Dr. Ian Spohn, NDIan Spohn, ND, is a staff naturopathic doctor for Energique who enjoys challenging the dogmas of both conventional and alternative medicine. He is a passionate supporter of the paleo diet and classical homeopathy.

The pathophysiology of atopic dermatitis, or eczema, is well-understood and can be boiled down to two main issues: impaired skin barrier function and a TH2-dominant immune response. The factors accounting for eczema’s characteristic rash, as well as its close relation to asthma, can be broken down as follows:

  • Impaired skin barrier function = excessive epidermal water loss, i.e., chronically dry, flaky skin
  • Dry, flaky skin provides food for saprophytic organisms = enables overgrowth of pathogens on the skin
  • Combined with poor innate immunity = allows overgrowth of pathogens on the skin
  • TH2-dominant immune system = chronic redness and itching, ineffective immune response
  • Ineffective immune response = sensitization to fungal antigens, delayed hypersensitivity response
  • Hypersensitivity to fungal antigens = asthma inducible by airborne molds and fungi

Basically, everything can be seen as a ripple effect of losing too much moisture from the skin and the body using an inadequate immune response to handle the consequences thereof.


As already mentioned, one of the known, fundamental problems in eczema is the see-saw imbalance between the TH1 and TH2 immune responses; more specifically, the dominance of the TH2 response at the expense of the TH1 response. This fact indeed can help explain eczema’s predilection to affect infants and children, and even their tendency to outgrow it. The newborn’s immune system begins life heavily skewed towards the TH2 response and gradually becomes more TH1 dominant with age. It is believed that TH2 dominance is actually crucial to maintaining a pregnancy; i.e., a strong TH1 response would attack the mother’s placenta, recognizing its cells accurately as non-self. Normally, in the months after birth the infant’s immune system will switch to TH1 dominance, thus checking and suppressing the TH2 response. If this doesn’t happen on time, or if it happens incompletely, atopic diseases may be the result. Most children, even if they are somewhat late in doing so, will eventually develop a competent TH1 response, at which point it may be observed that they have “outgrown” their eczema. But some children do not and go on to develop other atopic disorders, like asthma, or deal with eczema as a lifelong condition. And even if a child does outgrow eczema, it still implies that there was something fundamentally wrong with the immune system early on, which if allowed to go uncorrected may lead to other problems later in life—frequent ear infections, frequent colds, recurring strep throat, allergies, auto-immune disease, cancer. The nature of the diseases from which we suffer changes continually with each stage of life, as does the immune system which is constantly evolving, but it is a weak or aberrant immune system which remains the common denominator in all of these conditions. Finding and correcting the root of the problem early on, to strengthen the struggling immune system, may be crucial to preventing these other, more serious diseases down the road. Suppressing the immune system early on, with steroid creams and the like, will probably only compound the problem and initiate a spiraling cascade of gradually deteriorating health with age. It begs the question: does anyone really ever outgrow their disease, or does the nature of our disease simply change to match our ever-developing and maturing physiology?


The conventional approach to treating eczema involves moisturizing lotions to support the skin barrier, with corticosteroids and/or antihistamines to down-regulate the immune response. On the other hand, a natural approach to treating eczema should help the body strengthen its own skin barrier and (it would seem paradoxically) up-regulate the immune response. What! But isn’t the immune system to blame? Isn’t that what’s causing all the redness, the mast cells, the itching, the histamine, the sea of inflammatory cytokines, etc.? The answer is actually more nuanced. Due to the intricacies of the immune system, it is not necessary to use immune suppressants to lower the humoral (TH2) immune response; the very same thing can actually be achieved by strengthening and supporting the other parts of the immune system. A stronger innate immune system, for example, will lessen the body’s dependence on adaptive immunity, of which the TH2 response is a major part. Also, a stronger cell-mediated TH1 response will directly suppress an overactive TH2 response. If you could achieve the same effect by either strengthening or inhibiting the patient’s immune system, would there even be any question which of the two is a better approach? To be effective, a natural approach to eczema treatment should therefore aim to support three things: a healthy skin barrier, a strong innate immune response, and a dominant TH1 immune response.


Currently, much of the research on eczema is focused on genetic mutations in the filaggrin gene. Filaggrin is a skin barrier protein, mutations of the genes coding which can result in a weaker skin barrier. People with certain mutations in this gene tend to be more likely to develop eczema and experience it more severely when they do. But there’s a second important factor determining skin barrier function, which unlike one’s genes can be supported through a healthy diet or supplementation. Filaggrin mutations only seem to make one’s skin more vulnerable to developing eczema, in contrast to diseases like cystic fibrosis which have more of a direct correlation between the mutation and the disease. So it is unlikely that these mutations can completely account for the problem. Indeed, the most important factor in preventing dry skin is ceramide, the waxy substance which accounts for the natural oiliness of our skin. This moisturizer is normally made in a layer of the skin called the stratum corneum and creates a natural barrier impermeable to water, which thus keeps moisture inside the skin. Dry skin is often due to a lack of ceramide, and, in fact, moisturizing skin lotions only work by replacing this natural ceramide with topically applied oils, derived from petroleum but having similar properties. What can cause a lack of ceramide? Ceramide basically has two ingredients: palmitic acid and serine. Its synthesis also requires one vitamin cofactor, B6, to catalyze the transamination reaction that attaches the serine to the palmitic acid. Serine is a non-essential amino acid, and palmitic acid is a basic component of saturated fat, so if a nutrient deficiency is to blame for dry skin, it is most likely to be vitamin B6. It is known that vitamin B6 is helpful for seborrheic dermatitis, although randomized trials have not shown it to have much effect on atopic dermatitis, at least not in isolation. This may be because it only addresses one dimension of the disorder, and vitamin deficiencies rarely exist in isolation. As will be mentioned below, other nutrient deficiencies may be involved also.


Beyond the TH1/TH2 imbalance, eczema has also been associated with a breakdown of the innate immune system. The body does not even need to decide whether to mount a cell-mediated TH1 or humoral TH2 immune response until after the innate immune system has failed. One weapon that normal, healthy skin uses to fight microbes is cathelicidin. Cathelicidin is a protein which literally pokes holes in microbes, destroying them. It is normally used by white blood cells, but quite a lot of it is also found in skin cells. It is integral to preventing the overgrowth of microbes on the skin, and the best way to increase cathelicidin levels is vitamin D. Not only has supplementation with vitamin D been shown to increase cathelicidin levels, but research has shown that individuals with eczema tend to have lower vitamin D levels and that vitamin D supplementation can help reduce eczema severity.[i] It is interesting that the filaggrin mutations which predispose people to eczema seem to be the most prevalent in very fair-skinned people, the Irish for example, and it is these same, generally pale people whose skin will absorb the most UV light and thus make vitamin D most efficiently. It is possible that certain types of skin simply don’t make as much filaggrin because they don’t need as much filaggrin, assuming of course that the skin has adequate exposure to UV light, and so the epidemic lack of sun exposure and vitamin D consequent to the modern lifestyle simply hits this type of skin the hardest. While this is just a theory, it remains true that vitamin D probably has more supporting research than any other nutrient for eczema.


The maturation and activation of T-suppressor cells, a process which normally occurs in the thymus gland, is crucial to developing a healthy TH1 immune response and suppressing an overactive TH2 response. It is also a process that seems to occur deficiently in atopic individuals and may be attributed to reduced activity of a specific enzyme, delta-6-desaturase.[ii] Basically, for the thymus gland to create mature, active T-suppressor cells, it needs to be stimulated to do so with prostaglandin E1. To make prostaglandin E1, the body needs its precursor, gamma-Linolenic acid (GLA), an essential fatty acid. GLA is actually quite difficult to obtain from food, since most foods have extremely low levels of it. Good sources of GLA are not typically consumed as foods, the best sources being evening primrose oil, borage oil, and black currant seed oil. The abundance of GLA in evening primrose oil probably accounts for its long history of use in eczema. Normally, the body makes its own GLA, converting it from the precursor linoleic acid, an essential omega-6 fat which is relatively abundant in the western diet (in fact, often too abundant). This is where the delta-6-desaturase enzyme comes in. To function properly, and thus to synthesize the prostaglandins required for thymic function and TH1 immunity, this enzyme requires B6, zinc, and magnesium as cofactors. Zinc is also required to maintain the function of the immune system generally and is becoming increasingly deficient in the processed western diet, as is magnesium, but each of these is crucial to preventing atopy and allergic disorders. Probiotics are another strategy to support the TH1 immune response, one which is gaining scientific support in the treatment of eczema.

There remains no single, bulletproof solution to atopic dermatitis, at least none that have any scientific support. One of the problems with researching single treatment modalities in isolation, the approach presently favored by science, is that with a multifactorial disease like eczema, simply fixing one element of the problem may not be sufficient to resolve the disorder. This is an issue with many diseases thought to be treatable with diet and lifestyle: where the research focuses on introducing single nutrients or related interventions one at a time, or when it tries to research holistic effects and is forced to rely on epidemiological data and diet-recall questionnaires, both of which are extremely difficult to interpret with scientific precision. The quest continues to find a simple, natural cure for eczema, though in reality a more broadly holistic approach is probably necesssary.

[i] Kim MJ, Kim SN, Lee YW, Choe YB, Ahn KJ. Vitamin D Status and Efficacy of Vitamin D Supplementation in Atopic Dermatitis: A Systematic Review and Meta-Analysis. Nutrients. 2016; 8(12):789. Published 2016 Dec 3. doi:10.3390/nu8120789

[ii] Novak, Bieber, Leung. Immune Mechanisms Leading to Atopic Dermatitis. Journal of Allergy and Clinical Immunology 2003; 112(6): S128-S139. Accessed online at https://www.jacionline.org/article/S0091-6749(03)02369-8/pdf


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