An Update on Pediatric Atopic Dermatitis and Food Allergies.

An otherwise healthy 15-month-old female presented to Pediatric Dermatology for evaluation and management of moderate atopic dermatitis since 4 months of age. The patient had eczematous dermatitis with a waxing and waning course, with significant pruritus, sleep disturbance, and no symptom-free periods. The family had previously been instructed to use a combination of daily moisturizers with hydrocortisone 2.5% ointment during flares, but because of concerns about steroid side effects used only very small quantities of prescription medication. At 8 months and while exclusively being breastfed, the patient was evaluated by an allergist. Mother had noticed that when she ingested large amounts of egg, the infant’s eczema wouldflare.Whensheremoved eggfrom her diet,the eczema improved but did not resolve. Skin testing was performed on the child and was positive to egg and negative to milk and peanut. Serum IgE food allergy (FA) testing at 14 months was positive to milk, wheat, and tree nuts; however, the child ingested wheat and tree nuts regularly without any noted symptoms. The family limited the patient’s dairy intake because of concerns that it exacerbated the dermatitis but did not see significant improvement. Physical examination was significant for diffuse eczematous plaques with lichenification and moderate thickening on the neck and upper and lower extremities favoring the antecubital and popliteal fossae. Scattered erythematous, edematous plaques, and excoriations were also present diffusely. Approximately 30% of the body surface area was involved. The diagnosis of atopic dermatitis was reviewed in detail including clinical course, treatment options, and possible triggers and trigger avoidance. The role of FAs and potential false positive food-specific IgE testing were discussed in detail, and the patient was started on a treatment plan to control her atopic dermatitis using triamcinolone ointment 1%, 30-40 g per week for the first 2 weeks, with a tapered-dosing schedule. No change in diet was recommended except for continued avoidance of egg. At her 1-month follow-up appointment, the patient’s skin symptoms were significantly improved. Physical examination revealed mild hypopigmentation with small focal areas of erythema and mild lichenification in the antecubital fossae and neck, with no exudation or excoriation. Importantly, the patient’s mother reported significantly improved quality of sleep and decreased pruritus. The mother was advised to continue the atopic dermatitis treatment as planned and continue to follow-up with her allergist to monitor for possible outgrowing of the egg allergy. Atopic dermatitis is the most common chronic, relapsing inflammatoryskinconditioninchildrenworldwide,affecting 5%-20% of pediatric patients. 1 It is a complex disease mediated by both genetic and environmental factors arising from dysregulation of the immune system, dysfunction of the epidermal barrier, and inflammation. 2 It is characterized by pruritus and skin changes such as xerosis, erosions, and excoriations. Even mild cases can have a profound impact on patient quality of life. Although it has been known for many years that atopic dermatitis and FA are highly associated, the role of FA in the pathogenesis and severity of atopic dermatitis is still a subject of controversy. FAs affect approximately 4%-6% of children and 3%-4% of adults. 3,4 The prevalence of FA is significantly higher in