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For other articles and previous issues click here. March 8, 2004 Understanding
Eczema A child scratches furiously while his desperate mother looks for answers why. The peiatrician recommends medication, but when it wears off, the scratching begins again. The frustration and loneliness of a child whose skin condition causes other children to criticize and adults to stare are difficult to realize. A parent will search for “magic cures” to relieve the child’s discomfort. A dietitian knowledgeable in diagnosis and treatment of food allergies can provide the supportive medical nutrition therapy the family needs. Many children suffer from allergic skin disorders. Atopic dermatitis (AD), also known as eczema, is an allergic skin disorder most commonly affecting children under the age of 11. The percentage of children with AD has increased from 3% to 10% in the past 30 years. The prevalence is on the rise, with 80% of children with AD developing symptoms before 12 months of age. One-half of these children may be symptom-free by the age of 2, while some never completely clear.1 AD tends to run in families and often coexists with other atopic diseases, such as rhinitis and asthma.2 Symptoms of AD include itching of varying intensity, flaky, scaly skin, and, in severe cases, oozing lesions. These symptoms may be some of the first signs that a child has allergies. Eczema patches usually appear on the face and in creases of the ears, elbows, knees, and buttocks. A phenomena known as Dennie’s line appears in the fold across the lower eyelids. In older children, the same areas may be affected, along with the skin of the outer arms and legs. Itching and redness can be so severe that scratching may lead to bleeding and an increased risk of infection. Emotional factors such as stress will worsen the condition. Nonallergenic factors such as sweating, irritating fabrics, and irritating soaps are also triggers. Quality of life for a child with eczema diminishes due to low self-esteem and the inability to socialize with others caused by self-consciousness about skin appearance. In fact, other family members may be indirectly affected. The favorite pet may need to be removed from the house, along with stuffed animals, other dust catchers, and carpeting. Expensive environmental control measures may be taken. Sleep is often disrupted due to itching that worsens at night; the child may be irritable and cranky, demanding more attention than siblings; and the whole family may need to follow a special diet to ensure that the affected child follows suit. Diagnosis There is no single test that diagnoses eczema. Physical assessment is the first step in the diagnostic process. AD needs to be differentiated from urticaria or hives, seborrhea, diaper dermatitis, diaper dermatitis with candida, and contact dermatitis. Symptom history and family history of allergy provide clues helpful in diagnosis. Questions will be asked about when symptoms worsen and whether they occur during or after ingestion of certain foods. Because symptoms are chronic, determining whether or not food is the cause may require recording food intake along with occurrence and intensity of symptoms for a period of at least seven to 10 days. Symptoms triggered by food may be immediately after ingestion of a specific food or due to regular ingestion of the offending food in small amounts. Allergy skin tests or a blood test for circulating immunoglobulin E antibodies are also useful in identification of possible food and inhalant triggers. Dust, dust mites, pet dander, and pollen may cause flare-ups. The condition may be caused by a combination of food and inhalant triggers, making trigger identification difficult. It is not uncommon for symptoms to respond to food even when the skin test is negative. It is possible for symptoms to partially clear when the offending food is removed from the diet and for further clearance to occur when inhalant triggers are controlled. Once possible food triggers are identified, an elimination diet should be followed for at least two weeks. During this time, the parent must closely observe the skin for changes. If there is no change in the condition of the skin, food may not be the cause. If the skin improves, the diet should continue until the skin clears as much as possible. The relationship of immediate food hypersensitivity to AD can be verified by double-blind, placebo-controlled food challenges (DBPCFC). A challenge may be the final step in the diagnostic process. Treatment Elimination Diets If symptoms clear when one or more foods are removed from the diet and return when the foods are challenged, an elimination diet is indicated. The specific food or foods causing the eczema need to be eliminated from the diet for a longer period of time than during the diagnostic phase. In children under 2 years of age, eliminating the food for one year may be recommended. Foods cited as trigger foods include milk, eggs, soy, wheat, fish, peanuts, and tree nuts. Any food has the potential to be allergenic and cause symptoms. Subsequent reintroduction of the food is necessary after a period of elimination to determine whether or not the food is still a trigger. Timing of reintroduction depends on the severity of the condition and response to trigger foods and should be dealt with on a case-by-case basis. The Allergy Report of the American Academy of Allergy, Asthma, and Immunology recommends reevaluation every four to six months. Food challenges play an important role in prevention of eliminating foods essential for growth and development longer than necessary. If a food allergy is the cause, challenges should be performed under the direction of a physician and in an office or clinic, where reactions can be treated immediately. This is especially important if there has not been 100% compliance with eliminating the suspected food allergens. Even small amounts of a food can maintain sensitization, leading to worsening of rather than improvement in symptoms. Food allergens have been found in breast milk. Maternal elimination of foods to which the child tested positively on an allergen skin test or a DBPCFC is recommended for breast-fed babies. A nonrestricted maternal diet in the breast-fed infant may sustain AD.3 Food challenges can be done by having the mother reintroduce the offending food into her diet after the last feeding in the evening and breast-feeding the baby the next morning. The morning-feeding procedure should be done in a medical office or clinic setting. The recommendations of the American Academy of Pediatrics should be followed when introducing new foods. This is especially important for children with a family history of atopy. It is recommended to avoid eggs until the age of 2. Infant formulas are primarily cow’s milk and soy-based, both of which have been cited as trigger allergens for AD. Breast milk is the optimal source of nutrition for infants through the age of 1; however, the maternal diet will need to be free of the suspected allergenic foods during elimination. Partial casein or whey hydrolysates may decrease the occurrence but may not be hydrolyzed enough to allow for total clearance of symptoms. Amino acid-based formulas may be the most effective formulas in allowing symptoms caused by food allergy to clear. Skin Care Skin care, including baths, topical corticosteroids, and ointments, is often the standard treatment until a cause is determined. Daily baths and creams may be all that is necessary to relieve mild cases of eczema. Recommendations for bathing vary among physicians. Baths should be in tepid water using unscented soaps and shampoos. The pat-dry method of drying the body is preferred to prevent further irritation. Prescribed creams and lotions are applied after the skin is dry. Keeping the child’s nails trimmed and covering his or her hands while sleeping helps prevent the child from scratching the skin open. Medications Medications that are used are primarily antihistamines to relieve the itch and control the effects of inhalant triggers. Antibiotics and antivirals are used when eczema patches are bleeding, oozing, and infected. Once infected, aggressive treatment is necessary because the condition becomes more difficult to control. Steroid creams and ointments are used in severe cases but have side effects, including skin thinning, discoloration, burning, contact dermatitis, and stretch marks. Systemic side effects are rare and include adrenal suppression, growth retardation, and increased intraocular pressure. It is important to use the least potent steroidal cream that will clear the skin to minimize side effects. Potent steroid creams cannot be used on the face, and the efficacy of mild steroids are not adequate for mild to severe AD. Most recent developments in ointments include nonsteroidals used for moderate to severe eczema. Nonsteroidals inhibit the release of inflammatory mediators from mast cells and basophils that stimulate symptoms. The safety and efficacy of these ointments have been demonstrated for periods of up to one year in children. It does not interfere with collagen synthesis or cause skin atrophy.2 Supplements Supplements may be necessary to replace nutrients missing from the diet due to restriction of offending foods. There are substitute foods available; however, many are not readily accepted by children and are costly for a family on a limited budget. Elimination of milk and milk products significantly reduces the amount of calcium in the diet. Nondairy, high-calcium foods may not be able to be included in amounts needed to meet calcium requirements. It is often easier to provide a calcium supplement. There has been conflicting evidence regarding the efficacy of supplements such as evening primrose oil, black currant oil, and gorage seed oil. Not enough research has been conducted to justify the use of flax seed oil, especially in young children. Antioxidants have been shown to enhance immunity and improve lung function in patients with asthma; however, research in young children is limited. Side effects must be considered, especially increased bleeding with long-term use of antioxidants. Probiotics are recommended as beneficial to health in many ways. They have been shown to alleviate inflammation and symptoms associated with eczema when administered prenatally and postnatally. Probiotic strains of lactobacillus species were shown to improve skin manifestations in infants with AD.4 Prognosis By the age of 2, approximately one-half of children with eczema will clear. Approximately 35% will develop asthma and hay fever later in life. The age and likeliness of clearing depend on the age of onset and compliance with the treatment protocol. Prevention Since 27% of infants born to allergic mothers have AD, it may be beneficial for the mother to avoid milk, eggs, and peanuts in the third trimester of pregnancy and during lactation.3 It is thought that the first exposure to the allergen when the infant becomes sensitized may be in utero or during breast-feeding. Probiotics may play as much of a role in prevention as they do in treatment. Several studies on the role of probiotics were conducted in Finland and produced strong evidence regarding protective effects of probiotics in the treatment of eczema and allergic respiratory disorders. This is an area that continues to be researched to clarify the mechanism for the protective effect. A Finnish study of 62 mother-infant pairs demonstrated that the administration of probiotics to the pregnant and lactating mother increased the immunoprotective potential of breast milk. The risk of developing AD during the first two years of life in infants whose mothers received probiotics was significantly reduced in comparison with infants whose mothers received a placebo.5 — Debra Indorato, RD, LDN, Approach Nutrition and Fitness, is a nutrition consultant in private practice in Chesapeake, Va. References 1. Eczema statistics. Available at: http://www.aaaai.org/media/resources/media_kit/allergy_statistics.stm.
Accessed August 4, 2003. Resources • American Academy of Allergy, Asthma &
Immunology • Asthma and Allergy Foundation of America • Food Allergy and Anaphylaxis Network • Food Allergy Research and Resource Program
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