Episode 49: All about the skin: eczema, acne and antibiotics

Dr. Caroline West:
Thank you and welcome to our podcast. I'm Dr. Caroline West. I'm a GP and medical advisor to NPS MedicineWise. Now, our skin is one of our most precious organs. Amongst other things, it helps us regulate heat, feel sensations, and ward off infections, as a first line of defence. Many of us, though, will suffer with a skin condition at some stage, like eczema or acne. Appropriate management makes all the difference, not just to how the skin functions, looks and feels, but also to how someone feels about themselves and their quality of life. To take us through the latest on skin, dermatologist, Dr. Li-Chuen Wong, joins me. She's a member of the Australasian College of Dermatologists and is the head of the Dermatology Department at Children's Hospital, Westmead. Dr. Wong has declared she is on numerous advisory and research groups, working with pharmaceutical companies. Thanks for joining me.

Dr. Li-Chuen Wong:
Thank you, Caroline. Thank you for the privilege of having a chat with you today.

Dr. Caroline West:
Well, I'm certain that I'll learn plenty myself, because as a GP, I often see people with skin conditions and eczema is probably the thing I see most commonly, because so many people have it, particularly children. Can you take me through just a quick snapshot of how common it is and what it's like out there, in terms of the distribution between kids and adults, for example?

Dr. Li-Chuen Wong:
Yes, in fact, it is incredibly common and 20% of our paediatric population would suffer from eczema or atopic dermatitis, in some form or another. Mostly, thank goodness, it's mild, but sometimes it can be so severe and debilitating. And I think the statistics that I most recently read was, in Australia, there are 100,000 Australians that are suffering from very, very severe atopic dermatitis.

Dr. Caroline West:
Wow.

Dr. Li-Chuen Wong:
And we are seeing more and more, and recognizing that it is not just skin deep, and it is not just itchy skin, but profoundly can be so debilitating, not only for the child, for how they develop, but also for the whole family. And we are learning more and more about how important it is to treat all aspects of their psychological, psychosocial development.

Dr. Caroline West:
Oh, it can have a huge impact on how somebody feels about themselves. And of course, for a parent managing a small child, it can be very stressful, having a kid with severe eczema, in particular. But if we think about eczema, how do we actually work out whether it's eczema, or whether it's just a transient sort of skin irritation? How do we actually define it?

Dr. Li-Chuen Wong:
So usually eczema will present around three months of age. And what we see is the typical, we are all familiar with, the very red, itchy, scaly skin. Thankfully, if it's mild, it will just be in the flexural of the limbs, maybe on the face a little bit. But then the main feature is that it is itchy and that's going to differentiate it from a transient rash that maybe you might get, for instance, associated with a viral infection. So, if it's itchy, and also a clue is that there's a good family history of not only parents getting eczema, but as well an atopic background, as well having hay fever and asthma. Then that will point towards this being atopic dermatitis.

Dr. Caroline West:
And is it one of those things that in kids, because I know with kids asthma, for example, they can sometimes grow out of it, or it can change, in terms of its pattern.

Dr. Li-Chuen Wong:
Yeah.

Dr. Caroline West:
What's a story with eczema?

Dr. Li-Chuen Wong:
So the mantra that I say to all my patients and their families is that there is no cure and no one wants to hear that. Who wants to hear that, when they come to see you? But there is no cure because it is a genetic and chronic condition. But certainly, we can clear, we're aiming to control their eczema, and every year it does improve. So clinically, by the time they get to school, mostly kids are able to sit on the carpet, for instance, and not get too affected. But you never outgrow it, as such. So, the example that I give is, they do pretty well during school, and then at 18, they decide to go backpacking with their mates. And they go to the Himalayas, and they wear woollen scarves, woollen beanies. They're not eating well. They're not sleeping well. And they ring home, and they go, "I've just got this really itchy rash. What is it?" And you say, "Oh, well. You've got eczema. You've always had eczema." So, if the right triggers are there, then they will get a flare throughout their life.

Dr. Caroline West:
And just take me through the genetics, because that's really interesting, what we've sort of discovered about those links with eczema.

Dr. Li-Chuen Wong:
Well, all the time we're learning more about the polygenetics and the different endotypes that then will determine what the phenotypes are. But we've known for quite some time now, about the filaggrin mutation, which causes the skin barrier defect. And that's really important, because we know that a defective skin barrier is what is going to potentially, at times, lead to the development of allergies. But it's key to try and get that skin barrier back in intact, if we're going to have any chance of longevity in remission and looking after the skin. So, the filaggrin mutation. We also know that there is a dysregulation of the IL-4 and the IL-13 pathway. And recently, we've had game changing medications that now target the IL-4 and IL-13 pathway, and really, making the treatment of severe eczema so much more bearable.

Dr. Caroline West:
I mean, that's really interesting. Perhaps we can come back to that, because those are the biologics that you are talking about there, that some people have heard about. So, I'd like to come back to that, because I find that really interesting, with where things are heading. But if we go back to this sense of the treatment arc, if you like, because I guess that a lot of people, when they have eczema, will be trying stuff themselves, to start with, before they come in, particularly parents with eczema in children. It may be sometime before they even present. But what are some of the simple things that people can do that actually make a difference to eczema in its trajectory?

Dr. Li-Chuen Wong:
So I think, to start off with, the first conversation to have, is that it's important to know the triggers. And even if you are doing everything right for your child, if the weather changes from suddenly very hot to very cold, so sudden changes of weather will flare eczema, as will viral infections, regardless of whether it causes gastro or an upper respiratory tract infection. Viral infections will cause a flare, as well if you're run down. Systemically your immune system is challenged, and vaccinations will also always flare eczema. So, I have seen, following the COVID vaccinations, all my eczemas have gone off. And so those things we really can't prevent. But what we can is that it's important to avoid anything rough on our skin, because the basic defect is this defective, or very sensitive, skin barrier. So, removing all tags off clothes. Making sure that you are not wearing rough clothes, like woollen jumpers, woollen scarves. Avoiding lamb skin, sheep skin underlays. And then avoiding anything fragranced. So, there's a great myth that if it's organic and if it's natural, it's going to be good for the skin. But if it has a fragrance, it's going to irritate the skin. So, avoid calendula products, MooGoo goat's milk soap. Anything that has a fragrance, including Dettol, cleaning products, and fragranced softeners. And that really then just cuts down, very quickly, how irritated our skin can get. I always say to parents, to moisturize before you take your kid into the pool for swimming lessons, because that allows a barrier to be formed on the skin. And always rinse off at the pool, immediately, and moisturize. And try to avoid contact with grass, carpet and sand. But saying that, kids, they gravitate like magnets to sand pits, and so you can't stop that. That's developmental, but you know that that's going to trigger a mild flare.

Dr. Caroline West:
So it's interesting, isn't it? With the tags and I hadn't heard that one before, actually. That's a really good sort of tip, isn't it? To sort reduce any of those little niggly bits that might scratch or irritate the skin. But what about all the synthetics? I mean, I know you've mentioned a lot about wool, but a lot of kids, they're lucky to even have anything wool in the cupboard anymore. Their grandmas don't knit them scarves and jumpers anymore. They're all wearing these synthetics. I mean, are we getting the same sort of problem with these sorts of strange synthetic fibers or not?

Dr. Li-Chuen Wong:
I think that there's so much money that you have to spend when you have a child with eczema, or you have eczema, and so to then search for that... It's like the golden egg, to find a pure cotton top. So, I just say smooth, anything smooth is okay. And, in fact, to do wet dressings at home, which we can talk about later, the cheapest way to get it, is go to Target or Kmart and get leggings. So there is going to be some micro or some synthetic fibers in there, but it's smooth. And you can use that as a wet dressing. So, I don't mind smooth, cheap clothing.

Dr. Caroline West:
So the wet dressings, let’s move onto that, because you've sort of taken us there, but you're talking about using a cream, like a steroid cream, on the skin and that will often be the first thing that's prescribed for a child, apart from these other basic things that people can do for themselves. And this can be applied, I mean, I've seen all sorts of pitfalls here, though. I mean, one of the things I've seen is that, particularly if a child has eczema, that parents are very reluctant to use much of this cream on them, because they've either been told, "Use it really sparingly," by a well-meaning person, or a pharmacist has mentioned, "Look out for how much you use." Or they've seen something on TikTok that says, "Oh, my goodness. Your child will have steroid withdrawal syndrome." What sort of messages do we need to put out there, about the use of these creams?

Dr. Li-Chuen Wong:
So the key is to say that, well, I say, that steroids is actually natural. We make it ourselves. And we are only using topical steroids to the affected areas, and it is absolutely safe to use it, but I use it intensively. So, you hit it hard, you use it intensively, until there's absolute complete clearance, so that the skin barrier is back intact. And then you stop. If you use it intermittently, like this, there is just no evidence at all that you're going to run into any problems. And recently, there's been a whole new wave of steroid phobia, because of the new TikTok videos that you've spoken about, of the red man syndrome, or the hashtag, steroid withdrawal syndrome. And that is very, very rare and it's usually seen, well, when it's present, it's in females and adults, where they've used super potent topical steroids, generally on the face or in a genital region, daily, for over a year. And that's just not the way that we're going to treat eczema. So, we treat it really hard, three times a day and then stop. And it's effective and the families actually think, "Oh, my gosh. We are doing something that actually is going to work," and they can see the result. Because, otherwise, to use a steroid sub optimally, daily, and a weaker steroid, you're just never going to see any improvement. Everybody gives up.

Dr. Caroline West:
So would you have to get an authority script, because to be honest, the actual amount that's dispensed on a regular script is so minuscule that it's not going to cover much. If you've got a kid with eczema all over their legs, it's like one tube is going do one or two days. So, what should GPs, in particular, be thinking about here when they're initiating this sort of management?

Dr. Li-Chuen Wong:
So I would give an authority script and they're streamlined numbers that you can get easily. And I like using a strong, potent topical steroid for the body, such as Eleuphrat ointment. And ointment more than cream, because ointment will penetrate better and doesn't have preservatives like a cream. And give enough so that the message is that it's safe. You're happy to give a good quantity and it's also then cost-effective. And I then want to say that there will be people, like your next-door neighbour or Facebook, to say, "Are you sure you should be using it?" And I suppose that's where you rely on your therapeutic relationship, because if you can just say, "Trust me for six weeks. And then we'll chat. And then you can decide whether how things have gone." But just that initial leap of faith is so important to get going.

Dr. Caroline West:
Because I've seen kids where it's been very undertreated, because the parents have been so hesitant to get in there, aggressively, to get on top of it, because they're very worried about side effects. And then the child's just miserable. For starters, they don't sleep because their skin is just so irritated that they're up all night and then it's much harder to settle them. And its misery all around.

Dr. Li-Chuen Wong:
It is, and if you have a little child who isn't sleeping, then we're up for failure to thrive, which is just awful. And if the child doesn't sleep, everyone is miserable, as you say. The family's miserable. It's just a world of pain.

Dr. Caroline West:
And you mentioned earlier on, Li-Chuen, about the biologics and where we are moving to, in terms of the treatment for severe eczema. What's the story there? What's sort of come into the system and is used now?

Dr. Li-Chuen Wong:
Well, I tell you what. It's the happiest time ever to be a dermatologist, and paediatric dermatologist, because finally we actually can help. It's miraculous. It's a game changer. So dupilumab, or Dupixent, is an IL-4, IL-13 inhibitor.

Dr. Caroline West:
Can you explain what that is? Because we'll have some listeners who are consumers and they'll be going, "What earth does that mean?"

Dr. Li-Chuen Wong:
It's an antibody. It's a monoclonal antibody that targets IL-4, or interleukin 4 receptor. So basically, when we have eczema, we have this pathway that in general is okay, but there are a couple of points in that pathway, like a path going up to your front door and a couple of the stones are crooked and you're going to trip. And every time you trip you get a flare of eczema. So basically, the IL-4, this dupilumab, comes and it's like cement and it sticks on that crooked pathway, on that crooked bit, so you don't trip and you can get to your front door. And as a consequence, it is indefinite treatment, because as soon as you take the IL-4 away, which is given subcutaneously every fortnight, if you take it away, then of course, your pathway is going to be botched up again. So, it is ongoing treatment. And it is for moderate to severe atopic dermatitis, from 12 years upwards. And for severe atopic dermatitis, from 6 years upwards, 6 to 11 years. But that's not here in Australia yet. It's not PBS approved.

Dr. Caroline West:
But you think that it's on the way, possibly?

Dr. Li-Chuen Wong:
Absolutely. And it's FDA approved already, for 6 months to 5 years. And it's just wonderful, because for those really severe atopic kids, atopic dermatitis kids, if we can stop their skin barrier from ever becoming terribly bad, then they will not have that trajectory of severity. So, we can just stop the process, right at the get-go.

Dr. Caroline West:
And when you say subcutaneous, you're talking about here, for those listeners, you're talking about a subcutaneous injection. So that's a tiny weeny needle. That's administered at home, by a parent, once every two weeks, for these children. And this is the medication that is not here yet, but it is on its way?

Dr. Li-Chuen Wong:
And it's a pen. And it's like a diabetic, little, tiny needle. And, in terms of side effects, the most common side effect about 20% to 30% might experience conjunctivitis. And that passes. It's usually seen, the more severe your eczema, the more likely you might experience this temporary conjunctivitis. And the more periorbital involvement as well, you are more likely to get itchy eyes. And just with regular use of eyedrops, a bit of topical steroid eyedrops, that passes. And it's very well controlled.

Dr. Caroline West:
And is that the only biologic that is going to be available, or is available? Is this leading to an explosion in this area and everybody's coming on board and trying to develop these tools for eczema?

Dr. Li-Chuen Wong:
There are a number of other mAbs, or these monoclonal antibodies, that, by the way, have all these incredible names that no one can pronounce. So, they're all overseas at the moment. They haven't yet hit Australia. But we do have a tablet, that is what we call a small molecule, and it is a JAK1 inhibitor. It's called upadacitinib. And it comes in 15 milligrams and 30 milligram tablets. It's as well for moderate to severe atopic dermatitis. So, the JAK1 STAT pathway is another pathway that we know is wonky, in the development of atopic dermatitis. So, this is yet another inhibitor in the JAK1 pathway, that, again, helps with severe eczema. And for adolescents, from 12 to 17 years of age, it's one tablet a day, 15 milligrams a day. And for adults it's one to two tablets a day.

Dr. Caroline West:
I mean, as you say, this is a really exciting shift, isn't it? In terms of our management of eczema, because for years we've just relied on the same old, same old. And suddenly, we've got these new approaches on the horizon, which as you say, are going to be game changers and will make all the difference to those kids that have it really severely. Because you and I both know and anybody who lives with someone, or has had it themselves severely just knows, as we've talked about, how miserable it can make you and how it can be so disruptive to the rest of your life, your quality of life. And so that's fantastic to hear. And I know that you're a specialist, not just in children, but also adult dermatology. But, of course, I suppose in the smaller children, eczema is the most common thing. But as kids move into those adolescent years, a lot of kids who have never had eczema or any other conditions, will develop acne. And I was keen to ask you about that as well, because I think that's another skin condition that people are very interested in knowing what's going on, in terms of approaches. And GPs, too, are very keen to be upskilled. So just give us a quick overview of acne. What do we know about it and what causes it?

Dr. Li-Chuen Wong:
So we know that it's pretty much inevitable, going to get some sort of acne during puberty. The milder forms are just predominantly what we call comedonal acne, which is blackheads and whiteheads, non-scarring. And for that sort of acne, the use of topical treatments, keratolytics, we call them, such as adapalene, or Differin, or the retinoic acids, are really fantastic. And you use that every single day, to the whole area, because the thinking is that it's not spot treatment. It's trying to prevent under the surface blackheads and whiteheads from also developing. So, you want to just do field treatment. And then you get moderate acne, which usually they're papules and pustules. Hopefully, without associated scarring. And for that sort of acne, you would consider going up the therapeutic ladder, topical agent, as well as oral medication. That would be either in the form of an inflammatory antibiotic, Minomycin or doxycycline, one of the tetracyclines. Or spironolactone, which is more hormonally based. Or the oral contraceptive pill, with the lower dose estrogen pills, such as Yaz or Yasmin, being particularly good for acne.

Dr. Caroline West:
And so with the antibiotics that you've mentioned, the Minomycin, for example, or doxy. So if you're going to use that as an anti-inflammatory, and you use it twice a day, is that right? And then how long would you actually use it for? A, how would long would it take to get a response? And then B, if you did get a response, how long do you leave somebody on it?

Dr. Li-Chuen Wong:
So firstly with these oral anti-inflammatory antibiotics, the main thing is to tell the family and the patient, that it is not going to be a quick fix. You're not going to take it, and then the formal is in three days and you're going to have beautiful clear skin. So, it does take six weeks, before it starts to turn the corner. And you're looking at about two to three months before you think, "Ah, yes. This is actually working." And it has to be regular. You've got to take it regularly, every day for a good response. But in the past, we used to keep patients on anti-inflammatory antibiotics for 18 months, two years. And we now know that we don't need to do that. And in fact, that's really important, because of this growing concern about antibiotic resistance. So, if you see that they're starting to respond after two to three months, I would keep them on for another three to four months, and then if things are good, start to wean off and just then keep on with the topical agents. So, you're looking at about six to nine months.

Dr. Caroline West:
Okay. So, you talked about antibiotic resistance, which I guess everybody understands that concept, as the longer you're on it, the more that's likely. But what about the gut microbiome? So, if you're on a low dose antibiotic, surely that mucks up your gut microbiome, and then leaves you vulnerable to perhaps an unintended consequence of something else happening? Is that the case or not?

Dr. Li-Chuen Wong:
Well I tell my patients that are taking the Minomycin, to then try and take a probiotic at the other end, to counteract that. But I'm not seeing, thankfully, much in the way of side effects with gut issues.

Dr. Caroline West:
Okay, that's good. What about Roaccutane? So obviously, that's going to go in with the big guns, if somebody has severe or moderate to severe acne. What's the story with Roaccutane?

Dr. Li-Chuen Wong:
So Roaccutane, it's just wonderful. And it is usually used for the most awful, scarring, noduli tic, those painful, awful lesions, that it's just terrible. And it is a vitamin A-derived medication. What it does is it decreases the activity and the number of all your oil glands. So, it works beautifully, and it also helps with collagen remodelling, elastin remodelling. So, it helps as well with associated scarring, which is really important. The main side effect then is, of course, the associated dryness. But we are moving now from treating full on, a full-on war, with huge doses and your lips are falling off, your skin is so dry. We're moving now, to instead treat with lower doses of Roaccutane, because we know that it works just as well and just as fast. But the side effect profile is far less. Like you will only experience the mildest of dry lips and, or skin dryness.

Dr. Caroline West:
Because the original dose was what, 40 milligrams or something?

Dr. Li-Chuen Wong:
40 to 60 milligrams.

Dr. Caroline West:
And I've seen patients get really great responses that have been under dermatologists being on 10.

Dr. Li-Chuen Wong:
Yes.

Dr. Caroline West:
Or 10, not even every day, and still getting good response. So, it's fascinating to see how we're sort of lowering the line. That comment in the medicinal world, that we suddenly suggest, "Okay, take less and less and less." But for Roaccutane, it seems as though we're getting clues that perhaps a tiny bit nudges the system, enough to get results.

Dr. Li-Chuen Wong:
And the way I like to do it, is I like to treat at low dose, but for double the time. And the benefit for that is yes, we have more time for the body to regenerate, with the collagen remodelling, but it also then controls the predisposition to get a flare, during the time when these kids are most likely doing important things like the HSC. That's when, really, acne is at its worst. And you just don't need to think about acne, when you've got other stuff going on. And I suppose the other thing to talk about Roaccutane, is we now know that there is really no causal link and no concern about taking Roaccutane and the development of mood change and depression, which was quite a worry in the past. But there's really good, solid evidence to suggest that, in fact, that there is no link. But the converse that if you've got awful acne you are going to feel depressed and anxious and overwhelmed, socially.

Dr. Caroline West:
Well, that's reassuring because I guess a lot of people got spooked about using it, because they thought perhaps that increases suicidal thoughts or behaviours. And that's just something that nobody wants to go there with that. But as you say, the psychological ramifications of having severe acne, it can be quite profound. The other thing I wanted to ask you about was just the lifestyle interventions that are involved with skin, because a lot of people would like to really do something themselves, in terms of nutrition. And there's an enormous amount of interest in nutrition and skin. And I know that, in the old days, there used to be this, what we thought was a myth, chocolate gives you acne. And we sort of tried to dispel that myth, and then perhaps we are having to go back on our tracks and of go, actually there is evidence that there are some links between nutrition and skin. Talk me through that.

Dr. Li-Chuen Wong:
Yeah, that's right. It's come full circle. So now we know that that acne is triggered, and you will get a flare if your insulin levels are high. And that happens when you eat a lot of glucose, and therefore, sugary drinks. Fizzy drinks. Lollies. A whole Favourites box of chocolates will definitely set you off. Easter is the worst time for acne. And so, if you can eat a low GI diet in contrast and avoid anything white, I say. So, no white bread, white pasta, that will definitely help. And a low GI diet will then give you a constant and steady low stream of insulin release. I also tell patients to exercise regularly, because that increases metabolic rate and is also good for mood and for wellbeing, but great for acne. And to avoid whey-based products. So, milk, basically. So there are studies to show that, if you drink half a carton of milk, that's going to really flare your acne. And if you are trying to bulk up, like so many teenage boys are, then bulk up with other protein powders other than whey-based protein powders. So, pea protein powder is good. Bone broth. Or brown rice powder. They're all good.

Dr. Caroline West:
That's all really great advice. And what about some of the other things? People say to their kids and their patients, "Don't ever pick pimples."

Dr. Li-Chuen Wong:
They're so right.

Dr. Caroline West:
They're so right. Don't pick them. Don't pick those pimples. And what about the sun? Because I guess every teenager that gets an outbreak goes, "I'll just go on sunbake now, because it will somehow clear my skin."

Dr. Li-Chuen Wong:
No, everybody needs an AVO taken out against their skin. They can't pick and they can't let their mother pick for them as well, because it leads to post-inflammatory hyperpigmentation or inflammation. And especially if you have Asian or Mediterranean skin, that's what you're going to be left with, to remind you of your pimple. And then, if you go out in the sun, double trouble, because you will then get more post inflammatory hyperpigmentation. So, sit on your hands and use the topical Differin, or retinoid, or keratolytic, to that spot, to try it and decrease the inflammation quickly.

Dr. Caroline West:
Mm-hmm. And what amount if people get scarring? Have we come up with things that can actually make a difference? Because a lot of people have unfortunately got quite profound acne scarring on their face, which they're very self-conscious about. What can be done when there is scarring on the face like that?

Dr. Li-Chuen Wong:
So there is. And that's the other thing. We treat aggressively. We treat with Roaccutane. And then once the acne is over, there are physical treatments that can be so helpful, such as resurfacing lasers, like Fraxel resurfacing laser. There is medium depth chemical peels can also be helpful. And subcision. So actually, breaking up the fibers of scarring, underneath the skin surface, can be helpful as well. So, there's a lot that we can do now.

Dr. Caroline West:
But none of those are on Medicare, are they? So, if you've got somebody who's from a sort of background where access and cost is tricky, I mean, Fraxel is going to cost-

Dr. Li-Chuen Wong:
A lot.

Dr. Caroline West:
I don't know, 1200, 1500 a go. And you might need multiple treatments. Is there anything that's sort of available for people that don't necessarily have the funds to explore those options?

Dr. Li-Chuen Wong:
Yep. So, you would definitely treat aggressively, as we said, and then you could even try just cosmeceuticals. So, there's good evidence to say that if you use vitamin A topically, after you've stopped the Roaccutane, and as well nicotinamide, or hyaluronic acid, that can be very helpful if you use it on a regular basis. And, of course, use of sunscreen, SPF 50 sunscreen will as well help with reducing the pigmentation of acne scarring.

Dr. Caroline West:
Oh, that's good to be reminded of those things. And one last thing I wanted to pick your brains on, while I have you here, because it's great to learn all of this about the skin, and certainly get an update. But there was one other thing I wanted to explore, which was this whole area of skin and whether we are, in fact, using too many antibiotics with skin conditions. Because what I observe is that a lot of people are quite liberal with dispensing antibiotic scripts for oral antibiotics, particularly if somebody's had a little skin excision, or they've got a red spot on around their fingernail, or something like that, they go take these antibiotics just in case. Do we need to rethink our relationship with antibiotics in the skin a little?

Dr. Li-Chuen Wong:
I think we do, because we're just seeing an increase in antibiotic resistance, which is a little worrying, because there is also, we now know that if you have antibiotic-resistant cells that they can then be spread through into the environment and into other people. So, it does spread. We've got to be really careful about how we prescribe our antibiotics. And we do use a lot of it, in dermatology, for acne. As you say, for perioperative skin infection control, but also hidradenitis suppurativa. Rosacea as well. But there are alternatives. So, I think we've just got to get our mindset different, to think of other alternatives. For instance, so when we treat acne, you would only use a topical antibiotic, if it was used in conjunction with a keratolytic, and, or benzoyl peroxide, because there is no resistance that can ever develop with the benzoyl peroxide, and it helps prevent or lower the risk of topical antibiotic resistance.

Dr. Caroline West:
Can I just tease it out a little bit? So, if somebody was going to use that combination, which is a prescription topical antibiotic? And then they'd use it with over the counter benzoyl peroxide, is that what you're saying? And do you mix them together or does one go on first?

Dr. Li-Chuen Wong:
Yes, you can do that. You can just buy Benzac Wash separately, or benzoyl cream, which is Benzac cream, which comes in a 2.5%, 5%, and 10%. Or you can get topical creams that have a mixture of, for instance, clindamycin topically with benzoyl peroxide, and that's called Duac. So, you can get an all in one, and you would therefore choose that, in contrast, to just getting ClindaTech lotion.

Dr. Caroline West:
And the Duac is prescription only, for people listening. So talk to their GP about the Duac, or the combo of that treatment. Okay, well that's good. So yes, we need to redefine our relationship, as you say, because antibiotic resistance globally, is a real problem. And I guess that every little bit makes a difference, in terms of reducing our chances of developing resistance, and overusing things and having unintended consequences as a result. That's really important. So, thanks for that update on those very interesting areas, eczema and acne and also our antibiotic use and skin. I've certainly learned a lot today and I'm sure our listeners have, too, those health professionals listening. And also, consumers, who are naturally very interested in their skin, or the skin of somebody else they know. That's all we have time for, but thank you very much to dermatologist, Dr. Li-Chuen Wong. Thank you, Li-Chuen, for being with us.

Dr. Li-Chuen Wong:
Thanks, Caroline. Thank you very much.

Dr. Caroline West:
And if you'd like any more information on anything you've heard in this podcast, please go to our website, at nps.org.au. And also, if you'd like information on CPD Points associated with this activity. I'm Dr. Caroline West. Bye for now. See you next time.