57 Dietary Management of Atopic Eczema

Chapter 57 57 Dietary Management of Atopic Eczema

C. Kugler

57.1 rioration of the skin may be observed up to 48 h after Definitions consuming the food. In addition to deterioration of the atopic eczema, simultaneous manifestations may also Adversereactionstofoodareatopicthathasincreased occur in other systems such as in the gastrointestinal in importance over the last few years. In addition to tract and the respiratory tract. toxic reactions, such as mushroom poisoning or allergy-like reactions caused by histamine (e.g., fish poisoning), these clinical pictures are differentiated as to 57.2 whether food hypersensitivity or food intolerances are Prevalence of Adverse Reaction to Food involved [25]. in Atopic Eczema Food allergies are based on immunological mechanisms, which cause patients to form allergen-specific Although food allergy is often presumed, it affects far antibodies (e.g., against cow’s milk protein), most fre- fewer patients with atopic eczema than generally quently triggered by the immediate-type, immuno- assumed. About 30% of children with atopic eczema globulin-mediated reaction [19]. may have food allergy. In adults, the figure is somewhat All other nonimmunologically triggered reactions lower. [17]. The prevalence of food allergy is correlated are assigned to food intolerances [5]. These include: with the severity of the atopic eczema: whereas there areveryfewfoodallergiestobefoundinthecaseof 1. Metabolic reaction due to an enzyme deficiency localized atopic eczema, the frequency increases in 2. Pharmacological mechanisms patients with moderate and severe atopic eczema [14]. 3. Unknown mechanisms (food idiosyncrasy). In the United States, six food allergens (hen’s eggs, Lactoseintoleranceisthemostfrequentlyoccurring cow’s milk, peanut, soya, fish, and wheat) are responsi- among the enzymatic intolerances. ble for more than 90% of the test reactions [29]. Aller- Pharmacological intolerances are shown by patients gies to food in terms of cross-reactions to pollen are afterconsumingfoodsthathaveahighcontentofbio- rarerinchildhoodbutmorecommoninadults.Typi- genic amines or of histamine-releasing substances. cal examples of cross-reactivity between foods and Food additives such as flavor enhancers or preserva- pollenareapple,birch,celery,mugwort,hazelnut,and tives (sulfites) used on foods may cause a food intoler- birch pollen [26]. Adverse reactions to food occur ance in some people. The symptoms of food intoler- rarely. ance vary and can be mistaken for those of a food allergy, i.e., they may cause a worsening of eczema in cases of patients suffering from atopic eczema. Major trig- 57.3 gers are food additives: preservatives, coloring agents, Diagnosis antioxidants, and naturally occurring ingredients [10]. Food may trigger and sustain an atopic eczema. The The diagnostic system for adverse reactions to food symptoms of an early reaction usually occur within a comprises several steps. There is no laboratory test that few minutes to 2 h [19]. Late reactions involving a dete- provides proof [21, 27]. The diagnosis is sometimes 57.4 Diagnostic Types of Diet 535 very simple if an exacerbation of the skin can be repeat- Exampleofanoligoallergenicdiet edly associated over time with a food and allergy tests Cereals: Rice support this finding. However, diagnosis is frequently Meat: Lamb, turkey difficult and time-consuming, in particular if late reac- Vegetables: Cauliflower, broccoli, zucchini tions do not provide a clear pointer to a food or if Fruits: Pear, banana adverse reactions to food are involved for which no lab- Fat: Sunflower oil, none-milk margarine Drinks: Mineral water, tea oratory test provides clear information. For this rea- Condiments: Salt, sugar son, it is necessary to undertake a step-by-step procedure that is geared to the patient in question [19]. The first and most important step in allergological diagnosis is taking the history. A clear case history may Ifthereisnoimprovementintheeczemawhilefollow- make further steps unnecessary [33]. If there are symp- ing the elimination diet, an adverse reaction to food toms that are difficult to interpret, further diagnostic appears to be improbable as a challenging factor. If procedures may be planned after an exact history [4, 5, thereisanimprovementinthesymptoms,afoodchal- 30]. lenge follows with the suspected food, under medical In addition to the history, patients should keep a supervision. diet diary. On occasions, the symptoms can be In the case of a nonspecific suspicion, an oligoanti- assigned to a particular food. The interpretation of the genic diet can be followed, using those foods that rarely records is, however, difficult because of undeclared trigger allergies in the corresponding age group and “hidden” food allergens [22]. Also, foods that are that are not conspicuous in the history. The diet com- assumed by patients (or parents) are more heavily prises approximately 15 foods that are not suspected of emphasized. triggering allergies in the case of the patient. The diet is The in vitro diagnostic system is conducted with the put together individually for each patient and carried demonstration of specific immunoglobulin in serum outforatleast10days.Thereisthenafoodchallenge (RAST). In the case of a nonspecific suspicion, the or a follow-up diet. The elimination diet comprises an allergens that are the most frequent for the age are test- oligoantigenic diet for older children, adolescents, and ed. A high specific IgE demonstrates a sensitization to adults with nonspecific suspicion of a food allergy. a food, but does not allow any conclusions to be drawn Inthecaseofbabieswhoarebeingbreast-fed,the as to a relevant allergy. As with RAST, a positive result mother (depending on the suspected and challenged in the skin prick test has the function of being only a food) should follow a corresponding elimination diet pointer to the subsequent oral challenge. It is by no before and during the oral challenge tests, since in rare means an indication for a therapeutic diet [20]. cases there may be a transfer of allergens to the child via the mother’s milk when the mother is taking food rich in allergens [30], thus falsifying the result of the 57.4 challenge. Diagnostic Types of Diet An improvement in the complaints following the elimination diet may be merely a pointer to the clinical 57.4.1 relevance of the suspected trigger. Only a subsequent Elimination Diets challenge provides the necessary confirmation. If there is a specific suspicion that one or more foods If the symptoms improve after the oligoantigenic trigger an allergy for a patient, a so-called specific diet, foods are systematically added every 2 or 3 days elimination diet (e.g., avoiding cow’s milk) is carried until the diet again corresponds to a “normal” diet and out. Babies are given a compatible formula, e.g., ex- until all foods have been identified that trigger the tensively hydrolysed formula (Nutramigen, Pregesti- adverse reaction. mil, Alfar´e) or a formula made of an amino acid mix- ture (Neocate, Pregomin AS). Allergic symptoms have also been reported after hydrolysed protein prepara- tions, extending as far as anaphylactic reactions [6, 23, 28]. 536 57 Dietary Management of Atopic Eczema

57.4.2 using skin or blood tests. Diagnostic diets are unavoid- Food Challenges able in these cases. Allergy clinics usually work togeth- 57.4.2.1 er with nutritional specialists who have experience in Double-Blind Placebo-Controlled Oral Food Challenge this field. Such nutritional specialists are able to provide patients with individual counseling and to com- The gold standard in food allergy diagnosis is the dou- pilethedietbeforesuchadrasticdietisfollowed.The ble-blind placebo-controlled food challenge (DBPCFC) pseudoallergen-poor diet [34] (without additives, [1,3,4,18,31].Theoralchallengeisintendedeitherto avoiding biogenic amines, and naturally occurring prove a food allergy so as to eliminate the food in ques- salicylic acid) is carried out over a period of approxi- tion for a certain time or to show that foods are not a mately 4 weeks and is then tested under inpatient con- challenging factor for the atopic eczema and unneces- ditions with a pseudoallergen-rich diet over at least sary dietetic restrictions can be lifted. 2 days. In the case of this challenge, it is important that Patients who have reactions to foods that can be des- as high as possible doses of the suspected food or addi- ignated with certainty as anaphylactic are usually not tives are administered since the reactions are dose- subjected to challenge testing [4]. dependent. If a patient reacts during the challenge, the Particularly in the case of time-delayed reactions, it procedure is stopped. The test substances are packaged is difficult to decide whether there is a connection and administered individually and in capsules so the between the consumption of a food and the symptoms. ingredients that have caused the reaction in the high- The DBPCFC guarantees a more objective diagnosis. pseudoallergenic diet are known. Resolution comes in 48 h, after the doctor has deter- mined whether the patient has reacted or not. 57.4.2.3 An exacerbation in the skin finding is evaluated Challenges in the Case of a Suspicion of Cross-Reaction using a standardized evaluation sheet, e.g., the SCO- to Pollen RAD [12]. Double-blind placebo-controlled challenge foods Patients who have a pollen allergy also react to food in may be administered, for example, in extensively a number of cases, since there are cross-reactive struc- hydrolysed formula. The challenging food may also be tures in both sources of allergens. The oral allergy syn- pur´eed with compatible mashed foods (e.g., mashed drome frequently occurs with oropharyngeal symp- potato) or stirred into pudding (soy pudding). A pro- toms, but there are also patients with eczema (fre- tein-freemashbasedoncarobbeanflourandricehas quently late reactions) and urticaria. The allergens are provenitsworth.Thefoodsaremaskedasrequired in many cases unstable and react to heat, i.e., some pro- with q -carotene, beet, currant, or carrot juice (if aller- cessed products may be tolerated or the symptoms do gologicallypossible).Tomatchtheflavor,aflavoring not occur so forcefully. This necessitates a particularly agent (orange) is added, sweetened with sugar, or thick careful procedure in taking the history as well as in the pear juice. challenge. In the case of the subsequent challenge, all Because of the feared early reactions, oral challenges products that contain pollen-associated food are should be carried out by titration (increasing the quan- avoided over a certain period of time. The challenge is tity every 30 min), beginning, for example, with 0.2 ml. then made with the suspected products. The total challenge dose should correspond to about an Pollen-associated food allergies within the meaning average daily consumption (e.g., 1 hen’s egg, 150 ml of an oral allergy syndrome (OAS) [24] can mostly be milk) [9]. diagnosed on the basis of clinical experience in con- junction with the corresponding sensitization patterns and do not necessarily require oral challenges. 57.4.2.2 Challenges in the Case of an Adverse Reaction to Food Inthecaseofasuspicionofanadversereactiontofood that is not based on immunological mechanisms and, for this reason, no antibodies are formed, there is no possibility of obtaining pointers to the triggers by References 537

57.5 10 mg/l. In addition, the regulation also applies to alco- Nutritional Recommendations When There Is holic drinks if they contain one of the above-men- aFoodAllergy tioned ingredients or allergens. There also continues to be no obligation to label ingredients in very small If a food allergy has been diagnosed, treatment consists quantities ( e 2%)soastoavoidextremelylong“listsof in an individually adapted elimination diet. This ingredients”andthusavoidoverregulation.Thistoler- should involve substitution of the ingredients that can- ance limit does not apply, however, to allergens which not be properly provided on the basis of the elimina- are included in the list [7, 11, 32]. tion (e.g., calcium in the case of a cow’s milk allergy). Contamination (cross contact) may develop as a Counseling provided by a dietitian who is trained in result of producing various composite food on the same the allergological field is essential for implementing production lines. This contamination cannot always be the medically prescribed diet. In addition to informa- excluded in spite of special cleaning processes. The pro- tion on avoiding proven allergens and the production ducers safeguard themselves by noting that the product of suitable meals, factors that are important for the “may contain traces of nuts,”for example. However, this patient’s quality of life should also be taken into indication should be an exception and not, as the case account: security by way of consistently avoiding the today, printed on all products to provide a safeguard trigger or triggers and proper nutrition are the basic against consumers’ liability claims [32]. elements for good disease management. However, the patient’s perceived quality of life will also depend to a large extent on whether he or she is being offered 57.6 acceptable alternatives for the eliminated food [9]. Prognosis for Food Allergies Elimination of food without a secure diagnostic system is not reasonable for the patient. There are several Studies have demonstrated the disappearance of food casereportsofmajorsideeffectsresultingfromstrict, allergy symptoms in up to one-third of children and one-sided diets [8, 13, 15]. The period of consistently adults in 1–3 years, although positive skin tests and avoiding the noncompatible food should be 1 year for positive serum IgE levels may persist. This is why there children [19]. Thereafter, there must be retesting to is the demand that clinical relevance be checked at reg- evaluate the current clinical status. ular intervals. Since there is no reliable laboratory test The moste common food allergens are found in a for the prognosis, the oral challenge must be repeated wide variety of processed foods [16, 22]. In Europe the after 12–24 months. Evidence suggests that the proba- use of these foods is nowadays possible since a new bility of outgrowing a food allergy depends upon the directive from the European Parliament and of the food allergen and the patient’s compliance with the Council is in practice. elimination diet. Allergies to peanut, nuts, fish, and Twelve groups of food independent of the concen- other seafood appear to be more persistent. tration of allergens must be labelled since November 2004. Member states of the EU shall bring into force, by 25 November 2004 the laws, regulation and administra- tive provisions necessary to: Permit, as 25 November References 2005, the sale of products that comply with the directive; and prohibit, as from 25 November 2005, the sale 1. Anderson JA (1994) Milestones marking the knowledge of of products that do not comply with this directive. Any adverse reactions to food in the decade of the 1980s. Ann products which do not comply with this directive but Allergy 72:143–154 2. Bahna SL (1994) Blind food challenge testing with wide- which have been placed on the market or labelled prior open eyes. Ann Allergy 72:235–238 to this date may, however, be sold while stocks last. 3. Bock SA, Atkins FM (1990) Patterns of food hypersensitivi- Thesetwelvegroupsoffoodarecerealscontaining ty during sixteen years of double-blind, placebo-controlled gluten,crustaceans,eggs,fish,peanuts,soybeans,milk food challenges, J Pediatr 117:561–567 4. Bock SA, Sampson HA, Atkins FM, Zeiger RS, Lehrer S, (including lactose), nuts, celery, mustard and sesame Sachs M, Bush RK, Metcalfe DD (1998) Double-blind, place- seedsaswellastheirproductsandsulphurdioxideand bo-controlled food challenge (DBPCFC) as an office proce- sulphites at concentration of more than 10 mg/kg or dure: a manual. J Allergy Clin Immunol 82:986–997 538 57 Dietary Management of Atopic Eczema

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