“Dermatitis” means skin inflammation. It is a term used to describe a group of inflammatory skin disorders usually characterized by red, itchy rashes.

The term “eczema” is sometimes used interchangeably with dermatitis. However, eczema usually refers to atopic dermatitis, a common type of dermatitis.¹

In this protocol, “eczema” and “atopic dermatitis” are used synonymously.

Eczema affects approximately 13% of children and 5.5% of adults in the US.^2-4 It is a chronic and sometimes lifelong condition. Although the vast majority of cases begin in infancy or childhood, the number of adults, including older adults, experiencing new-onset eczema has been increasing.⁵ In addition to its direct effects on the skin, eczema can take a toll on social and emotional wellbeing.⁶

Although there is no cure for eczema, it can be managed in part through daily self-care including the use of appropriately formulated moisturizers. Limiting intake of highly processed and fast foods, incorporating fermented and cultured foods, and avoiding foods identified as contributing to symptoms using an elimination diet are strategies that may reduce eczema flare-ups.^7-11 In addition, nutrients such as vitamin D, gamma-linolenic acid (GLA), and probiotics have been shown in clinical trials to reduce eczema symptoms.

Dry skin and severe itching are the hallmarks of atopic dermatitis. Eczema often oscillates between periods of exacerbation (flare-ups) and periods in which symptoms lessen. In addition, diagnostic criteria indicate the following may be present¹²:

• Red bumps (papules) and rash-like patches, which may be dark brown or purple in darker skin tones
• Oozing and crusting along with small fluid-filled blisters (occasionally)
• Scaling and cracking
• Changes in skin pigmentation
• Skin thickening and darkening over time

Young children may be affected on the cheeks and scalp or may have a widely distributed eczematous rash, whereas the backs of the knees and folds of the elbows are more likely to be affected in older children and adults.¹²

Other forms of dermatitis may cause slightly different symptoms, such as coin-shaped lesions in nummular dermatitis.¹³

The common underlying feature of all types of dermatitis is dysfunction of the skin barrier. This is why topical therapies are important in managing symptoms. In a vicious cycle of impairment, the breakdown of healthy skin function can lead to immune system hyperactivation, triggering inflammation and susceptibility to allergies, and disrupt the skin microbiome, resulting in more immune activation, inflammation, and skin barrier dysfunction.¹⁴

The Anatomy and Function of Skin

Skin is the largest of the body’s organs and consists of three layers: the epidermis, dermis, and hypodermis.¹⁵ The skin’s barrier function includes acting as the body’s first defense against solar radiation; physical trauma; and toxic, infectious, and allergenic threats in the environment. Critically, skin helps protect against water loss.^16,17 The ability of the skin to act as a barrier relies on mechanical, chemical, immunologic, and microbial means.¹⁷

Figure 1: Skin showing changes due to dermatitis. Credit: Designua, Shutterstock

Skin Barrier Dysfunction

The stratum corneum, the outermost surface of the epidermis, is made up of specialized cells (corneocytes) that are tightly connected in a strong matrix of proteins (eg, keratin and filaggrin) and lipid compounds (eg, cholesterol, ceramides, and free fatty acids).¹⁷ The breakdown of lipids into free fatty acids helps maintain an acidic pH on the skin surface, which inhibits colonization by pathogens.¹⁸ Filaggrin is also a source of breakdown products that have antimicrobial action and are part of a group of surface compounds known collectively as natural moisturizing factor.^12,19 The stratum corneum regulates skin permeability, controlling water loss and preventing invasion of foreign substances and pathogens. An impaired stratum corneum, typically characterized by increased pH (lower acidity), decreased filaggrin, and changes in ceramide concentrations, is the defining feature of skin barrier dysfunction and a key characteristic of dermatitis.^12,19,20 Age-related impaired skin barrier function may play a role in eczema in older individuals.²¹

Figure 2: Dermatitis. Credit: VectorMine, Shutterstock.

Immune Dysfunction

Skin cells (keratinocytes) and immune cells residing in the epidermis are responsible for initiating an immune response to pathogens and other foreign substances. Allergic and other types of skin disease characterized by immune over-activation are important contributing factors in many cases of dermatitis.¹⁶ A subgroup of eczema patients have been found to have high serum levels of IgE antibodies, which activate release of histamine. High IgE levels in eczema patients indicate allergic sensitization and are associated with an increased risk of developing food allergies, allergic rhinitis (hay fever), and asthma.^16,22,23 In fact, children with eczema have been reported to have a six-fold higher risk of developing a food allergy (IgE-mediated), as well as three-fold higher risk of both allergic rhinitis and asthma later in life.^24-27 About 50–75% of children with eczema will develop allergic rhinitis and asthma, a phenomenon known as “atopic march,” and the risk increases with severity of eczema.²⁴ In atopic march, skin barrier dysfunction related to eczema allows allergens to penetrate the body, perpetuating skin inflammation as well as sensitizing the immune system and triggering allergic reactions.^24,28 In older adults, age-related changes in immune function, such as immune senescence, may be a contributing factor in the manifestations of atopic dermatitis.^5,21 In addition, non-allergic chronic conditions have been found to be more prevalent in elderly individuals with eczema than those without eczema.⁵

Microbiome Imbalance

The skin microbiome is critical for creating an environment that is inhospitable to pathogens and regulating healthy immune activity in the skin and preventing skin disease. Imbalance in the bacterial and fungal communities (such as yeast, or Candida spp.) living on the skin is a common feature in dermatitis and contributes to barrier dysfunction and immune dysregulation.^14,18,29,30 The skin microbiome is influenced by internal conditions (eg, genetics and aging) and external exposures (eg, allergens, hard water, and pollution).^21,31 A number of studies have also reported alterations in the gut microbiomes of eczema patients, including infants who later developed eczema, suggesting gut microbial imbalance (dysbiosis) may be a contributing cause of dermatitis. Gut dysbiosis has body-wide effects on immune function that can result in poorly controlled inflammatory responses in diverse tissues, including skin.^32,33

Some risk factors for dermatitis cannot be changed. Non-modifiable risk factors include:

• Family history. Family history of allergies, such as eczema, asthma, or allergic rhinitis (hay fever), is the strongest risk factor for eczema.¹²
• Allergies. Allergies are closely linked to, and appear to exacerbate, eczema.^12,16,24
• Female gender. Being female may increase eczema risk.³
• Being very young. This increases risk, since an estimated 70–85% of eczema cases begin by the age of five years.^22,34 About 60% of these cases resolve during adolescence.³⁵

Other factors correlated with eczema risk may be modifiable, such as:

• Infant formula feeding. Infants fed formula or solid food in the first few months of life have a higher risk of allergic disease, including eczema, than those fed only breast milk during their first four to six months.^36,37
• Antibiotic exposure. Children treated with antibiotics in the first years of life have been found to be more likely to develop eczema, as well as asthma and allergies.³⁸
• Environmental exposure. Urban children are more prone to eczema than their rural counterparts. This may be due to increased pollution in urban settings, and/or the “hygiene hypothesis,” which asserts that early exposure to certain non-pathogenic microbes (eg, through contact with farm animals, pets, siblings, and other children), builds natural immune tolerance.¹² Pollution has also been implicated in the rising onset of new eczema in elderly individuals.³⁹
• Obesity. Obesity, especially in childhood, has been correlated with eczema.⁴⁰
• Living at higher latitudes. Individuals who live at higher latitudes tend to have lower serum vitamin D levels, a factor that has been correlated with increased risk and severity of eczema in some studies.^41,42 This also may be due to less exposure to UV light in early infancy.⁴³
• Hard water. Observational studies have found eczema is more common in regions with increased levels of water hardness.³¹
• Nutrient deficiencies. Deficiencies of essential nutrients, including vitamin A and carotenoids, vitamin D, vitamin B6, zinc, selenium, and essential fatty acids, may contribute to eczema, as well as other skin and allergic conditions.^44-46
• Stress. Stress can aggravate all types of dermatitis.⁴⁷

Topicals

Daily use of moisturizers is a cornerstone of therapy for dermatitis and eczema. In fact, most studies show that, for eczema, twice-daily application is indicated.⁵⁵ Properly formulated moisturizers can help repair skin barrier function, and clinical research shows daily moisturizer use is beneficial in children and adults with eczema. Furthermore, continuous use of moisturizers may help prevent eczema in infants at high risk.^55,56

Therapeutic moisturizers should have a similar acidity to skin, with a pH of 4-5, and may contain any of the following^55,57:

• Occlusives (protectants), such as lanolin, petrolatum, mineral oil, waxes, dimethicone, and silicone, block water loss through the skin, provide protection against skin irritants, and may reduce inflammation.^55,57,58
• Humectants (hydrating agents) like glycerin, hyaluronic acid, urea, and lactate are used to draw moisture from the environment and deeper skin layers.^55,57,59
• Emollients (moisturizing agents) provide fatty acids that penetrate the spaces between corneocytes, softening the skin surface.^59,60 Plant oils, especially those rich in linoleic acid or gamma-linolenic acid (eg, sea buckthorn oil and borage oil), are emollients sometimes included in therapeutic moisturizers, and may help inhibit inflammation and improve skin barrier function.⁵⁷
• Therapeutic agents are added to moisturizers for their specific actions. For example, the US Food and Drug Administration (FDA) requires all over-the-counter moisturizers claiming to help treat eczema to contain either a low-potency steroid (hydrocortisone) or colloidal oatmeal, a moisturizing skin protectant with anti-inflammatory, antioxidant, and anti-itch effects.⁵⁵ Ceramides are another therapeutic ingredient in some moisturizers, and it has been proposed that combining them with cholesterol and free fatty acids may lead to the greatest benefit.⁵⁷ Other potentially therapeutic ingredients for topical use include antioxidants and skin probiotics.^55,59,61
• Wet wraps. Application of moisturizing and/or therapeutic agents underneath a wet layer of clothing or a bandage may be useful as well. A dry layer of clothing or bandage is placed on top of the damp layer and left over night to sooth flare-ups.⁶²

Daily bathing or showering with warm, but not hot, water for 5–15 minutes promotes skin hydration.^69,70 The use of gentle cleansers, only if needed, is recommended. After bathing, patting (rather than rubbing) dry and immediately applying an appropriate moisturizer is recommended.⁶⁹

Bleach baths, performed using a 0.005% solution of sodium hypochlorite (typically made by adding ¼–½ cup of 6% household bleach to 40 gallons of water),⁷¹ have long been recommended for treating eczema.⁷² Bleach baths have been reported to improve eczema symptoms, decrease inflammation and itching, and restore a healthy skin microbiome by reducing the presence of Staphylococcus aureus, a potential pathogen and frequent colonizer of eczematous skin.⁷³ Laboratory models, however, have been unable to demonstrate antiseptic effects from a 0.005% sodium hypochlorite solution,⁷¹ suggesting bleach baths may have more direct anti-inflammatory and anti-itch effects.⁷² Nevertheless, their benefits appear to be modest: A systematic review and meta-analysis that included data from 10 randomized controlled trials with a total of 307 participants found bleach baths were likely to reduce eczema severity, as reported by a clinician, by roughly 22%, but did not have meaningful and consistent impacts on other outcomes important to eczema patients.⁷⁴ It is important to note more concentrated solutions are not safe and may worsen skin barrier function and cause serious injury.⁷¹

Identifying and avoiding triggers, including allergens and irritants, can be a key practice for some individuals with dermatitis. Common triggers include soaps and detergents, fragrances, wool, temperature and humidity extremes, tight clothing, and stress.⁶⁹ Frequent hand washing and prolonged use of personal protective gear like medical gloves and face masks can also aggravate eczema and dermatitis; gentle cleansers and frequent use of moisturizers may help those whose work or daily activities require exposure to these kinds of skin irritants.⁷⁵

Food allergies and sensitivities, while unlikely to be the main cause, may be an important contributing factor in atopic dermatitis, particularly in moderate-to-severe cases. Studies indicate as many as 53% of children with eczema have food allergies detectable with skin prick or blood tests, and up to 33% of those with moderate-to-severe eczema show reactions on food challenge tests.⁶⁹

Cow’s milk, chicken eggs, peanuts, and soybeans are the most common food triggers in younger children, while older children are more likely to react to wheat, tree nuts, fish, and shellfish.⁶⁹

Food sensitivity (involving IgG antibodies) or allergy (IgE-mediated) testing may be helpful in determining whether certain foods are aggravants in cases of persistent eczema.

An elimination diet in particular has been shown to be a useful tool for identifying trigger foods and generating an individualized dietary plan.⁷ In addition, high intakes of fast foods, highly processed foods, meat, and energy drinks have been linked to increased eczema risk, while consumption of fermented foods (like kimchi and yogurt) has been correlated with decreased risk.^8-11

Vitamin D

Adequate vitamin D levels are important to a number of skin conditions, including eczema.⁷⁶ Meta-analyses of data from observational studies indicate blood vitamin D levels are lower in atopic dermatitis patients than those with healthy skin.^41,77 Another systematic review and meta-analysis that included findings from four observational studies noted children born to mothers with lower vitamin D status during pregnancy had a higher risk of developing eczema.⁷⁸

A placebo-controlled trial with 65 eczema-affected participants used a vitamin D dose of 125 mcg (5,000 IU) per day for 12 weeks, in conjunction with standard therapies, and found those who achieved a blood vitamin D level of 20 ng/mL (50 nmol/L) or higher experienced symptom score improvement.⁷⁹ Another placebo-controlled trial with 24 subjects found 50 mcg (2,000 IU) vitamin D daily for four weeks not only improved eczema symptom scores but also led to reduced skin colonization by S. aureus, a bacterium associated with skin barrier dysfunction.⁸⁰ A meta-analysis of data from four randomized placebo-controlled trials found vitamin D supplementation, at doses of 25 mcg (1,000 IU) or 40 mcg (1,600 IU) daily for 1–2 months, effectively reduced eczema symptom severity scores.⁷⁷ A more recent meta-analysis had similar findings.⁴¹

Gamma-linolenic Acid

Gamma-linolenic acid (GLA) is an omega-6 fatty acid with anti-inflammatory effects, and some evidence suggests individuals with atopic dermatitis have a deficiency of the enzyme needed to convert linoleic acid (a common plant-derived omega-6 fatty acid and an essential nutrient) to GLA.^81,82 Borage, evening primrose, black currant, and sea buckthorn oils are especially rich in GLA.⁸³ A randomized controlled trial in 50 eczema patients found evening primrose oil, at a dose of 1,800 mg or 3,600 mg (providing 160 mg or 320 mg of GLA, respectively) per day (depending on age), improved eczema symptoms more than the same dose of soybean oil after four months.⁸⁴ In another controlled trial with 130 adult subjects with dry skin or mild-to-moderate atopic dermatitis, a diet enriched with 200 mg GLA per day for 12 weeks improved skin hydration and reduced skin inflammation more than a diet enriched with a soybean/canola oil mixture.⁸⁵ A trial that included 50 individuals with atopic dermatitis found 500–6,000 mg of evening primrose oil daily, depending on age, for five months was more effective than sunflower oil at reducing eczema symptoms and improving clinical features. Other research in pregnant mothers and infants suggests GLA supplementation may delay the onset and reduce the severity of eczema in childhood.^86,87

Plant-derived Ceramides

Skin barrier dysfunction is a key component of dermatitis. Changes in concentrations of ceramides in the skin can contribute to impaired skin barrier function. As a result, ceramides have been increasingly used in topical formulations to protect the integrity of the skin and improve skin hydration.

Ceramides can be formulated into oral preparations as well. These formulas may contain ceramides derived from various plant-based sources such as wheat and konjac. Oral ceramides have been proposed for use in skin conditions such as dermatitis and eczema. Several animal models have shown that oral administration of plant- or bacterial-derived ceramides improved stratum corneum water content, reduced transepidermal water loss, suppressed expression of inflammatory cytokines (eg, interleukin-1 beta [IL-1β] and IL-6), and improved skin flexibility and recovery.^162-164

Oral intake of plant-derived ceramides has been shown to improve several aspects of skin health in clinical studies as well. In one clinical study, children with atopic dermatitis were given 1.8 mg daily of konjac-derived ceramides or placebo for two weeks. By the end of the study, skin symptoms and allergic responses improved in the 25 children in the treatment group, but not in the 25 children in the placebo group.¹⁶⁵ The same dosage of ceramides was shown to decrease transepidermal water loss in 42 healthy adults after 8-12 weeks compared with placebo.¹⁶⁶ And in 14 adult participants aged 20-54 years with mild-to-moderate atopic eczema, 1.8 mg daily of ceramides from konjac decreased transepidermal water loss after 2-8 weeks compared to baseline.¹⁶⁷ In a clinical study that enrolled 51 participants randomized to receive placebo or 5 mg per day of ceramides from a konjac extract, intake of ceramides significantly decreased skin dryness, redness, and itching after 3-6 weeks.¹⁶⁸ Ceramides derived from wheat have also been shown to improve skin health: a placebo-controlled trial that enrolled 51 women aged 20-63 years with dry skin found that 350 mg of wheat extract oil, rich in ceramides, improved skin hydration after three months of use compared with placebo.¹⁶⁹

Probiotics

Numerous clinical trials have shown oral probiotic supplements can reduce both the risk and severity of eczema. Thorough reviews of randomized controlled trials have found certain probiotics, when taken during pregnancy or given during infancy or childhood, can be effective in preventing and treating atopic dermatitis. The best effects have been demonstrated using Lactobacillus species, usually in combination with Bifidobacterium species.^88-90 Probiotic strains of L. paracasei, L. rhamnosus, L. acidophilus, L. GG, L. casei, L. salivarius, L. plantarum, B. longum, B. animalis subspecies lactis, and B. bifidum, used in various combinations providing a total of 1 billion colony forming units (CFUs) or more per day, are among those found to have positive effects on atopic dermatitis.^88,89

Whey Protein

Whey protein comes from cow’s milk and differs from casein (the main cow’s milk protein) in its make-up, consisting of lactoglobulins, immunoglobulins, bovine albumin, and lactoferrin.⁹¹ Small peptides resulting from partial hydrolysis of whey protein are thought to stimulate balanced immune activation leading to enhanced immune tolerance.⁹² A meta-analysis of findings from eight randomized controlled trials found a partially hydrolyzed whey infant formula, in place of or in addition to breast milk, reduced eczema risk compared with cow’s milk-based formulas in infants with a high risk of allergy and eczema due to family history.⁹³ The results of a review of eight clinical trials further suggests partially hydrolyzed whey-based formula may reduce the risk of atopic dermatitis not just in high-risk infants but in the general infant population, while supporting normal growth and development.⁹⁴ Animal research suggests partially hydrolyzed whey formula improves skin barrier function,⁹⁵ which may account in part for its beneficial effects in the context of eczema.

It is important to note that partially hydrolyzed whey-based formulas are not appropriate for infants known to have cow’s milk allergy.⁹⁶

Vitamin E

Vitamin E is a fat-soluble nutrient that lowers oxidative stress and protects fatty compounds in the body from free radical damage. It has long been known to have an important role in skin health, and low levels have been observed in people with various inflammatory skin problems, including atopic dermatitis.^97,98 In a randomized placebo-controlled trial in 70 subjects with atopic dermatitis, 400 IU of vitamin E (form not specified) daily for four months reduced eczema symptoms.⁹⁹ A placebo-controlled trial with 45 participants found 600 IU of dl-alpha-tocopherol (equivalent to about 300 IU of active d-alpha-tocopherol) per day and 40 mcg (1,600 IU) of vitamin D3 per day each reduced eczema symptoms more than placebo, but treatment with both vitamin E and vitamin D had an even greater positive effect.¹⁰⁰ Another trial included 96 subjects with atopic dermatitis and compared treatment with 400 IU of d-alpha-tocopherol daily to placebo. After eight months, great improvement or near complete resolution occurred in 30 (60%) of 50 vitamin E-treated participants but only 1 (2%) of 46 of those given placebo.¹⁰¹

Topical vitamin E is frequently recommended as part of atopic dermatitis treatment.¹⁰² A cream containing vitamin E as well as green tea catechin (epigallocatechin gallate, or EGCG) and grape seed procyanidins improved skin symptoms more than a placebo cream in a 28-day clinical trial that included 44 participants with atopic dermatitis affecting the face and/or neck.¹⁰³ Despite its safety, rare cases of contact dermatitis due to an allergic reaction to topical vitamin E have been reported.¹⁰⁴

Melatonin

Sleep disorders are common in those with atopic dermatitis, and while intense itching is an obvious factor, evidence suggests it does not fully explain the relationship.^53,54 Poor sleep plays a role in diminished quality of life and triggers a stress response that may even contribute to worsening eczema, thus leading to a vicious cycle.¹⁰⁵ Melatonin, a hormone produced in the brain as well as in skin cells, is thought to have a role in dermatitis.¹⁰⁶ Melatonin not only regulates circadian rhythms like the sleep and wake cycle, it also reduces skin oxidative stress and inflammation, protects skin against solar radiation damage, and appears to promote wound healing and skin barrier health.^53,54,106

An observational study noted lower melatonin levels were associated with greater eczema severity, more intense itch, and poorer sleep in 36 adults with atopic dermatitis.¹⁰⁷ A randomized controlled trial investigated the effect of 6 mg of melatonin nightly in 70 children, aged 6–12 years old, with eczema. After six weeks, melatonin-treated children had greater improvement in scores on a symptom severity index and a sleep habit questionnaire compared with those given placebo, although no improvement in itching, time to fall asleep, or total time asleep were recorded. In addition, melatonin decreased levels of IgE, an antibody type linked to atopic dermatitis and other allergic conditions.¹⁰⁸ In a crossover trial in 48 children aged 1–18 years old with atopic dermatitis, 3 mg of melatonin nightly for four weeks was more effective than placebo at reducing eczema symptom scores and shortening the time to fall asleep.¹⁰⁹

Topical melatonin may have advantages over oral melatonin since it raises skin melatonin concentration while bypassing metabolism in the digestive tract.¹⁰⁶ A study using a mouse model of atopic dermatitis indicated topical melatonin may also have beneficial effects.¹¹⁰

Omega-3 fatty acids

Omega-3 fatty acids, like eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) from fish oil, have well-known anti-inflammatory effects. Some research suggests higher intake of these fatty acids during pregnancy and nursing is associated with lower risk of infant and childhood eczema and other allergic conditions, but not all studies agree.^111,112 Likewise, most, but not all, studies have noted a correlation between higher fish intake during infancy and childhood and lower incidence of allergic diseases including atopic dermatitis.¹¹³ In a controlled trial that included 53 adults with atopic dermatitis, eight weeks of treatment with 5.4 grams of DHA daily resulted in reductions in eczema symptoms scores compared with a saturated fat placebo.¹¹⁴ A trial that included 31 atopic dermatitis patients given either 10 grams (about 2 teaspoons) of fish oil, providing 1.8 grams of EPA, daily or a placebo containing olive oil found fish oil-treated subjects had greater reductions in scaling, itching, and overall severity after 12 weeks.¹¹⁵ In another trial in 22 patients with moderate-to-severe eczema, 10 days of daily intravenous (IV) treatments with 200 mL of a 10% fish oil emulsion or a 10% soybean oil (high in the omega-6 fatty acid, linolenic acid) emulsion led to improvements in eczema symptoms, but the benefits were greater in those treated with IV fish oil.¹¹⁶

Zinc

Zinc is needed for normal skin function and repair, and zinc deficiency has been reported to be more common in those with atopic dermatitis.¹¹⁷ However, few clinical trials have examined the use of zinc to treat eczema. A controlled trial in 58 children with eczema, aged 2–14 years, whose hair zinc levels were low found 12 mg of zinc (as zinc oxide) daily for eight weeks reduced itching and improved skin hydration.¹¹⁸ However, zinc sulfate, at a dose of 185.4 mg (equivalent to about 43 mg of elemental zinc) daily, did not improve symptom severity in an eight-week placebo-controlled trial in 50 children aged 1–16 years with atopic dermatitis and unknown zinc status,¹¹⁹ suggesting appropriate dosing and patient selection may be key to getting good results.

Topical zinc may also have a role in managing atopic dermatitis. In an uncontrolled clinical trial, a zinc oxide cream that contained anti-inflammatory herbal extracts and starch was used to treat 30 children with mild-to-moderate atopic dermatitis affecting the face, arms, or trunk. After six weeks, 87% of the children had >50% improvement in eczema symptom severity scores.¹²⁰ One interesting study found that sleeping in garments made with a zinc oxide-impregnated material for three consecutive nights reduced symptom severity and itching and led to improved sleep in individuals with atopic dermatitis.¹²¹

Honey

Honey is a complex substance made mostly of fructose and glucose, but is also rich in flavonoids, organic acids, and other phytochemicals, some of which have potent anti-inflammatory, oxidative stress-reducing, and antimicrobial capacities.¹²² In an uncontrolled pilot trial, 16 atopic dermatitis patients with two or more similar lesions were given pure manuka honey to apply to some of their lesions every night for seven consecutive nights, covering it with gauze and washing it off in the morning. Two patients experienced worsening of their skin symptoms within two nights and discontinued honey treatment; however, in the remaining 14 participants, treated lesions improved while untreated ones did not. In addition, three (21%) of the 14 reported sustained improvement one year later.¹²³ One study found a topical compound made of equal parts honey, beeswax, and olive oil substantially improved symptoms in eight (80%) of 10 untreated atopic dermatitis patients. In the same study, 11 atopic dermatitis patients who were being treated with topical corticosteroids replaced this treatment with a corticosteroid plus honey/beeswax/olive oil mixture, using varying ratios. Five (45%) of the 11 had no worsening of symptoms even after using a formula providing 75% less corticosteroid than they had been using at the beginning of the study.¹²⁴

Curcumin

Curcumin, a yellow pigment flavonoid from turmeric, has well-known anti-inflammatory effects. Preclinical evidence indicates both oral and topical curcumin may have a role in treating skin disorders, including atopic and contact (or irritant) dermatitis.^125,126 In an open clinical trial that included 42 atopic dermatitis patients receiving standard topical care, those who also took 500 mg of curcumin phytosome (a bioavailable form of curcumin) twice daily had better skin hydration and elasticity and lower symptom severity compared with those who used standard measures alone.¹²⁷ A cream made with extracts of six medicinal herbs, including turmeric, was reported to decrease eczema symptoms after four weeks in 150 atopic dermatitis patients.¹²⁸ In a placebo-controlled trial with 96 participants, 1 gram of curcumin daily for four weeks reduced itching and increased quality of life in men with chronic dermatitis due to toxic mustard exposure.¹²⁹ Studies in mice suggest curcumin can suppress the inflammatory response involved in atopic dermatitis and lower the risk of progressive allergic disease.^130,131

Quercetin

Quercetin is one of the most abundant flavonoids in the diet and has been shown to inhibit inflammatory signaling and reduce histamine release. Numerous laboratory and animal studies indicate quercetin has the potential to help in treating atopic dermatitis.^132,133 In 10 nickel-allergic volunteers, taking 2 grams per day of quercetin for three days reduced their nickel reactions: eight subjects had 50% reductions and two had 100% reductions in their reactions.¹³⁴ In addition, 1 gram of quercetin, taken two hours before light exposure, was reported to reduce photosensitivity dermatitis (an eczema-like reaction to light [usually sunlight] exposure) in a study with nine subjects.¹³⁴

Vitamin C

Vitamin C is a water-soluble free radical scavenger that is highly concentrated in the skin’s outermost layer.¹³⁵ Vitamin C has an important role in maintaining the skin barrier, and some evidence suggests it has anti-histamine and anti-allergy effects.^135-137 Skin affected by atopic dermatitis has been found to have lower vitamin C concentrations than healthy skin.¹³⁸ A study in 17 adults with atopic dermatitis found decreasing blood vitamin C levels were associated with decreasing skin ceramide (a protective lipid) levels and increasing severity of eczema symptoms.¹³⁹ A study that included 65 women with a history of allergies found a diet richer in vitamin C increased vitamin C levels in breast milk and was associated with lower incidence of atopic dermatitis in their offspring during their first year of life; however, supplemental vitamin C had no effect on breast milk levels or risk of atopic dermatitis in the infants.¹⁴⁰ Although vitamin C is not easily absorbed into the skin, a topical cream containing vitamin C in a zinc oxide base was found to reduce skin inflammation in a mouse model of atopic dermatitis.¹⁴¹

Vitamin A and Carotenoids

Vitamin A is a fat-soluble essential nutrient needed for immune function and healthy mucosal (eg, lining of the gut and respiratory system) and epithelial (eg, skin) barrier function. Vitamin A deficiency is associated with skin inflammation, poor wound healing, disruption of the skin microbiome, and increased skin infection risk.¹⁴² Carotenes are precursors to vitamin A and, along with related compounds called carotenoids, have unique immune-modulating and antioxidant effects. Observational evidence indicates individuals with atopic dermatitis have abnormal vitamin A metabolism, lower skin and blood levels of vitamin A, and lower blood levels of the carotenoids lutein and zeaxanthin.^46,143 Studies in animal models of atopic dermatitis indicate beta-carotene and the carotenoid astaxanthin may have anti-eczema effects.^144,145

Sea Buckthorn

Sea buckthorn oil is rich in flavonoids, carotenoids, polyunsaturated fatty acids (like GLA), and other phytochemicals, and has been used historically to treat dermatitis and other skin disorders. Preclinical evidence shows it may possess antimicrobial, anti-inflammatory, and wound-healing effects.¹⁴⁶ One laboratory study indicated sea buckthorn oil may reverse the negative effects of S. aureus on skin cell function,¹⁴⁷ and several animal studies suggest it can reduce eczema.^148,149 A clinical trial in 49 atopic dermatitis patients found 5 grams of oil derived from sea buckthorn’s fruit pulp, taken daily for four months, led to significant symptom improvement.¹⁵⁰

In cases of atopic dermatitis that does not improve sufficiently with self-care and nutritional approaches, a health care provider may suggest topical anti-inflammatory agents, such as topical corticosteroids or the calcineurin inhibitors tacrolimus (Protopic) or pimecrolimus (Elidel), as the first line of therapy.^5,151,152 It is important to note that long-term use of topical corticosteroids can have a number of negative effects, including damaging skin structure, causing rebound inflammation and dilation of superficial capillaries, interfering with skin repair, and increasing susceptibility to skin infections.¹⁵³ Therefore, people with eczema should discuss the use of these topical medications with a qualified health care provider.

Newer topical medications for atopic dermatitis include crisaborole (Eucrisa, a phosphodiesterase 4 inhibitor) and ruxolitinib (Opzelura, a Janus kinase inhibitor), both of which suppress inflammation.¹⁵¹

Oral antihistamines are sometimes helpful in conjunction with these therapies, especially for reducing itch, and oral antimicrobials may be useful in cases with apparent infection.^5,152,154 Oral antihistamines like diphenhydramine (Benadryl) or cetirizine (Zyrtec) are sometimes prescribed for itching due to eczema; however, many eczema patients experience intractable itch that does not respond fully to antihistamine therapy.^151,155 Emerging preclinical and clinical evidence suggests agents that inhibit H4 histamine receptors (as opposed to the H1 histamine receptors targeted by traditional anti-allergy medications) may have a role in treating skin disorders characterized by itch.¹⁵⁶ Generally, sedating (first-generation) antihistamines are preferable for night time use, and non-sedating (second-generation) antihistamines are better suited for daytime use.

Light therapy using narrow-band ultraviolet B light has been found to benefit those with chronic, moderate-to-severe, atopic dermatitis.¹⁵⁴

Oral immunosuppressive drugs are sometimes recommended in moderate-to-severe cases or flare-ups, but all these medications can cause serious adverse side effects and are best used short-term. They include oral corticosteroids like prednisone (Deltasone), or alternatives such as cyclosporine (also spelled ciclosporin) (Sandimmune), dupilumab (Dupixent), methotrexate (Rheumatrex), or azathioprine (Imuran).¹⁵⁴

Allergen-specific immunotherapy may be useful as well. Immunotherapy involves regular, repeated exposure to low doses of the allergen thought to contribute to symptoms. Over time, the repeated low-dose exposures may help “train” the immune system to tolerate the trigger rather than react to it with inflammation. Immunotherapy is generally delivered under the skin (subcutaneous) or under the tongue (sublingual).¹⁵⁷

What is atopic dermatitis?

Atopic dermatitis, which is also called eczema, is a common red, itchy skin condition related to allergies.¹

How is atopic dermatitis treated?

Daily use of therapeutic moisturizers is the cornerstone of eczema treatment. Steroid creams and other anti-inflammatory treatments are widely used during flare-ups.¹⁵¹

What causes atopic dermatitis?

The cause is multifaceted, and may include immune over-reactivity (like allergy), changes in the gut and skin microbiomes, pollutants in the environment, and other factors.^12,14,32

Is atopic dermatitis contagious?

No, you cannot get atopic dermatitis from someone with this condition.

Is atopic dermatitis the same as eczema?

Typically, the term eczema is used to mean atopic dermatitis, but sometimes it is used more broadly to describe any type of skin inflammation.¹

What does eczema look like?

Usually, eczema appears as pink, red, dark brown, or purple patches, and red bumps. More severe eczema may have scaling, cracking, oozing, and crusting. Over time, skin with eczema becomes thickened due to chronic scratching.¹²

Can you treat eczema without steroids?

Yes, many people manage mild eczema with careful bathing and moisturizing habits; avoiding allergenic foods; reducing stress; taking targeted supplements; and occasionally using over-the-counter, steroid-free, topical medications.¹⁵¹

How do you treat eczema on the scalp?

Seborrheic dermatitis (commonly referred to as dandruff) is very similar in appearance to eczema, but it is local to regions with hair, like the scalp. This condition is commonly treated with a medicated shampoo, however, topical steroids may be prescribed.¹⁵¹

How do you treat eczema around the eyes?

Eczema around the eyes may lead to serious complications, including those that may impact vision, and should be treated by an eye specialist, known as an ophthalmologist.¹⁵⁸

What nutrients may be good for eczema?

Vitamin D,¹⁵⁹ gamma-linolenic acid,¹⁶⁰ probiotics,⁹⁰ whey protein,¹⁶¹ and vitamin E¹⁰⁴ are some nutrients that may help with eczema.

How is eczema diagnosed?

Several diagnostic criteria have been developed to help facilitate eczema diagnosis and epidemiologic study. The diagnosis is generally made clinically by an experienced health care provider.