic bacteria, many patients with even a little bit of damage to their skin barrier are colonized by it. Meaning it's kind of sitting there. It shouldn't be there, but it's sitting there, kind of like, one could imagine folks who are up to no good standing around in a dark part of the city at night.

[Amy Risley] Waiting to get into trouble.

[Dr. Peter Lio] Waiting to get into trouble. Haven't done anything wrong yet, but it's like, hmm, don't you guys have anywhere else to be right now? What are you guys waiting for? Why are you eyeing everyone who walks by? That's the first stage. Then of course, if the skin barrier really is damaged, then it can form a true secondary infection, sometimes in the form of impetigo, that honey colored crusting, and sometimes a real deeper infection like cellulitis, or I've even had cases over the years where it actually gets into the bloodstream and they have bacteremia or sepsis. They're quite ill, very scary.

Viruses can also do it. The most common one to take advantage of this is the cold sore, virus herpes simplex virus, and patients can get a condition called eczema herpeticum. That's when the cold sore virus, which normally might just make a couple of little blisters by your mouth, in these patients, because their skin barriers damaged, it can spread all over. They can get extremely sick. You can even die from the cold sore virus in this context, and it's actually a bit scary. So, those patients sometimes will say, you have to go to the hospital, we have to get you intravenous antiviral medicine to kill this thing so it doesn't hurt you. That's just some of the stuff that we see.

[Amy Risley] Having a healthy skin barrier that's functioning and not leaky is really critical to your overall health and wellness. We often think about skincare as an anti-aging vehicle and women start to use skincare, maybe in their teens, early 20s, but really, we're not talking about skin barrier health as something that we all should do as part of our sort of daily hygiene. We think about brushing our teeth and wearing our sunscreen, and we learn all these things from an early age, but we don't talk about taking care of the skin barrier from an early age. What do you think that we could be and should be doing from childhood to really look after that barrier and how important is it to include a skin barrier regimen as part of our daily hygiene?

[Dr. Peter Lio] Gosh, it's so amazing that the barrier works as well as it does, and it's something, you're right, we take it for granted. You just assume your skin barrier will be great. I think we are learning more and more that probably, and this is still in the hypothesis domain, but we think that a lot of the aspects of modern life might be why we're seeing trouble with the skin barrier and now we're seeing more eczema than we've ever seen before. Historically, this has been around for quite some time, but never in the numbers that we're seeing.

Sometimes you look at these things and since World War II, it's multiple, multiple times more. Clearly, it's not just genetic. That explains some of it, but there must be some part of the contribution from the environment. It may have something to do with modern life. Sometimes we think it's our bathing practices, that we bathe a lot more than in old times. People probably didn't bathe as much. And maybe some of the products we're using on our skin, like particularly harsh soaps and cleansers. They really strip a lot of the natural fats and lipids.

I think part of the problem is we don't exactly know what to teach yet and I think that's been a little bit of a sticking point. We don't know what to say, but I think in general, I do think that high risk families should try to use the gentlest, gentlest products on the baby's skin and on their own skin to try to use things. I, for example, am a big fan of more oil based cleansers now. I think that's a really nice niche. I believe you guys have one too. That's quite nice.

[Amy Risley] We do. Thank you.

[Dr. Peter Lio] Yes.

[Amy Risley] Foaming Oil Cleanser.

[Dr. Peter Lio] Absolutely. I think that's a better way for a lot of patients. I also think that yes, using a good moisturizer to protect your skin, particularly after bathing is a really good best practices. Again, we don't want people putting unnecessary chemicals. I don't want them exposed to stuff they don't need to be. So, that's why I think finding a good high quality moisturizer that feels good and is accessible can really make a big difference, but I'm excited to see, as we learn a little bit more and more of these studies come out, maybe we will have a better consensus guideline to say, look, everyone should do X, Y, and Z for their babies. Until then, we're a little bit stuck.

[Amy Risley] And just learn how to put moisturizer on from an early age. The interesting thing is, is body care is really growing as a category of skin care right now, certainly at Sephora, it's starting to explode. I'm so happy about that because we don't often think about from the neck down, and the face is wonderful, but it's a tiny percentage of our overall skin barrier, and the rest of us really needs that nurture and care and hydration as well.

It would be wonderful if we could get barrier health included as part of all of our sort of daily health regimen or hygiene regimen from an early age. You're also trained in acupuncture, and how does medical puncture sort of factor into treatment of skin issues and how does it particularly work in helping with dermatological skin concerns?

[Dr. Peter Lio] I think it really has a role as a nice adjunctive treatment. Very rarely, unfortunately, I wish it could just fix stuff with just a few needles, but it's generally not very powerful for a lot of my patients, but it's a really nice adjunctive or supportive treatment, particularly for people that have stress related disease, particularly for people that are having trouble with sleep as well, and itch. All of those things that can make a really big difference over time, but it's not a very fast operating treatment, at least in the skin.

For things like neck pain, muscle pain, back pain, it can be much faster and much more definitive, but in my domain, it's a little bit more of a helper outer, but in that context, it can be wonderful and it's made the difference for a lot of patients. Especially sometimes we have a patient who's debating if they need to go on a more powerful systemic medicine. Sometimes we can take our topicals, add something like acupuncture, acupressure, and they say, okay, we got it. I'm okay now. I didn't need to go to that next level because this little extra piece has now given me what I needed to get to the spot that I'm comfortable.

[Amy Risley] Yeah. How long is a typical course of acupuncture in order for it to really be effective?

[Dr. Peter Lio] One of the hard parts about acupuncture in the US is that we do things a little differently. I learned a Japanese style, and my teacher, Kiiko Matsumoto, used to talk about how people could come in three times a week for an hour treatment, but that's really tough in the states. Often people are driving and parking, and so it often becomes hard of once a week, plus it's a lot more expensive to do it here. If you're doing it three times a week and it's more accessible, it can be more of a community style and it's very affordable, but here it becomes kind of expensive.

We try to weigh all those pieces and try to find the best balance for patients. But in general, you're talking about several, at least several treatments to even start to see some real deep effects. So, maybe three to six treatments before you see stuff, and then many patients need to do it on and off for months before they really can do much better. Which again, if somebody comes to me and they're miserable, that's why I'm not going to say, we're going to start with that. It's not totally fair for again, for most of my patients.

Sometimes it can make a big dramatic change, but in my experience, usually I'll start other things first and start that concomitantly and then slowly that will help build them up to state where they're better?

[Amy Risley] Do you practice acupuncture in your practice currently?

[Dr. Peter Lio] I really don't do much anymore. It actually is really tough. Dermatology, as you may know, is pretty fast paced. So, to have a room for an hour is tough. I actually work with some great acupuncturists around the city and get to refer to them. One of whom does a community style acupuncture, which is great. He'll have five or six patients all together, and by doing that, he can make it extremely affordable and extremely convenient. I have a lot of patients who like that route.

[Amy Risley] Oh, what a fantastic concept. I love that. I also wanted to ask you a little bit about pH, and one of the National Eczema Association presentations, you held of a slide that showed different moisturizers and those that are sort of below the 5.5 pH level that is sort of the skin similar pH and those that are more alkaline. Can you talk a little bit about the thinking on pH levels and topical skincare products and how they may or may not affect eczema?

[Dr. Peter Lio] Yes. We know that the skin does like to be more acidic, way more acidic than our blood. This concept is called the acid mantle. If you have a strong acid mantle, you have a better skin barrier, you also keep staph bacteria levels down. If you get more alkaline on your skin, this begins to backfire. A lot of the enzymes start to go crazy, you get skin barrier damage. Staph actually grows. You can see these curves, it's quite impressive. Ideally, we want to try to do things that will support that lower pH, that more acidic pH on the skin.

It is a little tricky because we looked at, in that paper, a number of different moisturizers and thought, maybe it would be better to use the more acidic ones, but as we discussed, moisturizers are complex, it's really sort of an emergent property. They have all these pieces together. While I think it could be a great feature to have some sort of an acid in there to bring its pH down a little lower, sometimes that is overshadowed or outweighed by other aspects of the moisturizer and it's tricky.

Some of my favorite ones are more neutral or maybe even a little bit alkaline, so it is a little strange, but I think that would be awesome, and it is fallen out of favor. It was a very hot topic in the 70s and 80s, and I feel like it really not something that's being published about a lot right now. So, I'm kind of hoping it comes back because I think it's important.

[Amy Risley] Interesting. Well, at Sephora, there have been quite a few brands that have really started to talk about the acid mantle and the pH of their products. In fact, there are a few brands that actually published the exact pH of each of their moisturizers and cleansers on their product pages and we get lots of questions from consumers about the pH level of our products and they seem to understand that you want something more acidic than the skin's sort of natural pH in order to manage some skin concerns.

It would seem that people are starting to become more educated about pH and it's becoming a hot topic again, which was really interesting. When I saw your presentation, I thought, that's kind of cool because we're all getting just more educated now. We do keep all of our eczema products at about a 4.8 pH. We really are very careful in how we manage those to make sure that they're the right acidity to make sure that we're not disrupting that acid mantle. It's great to hear that you're a believer.

[Dr. Peter Lio] Absolutely.

[Amy Risley] Yeah. Dr. Lio, you talked a little bit about hypnotherapy, and specifically in helping people manage sort of itch. How can hypnotherapy be helpful and what do you see as sort of the effects of treating a patient with some form of hypnotherapy as an adjunct to other treatments?

[Dr. Peter Lio] I think, since that lecture, we talked about where I had those treatment tetrahedra, in those four points, I've actually added a fifth. From my updated lectures, I now show a hand with the five pillars. The fifth pillar that I added is the psyche. It's the mind body connection. I think I was not giving that enough credence and enough focus because there really is an important aspect of the mind on the skin and on our overall health. This doesn't just mean being depressed or anxious, but it also means, very literally, when people are under stress, their skin barrier begins to fall apart.

You can actually show this, even in healthy volunteer, if we keep you up overnight for a night or two, your skin barrier is actually weakened. This mind, body connection goes that way. But also, of course, we know there's habits and there's these behavioral circuits or cycles that'll see a lot of times. A lot of my adolescent patients, as soon as they take off their shirt to show me, they start scratching. I don't know if they're even itchy at that exact moment, but that's their thing. And the parents will be like, "See, this is what he does every night."

Little babies too, before they go to sleep, they'll have these scratch routines. Sometimes I find that using something like hypnosis as a way to break those cycles to help cool anxiety, to help just really get patients focused back on a mindfulness state can be incredibly powerful and incredibly important. Again, you don't have to always go see a hypnotherapist. There's even ways to learn on the internet, there's books. But a lot of times, I'll like them to see someone for a visit or two, a handful of visits. It doesn't have to be super expensive, and then many them will even give you your recording so you can play it back.

I've actually gone. I mean, I've tried it, it's wonderful. I have my recording, so if I'm feeling anxious or stressed, I can pop in my AirPods and listen and bring myself right back to that hypnotic state, which is similar to meditation in a lot of ways, sort of a meditative state that helps from the outside.

[Amy Risley] How do you assess whether or not the skin barriers become damaged? How do you look at that?

[Dr. Peter Lio] Yeah. Great. So, there are kind of two major techniques. Although there are others of course, that you can use, but the two major ones are one's called corneometry, and it's a little machine that looks at the hydration state of the stratum corneum, how much water's in there. The other one is called TEW, so the transepidermal water loss, the T-E-W-L, or TEWL meter is what the machine, sometimes I refer it, and that's actually looking at how much water is coming through the skin.

Ideally, your skin should be pretty solid against water, it should be blocking water, but if it's broken up, then you'll actually see sort of water vapor coming out of the skin at an alarming rate. You can actually measure that with a little machine. Now, there's a lot of caveats, it's a little tricky to do, but because it changes even throughout the day sometimes. But you can get a sense of where things are at. Those are two ways that are commonly used in research studies to barrier sense.

[Amy Risley] And you can see changes that quickly if you keep someone up overnight or you sort of put them in a stressful situation for a couple of days, even that will show a change in the skin barrier health.

[Dr. Peter Lio] It sure does.

[Amy Risley] Is there an eczema cure insight in your opinion?

[Dr. Peter Lio] I wish. I don't think we have the C word yet. The cure word is a big word, because we still don't exactly know what it is, and I think that's hard. As we said, we don't even think it's one thing. I think we have better treatments than ever before. The past 50 years, we've had such little activity in eczema. There's been such limited innovation. Now, we're seeing this explosion of new ideas. I think this is the beginning. I think this is the decade of eczema we're about to enter. We're going to see all sorts of new ideas, new products. One of the things we do is, when we get new drugs to treat something, we learn about the disease, because we can say, ah, look, it didn't help this person. It did help this person.

The fancy term for that is a diagnosis ex adiuvantibus. We can understand it better by what helped. As we get these very targeted new medicines, I think we're going to learn more about it than ever before. I am hopeful that a cure will be in the books at some point. I just don't know when. Right now, I'm grateful to have some treatment options to get people better and out of misery.

[Amy Risley] I'm excited for that cure as well. It's great that there's so much more excitement and energy being put into eczema. As you said, this is the decade of eczema, so that's fantastic for all of us out there that suffer. Dr. Lio, it's been an absolute pleasure to speak to you today, and I really appreciate all of the incredible information that you've given to us and our listeners about eczema. Appreciate all the work you're doing for the cause. And thank you for being here on Total Skin Nerds today with us.

[Dr. Peter Lio] Thank you for having me. This was awesome.

[Amy Risley] To learn more about Dr. Lio's work, visit his websites, www.dermchicago.com, and www.chicagoeczema.com.

I learned so much from talking with Dr. Lio. He combines deep scholarship with a devoted clinical practice and a level of kindness you can feel. Here are three things I can't stop thinking about. One, pH, as a skincare metric is a fascinating concept and a key component of skin barrier health. Dr. Lio is a big believer that using products with the right pH is critical to managing eczema, and so am I. I'm fascinated by emerging research about acidity and alkalinity relative to skin healthy, and I can't wait to dig in and learn more.

Two, hypnotherapy, acupuncture, and acupressure are all very much of interest to me. I love Dr. Lio's exploration of these different modalities to treat eczema. Three, Dr. Lio spoke about finding treatments that would surprise and delight his patients, especially by tapping into different traditions. I'm inspired by his openness and the way he's seeking to create harmony with medicine. But this isn't only inspiring from a medical point of view. Wanting to care for people by introducing a sense of surprise and delight is just an admirable daily practice, no matter what you do for a living. I'll be thinking about how to implement these gestures more in my own life.

Thank you for listening to this episode of Total Skin Nerds. Please subscribe to our show on iTunes and Spotify. Total Skin Nerds is produced by Rob Corso, Casey Kahn and Howie Kahn for FreeTime Media. Our theme music is by John Palmer. Special thanks to [Catherine 00:52:07] Spears, [Cara Canning 00:52:08], Jenny Chen, Jane Meredith and Megan Collins. And I'm your host Amy Risley. Till next time, nerds.

[Amy Risley] Total Skin Nerds is brought to you by Skinfix. We're clean, clinic active and on a mission to help heal your skin.

Speaker 4: Total Skin Nerds is a podcast created to educate. It is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical advice. If you are looking for help with a skin concern, we would encourage you to seek the advice of a board certified dermatologist, functional medical practitioner, or other qualified healthcare provider.

You can find a registry of board certified dermatologists in the US at find-a-derm.aad.org and in Canada at dermatology.ca. For a registry of qualified functional medical practitioners, you can visit ifm.org. Thank you so much for joining us on this episode. We hope that you enjoy listening to Total Skin Nerds as much as we enjoy making it.

July 08, 2022