FAMP-IT
Food Allergy Management and Prevention
Support Tool for Infants and Toddlers
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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.

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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.

Early Food Introduction
Skincare and Eczema Management
IgE Mediated Food Allergy
Non-IgE MediatedFood Allergy

EMR
Documentation

Patient
Instructions

Cutaneous Allergen Sensitization Skincare and Eczema Management Referral for Dermatology/Allergy

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.

eczema examples
Courtesy of the Food Allergy Center for Food Allergy & Asthma Research

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 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.

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
  10. 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.
  11. Leung DYM, Berdyshev E, Goleva E. Cutaneous barrier dysfunction in allergic diseases. J Allergy Clin Immunol.2020;145(6):1485–1497.
  12. Lack G, et al. The dual-allergen exposure hypothesis: Revisited and updated. Allergy. 2022;77(1):7–16.
  13. Brough HA, et al. Environmental peanut exposure and the risk of peanut sensitization and allergy. J Allergy Clin Immunol. 2020;145(2):633–643.
  14. Smeekens JM, et al. Household food allergen exposure and sensitization in early life. Curr Allergy Asthma Rep.2021;21:48.
  15. 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.
  16. Greenhawt M, et al. Peanut allergen persistence on hands and the effect of handwashing. Ann Allergy Asthma Immunol.2021;127(2):214–220.
  17. Maloney JM, et al. Persistence of peanut protein in saliva after ingestion. J Allergy Clin Immunol. 2020;146(4):889–891.
  18. 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.
  19. Flohr C, et al. Atopic dermatitis and the risk of food allergy. Allergy. 2021;76(3):748–761.
  20. 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.
  21. Leyva-Castillo JM, et al. Epithelial-derived cytokines in allergic skin inflammation and food allergy. Nat Rev Immunol.2023;23(4):233–247.

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