The 5 Internal Drivers of Eczema That Steroid Creams Cannot Fix
Medically reviewed by Dr Jeff Khoo, Medical Director, Revix Clinic
Quick answer: Eczema (atopic dermatitis) keeps coming back because steroid creams and moisturisers only manage the visible inflammation without addressing the internal drivers that trigger and sustain it. The 5 most common internal drivers of persistent eczema are gut dysbiosis and increased intestinal permeability, immune system dysregulation, skin barrier genetic dysfunction, food sensitivities and dietary triggers, and chronic stress and cortisol elevation. These drivers map onto the 4 Drivers of Health framework — particularly Inflammation and Recovery. Until these are assessed and managed, eczema tends to cycle between flare and remission indefinitely.
You know the cycle. Your eczema flares. You apply the steroid cream. It calms down. You stop the cream. It flares again — sometimes worse than before.
You have tried different moisturisers, avoided certain soaps, changed your detergent. Nothing produces lasting control. The eczema always comes back.
This is the lived reality for millions of Malaysians with eczema — and the reason it keeps recurring is not that you are using the wrong cream. It is that the internal drivers of your eczema have never been identified or addressed.
Why Steroid Creams Are Necessary But Not Sufficient
Topical corticosteroids reduce inflammation at the skin surface. They are effective, necessary during active flares, and medically appropriate. But they do not change the internal environment that triggers the flare in the first place.
Think of it like a fire alarm: steroid cream silences the alarm (the visible rash). But the fire (the internal inflammatory trigger) is still burning. When the cream is stopped, the alarm sounds again because the fire never went out.
Long-term steroid use also carries risks: skin thinning, rebound flares, reduced effectiveness over time, and potential for steroid dependency. These risks make it even more important to address the drivers that keep triggering flares.
The 5 Internal Drivers of Persistent Eczema
Driver 1: Gut Health and the Gut-Skin Axis
The connection between gut health and skin conditions is well-established for eczema. Gut dysbiosis (imbalanced gut bacteria) and increased intestinal permeability (often called leaky gut) can drive eczema through several pathways:
- Immune activation: An imbalanced gut microbiome shifts the immune system toward the Th2 response — the same immune pathway that drives eczema inflammation
- Systemic inflammation: When the gut barrier is compromised, inflammatory molecules enter the bloodstream and reach the skin, triggering or worsening eczema flares
- Impaired immune tolerance: A healthy gut trains the immune system to distinguish between harmful and harmless substances. Dysbiosis impairs this training, increasing the likelihood of overreaction to food proteins, environmental allergens, and skin microbes
Research consistently shows that people with eczema have measurably different gut bacterial profiles than people without eczema. Reduced diversity and specific bacterial imbalances are common findings.
Driver 2: Immune System Dysregulation
Eczema is fundamentally an immune-mediated condition. The immune system overreacts to triggers that should be harmless, producing the characteristic inflammation, itching, and rash.
Key immune factors in eczema:
- Th1/Th2 imbalance: Eczema is associated with an overactive Th2 immune response, which drives IgE production, mast cell activation, and the characteristic itching and inflammation
- IgE elevation: Many people with eczema have elevated IgE antibodies, reflecting immune hypersensitivity
- Barrier-immune crosstalk: When the skin barrier is compromised, allergens and microbes penetrate more easily, triggering immune responses that worsen the barrier further — creating a self-reinforcing cycle
Driver 3: Skin Barrier Dysfunction
The skin barrier is the body’s first line of defence. In eczema, this barrier is often genetically weakened — most commonly through mutations in the filaggrin gene, which affects up to 30% of eczema sufferers.
A compromised barrier allows moisture to escape (causing dryness), allergens and irritants to penetrate (triggering immune response), and microbes to colonise (particularly Staphylococcus aureus, which worsens eczema). This barrier dysfunction is both a cause and a consequence of eczema — inflammation damages the barrier further, which allows more triggers through, which causes more inflammation.
Driver 4: Food Sensitivities and Dietary Triggers
For some eczema sufferers, specific foods trigger or worsen flares. Common culprits include dairy, gluten, eggs, soy, nuts, and shellfish. However, food triggers are highly individual.
In Malaysia, dietary factors are particularly relevant:
- High-glycemic diet: Frequent white rice, sweetened drinks, and processed foods increase systemic inflammation
- Processed and fried foods: Common in Malaysian cuisine, these can promote gut inflammation and immune activation
- Food additives: Preservatives, colourings, and flavour enhancers in processed foods can trigger eczema in sensitive individuals
Elimination diets under medical guidance can help identify specific triggers, but should be done carefully to avoid nutritional deficiencies.
Driver 5: Stress and Cortisol
Anyone with eczema knows: stress makes it worse. This is not psychological — it is physiological. Chronic stress elevates cortisol, which disrupts the skin barrier by reducing ceramide production, shifts the immune response toward the Th2 pathway that drives eczema, increases inflammation through sustained immune activation, and impairs sleep, which reduces the body’s overnight repair capacity.
In Malaysia’s high-stress urban environment, the stress driver is pervasive and often unaddressed.
How These Drivers Connect Through the 4 Drivers of Health
The 5 eczema drivers map directly onto the 4 Drivers of Health:
- Inflammation: Gut dysbiosis, immune dysregulation, dietary triggers — all increase the inflammatory load that drives eczema
- Recovery: Stress, poor sleep, cortisol elevation — all impair the body’s ability to repair the skin barrier and regulate immune responses
- Metabolism: Blood sugar instability and insulin resistance increase systemic inflammation, worsening eczema
- Hormones: Cortisol dysregulation and hormonal fluctuations can modulate immune function and barrier health
What a Root-Cause Approach to Eczema Looks Like
Step 1: Comprehensive Assessment
Beyond examining the rash, assessment should evaluate gut health indicators, dietary patterns and potential triggers, stress and sleep quality, treatment history (steroid use patterns, what has and has not worked), and skin barrier health.
Step 2: Manage Active Inflammation
Appropriate anti-inflammatory treatment to control active flares — this may include topical treatments, barrier repair, and lifestyle modifications.
Step 3: Address Internal Drivers
Gut health optimisation through dietary guidance and targeted supplementation. Stress management and sleep improvement. Identification and management of dietary triggers. Skin barrier support through appropriate moisturisation and barrier-repair ingredients.
Step 4: Build Resilience
The goal is not eliminating every trigger but building the body’s resilience so that triggers produce milder responses. This involves strengthening the gut microbiome, improving barrier function, and reducing overall inflammatory load.
How Revix Clinic Approaches Eczema
At Revix Clinic, we approach eczema through the 4 Drivers of Health framework — recognising that lasting eczema management requires addressing the internal inflammatory environment, not just suppressing the visible rash.
Revix Clinic Eco Santuari, Kota Kemuning, Selangor
Revix Clinic Setia Alam, Shah Alam, Selangor
FAQs About Eczema
Why does my eczema keep coming back?
Eczema recurs because the internal drivers — gut dysbiosis, immune dysregulation, barrier dysfunction, food sensitivities, and stress — remain active even when topical treatment controls the visible rash. Addressing these drivers reduces the frequency and severity of flares.
Can gut health cause eczema?
Gut health strongly influences eczema. Gut dysbiosis can shift the immune system toward the inflammatory Th2 response that drives eczema, increase systemic inflammation, and impair immune tolerance. Improving gut health is an important component of comprehensive eczema management.
Can stress make eczema worse?
Yes. Chronic stress elevates cortisol, which disrupts the skin barrier, shifts immune responses toward inflammation, and impairs overnight skin repair. Stress management is a legitimate and important part of eczema treatment.
Should I stop using steroid cream?
Do not stop prescribed medication without medical guidance. Steroid creams are appropriate for managing active flares. The goal of a root-cause approach is to reduce the frequency of flares so that steroid use is needed less often — not to eliminate it entirely.
Can diet affect eczema?
Yes. Specific foods can trigger eczema flares in some individuals, and dietary patterns that promote inflammation can worsen eczema generally. Identifying individual triggers through guided elimination and addressing overall dietary inflammation can meaningfully reduce eczema severity.
Is eczema curable?
Eczema is a chronic condition that can be managed but not cured in most cases. With comprehensive management addressing internal drivers, many people achieve long periods of remission with significantly reduced flare severity when flares do occur.
