‘Enhanced’ Eczema Treatment Cut Food Allergy Risk, but at What Cost?

Enhanced treatment of atopic dermatitis with topical corticosteroids significantly reduced hen’s egg allergy compared with conventional reactive treatment in infants, but also resulted in adverse effects on growth, a randomized controlled trial in Japan showed.

Among 640 infants ages 7 to 13 weeks, 31.4% of those who received enhanced treatment to clinically affected and unaffected skin developed hen’s egg allergy compared with 41.9% of those who received reactive treatment to clinically affected skin only (P=0.0028), reported Yukihiro Ohya, MD, PhD, of the National Center for Child Health and Development in Tokyo, and co-authors.

However, compared with conventional treatment, enhanced treatment also reduced infant height (mean difference -0.8 cm, 95% CI -1.22 to -0.33) and weight (mean difference -422 g, 95% CI -553 to -292) at 28 weeks, they noted in the Journal of Allergy and Clinical Immunology.

“We highlight the potential of well-controlled atopic dermatitis management as a component of a food allergy skin prevention strategy for high-risk atopic dermatitis in infants,” the group wrote.

In order to avoid the adverse effects of topical corticosteroids, they added, “the enhanced atopic dermatitis treatment protocol described in this trial should be modified before it can be considered as an approach to prevent food allergy in daily practice.”

Atopic dermatitis is a strong risk factor for food allergy, the researchers explained, and it’s believed that early intervention or prevention of atopic dermatitis can reduce the risk of food allergy. One aim of this study was to expand treatment beyond application only when a rash occurred.

“With respect to early interventions for preventing or treating atopic dermatitis in past several trials, those using only emollients (moisturizers) or pimecrolimus as reactive treatment on affected skin did not prevent food allergy,” Ohya and team explained. “Emollients and weak anti-inflammatory medication applied only to clinically affected skin lesions might be insufficient to prevent food allergy. Proactive treatment is a long-term maintenance approach using low-dose intermittent anti-inflammatory topical agents such as topical corticosteroids to previously affected or usually relapsing body areas.”

When comparing the two treatment groups, the proportion of participants who were positive for hen’s egg white immunoglobulin E was smaller in the enhanced group, at 44.9%, compared with 52.5% in the conventional treatment group.

Both wheezing episodes (6.9% vs 5.6%) and immediate reactions to any foods prior to oral food challenges (1.57% vs 1.55%) were similar between the two treatment groups.

Patients in the enhanced treatment group did have a higher use of rescue medication (2.2% vs 0%), but experienced more disease-free days from atopic dermatitis (risk difference 1.69%, 95% CI 1.66-1.73).

“Our ongoing cohort study (PACI-ON) will evaluate the individual and combine further effects of the early introduction plus enhanced skin care on food allergy prevention and how long-term outcomes will be,” Ohya and colleagues noted.

For this multicenter, parallel-group, open-label trial conducted at 16 Japanese hospitals from July 2017 to February 2021, the researchers included 640 infants with atopic dermatitis who were randomly assigned in a 1:1 ratio to enhanced early skin treatment or conventional reactive treatment using topical corticosteroids.

Patients in both treatment groups applied Heparinoid cream twice a day during the study period. The enhanced treatment group applied alclometasone dipropionate 0.1% to the entire face and betamethasone valerate 0.12% to the whole body twice a day for 14 days, while those in the conventional treatment group used them only in response to rashes, based on the severity of the rash.

Hen’s egg allergy was confirmed by oral food challenge at 28 weeks of age.

Serious adverse events were more common in the enhanced treatment group than the conventional treatment group (5.3% vs 1.9%) but events were determined to be “not fatal, life-threatening, nor permanent,” Ohya and colleagues noted.

Study limitations included the fact that both physicians and caregivers were not able to be blinded to treatment, and treatment for atopic dermatitis was a fixed trial for all infants.