By Dr. Michael Pistiner
Published On: Apr 29, 2022
Last Updated On: Sep 28, 2022
We partnered with the Asthma and Allergy Foundation of America (AAFA) in observation of National Asthma and Allergy Awareness Month, and asked what board-certified allergist, Michael Pistiner, MD, MMSc, wished more people with eczema knew about allergies. Dr. Pistiner is a spokesperson for AAFA, and a member of AAFA’s Medical Scientific Council. He is the Director of Food Allergy Advocacy, Education and Prevention for the Massachusetts General Hospital for Children, Food Allergy Center.
#1. There’s a connection between childhood atopic dermatitis (the most common type of eczema) and allergies
The atopic march, also known as the allergic march, refers to the concept of a stepwise development of conditions considered allergic in nature, many of which may share risk factors like family history or environmental exposures and may occur in the same people. Usually, the allergic march starts with atopic dermatitis (AD), followed by food allergy, asthma and allergic rhinitis (hay fever).
AD is often the first to present. AD is characterized by skin barrier dysfunction, itchy skin and inflammation. Studies suggest that AD and AD severity are risk factors for the development of subsequent allergic issues like food allergy and asthma. What we understand about atopic dermatitis is rapidly changing. New information is coming out about the causes and the comorbidities that come with AD, like allergic issues and infection. There’s also so much more information about new treatments and potential prevention strategies.
#2. It’s important to build a solid healthcare team
I can’t emphasize enough about the importance of developing a strong relationship with your healthcare team and including a dermatologist or allergist, if needed. Have an open line of communication. Update your healthcare team about your symptoms or your child’s symptoms and any medical issues; at the same time, keep up to date with all the new information about how to best manage AD and its comorbidities; and work to prevent the development of new conditions like food allergy, asthma and allergic rhinitis.
Along the same lines, try to find a clinician who is comfortable managing AD and work with them to get the best results when trying to prevent and treat flares. Share any feelings, fears or doubts that come up with your healthcare team so you can learn from them, and they can learn from you.
This is important in shared medical decision making and will help maximize the care for you or your child; shared decision making is an approach used in a clinical setting to empower patients to make informed decisions alongside their doctor when faced with treatment and management options. Work with your primary care team and your specialist, such as a dermatologist or an allergist, to make sure that both short-term and long-term management is matched to the AD symptoms you or your child are experiencing.
#3. Be cautious with exposure to potential allergens for children with AD
Recent studies have supported an emerging line of thinking called the Dual Exposure Hypothesis, which suggests that:
- The skin may be the source of allergic sensitization;
- Skin barrier dysfunction and inflammation commonly seen in AD may be facilitate allergens/irritants coming in contact with the inflamed skin;
- Eating food prior to the development of a food allergy may help protect from subsequently developing a food allergy to that food;
- The gut seems to be the tolerizing method of exposure to food; tolerance is when you can eat a food without having an allergic reaction.
So it seems that skin exposure may sensitize and gut exposure may tolerize. In one study of children with moderate or severe eczema, researchers determined that a delay in introducing developmentally appropriate food contains peanuts after six months of age can increase a child’s risk of developing a peanut allergy. National guidelines based on studies like Learning Early About Peanut (LEAP) encourage checking in with your healthcare team about early introduction of peanut (non-choke, developmentally-appropriate forms) with the target of four to six months of life if your child has severe eczema. Some studies suggest that chronic skin exposure to environmental peanut and other foods may lead to sensitization and ultimately food allergy in kids who don’t have the opportunity to eat them.
Although not in any guideline yet, I have been recommending to the families I care for that, especially for children with AD, if parents are eating an allergen that the child isn’t yet eating try to remember to wash your hands after eating those foods, especially prior to applying creams or ointments to the baby and prior to diaper changes. Also trying to avoid eating those foods in areas that might cause exposures to the baby’s skin and consider limiting where you eat to the kitchen.
Remember: there is no reason to delay the introduction of common food allergens beyond four to six months of life. Talk to your healthcare team about when to consider food allergen introduction to a child’s diet early so you can plan and do any screening if necessary.