Eczema is such a common problem in both children and adults that you would think there would be a plethora of research, right? Well, that’s only partly true. While there is a significant amount of research in primarily neonates and some on pediatric patients, there is not a lot of research on adults with eczema. But in my practice, I see a good number of patients who present with, among other disorders, eczema.
The prevalence of this disease rivals the prevalence of diabetes. In the United States, more than 10 percent of the adult population is afflicted (1). Twice as many females as males are affected, according to one study (2). Thus, we need more research.
Eczema is also more broadly referred to as atopic dermatitis. The cause is unknown, but it is thought that nature and nurture are both at play (3). Eczema is a chronic inflammatory process that involves symptoms of pruritus (itching) pain, rashes and erythema (redness) (4). There are three different severities: mild, moderate and severe. Adults tend to have eczema closer to the moderate-to-severe range.
Factors that can trigger eczema flare-ups include emotional stress, excessive bathing, dry skin, dry environment and detergent exposure (5). Treatments for eczema run the gamut from over-the-counter creams and lotions to prescription steroid creams to systemic (oral) steroids. Some use phototherapy for severe cases, but the research on phototherapy is scant. Antihistamines are sometimes used to treat the itchiness. Also, lifestyle modifications may play an important role, specifically diet. Two separate studies have shown an association between eczema and fracture, which we will investigate further.
Let’s look at the evidence.
ECZEMA DOESN’T JUST SCRATCH THE SURFACE
Eczema causes cracked and irritated skin, but it may also be related to broken bones. In a newly published observational study, results showed that those with eczema had a 44 percent increased risk of injury causing limitation and an even more impressive 67 percent risk of bone fracture and bone or joint injury for those 30 years and older (6). And if you have both fatigue or insomnia and eczema, you are at higher risk for bone or joint injury than having one or the other alone. Antihistamines may cause more fatigue. One reason for increased fracture risk, the researchers postulate, is the use of corticosteroids in treatment.
A side effect of steroids is that they may weaken bone, ligaments and tendons and may cause osteoporosis by decreasing bone mineral density. Chronic inflammation may also contribute to the risk of bone loss. There were 34,500 patients involved in the study ranging in age from 18 to 85.
Another study corroborates these results that eczema increases the risk for sustained injury (7). There was a 48 percent increased risk of fracture at any location in the body and an even greater 87 percent increased risk of fracture in the hip and spine when compared to those who did not have eczema. Interestingly, researchers’ hypotheses for the causes of increased fracture risk were similar to those of the above study: systemic steroid use and chronic inflammation of the disease. The researchers analyzed the database from NHANES 2005-2006, with almost 5,000 patients involved in this study. When oral steroid was given for at least a month, there was a 44 percent increased risk of osteoporosis. For those who have eczema and have been treated with steroids, it may be wise to have a DEXA scan.
ARE SUPPLEMENTS THE ANSWER?
The thought of supplements somehow seems more appealing for some than medicine. There are two well-known supplements for helping to reduce inflammation, evening primrose oil and borage oil. Are these supplements a good replacement for medications or at least a beneficial addition? The research is really mixed, leaning toward ineffective. In a recent meta-analysis (involving seven randomized controlled trials, the gold standard of studies), evening primrose oil was no better than placebo in treating eczema (8). The researchers also looked at eight studies of borage oil and found there was no difference from placebo in terms of symptom relief. One positive is that these supplements only had minor side effects. But don’t look to supplements for help.

WHERE ARE WE ON THE
DRUG FRONT?
The FDA has given fast track processing to a biologic monoclonal antibody known as dupilumab (9). In trials, the drug has shown promise for treating moderate to severe eczema when topical steroids are not effective. We will have to wait to see what the verdict is on this drug in development.

DO PROBIOTICS HAVE A PLACE?
When we think of probiotics, we think of taking a pill. However, there are also potentially topical probiotics with atopic dermatitis. In preliminary in-vitro (in a test tube) studies, the results look intriguing and show that topical probiotics from the human microbiome (gut) could potentially work as well as steroids (10). This may be part of the road to treatments of the future. However, this is in very early stage of development.

WHAT ABOUT LIFESTYLE
MODIFICATIONS?
Wouldn’t it be nice if what we ate could make a difference in eczema? Well, in a study involving pregnant women and their offspring, results showed that when these women ate either a diet high in green and yellow vegetables, beta carotene or citrus fruit there was a significant reduction in the risk of the child having eczema of 59 percent, 48 percent and 47 percent, respectively, when comparing highest to lowest consumption quartiles (11). This was a Japanese study involving over 700 mother-child pairings.
Elimination diets may also play a role. One study’s results showed when eggs were removed from the diet in those who were allergic, according to IgE testing, eczema improved significantly (12).
From an anecdotal perspective, I have seen very good results when treating patients who have eczema with dietary changes. My patient population includes about 15-20 percent of patients who suffer some level of eczema. Recently, a young adult had eczema mostly on the extremities. When I first met the patient, these were angry, excoriated, erythematous and scratched lesions. However, after several months of a vegetable-rich diet, the patient’s skin had all but cleared.
I also have a personal interest in eczema. I suffered from hand eczema, where my hands would become painful and blotchy and then crack and bleed. This all stopped for me when I altered my diet over eight years ago.
Eczema exists on a spectrum from annoying to significantly affecting a patient’s quality of life (13). Supplements may not be the solution, at least not borage oil or evening primrose oil. However, there may be promising topical probiotics ahead and medications for the hard to treat. It might be best to avoid long-term systemic steroid use; it could not only impact the skin but also may impact the bone. But don’t wait to treat the disease. Lifestyle modifications appear to be very effective, at least at the anecdotal level.
REFERENCES:
(1) J Allergy Clin Immunol. 2013;132(5):1132-8. (2) BMC Dermatol. 2013;13(14). (3) Acta Derm Venereol (Stockh) 1985;117 (Suppl.):1-59. (4) uptodate.com. (5) Br J Dermatol. 2006; 1553:504. (6) JAMA Dermatol. 2015;151(1):33-41. (7) J Allergy Clin Immunol. Online Dec. 13, 2014. (8) Cochrane Database Syst Rev. 2013;4:CD004416. (9) Medscape.com. (10) ACAAI 2014: Abstracts P328 and P329. (11) Allergy. 2010 Jun 1;65(6):758-65. (12) J Am Acad Dermatol. 2004;50(3):391–404. (13) Contact Dermatitis 2008; 59:43–7.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management.  For further information, go to the website www.medicalcompassmd.com and/or consult your personal physician.

To eat fat or to not eat fat is a question that has been dogging the medical community for years. It would seem, at least on the surface, that this should be a simple answer, and it is. Of course, we should eat fat. However, what type of fat is good for us and what type of fat may be detrimental is where it gets downright murky. Is low fat beneficial, or is a normal fat or even a high fat amount okay in our diet? We are constantly discussing fats because they could have an impact on chronic diseases, such as heart disease, stroke, cancer and obesity (1).
The problem is that we are focusing potentially on the wrong issue. It may not be about choosing one macronutrient over another. There are three macronutrients: fats, carbohydrates and protein. You would think with just three macronutrients there can’t be that many permutations to find a diet that works. The upshot is that it may be more important to focus on the diet as a whole rather than on the individual macronutrients. Unfortunately, there is no one specific balance that will fit the population at large.
The reason for writing this article is twofold: There is a recent study touting that fat consumption is not an issue; and there are potential new dietary guidelines on the horizon from the Department of Health and Human Services and the Department of Agriculture as a result of advisory committee recommendations. The government usually follows the recommendations of the advisory committee.
The advisory committee has suggested lifting the current dietary recommendation of 35 percent fat restriction (2). Does this mean we should eat more fat? Not necessarily. However, they have maintained that saturated fat remain less than 10 percent of the diet. This is not as severe as the American Heart Association, which recommends limiting saturated fat to 5 to 6 percent of your diet. Another significant advisory panel recommendation is that the 300-mg cholesterol restriction be removed. The advisory panel emphasized the importance of consuming unsaturated fats including nuts, fish, olive oil and vegetable oils.
It is difficult to cut fat. Do you replace it with protein or with carbohydrates? Food manufacturers have been replacing fat with sugar in processed foods. I know because when fat-free cookies were popular in the 1990s, my wife and I felt guiltless eating them all, although we were overwhelmed by the sugar.
The government is now more interested in reducing sugar than fats. We overconsume sugars by at least twofold. The advisory committee was in line with my comments above about focusing on the whole rather than looking at the parts. We cannot see the forest for the trees.
Let’s cut through the fat and look at the research, metaphorically speaking of course.

SHOULD WE LIMIT FAT AND
SATURATED FAT?
This is a loaded question. In a recent meta-analysis involving a group of six randomized controlled trials, the gold standard of studies, results showed that there were no statistically significant changes in the treatment groups (which one would think would be a “low fat” group) and control groups in regard to overall mortality and heart disease (3). The actual trials were performed from 1977 to 1983. The intent of the meta-analysis was to determine whether or not the original recommendations regarding fat and saturated fat restrictions were based on solid results. The researchers concluded that they were not.
Interestingly, five of six trials did not actually look at limiting overall fat to less than 30 percent or at reducing saturated fat to less than 10 percent. Instead, the trials replaced saturated fat with vegetable oils, which are high in polyunsaturated fats, specifically omega-6s. What is the significance of omega-6s? Keep reading!

ULTIMATELY, WHAT IS THE PROBLEM IF FAT IS NOT THE ISSUE?
There are two questions that stem from either reducing fat overall or replacing saturated fat with polyunsaturated fats. The first is: With what are you replacing the fat? The second is: Are all polyunsaturated fats safe or harmful, compared to saturated fats? Studying saturated fats is complicated because studies that show equivocal  non-harmful results with these types of fats also contained unsaturated omega-3s as well (4). Even if saturated fat has shown no harmful effects, it has not demonstrated beneficial effects either.

REPLACING FATS WITH
CARBOHYDRATES
We had this long-standing belief that fats were the culprit in obesity, metabolic syndrome and diabetes. However, studies have shown that replacing fats with carbohydrates has resulted in an increase in obesity and diabetes, rather than a decrease. In an epidemiologic study, results show that refined carbohydrates, specifically corn syrup, increase the risk of diabetes, while fiber decreased the risk. Fat and protein had no effect (5). In other words, reducing fat may not be the best idea, depending on whether you’re replacing that fat with refined carbohydrates or not.

NOT ALL POLYUNSATURATED FATS ARE EQUAL
Certain types of fat may be more beneficial than others. A study comparing polyunsaturated fats, which include omega-3 fatty acids and omega-6 fatty acids, and their replacement of trans fats and saturated fats showed mixed results (6). Diets that contained both omega-3s and omega-6s had reductions in the risk of heart attack and heart disease death when compared to those containing omega-6s alone, which appeared to increase the risk of heart disease mortality. Certain vegetable oils contain high amounts of omega-6s such as safflower oil.
In the Sydney Diet Heart Study, there was a trend toward increased cardiovascular disease when replacing saturated fats with polyunsaturated omega-6 fatty acids referred to as linoleic acid (7).
Both of these trials were not without their statistical weaknesses. However, caution should be advised when replacing saturated fats with polyunsaturated fats; you should include an increase in omega-3 fatty acids and not necessarily an increase in omega-6s solely.

WHAT TYPE OF DIET IS BENEFICIAL?
Diets rich in heart-healthy foods are better than low-saturated-fat diets at reducing LDL (“bad”) cholesterol levels, a risk factor for heart disease, according to the results of a randomized controlled trial (8). Patients were randomized into three groups: one low-saturated-fat group and two portfolio diet groups, one with intensive counseling and one with moderate counseling. The portfolio diet was a heart-healthy plant-rich diet consisting of viscous fibers (referred to as sticky fibers), nuts, plant sterols, vegetables and soy proteins. Both portfolio diet groups experienced significant reductions in LDL similar to that of an early type statin while the low-saturated-fat diet did not. The study duration was six months, and it involved over 350 participants.
Thus, we need to focus on the diet as a whole, such as the Mediterranean diet, not on a single component, for that is when we get ourselves in trouble. Also, just because the fat is unsaturated does not mean it is necessarily healthy. Omega-3 fatty acids are most likely beneficial. Some vegetable oils are loaded with omega-6 fatty acids that induce inflammation and may be no better than saturated fats. It is important to maintain a reduction in saturated fat as long as it does not mean replacement with refined carbohydrates or potentially harmful omega-6s, though not all omega-6 fatty acids are created equal either.
REFERENCES:
(1) uptodate.com. (2) health.gov. (3) Open Heart 2015;2. (4) Ann Intern Med. 2014; 160(6):398-406. (5) Am J Clin Nutr. 2004;79(5):774-779. (6) Br J Nutr 2010;104:1586–600. (7) BMJ 2013;346:e8707. (8) JAMA 2011; 306:831-839.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management.  For further information, go to the website www.medicalcompassmd.com and/or consult your personal physician.