Atopic Dermatitis

Eczema is a genetic and environmental condition that is associated with skin lipid deficiencies, lipid production deficiencies, and filaggrin mutations.  A filaggrin mutation prevents your skin from making a very important protein that helps the skin to hold on to water.This mutation is present in approximately 50% of people who have atopic dermatitis.

These problems leave the skin excessively disrupted, dry, itchy and result in an elevated skin pH.  Elevations in skin pH lead to the breakdown of the enzymes that manufacture skin lipids and also make the skin more susceptible to infection with Staph. aureus and candida.

The skin barrier becomes disrupted, even more itchy susceptible to infection with Staph. aureus, and develops allergy to many chemicals that are applied to it.

Who Gets Atopic Dermatitis & At What Age?

Atopic dermatitis usually begins in infancy, but can begin in adulthood as well. There is a broad spectrum of disease severity; from very mild, to mild-to moderate, to moderate to severe, and severe.

New onset atopic dermatitis in an adult is quite rare and can often be confused for similar-looking conditions like a systemic contact dermatitis and must be carefully evaluated.

It is difficult to live with atopic dermatitis.  There is constant itching, scratching, bleeding, infection and loss of sleep. By addressing the myriad problems of atopic dermatitis simultaneously, one can gain and maintain control of their eczema.

What is it like to have Atopic Dermatitis?

In simple terms… it stinks. Hayden, age 9, explains her experience with Atopic Dermatitis:

 Before & After Treatments

Severe Atopic Dermatitis

In severe atopic dermatitis, the face is dry and scaly with dark circles under the eyes. My general feeling is that kids whose faces look like this seem to have some environmental allergies (hayfever) and asthma more so than kids whose faces don’t look like this. I have seen some benefits from sublingual allergy therapy in these children. Severe Atopic Dermatitis requires dedication and commitment to treat.

Moderate Atopic Dermatitis

Moderate atopic dermatitis affecting the folds of the body. This area is particularly susceptible to eczema due to the lower pH and resultant accommodating environment for the growth of Staph. aureus.

Mild Atopic Dermatitis

Mild atopic dermatitis can affect any part of the body just as it does in more severe forms of atopic dermatitis. If you or your baby have very mild disease, be sure to moisturize it at least twice a day.  This can prevent it from continuing and may even clear it up completely. Mild atopic dermatitis in a 11 year old boy before and after three weeks of TrueLipids Relieve & Protect Ointment 2x/day.

What can make your Atopic Dermatitis Flare?

 1. Sickness or Illness

Atopic Dermatitis will flare when you are sick.  When you have an illness like the flu or another virus, your body produces inflammatory molecules that help your immune system to fight of the infection. Unfortunately, those same inflammatory molecules drive your eczema and will often make it flare. Here are a few simple solutions:

• Use your hypoallergenic moisturizers twice as often as you normally would.
• Be sure to be vigilant in taking care of your eczema when you are sick.  You may need a few extra doses of a topical steroid, or you may need topical steroids if your eczema is under control.

Our friend Hayden learns how to keep her eczema under control when she is sick:

2. Irritant Reactions to Skin Care Products

When your eczema is active and in full force, it is next to impossible to tell if you are allergic to or irritated by something in your skin care products. Many of my patients have found that once they get their eczema under control, using a small amount of a new (or old) product first is a good idea and an easy way to tell if they are allergic to it.

Because your skin is normal, you will actually be able to tell if there is a problem.

Our friend Hayden learns that she cannot use certain baby sunscreens that she used to use before when her eczema was severe.  The sunscreen was probably part of the problem:

 3. Allergic Reactions to Chemicals in Your Skin Care Products

Allergic contact dermatitis; an allergic reaction to chemicals that come in contact with the skin, is an extremely common problem in children and adults who have atopic dermatitis.

The most effective method for determining if and what one is allergic to is patch testing. Patch testing is often not considered in children, but really should be.

Some studies have shown that up to 90% of children who are patch tested will be allergic to at least one relevant chemical. When you know what you are allergic to, you can learn how to avoid it and may find that your eczema will finally able to brought under control.

Here is a case of allergy to bacitracin. This patient had been putting Neosporin® on all of her scabs an itchy spots of eczema. Once she learned that she was allergic to bacitracin, which is in Neosporin®, she was able to avoid it. While this did not make her eczema go away, it made it significantly easier to get it under control.

4. Infection

Infection with Staph. aureus, Strep., molluscum and strep can commonly be a problem in exacerbating and making atopic dermatitis recalcitrant to treatment. It is important to treat the infection in order to calm down the eczema.

After eczema, many people say it is weird to have normal skin.

Important Points to Remember

1. Moisturize Your Skin

Do this at least 2x per day, and preferably, 4x per day. I have noticed that my patients who moisturize four times a day will get better faster and seem to be much more likely to keep their skin under control than those who don’t moisturize or who only moisturize two times a day.

Preventative moisturization studies have been done on the infant siblings or children of those who have eczema.  Normally, between 50-80% of these infants will develop eczema.  When these babies were moisturized twice a day, a very significant number of them did not develop eczema though they statistically would have. (Simpson et. al., 2010)

This study is one of the most insightful studies on atopic dermatitis of all time.  It tells us is that our immune system is a very important part of skin and that the skin is a very big part of the immune system.  When the skin barrier is disrupted, the immune system is left wide open to the environment and can easily trigger an inflammatory and/or allergic response.

This inflammation leads to the atopic march; the onset of eczema followed by asthma and hayfever.  In my opinion, it is likely that preventative moisturization will likely also prevent the onset of asthma in children.

2. Lotion is Not a Good Moisturizer for Eczema

Lotions are generally made with a very high water, and very low oil content. For very mild eczema on the cheeks of babies or elsewhere, I may recommend a lotion,  but for most cases I will use something more moisturizing. The skin needs a moisturizer with a very high oil content so that it can hold water in the skin and prevent it from evaporating. This evaporation is called Transepidermal Water Loss or TEWL.

In general, the thicker a moisturizer is, the more effectively it will prevent TEWL from happening. So, a cream will be more effective at moisturizing than a lotion, and an ointment will likely be more moisturizing than a cream.

3. Layer Your Moisturizers

If you are trying to deliver more water content to the skin, one strategy can be layering higher water-content moisturizers underneath one that contains more oil. For example, you can apply a lotion or cream on the bottom followed by an ointment on top. This is my favorite way to moisturize dry, eczema-prone skin; a cream on bottom and ointment on top.

4. Don’t Use Soap

Well, unless you are stinky or dirty.

Soap is full of surfactants whose job is to remove dirt and OIL. Soaps are very efficient at removing the naturally occurring oils in the skin that are so vitally important for keeping the skin barrier intact and healthy. Some surfactants like sulfates have even been shown to potentiate the absorption of other allergenic chemicals when used on atopic skin. Soap should be reserved for areas like the face, armpits and bottom. Everywhere else should simply be rinsed with water.

5. Avoid Specific Products

You need to familiarize yourself with products that contain chemicals that are commonly allergenic in people who have atopic dermatitis. The following is a list of chemicals that have been found to be relatively common in people who have atopic dermatitis. For more in-depth information on each of these chemicals and how to avoid them, please visit our Toxins & Allergens page.

• Nickel sulfate
• Potassium dichromate
• Cobalt chloride
• Gold
• Phenylenediamine
• Tixocortol-21-pivalate
• Budesonide
• Betamethasone
• Clobetasol
• Dexamethasone
• Propolis

Fragrance Mix I: This is a mix of 8 fragrances, cinnamic alcohol, cinnamic aldehyde, eugenol, isoeugenol, feraniol, hydroxycitronellal, oak moss absolute, amylcinnamaldehyde. You can find this in baby lotions, soaps, deodorants, toothpaste, cosmetics, perfumes, colognes, scented candles and sprays, and essential oils.

Fragrance Mix II: This contains lyral, citral, farnesol, citronellol, hexyl cinnamaldehyde, coumarin, 3 myroxylon pereirae-based chemicals, specificallycinnamic aldehyde. It also contains many chemicals that are found in essential oils.

• Compositae
• Cocamidopropyl Betaine
• Balsam of Peru
• Neomycin Sulfate
• Bacitracin
• Benzalkonium chloride
• Glutaraldehyde
• Disperse Dyes (blue 106/124; yellow 3/9)
• Colophony
• Lanolin
• Carba Mix
• Cinnamic aldehyde
• Formaldehyde
• Formaldehyde releasing preservatives (including quaternium-15, imidazolidinyl urea, DMDM hydantoin, and 2-bromo-2-nitropropane-1,3-diol)
• Thimerosal

Not more common in people with atopic dermatitis, but common overall allergens  include methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) and sorbitan sesquioleate.

An emerging allergen is phenoxyethanol.  Phenoxyethanol has replaced parabens, formaldehyde releasers and MCI/MI in many formulations over the past few years and, because it is being more widely-used, more and more cases of allergic reaction are being reported.

*Note: while allergy to the paraben family of preservatives is not uncommon, parabens are not necessarily more allergenic in atopic dermatitis compared to people who do not have atopic dermatitis

6. If Needed, Use Topical Steroids

I understand the desire we all have to limit the use of topical steroids. This is why I make such a tremendous emphasis on skin barrier optimization and repair so as to limit the necessity for inflammation-calming steroids. On the other hand, if your skin is inflamed, the inflammation needs to be turned off.  Inflammation is like a little immunological fire. If you only put it part way out, it will come right back. On the other hand, if you completely put it out, chances are it won’t come back until another new fire is started.

There are many different strengths of topical steroids and the strength used is dictated by the location on the body where they are needed and by the severity of the eczema. For example, mild eczema can be treated with a very low potency steroid like 1% hydrocortisone. Inflammation is only one part of atopic dermatitis, but is it a pivotal part that, if ignored, all the other treatments in the world won’t do much. So, don’t be afraid to use steroids when you need to.

7. Do Not Under-Use Topical Steroids

I have many patients who come to see me and are frustrated that their eczema did not go away even though they had faithfully used their topical steroid prescription…..for two days. It will take time to reverse the inflammation involved in moderate and severe atopic dermatitis. Mild atopic dermatitis will be faster.

I always recommend using the topical steroids as long as the skin is inflamed and abnormal-looking; this means that even where the little hair follicles on the abdomen and trunk that are more prominent need a little whiff of steroid. As the skin heals and returns to looking completely normal, stop using the steroids IN THAT AREA. If you still have little patches of inflamed and abnormal skin, then keep using the steroid until it normalizes too.

8. Do Not Over-Use Topical Steroids

As discussed above, topical steroids should be used as long as the skin is still inflamed. Once the inflammation is gone and the skin normalizes, then taper off of the steroid while continuing your layered maintenance moisturization. This is your best bet for staying in control of your eczema.

9. Use the Right Strength

Make sure you use the right strength of steroid in the right place. A weak steroid like 1% hydrocortisone can be safely used almost anywhere on the body for relatively extended periods of time. In many cases, this may be all that is needed. For thicker, more inflamed areas of skin on the the arms or legs, then a stronger steroid may be indicated.

For very severe and thickened eczema on the hands and feet, a super potent steroid may be necessary for a week or two…or three. As the skin improves, you can step down in the potency of the steroid you are using and eventually use only 1% hydrocortisone until the skin is completely normal looking. The highest risk areas for stretch marks on the body are between the thighs, the armpits and breasts.

Luckily, these areas are seldom so severely affected that they need to be treated with very strong steroids. A 1% hydrocortisone is often sufficient.

10. Steroids Are Not Moisturizers

Unless they were specifically engineered to do so, steroids are not used to repair the structure of the skin barrier, the are used to turn off inflammation.  In fact, steroids have been shown to decrease skin lipid production, profilaggrin and filaggrin production, to decrease collagen production and to increase the skin pH. (Sheu et. al., 1997,and Sheu et. al., 1998)

Fortunately, the addition of skin barrier lipids and acidic buffering of the skin has been shown to reverse the skin lipid and pH defects caused by topical glucocorticoids. For this reason, be certain to use a moisturizer that replaces the skin lipids and optimizes the pH when you are using topical steroids.

11. Don’t Use Anything You’re Allergic To

Studies show that approximately 12% of people with atopic dermatitis are allergic to at least one class of topical steroid. Luckily, there are five different classes of steroids and if you are allergic to those in one class, you will likely be able to use one from another class. A steroid allergy can be very tricky to diagnose is if very often not-considered and missed.  A few things that may indicate a steroid allergy include

12. Get Patch Tested

Patch testing is a form of allergy testing that dermatologist do and which entails having some patches that are embedded with the suspected chemicals and are then applied to your skin. The patches are left in place for 48 hours in most cases and are then removed and your skin is evaluated for any reaction. The evaluation process is repeated 48 hours after this again.

13. Know If You’re Allergic

If your eczema is particularly severe, has recently flared, is worse around the hands, face and feet, or only clears with ultra-potent steroids, then you may be allergic to something that is coming in contact with your skin. Studies have shown that anywhere from 30 to 90% of people with atopic dermatitis who are patch tested are allergic to at least one chemical that their skin is exposed to.

In this study, the authors even recommend patch testing as a way to get off of steroids and other forms of immunosuppression. When you can find the culprit allergen and get it out of your regimen, your eczema will almost certainly improve..

14.Vinegar Baths

Vinegar has many antibacterial qualities and is often used for many different types of infection. While there are no randomized controlled studies using vinegar to treat atopic dermatitis, I recommend their use in my practice on a regular basis and have seen some wonderful benefits. Because the pH of tap water in many areas can be as high and 9 or 10, it may be best to buy a pH meter to test the pH of your water and include enough vinegar to bring the pH down closer to natural skin levels.

Another option is to do vinegar sprays or to apply a pH-adjusting gel to the most affected areas after bathing or after bleach baths. The purpose being here is to bring the pH down to the optimal area for skin lipid production. Tap water has been shown to elevate your pH outside of the range where skin lipids can be made for up to six hours! If we can help speed up this process, the skin may have more time to make the lipids that the skin barrier needs. See more below on the role of pH in the skin barrier.

15. Never Let Your Skin Form a Scab

I always tell my patients that no scab equals no scar (in most cases).  A scab is like a little rock sitting in the middle of a wound bed. There are new little skin cells that are trying to grow in and fill in the defect of skin.  If there is a rock (a scab) in the way, the little skin cells have to slowly grow underneath it and push it away.

This takes a tremendous amount of time, leads to more scarring, and I think it also leads to more infections. When you have a dry, hard scab stuck on top of the skin, it is inflexible and, when you bed, you make little tears underneath the scab which then leads to bleeding and more scab building up. You will find that keeping a hypoallergenic ointment like TrueLipids Relieve & Protect Ointment on your skin at all times may help to protect it and may help prevent more scabs from forming.

In order to help severe eczema to heal, be sure to moisturize it frequently enough:

16. Always Wash Food

A recent study showed that parents who quickly washed food off of their children’s hands and face were less likely to become allergic to foods. Eczema on the cheeks and around the mouth and on the hands can sometimes be associated with a food allergy.

The Science of Atopic Dermatitis

Key problems in the skin barrier lead to atopic dermatitis:

1. A Defective Skin Barrier with Deficient Lipid Production
2. Loss of water because of the lipid deficiency
3. Loss of Highly Acidic skin pH
4. Infection from Staph. aureus, molluscum, Candida, other yeasts
5. Skin Becomes Itchy due to above factors
6. Skin irritation and allergy to chemicals develop
7. Inflammation Develops
8. Ca++ gradient becomes impaired and leads to abnormal cellular cycling

Each of the above problems are integrally related to each other. Research is ongoing trying to find which is the chicken and which is the egg, but there is abundant research pointing to faulty lipid production in the skin that then possibly leads to all the other problems.

The skin barrier is made up of many different lipids that are responsible for maintaining body temperature, preventing the loss of water from the skin, and for protecting the skin from allergens, toxins, and infection. A deficiency in the skin barrier lipids is the first part of several defects in atopic skin:

1. A Defective Skin Barrier

Not enough lipids, not the right lipids, and lipids are not processed correctly. Healthy skin protects us from bacteria, viruses, fungus, chemical allergens, irritants, and from the loss of water. It helps us to regulate our temperature and protects us from trauma. When the skin barrier is not functioning correctly, the barrier becomes dry, and then itchy, rashy, scaly and painful.

In atopic dermatitis, there are deficiencies in the production of several different lipids. These lipids are what give us an intact skin barrier.

Normal skin should have the following lipids:

Dry skin has been shown to be deficient in cholesterol esters relative to the cholesterol content. (Fulmer et. al.,1986).  Atopic Skin has been shown to have too much cholesterol relative to cholesterol esters too (Di Nardo et. al., 1998). Aging skin also has cholesteryl ester deficiency.

Cholesterol esters become deficient relative to cholesterol in aging, dry, and eczema-prone skin.  The relative excess of cholesterol may possibly be contributing to the problem of atopic dermatitis.

Dry and eczema prone skin has been shown to be deficient in Ceramide 3, Phytosphingosine, and Very Long Chain Fatty Acids. These lipids are a required part of the healthy skin barrier. If the skin doesn’t have the right lipid precursors to make ceramides and other lipids, then it cannot repair itself. The skin needs the right lipids to be soft and healthy and to protect itself from the environment:

Dry skin, aged skin and eczema prone skin share some common lipid deficiencies:

Below Left: A normal skin barrier contains all the necessary skin lipids allowing for normal formation of a lipid bilayer to protect against water loss, overheating, irritants, toxins allergens and infection.

Below Right: When skin lipids are deficient, the skin barrier becomes disrupted and susceptible to many organisms, allergens, and infection and inflammation.Ce

Eczema prone skin, dry skin AND aged skin has been shown to be deficient in a particular Ceramide called Ceramide 3 (Rogers et. al.,1966). Ceramide 3 is made from a fatty acid plus another lipid called phytosphingosine. Phytosphingosine has also been shown to be deficient in dry skin skin and atopic dermatitis.

This means one of the reasons that disrupted skin can’t make enough Ceramide 3 is because it doesn’t have enough phytosphingosine and/or it may not have the right fatty acids or enough of the right fatty acids to make it. This is like making a cake without enough oil: if you don’t have enough oil, the cake (and your skin) will be too dry and unpleasant.

Ceramide 3, phytosphingosine, cholesterol esters and very long chain fatty acids leave the skin barrier vulnerable to desiccation, irritation, infection and inflammation.

When the skin has a deficiency or an imbalance in these fats, it cannot hold on to water and it becomes dry, cracked, rashy and open. Bacteria, viruses, fungi, and chemicals activate the immune system. The immune system becomes reactive and/or allergic to these organisms and chemicals and the skin become itchy, rashy, oozy and uncomfortable:

The use of moisturizers that contain the deficient skin barrier lipids and that do not contain the lipids that are present in excess is helpful in restoring skin barrier function and in helping to put the skin back into the state of equilibrium. Cholesterol is likely to be a byproduct that is left over in the ceramide manufacturing process. If excess cholesterol is given to atopic, dry or aged skin, the skin may not be able to use it and it may even be part of the problem.

2. Water Loss

Because dry, aged and eczema-prone skin is missing many of its lipids, the skin loses its ability to be water-proof. The skin can no longer effectively keep water from evaporating nor from getting in.

Because dry and atopic/eczema-prone skin is missing many lipids, the skin cannot hold onto water. Dermatologists call this loss of water “Transepidermal Water Loss” or TEWL. When the skin is losing too much water, it gets dried out and then it begins to itch, and usually, you begin to scratch!

One of the best things in the world to prevent water loss is a very heavy emollient. Plain old white petrolatum is known to be the gold standard and possibly most effective thing for preventing water loss.

Unfortunately, many people dislike how sticky, occlusive and greasy petrolatum is and how sits on the surface of the skin and doesn’t moisturize very well.  Petrolatum also lacks any of the lipids that are deficient in aged, dry and eczema-prone skin.

TrueLipids® Relieve & Protect Ointment has 50% of the most-purified grade of white petrolatum. In addition, TrueLipids Ointment has several other very effective molecules that prevent the loss of water; paraffin wax, microcrystalline wax, candelilla wax and another lipid called isostearyl isostearate. Isostearyl isostearate has been shown to be one of the most efficient lipids in the world at preventing water loss from the skin. (Pennick et al, 2010)(Pennick et al, 2012) (Dederen et al, 2012).

3. Loss of the Acidic pH in the Epidermis:  pH-Protect®

The skin in atopic dermatitis has an elevated pH in many cases due to loss of filaggrin and free fatty acids, to infection and inflammation, and to other not-yet understood reasons.  It is very important that a skin care product optimize the pH of the skin barrier, such as pH Protect™. This is a system that is used in the aqueous TrueLipids formulations (formulations that contain water such as creams and lotions). for essentially “Protecting” the pH of the skin.

Normally, the skin has many free fatty acids in the top layer. This layer is called the “Acid Mantle”.  These free fatty acids in conjunction with the skin’s own buffering system are what give healthy skin an acidic pH–optimally between 4.6 and 5.6.

Within the optimal pH values, our skin has two major enzymes (beta-glucocerebrosidase and acid sphingomyelinase) that are responsible for manufacturing ceramides and other lipids that keep the skin healthy and intact:

When the epidermis is disrupted by any sort of rash as in atopic dermatitis, eczema, acne, rosacea and even in aged skin, the pH goes up. This increase in pH is due to a deficiency of filaggrin and the lipids in the acid mantle of the skin. The enzymes that make the skin lipids get chopped up when the pH goes up and ceramide and lipid production come to a halt. The skin can no longer repair itself. Dry Skin becomes even drier skin!

The use of soaps, bleach, and even plain tap water will increase the pH of the skin. Tap water alone has been shown to increase the pH of the skin for at least six hours! During this time, the enzymes that make lipids in your skin slow down or stop functioning altogether.

Our skin has buffering systems that work with the acid mantle lipids of the skin to help to restore the acidic pH. If the optimal pH of the skin can be maintained, restored or optimized more quickly, the enzymes that make this skin-repairing lipids will be able to make more lipids more efficiently and thus to repair the skin barrier more effectively.

4. Good Bacteria vs Bad Bacteria

An acidic pH is necessary to support a healthy skin microbiome. A microbiome is a community of organisms that thrive in a particular environment. In this case, we are talking about the skin’s microbiome. Changes in the skin pH have been associated with changes in the microbiome of the skin.

The lack of acidity in more alkaline skin fosters the growth of harmful bacteria like Staphylococcus aureus (atopic dermatitis) and Propionibacterium acnes (acne), while inhibiting the growth of “friendly” bacteria such as Staphylococcus epidermidis. This shift in the microbiome of the skin leads to the cycle of increased alkalinity, superinfection of pathogenic bacteria, and a disrupted epidermal barrier.

Interestingly, if you ask a really old dermatologist, they will tell you of how they used to treat infections with Staph. aureus by inoculating the skin with Staph. epidermidis!  It is not clear why this is not done today in the age of antibiotic resistance, but I am sure you can imagine a few reasons why. A few studies have recently come out that are beginning to investigate this form of therapy.

5. Infection & Decreased Lipid Production

As if to add insult to injury, when the pH of the skin rises above 5.7 as it does when infection is present, the machinery in the skin cells that actually makes the good fats also come to a halt and the existing fats are degraded. (Hachem, et al, 2010).

Glucono delta-lactone, a polyhydroxy acid, has been shown to be an effective acidifier, skin moisturizer, water loss inhibitor and antioxidant.  It is important that pH skin care products be at the optimal level for skin lipid production.

Glucono delta-lactone is an optimal epidermal acidifier for many reasons.  It does not easily crystallize and become a salt and an irritant to the skin (like citric and lactic acid do). It is also superior to other acids at decreasing the loss of water in skin that has been stripped of its lipids by soap. (Derardesca, et al, 1997).

Glucono delta-lactone also blocks the formation of hydroxyl radicals, thereby serving as an antioxidant.  It is known to enhance stratum corneum desquamation (it helps the skin to exfoliate), improve skin appearance, and prevent skin irritation. These are all beneficial things for dry, irritated, acne, rosacea, aged and eczema-prone skin.

Glucono delta-lactone has also been shown to protect against UV radiation-induced elastin promoter (an enzyme that metabolizes the elastin in your skin) activation. In human studies, it was determined that glucono-delta lactone treatment does not result in a significant increase in sunburn cells. (Bernstein, et al, 2004).

Sunburn cells are cells that look like they have been killed or mutated under the microscope. They are a result of overexposure to sun and they are seen when using alpha-hydroxy acids like glycolic acid.  It is thought that this beneficial effect of gluconolactone is a result of its anti-oxidant and free-radical scavenging abilities.