Karey was in her 20s and accompanied by her mother. Her face looked as if someone had splashed reddish-pink paint on it. One eyelid was swollen half shut. On the desperation scale, Karey’s mom was clearly off the chart, distraught that her otherwise smart, lovely daughter should have been dealt such an unfortunate hand.

They spoke at the same time, “I my have daughter has eczema.”

Karey was a theater major in the city. She’d always been a sensitive child, lots of ear infections as a toddler-- and lots of antibiotics given in response. Skin rashes throughout childhood came and went and then came back again with daunting persistence. Tracy had been to most of the leading dermatologists in the city as well as getting an audience with the big wigs at one of the university hospitals.

“Cortisone. Steroids. That’s all anyone ever gives her,” Mom laments. “And antihistamines for itching, but they are so sedating. I’ve been slathering her with steroid creams since she was four years old! The creams work okay-- until you stop using them. Doctors all say they’re harmless, but I can’t believe it doesn’t get into your system. They also offered stronger drugs to suppress her immune system, but when I read the side effects I just couldn’t.”

I smiled and focused on the patient. “Karey,” I began. “You’ve lived with this for years. Tap in to your intuition and start listing everything you know that makes your eczema worse.”

“When I eat convenience food, for one,” she began.

“There’s so much of it in the vending machines in the dorm. Oh, and stress. Like when I was assigned a show to direct, which was exciting but very stressful. And my period. I’m pretty sure I have PMS and eczema together.” She paused. “I can’t seem to think of anything else.”

I asked her to describe a typical day of eating, including skipped meals and snacks.

Karey rolled her eyes. “This is embarrassing. Especially with her (glancing at Mom) sitting here. I usually don’t have time for breakfast, but I sometimes grab a bagel and some coffee on the way to class. When I do eat breakfast, it’s dehydrated scrambled eggs in the cafeteria. Before lunch I’ll also have a granola bar or some corn chips or a turkey jerky. The rest of the day I eat in the cafe because of my meal ticket: burger, fries, spaghetti, pizza. The fried chicken is really good. Some cookies or yogurt for dessert.”

“And to drink?”

“Milk, soda, coffee. I like milk. Sometimes OJ in the morning.”

“The doctors already tested her for food allergies,” Mom volunteered. “The scratch tests all came back negative.”

I explained that the scratch tests done by allergists looked for immediate reactions to foods (think IgE), like when your lips swell with strawberries or you start itching with shrimp. Food sensitivities, on the other hand, occur more slowly, two or three days after eating a culprit food. First you eat the food, digest and absorb it, and then if you’re sensitive your immune system creates antibodies (in this case, IgG) against it.

“We’re going to look for the antibodies because it’s these antibodies attacking food molecules that are responsible for your eczema.”

I examined Karey’s skin and hair. It struck me that everything about her was extremely dry. Even the areas of skin not affected by the eczema were flaky, as was her scalp. And her hair was unhealthy looking.

“Karey,” I began. “It’s not just that I think your diet is pretty awful, which it is, but it’s very likely we’re dealing with an issue of food sensitivities. The usual food sensitivity suspects are dairy, egg, corn, gluten, sometimes citrus, and even soy. (The official list you’ll see obligatorily plastered on restaurant walls around town includes fish, shell fish, nuts and peanuts). If you look over your typical day, every meal contains something that includes these ingredients.

"You’re also likely to have some vitamin and mineral deficiencies, as well as deficiencies in what are called essential fatty acids.”

I watched as Karey counted the six common offending foods on her red and itchy fingertips. Then, like a chorus, the two of them, “I my daughter can’t stop eating ...”

I handed her a folder about an elimination diet. It’s kind of a “Ctrl-Alt-Del” for your body’s digestive system and, by extension, its inflammatory signaling. With careful planning, you eliminate the most likely offending foods from your diet for 30 days. Then, again with careful planning, you slowly one by one introduce them back. You wait and watch for the return or exacerbation of symptoms.

In addition to the food elimination diet, I recommended two important diagnostic tests that she request from her family doctor or NP: a blood test for sensitivities to ninety six commonly eaten foods and a urine test that would look for what we’re today calling intestinal hyperpermeability.

(This second test is controversial in some Functional Medicine corners where practitioners argue, with some merit, that finding evidence of intestinal hyperpermeability (kind of colloquially called “leaky gut”) is not in itself useful because it still doesn’t tell you “why” or“ what lead to this.” But the power of this information-- even if it doesn’t on the surface give you the why or how-- can be tremendously motivating for a patient. The test is inexpensive and non-invasive. We think it’s worth it.)

We would also test her for nutrient and micronutrient deficiencies. Sure enough, her omega 6/omega 3 ratio was all out of whack. I gave her an herbal formula for her PMS and to help calm her body’s response to stress. And recommended a high quality fish oil.

Finally, because of all those childhood antibiotics, I wanted to test Karey for candida overgrowth, a real villain when it comes to leaky gut.

Our nutritionist walked Tracy and her mom through the food allergy elimination diet, offering all sorts of healthful and tasty substitutions that are rarely linked to any allergic reactions.

A second route to treating chronic skin infections, especially psoriasis but eczema as well, is traditional Chinese medicine. The Avicenna Centre outside of Brighton, England offers postgraduate study in dermatology where practitioners learn to prepare individualized herbal formulations that have produced remarkable results.

Since a school production was coming up and Tracy would be on stage in a few weeks, it wasn’t too difficult to extract a promise that she’d make every effort to comply with her new way of eating.

Three weeks later, mom showed up for the follow-up visit without Karey to review the food sensitivity blood test and the leaky gut results. Apparently Karey had a last minute rehearsal that clashed with our appointment.

I showed her mother the food sensitivity results (several foods flashing red) as well as the intestinal permeability ones. Just as expected, Karey’s small intestine was leaking large molecules of incompletely digested food into her blood stream, like a sieve.

A photo of Karey on her phone showed significant progress in clearing the eczema. And all we’d done so far was the elimination diet, some fish oil and herbs. Then apparently for dramatic effect, Mom pulled out a paper bag and dumped onto the examining table a pile of twisted, sticky tubes of various cortisone creams and half-empty bottles of antihistamines.

Mom smiled. “I had to show you what her life had been. Now I can throw them out.” And she swept them all into a nearby wastebasket, with a final dramatic flourish.

“Something has been irritating her skin all these years.”

“And how are you doing with all this?”

She paused. “What can I say? I’m her mother. I used to look at her, at those terrible rashes and my heart would break. She’s so beautiful, even if I am her mother. When I peeked in and saw her looking in the mirror, touching her cheek and smiling, I realized I’d never seen her do that and I started crying. Then she saw me and we both started crying. She’s very happy. We’re very happy.”

The magic of Functional Medicine. But you can’t do this in 17 minute office visits. And sometimes the insurance network you’re in won’t let you do it at all. That’s the world we’re in. And why more and more folks want out.

Mike Barr, a long ago Poz Senior Contributing Editor and founding member of and scribe for the Treatment Action Group (TAG), is a functional medicine practitioner, acupuncturist and herbalist in NYC. Reach out to him here.