strongest genetic risk factor is due to mutations of the filaggrin gene (4). Filaggrin is a protein responsible for collecting keratin filaments which are subsequently cross-linked to create scaf-folding for the extracellular lipid matrix on the outermost layers of the dermis (38). Proper skin barrier function is de-pendent on a functional filaggrin gene (Maloh, 2022). In addition to aggregat-ing keratin filaments, the breakdown product of filaggrin is a component of natural moisturizing factors (NMFs) which play a role in the skin’s ability to retain moisture and maintain an acidic surface pH (5). Mutations in the filaggrin gene dis-rupt the stratum corneum, making it more susceptible to infiltration by path-ogens, allergens and toxins (Kawasaki, 2012). This lays the groundwork for a chronically inflamed environment. Ini-tially, the infiltration causes a TH1 im-mune response which produces inflam-matory cytokines such as interleukin-1 (IL-1) and tumor necrosis factor beta (TNFB) (Traub, 2016). The presence of this inflammation paired with increased trans-epidermal water loss (TEWL) compromises the protective effective of the skin barrier. If inflammation is pres-ent for long enough, the TH1 response switches to a TH2 response, represented by basophils, monocytes, eosinophils, and other cytokines that propagate in-flammation and pruritus (Elias, 2009). In addition to mutations in the filag-grin gene, other components that can affect the protective barrier including changes in lipid composition, increased skin pH, alterations in the skin microbi-ome, itching, and weakened tight junc-tions (Zhu, 2018). current hypotheses. One popular thought is that there is a link between increased intestinal permeability (or “leaky gut”) and atopic dermatitis. Cytokines that are associated with atopic dermatitis (IL-4 and IL-13) have been found to up regu-late claudin-2, a protein associated with intestinal permeability (Maloh, 2022). Another association that has been ex-plored is food allergies and AD. There are studies that suggest that a disrupted skin barrier allows for allergens to pene-trate the skin, leading to increased sys-temic inflammation and increased sensi-tization for food allergens (Bergmann, 2013). Foods that are commonly associ-ated with atopic dermatitis are peanuts, dairy, and eggs (Burks, 1998) 2020) while the holistic approach aims at restoring balance within the body and removing obstacles to cure. CONVENTIONAL APPROACH ENVIRONMENTAL TRIGGERS DIET Individuals with atopic dermatitis are more likely to experience gastrointesti-nal issues, such as diarrhea, and vomit-ing compared to a control group (Caf-farelli, 1998). On the flip side, individuals with functional gastrointes-tinal disorders, such as IBS and consti-pation, tend to have a higher prevalence of atopic dermatitis compared to indi-viduals without (45). While there seems to be a connection between digestive system and atopic dermatitis, it is poorly understood and there isn’t enough evidence to support www.Cndoctor.ca Various factors can decrease or worsen exacerbations, including humidity, tem-perature, and aeroallergen exposures. Within the home environment, it can be helpful to keep a humidifier in the patient’s room (Gallay, 2020) and avoid air conditioning. While air conditioning hasn’t been found to worsen AD symp-toms, it can weaken the skin barrier by increasing skin pH and reducing the degradation of filaggrin into NMFs (nat-ural moisturizing factors) (Gallay 2020). Exposure to phthalates, or a chemical additive to plastics, has also been linked with an increased incidence of AD (Wang, 2014). Phthalates can be found in multiple places within the home, in-cluding toys, food wrappings, cosmetics, and dust (Wang, 2014). It has been found that early exposure to monoben-zyl phthalate is significantly associated with the development of AD (Wang, 2014). Similarly, there is a strong asso-ciation with AD development and the exposure to butyl benzyl phthalate (Bornehahg, 2004). It is thought that phthalate may increase the incidence of AD because it stimulates the thymic stromal lymphopoietin (TSLP), a cy-tokine that triggers a TH2 response (Shigeno, 2009). The first-line therapy for mild-moderate atopic dermatitis is topical corticoster-oids. The appropriate agent is selected based on factors such as patient age, areas of body treated, xerosis and patient preference (Weinstein, 2020). Other options that the practitioner has for mild-moderate atopic dermatitis include topical calcineurin inhibitors and topical PDE4 inhibitors. For refractory and severe AD, the practitioner can consider phototherapy with a broad-and narrow-band UVB, biologic agents in patients over 12 years old, or other systemic agents such as methotrexate (Weinstein, 2020). The practitioner must proceed with caution when selecting a systemic agent due to significant adverse effects and the requirement of regular monitor-ing (Weinstein, 2020). TRADITIONAL CHINESE MEDICINE Traditional Chinese Medicine views healing through the lens of bringing balance to the body. The underlying pattern of atopic dermatitis is the com-bination of heat, damp, and wind, and thus herbs that have the energetic func-tions of cooling, drying, and dispelling wind are used. These herbs tend to have anti-inflammatory and antibiotic prop-erties (Chen, 2015). A common combi-nation of herbs include Xiao Feng san -clear wind powder (Chen, 2016; Cheng, 2011). Depending on the under-lying pattern of the atopic dermatitis, additional herbs can be added at the practitioners’ discretion. NATUROPATHIC APPROACH THERAPEUTIC INTERVENTIONS FOR TREATING ECZEMA The nature of atopic dermatitis is that it is a relapsing and remitting condition; there is no cure (Weinsteine, 2020). Conventional therapies aim at minimiz-ing and controlling flares (Weinstein, The naturopathic approach to atopic dermatitis focuses on finding the root cause of the individuals’ AD, removing obstacles/barriers to healing, and sup-porting the body’s natural ability to heal itself. In a given patient, that may look like adding supplements/herbs/nutri-ent-rich foods to overcome any deficien-cies and to stimulating healing; adapting the external environment to remove/re-duce triggers; providing options for stress reduction; and offering topical therapies to bring relief to existing lesions. March/April 2022 Chiropractic and Naturopathic Doctor 11
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