What Role Does Diet Play in Managing Atopic Dermatitis?

Medscape

13-06-2025

Eliminating 'problematic' foods or ingredients from the diet is not a sensible measure to apply across all patients with atopic dermatitis (AD), although it may be beneficial for a subset of patients with moderate-to-severe disease who also have documented food allergies. This point was emphasized in several presentations at The World Congress of Pediatric Dermatology (WCPD) 2025 Annual Meeting, held recently in Buenos Aires, Argentina.
'There is currently no role for routine elimination diets in all patients with AD,' said Sandipan Dhar, MD, professor and head of the Department of Pediatric Dermatology at the Institute of Child Health in Kolkata, India, and current vice president of the International Society of Pediatric Dermatology.
Dhar noted that when you google the words 'diet' and 'eczema,' about half of the results come from self-proclaimed 'experts,' 30% from educational websites, and 20% from promotional sites. Among the top 10 results, 80% recommend avoiding milk or dairy, and 50% suggest avoiding soy, wheat, and gluten.
However, only 3%-10% of patients with AD also have food allergies, though that proportion can rise to one third among individuals with moderate-to-severe disease, Dhar explained. 'Remember: Dietary restriction makes no sense in pediatric or adult patients with mild AD.'
Although there are no clear diagnostic criteria, young children with severe AD are more likely to have food allergies, said Dhar. A 2015 population-based cohort study of more than 4000 infants found that those with AD had a sixfold increased risk for food allergy to cow's milk, egg, or peanuts.
Effectiveness of Elimination Diets
Dhar stated that a review of the literature shows 'mixed results' regarding the usefulness of elimination diets in AD, with few randomized, double-blind studies published in the past 20 years supporting a role for food allergy in clinical manifestations of the disease. A 2008 Cochrane review concluded that there is 'little evidence' supporting the use of exclusion diets in unselected individuals with AD.
In 2009, Dhar led an open-label, uncontrolled pilot study in a selected group of 100 infants and children with severe AD. Participants were asked to strictly avoid milk and dairy products, all types of nuts, egg, marine fish, shrimp, eggplant, and soy for 3 weeks. The study found a statistically significant reduction in disease severity scores.
However, Dhar clarified that he now critiques his own study ('this is how science progresses') and that the concept of strict food avoidance has evolved. In the past decade, numerous studies have shown that delaying the introduction of foods such as milk, egg, wheat, and peanuts during infancy actually increases the risk of developing allergies to those foods. In the landmark 2015 LEAP trial from the UK, early introduction of peanuts starting at 4 months of age in infants aged 4-11 months with severe AD and egg allergy significantly reduced the risk for peanut allergy compared to those who avoided peanuts until age 5.
María Fernanda Greco, MD, a panelist at the congress and head of Pediatric and Adolescent Dermatology at the British Hospital in Buenos Aires, Argentina, agreed that there is no single dietary approach suitable for all patients with AD.
However, she emphasized that 'there is growing interest in the role of the gut microbiome in skin health' and suggested that enhancing the gut barrier through diets that promote intestinal health, as well as probiotic supplementation (eg, Lactobacillus and Bifidobacterium found in yogurt and fermented foods) or prebiotics (found in garlic, onions, and bananas), may help improve the skin barrier and reduce disease severity in the short term. For example, a 2021 randomized Polish study found that a probiotic preparation containing three strains ( Lactobacillus rhamnosus ŁOCK 0900, L rhamnosus ŁOCK 0908, and L casei ŁOCK 0918) increased the likelihood of improvement by sixfold over 3 months in children younger than 2 years with AD and cow's milk protein allergy. However, the benefits did not persist after 9 months.
Supplementing with omega-3 polyunsaturated fatty acids may also help modulate inflammatory responses and improve symptoms, she added.
'It's difficult to take a definitive stance [on the role of diet in AD], but I believe that with each patient, we need to assess whether they might benefit from supplementation, food avoidance, or allergy testing,' Greco concluded.
Dhar closed the session by emphasizing that until future studies clarify the relationship between food allergies, AD, and the immune pathways that regulate tolerance and immediate hypersensitivity, clinical decisions about elimination diets should be based on reflective, cautious interpretation of the available evidence.
And if an elimination diet is pursued, it should be personalized 'based on the patient's needs, the severity of eczema, and documented correlations between dietary intake and skin flares or food allergies — without neglecting nutritional balance,' he concluded.
Dhar disclosed advisory or thought-leader roles with some pharmaceutical companies, though his presentation did not reference any commercial products. Greco declared having no relevant financial conflicts of interest.