As part of our desire to spotlight leaders in the field of dermatology, the following is the second of a two-part article on Peter Lio, MD, FAAD, an expert in Atopic Dermatitis. Dr. Lio is a Clinical Assistant Professor of Dermatology & Pediatrics at Northwestern University Feinberg School of Medicine, and a physician with Medical Dermatology Associates of Chicago. If you missed Part 1, you can read it here.
This article was written and edited by Dr. Susan Huang and Dr. Garry Choy, both physician writers and editors contributing to dermRounds Dermatology Network.
dermRounds: Dr. Lio, we are excited to have you join us today as an expert in Alternative Therapies for Atopic Dermatitis. This is an area that many of us did not have exposure to during our training.
Dr. Lio, can you tell us how you became interested in alternative therapies?
Dr. Lio: I'm always drawn to the cutting edges, the fringes, and the unanswered questions in medicine and science. I feel like that is where the really interesting stuff is happening, even though you sometimes get folks who are dismissive and skeptical. I had read David Eisenberg's book Encounters with Qi, about his experience as a Harvard medical student in China, and it made a huge impact on me. I actually got to work with Dr. Eisenberg and Dr. Ted Kaptchuk a little bit between the summer of first and second year of medical school and I was fascinated. I nurtured this interest throughout medical school, reading and learning on the side, since you're right: we didn't cover this in school! It culminated with me putting my money where my mouth was, so to speak, and I did formal acupuncture training the first year out of residency. It was a pretty transformative experience, and I felt like a medical student again, learning a new language and new ideas, seeing master clinicians that I wanted to learn from... I collaborated as an author on Dr. Andrew Weil's interesting book Integrative Dermatology and wrote a book of my own with several colleagues in 2015 called Handbook of Integrative Dermatology: An Evidence-Based Approach. Last year Dr. Reena Rupani and I started up the Integrative Dermatology Expert Resource Group at the American Academy of Dermatology, and we viewed it as a very positive sign of the times that the AAD supported us in this endeavor. The number of interested dermatologists is actually quite large, and I think there are some exciting things that will come from this!
dermRounds: We understand that you practice acupuncture as well. Do you do this in your current dermatology practice? How was the experience of learning Eastern medicine, which is built on a completely different foundation from Western medicine? How did you reconcile the two?
Dr. Lio: I don't actively practice acupuncture anymore, though I do miss treating patients with it. The truth is, like any procedure, the best practitioners are doing it a lot and constantly honing their skills. As I got farther from my training and realized that I was not going to do it enough to continue to improve, I felt it was best left as an interest. I still refer a number of patients to experienced acupuncturists and love working with them as a form of integrative medicine, however, and even did a study of acupressure for itch a few years ago.
Although it can be tough to reconcile Eastern concepts and Western approaches, it's one of those things that does come together beautifully for many patients. It reminds me of the (perhaps apocryphal) story about how physicists and engineers were convinced that bumblebees should not be able to fly given what is known about flight dynamics... and yet they do!
dermRounds: Can you give us an overview of some of the alternative therapies which you have had good success with in atopic dermatitis?
Dr. Lio: Here are a few of my favorites that I go back to, and I will reference a few books and articles below as well. The key thing is that the data is *great* for any of these, for if it were, they wouldn't be "alternative" anymore, right?! Coconut oil, despite some of the fatigue from everyone talking about it, really does make sense and actually seems to help some folks. Sunflower seed oil as well. Acupuncture or acupressure for itch also can make a big difference for some. Topical vitamin B12 seems to have a measurable anti-inflammatory effect, which is mild but does seem to be enough for some patients. Probiotics have a long and complex history, but I do think they help prevent AD in some patients and may mitigate it a bit in some existing patients. Vitamin D helps a group of people but seems to be best in those who report flaring in the winter months. Cannabinoids have real promise for itch as well. Oral L-histidine may boost filaggrin production which could help skin barrier.
dermRounds: Can you point us in the direction of helpful articles to read so that we can learn more about these therapies?
Dr. Lio: The books mentioned above go into very deep detail, and a few articles some which are fairly current include:
Atopic dermatitis: addressing allergy, infection, itch and compleme... Ahluwalia J, Davis DM, Jacob S, Waldman A, Ong PY, Cohen S, Friedman A, Lio P, Jetter N, Bienstock J, LeBovidge J, Spergel J, Fonacier L. Semin Cutan Med Surg. 2017 Sep;36(3):112-117.
Vieira BL, Lim NR, Lohman ME, Lio PA. Am J Clin Dermatol. 2016 Dec;17(6):557-581.
Goddard AL, Lio PA. Evid Based Complement Alternat Med. 2015;2015:676897.
Lio PA. Curr Allergy Asthma Rep. 2013 Oct;13(5):528-38.
dermRounds: Besides atopic dermatitis, do you use these alternative therapies for any other skin conditions?
Dr. Lio: I do use some alternatives for acne and psoriasis, but I truly think that AD has the most interesting alternative studies, in part because there is so much unmet need.
dermRounds: What has your experience been in getting insurance to cover these therapies for patients?
Dr. Lio: The good thing about alternatives is that they are often very inexpensive. Coconut oil, for example, is often less expensive than a commercial moisturizer, and nothing approaches the cost of biologics. Because there is little data on these by definition, they are generally not approved prescriptions, so insurance is left out of the equation. This can be a good thing since it can be simpler to access them, but also is important to keep in mind as non-covered products add huge cost burden for patients and are often forgotten. Also, one of the problems is that they are unregulated and therefore harder to know if their quality and claims are consistent since they are outside of the FDA's protective purview.
Peter Lio, MD, FAAD is a Clinical Assistant Professor of Dermatology & Pediatrics at Northwestern University Feinberg School of Medicine. Dr. Lio received his medical degree from Harvard Medical School, completed his internship in Pediatrics at Boston Children’s Hospital, and his Dermatology training at Harvard where he served as Chief Resident in Dermatology. While at Harvard, he received formal training in acupuncture. Dr. Lio served as a full-time faculty at Harvard (Beth Israel & Children’s Hospital Boston) from 2005-2008 before returning to his native Chicago to join Northwestern and Lurie Children's Hospital. Dr. Lio is the founding director of the Chicago Integrative Eczema Center and has spoken nationally and internationally about eczema and atopic dermatitis, as well as alternative medicine. He remains active in clinical research, serves as a section editor for the Archives of Diseases in Childhood, and has published two textbooks and over 100 papers in the peer-reviewed literature. He has received a Leader of Distinction Award, a Presidential Citation from the American Academy of Dermatology, and numerous teaching awards. He currently serves as a board member and scientific advisory committee member for the National Eczema Association.
Disclosure: Dr. Lio has served as a consultant/advisor and speaker for Regeneron, Sanofi Genzyme, Anancor, and Pfizer.