Nanette B. Silverberg, MD; Mary Lee-Wong, MD; Gil Yosipovitch, MD, PhD
Drs. Silverberg and Lee-Wong are from Mount Sinai St. Luke’s-Roosevelt Hospital and Beth Israel Medical Centers of the Icahn School of Medicine at Mount Sinai, New York, New York. Dr. Silverberg is from the Department of Dermatology and Dr. Lee-Wong is from the Division of Allergy and Immunology, Department of Medicine. Dr. Yosipovitch is from the Department of Dermatology and Itch Center, Lewis Katz Medical School,Temple University, Philadelphia.
The authors report no conflict of interest.
Correspondence: Nanette B. Silverberg, MD, Department of Dermatology, 1090 Amsterdam Ave, Ste 11D, New York, NY 10025 (nsilverb@chpnet.org).
Dietary restrictions in treating AD can have negative consequences, including reduced birth weight when initiated in pregnancy,19 osteomalacia from vitamin D deficiency,44 and nutritional deficiencies (eg, calcium, phosphorus, iron, vitamin K, vitamin D, zinc, vitamin A, B1, B2, B6, niacin, cholesterol, and/or vitamin C deficiencies).45 Excess dietary intake of vegetables in individuals with extensive food allergies can result in carotenemia.46 Protein-restricted diets from use of rice milk or dietary protein restriction can result in kwashiorkorlike protein malnutrition and marasmus.47-49 Nutritional counseling and/or supplementation is recommended for patients with food-restricted diets.
Avoiding Fragrance in Food
Food intolerance often is reported by AD patients. In allergies, food intolerance refers to side effects such as gastrointestinal symptoms; in dermatology, food intolerance can include itching, systemic flares of allergic contact dermatitis (eg, fragrance allergy), or true IgE-mediated allergies such as oral allergy syndrome. Oral allergy syndrome (pollen-food allergy syndrome) is an epitope-spread phenomenon related to an allergy to tree pollen, causing broad allergy to specific groups of fruits and nuts.50 Food triggers in AD include kiwi, milk, apple, tomato, citrus fruits, tree nuts, and peanuts. Oral allergy syndrome is common in food-sensitive AD patients (51.2%) followed by gastrointestinal symptoms (23.5%) and worsening AD (11.4%).51 Sensitization to fragrance can cross-react with foods (eg, balsam of Peru and tomatoes).52 A tomato allergy can be detected either by a skin-prick test or a food patch test in this setting.53 An allergist should be consulted if oral allergy syndrome is suspected.
Conclusion
Food allergies are more common in AD patients and patients should be referred to an allergist for evaluation and management. Strict dietary practice is not recommended, while avoiding proven food allergens in AD could be beneficial. Dermatologists should be aware that patients with dietary restrictions may lack key nutrients, manifesting with nutritional deficiencies in the skin; therefore, nutrition counseling may be needed in the most severe AD/allergy patients. This field is evolving; therefore, ongoing study and evaluation of interventions as they relate to AD will be needed to assess best practices for diet in AD over time.
