ATOPIC DERMATITIS

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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

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ACTION ITEMS​

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HELPERS

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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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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:

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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.

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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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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. 

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REFERENCES

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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