Managing Pediatric Atopic Dermatitis

Key highlights

The prevalence of atopic comorbidities in AD at any age is higher than in the general population, with AD and these comorbidities exhibiting numerous shared genetic risk variants⁵. More severe AD is associated with an increased likelihood of atopic comorbidities, including asthma^2,6.

Article of interest:

Ghezzi M et al. Barrier Impairment and Type 2 Inflammation in Allergic Diseases: The Pediatric Perspective. Children (Basel). 2021 Dec 9;8(12):1165.

The Atopic March

The concept of the "atopic march" describes the sequential progression of AD, food allergy (FA), allergic asthma (AA), allergic rhinitis (AR), and allergic conjunctivitis (AC)². According to this theory, the disruption of the epidermal barrier in AD triggers sensitization to epicutaneous allergens and inflammation, leading to an immune response that subsequently extends to other epithelial surfaces, including the gastrointestinal tract, resulting in food allergies, the upper respiratory tract, leading to allergic rhinitis, and the lower respiratory tract, contributing to allergic asthma^2,3.

Food Allergy in Young Children with AD

Infants with AD have a six-fold higher risk of developing IgE-mediated food allergy compared with infants without AD⁷. Symptoms often include gastrointestinal issues such as vomiting, diarrhea, constipation, cramps, and lung manifestations.

Management of Food Allergy: Do’s and Don’t

Dermatologists and general practitioners frequently search for links between skin exacerbations and food, leading to prescribed skin prick tests and specific IgE tests in blood. However, sensitization to many food elements is often found in children with AD, resulting in prescribed diets⁷.

1. Restrictive diets

Recent studies have shown the importance of including common food allergens in the diets of infants⁹. Dietary elimination for the treatment of AD may slightly improve the condition but does not account for the potential harm of a diet in young children. Some studies suggest that diet restriction at a young age can increase the risk of developing food allergies, as exposure to different types of food is necessary to maintain immune tolerance. Elimination of certain foods may improve AD in some patients with true food-triggered AD but can also lead to the future development of IgE-mediated FA, including anaphylaxis. Furthermore, children who eliminate two or more foods from their diet are more likely to reach lower height percentiles and be vitamin D deficient. Therefore, a general diet based on specific IgE tests should be approached with caution^7,8.

2. IgE testing

Specific IgE testing may be useful in predicting food allergy in patients with moderate-severe AD, but the decision points may be much higher than those that apply to a less atopic population⁸. Furthermore, IgE testing alone is not diagnostic for food allergies, so adding a diagnostic oral food challenge could help guide the clinical significance of specific IgE sensitization¹⁰.

The Benefits of Early intervention in Children

An intact skin epithelium is crucial for preventing further allergic manifestations. There is some evidence, although not established, that early application of skin emollients can reduce the risk of AD development or delay its onset¹¹. This also raises the question of whether treatment with biologics that restore epithelial barrier integrity may prevent the inflammatory response and the development of the atopic march¹². Since treatment with biologics is now approved at a very young age, future research will be able to answer this question¹².

Conclusion