Atopic dermatitis (AD) is often used interchangeably with the term “eczema”, but perhaps is more accurately thought of as a specific type (or, more likely, a collection of similar subtypes) of eczema that often includes other allergic diseases such as food allergies or asthma (Bos et al. 2010). Regardless of its name, it represents a chronic, relapsing, itchy skin disease that often begins in the first years of life, but affects patients of all ages. Its etiopathogenesis is complex and still not fully elucidated, but is likely related to a combination of skin barrier dysfunction, allergic/immunologic aberrations, microflora abnormalities and pruritus (Kabashima 2013; Kong et al. 2012).

AD affects up to 20% of children in developed countries, and recent estimates are as high as 10% of adults having some form of eczema as well (Silverberg and Hanifin 2013). For such a common condition, however, a great number of questions remain. As with other areas of alternative and complementary therapies, scattered small and medium-sized studies with fundamental differences in methodology defy meaningful pooling of the evidence.

The conventional approach to management is multifaceted and includes addressing the four main areas of dysfunction with moisturization, anti-inflammatory agents, anti-microbials, and anti-pruritic therapy. Allergen identification and avoidance is also helpful when possible (Lio et al. 2014). While most of these areas are uncontroversial, the main area of contention seems to lie within the realm of anti-inflammatories: topical corticosteroids are highly effective, but have a significant number of concerning side effects that make them unwelcome for certain patients. Importantly, this perception may lead to poor adherence to the plan: one recent report found that parents and adult atopic patients surveyed reported fearing topical corticosteroids, and more than one third admitted nonadherence to treatment (Aubert-Wastiaux et al. 2011). Moreover, there is a perception that their effect—as well as that of the topical calcineurin inhibitors—is merely symptomatic, and fails to address the root of the problem. This makes for a very rich area in alternative medicine, with many possible approaches, limited only by the relative lack of quality studies. However, in sifting through a large number of papers, several promising therapies surface and appear to be at the very least worthy of further consideration, meeting the stringent criteria of apparent safety, possible efficacy, and feasibility for a conventional practitioner.

There seem to be multiple subtypes of eczema, most of which are poorly characterized. Of particular importance (Figs. 9.1 and 9.2):

Exudative and oozing lesions, “wet pattern” tends to respond particularly well to antimicrobial therapies (such as dilute bleach baths or compresses with aluminum acetate). Eczema prominent on the head and neck area of young adults seems to be intimately related to seborrheic dermatitis and may share Malassezia yeast overgrowth and/or sensitivity as a contributing factor. Pulsing with oral anti-yeast agents such as itraconazole can sometimes result in dramatic improvement without immunosuppression.

See Tables 9.1 and 9.2.

Natural oils have been used as part of massage therapy and as topical treatments on the skin for generations (Danby et al. 2013). Sunflower (Helianthus annus) seed oil is rich in linoleic acid, and has been used topically in the treatment of essential fatty-acid deficiency, rapidly reversing the disease (Lodén and Andersson 1996). These essential fatty acids can also help maintain the skin barrier and decrease transepidermal water loss, both important features in thinking about the barrier problem in atopic dermatitis (Eichenfield et al. 2009). Several studies have also suggested that there are anti-inflammatory properties of sunflower seed oil, perhaps via the PPAR pathway, marking another seminal part of the pathogenesis of AD (Eichenfield et al. 2009). There is some thought that preparations that contain higher amounts of linoleic acid versus oleic acid may be more beneficial in this role and there is some clinical data to bear this out (Eichenfield et al. 2009). Very safe and fairly inexpensive, sunflower oil seems a reasonable consideration for any patient with AD, so long as there is not a known sunflower seed allergy.

Coconut oil (Cocos nucifera), particularly virgin coconut oil (VCO),¹ has been shown to be comparable with mineral oil as an emollient (Agero and Verallo-Rowell 2004). In addition, it has also been shown to address another important aspect of atopic dermatitis: staphylococcal colonization. In a randomized controlled trial it was found to clear an impressive 95% of staphyoloccal colonization in patients with AD (Verallo-Rowell et al. 2008). And, similar to the findings of sunflower seed oil, VCO has been shown to improve barrier function in low birthweight babies (Nangia et al. 2008). When put to a more clinical test, it actually outperformed mineral oil in treating pediatric AD over 8 weeks in a randomized trial (Evangelista et al. 2014), thus making it an important alternative consideration.

Cardiospermum halicacabum grows throughout India and has long been used for medicinal purposes (Tyler et al. 2012). A number of active agents have been identified among its many compounds, including anti-inflammatory factors (Koch et al. 1996). There are some clinical data suggesting modest improvement in redness and decreasing the need for corticosteroids in clinical studies (Jong et al. 2013). As it is inexpensive and available in over-the-counter preparations, this may be useful as both a complementary medicine or even as an alternative to corticosteroids in some situations.

Vitamin D (commonly referred to in its D3 form as cholecalciferol) is a fat-soluble hormone with many effects beyond the intestinal absorption of calcium and phosphate. It can also affect immune function and increasing the levels of cathelicidin, which are important anti-bacterial proteins on the skin (Höck 2014). It also appears to improve the skin barrier function, thus making it very enticing as a possible therapy in AD. There is some controversy about supplementation in conventional medicine, so we felt it was reasonable to discuss it here. A recent paper analyzed 58 articles on the role of vitamin D in AD and made several important conclusions: (1) There is an inverse relationship between vitamin D levels and AD severity; (2) Repletion with vitamin D promotes the epidermal barrier; and (3) Clinical trials suggest a therapeutic benefit from vitamin D supplementation, though the trials are small and limited (Mutgi and Koo 2013

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