Pediatric psoriasis, eczema: Triggers and therapies
In part two of our discussion, Kelly Cordoro, M.D., associate professor of dermatology and pediatrics at the University of California in San Francisco, discusses environmental and microbial triggers and when to choose systemic therapies with Dermatology Times editorial advisor, Elaine Siegfried, M.D.
Check part one of this three part series: Clinical pearls in pediatric dermatology
Environmental and food triggers
Dr. Siegfried: On to the next controversy: Many parents are convinced that their child has an environmental or food trigger that can be easily identified and eliminated. How do you address this?
Dr. Cordoro: We call these families the search-and-destroy families. I will explain to them that I understand they are on a search-and-destroy mission, and then I tell them why it won’t work. We talk about the concept of food allergy and how it correlates with the skin condition. I think there’s a lot of misunderstanding as well as a general lack of education.
In the majority of patients, if not all, food allergy does not cause eczema, but it can contribute. I explain when we will test. I believe in what we wrote in the guidelines and what the data supports, which is why I will evaluate for food allergy if two conditions are met: The skin hasn’t responded to a good, comprehensive, skin-directed regimen; and the parents notice a relevant reaction to a specific food. If these two things happen, they get specific testing.
READ: Pediatric psoriasis
The most profound observation I have made in the clinic — and I am sure you have as well — is when a parent brings a child who is head-to-toe atopic dermatitis: scratching, digging, lichenified, oozing, weeping in some areas, bleeding in others, miserable, not sleeping, and that’s the same child who is on an elimination diet. It’s really hard to get the parents to make that mental link between having eliminated almost everything that they could be allergic to and yet the child is still in this state.
Two things that I spend the most amount of time counseling about are the idea that food can play a role, but it’s not the only thing that contributes to eczema; and steroid phobia.
Dr. Siegfried: Mark Boguniewicz, M.D., at Denver National Jewish Medical and Research Center, has a program in which patients with suspected food allergy travel great distances for food allergy evaluation. Many of these patients also have severe eczema. The patients stay at a hotel across the street and receive intensive daily outpatient skin care. Once their skin is sufficiently cleared, they participate in double-blind, placebo-controlled food challenges.
A 2010 retrospective analysis reviewed the outcomes of over 100 of these patients. Food challenges were negative to ~90% of the foods tested, especially in children on restricted diets for atopic dermatitis. Although these families have strictly avoided multiple foods for years, Dr. Boguniewicz was as amazed as you by their inability to recognize the limited impact that dietary restriction had on their child’s severe eczema. He is equally surprised by their hesitation to liberalize their child’s diet. One of his biggest jobs is to help them overcome their fear of foods.
Dr. Cordoro: I’m glad to hear about that. I have not read that study. Dr. Boguniewicz has done some fabulous work on chronic urticaria as well. He is such a practical clinician researcher. I think that’s the type of information that parents need to hear and understand. I have also found that the quality in the information that the patients will receive from allergists is very disparate. Sometimes allergists understand this concept and sometimes they don’t. They may themselves be on an elimination mission.