A recent invited commentary responding to a JAAD "Game Changer" article about Bronsnick et al.'s 2014 review reported that dietary changes are not strongly supported by current evidence for preventing or treating atopic dermatitis.
The authors reviewed updated guidelines and noted that breastfeeding may help reduce atopic dermatitis (AD) risk, but probiotic use and food elimination diets remain unproven and potentially harmful if not guided by specialists.
"There is lack of evidence to support maternal dietary restrictions either during pregnancy or during lactation to prevent atopic disease," wrote authors Katherine E. Herman, MD, PhD; Lisa A. Beck, MD; and Kirsi M. Järvinen, MD, PhD. Regarding maternal allergen avoidance diets, they note there are no randomized controlled trials (RCTs), though such trials are currently ongoing. They cited the American Academy of Pediatrics (AAP) and emphasized the need for coordinated care across specialties.
Published in the Journal of the American Academy of Dermatology, the commentary notes studies have suggested that probiotics could prevent AD, but the findings are limited. Only certain bacterial strains have shown any benefit, and trial designs have varied.
Therefore, the evidence supporting probiotic supplementation is still of low certainty according to the authors. Ongoing trials test different strains and treatment timing—before and after birth—to determine if they help prevent AD.
The commentary also stated that unnecessary food elimination diets may do more harm than good. Updated guidelines from the American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI) discourage this approach. Eliminating food early in life may increase the risk of IgE-mediated food allergy. Food tolerance is supported by regular and early oral exposure to a variety of foods.
Physicians were advised to refer patients with suspected food allergies, especially infants with severe AD, to allergy/immunology specialists. The authors also warned against ordering panel-based food IgE testing, which may lead to unnecessary food avoidance and parental stress while waiting for specialist consultation.
On infant feeding, the authors noted updated guidance from the AAP that now states: "There is evidence that exclusive breastfeeding for the first 3 to 4 months decreases the cumulative incidence of eczema in the first 2 years of life." This is a shift from earlier thinking that breastfeeding had no protective effect.
Hydrolyzed formulas are also no longer recommended to prevent atopic disease. A recent meta-analysis found no strong evidence that partially or extensively hydrolyzed formulas reduce allergic risk, even in infants considered high risk.
The authors concluded that prevention and treatment strategies for AD and food allergy are changing quickly. They stressed the importance of communication among dermatologists, allergists, pediatricians, and obstetricians. "It is daunting for clinicians to stay current with shifting recommendations," they wrote.
Funding sources: U19AI117673 (LAB), U01AI173032 (KJS). Author disclosures are available in the original article.