The comprehensive approach of modern functional medicine for atopic eczema (dermatitis) and other forms of dermatitis offers unparalleled health benefits.
Skin diseases are a common problem affecting millions of people worldwide. Among skin disorders, atopic eczema, also known as atopic dermatitis, affects more than one million Australians, mostly children, adolescents, and young adults. Atopic eczema (dermatitis) is a dry, itchy, inflammatory skin disorder that affects as many as 20% of all children and 3% of adults worldwide (Nutten 2015).
Studies have shown this condition has doubled or even tripled in some industrialised countries over the past decades (Kowalska-Olędzka 2019, Nutten 2015).
In Australia, research on eczema prevalence (how common is a disease) has shown that among 4-year-old children, there was a prevalence of about 16% in 2017 (Peters 2017). Among 1-year-old children, there was a prevalence of about 20.3% in 2013 (Martin 2013).
What is atopic eczema?
Atopic eczema (dermatitis) is a type of inflammatory condition of the skin, characterised by the development of rashes on the skin of arms and other parts of the body. Other common symptoms include:
- dry skin
- Itching (which may be more severe at night)
- Red patches on the hands, feet, ankles, wrists, neck, upper chest, eyelids, inside the bend of the elbows and knees, and in the face and scalp of infants
- Small, raised bumps, which may leak fluid and form a crust when scratched
- Thickened, cracked, scaly skin
The pathogenesis of atopic eczema (dermatitis) is influenced by multiple factors, including genetics, immunology, environmental factors, and infections that cause dysfunctions of the skin barrier and inflammation. Having a family history of atopic eczema (dermatitis), for example, increases your chances of developing this condition (Alford 2004, reviewed in Ravn 2020).
Recently, studies have identified a gene called FLG, strongly associated with atopic eczema (dermatitis). The FLG gene encodes a protein called filaggrin, which is involved in skin barrier integrity. Skin barrier integrity is an important component of your immune system, as it prevents pathogens and toxins from entering the body. Studies have shown that 50% of people with atopic eczema (dermatitis) harbour mutation in their FLG gene, impairing its function. This finding strongly suggests a role for the FLG gene and skin barrier integrity in the development of atopic dermatitis (Palmer 2006). However, while it is well established that atopic eczema (dermatitis) has a strong genetic component, not all the specific genes involved have been identified yet.
From an immunological perspective, atopic dermatitis and atopic eczema belong to a special syndrome known as atopy. Other forms of atopy include extrinsic allergic asthma, rhinitis allergica, conjunctivitis allergica and some food allergies. People with atopic dermatitis have an altered immune system, characterised by an overproduction of Immunoglobulin E (IgE). IgE is a special type of immune cell commonly released by our immune system to lead an immune reaction in response to specific particles or allergens (any substance that causes allergic reactions). People with atopic eczema (dermatitis) suffer from alterations to their regulatory T-cells and their innate immune system. As a consequence of this alteration, there is a decrease in the levels of antimicrobial peptides, a key component of a normal skin innate immune system. This may explain why people with atopic eczema (dermatitis) are more prone to develop infections (Nutten 2015, Fiset 2006).
The development of atopic eczema (dermatitis) occurs through genetic predisposition, altered skin barrier function and immunological dysfunctions. However, there is one more factor that acts as an important trigger: the environment.
Environmental drivers of eczema
The environment where you live is an important driver of atopic eczema (dermatitis), an observation backed by the significant variations in the prevalence of this disease between countries. For example, climate, urban versus rural setting, diet, breastfeeding, and time of weaning, obesity and physical exercise, tobacco smoke, and pollution have been proposed as potential risk factors (Nutten 2015).
Diet is a major factor that affects multiple biological pathways that, ultimately, affect your health, even before you are born. Earlier this year, a study evaluated the dietary costumes of 2,160 mothers during their pregnancies and found a significant association between the type of diet mothers followed and the chance their infant would develop eczema. One key finding was that infants from mothers who followed a plant-based diet, regardless of their ethnicity, were less likely to develop eczema (Zulyniak 2020).
A recent review on the use of dietary interventions and supplements for the treatment of eczema found evidence for various dietary interventions, including:
The use of synbiotics (a mixture of prebiotics and probiotics) is associated with reduction of eczema severity (Chang 2016)
Multiple vitamins are associated with skin and immune health, including vitamins A, C, D, E, niacin and K2. For example, various studies in adults and children report lower levels of vitamin D in patients with eczema, as well as improvement in acne-associated symptoms (Kim 2016a, Kim 2016b). Vitamin D is also an important factor, alongside other micronutrients like Vitamin A, for optimal immune and intestinal barrier function (Cantorna 2019). Vitamin C is an antioxidant and a key component for the production and regulation of collagen. Collagen helps with the maintenance skin extracellular stability, strength and elasticity (Cosgrove 2007). Vitamin E is normally produced in the skin surface and help protect against free radicals. This vitamin also involved with immune function, cell signaling, and gene expression (Nachbar 1995, Azzi 2004)
This fatty acid helps maintain skin health through a decrease of skin inflammation, as well as reduction of redness, itching, and scaling of the skin (Pilkington 2010, Nigam 2018)
Zinc, Selenium, Silica, and Sulphur are some of the important micronutrients that sustain skin health. Zinc, for example, is one of the most common components of the skin and deficiencies of this mineral are associated with multiple skin conditions (Ogawa 2018). Zinc is also involved with the skin’s immune function, protein synthesis, wound healing, DNA synthesis, and cell division, it protects against ultraviolet radiation and has anti-inflammatory effects (Ogawa 2018, Shankar 1998, MacDonalds 2000, Wu 1987). Sulfur is an important building block for collagen and glutathione synthesis (Lu 2013)
Other important micronutrients involved with skin health include biotin, essential for fatty acid metabolism, pantothenic acid, which aids in wound healing and health of keratinocytes (the most common type of skin cell) (Park 2015).
Another environmental factor proposed in atopic eczema (dermatitis) is microbial exposure. Studies have found support to the idea that the decrease in early childhood exposure to microbial infections has led to an increase in the susceptibility to allergic conditions (Flohr 2011).
These environmental factors may help explain why an important observation in the epidemiology of atopic eczema (dermatitis): the steady increase in the prevalence of this and other allergic conditions over the past decades. Studies suggest that this increase in allergic conditions may be a consequence of migration to highly industrialised countries, where migrants are exposed to pollutants and new allergens, changed their diet and housing conditions (Mingomataj 2007, Tricon 2006, McGirt 2006, Ong 2002). Some environmental factors that studies have supported as potential triggers of atopic dermatitis include (as reported in Rutkowski 2014):
- Indoor allergens, such as mites, animal dander (dogs, cats, mice), cockroaches, fungi, moulds, yeasts
- Outdoor allergens, such as pollens or fungal spores
- Outdoor/indoor air pollutant, such as carbon monoxide, carbon dioxide, nitrogen dioxide, sulphur dioxide, polycyclic aromatic hydrocarbons, ozone, and particulate matter (PM)
- Infectious agents
- tobacco smoke, including passive smoking, maternal prenatal smoking, postnatal environmental tobacco smoke exposure and active smoking
- occupational sensitizers, such as flour, soybean dust, wood dust, grain dust, formaldehyde, nickel, platinum, vanadium salts
- Certain foods, like peanuts, tree nuts, wheat, soy, egg
- Diet, unhealthy diets can lead to obesity and other problems that can pave the way for allergic conditions
- ticks, and other insects
Another important factor linked to atopic eczema, identified in recent years, is the skin microbiota.
Focus on: Human Microbiota and Eczema
Our skin is home to millions of microorganisms, including bacteria, fungi and viruses, which together constitute the skin microbiota. A healthy skin microbiota is characterised by an optimal balance in the species composition and density of the different microorganisms. Alterations to this balance cause skin dysbiosis, where certain species overgrow, reducing the diversity of species in the skin leading to health problems (Byrd 2018).
For example, one study reported a different composition of skin bacteria in patients with atopic eczema (dermatitis), including an overrepresentation of the bacterium Staphylococcus aureus in severe stages of the disease. In contrast, Staphylococcus epidermidis has been shown to be the dominant skin microbe during the early stages of atopic eczema (Byrd 2017). Another study identified that skin prone to develop eczema had elevated levels of bacteria from the genus Streptococcus and Gemella, and reduced levels of Dermacoccus bacteria, compared to healthy skin (Chang 2016).
Further understanding of eczema and skin microbiota dynamics may help identify new treatment options that consider the integrity of the skin, skin microbiota, and associated pathways.
Beyond the skin microbiota, the Australian Centre for Functional Medicine also recognises the important role played by the gut microbiota, which can influence systemic inflammation, oxidative stress, glycemic control, and tissue lipid content. Alterations to the optimal function of the gut microbiota can lead to increased intestinal permeability, which can lead to inflammatory alterations and promote conditions like atopic eczema.
Atopic eczema at the Australian Centre for Functional Medicine
Standard medical treatment for atopic dermatitis (eczema) involves topical steroidal creams, corticosteroids, immunomodulators, or antihistamines, all of which require continued use with variable outcomes. More importantly, these medical treatments do not address the complex underlying causes behind atopic dermatitis.
In contrast to conventional medicine, the Australian Centre for Functional Medicine takes a comprehensive and multidisciplinary approach.
What to expect
For patients at the Australian Centre for Functional Medicine who suffer from atopic eczema, the first step is to test for immune reactivity to different allergens. This will help us establish a baseline in terms of a patient’s immune function. Among the tests we perform, we consider:
- Wheat/gluten proteome reactivity and autoimmunity
- Gluten-associated cross-reactive foods and food sensitivity
- Multiple food immune reactivity screen
Testing for these allergens is done through an advanced array testing platform, unique in Australia and only available at the Australian Centre for Functional Medicine.
These tests will provide evidence of any immune reactivity against common allergens and guide us on your treatment’s next steps. Depending on the results of this and other tests and on the specific traits of the patient, we may propose a radical change in diet. For example, we have seen amazing results in patients with atopic eczema within 30 – 60 days of a specially designed diet.
Our comprehensive testing will also assess the health of your gut microbiota, acknowledging the important connection between the gut microbiota, immune health, and optimal intestinal permeability function. Depending on the result of these gut-related tests, we may also suggest including specific foods in a patient’s diet that will benefit gut bacteria, including certain vegetables and probiotics. Our goal is to improve your dietary input of important micronutrients, like vitamins A, C, D, E, and K2, zinc, selenium, biotin, omega 3S, and several others. These micronutrients have important roles in a different biological process that affect skin health.
And you will be on the right path to leave eczema behind and improve all aspects of your health.
- Nutten S. Atopic dermatitis: global epidemiology and risk factors. Annals of nutrition and metabolism. 2015;66(Suppl. 1):8-16. Read it!
- Kowalska-Olędzka E, Czarnecka M, Baran A. Epidemiology of atopic dermatitis in Europe. Journal of drug assessment. 2019 Jan 1;8(1):126-8. Read it!
- Martin PE, Koplin JJ, Eckert JK, Lowe AJ, Ponsonby AL, Osborne NJ, Gurrin LC, Robinson MN, Hill DJ, Tang ML, Dharmage SC. The prevalence and socio‐demographic risk factors of clinical eczema in infancy: a population‐based observational study. Clinical & Experimental Allergy. 2013 Jun;43(6):642-51. Read it!
- Peters RL, Koplin JJ, Gurrin LC et al. The prevalence of food allergy and other allergic diseases in early childhood in a population‐based study: HealthNuts age 4‐year follow‐up. J. Allergy Clin. Immunol. 2017; 140: 145–53.e8. Read it!
- Zulyniak MA, de Souza RJ, Shaikh M, Ramasundarahettige C, Tam K, William N, Desai D, Lefebvre DL, Gupta M, Subbarao P, Becker AB. Ethnic differences in maternal diet in pregnancy and infant eczema. PLoS One. 2020 May 14;15(5):e0232170. Read it!
- Solman L, Lloyd‐Lavery A, Grindlay DJ, Rogers NK, Thomas KS, Harman KE. What’s new in atopic eczema? An analysis of systematic reviews published in 2016. Part 1: treatment and prevention. Clinical and experimental dermatology. 2019 Jun;44(4):363-9. Read it!
- Chang YS, Trivedi MK, Jha A, Lin YF, Dimaano L, Garcia-Romero MT. Synbiotics for prevention and treatment of atopic dermatitis: a meta-analysis of randomized clinical trials. JAMA pediatrics. 2016 Mar 1;170(3):236-42. Read it!
- Kim MJ, Kim SN, Lee YW, Choe YB, Ahn KJ. Vitamin D status and efficacy of vitamin D supplementation in atopic dermatitis: a systematic review and meta-analysis. Nutrients. 2016a Dec;8(12):789. Read it!
- Kim G, Bae JH. Vitamin D and atopic dermatitis: A systematic review and meta-analysis. Nutrition. 2016b Sep 1;32(9):913-20. Read it!
- Cantorna MT, Snyder L, Arora J. Vitamin A and vitamin D regulate the microbial complexity, barrier function, and the mucosal immune responses to ensure intestinal homeostasis. Critical reviews in biochemistry and molecular biology. 2019 Mar 4;54(2):184-92. Read it!
- Cosgrove MC, Franco OH, Granger SP, Murray PG, Mayes AE. Dietary nutrient intakes and skin-aging appearance among middle-aged American women. The American journal of clinical nutrition. 2007 Oct 1;86(4):1225-31. Read it!
- Nachbar F, Korting HC. The role of vitamin E in normal and damaged skin. Journal of Molecular Medicine. 1995 Jan 1;73(1):7-17. Read it!
- Azzi A, Gysin R, Kempná P, Munteanu A, Negis Y, Villacorta L, Visarius T, Zingg JM. Vitamin E mediates cell signaling and regulation of gene expression. Annals of the New York Academy of Sciences. 2004 Dec;1031(1):86-95. Read it!
- Peterkofsky B. Ascorbate requirement for hydroxylation and secretion of procollagen: relationship to inhibition of collagen synthesis in scurvy. The American journal of clinical nutrition. 1991 Dec 1;54(6):1135S-40S. Read it!
- Pilkington SM, Rhodes LE. Omega-3 fatty acids and skin. InNutrition for Healthy Skin 2010 (pp. 91-107). Springer, Berlin, Heidelberg. Read it!
- Nigam D, Yadav R, Tiwari U. Omega-3 Fatty Acids and Its Role in Human Health. In Functional Food and Human Health 2018 (pp. 173-198). Springer, Singapore. Read it!
- Ogawa Y, Kinoshita M, Shimada S, Kawamura T. Zinc and skin disorders. Nutrients. 2018 Feb;10(2):199. Read it!
- Shankar AH, Prasad AS. Zinc and immune function: the biological basis of altered resistance to infection. The American journal of clinical nutrition. 1998 Aug 1;68(2):447S-63S. Read it!
- MacDonald RS. The role of zinc in growth and cell proliferation. The Journal of nutrition. 2000 May 1;130(5):1500S-8S. Read it!
- Wu FY, Wu CW. Zinc in DNA replication and transcription. Annual review of nutrition. 1987 Jul;7(1):251-72. Read it!
- Lu SC. Glutathione synthesis. Biochimica et Biophysica Acta (BBA)-General Subjects. 2013 May 1;1830(5):3143-53. Read it!
- Flohr C, Yeo L. Atopic dermatitis and the hygiene hypothesis revisited. In Pathogenesis and Management of Atopic Dermatitis 2011 (Vol. 41, pp. 1-34). Karger Publishers. Read it!
- Park K. Role of micronutrients in skin health and function. Biomolecules & therapeutics. 2015 May;23(3):207. Read it!
- Alford SH, Zoratti E, Peterson EL, Maliarik M, Ownby DR, Johnson CC. Parental history of atopic disease: disease pattern and risk of pediatric atopy in offspring. Journal of allergy and clinical immunology. 2004 Nov 1;114(5):1046-50. Read it!
- Ravn NH, Halling AS, Berkowitz AG, Rinnov MR, Silverberg JI, Egeberg A, Thyssen JP. How does parental history of atopic disease predict the risk of atopic dermatitis in a child? A systematic review and meta-analysis. Journal of Allergy and Clinical Immunology. 2020 Apr 1;145(4):1182-93. Read it!
- Mingomataj E. Changing World As Principal Reason For Atopy Rising Trend. The Internet Journal of Asthma, Allergy and Immunology. 2007;5(2). Read it!
- Tricon S, Willers S, Smit HA, Burney PG, Devereux G, Frew AJ, Halken S, Høst A, Nelson M, Shaheen S, Warner JO. Nutrition and allergic disease. Clinical & experimental allergy reviews. 2006 Sep;6(5):117-88. Read it!
- Fiset PO, Leung DY, Hamid Q. Immunopathology of atopic dermatitis. Journal of allergy and clinical immunology. 2006 Jul 1;118(1):287. Read it!
- McGirt LY, Beck LA. Innate immune defects in atopic dermatitis. Journal of allergy and clinical immunology. 2006 Jul 1;118(1):202-8. Read it!
- Ong PY, Ohtake T, Brandt C, Strickland I, Boguniewicz M, Ganz T, Gallo RL, Leung DY. Endogenous antimicrobial peptides and skin infections in atopic dermatitis. New England Journal of Medicine. 2002 Oct 10;347(15):1151-60. Read it!
- Rutkowski K, Sowa P, Rutkowska-Talipska J, Sulkowski S, Rutkowski R. Allergic diseases: the price of civilisational progress. Advances in Dermatology and Allergology/Postȩpy Dermatologii i Alergologii. 2014 May;31(2):77. Read it!
- Palmer CN, Irvine AD, Terron-Kwiatkowski A, Zhao Y, Liao H, Lee SP, Goudie DR, Sandilands A, Campbell LE, Smith FJ, O’Regan GM. Common loss-of-function variants of the epidermal barrier protein filaggrin are a major predisposing factor for atopic dermatitis. Nature genetics. 2006 Apr;38(4):441-6. Read it!
- Byrd AL, Belkaid Y, Segre JA. The human skin microbiome. Nature Reviews Microbiology. 2018 Mar;16(3):143. Read it!
- Byrd AL, Deming C, Cassidy SK, Harrison OJ, Ng WI, Conlan S, Belkaid Y, Segre JA, Kong HH, NISC Comparative Sequencing Program. Staphylococcus aureus and Staphylococcus epidermidis strain diversity underlying pediatric atopic dermatitis. Science translational medicine. 2017 Jul 5;9(397):eaal4651. Read it!
- Chng KR, Tay AS, Li C, Ng AH, Wang J, Suri BK, Matta SA, McGovern N, Janela B, Wong XF, Sio YY. Whole metagenome profiling reveals skin microbiome-dependent susceptibility to atopic dermatitis flare. Nature microbiology. 2016 Sep;1(9):16106. Read it!