From Dave Stukus, Nationwide Children’s: Eczema: Separating Fact from Fiction
Many parents are told that if they can find the ‘cause’ of their child’s eczema and eliminate exposure, then their skin will improve. Unfortunately, this is not the case because the cause of eczema is a disrupted skin barrier, which leads to excessive water loss, dryness and itching.
Parents with a history of allergies or eczema often have babies with eczema. About 40% of children with eczema have a mutation in a protein called filaggrin, which is important in reducing the gap between skin cells. If the skin barrier is disrupted, as in eczema, then irritants and allergens are more likely to pass through and cause irritation, itching, and rash, but this is not the ‘cause’.
Children with eczema, especially those with persistent, severe cases affecting most of their body, are at higher risk to develop allergies and asthma as they get older….
In rare instances, specific foods may be a major contributor to a child’s eczema, but this is the exception and typically affects infants less than one year of age with truly unmanageable, severe eczema, despite good daily skin care.
Breastfeeding mothers everywhere are incorrectly told to stop eating dairy or other foods to ‘treat’ their baby’s eczema. Not only is this unnecessary for most mothers but can lead to significant problems associated with a restricted diet…and not actually treat the eczema.
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Dr. Dave Stutkus shared some slides (on twitter) recently based on a lecture at Nationwide Children’s. Since I see children everyday who are undergoing poorly-conceived allergy testing, I wanted to share some of them.
- Excluding foods from diet based on allergy testing without concurrent symptoms can lead to allergies rather than tolerance:
- Newer antihistamines are safer
- Most individuals with penicillin allergy are not truly penicillin allergic. Also, there is a low rate of cross-reactivity with most cephalosporins.
- Proper allergy testing relies on the basic understanding that sensitization is not equivalent to being allergic. In addition, allergy testing has a high rate of false positives; therefore, testing needs to be limited (avoid broad panels).
Also, link to AAP guidelines on breastfeeding & eczema and introduction of foods to minimize development of allergies: The Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary
Restriction, Breastfeeding, Hydrolyzed Formulas, and Timing of Introduction of Allergenic Complementary Foods
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A recent retrospective cross-sectional cohort study (N Marcus et al. J Pediatr 2018; 196: 154-60, editorial page 10) identified 273 transplant recipients with a median followup of 3.6 years. This cohort included 111 liver transplant recipients, 103 heart transplant recipients, 52 kidney transplant recipients, and 7 multivisceral transplant recipients.
- 92 (34%) developed allergy or autoimmunity after transplantation.
- Allergic problems included eczema (n=44), food allergy (n=22), eosinophilic gastrointestinal disease (n=11), and asthma (n=28)
- Autoimmunity problems developed in 6.6% (18) including autoimmune cytopenias (n=10). Two patients died due to autoimmune hemolytic anemia and hemophagocytic lymphohistiocytosis.
- Allergic problems typically developed during the first year after transplantation and rarely after 5 years following transplantation.
- ~20% required a change in immunosuppression
- ~50% improved with time
In the editorial, the Dr. Helen Evans notes that the increasing reporting of atopic/allergic disorders could be due to recognition but could also be due, in part, to the widespread adoption of tacrolimus instead of cyclosporine for immunosuppression.
My take: Many have said that organ transplantation, which is life-saving, substitutes one problem for another. This is an example of an additional burden, often related to immunosuppression, that patients and families have to manage afterwards.
Chattahoochee River, Island Ford
An image report (YM Dawkins et al. Clin Gastroenterol Hepatolo 2016; 14: xxxv-xxxvi) describes a 30-year-old with ulcerative colitis who developed nummular eczema two years after the start of infliximab. He was treated with topical agents and a course of systemic corticosteroids. The authors note that in a few patients, withdrawal of anti-TNF therapy is needed, but this was not needed in their patient.
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