Dr. Jonathan Silverberg weighs in with ESC

ESC recently spoke with world-renown dermatologist, researcher, and eczema expert, Dr. Jonathan Silverberg MD, PHD, MPH, director of Clinical Research at George Washington University School of Medicine and Health Sciences in Washington, D.C., on the evolution of eczema management and what the future holds for eczema sufferers.

Q: What has been the most significant breakthrough when it comes to our current understanding of eczema and atopic dermatitis?

A: “If you had asked me 10 years ago, I would have said the discovery of the filaggrin gene mutation and the importance of managing the skin barrier. While these breakthroughs were very important, we are now coming to realize the immune-mediated aspect of atopic dermatitis. We’ve always known it’s an inflammatory disease, and treatments like topical steroids have reflected that, however the most recent discoveries, such as targeting T helper-2 cytokine pathways, have made such a difference in our understanding. By selectively regulating these pathways, and finding new ways to target them, we have established the immune nature of AD and opened the doors for future treatments and research.

The next big question we are looking to unlock is around whether we will find a single ‘magic pill’ that that works reliably in all patients.  In teaching, we commonly describe the condition as ‘heterogenous’ meaning it is complex and varied in how it presents. No two patients are the same, and it is fascinating that as we enter the era of precision medicine, I wonder if we will ever get to a place where we find one single treatment that works reliably in eczema (the same way we are seeing treatments advance for psoriasis for example).

The future could look to treating the different nuances of this disease and evolving past the ‘primitive’ way eczema was described in the past. We now know eczema is very complex – some people respond well to moisturizing, some have success with trigger avoidance, some experiences flares from heat, yet others are triggered by the cold, and so on. By looking at the nuances of the condition, we realize there is much we don’t know yet, and there may be new treatment approaches as a result.

We are also starting to understand that in order for treatment to advance, we need to better characterize patients and their symptoms. We recently published a study that examined the treatment of individuals with eczema based on itch and the severity of lesions. We found that some individuals with more severe itch were only treated as mild or moderate based on the severity of their lesions (rashes). It suggests that we may be too focused on the presentation of the skin, and more attention needs to be focused on nuances like itch and other symptoms that can affect overall quality of life. Another example is the growing attention to diversity and how eczema presents across a spectrum of skin tones. We are moving away from a ‘one size fits all’ solution and research will need to adapt to this approach.

The good news is that there are a number of new therapies coming to market soon that help treat different immune system pathways, giving patients more options and choice when looking for a more personalized treatment plan.”

ESC thanks Dr. Silverberg for his volunteer contribution to this article. Disclaimer: Information provided by Eczema Society of Canada does not constitute medical advice. All medications, interventions, and treatment plans have risks and benefits, and it is important that individuals discuss their or their child’s specific health care needs with a qualified health care professional.