Atopic dermatitis treatment reduces food allergy among infants, but inhibits growth
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Key takeaways:
- 31.4% of infants on enhanced treatment and 41.9% of patients on conventional treatment developed hen’s egg allergy.
- The enhanced treatment group had mean differences of –0.8 cm in height and –422 g in weight.
The use of topical corticosteroids to treat atopic dermatitis in infants also may help prevent hen’s egg allergy, but it may inhibit the baby’s growth as well, according to a study published in The Journal of Allergy & Clinical Immunology.
Before it can be considered for preventing hen’s egg allergy, the treatment described in this study will need to be modified, Kiwako Yamamoto-Hanada, MD, PhD, chief of the allergy center at the National Center for Child Health and Development in Tokyo, and colleagues wrote in the study.
The study enrolled 640 infants aged 7 to 13 weeks who had experienced AD for at least 28 days, with 318 randomly assigned to receive enhanced early skin treatment and 322 randomly assigned to receive conventional, reactive therapy at 16 hospitals in Japan between July 18, 2017, and Feb. 18, 2021.
During the intervention, both groups of infants were treated with heparinoid (Hirudoid, Medinova AG) twice a day.
Enhanced treatment also included alclometasone dipropionate 0.1% for the whole face and betamethasone valerate 0.12% for the whole body except the scalp and face twice a day from day 0 to day 14. Maintenance treatment then continued these medications twice a week from day 15 through age 28 weeks.
The conventional group only used alclometasone dipropionate and betamethasone valerate reactively on affected skin depending on the severity of the rash.
Median daily doses included 0.3 g (range, 0.04-1.24) of alclometasone dipropionate in the enhanced group and 0.22 g (range, 0-2.01) in the conventional group, as well as 1.57 g (range, 0.19-3.6) in the enhanced group and 0.01 g (range = 0-2.69) in the conventional group.
Also, caregivers were instructed to introduce solid foods to their infants at age 5 or 6 months and to continue breastfeeding through age 6 months. After an oral food challenge at 28 weeks, infants started consuming hen’s egg as well.
Based on the OFC, 31.4% of the enhanced group and 41.9% of the conventional group had hen’s egg allergy (P = .0028). Results among the 591 infants who were in the per-protocol set (PPS) were similar, the researchers said.
Also, 44.9% of the enhanced group were positive for hen’s egg white IgE, defined as IgE sensitization, compared with 52.5% of the conventional group (risk difference [RD], –7.6%; 95% CI, –15.4% to 0.2%).
However, 2.2% of the patients in the enhanced group required rescue medication, whereas none of the patients in the conventional group required it (RD, 2.2%; 95% CI, 0.6%-3.8%). The enhanced group also had more AD-free days (RD, 1.69%; 95% CI, 1.66%-1.73%).
Both groups had similar histories of immediate reaction to any food before OFC and wheezing episodes as well as similar Infants’ Dermatitis Quality of Life Questionnaire and Family Impact of Childhood Eczema Questionnaire scores.
Further, the enhanced group had lower Eczema Area and Severity Index (EASI) scores, with all its patients clear or almost clear of AD or reporting mild AD at age 28 weeks. No moderate or severe cases of AD were reported.
Also, 78.3% of the enhanced group and 64.3% of the conventional group reported 75% improvements in their EASI scores, with the enhanced group experiencing lower Patient Oriented Eczema Measure scores during the study period as well.
Although none of the events were fatal, life-threatening or permanent, 5.3% of the enhanced group and 1.9% of the conventional group experienced serious adverse events (RD, 3.5%; 95% CI, 0.6%-6.4%).
Six of the infants in the enhanced group experienced temporary growth reduction, and five of these cases were considered serious adverse events. Diagnosed with failure to thrive, these infants were admitted to the hospital due to lack of parental feeding volume.
Medical staff provided appropriate feeding, and all these infants improved without the need for venous volume resuscitation. Proportions of adverse drug reactions were similar between the groups as well.
The enhanced group had lower body weight (mean difference, –422 g; 95% CI, –553 g to –292 g) and body height (mean difference, –0.8 cm; 95% CI, –1.22 cm to –0.33 cm) at age 28 weeks.
The researchers attributed the difference in height to the increased doses of topical corticosteroids among the enhanced group. But they noted that systemic absorption of these drugs typically induces weight gain, making it difficult to attribute the difference in weight to the treatment.
Based on these findings, the researchers concluded that early enhanced treatment led to a 10% absolute reduction in hen’s egg allergy onset among infants diagnosed with AD.
However, the possible causal relationship between the enhanced treatment and the differences in growth prompted the researchers to recommend against using the enhanced course of AD treatment to prevent food allergy in real-world settings. Modifications should be in place, the researchers continued, before it is reconsidered.
Perspective
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This study, which is consistent with my clinical experience, is important because it demonstrates that controlling AD early in life can reduce food allergy. But due to the adverse effects of potent topical steroids on growth, routine use of this course of treatment is not recommended. I agree with this, as the Hippocratic oath instructs us to first do no harm. This treatment could be modified to be safe and effective, but it likely would require the use of a nonsteroidal anti-inflammatory therapy. Next, researchers should identify topical anti-inflammatory therapies that safely control AD.
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