Letters to the Editor
We commend Dr. Peter Lio for reporting the substantial series of patients who had notable improvement instituting the compounded antibacterial, steroid, and moisturizer (CASM) Aron Regimen.1 (Read Dr. Lio’s article here)
This regimen works because it has the added benefit of decreasing the bacterial load, addressing the inflammation, and encouraging barrier repair through moisturization. Not discussed in the article, however, are patients who have emphatically embraced the regimen, only to find that they are unable to withdraw from the treatment, and who notably end up at an eczema referral center in an iatrogenic-dependent state. Some are steroid-dependent, others are steroid allergic, and others develop steroid tachyphylaxis. Such a pattern is self-propagating, where patients find previous doses of steroids ineffective and require increased concentrations of treatment. Thus, creating a propensity for the development of dependency and contact allergy.
The acid mantle is essential for normal protection against harsh environmental exposures. Under normal physiologic conditions, the barrier is largely maintained by the phospholipase A2, sodium-hydrogen exchanger 1, and polycarboxylic acid pathways.2 Alteration of these pathophysiologic mechanisms allows for breakdown of this barrier and increased skin pH. Consequently, the stratum corneum loses its protective capacity and the skin is susceptible to disturbances that perpetuate barrier dysfunction.2
There is no doubt that the relationship between atopic dermatitis (AD) and Staphylococcus aureus is complex.3 And, in fact, the increased Staph colonization and resultant decrease in microbiome diversity are important elements displayed in the immunologic aberrancies found in AD patients. The role of Staph in decreased healing of skin and activation of the immune system allows for sustained inflammation.2
Antibiotics versus Bleach Baths?
Though I introduced the methods for dilute bleach baths at the 2004 Society of Pediatric Dermatology meeting, I no longer endorse their use. While antibiotics and dilute bleach baths are effective in reducing the Staph load,4 both demonstrate significant long-term risk.
Mupirocin has the risk of encouraging development of antimicrobial resistance (especially in MRSA) with extended or long-term use5 and further impairs the restoration of microbiome diversification. Mupirocin is indicated for use upon only 10 square centimeters of the body and may also have adverse effects on the renal system.6 Alternatively, bleach baths increase skin pH, which subsequently disturbs the acid mantle, breaks down proteases and cathelicidins, slows the production of antimicrobial peptides, slows skin barrier lipid production, promotes barrier disrepair, and further enables Staph proliferation by increasing the skin barrier pH—all of which propagate immunologic disturbance.7
Steroids, antibiotics, and bleach baths may serve specific purposes in the AD patient when used correctly. However, use does potentially lead to attenuation of the skin barrier’s functional capacity with altered immunologic milieu in favor of the development of AD symptoms. These therapies ultimately obtund healing and set a potential course for the development of topical steroid dependence, allergy, addiction, and withdrawal.
The greatest clinical efficacy is seen by combining skin barrier acidification (natural enhancement of antimicrobial activity) with the appropriate strength of steroid for a limited time along with skin barrier optimization with bio-corrective moisturizers and by practicing avoidance of highly prevalent allergens.
In terms of immunology, atopic dermatitis is really three separate disease states, expressed clinically as mild, moderate, and severe, with associated immune dyscrasia.
Each condition has varying degrees of the following “features” that are propagated by the elevated skin barrier pH: dysfunctional skin barrier acidification, suppression of skin barrier lipid production, depression of antimicrobial peptide production, inflammation, allergic contact dermatitis, and disruption of the calcium gradients, which, in turn, disrupt cellular turnover. Each of these features are exacerbated as the skin barrier pH rises. The pH of dilute bleach baths (pH of 8.9 in Utah tap water) is far above the ideal skin barrier pH of 4.6 to 5.6 and fosters the growth of pathogenic organisms that thrive in an elevated pH environment such as S. aureus, Pseudomonas, Candida albicans, P. acnes, and others that prefer an elevated pH.8,9
Addressing and ameliorating causal features in AD can affordably and reliably induce disease remission. The key is to decrease the skin barrier pH while simultaneously addressing inflammation, allergy, disrupted skin barrier lipid production, and altered calcium gradients. In addressing these properly, the skin barrier can be supported to restore itself back to good health and be maintained in an optimized state with limited exposure to glucocorticoids and NO exposure to antibiotics.
Since embracing the benefits of skin barrier acidification in clinical practice, antibiotics have been eliminated as a mainstay treatment of AD in our practice, the largest eczema referral center in the state of Utah and the world’s first dedicated online eczema clinic. In addition, my patients have been able to entirely circumvent the use of oral or systemic immune suppression.
—Cheryl Lee Eberting MD and
Chandler W. Rundle, BSY
Cheryl Lee Eberting, MD is the Founder and CEO, CherylLeeMD Sensitive Skincare, and Medical Director, Alpine Dermatology & Laser, Alpine, UT. To learn more about bio-corrective skin barrier treatment protocols for atopic dermatitis, please refer to www.CherylLeeMD.com/protocols.
Chandler W. Rundle, BS, is a MSIII at the School of Medicine, Loma Linda University, Loma Linda, CA.
Disclosures: Dr. Eberting is the inventor of the TrueLipids biocorrective™ moisturizers and the inventor of TrueCider™ skin barrier acidification technology. Dr. Eberting is also the CEO and founder of AZOVA, Inc. and of www.EczemaClinicOnline.com
1. Lio P. Triple Threat In defense of the Aron Regimen for resistant atopic dermatitis. Pract Dermatol.
2. Rundle CW, Bergman D, Goldenberg A, Jacob SE. Contact dermatitis considerations in atopic dermatitis. Clin Dermatol. 2017;35(4):367-374. doi:10.1016/j.clindermatol.2017.03.009.
3. Anna BM, Grazyna A, Wojciech D, et al. Nickel allergy and relationship with Staphylococcus aureus in atopic dermatitis. J Trace Elem Med Biol. 2016;33(Supplement C):1-7. doi:10.1016/j.jtemb.2015.06.009.
4. Barnes TM, Greive KA. Use of bleach baths for the treatment of infected atopic eczema. Australas J Dermatol. 2013;54(4):251-258. doi:10.1111/ajd.12015.
5. Hogue JS, Buttke P, Braun LE, Fairchok MP. Mupirocin Resistance Related to Increasing Mupirocin Use in Clinical Isolates of Methicillin-Resistant Staphylococcus aureus in a Pediatric Population. J Clin Microbiol. 2010;48(7):2599-2600. doi:10.1128/JCM.02118-09.
6. Jacob SE. Percutaneous absorption risks in atopic dermatitis. Br J Dermatol. 2017;177(1):11-12. doi:10.1111/bjd.15439.
7. Eriksson S, van der Plas MJA, Mörgelin M, Sonesson A. Antibacterial and antibiofilm effects of sodium hypochlorite against Staphylococcus aureus isolates derived from patients with atopic dermatitis. Br J Dermatol. 2017;177(2):513-521. doi:10.1111/bjd.15410.
8. Panther DJ, Jacob SE. The Importance of Acidification in Atopic Eczema: An Underexplored Avenue for Treatment. Barbarot S, Thomas K, eds. J Clin Med. 2015;4(5):970-978. doi:10.3390/jcm4050970.
9. Lee NR, Lee H-J, Yoon NY, Kim D, Jung M, Choi EH. Acidic Water Bathing Could Be a Safe and Effective Therapeutic Modality for Severe and Refractory Atopic Dermatitis. Ann Dermatol. 2016;28(1):126-129. doi:10.5021/ad.2016.28.1.126.
Please see the online version of the article “Skin Bugs and Travel Bugs: An Update for Clinicians,” which originally appeared in our October edition.
The new article includes updated images as well as full photo credits:
To comment on something you’ve read in Practical Dermatology®, email firstname.lastname@example.org.
You can also share ideas for stories.
Also, be sure to connect with us via social media.