Eczema: managing the skin barrier

Eczema — atopic dermatitis — is a chronic inflammatory skin condition causing dry, itchy, inflamed skin. It affects around one in five Australian children and a smaller proportion of adults, and it tends to run in families alongside asthma and hay fever.

This article covers what supports the skin barrier and what the evidence actually shows. It is general information rather than treatment advice, and it does not replace assessment by your GP or a dermatologist.

What is going on in the skin

Two things at once.

A barrier that leaks. Healthy skin holds water in and keeps irritants out. In eczema the barrier is impaired — often involving the protein filaggrin, which is genetically reduced in a substantial proportion of people with eczema. Water escapes, the skin dries, and irritants get through more easily.

An immune system that overreacts. The skin’s immune response is heightened, producing inflammation, redness and itch out of proportion to the trigger.

The itch-scratch cycle then does its own damage: scratching further breaks the barrier, which lets more through, which drives more inflammation, which itches more.

Moisturising is the treatment, not the afterthought

The single most important thing, and consistently the most under-done. Emollients reduce flares, reduce the amount of steroid needed, and are the foundation of every credible management approach.

What matters in practice:

• Frequency over product. Twice daily minimum, and more during a flare. The best moisturiser is the one you will actually apply that often.
• Ointments and thick creams over lotions. Lotions are mostly water and evaporate.
• Within a few minutes of bathing, onto skin that is still slightly damp.
• Fragrance-free. Fragrance is a common irritant, and “natural” fragrance is not exempt — essential oils are among the more frequent contact sensitisers.
• Generous amounts. Most people use a fraction of what is needed.

Bathing

Short, lukewarm baths or showers rather than long hot ones. Soap-free wash rather than soap, which strips lipids from an already-compromised barrier. Pat dry rather than rub, and moisturise immediately after.

Bleach baths — a very dilute sodium hypochlorite bath — have reasonable evidence for reducing severity in moderate to severe eczema with recurrent skin infections. Concentrations matter and this is something to set up with a doctor, not by eye.

Identifying triggers

Common ones: soaps and detergents, wool and synthetic fabrics against the skin, heat and sweat, low humidity, dust mite, stress, and — in a minority — specific foods.

A trigger diary kept for a few weeks is more useful than it sounds, because triggers are individual and memory reconstructs them badly.

Diet: what the evidence supports

This is where care is needed, because the gap between what is claimed and what is established is wide.

Food allergy does play a role in some children with moderate to severe eczema, most often cow’s milk, egg, peanut, wheat and soy. Where a genuine allergy exists, identifying it matters.

Elimination diets without a confirmed allergy are not supported and carry real risk. Removing food groups from a child’s diet on suspicion can cause nutritional deficiency, and — this is the part that is counterintuitive — avoiding a food a child is not allergic to can cause an allergy to develop by removing tolerance. Elimination should follow proper allergy assessment rather than precede it.

Probiotics have mixed evidence. Some trials of specific strains given in pregnancy and infancy show a modest reduction in eczema incidence; evidence for treating established eczema is weaker.

Vitamin D supplementation has some supportive evidence where levels are low, and less where they are not.

Evening primrose oil and borage oil have been well studied and reviews have not found meaningful benefit, despite their persistent popularity.

Omega-3 evidence is inconsistent.

The honest summary: general diet quality supports general health, specific dietary claims for eczema are mostly weaker than marketed, and restricting a child’s diet without confirmed allergy is more likely to cause harm than benefit.

Where medical treatment fits

Topical corticosteroids are the mainstay for flares and are effective. Steroid phobia is common, widespread, and largely misplaced — under-treating a flare means longer inflammation, more scratching and more barrier damage than using an appropriate-strength steroid for a short course. Use what your doctor prescribes, at the strength prescribed, for the duration prescribed.

Other options — topical calcineurin inhibitors, and for severe disease newer systemic treatments — are matters for a GP or dermatologist.

When we will refer you on

• Eczema that is not controlled by moisturising and prescribed treatment
• Signs of infection: weeping, yellow crusting, rapidly worsening redness, fever
• Painful blistering with fever, which can indicate eczema herpeticum — this needs same-day medical attention
• Sleep significantly disrupted by itch
• Any eczema in an infant that is spreading or not responding

Where naturopathy fits

A naturopathy consultation at Brunswick Health can look at diet quality, sleep, stress and skin care routine, and work alongside your GP’s management rather than in place of it. What it will not do is diagnose a food allergy or tell you to stop a prescribed treatment — both of those belong with your doctor.