Immunosuppressives can help, but with serious side effects

By David Dunaief, M.D.

Eczema is relatively common, affecting 20 percent of children and 10 percent of adults around the world (1). If you are one of the many who experiences eczema, you know the symptoms, which can include skin rashes, itching, pain and redness.

Eczema is a chronic inflammatory process, and it’s likely caused by a combination of genetics and environmental or lifestyle issues (2). Investigation into potential causes is a growing field.

The National Eczema Association details the seven different kinds of eczema on its website, nationaleczema.org. Atopic dermatitis is the most frequently occurring.

While there is no cure, some treatments can ease symptoms and reduce flare-ups. These range from over-the-counter creams and lotions, antihistamines for itchiness, prescription steroid creams, oral steroids, and injectable biologics. Some use phototherapy for severe cases, but there’s not a lot of research suggesting this is effective. Interestingly, diet may play an important role.

Two studies have shown an association between eczema and fracture risk, which we will look at more closely.

Eczema and diet

In a Japanese study involving over 700 pregnant women and their offspring, results showed that when the 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 (3).

Elimination diets may also play a role in identifying allergic causes. One study’s results showed when eggs were removed from the diet of those who were allergic, according to IgE testing, eczema improved significantly (4).

In my practice, I have seen very good results when treating patients who have eczema with dietary changes. My practice has many patients who suffer from some level of eczema. For example, a young adult had eczema mostly on his extremities. When we first met, these were angry, excoriated, inflamed lesions. However, after several months of a vegetable-rich diet, the patient’s skin improved significantly. These results are not unique.

Do immunosuppressives provide a solution?

Injectable biologics are generally recommended for moderate to severe atopic dermatitis when other treatment options have failed (5). Three are approved by the FDA, dupilumab, tralokinumab-ldrm, and lebrikizumab-lbkz.

In trials, they showed good results when topical steroids alone were not effective. Like other monoclonal antibodies, they work by limiting your immune system response. 

Other oral immunosuppressives, such as those used to inhibit organ rejection in transplant patients, are options, as well.

Unfortunately, any suppression of the immune system’s response, whether oral or injectable, leaves the door open for side effects, including serious infections.

Can supplements help reduce symptoms?

Two well-known supplements are known to reduce inflammation, evening primrose oil and borage oil. Are they good replacements for – or additions to – medication? The research is mixed, leaning toward ineffective. There are also some important concerns about them.

In a meta-analysis of seven randomized controlled trials, evening primrose oil was no better than placebo in treating eczema (6). Researchers also looked at eight studies of borage oil and found there was no difference in symptom relief than placebo. 

While these supplements only had minor side effects in the study, they can interact with other medications. For example, evening primrose oil in combination with aspirin can cause clotting problems (7). If you do try them, be sure to consult with your physician first.

What’s the relationship between eczema and bone fractures?

Several studies have examined the relationship between eczema and bone fractures. One observational study of 34,500 patients showed that those with eczema had a 44 percent increased risk of injury causing limitation and a 67 percent risk of bone fracture and bone or joint injury for those over age 29 (8).

Those with both fatigue or insomnia in combination with eczema are at higher risk for bone or joint injury. The researchers postulated that corticosteroid treatments could contribute, in addition to chronic inflammation, which may also add to bone loss risk. Steroids can weaken bone, ligaments and tendons and can cause osteoporosis by decreasing bone mineral density.

A study of over 500,000 patients found that the association between major osteoporotic fractures and atopic dermatitis remained, even after adjusting for a range of histories with oral corticosteroids (9). Also, fracture rates were higher in those with severe atopic dermatitis.

If you have eczema, talk to your physician about having a DEXA (bone) scan to monitor your bone health.

There is an array of possibilities in development, from topical to oral to injectable treatments, which might provide future relief. Until then, partner with your physician to identify solutions that will work for you, but ensure you understand the side effects of what you’re taking. Diet adjustments appear to be very effective, at least at the anecdotal level.

References:

(1) naiad.nih.gov. (2) Acta Derm Venereol (Stockh) 1985;117 (Suppl.):1-59. (3) Allergy. 2010 Jun 1;65(6):758-765. (4) J Am Acad Dermatol. 2004;50(3):391-404. (5) JAMA Dermatol. 2015;151(1):33-41. (6) Cochrane Database Syst Rev. 2013;4:CD004416. (7) mayoclinic.org (8) J Allergy Clin Immunol Pract. 2021 Sep 24;S2213-2198(21)01018-7. (9) nationaleczema.org.

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