Episode 23: Pollution to pollen, floods to fires: how does climate change affect children with sensitive skin?
Our skin protects us from our environment, and global warming is changing that environment. In turn, new research suggests our changing environment can alter our skin. In this episode we explore the impact climate change has on children with eczema and allergies. Our guests are: Dr. Mary Prunicki, Director of Air Pollution and Health Research at the Sean N Parker Centre for Allergy and Asthma Research, Stanford University; Dr. Marc Rothenberg, Director of Allergy and Immunology at Cincinnati Children’s Hospital; Dr. April Schachtel, chief of dermatology for the VA Puget Sound healthcare system in Washington State; and Dr. Markus Boos, pediatric dermatologist at Seattle Children's Hospital. (Please consider supporting our podcast, with a tax deductible donation). If you are interested in this topic, check out our 2022 research symposium highlights. Read the transcript.
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In this episode, we want to explore the relationship between our rapidly changing global climate. And allergic diseases, especially eczema. We know that exposure to small particulate air pollution generated by cars, industry in wildfires. Impacts the health of children by promoting inflammation and oxidative stress. In early life, these types of exposures impact the development of the immune system Air pollution associated with climate change may compromise the skin. And trigger or exacerbate eczema. Unfortunately, we're seeing that eczema has dramatically increased in prevalence worldwide.
With us to explore these relationships today, are four experts. First is Dr. Markus Boos. He is a pediatric dermatologist at Seattle Children's Hospital, and an Associate Professor in the Department of Pediatrics at the University of Washington School of Medicine. He has a special interest in the effects of wildfires on the skin. Next we have Dr. April Schachtel, she's Chief of Dermatology for the Veterans Administration, Puget Sound healthcare system in Washington. Her research interests include climate change effects on the skin. We also have Dr. Mark Rothenberg, director of the Division of Allergy and Immunology at Cincinnati Children's Hospital. His research focuses on allergic inflammatory disease, especially eosinophilic disorders. And he has two recent papers looking at the link between the allergy epidemic and climate change.
And finally we have Dr. Mary Prunicki, who is the director of Air Pollution and Health Research within the Sean N Parker Center for Allergy and Asthma Research at Stanford University. Her research investigates the impact of air pollution, including climate change induced wildfires on the immune system. Thank you all for joining us and welcome to the podcast.
Thank you very much.
Pleasure to be here.
So I wanted to ask just like informally. What got you interested in this topic?
I can go. So I look at how air pollution and wildfires impact specifically immune health. And, I'm the mother of three girls that have allergies. So I think I've experienced almost every form of it, so I get both, uh, lab experience and at home experience in the topic. So, thank you for having me.
I have two little kids one of whom has mild to moderate eczema but when I think about
the world we're leaving to our kids. I think about climate change first and foremost.
Yeah. I would echo that. Climate change affects the children that I see every day, and children don't have the voices that we do as adults. And I have twin boys, myself, they're 11 and just like Dr. Schachtel was saying, I worry about what life is going to look like for them. Cuz it affects us, not in some distant future. These heat waves that are ongoing in our country and in Europe, they're affecting people now.
Great. Yeah. Thank you for that.
I am from Vancouver, Canada. So up the road from Seattle and was it last summer, that crazy heat wave that ripped through Seattle and was like a hundred degrees.
Yeah, I think that really made it hit home. Like climate change is very real. There was a big increase in deaths.
I was around for the heat wave. I just remember my boys. They like mild temperatures. And they're like, what is going on?
Yeah. In some ways, even though they're super unpleasant, it does, I think, orient you to the urgency of the issue in California. We've had these tremendous wildfires. And that has really brought, I think, climate change to the fore for a lot of people.
So I first wanted to ask if you could explain why we're even thinking that there's a connection between climate change and the increasing prevalence of AD. Dr. Boos, let's start with you.
Okay, What we're talking about is the negative health impacts that come from the combustion of fossil fuels and then also from natural events that are happening like wildfires, their extent and their speed is very atypical. . And I think that for too long, we've been focusing so much on the genetics of disorders that we are missing the biggest impact, which is what sort of space does our skin exist in. For most skin conditions it's less about your genetics and more about your environment.
Dr. Rothenberg, what are your thoughts?
We know that there is not a nearly, even 50% concordance, even in identical twins. So the question then becomes what are the factors that are interacting with the genes? And, a great deal of the allergy epidemic may be in fact, emerging because of changes in the climate. With global warming, we know that there's a change in the. Pollination
processes. Flooding dust storms and heat waves that not only affect microorganisms such as mold, but they also promote airway hyperactivity.
And we know that air pollution itself is not only a stimulant for allergic inflammation, but it also is a potent activator of the innate immune system.
So there's a number of mechanisms by which global warming and climate change can impact the allergic reaction. And we think that this is potentially driving the epidemic today and will be even more of a potential problem as we go forward.
Thank you for that. I think, Understanding that atopic dermatitis can't be explained by genetics alone is important because I think there's a misconception it is an entirely genetic condition. When really it's this interplay of exposures and genetics and other things, and it's such a complex condition.
I would add that it's hard to study because what we think of as eczema probably is so many different things itself is complicated. And then there's so many different aspects of climate change that make eczema worse. So when you try to really look at the different parts of climate change, you're gonna be seeing different impacts of each one on eczema.
And I have some patients that it's like wintertime and it's cold and it's dry and that's when they're eczema flares and others who they flare it in the summertime when, like it's humid and it's hot and they're sweating. There's so many variables at once.
Right. It does seem extremely difficult, but I do think that there has been recent research that at least starts to elucidate the relationship a little bit. And I think the strongest area when we look at all these different possible ways that climate could impact skin health is in the area of air pollution.
Air pollution
We're starting to see a body of evidence that air pollution does seem to impact skin health. Could one of you talk a little bit about that?
Sure so with air pollution we've shown that the more you're exposed to it, the more likely you're going to have a community having increased rates of these allergic diseases. We've looked at children and found that air pollution actually down regulates the production of a healthy immune cell. So the gene itself doesn't actually change. It's just
the amount it's down regulated. And so kids who are exposed to more air pollution have less of this healthy immune cell, and that causes an overall immune dysregulation.
Some of the recent work that we've done and have involved wildfires. And we see increases in the inflammatory reaction and that cascade will impact how the skin is regulated.
During and right after the campfire here in California in 2018, studies found an increase in visits to a dermatology clinic for both atopic dermatitis and itch. And also hospitalizations for children uh, asthma exacerbation. Um, this is one of the first times that they've actually linked smoke to an increased incident of atopic dermatitis. So I think wildfires associated with climate change are going to make these types of problems more and more common unfortunately.
Great. Thank you for that. Um, Dr. Prunicki. Could one of you talk a little bit about what specifically happens to the skin. Um, when it's exposed to air pollution for example.
The evidence is clear that air pollution triggers eczema and sometimes it creates free radicals that directly damage the skin. We also know that we have proteins that exist in our skin cells that serve to sort of like detoxify the skin. What they're doing is eliminating these products of fossil fuel combustion from the skin, but in the process, they also stimulate an inflammatory cascade. We know that it makes the nerve endings more sensitive to itch. We know that it makes the skin more dry and it loses its water more easily when these compounds that are formed from fossil fuel combustion, come in contact with our skin.
Right. So these exposures are promoting inflammation in the body and compromising the skin, and its ability to sort of do its job. We're a nonprofit that focuses specifically on children with allergic diseases and especially moderate to severe eczema. Could one of you talk a little bit about how these exposures impact children specifically and what do we know about that from research?
We cite a study out of Germany that showed that children who lived closer to state roads or the autobahn were more likely to have symptoms of eczema in addition to asthma and seasonal allergies. So there's this idea that the closer you are to these sources of pollution, the more likely it is that you're going to manifest atopic dermatitis.
We looked at children living in the Fresno area of California. Fresno is always in the top four of the worst air quality cities in the nation. And they always get wildfires during the
summer. And these kids unfortunately have elevated rates of asthma in comparison to others in California and in the nation. And that's putting them at a disadvantage in terms of their allergic health even at a young age.
Is there something about a young child's immune system, um, that is particularly vulnerable to these impacts.
Children have immature systems, they breathe more frequently than we do as adults. Their heart rate is faster, their kidneys don't filter quite as well as adults. So what that means is that the same exposure affects me as an adult less than a child who was exposed to that same amount. There's also the element of how do we live our lives. As adults, we're often inside but we're trying to tell our kids go outside and play, go outside and get some fresh air. What if that air isn't fresh, right? And so I think that sort of like behavioral things may expose kids to more ambient pollution, or the stresses of heat.
There's been a few studies too, that look at exposure to pollution in utero, that then may alter things at an epigenetic standpoint that then once the baby is born and the child starts developing, that may make them more prone to like starting off the cascade of atopic dermatitis.
Right. It points to this really critical period during pregnancy and early childhood where it's so important. For the immune system to be trained correctly. And not disrupted through exposures that confuse the immune system i think
I wanted to back up just a little bit, because today we've been talking about allergic conditions together. So we're talking about asthma, eczema, food allergy and so on. And it may not be known to our listeners that they are related. Could you explain this a little bit how are they related and how do they usually go together. Let's start with you, Dr. Rothenberg.
Yes the immune system is not one immunological organ, the immune cells are moving around in the blood.When you have an allergic inflammatory disease, like any of the ones you mentioned, the immune cells respond differently. So then instead of having more of a fight against a pathogen, you have an exaggerated hypersensitivity that causes different manifestations in different tissues. So in the skin, the cytokines will cause itching, in the lung that same cytokine is gonna cause narrowing of the airway. So the bottom line is that the immune system is communicating and mobile and will cause a different response in different organs. And that's why in patients, sometimes it's helpful to treat the systemic allergies and you'll see that some of the other responses
are abated.
Yeah, definitely. We're seeing that with some of the new therapies for eczema or atopic dermatitis, the children who are treated with them often see their food allergy or their asthma improve as well. So it's really interesting.
Air pollution and barrier function
It's important to realize that even though a patient with eczema mainly is suffering in the skin, there are other changes that are going on and even the airways of patients that have just eczema have a different type of inflammation in response to stimuli. So we can easily imagine how changes in the environment are going to impact the immune system whose function is to respond to the environment, that's really what the immune system is designed to do to keep the body safe. Despite the exposures to different conditions.
Yes. And we know now that inflammation associated with eczema extends well beyond the site where you may see a rash. That it's really in the body so i appreciate that point.
So we've talked about air pollution quite a bit. In part, because I think that's where the most research is, but what are some other ways that climate change could impact allergic diseases. Based on the research or perhaps theoretically.
What are your thoughts? Dr. Schachtel.
Pollen
I think it's important to talk about pollen as part of climate change, increasing carbon dioxide levels stimulates the growth of some plants that we really do not want to grow, like ragweed and poison ivy and others that put pollen into the air. So we know that increased pollen in the air is definitely linked to conditions like asthma. But can lead to flares of eczema too.
And also we're seeing increased precipitation and flooding with climate change. And then you see so many downstream effects from flooding that are also difficult to tease out. So increased humidity, the flooding direct effect on the kids increased infections and you definitely see a lot of increased eczema after floods.
We recently wrote a paper looking at how does warming of the world affect the skin. And in a continually like warming world there may be more Staph aureus bacteria on our
skin. And we know that Staph colonization can trigger eczema flares.
Is there reason to believe that we're creating a climate that's more favorable to Staph and therefore it will become more of a problem for skin?
Higher humidity and temperature is a better environment for Staph aureus to grow in compared to benign Staph bacteria, like Staph epidermidis. And then you have an eczema flare, and that's a better environment for it to grow in.
Yeah. And I was curious too, cuz earlier we were talking about heterogeneity and some people seem to have eczema. That's particularly driven by staff colonization or interrelated with it in certain ways, whereas other people don't seem to have that involvement.
Staph is definitely seen also after flooding; that's the most common infection seen after floods.
Stress
One other thing to highlight. There's like the direct impact of the pollution, the heat, the humidity, whatever it is. And then there's a layer above that too, which is the mental health aspect of it. When we are stressed, many skin conditions get worse, including eczema. And in the context of climate change and like natural disasters, right. Where there's like a Tsunami or hurricane or flooding, right? Like those are really stressful events. And so you might flare because your body is stressed out.
Yeah, that's a good point. And I hadn't thought about that, but if you're in an area with horrible wildfire smoke and you need to leave the area because it's so bad there's a fair amount of stress. Plus you have these exposures, which are not good for your health.
Causative or exacerbative
And, I did wanna kind of draw a distinction too, because I think there's two questions, I guess on the table. One is what is the relationship between climate changes and the development of allergic diseases like atopic dermatitis. And then what is the relationship to triggering of symptoms, which are two different things in a lot of ways. What do we know about the effects of climate change on pushing a child towards a diagnosis of an atopic condition, like eczema in the first place versus those exposures
leading to an exacerbation of symptoms.
Most of the papers I have read. The air pollution increased incidents and increased severity. So I think right now just broadly speaking we can think about these factors as being bad for both things.
Which makes sense because in both circumstances, you're aggravating the immune system or putting pressure on it in a way that might cause it to tilt.
We do know that In animal systems that exposure to air pollution can trigger allergic sensitisation.
Initially that may be what leads to overall dysregulation in the immune response in a child. But then it could also be what triggers that flare later on once you're in that allergic state.
Yes
I think that's really helpful. So here's a question from a parent that usually comes up in all of our episodes. What can I do now to minimize risk? Dr. Prunicki let's start with you on this one.
Sure. To start with, parents would do well to know their indoor air quality for their child. And if the indoor air quality is subpar, look into ways to improve the in indoor air quality, such as the air filters, paying attention to the outdoor air quality before your child goes outside and especially exerts himself especially when there's wildfires going on. Knowing the pollen counts, if your child suffers from allergic disease.
Some preventative mitigation measures such as being prepared. If there is a wildfire having an n95 mask available. Some people talk about healthy indoor space, while the child is sleeping to try to improve their air quality. So I think those are some of the things that parents can do.
Yeah, for me personally, I live in a high wildfire area. And when they say like you know, unsafe for sensitive populations, I, I never thought that was me or my family, like, well, you know, we're mostly healthy. Even though we do have AD in the family, and so I appreciate that point. I think it is very actionable and, uh, probably caution is warranted with that, given some of these emerging studies.
Would anyone else like to add to what Dr.Prunicki said.
They have these like air quality index guides there's apps for them. So you can look at it and it tells you like what the air quality is like in your city. And I think downloading something like that and really giving a good look at it is important. We can't wrap our kids up in like bubble wrap, they have to be out for their mental health and for their physical development. Like we want them out there and engaging in the world, but these are things that we could do.
When I'm looking at a child with eczema and I'm like, okay, you have it in the classic areas. In the crooks of your elbows and it's behind your knees. And also your face. And from your short sleeves down, when I see that I'm like, okay, every day at the end of the day, you have to rinse off. Cause we don't wanna be marinating in that schmutz that it's on there. Let's get it off and then moisturize, apply your steroids, whatever you need to do.
Yeah. I appreciate that. Any other thoughts on what parents can do to mitigate this risk?
I think that um, Certainly controlling temperature is important and with hot weather and increasing temperatures, air conditioning and cooling temperatures is important. And also thinking about your community and those who are not as fortunate to have air control measures and to try to assist in the community, whether it be in the shopping malls or other regions where people can go to be in controlled environments.
Support the science
I wanted to say another way people could help is to think about supporting the research about this to bring this to the attention of funding authorities.
Climate change
I think that another point about the environment is, just because air pollution is happening, doesn't necessarily mean that's directly from the climate change. This is an interactive process where clearly air pollution is a contributor to climate change, and I think more needs to be focused on what is the direct effect of the climate change on health and disease with a focus on allergic manifestations.
Yeah. In this episode, we've really been talking about what research exists. But admittedly it's in its infancy and we have a lot more to learn about this and so our final question is what research is needed on this topic now what are your thoughts on that?
Research needed
If I could wave a magic wand we would perform a really well done randomized controlled trial using air filters for children that are exposed to wildfires and and looking at how the use of the air filter changes the immune functioning, the clinical symptoms and also things like test scores because now there's, data showing that kids who are in poor air quality at school actually don't perform as well. So I think there's a lot of areas where an improvement in our air quality could impact the quality of life for a child.
I'm very worried that we're going to come out with some great air filter. That's very expensive and that's obviously not gonna work for most of the world where people are feeling this the very worst. So that focus on equity and intervention is what I'd like to see the most.
I think mitigation effects is important. And what other things have we not leveraged in our thinking about how we can approach this.
Yeah. And I think speaking from our community and parents wanna know what can be done. So mitigation research would be really of high interest, I think, to our group as well.
This is a complex process. And I think some of the interests today is to understand how climate change is particularly affecting the immune system then manifesting as allergic disease. I would strongly advocate for multidisciplinary approaches, which will be undoubtedly contributing to the answer to your question, but not necessarily in a direct matter right now.
Social inequality
For sure. I actually also really appreciated what you said, Dr. Schachtel about some of these inequities that are, um, structural. And so they require a political response, they require a policy response. Because we're talking about deep-rooted health disparities and people not having choices in terms of where they live and the exposures that they experience. I wanna acknowledge that and say that we should be looking at who is leading on those issues and looking for solutions for all children, not just the kids that can make these changes. So I really appreciate that, especially where we see that eczema disproportionately impacts children with skin of color, African Americans, Hispanics, and so on. So there really does need to be, I think, a focus on that ensuring
that these children aren't disproportionately exposed to things which are going to cause them these health effects, which are miserable, as we all know.
So with that, thank you for this great discussion today. It was really interesting and I thank you for joining the podcast.
Really appreciate it.
Thank you so much for having me.
Thank you for having us. We appreciate the highlight on this topic.
We look forward to moving the field ahead to improve the lives of people suffering from and other allergic diseases. Thank you for your attention today.
