Under the Microscope: Eczema and Emotional Issues in Children
The National Eczema Association funds Dr. Joy Wan’s research on mental health problems in children with atopic dermatitis.
Published On: Dec 5, 2023
Last Updated On: Jan 3, 2024
Should I cut eggs from my diet to help my eczema? Did that bread cause my eczema flare? These are questions that many people with the most common form of eczema, atopic dermatitis (AD), may ask themselves as they try to manage their condition. But should you eliminate foods from your diet because of eczema? Is it safe to completely cut out foods to help treat AD? Where did this diet trend for eczema even come from?
Over the last few decades, there have been ongoing conversations in the medical community about the role of food and AD and whether food elimination diets should be considered a treatment approach for improving AD symptoms.1,2
Unfortunately, some of these conversations have led some eczema patients and their caregivers to incorrectly assume that food is the root cause of AD, and they eliminate certain foods without consulting a physician.
“Food can certainly be part of AD, but it is rarely the root cause,” said Dr. Peter Lio, clinical assistant professor of dermatology and pediatrics at Northwestern University, and co-founder and co-director of the Chicago Integrative Eczema Center. “If AD is left untreated or undertreated, there may be a risk of developing more food and other allergies as the skin barrier is not working properly and the immune system is overreacting.”
Eliminating certain foods from your diet may have unintended consequences, including actually increasing the risk of developing food allergies.3
A paper published in 1987 reported that out of 675 adult AD patients placed on elimination diets for one month, 262 experienced improvements in AD symptoms. One to three years after the original study, those 262 patients were surveyed again and 144 of them reported long-term improvement of their AD symptoms, which they attributed to elimination diets.4
In this 1987 paper, the patients reported that some of the foods that made their AD symptoms worse were chocolate, beer, wine, tea, soda, citrus fruit, certain spices, nuts, shrimp and bread made with wheat flour.4 However, there were problems with this study. For example, the elimination of foods was not specified for each patient and there was no real control group. Actual allergies to the above foods were not confirmed through allergy testing. Nevertheless, due to the results of this and other similar studies, both patients and clinicians began trying food elimination diets to control AD symptoms.
In 1992, other publications reported associations between allergens ingested by a mother and breastfeeding infants with AD.2 To help the infants with AD symptoms, mothers were encouraged to stop eating potential allergens like cow’s milk, eggs and nuts and were told to supplement their baby’s diet with formula.2
However, over time, reports began popping up in the literature indicating that infants with AD were not receiving proper nutrition on these elimination diets and that certain formulas were having a detrimental impact on infants.5,6 In 2012, a new paper recommended that children with AD be tested for true food allergies and seek counseling by a nutritionist if parents planned to remove dietary elements.6
Despite the shift in thinking by the medical community, the practice of food elimination diets to control AD symptoms remained common. In 2015, researchers reported that up to 75% of children with AD had tried food elimination diets where they cut out all dairy products, including eggs and cow’s milk.7
In a recent systematic review of scientific literature on AD, researchers concluded that there is no overall benefit to food elimination for patients with AD.1,3,7,8 Based on this review, there was no improvement in AD symptoms within the first few weeks after starting an elimination diet. There was also no long-term improvement in the number and severity of flares, and there was no long-term reduction in AD treatment regimens.1,3,7,8
Rather, these reports argue that treatment of AD with topical medications and other treatment approaches should be thoroughly explored prior to removing any foods from a patient’s diet. When a true food allergy is suspected, an eczema patient should be tested by an allergist prior to any food removal.
“We do not recommend any food elimination diets unless there is a positively identified true food allergy,” said Dr. Jonathan Spergel, allergist and chief of the allergy program at Children’s Hospital of Philadelphia.
What does it mean to have a true food allergy? A food allergy provokes an immune system reaction that affects numerous organs in the body, and it can cause a range of symptoms, some of which are life-threatening. When the body comes into contact with the food, the body mounts an immune reaction, called an immunoglobulin E (IgE) reaction.
A food allergy can cause skin reactions like hives, itchiness and swelling of the skin. It can also cause vomiting and diarrhea. Food allergies can also cause anaphylaxis reactions like difficulty breathing, dizziness or loss of consciousness. A true food allergy is associated with this IgE reaction every time the person is exposed to the food.1
There are differences between a food allergy and food sensitivity. Food sensitivity, or food intolerance, occurs when a person has trouble digesting certain foods. Food sensitivity can occur when the skin or gut comes into contact with a specific food. Food sensitivity can lead to bloating, gas, abdominal pain and diarrhea. It can also cause a rash, but this reaction is not the same as AD.1
Research shows that AD is associated with a higher risk for food allergies. People with more severe AD symptoms are more frequently diagnosed with food allergies compared to the general population without AD.9
Patients with mild AD rarely have evidence of true IgE reactions to food.9 Around 50% of children with AD and 35% of adults with AD have been sensitized to allergens found in the environment and in food.9 However, this does not mean they have a true allergy.
So how do you know if you have a true food allergy? Diagnosing a true food allergy can be tricky. “To test for a true food allergy, allergists use the skin prick test or test for a specific antibody (IgE to the suspected food) reaction,” Dr. Spergel said.
These tests are not always accurate. “Both of these tests can turn out falsely positive, meaning the patient does not really have that allergy,” Dr. Spergel explained. “In children with AD, the false positive rate can be over 50% because AD can drive IgE production that has nothing to do with a food allergy.”
Instead, Dr. Spergel said, “The gold standard for diagnosing food allergy is for the clinician to do a food challenge and monitor the reaction. An allergic food triggers an immediate rash every time a person comes in contact with that food. Every single time.”
The role of diet in AD is complex and can be confusing. If you suspect a certain food is making your AD symptoms worse, it’s important to talk with your doctor about the possibility of allergy testing.
But it’s important to remember that current medical standards dictate that the physician must focus on skin treatment as their first approach to improving AD symptoms. If medications are not adequately treating AD symptoms, the physician may then recommend allergy testing, most likely for nut, milk, egg, wheat and soy.1 This will help determine whether there is a true food allergy that can be eliminated to improve immune health and reduce AD symptoms.
“This is anecdotal rather than scientific, but a large number of my patients who have drastically changed their diets tell me that they did see some improvement in their AD symptoms,” said Dr. Lio. “It is not clear if this is because people who were experiencing the worst symptoms would have improved anyway with or without dietary changes or if there really is some anti-inflammatory benefit to some of the most common changes. For example, by cutting out gluten and dairy perhaps people inadvertently eat a healthier, anti-inflammatory diet.”
Along these lines, a 2022 paper showed that AD patients reported that they believed they did experience benefits after eliminating certain foods from their diet.1 This is evidence that certain foods may negatively impact the immune system. However, we need more controlled scientific studies to really understand it.
“What is really needed is longer, better controlled studies [on diet and AD], which can be extremely expensive and difficult to conduct,” Dr. Lio said. “These types of studies would help tease out connections between diet, the microbiome and the immune system.”
In the end, we are back to the concept that one size does not fit all when it comes to diet and AD symptom management. There should be a give and take discussion between patients and their healthcare providers about the role of food in AD management. Most importantly, patients are not advised to remove foods from their diet without oversight from a healthcare provider.
Recently, researchers have been exploring how specific metabolic pathways (how food gets broken down into molecules for use within the body) are controlled by multiple types of bacteria.10 The products made by bacteria breaking down their food can have a massive effect on how the human immune system functions. We are reliant on bacteria to help us process food and create products that are put to use in many ways within our bodies.10
Even though we know that AD is associated with colonization of our gut and skin microbiomes with disease causing bacteria, we do not yet know which foods may be important for maintaining the healthiest microbiome. It is possible that adding rather than eliminating certain foods from our diets may help improve the microbiome, calm overactive immune reactions and improve symptoms of inflammatory diseases.
“Many studies are currently ongoing about the role of diet and the microbiome in regulating skin diseases,” Dr. Lio said. “This is an incredibly complex, entirely new field and current studies just lead to more questions! There are many knowledge gaps in understanding the microbiome and we are really just at the very beginning. Some questions include, ‘How do different species of microorganisms influence each other’s colonization and function? What roles do the host and environmental factors play in the microbiome? Why do different microbial species colonize different areas of the human body?’”
Ultimately many more years of research are needed to understand this complex area of study and come up with answers about whether diet, the microbiome, and the immune system can be delicately modulated to help improve AD symptoms.
For additional information on how diet affects eczema, visit NationalEczema.org/diet-nutrition.
References:
1. Rustad AM, Nickles MA, Bilimoria SN, Lio PA. The role of diet modification in atopic dermatitis: Navigating the complexity. Am J Clin Dermatol. 2022;23(1):27-36. doi:10.1007/s40257-021-00647-y
2. Sampson HA. Food hypersensitivity and dietary management in atopic dermatitis. Pediatr Dermatol. 1992;9(4):376-379. doi:10.1111/j.1525-1470.1992.tb00636.x
3. Oykhman P, Dookie J, Al-Rammahy H, et al. Dietary elimination for the treatment of atopic dermatitis: A systematic review and meta-analysis. J Allergy Clin Immunol Pract. 2022;10(10):2657-2666.e8. doi:10.1016/j.jaip.2022.06.044
4. Veien NK, Hattel T, Justesen O, Nørholm A. Dietary restrictions in the treatment of adult patients with eczema. Contact Dermatitis. 1987;17(4):223-228. doi:10.1111/j.1600-0536.1987.tb02717.x
5. David TJ, Waddington E, Stanton RH. Nutritional hazards of elimination diets in children with atopic eczema. Arch Dis Child. 1984;59(4):323-325. doi:10.1136/adc.59.4.323
6. Keller MD, Shuker M, Heimall J, Cianferoni A. Severe malnutrition resulting from use of rice milk in food elimination diets for atopic dermatitis. Isr Med Assoc J. 2012;14(1):40-42.
7. Tait C, Goldman RD. Dietary exclusion for childhood atopic dermatitis. Can Fam Physician. 2015;61(7):609-611.
8. Eigenmann PA, Beyer K, Lack G, et al. Are avoidance diets still warranted in children with atopic dermatitis?. Pediatr Allergy Immunol. 2020;31(1):19-26. doi:10.1111/pai.13104
9. Papapostolou N, Xepapadaki P, Gregoriou S, Makris M. Atopic dermatitis and food allergy: A complex interplay what we know and what we would like to learn. J Clin Med. 2022;11(14):4232. Published 2022 Jul 21. doi:10.3390/jcm11144232
10. Stec A, Sikora M, Maciejewska M, et al. Bacterial metabolites: A link between gut microbiota and dermatological diseases. Int J Mol Sci. 2023;24(4):3494. Published 2023 Feb 9. doi:10.3390/ijms24043494
The National Eczema Association funds Dr. Joy Wan’s research on mental health problems in children with atopic dermatitis.
Madalyn Meagher Hamm refuses to allow eczema to control her life, but she admits some days are rough. She wants others to know it’s OK for both emotions to exist.
Test your knowledge to see if you know these surprising facts about contact dermatitis.
Michelle Williams, from Frisco, Texas, shares how she and her family discovered the National Eczema Association and what it means to her to give back.
Evidence-based articles, expert-sourced lifestyle tips and stories from your community.