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

Paul Oykhman; Jared Dookie; Husam Al-Rammahy; Anna de Benedetto; Rachel N Asiniwasis; Jennifer LeBovidge; Julie Wang; Peck Y Ong; Peter Lio; Alvin Gutierrez; Korey Capozza; Stephen A Martin; Winfred Frazier; Kathryn Wheeler; Mark Boguniewicz; Jonathan M Spergel; Matthew Greenhawt; Jonathan I Silverberg; Lynda Schneider; Derek K Chu

doi:10.1016/j.jaip.2022.06.044

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

J Allergy Clin Immunol Pract. 2022 Oct;10(10):2657-2666.e8. doi: 10.1016/j.jaip.2022.06.044. Epub 2022 Jul 19.

Authors

Paul Oykhman¹, Jared Dookie², Husam Al-Rammahy³, Anna de Benedetto⁴, Rachel N Asiniwasis⁵, Jennifer LeBovidge⁶, Julie Wang⁷, Peck Y Ong⁸, Peter Lio⁹, Alvin Gutierrez¹, Korey Capozza¹⁰, Stephen A Martin¹¹, Winfred Frazier¹², Kathryn Wheeler¹³, Mark Boguniewicz¹⁴, Jonathan M Spergel¹⁵, Matthew Greenhawt¹⁶, Jonathan I Silverberg¹⁷, Lynda Schneider⁶, Derek K Chu¹⁸

Affiliations

¹ Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
² Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
³ Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
⁴ Department of Dermatology, University of Rochester Medical Center, Rochester, NY.
⁵ Origins Dermatology Centre, University of Saskatchewan, Regina, Saskatchewan, Canada.
⁶ Division of Immunology, Boston Children's Hospital, Boston, Mass.
⁷ Icahn School of Medicine at Mount Sinai, New York City, NY.
⁸ Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, Calif.
⁹ Northwestern University Feinberg School of Medicine, Chicago, Ill.
¹⁰ Global Parents for Eczema Research, Santa Barbara, Calif.
¹¹ University of Massachusetts Chan Medical School, Worcester, Mass.
¹² Department of Family Medicine, UPMC St Margaret, Pittsburgh, Pa.
¹³ Department of Pediatrics, University of Florida, Gainesville, Fla.
¹⁴ Divison of Allergy-Immunology, Department of Pediatrics, National Jewish Health and University of Colorado School of Medicine, Denver, Colo.
¹⁵ 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.
¹⁶ Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
¹⁷ Department of Dermatology, George Washington University School of Medicine and Health Sciences, Washington, DC.
¹⁸ 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.

PMID: 35987995
DOI: 10.1016/j.jaip.2022.06.044

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.

Keywords: Atopic dermatitis; Dietary elimination; Dietary exclusion.

Publication types

Meta-Analysis
Systematic Review

MeSH terms

Dermatitis, Atopic* / epidemiology
Dermatitis, Atopic* / therapy
Diet
Eczema*
Humans
Immunoglobulin E
Infant
Pruritus
Sleep Initiation and Maintenance Disorders*

Substances

Immunoglobulin E