Food Allergy and Atopic Eczema

Professor Gideon Lack

King’s College London

Relationship between Food Allergy &

Atopic Dermatitis

� Food allergy Atopic dermatitis

� Atopic dermatitis Food allergy

� Atopic dermatitis Food allergy

Prevalence of AD in FA

91.388.1

42

0

10

20

30

40

50

60

70

80

90

100

Peanut Allergic Egg Allergic Unselected

% w

ith

ecze

ma

p

Prevalence of food allergy* and atopic

dermatitis

� Sampson 1985 56%

� Sampson 1995 73%

� Eigenmann (Baltimore) 1998 37%

� Eigenmann (Geneva) 2000 27%

� Niggemann 1999 81%

� Roehr 2001 55%

* Proven by DBPCFC

The relationship between eczema severity and the frequency of high-risk IgE food sensitization (HR-IgE-FS) to foods according to the age of onset of eczema is shown. The children with the most severe eczema (Q4), and the earliest age of

onset (3 months), had the greatest frequency of HR-IgE-FS

D. J. Hill, C. S. Hosking, F. M. de Benedictis, A. P. Oranje, T. L. Diepgen, V. Bauchau and the EPAAC Study Group. Clin Exp Allergy. 2008 Jan;38(1):161-8.

Does food allergy cause atopic

dermatitis?

� Oral Provocation Studies

� Interventional Studies

Oral Provocation Studies

� 139 children, mean age 13 months

� Mild AD 59%, Moderate 32%, Severe 9%

� Suspected food involvement by doctor or

parent

Niggemann B. J Allergy Clin Immunol 2001; 108: 1053-1058

106 challenges in

64 patients

49 Negative

challenges

57 Positive

challenges

DBPCFC to milk, egg, wheat and soy in children

median age 2 years with AD and suspected FA

56.5% Delayed

eczematous

Lesions*

43.5% Immediate

reactions

only

12% Delayed

eczematous

lesions only

45% Delayed

eczematous

lesions after

immediate symptoms

Delayed = >24hrs

*Mean increase in

SCORAD 14.2, p

Causes of late eczematous reactions

Milk

28%

Egg

27%

Soya

9%

Wheat

21%

Other

15%

Breuer K. Clin Exp Allergy 2004; 34: 817-24.

Does food allergy cause atopic

dermatitis?

� Oral Provocation Studies

� Interventional Studies

Interventional studies: Can Dietary

Restriction Improve Atopic Dermatitis?

� 16 interventional studies to address this

� No meta-analyses

� Varying

� Study populations

� Intervention

� Design

� Outcome measures

Fiocchi et al. Allergy 2004; 78: s78-85.

Review of Studies

� 15 of 16 studies report some response, but

variable

� Interventions most effective in infants

� Successful interventions include egg, milk &

wheat avoidance

� Effect is generally small

Fiocchi et al. Allergy 2004; 78: s78-85.

Relationship between Food Allergy &

Atopic Dermatitis

� Food allergy Atopic dermatitis

� Atopic dermatitis Food allergy

� Atopic dermatitis Food allergy

Cutaneous Route

IgE

“Allergy”

Saloga et al. Am J Respir Crit Care Med 1994; 149: 65-70

Strid et al. Eur J Immunol 2004; 34: 2100-9

PEANUT TOLERANT (NA)

PEANUT ALLERGY(PA)

Route of peanut exposure

Cutaneousexposure

Oral exposure

CLA + T cells

α4β7+ T cells

Chan et al. Allergy. In Press.

0%

20%

40%

60%

80%

100%

1 2 3 4 5 6 7 8 9 10

Peanut Allergic

Per

cen

tag

e o

f to

tal

pro

life

rati

on

(%)

CLA%

B7%

0%

20%

40%

60%

80%

100%

1 2 3 4 5 6 7 8 9 10

Peanut Non Allergic

Per

cen

tag

e o

f to

tal

pro

life

rati

on

(%)

CLA%

B7%

CLA+ and α4β7+ proliferation as a percentage of total CLA+ and α4β7+ proliferation to 400µg/ml peanut in each patient on day 5, showing proliferation to peanut predominating in the CLA subset of PA patients and a more mixed response in peanut tolerant (NA) patients.

Chan et al. Allergy. In Press.

Peanut allergy is associated with:

Lack G et al. NEJM 2003; 348: 977-985

� Eczema: OR = 2.6, 95%CI 1.4 - 5.0

� Oozing crusted rash: OR = 5.2, 95%CI 2.7 - 10.2

� Topical Arachis oil: OR = 6.8 , 95%CI 1.4-32.9

n=97

0.2

.4.6

.81

Pro

portio

n pe

anut

-alle

rgic

0 50 100 150Average total household peanut consumption during 1st year (g/week)

n=286

Fox AT et al. J Allergy Clin Immunol 2009; 123: 417-23.

Proportion of allergic children with peanut allergy as a function of

household peanut consumption during infancy, and as a function of

maternal peanut consumption during pregnancy

p=0.017

p=0.068

2.3

Bed-sheet(mcg/m 2)

Pillow-case(mcg/m 2)

Household peanut consumption and infant

environmental peanut exposure

Filaggrin

• Filaggrin forms a dense protein lipid matrix regulating permeability of the skin to water and external particles

• Loss-of-function filaggrin mutations:– Common (up to 10%) in Caucasian populations– Associated with up to 50% of moderate-severe eczema– Associated with peanut allergic (OR 5.3; CI 2.8-10.2) I UK and Canada

even after controlling for coexistent eczema (p=0.0008)

Sandilands A et al. Nature Genetics 2007;(5):650-4.Brown SJ et al. JACI 2011; 127(3-4): 661–667

Adapted from Irvine AD et al. N Engl J Med 2011;365:1315-27

Normal Patient Filaggrin Deficient Patient

Adapted from Irvine AD et al. N Engl J Med 2011;365:1315-27

Summary

� Food allergy Atopic dermatitis

� Atopic dermatitis Food allergy

� Atopic dermatitis Food allergy