Interview with Rakhi Roy - How to Treat Eczema

Nutritionist Rakhi Roy

Credit: Rakhi Roy, MS, RD, LDN.

Q: What is your background and experience in nutrition and wellness? How did you become interested in this area of health?

A: I didn’t always know that I wanted to work in nutrition and wellness. I studied theater and was pursuing a career in acting before I went to a Registered Dietitian (RD) to determine what to treat eczema with. My skin was a big insecurity of mine, my medications were no longer effective and my worsening skin flares were getting in the way of my auditions and booking more work. I felt like I had tried everything in the book except focusing on nutrition, so I decided to give that a try. Making changes to my diet was the best decision I made because I finally felt like myself again. I decided I wanted to help others with chronic disease feel supported through nutrition, so I went back to school to get my Master’s and complete my 1200 clinical hours. 

Q: What are some common health issues you see in patients?

A: I mostly work with eczema, psoriasis, TSW skin condition (Topical Steroid Withdrawal), and IBS (Irritable Bowel Syndrome) patients. So a lot of skin and gut issues -- the two are very much connected.

Q: You’ve mentioned Topical Steroid Withdrawal (TSW skin condition). Could you please tell us more about this condition? How does TSW occur and how is it treated? 

A: According to ITSAN (the non-profit support organization for TSW), Topical Steroid Withdrawal, also known as Topical Steroid Addiction (TSA) or Red Skin Syndrome (RSS), is a debilitating condition that can arise inadvertently from the use of topical steroids prescribed by doctors to treat skin problems such as eczema. Not everyone who uses topical steroids will develop TSW skin condition and it is unclear why some individuals experience TSW as a result of topical steroid therapy and why others do not. 

Topical Steroid Withdrawal symptoms are characterized by red, itchy, burning skin that can appear after stopping topical steroid treatments, or even between treatments. Topical steroids can be effective for a period of time to treat the skin condition. As time passes, however, applying topical steroids becomes less effective and can actually cause an adverse reaction: the original topical steroid withdrawal symptom escalates as it spreads to other areas of the body. In the case of eczema, this “progression” is often mistaken for worsening eczema, contact dermatitis, an infection, or an allergic reaction. In addition, TSW skin condition comes with severe secondary complications, such as skin oozing, open wounds, sleep disturbances, body temperature dysregulation, and hair fall out. Many sufferers are bedridden and housebound for months to years before their topical steroid withdrawal symptoms abate.

This condition can also arise for individuals who have used topical steroids as acne treatment, or caregivers who neglect to wash their hands after applying topical steroids on someone else. Also note that over the counter cortisone and hydrocortisone creams, which are commonly marketed for bug bites or hives, are also steroids and, although of milder potency, these creams should be used with caution as they can thin the skin and suppress the immune system of the skin.

Q: What are your go-to solutions and tips for people asking what to treat eczema with and/or similar conditions?

A: A regular skincare routine that focuses on skin barrier protection with minimal products and a minimally processed, varied and colorful diet rich in vitamin A, vitamin D, B vitamins, and protein. I recommend at least 20 grams of protein per meal, chewing food thoroughly in a relaxed state to help with absorption in the gut, and no alcohol when skin is flared (no one likes to hear this but alcohol puts a lot of stress on the body, dilates the blood vessels, and dehydrates the skin). These are my most frequent recommendations as what to treat eczema with.

Q: For those with skin conditions such as eczema and TSW, how do you recommend treating wounds and flared skin? 

A: The 2 things that eczema and TSW skin condition patients have in common is an impaired skin barrier and immune system dysfunction. Eczema typically occurs from external or internal triggers, so it’s important to identify what triggers the flares, avoid the triggers and moisturize to seal the skin barrier. With TSW (which is not to be confused with eczema) the skin is very thin from the use of medications and the immune system is overreacting to everything, but it’s not a true allergic reaction. Your skin is the largest organ of your body and is fighting daily to protect itself from the outside world, so when it becomes very thin it loses normal functionality. In this case, it’s harder to pinpoint what’s causing the flare, and moisturizers actually might be more irritating to the damaged skin so we have to go about treating TSW differently. Protecting TSW skin with a physical barrier (i.e. moist wound healing dressings) so skin is not chronically being reopened when scratched will give it the best chance to heal. 

I accidentally discovered the benefits of medical grade Manuka honey for eczema and TSW skin condition after working with so many wound patients in the elderly nursing homes and spinal cord injury rehabs where susceptibility to pressure wounds and bed ulcers are high. As a wound dietitian in the clinical setting, I have to ensure that my patients eat enough calories, protein, vitamin C, and other micronutrients for their skin to heal; but there’s a different magic to wound healing that I learned while working with my team of wound nurses when they used medical grade Manuka honey on the skin.

I recommend cleansing the wound with saline wound wash and covering with medicinal grade manuka honey bandages. The Medihoney branded bandages we used in the rehabs were quite sticky and not practical for everyday life outside our clinical use, so I was pleased to discover FirstHoney!

Q: Could you please describe the difference between moist and dry wound healing?

A: Protecting the skin during wound healing is key to prevent further injury and allow new skin cells to form. Many times I hear people say “I don’t understand, I let my skin or wound air out, why isn’t it healing”. Contrary to popular belief, the skin heals faster in a moist environment. Moist doesn’t mean wet, it just means covered under slightly humid conditions to allow new healthy skin cells to “swim” easier (so to speak) than having to push up against dried, hardened scabbed skin that has been open to the air. Using gauze to cover a wound is also considered dry wound healing as the wound exudate can adhere and dry to the gauze, damaging newly formed skin cells when the gauze is ripped off. Using Manuka honey bandages, foam dressings, or calcium alginate can provide moist wound healing after a saline wash is used.

Q: Anything else you would advise for those with eczema and TSW skin condition?

A: All the cliche things of just going back to the basics are true for a reason. Eating a varied whole-food diet, getting enough sleep, drinking enough water, moving your body, and allowing your body to work with nature (with some help from nature-made skincare) can go a long way.

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