Eczema, a chronic skin condition affecting over 30 million Americans, continues to present a challenge for patients and healthcare providers. The prevalence of eczema has surged over the years, with a staggering 15-30% of children and 2-10% of adults affected globally.
Symptom-based treatments often only provide temporary relief, leaving individuals wanting longer-lasting solutions. By addressing the factors that may contribute to a patient's symptoms, a holistic approach to eczema offers hope for longer-lasting symptom management and improved quality of life.
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What Is Eczema?
Eczema refers to a group of inflammatory skin conditions characterized by red, itchy, and inflamed patches on the skin. It is a non-contagious condition that often begins in childhood but can persist into adulthood. (16)
There are seven types of eczema:
- Atopic dermatitis
- Contact dermatitis
- Dyshidrotic eczema
- Neurodermatitis
- Nummular eczema
- Seborrheic dermatitis
- Stasis dermatitis
Of these subtypes, atopic dermatitis is the most common. Each type of eczema has its own set of triggers and management requirements, but one individual can have multiple types of eczema simultaneously. (16)
Eczema Signs & Symptoms
Eczema can vary in severity, from mild dryness and occasional itching to intense itching, pain, and thickened skin. The affected areas of skin will appear flaky and bumpy, often with excoriations (scratches). Rashes can be red, pink, purple, brown, or gray, depending on skin tone. (16)
Eczematous rashes can occur anywhere on the body, but the rash distribution often varies depending on the patient's age. (13, 36)
- Infants tend to have involvement of their face, especially the cheeks, forehead, and around the mouth.
- As the child ages, the rash tends to become more localized to the extensor surfaces of the wrists, elbows, ankles, and knees.
- Adults are often affected with rashes located on the flexural surfaces of the elbows and knees.
Besides the classic rash, other physical exam findings are often noted in patients with eczema, including:
- Crease-like wrinkles just below the lower eyelid (Dennie-Morgan lines)
- A transverse crease across the bridge of the nose ("allergic salute")
- Hypopigmented patches or fine-scaling plaques on the face (36)
Root Causes of Eczema
Eczema results from a combination of genetic and environmental factors that may stimulate the immune system and disrupt the skin barrier.
Genetics
Research shows that eczema has a genetic component, supported by the fact that it is more common in individuals with a family history of eczema, dermatitis, asthma, and allergies (16).
More than 50% of patients with eczema have a genetic mutation in the filaggrin (FLG) gene, which is responsible for forming the outermost protective layer of skin. Defects in the FLG gene may result in a less effective skin barrier, affecting the ability to retain water, modulate the skin barrier's pH, and manage exposure to infectious pathogens.
Infection
People with eczema may have reduced numbers of β-defensins in the skin, which help protect the skin against infectious agents. A decrease in these proteins can lead to increased colonization and infection with opportunistic pathogens, especially Staphylococcus aureus and Candida albicans.
Gut-Skin Axis
Recent research has highlighted the gut microbiome's significant influence on skin health, bringing rise to the notion of the gut-skin connection. The gut microbiome plays a crucial role in modulating the immune system, regulating inflammation, and maintaining the integrity of the intestinal barrier. When imbalances occur in the gut microbiome, commonly known as dysbiosis, it can lead to increased intestinal permeability, referred to as "leaky gut." This compromised barrier function may allow toxins, pathogens, and undigested food particles to enter the bloodstream, potentially triggering an immune response and systemic inflammation. This inflammation can manifest on the skin as various dermatological conditions, including eczema. (55)
Allergies
Allergies play a significant role in the development and exacerbation of eczema. Individuals with eczema tend to be predisposed to allergic conditions such as asthma, hay fever, and food allergies (collectively called the "allergic triad"). The immune system in people with eczema may react abnormally to certain substances, known as allergens, potentially triggering an inflammatory response in the skin. When exposed to these allergens, the immune system releases histamines and other inflammatory mediators, leading to itching, redness, swelling, and the characteristic rash associated with eczema.
Common allergens that can exacerbate eczema symptoms include:
- Dust mites
- Pet dander
- Pollen
- Mold
- Foods: dairy, eggs, wheat, soy, peanuts
- Chemical irritants, like harsh soaps or detergents
How to Diagnose Eczema
The following section will be specific to diagnosing atopic dermatitis, the most common form of eczema. Atopic dermatitis can be diagnosed and managed in a primary care setting. The American Academy of Dermatology (AAD) has published validated guidelines to streamline the diagnostic process.
Step 1: Clinical Evaluation
The diagnosis of atopic dermatitis is made clinically without a definitive laboratory test. The AAD's diagnostic criteria differentiate essential features that must be present for diagnosis, important features that support the diagnosis, and nonspecific features that suggest the diagnosis.
Before atopic dermatitis is diagnosed, the following dermatologic conditions should be excluded from the differential:
- Scabies
- Seborrheic dermatitis
- Contact dermatitis
- Ichthyoses (a group of skin disorders characterized by dry, scaly, or thickened skin)
- Cutaneous T-cell lymphoma
- Psoriasis
- Photosensitivity dermatoses
- Immune deficiency diseases
- Erythroderma ("red skin") of other causes
AAD Diagnostic Criteria for Atopic Dermatitis
Essential Features
The following must be present for diagnosis:
- Pruritis (itching)
- Acute, subacute, or chronic eczematous rash with typical morphology and age-specific patterns
Important Features
The following are seen in most cases and add support to the diagnosis:
- Early age of onset
- Atopy (genetic tendency to develop allergies)
- Xerosis (dry skin)
Associated Features
The following help suggest the diagnosis but are too nonspecific for diagnosing atopic dermatitis on their own:
- Atypical vascular responses (e.g., facial paleness, white dermographism, delayed blanch response)
- Keratosis pilaris, pityriasis alba, hyper linear palms, ichthyosis
- Ocular/Periorbital changes
- Other regional findings (e.g., perioral changes, periauricular lesions)
- Perifollicular accentuation, lichenifications, prurigo lesions
The severity of eczema should also be classified (mild, moderate, or severe). This is an important step because the severity guides appropriate management recommendations for flare management. The Scoring Atopic Dermatitis (SCORAD) calculator is the most widely used clinical tool to classify atopic dermatitis severity.
Step 2: Laboratory Testing
While laboratory testing is not required for diagnosis, the following testing options can assist doctors in identifying eczema triggers and onboard effective management protocols for eczema symptom management.
Allergies & Sensitivities
About 80% of patients with eczema will have an elevated total and/or allergen-specific serum IgE level, making it the most consistent associated laboratory finding of eczema. Serum IgE panels screen for allergic responses against environmental and dietary allergens. It should be noted that environmental allergen panels are region-specific and should be selected based on the areas where the patient resides or frequently visits. Examples of serum allergy panels include:
- IgE Allergy Explorer by Diagnostic Solutions
- Total IgE by Alletess Medical Laboratory
- Environmental Allergy Test (88 Antigen IgE) by Infinite Allergy Labs
- IgE Food Antibodies by Genova Diagnostics
A statistically significant correlation has been noted between Candida albicans IgE antibodies and the severity of atopic dermatitis. Antifungal therapy also appears to improve skin lesions. Therefore, C. albicans IgE antibodies should be ordered if not already excluded in other allergy testing. The Mold IgE Allergy Test by Mosaic Diagnostics is one panel that includes this biomarker.
Children with eczema commonly have delayed (non-allergic) reactions to food sensitivities. Food sensitivity testing measures non-IgE antibodies to confirm the presence of food sensitivities so that a therapeutic elimination diet can be initiated to help manage immunologic hyperactivity and support intestinal health. Examples of food sensitivity tests include:
- 96 IgG Food Sensitivity Panel by Alletess Medical Laboratory
- Basic Food Sensitivity Panel - 96 Foods by Ayumetrix
- Alcat Test: 50 Food Panel by Cell Science Systems
Comprehensive Stool Test
A comprehensive stool test measures biomarkers to evaluate for intestinal dysbiotic patterns, intestinal inflammation, and intestinal permeability that may influence gut and skin barrier function. Popular tests include:
- GI-MAP + Zonulin by Diagnostic Solutions
- GI360 by Doctor's Data
- GI Effects Comprehensive Profile - 3 day by Genova Diagnostics
Micronutrient Testing
Certain nutrients are known to be essential for skin health and reducing inflammation. Nutrient deficiencies may result from impaired gut function, dysbiosis, and dietary restrictions. A micronutrient test, such as one of the panels listed below, can screen for deficient or suboptimal levels of essential nutrients, such as vitamin C and zinc, which are important for managing inflammation and supporting skin health.
- Micronutrient Test by SpectraCell
- Cellular Micronutrient Assay by Cell Science Systems
- NutrEva FMV by Genova Diagnostics
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Management Plan for Eczema
A comprehensive management plan for eczema aims to achieve short-term symptom relief and long-term management of dermatologic lesions.
Step 1: Manage Inflammation
Here's Why This Is Important:
Managing inflammation can help reduce the severity of eczematous lesions and symptoms, thereby helping to prevent persistent itching and its potential consequences, such as secondary infections or skin scarring. By addressing inflammation early, management can help break the cycle of irritation and damage to begin the skin healing process.
How Do You Do This?
First-line recommendations that should be given to all patients with eczema include those related to hygiene and moisturizers. Daily bathing should be limited to five to ten minutes in lukewarm water to avoid irritating the skin. Patients should use soap-free, dye-free, fragrance-free, and hypoallergenic cleansers. (23)
Emollients with a high oil content should be applied within three minutes of bathing to seal moisture into the skin. Emollients help retain skin moisture, decrease disease severity, and prolong the duration between disease flares. As such, emollient moisturizers remain a mainstay of eczema maintenance therapy.
Topical steroids are the first-line medication prescribed for eczema flares to help manage inflammation. Additional medications may be prescribed for the management of moderate-to-severe flares. (9) These include:
- Topical calcineurin inhibitors (tacrolimus and pimecrolimus)
- Crisaborole
- Dupilumab
Topical herbal preparations containing licorice and lavender have also been shown to help manage the severity of redness, swelling, and itching of eczematous lesions.
Phototherapy, also known as light therapy, is a treatment modality that utilizes specific wavelengths of light to help manage eczema symptoms. Several types of phototherapy use UVA and UVB rays. Research shows that phototherapy may help reduce inflammation, itching, and scaling associated with eczema. Phototherapy is considered safe, well-tolerated, and effective when administered 2-3 times weekly for 1-3 months. (19)
Step 2: Identify and Manage Triggers
Here's Why This Is Important:
Identifying and managing eczema triggers may help prevent flare-ups and reduce the frequency and severity of symptoms. Patients can gain better control over their skin health by identifying and managing specific irritants or allergens that provoke the condition.
How Do You Do This?
If testing reveals positive allergies or sensitivities, patients should be counseled on lifestyle and dietary modifications to avoid triggers and irritants.
A therapeutic elimination diet that removes identified IgE and IgG-mediated food triggers may be a primary goal of managing patients with eczema. An elimination diet is generally recommended for at least 6-12 weeks, during which highly reactive foods are eliminated from the patient's diet. During this time, the patient should focus on eating a nutrient-dense, anti-inflammatory diet emphasizing whole fruits, vegetables, omega-3 fatty acids, and fermented foods to help manage inflammation, support immune function, and promote a healthy gut microbiome. (35)
After the elimination phase, patients may begin to reintroduce IgG food sensitivities to challenge the patient's food tolerance and begin to expand dietary variety. Each reintroduction should be performed individually over three days, during which the patient should closely observe for any changes or exacerbations of eczema symptoms. Foods that do not elicit adverse reactions can be reincorporated into the diet, whereas foods that trigger eczema should continue to be avoided. (15)
In one study that evaluated the effectiveness of dietary modifications in managing atopic dermatitis, researchers found that patients who removed flour products, gluten, and nightshades from their diets and added vegetables, organic foods, and fish oil reported the best skin improvements.
Step 3: Support Gut Health
Why Is This Important?
Intestinal dysbiosis can disrupt immune function and promote inflammation, potentially exacerbating eczema symptoms. Additionally, 90% of patients with atopic dermatitis are colonized with Staph aureus, which increases their risk of skin infections. Antibacterial therapies to manage Staph aureus colonization may help reduce eczema severity. (23, 28)
How Do You Do This?
Pharmaceutical methods of managing Staph infections include oral antibiotics, intranasal mupirocin ointment, and bleach baths. However, each modality has its own set of side effects and should be used with caution.
The following are natural options to consider for managing Staph aureus and promoting a balanced microbiome:
- Herbal antimicrobials, such as garlic, echinacea, oregano oil, and goldenseal
- The emollient effect of coconut oil has been successfully demonstrated in patients with atopic dermatitis. Coconut oil has natural properties that may support a healthy balance of the skin's microbiome. One study showed that applying virgin coconut oil twice daily for one month resulted in a 95% reduction of Staph aureus for patients with atopic dermatitis.
- Lower serum vitamin D levels have been associated with a higher rate of bacterial skin infections, and vitamin D supplementation (around 1,600 IU daily) has been shown to help manage the clinical signs of eczema.
Step 4: Support and Maintain a Healthy Skin Barrier
Why Is This Important?
A weakened skin barrier can lead to a cycle of dryness, irritation, and inflammation. This compromised barrier allows moisture to escape and irritants to penetrate the skin more easily, potentially exacerbating symptoms and leading to further degradation of the skin barrier.
How Do You Do This?
Chronic stress may disrupt the integrity of both the skin and the intestinal barriers, contributing to inflammation and skin disorders. Some research shows that patients receiving psychotherapy and standard medical care have greater improvements in skin symptoms than those who just receive standard medical care. Counsel patients on stress management through the following means:
- Cognitive behavioral therapy (CBT)
- Mind-body therapies, including meditation, mindfulness-based stress reduction, hypnotherapy, biofeedback, and guided imagery
- Gentle exercise, including tai chi and yoga
- Getting at least 8 hours of good-quality sleep
Balancing the gut microbiome can modulate the gut-brain and gut-skin axes. In doing so, patients may feel reductions in stress/anxiety levels and notice improvements in skin health. Butyrate is a short-chain fatty acid known as the preferred fuel source of cells lining the small intestine. It may help manage inflammatory cytokines and support tight junctions. The severity of atopic dermatitis inversely correlates with the abundance of butyrate-producing bacteria. Probiotics containing Lactobacillus and Bifidobacterium species are most commonly used to help manage skin inflammation in patients with eczema.
L-histidine is essential for synthesizing FLG and regulating the skin's moisture content. Oral supplementation with L-histidine (4 grams daily) has resulted in a 34% reduction in atopic dermatitis severity and a 33% reduction in reported topical corticosteroid use by patients. (24)
The Risks of Untreated Eczema
Infection is a common complication of eczema due to constant scratching and broken skin, which provides an entry point for infectious pathogens. Persistent inflammation and scratching can also lead to skin scarring and lichenification, where the skin becomes thickened and leathery. (23)
Additionally, the chronic discomfort and visible symptoms of eczema can contribute to emotional distress, negatively impacting quality of life and potentially leading to anxiety and depression (5).
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Key Takeaways:
- A growing body of evidence supports an integrative approach for effective long-term eczema management.
- A multimodal management plan utilizing dietary modifications, pharmacologic medications, and natural supplements may help support skin and gut barriers by managing inflammation and promoting a healthy microbiome.
- The sample management protocol outlined in this article provides a framework to be utilized in clinical practice, customized as needed based on the patient's needs.
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