Dr. Peter Lio discusses his highlights from the panel discussion, Complex Eczema/Urticaria/Allergy Cases, at the 6th Annual Elevate-Derm Alliance Conference at the JW Marriott Water Street in Tampa, Florida.

In this video

Interviewed by dermatology PA Buchi Nita, Dr. Lio walks through a five-year-old with severe atopic dermatitis and recurring infections, where the central question is "what is the role of staph." He explains that once the microbiome is "out of whack," staph can dominate and release toxins that drive itch, inflammation, and barrier damage — and because some of these children can become septic, "all the stakes are higher." Rather than reaching first for immunosuppression, he leans on biologics, noting that all four seem to decrease (or at least not raise) skin infection rates. He is candid that the right decolonization approach is still unsettled: dilute bleach baths probably don't actually kill staph, hypochlorous acid and topical probiotics remain question marks, and he cites a Philippines study in which virgin coconut oil twice daily cleared staph in 95% of colonized patients. His bigger point is that getting the eczema controlled restores a "virtuous cycle of healing," so antibiotics usually aren't needed absent true infection. He also questions keeping patients on hydroxyzine, citing the Choosing Wisely message that antihistamines don't treat AD itch and long-term dementia concerns with first-generation agents.

In the second case — a 20-year-old with severe AD, asthma, and positive patch testing — Dr. Lio uses the free six-question Atopic Dermatitis Control Tool (ADCT) to surface just how out of control patients really are, and moves to systemics right away. He often frames systemics as a potential short- or medium-term "reset" to break the cycle before maintaining on topicals. This patient developed conjunctivitis on dupilumab, then had side effects and long-term hesitancy on a JAK inhibitor (he calls the reported cardioprotective effect "still quite speculative"), and ultimately became a "slam dunk" on nemolizumab as monotherapy. He describes nemolizumab as not the most reliable but reliably strong on itch, with a favorable safety profile, no eye issues, and a nearly painless 0.49 mL injection — all reasons he emphasizes shared decision-making so the patient is genuinely "excited" about the choice.

  • In infection-prone AD, ask "what is the role of staph" — the microbiome can reach a resilient, staph-dominant state, and biologics are attractive because they don't raise infection rates the way broad immunosuppression can.
  • The right staph strategy is still uncertain: dilute bleach baths likely don't kill staph, topical antibiotics don't help colonization, and controlling the eczema itself restarts the "virtuous cycle of healing."
  • Reconsider antihistamines like hydroxyzine — they don't treat AD itch, and first-generation agents carry long-term dementia concerns; keep them only for concomitant rhinitis or urticaria.
  • Use the ADCT (six questions, ~45 seconds, score ≥7 = out of control) to reveal poor control, and consider pitching systemics as a short- or medium-term reset before maintaining on topicals.
  • Nemolizumab isn't the most reliable for skin but reliably improves itch, has a strong safety profile, no eye issues, and a nearly painless small-volume injection — making it a good fit under shared decision-making.