Insights and Strategies for Difficult Skin Conditions
Insights and Strategies for Difficult Skin Conditions
By Lisa Murray, RDN, LD
Eczema, psoriasis and rosacea are common skin conditions, yet very difficult (and at times impossible) to resolve. The problem lies in the fact that sometimes we just cannot discover and/or eradicate the root problem. Also, the longer those changes within the skin have persisted, the more difficult they are to normalize. For decades, we have known about the role of toxins, both endogenous and exogenous, in the development of these skin disorders and research on genetic factors is providing new insight. Food allergies, and even just poor digestion, play a significant role in many cases. The use of food enzymes, and in some cases the addition of HCL, have resulted in improvement where diet changes have made little difference. The role of the liver, in helping detoxify or remove offending substances, is also an important component of treatment. My own personal clinical observation of the conventional medical approach of using immune suppressing steroid creams usually only forces the body to seek out and find a new area to use as its “toxin elimination field” (kind of like a leach field, pardon the analogy), whereby these toxins irritate the skin and alert the immune system to begin its cascade there as well. In the case of eczema, we call this the “atopic march”, which may often include the onset of allergic rhinitis, using the nasal membranes and mucus as elimination vehicles.
THE IMMUNE SYSTEM COMPONENT
Skin provides protection from foreign invaders in several ways. Apart from the physical barrier, there are specialized cells of the immune system throughout the layers of the skin. The chain reaction of events triggered by whatever the skin decides is a foreign invader causes alterations in the structure and function of the layers of the skin. The protective function of the epidermis is partially lost and as it opens to release its burden from the inside out, it becomes vulnerable to penetration of harmful substances and organisms from the outside in. This can additionally lead to irritation or infection from the penetration of many things that would normally be kept out by intact skin and the immune cascade continues.
ECZEMA (ATOPIC DERMATITIS)
Eczema, also known as atopic dermatitis (AD), occurs when “foreign” substances on or in the skin cause an “allergic” immune response. We know it to be an allergic response because blood testing will normally show increased levels of IgE antibodies as well as certain white blood cells. Detailed examination of the skin, as well as other indirect tests, show that the immune system is highly active in all forms of eczema. These features indicate that eczema is not only something that goes on within the layers of the skin, but is part of a systemic process of immune system activity. Patients with AD have higher rates of allergies than the general population and AD is highly associated with allergic rhinitis. The triggers for eczema can be endogenous from food or inhaled allergens or exogenous from contact with an irritant or allergen. Patients with atopic dermatitis often have sensitization against a variety of environmental allergens. AD is a complex condition with a strong genetic component and the relationship between allergy being a cause and/or an exacerbating factor of AD is still debated. A strong association with the mutation of the filaggrin gene has raised recent interest in the role of skin barrier impairment in the development of AD. Filaggrin (filament aggregating protein) is a filament-associated protein that binds to keratin fibers in epithelial cells. Research has reported two common European mutations to the filaggrin gene that predispose to eczema and secondary allergic diseases.
Exposure to microbes can play a role in the development of eczema because bacteria or yeast can be allergens or irritants. A 2013 study at the University of Michigan discovered that a toxin, a molecule called delta toxin, produced by the bacteria Staphylococcus aureus, causes the skin to react producing an eczema-like rash. But other strains of staph that did not carry the gene for delta toxin did not produce the rash. As we know, staph is a common bacteria on human skin and occasionally causes infection, but this leads us to wonder: How many different types of normal skin bacteria can produce toxins to which some people will react?
In AD there are two phases to the immune response: acute and chronic. The first phase is a type 1 hypersensitivity response, characterized by elevated levels of IgE antibodies. The IgE antibodies bind to mast cells in the skin, resulting in degranulation and secretion of histamine, leukotrienes and prostaglandins. The resulting vasodilation and increased permeability lead to inflammation of the skin in the affected area. That is the acute stage. But then there is a second stage. A review article published in Current Opinion in Allergy and Clinical Immunology, 2004  states:
“The initial phase with acute lesions is predominated by T helper cell type 2 (Th2) cytokines followed by a second Th1-dominated phase that is associated with eczematous chronic atopic dermatitis lesions. In this regard, atopic dermatitis is different from other forms of acute allergic manifestations, as it exhibits a mixture of type I and type IV-like hypersensitivity reactions.”
Th1-type cytokines tend to produce the proinflammatory responses responsible for perpetuating autoimmune responses, so immune system modulation as well as inflammation modulation must be part of treatment, not just removal of allergens.
Psoriasis is an inflammatory skin disorder with excessive hyperproliferation of skin cells. The skin cells accumulate faster than they can be shed, resulting in patches of red thickened skin, covered with silvery scales. Immune dysregulation plays a central role and many factors that affect the immune system such as stress, medications, allergies, illness, infection and inadequate nutrition also affect the onset or severity of psoriasis symptoms. Psoriasis has various triggers but most well known is skin injury or trauma. People with psoriasis often develop it after an assault to the skin—as simple as a scratch, an irritation, a sunburn or repeated pressure. Psoriasis is basically an immune response targeted to a localized area. It seems like the body keeps trying to repair the skin by continuing to create new cells, layer upon layer. Long considered an autoimmune disorder, one in which the body is attacking its own tissues, autoantigen triggers have been unknown until recently. Research findings indicate that our body’s own antimicrobial peptides can trigger psoriasis. While they play a key role in protecting injured skin and providing an important defense against harmful bacteria, research has found that the antimicrobial peptide, LL37, can be an autoantigen. According to findings, LL37 triggers an immune cell response in at least 46% of people with psoriasis—and up to 75% of those with moderate-to-severe disease. While antimicrobial peptides are proinflammatory, their expression is modulated by vitamin D. This well explains why psoriasis improves when exposed to sunlight and why UV light therapy is an effective method of treatment. Adequate vitamin D supplementation may produce similar results, especially as part of a protocol to support healthy immune response.
Rosacea is a common skin condition that causes redness and visible blood vessels in your face and may also produce small red bumps. Characterized by inflammation of blood vessels, redness, histological changes and vascular degeneration of the facial skin, exposure to the weather and damage by wind or sun is implicated in its genesis. Many believe that rosacea may be a vascular disorder because of its association with flushing, redness and visible blood vessels. Rosacea has been linked to low stomach acid and infection by H. pylori, but recent studies have shown that H. pylori was no more common in patients with rosacea than in those without. Still, rosacea often improves with antibiotic therapy. A more recent finding is that people suffering from rosacea tend to have more Demodex mites on their face. Instead of 1 or 2 per square centimetre of skin, the number rises to 10 to 20. What are demodex? These are microscopic arachnids that are part of our facial epidermal ecosystem. Everyone has them and attempts to eradicate them completely do fail, because we pass them to each other. Demodex are thought to consume sebum and increases in sebum production may cause a population boom which causes irritation in the face. Why? Because when a mite dies, they release bacteria and toxins which can cause irritation and inflammation. Again, another reason why antibiotic therapy reduces the symptoms of rosacea. While there are many theories, the underlying causes of rosacea have yet to be scientifically proven.
THE INFLAMMATION COMPONENT
Eczema, psoriasis and rosacea are all inflammatory conditions. Natural therapeutic foundations for treating inflammatory skin conditions are largely the same as for any inflammatory condition. Choosing interventions which will help modulate both the immune component and the inflammation component, reducing inappropriate hyperactivity while allowing for normal responses is key. From both research and clinical outcomes, adequate intake of essential fatty acids and their proper balance is important. Omega-6 PUFAs have a particular role in the structural integrity and barrier function of the skin. Research on the clinical application of essential fatty acid supplements for eczema have had mixed results. Some people respond better to omega 6 fatty acids like linoleic acid from sunflower, flax or evening primrose oil while others may respond well to fish oil.  Like always, it really comes down to each person’s diet; what they’re eating and not eating and how they metabolize their nutrients.
In any case, a practitioner can’t go wrong by taking the wholistic approach of recommending an anti-inflammatory diet: reducing/eliminating pro-inflammatory foods while increasing overall intake of EFA from a wide variety of healthy fats. Liberal use of olive oil on vegetables and salads and for sautéing, while avocado and coconut oils are excellent for higher heat cooking. Consuming avocados, flax seed oil and a wide variety of seeds and nuts daily along with more fish are often new concepts to many patients, but an important part of treatment for inflammatory skin disorders. Turmeric or curcumin can provide important underlying inflammation modulation, while reishi mushroom can help provide immune system modulation
BASIC NUTRIENT NEEDS OF THE SKIN
The nutritional needs of healing skin need to be supported during any treatment process for optimal results. Vitamin C is necessary for the proper development of collagen and skin tissue. Zinc is antimicrobial and antioxidant, supporting the immune system within the skin, controlling inflammation and regulating cell production and turnover. With up to six times more of the mineral in the top epidermis layer of your skin than is found in the lower layers, zinc is critical for healthy skin but deficiency is common around the globe. Zinc plays a role in DNA synthesis, cell division, protein synthesis and in promoting the proper structure of proteins and cell membranes. Zinc-dependent enzymes are involved in the conversion of essential fatty acids to anti-inflammatory prostaglandins. It’s also necessary to produce gastric HCL. Vitamin A influences the physiology of the skin by promoting epidermal differentiation and modulating dermal growth factors. Vitamin E is an important antioxidant in the skin and anti-inflammatory as well. Vitamin E interferes in inflammation signaling, preventing inflammatory damage by decreasing inflammatory prostaglandin synthesis, interleukin production and the induction of cyclooxygenase-2 (COX-2). Vitamin A and E seem to work better in tandem than either one alone, suggesting an important synergy that allows vitamin A to be more effective at lower doses. And finally, we come to vitamin D. Keratinocytes, the primary cell type in the epidermis, possess the enzymes needed to convert vitamin D to its active form: 1,25-dihydroxyvitamin D3, which functions locally to regulate the epidermal proliferation and differentiation. Also, the active form of vitamin D functions as a steroid hormone, which decreases inflammation as well as modulates the immune response.
ONE SUCCESS STORY
Many years ago, I worked with a patient in her early 40s who complained of severe scalp psoriasis which she said started at about age 14, so she had the condition for about 30 years. Somewhat better in the summer and terribly bad in the winter (she always lived in a cold northern climate), she had generally very dry skin and follicular hyperkeratosis—signs of nutritional deficiencies of essential fatty acids, vitamin A, vitamin E and B-complex vitamins. Over the years prior, she tried whatever types of elimination diets that were reported to help. She eliminated meat, nightshade vegetables, dairy, gluten and grains for months at a time with no change to her condition. I recommended a repletion regimen of vitamin D, vitamin A, vitamin C, fish oil (or cod liver oil), a robust multivitamin with plenty of zinc, vitamin E and B-vitamins, along with a reishi mushroom formula. I asked her to make five dietary changes: 1.) to eat fish at least four times a week, 2.) consume both cooked and raw greens every day, in addition to her usual lunch and dinner vegetables, 3.) consume a quarter cup of nuts and seeds daily, 4.) use only olive oil for cooking and salads, 5.) eliminate sugar. Her psoriasis and other skin problems gradually improved and within a year, she was psoriasis free.
However, her psoriasis came. Away from home, she purchased some hair products at a drugstore, which irritated her scalp, and triggered her psoriasis. She then realized that the drugstore shampoo she used as a teenager as well as many other chemicals in her hair products over the years, could have been contributing to her condition all along. The reason I remember this so clearly is because we often overlook the obvious: everyday chemicals present in our bath, skin, hair and body “care” products and in dish and laundry detergents are irritants that commonly cause skin reactions! Some of these chemicals are extremely toxic and it’s no wonder why our skin would rebel. The immune response, after all, is there to protect us from “bad stuff”! We all have differing genetic programming when it comes to chemical and toxin tolerance or reactivity, but nutrient deficiencies can predispose individuals to poor barrier integrity. Ensuring that your patients change to all natural skin care products is an easy and in my opinion, most important first step to: 1.) remove offending irritants and 2.) support the process of healing. Liquid body soaps and shampoos that contain only gentle natural ingredients are usually less irritating to sensitive skin and reduce toxin and allergen exposure for a majority of people.
THE INTEGRATIVE APPROACH WORKS
The nutritional foundations integrative practitioners offer to patients will usually greatly improve and often eliminate their skin problems. Many patients (and practitioners!) compliant with integrative natural treatment for a completely different health issue may often find their skin issues resolve over time as well. Here are the basics:
- Identification and avoidance of known, suspected or potential allergens
- Ongoing detoxification and liver support
- Improving both diet and digestion
- Repletion of nutrient deficiencies integral to healthy skin
- The use of supplements which calm and support healthy, normalized inflammation and immune responses
- Changing to all natural hair, skin and household cleaning products to reduce chemical irritants
- Stress reduction and hormonal balance
It’s important that patients understand that whether it takes six months or five years, staying the course with diet and lifestyle changes and continued focus on improving their overall health will eventually lead to success!
Lisa Murray, RDN, LD
Lisa is a Licensed Dietitian/Nutritionist and Medical Educator for Emerson Ecologics. Herbalist, nutrition counselor, writer and educator, Lisa’s passion is teaching others how to integrate botanicals and nutrition supplements into a healthy diet and lifestyle, for optimal health and healing.
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