New treatments are evolving

By David Dunaief, M.D.

If you have eczema, you’re familiar with its symptoms, which can include rashes, itching, pain and redness. What may not be as clear are its causes and potential implications.

Eczema is a chronic inflammatory process, and it’s likely caused by a combination of genetics and lifestyle choices (1).

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 sufferers 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 separate studies have shown an association between eczema and fracture risk, which we will investigate further.

How does diet affect eczema?

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 (2).

Elimination diets may also play a role. One study’s results showed when eggs were removed from the diet of those who were allergic, according to IgE testing, eczema improved significantly (3).

From an anecdotal perspective, I have seen very good results when treating patients who have eczema with dietary changes. My patient population includes 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, erythematous and scratched lesions. However, after several months of a vegetable-rich diet, the patient’s skin improved significantly.

Do supplements help reduce eczema symptoms?

There are two well-known supplements for helping to reduce inflammation, evening primrose oil and borage oil. Are these supplements a good replacement for – or addition to – medications? The research is really 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 (4).

The researchers also looked at eight studies of borage oil and found there was no difference from placebo in terms of symptom relief. 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 (5).

The upshot? Don’t expect supplements to provide significant help. If you do try them, be sure to consult with your physician first.

Are biologics a good alternative?

Injectable biologics are among the newest treatments and are generally recommended when other treatment options have failed (6). There are two currently approved by the FDA, dupilumab and tralokinumab.

In trials, these injectable drugs showed good results, improving outcomes for moderate to severe eczema sufferers when topical steroids alone were not effective. Like other monoclonal antibodies, they work by interfering with parts of your immune system. They suppress messengers of the white blood cells, called interleukins. This leaves a door open for side effects, like serious infections.

Does eczema affect bone health?

Several studies have examined the relationship between eczema and broken bones. 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 30 years and older (7).

If you have both fatigue or insomnia in combination with eczema, you are at higher risk for bone or joint injury than having one or the other alone. The researchers postulated that corticosteroids used in treatment could be one reason, in addition to chronic inflammation, which may also contribute to bone loss risk. 

Steroids may weaken bone, ligaments and tendons and may cause osteoporosis by decreasing bone mineral density.

A study of over 500,000 patients tested this theory and found that the association between major osteoporotic fractures and atopic eczema remained, even after adjusting for a range of histories with oral corticosteroids (8). Also, fracture rates were higher in those with severe atopic eczema.

For those who have eczema, it may be wise to have a DEXA (bone) scan.

Eczema exists on a spectrum from annoying to significantly affecting a patient’s quality of life. Supplements may not be the solution, at least not borage oil nor evening primrose oil. However, there may be promising medications for the hard to treat. It might be best to avoid long-term systemic steroids because of their long-term side effects. Diet adjustments appear to be very effective, at least at the anecdotal level.

References:

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