How can eczema/atopic dermatitis be prevented in an infant with a family history of the condition?

How to Prevent Eczema/Atopic Dermatitis in High-Risk Infants

For infants with a family history of atopic disease, start moisturizers only when dry skin appears, rather than from birth, and focus on exclusive breastfeeding for 3-4 months while introducing allergenic foods at 4-6 months without delay. 1

Primary Prevention Strategy for High-Risk Infants

Moisturizer Application Approach

The most recent Taiwan guidelines (2022) recommend against universal prophylactic moisturizer use from birth. 1 Instead, high-risk infants (those with a first-degree relative with allergic diseases) should begin moisturizers only when clinical features of dry skin develop. 1 This represents a shift from earlier recommendations, as the largest and highest-quality trial (BEEP, 2023) definitively showed that daily emollient application during the first year does not prevent atopic dermatitis, food allergy, asthma, or hay fever. 2

The evidence reveals an important nuance: while some earlier studies suggested moisturizers might delay AD onset in high-risk populations, the protective effect disappears within one year after cessation, and recent data show no long-term prevention benefit. 3, 2 More concerning, one trial found that skin care interventions may actually increase the risk of IgE-mediated food allergy (RR 2.53). 4

Feeding Recommendations

Exclusive breastfeeding for 3-4 months decreases AD risk in the first 2 years of life. 1 This is the most evidence-based dietary intervention for prevention.

Do not delay introduction of allergenic foods (peanuts, eggs, fish) beyond 4-6 months. 1 Current evidence shows insufficient support for delayed introduction as a prevention strategy, and emerging data suggests early diversified food introduction may actually prevent food allergies. 1

Maternal dietary restrictions during pregnancy or lactation are not recommended for AD prevention, as current evidence does not support this approach. 1

What NOT to Do

• Do not recommend hydrolyzed formulas for AD prevention—there is lack of consensus on whether partially or extensively hydrolyzed formulas prevent allergic diseases. 1
• Do not prescribe probiotics for prevention—while they may modulate the microbiome, benefits remain controversial with no firm recommendation possible. 1
• Do not recommend vitamin D supplementation for primary prevention—no conclusive benefits have been demonstrated despite vitamin D's role in skin barrier function. 1

Critical Safety Considerations

Prophylactic moisturizer use probably increases the risk of skin infections (RR 1.33, with 17 more cases per 1000 infants). 4 This represents an important harm that must be weighed against the lack of prevention benefit. Additionally, there is increased risk of infant slippage and stinging/allergic reactions to moisturizers. 4

Practical Algorithm for Counseling Parents

1. Assess family history: If first-degree relative has atopic disease, infant is high-risk 1
2. Recommend exclusive breastfeeding for 3-4 months 1
3. Introduce allergenic foods at 4-6 months without delay 1
4. Monitor for dry skin: Only start moisturizers when dry skin clinically appears 1
5. Avoid prophylactic moisturizers from birth in all infants 2, 4
6. Do not restrict maternal diet during pregnancy/lactation 1

Common Pitfalls to Avoid

The most critical pitfall is recommending universal emollient application from birth, as this practice is not supported by the highest-quality evidence and may cause harm through increased infection risk. 2, 4 The 2023 BEEP trial with 1,394 infants followed to age 5 years provides definitive evidence against this approach. 2

Another pitfall is delaying allergenic food introduction, which contradicts current evidence showing no prevention benefit and may actually increase food allergy risk. 1