What diet should a patient with atopic dermatitis (atopic eczema) follow to avoid exacerbating symptoms?

Dietary Recommendations for Atopic Dermatitis

Do not routinely recommend food elimination diets to patients with atopic dermatitis unless there is documented, clinically relevant food allergy confirmed by proper diagnostic testing including oral food challenge. 1

The Evidence Against Routine Dietary Restrictions

The American Academy of Dermatology guidelines are clear and emphatic on this point:

• Elimination diets should NOT be initiated based on the presence of atopic dermatitis or a suspicious history alone. 1

• Food allergies are actually relevant triggers in only a small subset of AD patients—approximately 35% of children with moderate-to-severe disease—making routine dietary restrictions inappropriate for most patients. 2, 3

• The true frequency of food allergies causing isolated AD flares is probably low, and there is frequent misattribution of AD flares to food-related issues. 1

When to Consider Food Allergy Evaluation

A structured approach is warranted only in specific circumstances:

Criteria for Testing 1, 2, 4

• Age: Child under 5 years old
• Severity: Moderate-to-severe atopic dermatitis
• Treatment failure: Disease persists despite optimized topical corticosteroid therapy and adequate emollient use
• OR: Reliable history of immediate allergic reaction after specific food ingestion

Limited Testing Approach 2, 4, 3

If criteria are met, consider testing only for the most common allergens:

• Cow's milk
• Hen's eggs
• Wheat
• Soy
• Peanuts

Critical Diagnostic Algorithm

Never prescribe elimination diets based on positive allergy tests alone. The proper sequence is essential:

Step 1: Keep a Food Diary 1, 2

• Record symptoms and food intake for correlation
• Look for consistent patterns between specific foods and symptom flares

Step 2: Allergy Testing (If Indicated) 2, 4

• Skin prick testing or specific IgE levels
• Critical caveat: These tests have poor positive predictive value (40-60%) and only indicate sensitization, not true allergy 2, 4
• High negative predictive value (>95%) means negative results effectively rule out food allergy 2

Step 3: Diagnostic Elimination Diet (If Testing Suggests Allergy) 1, 4

• Eliminate suspected food for 4-6 weeks only
• If AD remains stable or worsens, the food is unlikely a relevant trigger 1

Step 4: Oral Food Challenge Under Medical Supervision 1, 2, 4

• This step is essential and non-negotiable
• Improvement during elimination may be coincidental or placebo effect 1, 2, 4
• Double-blind placebo-controlled food challenge is the gold standard 4, 5
• A retrospective study showed that 84-93% of avoided foods could be returned to the diet and tolerated after proper challenge testing 1

Major Pitfalls and Harms to Avoid

Nutritional Consequences of Unnecessary Restrictions 1, 2, 4

Excessively restrictive diets, especially in atopic children, have caused:

• Weight loss and poor growth
• Calcium deficiency
• Hypovitaminosis
• Kwashiorkor (severe protein malnutrition)

Common Clinical Errors 2

• Prescribing avoidance without treating the underlying atopic dermatitis is incorrect management
• Many children have inadequately treated AD, not food allergy
• Optimize topical therapy first before attributing symptoms to food

The Reality Check 2, 4

• 50-90% of presumed food allergies based on symptoms or positive tests are not true allergies 4
• Even in those with confirmed food allergy, avoidance diets are helpful for preventing IgE-mediated immediate reactions but are unlikely to affect the overall course of AD 1

When Long-Term Avoidance Is Justified

Multiple dietary restrictions and long-term dietary avoidance should only be undertaken with documented, clinically relevant food allergies confirmed by oral challenge. 1

If prolonged elimination is necessary:

• Provide proper medical supervision 1
• Arrange nutritional counseling from a dietician 1
• Include appropriate supplementation 1
• Regular re-evaluation is necessary as most children develop tolerance over time 2

The Bottom Line for Clinical Practice

Effective treatment of atopic dermatitis remains skin care and topical therapies, even in the presence of confirmed food allergy. 2 The focus should be on optimizing topical corticosteroids and emollients rather than pursuing dietary restrictions in the vast majority of patients. 2

Referral to an allergist is recommended for proper diagnostic testing, supervised oral food challenges, formulation of emergency anaphylaxis action plans, and prevention of unnecessary dietary restrictions. 2