Dietary therapy and allergen elimination
Food allergy is not synonymous with atopic dermatitis, yet in 30–40% of young children, it acts as a leading trigger for exacerbations. Imposing strict restrictions without valid reasons is unacceptable, as it diminishes the child's quality of life.
An elimination diet trial is introduced for 2–4 weeks. The golden rule is adequate nutritional substitution of the excluded foods to prevent deficiencies. If there is no clinical improvement, the product is reintroduced into the diet.
Management strategy for cow's milk protein allergy (CMPA):
- Formula feeding: switch to formulas based on extensively hydrolyzed protein. In case of concomitant lactase deficiency, lactose-free hydrolysates are indicated.
- Breastfeeding: strict hypoallergenic maternal diet with complete avoidance of any dairy products.
Typically, elimination lasts from 4 to 6 months, and up to a year in cases of severe sensitization. It is important to remember cross-reactivity: in CMPA, beef can become a trigger, while in egg allergy, chicken meat can.
To accurately diagnose a food allergy, a triad is required: a clear medical history (e.g., reaction 30 minutes after formula feeding), high titers of specific IgE, and positive skin prick tests.
Topical therapy: TCS use
Topical glucocorticosteroids (TCS) are the first-line drugs for rapid suppression of inflammation in the acute phase. Their potency depends directly on the vehicle.
Rule for matching the drug form to the lesion type:
- Lotions and emulsions — used for pronounced exudation (weeping) and on the scalp. Applying ointments to weeping areas is a major error.
- Creams — optimal for acute and subacute processes without exudation, as well as for skin folds.
- Ointments — used for subacute and chronic inflammation.
- Greasy ointments — necessary for severe chronic courses with lichenification and marked xerosis (dryness). Creams are ineffective under such conditions.
Risks in pediatrics: The stratum corneum in infants is extremely thin, which sharply increases the risk of systemic drug absorption. Fluorinated TCS are strictly contraindicated on the face, skin folds, anogenital area, and diaper dermatitis zones. In the presence of pustular infections (pyoderma), hormones are temporarily contraindicated until the infection is completely cured.
Second-line therapy and management of complications
If TCS are ineffective or their use is limited, topical calcineurin inhibitors (TCIs) — pimecrolimus (1% cream) or tacrolimus (0.003% ointment) — are prescribed for moderate to severe cases.
Emollients remain a mandatory component of treatment at all stages. They moisturize the skin, relieve dryness, and reduce its permeability to allergens.
In case of bacterial infection of excoriations, topical antiseptics are included in the regimen. If systemic symptoms appear (fever, intoxication), systemic antibiotics are added. The development of a severe viral complication — Kaposi's varicelliform eruption — requires the immediate administration of antiviral agents (acyclovir).
Systemic and supportive therapy
Systemic antihistamines are used to suppress pruritus, edema, and erythema. Preference is given to non-sedating second-generation agents (cetirizine, levocetirizine) due to their prolonged action and high receptor affinity.
Systemic glucocorticoids are a deep reserve. They are administered parenterally in a short course (4–7 days) only for extremely severe, uncontrolled exacerbations. In the most resistant cases, the use of immunosuppressants (cyclosporine) may be justified.
Vitamins (B5, B6), antioxidants, and enterosorbents are used as adjuvant therapy. Magnetotherapy, climatotherapy, and reflexology also show positive dynamics.
Prognosis
The outcome largely depends on the age of onset and the timeliness of treatment.
- Favorable prognosis: with early manifestation (in the first year of life) and adequate therapy, spontaneous resolution occurs by preschool age (1.5–5 years) in most children.
- Unfavorable prognosis: late onset (older than one year) and persistence of symptoms after 5 years significantly increase the risk of chronicity and transition of dermatitis into adulthood.
The 'W-R-D' rule for choosing steroid formulation: Weeping — emulsion/lotion, Red (in skin folds) — cream, Dry/lichenified skin — ointment.
Class and exam questions
Can ointments be applied to weeping areas?
No, this is considered a major clinical error. Exudative lesions (with weeping) are indications exclusively for lotions or emulsions.
How long should a child remain on a dairy-free diet for cow's milk protein allergy?
The standard duration of an elimination diet is from 4 to 6 months. In cases of high sensitivity, the diet may be extended up to 1 year until tolerance develops.
What else to study on this topic
- Diagnostic criteria for cow's milk protein allergy.
- Differential choice between generations of antihistamines.
- Clinical features and treatment of Kaposi's varicelliform eruption.
- Mechanism of action and application rules for topical calcineurin inhibitors.
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Other topics in "Chapter 5. Allergic Diseases"
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