NDR2014 Skin Food Intolerances

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


• 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


• 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

Dr. Ruiz

Dr. Ruiz

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


• 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


• 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


• 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


• 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


• 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!

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NDR2014 Skin Food Intolerances