Several years ago I heard about a Dermatologist in London–Dr. Richard Aron–who was prescribing a combination of a topical steroid, a topical antibiotic, and a moisturizer with amazing results for atopic dermatitis. At the time, I simply thought that this was pretty much what we were doing already, and that it was not really worth much extra attention.
Fast forward to last year, when one of my more seasoned patients with pretty severe eczema approached me about it. She said that she had read a lot on Facebook and that his following was impressive with very convincing stories. She had one of his recipes and asked if we could try it. Looking at it carefully–betamethasone valerate mixed with mupirocin in a Vanicream base–it seemed innocuous enough to try. It is important to note that this patient had severe eczema and was doing all of the right things already: using a potent-enough topical steroid correctly and in sufficient amounts, doing dilute bleach baths nightly, and applying moisturizer aggressively to protect and hydrate the skin. Things were better, but she still suffered and we continued to flirt with the idea of going on cyclosporine, the powerful immunosuppressant that can help to break the cycle, but carries with it a host of possible side effects. Suffice it to say that I was initially not very optimistic…
Let me pause the narrative to point out that there are really three innovations with the so-called “Aron Regime”:
1. Mixing a topical antibacterial agent with the steroid, while not necessarily a new idea, is important, especially as we are learning more and more about how the microbiome (the community of bacteria that normally reside on our skin) is abnormal in atopic dermatitis. In fact, a recent paper described a toxin (called “delta toxin”) produced by the abnormal but ever-present staphylococcus aureus bacteria on the skin that can actually induce eczema on healthy skin! (Nakamura, 2013)
2. Using a low-potency corticosteroid but with increased frequency of application is unconventional, and to my knowledge, not well-studied. In fact, there are studies that would suggest precisely the opposite: that once daily application of a corticosteroid may actually be sufficient to get a medical effect. (Bleehen, 1995). However, there may be theoretical benefits to using a less-potent preparation more frequently, including the possibility that the skin barrier damage is decreased. With this, however, comes the fact that a moisturizer base is being applied multiple times daily, which clearly can have benefits of its own. Further studies are needed to assess this, but it certainly is thought-provoking.
3. Having only one thing to do rather than 3, 4, or even more steps is great. While there is no doubt that 5 or 6 daily applications is a lot, it is somewhat simpler than having a complex morning and evening routine. And it really only lasts for the first week, after which the tapering can begin, going down to 3 times daily application, then twice daily, then once, then ideally, off of the compounded cream. This compared to soaking, then patting dry, then applying the medicine, then a moisturizer, then a damp layer, then a dry layer, etc… which can become very tedious for some patients and families. Some have mentioned that part of the reason it may work so well is simply because patients are able to actually stick to the regimen because it is so straightforward.
Back to the story…
At the one week mark, I called the patient to ask how things were going. She was ecstatic, saying that this was better than anything we had done before. In fact, she was sort of mad at me for “holding out” on this treatment for so long. Was she cured? No, not at all. But was she better? Absolutely. And it allowed us to avoid needing the cyclosporine, which I consider a big win. Were this the only story, I wouldn’t be writing this. Some version of the above has now happened to about 2 dozen of my patients and I have to say that the results are generally very similar and very encouraging.
It has not been all roses, however; there have been some caveats as well:
• A few patients have found the cream base too irritating–in those cases, I’ve cobbled together an ointment version of the compound, sometimes with good effect.
• Several patients also simply did not respond to it sufficiently, and did end up needing to go on more powerful topical medications or immunosuppressants. I can say with confidence that it–at least the way I am using it– is not 100% effective by any means.
• It can be fairly expensive since it has to be compounded by a compounding pharmacy, and this adds a layer of complexity for the patient.
• There is some concern that mupirocin-resistant bacteria may emerge from such prolonged and widespread use. This certainly seems possible, but if we weigh this against the need for frequent oral antibiotics (which is much more likley in severe, uncontrolled eczema), it seems to be a rather small price to pay.
• There is some concern that increasing the application of steroids and the relatively prolonged duration of use could increase the risk of side effects. While this is certainly possible, Dr. Aron maintains that he has not seen many side effects after many years of using this approach. Still, this represents an off-label use for these medications and caution is advised until further studies can validate his experience. We know that there are real risks to using topical steroids, and it is foolish to think that somehow this method is totally immune from them. That said, with close supervision and in the right context, the risks seem to be outweighed by the benefits.
In sum, I freely admit that while I am an eczema expert and very much devoted to understanding (and beating!) this terrible disease, I do not have all the answers. I need–we all need–new ideas, new approaches, creativity and innovation. I want to embrace and celebrate these things, especially when the are taking familiar and tested ideas and using them in new ways. Especially when no one has a conflict of interest to sell a product. And, perhaps most of all, especially when I get the sense that it is coming from someone who is truly dedicated to his or her patients. Fortunately, all three of these apply here.
Maybe the Aron Regime will simply be a footnote in the long history of eczema, but perhaps it will be something more: a point of departure for new approaches in treating AD. The only way to know for sure is to study it and its principles, and to do that, we must first keep an open mind.
References:
1. Staphylococcus δ-toxin induces allergic skin disease by activating mast cells. Nakamura Y, Oscherwitz J, Cease KB, Chan SM, Muñoz-Planillo R, Hasegawa M, Villaruz AE, Cheung GY, McGavin MJ, Travers JB, Otto M, Inohara N, Núñez G. Nature. 2013 Nov 21;503(7476):397-401. doi: 10.1038/nature12655.)
2. Fluticasone propionate 0.05% cream in the treatment of atopic eczema: a multicentre study comparing once–daily treatment and once–daily vehicle cream application versus twice-daily treatment. Bleehen SS, Chu AC, Hamann I, Holden C, Hunter JA, Marks R. Br J Dermatol. 1995 Oct;133(4):592-7.