Food Allergy Management and Prevention Support Tool for Infants and Toddlers
Eczema and Cutaneous Allergen Sensitization
The following section offers detailed information on eczema and its relation to cutaneous allergen sensitization. Key takeaways include:
While early oral introduction of allergens like peanut may help induce tolerance, routine skin exposure to food may increase the risk of developing IgE to the food (sensitization) and ultimately the development of a food allergy (1,2,3).
Studies have demonstrated the presence of food proteins in the environment. While most studies have focused on peanuts, the findings may be helpful when approaching other foods (1).
Several studies have linked environmental peanut allergen exposure to sensitization and food allergy to peanut (1,3,4,7).
Although this association has been shown in individuals with healthy skin, eczema may increase the risk (4).
The development of Atopic Dermatitis is multifactorial, including genetic predispositions, skin barrier disruption, environmental triggers, and immune dysfunction, increasing the risk of sensitization to environmental food exposure.
Considerations for caregivers:
Suggest washing hands before applying creams or moisturizers and before diaper changes, especially after handling allergens.
Cleaning surfaces and hands that come in contact with peanut may help decrease environmental exposures to peanut and other allergens (5,6).
Cutaneous Allergen Sensitization
While early oral introduction of allergens like peanut may help induce tolerance to food, routine skin exposure to food may increase the risk of developing IgE to the food (sensitization) and ultimately the development of a food allergy (1,2,3).
Studies have demonstrated the presence of food proteins in the environment. While the majority of studies have been done with peanuts, information learned may be helpful when approaching other foods (1). There is evidence of detectable peanut protein on high-touch surfaces in kitchens, detected after peanut is consumed (5). Dust samples in carpets, mattresses, and play space have also been detected (3,4,5). Peanut proteins have also been shown on hands (6) and in saliva after consuming peanut (8). All can be sources of environmental food exposures. Cleaning surfaces and hands that come in contact with peanut may assist with decreasing environmental exposures to peanut and other allergens (5,6).
Several studies have linked the presence of environmental peanut allergen and sensitization and food allergy to peanut (1,3,4,7) Although this association has been shown in those with healthy skin, eczema may increase risk (4). Skin barrier dysfunction and inflammation may be components of eczema that increase risk of sensitization to environmental food exposure. Although the majority of studies have been on peanut similar trends likely exist for other foods as well.
Courtesy of the Food Allergy Center for Food Allergy & Asthma Research
DualExposure Hypothesis
Under the dual-exposure hypothesis, if a child experiences frequent environmental exposures through their skin, but avoids oral exposure of an allergenic food (e.g. peanuts), they may be more likely to develop an allergy to peanut. When a child is routinely exposed to a food allergen via the skin (e.g. food touches the skin), the immune cells of the skin are more likely to cause sensitization to that food. This is especially true if the skin is inflamed or irritated, as is the case with eczema
Guidance for caregivers
Handwashing and appropriate surface cleaning have been shown to significantly reduce detectable peanut allergen levels and may help mitigate environmental exposure. Encourage caregivers to wash hands after eating and before changing baby’s diaper or putting on lotion. Maintaining a regularly cleaned environment can also help, such as wiping down common surfaces and washing bedding that baby comes in contact with.
Eczema Information
What is eczema?
Eczema, atopic dermatitis, is a chronic skin condition clinically diagnosed by the presence of characteristic features such as pruritus, scaling, and lichenification that commonly relapses, with the onset of disease usually occurring before 1 year of age.
The prevalence of AD has been increasing, affecting on average 12.6% of children in the United States, and as high as 25%, disproportionately affecting black and hispanic populations.
While most cases of AD start before the age of 1, many children will outgrow the condition in the future.
Common Location of Eczema?
The distribution of eczema varies with age, with the most common location being the flexor regions, such as behind the knees and inner elbows. Infants often present with eczema on the cheeks, trunk and extremities, where teenage children more commonly present with eczema of the hands and feet.
Diagnosis of Eczema
The American Academy of Dermatology recommends clinical diagnosis of atopic dermatitis based on historical features, morphology and distribution of skin lesions, and associated clinical signs, without requiring laboratory testing.
Eczema Severity Scoring
The following validated tools can be considered when practical.
Sheehan WJ, Taylor SL, Phipatanakul W, Brough HA. Environmental food exposure: what is the risk of clinical reactivity from cross-contact and what is the risk of sensitization. The Journal of Allergy and Clinical Immunology: In Practice. 2018 Nov 1;6(6):1825-32.
Lack G. Update on risk factors for food allergy. Journal of Allergy and Clinical Immunology. 2012 May 1;129(5):1187-97.
Brough HA, Kull I, Richards K, Hallner E, Söderhäll C, Douiri A, Penagos M, Melen E, Bergström A, Turcanu V, Wickman M. Environmental peanut exposure increases the risk of peanut sensitization in high‐risk children. Clinical & Experimental Allergy. 2018 May;48(5):586-93.
Brough HA, Liu AH, Sicherer S, Makinson K, Douiri A, Brown SJ, Stephens AC, McLean WI, Turcanu V, Wood RA, Jones SM. Atopic dermatitis increases the effect of exposure to peanut antigen in dust on peanut sensitization and likely peanut allergy. Journal of Allergy and Clinical Immunology. 2015 Jan 1;135(1):164-70
Brough HA, Makinson K, Penagos M, Maleki SJ, Cheng H, Douiri A, Stephens AC, Turcanu V, Lack G. Distribution of peanut protein in the home environment. Journal of allergy and clinical immunology. 2013 Sep 1;132(3):623-9.
Perry TT, Conover-Walker MK, Pomés A, Chapman MD, Wood RA. Distribution of peanut allergen in the environment. Journal of Allergy and Clinical Immunology. 2004 May 1;113(5):973-6.
Brough HA, Liu AH, Sicherer S, Makinson K, Douiri A, Brown SJ, Stephens AC, McLean WI, Turcanu V, Wood RA, Jones SM. Atopic dermatitis increases the effect of exposure to peanut antigen in dust on peanut sensitization and likely peanut allergy. Journal of Allergy and Clinical Immunology. 2015 Jan 1;135(1):164-70.
Maloney JM, Chapman MD, Sicherer SH. Peanut allergen exposure through saliva: assessment and interventions to reduce exposure. Journal of Allergy and Clinical Immunology. 2006 Sep 1;118(3):719-24.
Northwestern Medicine. (n.d.). Infant Atopic Dermatitis Severity Scorecard: vIGA-ADTM with examples. iREACH Training Materials (Early Peanut Product Introduction Tools for Pediatric Clinicians. https://www.feinberg.northwestern.edu/sites/cfaar/docs/Pediatric%20Clinician%20Atopic%20Dermatitis%20Severity%20Scorecard2.pdf
Turner PJ, Campbell DE, Boyle RJ, Levin ME. Primary prevention of food allergy: Translating evidence from clinical trials to population-based recommendations. J Allergy Clin Immunol. 2021;147(6):2020–2029.
Leung DYM, Berdyshev E, Goleva E. Cutaneous barrier dysfunction in allergic diseases. J Allergy Clin Immunol.2020;145(6):1485–1497.
Lack G, et al. The dual-allergen exposure hypothesis: Revisited and updated. Allergy. 2022;77(1):7–16.
Brough HA, et al. Environmental peanut exposure and the risk of peanut sensitization and allergy. J Allergy Clin Immunol. 2020;145(2):633–643.
Smeekens JM, et al. Household food allergen exposure and sensitization in early life. Curr Allergy Asthma Rep.2021;21:48.
Perry TT, et al. Distribution of peanut allergen in the environment and effectiveness of cleaning methods. J Allergy Clin Immunol. 2020;145(2):667–669.
Greenhawt M, et al. Peanut allergen persistence on hands and the effect of handwashing. Ann Allergy Asthma Immunol.2021;127(2):214–220.
Maloney JM, et al. Persistence of peanut protein in saliva after ingestion. J Allergy Clin Immunol. 2020;146(4):889–891.
Brough HA, et al. Atopic dermatitis increases the effect of environmental peanut exposure on peanut sensitization. J Allergy Clin Immunol. 2020;146(2):367–375.
Flohr C, et al. Atopic dermatitis and the risk of food allergy. Allergy. 2021;76(3):748–761.
Strid J, Hourihane J, Kimber I, Callard R, Strobel S. Epicutaneous exposure to food allergens and the development of food allergy. Clin Exp Allergy. 2022;52(4):465–477.
Leyva-Castillo JM, et al. Epithelial-derived cytokines in allergic skin inflammation and food allergy. Nat Rev Immunol.2023;23(4):233–247.
Eczema Management
Current practice parameters recommend treatment options to both prevent eczema flare-ups and manage symptoms in infants and toddlers. The following section provides guidance on several topics for shared decision-making with caregivers:
Moisturizers
Baths
Prescription moisturizers
Corticosteroids
Topical calcineurin inhibitors
Wet wraps
Bleach baths
Preventative Care
The following recommendations can be used to prevent eczema flare-ups and worsening of symptoms in infants and toddlers.
Moisturizers
The best preventive care for Atopic Dermatitis is moisturization, as it enhances the skin barrier to protect from allergens, pathogens, and injury while also reducing water loss, which can predispose skin damage. The recommendation for caregivers is to:
Apply fragrance-free, thick-texture moisturizer with low water content daily, especially after bath, shower, or hand washing.
Apply moisturizer at least daily, especially within 3 minutes after bathing, to lock in the moisture. Waiting too long after bathing can dry out a child’s skin.
Wash hands before applying the moisturizer, to avoid trapping any allergens or germs that may be on hands against the child’s skin.
Use moisturizers that are fragrance- and dye-free, as they will be less irritating on the baby’s skin.
Avoid Triggers
Avoiding triggers such as low humidity, and skin irritants like harsh soaps, detergents, and contact allergens should be recommended to patients with eczema.
Soak and Seal Method
Daily short baths with lukewarm water and gentle cleaners, with an emphasis on moisturizer immediately after, is the most common pediatric dermatologist recommendation for patients with eczema. The recommendations for caregivers are:
The child should be given short bath of about 10-15 minutes daily in lukewarm water with gentle cleanser.
The caregiver should gently pat (not rub) off the water using a towel and leave the skin slightly damp.
Topical steroids or medications should be applied as prescribed after the bath.
Moisturizer should then be applied all over the body, within 3 minutes. The moisturizer should be absorbed into the skin before clothes are placed on the child.
Treatments
The following recommendations can be used to help caregivers manage their baby’s eczema symptoms. Before initiating any new therapy:
Ensure correct diagnosis and identify complicating diagnoses
Provide education on the disease and provide an action plan
Address trigger avoidance
Ensure proper medication use/adherence
Encourage application of a fragrance-free, dye-free, and additive-free moisturizer as needed for symptomatic benefit
Topical Treatment – Over-the-Counter Moisturizers
In addition to preventative care, moisturizers should be used as part of treatment. Bland and fragrance-free options are best, with other considerations based on benefits and shared decision-making. These can include:
Moisturizer form, including lotion, cream, gel, or ointment
Cost
Acceptability
Accessability
Topical Treatment – Prescription Moisturizers
Patients who have not improved sufficiently with routine use of standard OTC moisturizer may prefer a trial of prescription moisturizer before adding topical anti-inflammatory medications. This may be insurance- and cost-dependent. Examples include: Atopiclair, Eletone, Epiceram, MimyX, Neosalus, Zenieva, and PruMyx (3)
Topical Treatment – Corticosteroids
Topical steroids are effective in the treatment of eczema. For patients with uncontrolled AD refractory to moisturization alone, the addition of a topical corticosteroid (TCS) is strongly recommended. If topical steroids are needed, recommend applying 1-2 times a day for 7 days on active lesions and continue application for 2-3 days after eczema lesions have resolved. (3)
Exactly which potentcy level (high, medium, low) TCS to use depends on previous treatment history, site of applications, cost, accessibility, values, and preferences
Avoid high-potency for prolonged periods (>4 weeks) and limit its use on sensitive areas like face, folds, or groin
Action plans could help if required to have different potency for different sites of the body depending on severity of AD activity, such as a weaker steroid for use on the face
Other topical treatments
Additional topical treatments exist, but are recommended depending on other factors, such as age, eczema severity and location, and effectiveness of previous treatments. (3) They can include:
Topical calcineurin inhibitors (TCI)
Pimecrolimus and Tacrolimus 0.03% approved for 2 years and older
Can be utilized for more sensitive areas like face and folds
Great option for AD flares
Wet wraps
Wet wrap therapy can be useful for eczema flares (1)
After the bath, caregivers should apply moisturizers, moisten clean clothes or gauze, and wrap the affected areas on the patient
Apply for 4-7 days for minimum of 1 hour to maximum overnight once per day
PDE4 inhibitor (crisaborole 2% ointment)
Approved for age 3 months and older
Conditionally recommended for mild-moderate AD refractory to moisturization alone
Adverse effects are more prominent in sensitive areas
Treats mild AD flares and smaller benefits in severe cases
Can be recommended for patients that highly value noncorticosteroid treatments
Small improvements in achieving AD remission, itch, quality of life, and reducing the chance of flare-up
Antimicrobials – NOT recommended in patients with uncontrolled AD with no serious bacterial skin infection
Patients who place a high value on polypharmacy and antimicrobial resistance prefer avoiding adding to standard care. For severe skin infections, guidance from the Infectious Disease Society of America addresses when to use systemic or topical antimicrobials.
Preferred addition for those who are immunocompromised or suppressed, severe infection or history of severe infections, severe AD, or who place high value on avoiding complications of bacterial skin infections
Non-topical treatment – Bleach Baths
Dilute bleach baths are conditionally recommended for patients with moderate-severe AD in addition to topical therapy. (3) In children with moderate to severe eczema, bleach baths may reduce the severity (1). Use unconcentrated household bleach. Fill a bathtub with lukewarm water (about 40 gallons) and add 1/2 cup of bleach. Have the child soak for 10 minutes and then rinse off fully with warm tap water and continue with the child’s skincare routine. Before making this recommendation, consider:
How these baths will fit into routine
Used as an adjunct to otherwise good skin care
Provisions are clear and written instructions provided
The extent of open skin (cracks, fissures, excoriations) may make bleach baths less tolerable to some patients
Likely to see effects in AD severity within 4 weeks
Conditional due to low certainty of benefits and potential harms with open skin
Non-topical treatment – Elimination diet
Elimination Dietswith or without skin testing is conditionally NOT recommended with AD compared with an unrestricted diet. (3) When brought up by a caregiver, consider:
Young age of patient and risk factors for developing IgE-mediated food allergy favor against pursuing elimination diet
Risk for malnutrition
This carries a high risk of false-positive results, which may lead to unnecessary dietary restriction in sensitized but asymptomatic infants, subsequently increasing the risk of developing a true IgE-mediated food allergy.
Those who pursue this provide strategies to mitigate harm; what managing a food allergy entails and scheduling close follow-up (w/i 4 weeks)
Treatments requiring referral
Allergen Immunotherapy, Systemic treatments, and Narrow-band UV-B light (3)
Courtesy of the Food Allergy Center for Food Allergy & Asthma Research
References
Bakaa L, Pernica JM, Couban RJ, et al. Bleach baths for atopic dermatitis: A systematic review and meta-analysis including unpublished data, Bayesian interpretation, and GRADE. Ann Allergy Asthma Immunol. 2022;128(6):660-668.e9. doi:10.1016/j.anai.2022.03.024
Northwestern Medicine. (n.d.). Infant Atopic Dermatitis Severity Scorecard: vIGA-ADTM with examples. iREACH Training Materials (Early Peanut Product Introduction Tools for Pediatric Clinicians. https://www.feinberg.northwestern.edu/sites/cfaar/docs/Pediatric%20Clinician%20Atopic%20Dermatitis%20Severity%20Scorecard2.pdf
Chu, D. K., Schneider, L., Asiniwasis, R. N., Boguniewicz, M., Casale, T. B., Chu, A. W. L., Eigenmann, P. A., Fleischer, D. M., Greenhawt, M., Horner, C. C., Mack, D. P., Milner, J. D., Oppenheimer, J., Schneider, A. T., Searing, D. A., Spergel, J. M., Stukus, D. R., Venter, C., Wang, J., … Golden, D. B. K. (2024). Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations. Annals of Allergy, Asthma & Immunology, 132(3), 274–312. https://doi.org/10.1016/j.anai.2023.11.009
Eczema Management Techniques
These sections contain the same information as in the PDF handouts throughout this section, but are formatted for easier placement within EMR systems to place in after visit patient handouts.
General Skincare:
Apply moisturizer at least daily, especially within 3 minutes after bathing to lock in the moisture. Waiting too long after bathing can dry out your child’s skin. Make sure to wash your hands before applying the moisturizer, as you want to avoid trapping any allergens or germs that may be on your hands against your child’s skin. Use moisturizers that are fragrance-free and dye-free, as they will be less irritating on your child’s skin.
Eczema Management:
Soak and Seal Method
Give your child a bath in lukewarm water with gentle cleansers. After getting out of the bath, gently pat (do not rub) off water using a towel and leave the skin slightly damp. Apply any topical steroids or treatment to the skin. Apply moisturizer all over the body, within 3 minutes, and wait for the moisturizer to absorb into the skin before putting on clothes.
Steroid Use
Topical steroids are effective in the treatment of eczema. If topical steroids are needed, apply 1-2 times a day for 7 days on active lesions and continue application for 2-3 days after eczema lesions have resolved. Make sure to use less strong steroids on the face.
Wet Wraps
Wet wrap therapy can be useful for tougher to manage eczema. After getting out of the bath and applying moisturizers, moisten clean cloth/gauze and wrap the affected areas. Cover the wet wraps with dry covers and leave overnight.
For Eczema
Eczema History:
This text can be used in the patient history to document how the patient’s family manages and treats the patient’s eczema. You can copy and paste it into your EMR system to use during well-child visits or follow up appointments.
The patient [HAS/HAS NOT] been prescribed topical steroids. If so, they are [LIST STEROIDS WITH POTENCY AND FORMULATION)]. The patient uses it [INSERT AMOUNT PER DAY] a day and needs it [INSERT FREQUENCY/MONTH] month. Other skincare regimen consists of [INSERT SKINCARE REGIMEN – INCLUDE MOISTURIZATION AND OTHER MEDS, SUCH AS CALCINEURIN INHIBITOR]. Eczema has been complicated by [CHOOSE ONE OR MORE: NONE, HYPOPIGMENTATION, SCARRING, SUPER INFECTION, NEED FOR ORAL STEROIDS, NEED FOR ORAL ANTIBIOTICS, NEED FOR ORAL ACYCLOVIR]. The caregiver [DOES/DOES NOT] wash his/her/their hands before applying topical creams and/or ointments.
Referral for Dermatology/Allergy
Effective AD management may require a collaborative approach. This page is designed to guide you through:
The role of a Pediatric Allergist and Pediatric Dermatologist
When to seek referral to a specialist within Dermatology or Allergy
The role of the integrated care model in ensuring a seamless transition from primary to specialized care
Pediatric Allergist
A pediatric allergist is a medical doctor who specializes in managing allergic issues for children. Allergists perform the following procedures to screen patients for allergies and can help patients interpret the results to proceed with allergy management:
Skin prick testing (SPT): also known as a scratch test, a tiny droplet of an allergen is placed on the skin, then lightly scratched. Allergists wait 15 minutes to observe for a reaction in the form of a hive
Blood testing: a blood test called Immunocap Specific IgE, measures the concentration of antibodies created in response to the presence of antigen that the body deems harmful
Oral Challenges: a procedure where a patient is administered incrementally increasing doses of a food or drug to assess if they are tolerant to it.
When experiencing any of the following allergic issues, an allergist can also assist patients in determining the best course of treatment:
Anaphylaxis, a severe allergic reaction involving one or more bodily symptoms
Food Allergies, in which a patient may experience any of the following symptoms, including but not limited to urticaria, angioedema, itching, wheezing, or gastrointestinal symptoms, if they are exposed to a food allergen they are allergic to.
Drug allergies, such as to different medications
Environmental allergies, to things common in different environments, including pollen, dust, pet dander, and mold.
Stinging insect allergies, such as to bees
Pediatric allergists also help manage non-IgE mediated allergies and various atopic conditions, including the following:
Allergic rhinitis, inflammation of the nose in response to allergens in the air and surroundings. This may cause symptoms including stuffy nose or rhinorrhea (a runny nose)
Asthma, and related issues including therapies, reliever medications, and associated rhinitis or sinusitis
Atopic Dermatitis (eczema), and all other issues related to eczema, including, contact dermatitis, environmental allergies, etc.
Eosinophilic GI disorders, and helping patients determine what foods may be causing GI issues
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Older populations can participate in studies that utilize immunotherapies (including oral immunotherapy, subcutaneous immunotherapy, or sublingual immunotherapy), which may help research subjects decrease the likelihood of reacting to foods that they are allergic to.
A pediatric dermatologist is a medical doctor who specializes in managing issues pertaining to the skin, hair, and nails. Similar to a pediatric allergist, they can also work with patients in managing medical issues, including the following:
Atopic diseases, such as atopic dermatitis (eczema)
Urticaria (hives)
Pediatric dermatologists also assist patients with issues specific to that patient’s age group. In infants and toddlers, this can sometimes include
Infantile hemangioma: blood vessels that may have grown out of control during development, and are likely to create red rubbery lesions on the skin
Psoriasis: a skin disease that causes itchy, dry patches
Cradle cap: itchy and/or oily scales that may appear on an infant’s scalp
They may prescribe that you use specific medications or products, including ointments and creams that may help in resolving/improving certain skin conditions. They work closely with a patient’s pediatrician in order to create the best care plan for a patient’s needs.
If you would like to refer your patient to a pediatric dermatologist, American Academy of Dermatology (AAD) has information on how to find a local dermatologist in your community.
