Eczema
Root-Cause Care for Eczema
Eczema is a skin barrier problem and an inflammation problem, and both have roots that go well beneath the skin.
The Basics
What eczema actually is
Eczema, also called atopic dermatitis, is two problems happening at once. The skin barrier is weaker than it should be, so moisture escapes and irritants, allergens, and bacteria get in more easily. At the same time, the immune system is primed to overreact, which drives the redness, itching, and inflammation you see and feel.
Eczema can look different from person to person. The most common form shows up in the creases of the elbows and knees, on the hands, and on the neck. Dyshidrotic eczema causes small, intensely itchy blisters on the palms and soles, and nummular eczema forms round, coin-shaped patches. They share the same underlying problems, which is why the root-cause approach is similar for all of them.
Why eczema keeps coming back
If you have eczema, you have probably been told to moisturize, avoid triggers, and use a steroid cream when it flares. Those things can really help, and stronger options like calcineurin inhibitors and biologic injections can be a lifesaver for some people. What none of them tells you is why your skin barrier keeps breaking down and why your immune system keeps overreacting. That is where I start.
A word about topical steroids
If you have used topical steroids for a long time, stopping them suddenly can trigger a painful rebound known as topical steroid withdrawal, or TSW. It can also happen after stopping other prescription creams, such as calcineurin inhibitors.
TSW often looks different from regular eczema. People describe burning, bright red skin that can spread well beyond the original rash, oozing, and skin that turns thick and wrinkled. Many also have night sweats, trouble regulating their body temperature, and relentless itching, and it can take a real emotional toll.
You don't have to stop anything to work with me. If a taper makes sense, we plan it slowly and carefully, and testing can show how long-term steroid use may be affecting your own cortisol levels.
What I Look For
What is often driving it
Eczema rarely has a single cause. These are the patterns I look for most often, some at the surface of the skin and some deeper inside the body.
From the Outside
A weakened skin barrier
Your outer layer of skin works like a brick wall. The skin cells are the bricks, and a protein called filaggrin helps hold them together. As filaggrin breaks down, it releases natural moisturizing factors, the compounds that keep your skin hydrated and slightly acidic.
Some people with eczema carry a genetic change that lowers filaggrin. Even without that change, filaggrin drops during flares, because the inflammation itself switches off the proteins your skin needs to repair.
One building block of filaggrin is an amino acid called L-histidine. In a small, placebo-controlled study of adults with eczema, taking L-histidine daily for four weeks reduced eczema severity by 34 percent, and it was well tolerated (Gibbs, 2020). It is not a cure, but it is a good example of supporting the skin barrier from the inside.
The pH of your skin
Healthy skin is slightly acidic, and that acidity matters because your skin's natural antimicrobial defenses only work in that range. In eczema, the skin drifts toward neutral, and Staph aureus, which prefers a more neutral surface, gets the upper hand.
Staph aureus and the nose
Staph aureus is a bacterium that thrives on eczema-prone skin. It releases toxins that worsen inflammation and slow healing, and it tends to collect in the creases of the elbows and knees.
For many people, the nose is Staph's home base. It lives in the nostrils and repopulates the skin from there, which is why treating the nose can matter as much as treating the rash. Repeated skin infections also lead to rounds of oral antibiotics, which disrupt the gut microbiome and can make the bigger picture worse.
The itch-scratch cycle
Eczema itch is often worst at night, and many people lose sleep over it several nights a week. Scratching brings brief relief but damages the barrier further, which lets in more irritants and keeps the inflammation going. Over time, it can thicken the skin and leave darker or lighter patches, so calming the itch is part of the treatment, not just a comfort measure.
From the Inside
Gut inflammation and leaky gut
When the gut lining is compromised or there is a bacterial imbalance, the immune system stays on high alert, and that activation often shows up in the skin.
People with eczema often have fewer of the beneficial bacteria that produce butyrate, a compound that feeds and protects the cells lining the gut. When those protective bacteria are low, the gut lining becomes more permeable. Bacterial fragments can then slip through and drive the kind of inflammation that shows up as eczema. Many people with eczema also have bloating, constipation, or IBS and assume the two are unrelated, but they often are connected.
Food triggers
Food plays a bigger role in some people than in others. It is most often a major trigger in babies and young children with moderate to severe eczema, and less often the main driver in adults. Dairy, wheat, eggs, soy, and peanuts are common culprits, and some people also react to nightshades. The only reliable way to know your triggers is a structured elimination and reintroduction.
The relationship can also run the other way. When inflamed skin lets food proteins in, the immune system can learn to react to those foods, which is one more reason calming eczema early matters.
Yeast
An overgrowth of Candida in the gut can play a role. Malassezia, a yeast that normally lives on the skin, can also penetrate a weakened barrier and trigger an allergic-type reaction, particularly on the face, head, and neck. Some people who develop new facial redness while taking the biologic Dupixent improve with antifungal treatment, which suggests yeast may be part of that picture.
Source: Gibbs NK. l-Histidine Supplementation in Adults and Young Children with Atopic Dermatitis (Eczema). J Nutr. 2020;150(Suppl 1):2576S-2579S. doi:10.1093/jn/nxaa200
C: Cut inflammatory foods. An elimination diet focused on the most common eczema triggers, followed by careful reintroduction.
L: Lower toxic burden. Fragrance-free, simple personal care products, and a patch test before anything new touches your skin.
E: Eliminate gut pathogens. Stool testing to find overgrowths like Staph, Strep, or Candida, along with attention to the skin and nasal microbiome.
A: Absorb key nutrients. Targeted support for the nutrients your skin uses to rebuild its barrier.
R: Rebuild and Restore. Repairing the gut lining, and calming a nervous system that has often been through months or years of itching and poor sleep.
For Parents
Eczema in children
I occasionally see children with eczema, and the approach is similar, with a few important differences. Food triggers are more common in young children, so diet often plays a bigger role. Babies' cheeks are especially vulnerable, because the skin there takes years to build its full moisture-holding capacity, and food and saliva break it down further.
Children with early eczema are also more likely to develop food allergies and asthma later on, a pattern often called the atopic march. Calming eczema early may help interrupt it.
With children, I start slowly, use simpler formulas with fewer ingredients, and choose products that are safe for their age.
What to expect
Eczema-prone skin can be reactive, so we start slowly and keep each plan as simple as possible. If you flare, we pause anything new and reintroduce it one step at a time. The encouraging part is that the calmer your skin gets, the more foods and treatments it can tolerate.
Ready to find out what is driving your eczema?
A free consultation is the best way to see whether this approach is the right fit for you.