Integrative Summary

Eczema, also known as atopic dermatitis, is a common, chronic condition of the skin that affects many children and adults.[1] In western and naturopathic medicine, eczema is understood as the genetically predisposed combination of a defective skin barrier and an increased inflammatory response. In ayurvedic theory, increased vata and pitta are at the core of the cause of eczema, while imbalances of heat, wind, and Qi explain eczema according to traditional Chinese medical philosophy. Although these factors may sound different, there are many ways that the different disciplines overlap and can be used together for therapy.

Integrative Summary Table
Medical PerspectiveWhat Causes It?What Can Make It Better? 

Western Medicine

  • Defective skin barrier
  • Overactive immune system and inflammation
  • Increased sensitivity to itch stimulants
  • Decreased ability to fight skin infections
  • Improve skin barrier
  • Reduce inflammation
  • Decrease itch
  • Use of antibiotics when necessary

Ayurvedic Medicine

  • Excess of Vata
  • Excess of Pitta
  • Reduce vata
  • Reduce pitta

Traditional Chinese Medicine

  • Excessive wind, damp, heat
  • Excessive Dampheat
  • Qi deficiency with dampness
  • Dispel wind, damp, heat
  • Drain and dry dampheat
  • Boost Qi and drain dampness

Naturopathic Medicine

  • Skin barrier dysfunction
  • Immune dysfunction
  • Improve barrier
  • Optimize inflammation

Symptoms

Eczema is characterized by chronically dry, itchy and scaly skin. When scratched and irritated the skin can become red, itchy, and swollen with oozing and weeping. The skin of the cheeks, wrists, inner elbows and knees are most commonly affected in babies and young children. In older children and adults, the skin of the neck, inner elbows and the backside of the knees are affected more commonly. Eczema tends to be worse in childhood with improvement in adolescence and adult years. However, in some cases eczema can persist into adulthood.

Causes

Western Medicine

Normally the skin works as a protective barrier; in skin affected by eczema the barrier is deficient, compromising its effectiveness. This makes it easier for dryness and irritation to set in. The immune system is also overactive in people with eczema leading to the frequent signs of redness and swelling. Research has shown that people with eczema produce less antibiotic substances on the skin[2], which may explain why there is an increased risk for skin infections.

The population of bacteria on the skin, known as the microbiome, appears to be important in those with eczema. While everyone has bacteria on their skin, people with eczema appear to have an unhealthy population that is dominated by the bacteria Staphylococcus aureus.[3] Studies are currently underway to understand how the microbiome can be switched to a more healthy state in hopes that this can improve control of eczema.

Naturopathic Medicine

Eczema, also called atopic dermatitis, is a chronic inflammatory skin condition. Although eczema is found in almost any age group, it is more common in children.[6] The development of eczema is typically based on four different factors that include:

  • Genetic susceptibility: Eczema is an inherited disease and is commonly found in families.
  • Immune dysfunction: The immune system plays a role in the development of eczema[7] and frequent bouts of exposure to irritating chemicals can worsen eczema.
  • Terrain: Terrain refers to the overall quality of health of the body as it has been influenced by factors such as genetics (see above), life experience (major life events, nutrition and intoxicants), and suppressive therapies (such as antibiotics, radiation, chemotherapy, etc.) that a person has received throughout life. All of these factors can influence eczema by reducing the overall healthy state of the skin.
  • Epidermal barrier dysfunction: A mutation in a gene that controls barrier function causes people to have a predisposition to the development of eczema and other “atopic” conditions, such hay fever and asthma.[8]

Ayurvedic Medicine

Eczema is due to:

1) Excess of vata

2) Excess of pitta

Water is naturally lost through the skin, and this is known as transepidermal water loss (TEWL). As vata represents movement, TEWL is an example of it. In people with eczema, TEWL is increased because the skin barrier does not work properly, increasing vata. In turn, the skin is more sensitive to irritating substances, aggravating pitta to increase. With this increased pitta in the skin comes inflammation. In some cases, the skin can become infected, which is also a representation of pitta.

In eczema, itching represents an increase of the vata dosha. In more severe cases where chronic itching leads to thickened skin and swelling, the kapha dosha can also be increased to a point of imbalance. When the kapha dosha is out of balance, this leads to a domino effect that worsens itchiness even further. Increases in the kapha dosha are more rare and are seen in more severe disease, which reflects that the skin’s attempt to protect against an imbalanced increase in the pitta and vata doshas.

Traditional Chinese Medicine

Traditional Chinese Medicine (TCM) explains eczema as a weakness in the body’s vital energy, called Qi, which allows external pathogenic factors to attack—causing itchiness, inflammation and dry, red skin.[4] The most common pathogenic factors causing eczema are combinations of wind, heat and dampness.[5]

The imbalance is determined by evaluating the entire person, including skin symptoms and appearance, as well as digestion, sleeping and overall wellbeing. When wind and heat are predominant the eczema appears as dry, cracked and reddened skin. When damp heat is more pronounced the eczema appears with crusting and blisters. The lack of Qi is indicated by poor appetite and pale skin.  

Risk Factors

Environment

Climate

Cold and dry environments may aggravate eczema. Cold temperatures worsen the function of the skin barrier.[13] An international study found that colder temperatures were associated with a greater incidence of eczema.[14] The same study showed that there was less eczema present as indoor humidity increased.[14]

Increases in vata worsen eczema; studies have found that cold and dry climates are associated with greater prevalence of eczema.[15,16] 

Dry climates act as heat and wind causing further dryness in the skin. Excessively humid and rainy weather also leads to greater dampness on the skin. Evidence suggests that both very dry and very wet climates are associated with more severe eczema.[16]

Allergens

Allergens that cause a general allergic reaction of the skin can worsen eczema by causing frequent bouts of skin irritation, known as contact dermatitis or irritant dermatitis. Common environmental causes of contact dermatitis include dust mites, cat dander, animal saliva and latex.[17] Particulate air pollution has been shown to worsen the epidermal barrier function and increase the risk of eczema.[18]

Genetics

Genetics

Research shows that there is a genetic component to the development of eczema.[9] People with eczema have an abnormal protein in their skin barrier, leading to a disruption in skin function. This protein, known as filaggrin, is normally a part of a healthy skin barrier. Breakdown products of filaggrin form what is known as the natural moisturizing factor, which keeps skin hydrated.[10,11] Studies have estimated that the number of people with eczema that have an abnormal filaggrin protein may be as low as 25% to as high as 50%.[12]

Constitution

Some people have poorly working skin barriers, which reflects a tendency of vata imbalance. Those with relatives that have vata imbalances and eczema have a greater chance of developing eczema as well.

Lifestyle

Diet

Foods that aggravate pitta and vata should be eaten in small quantity. Within Ayurveda, foods have six different tastes and actions (known as vipaks) that can be used to plan a diet to balance a person’s imbalance. Foods that are sour or astringent should be decreased in the diet to balance aggravated vata. Citrus foods are one example because they have a sour quality in Ayurveda. This is supported by a study that found orange intake can worsen eczema.[19]

The foods commonly shown to worsen eczema are eggs, milk, grains (barley, rye, and wheat), soy, nuts, and meats like beef, pork, seafood and poultry. [17]

Clothing

Clothing is an important, often underestimated contributing factor to eczema. Wool and other rough fabrics can worsen eczema[20-22] and itchiness. 

Smoking

The harmful effects of smoking are well-known, but many who suffer from eczema may not realize that it can worsen their symptoms, and the symptoms of those around them. Smoking can increase the risk of hand eczema,[23] and exposure to environmental tobacco smoke at home can increase the risk of eczema in school children.[24]

Products

Soap

Because skin affected by eczema has a deficient barrier, it is more sensitive to products that have the ability to be irritating and drying. Soaps can both irritate and dry the skin, and should be used judiciously in those with eczema. In particular, the arms and legs are more sensitive to the potential negative effects of soap as they tend to make natural oils less than the face, chest, and back. Research has shown that totally avoiding soap is not healthy either. One study conducted with 130 eczema sufferers who did not use any soap for 30 days showed that restarting soap use while bathing was helpful to their eczema if a moisturizer was used immediately after bathing.[25] Overall, soap can be irritating to the skin but should be used once in a while, immediately followed by the use of a moisturizer after bathing. Another option is to use a non-soap cleanser. 

Soaps aggravate the vata dosha. Products like bar soap, liquid soap, dishwashing detergents, and body washes all contain ingredients that can strip the skin’s naturally protective oils, weakening it.[26] People with eczema have been shown to produce less skin oils [27], and the use of soaps will further decrease the natural oils present, worsening eczema.

Soap acts as external wind heat and wind dampness that strips the skin of natural health oils. Soaps lead to dry skin and further increases in transepidermal water loss (TEWL), a measure of how quickly water is lost through the skin. The drying effects of soaps are worsened in eczema because there may be a propensity for dry skin and allergies, which is understood as a weakness of Qi.[28] 

Fragrance-containing cream

Fragrances are found in many creams and lotions. These chemicals can be irritating in general,[29] and particularly in people with eczema.[30] However, buying fragrance-free does not mean that a skin product does not have any fragrance. Many fragrances can be used in a product if they have another function, such as the fragrance benzyl alcohol that also acts as a preservative. This is an important caveat to remember when evaluating products that claim to be “fragrance free.” 

Sleep

Sleep deprivation and poor sleep quality both lead to aggravation of vata. In eczema, this begins a vicious cycle where poor sleep worsens itching and rashes, leading to poor sleep quality.[31,32]

Stress

Circulation and flow of Qi, our body’s energy, is imperative for a healthy life. Stress inhibits the flow of Qi leading to stagnation that can cause the build up of heat within the body. Recent studies have shown the relationship between stress and inflammation in people with atopic dermatitis(eczema).[33]

Treatments

Overview

Eczema is a chronic condition with often no permanent cure. Regardless of whether a western or complementary medical approach is implemented, it requires constant attention and care. The typical treatment for eczema has two goals:

  1. To improve the skin barrier.
  2. Reduce inflammation in the skin.

Changes that reduce the imbalance of the pitta and vata doshas are helpful. In some cases, an imbalanced kapha dosha may need to be balanced as well.

TCM therapy first aims to remove the pathogen and then to strengthen the body's energy. TCM uses personalized diagnosis and therapy to address the specific imbalance each patient is experiencing. Traditional Chinese medicine therapy may include herbal medicines, acupuncture and topical moisturizers.

Eczema is manageable, but there is no absolute cure, so it requires frequent evaluation by trained medical professionals to control flares and prevent symptoms from worsening. Eczema is complex and a study has shown that many patients do not realize all of the factors that can affect their condition[34]. Naturopathic medicine follows the belief that patient and/or parent education is a crucial component of any treatment plan. When the patient understands the condition, they can learn to recognize and avoid the individual “triggers” that worsen the symptoms they experience. A naturopathic practitioner will develop a treatment plan that works with natural symptom controls before, or in conjunction with, synthetic/pharmaceutical controls. Prevention is also important to consider because preventing the exposure to irritants will minimize chronic inflammation, which leads to worsening of eczema.

Medications

Anti-inflammatory medications

A physician may prescribe prescription-strength medications, such as steroids or calcineurin inhibitors, for reducing inflammation in the skin. This is a temporary means to help the skin heal faster.

  • Topical steroids are a common class of medications for eczema and work by suppressing the immune responses of the skin. While quite effective in treating the condition, up to 20% of patients are not satisfactorily treated with topical steroids[35] and may require additional treatments. Topical calcineurin inhibitors are another class of anti-inflammatory agents prescribed as an alternative to topical steroids.
  • Oral anti-inflammatory and immune suppressing medications are used in more severe cases. Some examples include cyclosporine, azathioprine and systemic steroids. 

Antibiotics

If there are any signs of secondary infection (such as swelling, redness, pus, and pain) topical and/or oral antibiotics may be prescribed to reduce inflammation and treat the infection. The bacteria S. aureus tends to overgrow in people with eczema and antibiotics are directed toward controlling its overgrowth.

Products/Treatments

Moisturizers

The use of a skin cream/moisturizer is important in bolstering the skin barrier and in maintaining hydration. These should be applied daily and after bathing, especially if soap was used. There are many different kinds of moisturizers available and these should be carefully selected. For example, some moisturizers are much heavier due to an ointment base while others may be lighter due to a cream or lotion base. Moisturizers containing ceramides are recommended to address the inherited deficiency of these water-retaining compounds in the skin.

Moisturizers can reduce vata-related effects and bolster kapha-related effects (when used carefully). Several naturally-derived oils can be helpful in reducing pitta including olive, coconut, primrose and sunflower oils. Here are a few oils that have shown promise:

  • Coconut oil: Studies have shown that although both coconut and olive oil are helpful for combating eczema, the aforementioned may be more beneficial in reducing harmful bacteria.[36]
  • Primrose oil: A clinical study showed that oral primrose oil improves eczema.[37]
  • Sunflower oil: Sunflower oil is rich in linoleic acid, which is an antiinflammatory agent. It should be used with caution on premature babies as it may affect how their skin matures.[38] 
  • Omega-3 oils: Studies have shown that oral omega-3 oils from fish are beneficial in eczema. 

Herbs

Chinese herbs are given in multi-herb formulas, most often in dehydrated powders or raw herbs that are cooked into strong teas or decoctions. Research has shown a link between Chinese herbal medicine and a reduction in the need for corticosteroid use in children.[39]

  • Topical Herbs. Herbs are also used topically. Sometimes they are applied straight to the skin as a moist compresses or they may be mixed with a moisturizer. Common combinations of herbs are Huangbai (Cortex phellodendri), Zicao (Radix arnebiae), and Diyu (Radix sanguisorbae).[40] For redness, papules, and erosion the single herb Qing Dai (Indigo powder) can be mixed with moisturizer as a topical soothing balm. [41]
  • Oral Herbs. The herbal ingredients of therapeutic formulas are customized to each patient to address the specific imbalances causing eczema. Xiao Feng San (Clear Wind Formula) is a commonly used formula for reducing eczema caused by wind, heat and dampness. [5] This contains herbs with antibiotic and anti-inflammatory properties.[42] If damp heat and toxicity are the causes of eczema, the herbal formula Huang Lian Jie Du Tang (Copitis formula to clear toxins) is often used. [5] This formula contains Huang lian (Coptis chinensis), a powerful herb that has shown antibiotic effects against Staphylococcus aureus, a bacteria known to colonize skin with eczema.[3,43] Ku shen (Sophora flavescens) is another herb that dries dampness. Studies have shown that it reduces inflammation, itch, and inhibits the growth of aureus.[5] 

Several botanicals agents have been studied: 

  • Oats: Some believe that oats may worsen eczema, due to common reactions that many individuals have to other grains and cereals.   Indeed, certain people with eczema may react to using oat-based topical agents.[44] However, one study used various oat-containing products and found no adverse reactions,[45] and other studies have shown the use of oats to be quite beneficial for patients with eczema.[46,47] Therefore, the use of oats must be evaluated individually and carefully.
  • Licorice root and feverfew may also reduce inflammation.[46].

 

Probiotics

Supplementation with probiotics during and after pregnancy may decrease a baby’s rate of developing childhood eczema.[48] Topical probiotics may also be helpful for eczema[49]. The benefits may be due to an improvement in skin barrier function following the use of probiotics.[50] This is a growing area of research and more studies are needed to better understand how the dose and species of probiotics may make a difference to eczema.

Procedures

Acupuncture

Acupuncture is commonly used for eczema to stop itching and promote overall wellness. The physiologic mechanisms that acupuncture employs to reduce pain are also effective for stopping itch.[51]

Hydrotherapy

Different forms of hydrotherapy with the potential to improve eczema may include wet wraps, vinegar, oatmeal baths, bleach baths,[52,53] balneotherapy, mineral baths,[49] or even an extended stay at a specialized hydrotherapy center.[54] 

Nutrition

Diet

Dietary changes are one of the core principles in Ayurvedic approaches to treatment. The diet should focus on balancing the aggravated vata and pitta doshas that are seen with eczema. Diets that reduce the amount of sours, bitters, and astringents (pickeled foods) may be helpful. A study in Denmark showed that carefully planned elimination diets were helpful in 39% of the 675 people that participated in the study.[55] The study also found that there was long term improvement over 1-3 years in 70% of those that continued in the long-term follow up study.[55] Many of the eliminated foods were of an astringent, bitter and sour quality. Elimination diets should be done carefully as they can lead to poor nutrition in both children and adults. They should be done under the direction of a health professional.

A naturopathic practitioner will often have a patient begin an elimination diet in order to to identify hidden food allergens or irritants that may be causing some or all of the symptoms. This diet entails the removal of common foods for several weeks before carefully adding them back, one at a time, to determine which foods are problematic. It is important that the elimination diet is completed under the supervision of a trained health professional and that a child is not deprived of essential nutrients.

Supplements

  • Vitamin D: Although vitamin D’s role in the treatment of eczema is debated, patients with a history of atopic dermatitis often have reduced vitamin D levels,[56] while eczema has improved with vitamin D supplementation.[49]
  • Glutamine: In a study of low birth weight infants supplemented with the amino acid glutamine, it was shown that the infants who received glutamine had lower rates of developing eczema.[57] Similar results have been shown in mouse models.[58] 
  • Omega-3 fatty acids as well as omega-6 oils (primrose, flax, borage, hemp) are beneficial in eczema.[59] 

Breastfeeding

Breast milk can boost a child’s immune system, reducing the risk of developing atopic diseases like eczema.[48] Also, breast milk may help select for healthy bacteria to grow in the gut and one theory suggests this can reduce systemic inflammation and the development of eczema.

Lifestyle

Dilute bleach baths

Dilute bleach baths help to control the overgrowth of the S. aureus bacteria on the skin when used consistently twice weekly over 3 months.[59] The nose can harbor S. aureus and bleach bath studies have found that application of the an antibiotic ointment (mupirocin ointment) into the nose along with the bleach baths was effective in reducing S. aureus on the skin.[59] Dilute bleach baths are similar to taking a dip in a swimming pool and have been shown to be safe on the skin.[61]

Humidify environment

Humid weather can counteract imbalances in vata since moisture in the environment can slow down water loss through the skin. Indeed, eczema is less common for those in humid climates.[16] The use of a humidifier can be helpful for counteracting eczema. Importantly, humidifiers should be carefully cleaned to reduce bacterial and fungal growth.

Reduce soap use

Reducing soap use can help with correcting vata imbalances. Soaps may still need to be used in areas that are moist and oily (such as the armpits and groin), but people with eczema may improve with reduced soap use to the body, arms and legs. If soap is absolutely necessary, products that contain sodium lauryl sulfate should be avoided at the very least.[62]

Stop smoking

Second-hand smoke can aggravate eczema. Reducing smoking, or smoking cessation altogether, can lead to a decrease in allergic responses of those exposed to second-hand smoke.[63,64]

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