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Food Allergies, Part 2

Torie Grant, MD MHS and Neda Frayha, MD
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Sometimes it can seem like every other child we see has a food allergy. How prevalent are food allergies in the general population, and how can we best diagnose and manage them? To shed light on these questions, as well as recent guideline changes in the allergy community and novel therapies on the horizon, PC RAP welcomes back Dr. Torie Grant, a Med/Peds allergist and immunologist at Johns Hopkins. She sits down with Neda to share the full scoop on food allergies.

 

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Stephen P. -

Is eczema ever the only symptom of food allergy and if so how often? It seems that many infants and toddlers can be placed on restrictive diet based on severe eczema and positive ige screen. Thanks for the extremely informative segment!

Neda F., MD -

Hi Stephen. Thanks for your question! I'm asking Dr. Grant and will let you know when I hear back. Take care -- Neda

Neda F., MD -

Hi Stephen. Here's Dr. Grant's really thoughtful reply:

"This is a tricky question. The simplest answer is: No, eczema does not present as the only symptom of food allergy, but of course it's not that simple. In terms of an immediate IgE-mediated allergy, we would not say that eczema is a presenting symptom - think immediate hives, lip swelling, trouble breathing, wheezing, cough, rhinorrhea, itchy throat, throat tightness, hypotension, etc. However, children (adults, too, but more common in children) with eczema are often sensitized to multiple foods. Sensitized meaning that that make specific IgE to certain foods, but don't have immediate symptoms. ~10% of the population is sensitized (+IgE) to peanut, but roughly only 1-2% is allergic (has acute symptoms upon ingestion). Patients with moderate-to-severe eczema tend to have a high total IgE and when you send a broad food panel, many foods are going to come back "positive." If they are not having immediate reactions, they are not what we would call food allergic. But as we all know, eczema is a multifactorial disease and while food can be a contributing trigger, we think of it as a small slice of the pie. Heat, humidity, dry air, illness, infection, stress, environmental allergens, etc. all are eczema triggers and often play bigger roles than foods. Far and away the most significant risk factor for moderate-to-severe eczema is genetics. Understandably, patients and families tend focus on the "positive" food allergy test results because this is tangible and they see it as something they can modify to fix their disease. The most common positive IgE result associated with eczema is egg, but almost any food can be positive.

If a child is tolerating a food (meaning not having acute reactions), but has moderate-to-severe eczema, I always first focus on their skin care regimen. I recommend aggressive application of emollients (Vaseline, petrolatum, Hydrolatum, CereVe, Eucerin, Aquaphor, and ointment is better than cream which is better than lotion) often 3-4 times per day with use of topical steroids BID. Make sure you are prescribing them the 454 gram tubs so they have enough. The 30 gram tubes are never enough. This is often difficult because of how time consuming it can be and how greasy the emollients are, but with good skin care most food can be successfully left in the diet.

If a child is sensitized to a food - peanut, egg, and milk being the classic examples - and eating this on a regular basis with no acute reactions, and then this food is removed from the diet based solely on testing due to eczema, that child risks developing an acute IgE-mediated allergy to that food. For example, an 18-month-old male has bad eczema and is eating eggs and peanut butter without acute symptoms. Testing for food allergies is done and both peanut and egg are "high." The decision is made to take peanut out of the diet. 1-2 years later this child eats a peanut butter cookie and has anaphylaxis. Had the peanut been left in the diet and the focus turned to skin care, this child would have continued to tolerate peanut and not gone on to develop a true peanut allergy. However, removing a food from a child considered to be at high risk for food allergy (based on his moderate-to-severe eczema) puts that child at risk for developing a true food allergy (see the LEAP study). We would also advocate to leave these foods in the diet.

That was a very long-winded answer. Here are the take-home points.

1. I would recommend against sending food allergy testing in a child without symptoms of an acute food reaction.

2. If food allergy testing has already been sent, I would recommend referring that child to an allergist before making any changes to the child's diet.

4. Eczema is a multifactorial disease and food can play a small role, but many other factors contribute, the largest being genetics. Focus on aggressive hydration of the skin with emollients. Parents are also often not using topical steroids or enough topical steroids."

Stephen P. -

Thanks for your time and thoroughness! This will be very helpful for my next eczema infant with a parent fixated on food as culprit. You obviously see this frequently. This was very practical and informative. Thanks for the selection of the topic, and thanks to Dr Grant for sharing her expertise!

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Primary Care RAP Written Summary April 2020 1 MB - PDF

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