Diet in Dermatology: Translating Evidence Into Practice

Rajani Katta MD

 

Clinical Professor of Dermatology

McGovern Medical School, University of Texas Houston

Clinical Assistant Professor of Medicine

Baylor College of Medicine


 

OVERALL FRAMEWORK

  1. Review risk of potential co-morbidities for each skin disease/ condition

  2. Discuss potential triggers: eating patterns/ foods/ nutrients that may worsen skin disease

  3. Discuss potential “helpers”: eating patterns/ foods/ nutrients that may help in the treatment of skin disease

PSORIASIS

  1. Reduce risk of co-morbidities (Patients with pso at elevated risk of CV disease, DM, HTN, dyslipidemia, metabolic syndrome)

    1. Diets supported by evidence to reduce risk: Mediterranean, DASH

  2. Helpers

    1. Weight loss to improve response to therapy

    2. Weight loss to improve PASI scores

  3. Triggers

    1. Increased risk of celiac disease

    2. Gluten-free diet may help those with gluten antibodies

ACTION ITEMS

1. Screen during history and physical:

             -BMI

             -History of GI symptoms (screen for gluten allergy/hypersensitivity)

2. Educate on increased risk of co-morbidities

3. Eval by primary MD

4. All pts >45 should be screened for DM; consider HgA1C to indicate 3mo of BS

5. If overweight/obese, or with family history, or of certain ethnic groups, or other risk factors, screen at younger age

6. If overweight/obese and with pre-diabetes, refer to diabetes prevention program for both diabetes prevention and weight loss

7. If overweight/obese discuss referral to nutritionist

REFERENCES

Armstrong EJ, Harskamp CT, Armstrong AW. Psoriasis and major adverse cardiovascular events: a systematic review and meta-analysis of observational studies. J Am Heart Assoc 2013; 2:e000062.

 

Bhatia BK, Millsop JW, Debbaneh M, et al. Diet and psoriasis, part II: celiac disease and role of a gluten-free diet. J Am Acad Dermatol. 2014 Aug;71(2):350-8.

 

Debbaneh M, Millsop JW, Bhatia BK, et al. Diet and psoriasis, part I: impact of weight loss interventions. J Am Acad Dermatol. 2014 Jul;71(1):133-40.

 

Fleming P, Kraft J, Gulliver WP, et al. The relationship of obesity with the severity of psoriasis: a systematic review. J Cutan Med Surg. 2015 Sep-Oct;19(5):450-6.

 

Ford AR, Siegel M, Bagel J, et al. Dietary Recommendations for Adults With Psoriasis or Psoriatic Arthritis From the Medical Board of the National Psoriasis Foundation: A Systematic Review . JAMA Dermatol.Published online June 20, 2018. doi:10.1001/jamadermatol.2018.1412

 

Gisondi P, Del Giglio M, Di Francesco V, et al. Weight loss improves the response of obese patients with moderate-to-severe chronic plaque psoriasis to low-dose cyclosporine therapy: a randomized, controlled, investigator-blinded clinical trial. Am J Clin Nutr. 2008 Nov;88(5):1242-7.

 

Michaelsson G, Gerden B, Hagforsen E, et al. Psoriasis patients with antibodies to gliadin can be improved by a gluten-free diet. Br J Dermatol. 2000 Jan;142(1):44- 51.

 

Millsop JW, Bhatia BK, Debbaneh M, et al. Diet and psoriasis, part III: role of nutritional supplements. J Am Acad Dermatol. 2014 Sep;71(3):561-9.

 

Takeshita J, Grewal S, Langan SM, et al. Psoriasis and comorbid diseases: epidemiology. J Am Acad Dermatol. 2017 Mar;76(3):377-90.

 

Upala S, Sanguankeo A. Effect of lifestyle weight loss intervention on disease severity in patients with psoriasis: a systematic review and meta-analysis. Int J Obes (Lond). 2015 Aug;39(8):1197-202.

ATOPIC DERMATITIS

  1. Reduce risk of co-morbidities

    1. More research needed, but severe AD may be associated with higher risk of heart disease

  2. Helpers

    1. Synbiotics in adults and children over the age of 1 year

    2. Healthy fats may reduce TEWL

  3. Triggers

    1. There are 3 main types of foods allergies that may result in flares of AD (and likely more)

    2. These include IgE-mediated, immediate-type hypersensitivity/ delayed eczematous reactions which may flare AD up to 48 hours later/ and systemic contact dermatitis, which may also lead to a delayed flare

ACTION ITEMS​

HELPERS

Randomized controlled trials show that synbiotics help in the treatment of AD in adults and children over the age of one year old. However, a few important points:​

  1. There is a wide range of individual variability in these trials. That means this may help for some patients, and not at all for others.

  2. Multiple trials have been conducted, but these have used different strains, dosages, and duration of probiotics. They have also used of variety of prebiotics.

  3. These factors make it difficult to recommend a particular probiotic or prebiotic across the board.

  4. As a physician, before you recommend a particular probiotic supplement, you will need to research the strains, dosage, and formulation. This also includes questions of the viability of the organisms in the probiotic. Some experts have recommended individually sealed capsules, or refrigerated bottles, in order to improve the viability of the organisms.

  5. Regardless of whether a patient is taking probiotic supplements, it is vital that they follow a diet that encourages the growth of good gut microbes. 

  6. Discuss dietary recommendations that promote the growth of good gut microbes:

DIETARY RECOMMENDATIONS THAT PROMOTE THE GROWTH OF GOOD GUT MICROBES 

  • Multiple studies have indicated that the flora of patients with AD varies from others. For example, the gut flora of those with AD contains fewer beneficial microbes.

  • Studies have found that a diet high in processed foods and low in fiber can change the composition of the gut flora within one day.

  • Therefore, the basis of a good gut diet is a diet naturally rich in fiber, including from fruits, vegetables, and whole grains.

  • The science behind this is well explained in a book by Dr. Gerard Mullin of Johns Hopkins:  "The Good Gut Diet." 

  • Diets such as the Mediterranean diet or DASH diet emphasize foods that are naturally rich in fiber, including a high intake of fruits and vegetables and unrefined grains. These would therefore be appropriate. 

  • In addition, patients may consume a variety of fermented foods containing live active cultures of microbes. 

  • Processed foods, however, that contain "live active cultures", such as snack bars, have not been studied well. They appear to have a much lower dose and diversity of microbes, so do not appear promising.

TRIGGERS

  • Issue of food allergies in eczema is very complex

  1. If a patient is concerned about food allergies, ask they have experienced symptoms within a few hours of specific foods. If the history is suspicious for IgE-mediated immediate type hypersensitivity, refer to allergy for skin prick testing or blood tests.

  2. If the patient is concerned, but has not identified specific foods, recommend a food diary. 

  3. Whenever they experience a flare of dermatitis, they should look for foods ingested within the previous 48 hours. This may help identify possible triggers of delayed eczematous reactions.

  4. As the immunological pathway behind this type of allergy is not known, confirmation would require a double-blind placebo controlled food challenge. 

  5. A single food elimination diet for four weeks may also be tried.

  6. If a patient has dermatitis resistant to therapy, patch testing is typically recommended. 

  7. If particular allergens such as fragrance, nickel, and propylene glycol are identified on patch testing, then an elimination diet of related foods may be considered. 

  8. Typically these are not recommended, though, until avoidance of topical allergens has been successfully completed for 8 weeks and residual dermatitis remains. 

REFERENCES

Chang YS, Trivedi MK, Jha A, Lin YF, Dimaano L, Garcia-Romero MT. Synbiotics for prevention and treatment of atopic dermatitis: a meta- analysis of randomized clinical trials. JAMA Pediatr 2016; 170(3): 236–42.

 

Katta R, Schlichte M. Diet and dermatitis: food triggers. The Journal of Clinical and Aesthetic Dermatology 2014 Mar; 7(3): 30.

 

Schlichte MJ, Vandersall A, Katta R. Diet and eczema: a review of dietary supplements for the treatment of atopic dermatitis. Dermatology Practical & Conceptual 2016 Jul; 6(3): 23.

 

Silverwood Richard J, Forbes Harriet J, Abuabara Katrina, Ascott Anna, et al. “Severe and predominantly active atopic eczema in adulthood and long-term risk of cardiovascular disease: Population-based cohort study.” BMJ. May 23, 2018. DOI:https://doi.org/10.1136/bmj.k1786

ACNE

  1. Helpers

    1. Low glycemic-index diet for 10-12 weeks has been shown to result in clinical improvement, beneficial changes in serum hormone levels, and change in sebum levels. By skin biopsy, has also resulted in less skin inflammation and reduced sebaceous gland size.

  2. Triggers

    1. Role of dairy unknown; may be a trigger in some individuals

    2. Case series of whey protein supplements triggering severe acne, resistant to treatment

  3. More research needed

    1. Role of zinc, omega-3 fatty acids, fiber, probiotics, antioxidants

ACTION ITEMS

  1. Educate on role played by sugar and processed carbs

  2. For motivated individuals, consider further education on low glycemic index dietary recommendations

  3. Emphasize that diet is only ONE aspect of therapy

  4. Consider individual patient and feasibility of dietary change

  5. Consider d/c of whey protein supplements

  6. Explain that role of dairy remains unknown, but may possibly serve as a trigger in some individuals

REFERENCES

Bowe WP, Joshi SS, Shalita AR. Diet and acne. J Am Acad Dermatol 2010; 63: 124-41.

 

Kwon HH, Yoon JY, Hong JS, et al. Clinical and histological effect of a low glycaemic load diet in treatment of acne vulgaris in Korean patients: a randomized, controlled trial. Acta Derm Venereol 2012; 92(3): 241–246.

 

Silverberg NB. Whey protein precipitating moderate to severe acne flares in 5 teenaged athletes. Cutis. 2012 Aug;90(2):70-2.

 

Smith RN, Braue A, Varigos GA, Mann NJ. The effect of a low glycemic load diet on acne vulgaris and the fatty acid composition of skin surface triglycerides. J Dermatol Sci 2008; 50(1): 41–52.

 

Smith RN, Mann NJ, Braue A, Mäkeläinen H, Varigos GA. The effect of a high-protein, low glycemic-load diet versus a conventional, high glycemic-load diet on biochemical parameters associated with acne vulgaris: a randomized, investigator-masked, controlled trial. J Am Acad Dermatol 2007 Aug; 57(2): 247-56.

 

Smith RN, Mann NJ, Makelainen H, Roper J, Braue A, Varigos GA. A pilot study to determine the short-term effects of a low glycemic load diet on hormonal markers of acne: a nonrandomized, parallel, controlled feeding trial. Mol Nutr Food Res 2008; 52: 718–26.

ROSACEA

  1. Reduce risk of co-morbidities

    1. Population study of close to 50K individuals indicated increased risk of GI conditions/ diseases in pts with rosacea

  2. Helpers

    1. Case series of SIBO (small intestinal bacterial overgrowth) treatment resulting in long-term resolution of rosacea

    2. Therefore, recommend measures that support gut flora, including prebiotics and probiotics

  3. Potential triggers include foods and beverages that result in vasodilation, either directly or via neurogenic vasodilation via role of TRP channels [transient receptor potential channels]

    1. Hot beverages

    2. Alcohol

    3. Capsaicin-related: spicy foods, red pepper, cayenne pepper

    4. Cinnamaldehyde-related: cinnamon, tomatoes, citrus, chocolate

ACTION ITEMS

  1. Screen with history for GI co-morbidities

  2. Refer to GI if necessary

  3. Education on food and beverage triggers, including handout

  4. Consider either food diary or 8-week elimination of potential rosacea triggers

REFERENCES

Aubdool AA, Brain SD. Neurovascular aspects of skin neurogenic inflammation. J Investig Dermatol Symp Proc. 2011 Dec;15(1):33-9.

 

Drake L. National Rosacea Society. Hot sauce, wine and tomatoes cause flare-ups, survey finds. Rosacea Review. Fall 2005. Available at: https://www.rosacea.org/ rr/2005/fall/article_3.php. Accessed November 13, 2017.

 

Drago F, De Col E, Agnoletti AF, et al. The role of small intestinal bacterial overgrowth in rosacea: a 3-year follow-up. J Am Acad Dermatol. 2016 Sep;75(3):e113-e5.

 

Egeberg A, Weinstock LB, Thyssen EP, et al. Rosacea and gastrointestinal disorders: a population-based cohort study. Br J Dermatol. 2017 Jan;176(1):100-6.

 

Scheman A, Rakowski EM, Chou V, et al. Balsam of Peru: past and future. Dermatitis. 2013 Jul-Aug;24(4):153-60.

 

Weiss E, Katta R. Diet and rosacea: the role of dietary change in the management of rosacea. Dermatology Practical & Conceptual 2017 Oct; 7(4): 31.

ADDITIONAL READING

SKIN CANCER

Katta R, Brown DN. Diet and skin cancer: The potential role of dietary antioxidants in nonmelanoma skin cancer prevention. Journal of Skin Cancer 2015 Oct 25; 2015.

 

Chen AC, Martin AJ, Choy B, Fernández-Peñas P, et al. A Phase 3 Randomized Trial of Nicotinamide for Skin-Cancer Chemoprevention. N Engl J Med 2015 Oct 22; 373(17): 1618-26.

INFLAMMATION

Buckley DI, Fu R, Freeman M, Rogers K, Helfand M. C-reactive protein as a risk factor for coronary heart disease: a systematic review and meta- analyses for the US Preventive Services Task Force. Annals of Internal Medicine 2009 Oct 6; 151(7): 483-95.


 

Shivappa N, Steck SE, Hurley TG, Hussey JR, Hébert JR. Designing and developing a literature-derived, population-based dietary inflammatory index. Public Health Nutrition 2014 Aug; 17(8): 1689-96.

MORE ON PREBIOTICS AND PROBIOTICS

Chang YS, Trivedi MK, Jha A, Lin YF, Dimaano L, Garcia-Romero MT. Synbiotics for prevention and treatment of atopic dermatitis: a meta- analysis of randomized clinical trials. JAMA Pediatr 2016; 170(3): 236–42.

 

Gueniche A., Phillippe D., Bastien P., Reuteler G., Blum S., Castiel- Higounenc I. Randomised double-blind placebo-controlled study of the effect of Lactobacillus paracasei NCC 2461 on skin reactivity. Benef Microbes 2014; 5: 137–145.

 

Hacini-Rachinel, F., Gheit, H., Le Luduec, J. B., Dif, F., Nancey, S., & Kaiserlian, D. (2009). Oral probiotic control skin inflammation by acting on both effector and regulatory T cells. PLoS One 2009; 4(3): e4903.

 

Holscher HD. Dietary fiber and prebiotics and the gastrointestinal microbiota  Gut Microbes 2017; 8(2): 172–184.

THE DIABETES PREVENTION PROGRAM

Ratner RE. An Update on the Diabetes Prevention Program. Endocr Pract 2006;12:20-24.

SUMMARY

  1. The Medicare Diabetes Prevention Program is a structured intervention

  2. For those who meet the criteria, participation in this 1-year program may be covered by Medicare and by some commercial insurance plans

  3. Goal: prevent type 2 diabetes in those with prediabetes

  4. A minimum of 16 “intensive” core sessions of a CDC-approved curriculum over 6 months

  5. Group-based, classroom-style setting

  6. Followed by less intensive monthly meetings

  7. Overall, 25 sessions over 1 year

  8. Reduction of new cases of type 2 diabetes by 58% overall and 71% in those over age 60

  9. Instruction and support from Lifestyle Coaches

  10. Learn how to incorporate healthier eating and moderate physical activity

  11. Learn how to incorporate problem-solving and coping skills into daily lives

  12. Focus on small, measurable goals

  13. Goal to achieve at least 5% weight reduction

YMCA Diabetes Prevention Program Physician Referral Form

  1. BMI >25 (or 22 if Asian)

  2. Lab tests indicating pre-diabetes

    1. Fasting plasma glucose 100-125

    2. 2-hour plasma glucose 140-199

    3. Hemoglobin A1C 5.7%-6.4%​ 

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