Episode 26: Embracing your allergies: how micro-exposures to an allergen can make eczema better.
Could allergy drops (or shots) be the answer to reducing eczema flares? More and more research suggests that immunotherapy can improve eczema symptoms. Immunotherapy is safe for kids, easy to use and cheap. We discuss how the treatment works and it’s potential to improve lives, especially for kids who can’t access expensive treatment programs. Our guests are Dr. Derek Chu, a clinician scientist from McMaster University in Canada, and Dr. Sarah Langer, a pediatric immunologist from the University of Sao Paulo, Brazil. (P.S. If you like our podcast consider supporting it with a tax deductible donation). Read the transcript.
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Lynita: For this podcast, we speak to two researchers studying immunotherapy for eczema. We'll start by explaining immunotherapy. And then we'll speak to a researcher in Brazil about an exciting study that they completed last year. Then we will circle back to get an overview of how immunotherapy could work for your child. But now I shall hand over to the founder of global parents for eczema research. Korey Capozza.
[00:00:23] Korey: Welcome to the podcast. I'm really excited to introduce our guest today, Dr. Derek Chu, who is a clinician scientist at McMaster University in Ontario, Canada. He has a research focus on using the best evidence and patient partnership to achieve optimal outcomes in allergy care, including eczema care. He co-chairs the upcoming quad AI and A C A A I atopic dermatitis guidelines, and at McMaster, directs the challenge clinic for allergy diagnosis, research and treatment.
And also Dr. Chu is a frequent collaborator with our organization, GPER, and has been a real champion of including patients and parents in guideline development, as well as in all aspects of care. So I'm really excited to welcome you to the podcast today.
[00:01:09] Derek: Thanks so much. Really looking forward to it.
Our second guest today is Dr. Sarah Langer. She is an allergist and pediatric immunologist at the university of Sao Paulo in Brazil. And today she'll be talking about her recently published studies showing that house dust might immunotherapy can improve eczema symptoms. So Dr. Langer, welcome to the podcast as well.
[00:01:31] Sarah: Thank you so much for the invitation.
Korey: So we're excited to kick off this podcast today and dig into some of the research that's been recently published on this topic. And as a parent, I thought it was really interesting because I think I had only really heard about immunotherapy as a treatment for allergies and not so much for eczema.
[00:01:50] Korey: I think often this approach is not something maybe parents hear about unless they're visiting an allergist who has this in their toolkit. So, I wondered if you could talk a little bit about immunotherapy first. Like what is it and how could it be used in the treatment for eczema?
[00:02:07] Derek: Yeah, that's great. I'm very happy to. So I guess the first bit is that when we think about allergy, it means that there is something very specific in the environment that you'll react to every time. Allergen immunotherapy is the thought that we can use very controlled small doses of the same substance that would otherwise cause that allergic
So Essentially there are parts of your body that cause inflammation and there are other immune cells that help reduce inflammation. They naturally do that and by doing immunotherapy, we are boosting those cells that calm inflammation down and say, Hey, look, actually, that dust mite, that's there, maybe you don't need to be so vigorous against, and by doing that, they can calm down the surrounding inflammation that's going on, reduce the irritation the other cells that are neighboring it and not cause much profound itch skin changes, et cetera.
[00:03:02] Korey: Yeah, it, it reminds me in a way of like I, I remember training a puppy that would become overly alarmed by other dogs and just sort of introducing it to interact with dogs more often until it would calm down. So, getting accustomed, I guess, to that, yeah, to that factor. So it's not overreacting when it sees it in a way.
[00:03:21] Derek: Exactly. In this controlled, slow way using it repeatedly, that it would actually train the immune system to be less allergic, perhaps even to have some kind of long lasting change in the way that the immune system behaves to make you far less allergic, maybe don't even react to it when you're around that substance.
Basically we give them in controlled small amounts by injection. Normally that has been about weekly to start, and then after a certain amount of time, usually a few months, we then switch to once a month. The alternative route, a little bit newer, has been something called sublingual immunotherapy, which means drops or tablets placed underneath the tongue and they dissolve or they can be swallowed after. And that is done once a day for a number of months before it reaches effect. And then less frequent if it's working. So it's very well established in things like environmental allergies or hay fever, also in asthma that they can improve both those outcomes. But the big question was before our
study is does it actually make a difference in atopic dermatitis or eczema?
Korey: Fantastic summary. Thank you for that. So Dr. Langer, I wanted to pose a question to you. We know that dust mites are one of the most important and common airborne allergens that can trigger eczema. And you did an interesting study looking at immunotherapy for house dust mite allergy.
And I think the challenge is that house dust mites are literally everywhere. So you can't really remove the trigger from a child's environment completely. And the question is then like, , what can you do to train the immune system so that it's not overreacting to dust mite all the time? So, could you talk a little bit about how you got this idea for this study?
[00:05:06] Sarah: Some doctors started using immunotherapy for eczema , and they start seeing very good results.
Korey: So you were hearing from other doctors that this could be a treatment for eczema, basically. And then you did this study and it was a randomized placebo controlled trial. This was an immunotherapy that was oral. So it was taken by mouth. But explain how it worked a little bit.
[00:05:34] Sarah: So using the drop system, we have progressive concentrations. So we started with the extract very diluted. So the patient started using one drop. And goes up the concentration like that for five months to 8 drops and stay there using eight drops three days in a week. And, the total time of treatment is 18 months. 18 months is a very low time for immunotherapy. So after 18 months we saw that patients decreased the score of SCORAD that evaluate the levels of eczema. And we had the decrease of the levels of these patients from the baseline to the end of the study. When we saw the numbers, we were very happy.
We had some kind of placebo effect, but we saw that in the treatment group, the decrease was more important and statistically significant. We also saw that another score that's very important: the investigator global evaluation. And our patients in the group of immunotherapy reach it zero and one in a statistic. In comparation to the placebo group. So this is a very important result.
Korey: So basically on both of these measures of eczema severity, which are measured by the doctor, you saw a decrease from the beginning of the study to the 18 month mark.
So given these findings, how do you think this type of immunotherapy fits into eczema treatment in Brazil.
[00:07:29] Sarah: Most of our patients were very poor. So here in Brazil, we don't have any kind of medication for them, in the public service. And when we speak to them they have to pay for moisturizers that here the price is like a cosmetic. And also we don’t have dupilumab here, we don't have so easy access. I think it'll be nice to have a treatment that we are able to give to our patients because many treatments for a are not a reality in Brazil, even the moisturizers and the cleansers. They're very expensive. So if we could do something that could get the lesions better and the patients could focus on using good moisturizers, but didn't have to expend their money in corticosteroids and immunosuppressants. That would be great.
Korey: Yeah, you make a really good point that this could be a low cost treatment that could benefit a lot of people, especially in the developing world. Where there just isn't access to some of these newer generation treatments. I was curious, lot of people, in addition to having a sensitivity to dust mites, also react to toxins produced by staph bacteria. And we know staph bacteria is an issue for people with eczema; it's over present on the skin, and can possibly also trigger or exacerbate, eczema symptoms. So you, could you talk about if immunotherapy could be used to train the immune system? Not to react so much to staph aureus toxin.
[00:09:20] Sarah: So we study the sensitization to staph aureus and saw some very interesting changes after immunotherapy. So the labs are starting to produce immunotherapy for bacteria.
And this is a point of controversial thoughts: if it's going to work, if it's not, if we should use, if not. And maybe we could try.
Korey: Yeah, I think that's kind of an exciting area because part of what it seems is going on is in a subset of patients that have an over-reactive response to Staph or Staph aureus toxin. That seems to be what sort of pushes them towards more severe disease or eczema. And if we could figure out how to head that off, that could be really important for these kids and prevent more severe disease. Dr. Chu. I want to circle back to you and ask what you found in this big systematic review that you did. About immunotherapy for eczema. And what lessons we can take away from it for patient care. And especially for parents.
[00:10:24] Derek: So we reviewed about 23 randomized trials. In both 2000 different participants assigned randomly to immunotherapy. For corresponding standard of care. This is all added on top of very good skin care already. You know, your moisturization, avoiding irritants, otherwise, and bathing routines as well as topical treatments. So, if you're put onto immunotherapy, normally the effect takes about two, three months to start to kick in which is the normal expected range, to do that, a customization or, training.
And in those that were on standard care alone, about 26% of them reduced their eczema severity in half. In contrast, if they were on immunotherapy about 40% reduced their eczema severity in half. The eczema severity is things like redness, itching, sleep disturbance, as well as what the clinician might say about how the appearance is. We also saw improvements not only in the eczema severity itself, But also we saw improvements in quality of life. So there with standard care alone about 40%, got better in terms of their quality of life. And that went up to about 56% in those with allergen immunotherapy.
There were downsides and the downsides were as expected. So normally very mild and very well tolerated treatments with subcutaneous immunotherapy cuz you're getting a little bit of what you're allergic to. You get usually a little bit of redness or a small hive in the arm that you get it injected in and mild and goes away by itself.
