Diet represents ‘one piece of the puzzle’ in managing atopic dermatitis

Key takeaways:

• Clinicians should discuss the role of diet with patients looking for nutritional solutions for atopic dermatitis.
• While certain diets can be harmful, evidence suggests anti-inflammatory diets are beneficial.

ORLANDO — Nutrition plays a role in the management of atopic dermatitis, according to research presented at the American Academy of Dermatology Annual Meeting.

“Conventional medicine, including dermatology, has historically underemphasized nutrition, where discussions often focus on topical and systemic treatments,” Peter A. Lio, MD, clinical assistant professor of dermatology and pediatrics at Northwestern University Feinberg School of Medicine, told Healio. “However, there has been a resurgence of interest in the role of diet, particularly as we gain a better understanding of the gut-skin connection and the impact of inflammation on chronic conditions like atopic dermatitis.”

Social media, the rise of alternative medicine and patient-driven interest have primarily fueled this shift, Lio explained, but clinicians must occupy a role in this movement.

Peter A. Lio

“We must ensure that discussions are based on solid evidence rather than trends or misinformation,” he said.

Food is not the ‘root cause’ of AD

Many families believe that diet is the “root cause” of AD, according to Lio. And while diet is involved in the development of AD, this does not mean that it results from a food allergy.

Lio showed that a study of 1,186 double-blind, placebo-controlled food challenges found sensitization to occur more significantly in children who already had previously existing AD. Children with AD and worsening AD as the only symptom had similar reactions as those in the placebo group, leading researchers to believe that AD flares without other allergic symptoms are unlikely to be caused by a food allergy.

Another study demonstrated that approximately 80% of foods believed to worsen AD do not. This was corroborated by another study which found that although AD severity is correlated with food allergy, 80% of patients do not experience worsening of AD because of a food allergy.

In fact, patients perceive adverse reactions to food at a rate that is 10 times their true prevalence, according to Lio, and this can lead patients to try elimination diets, which can cause more harm than good.

Elimination diets hold risks

“Over-restriction due to misguided elimination diets can lead to nutritional deficiencies, worsening skin barrier function and immune health,” Lio told Healio. “Importantly, avoiding foods may even result in our worst fears becoming a reality as true food allergies seem more likely when foods are avoided.”

In a retrospective study, 298 patients attempted to treat their eczema by avoiding previously tolerated foods. This resulted in 19% developing symptoms of acute IgE reactions after the foods were reintroduced, of which 30% were considered to be anaphylaxis.

In another study, 530 infants that previously had a negative skin prick test for peanuts were split into two groups: the avoidance group and the consumption group. By the end of the study, 1.9% of subjects who consumed peanuts and 13.7% who did not later developed a peanut allergy (P < .001).

According to Lio, studies like these serve as cautionary tales of the risks of elimination diets; however, other dietary choices can help AD.

“Over-restrictive diets can be harmful, especially in children, leading to nutritional deficiencies and an increased risk of developing new food allergies,” Lio told Healio. “At the same time, emerging research suggests that dietary choices can play a supportive role in AD management, making it crucial for dermatologists to provide informed, balanced guidance.”

Supportive foods for AD management

According to Lio, there is no single “best” diet for AD, but a “well-rounded, anti-inflammatory diet rich in whole foods is generally beneficial,” he said. “Mediterranean-style eating patterns, which emphasize fruits, vegetables, healthy fats and lean proteins may help modulate inflammation.”

For example, oolong tea, known for its anti-inflammatory properties, has been found to alleviate recalcitrant AD, according to Lio’s presentation. In a study, 118 patients with recalcitrant AD drank oolong tea three times daily after meals. After 1 month, 63% of patients showed marked to moderate improvement in their AD. After 6 months, 54% still observed a “good” response.

Similarly, researchers believe oral hempseed oil may improve AD after a study of 20 adults with AD found that the daily consumption of 2 tbsp of hempseed oil lessened skin dryness, itchiness and topical medication use vs. controls.

“While true food allergies are uncommon direct triggers,” Lio told Healio, “the overall inflammatory state of the body, gut microbiome health and dietary factors such as antioxidants, omega-3 fatty acids and vitamin D can influence AD severity.”

Applications

A recent study of 211 patients found that 57% of patients reported discussing diet with a health care provider, Lio explained, but 38% felt the discussion was unhelpful. Almost 70% of the children reported attempting to exclude foods from their diet to treat their AD.

“My No. 1 advice is to engage in the nutrition conversation with patients rather than dismissing it,” Lio told Healio. “Patients are already exploring dietary chances, and if we don’t guide them with evidence-based recommendations, they may turn to unreliable sources.”

Lio stressed it is important to correct misconceptions, such as the overdiagnosis of food allergies, and help patients create dietary patterns that support skin health rather than engage in extreme restrictions.

“I also think involving colleagues with more knowledge is a good thing,” he said. “I frequently advise involving a registered dietitian or certified nutrition specialist to help navigate these turbulent waters.”

While the role of diet is helpful, Lio emphasized a continued focus on moisturization, targeted medications and lifestyle modifications for the management of AD.

“Diet is just one piece of the puzzle in managing AD,” he said. “Patients should feel empowered to make dietary choices that support overall health while ensuring they receive proper dermatologic care.”

References:

• Callaway J, et al. J Dermatolog Treat. 2005;doi:10.1080/09546630510035832.
• Chan J, et al. Clin Exp Dermatol. 2019;doi:10.1111/ced.13955.
• Chang A, et al. J Allergy Clin Immunol Pract. 2015;doi:10.1016/j.jaip.2015.08.006.
• Du Toit G, et al. N Engl J Med. 2015;doi:10.1056/NEJMoa1414850.
• Ehlers I, et al. Acta Derm Venereol. 2001;doi:10.1080/00015550152572930.
• Hanifin JM. West J Med. 1989;PMCID:151:649-650.
• Hill DJ, et al. Pediatr Allergy Immunol. 2004;doi:10.1111/j.1399-3038.2004.00178.x.
• Roerdink EM, et al. Ann Allergy Asthma Immunol. 2016;doi:10.1016/j.anai.2016.01.022.
• Thompson MM, et al. J Am Acad Dermatol. 2005;doi:10.1016/j.jaad.2005.04.065.
• Uehara M, et al. Arch Dermatol. 2001;doi:10.1001/archderm.137.1.42.