Ask the Ecz-perts: Keto diet, food allergies, natural creams, mental health

In Ask the Ecz-perts, leading medical experts answer your most pressing questions about eczema and its related conditions.

Q: Why do most eczema treatments only address symptoms?

The problem with eczema is that we don’t really know what causes it. We believe there are a number of complex, potential etiologies, and our environment potentially has an effect as well. We really don’t know about other aspects of the immune system that possibly play in causing eczema. Therefore, it’s really hard to create a treatment and target a treatment for a very specific cause.

Most of the treatments for eczema will help with the itching, the redness, the inflammation and treat the symptoms. But, of course, we know that eczema is a chronic, coming-and-going or relapsing disease that may require continuous treatment down the line.

JiaDe (Jeff) Yu, MD, board-certified dermatologist and fellowship-trained pediatric dermatologist at Massachusetts General Hospital

Q: Would the same treatment be offered for Staphylococcus aureus skin infections despite the severity (mild/moderate and severe) of the eczema? 

If the skin looks actively infected (oozing, honey crusting, bright red) then it should be treated regardless of the severity. Ideally, cultures of the infected area can direct treatment based on the bacteria that is growing and the its antibiotic susceptibilities. For example, some people have a methicillin-resistant strain of Staphylococcus aureus (MRSA) that also may be resistant to clindamycin, a common treatment of MRSA.

Kanwaljit K. Brar, MD, pediatric allergist and immunologist at National Jewish Health

Q:  This might sound crazy, but I truly believe that I developed AD when I started doing keto. Is this possible or was it just a coincidence?

The ketogenic diet is very interesting and has been studied in a number of conditions, but it is most commonly used to help control certain types of epilepsy. In this context, it is thought to work by altering the energy metabolism of neurons in the brain. More recently, ketogenic (“keto”) diets have been used for weight loss as well and, though still somewhat controversial, do seem to work for many patients.

Remarkably, there is a skin condition that is sometimes seen in patients on ketogenic diets sometimes referred to as “keto rash.” Its proper name is prurigo pigmentosa, and as the name suggests, it is often very itchy and can look somewhat like eczema.

Importantly, topical and systemic steroids are not effective for this condition, but once patients break ketosis, it usually improves. Sometimes, anti-inflammatory antibiotics such as doxycycline or dapsone are used as well and may provide some relief in the inflammatory phase.

So, it is possible that it was a coincidence, but it is also possible that something like prurigo pigmentosa developed during the keto diet and is either still going on, or was enough to create an itchy, inflammatory state that did indeed trigger the onset of the AD.

It is also possible that something about the diet change in and of itself was enough to shift things to a more pro-inflammatory state in the body which unmasked the eczema. Those are just some of the possibilities, so it’s important to find a good dermatologist or allergist willing to take a close look, review things carefully and maybe even do a biopsy of the skin to help pin things down.

 Peter A. Lio, MD, assistant professor of clinical dermatology and pediatrics dermatology at Northwestern University Feinberg School of Medicine

Q: Are there any specific foods that may be causing my eczema, and is there a way to test what those food groups might be?

 That’s the million-dollar question and a very complex topic. We certainly don’t know of a root cause that leads to eczema, and potential food triggers for one person may be very different for another person. The notion of true food allergies causing eczema is still under debate.

That being said, if it’s a true allergic reaction, it can occur within minutes after ingesting the culprit food. In that case, it may be worthwhile having an allergist do a true allergy test. Frankly, there is really no easy and good test to confirm food allergies. All the skin tests and blood tests are not reliable just yet.

There is the gold standard double-blind controlled food challenge test, and it may be very cumbersome to do, but if there’s a reliable reaction to certain food that one is eating, I usually suggest it may be worthwhile to look into potential food testing.

That being said, elimination diets should be implemented with very extreme caution under the guidance of a healthcare professional. If an elimination diet is done incorrectly, it can lead to malnutrition — especially in growing children — and malnutrition can seriously impact the health of individuals having eczema.

Vivian Shi, MD, assistant professor of medicine in dermatology at the University of Arizona and director of its Eczema and Skin Barrier Specialty Clinic.

Q: Is eczema impacted by gut health, and if so, what is the best way to improve it?

 Recently, the notion of “leaky gut” has become really popular in the eczema community. Leaky gut is the notion that maybe there is a little breakage in the gut that causes overgrowth of certain bacteria that ultimately lead to eczema. We have very preliminary data right now to show that maybe when the microbiome of the gut is disrupted, it can lead to an overgrowth of some of the bad bacteria and an undergrowth of some of the good ones. But how that relates to the clinical effect of eczema remains unanswered.

There are some preliminary studies showing that certain probiotics in the family of Lactobacillus and Bifidobacteria can potentially improve some clinical effects in children and adults with eczema. But we need larger and better designed studies and randomized double-blind controlled trials in order to prove the long-term efficacy and safety of these modalities.

Vivian Shi, MD, assistant professor of medicine in dermatology at the University of Arizona and director of its Eczema and Skin Barrier Specialty Clinic.

 Q: Is there any way to treat eczema without medications, and what are the best natural creams to treat eczema?

 Everyone will have their own journey with eczema and eczema treatments. Also, the way we define medications is unique to all of us. So, I do think it is possible to empower our own bodies to help treat and control eczema.

There are a couple of ways to do this. The most important thing is moisturization. If we can moisturize our skin and make our skin barrier as healthy as possible, our eczema will remain more controlled and more treatable. This could be done with natural moisturizers, such as sunflower oil or coconut oil. But the most important thing to remember is we want something that contains more oil than water so that we can help retain moisture in our skin.

The second component is to treat skin inflammation, whether by using a topical medication or a natural anti-inflammatory agent. We want to address inflammation because it can lead to more chronic flares and harder to treat conditions. We also want to address systemic inflammation, and this can be done through mind-body medicine, such as exercise and nutrition.

Mamta Jhaveri, MD, assistant professor of dermatology at the Johns Hopkins University School of Medicine.

Q: Is there a correlation between trauma and eczema, and do you foresee therapies such as mindfulness meditation being included in future research?

 Eczema is a unique and complicated condition with many factors involved. One of the most important factors that plays a role in eczema is stress. Whether the trauma is emotional or physical, it can cause stress in our bodies, which can lead to more itching, more inflammation and an increase in flares that make it harder to control the disease. Stress can also impact your sleep and nutrition, which also play a role in skin health.

I think mindfulness meditation can help because it has been shown to help decrease stress, improve sleep and decrease inflammatory markers in the body. With eczema, we have an over-sensitization of our itch receptors, which are in the superficial layer of our skin. That can set off extra firing of these itch receptors, even when unnecessary. Meditation can help us deactivate that in our central brain to let the itch and inflammation pass without always having to engage our itch-scratch cycle.

Mamta Jhaveri, MD, assistant professor of dermatology at the Johns Hopkins University School of Medicine

Do you have a question for our eczperts? Email them to editor@nationaleczema.org.

https://nationaleczema.org/ask-the-eczperts-eyelid-microbiome/