Atopic eczema or dermatitis (AD) often starts in infancy and the good news is that for most children it spontaneously resolves by the age of seven. However, AD doesn’t like to conform and so for some, AD remains until puberty, may return in later adulthood and for the very unlucky stays with them throughout their lives.
Unfortunately for some children, the early onset of AD also signals the start of the ‘atopic march’, with the appearance of hay fever and even asthma, either in tandem with the AD or in some cases instead of (1).
In addition, whilst more boys are diagnosed with allergies in childhood, in adulthood women are significantly more likely to be diagnosed with a food allergy and the menopause has been identified as a time when AD flares can either increase or disappear. (17,18).
So why do some people get AD?
Helping clients with AD is my vocation, as I have suffered from this condition since I was 6 months old. I am so interested in this topic that I have just completed a Master of Science with a dissertation entitled: ‘Examine how nutrition can be used as a complementary tool for the support of eczema/chronic atopic dermatitis (AD)' and I will share some of what I learnt below:
Multiple causes have been identified including skin barrier disruption, mutations in the filaggrin gene, gut microbiome (gut bacteria) imbalance, as well as immunological (allergy/intolerances) and environmental triggers, yet there is still no definition of what causes AD. This lack of definitive cause leads to dermatologists and allergy specialists telling their patients that eczema is uncurable and that it can only be modulated by use of corticosteroids and other topical creams and emollients (2,3).
There are, however, several areas of research that might shed more light.
You may have heard of leaky gut, but it could be that AD sufferers have leaky skin which may be caused by the mutation of a skin protein gene called filaggrin (FLG). Basically, FLG is used to seal the skin barrier and acts to both stop water loss and potential pathogens crossing into the bloodstream. What this means in practice is that whilst the water loss creates the dry, flaky and itchy skin so well-known to eczema sufferers, the ‘leaky skin’ could also be allowing environmental and even food allergens to cross, triggering an immune reaction and inflammation. Up to 48% of AD sufferers have been found to carry this mutated FLG gene (FLG-null-allele) which makes it a very exciting area of research. (4–6).
The FLG research has also been linked to another area of AD research, the ‘dual allergen exposure hypotheses’ (12) relating to inappropriate immune response. This area of research suggests that the FLG affected ‘leaky skin’ exposes the AD sufferer to food antigens via touch. The food particle enters the bloodstream via the skin and is quickly identified as a foreigner by the person’s immune system. This causes the body to go into high alert, triggering inflammation and labelling that food antigen as a future threat. A vicious cycle then ensues with the inflammation causing further damage to the skin barrier and leading to even more risk of exposure to food and environmental antigens.
Recent studies have found that this type of food antigen exposure can lead to subsequent ingested food sensitivities and intolerances and provides a potential explanation as to why so many AD sufferers know that they react to certain foods, despite negative allergy testing. (13).
Studies have shown that child AD sufferers are at higher risk of IgE mediated food allergies but also non-IgE Mediated (delayed) allergies (14). Diagnoses are made via either a blood draw to test for specific IgE antibodies or via Skin Prick Test (15). Other possible tests include the Atopy Patch Test, IgG testing and the Elimination Diet. In children caution must be applied to the Elimination Diet as it is thought that continuous consumption of a trigger food will result in it being better tolerated and that the removal of this food from the diet for a period may result in an increased risk of severe allergy or even anaphylaxis (16).
The gut microbiome has become a key research focus within the last decade, both in terms of health generally but also specifically in relation to AD. Intestinal hyperpermeability (leaky gut) and gut microbiome (bacteria) imbalance are linked to worsened immunity, higher rates of inflammation and risk of allergies and intolerances. AD patients have been identified as being at higher risk of both these (10,11).
Recently research has started to focus on the skin microbiome (bacterial population). This research has identified that individuals with atopic eczema suffer from skin microbiome dysbiosis (imbalance) with a skew to an overgrown population of staphylococcus epidermidis and staphylococcus aureus (7,8). My clinical experience has often found individual clients who demonstrate a link between both skin and gut dysbiosis (9) and this is an area I am passionate about.
As mentioned in the introduction, AD doesn’t like to conform. Whilst there are some common recommendations to all AD sufferers, no two nutrition recommendations are alike, just like no two people’s skin or gut microbiomes are alike. What may work for one, will not work for another.
Supporting clients with this condition involves the combining of many pieces of information with practitioner knowledge. Seeking out the individualised manner of eating that allows that person to eat the most varied diet possible, whilst being aware of those foods and environmental triggers that may cause a flare.
The main objective is to provide the empowerment that allows for each client to have a sense of control, whilst having the knowledge to face new challenges, in line with AD’s non-conformist tendencies.
Below are some of the key nutrients that research has found to be supportive for AD sufferers:
Whilst a deficiency in zinc status has been long thought to be linked to AD, studies using supplementation did not show any benefits (25,26).
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2. Nutten S. Atopic dermatitis: Global epidemiology and risk factors. Ann Nutr Metab. 2015;66:8–16.
3. Lopez Carrera YI, Al Hammadi A, Huang YH, Llamado LJ, Mahgoub E, Tallman AM. Epidemiology, Diagnosis, and Treatment of Atopic Dermatitis in the Developing Countries of Asia, Africa, Latin America, and the Middle East: A Review. Dermatol Ther (Heidelb) [Internet]. 2019;9(4):685–705. Available from: https://doi.org/10.1007/s13555-019-00332-3
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13. Tricon S, Willers S, Smit HA, Burney PG, Devereux G, Frew AJ, et al. Nutrition and allergic disease. Vol. 6, Clinical and Experimental Allergy Reviews. 2006. p. 117–88.
14. Abuabara K, Margolis DJ. Do children really outgrow their eczema, or is there more than one eczema? J Allergy Clin Immunol. 2013;132(5):1139–40.
15. Dhar S, Srinivas SM. Food allergy in atopic dermatitis. In: Indian Journal of Dermatology. 2016.
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17. Chen W, Mempel M, Schober W, Behrendt H, Ring J. Gender difference, sex hormones, and immediate type hypersensitivity reactions. Allergy Eur J Allergy Clin Immunol. 2008;63(11):1418–27.
18. Pali-Schöll I, Jensen-Jarolim E. Gender aspects in food allergy. Curr Opin Allergy Clin Immunol [Internet]. 2019;19(3). Available from: https://journals.lww.com/co-allergy/Fulltext/2019/06000/Gender_aspects_in_food_allergy.12.aspx
19. Rusu E, Enache G, Cursaru R, Alexescu A, Radu R, Onila O, et al. Prebiotics and probiotics in atopic dermatitis. Exp Ther Med. 2019 Aug;18(2):926–31.
20. 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. 2016;8(12):8–17.
21. Navarro-Triviño FJ, Arias-Santiago S, Gilaberte-Calzada Y. Vitamin D and the Skin: A Review for Dermatologists. Actas Dermosifiliogr. 2019 May;110(4):262–72.
22. Balić A, Vlašić D, Žužul K, Marinović B, Bukvić Mokos Z. Omega-3 Versus Omega-6 Polyunsaturated Fatty Acids in the Prevention and Treatment of Inflammatory Skin Diseases. Int J Mol Sci. 2020 Jan;21(3).
23. Williams HC, Chalmers J. Prevention of Atopic Dermatitis. Acta Derm Venereol. 2020 Jun;100(12):adv00166.
24. Thomsen BJ, Chow EY, Sapijaszko MJ. The Potential Uses of Omega-3 Fatty Acids in Dermatology: A Review. J Cutan Med Surg. 2020;24(5):481–94.
25. Gray NA, Dhana A, Stein DJ, Khumalo NP. Zinc and atopic dermatitis: a systematic review and meta-analysis. J Eur Acad Dermatol Venereol. 2019 Jun;33(6):1042–50.
26. Vaughn AR, Foolad N, Maarouf M, Tran KA, Shi VY. Micronutrients in Atopic Dermatitis: A Systematic Review. J Altern Complement Med. 2019 Jun;25(6):567–77.