Skin and Diet

by Katta MD
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
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Review risk of potential co-morbidities for each skin disease/ condition
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Discuss potential triggers: eating patterns/ foods/ nutrients that may worsen skin disease
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Discuss potential “helpers”: eating patterns/ foods/ nutrients that may help in the treatment of skin disease
PATIENT HANDOUTS
Handouts: https://www.skinanddiet.com/overview
Quick Reference Infographics: https://www.skinanddiet.com/infographics
REFERENCES
PSORIASIS
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Reduce risk of co-morbidities (Patients with pso at elevated risk of CV disease, DM, HTN, dyslipidemia, metabolic syndrome)
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Diets supported by evidence to reduce risk: Mediterranean, DASH
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Helpers
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Weight loss to improve response to therapy
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Weight loss to improve PASI scores
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Triggers
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Increased risk of celiac disease
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Gluten-free diet may help those with gluten antibodies
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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
ATOPIC DERMATITIS
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Reduce risk of co-morbidities
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More research needed, but severe AD may be associated with higher risk of heart disease
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Helpers
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Synbiotics in adults and children over the age of 1 year
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Healthy fats may reduce TEWL
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Triggers
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There are 3 main types of foods allergies that may result in flares of AD (and likely more)
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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
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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:
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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.
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Multiple trials have been conducted, but these have used different strains, dosages, and duration of probiotics. They have also used of variety of prebiotics.
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These factors make it difficult to recommend a particular probiotic or prebiotic across the board.
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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.
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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.
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Discuss dietary recommendations that promote the growth of good gut microbes:
DIETARY RECOMMENDATIONS THAT PROMOTE THE GROWTH OF GOOD GUT MICROBES
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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.
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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.
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Therefore, the basis of a good gut diet is a diet naturally rich in fiber, including from fruits, vegetables, and whole grains.
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The science behind this is well explained in a book by Dr. Gerard Mullin of Johns Hopkins: "The Good Gut Diet."
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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.
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In addition, patients may consume a variety of fermented foods containing live active cultures of microbes.
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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
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Issue of food allergies in eczema is very complex
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Patient handout: https://www.skinanddiet.com/diet-and-eczema-food-triggers
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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.
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If the patient is concerned, but has not identified specific foods, recommend a food diary.
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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.
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As the immunological pathway behind this type of allergy is not known, confirmation would require a double-blind placebo controlled food challenge.
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A single food elimination diet for four weeks may also be tried.
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If a patient has dermatitis resistant to therapy, patch testing is typically recommended.
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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.
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Typically these are not recommended, though, until avoidance of topical allergens has been successfully completed for 8 weeks and residual dermatitis remains.
REFERENCES
ACNE
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Helpers
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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.
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Triggers
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Role of dairy unknown; may be a trigger in some individuals
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Case series of whey protein supplements triggering severe acne, resistant to treatment
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More research needed
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Role of zinc, omega-3 fatty acids, fiber, probiotics, antioxidants
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ACTION ITEMS
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Educate on role played by sugar and processed carbs
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For motivated individuals, consider further education on low glycemic index dietary recommendations
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Emphasize that diet is only ONE aspect of therapy
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Consider individual patient and feasibility of dietary change
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Consider d/c of whey protein supplements
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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.
ROSACEA
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Reduce risk of co-morbidities
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Population study of close to 50K individuals indicated increased risk of GI conditions/ diseases in pts with rosacea
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Helpers
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Case series of SIBO (small intestinal bacterial overgrowth) treatment resulting in long-term resolution of rosacea
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Therefore, recommend measures that support gut flora, including prebiotics and probiotics
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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]
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Hot beverages
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Alcohol
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Capsaicin-related: spicy foods, red pepper, cayenne pepper
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Cinnamaldehyde-related: cinnamon, tomatoes, citrus, chocolate
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ACTION ITEMS
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Screen with history for GI co-morbidities
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Refer to GI if necessary
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Education on food and beverage triggers, including handout
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Consider either food diary or 8-week elimination of potential rosacea triggers
REFERENCES
SKIN AGING
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Role of oxidation
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Promote foods naturally rich in antioxidants
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Fruits, vegetables, whole grains, spices, herbs
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Role of inflammation
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Promote anti-inflammatory foods
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Similar to foods naturally rich in antioxidants
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Omega-3 fatty acids
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Role of glycation
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“Sugar sag”
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Review strategies to reduce blood glucose levels: https://www.skinanddiet.com/stop-sugar-spikes
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REFERENCES
ADDITIONAL READING
SKIN CANCER
INFLAMMATION
MORE ON PREBIOTICS AND PROBIOTICS
THE DIABETES PREVENTION PROGRAM
Ratner RE. An Update on the Diabetes Prevention Program. Endocr Pract 2006;12:20-24.
SUMMARY
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The Medicare Diabetes Prevention Program is a structured intervention
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For those who meet the criteria, participation in this 1-year program may be covered by Medicare and by some commercial insurance plans
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Goal: prevent type 2 diabetes in those with prediabetes
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A minimum of 16 “intensive” core sessions of a CDC-approved curriculum over 6 months
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Group-based, classroom-style setting
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Followed by less intensive monthly meetings
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Overall, 25 sessions over 1 year
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Reduction of new cases of type 2 diabetes by 58% overall and 71% in those over age 60
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Instruction and support from Lifestyle Coaches
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Learn how to incorporate healthier eating and moderate physical activity
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Learn how to incorporate problem-solving and coping skills into daily lives
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Focus on small, measurable goals
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Goal to achieve at least 5% weight reduction
YMCA Diabetes Prevention Program Physician Referral Form
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BMI >25 (or 22 if Asian)
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Lab tests indicating pre-diabetes
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Fasting plasma glucose 100-125
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2-hour plasma glucose 140-199
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Hemoglobin A1C 5.7%-6.4%
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