The treatment of atopic dermatitis (AD) is undergoing a revolution thanks to biologics. Now, an allergist and a dietitian told pediatric dermatologists that the treatment of a related condition – food allergy – is also undergoing a dramatic transformation as the management approach evolves away from blanket avoidance of allergens.
“Over the past 15 years, we’ve seen a shift from a very passive approach where generally we just advised patients to avoid the things they’re allergic to,” said U.K. pediatric allergist Adam Fox, MBBS, MD, in a presentation at The World Congress of Pediatric Dermatology (WCPD) 2021 Annual Meeting. “Now, we have a much better understanding of how allergy develops and strategies to minimize the risk of allergy happening in the first place,” he said.
According to Carina Venter, PhD, RD, associate professor of pediatrics-allergy/immunology at the University of Colorado, Denver, who also spoke at the conference, an estimated 20% to 30% of patients with AD also have food allergies, and up to 90% of infants with cow’s milk allergy develop skin symptoms.
It may not be necessary for a breastfeeding mother to avoid food allergens if a child is allergic, said Dr. Fox, of Guy’s and St. Thomas’ NHS Foundation Trust, London. “A lot of parents will automatically assume that if their child has an egg or milk allergy, then it’s a good idea to completely eliminate that from their diet if they’re breastfeeding,” but it is “surprisingly uncommon” that this approach makes a difference, he said. “Less goes through the breast milk than people imagine,” he said.
He noted that eliminating foods from the breastfeeding mother’s diet may have negative consequences. “There’s always that risk that if you make life harder for the breastfeeding mom because they’re going to have to avoid all sorts of foods, they’ll be more likely to discontinue breastfeeding. You really need a compelling reason to stop the food.”
As for children themselves, Dr. Fox suggested that there’s often no connection between AD and food allergies. “What will commonly happen when you see and diagnose these kids is that their eczema has been quite significantly undertreated,” he said. “Once you just get them on the right [regimen], they don’t need to be cutting the food out of their diet. It’s just making their life unnecessarily harder.”
Dr. Venter said there may be little choice but to avoid a trigger food if a child develops AD with exposure. However, she noted, it’s important to understand that avoidance of certain foods could make the allergy – and AD – worse. “If you have a child or an adult with atopic dermatitis that’s not controlled by an optimal topical treatment, and you do consider avoidance, we need to be aware that development of more severe IgA-mediated symptoms can happen in a short period of time,” she said.
In a slide that Dr. Venter presented, the dilemma for physicians was expressed this way: “The potential benefit of food avoidance as a management strategy for some patients with AD must now be weighed against the strong evidence that unnecessarily avoiding a food in kids with AD increases the risk of developing anaphylaxis to that food.”
What should pediatric dermatologists do to balance the risks of allergen exposure to the risks that children will develop permanent allergies? Dr. Venter pointed to guidelines about AD that were developed by the U.K.’s National Institute for Health and Care Excellence. She also highlighted the International Milk Allergy in Primary Care recommendations.
She suggested considering creative ways to bypass complete avoidance and boost a child’s tolerance of allergens if possible. “If we’re going to keep a child with eczema on a mold-free diet for a longer period of time, is there perhaps a role for regularly introducing small amounts of yogurt or even small amounts of milk in the child’s diet to at least keep immune tolerance without necessarily aggravating eczema symptoms?”
Dr. Fox has consulted for DBV and Aimmune through his employer, NHS Trust. He serves as president of the British Society for Allergy and Clinical Immunology and as chair of the Allergy UK Health Advisory Board, both of which receive funding from drug companies. Dr. Venter has received support for allergy-related research from the National Peanut Board.
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