A common question parents ask is if certain foods might be making their infant’s or child’s eczema worse. This is an important, yet tricky, question as a nutritious, well-balanced diet is especially important for the health of a child’s skin, body, and mind. That being said, there are safe ways to improve your child’s eczema by adjusting their diet. This blog reviews how I think about the relationship between food and eczema (atopic dermatitis), and I hope you find these tips helpful in exploring triggers while ensuring that you do not restrict your baby’s or child’s diet without a clear benefit to their eczema.

How can I tell if food allergy or food sensitivity might be triggering my child’s eczema?

Food allergies are more likely to play a role in younger children whose eczema is severe and does not respond to steroid creams and moisturizers. Various signs may include:

Clear signs:

• • Immediate reactions: Itchy rashes (urticaria or hives), lip swelling, vomiting, or wheezing within seconds to minutes of being exposed to a food. This is a clear sign of food allergy and the food should be avoided completely until you see your pediatrician or allergist
  • Delayed reactions: Eczema worsening 1-2 days after eating a specific food. This is rare and harder to figure out. Advice on identifying this type of delayed reaction is provided in the next section of this blog (“How can I check for delayed reactions to food?”)

Suggestive signs:

• • Onset of eczema before 6 months of age
  • Rashes (such as hives) when suspected foods touch the skin
  • Unexplained stomach symptoms (persistent vomiting or spitting up, diarrhea, constipation, or bloating)
  • Your child’s growth is faltering
  • There is a family history of food allergies

Signs that food is unlikely to be playing a role:

• • Eczema started after 2 years of age
  • Eliminating a food for 4 weeks does not lead to clear and significant improvements in symptoms

How can I check for delayed reactions to food?

As eczema is a condition that tends to get better or worse based on many environmental, developmental, and emotional factors, pinpointing a specific delayed food trigger can be complicated. The most reliable way to know if a food sensitivity is triggering your child’s eczema is to completely avoid one food for 4 weeks. Common dietary triggers in young children are cow’s milk, eggs, peanut, soy, nuts, and fish. You should aggressively check ingredients on all products during this time to ensure 100% avoidance of the specific food item. After 4 weeks, let your child eat the food for two days. If your child has a flare of eczema during the 1-2 days of reintroducing the food, it is possible that your child’s eczema is aggravated by that food.

It is helpful to take photographs of your child’s skin on (1) the first day of the elimination diet, (2) two weeks into the diet, (3) at the four-week conclusion of the diet, and (4) at two days after reintroducing the food. If you are still unsure whether the food elimination helped or not, you can try the four-week avoidance test one more time.

DO NOT try this test if your child gets swollen lips, hives, or wheezing when exposed to foods. This kind of immediate type of food allergy should be evaluated with the help of your pediatrician and an allergist.

Are there tests that can help find food triggers?

Blood tests and skin prick allergy tests can be very helpful, when combined with a good history, in identifying foods that might cause an immediate reaction to food (i.e., reactions that occur within 30 minutes of exposure to a food). Sometimes the same foods that are causing immediate reactions will also cause delayed eczema flares 1-2 days later. In these cases, seeing an allergist can be helpful in identifying some of your child’s food triggers. The most common foods in this category are cow’s milk and eggs in young children and pollen-associated foods in older children.

Ruling out allergies is another way blood tests and skin prick tests can be helpful. A negative blood test and/or skin prick test can often be very helpful in reliably telling us that your child does not have a dangerous allergy to certain foods.

Can formula trigger eczema flares?

In young infants with severe atopic dermatitis, cow’s milk protein allergy (CMPA) can be an important trigger. Signs of CMPA can include resistant eczema, weight loss, diarrhea, vomiting, bloating, and spitting up. If you think cow’s milk might be playing a role, you should discuss doing a 4-week trial of replacing cow’s milk formula with either a low allergenic “extensively hydrolyzed protein” formula (e.g. Nutramigen or Similac alimentum) or an “amino acid based formula” (e.g. Neocate or Nutramigen AA). These cow’s milk replacements typically do not taste as good as standard formula milk, so you should be prepared for a short struggle to get your child into one of these products.

After 4 weeks, assess how your child’s eczema has been. If it has significantly improved, you should talk to your pediatrician about continuing a healthy diet as you wean from formula and transition to a milk free diet. A nutritionist can be helpful in ensuring you provide enough calcium, protein, and calories to support the growth of your child—maintaining a healthy milk free diet is not easy and you shouldn’t attempt it alone!

Can foods aggravate eczema in other ways?

Some foods might aggravate eczema through non-allergic reactions that involve histamine pathways. In these cases, areas of the body in direct contact with sufficient amount of the foods, such as the cheeks or hands, flare. Creating a barrier by applying a thick cream (such as Vaseline or Aquaphor) to the face before and after eating these foods may help your child enjoy these foods without flaring their eczema. Alternatively, just limiting the quantity of these foods that your child eats may be enough to prevent flares (rather than avoiding them completely). However, strictly avoid these foods if they are causing lip swelling or wheezing or immediate itching all over the body—these could be signs of a true allergy that should be evaluated by your pediatrician and an allergist.

High histamine foods include:

• • Dairy products (like yogurt)
  • Dried fruits (like raisins or cranberries)
  • Avocados
  • Eggplant
  • Spinach
  • Processed meats (like sausage or other breakfast meats)
  • Shellfish (like shrimp)

Foods that trigger histamine reactions may include:

• • Bananas
  • Tomatoes (like in spaghetti sauce)
  • Many beans (like baked beans)
  • Papaya
  • Chocolate
  • Citrus fruits (oranges, kiwi, strawberries, pineapple, and plums)
  • Some food dyes and other additives

Are there foods that help eczema?

Children with a nutritious, well balanced diet tend to do best. Several epidemiological studies have shown an association between the diversity of foods given in the first year of life and protection from atopic dermatitis (eczema). As low iron levels in the body can cause itching, and is common in children with eczema, increasing iron in the diet (through green vegetables and red meat) can be helpful. Choosing natural foods with complex carbohydrates instead of processed foods and simple sugars (i.e. sugary beverages) may also reduce inflammation and reduce eczema flares.

Should I balance short-term benefits with potential long-term risks?

Yes! There is convincing evidence that exposing children to a wide variety of foods early in life makes them less prone to developing food allergies. This is especially true for peanuts, where early introduction of infant-safe forms of peanuts between 4 to 6 months of life may prevent peanut allergy. The American Academy of Pediatrics has published guidelines to help pediatricians and families decide how to introduce peanuts to low and high-risk infants in order to prevent peanut allergies (https://www.aappublications.org/news/2017/01/05/PeanutAllergy010517). Similar research is being performed for egg and other food allergens (https://pediatrics.aappublications.org/content/143/4/e20190281#sec-9). Before embarking on dietary restrictions, I strongly suggest that caregivers discuss with their medical team the potential short-term benefits of eczema improvement through food avoidance versus the long-term risks of losing tolerance to food allergens through dietary restriction. Many patients decide that they prefer to avoid processed foods and sugars and apply an occasional topical steroid for eczema flares rather than forego the benefits of a diverse and well-balanced diet.

Looking for other good sources of information on atopic dermatitis (eczema) and diet? Check out these links!

“Everything You Need to Know About Eczema and Food Allergies” by the National Eczema Association

https://nationaleczema.org/eczema-food-allergies/

“Diet and your Child’s Atopic Eczema” by The Nottingham Support Group for Carers of Children with Eczema

http://www.nottinghameczema.org.uk/documents/diet-and-your-child-14diet1212.pdf

“Childhood Eczema” by The American Academy of Dermatology https://www.aad.org/public/diseases/eczema/childhood

“Atopic Dermatitis (Eczema)” by The Society for Pediatric Dermatology

https://pedsderm.net/site/assets/files/1028/spd_atopic_dermatitis_color_web_final2.pdf