After 2 years of deliberations, evidence review, and public comments, the National Institute of Allergy and Infectious Diseases released a first-of-its-kind guideline for physicians on the diagnosis and management of food allergy in the United States.
While the document, which was released on Dec. 6 by the NIAID, is not specifically targeted at dermatologists, it is imperative that we become familiar with these guidelines to help improve the care of our patients with atopic dermatitis. The Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-sponsored Expert Panel is available for free at that the agency Web site, and has been published in The Journal of Allergy and Clinical Immunology (2010;126:1105-18).
By Dr. Lawrence F. Eichenfield
The evidence is clear that clinically relevant food allergies are more common in patients with moderate to severe atopic dermatitis. Therefore, as dermatologists, we must recognize that we are taking care of patients who are at an increased risk for significant food allergies. In fact, data show that as many as 30%-40% of patients with moderate to severe atopic dermatitis may also have a food allergy.
It is especially important to keep this in mind when seeing pediatric patients. Children are particularly at risk for food allergies, including anaphylaxis. The food allergies that are most common in children with atopic dermatitis are milk, egg, peanut, wheat, and soy.
The NIAID guidelines panel concluded that in children under age 5 years with moderate to severe atopic dermatitis whose condition is persistent despite optimized management with topical therapy, or where there is a reasonable history of an immediate allergic reaction after ingesting a specific food, physicians should consider having the child tested for food allergies.
Skin prick and serum IgE tests are reasonable options for allergy testing. Physicians should steer clear of other testing methods, which the NIAID guidelines show are not supported by evidence. However, even skin prick and serum IgE tests have their limitations. These tests are considered overly sensitive and in testing a large population, many individuals will have positive tests but will not have clinically notable allergic responses when challenged with the food.
These false positives can create a great deal of confusion, and patients and their families need to be counseled that a positive test doesn't necessarily mean that they are allergic. There is a real risk that people will have their children avoid foods that could have a significant impact on their growth and development.
At Rady Children's Hospital, we have seen two children in the last 6 months who had significant malnutrition because their families were avoiding broad sets of foods because of concerns that foods might be contributing to severe eczema.
Another important take-home message from the new guidelines is that food allergen avoidance is rarely useful in treating atopic dermatitis. However, if someone with atopic dermatitis has a clinically significant food allergy, which might include hives, gastrointestinal effects, or angioedema, for instance, avoidance is a reasonable strategy.
Even when a food allergy is not the trigger for a dermatologic condition, it is important for dermatologists to ask patients about possible allergic reactions related to food. Since our atopic dermatitis patients are at increased risk for food allergies, our time with them can be an opportunity to prescribe intramuscular epinephrine as a treatment for potential, acute, life-threatening food allergies. EpiPens and EpiPen juniors are appropriate for individuals at almost any age and can be life saving.
The guidelines provide important information on non-IgE allergies to food such as allergic contact dermatitis and the rare systemic contact dermatitis, as well as IgE-mediated contact urticaria. These are all conditions that dermatologists should be aware of as other manifestations of food allergy.
Dermatologists can have confidence that these guidelines are thoughtful and evidence-based and were developed with significant input from the dermatology community, including participation by the American Academy of Dermatology, the Society for Investigative Dermatology, and the Society for Pediatric Dermatology.
Dermatologists continue to be the experts in the diagnosis and management of atopic dermatitis and can help to determine optimal disease care for our patients. We have a responsibility to be aware of the new food allergy guidelines and specifically the recommendations related to consideration of food allergy in children with seemingly intractable atopic disease.
Dr. Eichenfield is chief of pediatric and adolescent dermatology and professor of pediatrics and medicine (dermatology) at Rady Children’s Hospital and University of California, San Diego, and served as a member of the expert panel that developed the NIAID food allergy guidelines. Dr. Eichenfield has received funding and grants from a variety of not-for-profit foundations, as well as Astellas, Ferndale, Johnson and Johnson, Novartis, Sinclair, Stiefel, and Therapeutics Inc.