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Stop Considering Atopic Dermatitis as an Allergic Disease

Bramuzzo, Matteo; Longo, Giorgio; Ventura, Alessandro

Journal of Pediatric Gastroenterology and Nutrition: July 2013 - Volume 57 - Issue 1 - p e9
doi: 10.1097/MPG.0b013e3182923772
Letters to the Editor

Department of Pediatrics, Institute for Maternal and Child Health IRCCS Burlo Garofolo, University of Trieste, Trieste, Italy

To the Editor:

We read with interest the review by Iyengar and Walker (1) about the implications of breast milk in the development of atopic disease; however, we strongly disagree in considering children's atopic dermatitis (AD) as an allergic disease.

The majority of cases of AD emerge in the absence of signs of immunoglobulin E–mediated sensitization (2) and many children will not develop it (3). Increasing evidences confirm that AD is the result of a primary epidermal barrier defect, mainly residing in filaggrin abnormalities (4), which increases skin permeability and allows environmental allergens, such as food allergens, to penetrate and stimulate a TH2 immune response (5); the more the skin is altered, the earlier and the stronger the sensitization (6). Nowadays, because of these facts, we must accept that the traditional way to conceive the cause and effect between allergy and AD has been inverted (7).

We believe that future studies about the effects of breast-feeding or of environmental factors, such as hydrolyzed formulas, on the development and expression of allergy should be based on immunoglobulin E–mediated symptoms and not on the evaluation of AD. If breast-feeding has positive effects on the clinical expression of AD, mechanisms other than allergy must be considered.

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1. Iyengar SR, Walker WA. Immune factors in breast milk and the development of atopic disease. J Pediatr Gastroenterol Nutr 2012; 55:641–647.
2. Illi S, von Mutius E, Lau S, et al. The natural course of atopic dermatitis from birth to age 7 years and the association with asthma. J Allergy Clin Immunol 2004; 113:925–931.
3. Novak N, Bieber T. Allergic and non-allergic forms of atopic diseases. J Allergy Clin Immunol 2003; 112:252–262.
4. Bieber T. Atopic dermatitis. N Engl J Med 2008; 358:1483–1494.
5. Dubrac S, Schmuth M, Ebner S. Atopic dermatitis: the role of Langerhans cells in disease pathogenesis. Immunol Cell Biol 2010; 88:400–409.
6. Hill DJ, Hosking CS, de Benedictis FM, et al. Confirmation of the association between high levels of immunoglobulin E food sensitization and eczema in infancy: an international study. Clin Exp Allergy 2008; 38:161–168.
7. Lack G. Epidemiologic risks for food allergy. J Allergy Clin Immunol 2008; 121:1331–1336.
© 2013 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,