Atopic dermatitis (AD) is a chronically relapsing eczematous skin disorder. It is the cutaneous manifestation of the atopic diathesis, and is associated with other atopic diseases such as allergic rhinoconjunctivitis and/or bronchial asthma. AD affects people of all ages, though it is more common in children, nearly 80% of whom eventually develop rhinitis or asthma.

AD is very common, and over the past half century, the prevalence of all atopic disorders has risen. The reason is still subject to debate. In 1989, Dr. David Strachan of St George’s Hospital, London proposed the “hygiene hypothesis,” attributing the propensity toward the atopic diseases to a reduced exposure to microbial infections in early life, especially in developed countries. This is thought to result in a transient shift to the Th2 cytokine profile and an increase in IgE antibody formation. Strachan’s hypothesis has yet to be proven, and is still controversial, though it has won many adherents over the last decade.

Whatever the reason, the increased prevalence of AD, compounded by managed-care mandates to deter specialist consultation, means that a growing number of AD patients are managed exclusively by primary care clinicians.

New guidelines for conventional treatment for AD were published in March 2004 (Hanifin JM, et al. J Am Acad Dermatol 2004 Mar; 50(3): 391–404). Topical corticosteroids remain the mainstay. However, long-term steroid use is limited by skin atrophy, telangiectasia and striae. Many clinicians believe long-term use is free of major adverse effects, but there are no data to support that view.

Topical calcineurin inhibitors (Pimecrolimus [Elidel] and Tacrolimus [Protopic]), are a new class of drugs for AD. Though they clear symptoms, they are not without risk. In March, the FDA issued an advisory about potential cancer risk, and stipulated that these drugs only be used when other therapies have failed.

Naturopaths who treat AD tend to focus more closely on food allergies as potential AD triggers, something many allopathic physicians tend to dismiss. We also treat primarily with botanicals and nutritional supplements, using steroids and other drugs only when absolutely necessary. In over 20 years of clinical experience, I have seen many patients improve greatly, while discontinuing topical corticosteroids. Here are a few facets of our approach:

1. Inform the patient and family that AD is a “chronic, inherited allergy.” Give constant support in dealing with exacerbating factors. “Hygiene hypothesis” aside, it is clear that atopy runs in families and has some basis in genetics.
2. Improve cutaneous hydration by avoiding harsh detergents like sodium lauryl sulfate, and using only mild soaps such as Dr. Bronner’s pure castile soaps. Apply emollients to prevent water loss within three minutes after bathing.
3. Florasone (Boericke & Tafel), a cream containing extract of Cardiospermum (a flowering tropical vine from India and Africa), and Eucerin cream (with Calendula oil and Stellaria media tincture added to the point of solubility) are the most effective and well-tolerated topicals I have found for AD. Chamomilla cream (Camocare) is effective in children (Blumenthal M, et al. Herbal Medicine: Expanded Commission E Monographs 2000).
4. Avoid irritants that stimulate itching, such as rough-fibered clothing (wool), a dusty and dry environment, sweating, and chemical exposures.
5. Treat secondary infections; trim nails to minimize trauma from scratching.
6. Eliminate rapid skin temperature changes. Most AD is worse in winter due to lower humidity; reduce bathing and use of soap in winter.
7. Reduce stress and fatigue; consider meditation, relaxation exercises. For patients with sleep disruption due to itch, consider cautious sedation with herbal sedatives and/or antihistamines (Quercetin 250 mg qid).
8. Avoid topical and systemic steroids if at all possible. They can induce significant rebound effects when withdrawn. Further, their suppressive effect may lead to more serious conditions like asthma. While the theory of “suppression” is as yet unproven, it is widely held among NDs and other natural medicine practitioners, and corresponds with what we observe in practice.

It is also helpful to try to identify and eliminate food allergens (cow’s milk products, eggs and wheat are the most common). The role of food allergy in AD has been repeatedly verified, though many conventionally trained doctors still dismiss it as a major contributing factor. This may be due to the fact that most conventionally-trained physicians overlook IgG-mediated reactions (Orange AP, et al. Ann Allergy Asthma Immunol 2002; 89(6 Suppl 2): 52–55), and that skin tests are not well-correlated with food allergy signs and symptoms (Sampson HA, et al. J Allergy Clin Immunol 1984; 74: 26). If a patient is eliminating dairy products, make sure they are taking supplemental calcium and vitamin D, to prevent deficiency.

Probiotic treatment during pregnancy and nursing may delay the onset of AD in infants and children (Kalliomaki M, et al. Lancet 2001; 357: 1076–1079). Lactobacillus rhamnosus GG has been shown to significantly reduce AD symptoms in infants with cow’s milk allergy (Allergy 2005; 60: 494–500).

AD patients usually benefit from eating fish high in omega 3’s (wild salmon, halibut, mackerel, herring, sardines) at least twice weekly. They should also increase intake of other high quality fats (olive oil, nuts, seeds, avocados), while avoiding pro-inflammatory fats (i.e., red meat, fried foods, hydrogenated oils, etc.). For those who won’t eat fish, supplementation with fish oils is essential. Be aware that evening primrose oil, flaxseed oil, and borage oil have not been proven beneficial in AD; I encourage my vegetarian/vegan patients with AD to make an exception for fish oils.

Topical Vitamin B12 (0.07%) has been shown to be effective in AD (Stucker M. Br J Derm 2004; 150: 977–983). B12 is a scavenger of nitric oxide, which stimulates vasodilation, erythema, and edema and has a role in T-lymphocyte function. It may slow cytokine production and potentiate induction of suppressor cells. A controlled trial of oolong tea (10 g teabag steeped 5 minutes in 1 liter water, divided and drunk after each meal) showed significant benefit (Uehara M, Sugiura J. Arch Dermatol 2001; 137: 42–43).

Some AD patients will benefit from a homeopathic approach. A study of seventeen patients with intractable AD treated with individualized homeopathy showed over 50% improvement in overall skin condition in all patients (Itamura R, Hosoya R. Homeopathy 2003 Apr; 92(2): 108–114). More clinical research is needed to adequately assess the naturopathic approach to the treatment of AD, although preliminary results are encouraging.

Michael Traub, ND, is past-president of the American Association of Naturopathic Physicians. He practices in Kailua-Kona, Hawaii. Monica Scheel, MD is a dermatologist at Kaiser Permanente Kona Clinic. They are collaborating on a book about natural medicine for skin disorders.