Post on 18-Jan-2016
Management of
Food Sensitivity and
Skin Diseases
Adela Jamorabo-Ruiz, RND, MSN, DPA, PhD
Professor of Nutrition and Food Science
Nutrition-Dietetics
2014
Dr. Ruiz
Food Sensitivity
• Food sensitivity is any adverse reaction to
foods both immunological and non-
immunological. This covers a wider scope of
reaction than just that caused by true
allergies.
• A food allergy is an immunologic response to
a food protein and may be life-threatening.
• A food intolerance is a digestive issue that is
not life-threatening and is usually related to
carbohydrates in foods (lactose intolerance).
Dr. Ruiz
Food Allergies
• Food-hypersensitivity reactions or adverse
reactions to foods that involve an immune
response (IgE) releasing histamine & serotonin
• True food allergy is an immune-mediated,
hypersensitivity response to a food (usually
protein), which often occurs within 2 hr
(immediate reaction) or within 48 hr (delayed).
• Most common results of food allergies are GI
related (70%); 24% are skin related; 4% are
respiratory: 2% are from other body system
responses. Dr. Ruiz
Food Allergies
• Only about 5% of children are diagnosed with true food allergies (*eggs, fish, *milk, peanuts, shellfish, *soybeans, walnuts & other tree nuts, wheat)
*Some children outgrow their allergies.
• A protein in food is the most common allergic component.
Major Food Allergens
Allergen Remarks Milk Patients may develop deficiencies in protein, riboflavin, calcium,
and vitamins A and D. Eggs Egg yolk is generally tolerated. Check for iron deficiency. Wheat Check for B vitamins and iron. Fin Fish Suggest other sources of protein. Shellfish Crab and shrimp are often implicated. Protein and omega-3
fatty acid should come from other sources. Soy Protein and other nutrients may be needed from other sources. Peanuts Protein and other nutrients may be needed from other sources. Tree nuts Protein and other nutrients may be needed from other sources. Spices Sesame is a fairly common allergen. Artificial food dyes
Tartrazine may cause itchiness or hives in sensitive individuals.
Source: Escott-Stump, S. 2008. Nutrition and Diagnosis-Related Care 6E. Lippincott, Williams & Wilkins. PA.
Dr. Ruiz
Food Intolerance
• A digestive system response rather than an
immune system response; occurs when something
in food irritates a person’s digestive system or
when a person is unable to properly digest, or
breakdown, the food.
• Caused by: Enzymatic defects in the digestive
system, or the defect of a vasoactive
pharmacological substance or chemical substance
and food additive present in food.
Dr. Ruiz
Food Intolerance
• Lactose Intolerance - the person lacks the enzyme lactase necessary to properly digest certain proteins found in food.
• Dye and MSG - chemical ingredients added to food to provide color, enhance taste and protect against the growth of bacteria may cause intolerance.
• Sulfites, which may occur naturally—as in red wines—or may be added to prevent the growth of mold
•
Carbohydrate in food such as lactose, galactose,
glucose and fructose, as well as vasoactive amine
and some chemical substances are the cause of
food intolerance.
Dr. Ruiz
Symptoms
Food Allergies:
• Rash or hives
• Nausea
• Colicky abdominal pain
• Diarrhea
• Itchy skin
• Shortness of breath
• Chest pain
• Swelling of the airways
to the lungs
• Anaphylaxis
Food Intolerance:
•Nausea
•Stomach pain
•Gas, cramps or bloating
•Vomiting
•Heartburn
•Diarrhea
•Headaches
•Irritability or nervousness
Symptoms can appear in as little as a few minutes or may take up to an hour
Negative reaction,
often delayed
Dr. Ruiz
Diagnosis of Food Allergy
• ORAL CHALLENGE
– consists of having a patient eat a food suspected of
previously causing symptoms in a controlled fashion
under medical supervision.
– This is done by feeding gradually increasing doses
of the suspected food at predetermined time
intervals (such as every half hour) until a reaction
occurs or a normal amount of the food is eaten
without causing symptoms.
Dr. Ruiz
Diagnosis of Food Allergy
• Double-blind, placebo-controlled food
challenge (DBPCFC).
– The suspected allergen (e.g, milk, fish, soy) is
placed in a capsule or hidden in food and fed to the
patient under strict supervision.
– Capsules or foods which do not contain the allergen
are also fed to make sure the observed reaction is
to the allergen and not to some other factor.
– Considered the gold standard for food allergy testing; identify
the most common allergens and determine what foods and
additives do not cause allergic reactions.
– Done by a board-certified allergist. Also used to determine if
the person has “outgrown” a certain allergy.
Dr. Ruiz
Diagnosis
SKIN TESTING • Considered most sensitive test. Clinical symptoms seen
in about 30% of all tests. Should be followed by food
challenge.
*A drop of allergen extract is placed on the skin -
usually the back - and a needle is passed through the
extract to make a tiny puncture in the skin.
*If the patient has IgE antibodies to the allergen, a hive
will appear at the site within about 15 minutes.
*Tests can be placed 2-inches apart across the back,
so many allergens can be tested at the same time.
Dr. Ruiz
Diagnosis
• Radioallergosorbent (RAST) test – Some skin conditions (such as severe eczema or
atopic dermatitis) might make skin testing impossible, or the physician might suspect that a patient is so sensitive to an allergen that a skin test could be dangerous.
– Serum mixed with food, food on paper disc and then washed with radioactively labeled IgE.
– An advantage of the RAST test is that it’s not affected by antihistamines or other medications that the patient may be taking.
Dr. Ruiz
Diagnosis of Food Allergy
• INTESTINAL BIOPSY
– Histological examination of inflammatory changes
of villi.
– Diagnostic for celiac disease and enteropathies.
Dr. Ruiz
Dietary Management of Food Allergy
• ELIMINATION DIET – diagnostic test diet where the offending protein-rich food is eliminated one after the other until the exact food causing the allergy is noted.
• AVOIDANCE DIET – gluten-free, milk-free
• DESENSITIZATION DIET – food causing allergy is given gradually in increasing amounts over time.
Dr. Ruiz
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Dr. Ruiz
Gluten-free Diet
• Gluten is a specific type of protein found in wheat, rye and barley. Going gluten-free means avoiding these grains.
• Two terms to watch for are malt (which is made from barley) and hydrolyzed vegetable protein (it often contains wheat).
• And while oats do not contain gluten, they may also increase symptoms, including abdominal pain, bloating, and diarrhea.
Dr. Ruiz
Breastfeeding and Food Allergies
• Various researches have demonstrated that prolonged breastfeeding reduces the incidence of allergic diseases.
• While breastfeeding does not prevent food allergies from occurring, it may delay the onset and severity of the allergy.
• The diet of the mother during lactation would need to be allergen free, because food allergens can be transferred in breast milk.
• Breastfeeding is the preferred feeding for infants, including those with allergy to cow and soy milk.
Dr. Ruiz
Breastfeeding and Food Allergies
• When breastfeeding is not possible, the use of a
protein hydrolysate formula such as Alimentum®
for infants with clinical symptoms of allergic
sensitivity is recommended.
• Delaying the introduction of solid foods until 6 to
8 months may also be beneficial.
• Children should avoid highly allergenic foods
such as dairy products, eggs, peanuts, soy, fish,
and shellfish until 18 to 24 months or older.
Dr. Ruiz
The Human Skin
• The skin is the outermost protective structure of
the body and considered as the largest organ
system that provides a boundary between the
inner body and the surrounding environment.
• Functions:
– through its sweat glands and blood vessels, it can
regulate body temperature;
– through nerve endings, it can respond to sensations
of pain, touch and temperature; and
– through its thick coverings, it can protect the
underlying tissues from mechanical injury.
– It also has an excretory function.
Dr. Ruiz
The Human Skin
With an average surface area of 1.7 square meters,
the skin is composed of double-layered, tough
and resilient epithelium.
• Epidermis - outer layer, is a very thin waterproof
barrier of 0.04 to 1.5 mm thickness, yet has the
greatest metabolic activity including the
production of pigment melanin.
– It is also the site of vitamin D synthesis.
– From the epidermis, arise the skin attachments such as
hair, nails, sebaceous and sweat glands.
Dr. Ruiz
The Human Skin
• Dermis- beneath the epidermis; sometimes called
the corium or true skin, is rich in blood vessels,
nerves or sweat and sebaceous glands.
– It is a storehouse for water, blood and electrolytes.
• Subcutaneous gland tissue – innermost layer, is
a depot for body fats and helps to support the body
Dr. Ruiz
Skin Nutrition
• Poor nutrition can disturb the health of the skin. Its
normal function depends heavily on adequate diet.
– The epidermis require sufficient amino acids and vitamin
A for normal
– The essential fatty acids (EFA) are needed for normal
epidermal permeability.
• Nutritional deficiencies, namely vitamin C, protein,
or copper can alter collagen formation of the skin
and this makes it inclined to physical damage.
• Demand for energy, fluids, folic acid, and protein
are increased during extensive skin inflammation.
Dr. Ruiz
Skin Nutrition
• Skin wrinkling in a sun-exposed site in older
people of various ethnic backgrounds may be
influenced by the types of foods consumed.
– An international study of eating patterns and skin
aging of more than 400 adults aged 70 and older
living in Australia, Greece and Sweden (Purba, 2001)
… those with a higher intake of vegetables, olive
oil and monounsaturated fat and legumes, but a
lower intake of milk/milk products, butter,
margarine & sugar products had less skin wrinkling
Dr. Ruiz
Skin Nutrition
• Skin is very susceptible to oxidative damage due to
its high content of lipids, proteins and DNA, which
are extremely sensitive to the oxidation process.
– By consuming vegetables, legumes and olive oil, oxidation
of the skin could be protected against sun damage
• Other than dietary deficiencies or excesses, skin
changes may result from factors such as nutrient-
drug interactions, and allergy or hypersensitivity.
– Conditions that irritate, clog or inflame the skin can cause
symptoms such as redness, swelling, burning and itching.
– Allergies, irritants, genetic makeup and certain diseases
and immune system problems can cause dermatitis, hives
and other skin conditions. Dr. Ruiz
Skin Abnormalities Related to Nutrition
• The normal development, function and
maintenance of the skin is affected to a large
extent by nutrition.
– Although the skin is one of the less sensitive
indicators of minor states of malnutrition, it is usually
affected by more prolonged nutritional deficiencies,
the reason why it is used as an index of health.
– Any nutritional deficit, which interferes with its
functions, will alter the appearance of the tissues and
impair its thermoregulatory function. It may even
denervate the skin making it more susceptible to
mechanical injury.
Dr. Ruiz
Skin Abnormalities Related to Nutrition
• Protein deficiency - dry,
scaly, inelastic skin, gray
pallid appearance
• EFA deficiency -
eczematous skin lesions
There are a number of dermatoses related to
dietary deficiencies and metabolic disorders.
Dr. Ruiz
Skin Abnormalities Related to Nutrition
• Riboflavin deficiency – angular
and seborrheic dermatitis
• Vitamin A deficiency – follicular
hyperkeratosis and
desquamation of epithelial cells
– phrynoderma is roughness of the
skin due to the follicular rxn
– pachyderma (elephant skin)
where the areas of the affected
skin are thick, rough and thrown
into folds like the skin of elephant
Dr. Ruiz
Skin Abnormalities Related to Nutrition
• Niacin deficiency – bilateral dermatitis
• Ascorbic acid deficiency – the skin may show
secondary changes such as petechial
hemorrhage and inelasticity.
– Acne, presence of broken hairs especially on the
legs and thighs, coiled hairs within hair follicle, and
poorly formed hairs.
Dr. Ruiz
Skin Abnormalities Related to Nutrition
• Hypervitaminosis A – skin
lesions resemble those of
vitamin A deficiency, there is
dry itching skin and swelling
over long bones.
– May also result in fissures of lips,
alopecia and hyperpigmentation
• Biotin deficiency – skin of the face and hands becomes
dry, shining, and scaling. The oral mucosa and tongue are
swollen, magenta in color, and painful.
• Phenylketonuria – one symptom is dry & eczematous skin
Dr. Ruiz
Skin Abnormalities Related to Nutrition
• Zinc deficiency – aka acrodermatitis enteropatica (AE),
due to a hereditary disorder characterized by inability of the
zinc to absorb in the gut.
• Infants with this problem develop a characteristic dermatitis on the
face, hands, anogenital areas, and feet consisting of an eczematous
rash with some pustular lesions.
• The syndrome can be reversed by simple oral supplementation with
zinc in doses of 3 to 4 times the RDA.
• People with AE may need zinc supplementation since absorption of
this mineral is impaired in this condition. Protein foods of HBV
emphasized in the diet
• Iron toxicity – aka hemochromatosis, the skin has a
characteristic slate gray coloration.
• Iron overload is often due to multiple blood transfusions
Dr. Ruiz
Pressure Ulcers (Bedsores)
• Pressure ulcers - caused by ischemia that occurs when
pressure on the tissue > pressure in capillaries, and thus
restricts blood flow into the area.
• Can develop in bedridden patients esp. when there is
chronic debilitating illness; after surgery or injury where
unrelieved pressure on the skin prevents the blood from
bringing nutrients and oxygen and removing wastes.
• Muscle tissue, which needs more oxygen and nutrients
than skin does, shows the worst effects from prolonged
pressure.
• Completely treatable if found early; without medical
attention, bedsores can become life-threatening
Dr. Ruiz
Pressure Ulcers (Bedsores)
• Management – Healing requires treatment of the
ulcer, relief of the pressure and zinc supplements.
• A high calorie diet with sufficient protein and
vitamin C is required.
• Ensure adequate fluid intake.
Dr. Ruiz
Atopic dermatitis is a chronic skin disease characterized by itchy, inflamed
skin and is the most common cause of eczema. The condition tends to
come and go, depending upon exposures to triggers or causative factors.
Factors that may cause atopic dermatitis (allergens) include environmental
factors like molds, pollen, or pollutants; contact irritants like soaps,
detergents, nickel (in jewelry), or perfumes; food allergies; or other
allergies.
Around two-thirds of those who develop the condition do so prior to 1 year
of age. When the disease starts in infancy, it is sometimes termed infantile
eczema.
Atopic dermatitis tends to run in families, and people who develop the
condition often have a family history of other allergic conditions such as
asthma or hay fever.
Types of Eczematous Dermatitis
Atopic dermatitis is the most common of the many types of eczematous
eruptions, and often people often inappropriately use the two terms
interchangeably. There are many terms used to describe specific forms
of dermatitis that may closely resemble atopic dermatitis
Dr. Ruiz
• Eczema Treatment: Immunomodulators
and UV Therapy
• Newer drugs called topical immunomodulators are
available to help treat eczema.
• These drugs help control inflammation and reduce
immune system reactions when applied to the skin.
• These drugs are thought to be about as effective as
corticosteroids but are considerably more expensive.
• For extreme cases of eczema, therapy using ultraviolet
light may be prescribed.
• In adults, drugs that suppress the immune system may
also be an option in the more severe cases.
Dr. Ruiz
Acne Vulgaris
• Acne lesions develop from a combination of increased androgen (which causes increased sebaceous gland activity and follicular keratinization) and the action of Propionibacterium acnes. – Lipases of these bacteria cause the breakdown of
sebum into free fatty acids, which in turn cause acute inflammation.
• Treated primarily using medications such as oral antibiotics, topical applications of benzoyl peroxide, and tretinoin, an oral synthetic retinoid 13-cis-retinoic acid, and a vitamin derivative
• Balanced diet with adequate zinc and vitamin A.
Dr. Ruiz
Psoriasis
• Its cause is not fully
understood. Genetic.
– Possible psoriasis triggers
include emotional stress, skin
injury, systemic infections,
certain medications (like
lithium and beta-blockers),
smoking or drinking alcohol,
and changes in climate that
dry the skin.
• An immune-mediated disease which affects the
skin and joints and characterized by patches of
red raised skin and silver scales of dead skin.
Dr. Ruiz
Psoriasis • The exact cause is
unknown, but experts
believe that the immune
system, genes, and
environmental factors play
central roles.
• Normally, old skin cells are replaced with new ones q 4 wks.
• In people with psoriasis, the immune system triggers
inflammation, causing new cells to move to the surface every
three or four days. The resulting buildup forms the rash.
• Psoriasis cannot be passed from person to person, but it
does tend to run in families.
Dr. Ruiz
Psoriasis Management • Medical treatment does not cure psoriasis, so
therapies are directed at symptom management. • Topical and systemic treatments provide varying
degrees of temporary relief that can clear psoriasis for
periods of time. Restrict sodium if on steroids.
• Use of omega-3 fatty acids are not yet conclusive
but inclusion of more seafood especially tuna may
be useful.
• Vitamin D and E may also have some benefit as
well as increased use of zinc from meat, seafood
and whole grains.
• Other clinicians advocate the use of gluten-free
diets to manage psoriasis.
Dr. Ruiz
Psoriasis Management
Climatotherapy
• For decades, people have claimed that visiting
the Dead Sea in Israel is a powerful treatment
for psoriasis. The sun and water, which is 10
times saltier than the ocean, are believed to be a
healing combination.
• Scientific evidence suggests this form of
climatotherapy works.
• In studies, 80% to 90% of patients improved
after visiting the Dead Sea.
• Almost half saw their rash disappear for the
next several months.
Dr. Ruiz
Dermatitis Herpetiformis (DH)
and Ioderma
In DH, patients experience intense itching and
discomfort. • This condition is characterized by chronic, intensely
pruritic, polymorphic, vesicles usually appearing on
extensor surfaces, namely elbows, knees, buttocks, and
scalp.
• There are also varying degrees of atrophy of the jejunal
mucosa and patients are sensitive to gluten.
• It is known to be aggravated by iodides and wheat flour
gluten.
• Localized pustular and furuncoloid skin lesions (ioderma)
appear as a result of taking medications containing
iodides or eating foods rich in iodide.
Dr. Ruiz
Dermatitis Herpetiformis (DH)
and Ioderma
Management: • The rash of DH is gluten-dependent and there are several
advantages to a gluten-free diet (GFD) :
1) the need for medication is reduced or abolished;
2) there is resolution of enteropathy;
3) a general feeling of well-being; and
4) protective effect against development of lymphoma.
• Patients with DH often have malabsorption. A GFD
improves absorption of essential nutrients and prevents
alimentary deficiencies of iron, vitamin B12 and folate.
• Iodine-containing food (fish, kelp, iodized salt and vitamin)
may be avoided in patients who do not respond to a GFD,
as iodides worsen DH. Dr. Ruiz
Thank you for your attention!