Episode 34: Research Highlights of 2023
Our latest podcast episode highlights some of the top research discoveries of 2023 related to eczema. Tune in to learn about new needle-free Epi-Pen alternatives, painless tests for detecting eczema before it appears, and insights about how to address anxiety and depression related to eczema. Guests include Albert Chong of University of Southern California, Dr. Ruchi Gupta of Northwestern University, Dr. Ian Myles of NIH, and Dr. Kiwako Yamamoto-Hanada of National Children's Hospital, Tokyo. (If you like our podcast consider supporting it with a tax deductible donation.) Read the transcript.
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[00:00:00] Lynita: Welcome to the Eczema Breakthroughs podcast. In this episode, we cover some of the research highlights from 2023, with four speakers.
Firstly, we talk about a paper published this year, highlighting the significant mental health burden experienced, not just by eczema patients, but also by caregivers.
Our next guest explains the new treatments coming soon for anaphylaxis. The next speaker summarizes the big advances this year alone in understanding the changes in skin that preceded the visible signs of eczema. This new understanding has come about because we now have non-invasive techniques for analyzing skin in babies. And we talk to a researcher who has developed one such non-invasive test. But let's get started. First up, we're going to talk to Albert Chong. He is the first author of the paper: Patients and caregivers preferences for mental health care and support in atopic dermatitis. Albert welcome to the podcast, tell us about your experience with eczema and how you found yourself writing this paper.
[00:01:01] Albert: Yeah. Thanks so much, Lynita. It's a huge pleasure to be here. I have had eczema like my entire life. When I was in middle school, my peers would actually call me a lizard because of the texture of my skin. And, I was so self-conscious about, you know, how people might be judging or pitying me. Patients end up having to bear the weight of these words and this is in addition to the pain and right? So many things go on in the inner experience of patients with eczema that affect the mental health. And that's why I'm so passionate about this subject now. And that's why we came up with this study to look at how patients and caregivers want their mental health addressed in this disease.
[00:01:39] Lynita: Yeah. We always think about eczema as the disease, but there is really two parts to the eczema experience.
[00:01:46] Albert: Right. There are so many things that could contribute to poor mental health among patients. There's this whole thing of stigma and social isolation, wanting to stay at home, but also the itch itself is so terrible. I remember, one of my housemates said that it was almost as if I lived with a monkey sitting on my back and I couldn't escape. It was just this daily bother from my skin that you just have to deal with. Sleep disturbance is a huge thing, neuro-inflammation could also contribute, and overall, just very poor quality of life.
Prevalence of mental health issues
[00:02:15] Lynita: How prevalent are mental health issues?
[00:02:17] Albert: yeah, there's a huge mental health impact on both patients and caregivers. We asked patient and caregivers about mental health symptoms during the worst two weeks of their eczema symptoms. And we found that over 70% of patients and caregivers had risk for anxiety, and over half of them had risk for depression. So definitely in both groups we see huge impacts.
[00:02:38] Lynita: I know as a parent, one of the things that really got me down was wondering what the future held and how you capture that in a paper? I don't know.
So did you find a difference between the caregivers versus eczema patients?
[00:02:52] Albert: Yes, I expected to find more mental health detriments among patients, the ones who are actually suffering the disease. But caregivers actually reported worse overall mental health and risk for anxiety. So, we need to pay attention to caregiver mental health as well. Half of adult patients sought help for their mental health while only a quarter of caregivers sought help. Um, one possibility is that maybe caregivers are prioritizing obtaining care for their children and not really having the energy left over to care for themselves.
Is it selfish?
[00:03:23] Lynita: One thing I struggle with as a parent is: the person that's really suffering here is my child. But I'm saying, “Hey, hang on. What about me? What about me?” And it does feel really selfish, I guess, am I being selfish?
[00:03:37] Albert: You know, all lived experiences are valid. So if the parents feel like they're suffering, they're suffering. It's important that we think about caregiver mental health because caregivers are such a critical part of caring for the eczema of their children. So, no, I wouldn't call you selfish. I think it's excellent that you're thinking about your mental health because we need you to be in the best mental state to take care of the child, right? So I think it's very reasonable.
[00:04:02] Lynita: Thank you I appreciate that answer.
What help do patients want to help their mental health
[00:04:05] Lynita: And what did caregivers want once they did seek help?
[00:04:08] Albert: So everyone agreed that the most important thing for mental health was more effective management for the eczema. And this is not surprising, right? What was surprising though was that over 40% of adult patients actually endorsed three strategies, wearing long sleeve clothing, avoiding social situations, and more alone time. Now, this suggests that a lot of the mental health burden on adult patients could be the visibility of the disease. But two of these strategies are counterproductive because real life interaction is important for mental wellbeing.
[00:04:39] Lynita: So, the mental health of patients is really affected by how they feel perceived. But there could be some negatives as well, because trying to avoid being perceived badly could mean isolating yourself, which could be a bit of a vicious cycle really.
[00:04:54] Albert: Absolutely. You hit it right on the head
What help do caregivers want to help their mental health
[00:04:56] Lynita: Yeah. So let's go to caregivers now.
[00:04:59] Albert: Caregivers agreed with patients that the most important thing, was to treat the eczema better and manage the itch. But, 30% of them also endorsed connecting with other caregivers of children with eczema. Korey Capozza and Michelle Tu, they did a study recently showing that providing these supportive networks with other caregivers somewhat improved the eczema symptoms reported.
[00:05:19] Lynita: You know, GPER has this beautiful caregiver program which is amazing and it's all based on evidence-based research. So any parents that are looking for support, this is a good place to look.
So caregivers think that improving their mental health could be achieved by just improving their child's eczema.
[00:05:39] Albert: Absolutely. Patients really want mental health help from providers who understand what they're going through.
[00:05:46] Lynita: It really highlights that we need our dermatologists, allergists and specialists to see the signs of mental health and be educated about what to do.
[00:05:56] Albert: And that's where our study comes in to try to show providers what it is patients and caregivers want for their mental health.
[00:06:02] Lynita: Yeah, thank you Albert and Global Parents for Eczema Research for putting the spotlight on this issue, so that families can focus on living their best lives and building happy memories.
[00:06:12] Albert: Oh, it's been a huge pleasure. Thanks for having me.
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[00:06:15] Lynita: I'm very excited to bring you our next guest today, who, like me, is a mother of a child who carries an epi pen: Dr. Ruchi Gupta. She is Professor of Pediatrics and Medicine, founding director of the Center for Food Allergy and Asthma Research and vice chair of the Anaphylaxis Committee with the American Academy of Allergy, Asthma, and Immunology. Dr. Gupta, welcome to the podcast.
[00:06:40] Dr. Gupta: Thank you. So happy to be here.
[00:06:42] Lynita: We're talking today, about anaphylaxis, because many children with eczema at some point end up carrying an EpiPen, what is anaphylaxis?
[00:06:53] Dr. Gupta: it's a severe reaction that usually occurs 30 minutes after your trigger. And you have to be aware of anaphylaxis because your body can react pretty rapidly. Onset is usually very quick and it can impact any organ system. So we talk a lot about skin: Hives, swelling, itching. That's one. Then you talk about throat closing, kind of oral symptoms. You can go into the lungs. So trouble breathing, feeling like your chest tightness. Um, GI, so vomiting. And then you can even have neuro and cardiovascular. So you can feel faint and have a drop in blood pressure. So there's a lot of different symptoms. But if you or your child have had that trigger, let's say peanut, one of the most common ones. Then you observe that reaction, and if it goes in and starts causing either something very severe, like a drop in blood pressure, fainting, trouble breathing, or even a couple of things that are scaring you, hives, vomiting, um, then it's time to get that epinephrine out and use it.
And, you know, a young child, if they are starting to get really irritable, if you're seeing hives, if they're throwing up and you're having these multiple symptoms happening with them, I feel like parents know their children and if you feel something is really off just use epinephrine. Because um, it makes the child feel better very, very quickly. So the tiny shot is really negligible. And we've talked to so many kids who've had it. And, they say they don't even feel the shot. They just feel better right away. It's a very safe medication. Epinephrine is our normal adrenaline, you know, and there's very few negative consequences of using it.
[00:08:39] Lynita: There is going to be the circumstance though when it happens for the first time.
[00:08:43] Dr. Gupta: Yeah.
[00:08:43] Lynita: And in that case, I guess knowing the symptoms and having a plan in your head of what you're going to do is probably really good. When I was given my EpiPen we were also told to go to ER after you've administered it. Is that still the advice?
[00:09:00] Dr. Gupta: Yeah, so the advice has been for years that if you use epinephrine go to get medical care, I'd say about 20 percent of times you may need a 2nd one, so be prepared for that, even if they are feeling better, just keep them in and observe them for a couple hours. And any kind of trouble breathing or feeling like your throat is closing up or, or faint feeling that's, that's when you need a 2nd one.
During COVID people didn't want to go to the emergency room, and during that time period, nothing happened, right? No negative outcomes. So, now we still say go, but we are revisiting this in the anaphylaxis committee.
I'll never forget this one mother, who was crying to me, she said, I know my daughter needed it and I didn't use it because I'm a single mom. My other daughter is asleep at home. I don't know how I'm going to call 911 and who's going to watch my other child? And all these thoughts are racing through her mind while she's trying to decide to give epi to her daughter. So when I hear stories like that, it is so heartbreaking. And in those cases, I was like, you just give it and don't worry about going.
[00:10:10] Lynita: It's a really scary situation. I can relate so much to that. So thank you for explaining what parents should do and just giving us that confidence to know that we're not going to make a mistake, I think.
[00:10:21] Dr. Gupta: No, I think we put too much guilt and pressure on ourselves, and if there's one thing I can do, I would love to take away that guilt and pressure.
[00:10:30] Lynita: Yes. Um, what can you tell us about new ways of delivering epinephrine or alleviating anaphylaxis?
[00:10:39] Dr. Gupta: So it is an exciting time. We have treatments coming out and we have new epinephrine autoinjectors! So, there are 2 companies currently making nasal epinephrine, definitely, I think, easier and more comfortable to administer. And then there's a 3rd company that's making a sublingual epinephrine. So you stick the strip under your tongue. So there's 3 new modalities of epinephrine that hopefully will be out, um, I'm hoping at least one of them comes out by next summer 2024 and then maybe the other two by next fall or spring of 2025. These are slightly smaller, easier to carry and definitely simpler to use.
[00:11:21] Lynita: And are they as effective?
[00:11:24] Dr. Gupta: The FDA is being very, very careful and making sure that they are equivalent. Or better, but, yes, all the data all 3 have produced do show that they are equally just as good as the auto injector right now.
[00:11:42] Lynita: I guess watch this space next year particularly.
[00:11:44] Dr. Gupta: Yes, next year, and, the other exciting thing is there's new treatments coming out at least for food allergies. And so one of them is oral immunotherapy the other one is sublingual immunotherapy, and the third that had a really positive study recently is the epicutaneous immunotherapy. So it's the patch. So you wear the patch and small amounts of protein through your skin help desensitize you. And then there's a couple biologics which are just a shot you would take every month or so. And that would help block different parts of the cascade. So, I think we're going to not only have new epinephrine, but we will also have some new treatments.
[00:12:29] Lynita: That's really exciting. Thank you. That's been a really wonderful review of what's going on in anaphylaxis and it's really good to be aware of these prevention opportunities. With that, thank you, Dr. Ruchi Gupta for joining us today.
[00:12:41] Dr. Gupta: Awesome Thank you so much. I really, really appreciate it.
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Our next segment comes from our research symposium that was held in November. And I will let Korey introduce our next speaker.
[00:12:53] Korey: It's my pleasure now to introduce Dr Ian Myles. He is head of epithelial therapeutics unit at the National Institute of allergy and infections disease at the NIH. His research focuses on the skin microbiome and its role in the development and treatment of eczema, and he'll be talking about advances in the detection of skin barrier changes in early life that will allow us to intervene with children early on to prevent AD. So, thank you very much. Dr Myles.
Okay. I’m going to talk today about why did the skin go down the route of eczema in the 1st place and also why would it go back and forth? Why do you get a flare despite not having any obvious trigger.
Skin biopsy/tape
The 1st thing that had to be done because, as you know, this is a pediatric disease, most kids are going to present very early in life, you can't go biopsying and doing a bunch of invasive tests. But now we have non-invasive ways of looking at this. Skin swabs, and then the tape strips. So neither one of these are painful. That's the important part.
So now a little bit more detail is known on the skin using the tape strips to see who would develop atopic derm. A lot of it is around ceramides, sphingomyelins, sphingosines, phospholipids, and omega 3s.
So family history was a risk factor, but what was interesting, a lot of the things that you think of that go along with that did not really bear out. So C sections and season of birth didn't bear out. Filaggrin expression was useless in terms of its ability to predict who went on to get atopic term. But family history, an increase in IL 13, and then these abnormalities and the ceramides and sphingolipids, those individuals had a 54 fold chance of developing atopic derm.
One study that we were involved in, was using the swabs and then we're just looking at the microbes of kids followed out to 3 years of age. And again, who went on to get eczema who didn't. And there was a defect in the patients in their first week of life. So this is well before they've ever developed atopic derm. So we're picking up the same lipid abnormalities, but we're picking them up in the microbiome specifically, that the microbes are not making the correct amount of lipids for you as a way of predicting who would go on to get atopic derm.
The upshot of what I'd want to stress here is that if your skin microbiome is producing the correct amount of these lipids, then it looks like you're going to be okay, you're not going to go on to develop eczema.
2023 Research: lipid production <> AD development
In fact 5 papers just this year alone, and more, are showing that if your skin is not producing the correct amount of those lipids, either directly or maybe through the microbiome that is who ends up having risk for atopic derm.
And so, the reason why this matters is traditional approaches, are not really telling you what the first domino to fall is. And why did my kid get eczema in the first place? And then are they having a flare when you don't perceive any um, change in anything that you're doing in your life? And really what we want to know is who's knocking over the first domino. Right, what is the environmental factor that's doing that? Now that we have non-invasive ways of looking at this and predicting who's going to go on to get eczema, could we start to look for different toxins and then could we start doing actual targeted interventions, so hopefully you can stop the process from very early on.
Thank you so much Dr. Myles I think that was fascinating and one of the things to really highlight is these are breakthroughs, major breakthroughs, in our ability to detect who will develop eczema and so many of those papers were published just this year. Opening up the possibility to really be able to predict who will go on to develop eczema and to come up with interventions to prevent that from happening.
Right? The science is ready. Like, it clearly is pointing to just consistent one thing after the other: it is a sphingomyelid, phospholipid, ceramide problem that predates everything.
It's a major, major advancement, I think, in the field. These tests are not invasive. They're not biopsies. They're not painful. And so we can use them with children in a way that's going to be very, very effective. So I think it's extremely exciting. . . So, thank you very much Dr. Myles.
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[00:16:55] Lynita: The next speaker has developed one of the tests that Dr. Myles referred to. That can extract genetic material from the oils on the surface of our skin. Dr. Kiwako Yamamoto-Hanada is Chief of the Allergy Center at the National Center for Child Health and Development at the National Children's Hospital in Tokyo, Japan. Welcome to the podcast.
[00:17:19] Kiwako: Thank you very much for having me today.
[00:17:23] Lynita: Can you tell us about this technique that you have developed for testing eczema in newborns?
[00:17:29] Kiwako: This is a non-invasive technology taking sebum from a baby. And sebum includes RNA. RNA has a lot information about skin molecules.
[00:17:39] Lynita: You can take sebum from the baby?
[00:17:41] Kiwako: Yes.
[00:17:43] Lynita: Sebum is… is it like, the oil that is on our skin?
[00:17:46] Kiwako: Yes,
[00:17:47] Lynita: And how do you take the test?
[00:17:53] Kiwako: We wipe the face and you can find the lipids on the babies.
[00:17:53] Lynita: You take the lipids from the skin on the face. Just like a tissue that absorbs oil?
[00:17:53] Kiwako: Yes.
How better than tape ?
[00:18:00] Lynita: How is it different to the skin tape which is another non-invasive test?
[00:18:05] Kiwako: Tape stripping: we need to repeat it more than 15 times on the skin, so, minimally invasive, I think. Sometimes tape stripping causes a skin rash however, our new technology is not invasive, just wiping on the face.
[00:18:23] Lynita: So, the tape stripping is minimally invasive and you have to repeat it 15 times or so, and you could create a rash. And the advantage of your test is that you can collect oils from our sebaceous glands and hair follicles. But also from the surface layers of the skin and this sebum contains RNA, which is similar to DNA. Is that correct?
[00:18:48] Kiwako: RNA changes daily depending on the environment. On the other hand, DNA remains unchanged.
[00:18:55] Lynita: Um, so our RNA is changing all the time depending on the exposures in our environment, or inflammation.
[00:19:02] Kiwako: Yes,
[00:18:55] Lynita: And what did you find from your test?
[00:19:06] Kiwako: We found at age of one month biomarkers related to the barrier functions decreased in the eczema babies.
[00:19:22] Lynita: At one month you could see from the RNA that the skin barrier was not as strong in babies that had eczema?
[00:19:21] Kiwako: Yes
[00:19:22] Lynita: It's probably before we have even realized that the baby is going to have eczema.
[00:19:26] Kiwako: Yeah, I think that a young baby already started having eczema. So we would like to detect eczema baby as early as possible using this type of technology.
[00:19:37] Lynita: Definitely. So the barrier function is decreased, but also the immune response is… over reactive?
[00:19:45] Kiwako: Yes. Eczema baby showed that enhance immune response already.
[00:19:49] Lynita: So what you're finding from your study is it's not just one thing that changes it's multiple things. Is there anything else?
Antimicrobial decrease
[00:19:59] Kiwako: We also found a decreased Anti-microbial defense marker. This mean that eczema babies tend to have more skin infection compared to healthy babies.
[00:20:12] Lynita: Your study is really confirming that eczema baby's skin is more prone to this overgrowth of certain bacteria like Staph.
[00:20:20] Kiwako: Yes. So I think originally eczema baby have decrease anti-microbial defence proteins, and then have more bacterial infection, like Staphylococcus aureus.
[00:20:31] Lynita: What you're saying is the excess Staphylococcus aureus that we see on baby's skin is probably there because they have this lower antimicrobial capacity in their skin.
[00:20:44] Kiwako: Uh, yeah, I think so.
[00:20:46] Lynita: Uh, so it's really a three prong hit with eczema. You've got decreased barrier function, you've got increased immune response, plus this decrease of the antimicrobial defense system.
[00:20:59] Kiwako: yes.
[00:21:00] Lynita: Oh dear.
[00:21:01] Kiwako: yes.
[00:21:02] Lynita: I'm curious, what is next for this research?
[00:21:06] Kiwako: I would like a screening system for early stage of eczema in young infants.
[00:21:12] Lynita: I think that would be wonderful. If we could screen our high risk babies when they're younger, before they even start showing the first signs of eczema. And thank you for the work you were doing. We look forward to seeing where it leads.
Thank you so much, Dr. Yamamoto-Hanada, it's been such a pleasure to speak with you.
[00:21:30] Kiwako: Thank you.
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Join us again next year as we follow eczema breakthroughs that make a difference for children and their caregivers. Wishing everyone a happy and eczema free 2024.
