A leading dermatologist says emerging research shows the need for a far more integrated approach to treatment and management of allergic conditions, since they all appear to be linked to a single overactive immune response – Type 2 inflammation.
Dr. Alexander Zink makes the case that doctors who treat patients with atopic dermatitis, asthma, food allergies and rhinitis must develop a more cooperative and holistic approach. As well, patients need to be tuned into the potential for having more than one allergic condition, says Zink, a dermatologist and public health specialist at Technical University of Munich.
“Through well-established observations, such as the fact that these diseases often co-exist in the same person, or run in families, healthcare providers have suspected there is some connection between these diseases for many years,” Zink said during a webinar on Oct. 28. “However, the specific nature of that connection has become clearer as the science behind Type 2 inflammation emerges.”
He stressed that patients being treated for one allergy-based disease need to become aware of how they are feeling and when they are feeling it, and share that with their specialist. Symptoms that may seem random, may relate to other allergic conditions.
“You are more likely to talk about something if you know about it,” he said during the webinar, which was sponsored by Sanofi Genzyme and Regeneron. “For example, if I am seeing a patient with atopic dermatitis, I will only know he has nasal polyps (small, non-cancerous growths related to allergies) if he knows to talk about those symptoms in the first place. A holistic healthcare approach means actively looking for patients with symptoms that signify other diseases.”
Treating the ‘Whole Patient’
Previously thought to be a childhood disease, about 16.5 million adults in the U.S. alone have atopic dermatitis, the most common form of eczema. About 25 million Americans have asthma, or one in every 13 people. To understand Zink’s point about disease relationships, consider that about 35 per cent of people with severe asthma have atopic dermatitis. Then factor in that 50 per cent of those with atopic dermatitis and 50 per cent of people with chronic rhinitis also have asthma.
“Everyone knows how common these diseases are and how many millions of people are affected. All this can lead to more interconnected care, with the patient treated by a group of doctors,” Zink said. He says the “whole patient” needs to be treated and explains connectivity and potential symptoms to his patients.
As a dermatologist, he is working with ear, nose and throat doctors and pulmonary specialists. In future, he hopes to bring other specialists into the network, too.
Zink encourages his patients to keep records of their daily lives – such as what they eat, how they sleep, and what happened at work or at school. They should write how they physically and mentally feel each day, too. Itch, for example, may be two or three on a scale of 10 most days, but may suddenly shoot up to an eight or nine. What were the environmental factors that day? What could have exacerbated the condition? Details like that, he said, can help doctors to discern patterns and weigh the most effective treatments.
Type 2 inflammation involves the allergy-skewed Th2 cells, which produce chemical messengers that drive B cells to produce the antibodies known as IgE. These IgE antibodies will respond to specific allergens, such as peanut or tree pollen or cat dander.
Type 2 Inflammation in EoE, Asthma
Zink cautioned that Type 2 inflammation can get worse with each successive generation. A grandmother may have atopic dermatitis, her daughter may have that and asthma, while her granddaughter may have both plus allergies. Beyond that, the science is still emerging.
For instance, researchers are currently investigating the role Type 2 inflammation may play in chronic spontaneous urticaria, or hive outbreaks that last six weeks or more, as well as eosinophilic esophagitis. EoE is a form of food allergy that involves elevated levels of eosinophils (white blood cells) in the esophagus. The esophagus becomes inflamed and scarred, leading to difficulty swallowing and chronic pain.
Although there is no single test that can diagnose Type 2 inflammation, Zink says tests for inflammatory markers such as eosinophils and IgE can give doctors insight into whether Type 2 inflammation underlies the disease. In asthma, the test for nitric oxide can measure airway inflammation.
“Treatment guidelines, such as the Global Initiative for Asthma 2019 have recently recommended measuring these biomarkers, along with other factors such as the need for maintenance oral corticosteroids, as part of identifying Type 2 inflammation in the airways in patients with severe asthma,” he said.
Support for Type 2 Diseases
Jennifer Austin, the executive director of the International Alliance of Dermatology Patient Organizations, or GlobalSkin, told the webinar that one thing people can do to learn more is connect with their local patient group. “A lot of patient go into appointments not knowing what questions they want, or even should know, to ask,” said Austin, who is based in Ottawa, Canada. “Some patient organizations provide step-by-step guides as to what to expect and discuss with the doctor.”
And Karin Hafner, who was diagnosed with eczema as an infant, noted that until she founded an online community for skin diseases with resources and the latest information, she was ashamed of what she looked like.
“I believed many people would find me disgusting,” said Hafner, who lives in Salzburg, Austria. “Now, I no longer feel helpless.”
Her message to others with severe eczema: “Don’t bury your head in the sand. Look for a dermatologist you can trust and talk with your family and friends about this disease. I will continue to work tirelessly and educate people to seek specialists,” said Hafner.