Integrative Medicine for Atopic Dermatitis: Q&A With Vivian Shi, MD, Part 2
In part 2, Vivian Shi, MD, assistant professor of dermatology in the Department of Medicine at the University of Arizona and Banner University Medical Center and director of the Eczema and Skin Barrier Clinic and Follicular Disorder Clinic in Tucson, Arizona, discusses which products and ingredients patients should avoid, the Eczema Action Plan, and the top questions she receives most from her patients. Part 1 covered the nonpharmacologic treatment options she discusses with her patients, such as acupuncture, and how she approaches integrative medicine.
Q. What products or ingredients do you advise your patients to avoid?
A. I live in Tucson, Arizona, where patients tend to gravitate and are open to complementary and alternative medicine (CAM) therapies, so it offers great opportunities for me to incorporate integrative approaches to their skin care and treatment. AD is the poster child for integrative dermatology, however, sometimes people rub topical compounds and products on their skin that may be irritating and may even flare their AD. While many “natural” topical compounds are great moisturizers, we have to be cautious when selecting them. For example, poison ivy is natural but we would not rub that on our skin.
One of the products patients with AD should avoid is essential oils. Essential oils are very different from the natural oil in nuts or seeds. Natural nut- or seed-based oils are made by pressing the nut/seed under high pressure without adding any chemicals or ingredients. Essential oils, however, are extracted from the aromatic parts of the plant, such as a flower or leaf. The oils typically are extracted by a process called steam circulation, where the components of the plant are added to heat and chemicals are added to extract the fragrance, as well as aromatic compounds, and sometimes a carrier oil. The whole process often adds and creates irritating compounds such as terpenes and terpenoids, as well as irritating fatty acids.
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I tell patients to avoid using essential oils as a moisturizer, but most commonly people use it in aromatherapy. I also recommend against using essential oils for aromatherapy because they can develop airborne contact allergy that may flare AD. In addition, I work closely with my patients to learn about ingredient selection in their moisturizers, especially to avoid drying agents, which includes products containing alcohol, retinols, or vitamin A. Sometimes a product will say anti-aging or retinol formula and these products will have alpha-hydroxy-acid or retinoid, which is good for skin aging and acne but can be irritating to the dry and sensitive skin of people with AD. Other ingredients are synthetic dyes and certain preservatives, as well as any known allergen. For example, if a patient is allergic to peanuts, they should make sure the product does not have peanut oil.
For moisturizers, the FDA has limited regulations for what can be labeled for sensitive skin or AD-prone skin. Even if a product is labeled for sensitive skin or AD skin, it may still contain risky ingredients such as allergens, fragrance, and synthetic dyes. It’s also important to keep in mind that what is an allergen to one person may not be an allergen to another person. These are some of the general considerations for selecting topical products for AD patients.
Q. What are some of the top questions patients ask about skin care?
A. In addition to the bathing question, another topic that is frequently mentioned is “I read that individuals with AD are more prone to infection.” In that case, the patient wants to try to get rid of the infection and will lather over-the-counter antibiotic cream, such as neomycin, polymyxins, and sometimes they will actually use a loofa to scrub their skin or bathe more often because they think this will decolonize their skin. I highly recommend against using over-the-counter antibiotic because they are relatively common allergens to our skin. I also advise patients not to scrub the skin because AD skin already has a very defective skin barrier and using a loofa or scrub is essentially like scratching your skin. It breaks the skin barrier allowing more allergens, irritants, and microbes to enter causing more inflammation.
Probiotics are frequently brought up as well. The microbiome are the microorganisms that live on the skin and other organs in the body that are exposed to an external environment, with the highest variation in the intestines and the skin because both have the most exposure to an external environment. In AD, instead of a balanced speciation in the skin and gut there are too few beneficial bacteria and there is overgrowth of the pathogenic bacteria. What we try to do is restore this balance because having too much pathogenic bacteria and frequent antibiotics use can disrupt the microbial balance and this is associated with damage to the skin and lining of the intestines. However, this is a controversial topic.
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