Food avoidance in atopic dermatitis increases risk for food allergy

Published Online: February 2105

Foods have been shown to be a trigger in 20-30% of cases of moderate-severe atopic dermatitis (AD). After diagnosis of food-triggered AD, patients are typically instructed to begin elimination diets of the offending agent. However, reports have suggested that after long periods of elimination, foods that were previously tolerated can cause immediate reactions, including anaphylaxis.

Recently published in The Journal of Allergy and Clinical Immunology: In Practice, Chang et al report a retrospective chart review of children who presented for evaluation of food-triggered atopic dermatitis to the allergy-immunology clinic at the Ann & Robert H. Lurie Children’s Hospital of Chicago. Data were collected from the initial evaluation and subsequent follow-up visits, including the results of allergy evaluations and food exposure. The authors determined the frequency and identified characteristics of patients with food-triggered atopic dermatitis who developed immediate type reactions to food.

At the initial visit, 183 of 298 (61.4%) patients were diagnosed with probable food-triggered AD. The most common foods attributed to eczema flares were milk (57.5% of patients), egg (30.6%), and soy (21.0%). Of the 206 patients with follow-up, 132 were diagnosed with food-triggered atopic dermatitis. Among 54 patients (40.9% of those with follow up, 18.1% of the total initial cohort) there were 60 immediate reactions upon accidental ingestion or oral food challenge in the clinic during the follow-up period. Alarmingly, 25 patients (19.8% of these with follow up, 8.4% of the entire cohort) had no previous history of immediate reactions at their initial presentation, but developed a total of 31 immediate reactions during follow-up, including anaphylaxis. Milk (n=21), egg (n=16), and peanut (n=9) were the most common triggers. Interestingly, avoidance of the food was associated with development of an immediate reaction. Relative abundance of food triggers did not differ between children with and without immediate reactions, with milk, egg and peanut being the most common in both groups.

In summary, 18.9% of children with no previous history of any immediate reaction developed a new immediate reaction to food. One clear risk factor for developing immediate reactions was avoidance of the culprit food. The authors concluded that careful consideration is necessary before prescribing strict elimination diets because avoidance may increase the likelihood of developing immediate reactions in the future. They additionally suggested that patients may benefit from keeping tolerable amounts of a triggering food in the diet and also suggest that patients with food-triggered AD warrant an emergency action plan and self-injectable epinephrine.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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