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COMMENTARY
Year : 2021  |  Volume : 22  |  Issue : 2  |  Page : 136-140

Diet in Pediatric Dermatology


Department of Pediatric Dermatology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India

Date of Submission16-Jan-2021
Date of Decision20-Jan-2021
Date of Acceptance26-Jan-2021
Date of Web Publication31-Mar-2021

Correspondence Address:
Sahana M Srinivas
Department of Pediatric Dermatology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.ijpd_10_21

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  Abstract 


Relation between dietary habits and pediatric dermatoses is well established in literature. Every dermatologist needs to have a thorough evidence-based knowledge of all the skin conditions that are affected by food either directly or indirectly, especially in today's world, where patients are looking for holistic solutions for all their ailments. Nutritional deficiencies, metabolic conditions, dermatitis herpetiformis, and urticaria are well-known entities related to food. Apart from these, a few skin conditions such as atopy, acne, and psoriasis have some correlation to food intake. A thorough knowledge of diet and its effect on dermatological conditions is important where alternative systems lay a lot of stress on the kinds of food that may be consumed in certain skin conditions. Parents should be counseled about the myths related to dietary modifications as this may lead to nutritional deficiencies in children.

Keywords: Diet, nutrition, pediatric, skin disorders


How to cite this article:
Srinivas SM. Diet in Pediatric Dermatology. Indian J Paediatr Dermatol 2021;22:136-40

How to cite this URL:
Srinivas SM. Diet in Pediatric Dermatology. Indian J Paediatr Dermatol [serial online] 2021 [cited 2021 Apr 18];22:136-40. Available from: https://www.ijpd.in/text.asp?2021/22/2/136/312810




  Introduction Top


Diet and nutritional therapies play an important role for various dermatoses in pediatric age group. At one end of the spectrum, there are certain dermatological conditions such as protein energy malnutrition (marasmus/kwashiorkor), pellagra, and acrodermatitis enteropathica due to deficiency of specific nutrients which improves with correction, but at the other end, there are dermatoses such as atopic dermatitis (AD), psoriasis, and urticaria where the role of diet is not specific and has a questionable place in management recommendations.[1],[2] Between these extremes, the role of diet showing ameliorating/deteriorating effect on certain skin conditions is not clear. This article will review the evidence-based dietary impact on the most common skin disorders in pediatric age group.


  Classification Top


The various dermatological disorders where dietary interventions may influence the onset or course of the skin diseases have been classified in [Table 1]. We have discussed the role of diet in selected pediatric dermatoses.
Table 1: Dietary influences on various skin disorders in pediatric age group

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  Atopic Dermatitis Top


AD is the most common skin condition in pediatric age group, and the role of diet is debatable till date. There is lot of misconceptions among caregivers regarding diet in AD and this is mostly attributable to the online research which gives innumerable advices regarding avoidance of certain foods in AD. The documented prevalence of food allergy is 20%–60%. One-third of the allergy is seen in moderate-to-severe AD and 60% of them occur in infancy.[3] Food allergy can manifest as IgE-mediated immediate and non-IgE-mediated late eczematous reactions. IgE sensitization to food in atopics is associated with asthma and allergic rhinitis. Common food allergens include cow's milk, egg, soya, wheat, peanut, and seafood.[4] IgE-mediated food allergy occurs within few minutes to hours after exposure manifesting as pruritus, erythema, urticaria, angioedema, morbilliform eruption, and allergic contact dermatitis along with nondermatological features such as vomiting, diarrhea, pain abdomen, and anaphylaxis. Non-IgE-mediated late eczematous reactions are T-cell mediated and is seen 2–6 days after ingestion. They can occur as an isolated reaction or along with immediate type reaction.[3],[4] Consumption of specific allergen present in foods and dairy products such as latex, nickel, balsam of peru, cobalt, propylene glycol, and formaldehyde may lead to widespread or localized cutaneous reactions. This is more commonly seen in adults in a previously sensitized contact allergen but rarely seen in children.[2],[4]

Parents often attribute food causing exacerbation of AD. Although many studies have documented that food allergy can exacerbate AD, the contribution of these allergies is questionable. There is not much role of routine elimination diet in AD as it can lead to nutritional deficiencies and growth retardation. A Cochrane systematic review based on randomized control trials has shown no significant benefit of elimination diet in unselected patients with AD. However, removal of proven-specific food allergen has found beneficial in AD.[3],[5] Egg and milk-free diet after documented sensitization has shown improvement in the severity of AD. Parents giving a history of exacerbation of AD due to some food may not be a reliable indicator as they may be presumed food allergy. Routine testing for food allergies is not recommended. A proper history, examination, and appropriate investigation are necessary to document food allergy. Investigations include skin prick test (SPT), serum IgE levels radio allergen sorbent test (RAST), and oral food challenge. The gold standard for diagnosis is double-blind placebo-controlled food challenge though it is impractical in clinical practice. SPT and RAST have 85% sensitivity and 30%–60% specificity.[6] Complimentary food rich in nutrients should be given if elimination diet is followed.

Both Prebiotics and probiotics alter intestinal microflora and reduce intestinal inflammation. There is inconsistent evidence of the use of probiotics/prebiotics in AD, although recent meta-analysis of 25 randomized controlled trials has shown significant improvement in SCORAD values with synbiotics (mixture of Lactobacillus and Bifidobacterium) as compared to probiotics alone.[7] These synbiotics given over a period of 8 weeks, showed statistically significant improvement, especially in moderate-to-severe AD.[4] There are conflicting data regarding elimination diet, adding probiotics, and fish oil supplementation in pregnancy and lactation for preventing AD in infancy. Cochrane review and many studies have documented restriction of maternal diet during pregnancy and lactation does not prevent the subsequent development of AD.[8]

Recently, there has been surge of articles regarding Vitamin D deficiency associated with AD. Although it is unclear whether Vitamin D supplementation improves AD, there are few randomized clinical trials that have shown reduction of severity of AD.[9] A common question we come across by parents is use of fish oil/cod liver oil (omega 3 polyunsaturated fatty acids) for improvement of AD. Although gamma linolenic acid, of the omega-6 family, has no proven role in the treatment of AD, there are some promising results shown by supplementation of omega-3 fatty acids, though not yet substantiated by randomized trials.[10]


  Psoriasis Top


The role of dietary supplementation with vitamins, essential fatty acids (omega 3 fatty acids) in pediatric psoriasis is unclear due to a lack of trials. However, antioxidants (selenium, coenzyme Q10, and Vitamin E) have shown to improve the severity in arthropathic and erythrodermic psoriasis.[4] Association of metabolic syndromes with psoriasis in children is well documented in literature. Recent studies have shown the association of pediatric psoriasis with obesity.[11] Mild-to-moderate psoriasis has been associated with overweight and moderate-to-severe psoriasis with central obesity. Children with psoriasis have increased prevalence (30%) of metabolic syndrome with 2–4 times the risk of hyperlipidemia, hypertension, diabetes mellitus, rheumatoid arthritis, and Crohn's disease.[11] Although lifestyle modification is warranted in this situation, it is still unclear whether weight loss reduces psoriasis severity in children as compared to adults. There is evidence of Vitamin D deficiency in psoriasis, but there are insufficient data regarding Vitamin D as oral therapy for treatment of psoriasis. Psoriasis with antigliadin antibodies may respond to gluten-free diet.[4] There are no trials for fish oil therapy in psoriasis in children. There is no evidence for Vitamin D supplementation in psoriasis is effective in children.[4]


  Acne Top


Over many years, there has been a causal link between diet and acne and hypothesis and myths continued to dominate the debate. Recent research has shown that dairy products, mainly skimmed milk, chocolate, hyperglycemic foods, processed cheese, iodine, and excessive whey proteins may play a role, but yet there are no clinical trials. High glycemic diet increases the production of insulin and insulin-like growth factor (IGF-1) that induces the keratinocyte and sebocyte proliferation and enhances lipogenesis. IGF-1 also increases the production of DHEAS and testosterone.[4],[12] Cow's milk contains 5-α-reduced androgens, casein, and whey proteins that increase IGF-1 and insulin. Skimmed milk also increases the production of IGF-1 by 20%–30% in children. Few prospective studies have documented a positive correlation between milk consumption and acne severity.[13] Although zinc, EFA, and DHA that have found to be effective for acne due to its anti-inflammatory properties, clinical trials are lacking.[12] Zinc has bacteriostatic effect on Propionibacterium acnes, downregulates the production of IGF-1 and expression of IGF-R, inhibits 5α reductase, and inhibits neutrophil chemotaxis.[14] Dietary counseling can be considered as an adjuvant therapy for acne.


  Urticaria and Anaphylaxis Top


Food hypersensitivity can occur as an adverse effect to food or a food additive and can be manifested as urticaria or anaphylaxis. IgE-mediated food allergy in children is associated more with acute urticaria than chronic urticaria and is responsible for 7% cases of childhood urticaria.[15] There can either be a specific allergy (milk, nuts, fish, and eggs) or through a nonspecific histamine release (shellfish). Cow's milk and egg sensitivity is usually lost in early childhood, whereas peanut, nut, and seafood sensitization tends to be long lasting.[15] Anaphylaxis is a life-threatening condition occurring within seconds of exposure to food allergens (egg, peanuts, milk, and fish). Pseudofood allergens such as coloring agents (carmine and annatto), tartrazine, preservatives, monosodium glutamate (MSG), and sweeteners can cause urticaria, angioedema, and anaphylaxis. MSG has been associated with chronic idiopathic urticaria not only in adults but also in children.[16] Oral provocation test is the only diagnostic test for pseudofood allergen reactions. Counseling parents about the dietary habits are extremely important in management of anaphylaxis.


  Food Allergy and Persistent Diaper Dermatitis Top


Diaper rash may be the only indication of food allergy. Persistent and severe diaper dermatitis for longer than a month along with gastrointestinal symptoms may be associated with food allergy. Diaper dermatitis is less common in breastfed infants as the feces have lower PH, lower lipase, and protease activity.[17]


  Vitiligo Top


Vitiligo is associated with a lot of psychosocial aspects, especially in Indian scenario. Parents are always in search of cure not an assurance, which inclines them to alternative medicine approaches, websites, and lay publications recommending unsubstantiated dietary supplements. There is wide belief that sour foods such as citrus fruits, yoghurt, milk, and fish should be avoided in vitiligo. Review of literature has shown there are no controlled studies in assessing the role of diet in the management of vitiligo. There are some preliminary reports of the presence of gluten in diet may help vitiligo; however, there is an insufficient evidence.[18] The role of oral supplements such as vitamins, minerals, and botanicals has been studied in vitiligo due to their antioxidant and immunomodulatory activity but has shown no beneficial results. However, they can be used as adjunct therapy to topical agents and phototherapy rather than monotherapy.[18]


  Diet in Hair and Nail Disorders Top


Telogen effluvium, premature canitis, and koilonychia have been associated with nutritional deficiency, iron deficiency, and food faddism in children. Association with celiac disease and pernicious anemia has been contributory in alopecia areata and premature canitis. Genome-wide association studies have shown genes involved in retinoid synthesis is dysregulated in alopecia areata. In such cases, high Vitamin A diet can increase the hair loss but evidence is still elusive. Although the role of Vitamin D in alopecia areata is widely talked, there is an insufficient evidence.[4],[9]


  Nutritional Assessment in Dermatoses Top


Acute skin failure conditions have been associated with hemodynamic changes, metabolic abnormalities, fluid and electrolyte imbalances, and loss of nutrients, proteins, and iron. There is also impaired absorption and utilization of iron and Vitamin B12. Children >10% body surface area have an increased nutritional requirement.[19] Nutritional therapy is at most important in the management of epidermolysis bullosa. Children with epidermolysis bullosa have frequent mouth and esophageal blistering, difficulties in chewing , and swallowing food due to pain and gastroesophageal reflux giving rise to inadequate food intake. Frequent blistering can also cause protein loss. The above causes can lead to nutritional deficiency, anemia, growth failure, lethargy, failure to thrive, and poor wound healing.[20] Multidisciplinary approach with appropriate protein and caloric replenishments and dietary interventions are necessary in such situations to improve the quality of life.


  Other Skin Disorders Top


Although rosacea and mastocytosis are not commonly seen in children, one should be cautious about foods rich in histamine (shellfish, chocolate, tomatoes, spinach, and banana) that can trigger histamine release from mast cells and induce flare in both the conditions.[4] Dietary habits of carbonated drinks, nuts, citrus fruits, and spicy foods play no role in recurrent aphthous ulcers but may contribute to the pathogenesis by hypersensitivity.[1],[2] There are several reports of fixed drug eruptions induced by cashews, peanut, lentil, strawberry, asparagus, lactose, tonic water (quinine), cheese crisps (tartrazine), seafoods, artificial flavors, colors, and preservatives in foods and medications.[1] There are a few anecdotal cases reports on the role of zinc therapy in multiple warts but further studies have not shown any convincing evidence of its efficacy.


  Conclusions Top


Dietary counseling should be given based on proven evidence regarding foods that modify the course of disease and not on myths. Further clinical trials are required to bridge the knowledge gap regarding the role of diet in these dermatoses.


  Key messages Top


  • The current evidence regarding AD and dietary restriction is lacking.
  • At present there is no role of routine elimination diet in all cases of AD
  • Elimination diet is beneficial in preselected group of children who show some evidence of allergy to specific allergen through allergy tests
  • Dietary restriction plays a role in a section of moderately severe/severe AD
  • Avoidance of food with proven food allergy is beneficial
  • There is still inconsistent evidence regarding use of probiotics/prebiotics in AD, hence not recommended
  • There is evidence that children with psoriasis have an increased risk of obesity and metabolic syndrome. Dietary interventions and weight reduction may improve psoriasis in children
  • Fish oil supplements and oral vitamin D therapy has no role in pediatric psoriasis
  • High glycemic diet induces production of insulin and insulin-like growth factor -1 influencing acnegenesis in adolescence
  • Various foods and food additives can cause acute urticaria and anaphylaxis
  • Oral supplementation like vitamin and minerals and dietary restriction has no role in vitiligo
  • There is no role of diet in alopecia areata and zinc supplementation in warts in children


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Reese I, Werfel T. Do long-chain omega-3 fatty acids protect from atopic dermatitis? J Dtsch Dermatol Ges 2015;13:879-85.  Back to cited text no. 10
    
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Andreozzi L, Giannetti A, Cipriani F, Caffarelli C, Mastrorilli C, Ricci G. Hypersensitivity reactions to food and drug additives: Problem or myth? Acta Biomed 2019;90:80-90.  Back to cited text no. 16
    
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  In this article
Abstract
Introduction
Classification
Atopic Dermatitis
Psoriasis
Acne
Urticaria and An...
Food Allergy and...
Vitiligo
Diet in Hair and...
Nutritional Asse...
Other Skin Disorders
Conclusions
Key messages
References
Article Tables

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