Episode 20: Are all moisturizers for eczema created equal? The answer appears to be no!
Are certain types of moisturizers better than others for eczema? What is the best way to apply it? In this episode we ask our guest speakers, both researchers who have studied this topic, to weigh in: Dr. Tina Sindher, Clinical Associate Professor of Pediatrics from the Allergy and Clinical Immunology group at Stanford University and Dr. Ian Myles head of the Epithelial Therapeutics Unit at the National Institute of Allergy and Infectious Disease. P.S. If you like our podcast consider supporting it with a tax deductible donation. Read the transcript.
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Welcome everybody to this episode of the eczema breakthroughs podcast. I'm Korey Capozza, executive director of Global Parents for Eczema Research. And I'm really excited for this episode today. We're going to be exploring moisturizer therapy for eczema, which is the mainstay of treatment and management for most kids.
Children with eczema are typically putting on moisturizer several times a day, but we actually know very little about the safety and efficacy of different formulations that we're putting on their skin, surprisingly. And moisturizers are often referred to as a class and explained to be all the same. A lot of the times. Although we often hear that a thicker moisturizer is better, we don't know that much about different types of moisturizers. However, we are just now starting to learn through research that the ingredients in these different products do matter, and some are likely to improve eczema more while others may even make it worse. So this simple question is one of the most pressing in our community, given the amount of product that is being put on children to manage eczema. And yet we really don't know about the relative benefits or drawbacks of different moisturizer options.
Our guests today have both recently published research on this topic and are here to answer our questions. Dr. Tina Sindher is an associate professor at Stanford university in California. Her research focuses more broadly on the prevention of eczema and food allergies and her article recently published in 2022, looked at the impact of different types of moisturizers on skin barrier funds. And we also have Dr. Ian Myles, he's head of the epithelial therapeutics unit at the national Institute of allergy and infectious disease has recently published research which looked at how common moisturizers may modify the skin microbiome, especially in eczema patients. Dr. Myles is a previous podcast guest and a member of our board. So welcome Dr. Sindher and Dr. Myles to the podcast.
Thank you for having us.
Great. So I think our first question was simply, why did you pursue this research? What got you interested in it?
Thank you for asking that question. As an allergist, we're primarily, my work, focuses on food allergy. I got into this topic from that lens and looking at strategies for food allergy prevention. So food allergy affects about 10% of children. And in our research unit, we've found that in the patients we were treating that up to 80% of them have, or had, a history of eczema pre-existing as an infant.
And there is the concept of atopic March, which essentially explains this. That you start on this allergic journey from your skin. So you have early dry skin or eczema, and that kind of leads you to development of subsequent other kinds of allergies to food allergy, developing asthma or seasonal allergies.
So there has been a lot of interest in the prevention aspect. That is, if we treat eczema or dry skin, can we potentially put a break on this process of atopic march and potentially reduce allergies down the line?
And Dr. Myles, what was the impetus for your research on this topic? Looking at the microbiome specifically.
Yes. I think we came at it from basically the opposite direction. So saying you have a bunch of kids with eczema, what can we do to make them better? Our question was, why are all the kids suddenly developing eczema now in the first place? And we tend to focus on the microbiome as being maybe one of the root causes of where things are going wrong. And so just wanted to know, what choices do parents have that they're applying to their skin? Maybe it's helping, like maybe there are ingredients in that product that are beneficial, but if they come at the expense of the microbiome, maybe even doing harm. Actually directly measuring what they do to the skin microbiome, maybe that will give you a better choice of improving your selection for products.
Right. And why is the microbiome important and eczema? Why would you look at that instead of say skin barrier function as Dr. Sindher did?
So the microbiome would be necessary to support normal skin. And all the different metrics that you would think of for eczema. So you need a microbiome to have normal skin barrier function. You need the normal microbiome to prevent Staph aureus from coming in and creating even more damaging problems. But basically there is no function your skin performs that it performs normally, if you take away the microbiome. And so you have to have that there for all those normal functions.
Right. And I think, we're starting to understand with eczema, there's a bunch of things going on. One of them is inflammation. The skin barrier isn't working well. So things are leaking in. Contributing to this overactive immune response. And then we have the bacteria on the skin are out of balance. And so you have this overgrowth of Staph bacteria, which may further exacerbate all these symptoms that are going on with inflammation and so on. The skin microbiome is part of the Inflammatory response run them off that we see. So it's not just showing up the skin barrier function, but also rebalancing the different bacteria on the skin that seemed to be important.
So one, have you looked at skin barrier function? One of you looked at the microbiome. Can you talk about how you studied this and what you found when you started looking at the issue of products? Let's start with you Dr. Sindher.
Yeah, we have found, based on other large studies and pilot studies that petrolatum based moisturizers may not be as effective as we previously thought. And in pilot studies, at least again, this is a very small sample size. So it's really hard to make large general comments from it. But what we found is the tri lipid-based creams seem to do a better job than the paraffin based creams, over a short period of time.
For this pilot study that we published, we looked at something called transepidermal water loss, essentially how much water you're losing through your skin. And we found that the tri lipid based moisturizer did a better job of restoring your barrier function versus a paraffin based moisturizer.
So with the pilot study that you did, and it was a relatively small number, as you mentioned: so you had these kiddos applying one type of moisturizer to one arm and the other type of moisturizer to the other. And they did that for five weeks. Is that right?
Yeah, you're absolutely right. Small group of kids, these were already food allergic kids. We did paraffin based cream on one arm, the tri lipid based moisturizer on the other. We just kept it short to see, even after just a few weeks of treatment, did it make a difference or not. And we measure dry skin through our transepidermal water loss device that measured how much water was being lost to the skin.
What was the size of the difference between the two?
We did find kind of significant differences between the two arms, essentially. The arm that was receiving the tri lipid based cream did have a reduction in transepidermal water loss compared to the arm that was receiving the paraffin based moisturizer.
Great. Now thank you for that explanation. I think it's one of the only studies I've seen that looked at different formulations in that way. So I think it's very intriguing and hopefully, we'll get more answers from the larger study that you're doing and maybe others will follow up on given that interesting finding.
Ian, I wanted to ask you about the work that you did, It was a multi-layer study, and talk a little bit about what you were looking at and what you found.
Yeah, so we started picking things through the patch test system. So I think some of your listeners may be familiar with that, where you go to a dermatologist, they put a sticker on your back with a certain chemical and they're trying to see if you have contact dermatitis, so a different kind of skin allergy disease. So you can buy a whole kit of these. And we tested all of them. And these kits are supposed to be somewhat indicative of everything sold in North America. So if you go get a topical product, what things are going to be in there, and we test those against the microbiome, the same way you might an antibiotic to say, like, does penicillin kill this? Now I want to see: does parabens or paraffins kill off these bacteria. So that was the first step to say which ones of these look suspicious in terms of killing off organisms on a Petri dish. Which ones will kill off the bacteria that we know are associated with healthy skin and which ones will kill off the bacteria associated with atopic derm, especially diseased skin, and then comparing the two.
And then the second one was taking mice and you can induce atopic derm in the mouse, and then we can give it Staph aureus, which clearly makes the disease much worse, or we can give bacteria like Staph epidermidis, which can make the disease better, or Roseomonas mucosa which can make the disease better. And then we turned around and started treating the mice with these different lotions to see, can I make their disease better or worse, depending on which moisturizer I choose.
And then the very last part was a very small number of people where we then went back to the patch. And we do a swab of the microbiome and then put a little sticker on with a particular lotion that we've just bought at the store. And we went to department store and just look for anything with the word eczema on the label to see, hey, this is clearly being marketed to the patients, let's go test this to see if it would influence the microbiome and then did a swab afterwards to see how did the microbiome shift when it was exposed to Vaseline on one end of the spectrum in some high-end product on the other. And what we found is that it's often very complicated in the sense that two wrongs can cancel each other out and to otherwise benign ingredients, if you combine them just so it will start killing off these organisms. We did find some concerning things, a pattern with parabens. And I know that most of the eczema products hype that they're paraben-free, lanolin would be another one that I was concerned about. Unfortunately it wasn't a perfect recipe that we could tell people just use this and you'll be totally safe.
Thank you for that. And I should add that antibiotic effects in the scenario that you're talking about are not good. Because sometimes I think parents are focused on controlling that Staph, through an antibiotic topical therapy or whatnot. But what you're talking about is - antibiotic effects that basically tilt the microbiome towards balance, right?
I would say uncontrolled antibiotic effects because ideally you'd want a lotion that killed off Staph aureus and left everything else untouched. And that's hard to do. We could formulate something that did that, but that's not what the standard over the counter will do.
Interesting. It does seem like there is so much more we need to know about moisturizer therapy for eczema. There's not just the formulation, which is part of what you both looked at and different impacts that has on the skin, but also how you put it on. And I'm just really curious if either of you have thoughts on this, because we know that Staph is a problem for these kiddos with eczema. And yet we have these tubs of cream that you're dipping your hand in and reusing and when there’s Staph in the household, this has to be a reservoir for potentially harmful bacteria to hang out. And it seems like we need a lot more guidance on moisturizer therapy and what's the best way to go.
The other thought that came to mind is just a parent, a parent, with a high-risk kid who has eczema. You may not be thinking about introducing a allergy to them through the skin because it's relatively new knowledge that we have. So if you have peanut butter or peanuts or different things in the house, if you haven't washed your hands carefully, before you start smothering your child in moisture. You could actually be putting those things onto their skin in a way that primes them for food allergy. So these are all things we don't learn about as parents typically with eczema management.
And do you have thoughts on either of those things and how we can optimize moisturizer therapy for these children with eczema?
There was a recent study that was published in 2021 by Perkins and they were part of this large
European cohort of children's study for food allergy and at the end of this study, they asked the parents through questionnaires, their history of eczema and asked about their moisturizer use. And the study actually found that those that use more moisturizers and more frequently had a higher risk of food allergy. So when the paper first came out, it got a lot of the allergists thinking about the microbiome and whether parents' hands as they're reaching into the tub, if they're not cleaned ahead of time and they're applying the cream on their child's body, is there some version of either auto inoculation or transferring the microbiome from the parent's hands to the child's hands. These are all thoughts we had, it's not something that we have looked at. Like we haven't done swabs and seen, clean hand versus non clean hand. And, after you applied the cream, what does it look like? But what we are advising the parents is to before touching their baby's skin, if they're severe eczema, to wash their hands we're asking them to scoop out the recommended amount of the moisturizer and then use it from that directly. And the washing hands is for us to address the microbial concern.
The other item I wanted to mention also was the ‘through this skin exposure to allergens’, one of UK team members that we're working with, they have done extensive research looking at peanut dust in the household. And it's found in the child is bedding their blankets and those that develop peanut allergy down the line did have higher levels of peanut dust in their homes. So washing hands to remove that allergen I think will all kind of help us right now. But again, this is based on our suspicions from the prior trials, not something we have actively looked at.
Yeah, that was such an interesting finding from that study. And then from systematic reviews that have been done since then, that applying moisturizer early in life and infancy did not protect against food allergy, as you said. But not only that, didn't it increase the risk of infections among these kids? That was really surprising and maybe points to some of these issues with moisturizing, perhaps, and just the over abundance of Staph perhaps in these children. And in our kind of aggressive approach to treating eczema are we sometimes doing more harm than good?
Exactly. If the commensal microbiome. Like, what's supposed to be there and help protect you might be getting decreased while the Staph is increasing. This study particularly looked at parent report, right? So we're the kids who were overusing moisturizers, the ones who had severe eczema to begin with and having severe eczema. they're at high risk for infections. So that is something to keep in mind: is it may not be related to the moisturizer itself, but it plays a role, but also the characteristic of the skin and the child and the family history.
Parents and our network they really want the practical question asked, and know we may not be there, but given what we know so far from the study, we just mentioned the large food allergy prevention study that involved aggressive moisturizer therapy in infancy and the studies that you have done, what can we tell parents about moisturizer therapy for children with eczema? Like, any guidelines you would offer them? In terms of what to look for or how to do it.
Yeah. Right now we have a very wishy-washy answer. It's not the clarity that I know people want to hear. I think if I were placing bets on one day, when this is answered, what will be the response? I will say the fewer ingredients, probably the better. And I think that just like you would not expect a gallon of milk to sit in your refrigerator for 10 years, maybe it’s okay that your lotions or your moisturizers have expiration date. We might have to start accepting the fact that it's better, that they go bad and have a shelf life than to be so filled with other things that may not be doing any good or maybe even counterbalancing effects.
Just, as an analog, we're starting to learn now, like super processed food with a lot of preservatives is not the best for your health. And maybe we're at the dawn of understanding what that looks like for the skin in terms of what we put on it and was actually beneficial to that word. Did you want to add anything to that?
So what I have learned to say to families again, to avoid scented items the fewer ingredients the better. I promote more of the thicker creams like anything that comes in a pump and you're not double-dipping. If you don't have dry skin and you don't severe eczema it may not matter so much, at least from the food allergy perspective. But if you were at risk, I do encourage frequent moisturizing to the best that the family is able to do. We actually encourage frequent bathing. showers getting your skin as clean as possible, and then moisturizing right after while the skin is still damp, not rubbing too much to prevent the irritation. I've had a lot of families, my family included were very pro-natural oils. I will say that after seeing the Perkins paper and speaking to a few other experts in the field, I'm moving away from using oils as a moisturizer: olive oil, coconut oil. One concern is that the oils might actually open up the barrier more and increase the allergen entry through the skin.
What I sort of hear you saying, taken together, the fewer ingredients the better, fewer fragrances and additives and things like that. The pump, or some type of tube, may be better than a tub for keeping it uncontaminated. Wash hands ahead of time when you're applying to infants. So you're not introducing peanuts and other allergens onto the skin and a child that's at high risk for food allergy. And then can we say at this point that a tri lipid might be a better choice than a paraffin based moisturizer or maybe that's just an intriguing lead at this point. Any thoughts on that?
Yeah based on the early pilot studies and some large studies, the tri lipid does hold a lot of promise. Yes, in a short period of time, we did see a difference, but over a larger period of use it may not matter in the setting of transepidermal water loss and the barrier defect and development of food allergy down the line. But I'm curious to hear what your thoughts are on this to Dr. Myles.
Yeah, I think that the lipid-based is probably going to be better. Cause as long as what is necessary to keep it shelf stable is not too aggressive. You're cooking oils you have a tight seal that goes on it to keep them from going rancid. Your lotions you typically do not, particularly if they're just in a pump or a squeeze bottle. So to keep those liquids stable, so for ceramides, they've been spiked into all kinds of products that you can find at the store right now, they have to modify the lipids in such a way that I am not as confident that the end product is as beneficial as the molecule that they started with because they've processed it. So processed sugar is different from just sugar out of an apple something like that. But yeah you know, as federal government, I'm not allowed to say the brand names of what we use, but it is published in the paper if people want to look up which ones would be more ideal for the microbiome. And we did look at some of the oils, cause I know people use that fairly frequently.
Yes. And we'll include a link to both of your papers, on our podcast summary, that will be on the webpage and on the different platforms.
A question from a patient, an adult patient. This is Mike de Fabio from New Jersey asks, can your skin become dependent on moisturizer if you're constantly moisturizing yourself, does it adapt to that and stop producing the natural moisturization or the things that it normally would have done, if it wasn't being moisturized all the time. Any thoughts on that?
Don't know that your skin would necessarily stop making its natural products every single cell in your skin is different 42 days from now than it is today. So I'd say that's a theoretical possibility, but hasn't been tested. So the known benefits outweigh the theoretical concerns.
In my mind, tri lipid where it's trying to restore your skin's natural liquid composition in the setting of eczema, that natural state is a skew. And so in my mind, a moisture is helping stabilize that. So I'm thinking that if you don't have it, you're going back to your natural state where it is unbalanced. So it's hard for me to answer that question, but I suspect if that's your skin's natural state, you probably will need moisturizers for a long time.
Great. And then here's the question from a parent Armando in California. He asks, some of these moisturizers have additives and chemicals and different things in them. And especially when children are young, we're applying a moisturizer multiple times a day for the moderate to severe kiddos. What do we know about these different ingredients, potentially getting into the bloodstream or becoming systemic?
They absolutely get into the bloodstream and become systemic and it depends on how bad the kid's skin is to begin with is how far it penetrates. And some of these things can be metabolized away. I would say, just because it gets into the systemic compartment doesn't necessarily mean that you could assume that it wreaks havoc there, it is still going to be some dosing and other studies that would be necessary. I am concerned when some of these things are so synthetic that no human has ever been exposed to it until 1980 or something. And then all of a sudden you're giving it to a child in a very developmentally sensitive stage in their immune development. So yeah. Okay. It is a potential concern. And there are studies though that have shown that you can lather an adult with some of these products and pick up, for example, polyethylene glycol in their serum after you apply it topically, this was just in adults, not children with eczema. So you can get it into your systemic compartment with a quote unquote normal skin.
So it's a provocative question. And I think parents need to weigh those concerns against shoring up the skin barrier with moisturizer therapy, which is a mainstay of eczema treatment. And, Using these moisturizers to protect the skin. So a difficult one because with compromised skin and out of control eczema, these kids don't sleep and they're miserable and their quality of life is quite terrible. I think it's something that as parents, we need to process. I understand that, sometimes you have to do these short-term things to get the eczema under control, but to be watching it because putting a lot of anything on a young child is for sure concerning.
These are worries that we have as well, since we haven't studied a lot of these moisturizers for a long period of time. So it's hard to know, down the line, how this will affect the way our immune system functions. And like you said, over a short period of time, the goal in severe eczema is controlling the inflammation because uncontrolled inflammation is we're sending the barrier, we're sending the microbiome, but in the process, you may be doing some harm along the way. And I think it's very important to be aware of the risks as much as we can and make an informed decision and do what makes most sense for the child at hand and where they're eczema care is and how they're doing.
Yeah.
I would say to that as well: Uncontrolled eczema is a guaranteed problem versus the theoretical concerns for some of these moisturizers. So I think right now you make the most informed pro moisturizer choice that you can. And that may change and your choice of moisturizing may get more informed, but I don't think total avoidance because of theoretical concerns is the right path right now.
Yeah. Thank you for that summary. I think that's right. So let's help parents make an informed choice based on the little that we know right now. We talked a little bit about some rules of thumb. So this is another question about, are there specific ingredients. To sort of avoid? We hear about petroleum type ingredients, ceramides, paraffins, urea...
When I go to the store and if I'm looking for something for my child that does not have eczema, but just looking for my child. I would avoid parabens. I will avoid lanolin. something called amerycol benzyl alcohol. I agree that fragrance free is probably your better bet, but oftentimes it depends on where the fragrance comes from. Cause the fragrances tend to be up to 12 or 13 different things and each chemical has its own different behaviors when you separate them out. Now this is based just on my work, right? This is just will it kill off my kids' healthy microbiome. So I can't say, would it be good or bad for your child because your child might have an overgrowth of Staph aureus that needs to be addressed on some level. So it's difficult, but I would say the fewer ingredients the better.
Yeah, thank you for that, really helpful tips. Another one, this is more anecdote rule of thumb , but parents of kids with more severe eczema, we look for alcohol because it stinks. Sometimes ingredients just cause pain when you put them on, because the skin is so raw that the presence of alcohol will hurt them. And it always surprised me as a parent, that products for eczema would contain those ingredients that cause pain. I think that should be a minimum to have those out of there. I feel like in the parent community, that's known.
When the word eczema shows up on the bottle, that is only a comment on a very specific FDA rule that says if certain ingredients are in there, you're allowed to say, this is for eczema. For the life of me, I cannot find how they selected those ingredients and what was the evidence behind each one. But there are about 18 or 20 different ingredients that if your product has at a certain concentration, you get to tell people this is for eczema. Looking at the list, not all of them are benevolent, they would not be things that I would put in there. And as you say, lanolin, or ? is a form of alcohol, some of the amerycol these are things that are on that list you'd want to avoid those, even though it says for eczema on the bottle.
As a minimum, it should not be causing kids who are already suffering so much further pain or harm. And I wish there was a way to screen those out. And maybe it's something for us to work on in the future. So appreciate your being part of this podcast and anything to add, any final words to add before we wrap up either of you.
You know, skin is just one part of your body and you are still a whole organism. So really just, focusing on microbial health, not just for your skin before your gut may play a role together. So I think just being aware of the research and what's proven, not proven it's a great exercise and making informed choices down the line.
Right. And we're finding all these things are so interrelated. It's been really fascinating the last five to 10 years to see the interplay between these conditions that we thought were separate when in fact there's a dance there that we're untangling for sure. I think there is more to learn about moisturizer therapy and how to optimize it for children with eczema, given the complexity of different things that are going on in the skin, as far as the microbiome and inflammation and skin barrier function. And we're just starting to get more information to guide parents. And we've talked about some of those rules of thumb today that I think are very practical. So with that, thank you both for coming on the podcast today.
Thank you so much
Good. Thank you.
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