-IBIS-1.7.6-
tx
cutaneous system
eczema
Nutrition
dietary guidelines
eating principles:
Treat food sensitivities: Identify and eliminate food sensitivities. Begin with a four-day rotation diet and the elimination of all major allergens. Milk, eggs and peanuts represent the aggravating food in approximately 81% of cases. With improvement likely allergens can be reintroduced, one at a time, and the diet can gradually become more inclusive. Animal products should be kept to a minimum. The addition of more oil-rich fish to the diet, such as salmon, herring, mackerel and halibut, can be beneficial.
(Burks AW, et al. Allergy Proc 1989 Jul-Aug;10(4):265-269; Matthew D, et al. Lancet 1:321, 1977; Sampson H, Jolie P. NEJM 311:371-376, 1984; Niggemann B, et al. Clin Exp Allergy 1999 Jan;29(1):91-96; Lever R, et al. Pediatr Allergy Immunol 1998 Feb;9(1):13-19; Eigenmann PA, et al. Pediatrics 1998 Mar;101(3):E8; Burks AW, Jet al. J Pediatr 1998 Jan;132(1):132-136; Soyland E, et al. Br J Dermatol 1994 Jun;130(6):757-764.)
High fiber diet
Vegan diet
Elimination/rotation diet, rotation diet, rotation diet expanded
Correct low stomach acid, if appropriate
therapeutic foods:
Foods rich in Vitamins A and B-complex
Foods rich in Silicon (Jensen)
Increase omega-3 and omega-6 fatty acids: vegetable, nut, seed oils, salmon, herring, mackerel, sardines, walnuts, flaxseed oil, evening primrose oil, black currant oil, Black bass, rye, avocados, sea vegetables, whey, apple, cucumbers, millet, rice polishings, rice bran, sprouts
(Bjorneboe A, et al. Br J Dermatol 1987 Oct;117(4):463-469; Jensen, 63.)
Cabbage or huckleberry (externally as a pack)
Potato, broccoli, dandelion, mung bean, seaweed, pearl barley, adzuki beans, cornsilk, water chestnuts, winter melon, watermelon (Ni, 126.)
Burdock (Marz)
fresh juices:
Carrot, celery, spinach, and parsley (Walker, 135.)
Carrot
Carrot, beet, and cucumber (Walker, p. 135.)
Spinach (Walker, 135.)
Carrot, celery, lemon (Jensen, 63.)
Cucumber, endive, pineapple (Jensen, 63.)
specific remedies:
Dandelion and cornsilk tea (Ni, 126.)
Mung beans and pearl barley tea (Ni, 126.)
Seaweed and winter melon soup (Ni, 126.)
Adzuki beans, pearl barley, and cornsilk tea, and eat solids, three times daily (Ni, 126.)
Take 60-150 g of pomegranate skin add water and simmer until it thickens; wash the affected area several times a day (Yin-fang and Cheng-jun, 26.)
Take 150 g of mango skin and simmer in water; wash the affected area several times a day (Yin-fang and Cheng-jun, 26.)
Take 250-500 g of pickled plums (plums soaked in vinegar), crush, add water and simmer. Use the liquid to wash the affected area several times a day (Yin-fang and Cheng-jun, 36.)
Take 250 g fresh raspberries, or 75 g dried fruit, add water and simmer until reduced to a thick liquid. use this to wash affected area three times daily
Simmer the crushed shell of a fresh coconut in water. Wash the affected areas with this liquid three times daily (Yin-fang and Cheng-jun, 87.)
Peel, seed, and crush unripe papaya and add 30 g each salt and vinegar. Mix well, then strain and rub liquid on affected parts (Yin-fang and Cheng-jun, 91.)
treatment principle:
treat increased intestinal permeability, intestinal dysbiosis, and systemic candidiasis, if indicated. (Savolainen J. Clin Exp Allergy 1993 Apr;23(4):332-339; Jackson PG, et al. Lancet 1981 Jun 13;1(8233):1285-1286.)
avoid:
Avoid arachidonic acid: Found in animal foods, this substance gives rise to inflammatory leukotrienes of the four series.
Beef: (Fiocchi A, et al. J Am Coll Nutr 1995 Jun;14(3):239-244.)
Food intolerances: Milk, eggs and peanuts represent the aggravating food in approximately 81% of cases. (Burks AW, et al. Allergy Proc 1989 Jul-Aug;10(4):265-269; Matthew D, et al. Lancet 1:321, 1977; Sampson H, Jolie P. NEJM 311:371-376, 1984; Iacono G, et al. Clin Exp Allergy 1998 Jul;28(7):817-823; Lever R, et al. Pediatr Allergy Immunol 1998 Feb;9(1):13-19; Fourrier E. Allerg Immunol (Paris) 1997 Jul;29 Spec No:25-27; Burks AW, Jet al. J Pediatr 1998 Jan;132(1):132-136.)
Dairy, meat, alcohol, hot sauces, spicy foods, fried foods, fatty foods, rich foods, salty foods, stimulating foods, coffee, caffeine.
supplements
Borage oil: 2-3 g per day, has higher concentration of GLA (Gamma-linolenic acid).
(Wright S, Burton J. Lancet Nov. 20, 1982, 1120-1122.)
EPA (Eicosapentaenoic acid) and DHA (docosahexanoic acid): 540 mg EPA and 360 mg DHA daily, or flaxseed oil 10g daily. Patients with atopic dermatitis appear to demonstrate altered essential fatty acid (EFA) and prostaglandin metabolism, particularly low levels of longer-chain polyunsaturated fatty acids such as gamma-linolenic acid, arachidonic acid, and the long-chain omega-3 oils, eicosapentaenoic acid (EPA) and docosahexanoic acid.
(Bjorneboe A, et al. Br J Dermatol 1987 Oct;117(4):463-469; Lindskov R, et al. Allergy 1992 Oct;47(5):517-521; Manku MS, et al. Br J Dermatol 1984 Jun;110(6):643-648.)
Evening primrose oil (EPO): 2-3 g per day, usually 45 mg/cap of gamma-linolenic acid (GLA). Use topically, especially in infants. Research on the effects of evening primrose oil upon atopic dermatitis has arrived at inconsistent outcomes, with the largest largest and best structured study finding no demonstrable benefits. (Hederos CA, et al. Arch Dis Child 1996 Dec;75(6):494-497; Biagi PL, et al. Drugs Exp Clin Res 1988;14(4):285-290; Wright, S., Burton, J. Lancet Nov. 20, 1982, 1120-1122; Manku MS, et al. Br J Dermatol 1984 Jun;110(6):643-648; Morse PF, et al. Br J Dermatol 1989 Jul;121(1):75-90; Stewart JCM, et al. J Nutr Med 2:9-15, 1991; Berth-Jones J, Graham-Brown RA. Lancet 1993 Jun 19;341(8860):1557-1560.)
Gamma-linolenic acid (GLA): 250-500 mg per day
Vitamin A: 50,000 IU per day (Strosser, 1952)
Beta carotene
Vitamin E (mixed tocopherols): 400-800 IU per day
Vitamin B-complex
Quercetin: 500-800 mg three times daily, 5-15 minutes prior to meals
Selenium (Juhlin, 1982.)
Zinc picolinate: 30 mg three times daily
HCl: 5-90 grains with meals, if low stomach acid
Zinc: 45-60 mg per day, decrease as conditions clears; zinc is necessary to the activity of delta-6-desaturase, the enzyme responsible for converting linoleic acid to gamma-linolenic acid.
Zinc oxide topically with Vitamin E
Silica (Jensen)
» drug interaction:
Prednisone/prednisolone:
- causes Sodium retention
- causes reduced activation of Vitamin D (Travato, 1991; 44:1651-1658; Tuttle, 1982; 126: 1161-1162); 1,25(OH)2D3 can be measured to determine if supplementation necessary, with low levels can use calcitriol
- causes increased urinary excretion of Zinc, Vitamin K and Vitamin C (Buist, 1984; 4 (3):114)
footnotes
Anderson JA. Milk, eggs and peanuts: food allergies in children. Am Fam Physician 1997 Oct 1;56(5):1365-1374. (Review)
Abstract: True food allergies are much less prevalent than is generally believed. They are more common in infants and children under age three than in older children and adults. Infant colic generally is not caused by a food allergy. In infants, urticaria, eczema or gastrointestinal bleeding may be due to foods such as milk and eggs, but clinical tolerance usually develops within a few years. Peanuts, tree nuts, seafood and seeds, as well as milk and eggs, can cause anaphylaxis in highly allergic children, and reexposure to such foods presents the risk of life-threatening reactions. Immediate-reacting allergy skin tests and in vitro IgE antibody tests can be used to screen for food allergy. Only food challenge, however, can confirm a reaction to a particular food. Management of food allergy, once the initial symptoms are confirmed, consists of avoidance of specific foods, sometimes for a lifetime. All children at risk for food anaphylaxis should be identified, and their parents or caretakers should be prepared to administer epinephrine before taking the child to the emergency rooom.
Arshad SH, Matthews S, Gant C, Hide DW. Effect of allergen avoidance on development of allergic disorders in infancy. Lancet 1992 Jun 20;339(8808):1493-1497.
Abstract: There is much evidence that the development of allergic disorders may be related to early exposure of allergens, including those in breastmilk. We have tried to find out whether avoidance of food and inhaled allergens in infancy protects against the development of allergic disorders in high-risk infants. In a prenatally randomised, controlled study 120 infants with family history of atopy and high (greater than 0.5 kU/l) cord-blood concentrations of total IgE were allocated randomly to prophylactic and control groups. In the prophylactic group (n = 58), lactating mothers avoided allergenic foods (milk, egg, fish, and nuts) and avoided feeding their infants these foods and soya, wheat, and orange up to the age of 12 months; the infants' bedrooms and living rooms were treated with an acaricidal powder and foam every 3 months, and concentrations of Dermatophagoides pteronyssinus antigen(Der p l) in dust samples were measured by enzyme-linked immunosorbent assay. In the control group (n = 62), the diet of mothers and infants was unrestricted; no acaricidal treatment was done and Der p l concentrations were measured at birth and at 9 months. A paediatric allergy specialist unaware of group assignment examined the infants for allergic disorders at 10-12 months. Odds ratios were calculated by logistic regression analysis for various factors with control for other confounding variables. At 12 months, allergic disorders had developed in 25 (40%) control infants and in 8 (13%) of the prophylactic group (odds ratio 6.34, 95% confidence intervals 2.0-20.1). The prevalences at 12 months of asthma (4.13, 1.1-15.5) and eczema (3.6, 1.0-12.5) were also significantly greater in the control group. Parental smoking was a significant risk factor for total allergy at 12 months whether only one parent smoked (3.97, 1.2-13.6) or both parents smoked (4.72, 1.2-18.2).
Berth-Jones J, Graham-Brown RA. Placebo-controlled trial of essential fatty acid supplementation in atopic dermatitis. Lancet 1993 Jun 19;341(8860):1557-1560.
Abstract: Treatment of atopic dermatitis with essential fatty acids remains controversial. A double-blind, placebo-controlled, parallel-group study was done to investigate the response of patients with atopic dermatitis to essential fatty acid supplements. Patients with atopic dermatitis were randomised to receive evening primrose oil, evening primrose oil and fish oil, or placebo for 16 weeks. Disease activity was monitored by clinical severity scores recorded by the investigator, topical steroid requirement, and symptom scores recorded by subjects. Of 123 subjects recruited, 102 completed the treatment period. No improvement with active treatment was demonstrated. Our study, which avoided the methodological and analytical problems of previous studies, found no effect of essential fatty acid supplementation in atopic dermatitis.
Biagi PL, Bordoni A, Masi M, Ricci G, Fanelli C, Patrizi A, Ceccolini E. A long-term study on the use of evening primrose oil (Efamol) in atopic children. Drugs Exp Clin Res 1988;14(4):285-290.
Abstract: The effect of essential fatty acids on atopic eczema is controversial. Some workers have reported that patients with atopic eczema improved following oral treatment with evening primrose oil (an oil with a high concentration of gamma-linolenic acid), but others have disputed this. This study was designed to look at the effect of evening primrose oil as a long-term oral supplementation for children with atopic eczema. Treated children dramatically improved their clinical condition after 4 weeks of therapy, and this improvement was maintained during the whole period of treatment (20 weeks). At the same time, modifications in plasma, neutrophil and lymphocyte fatty acid composition were detected.
Bjorneboe A, Soyland E, Bjorneboe GE, Rajka G, Drevon CA. Effect of dietary supplementation with eicosapentaenoic acid in the treatment of atopic dermatitis. Br J Dermatol 1987 Oct;117(4):463-469.
Abstract: The effects of a dietary supplement of n-3 fatty acids in patients with atopic dermatitis were investigated in a 12-week, double-blind study. The experimental group received 10 g of fish oil daily, of which about 1.8 g was eicosapentaenoic acid. This amount of eicosapentaenoic acid can be obtained from a daily intake of fat fish. The controls received an iso-energetic placebo supplement containing olive oil. Compliance was monitored by gas-chromatographic analysis of the fatty acid pattern in serum phospholipids. Results favoured the experimental group with regard to scale (P less than 0.05), itch (P less than 0.05) and overall subjective severity (P less than 0.02) as compared to the controls.
Burks AW, James JM, Hiegel A, Wilson G, Wheeler JG, Jones SM, Zuerlein N. Atopic dermatitis and food hypersensitivity reactions. J Pediatr 1998 Jan;132(1):132-136.
Abstract: OBJECTIVE: To determine the role of food hypersensitivity in atopic dermatitis and to determine whether patients with atopic dermatitis who had food hypersensitivity could be identified by screening prick skin tests using a limited number of food allergens. STUDY DESIGN: Patients with atopic dermatitis attending the Arkansas Children's Hospital Pediatric Allergy Clinic underwent allergy prick skin testing to a battery of food antigens. Patients with positive prick skin tests underwent double-blind, placebo-controlled food challenges. RESULTS: One-hundred sixty-five patients were enrolled and completed the study. Patients ranged in age from 4 months to 21.9 years (mean 48.9 months). Ninety-eight (60%) patients had at least one positive prick skin test. A total of 266 double-blind, placebo-controlled food challenges were performed. Sixty-four patients (38.7% of total) were interpreted as having a positive challenge. Seven foods (milk, egg, peanut, soy, wheat, cod/catfish, cashew) accounted for 89% of the positive challenges. By use of screening prick skin tests for these seven foods we could identify 99% of the food allergic patients correctly. CONCLUSIONS: This study confirms that most children with atopic dermatitis have food allergy that can be diagnosed by a prick skin test for the seven foods.
Burks AW, Williams LW, Mallory SB, Shirrell MA, Williams C. Peanut protein as a major cause of adverse food reactions in patients with atopic dermatitis. Allergy Proc 1989 Jul-Aug;10(4):265-269.
Abstract: Peanuts, along with milk and eggs, have been documented to account for approximately 80% of adverse reactions to foods in patients with atopic dermatitis. Over the past 3 years, we have evaluated 71 patients with atopic dermatitis, ranging from mild to severe in nature. These patients were initially evaluated by allergy prick skin testing and when appropriate had double-blind placebo-controlled food challenges done. Thirty-nine (55%) patients had a positive prick skin test to one of the foods tested. There were 80 food challenges performed with peanut, accounting for 12 (32%) of the 38 positive challenges in 23 (31%) patients. As in earlier studies, patients developed skin (97%), respiratory (55%), and gastrointestinal (32%) symptoms during the challenge. Of the five patients with histories of prior anaphylactic reactions four (80%) were to peanut. These studies indicate that children with all degrees of atopic dermatitis may benefit from evaluation for food hypersensitivity. They also show that peanut is a major food protein responsible for these reactions.
Caffarelli C, Cavagni G, Deriu FM, Zanotti P, Atherton DJ. Gastrointestinal symptoms in atopic eczema. Arch Dis Child 1998 Mar;78(3):230-234.
Abstract: AIMS: To determine the prevalence of gastrointestinal symptoms in children with eczema and the association of such symptoms with the extent of eczema or skin prick test results. METHODS: Sixty five children with atopic eczema and a control group matched for age and sex were recruited. Their parents completed a questionnaire about the children's gastrointestinal symptoms. The children's skin was examined; their weight, height, and abdominal circumference were measured; and skin prick tests were carried out. RESULTS: Gastrointestinal symptoms, especially diarrhea, vomiting, and regurgitation, were more common in the children with eczema. Diarrhea appeared to be associated with the ingestion of specific foods. Gastrointestinal symptoms were related to diffuse eczema and positive skin prick tests to foods. There was no anthropometric differences between the patient and control groups. CONCLUSIONS: A gastrointestinal disorder is common in children with eczema, especially with diffuse distribution. This may be responsible for substantial symptoms and may play a part in the pathogenesis of the disease and in the failure to thrive with which it is sometimes associated.
Eigenmann PA, Sicherer SH, Borkowski TA, Cohen BA, Sampson HA. Prevalence of IgE-mediated food allergy among children with atopic dermatitis. Pediatrics 1998 Mar;101(3):E8.
Abstract: OBJECTIVE: There is a growing body of clinical and laboratory evidence to support the notion that food allergy plays a role in the pathogenesis of atopic dermatitis (AD). However, the incidence of IgE-mediated food allergy in children with AD is not well established. DESIGN: A prospective study to determine the prevalence of IgE-mediated food hypersensitivity among patients referred to a university-based dermatologist for evaluation of AD. SETTING: University hospital pediatric dermatology clinic. PATIENTS: A total of 63 patients with AD were recruited (35 male; 32 white, 24 African-American, 7 Asian). METHODS: Patients were assigned an AD symptom score (SCORAD) and were screened for food-specific serum IgE antibodies to six foods (milk, egg, wheat, soy, peanut, fish) known to be the most allergenic in children. The levels of food-specific serum IgE were determined by the CAP System fluoroscein-enzyme immunoassay (CAP); patients with a value >/=0.7 kIUa/L were invited for an additional allergy evaluation. Those with CAP values below the cutoff were considered not food allergic. Patients were considered to be allergic if they met one of the following criteria for at least one food: 1) reaction on food challenge; 2) CAP value more than the 95% confidence interval predictive for a reaction; 3) convincing history of an acute significant (hives, respiratory symptoms) reaction after the isolated ingestion of a food to which there was a positive CAP or prick skin test. RESULTS: A total of 63 patients (median age, 2.8 years; median SCORAD, 41.1) were recruited; 22 had negative CAP values (without a significant difference in age or SCORAD score, compared with the 41 with positive specific IgE values). Further allergy evaluation was offered to the 41 remaining patients; 10 were lost to follow-up and 31 were evaluated further. Of these, 19 underwent a total of 50 food challenges (36 double-blind, placebo-controlled, and 14 open), with 11 patients experiencing 18 positive challenges (94% with skin reactions). Additionally, 6 patients had a convincing history with a predictive level of IgE; 5 had a convincing history with positive, indeterminate levels of IgE; and 1 had predictive levels of IgE (to egg and peanut) without a history of an acute reaction. Overall, 23/63 (37%; 95% confidence interval, 25% to 50%) had clinically significant IgE-mediated food hypersensitivity without a significant difference in age or symptom score between those with or without food allergy. CONCLUSIONS: Approximately one third of children with refractory, moderate-severe AD have IgE-mediated clinical reactivity to food proteins. The prevalence of food allergy in this population is significantly higher than that in the general population, and an evaluation for food allergy should be considered in these patients.
Fiocchi A, Restani P, Riva E, Qualizza R, Bruni P, Restelli AR, Galli CL. Meat allergy: I--Specific IgE to BSA and OSA in atopic, beef sensitive children. J Am Coll Nutr 1995 Jun;14(3):239-244.
Abstract: OBJECTIVE: The use of lamb meat products has been suggested as an alternative diet for polyallergic children, although until now this clinical practice has not been supported by in-depth biochemical/immunological studies. The aims of this research were: to evaluate cross-reactivity between lamb and beef; to evaluate the role of BSA and OSA as allergens in beef allergic children; and to evaluate cross-reactivity between BSA and OSA. METHODS: 16 children suffering from atopic dermatitis (AD), aged 12 months-8 8 years (mean age 2.61 +/- 1.93 years) were found skin prick test (SPT)--positive to bovine meat; all of them were also SPT-positive to ovine meat and to milk. After a period of restricted diet, the selected 16 children were recalled; 12 AD-free children (8 males and 14 females, aged 12 months-4.33 years (mean age 2.21 +/- 1.05 years) were evaluated by SPT and radioallergosorbent test (RAST) for the following allergens: bovine meat, ovine meat, BSA 1 mg/ml, OSA 1 mg/ml. Double-blind, placebo-controlled food challenge (DBPCFC) with bovine serum albumin (BSA) and ovine serum albumin (OSA) were performed. For SPT, the results were expressed in mm of wheal, and 3 mm was considered as the end point; correlation between wheal diameters was calculated by Spearman rank test. For DBPCFC, according to the Sampson's experimental procedure, BSA and OSA were given in pear juice (the dermal negative response to the pear juice was verified by fresh food SPT before starting the oral challenge test). The total dose administered to the children corresponded to the amount of albumin present in 180 g of calf or lamb meat (90 and 63 mg respectively, as calculated by Sodium dodecyl sulfate polyacrylamide gel electrophoresis (SPS-PAGE). The administration of pear juice (containing placebo or albumin) and symptom evaluation were entrusted to medical people who did not know what the child received. RESULTS: All children tested SPT positive to bovine and ovine meat, and to BSA and OSA. Significant correlations were observed between the following diameters of wheal: BSA vs OSA (R = 0.846, p < 0.0001); ovine meat vs OSA (R = 0.769, p < 0.005); b.meat vs o.meat (R = 0.771, p < 0.005); and ovine meat vs BSA (R = 0.594, p < 0.043). In RAST, 6 of 12 children were positive to bovine meat, 3 to lamb meat, 4 to BSA and 3 to OSA. DBPCFC showed an immediate reaction to BSA or OSA in 2 and 3 children, respectively. One other child developed severe dyspnea, cough and asthma 3 hours after OSA challenge. CONCLUSIONS: BSA and OSA are important beef and lamb allergens; they share not only proteic sequences, but also allergenic properties. Clinical tolerance to BSA and OSA can be present in beef and lamb SPT-positive children.
Fourrier E. [Allergy to cow's milk]. Allerg Immunol (Paris) 1997 Jul;29 Spec No:25-27. [Article in French] (Review)
Abstract: After recalling the medical reluctance as well as the risks that there are in complete elimination of milk in infants, the author presents several clinical pictures and then a classification of the immunological types. Allergic shock of neonates, digestive and extra-digestive (skin
and respiratory airways) symptoms finally the rare chronic gastro-enteritis to cow milk. Non-reaginic food allergies: Acute gastro-enteropathy to cow milk, with villous atrophy and Heiner's syndrome, delayed hypersensitivities are studied, of difficult diagnosis that may cover almost all pathologies. They may be found in the digestive system, respiratory, the kidneys and even in the organs of behaviour. Migrane of food origin must be remembered. Development in regressive rules is a function of the type of allergy and the suddenness of the symptoms. Diagnosis is above all by questioning and confirmation or not by skin and in vitro tests. Certainty can only be shown by tests of elimination and re-introduction. The diet, at the same time of both diagnostic and therapeutic value, is based on the replacement of cow milk by foods that contain the same amount of proteins. It is essential, especially in the very small, to have perfect match of food so as to avoid any risk of a dramatic hypoprotinemia, which may happen if the child does not like the suggested diet, or if the parents cannot buy the substitution products. In such conditions great care must be taken to avoid provoking a crisis. Care must be taken to decide: If the elimination of cow milk is always justified each time. If it is, always check that the substituted protein is properly made, the family may change the diet mistakenly. It is better, finally, to keep the eczema, rather than die with it healed.
Gimenez-Arnau A, Barranco C, Alberola M, Wale C, Serrano S, Buchanan MR, Camarasa JG. Effects of linoleic acid supplements on atopic dermatitis. Adv Exp Med Biol 1997;433:285-289.
Hederos CA, Berg A. Epogam evening primrose oil treatment in atopic dermatitis and asthma. Arch Dis Child 1996 Dec;75(6):494-497.
Abstract: Essential fatty acids are claimed to have positive effects in atopic diseases. In a double blind, placebo controlled, parallel group study 58 out of 60 children, with atopic dermatitis and the need for regular treatment with topical skin steroids, completed a 16 weeks' treatment period with either Epogam evening primrose oil or placebo capsules. Twenty two of these subjects also had asthma. The parents used diaries to record symptom scores and concomitant medication. Peak expiratory flow was measured and disease activity was monitored by the clinician every four weeks. The plasma concentrations of essential fatty acids increased significantly in the group treated with Epogam capsules. The study demonstrated significant improvements of the eczema symptoms but no significant difference was found between the placebo and the Epogam groups. No therapeutic effect was shown on asthma symptoms or fidget.
Horrobin DF, Stewart C. Evening primrose oil and atopic eczema. Lancet 1990 Jul 7;336(8706):50. (Letter)
Horrobin DF, Stewart C. Evening primrose oil in atopic eczema. Lancet 1990 Apr 7;335(8693):864-865.
Iacono G, Cavataio F, Montalto G, Soresi M, Notarbartolo A, Carroccio A. Persistent cow's milk protein intolerance in infants: the changing faces of the same disease. Clin Exp Allergy 1998 Jul;28(7):817-823.
Abstract: BACKGROUND: Recent research has shown that cow's milk protein intolerance (CMPI) often persists beyond 4 years of age. AIMS: To evaluate the clinical and immunological characteristics of a group of infants with persistent CMPI. PATIENTS AND METHODS: Twelve infants (6 m, 6f) with persistent CMPI were followed up from birth until a median age of 5 years. The patients underwent CMP challenge each year to evaluate CMP-tolerance. As controls we followed 26 infants (12 m, 14 f) with CMPI that resolved within 1-2 years. RESULTS: A family history of atopic disease was found in 10/12 patients with persistent CMPI and in 10/26 controls (P<0.01). Clinical presentation changed over time: at onset symptoms were prevalently gastrointestinal, while at the end of the study there was an increased frequency of wheezing and constipation and a higher frequency of delayed reactions to CMP-challenge than at study commencement (9/12 vs 2/12; P<0.007). 11/12 infants with persistent CMPI and 3/26 controls (P<0.0001) presented multiple food intolerance. During the observation period 9/12 infants with persistent CMPI and 2/26 controls showed atopic disease: asthma, rhinitis, eczema (P < 0.0001). CONCLUSIONS: Persistent CMPI forms are characterized by: (a) considerable importance of familial atopic disease; (b) change in CMPI manifestations over time and more prolonged delay between CMP consumption and manifestation of symptoms; (c) very high frequency of multiple food intolerance and allergic diseases.
Jackson PG, Lessof MH, Baker RW, Ferrett J, MacDonald DM. Intestinal permeability in patients with eczema and food allergy. Lancet 1981 Jun 13;1(8233):1285-1286.
Abstract: Polyethylene glycol (PEG) was used as a probe molecule to investigate intestinal absorption in eight patients with eczema and evidence of food allergy and ten with eczema alone. In both groups absorption of molecules of larger molecular weight was greater than in normal
subjects but absorption of molecules of low molecular weight was normal. There was no difference in absorption between eczema patients with or without food allergy. These results suggest that there is an intestinal mucosal defect in eczema which exists whether or not there is coexistent food allergy. Half the patients with eczema alone and two of the eight with food allergy had more of the large molecular weight PEG recovered in their urine in the second 12 h after ingestion than in the first 12 h. This could be the result of abnormal permeability in the more distal small bowel or even in the colon.
Jensen, B. Foods That Heal. New York: Avery Publishing Group, Inc., 1988.
Lever R, MacDonald C, Waugh P, Aitchison T. Randomised controlled trial of advice on an egg exclusion diet in young children with atopic eczema and sensitivity to eggs. Pediatr Allergy Immunol 1998 Feb;9(1):13-19.
BACKGROUND: The role of exclusion diets in the management of atopic eczema in young children is uncertain. This randomised controlled trial evaluates the effect of excluding egg from the diet in young children with atopic eczema and sensitivity to eggs. Fifty-five such children were randomised either to a 4-week regimen, in which mothers were given general advice on care of eczema and additional specific advice from a dietician about an egg exclusion diet (diet group), or to a control group in which general advice only was given. Both groups continued conventional topical treatment. Disease activity was assessed by estimates of the surface area affected by eczema and by an arbitrary severity score. Possible egg sensitivity was identified by RAST before randomisation and after the trial by double-blind placebo-controlled egg challenge. RESULTS: The mean reduction in surface area affected by eczema was significantly greater (p = 0.02) in the group receiving dietary advice (from 19.6% to 10.9% area affected) than in the control group (from 21.9% to 18.9%). A significant improvement also occurred in severity score (p = 0.04): from 33.9 to 24.0 units for the diet group compared with a decrease from 36.7 to 33.5 in the control group. The study suggests that advice on the dietary exclusion of eggs is useful as part of the overall management of young children with atopic eczema and sensitivity to eggs.
Lindskov R, Holmer G. Polyunsaturated fatty acids in plasma, red blood cells and mononuclear cell phospholipids of patients with atopic dermatitis. Allergy 1992 Oct;47(5):517-521.
Abstract: Recent studies of polyunsaturated fatty acids (PUFA) in plasma and blood cell components of patients with atopic diseases have indicated disordered fat metabolism as linoleic acid (18:2n-6) tends to be increased while the more unsaturated fatty acids, such as gamma-linolenic acid (18:3n-6) and arachidonic acid (20:4n-6) are present in decreased amounts. To further clarify these abnormalities, we examined the PUFA content in phospholipids derived from plasma, red blood cells and mononuclear cells (MNC) in patients with atopic dermatitis. In plasma no significant differences were found between patients and controls. In red blood cells dihomo-gamma-linolenic acid (20:3n-6) was reduced in eczema patients, as compared with controls. The most significant findings in eczema patient MNC were reduced ratios of 20:4n-6/20:3n-6 in total lipids and in phosphatidyl ethanolamine (PE) and of 20:4n-6/18:2n-6 in both total lipids, phosphatidyl choline (PC) and PE. These findings indicate a disordered fatty acid metabolism in MNC of patients with atopic dermatitis. It is possible that these changes in the fatty acid profile of MNC may account for some of the immunological abnormalities seen in these patients.
Manku MS, Horrobin DF, Morse NL, Wright S, Burton JL. Essential fatty acids in the plasma phospholipids of patients with atopic eczema. Br J Dermatol 1984 Jun;110(6):643-648.
Abstract: We have measured all the essential fatty acids (EFA) in plasma phospholipids in forty-one adults with atopic eczema and fifty normal controls. The major dietary n-6 EFA, linoleic acid, was significantly elevated, but all its metabolites, 18:3n-6, 20:3n-6, 20:4n-6, 22:4n-6, and 22:5n-6 were significantly reduced. The major dietary n-3 EFA, alpha-linolenic acid, was also elevated, though not significantly, while all its metabolites were also significantly reduced. These observations suggest that atopic eczema is associated not with any defect of EFA intake, but with abnormal metabolism, possibly involving the enzyme delta-6-desaturase. Treatment with oral evening primrose oil produced partial correction of the n-6 EFA abnormality, but had no effect on the n-3 EFAs.
Matthew DJ, Taylor B, Norman AP, Turner MW. Prevention of eczema. Lancet 1977 Feb 12;1(8007):321-324.
Abstract: Infants of allergic parents were divided into 2 groups. The allergen-avoidance group was breast fed for 6 months. Supplementation, when necessary, was with soy rather than cows milk formula. All dairy products, fish, and eggs were avoided during the first 6 months. Avoidance of pets, horsehair mattresses, feather pillows and quilts was advised. Measures were taken to minimize house dust. All of these measures were discontinued at 6 months of age. Infants in the control group did not avoid the above antigens. The allergen avoidance group had significantly less eczema at 6 months AND AT ONE YEAR than the control group. Mean serum IgE levels were lower in the allergen-avoidance group at 6 weeks of age.
Morse PF, Horrobin DF, Manku MS, Stewart JC, Allen R, Littlewood S, Wright S, Burton J, Gould DJ, Holt PJ, et al. Meta-analysis of placebo-controlled studies of the efficacy of Epogam in the treatment of atopic eczema. Relationship between plasma essential fatty acid changes and clinical response. Br J Dermatol 1989 Jul;121(1):75-90.
Abstract: Gamma-linolenic acid in the form of a particular variety of evening primrose oil (Epogam) has been reported of value in the treatment of atopic eczema. Nine controlled trials of evening primrose oil were performed in eight centres. Four of the trials were parallel and five cross-over. Doctors and patients assessed the severity of eczema by scoring measures of inflammation, dryness, scaliness, pruritus and overall skin involvement. Individual symptom scores were combined to give a single global score at each assessment point. In the analysis of the parallel studies, both patient and doctor scores showed a highly significant improvement over baseline (P less than 0.0001) due to Epogam: for both scores the effect of Epogam was significantly better than placebo. Similar results were obtained on analysis of the cross-over trials, but in this case the difference between Epogam and placebo in the doctors' global score, although in favour of Epogam, failed to reach significance. The effects on itch were particularly striking. There was no placebo response to this symptom, whereas there was a substantial and highly significant response to Epogam (P less than 0.0001). When the improvements, or otherwise, in clinical condition were related to changes in plasma levels of dihomogammalinolenic and arachidoni acids, it was found that there was a positive correlation between an improvement in clinical score and a rise in the fatty acid levels.
Sampson H, Jolie P. Increased plasma histamine concentration after food challenges in children with atopic dermatitis. N Engl J Med 1984 Aug 9;311(6):372-376.
Abstract: 33 afflicted children underwent a 10 day elimination of allergic foods followed by food challenges. 35 challenges elicited symptoms, 31 of which involved the skin, 17 the gastrointestinal tract, 8 the nasal passages, and 6 the respiratory tract within 10-90 minutes. All 60 placebo challenges were negative.
Niggemann B, Sielaff B, Beyer K, Binder C, Wahn U. Outcome of double-blind, placebo-controlled food challenge tests in 107 children with atopic dermatitis. Clin Exp Allergy 1999 Jan;29(1):91-96.
Abstracts: BACKGROUND AND OBJECTIVE: Little is known about late phase clinical reactions during oral food challenges and the value of specific IgE in terms of sensitivity and specificity. METHODS: We therefore analysed retrospectively the clinical outcome of 387 oral provocations during double-blind, placebo-controlled food challenge tests in 107 children with atopic dermatitis. RESULTS: Eighty-seven (81%) children showed a positive clinical reaction to at least one challenge. The vast majority of children (94%) showed clinical symptoms to one or two allergens. One hundred and thirty-one of 259 (51%) of verum challenges and 1/128 (0.8%) placebo challenge were assessed as positive. Oral provocations with hen's egg showed the highest percentage of positive reactions (70%). Sensitivity of specific IgE to the four allergens tested was 90%, specificity 30%. Sensitivity of the parental history as a predictive factor was 48%, specificity 72%. Ninety-two of 131 (70%) children with positive verum provocations showed early reactions, 33 (25%) late and six (5%) combined early and late reactions. In 84/131 (64%) positive provocations one organ system was involved, while in 44 (34%) provocations two and in three (2%) challenges three organ systems were involved. Skin reactions were the most frequent clinical manifestation leading to positive reactions followed by gastro-intestinal and respiratory symptoms. There was no correlation between titration dose and specific IgE. The subgroup of non-sensitized children did not differ in terms of sex, age or titration dose from the total study population. CONCLUSION: Double-blind, placebo-controlled oral food challenges are helpful in distinguishing children with clinically manifested symptoms from those with food sensitization. Accurately identifying children with a clinical relevant food allergy may help to prescribe specific diets on a scientific basis, avoiding dietary limitations which may be unnecessary or even harmful.
Sampson HA. Food sensitivity and the pathogenesis of atopic dermatitis. J R Soc Med 1997;90 Suppl 30:2-8. (Review)
Savolainen J, Lammintausta K, Kalimo K, Viander M. Candida albicans and atopic dermatitis. Clin Exp Allergy 1993 Apr;23(4):332-339.
Abstract: The role of sensitization and exposure to Candida albicans in atopic dermatitis (AD) was studied with skin-prick tests, yeast cultures and immunoblotting in 156 young adults with AD attending the Department of Dermatology, University of Turku, during 1983-89. Eighteen patients with allergic rhinitis without eczema and 39 non-atopics were included as controls. Parameters associated with severe AD were simultaneous anti-C. albicans IgE and saprophytic C. albicans growth. A statistically significant correlation between C. albicans sensitization (specific IgE antibodies) and AD symptoms was observed only in patients with saprophytic C. albicans exposure. No correlation between C. albicans-specific IgE and AD severity was shown in patients without gastrointestinal growth. Furthermore, severe eczema was seldom seen in patients without saprophytic C. albicans growth. The most important IgE-binding components of C. albicans in immunoblotting were 27 and 46 kD proteins and mannan, a polysaccharide. IgG and IgA antibodies to C. albicans, mainly towards C. albicans mannan, were found in practically all 70 sera studied. These results suggest a continuous exposure and induction of IgE antibodies by C. albicans in AD patients. Severe phases of AD in colonized patients are associated with IgE synthesis against C. albicans. These findings suggest a role for C. albicans in the exacerbations of AD but the clarification of this subject needs double-blind placebo-controlled treatment trials.
Soyland E, Funk J, Rajka G, Sandberg M, Thune P, Rustad L, Helland S, Middelfart K, Odu S, Falk ES, et al. Dietary supplementation with very long-chain n-3 fatty acids in patients with atopic dermatitis. A double-blind, multicentre study. Br J Dermatol 1994 Jun;130(6):757-764.
Abstract: The purpose of this study was to investigate whether fish oil and/or corn oil had a beneficial effect on the clinical state of atopic dermatitis, and to evaluate the dietary intake of nutrients in this group of patients. In a double-blind, multicentre study lasting 4 months, during wintertime, 145 patients with moderate to severe atopic dermatitis were randomly assigned to receive either 6 g/day of concentrated n-3 fatty acids, or an isoenergetic amount of corn oil. As local treatment, only an emollient cream or hydrocortisone cream was allowed. The fatty acid pattern in serum phospholipids, and the dietary intake of nutrients were monitored in a subgroup of patients, and the results were compared with a group of patients with psoriasis. The overall clinical score, as evaluated by the physicians, improved during the trial by 30% in the fish oil (P < 0.001) and 24% in the corn oil group (P < 0.001). This was also consistent with the results from a selected skin area, and it was further confirmed by the total subjective clinical score reported by the patients. There were no significant differences in the clinical scores between the two groups at baseline, and at the end of the study. In the fish oil group, the amount of n-3 fatty acids in serum phospholipids was significantly increased at the end of the trial, compared with pretreatment values (P < 0.001), whereas the level of n-6 fatty acids was decreased (P < 0.001).
Stewart JCM, et al. Treatment of severe and moderately severe atopic dermatitis with evening primrose oil (Epogam): A multi-center study. J Nutr Med 1991;2:9-15.
Wright S. Atopic dermatitis and essential fatty acids: a biochemical basis for atopy? Acta Derm Venereol Suppl (Stockh) 1985;114:143-145.
The effects of dietary supplementation with evening primrose oil (Efamol) in 99 patients with atopic dermatitis were investigated in a double blind, controlled crossover study. Simultaneously, plasma phospholipid essential fatty acid status was determined in 50 of these patients before and after treatment. In a separate study, lymphocyte subsets and mitogen responses were investigated in 15 atopic patients before and after treatment. The conclusion is that evening primrose oil improves atopic dermatitis; an abnormality of the enzyme delta-6-desaturase is proposed to explain the biochemical findings. Finally, it is concluded that the therapeutic effect of evening primrose oil is unlikely to be mediated through a primarily immunological mechanism.
Wright S, Burton J. Oral evening primrose improves atopic eczema. Lancet 1982 Nov 20;2(8308):1120-1122.
Abstract: 60 adults and 39 children with moderate or severe atopic eczema received EPO or placebo (liquid paraffin), each for 12 weeks. In a randomized, double blind cross over trial adults took either 2, 4, or 6 capsules 2x per day and children received 1-2 capsules 2x per day. Each capsule contained 360mg of linoleic acid and 45mg of GLA. Standard treatment was continued during the study. In the low dose groups, in adults and children, itching was the only symptom significantly improved by the EPO. At higher doses, itching, scaling and general condition was significantly better on EPO than on placebo. Overall improvement in severity was about 43% in those taking high doses of the oil. Adults responded better than children, possibly because the dosage in children was inadequate. 14 responded more favorably to the antigen-avoidance diet versus only 1 on the control diet. There was no correlation between positive prick test to egg and cows milk antigen and response to the trial diet. No side effects were noted. In the low dose groups, there was a 30% overall improvement.