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Jonathan Silverberg Discusses Role of Environment on Atopic Dermatitis


Silverberg discusses how certain irritants and living situations may cause flares in patients with atopic dermatitis.

Associate professor of dermatology Jonathan Silverberg, MD, PhD, MPH, spoke with Dermatology Times® about the impact of environmental factors and irritants on the prevalence and severity of atopic dermatitis.


Jonathan Silverberg, MD, PhD, MPH: I'm Dr. Jonathan Silverberg. I'm a professor of dermatology at the George Washington University School of Medicine and Health Sciences in Washington DC, and I'm also the Director of Clinical Research and patch testing there. I live breathe and sleep all things atopic dermatitis, and in clinical care, see some of the worst of the worst in terms of really challenging cases.

Dermatology Times: What are you observing in atopic dermatitis as we transition from winter to spring?

Silverberg: I think it's important to note: there's no one-size-fits-all that applies for all patients, because for many patients, it can get a lot better as they move into the springtime, naturally, heat, humidity, moisture or being outdoors a little bit more, natural sun exposure. Indoor heating is not on as much. But for other patients, the heat, the sweat that comes with hotter weather can be a big issue, and actually can they can flare up more in the summertime. Maybe not so much in a cold weather place like Chicago, for example. But you know, you go to Houston, Miami where the heat and humidity become overbearing, sometimes they'll flare more there. And then sometimes it's not the most common situation, but sometimes even around spring, the pollens, the grasses, those airborne allergens can be a trigger for patients as well. So, you know, these are all things I think about with respect to seasonality, and I try to inquire of patients to get a sense of that time pattern, and then think about how to counsel them around avoidance, depending on when when their seasons are flaring.

Dermatology Times: What are some correlations between environmental factors and atopic dermatitis?

Silverberg: This issue of the potential relationship with proximity to highway exposures to pollutants, it has been discussed in different ways for already several decades; it's not by any means a brand new concept. And it's something that's a little bit, it's challenging to turn into a clear-cut clinical recommendation for some patients. That can actually represent an airborne contact dermatitis to rubber allergens that are literally aerosolized. And if you're really close to a highway, all that tire burning can be an issue. For other patients, it may be more or nonspecific, if you will, with respect to small particle air pollution and things like that. It's easy enough to say to patients, you know, live in an area far from the highway, where there's lots of great ventilation, circulation, trees, etc. But obviously, right, we all have our own living arrangements. And so it's not always feasible. But amongst those studies, that and researchers who have studied this proximity to the highways, one simple recommendation that they have made is just close the windows. Because, you know, of course, you'd love to have the windows open and get fresh air, but the air may not be so fresh. And so closing the windows and using HVAC systems, that we'll be able to adequately filter out some of those, those pollutants may be helpful in those situations. Another trick that I've learned from the allergy world is when we believe that there's airborne allergen exposures from walking outside, that when coming inside to just rinse off those clothing exposed areas like the face, head and neck in general, or maybe even arms hands, so that if there are any allergens that have aerosolized and are sitting on the skin, you just simply wash them off. These are very simple precautions, and they help, but sometimes you can't avoid those allergen exposures or irritants, exposures, and you end up having to treat through that.

Dermatology Times: What might the impact of the environment and air pollution on atopic dermatitis mean for the future of treatment?

Silverberg: I think a lot of this work is very important, at the very least from an epidemiologic perspective, that if we understand that this is playing an important role, that there may be, eventually an opportunity for policy interventions and things like that. I don't see us necessarily eradicating the world of rubber tires simply because of atopic dermatitis, but it is something that we definitely need to think about with respect to advocacy from an education perspective, we may not always be able to change patients living arrangements. But for those where there is flexibility, it can be relevant to know this to choose a domicile that's far from the highway or something along those lines. I've had people with atopic dermatitis reached out to me via email for years saying, you know, I'll move anywhere, right now. I'm at the stage of my life where I have that flexibility: where should I go where my eczema is least likely to flare? And of course, that's such a tough thing to answer for an individual patient. But it is something that patients can take into account as they are planning living arrangements and have flexibility. My thought of this is even if you can't control those exposures completely to at least be aware of them. Because then if you can kind of predictably you know, expect a flare you can predict when that next flare happens based on the exposures. Like, you know, yesterday was one of those terrible days of backed up traffic. And now you're going to end up, you kind of know that's going to be an issue for you the following day where your eczema might flare, you can almost think of pre-treating with some of your topical medications or other medications. Or, if you know, that you're in a situation where you're just getting exposed, repeated, repetitive exposures, and you can't avoid that. And it's going to lead to frequent uncontrolled flares, it may require stepping up to a more advanced therapy. But I think this really, it will depend patient by patient.

Dermatology Times: What should dermatologists be cognizant of when it comes to environmental factors/irritants?

Silverberg: I think at the high level, it will really will depend on the region where they're practicing, and the regions where their patients are living. This becomes a little bit less of an issue when practicing out in suburban areas that are more spread out, or in rural areas that are really more spread out. But certainly in urban areas, this becomes much more of a challenge. It may not be avoidable. But it's something that we have to acknowledge that there are many outside world triggers, that can exacerbate atopic dermatitis, doesn't mean that air pollution or aerosolized rubber particles are the root cause of the disease. But we have to recognize that they can be additional triggers that exacerbate things, and that may vary by different times of year or different even times of day, and to try to provide appropriate pragmatic counseling around it.

Dermatology Times: Aside from adjusting proximity to a high-traffic roadway, what can patients do to limit their exposure to environmental irritants?

Silverberg: One thing that has been proposed in the literature about this particular issue with relationship to proximity to the highway, it has been the potential value of doing epicutaneous patch testing or allergy patch testing. Not prick testing, because we're not worried about food allergens, or dust mites or things like that, but thinking about airborne contact dermatitis to rubber particles. And it's that it's not just an irritant reaction, and it might be an allergic reaction. If so, there may be value there of potentially doing patch testing to identify. And then because if that is the case, it may not just be the airborne exposures as a source of those allergens. There may be other sources that are modifiable, or perhaps even more modifiable for patients, than the proximity to the highway.

[Transcript edited for clarity]

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