Amie: Yes. Eczema is such a tricky beast for children and adults, and it certainly brings with it a rather large degree of suffering, at times. And I think, you know, one of the things I’m really excited to talk about today is, you know, with eczema, conventionally speaking, the approach tends to be pretty basic, external things, that are not without challenges. You know, corticosteroids, to name the big one. And I think the conversation we’re gonna have today, we’re gonna touch on steroid withdrawal, actually, a little bit, but what we’re really going to dive into is a naturopathic approach to actually clearing atopic dermatitis from the inside out, as well as providing relief where we can. And I think we’ve got… I don’t even really know where to start. I think maybe we might open this conversation with ensuring that you have the diagnosis right. And I say this both as a practitioner and also as a patient. If you are a patient, and you’ve assumed that you’ve got eczema, please get it checked out professionally, because we can get all kinds of strange rashes and skin irritations that may actually be something a bit different, that would change and inform the approach, and as practitioners, making sure that it is indeed eczema that you’re dealing with is certainly the first step. So, Rebecca, do you wanna take us through, you know, where you’ve seen this, fall over, and what you recommend doing about it?

Rebecca: Well, I always question the diagnosis when someone’s come to see me, and I encourage other practitioners to do the same, because it’s very easy to think that because the patient has been to see their GP, and in some cases even several dermatologists, to assume that the diagnosis is accurate. However, I have seen patients that have come to me and they’re convinced that they have atopic dermatitis, but when I look at their health history and the pattern of the disease, and the character and the anatomical locations, from my perspective, what I’m actually treating is something different. And that might be I’m treating psoriasis, or in fact, I’m treating atopic dermatitis. Sorry, seborrheic dermatitis, or acne rosacea, or lupus, or… There are many, many different diagnostic patterns that you can go through. And just because many of them are treated with the same drug in dermatological settings doesn’t mean that they’re the same disease. And from the perspective of a naturopath, or, you know, a functional medicine practitioner, we do bring a different lens to each of those different diagnoses. We don’t use the same strategies and the same medicines. And I think that’s probably where the departure lies, is that we’re looking at the condition through a different set of eyes.

Amie: Yes. A more holistic way of viewing where it’s coming from, which I think makes a huge difference, particularly as it informs the treatment. Actually, before I continue to pick your brains on atopic dermatitis, I’d love to know, how did your interest in skin things start? Like, what your trajectory and practice has been like that’s led you to having a particular passion for skin things?

Rebecca: Well, I think that I started to… I mean, as sometimes happens in practice, is that you sometimes see a number of different patients in a row, but they all sort of have the same thing. And that started with acne, common acne vulgaris. And I have personal experience with that as well. When I was a young woman, sort of transitioning from high school into my twenties, I suddenly got acne, which was a bit of a surprise to me. And I remember that pathway, which was a very conventional medical pathway, because I wasn’t, you know, I wasn’t yet a naturopath. And there just weren’t a lot of choice. There wasn’t a lot of choice. There weren’t options presented to me. It was just simply that “this is what you do.” And in fact, it’s exactly the same treatment that’s offered now, to the same patients. There’s nothing really new in the area of acne vulgaris, with treatment. And that, also, the psychological distress that goes along with having a skin condition is, I guess, I have a lot of empathy for these patients, because I’ve experienced it myself, and I know that it’s, you’re not just dealing with… Well, firstly, you’re dealing with maybe pain, irritation, inflammation, but then you also have to manage yourself. You have to manage your emotions and psychology around having the condition, because it’s public. Almost, you know, people can see it. It’s not something…it’s not like your fatty liver disease, that’s living inside your body. No one can see that, you know. So, it’s got, I guess that degree of complexity to it, so I think that’s why I’ve continued to wanna take ground in this area, and to provide people with options, because I feel like there aren’t that many out there currently.

Amie: Mm. I would agree. I have a very similar story to you, where I had acne as a teenager, and I went straight on the pill at 16. And then, when I started studying naturopathy, I realised it wasn’t treating the underlying cause. And you’re so right. Like, 25 years later, you know, it’s still the same. It’s antibiotics, oral contraceptive or Roaccutane, or a combination of those, none of which actually treat the root causes or provide sustainable results. And that’s disappointing regardless of what condition, you know, that may pertain to, but as you said, a skin condition is uniquely distressing, in that it’s visible to everybody else, you know. It’s not like anyone with high cholesterol or high blood pressure is walking around embarrassed of how that looks on your body, because you can’t tell.

But certainly, with acne or eczema or psoriasis, or seborrheic dermatitis, or any of those other skin conditions, there is… And unfortunately, because of that bidirectional relationship with the nervous system and the gut and the skin, or I suppose it’s a tri-directional relationship, what then becomes further, I guess, complicating is that impact of distress about the condition actually contributes to the persistence of it as well.

Rebecca: Yeah.

Amie: So… Yeah. So, there’s certainly a lot of moving parts, as far as, you know, assessing someone and supporting someone. I guess, when we’re thinking about diagnostics of atopic dermatitis, and the differentials between that and other things that present very similarly, there’s obviously external assessments that you can do, but I’m also really interested in hearing about the kinds of tests that you also run, in terms of blood tests or GI-MAP or any other types of functional testing, when you’re actually assessing someone who’s presenting to you with atopic dermatitis.

Rebecca: I don’t think there’s any one specific diagnostic test, unfortunately, and I think that’s probably one of the difficulties in dermatology in general, is that you’re often making, like, a clinical diagnosis [inaudible 00:09:16] some supportive evidence, you know, with pathology findings. And so, I tend to rely on some general blood work, like, some basic blood work, that even, that doctors use. So, we might look at something like a full blood count, and see if that’s normal or are they elevated, you know, eosinophils, basophils, perhaps serum IgG, total serum IgG… Sorry, IgE, immunoglobulin E. And then, if there is any tests run for specific allergies, sort of environmental allergies, or ordering those, they’re sort of the… You can order total blood histamine, and there is some value in it, but I guess, because it fluctuates so much from day to day to moment to moment, that, you know, anyone can have elevated blood histamine if they’ve been exposed to a trigger. So I’m not sure that that’s… And it’s kind of a no-brainer. If you’ve got a rash, that’s itchy, you’re very likely to have elevated histamine. It’s not necessarily going to guide treatment, unless you’re looking, I guess, at factors that contribute to that. So, perhaps histaminosis driven by estrogen, or dysbiosis, then… It’s, again, it’s more supportive materials. And it may help encourage treatment with the patient, and you might like to use it as a benchmark throughout the treatment, and look at blood histamine levels coming down, serum IgE coming down. So, sometimes, pathology isn’t just used for diagnosis. It’s also used for tracking the efficacy of your treatment, and for encouraging patients as well, that they’re doing all the right things and that they’re making progress.

From a functional medicine perspective, I look at food intolerance and allergy testing. I do…I like to do both together. I feel like more and more of patients arrive in front of me having very little investigation done around any kind of food reactions whatsoever. It’s a very typical message from dermatologists, unfortunately, that food has nothing to do with atopic dermatitis. I realise it’s not the only… I’m fully aware that it’s not the only driver, but given that our gut is a barrier between us and food, and that we can have responses to it, I think it’s useful to investigate it, and see if it is making a difference for that person.

And then I might look at things like intestinal permeability. Again, because of that interface with food. So, intestinal permeability markers, such as fecal zonulin. And also, if I am unsure about what’s going on, and there are some other co-occurring diagnoses with a patient, then things like fecal calprotectin, it can be really useful. Like, if you’re not sure, and then you see fecal calprotectin, that will lead you as a practitioner down another pathway, not just exploring atopy, like starting to look at is there an autoimmune involvement in this patient’s presentation. Secretory IgA, like, when it’s too low, then there’s insufficient gut-related mucosal immunity. If it’s too elevated, it’s another indicator of inflammation. It’s not so specific. Like, it could be atopic, it could be autoimmune. But it should certainly be highlighted if it is elevated. And then, in blood and fecal samples, you can also look for the evidence of celiac disease, or gluten enteropathies. And you can do that in blood, with immunoglobins, fecal immunoglobins. You can also measure the…or look at the genetic susceptibility, which I think’s also very helpful, and I often test for that in patients where it’s never been investigated, and particularly if they have a family history of autoimmunity. So, that’s just some of the tests that I might run up front.

Amie: Yes. Great foundations, and such a lovely place to start, and I’m really glad you mentioned genetic susceptibility to celiac, because I think, you know, the development of celiac disease is something that occurs over actually quite an extensive period of time, and by the time there are antibodies found in the blood, first of all, it’s too late to turn the ship around, and you’ve already developed one autoimmune disease, putting you at risk of another one, by an increased 30%. And what I’ve personally found in clinic is finding fecal antigens is kinda, like, one of those early warning signs. And usually, the blood still comes later than that, but even further upstream, looking at the genetic susceptibility allows you to identify that this dietary antigen is going to be a problem if anything else has succumbed, you know, is less than optimal. And when you already have the presentation of a skin disorder, knowing the connection between the skin and the gut, you can already tick that box, meaning, to continue to eat gluten in the face of having a genetic susceptibility to celiac disease, you’re just asking for more inflammation and trouble, and contributing to the problem. So, I think, you know, I know there’s a lot of conversation around whether removing gluten is necessary, and there’s a lot of arguments for and against, but ultimately, if you are finding genetic susceptibility, then every other conversation becomes redundant, in that case. So, yeah, thank you for sharing that with us.

And so, having done an assessment with a client, and, you know, identifying that, yes, they definitely have atopic dermatitis, and you’ve picked up what you’ve picked up on the markers, where do you begin, in terms of triaging the steps for a protocol? Because I know, you know, probably many of us clinicians have got this laundry list, and the whole map of everything mapped out for our client, but sharing 100 things to start with, for a client, doesn’t tend to go the way that we want. So, what do you try to prioritise with clients, knowing that it’s very individual, of course? Some, you know, some, for diet, it might be the more obvious place. But do you have a general order in which you tackle things?

Rebecca: Yeah, I do. And I’ll get into the, like, the sort of the phases of that, but I guess what I wanted to pre-frame is pre-framing, actually, which is meeting client, creating, actually, the client’s expectations, or the patient’s expectations, both for them and for yourself. Because most patients have been, if they have, are an adult with atopic dermatitis, this has been a long time in the making. They might have had atopic dermatitis since they were an infant. And it’s very common for patients to have that. And so, I… And it sounds a bit strange, but I sort of say to them, right at the beginning of the treatment program, I say that what’s likely is that you’re gonna go through, you’re going to continue to go through flare and remission cycles of your atopic dermatitis, even whilst you’re being treated by me. Because what we’re about to go through is we’re about to discover what are all the things that aggravate and drive your atopic dermatitis. And that’s like pulling on, it’s like having a ball of thread and pulling on all of the strings that sort of stick out. You don’t really know which one’s gonna completely unravel the ball of wool.

And usually, it’s not just one single thing. It’s rarely that. Particularly once someone has had a disease for decades, the disease itself and the chronic inflammation itself becomes part of the genesis of the disease. So, there’s many different factors to consider. So, basically, I say that to them up front, that this is what’s gonna happen, and that it’s not gonna be a clean, linear, process. And then I look at, fundamentally, first of all, trying to make them comfortable as quickly as possible. So, whilst… Because when you order tests, you know, it takes a while for those test results to come back, so I sort of combine all of…I try and get the initial testing done as quickly as possible, try and do as much testing, and gather as much objective data, as fast as I can. And whilst I’m waiting, like, for all those samples to be processed, then what I’m focusing on is their comfort, and usually starting to work on soothing the barrier. Because, in most cases, the barrier is excoriated. It’s erythrodermic. It’s, you know, it’s in poor shape. And because the skin is another organ of sensitisation, just like your lungs and your gut, covering up any broken skin is important. It’s as basic as that. Covering it up is a very good start. Like, if you can stop allergens from sensitising the immune system through the skin, that’s a really, really good start, whilst you’re doing all the additional work in the background.

So, initially, it might look like just doing nutrients and substances that stabilise mast cells, key nutrients that modulate the immune system. Like, we know that vitamin D is a really potent immune modulator, and we also know that the evidence shows that people with chronic atopic dermatitis often have genetic mutations on one or more SNPs that relate to vitamin D. It might be conversion receptor expression. Zinc, also a potent immune modulator, as well as skin barrier and gut barrier, repairer, and vitamin A, for its benefits with skin repair. And I pretty much just… Oh, this is another thing I wanted to highlight. I start with nutrients. Because I don’t yet know what this person’s immune system is going to do. If they’re a new patient, I don’t know how, what they’re going to react to.

So, that’s how I start out. And then once I get that objective data back, the test results start coming in, then I can tailor, I can start to tailor the treatment toward that patient. So, you know, do they need to do a food elimination? What kind? For how long? Do the intestinal permeability results show that they’ve got a really leaky gut? In which case, you know that you’re gonna be on a three-month program, of just gut repair, at the same time as doing food elimination. And then, that’s probably, once you’ve got those things in place, then what can we now work on environmentally, emotionally? How can we support, you know, all the other factors that are contributing to the atopic dermatitis? Does that provide enough of a guide?

Amie: Yes. I think that makes really good sense, starting with the nutrients, because those are things that are essential, regardless of their sensitivities. And as you said, you know, with atopic dermatitis patients, the bulk of them are zinc deficient. The bulk of them are vitamin D deficient. Many of them have issues with vitamin A, either because they’re not consuming enough in its, you know, active form, or there’s an issue with conversion from beta carotene, and all of those things just compound. And I think, you know, your approach allows the steadying of the ship, so to speak, which also calms the immune system down a little bit, which gives you more bandwidth to play with, as far as treatment protocols go, if you want to introduce herbs and things like that down the track. Yeah. Brilliant. I think that’s such a wonderful approach. And such a considered one, when it can be very tempting, when it comes to relieving someone suffering, just to just throw everything in.

So, you mentioned, initially, you’re looking at nutrients, and then you might start eliminating foods, and of course, at this stage, you will have likely received some test results back. You mentioned a little bit earlier about allergy testing, and I know you’re a big fan of utilising that. Is there a theme with what comes up more commonly with those who are struggling with atopic dermatitis, or is it just a bit of a mixed bag of lollies?

Rebecca: I’d say, environmentally, a lot of patients have allergies to dust mites and animal danders. Often pollens, as well. But I guess we have to consider also that that is the general battery of tests that’s done under the Medicare item number in Australia. So, they really only, up front, they test for pollens, danders, dust mites, maybe sometimes cockroaches, things like that. So, a lot of patients will come back with those, and sometimes what’s not separated out is which pollens, which danders, and that’s really useful information. I mean, obviously, there’s things that can’t be controlled. You can’t control the pollen count. But you can control, to a degree, your environment internally. Like, when you’re in your office or in your home, you can use air filtration systems to try and reduce the pollen count indoors. But it would be also useful for some patients to be able to anticipate, if there are certain pollens that they know they’re highly reactive to, and that time of year is coming around, then they can fortify themselves, you know, to know that that’s coming.

And with danders, I find that is an interesting area, because there’s so many people that don’t get tested, or they…or, this is even more alarming to me is that they know that they’re allergic to dogs, and yet they still have a dog. And they try and convince me that their dog is hypoallergenic, and I’m like, “Yeah, but that doesn’t mean it’s non-allergenic.” That just means that what we know is that certain breeds of dogs are less antigenic to some people. But we don’t know that you and that dog are a match made in heaven. You know, we don’t really know. Now, of course, I don’t expect people to get rid of their pets, but then there’s strategies that you can take around it, called, you know, maybe the dog doesn’t sleep on the soft finishings in the home, because then the fur and the dander is being transferred all over the place, so… And it has its own area, and maybe you’re not petting the dog as much or, you know, there’s strategies that can be put in place for those types of situations.

Amie: Yes.

Rebecca: But it does surprise me how rarely that’s now tested, especially in general practice, general medical care. Those just basic, routine, blood tests don’t appear to be done. And ultimately, it’s just, well, “Here’s some cortisone, and good luck.”

Amie: Mm. Yes. That’s so disappointing. And I can understand, from one perspective that perhaps the testing has been dropped, because if the only route you’re going is allopathic, it doesn’t inform any change in the treatment, does it? Because you’re just gonna be getting steroids. But from a functional medicine perspective, and looking for the root cause, these things can be the difference between you actually needing steroids, the dose that you require, how long you’re gonna require them for use. I mean, just thinking out loud, environmentally speaking, with dust mites, of course your home is not the only place you could be exposed, but if you’re being exposed to dust mites, that’s indicative that the space, a space you’re inhabiting, maybe multiple spaces, we look at your home first, is experiencing elevated moisture levels, and the relative humidity is over 60%, and that’s why dust mites are proliferating, and therefore, if you control the moisture, you can get rid of the dust mites, and then the allergy to them will dissipate. So, you know, if you’re looking for, you know, getting to the root cause and really solving the problem, actually understanding the nuances of this allergy testing can give you tools that you otherwise wouldn’t have access to, is what I’m hearing you say.

Rebecca: That’s right.

Amie: Yeah. Yeah. Yeah. Brilliant.

Rebecca: And mould. You know, when we talk about humidity also…

Amie: And mould.

Rebecca: … mould spores. Even if it’s not chronic inflammatory response syndrome, I mean, there’s two, as you know, that there’s two potential reactions. You could have an allergy to the mould spores, or you could be in the realm more of, like, the chronic inflammatory response syndrome, where it’s the mycotoxins that are affecting the immune dysfunction.

Amie: Yes. Oh, exactly. And mycotoxins, even if you don’t have a genetic susceptibility to SIRS, they all destroy the gut flora. They destroy barrier integrity, which then has a knock-on effect to nutrient absorption, zinc, and vitamin A, that then has a knock-on effect to the skin. And of course, the body’s always going to respond in an inflammatory way to persistent toxins. And indeed, just touching on water-damaged buildings and eczema, we know that an elevated ERMI score, and an ERMI is a test that you can run in a home or an office, to determine its overall moldiness as well as, it’s almost like a microbiome test for the space that you’re testing, and you can see the distribution amongst species, of normal fungal ecology versus water-damaged buildings. And an elevated ERMI, meaning a moldier home, particularly during infancy, is actually a predictor of asthma and eczema at seven years of age, and we know that in both children and adults, the severity of eczema is directly correlated to the degree of water damage in the buildings that are inhabited, and again, giving steroids is like trying to put out a bushfire with a garden hose. If you are living in a water-damaged building, and you’re constantly exposing yourself to these things, you’re just really, it’s an uphill battle, and one that you’re not gonna get very far, and it actually is kind of ridiculous, when you think about such a powerful driver of that disease being completely ignored. And I suppose, you know, if people are doing more extensive allergy tests, they might spot something, in terms of mould, if there has been IgE testing there. There are, of course, other ways to do it, but I always think, if someone has really bad eczema, or it’s really unresponsive to things, or they have odd reactions to supplements and herbs, to me, that’s almost always a red flag of a water-damaged building. And certainly, if, and this is for most people, most people aren’t monitoring the humidity at home, and therefore could potentially have elevated moisture levels, and aspergillus and penicillium.

So, certainly, there’s lots of things to keep in mind with the root cause, and I am gonna talk to you a little bit more about your treatment approach in a moment, but I just wanted to touch on something you mentioned before, which I think is really such an essential element that I think can be overlooked, and I can say this as a practitioner too. I can get very focused on, you know, treating the cause, fixing the nutrient deficiencies, using herbal medicines, and it can be easy when you’re in all of that to actually forget the emotional toll that health conditions can take on people, especially when it’s something that’s so publicly, externally. What do you do? How do you approach that? Do you have a referral network? Do you have tools? In terms of the emotional support of patients, how do you approach that?

Rebecca: Well, firstly, I make…I check in about their sleep. And this is another…it’s really unfortunate for people with eczema that their symptoms, as their own natural cortisol declines throughout the day, like for all of us, our symptoms tend to get worse in the afternoon and the evening. And so, then their sleep is disrupted, and they may have had chronically disrupted sleep for years or decades. And so, of course, that makes any one of us less resilient, when we don’t get adequate or deep, quality sleep. So, I’ll attend to that as much as I can in the treatment program. If they…like, if, let’s say if it’s an adult, and they’re not responding to the treatment that I give them for sleep, then I’ll refer them back to their GP for whatever’s needed to be prescribed. And I honestly am not…I’m a very middle-of-the-road practitioner, and I am the whatever works works, you know? And particularly around sleep, because it’s such a foundational part of health, but if you can’t sleep, you can’t heal. And so, I address a lot around sleep hygiene and practices, and, you know, the environment. But ultimately, if all of that’s…if they’re attending to all of that and they’re still not improving with their sleep, then I’ll refer back to their doctor, or maybe a sleep psychologist. Because if the sleep pattern’s been disturbed for a really long time, sometimes there are mental barriers towards sleeping, that have appeared over time.

And then, yeah, in terms of referral network around their mindset and psychology, sometimes it’s necessary to see a psychologist, or sometimes it simply is teaching, giving them tools, to gradually develop mindfulness around their thoughts, and, you know, giving just basic CBT tools. I’m obviously not a psychologist, but I can encourage them to use journaling techniques, or mindfulness breathing techniques. I’m lucky enough to work with coaches. I work with health coaches, so my patients have additional support with health coaching. And then, distraction techniques as well, because of the itching with eczema, then, you know, it’s useful for patients to learn how to distract themselves with something else, instead of itching. And bringing mindfulness to itching actually is a really important thing to do. It’s not so useful for children. Children don’t have the cognitive awareness yet to know when they’re being habitual versus reactive. But adults know, and they know that…and what I’ve seen is a cycle, where they’re not even physically or physiologically itchy, but they get stressed about something, and start scratching. And so, scratching has becomes, inadvertently, has become sort of a self-soothing mechanism for other things that are going on in their life. And so, I…that’s a really great tool that patients can bring to their own habitual scratching, because it does become habitual. Sometimes it’s not even, there’s not even anything there to itch anymore.

Amie: Mm. Yes. I think that’s such a good point, and I have heard that referred to as “the scratch that itches,” and it becomes this feedback system where they actually create an itch from the irritation. So, yeah, that’s some really powerful recommendations there, in terms of supporting people, especially adults, obviously, who have the wherewithal to be able to apply that. I wanna ask you a couple more things about your preferred ingredients that you rely on, and, you know, we’ve sort of talked about zinc and vitamin D, but I know there are other ones that you like to draw upon. What are your sort of favourite handful of things that you go to for atopic dermatitis?

Rebecca: I like quercetin and other bioflavonoids to stabilise mast cells. I like quercetin because it’s also, you know, it’s not a whole plant yet. You know, I’m not ready, generally, to prescribe whole plants, but quercetin, because it’s, you know, it’s extracted.

Amie: Yes.

Rebecca: So, that’s really useful. And glutamine for gut repair. I’d say, in most cases, with atopic dermatitis, there is significant leaky gut. It’s very, very unusual that I don’t find a patient who has leaky gut. Just as a side note, though, it’s interesting that when I test patients with psoriasis that they don’t, I’ve haven’t yet uncovered why that is yet, but it’s becoming more of a pattern. So, yeah, leaky gut, so, then you need glutamine and you need zinc, you know, to heal leaky gut. In addition to some probiotics that we know do a great job with leaky gut, like LGG and saccharomyces boulardii. So, those tend to get incorporated into treatment plans as well, because they’re very easy and low-reactive. Oh, and NAC and glutathione. I use those, because of the oxidative stress that’s caused by chronic inflammation. And I think that sometimes we forget about that, again, with atopic dermatitis, but because it’s this, regarded as just this superficial thing, like, it’s superficial, it’s on the outside, it’s not a chronic disease. But it is. You know? It’s a chronic disease, and so… And you can’t, with acute inflammation, you can use anti-inflammatory substances, herbs, topicals. But when something has a really chronic nature to it, [inaudible 00:36:01] I think it works better to also add in the antioxidants, to help interrupt that entire cycle, because we know that, you know, the…it even, chronic inflammation even alters the cycle of inflammation, so, NF-κB expression, and then the inflammatory cytokines that arise from that, so…

Zinc is also really great for that. So, zinc’s a, in my opinion, like, an absolute hero nutrient, when it comes to treating atopic dermatitis, because it has so many useful actions, and it’s quite well-tolerated, you know? And, obviously, you need to dose according to weight, especially in children. And you don’t need to really…I don’t think you need to do even really heroic doses with it, though. I think you can stick to somewhere between 15 and 20 milligrams, or if you wanna do high doses, do it every second day. But still get really beneficial effects from prescribing zinc. And often, you know, in those very, very highly-reactive patients, sometimes I don’t have much choice, at the start, about what I can prescribe. And so I might just be starting with two products, two things, two nutrients, and I’ll make sure that they’re single-ingredient formulations, and I’ll introduce each of them one at a time as well, to, so that I know what might be, if they get a reaction, then I know what’s causing it. And I’m often, I’m really surprised at how quickly zinc makes a difference.

Amie: Mm. That’s so brilliant. And it’s nice to know that it can actually be kind of simple as well. You don’t necessarily need to use a whole lot of things, in a really, you know, coordinated effort, to shift things. Sometimes it’s just a couple of instrumental nutrients to see a really big, big shift. Is there any value, do you find, in using collagen to support the skin, or is that something that you would maybe park?

Rebecca: Oh, yes.

Amie: Yeah. How do you approach that?

Rebecca: I’ll use collagen. I’ll usually use it after I’ve done food intolerance and allergy testing, because…

Amie: Sure.

Rebecca: …I have seen some patients that do have reactivities to beef, as well as bovine… You know, they’ll have reactions to casein, whey, and beef as well. And so, in which case you need to be mindful about which collagen you choose. But if they don’t have that as a sensitivity, then yeah, I will use beef collagen. And there are also marine-derived collagens on the market.

Amie: Yeah.

Rebecca: But I think it’s great, because then you’re providing the building blocks for making the new skin. And…

Amie: Yes.

Rebecca: …we all know that that takes time, you know, making the new skin. And I forgot to actually mention that at the start, is that that’s another thing I tell my patients. It’s like, well, you know, it takes a while for that one new skin cell that’s made, and to float to the top, you know, of the epidermis. And then you think of how many millions of skin cells you need to make to replace all of that broken skin.

Amie: Yeah. It’s huge. I mean, even if the turnover is, you know, four to six-weekly, you’ve gotta consider that underlying inflammation is still affecting the basal layer. So, you can see results quite quickly, but also, if you’re dealing with major systemic things, it might take a little bit longer too. There’s just a couple of little things I’d love to ask you as well, before we wrap up today, and one of those we have talked about off-air, and that was the advice around bleach baths. And I know it’s a bit of a contentious topic, in the sense that, naturopathically speaking, at first glance, it appears to be a really wrong thing to do. And of course, there’s a time and a place for everything, and there’s a reason why it became part of allopathic recommendations. So, I’d love to hear your perspective on where you think they’re appropriate, and perhaps where they’re not, but, and ultimately, their intended purpose and place in atopic dermatitis protocols.

Rebecca: Yeah. I find that bleach baths are recommended more for children. And primarily why they’re recommended is to control staphylococcus aureus populations. And we know that in patients, from the microbiome samples that are taken from patients who have atopic dermatitis, that they appear to have higher colony numbers of staph aureus, and that staph aureus is, becomes, again, over time, involved in the disease cycle of atopic dermatitis, so it’s important to control the staph aureus numbers. Also, because the staph aureus interferes with the lipid layer, it starts to interfere with ceramide production, and then if you don’t have good ceramides, then of course, your lipid bilayer and your skin gets compromised. So, there’s a really good reason for doing bleach baths, and it’s probably easier, when you think about it, than applying antiseptic to your entire body, that you can immerse yourself into something that… And, you know, when we, it sounds scary, bleach baths, but they’re talking about a few mils of it. It’s a controlled amount, in a very large volume of water.

Probably what practitioners don’t hear about is that after bleach baths, that the protocol is to apply emollients after the bleach bath, moisturizers and emollients, so that… Because the bleach will, with it being alkaline, it will increase permeability and dryness. You know, there will be what we call transepidermal water loss, like there is with any dry skin.

Amie: Yeah.

Rebecca: But I think it’s interesting. I was reading something about this the other day about the, sort of, you know, all the marketing around products that talk about, “oh, but it’s pH-neutral” and…or “it’s pH-acidic, so it’s more appropriate for people with damaged skin.” But no one’s ever talking about the fact that water isn’t always pH-neutral, especially tap water. It’s not. And so, when you’re…it’s usually a little bit alkaline. And so, you think about adding bleach to something that’s already alkaline anyway, I mean, how much more… It’s not gonna change the pH that much. Equally, I think… Oh, I’m gonna go a bit off topic. I won’t talk about that yet, but those…the marketing around eczema products sometimes really bugs me, because they, I think they scare people into using products that they don’t necessarily need.

Amie: Mm.

Rebecca: But, yeah. Bleach baths are good, and they’re good for the job that they’re doing, which is controlling staph aureus. And they’re not recommended forever. They’re just to control an infection at that time. And I just wanna touch on treating children, because they are prescribed more for children. And I think it’s really important, because children can… They’re a more vulnerable population. They can become, their condition can become unstable quickly. And if a child starts having really red, oozing skin, they might not even have a raised temperature yet, but they’ll quickly get a raised temperature. But they should be taken very quickly to their doctor or an ED. And whatever the prescription is for that, I say follow it. Like, if the doctor or the ED physician says that the child needs antibiotics to control the infection, then I think it’s always best to err on the side of caution with that. And you can clean up the mess of the antibiotics later. But you don’t want the condition to turn into something that is serious, you know, like, you know, cellulitis or something like that. That can happen. And I don’t think we sort of… I don’t think that always gets explained to patients either, around the primary care of their child’s eczema.

Amie: Yeah. Very important point, especially with how quickly kids can deteriorate, and taking quick action, if there’s any initial signs of that. And, the very last thing I wanted to just get your thoughts on is something I’m sure you’re seeing, unfortunately, more frequently than you’d like, and that is the topic of steroid withdrawal, because, certainly in, you know, parents who are treating kids with steroids, or adults that are being prescribed steroids for their eczema, I haven’t really met too many people who are like, “Oh, I really love that I’m using steroids to control my symptoms.” Most of them will say, “I’m not happy being on this, and I wanna get off it.” But I know, in terms of coming off steroids, it must be done really carefully, in order to avoid steroid withdrawal, and I think you’ve borne witness, many a time, to when things have gone wrong there. Do you wanna just highlight that issue for us, and how you approach that also?

Rebecca: Yeah. It’s a message that I start, again, at the beginning of a treatment program, and I’ll really reinforce with my patients that just because I’m, you know, overseeing your care doesn’t mean you can stop using steroids, and please don’t stop using them until you’re more stable, and we’ve had a conversation and we’ve got a strategy for this. And I’m… People still take themselves off their steroids, and then they end up in a flare, but it’s okay. We can clean that up. But it is really an important… I think what’s not explained to patients is how powerful those medications are. Those medications are suppressing an immune response. And if you’ve been using it for years, it’s been suppressing it for years. And so, the issue with steroids, it doesn’t matter whether they’re oral or topical, is that everyone experiences steroid rebound. When they stop using or taking a steroid, usually, there’ll be a transient flare in their inflammation, and that might be followed by remission afterwards, if it’s been, like, a short-lived situation that they’ve had to take the medication for, and that will just self-resolve. But when steroids have been used for months and years, they have completely disturbed the immune response and the HPA axis. So, that’s your body’s own ability to produce its own cortisol and cortisone has now been down-regulated. Because we all have that ability to produce our own natural anti-inflammatory. Cortisol, or cortisone, is a natural anti-inflammatory, and it’s made from cortisol.

So, it’s…there’s a dose, you know, that’s circulating around in the body. We know that people absorb steroids that they apply topically, that affects the HPA axis, then, you know, the hypothalamus-pituitary regulates then how much the adrenals create, your own adrenals create. And that’s probably a lot less now. If you’ve been using it for years and years and years, then you’re not making as much as your own cortisol. So, you take that drug away, and then there’s nothing left. There’s no safety net. That’s what the topical steroid withdrawal syndrome is all about. It’s that patients haven’t allowed… And this is not their fault. They’re just not, it’s not explained, to, how the drug affects their body, but… Sorry. What was I saying? So, you withdraw the drug, but that actually needs to be done slowly, so that the whole physiology can catch up with the change. That there’s… So, if you withdraw the drug gradually, there’s less of it available. Then that feedback mechanism, through the hypothalamus-pituitary-adrenal axis, can start to catch up. And it’ll be latent. Just like every endocrine axis, there’ll be a lag. And then the amount of cortisol and cortisone that your body’s making will start to slowly increase. But we don’t know how long that’s gonna take, and it’s gonna be different for every patient. It’s gonna be dose-dependent how, the duration of the cortisone management, the potencies of cortisone that they’ve been using, the frequency. You know, it’s…and also how permeable their skin is, because that’s the other thing is, like, the more permeable and broken your skin is, the more cortisone and cortisol you’re gonna absorb. So, when you’ve got a damaged barrier, your absorption of the cortisone and cortisol topically, the cortisone topically, is gonna be higher anyway.

Amie: Mm. Yes.

Rebecca: So, I’m usually doing all of that work with my patients, that pre-work that I talked about. And then I have a conversation about, now let’s try and step down the cortisone use. And so that might be, like, probably reducing frequency first, like, keeping the dose and the type of the cream or ointment exactly the same, and then reducing the frequency. So, if they’re using it three times a day, then we go down to reducing it twice a day, and then to once a day, and then every other day. But all the while, I mean, it’s your patient, right, so you’ve gotta be working together, to figure out what is the tolerable dose that they can reduce their steroids without feeling uncomfortable. Or if there is discomfort, it’s a manageable amount of discomfort. And that’s really the reality of it, is that it’s gonna be walking the line of manageable discomfort while the patient is reducing the steroid, as well as whatever other topical supportive management that you’re doing.

Amie: Mm. That’s such a comprehensive and intentional approach, in terms of tapering cadence, making sure that you’ve actually got support underneath, and you’ve addressed some of those root causes before you bother, and then managing it as you go through. Gosh. This whole conversation has just been full of so much practical, clinically applicable information, Rebecca. So, thank you so much for your time and for taking us through everything you know about atopic dermatitis.

Rebecca: Yeah. You’re welcome. And, you know, for, I think we talked about it off-air, that practical advice is what I like to impart to my patients, and to other practitioners who sometimes approach me for mentoring. And because of that, I’m soon be releasing a course that’s to support practitioners in treating atopic dermatitis confidently.

Amie: Mm. That’s gonna be so powerful. And we will make sure we put a link in the show notes, so that you can connect with Rebecca and hear about that as soon as it’s available. So, thanks again, Rebecca. That’s so wonderful to have your brains accessible to the rest of us who want to dive deeper into this. And thank you for joining us today. Remember, you can find everything we talked about in the show notes, or on the Designs for Health website. I’m Amie Skilton, and this is “Wellness by Designs.”