One reason for this is a well-documented genetic defect in filaggrin, a protein that helps in the formation of the stratum corneum. The stratum corneum is the uppermost layer of the epidermis and is a barrier against possible allergens, microbial incursions as well as other foreign substances. Lack of sufficient filaggrin to bulk up the skin barrier is also related to non-‘skin’ presentation of atopy, e.g. allergic rhinitis and asthma.

People who suffer from AD often suffer from increased transepidermal water loss (TEWL), decreased water binding (humectant) properties and reduced surface lipids e.g. ceramides. They also present with dysfunction in the production of antimicrobial peptides and in the molecular recognition of invading pathogens.

The earlier methods of topical treatment involved the use of emollients and humectants to bind in water and keep the water in. This is the moisturizing aspect of treatment.

The intercellular lipid matrix of the stratum corneum, consisting of ceramides, cholesterol and fatty acids, is also compromised, and so there came to be created more sophisticated products, each hoping to deliver enhanced moisturizing effect with exogenous delivery of ceramides, squalene and natural lipids of all forms.

In flare situations, there is first of all a clear presence of inflammation and possible microbial colonization, often with staphylococcus aureus.

It is not that difficult to reconcile the idea of epidermal barrier dysfunction with ‘exterior weakness’ in TCM. As for the broad concept of an imbalanced immune system, Chinese Medicine calls it ‘accumulated heat in the organs’ and it is to show that this accumulated heat is waiting to express when triggered.

To understand this imbalance better, we need to understand our cell-mediated immune response. Cell-mediated immunity uses T cells to recognize foreign bodies. Once identified, T cells call in the cytokine troops begin a cascade of immune reactions to protect the body.

There are 2 categories of T cells: T Helper cells (aka CD4 expression T cells) and T Cytotoxic cells (aka CD8 expression T cells). We are interested in T Helper cells here, which produce 2 classes of cytokines: Th1 cytokines and Th2 cytokines.

The issue with persons plagued with eczema is that the Th2 cytokines are upregulated in relation to Th1 cytokines. The elevated Th2 cytokines are associated with IgE-type responses, tissue eosinophilia, mast cell hyperplasia, and producing symptoms like catarrhal inflammation (watery mucus production) and hyper-responsive airways (e.g. in asthma).

The irony is that Th2 cytokines are predominantly anti-inflammatory (as opposed to Th1 cytokines that are pro-inflammatory). The “water” of Th2 cytokines are supposed to help douse out the “fire” of Th1 cytokines, but end up causing a different type of problem in atopic individuals.

Hence, most treatment regimes will include one or all of moisturization, anti-inflammation and anti-microbial treatment.

In terms of topical treatment, if you look at the range of products out there, the anti-inflammation comes from topical steroids, and the anti-microbial is often systemic use of antibiotics.

From the viewpoint of an herbalist, the added natural ingredients in some products are often understood within the Traditional Chinese Medicine framework as ‘heat-clearing herbs. Examples include calendula, neem, coptis. And their supplement counterparts include but are not limited to the antioxidant vitamins A, C and E.

Oils are often used for moisturizing purposes and from the traditional medicine viewpoint, these are yin enhancing and would include omega fish oils, coconut oil, jojoba oil, olive oil, and so on.

If the patient also presents with serous exudate, also known as oozing to the layperson, then herbs that clear damp are also added in. These include sophora root, poria and plantago seed.

Treatment from the point of TCM is focused on resolving the exterior with herbs like ledebouriella root, schizonepeta stem or bud or even the shedded skin of the cicada. Yin enhancers may include herbs like rhemannia, lily bulb, scrophulariae root, etc. And then there are also herbs that aid blood circulation too.

While some drugs like MTX and cyclosporine are sometimes prescribed to help suppress an ‘overactive’ immune system, Chinese medicine seeks to create a balance with the help of herbs. This balance is often dependent on the presentation of the patient, and after assessment of history, tongue and pulse diagnosis, as well as observing the skin as it presents itself, herbs are prescribed. During a flare state, herbs will be prescribed that possess anti-inflammatory and anti-microbial function. But there will also be herbs to help with balancing out the entire immune system.

Now, we move on to the concept of triggers.

A barrier dysfunction is likely to predispose to a certain kind of sensitivity. Sensory nerve fibres are more easily irritated by temperature changes, exposure to soaps, detergents and even changes in humidity of the environment. Allergens may be transmitted through the air (e.g. dust, perfume, cigarette smoke), through pets (e.g. cats and dogs), mite exposure, and last but never least, food.

An immune system predisposed to atopy-type reactions means that a cycle will start to build up. The skin reacts to external incursions by producing proteases and histamine, which result in the feeling of itch. Scratching relieves the itch but causes additional inflammation while also aggravating barrier dysfunction. This results in a vicious cycle where the skin presents with erythema, serous exudation, crusting and scaling, where some recovery is then disrupted by further skin damage and a form of immune reaction that only damages the skin even more.

In addition to the triggers listed above, there are triggers that clearly weaken and unbalance the immune system further. The greatest two disruptors are psycho-emotional stress and lack of restful sleep.

The strength of Traditional Chinese Medicine in the treatment of AD is (1) during the onset of a flare; and (2) for maintenance.

The multi-pronged attack by the numerous anti-microbial and anti-inflammatory herbs in a formula may not be as strong as a single steroidal compound, but just because it is not a single strong compound means there is less basis for the building of resistance or tachyphylaxis.

The herbal formula is revised, consultation after consultation, depending on how the patient is presenting at a particular point in time. This means that if the erythema phase component is not as severe, but now if oozing has started, the herbs can be changed to tackle the changing presentations. It is a very flexible form of medicine.

In the chronic stages, a lot of emphasis is on modulating immune function with diet and foods, all of which help to ‘balance’ out a genetic disposition toward ‘immune system imbalance’.

Already in the past, Chinese medicine has identified triggers, both from contact and also from food. Seafood has been easily identified as a trigger, as are bamboo shoots and duck. However, if we are to move toward a more personalized form of medicine, then the list of food triggers can only be a reference list. The same for lists created within the Occident, e.g. dairy, sugar, peanuts, nightshades, wheat, etc. They may apply to many, especially to atopic individuals with a high level of food intolerance, but it does not apply across the board.

Challenge testing is a great concept to learn from the Occident; as are skin prick tests and serum blood testing, which, while laden with false positives and negatives, may point the patient in the right direction for food otherwise difficult to identify as a trigger.

There is also that comprehensive framework on gut health developed by the naturopathic community over the last 150 years. The benefits of using commercially-prepared or food-source probiotics is only the most well-known form. There are other therapeutic tools used by the naturopathic community that are also immensely useful for those suffering from atopic dermatitis.

Apart from using the herbs personally mixed for their consumption, and undergoing acupuncture treatment for high-response areas or lesion-types, the treatment approach should be well-rounded that includes these other interventions:

1. Identifying and avoiding triggers – click to access article
2. Addressing the itch, reducing inflammation, maintaining moisture levels and managing barrier dysfunction – click to access article
3. Managing sleep and reducing psycho/emotional/social stress – click to access article

Seborrheic Dermatitis (SD) lesions sometimes look like Atopic Dermatitis (AD). Both are often referred to by the layman as Eczema. For good reason, because a weepy or bloody AD lesion does look like an SD lesion. Another reason why they can be similar is because the same commensal yeast lives off both Seborrheic Dermatitis and Eczema lesions. This yeast is called Malassezia or Pityrosporum.

You will see ear lesions in both conditions – Seborrheic Dermatitis lesions around the ears do fissure and resemble fissures seen in Atopic Dermatitis. Both also appear as early as the infant stage of childhood, and may extend throughout one’s life, as in the case of the 8-year-old girl in the review on the image.

When seborrheic dermatitis appears on an infant, it can appear as cradle cap (on the scalp and face) or nappy rash (around the groin). Cradle cap usually appears on the face (forehead, eyebrows, eyelids, nasolabial folds, ears) and may spread down to the neck and armpits. Nappy rash originates in the groin area and may spread down the inner thighs or up to the umbilicus/naval.

If a child suffers from Infantile Seborrheic Dermatitis, it really doesn’t bode well. There is a higher likelihood that the child may develop Atopic Dermatitis or Psoriasis later in life.

Eczema TCM treatment is usually a mix of east and west. Chinese medicine has been treating eczema for over 2000 years.

On the right, we see a classic example of atopic dermatitis / eczema presenting as Wind in the Four Bends (四弯风). The four bends refers to the flexures of the elbows and knees; wind refers to the inflammation and itch in these areas.

As you would have noticed in the BEFORE images of the elbows and back of knees, the lesions had spread beyond the these flexures, which is common especially if the patient is already using some form of steroid on the lesions.

In the case of this patient, she had already stopped the application of topical steroids about 6 months ago, and was going through the initial rebound flare. The rebound flare that follows cessation of steroid use will often cause skin inflammation to spread beyond the original eczematous lesions.

In the AFTER images, you can see that the erythema (redness) has faded away, the lesions are less dampy/weepy. What is left are some papular ‘bumps.’ For some patients, this outcome can be achieved within a few weeks; for others it may take longer.

Eczema is not an easy condition to treat. As modern-TCMs, we need to be knowledgeable about how eczema is being experienced by the sufferer. There should be adequate knowledge on how dermatologist approach treatment of eczema; there should also be awareness about new solutions to manage the itch and suffering.

One aspect that needs more than a cursory acknowledgement is stress. It is not easy recovering from eczema if your stress levels remain high – this is also true if you are suffering from TSW. If you are working in a shipyard or a car workshop or as a chef, the ongoing triggers do not support recovery. This is very unfortunate but true.

Similarly, if your eczema flare has come about due to a significant life event (divorce, death of a loved one, job loss), we have to acknowledge the need to find some way to sooth that pain that will keeps the nervous system constantly at the edge.

Not to mention, high levels of work stress e.g. finishing your master’s or phd program, non-stop work as a professional lawyer, incessant stress from being a mother, a wife and also a sufferer of eczema. Stress is often given too little credit for its contributions to systemic inflammation and inflammation on the skin.

Depending on the situation, we like to use acupuncture to treat eczema. It may should a little counter-intuitive, because the skin is already in such a bad condition, why stimulate it further with needles?

At Chinese Doc Singapore, Physician Julia works with gentle acupuncture to successfully treat eczema. In many of the cases, patients have even decided to use acupuncture alone because it is so effective. In other situation, the patients opt for herbal intervention to further reduce inflammation and speed up the recovery timeline.

How does acupuncture work? At one level, it serves to downregulate a hyper-stimulated nervous system. When you are suffering from eczema (and the same is true for Topical Steroid Withdrawal), the nervous system is hyper-stimulated because you feel the need to scratch, especially at night.

When the skin is flaring, the nervous system is amped up by several notches, resulting in vexation, irritability, inability sleep, feeling of heat in parts of the body, as well as a constant need to scratch. In such a situation, as many patient can attest to, the acupuncture can be very calming, and this calm mostly stays with the patient even after they leave the clinic.

Acupuncture is also able to sooth local inflammation on the skin, whether they present as skin reddening, bumps and nodules, or  even weepy erosions. If you are suffering from an eczema flare, you need try once to find out how your body responds to acupuncture.

We saw Dr. Mark for our then 4 month old baby who had eczema. We had tried homeopathy, naturopath, and then out of desperation a 5 day bout with steroid which showed absolutely no improvements. Then with the recommendation of grace ng from health champion we found mark. He’s quite possibly the youngest tcm doc we’ve met but not for a moment did we doubt his knowledge.

Despite informing us that infant eczema is tricky, he helped to improve our baby’s condition at such a speedy rate we weren’t expecting! He was constantly telling us to update him on our baby’s condition, he responded to our queries within the day and with our feedback, tweaked the formula of the herbs to suit our child. Our challenge with eczema is not over yet, but we are in a much better position with it now, after seeing mark, than we were 1 mth ago. We do not feel so helpless anymore.

– Mdm Frou (Mother of Child with Infant Eczema)

We much acknowledge that despite having successes with treatment infant with Chinese herbal medicine, there are cases with no significant response as well as cases with a clear response. Parents often combine Chinese herbs with other interventions and it is worth coming for a consult to discuss possible options for your infant.