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.

Consider suggesting that caregivers wash their hands before applying creams or moisturizers and prior to diaper changes, especially after handling allergens.

Dual Exposure 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 a sensitivity or 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

References

1. 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.
2. Lack G. Update on risk factors for food allergy. Journal of Allergy and Clinical Immunology. 2012 May 1;129(5):1187-97.
3. 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.
4. 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
5. 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.
6. 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.
7. 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.
8. 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.
9. 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

Moisturizing

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. Make sure to 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 child’s skin.

Soak and Seal Method

The child should be given a bath 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.

Steroid Use

Topical steroids are effective in the treatment of eczema. 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. Make sure to prescribe a weaker steroid for the face.

For eczema that is more difficult to manage, consider using the techniques below:

Wet Wraps

Wet wrap therapy can be useful for eczema flares. After the bath, caregivers should apply moisturizers, moisten clean clothes or gauze, and wrap the affected areas on the patient. The wet wraps should then be covered with dry covers and left on overnight.

Bleach Baths

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.

References

1. 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
2. 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

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.

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] 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.

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

For infants and toddlers specifically, pediatric allergists assist families to determine when and in what form to introduce commonly allergenic foods into the diet, and what strategies and steps to take in the lifestyle and in the home to prevent the development of food allergies. Allergists work closely with families to determine the best course of action for their child’s health needs and help guide families on how to integrate foods back into an infant or toddler’s diet over time and/or in a controlled setting. They are able to update families on the most up-to-date science when it comes to food allergies in this population.

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.

If you would like to refer your patient to a pediatric allergist, American Academy of Allergy, Asthma and Immunology (AAAAI) and American College of Allergy, Asthma, and Immunology (ACAAI) both have information on how to find a local allergist in your community.

Pediatric Dermatologist

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.