The recurring series “Overcoming Medical Dogma” is a collaborative effort between The Paleo Mom Sarah Ballantyne, PhD, scientist turned stay-at-home-mom, and Paleolithic MD Dr. Ernie Garcia, MD, Internal Medicine and Sleep Medicine specialist.  The goal of these co-written posts is to go beyond the typical physician-patient interaction where the patient describes symptoms, the physician diagnoses and prescribes medication and/or dispenses diet and lifestyle advice. In each post, we will discuss a common medical condition, the typical treatments that your doctor may recommend, and what you should know about these conditions that your doctor may not tell you. We will reference relevant research and present our recommendations for addressing this condition.  Lastly, we will address the benefits of pharmaceuticals (prescription and OTC) as well as home/natural remedies which may help.

What is Eczema?  Eczema is a general term used to describe a collection of skin conditions (the most common being atopic dermatitis) in which the skin is inflamed and irritated.  The inflammation in these skin conditions is in the epidermis, or outer layer of the skin, and this is the main distinction between eczema and other skin conditions.  The presentation varies and can include any of the following symptoms:  redness, skin edema (swelling), itching, dryness, crusting, flaking, blistering, cracking, oozing, or bleeding.  It can affect any area of the body and areas can range in size from quite small to very large.  Eczema affects about 10% to 20% of infants and about 3% of adults and children in the U.S. 

It was once thought that eczema was a primary immune system disorder, where an overactive immune system, led by a type of white blood cell called T-Cells, responded to environmental factors by initiating an inflammatory response.  This idea made sense because not only would inflammation produce the red, irritated skin characteristic of eczema, but this dysfunctional immune response also provided an explanation for the observed incidence of atopic dermatitis in conjunction with asthma, hay fever, and other allergies.  However, the most up-to-date research does not support this explanation. 

The most current research points to a different origin of eczema.  It is now thought that eczema results from structural defects in the epidermis resulting in “impaired barrier function”.  Essentially, abnormalities in the skin make it more permeable to toxins and antigens, which then causes an exaggerated immune response ¹.  You could think of this as “leaky skin”, where the skin no longer is able to fulfil its primary role as the first line of defence between the body and the outside world.  Once the barrier function of the skin is disrupted, various substances (like toxins, allergens, antigens; basically anything that the immune system views as a foreign invader) can “leak” in from the outside and this is what activates the immune response.  This model is supported by recent isolation of specific mutations in the gene for filaggrin, a structural protein in the epithelial cells of the skin.  This defective gene (and perhaps other similar gene mutations) may lead to a dysfunctional epidermal barrier and is likely the primary cause of eczema. 

What is your doctor likely to tell you about it?  Your doctor will likely tell you that the exact cause of eczema is unknown, but it’s thought to be linked to an overactive response by the body’s immune system to an irritant.  He or she may not be aware of the newest research on eczema, but that will not affect decisions on treatment.  It’s fairly common and not life threatening.

What is your doctor likely to prescribe?  Treatment of any skin condition should always start with proper care of your skin.  In the case of eczema, you should avoid triggers such as heat, perspiration, and low humidity, and keep the skin well hydrated at all times. The standard pharmaceutical treatment is the application of topical corticosteroid creams, which can be purchased in your local pharmacy or prescribed in stronger strengths by your doctor.  If allergies are suspected, a daily antihistamine such as loratidine (Claritin) may be suggested.  In severe cases, your doctor may prescribe an oral corticosteroid, such as prednisone. 

Now if you have your thinking hats on (and we’re sure you do), you are asking “If eczema is no longer considered a primary immune disorder, why is the standard of treatment aimed at stopping inflammation and controlling the immune response?”  The answer is that the symptoms of eczema are indeed caused by an immune response, but it is a response from environmental triggers entering the body through “leaky” skin as opposed to an immune system run wild and attacking itself. 

What should you know that your doctor may not tell you?As discussed above, the most current belief is that those with eczema carry a genetic predisposition to “disrupted epidermal barrier function” ¹.  This could be thought of as “leaky skin” and is a very analogous to a “leaky gut”.  In fact, because of the similar roles of the skin and the gut to act as a barrier, it is no surprise that eczema is also associated with increased intestinal permeability ², i.e., a leaky gut.  It is still unknown whether a leaky gut contributes to the development of eczema, however.   

Eczema is also often seen in conjunction with a multitude of autoimmune diseases.  For example, eczema occurs about three times more frequently in celiac disease patients and about two times more frequently in relatives of celiac patients, potentially indicating a genetic link between the two conditions.  For this reason, gluten sensitivity is suspected as a possible root cause for eczema, but that is still unconfirmed.  Anecdotally, many people find that their eczema goes away when they adopt a gluten-free diet.  Other people find elimination of additional foods, such as eggs, are required to see improvement.  There also appears to be a strong link between eczema and immune hypersensitivity ³.  For example, more than 50% of children with atopic dermatitis go on to develop asthma and allergies.  This may be related to the association with increased intestinal permeability or may reflect an as yet unknown common causal mechanism (such as a gene mutation or environmental factors).   

Although progress had been made toward understanding this complex condition and how it relates to other health issues, the cause of eczema remains unknown.  We are certain the coming years will bring more information and we will try to update everyone as it is available.

A Comprehensive Approach to Treatment:  We believe that a paleo diet is an excellent initial approach to dealing with eczema.  This is because a paleo diet reduces inflammation and heals the gut.  Including glycine-rich foods like homemade bone broth and organ meat can help speed the healing of both the gut and the skin (glycine is an essential component of connective tissue and the extracellular matrix that acts as a scaffold for cells).  Sun exposure and eating vitamin D-rich foods such as fish and organ meat can be very helpful in speeding healing (you might also consider a Vitamin D3 supplement, but check with your doctor first).  Consuming plenty of oily cold-water fish (at least three times per week) as well as eating grass-fed and pastured meat will also help because the high omega-3 content of these foods (and low omega-6 content) could help resolve inflammation.   

Anecdotally, most people report alleviation of their symptoms with adoption of a paleo diet.  In extreme cases, or in individuals who do not see alleviation of their symptoms with out-of-the-box paleo, it may be worth trying a more restricted implementation of the paleo diet, such as the Autoimmune Protocol, a paleo version of the GAPS diet, or even something as simple as completing the Whole 30 Challenge from Whole 9 Life.   

Over the counter topical corticosteroid creams may still provide some alleviation of symptoms (most notably the itching) and might be required initially.  Other moisturizers which may help heal the skin faster and relieve itching include extra virgin coconut oil and lotions containing calamine, aloe vera, arnica montana, Vitamin D and/or Vitamin E.  Diane Sanfilippo provides herbal supplement recommendations in her new book Practical Paleo (herbal supplement recommendations are generally beyond both of our backgrounds and we recommend that you consult with someone with specific training in these supplements such as a Naturopathic Physician).  If your attempts to control symptoms with diet and supplements alone do not produce adequate relief, we suggest visiting your doctor for advice on more specific pharmaceutical intervention in the form of stronger topical steroids or short courses of oral steroids in extreme cases.

¹ Elias PM and Steinhoff M  “Outside-to-Inside” (and Now Back to “Outside”) Pathogenic Mechanisms in Atopic Dermatitis. J Invest Dermatol. 2008 May; 128(5): 1067–1070.

² Pike MG et. al. Increased intestinal permeability in atopic eczema. J Invest Dermatol. 1986 Feb;86(2):101-4.

³ Boguniewicz M.  Atopic dermatitis: beyond the itch that rashes. Immunol Allergy Clin North Am. 2005 May;25(2):333-51.