Psoriasis vs Eczema: Diagnosis and Treatment Through Functional Medicine

There’s nothing like scratching an itch. But when it comes to eczema and even psoriasis, it’s a gift that keeps on giving. In many cases, you scratch it and then it just continues to itch even more until the scratching becomes wounds and those wounds struggle to heal, becoming even itchier. It’s like a boulder rolling downhill, picking up speed until you do something about it.

But, what’s to be done about it? You’ll find answers to that question and more in this post, which discusses the differences between diagnosis and management of eczema and psoriasis.

Two of the most common categories of skin rashes include eczema and psoriasis, and these categories both include several different subtypes within them. However, all of these subtypes share certain etiological similarities and have similar approaches to treatment even though they are individual types of eczema and psoriasis. At the same time, psoriasis and eczema share similarities, such as the inflammatory and immune components, but they are, of course, different things.

In this post, we’ll explain how psoriasis and eczema are similar but also how they’re different, so you can get a better understanding of the Psoriasis vs. Eczema equation and know how to best work with your doctor in approaching the issue, whether it’s you, your child, or someone else you know who is suffering.

Psoriasis vs. Eczema: Types of Conditions

Types of Eczema

Eczema on it’s own is not fully considered an autoimmune disease, though it is closely related to a dysfunctional immune response, and many of the treatments both in Functional Medicine and the traditional medical model treat it as though it is an autoimmune condition. Eczema commonly accompanies other autoimmune condition. However, while autoimmunity involves the immune system attacking the self, with eczema, the response is more like an allergy, with the immune system inappropriately attacking allergens and irritants due to a compromised skin barrier.

1. Atopic Dermatitis (Atopic Eczema)
   • Chronic condition, often begins in childhood. May even appear on babies, and may be confused with “baby acne.” (Baby acne typically appears within a few days of birth and resolves by 3 weeks, whereas rashes that persist or appears for the first time after 6 weeks of age are more likely to be eczema.)
   • Itchy, red, and inflamed skin, typically on the face, hands, and behind the knees. Underarms are a less frequent location for eczema, and may be more likely to be a yeast rash, such as Candida.
   • Linked to genetics and environmental factors (allergies, asthma, antibiotic use and other gut-related conditions).
   • Skin may also become “weepy,” or crusted from dried, oozing lesions.
2. Contact Dermatitis
   • Triggered by contact with irritants or allergens. When severe, contact dermatitis may closely resemble atopic dermatitis, and may easily be confused if the causative agent is not obvious.
   • Irritant Contact Dermatitis: Caused by direct irritation from substances (e.g., chemicals, soaps).
   • Allergic Contact Dermatitis: Caused by an allergic reaction to substances (e.g., poison ivy, nickel).
3. Seborrheic Dermatitis (“Cradle Cap”)
   • Red, scaly patches on oily areas of the body, such as the scalp, face, and chest.
   • Often associated with dandruff or oily skin.
   • Often appears on newborn babies and may persist for years if untreated. Because this is a type of dermatitis, if the inflamed skin is exposed to other irritants, it may progress to other forms of dermatitis such as atopic dermatitis.
4. Dyshidrotic Eczema
   • Small, itchy blisters on the hands and feet.
   • Often linked to stress, allergies, or sweating.
5. Nummular Eczema
   • Coin-shaped, deep red patches of irritated skin, usually on the arms, legs, or torso.
   • Often triggered by dry skin or winter weather.
6. Stasis Dermatitis
   • Occurs on the lower legs due to poor circulation.
   • Common in people with venous insufficiency or varicose veins. May also be accompanied by the appearance of bruising, spider veins and possibly even bleeding from ulcerations over veins.

Types of Psoriasis

Psoriasis is considered a true autoimmune disease, and sometimes is accompanied by other autoimmune symptoms like joint arthritis. With psoriasis, the immune system attacks itself, creating thickening and reproduction of skin cells which form the inflammatory plaques.

1. Plaque Psoriasis
   • Most common type, characterized by raised, red patches with silvery scales.
   • Typically affects elbows, knees, scalp, and lower back.
   • Tends to be worsened by certain medications, like beta-blockers and lithium. It’s also worsened by stress, infection, and injury.
2. Guttate Psoriasis
   • Small, drop-shaped, red lesions, often triggered by infections (e.g., strep throat, COVID).
   • Common in children and young adults.
   • May be worsened by puberty and other hormonal shifts.
3. Inverse Psoriasis
   • Red, shiny lesions that appear in skin folds (e.g., armpits, groin, under breasts).
   • Triggered by friction and sweating.
4. Pustular Psoriasis
   • Characterized by white pustules surrounded by red skin which eventually pop and flake/itch.
   • Can occur on any part of the body, but most common on hands and feet.
   • Easily confused with infectious rashes.
5. Erythrodermic Psoriasis
   • Extremely rare, severe form with widespread redness and peeling of the skin, often across the whole body.
   • Can be life-threatening and requires immediate medical attention.
6. Nail Psoriasis
   • Affects the nails, causing pitting, discoloration, and thickening. May affect one nail or multiple nails, as well as the nail bed.
   • Often seen with other types of psoriasis.

Differences Between Eczema and Psoriasis

It’s important to note that eczema and psoriasis are similar, but their differences are significant enough that they need to be treated differently. However, before we dive into the differences, it’s important to remember what is similar about them.

Both eczema and psoriasis are immune-mediated conditions, meaning it’s wrongful activity of the immune system that drives the condition. Both create inflammatory skin changes, which influence the microbiome of the skin, favoring the growth of inflammatory bacteria. This bacteria, typically related to Strep and other species, further triggers the immune response and worsens the condition. Because the gut microbiome also influences both the immune system and the skin microbiome, gut health plays a strong role in controlling both eczema and psoriasis.

Although the types of eczema and psoriasis are varied, in this discussion we will be focusing on the most common types, which inclue atopic dermatitis (eczema) and plaque psoriasis.

• Cause:
  • Eczema: Primarily linked to allergies, immune system dysfunction, or environmental factors that trigger an overreactive immune system. Eczema may also be triggered by food sensitivities as well as allergies.
  • Psoriasis: Caused by a self-reactive immune system, leading to rapid skin cell turnover and skin thickening. Psoriasis is not as closely linked to allergies as eczema, and is more likely to exist concomitantly with other autoimmune diseases. May be triggered by food sensitivities.
• Appearance:
  • Eczema: Typically presents with red, inflamed skin, and sometimes blisters that weep and form yellow crust.
  • Psoriasis: Characterized by raised, thickened, scaly, and often silvery patches.
• Itchiness:
  • Eczema: Often intensely itchy.
  • Psoriasis: May or may not be itchy, but can cause discomfort, pain or physical dysfiguration.
• Triggers:
  • Eczema: Allergens, stress, temperature extremes, and irritants. May also be paradoxically triggered by moisture and sweat, such as in the summer, or dry air as in the winter. In children, teething may worsen eczema.
  • Psoriasis: Infections, stress, injury to the skin, and certain medications.
• Location:
  • Eczema: Commonly affects the face, hands, feet, and behind the knees.
  • Psoriasis: Commonly affects the scalp, elbows, knees, and lower back.
• Chronicity:
  • Eczema: Often a long-term condition, that may flare up seasonally or when exposed to certain triggers.
  • Psoriasis: Also chronic and can have periods of flare-ups.
• Traditional Treatment:
  • Eczema: The traditional medical model treats eczema with moisturizers, such as colloidal oatmeal to reduce itching and petroleum-based skin protectants. Severe cases may be treated with corticosteroids such as (short term) hydrocortisone/clobetasone butyrate or (longer term) fluocinolone. Antihistamine medications may also be prescribed. Some providers may recommend skin-prick allergy testing. More recently, biologic medications such as Dupixent and Adbry have been approved for adults and children with eczema.
  • Psoriasis: Treated with topical steroids, phototherapy (including UV light exposure), and systemic chemotherapy (methotrexate) or biologic (Humira, Enbrel, Cimzia) medications for severe cases.

Psoriasis vs. Eczema: Functional Medicine Treatment

Through functional medicine, treating psoriasis and eczema both emphasize the same principles of building a foundation of health upon which the immune system can function normally. This necessitates overall good nutrition, exercise, sleep and stress management practices, control of exposure to environmental toxins, and accurate diagnosis of the underlying root causes of immune dysfunction.

Here’s the thing about immune dysfunction, whether overreactive to self or overreactive to triggers: it all depends on exacerbation of the Th2 division of the immune system, meaning the division of the immune system responsible for “fighting” and “killing” invaders. In both psoriasis and eczema, the Th2 division becomes overreactive, “fight” and “killing” things it shouldn’t. At the same time, there develops a relative deficiency in the activity of the Th1 immune system, which is responsible for cleaning up damaged cells. When these cells fail to be cleaned up properly, the Th2 immune system ends up creating an inflammatory response against those cells, too, snowballing the problem.

The Functional Medicine Basics for Psoriasis vs. Eczema

Gut Health: The gut mediates the immune system. Everything that enters our ears, eyes, nose, mouth and stomach ultimately gets to our digestive tract, where our bodies need to decide whether what we’ve swallowed is COVID, a turkey sandwich, or ourselves. Bacteria play a tremendous role in informing our immune systems in this way. In my practice, the starting point for all skin conditions is the gut: testing for the microbiome (probiotics, commensals and pathogens), as well as screening for intestinal permeability (“leaky gut”), the ability to break down protein, carbohydrates and fats as evidenced by stool residues, as well as screening for inflammatory markers like calprotetin, lactoferrin, lysozyme and changes in pH. I also look for chemicals that play a role in maintaining the gut barrier like butyrate.

Stress: With all immune-reactive conditions, stress makes matters worse. This is a highly individualized situation, and I cannot diagnose a person’s stress the way that they themselves can. I do screen for cortisol and DHEA on blood work as well as other markers of a chronic, dysfunctional stress response. But only a person themselves (or the person’s parent, in the case of a pediatric patient) can evaluate for stress. (Stressors in children often relate to moving homes, starting daycare or school, family conflict, teething, addition of new siblings, potty training, teething, and more.)

Nutrition: Micronutrient deficiencies as well as deficiencies of essential amino acids impact the skin barrier and immune system. I test patients in office for zinc, selenium, omega-3 fatty acids, vitamin D and ensure that their diet contains animal foods. It is nearly impossible to have enough healthy protein while maintaining carbohydrate intake on a vegan or vegetarian diet. It’s also essential to limit sugar, to avoid immune-reactive foods, and to treat insulin resistance if it is present.

Exercise: The benefits of exercise for stress reduction and immune system modulation are innumerable. That’s all I will say here. Adults and kids both need to move their bodies daily.

Sleep: Adults need 8-9 hours of sleep and children need 10-16, depending on their age. Screening for sleep problems is beyond the scope of this post but if you are concerned you may have sleep apnea, or that your child may be struggling with sleep, please have an evaluation done.

Toxins: This is the big one. The term “toxins” refers to chemicals (biological, synthetic or otherwise) that enter the body or come into contact with the skin and drive a dysfunctional immune response. These may include additions to personal care products, ingredients in medications or injected pharmaceuticals, pesticides, food additives, exposure to environmental toxins in air or water, and even household cleaning chemicals. If it triggers inflammation or an immune response, it will invariably trigger the eczema, or the psoriasis, of any sort. I recommend using the Environmental Working Group and Yuka apps as starting points for eliminating toxins.

Functional Medicine Treatment for Eczema

Beyond a firm foundation outlined above, functional medicine also offers specific strategies for treatment. In eczema, the keys are allergies, inflammation and supporting the skin barrier.

Allergies: I recommend blood testing for allergens and the foods you most commonly consume if you are an adult. Skin-prick allergy testing done by an allergist is not sufficient, and does not translate to eczema because these aren’t typically contact allergies driving the eczema response. It’s oral tolerance, or lack thereof. In my office, I run IgE blood test. For children, watch them like a hawk. Pay attention to any signs of redness, itching, hives, scratching, fussiness, reflux, vomiting or abdominal pain in the 3-6 hours following consumption of a particular food. If it happens more quickly, it is much more likely to be related to an IgE-mediated allergy. Then, when these foods have been identified, confirm the suspicion with an IgE blood test for each food. (Note: for milk, eggs, soy, peanut and certain other high-risk allergens, I recommend a “component panel” rather than just the IgE. Some foods have multiple identified immunogneic proteins, i.e. “Milk Component Panel” rather than “Milk, IgE.”)

When allergens have been confirmed via blood work, or even if the IgE is negative but the skin reaction is apparent, eliminate all sources of these foods for 6 months minimum. One skin is clear, reintroduce one-by-one to evaluate for tolerance. If IgE levels were detectible, re-test the IgE level after 6 months and consider reintroducing in your pediatrician or allergist office. Always consult with a physician when conusming allergenic foods.

Skin Barrier: Babies have thin skin with a poorly formed moisture barrier, making them more susceptible to irritants, especially chemical toxicants, abrasion, irritation, moisture, dryness and other triggers. I recommend using a thick, water-protective barrier ointment on all diaper changes, as well as a lotion containing saccharomyces ferment medium/filtrate such as Tubby Todd AOO. The chemicals in this fermentation filtrate protect the skin and calm inflammation, and also play a role in inhibiting the growth of inflammatory bacteria (see below.) Food-based oils do not make a good moisture barrier because they absorb quickly and are also likely to stain clothing. Instead, I recommend using either beef tallow or a beeswax-based non-petroleum product. That being said, I’m also okay with recommending Aquaphor, which contains petroleum and also castor oil, simply because it works really well and is much safer than steroids in the grand scheme of things.

In addition to topicals, supplementing with the amino acid L-Histidine upregulates the production of fillagrin, a protein that plays an extremely important role in mintaining the skin barrier. I recommend that my adult patients take 3-6 grams daily and pediatric patients somewhere between 0.25 and 1 gram depending on age and stature (capsules can be opened up and mixed with food). This needs to be supplemented long-term, for months or years, and takes time to create change so it should be combined with other strategies listed here. I also recommend my patients take an oral prescription of the probiotic saccharomyces boulardii as well as humic acid taken three times daily before meals to prevent overgrowth of commensal bacteria.

Inflammation: Inflamed skin favors the growth of inflammatory bacteria and that bacteria, in turn, worsens the immune response. It goes like this: eczema breaks out, and the skin barrier is compromised. Staphylococcus and other skin-dwelling bacteria take advantage of the situation and enter the cracks in the skin, triggering a worsened immune response, which worsens itching, prompts scratching and the eczema snowballs. This needs to be interrupted.

In extremely acute cases of eczema, I prescribe a triple-action ointment prepared using anti-fungal medication, antibiotic ointment and topical corticosteroid to be applied to the affected areas as follows: 4 times daily for 4 days, followed by 3 times daily for 3 days, twice daily or 2 days and then once daily for 1 additional day. This will help the itching/inflammation initially calm down, control infection and allow healing to begin. You can prepare this ointment at home using a 1:1:1 ratio by weight of Polysporin Ointment, Hydrocortisone 1% Ointment, and Miconazole 2% Ointment. Note that where indicated, you must use ointment rather than “cream.”

Once the skin has begun to calm down, or even if it hasn’t, I recommend my patients utilize a twice daily application of ozonated olive oil. The ozone in the olive oil produces reactive ozonides that kill bacteria, destroying their cell wall. They also stimulate the Th1 (healing) division of the immune system to clear infection, close wounds and restore the skin barrier. The OOO should not be used as a preventative, but should only be applied to areas of redness with limited spots of broken skin.

Functional Medicine Treatment for Psoriasis

Beyond a firm foundation outlined above, functional medicine also offers specific strategies for treatment. In psoriasis, the keys are prebiotics and oxidative control.

Prebiotics: Prebiotics are the precursor fibers to the growth of probiotics. Without enough “food” to keep them growing, probiotics will die off and not stick around long enough to do anything for the skin in terms of calming the immune system. Fructooligosaccharides tend to work best for psoriasis, but note that they will flare up individuals sensitive to FODMAPs or who are struggling with SIBO.

Oxidation: In addition to the benefits for eczema in controlling bacterial colonization, the Th1-stimulating properties of ozonated olive oil work tremendously well for psoriasis. OOO should be applied in a thin layer, twice daily, to any area that shows a flare. Take caution with areas of the scalp because the oil may create unfavorable changes to hair. For a standard shampoo, I recommend using a tar-based product. Coal-Tar Shampoo suppresses skin cell growth by preventing abnormal differentiation. It also helps calm inflammation and pain, and can be used as a topical wash for non-scalp areas. Coal-Tar ointment works well for non-scalp areas.

Moreover, UV exposure is essential for controlling psoriasis, as it has a similar effect to coal tar in controlling abnormal skin cell differentiation. We often think of UV exposure as a danger or risk but it provides tremendous benefits to the skin, especially inflamed skin such as in the case of psoriasis. I recommend my patients receive 30 mintues of direct sunlight exposure twice daily, or supplementation with a UV lamp or other at-home device. Note that UV lights are not the same as black lights, “blue lights,” or “sun lamps” used for reptiles.

A third factor in controlling psoriasis is omega-3 fatty acids which, when taken above daily requirements, control inflammation, immune reactivity and abnormal growth of tissue. I recommend a minimum of 4,000 mg daily for adults (often up to 8,000 mg daily) and a minimum of a standard adult dose for my pediatric patients. Be aware that doses this high might have a blood-thinning effect which can be dangerous when taking blood thinners, if having surgery, during injury or with those at risk of stroke.

Overall, skin conditions like eczema and psoriasis can be tricky to treat, and it can be very disheartening when seeing a PCP or dermatologist and receiving a lifelong steroid prescription.

That being said, functional medicine has so much to offer, wether for psoriasis vs. eczema. Natural healings can literally be in your hands!

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I’m Dr. Alexandra MacKillop, a functional medicine physician, food scientist and nutrition expert.

I specialize in women’s health & hormones, addressing concerns like fertility, PCOS, endometriosis, dysmenorrhea (painful periods), PMS symptoms like bloating and mood changes and more.

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