What is the relationship between diet and eczema management?

Diet and Eczema Management

Dietary manipulation is only indicated when a patient's history strongly suggests specific food allergies or when widespread active eczema is not responding to first line treatment. 1

Role of Diet in Eczema

Diet plays a limited but potentially significant role in eczema management for select patients. The relationship between food and eczema has been extensively investigated without reaching definitive conclusions, but certain patterns have emerged:

Food Allergies and Eczema

• Food allergies can trigger or worsen eczema in some patients, particularly in children
• Immediate hypersensitivity (type I) reactions to foods can occur in patients with eczema, ranging from contact urticaria to anaphylaxis 1
• Common food allergens include:
  • Eggs (particularly in infants)
  • Milk
  • Nuts
  • Fish
  • Wheat

When to Consider Dietary Intervention

Dietary manipulation should be considered in two specific scenarios:

1. When patient history strongly suggests specific food allergies 1
2. When widespread active eczema is not responding to first-line treatments 1

Evidence for Dietary Approaches

Exclusion Diets

• Targeted exclusion diets: May benefit 18-23% of children with severe eczema 2
• Egg-free diets: May benefit infants with suspected egg allergy who have positive specific IgE to eggs 3
• Few-food diets: In one study, 36% of children improved during the restricted diet phase, but only 23% maintained improvement long-term 2
• Adult patients: Some evidence suggests dietary restrictions may help adults with eczema, with one study showing long-term improvement in 70% of responsive patients, particularly those with atopic tendencies 4

Breastfeeding and Early Diet

• Evidence for breastfeeding and maternal avoidance of allergens during pregnancy/lactation in preventing atopy is conflicting 1
• In newborns with increased risk of atopy, exclusive breastfeeding during early months and delayed introduction of solid foods may inhibit or delay manifestation of atopic disease 5

Practical Approach to Dietary Management

Assessment Protocol

1. Identify potential candidates for dietary intervention:

   • Patients with severe eczema not responding to first-line treatments
   • Patients with clear history suggesting food triggers
   • Infants and young children more likely to benefit than adults

2. Diagnostic workup:

   • History taking, skin tests, and RAST may provide initial information but are insufficient for conclusive diagnosis 5
   • Controlled oral challenge tests should be performed to identify problematic foods 5

Implementation of Dietary Changes

1. Professional supervision:

   • All dietary restrictions should be conducted under professional supervision 1
   • Referral to a dietitian is recommended 1

2. Targeted approach:

   • Undirected exclusion diets are unnecessary and potentially harmful 5
   • Most reactive patients respond to only one or two food items 5
   • Individualized approach based on allergological workup is essential 5

3. Trial period:

   • Implement restricted diet for 4-6 weeks
   • If improvement occurs, gradually reintroduce excluded foods to identify specific triggers

Cautions and Pitfalls

• Risk of malnutrition: Exclusion diets, especially in children, can lead to nutritional deficiencies 5
• Anaphylactic reactions: Possible upon reintroduction of allergenic foods after prolonged exclusion 5
• Practical challenges: Dietary restrictions can be arduous to maintain long-term 2
• Limited evidence: Cochrane review found little evidence supporting exclusion diets in unselected people with atopic eczema 3
• Unreliable identification: Parental identification of provoking foods may not be reliable without controlled challenges 2

When to Refer to a Specialist

Referral to a specialist is indicated when:

• Dietary manipulation is being considered 1
• There is diagnostic doubt 1
• First-line treatments have failed 1
• Specialist opinion would be valuable in counseling patients and family 1

Holistic Management

Remember that diet is only one component of eczema management. The mainstay treatments remain:

• Emollients and proper bathing regimens
• Topical corticosteroids
• Avoidance of irritants (soaps, detergents, wool clothing)
• Treatment of secondary infections
• Antihistamines for severe pruritus