Non-pharmacological treatment modalities for atopic dermatitis

Non-pharmacological measures to improve the management of atopic dermatitis (AD) are as important as pharmacotherapy for true healing of the skin. Skin dryness (which contributes to inflammation, loss of suppleness (leading to fissuring), impaired barrier function, and increased adherence of Staphylococcus aureus organisms) can be overcome by the use of emollients. Ointments and creams provide better barrier function than lotions. Bathing is an important part of the management of AD. Regular, once-daily bathing in warm (not hot) water to hydrate the skin and debride crusts is important. Scented soaps should be avoided and replaced with a moisturising cleanser. After bathing, patients should pat the skin dry and apply emollients immediately. Routine use of topical or systemic antibacterial or antifungal agents is not recommended for AD, but during flares such agents may be invaluable. There is no specific diet for the treatment of AD. Elimination diets are not routine treatment and are potentially harmful. Food elimination should be reserved for those children who have been proven to be allergic to the specific food.http://www.samj.org.zaam201

Non-pharmacological treatment modalities for atopic dermatitis

Non-pharmacological measures to improve the management of atopic dermatitis (AD) are as important as pharmacotherapy for true healing of the skin. Skin dryness (which contributes to inflammation, loss of suppleness (leading to fissuring), impaired barrier function, and increased adherence of Staphylococcus aureus organisms) can be overcome by the use of emollients. Ointments and creams provide better barrier function than lotions. Bathing is an important part of the management of AD. Regular, once-daily bathing in warm (not hot) water to hydrate the skin and debride crusts is important. Scented soaps should be avoided and replaced with a moisturising cleanser. After bathing, patients should pat the skin dry and apply emollients immediately. Routine use of topical or systemic antibacterial or antifungal agents is not recommended for AD, but during flares such agents may be invaluable. There is no specific diet for the treatment of AD. Elimination diets are not routine treatment and are potentially harmful. Food elimination should be reserved for those children who have been proven to be allergic to the specific food.http://www.samj.org.zaam201

Summary of childhood asthma guidelines, 2021 : a consensus document

Asthma is the most common chronic illness of childhood. The prevalence is rising and the mortality and morbidity from asthma are unacceptably high in South Africa. It is important to make a correct diagnosis based, most importantly, on the clinical history and supported by investigations. The appropriate drug and device must be chosen to achieve good asthma control. Patients must be followed up regularly and their asthma control must be assessed. The treatment can then be adjusted according to the level of control. The COVID-19 pandemic has placed new challenges on the care of our asthmatics. Asthma education and adherence are important components of management of the condition.http://www.samj.org.zadm2022Paediatrics and Child Healt

Consensus statement of the management of severe, difficult-to-treat atopic dermatitis in adults and adolescents in South Africa and the role of biologics

The first biological agent for treatment of moderate-to-severe atopic dermatitis (AD), dupilumab, has recently been introduced to South Africa and guidance is required as to its place in therapy. Consequently, an expert panel was convened to reach consensus on 14 statements relevant to contemporary management of AD and the use of dupilumab. In summary, the objectives of therapy are to reduce skin inflammation and pruritus, restore skin-barrier function, avoid flares, and improve quality of life. Useful comprehensive scoring tools to assess severity of AD and guide decisions to step up from topical to systemic therapy (including to a biologic agent), include SCORing Atopic Dermatitis (SCORAD), Eczema Area and Severity Index (EASI) and Dermatology Life Quality Index (DLQI). In addition, a photographic record of pre-treatment and follow-up assessments is helpful. When systemic therapy is required, options include cyclosporin, which should be limited to short-term use, and off-label use of methotrexate. Systemic corticosteroids should be considered only in short courses for rescue therapy in the event of flares. New classes of medication for the treatment of moderateto- severe AD are in various stages of development. The two most prominent classes of new therapies are biologics and small molecules. Dupilumab is the first fully humanised monoclonal antibody (MAB) biologic approved for the treatment of moderate-to-severe AD. It is an effective and well-tolerated, long-term treatment and has a favourable safety profile.https://journals.co.za/journal/caciam2022Paediatrics and Child Healt

Diagnosis of food allergy : history, examination and in vivo and in vitro tests

One cannot depend on one single test to diagnose food allergy. A detailed history is an essential initial step in cases of suspected food allergy. Aspects of the history should be gathered separately for each food being considered, as a patient may experience different types of reactions with various foods, each of which requires individual diagnostic and management strategies. History alone is not diagnostic and additional measures of sensitisation or food challenges are often required. In suspected immunoglobulin E (IgE)-mediated allergy, skin-prick tests (SPTs) and/or measurement of serum specific IgE antibodies (ImmunoCAP) to suspected foods is used to prove sensitisation. Sensitisation does not, however, confirm clinical food allergy as these tests indicate an immunological response to the specific allergen, but the diagnosis requires a clear correlation between the test result and clinical reaction (by positive history or food challenge). The magnitude of the test result (SPT mean wheal size or ImmunoCAP level in kU/L) correlates with the likelihood of clinical allergy, but not the severity of a reaction. Choice of the allergens tested should be guided by the history, but limited to the lowest necessary number to avoid false-positive results. Tests for sensitisation to foods should not be performed when the history indicates that such foods are tolerated. Ninety-five per cent positive predictive values (where a clinical reaction can be predicted in 95% of cases) have been described for immediate reactions, but may be population specific. There are no validated tests to confirm non-IgE- or mixed IgE- and non-IgE-mediated food allergies. Diagnosis of this group of allergies depends on elimination of the suspected food, clearance of symptoms, and recurrence of symptoms on re-introduction of the food.http://www.samj.org.zahb201

Novel therapies in the management of food allergy : oral immunotherapy and anti-IgE

The process of oral immunotherapy (OIT) consists of a series of dose escalations with the immediate goal of inducing desensitisation and ultimately achieving a state of tolerance. Owing to the limitations of OIT, including side-effects and lack of proven efficacy in long-term tolerance induction, it is not yet recommended in routine clinical practice and should be restricted to the research setting. Studies using anti-immunoglobulin E (IgE) antibody in food allergy management are limited, but show promising results. The possible applications are for increasing the sensitivity threshold to certain foods such as peanut, and also for use in combination with OIT to enhance safety and rapidity of the OIT process; however, anti-IgE is not yet licensed for use in food allergy.http://www.samj.org.zahb201

Epidemiology of IgE-mediated food allergy

Despite the large number of foods that may cause immunoglobulin E (IgE)-mediated reactions, most prevalence studies have focused on the most common allergenic foods, i.e. cow’s milk, hen’s egg, peanut, tree nut, wheat, soya, fish and shellfish. Food allergy peaks during the first two years of life, and then diminishes towards late childhood as tolerance to several foods develops. Based on meta-analyses and large population-based studies, the true prevalence of food allergy varies from 1% to >10%, depending on the geographical area and age of the patient. The prevalence of food allergy in South Africa (SA) is currently being studied. The prevalence of IgE-mediated food allergy in SA children with moderate-to-severe atopic dermatitis is 40%; however, this represents a high-risk population for food allergy. Preliminary data from the South African Food Sensitisation and Food Allergy (SAFFA) study, which is investigating food allergy in an unselected cohort of 1 - 3-year olds, show a prevalence of 11.6% sensitisation to common foods. Food allergy was most common to egg (1.4%) and peanut (1.1%). Food allergy appears to be the most common trigger of anaphylactic reactions in the community, especially in children, in whom food is responsible for ≥85% of such reactions. In adults, shellfish and nut, and in children, peanut, tree nut, milk and egg, are the most common triggers of food-induced anaphylaxis.http://www.samj.org.zahb201

Vaccination in food allergic patients

Important potential food allergens in vaccines include egg and gelatin. Rare cases of reactions to yeast, lactose and casein have been reported. It is strongly recommended that when vaccines are being administered resuscitation equipment must be available to manage potential anaphylactic reactions, and that all patients receiving a vaccine are observed for a sufficient period. Children who are allergic to egg may safely receive the measles-mumps-rubella (MMR) vaccine; it may also be given routinely in primary healthcare settings. People with egg allergy may receive influenza vaccination routinely; however, some authorities still perform prior skinprick testing and give two-stage dosing. The purified chick embryo cell culture rabies vaccine contains egg protein, and therefore the human diploid cell and purified verocell rabies vaccines are preferred in cases of egg allergy. Yellow fever vaccine has the greatest likelihood of containing amounts of egg protein sufficient to cause an allergic reaction in allergic individuals. This vaccine should not be routinely administered in egg allergic patients and referral to an allergy specialist is recommended, as vaccination might be possible after careful evaluation, skin-testing and graded challenge or desensitisation.http://www.samj.org.zahb201

Severe food allergy and anaphylaxis : treatment, risk assessment and risk reduction

An anaphylactic reaction may be fatal if not recognised and managed appropriately with rapid treatment. Key steps in the management of anaphylaxis include eliminating additional exposure to the allergen, basic life-support measures and prompt intramuscular administration of adrenaline 0.01 mg/kg (maximum 0.5 mL). Adjunctive measures include nebulised bronchodilators for lower-airway obstruction, nebulised adrenaline for stridor, antihistamines and corticosteroids. Patients with an anaphylactic reaction should be admitted to a medical facility so that possible biphasic reactions may be observed and risk-reduction strategies initiated or reviewed after recovery from the acute episode. Factors associated with increased risk of severe reactions include co-existing asthma (and poor asthma control), previous severe reactions, delayed administration of adrenaline, adolescents and young adults, reaction to trace amounts of foods, use of non-selective β-blockers and patients who live far from medical care. Risk-reduction measures include providing education with regard to food allergy and a written emergency treatment plan on allergen avoidance, early symptom recognition and appropriate emergency treatment. Risk assessment allows stratification with provision of injectable adrenaline (preferably via an auto-injector) if necessary. Patients with ambulatory adrenaline should be provided with written instructions regarding the indications for and method of administration of this drug and trained in its administration. Patients and their caregivers should be instructed about how to avoid foods to which the former are allergic and provided with alternatives. Permission must be given to inform all relevant caregivers of the diagnosis of food allergy. The patient must always wear a MedicAlert necklace or bracelet and be encouraged to join an appropriate patient support organisation.http://www.samj.org.zahb201

Exclusion diets and challenges in the diagnosis of food allergy

Instituting an exclusion diet for 2 - 6 weeks, and following it up with a planned and intentional re-introduction of the diet, is important for the diagnosis of a food allergy when a cause-and-effect relationship between ingestion of food and symptoms is unclear. Food may be re-introduced after (short-term) exclusion diets for mild-to-moderate non-immunoglobulin E (IgE)-mediated conditions in a safe clinical environment or cautiously at home. However, patients who have had an IgE-mediated immediate reaction to food, a previous severe non-IgE-mediated reaction or a long period of food exclusion should not have a home challenge, but rather a formal incremental food challenge protocol in a controlled setting. An incremental oral food challenge (OFC) test is the gold standard to diagnose clinical food allergy or demonstrate tolerance. It consists of gradual feeding of the suspected food under close observation. It should be done by trained practitioners in centres that have experience in performing the procedure in an appropriate setting. An OFC must be performed in a setting where resuscitation equipment is available in the event of a severe anaphylactic reaction. OFCs are terminated when a reaction becomes apparent. Standardised and pre-set criteria are available on when to discontinue challenges. Patients who tolerate the full dose ‘pass’ the challenge and are advised to eat a full portion of the food at least twice a week to maintain tolerance. Those who have reactions have ‘failed’ the challenge, should avoid the food, receive education and implement risk-reduction strategies where appropriate. Patients should be observed for a minimum of 2 hours following a negative challenge and for 4 hours after a positive one.http://www.samj.org.zahb201