Nieporozumienie – to pierwsze słowo jakie przychodzi mi na myśl w kontekście związku alergii, w szczególności pokarmowej z Atopowym zapaleniem skóry.
MAŁE DZIECKO – POKARM – OBJAWY SKÓRNE – ALERGIA =AZS
Powyższy schemat myślowy jest bardzo często spotykany. Stawiamy znak równości pomiędzy podejrzewaną nadwrażliwością na pokarm a początkiem atopowego zapalenia skóry w szczególności gdy mamy do czynienia z niemowlęciem czy dzieckiem do ukończenia 2 roku życia. Faktem jest, że najwyższy odsetek pierwszych objawów AZS ma miejsce właśnie w tej grupie wiekowej. Zbiega się on z rozszerzaniem diety, nabywaniem dojrzałości przez układ pokarmowy i immunologiczny dziecka. Wtedy właśnie pierwsza nasza myśl rodzicielska, gdy zauważymy na skórze dziecka niechciane objawy podąża ku diagnozie: ALERGIA POKARMOWA i najprawdopodobniej początek AZS.
ALERGIA NIE JEST PRZYCZYNĄ AZS – POWSTAJE WTÓRNIE
Patogeneza AZS jest złożona. Biorą w niej udział geny, które są nieco inaczej zaprogramowane niż u ludzi ze zdrową skórą. Geny w głównej mierze niosą instrukcję obsługi dla prawidłowego funkcjonowania bariery skórnej, odpowiedzi układu immunologicznego na antygeny środowiska. Pod określeniem ATOPIA powinniśmy rozumieć stan rodzinnej nadwrażliwości „nadaktywności” naszego organizmu w odniesieniu do otoczenia. Ważne, aby nadmienić, że zjawisko atopii nie występuje u każdego z diagnozą AZS. W badaniach laboratoryjnych stwierdza się podwyższone miano CAŁKOWITYCH przeciwciał IgE, które nie mają znaczenia diagnostycznego w kierunku alergii. Należy na nie patrzeć jak na „świadków” toczących się reakcji alergicznych, które w AZS mają UŁATWIONĄ drogę tworzenia się.
Dlaczego? Ponieważ bariera skórna oraz błon śluzowych jest „nieszczelna”. Braki w składnikach budulcowych powodują, że o wiele więcej skóra chorego na AZS „przepuszcza” do środka – większa ilość normalnego składnika środowiska u osoby z atopowym zapaleniem skóry może wywołać alergię lub podrażnienie. Jeśli myślimy o patogenezie AZS to zawsze stawiajmy na szczycie piramidy tą inaczej funkcjonującą barierę naskórkową.
I teraz przechodzimy do „clue” tematu😉:
ATOPIA to nie ALERGIA
PODWYŻSZONE MIANO całkowitego IgE NIE JEST dowodem na istnienie alergii – ZWIĘKSZA tylko statystyczne ryzyko na rozwój choroby alergicznej.
ATOPIA nie oznacza, że alergia się rozwinie, dlatego nie zaleca się profilaktycznej diety eliminacyjnej u dzieci z AZS bez potwierdzenia związku pomiędzy konkretnym pokarmem, a objawami klinicznymi. Pamiętajmy, że leczymy pacjenta – nie badania laboratoryjne.
ALERGIA to stan nadwrażliwości przeciwko konkretnemu antygenowi, który został uznany za ALERGEN
MLEKO, JAJKO, SOJA, ORZESZKI ZIEMNE – ALERGIA POTWIERDZONA, DIETA ELIMINACYJNA WPROWADZONA, A OBJAWY NADAL SIĘ POJAWIAJĄ???
Wytłumaczenie nr.1
Dziecko oprócz alergii pokarmowej ma faktycznie początki AZS – potrzebna dłuższa obserwacja i ocena na podstawie kryteriów diagnostycznych. Jeśli wstępna diagnoza się potwierdzi to już wiemy, że alergia występuje w przebiegu AZS. Atopowe zapalenie skóry to skóra prezentująca zmiany chorobowe w wyniku reakcji na wiele czynników drażniących, skóra, którą charakteryzuje suchość zależna od braku zdolności utrzymania przez nią odpowiedniego poziomu nawilżenia. Dlatego nawet eliminując pokarmy, na które została stwierdzona alergia zmiany skórne mogą się pojawiać.
Wytłumaczenie nr.2
Oprócz alergii pokarmowej w mechanizmie IgE – zależnym, czyli takim, który może zostać zbadany w testach laboratoryjnych ( ALE DIAGNOZA, zawsze wymaga kontekstu klinicznego, czyli potwierdzonego związku przyczynowo – skutkowego z wywiadu od pacjenta) występują reakcje na pokarmy w mechanizmach IgE – niezależnych, gdzie patogeneza nie jest do końca poznana. Tutaj opierać się możemy WYŁĄCZNIE na wywiadzie od pacjenta i na tej podstawie eliminować dane pokarmy. Tutaj warto zauważyć, że TESTY LABORATORYJNE ujemne czy dodatnie nie mogą być jedyną podstawą diagnostyki ze względu na występowanie reakcji właśnie w tym drugim IgE – niezależnym mechanizmie.
Wytłumaczenie nr. 3
Mamy do czynienia z NIEALERGICZNĄ NADWRAŻLIWOŚCIĄ NA POKARMY. Ona jest najprawdopodobniej odpowiedzialna za większość łagodnych objawów skórnych w przebiegu AZS w połączeniu ze spożywaniem „podejrzanych” pokarmów. Tutaj laboratorium również nam nie pomoże.
Rozmowa z pacjentem, obserwacja związku pokarm – objawy czyli wywiad kliniczny ma podstawowe znaczenie w diagnostyce alergologicznej.
Alergia pokarmowa NIE TOWARZYSZY KAŻDEMU PRZYPADKOWI AZS
Alergia pokarmowa nie równa się diagnozie AZS
Alergia pokarmowa NIE jest przyczyną AZS
Alergia pokarmowa MOŻE występować w przebiegu AZS, może zaostrzać jego przebieg.
Alergia pokarmowa występuje WTÓRNIE do atopowego zapalenia skóry
Dieta eliminacyjna na określony pokarm NIE MUSI całkowicie eliminować objawów skórnych AZS, ponieważ patofizjologia schorzenia nie opiera się tylko i wyłącznie na podłożu alergicznym.
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