Modern Functional Medicine and Eczema (dermatitis): A better approach to tackle an old disease

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:

Probiotics

The use of synbiotics (a mixture of prebiotics and probiotics) is associated with reduction of eczema severity (Chang 2016)

Vitamins

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)

Omega 3

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)

Minerals

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):

- - - Obesity
    - 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.

Learn more about the microbiota in our skin and other parts of the body in our research and innovation journal article and our freely available e-book.

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.

We will also test and treat any deficiencies associated with stress, the HPA axis, heavy metal toxicity and other pathologies present in the body.

And you will be on the right path to leave eczema behind and improve all aspects of your health.

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