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COMMENTARY
Year : 2021  |  Volume : 22  |  Issue : 4  |  Page : 378-380

Diet in pediatric dermatology


Department of Dermatology, LTMGH HOSPITAL, SION, MUMBAI-400022, India

Date of Submission03-Apr-2021
Date of Acceptance16-May-2021
Date of Web Publication01-Oct-2021

Correspondence Address:
Sanober Burzin Daruwalla
Godrej Baug, Mumbai - 400 026, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.ijpd_51_21

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How to cite this article:
Daruwalla SB. Diet in pediatric dermatology. Indian J Paediatr Dermatol 2021;22:378-80

How to cite this URL:
Daruwalla SB. Diet in pediatric dermatology. Indian J Paediatr Dermatol [serial online] 2021 [cited 2021 Dec 6];22:378-80. Available from: https://www.ijpd.in/text.asp?2021/22/4/378/327452



“Tell me what you eat and I will tell you what you are,” wrote Anthelme Brillat-Savarian in the early 1900s. This still holds for most clinicians, especially in our robust specialty of dermatology. Right from the time, an embryo begins cellular multiplication and organ development deriving nourishment from the womb it parasitizes, to the growing child discovering his/her tastes and likes and interactions to the environment as he/she progresses to adulthood, we are often confronted with the woes of worried parents when it comes to the role of food in the development of many disorders. Separating myths from facts is often a herculean task, especially in a country like India where diverse food and cultural practices thrive. One such example is giving Gutti-a herbal concoction mixed with honey or ghee or simply placing a drop of honey over the tongue as prelacteal feed in new-borns. It is still being practiced in the many parts of the country. The scare of causing infant botulism does not seem to deter our population yet. My attempt shall be to outline the role that diet plays in various pediatric dermatological disorders.

“Half of what man knows today will be proved wrong in the next 5 years but the problem with mankind would be to know which half it is” said Cicero-the Roman thinker.

Similarly, the role of diet in atopic dermatitis (AD) is still controversial and evolving. While allergologists and pediatricians are convinced of the causative role of food in the onset of AD, dermatologists are convinced of the contrary. The common belief is that AD is caused by a food allergy and that restrictions in the diet will resolve the disease. Although the latter is not true, in reality many patients with AD do have food allergies.[1] Major theories support an immune-mediated inflammatory reaction to food allergens, thereby causing exacerbation of AD. Many patients have elevated serum concentrations of total and food-specific immunoglobulin E (IgE). Thus, IgE may contribute to the characteristic inflammation seen in the skin of patients with AD.[2]

Approximately 40% of infants and young children with moderate-to-severe AD and 8% of the general pediatric population are said to manifest a specific IgE-based food allergy.[3] Food allergies in AD can manifest in the form of urticaria, pruritus, and/or other cutaneous symptoms in the absence of flaring of the existing disease. Furthermore, both allergic and pseudo allergic reactions have been believed to be possible eliciting factors in various forms of urticaria. Chronic urticaria reactions in children due to food hypersensitivity are mainly due to coloring agents and preservatives, monosodium glutamate, and sweeteners.[4] Allergists generally recommend avoidance of or use of heavily denatured food (in the case of a milk/egg allergy) in the setting of documented IgE-mediated allergens.[5] An open pilot study in 100 Indian children conducted by Dhar and Banerjee on the effects of dietary elimination in AD showed a statistically significant decrease in the severity score after dietary elimination of milk and milk products, nuts, nut containing foods, egg, sea fish and prawns, brinjal, and soybean, for 3 weeks.[6] However, a Cochrane systematic review based on randomized controlled trials has shown no benefit from the elimination of egg or cow's milk and does not support the concept of dietary elimination.[7] Hence, diagnosing a food allergy is imperative, as misdiagnosis and implementation of a restrictive diet may lead to malnutrition. The skin application food test, developed by Oranje et al. is a reliable and child-friendly skin test for evaluating suspected food allergies in children younger than 4 years of age. Based on the mechanism of contact urticaria, it involves the application of the suspected culprit food in the same state as is consumed over the back of the patient, using large Finn chambers and reading the test results after 10, 20, and 30 min. However, the oral challenge test is still considered ideal for the final proof of diagnosis of food allergy.[8],[9]

Earlier it was believed that delayed exposure to certain foods would be of benefit, however, the exact opposite is proven to be true, as demonstrated in the learning early about peanut allergy trial.[10] It is now recommended in countries with a high prevalence of peanut allergies to introduce peanuts to an infant's diet between 4 and 11 months of age (evidence level 1 [highest level of evidence]), in an attempt to decrease the likelihood of the said food allergy.[11] This brings to mind the hermetic concept, which may be of benefit in such cases of food allergies. Hormesis (hormo in Greek = I excite) is the stimulation of any system by small doses of an agent, in which larger doses, harms the same system. The human body always responds in a nonlinear fashion in any situation. Understanding hormesis and extrapolating its use in cases of food allergy could reduce this burden significantly.

The root cause of AD is believed to be a combination of inflammation and barrier dysfunction associated with allergic diathesis. Hence, probiotics and prebiotics have some evidence in their favor as they have been theorized to work through a reduction in inflammation.[12] Moreover, a normal gut environment with food and normal bacterial flora might be the backbone of a good immune response. It is believed that minor changes in the initial stage of any organism might not hold good as time evolves in a dynamic human organism. It might even be counterproductive as there could be the infamous “butterfly effect” of physicist Edward Lorenz of weather predictions fame! Extremists view that drastic changes in diet would meet the same fate for the same scientific reasons. Hence, the question remains, to feed or not to feed? Nature always keeps her secrets closely guarded. We must keep our eyes and ears open to these revelations through regularly auditing our interventions and tailoring dietary modifications for each child individually.

“One man's meat is another man's poison”-Titus Lucretius Carus

Though the late poet Lucretius had another meaning in mind while he wrote the above lines, the words surely hold for the subset of babies born with inborn errors of metabolism. This group of disorders encompasses a specific enzyme defect that interferes with the normal metabolism of protein, fat, or carbohydrate. As a result of diminished or absent enzyme activity in these disorders, certain compounds accumulate in the body to toxic levels and the levels of others that the body normally makes may become deficient. Since there is no definite cure, treatment is dependent on supportive care and an appropriate diet. Right from restricting the daily protein content in children suffering from phenylketonuria and tyrosinemia, to forbidding milk and milk products, meat, cereals, and pulses to encompass a low methionine diet in homocystinuria, to avoiding possible sources of phytanic acid in Refsum's disease, this group of disorders requires thorough nutritional planning to provide adequate nutrients required for the child's growth, but at the same time preventing the accumulation of toxic substances that could be detrimental for the child.[13]

“Doing what's right isn't a problem. It's knowing what's right”-Lyndon B Johnson

Vitiligo has been a mentally crippling and debilitating disease with no respect to age, caste, or creed. With a myriad of dietary advice and food myths associated with the disease, it is often the responsibility of the caregiver to present what is known. Phenol containing naturally occurring plant phenols and phenolic compounds such as mango, cashews, and tea is reported to induce the release of interleukin-1α and tumor necrosis factor-α from keratinocytes, implicated in the pathophysiology of vitiligo.[14] Furthermore, food contaminants/additives/preservatives and cosmetic products produce oxidative stress in the skin and may thus aggravate vitiligo.[15] Furthermore, increased consumption of omega-6 in the form of vegetable oils and decreased intake of omega-3 may increase, in vivo, the production of free radicals and pro-inflammatory cytokines. Hence, the increased intake of omega-3 containing foods such as fish, flaxseeds, walnuts along with antioxidants might be beneficial.[16] In India, it is still believed that excessively sour foods should be avoided and the simultaneous consumption of milk and fish can cause vitiligo, but there has been no scientific data to support nor refute this belief.

“Human beings do not eat nutrients, they eat food”-Mary Catherine Bateson

However, there are several nutritional disorders with dermatologic manifestations such as kwashiorkor, marasmus, phrynoderma, scurvy, and pellagra which is rampantly seen in our country. Identification and appropriate nutrient correction are the mainstays of treatment. Another important subset of nutritional dermatosis no longer limited only to adolescents includes eating disorders in children such as restrictive food intake disorder, pica and anorexia nervosa. They may present with cutaneous features such as dry, coarse hair and skin, weight loss and lack of growth and require a multidisciplinary approach. Furthermore, childhood dermatitis herpetiformis is rare and may be misdiagnosed as AD, papular urticaria or scabies.[17] Initiation of a gluten-free diet is known to alleviate gastrointestinal symptoms, cause resolution of skin manifestation and decrease the chance of development of gastrointestinal lymphomas.[18] While diet has established its role in the pathology of various disorders, its therapeutic arm in the field of dermatology is expanding. From the use of rose syrup, milk or honey whilst administration of oral propranolol for infantile haemangiomas to the miraculous use of salt topically for the treatment of umbilical and pyogenic granulomas, there seems to be no limiting the therapeutic qualities of common household foodstuff.[19],[20] To summarize, the various dermatological disorders that affect the tender age of childhood in which diet has a role to play include[13] [Figure 1].
Figure 1: Summary of various dermatological disorders that affect the tender age of childhood in which diet has a role to play

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Feeding is the primary event in the life of an infant and young child and in turn the focus of attention for parents and other caregivers. One is often confronted and coaxed by parents for a daily supplement to help their child grow better. However is the indiscriminate use of such pills unless indicated rational? I fear not. While it is true that they are essential for growth and health, but the excess of these artificial chemicals might interact with the other body's needs during absorption in the intestine. With malnourishment affecting one child due to inadequate food intake in our country and elimination of food in the fed child to avert allergies on the other hand, showcases the myriad of disorders associated with food and its importance. As the famous Japanese saying goes-”One kind word can warm three winter months,” so also reassuring the parents and guiding them for what we think is best for their child is important.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Diet and Atopic Dermatitis; 2020. Available from: https://www.mdedge.com/dermatology/article/107185/atopic-dermatitis/diet-and-atopic-dermatitis. [Last accessed on 2020 Apr 13].  Back to cited text no. 1
    
2.
Johnson E, Irons J, Patterson R, Roberts M. Serum IgE concentration in atopic dermatitis *1Relationship to severity of disease and presence of atopic respiratory disease. J Allergy Clin Immunol 1974;54:94-9.  Back to cited text no. 2
    
3.
Sicherer S, Sampson H. Food hypersensitivity and atopic dermatitis: Pathophysiology, epidemiology, diagnosis, and management. J Allergy Clin Immunol 1999;104:S114-22.  Back to cited text no. 3
    
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Ehlers I, Niggemann B, Binder C, Zuberbier T. Role of nonallergic hypersensitivity reactions in children with chronic urticaria. Allergy 1998;53:1074-7.  Back to cited text no. 4
    
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Sicherer SH, Sampson HA. Food allergy: A review and update on epidemiology, pathogenesis, diagnosis, prevention, and management. J Allergy Clin Immunol 2018;141:41-58.  Back to cited text no. 5
    
6.
Dhar S, Malakar R, Banerjee R, Chakraborty S, Chakraborty J, Mukherjee S. An uncontrolled open pilot study to assess the role of dietary eliminations in reducing the severity of atopic dermatitis in infants and children. Indian J Dermatol 2009;54:183-5.  Back to cited text no. 6
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7.
Bath-Hextall F, Delamere FM, Williams HC. Dietary exclusions for established atopic eczema. Cochrane Database Syst Rev 2008. CD005203.  Back to cited text no. 7
    
8.
Oranje AP, Van Gysel D, Mulder PG, Dieges PH. Food-induced contact urticaria syndrome (CUS) in atopic dermatitis: Reproducibility of repeated and duplicate testing with a skin provocation test, the skin application food test (SAFT). Contact Dermatitis 1994;31:314-8.  Back to cited text no. 8
    
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de Waard-van der Spek FB, Elst EF, Mulder PG, Munte K, Devillers AC, Oranje AP. Diagnostic tests in children with atopic dermatitis and food allergy. Allergy 1998;53:1087-91.  Back to cited text no. 9
    
10.
Du Toit G, Roberts G, Sayre PH, Bahnson HT, Radulovic S, Santos AF, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med 2015;372:803-13.  Back to cited text no. 10
    
11.
Fleischer DM, Sicherer S, Greenhawt M, Campbell D, Chan ES, Muraro A, et al. Consensus communication on early peanut introduction and the prevention of peanut allergy in high-risk infants. World Allergy Organ J 2015;8:27.  Back to cited text no. 11
    
12.
Sidbury R, Kodama S. Atopic dermatitis guidelines: Diagnosis, systemic therapy, and adjunctive care. Clin Dermatol 2018;36:648-52.  Back to cited text no. 12
    
13.
Kaimal S, Thappa DM. Diet in dermatology: Revisited. Indian J Dermatol Venereol Leprol 2010;76:103-15.  Back to cited text no. 13
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14.
Birol A, Kisa U, Kurtipek G, Kara F, Kocak M, Erkek E, et al. Increased tumor necrosis factor alpha (TNF-α) and interleukin 1 alpha (IL1-α) levels in the lesional skin of patients with nonsegmental vitiligo. Int J Dermatol 2006;45:992-3.  Back to cited text no. 14
    
15.
Bickers DR, Athar M. Oxidative stress in the pathogenesis of skin disease. J Invest Dermatol 2006;126:2565-75.  Back to cited text no. 15
    
16.
Fernandes G. Dietary lipids and risk of autoimmune disease. J Clin Immunol 1994;72:193-7.  Back to cited text no. 16
    
17.
Templet JT, Welsh JP, Cusack CA. Childhood dermatitis herpetiformis: A case report and review of the literature. Cutis 2007;80:473-6.  Back to cited text no. 17
    
18.
Lewis HM, Renaula TL, Garioch JJ, Leonard JN, Fry JS, Collin P, et al. Protective effect of gluten-free diet against development of lymphoma in dermatitis herpetiformis. Br J Dermatol 1996;135:363-7.  Back to cited text no. 18
    
19.
Bagadia J, Jaiswal S, Bhalala KB, Poojary S. Pinch of salt: A modified technique to treat umbilical granuloma. Pediatr Dermatol 2019;36:561-3.  Back to cited text no. 19
    
20.
Daruwalla SB, Dhurat RS. A pinch of salt is all it takes! The novel use of table salt for the effective treatment of pyogenic granuloma. J Am Acad Dermatol 2020;83:e107-8.  Back to cited text no. 20
    


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