New Guidelines to Prevent Food Allergies in Pediatric Atopic Dermatitis Patients

“I think sometimes you have the impression that dermatologists and allergists don't see eye-to-eye when it comes to food allergies in our atopic dermatitis patients, but I think many of us do and we have a lot to teach each,” said Lacey Kruse, MD, FAAD, pediatric dermatologist at Ann & Robert H Lurie Children’s Hospital of Chicago. She teamed up with Rachel Robison, MD, pediatric allergist at Monroe Carell Jr. Children’s Hospital at Vanderbilt during their session “Preventing Food Allergy in Pediatric Atopic Dermatitis: Applying the New Guidelines to Your Practice” at the 2023 American Academy of Dermatology (AAD) Meeting in New Orleans, Louisiana.¹

Earlier today, Dermatology Times® posted a poll asking about your current approach to peanut allergies in your atopic dermatitis patients. According to Kruse’s insight during the session, the only wrong answer is “recommend peanut avoidance.”

Up to 50% of infants with early onset AD (<3 months old) develop food allergies.² The skin barrier is more permeable in infancy with decreased ceramides and increased TEWL. Along with that, the skin barrier is impaired in AD, even in asymptomatic skin. Those at highest risk of peanut allergy are infants with severe AD.

“When we think about how food allergy develops, we're thinking about the dual allergen exposure hypothesis. So, when a first exposure to a food is orally by mouth sort of as a food is intended to be exposed to the body, this suppresses food allergy and it suppresses sensitization and makes patients who their initial exposure to an allergen is via the oral route, less likely to develop sensitization and allergy,” explained Kruse. “Infants with AD are exposed to food antigens inadvertently through their skin. This induces immune cells enhancing allergy and leading to IgE antibodies or sensitization to that food. If a first exposure is through the skin, these patients are most much more likely to become allergic to that food because that first exposure was cutaneous rather than oral.”

The current food allergy guidelines set forth by the National Institute of Allergy and Infectious Diseases (NIAID), recommended that AD patients should be introduced between 4 to 6 months of age to prevent a peanut allergy. Allergen-specific immunoglobulin E (IgE) skin testing, formerly known as RAST, is recommended prior to the introduction of peanuts. The blood test measures all the levels of different IgE antibodies in a patient’s blood.

“Parents are often nervous about introducing peanuts or any other allergen to their child,” Robison shared. “Allergic reactions to food will mostly happen within minutes and up to 2 hours max. I sometimes have parents who introduce new foods to their child in the ER parking lot for the reassurance medical professionals are right there to help.”

Robison referred to a study to explain food reaction phenotypes in AD patients. Immediate reactions are IgE-mediated reactivity. Delayed, eczematous reactions up to 48 hours after food ingestion are likely no-IgE mediated. There are also combined immediate and late eczematous reactions. This retrospective analysis she discussed consisted of 106 double-blind, placebo-controlled food challenges in 64 children with AD and found that:

• Most positive results came from egg challenges.
• 43% occurrences were isolated immediate reactions.
• 45% of positive food challenges had combined reactions .
• 12% of positive challenges were delayed reactions.³

Aside from peanuts, Kruse and Robison share the importance for dermatologists to stay up-to-date on the top food allergens. According to US Food and Drug Administration (FDA), they include cow milk, egg, peanut, tree nuts, fish, shellfish, soy, wheat, and an up and coming one more physicians are seeing—sesame. These 8 allergens make up 90% of all food allergies.⁴

“I think it’s important to share what a food allergy is NOT,” Robinson pointed out. “I can do nothing about lactose intolerance, celiac disease, food protein induced proctocolitis, behavioral changes noted with foods, primary GI symptoms with foods, and diaper rashes.”

As an allergist, Robison shared her best practices for testing for foods in AD. She reminded session participants that milk, egg, and peanut are the most common contributors in pediatric patients with AD. When a clear food trigger is identified by the parent and the child has severe, treatment recalcitrant AD, she recommends looking into the issue further along with AD treatment. Age must be considered with risk. Each patient is different, and it’s important to gauge parental comfort with home introduction to allergens in infants younger than 6 months.

“Obviously you can’t give an infant a whole peanut,” said Kruse. “I like to recommend mixing a small amount of peanut butter or powder in breast milk to start. Parents can also incorporate baby-safe snack puffs. This must be given 3 times a week based on LEAP. Regular exposure for several years is best.”

References

1. Kruse L, Robison R. Preventing Food Allergy in Pediatric Atopic Dermatitis: Applying the New Guidelines to Your Practice. Presented at American Academy of Dermatology 2023 Annual Meeting; March 17-21, 2023; New Orleans, LA.

2. Martin PE, Eckert JK, Koplin JJ, et al. Which infants with eczema are at risk of food allergy? Results from a population-based cohort. Clin Exp Allergy. 2015;45(1):255-264. doi:10.1111/cea.12406

3. Center for Food Safety and Applied Nutrition. Food allergies: What you need to know. U.S. Food and Drug Administration. Published February 17, 2022. Accessed March 21, 2023. https://www.fda.gov/food/buy-store-serve-safe-food/food-allergies-what-you-need-know.

4. Breuer K, Heratizadeh A, Wulf A, et al. Late eczematous reactions to food in children with atopic dermatitis. Clin Exp Allergy. 2004;34(5):817-824. doi:10.1111/j.1365-2222.2004.1953.x