Dietary Elimination for the Treatment of Atopic Dermatitis: A Systematic Review and Meta-Analysis

Paul Oykhman, Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Jared Dookie, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
Husam Al-Rammahy, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
Anna de Benedetto, Department of Dermatology, University of Rochester Medical Center, Rochester, NY.
Rachel N. Asiniwasis, Origins Dermatology Centre, University of Saskatchewan, Regina, Saskatchewan, Canada.
Jennifer LeBovidge, Division of Immunology, Boston Children's Hospital, Boston, Mass.
Julie Wang, Icahn School of Medicine at Mount Sinai, New York City, NY.
Peck Y. Ong, Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, Calif.
Peter Lio, Northwestern University Feinberg School of Medicine, Chicago, Ill.
Alvin Gutierrez, Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Korey Capozza, Global Parents for Eczema Research, Santa Barbara, Calif.
Stephen A. Martin, University of Massachusetts Chan Medical School, Worcester, Mass.
Winfred Frazier, Department of Family Medicine, UPMC St Margaret, Pittsburgh, Pa.
Kathryn Wheeler, Department of Pediatrics, University of Florida, Gainesville, Fla.
Mark Boguniewicz, Divison of Allergy-Immunology, Department of Pediatrics, National Jewish Health and University of Colorado School of Medicine, Denver, Colo.
Jonathan M. Spergel, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa.
Matthew Greenhawt, Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
Jonathan I. Silverberg, Department of Dermatology, George Washington University School of Medicine and Health Sciences, Washington, DC.
Lynda Schneider, Division of Immunology, Boston Children's Hospital, Boston, Mass.
Derek K. Chu, Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact. McMaster University, Hamilton, Ontario, Canada; Research Institute of St Joe's Hamilton, Hamilton, Ontario, Canada. Electronic address: chudk@mcmaster.ca.

Document Type

Journal Article

Publication Date

10-1-2022

Journal

The journal of allergy and clinical immunology. In practice

Volume

10

Issue

10

DOI

10.1016/j.jaip.2022.06.044

Keywords

Atopic dermatitis; Dietary elimination; Dietary exclusion

Abstract

BACKGROUND: The influence of diet on atopic dermatitis (AD) is complex, and the use of dietary elimination as a treatment has conflicting views. OBJECTIVE: To systematically review the benefits and harms of dietary elimination for the treatment of AD. METHODS: We searched MEDLINE, Embase, AMED, PsycINFO, and the Cochrane Central Register of Controlled Trials from inception to January 18, 2022, without language restrictions, for randomized controlled trials (RCTs) and observational studies comparing dietary elimination and no dietary elimination for the treatment of AD. We conducted random-effects meta-analyses of eczema outcomes. We used the grading of recommendations, assessment, development, and evaluation approach to assess certainty of evidence (CRD42021237953). RESULTS: Ten RCT (n = 599; baseline median of study mean age, 1.5 years; median of study mean SCOring Atopic Dermatitis index, 20.7, range, 3.5-37.6) were included in the meta-analysis. Compared with no dietary elimination, low-certainty evidence showed that dietary elimination may slightly improve eczema severity (50% with vs 41% without dietary elimination improved the SCOring Atopic Dermatitis index by a minimally important difference of 8.7 points, risk difference of 9% [95% CI, 0-17]), pruritus (daytime itch score [range, 0-3] mean difference, -0.21 [95% CI, -0.57 to 0.15]), and sleeplessness (sleeplessness score [range, 0-3] mean difference, -0.47 [95% CI, -0.80 to -0.13]). There were no credible subgroup differences based on elimination strategy (empiric vs guided by testing) or food-specific sensitization. Insufficient data addressed harms of elimination diets among included RCTs, although indirect evidence suggests that elimination diets may increase the risk for developing IgE-mediated food allergy. CONCLUSIONS: Dietary elimination may lead to a slight, potentially unimportant improvement in eczema severity, pruritus, and sleeplessness in patients with mild to moderate AD. This must be balanced against potential risks for indiscriminate elimination diets including developing IgE-mediated food allergy and withholding more effective treatment options for AD.

Department

Dermatology

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