Natural History of Food-Triggered Atopic Dermatitis and Development of Immediate Reactions in Children

Management of food allergy based on oral food challenge

PURPOSE OF REVIEW

Food allergy is a growing health problem that affects both patients and society in multiple ways. Despite the emergence of novel diagnostic tools, such as component-resolved diagnostics (CRD) and basophil activation tests (BAT), oral food challenge (OFC) still plays an indispensable role in the management of food allergies. This review aimed to highlight the indications and safety concerns of conducting an OFC and to provide insights into post-OFC management based on recent findings.

RECENT FINDINGS

Standardized OFC protocols have regional diversification, especially in Japan and Western countries. Recent studies suggested that the interval between doses should be at least more than an hour. Furthermore, applying a stepwise method tailored to the patient's specific immunoglobulin E level and history of anaphylaxis seems to mitigate these risks. Recent surveys have shown that, following a positive OFC, options other than strict avoidance are also selected.

SUMMARY

OFC serves diverse purposes, yet the risks it carries warrant caution. The stepwise protocol appears promising for its safety. Subthreshold consumption following OFC shows potential; however, further research on its efficacy and safety is required. Management following OFC should be tailored and well discussed between clinicians and patients.

Atopic Dermatitis: Disease Background and Risk Factors

Multiple risk factors have been associated with the development of atopic dermatitis (AD). Recent advances in understanding the role of genetics in this disease have been made, with discovery of the filaggrin (FLG) gene as the most notable so far. In addition to FLG gene mutations as a risk factor for AD, a positive family history of atopic or allergic disease in either parent has been shown to confer a greater risk of developing AD. Atopic dermatitis usually presents early in life and is thought to represent the initial step in the "atopic march," which is characterized by the development of other atopic diseases later in life such as asthma, allergic rhinitis, and/or rhinoconjunctivitis, food allergies, and hay fever. Other comorbid diseases that have been associated with AD include increase risk of viral and bacterial skin infections, neuropsychiatric diseases such as attention-deficit hyperactivity disorders (ADHD), and autistic spectrum disorder (ASD). Patients with AD have also been found to have worse sleep quality overall compared to patients without AD. In this chapter, we will discuss the risk factors associated with development of atopic dermatitis as well as the most commonly reported comorbidities in patients with this disease.

Nurturing Infants to Prevent Atopic Dermatitis and Food Allergies: A Longitudinal Study

BACKGROUND

Atopic dermatitis (AD) at a young age often precedes the development of food allergies. Although AD affects millions of infants worldwide, prenatal and postnatal risk factors, and their association with the development of food allergies later on, are not fully elucidated. This study seeks to investigate AD epidemiology in infancy and its risk factors, examining early-life factors (both prenatal and postnatal) that could contribute to the later development of food allergies.

METHODS

Between January 2019 and December 2019, 501 infants were included in this prospective cohort study. Longitudinal data collection was performed through maternal interviews, the first one conducted within three days after the delivery and the second within 24 to 36 months after the delivery, encompassing variables such as demographics, family history of atopy, maternal smoking, antibiotic use during pregnancy, the mode of delivery, breastfeeding history, food practices, and greenness exposure within 3 days from delivery, while they were still in the hospital.

RESULTS

Maternal smoking during pregnancy (p = 0.001) and an older sibling atopy history (p = 0.03) was significantly linked to AD incidence. Cesarean section delivery (p = 0.04) was associated with a higher risk of food allergies in infants with AD. Having a garden at home correlated with a higher likelihood of AD (p = 0.01), and food elimination without medical guidance (p = 0.02) due to AD correlated with an elevated risk of food allergies.

CONCLUSIONS

Encouraging timely allergenic food introduction while promoting dietary diversity, rich in plant-based foods, maternal smoking cessation, and professional dietary guidance may help minimize AD and food allergy risk. Future studies should address the role of greenness in the development of AD and food allergies.

A review of food allergy panels and their consequences

Serum immunoglobulin E (IgE) assays to food specific IgE (s-IgE) are useful tools for the confirmation of clinical suspicion of food allergy. However, the specificity of these assays is poor given that sensitization is much more common than clinical food allergy. Therefore, the use of broad panels to assess sensitization to multiple foods often leads to overdiagnosis and unnecessary food avoidance. Unintended consequences that may occur as a result include physical harm, psychological harm, financial cost, opportunity cost, and even worsening of existing health care disparities. Although current guidelines recommend against the use of s-IgE food panel testing, these tests are widely available and frequently used. To limit the negative impacts of s-IgE food panel testing, further work is needed to effectively spread the message that these food panels may cause unintended harm to patients and families.

Food allergy-A holistic approach to dietary management. A joint EAACI Research & Outreach Committee and INDANA review

Following a diagnosis of IgE-mediated food allergy, to secure the best outcome, the patient should receive individualized advice tailored to their specific needs, which considers the type and presentation of the food involved, level of exclusion required, risk of cross-contamination and any variance required for age, ethnicity, financial issues, and lifestyle. Issues such as food labels "may contain" statements, and variation in the threshold of reaction and impact of cofactors should also be considered. Most important is the need to ensure that the diagnosis is robust, especially given the nutritional, psychological, and socioeconomic issues that can affect an individual with a diagnosis of food allergy. Unnecessary exclusion of one or more foods that have not triggered allergic reactions, especially in individuals with allergic comorbidities, can result in severe IgE-mediated reactions on re-exposure. Given that food allergies may change over time, the diagnosis should be reviewed, to determine whether resolution is likely, or new-food triggers are reported. Regular assessment is vital, especially during childhood, to ensure reintroduction occurs at an appropriate time, thus enabling increased diversity of the diet and improvement in the quality of life. For some, an IgE-mediated food allergy may necessitate the life-long exclusion of foods, and for others, a food habitually eaten suddenly triggers an allergic reaction in adult life. People of all ages, ethnicities, and socioeconomic backgrounds deserve individual advice on the management of their food allergy to support a healthy diet and improve quality of life.

Food allergy: cause or consequence of pediatric eosinophilic esophagitis? Potential implications of ultraprocessed foods in prevention and management

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease characterized by eosinophilic infiltration, leading to esophageal dysfunction, inflammation, and fibrotic remodeling. In the last few decades, there has been an increased prevalence of EoE at an alarming rate in the pediatric age. The pathogenesis of EoE is still largely undefined, and this limits the definition of effective strategies for the prevention and management of this condition. EoE is considered a multifactorial disease arising from a negative interaction between environmental factors and genetic background, causing an impaired esophageal epithelial barrier with subsequent abnormal allergen exposure activating type 2 (Th2) inflammation. Food antigens have been suggested as key players in Th2 inflammation in pediatric patients with EoE, but emerging evidence suggests a potential role of other dietary factors, including ultraprocessed foods, as possible triggers for the occurrence of EoE. In this paper, we discuss the potential role of these dietary factors in the development of the disease, and we propose a new approach for the management of pediatric patients with EoE.

Atopic dermatitis and food allergy: To Test or not to test

One of the most challenging clinical scenarios in the field of allergy and immunology is the patient with uncontrolled atopic dermatitis (AD) and potential food allergy. These two diagnoses often coexist, but false-positive testing to foods is also prevalent. Physicians and other health care professionals may be concerned that not testing enough foods could lead to worsened AD severity or future systemic food reactions. However, testing too many foods can cause unnecessary food avoidance with varied subsequent consequences. Adding to this dilemma, patients and families with AD often request food allergy testing or present with test results in need of interpretation. The best path forward for these patients is nuanced, but evidenced-based medicine indicates that "less is more" when it comes to food allergy testing in patients with AD. This review explores when food testing is indicated based on the latest research and guidelines in food allergy and AD.

Management of atopic dermatitis by pediatricians: A French national survey-based study

PURPOSE

Atopic dermatitis (AD) is a chronic skin disease affecting 10% of children in Europe. The treatment of AD is well codified; however, a gap sometimes exists between recommendations and medical practice. The objective of this study was to assess the practice of French pediatricians regarding the management of AD.

METHODS

We conducted a national practice survey from September 2021 to October 2021, using an online questionnaire emailed to pediatric physicians.

RESULTS

A total of 83 pediatricians from 33 different departments responded to the survey. The clinical features of AD were known by the majority of pediatricians, but 15 (18%) found the diagnosis difficult to establish. All pediatricians prescribed daily applications of emollients and 78 (94%) prescribed topical corticosteroids (TCS) during AD flares, but misuses remained: only 29 (35%) pediatricians prescribed TCS when eczema (even if minimal) appeared and 43 (52%) did so at the onset of pruritus, while 45 (54%) prescribed them for extensive or disabling eczema, and 53 (64%) when eczema persisted after an initial treatment with emollients. Regarding diet, 12 (14%) pediatricians recommended a diet low on or free of cow milk, 10 (12%) systematically referred children with AD to an allergist, and 20 (24%) delayed food diversification.

CONCLUSION

Despite improvements in AD management by French pediatricians in the past 15 years, barriers to its appropriate management still persist, including the misuse of TCS and inappropriate diets.

Children with Delayed-Type Cow's Milk Protein Allergy May Be at a Significant Risk of Developing Immediate Allergic Reactions Upon Re-introduction

Background

Cow's Milk Protein Allergy (CMPA) is the most common food allergy in children. The reaction is classified into IgE-mediated immediate reaction and delayed-onset, according to the underlying immune mechanism, and hence, the timing of the symptoms. Case reports suggest that children, with delayed CMPA reactions on elimination diet, may develop severe immediate reactions on reintroduction.

Aim

The objective of this study was to evaluate the incidence and the risk factors of developing immediate reactions to milk and dairy products in children with CMPA whose initial presentations were of delayed type.

Methods

A retrospective chart review of children, aged 0-12 years, presented with delayed type CMPA reactions to the allergy-clinical immunology clinics, was performed. The diagnosis was made clinically, and with appropriate allergy tests when indicated.

Results

Sixty children were included. Males:female ratio was 1.7:1. Family history of atopy was in 72%, and 57% had personal history of atopy. Sixty percent were not breast fed. The most common concomitant food allergy was egg. The most common initial presentation was diarrhea without protein loss or bleeding followed by exacerbation of atopic dermatitis upon exposure to dairy products. Immediate reactions developed in 21.6% upon re-exposure. There were significant associations with concomitant food allergy (OR 56.6 (3.15-1016.1) P<0.0001), especially eggs (OR 12.85 (3.09-53.5) P<0.01).

Conclusion

Children with CMPA, who present with delayed-type allergic reactions, may be at a significant risk of developing immediate reactions upon reintroduction. Evaluation of possible IgE-mediated allergic reactions before reintroduction may be advisable.

When Foods Cause Itch: Clinical Characteristics, Pathophysiology, and Recommendations for Food-Induced Skin and Mucosal Pruritus

Itch occurs in various dermatologic and systemic conditions. Many patients report that certain foods instigate itch, although there is limited published information in dermatology on food-induced pruritus. In addition, itch severity is rarely mentioned. Food can induce pruritus through either ingestion or direct contact with skin or mucosal membranes. The most common type of itch provoked by food is acute urticaria, often through the classical immunoglobulin E (IgE)-mediated pathway. Other mechanisms include non-IgE-mediated, mixed (IgE-mediated and non-IgE-mediated), T-cell-mediated, and nonimmune reactions. For patients presenting with urticaria, generalized pruritus, oral pruritus, or dermatitis, a thorough history is warranted, and possible food associations should be considered and assessed. Although any food seems to have the potential to elicit an immune response, certain foods are especially immunogenic. Treatment includes avoidance of the trigger and symptom management. Careful consideration should be used as to avoid unnecessarily restrictive elimination diets.

When Foods Cause Itch: Clinical Characteristics, Pathophysiology, and Recommendations for Food-Induced Skin and Mucosal Pruritus

ABSTRACT

Itch occurs in various dermatologic and systemic conditions. Many patients report that certain foods instigate itch, although there is limited published information in dermatology on food-induced pruritus. In addition, itch severity is rarely mentioned. Food can induce pruritus through either ingestion or direct contact with skin or mucosal membranes. The most common type of itch provoked by food is acute urticaria, often through the classical immunoglobulin E (IgE)-mediated pathway. Other mechanisms include non-IgE-mediated, mixed (IgE-mediated and non-IgE-mediated), T-cell-mediated, and nonimmune reactions. For patients presenting with urticaria, generalized pruritus, oral pruritus, or dermatitis, a thorough history is warranted, and possible food associations should be considered and assessed. Although any food seems to have the potential to elicit an immune response, certain foods are especially immunogenic. Treatment includes avoidance of the trigger and symptom management. Careful consideration should be used as to avoid unnecessarily restrictive elimination diets.

Atopic dermatitis

Atopic dermatitis (AD) is a very common skin disease associated with substantial burdens on patient health and quality of life. Knowledge regarding the pathogenesis of AD has expanded within recent years, leading to novel and efficacious therapeutic agents. Similarly, our knowledge of the impact of AD on patient's mental and physical health has also expanded. This review summarizes updates on the evolution, comorbidities, and therapeutic options of AD. AD is associated with increased cardiovascular risk, allergic diseases, and adverse mental health outcomes. Topical and systemic therapeutics have drastically altered the landscape of AD therapy in recent years.

Atopic Dermatitis and Food Allergy: Best Practices and Knowledge Gaps-A Work Group Report from the AAAAI Allergic Skin Diseases Committee and Leadership Institute Project

Allergists are often asked to evaluate children with atopic dermatitis (AD) for allergen triggers to disease. Testing, particularly for food triggers, often leads to elimination diets in an effort to improve AD control. However, the dual exposure hypothesis suggests that oral tolerance to food antigens is promoted through high-dose oral exposure, where sensitization occurs through lower dose cutaneous exposure. This suggests that strict elimination diets may pose some risks in children with AD. In addition, emerging evidence suggests an important role of skin inflammation in further allergic disease and the importance of dietary exposure to maintain oral tolerance. This work group report reviews current guidelines-based management for children with moderate-to-severe AD, the evidence for current recommendations for the evaluation and management of these children, provides a nuanced examination of these studies, and addresses current knowledge gaps in the care of these children.

Atopic Dermatitis: The Fate of the Fat

Atopic dermatitis (AD) is a chronic and relapsing inflammatory skin disease in which dry and itchy skin may develop into skin lesions. AD has a strong genetic component, as children from parents with AD have a two-fold increased chance of developing the disease. Genetic risk loci and epigenetic modifications reported in AD mainly locate to genes involved in the immune response and epidermal barrier function. However, AD pathogenesis cannot be fully explained by (epi)genetic factors since environmental triggers such as stress, pollution, microbiota, climate, and allergens also play a crucial role. Alterations of the epidermal barrier in AD, observed at all stages of the disease and which precede the development of overt skin inflammation, manifest as: dry skin; epidermal ultrastructural abnormalities, notably anomalies of the lamellar body cargo system; and abnormal epidermal lipid composition, including shorter fatty acid moieties in several lipid classes, such as ceramides and free fatty acids. Thus, a compelling question is whether AD is primarily a lipid disorder evolving into a chronic inflammatory disease due to genetic susceptibility loci in immunogenic genes. In this review, we focus on lipid abnormalities observed in the epidermis and blood of AD patients and evaluate their primary role in eliciting an inflammatory response.

Associations between sensitisation to allergens and allergic diseases: a hospital-based case-control study in China

OBJECTIVES

To assess the associations of sensitisation to common allergens with atopic dermatitis, allergic rhinitis and allergic asthma in adults.

DESIGN

Case-control study.

SETTING

Data were collected from the First Affiliated Hospital of Harbin Medical University in Harbin, China.

PARTICIPANTS

Cases were 5111 patients with physician-diagnosed atopic dermatitis (n=2631), allergic asthma (n=1320) and allergic rhinitis (n=1160) recruited from the department of allergy from March 2009 to December 2017. Controls were 2576 healthy adults who underwent physical examination at the same hospital during the same period.

MAIN OUTCOME MEASURES

Specific IgE levels to 16 common food, indoor and outdoor allergens were assessed in all participants. Adjusted ORs and 95% CIs for the association between allergen sensitisation and allergic diseases were estimated using multivariate logistic regression.

RESULTS

The prevalence of allergen sensitisation was higher in patients with atopic dermatitis (indoor=17.14%, outdoor=12.85%, food=21.44%), allergic rhinitis (indoor=23.18%, outdoor=26.81%, food=8.94%) and allergic asthma (indoor=24.65%, outdoor=16.46%, food=14.31%) compared with controls (indoor=11.03%, outdoor=6.84%, food=5.83%). After adjustment for potential confounding variables, there was a dose-response relevance between the levels of allergen-specific IgE and allergic diseases (p trend <0.0001). The number of allergens to which a patient was sensitised increased the risk of allergic diseases (atopic dermatitis: highest adjusted OR=4.28, 95% CI 2.57 to 7.11; allergic rhinitis: highest adjusted OR=13.00, 95% CI 3.76 to 45.00; allergic asthma: OR=2.37, 95% CI 1.67 to 3.37).

CONCLUSION

There was a dose-response relevance between levels of allergen-specific IgE and allergic diseases' prevalence, and multiple sensitisations increased the risk of allergic diseases. This study provides evidence for the prophylaxis of allergic diseases.

The Role of Diet Modification in Atopic Dermatitis: Navigating the Complexity

Diet has long been understood to have an intricate association with atopic dermatitis, although much remains unelucidated. Skin barrier dysfunction with dysbiosis and consequent impairment of immune tolerance likely underly the pathogenesis of coincident atopic dermatitis and food allergy. There is a wide range of possible skin reactions to food, complicating the diagnosis and understanding of food allergies. Many patients, parents, and providers incorrectly suspect diet as causative of atopic dermatitis symptoms and many have tried elimination diets. This frequently leads to inaccurate labeling of food allergies, contributing to a dangerous spiral of inappropriate testing, referrals, and dietary changes, while neglecting established atopic dermatitis treatment essentials. Alternatively, certain dietary supplements or the introduction of certain foods may be beneficial for atopic dermatitis management or prevention. Greater consensus on the role of diet among providers of patients with atopic dermatitis is strongly encouraged to improve the management of atopic dermatitis.

Different Approaches to Atopic Dermatitis by Allergists, Dermatologists, and Pediatricians

OBJECTIVES

Atopic dermatitis (AD) is the most prevalent chronic inflammatory skin disease, with a vast drug arsenal and guidelines available for its management and diagnosis and different medical specialties engaged in providing care. This study aimed to outline the therapeutic and diagnostic approaches to the AD of allergists, dermatologists, and pediatricians and verify whether they are compliant with the guidelines.

METHODS

A cross-sectional study using an electronic questionnaire administered through the SurveyMonkey® platform was disclosed by participating medical societies to their medical associates.

RESULTS

Of the 1,473 participating physicians, the use of moisturizers as part of AD treatment was observed among pediatricians (91.9%), dermatologists (97.5%), and allergists (100%; p=0.07). The preference for the use of new emollients was lower among pediatricians (57%) than dermatologists (75.9%) and allergists (71.4%; p < 0.001). The prevalence of wet-wrap therapy was lower among dermatologists (16.3%) than allergists (51%; p < 0.001). The recommendation of proactive treatment with topical corticosteroids was more frequently reported by allergists (65.3%) than pediatricians (43.3%) and dermatologists (40.8%; p < 0.001), and the same trend was observed in relation to proactive treatment using calcineurin inhibitors. The use of oral anti-histamines to control pruritus was mainly considered by pediatricians (69.2%) and dermatologists (59.2% p < 0.001). Clinical experience with systemic immunomodulating agents was greater among allergists (77.5%) and dermatologists (60.8%; p < 0.001), with cyclosporine being the most cited systemic immunomodulating agent. Environmental control of aeroallergens was recommended by pediatricians (89.8%), dermatologists (86.9%), and allergists (100%; p=0.01).

CONCLUSION

There were differences in the therapeutic and diagnostic approaches to AD used by allergists, dermatologists, and pediatricians and those recommended by the guidelines, especially regarding the use of wet-wrap therapy, proactive treatment with topical corticosteroids or calcineurin inhibitors, prescription of anti-histamines, recommendation of phototherapy, and control of aeroallergens.

Difficulties in interpretation of oral food challenge results

Oral food challenge is the gold standard in diagnosing food allergies; however, many testing protocols are available. The present article illustrates the difficulties associated with interpreting oral challenge tests with the example of a six-year-old boy with allergy to hen’s eggs. The symptoms observed on the first day of challenge indicated a negative result; however, the consumption of the cumulative dose resulted in anaphylaxis. The interpretation of the oral food challenge can be complicated. The criteria used to determine a positive or negative result are sometimes ambiguous. An accurate interpretation of the results is key to determining correct management in children with food allergy.

The Challenges of Managing Multiple Food Allergies and Consequent Food Aversions

The allergic march can often result in children with one food allergy phenotype developing other allergic manifestations as they grow older. In this grand round, we describe the case of a child with a diagnosis of eosinophilic esophagitis at an early age, who subsequently developed IgE-mediated allergy to milk and egg. Because of the onset of allergic rhinitis, an additional complication of the teenage years was the development of pollen food syndrome, which further affected the already complex dietary management. These multiple allergies had a consequent effect on nutritional status and provoked considerable psychosocial issues, which greatly affected the patient's relationship with food. This case illustrates that for complex patients, a cohesive approach and shared decision-making are essential for diagnosis and management. Working with the patient and also the whole family, and considering how best to support them, necessitates a flexible approach. Regular follow-up is important to address changing psychosocial and dietary needs and monitor the resolution of allergies and response to pharmacotherapy. Complex patients need the input of a comprehensive multidisciplinary team, with good access to dietetic and psychological support, to optimize quality of life for these individuals and their families.

Food Allergy Evaluation for Dermatologic Disorders

Food allergy evaluation for dermatologic disorders is warranted when Type 1 allergy is suspected, and includes skin prick testing (SPT) or measurement of specific immunoglobulin E (IgE) levels. The utility of these tests for identifying triggers is improved with clinical correlation, especially for contact urticaria, and protein contact dermatitis, which are mixed mechanism diseases. In atopic dermatitis (AD), patients are at risk for development of food allergy, and screening with SPT or IgE may be considered in severe AD, especially to guide early food introduction. Management of food-related AD exacerbations should focus on modifications in skincare before evaluating for allergy.

Update of the S2k guideline on the management of IgE-mediated food allergies

Not available.

Challenge of food allergy testing and avoidance in children with atopic dermatitis

Atopic dermatitis (AD) is a common presenting complaint by children and their caretakers to their primary care providers. On testing, children with AD frequently exhibit positive food-specific IgE levels in the absence of immediate allergic reactions. Misinterpretation of these false positive tests can lead to unnecessary food avoidance, which can have tremendous psychosocial, economic and nutritional consequences and, in some cases, facilitate the development of an immediate hypersensitivity to the food. We present a child with persistent AD who underwent broad testing that led to unnecessary food avoidance resulting in Vitamin D deficiency, growth failure and the development of an IgE-mediated food allergy. This case underscores the need for caution by primary care clinicians in using food avoidance diets as a treatment for AD and the importance of limiting allergy testing to foods only when the clinical history indicates an immediate hypersensitivity reaction.

Food Allergy from Infancy Through Adulthood

Food allergies are the result of immune responses that cause adverse reactions to foods. Immune responses to foods may produce a spectrum of symptoms and disorders, including acute allergic reactions and anaphylaxis, food protein-induced allergic proctocolitis, food protein-induced enterocolitis syndrome, food-dependent, exercise-induced anaphylaxis, and oral allergy syndrome (pollen-food allergy syndrome). Food-allergic responses also contribute to chronic inflammatory disorders such as eosinophilic esophagitis and atopic dermatitis. Although food allergy affects people from infancy through adulthood, there are allergic features that differ according to age (ie, presentation, triggers, and natural course) and have important implications for diagnosis, prognosis, and management. New food allergies can develop at any age, and we propose similarities in the etiology of de novo food allergy whether in infancy or adulthood. The approach to managing food allergy changes dramatically over the life course, and physicians and patients must respond accordingly to optimize care. Food allergy therapies are emerging, and the efficacy and safety of these interventions could differ by age group of those treated. In this review, we highlight interesting observations on the etiology and characteristics of food allergy presenting at different ages and discuss clinical management as it relates to life stage.

Conducting an Oral Food Challenge: An Update to the 2009 Adverse Reactions to Foods Committee Work Group Report

Oral food challenges are an integral part of an allergist's practice and are used to evaluate the presence or absence of allergic reactivity to foods. A work group within the Adverse Reactions to Foods Committee of the American Academy of Allergy, Asthma & Immunology was formed to update a previously published oral food challenge report. The intention of this document was to supplement the previous publication with additional focus on safety, treatment of IgE-mediated allergic reactions, guidance for challenges in infants and adults, psychosocial considerations for children and families participating in an oral food challenge, specific guidance for baked milk or baked egg challenges, masking agents and validated blinding recipes for common food allergens, and recommendations for conducting and interpreting challenges in patients with suspected food protein-induced enterocolitis syndrome. Tables and figures within the report and an extensive online appendix detail age-specific portion sizes, appropriate timing for antihistamine discontinuation, serum and skin test result interpretation, written consents, and instructional handouts that may be used in clinical practice.

Dietary Management of Eosinophilic Esophagitis: Tailoring the Approach

Eosinophilic esophagitis (EoE) is a unique form of non-immunoglobulin E-mediated food allergy, restricted to the esophagus, characterized by esophageal eosinophil-predominant inflammation and dysfunction. The diagnosis requires an esophago-gastroduodenoscopy with esophageal biopsies demonstrating active eosinophilic inflammation with 15 or more eosinophils/high-power field, following the exclusion of alternative causes of eosinophilia. Food allergens trigger the disease, withdairy/milk, wheat/gluten, egg, soy/legumes, and seafood the most common. Therapeutic strategies comprise dietary restrictions, proton pump inhibitors, topical corticosteroids, biologic agents, and esophageal dilation when strictures are present. However, avoidance of trigger foods remains the only option targeting the cause, and not the effect, of the disease. Because EoE relapses when treatment is withdrawn, dietary therapy offers a long-term, drug-free alternative to patients who wish to remain off drugs and still be in remission. There are currently multiple dietary management strategies to choose from, each having its specific efficacy, advantages, and disadvantages that both clinicians and patients should acknowledge. In addition, dietary regimens should be tailored around each individual patient to increase the chance of tolerability and long-term adherence. In general, liquid elemental diets devoid of antigens and elimination diets restricting causative foods are valuable options. Designing diets on the basis of food allergy skin tests results is not reliable and should be avoided. This review summarizes the most recent knowledge regarding the clinical use of dietary measures in EoE. We discussed endpoints, rationale, advantages and disadvantages, and tailoring of diets, as well as currently available dietary regimens for EoE.

Tackling Food Allergy in Infancy

Atopic dermatitis and food allergy are the most common allergic conditions affecting the infant population. Both immunoglobulin E (IgE)-mediated and non-IgE-mediated food allergy are seen in infancy. Early life feeding guidelines have changed dramatically over the past 30 years, more recently because of an improved understanding of IgE-mediated food allergy. This article focuses on identification, diagnosis, management, and prevention of food allergy in the infant population.

A basophil-neuronal axis promotes itch

Itch is an evolutionarily conserved sensation that facilitates expulsion of pathogens and noxious stimuli from the skin. However, in organ failure, cancer, and chronic inflammatory disorders such as atopic dermatitis (AD), itch becomes chronic, intractable, and debilitating. In addition to chronic itch, patients often experience intense acute itch exacerbations. Recent discoveries have unearthed the neuroimmune circuitry of itch, leading to the development of anti-itch treatments. However, mechanisms underlying acute itch exacerbations remain overlooked. Herein, we identify that a large proportion of patients with AD harbor allergen-specific immunoglobulin E (IgE) and exhibit a propensity for acute itch flares. In mice, while allergen-provoked acute itch is mediated by the mast cell-histamine axis in steady state, AD-associated inflammation renders this pathway dispensable. Instead, a previously unrecognized basophil-leukotriene (LT) axis emerges as critical for acute itch flares. By probing fundamental itch mechanisms, our study highlights a basophil-neuronal circuit that may underlie a variety of neuroimmune processes.

Diet Therapy in Eosinophilic Esophagitis. Focus on a Personalized Approach

Eosinophilic esophagitis (EoE) is a chronic allergic disease defined by a marked eosinophilic inflammation and symptoms of esophageal dysfunction. EoE is a heterogeneous disease and severely impacts the quality of life of affected patients. The current therapeutic management of EoE is based on two cornerstones: medication and diet therapy, both effective but limited by several critical issues. The choice of one or the other therapy might depend on the different disease phenotypes (allergic vs. non-allergic, inflammatory vs. fibro-stenotic), patient's age (adult vs. childhood-onset), food habits, patient/family preference, and familiar financial resource. Diet therapy is a successful treatment but limited by low patient adherence, the need for several endoscopies, food restrictions, psychosocial impact, and potential nutritional deficiencies. All these limitations could be effectively overcome with multidisciplinary and personalized management. This review summarizes the most recent evidence on the dietary elimination approaches and will provide a practical guide to clinicians in managing and implementing dietary therapy for patients with EoE.

Diagnosis of Peanut Allergy in Preschool Children: The Impact of Skin Testing With a Novel Composition of Peanuts

Peanut allergy is an increasing concern in younger children. Available bedside diagnostic tools, i.e., prick tests with commercial extracts or peanut-containing foods have only limited predictive values. In a cohort of preschoolers with both a history of allergic reactions and sensitization to peanut proteins, we aimed to characterize the impact of skin tests with a novel composition of peanuts LPP-MH. Almost one quarter (27/110) of preschool children, with a history of allergic reactions to peanuts and positive standard IgE-mediated tests for peanut allergy, can tolerate the reintroduction of peanut proteins into their diet after resolving their allergy and, thus, can avoid adverse health outcomes associated with the false diagnosis. In the younger age group, a quarter of peanut allergic children, display a relatively high threshold, potentially enabling an easier and safer oral immunotherapy protocol in this window of opportunity in childhood. The use of the novel diagnostic skin test, LPP-MH, significantly improves the predictive value of outpatient evaluation for the outcomes of peanut challenge as well as the expected threshold at which the PA child will react, thus, making for a better informed decision of how, when, and where to challenge.

Nutritional management of food allergies

Food allergy is a significant public health concern, with a rising prevalence. Elimination diets remain the cornerstone of food allergy management, and they are not without nutritional risk. Children who avoid nutritionally important foods, such as milk or multiple foods allergens, may be at greater risk. Even adults with food allergies may encounter challenges to meet current recommended dietary guidelines for health and reduced risk of chronic disease. The type of food allergy disorder will also impact nutritional risk. A food allergy affects food choices, nutritional intake, and health; therefore, guidance to provide nutritionally appropriate substitutes within the context of the elimination diet is invaluable.

Histoire naturelle de la dermatite atopique

Atopic dermatitis (AD) is a common frequent chronic inflammatory skin disease which begins frequently in infancy. The clinical expression of AD is a recurrent eczema on a dry skin. AD is a multifactorial disease characterized by two linked abnormalities: a skin barrier defect and a cellular inflammation, with type-2 main components. However, the pathophysiology of AD is not as simple as this description looks like. In this review, we will present a synthesis of current knowledge on natural history of AD and the involved factors, in order to clarify AD care. The evolution of AD is associated with many atopic comorbidities, following the "atopic march" scheme: IgE-mediated food allergy, allergic asthma and rhinitis occurring classically after AD. In fact, this is rarely the case, but the atopic march seems to be associated with AD severity. AD has also many neuropsychological complications which are essential to be detected. Other factors could influence the natural history of AD: genetic mutations on different genes (proteins of skin barrier, innate and adaptive immunity pathways), skin dysbiosis with colonization by Staphylococcus aureus, sensitization against environmental proteins. AD treatment is based on the restauration of the skin barrier using emollients and on anti-inflammatory drugs (notably topical corticosteroids) during the inflammatory flares. It is not recommended to treat the skin colonization by S. aureus, excepted in case of skin infection. The probiotics have no efficiency as curative treatment of AD, but could have an interest for the primary prevention, especially in at-risk populations. © 2019 Elsevier Masson SAS. All rights reserved.

Technical review on the management of eosinophilic esophagitis: a report from the AGA institute and the joint task force on allergy-immunology practice parameters

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus. Many new studies have been reported recently that describe EoE management. An expert panel was convened by the American Gastroenterological Association Institute and the Joint Task Force on Allergy-Immunology Practice Parameters to provide a technical review to be used as the basis for an updated clinical guideline. This technical review was developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Eighteen focused EoE management questions were considered, with 15 answered using the GRADE framework and 3 with a narrative summary. There is moderate certainty in the evidence that topical glucocorticosteroids effectively reduce esophageal eosinophil counts to <15 per high-power field over a short-term treatment period of 4-12 weeks, but very low certainty about the effects of using topical glucocorticosteroids as maintenance therapy. Multiple dietary strategies may be effective in reducing esophageal eosinophil counts to <15 per high-power field over a short-term treatment period, with moderate certainty for elemental diets, low certainty for empiric 2-, 4-, and 6-food elimination diets, and very low certainty that allergy-based testing dietary eliminations have a higher failure rate compared to empiric diet elimination. There is very low certainty for the effect of proton pump inhibitors in patients with esophageal eosinophilia. Although esophageal dilation appears to be relatively safe, there is no evidence that it reduces esophageal eosinophil counts. There is very low certainty in the effects of multiple other medical treatments for EoE: anti-interleukin-5 therapy, anti-interleukin-13 therapy, anti-IgE therapy, montelukast, cromolyn, and anti-TNF therapy.

Technical Review on the Management of Eosinophilic Esophagitis: A Report From the AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus. Many new studies have been reported recently that describe EoE management. An expert panel was convened by the American Gastroenterological Association Institute and the Joint Task Force on Allergy-Immunology Practice Parameters to provide a technical review to be used as the basis for an updated clinical guideline. This technical review was developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Eighteen focused EoE management questions were considered, with 15 answered using the GRADE framework and 3 with a narrative summary. There is moderate certainty in the evidence that topical glucocorticosteroids effectively reduce esophageal eosinophil counts to <15 per high-power field over a short-term treatment period of 4-12 weeks, but very low certainty about the effects of using topical glucocorticosteroids as maintenance therapy. Multiple dietary strategies may be effective in reducing esophageal eosinophil counts to <15 per high-power field over a short-term treatment period, with moderate certainty for elemental diets, low certainty for empiric 2-, 4-, and 6-food elimination diets, and very low certainty that allergy-based testing dietary eliminations have a higher failure rate compared to empiric diet elimination. There is very low certainty for the effect of proton pump inhibitors in patients with esophageal eosinophilia. Although esophageal dilation appears to be relatively safe, there is no evidence that it reduces esophageal eosinophil counts. There is very low certainty in the effects of multiple other medical treatments for EoE: anti-interleukin-5 therapy, anti-interleukin-13 therapy, anti-IgE therapy, montelukast, cromolyn, and anti-TNF therapy.

Are avoidance diets still warranted in children with atopic dermatitis?

Nearly 40% of children with moderate-to-severe atopic dermatitis (AD) have IgE-mediated food allergy (FA). This clinical observation has been extensively documented by experimental data linking skin inflammation in AD to FA, as well as by food challenges reproducing symptoms and avoidance diets improving AD. Although food avoidance may improve AD, avoidance diets do not cure AD, may even have detrimental effects such as progression to immediate-type allergy including anaphylactic reactions, and may significantly reduce the quality of life of the patient and the family. AD care should focus upon optimal medical management, rather than dietary elimination. Food allergy testing is primarily indicated when immediate-type allergic reactions are a concern. In recalcitrant AD, if food is being considered a possible chronic trigger, a limited panel of foods may be tested. An avoidance diet is only indicated in patients clearly identified as food allergic by an appropriate diagnostic food challenge, and after adequately informing the family of the limited benefits, and possible harms of an elimination diet.

Association of frequent intake of fast foods, energy drinks, or convenience food with atopic dermatitis in adolescents

PURPOSE

Specific food consumption, besides food allergy, may aggravate atopic dermatitis (AD). However, previous reports on the association between AD and food intake in adolescents are scarce. The aim of this study was to determine the relationship between AD and specific food consumption frequency in adolescents.

METHODS

A cross-sectional analysis using data from the Korea Youth Risk Behavior Web-based Survey 2017 was performed. The frequency of food consumption in the recent-diagnosed AD group (AD diagnosed within 12 months) compared to those in the previous-diagnosed AD (AD diagnosed more than 12 months ago) or control group were investigated.

RESULTS

A total of 53,373 participants were eligible for this study. The weighted prevalence of the recent-diagnosed AD and the previous-diagnosed AD was 7.39% and 18.00%, respectively. When compared with subjects with the previous-diagnosed AD, those with the recent-diagnosed AD were significantly more likely to frequently consume fast foods (odds ratio OR 1.405; 95% CI 1.150-1.717), energy drinks (OR 1.457; 95% CI 1.175-1.807), or convenience food (OR 1.304; 95% CI 1.138-1.495). Patients of the recent-diagnosed AD were significantly more likely to frequently consume fast foods (OR 1.374; 95% CI 1.155-1.634) than the control group. The differences in the frequency of specific food consumption among groups were more pronounced in high school students than in middle school students.

CONCLUSIONS

Frequent intake of fast foods, energy drinks, and convenience food was related to the recent-diagnosed AD in adolescents. Prospective cohort and interventional studies are needed to identify causal relationships.

The Role of Food Challenges in Clinical Practice

Food challenges are the criterion standard for establishing the presence or absence of food allergy. However, they remain underused because of their resource-intensive nature, inadequate reimbursement, and concern for the risk of anaphylaxis. Here, we review indications for performing food challenges, including scenarios of uncertain diagnosis, quality-of-life effects following food challenges, and the impact on office practice including coding and reimbursement issues. Demand for food challenges is likely to increase and allergists should be capable of providing this service to their patients when indicated.

Timing of Introduction, Sensitization, and Allergy to Highly Allergenic Foods at Age 3 Years in a General-Population Canadian Cohort

BACKGROUND

Early dietary introduction of highly allergenic foods has been associated with decreased risk of food allergy in high-risk infants.

OBJECTIVE

Early introduction of highly allergenic foods for lower risk infants was examined using Canadian Healthy Infant Longitudinal Development (CHILD) Study data.

METHODS

CHILD participants were recruited from the general population before birth. Every 6 months, caregivers reported food introduction and allergic reactions. At ages 1 and 3 years, sensitization to peanut, egg, and cow's milk was measured by skin prick testing (SPT) and atopic dermatitis diagnosed at clinical visits. Multivariable logistic regression was used to examine associations between timing of introduction to peanut, egg, and cow's milk and the presence at 3 years of sensitization (positive SPT) and probable clinical IgE-mediated allergy (sensitization with no current consumption and convincing history of allergic reaction to the specific food).

RESULTS

Among 2669 CHILD participants at age 3 years, 101 (3.80%) showed sensitization to peanut, 59 (2.21%) to egg, and 30 (1.12%) to cow's milk; 46 (1.78%) showed probable clinical IgE-mediated allergy to peanut, 4 (0.16%) to egg, and 2 (0.08%) to cow's milk. Infants introduced to peanut after 12 months had increased odds of sensitization (odds ratio [OR]: 2.38, 95% confidence interval [CI]: 1.39-4.07) and probable clinical allergy (OR: 4.04, 95% CI: 1.66-9.85) to peanut at 3 years. Associations persisted after exclusion of high-risk infants with moderate-to-severe atopic dermatitis in the first year/egg sensitization at 1 year.

CONCLUSIONS

General-population infants introduced to peanut after age 12 months were more likely to have sensitization and probable clinical allergy to peanut at 3 years.

Two cases of anaphylaxis due to contrast media during administration of nivolumab and ipilimumab in metastatic renal cell carcinoma

A combination therapy of nivolumab and ipilimumab is effective for advanced renal cell carcinoma, but there are concerns about immune-related adverse events. A 46-year-old man was hospitalized for metastatic renal cell carcinoma. On day 9, he received nivolumab and ipilimumab. On days 16 and 49, he presented with fever, skin rash, and hypotension after contrast-enhanced computed tomography. A 70-year-old man was hospitalized for metastatic renal cell carcinoma. On day 9, he received nivolumab and ipilimumab. On day 44, he presented with fever, skin rash, and hypotension after contrast-enhanced computed tomography. Both patients were diagnosed with anaphylaxis due to the contrast agent.

Tips and Tricks for Controlling Eczema

Eczema is a chronic, relapsing, and remitting disease that can affect patients from infancy through adulthood. Severity of eczema ranges from mild to severe and can be plagued with recurrent flares. These flares can be difficult to treat and may require use of different strategies to address the issue. In this article, the author addresses different therapeutic options that can be used in those patients with difficult-to-treat eczema.

Atopic Dermatitis Is a Barrier Issue, Not an Allergy Issue

Atopic dermatitis (AD) is a chronic, relapsing disease that typically manifests in childhood and improves with age. Studies have demonstrated that the presence of AD increases the risk of developing food allergy, allergic rhinitis, and asthma later in life. Although children with AD are more likely to produce allergen-specific immunoglobulin E, there is conflicting evidence that allergen avoidance improves disease severity. Furthermore, food-elimination diets in patients with AD may increase the risk of developing immediate, life-threatening reactions to the removed food. The most effective treatments of AD aim to repair and protect the skin barrier and decrease inflammation.

Anaphylaxis after wheat ingestion in a patient with coeliac disease: two kinds of reactions and the same culprit food

In recent years, the role of atopic dermatitis epidermal skin barrier defects in inducing a transcutaneous allergic sensitization is highly debated, possibly explaining why some children with eczema are sensitized to foods they have never eaten. In our specific situation, the association between coeliac disease and wheat allergy might be particularly harmful owing to unavoidable strict food avoidance. We describe the case of a young boy affected by coeliac disease who, after an occasional unexpected ingestion of gluten, experienced a complete anaphylactic reaction characterized by urticarial, labial angioedema, wheezing, and hypotension. To better investigate the state of allergic sensitization to wheat in our patient, we then performed the component resolved diagnosis, which showed Tri a19 2 kU/l and Tri a14 0.3 kU/l. These results demonstrated the association of IgE-mediated allergy to wheat and coeliac disease. The natural course of specific IgE in allergic patients who are on a food-free diet needs further investigation, such as the possible influence that the increasing popularity of gluten-free diets may have on the epidemiology of wheat allergy in westernized societies. National and International registers of cases of anaphylaxis may improve the still limited knowledge in this field. The final message of our contribution is that the decision to eliminate a food should to take into account a patient's awareness of possible consequences.