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Case Quiz

Evaluating Environmental and Food Allergies in an Infant with Severe Atopic Dermatitis

Supported by an independent educational grant from Pfizer

A 10-month-old male infant with severe atopic dermatitis (BSA 25%, including facial and scalp involvement) presents for evaluation and management of his AD. His mother notes that he has never successfully breastfed due to difficulties latching on, which resulted in the family feeding him a standard cow milk-based formula around a month of age (prior to which he had already developed very dry skin and eczema affecting his face and creases). Upon starting formula, he developed gastrointestinal distress including frequent vomiting and irritability, as well as microscopic blood in his stools, which led to him switching initially to an extensively hydrolyzed (hypoallergenic) cow milk-based formula and then to an amino acid-based formula which he still currently drinks. He has eaten several pureed fruits and vegetables without any problems, and is growing and developing well. His mother has been reluctant to feed him any “allergenic” foods like peanut, egg, or wheat, and is unsure about what to do with dairy given his history. She reports there are two dogs in the home, including a new puppy that they got a few months ago. She is not sure if the dogs may be a factor but feels his AD may have worsened a month or two after the dog was brought into the home. All of the following are appropriate next steps, EXCEPT:

A. IgE testing for foods including peanut, cow’s milk, egg white, tree nuts, wheat, soybean and advice to STRICTLY avoid any foods that the infant tests positive against, with regular follow up and repeat IGE testing every 6 months to determine if the child may be outgrowing the food allergies.

B. Screening prick-skin testing for foods including peanut, cow’s milk, egg white, tree nuts, wheat, soybean with the intent of pursuing oral food challenges to any foods that test positive

C. Prick-skin testing for dog, cat, dust mites, and a limited number of environmental aeroallergens to determine if something in the infant’s environment could be contributing to his atopic dermatitis

D. Explain to the mother that although food allergies do not cause AD, infants with moderate to severe AD are at higher risk for developing food allergies and that if screening testing is performed, it is not definitive for diagnosing a food allergy and further testing, including food challenges, may be necessary to accurately diagnose the food allergy.