Comorbidities of atopic dermatitis-what does the evidence say?

Phenotypes of Atopic Dermatitis and Development of Allergic Diseases

Importance

Atopic dermatitis (AD) is the most common inflammatory disease in childhood, and children with AD are more likely to develop other allergic diseases, including food allergy, allergic rhinitis, and asthma.

Objective

To determine the phenotypes of AD expression across 12 US birth cohorts and identify factors associated with phenotype and development of allergic diseases.

Design, Setting, and Participants

This cohort study compiled longitudinal data from 12 observational US birth cohorts across decades (children born from April 1980 to June 2019) in the Environmental Influences on Child Health Outcomes (ECHO) Children's Respiratory and Environmental Workgroup with follow-up to September 2022. Participants were enrolled prenatally; children with 3 or more AD assessments across the first 84 months of life were included in analyses. Data were analyzed from December 2020 to April 2024.

Exposures

Exposures included decade of birth, cohort type (population-based or high-risk), family history of asthma (mother, father, or sibling), birth order, gestational age at birth, delivery mode, breastfeeding, pet exposure, antibiotic use, environmental tobacco smoke exposure, allergic sensitization, peripheral blood eosinophil count, and total IgE.

Main Outcomes and Measures

Primary outcomes were AD phenotype, food allergy, allergic rhinitis, asthma, and wheeze. Longitudinal latent class analysis was used to identify underlying longitudinal patterns of AD expression, and associations of AD phenotype with allergic outcomes were examined using logistic regression, multinomial logistic regression, and linear regression.

Results

In 5314 children from 9 cohorts (1896 born in the 2000s [35.7%]; 2585 female [48.6%]; 1083 Black or African American [20.4%]; 3344 White [62.9%]; 350 other reported race [6.6%; including 8 American Indian or Alaska Native (0.2%); 58 Asian (1.1%); 4 Native Hawaiian or Pacific Islander (0.1%) and 280 multiracial or with any race not otherwise specified (5.3%)]), 3382 (63.6%) were from a population-based cohort, while 1932 (36.4%) were from a high-risk cohort. AD prevalence ranged from 24.1% (540 children) to 28.4% (1156 children) at each time point, and 5 phenotypes of AD were identified: transient early AD, early AD with potential reoccurrence, late-onset AD, persistent AD, and minimal or no AD. Compared with White children, Black children were at higher risk for AD (transient early AD: aOR, 3.26; 95% CI, 2.06-5.18; early AD with potential reoccurrence: aOR, 3.72; 95% CI, 2.35-5.90; persistent AD: aOR, 2.01; 95% CI, 1.54-2.63), as were children with other reported race (transient early AD: aOR, 2.31; 95% CI, 1.13-4.70; early AD with potential reoccurrence: aOR, 3.27; 95% CI, 1.73-6.18). Female children were significantly less likely to have early AD with potential reoccurrence (aOR, 0.45; 95% CI, 0.27-0.74) and persistent AD (aOR, 0.60; 95% CI, 0.49-0.74) than male children. Compared with miniml or no AD, phenotypes with early AD expression were associated with food allergy (transient early AD: adjusted odds ratio [aOR], 2.15; 95% CI, 1.48-3.08; early AD with potential reoccurrence: aOR, 2.43; 95% CI, 1.66-3.50; persistent AD: aOR, 2.26; 95% CI, 1.84-2.78), later AD expression was associated with allergic rhinitis (late-onset AD: aOR, 1.84; 95% CI, 1.38-2.43; persistent AD: aOR, 2.02; 95% CI, 1.64-2.48), and any AD disease was associated with asthma.

Conclusions and Relevance

In this birth cohort study of 5314 children, timing of AD expression was associated with increased risk for atopic march pathways. Identifying risk factors for AD phenotypes may inform targeted therapeutic prevention strategies.

Complement's involvement in allergic Th2 immunity: a cross-barrier perspective

Type 2 (Th2) allergic diseases are chronic conditions characterized by a Th2-polarized immune response to allergens. These diseases can be categorized by affected barrier sites: skin (atopic dermatitis, allergic contact dermatitis), gut (food allergy), and respiratory tract (e.g., asthma, chronic rhinosinusitis). The global prevalence of Th2 allergic diseases has increased the need for a deeper understanding of their pathophysiology. Several associations have been identified between genetic variants in the genes encoding components of the complement system and allergic disease. Moreover, levels of several complement proteins are elevated in patients with allergy. Experimental evidence demonstrates that the complement system plays a critical role in the development of these diseases across barrier sites. While site-specific differences exist in the complement components involved, key pathways, particularly C3 and C5, are prominent across the skin, gut, and lung.

Scientific developments in understanding food allergy prevention, diagnosis, and treatment

Food allergies (FAs) are adverse immune reactions to normally innocuous foods. Their prevalence has been increasing in recent decades. They can be IgE-mediated, non-IgE mediated, or mixed. Of these, the mechanisms underlying IgE-mediated FA are the best understood and this has assisted in the development of therapeutics. Currently there are two approved drugs for the treatment of FA, Palforzia and Omalizumab. Palfornia is a characterized peanut product used as immunotherapy for peanut allergy. Immunotherapy, involves exposure of the patient to small but increasing doses of the allergen and slowly builds immune tolerance to the allergen and increases a patient's allergic threshold. Omalizumab, a biologic, is an anti-IgE antibody which binds to IgE and prevents release of proinflammatory allergenic mediators on exposure to allergen. Other biologics, investigational vaccines, nanoparticles, Janus Kinase and Bruton's tyrosine kinase inhibitors, or DARPins are also being evaluated as potential therapeutics. Oral food challenges (OFC) are the gold standard for the diagnosis for FA. However, they are time-consuming and involve risk of anaphylaxis; therefore, alternative diagnostic methods are being evaluated. This review will discuss how the immune system mediates an allergic response to specific foods, as well as FA risk factors, diagnosis, prevention, and treatments for FA.

Enhancing Diagnosis of Psoriasis and Inflammatory Skin Diseases: A Spatially Aligned Multimodal Model Integrating Clinical and Dermoscopic Images

Psoriasis is a chronic inflammatory disease with significant physical and psychological impacts. To overcome the limitations of single-modality artificial intelligence models in diagnosing inflammatory skin diseases, we propose a multimodal framework-spatial alignment multimodal contrastive learning-integrating dermoscopic and clinical photographs and trained on the developed Peking Union Medical College Hospital - Inflammatory Skin Diseases dataset, which includes 8 inflammatory skin diseases. On the Peking Union Medical College Hospital - Inflammatory Skin Diseases dataset, our model achieved classification accuracies of 0.822 for an 8-class classification task and 0.911 for a binary classification task, outperforming single-modality models and simple fusion approaches. Furthermore, on the publicly available Derm7pt dataset, the proposed model surpassed 11 state-of-the-art multimodal methods, achieving an accuracy of 0.807. When used for diagnostic assistance, the model significantly improved the diagnostic accuracy of 20 dermatologists, increasing from 0.775 to 0.890 (P < .05). Among 110 test cases, 87 (79.1%) showed improved diagnostic accuracy. The model demonstrated notable enhancements in diagnosing specific conditions, such as lichen planus, acne, rosacea, and morphea. Validation using heatmaps confirmed that the model's attention aligned with key lesion features in most cases. This study introduces a multimodal model that bridges scale discrepancies between dermoscopic and clinical photographs, offering an efficient tool for diagnosing psoriasis and other inflammatory skin diseases.

Biologics and small molecules: the re-evolution in the treatment of atopic dermatitis in children and adolescents. Current state of the art and future perspectives

INTRODUCTION

In recent years, the understanding of atopic dermatitis (AD) pathogenetic mechanisms has expanded, and now it is recognized that Th2 immune axis dysregulation is pivotal to AD pathogenesis. The advent of biological drugs and small molecules has marked a revolution in the treatment of AD. Dupilumab, targeting IL-4 and IL-13, has been the first to demonstrate efficacy in treating moderate to severe AD by modulating type-2 inflammation pathways. Increasing knowledge of different immune axis and cytokines has fueled the development of new biologics and small molecules. JAK inhibitors, which target the JAK-STAT pathway, involved in cytokine signaling, represent a promising novel therapeutic strategy, enlarging the treatment options for moderate to severe atopic dermatitis.

AREAS COVERED

This comprehensive review aims to provide an updated and critical overview of the drugs currently in use and under investigation for the treatment of moderate to severe AD in children and adolescents, along with addressing the unmet needs and future research perspectives.

EXPERT OPINION

Biologics and small molecules offer the promise to enlarge the arsenal options for the treatment of AD. Since the patients' response to biologics depends on AD pheno-endotype, choosing the right biologic is crucial for ensuring therapy success.

Head and neck dermatitis: a variant of atopic dermatitis

Atopic dermatitis involves the head and neck area across all age groups. This manifestation is frequently referred to as "the head and neck dermatitis." Aside from a considerable deterioration of the quality of life, it poses a significant diagnostic and therapeutic challenge. The head and neck dermatitis may be mimicked by other inflammatory conditions such as seborrheic dermatitis or contact dermatitis. Furthermore, it can be associated with a wide range of infectious, ocular, psychiatric and hair disorders, which should raise clinical alertness and encourage a multidisciplinary management of the affected individuals. Skin lesions in the head and neck area are often difficult to treat, particularly because of a considerable exposure of this region to exacerbating factors and limitations regarding the use of some pharmaceuticals. Although several hypotheses explaining the recalcitrant course of head and neck dermatitis have been proposed, none of them provide successful solutions applicable in the daily clinical practice. This comprehensive review comprises the current insights on the pathogenesis, clinical presentation, and comorbidities of the head and neck dermatitis. Recommendations regarding possible treatments of this condition such as antifungals, as well as special considerations for the choice of biologics or JAK inhibitors in the candidates for systemic treatment are outlined.

[Translated article] Clinical-Epidemiological Profile, and Treatment Response in Relation to Associated Atopic Comorbidity in Atopic Dermatitis. Experience From the BIOBADATOP Registry

BACKGROUND

Despite advances made in treatments for atopic dermatitis (AD), information on its impact and interaction with atopic comorbidities, such as asthma, rhinoconjunctivitis, and ocular disease is limited. This study aims to assess the clinical-epidemiological characteristics of patients with AD - treatment response included - while taking into consideration atopic comorbidities like these.

MATERIALS AND METHODS

Data were analyzed from the multicenter BIOBADATOP registry (a prospective cohort of AD patients initiating systemic treatment). We conducted a descriptive analysis of the main characteristics collected in the registry in relation to atopic comorbidity.

RESULTS

We included a total of 509 patients, mostly adults (81.9%) with severe AD (73.7%). Patients with personal atopic comorbidity (64%) more frequently exhibited flexural dermatitis (89.7% vs. 81.5%), a higher mean of previous systemic treatments (1.6 vs. 1.3), and higher baseline values on the POEM scale (19.6 vs. 17.9). Patients with familial atopic comorbidity (40.7%) had a higher incidence of pediatric/adolescent patients (24.2% vs. 13.9%) and a history of allergic rhinoconjunctivitis (61.1% vs. 47.1%). No differences regarding treatment response were observed at the 6- and 12-month follow-ups based on the presence or absence of atopic comorbidities.

CONCLUSIONS

Results suggest that a history of atopic comorbidity is associated with an early onset and persistent course of AD. Although no differences were reported in the short-term treatment response, further follow-up is required to better understand the impact of comorbidities on AD.

Clinical-Epidemiological Profile, and Treatment Response in Relation to Associated Atopic Comorbidity in Atopic Dermatitis. Experience From the BIOBADATOP Registry

BACKGROUND

Despite advances made in treatments for atopic dermatitis (AD), information on its impact and interaction with atopic comorbidities, such as asthma, rhinoconjunctivitis, and ocular disease is limited. This study aims to assess the clinical-epidemiological characteristics of patients with AD-treatment response included-while taking into consideration atopic comorbidities like these.

MATERIALS AND METHODS

Data were analyzed from the multicenter BIOBADATOP registry (a prospective cohort of AD patients initiating systemic treatment). We conducted a descriptive analysis of the main characteristics collected in the registry in relation to atopic comorbidity.

RESULTS

We included a total of 509 patients, mostly adults (81.9%) with severe AD (73.7%). Patients with personal atopic comorbidity (64%) more frequently exhibited flexural dermatitis (89.7% vs 81.5%), a higher mean of previous systemic treatments (1.6 vs. 1.3), and higher baseline values on the POEM scale (19.6 vs. 17.9). Patients with familial atopic comorbidity (40.7%) had a higher incidence of pediatric/adolescent patients (24.2% vs. 13.9%) and a history of allergic rhinoconjunctivitis (61.1% vs. 47.1%). No differences regarding treatment response were observed at the 6- and 12-month follow-ups based on the presence or absence of atopic comorbidities.

CONCLUSIONS

Results suggest that a history of atopic comorbidity is associated with an early onset and persistent course of AD. Although no differences were reported in the short-term treatment response, further follow-up is required to better understand the impact of comorbidities on AD.

Bipolar disorder among individuals with atopic dermatitis: a case-control study in the All of Us Research Program

BACKGROUND

Atopic dermatitis (AD) has been associated with psychiatric comorbidities.

OBJECTIVES

To characterize the association between AD and bipolar disorder (BPD) with a case-control study of the National Institutes of Health All of Us Research Program.

METHODS

We used Systematized Nomenclature of Medicine diagnostic codes to identify cases of AD. Four age-, sex- and race/ethnicity-matched controls were found for each case using propensity score matching. After controlling for age, sex, race/ethnicity, income, smoking status and depression, the relationship between AD and BPD was evaluated using logistic regression.

RESULTS

We identified 13 431 AD cases and 53 724 matched controls. Participants with AD were more likely than controls to have BPD (7.8% vs. 4.6%, P < 0.001). After adjusting for demographics and comorbidities, we observed a significant association (odds ratio 1.49, 95% confidence interval 1.37-1.62; P < 0.001).

CONCLUSIONS

Compared with individuals without AD, individuals with AD have 1.49-fold increased odds of having BPD. Further investigation is needed to gain a better understanding of this association.

Investigating the complex roles of immunocyte phenotypes in the pathogenesis of dermatitis: a causal inference Mendelian randomization analysis

The etiology of dermatitis involves complex interactions between immune cells, genetics, and environmental factors. While immunocyte phenotypes have been linked to various forms of dermatitis, their causal role remains unclear. We conducted a two-sample Mendelian randomization (MR) analysis to investigate the causal effects between 731 immunocyte phenotypes and four types of dermatitis: atopic dermatitis, contact dermatitis, infective dermatitis, and seborrhoeic dermatitis. Genetic variants were used as instrumental variables, and the inverse variance-weighted (IVW) method was employed to assess causality. Sensitivity analyses were performed to ensure robustness. The forward MR analysis identified significant associations between 22 immunocyte phenotypes and atopic dermatitis, 8 phenotypes with contact dermatitis, 5 with infective dermatitis, and 6 with seborrhoeic dermatitis. The reverse MR analysis suggested potential bidirectional interactions of atopic dermatitis and CD3 on CD28 + CD45RA- CD8br (OR = 0.924, P = 0.012). This study revealed causal relationships between specific immunocyte phenotypes and dermatitis subtypes, providing novel insights into the immunopathogenesis of dermatitis and potential therapeutic targets.

The APOLO Study: A Cross-Sectional Analysis of Disease Characteristics and Patient Burden in Moderate-to-Severe Atopic Dermatitis in Portugal

INTRODUCTION

Atopic dermatitis (AD) is a chronic inflammatory skin disease with a substantial impact on patients' quality of life (QoL). This study aimed to characterize the burden of moderate-to-severe AD in the Portuguese population, focusing on patients' QoL and socioeconomic activities while describing their treatment patterns and healthcare resource use.

METHODS

This multicenter, cross-sectional, and non-interventional study in eight Portuguese referral AD centers recruited patients over 12 years old, seeking first-time AD care. Patients over 16 years old were analyzed, and data on demographics, clinical characteristics, treatment patterns, healthcare resource utilization, and burden of disease via patient-reported outcomes (PROs) were collected.

RESULTS

With a predominantly White cohort, a mean age of 30.0 years, and balanced gender distribution, the study highlighted the significant impact of moderate-to-severe AD on patients' QoL, with a mean Dermatology Life Quality Index score of 15.19. High levels of itch, lesional skin severity, sleep disturbance, and pain contributed to the substantial burden of disease. Productivity was impaired in 40.0% of patients and daily activities were disrupted in 50.0%. Average body surface area involvement was 45.82%, with a mean of 6.49 AD flares in the previous year. Dermatologists played a pivotal role in the patient journey, contributing significantly to the diagnosis (55.9%) and referral process (70.9%). Treatment patterns highlighted a historical reliance on topical therapies and an evolving landscape with post-visit inclusion of advanced therapies such as dupilumab (38.5%), conventional immunosuppressants like cyclosporine (31.2%), and baricitinib (6.8%).

CONCLUSION

This study unveils the intricate landscape of moderate-to-severe AD in Portugal, highlighting a substantial unmet need for optimal disease management. The role of dermatologists is crucial, yet limited adoption of advanced therapies in the face of significant disease burden prompts critical reflection.

Interleukin-4 and Atopic Dermatitis: Why Does it Matter? A Narrative Review

Atopic dermatitis (AD) is a common chronic inflammatory skin condition that significantly impairs patients' quality of life as a result of intense itching and persistent eczematous lesions. Although AD has a multifaceted etiology-including genetic predisposition, environmental triggers, barrier dysfunction, and dysregulated immune responses-interleukin-4 (IL-4) has a recognized central role in its pathogenesis. This narrative review explores the role of IL-4 in the pathophysiology of AD, its contribution to the atopic march, and the therapeutic impact of IL-4 inhibition. IL-4 plays a critical role in skin barrier dysfunction, dysbiosis, pruritus, and inflammation, all of which contribute to the debilitating symptoms of AD. Moreover, IL-4 is implicated in other atopic conditions, such as asthma, allergic rhinitis, and food allergies, underscoring its role beyond AD and its importance in the atopic march. Recent advances in targeted therapies, particularly IL-4/IL-13 signaling inhibitors, have changed AD management. Dupilumab, an IL-4 receptor antagonist, has demonstrated significant efficacy in reducing AD symptoms and enhancing patient outcomes in both children and adults. In addition to symptomatic relief, suppressing IL-4 signaling may also offer potential for disease modification, altering AD's progression and possibly preventing the onset of other atopic conditions. This review highlights the crucial role of IL-4 as a therapeutic target in AD. By understanding the role of IL-4 in AD pathogenesis and exploring the therapeutic implications of targeting IL-4 pathways, this work can contribute to guide future research concerning treatment approaches and also emphasize the need for early and targeted interventions to mitigate disease impact and ultimately improve patient quality of life.

Atopic dermatitis

Atopic dermatitis is the most common chronic inflammatory skin disease globally. Key features include an eczematous eruption accompanied by intense itch, which can have an enormous negative effect on patients' quality of life, especially in those with moderate-to-severe disease. Atopic dermatitis is part of a spectrum of atopic conditions that can also include several non-cutaneous organs such as respiratory (eg, allergic rhinitis and asthma) and gastrointestinal (eg, food allergy) systems. For decades, long-term disease control and maintenance were particularly challenging given that treatment options were limited to broad topical and systemic immunosuppressive agents. However, better insights into the pathophysiology of this condition over the past decade have led to the development and approval of safe and efficacious novel targeted treatment approaches. The updated pathophysiological understanding and the evolving therapeutic landscape of atopic dermatitis are discussed in this Seminar.

Acute urticaria and cardiovascular diseases

BACKGROUND

Acute urticaria (AU), characterized by sudden skin wheals, has been associated with various triggers. While chronic urticaria's cardiovascular comorbidities have been studied, AU's associations remain largely unexplored.

OBJECTIVE

This study aimed to identify prevalent cardiovascular comorbidities in AU patients and assess their clinical significance.

METHODS

A retrospective cohort study used data from Leumit Health Services, matching AU patients with controls. Demographic, clinical, and laboratory data were analyzed. Statistical analyses included Fisher's Exact Test and Mann-Whitney U test.

RESULTS

The AU group (72,851 individuals) showed no sex/ethnic distribution differences from controls (291,404 individuals). Systolic blood pressure, weight, BMI, glucose, hemoglobin A1c, C-reactive protein, eosinophil counts, total IgE levels were higher in AU (p < 0.001). Several cardiovascular comorbidities showed significant associations with AU, including valvular heart diseases (aortic regurgitation, mitral regurgitation, and pulmonary valve stenosis), cardiac arrhythmias (atrial fibrillation and others), deep vein thrombosis, diseases of capillaries, peripheral artery disease, cerebrovascular disease, coronary artery disease, and inflammatory heart diseases (pericarditis, heart failure, and hypertension) (p < 0.05). Medications, including antihistamines and glucocorticoids, were more prevalent in the AU group (p < 0.001).

CONCLUSION

This study's findings underscore the importance of recognizing cardiovascular comorbidities in AU patients and considering their implications for management. The observed associations provide insight into potential shared mechanisms between AU and cardiovascular diseases, though further research is needed to validate and expand upon these findings.

Examining the Prevalence, Characteristics, and Potential Links Between Skin Disorders and Autism Spectrum Disorder (ASD)

Background: Increasing evidence indicates that skin disorders may contribute to an increased risk of autism spectrum disorder (ASD). They can affect the quality of life, and they have an impact on social isolation, behavioral problems, cognitive scores, and some subscales of ASD. Methods: This study was an online questionnaire-based, observational, and cross-sectional study conducted during the period from August 2022 through January 2023 to examine dermatological manifestations among ASD individuals compared to controls. Descriptive and non-parametric tests were used for data analysis. Results: A total of 363 individuals with skin diseases were interviewed during the study period. In total, 189 (52.1%) of participants were autistic and 174 (47.9%) were controls. Asthma, anxiety, depression, and autoimmune disease were persistent in the ASD group compared to the controls (p < 0.001). The results also show that skin, food, and respiratory allergies were statistically significantly associated with ASD (50%, 22.2%, 14.8%, respectively) compared to the controls (26.4%, 10.3%, 7.5%, respectively) (p < 0.05). The most prevalent disease in the controls was eczema (15.5%), followed by dry skin (14.9%) and acne (10.3%). These diseases showed a statistically significant association with ASD compared to the controls (p < 0.0001). Conclusions: Our findings indicate that atopic disorders and comorbidities, including eczema, asthma, and allergies, are significantly associated with ASD. A large population-based study is warranted to clarify the prevalence of skin disorders among individuals with ASD, coupled with the study of the association between skin disorders and comorbidities to determine the relationship precisely.

Preventing NLRP3 inflammasome activation: Therapeutic atrategy and challenges in atopic dermatitis

Atopic dermatitis (AD) is a prevalent inflammatory skin disorder characterized by its chronic, persistent, and recurrent nature. The pathophysiology of this condition is complex, involving various factors including cell-mediated immune responses, compromised skin barrier function, and alterations in hypersensitivity reactions. These components synergistically contribute to the perpetuation of the bothersome "itch-scratch-itch" cycle. Recent research has highlighted the significant role of the NLRP3 inflammasome in the development of AD and other inflammatory conditions. Current research indicates that the NLRP3 inflammasome plays a pivotal role in both the acute and chronic phases of AD by modulating the Th2/Th1 immune deviation. Moreover, the pharmacological suppression of NLRP3 has shown promising results in mitigating the pathological aspects of AD. This review outlines potential drug development strategies that target the NLRP3 inflammasome as a therapeutic approach for AD and the challenges faced in this endeavor.

The A-Z of age-related dermatological diseases

Skin ageing is an inevitable process influenced by both intrinsic and extrinsic factors. Intrinsic aging leads to thinner, drier and less elastic skin with fine wrinkles, while extrinsic factors such as sun exposure, smoking and environmental stresses amplify these changes. Photo-ageing, in particular, causes deep wrinkles, uneven pigmentation and increases the risk of skin cancers. Age-related alterations in skin structure and function include thinning of the epidermis, reduced collagen and elastin and changes in fat distribution, all of which compromise the skin's barrier and mechanical properties. These changes not only increase the susceptibility to conditions such as xerosis, fungal infections and atopic dermatitis but also carry psychological implications. Interestingly, atopic dermatitis, often associated with childhood, has a secondary peak in older adults and may be linked to neurodegenerative conditions such as Alzheimer's disease. This article explores the interplay between skin aging, dermatological diseases, and their broader physical and emotional impacts.

Atopic dermatitis: Best of guidelines and yardstick

Background: Atopic dermatitis (AD), a common chronic inflammatory skin disorder is characterized by a complex pathology with skin-barrier abnormalities, immune dysregulation, and microbial dysbiosis. Patients' quality of life is often negatively impacted by persistent pruritus, sleep disturbance, and recurrent skin infections. In addition, patients may have comorbid atopic as well as nonatopic diseases. Objective: The objective was to help clinicians better manage AD by using new therapies and new indications, including a topical (Janus kinase [JAK]) inhibitor as well as monoclonal antibodies and oral JAK inhibitors, have been approved for AD. Methods: This review presents highlights from the American College of Allergy, Asthma and Immunology AD Yardstick Update, which incorporates Expert Commentary, and from the Joint Task Force (JTF) AD 2023 Guidelines that use Grading of Recommendations, Assessment, Development, and Evaluation methodology. Results: Practical pearls from the AD Yardstick Update Expert Commentary are presented, along with results from systematic reviews and meta-analyses that addressed specific recommendations on the role of (1) dilute bleach baths, (2) dietary avoidance and/or elimination diets, (3) allergen immunotherapy, (4) topical treatments, and (5) systemic treatments, informing the JTF 2023 AD Guidelines. These guidelines are noteworthy for addressing patient values and preferences. Conclusion: The AD Yardstick Update Expert Commentary and JTF 2023 AD Guidelines provide timely, practical, and trustworthy information to help clinicians manage patients with AD.

Atopic dermatitis: pathogenesis and therapeutic intervention

The skin serves as the first protective barrier for nonspecific immunity and encompasses a vast network of skin-associated immune cells. Atopic dermatitis (AD) is a prevalent inflammatory skin disease that affects individuals of all ages and races, with a complex pathogenesis intricately linked to genetic, environmental factors, skin barrier dysfunction as well as immune dysfunction. Individuals diagnosed with AD frequently exhibit genetic predispositions, characterized by mutations that impact the structural integrity of the skin barrier. This barrier dysfunction leads to the release of alarmins, activating the type 2 immune pathway and recruiting various immune cells to the skin, where they coordinate cutaneous immune responses. In this review, we summarize experimental models of AD and provide an overview of its pathogenesis and the therapeutic interventions. We focus on elucidating the intricate interplay between the immune system of the skin and the complex regulatory mechanisms, as well as commonly used treatments for AD, aiming to systematically understand the cellular and molecular crosstalk in AD-affected skin. Our overarching objective is to provide novel insights and inform potential clinical interventions to reduce the incidence and impact of AD.

Patient preferences for treatment attributes in moderate-to-severe atopic dermatitis: a discrete choice experiment

Purpose: Evidence on treatment preferences of patients with moderate-to-severe atopic dermatitis (AD) in the United States (US) is limited and an assessment of treatment preferences in this group is warranted.Materials and methods: An online discrete choice experiment survey was conducted (June 2023) among US adults with self-reported moderate-to-severe AD or experience with systemic therapy who had inadequate response to topical treatments. Preference weights estimated from conditional logistic regression models were used to calculate willingness to trade off and attributes' relative importance (RI).Results: Participants (N = 300; mean age: 45 years; 70% females; 52% systemic therapy experienced) preferred treatments with higher efficacy, lower risk of adverse events (AEs), and less frequent blood tests (p < .05). Treatment attributes, from high to low RI, were itch control (38%), risk of cancer (23%), risk of respiratory infections (18%), risk of heart problems (11%), sustained improvement in skin appearance (5%), blood test frequency (3%), and frequency and mode of administration (2%); together, AE attributes accounted for more than half of the RI.Conclusions: Participants preferred AD treatments that maximize itch control while minimizing AE risks, whereas mode of administration had little impact on preferences. Understanding patients' preferences may help improve shared decision-making, potentially leading to enhanced patient satisfaction with treatment, increased engagement, and better clinical outcomes.

Cyclosporin A-loaded dissolving microneedles for dermatitis therapy: Development, characterisation and efficacy in a delayed-type hypersensitivity in vivo model

Several drugs can be used for treating inflammatory skin pathologies like dermatitis and psoriasis. However, for the management of chronic and long-term cases, topical administration is preferred over oral delivery since it prevents certain issues due to systemic side effects from occurring. Cyclosporin A (CsA) has been used for this purpose; however, its high molecular weight (1202 Da) restricts the diffusion through the skin structure. Here, we developed a nano-in-micro device combining lipid vesicles (LVs) and dissolving microneedle array patches (DMAPs) for targeted skin delivery. CsA-LVs allowed the effective incorporation of CsA in the hydrophilic DMAP matrix despite the hydrophobicity of the drug. Polymeric matrix composed of poly (vinyl alcohol) (5% w/v), poly (vinyl pyrrolidine) (15% w/v) and CsA-LV dispersion (10% v/v) led to the formation of CsA-LVs@DMAPs with adequate mechanical properties to penetrate the stratum corneum barrier. The safety and biocompatibility were ensured in an in vitro viability test using HaCaT keratinocytes and L929 fibroblast cell lines. Ex vivo permeability studies in a Franz-diffusion cell setup showed effective drug retention in the skin structure. Finally, CsA-LVs@DMAPs were challenged in an in vivo murine model of delayed-type hypersensitivity to corroborate their potential to ameliorate skin inflammatory conditions. Different findings like photon emission reduction in bioluminescence study, normalisation of histological damage and decrease of inflammatory cytokines point out the effectivity of CsA-LVs@DMAPs to treat these conditions. Overall, our study demonstrates that CsA-LVs@DMAPs can downregulate the skin inflammatory environment which paves the way for their clinical translation and their use as an alternative to corticosteroid-based therapies.

Disease burden and patient characteristics associated with systemic therapy utilization among adults with atopic dermatitis: data from CorEvitas Atopic Dermatitis Registry

BACKGROUND

The decision to initiate advanced systemics in patients with atopic dermatitis (AD) is complex.

OBJECTIVES

To explore disease burden and clinical characteristics of patients with moderate-to-severe AD and identify characteristics associated with initiating new systemics.

METHODS

Data from prospective, longitudinal, non-interventional CorEvitas AD Registry were evaluated. Differences in demographic and clinical characteristics, comorbidities, disease severity (vIGA-AD™; body surface area (BSA); Eczema Area and Severity Index (EASI); SCORing AD [SCORAD]), and patient-reported outcomes (PROs) were assessed between systemic and non-systemic therapy groups.

RESULTS

Of 883 patients, 673 were newly prescribed systemics and 210 were not. Non-systemic therapy group had higher than expected rates of severe disease at enrollment based on vIGA-AD = 4 (39%), mean BSA involvement (31%), and mean EASI (19). PROs for non-systemic therapy group indicated elevated burden from AD on quality of life and poor disease control. SCORAD, peak pruritus in the past 24 h, history of biologics, and facial pallor, were significantly associated with initiation of systemics at enrollment.

CONCLUSION

While disease burden likely influences the initiation of systemic therapy, many patients with significant burden are not treated with systemics for unclear reasons. Further research is needed to identify other factors, beyond disease severity, that influence this decision.

Patients' preferences for systemic treatment of atopic dermatitis: safety and efficacy count the most

BACKGROUND

The advent of biologics and janus kinase inhibitors has revolutionized treatment of atopic dermatitis (AD).

OBJECTIVE

To investigate preferences of patients with AD for attributes of currently approved systemic treatments and assess influencing factors.

METHODS

An online discrete choice experiment was conducted in patients with AD throughout Germany to analyze preferences for outcome (probability of (almost) clear skin at week 16, probability of significant itch improvement, time to onset of itch relief and type of side effects) and process attributes (application method and frequency of laboratory tests).

RESULTS

Participants (n = 182, 75.3% female) considered side effects (Relative Importance Score (RIS): 31.2), (almost) clear skin (RIS: 24.2) and probability of itch improvement (RIS: 16.0) most important. Application method (RIS: 14.4), time to onset of itch relief (RIS: 7.4) and frequency of laboratory tests (RIS: 6.8) were less relevant. Preferences were significantly influenced by sex, age, psychiatric comorbidity, current therapy and health-related quality of life according to multivariate regression analysis.

CONCLUSIONS

Participants attached great importance to safety and symptom control. However, preferences were also dependent on individual characteristics, underscoring the importance of personal counseling. Conjoined with medical considerations, patients' preferences have fundamental impact on shared decisions for treatment of AD.

The epithelial barrier theory and its associated diseases

The prevalence of many chronic noncommunicable diseases has been steadily rising over the past six decades. During this time, over 350,000 new chemical substances have been introduced to the lives of humans. In recent years, the epithelial barrier theory came to light explaining the growing prevalence and exacerbations of these diseases worldwide. It attributes their onset to a functionally impaired epithelial barrier triggered by the toxicity of the exposed substances, associated with microbial dysbiosis, immune system activation, and inflammation. Diseases encompassed by the epithelial barrier theory share common features such as an increased prevalence after the 1960s or 2000s that cannot (solely) be accounted for by the emergence of improved diagnostic methods. Other common traits include epithelial barrier defects, microbial dysbiosis with loss of commensals and colonization of opportunistic pathogens, and circulating inflammatory cells and cytokines. In addition, practically unrelated diseases that fulfill these criteria have started to emerge as multimorbidities during the last decades. Here, we provide a comprehensive overview of diseases encompassed by the epithelial barrier theory and discuss evidence and similarities for their epidemiology, genetic susceptibility, epithelial barrier dysfunction, microbial dysbiosis, and tissue inflammation.

Factors associated with comorbidity development in atopic dermatitis: a cross-section study

Identifying the characteristics of atopic dermatitis (AD) patients with its comorbidity has become increasingly crucial. We aimed to investigate the relevant factors associated with comorbidities in adults with AD. We analyzed cross-sectional data through univariate and multivariate regression analyses, encompassing 439 adult cases of AD from the Clinical Research and Homogenization Diagnosis and Treatment Project for Type 2 Inflammatory Dermatosis. It was found that 231 patients developed at least one comorbidity. 161 cases had a positive family history of atopy, 292 exhibited elevated IgE levels. A family history of allergic rhinitis or sinusitis was found to be associated with concurrent diseases (OR (95% CI): 2.92 (1.41-6.06) in model 1; 2.71 (1.27-5.77) in model 2; 3.59 (1.75-7.37) in model 3; 3.38 (1.62-7.05) in model 4; 3.60 (1.83-7.08) in model 5; 3.56 (1.78-7.12) in model 6). The linkage between elevated IgE levels and concurrent diseases with different classifications was negative (OR (95% CI): 0.51 (0.33-0.79) in model 1; 0.51 (0.33-0.80) in model 2; 0.51 (0.33-0.79) in model 3; 0.52 (0.33-0.81) in model 4; 0.45 (0.29-0.71) in model 5; 0.47 (0.30-0.73) in model 6). Scores for familial atopy (OR (95% CI): 1.56 (1.00-2.44) in model 2; 1.59 (1.03-2.48) in model 4; 1.84 (1.19-2.84) in model 6) were positively associated with comorbidities. Factors associated with comorbidity development in AD included a family history of allergic rhinitis or sinusitis, elevated IgE levels and scores indicating familial atopy. These relevant factors might contribute to improved discrimination and early intervention for comorbidities in individuals with AD.

Bioactive Effect of Plasma-Rich in Growth Factors (PRGFs) on Cell-Based In Vitro Models of Skin Inflammation in Relation to Inflammatory Skin Disorders

Plasma rich in growth factors (PRGFs) has proven potentially beneficial as a bioregenerator in patients with chronic skin disorders due to its anti-inflammatory effect. However, its therapeutic potential may be limited by soluble autoimmune components associated with inflammatory dermatoses in blood plasma. To evaluate the impact of skin health status on cell bioactivity, PRGF was prepared from healthy (H) donors as well as from individuals with atopic dermatitis (AD), psoriasis (PS), or lichen sclerosus (LS). Leukocyte exclusion and heat inactivation (Immunosafe treatment) were evaluated as potential methods to reduce the inflammatory components of the samples under study. The biological effect of PRGF-derived formulations was investigated using cell-based in vitro skin inflammation models, including human dermal fibroblasts (HDFs) and human epidermal keratinocytes (HEKs) exposed to a pro-inflammatory environment. The data confirmed that viability, proliferation, and migration rates were enhanced in inflamed cell cultures supplemented with PRGF formulations compared to those maintained in standard culture media. Nevertheless, significant differences have been identified. About the healthy control, inflamed epidermal keratinocytes supplemented with most PRGF-based formulations obtained from pathological donors (PS/LS) showed lower viability. Heat inactivation significantly promoted cell proliferation in epidermal keratinocytes supplemented with SP (PS/LS) and L-PRP supernatant (LSP) samples (AD), and also cell migration in inflamed HDF (AD/H/LS) and HEK (AD/LS) models supplemented with LSP. Leukocyte exclusion improved cell behavior in terms of migration with the only exception of LSP from individuals with AD added to inflamed HEK cultures. In conclusion, PRGF derived from pathological patients contains autoimmune components that could compromise its effectiveness as a therapy for treating individuals with chronic inflammatory disorders. However, heat inactivation (Immunosafe treatment) or leukocyte exclusion could minimize local adverse effects.

Atopic Dermatitis (Eczema) Guidelines 2023: Highlights

Atopic dermatitis is a common chronic inflammatory skin disorder, with a complex pathogenesis. It is characterized by eczematous skin lesions, pruritus, and recurrent skin infections and has a negative impact on patients' and caregivers' quality of life. The American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma and Immunology Joint Task Force Atopic Dermatitis Guideline Panel recently released updated AD guidelines. This guideline focuses on addressing clinical questions using trustworthy guideline development standards, including mitigating the potential influence of financial and nonfinancial conflicts of interest, and Grading of Recommendations Assessment, Development, and Evaluation methodology. A multidisciplinary panel used systematic reviews and meta-analyses to inform specific recommendations addressing optimal use of topical treatments, dilute bleach bath, dietary avoidance/elimination, allergen immunotherapy, and systemic treatments. The comprehensive recommendations, emphasizing the third principle of evidence-based medicine-that evidence alone is never enough, and that patient values and preferences must be carefully considered when determining optimal treatments for patients and populations-provide a framework to support clinicians in selecting an optimal treatment plan for each patient. This review provides an overview of the guideline and discusses how those recommendations relate to current practice.

Navigating the evolving landscape of atopic dermatitis: Challenges and future opportunities: The 4th Davos declaration

The 4th Davos Declaration was developed during the Global Allergy Forum in Davos which aimed to elevate the care of patients with atopic dermatitis (AD) by uniting experts and stakeholders. The forum addressed the high prevalence of AD, with a strategic focus on advancing research, treatment, and management to meet the evolving challenges in the field. This multidisciplinary forum brought together top leaders from research, clinical practice, policy, and patient advocacy to discuss the critical aspects of AD, including neuroimmunology, environmental factors, comorbidities, and breakthroughs in prevention, diagnosis, and treatment. The discussions were geared towards fostering a collaborative approach to integrate these advancements into practical, patient-centric care. The forum underlined the mounting burden of AD, attributing it to significant environmental and lifestyle changes. It acknowledged the progress in understanding AD and in developing targeted therapies but recognized a gap in translating these innovations into clinical practice. Emphasis was placed on the need for enhanced awareness, education, and stakeholder engagement to address this gap effectively and to consider environmental and lifestyle factors in a comprehensive disease management strategy. The 4th Davos Declaration marks a significant milestone in the journey to improve care for people with AD. By promoting a holistic approach that combines research, education, and clinical application, the Forum sets a roadmap for stakeholders to collaborate to improve patient outcomes in AD, reflecting a commitment to adapt and respond to the dynamic challenges of AD in a changing world.

Vaccines and allergy: Back to the right places

Hypersensitivity reactions represent one of the most common causes of hesitancy for adherence to national vaccination programs. The majority of hypersensitivity reactions after vaccination are mild, and anaphylaxis is reported to be rare, although it remains challenging to estimate the frequency attributed to each single vaccine, either because of the lower number of administered doses of less common vaccines, or the administration of simultaneous vaccine in most of the vaccination programs. Although literature remains scattered, international consensus guides clinicians in identifying patients who might need the administration of vaccines in protected environments due to demonstrated hypersensitivity to vaccine components or adjuvants. Here we provide the current guidance on hypersensitivity reactions to vaccines and on vaccination of children with allergy disorders.

Reduced atopic march risk in pediatric atopic dermatitis patients prescribed dupilumab versus conventional immunomodulatory therapy: A population-based cohort study

BACKGROUND

Dupilumab effectively treats atopic dermatitis (AD); however, its role in halting the atopic march remains uncertain.

OBJECTIVE

To investigate dupilumab's effect on atopic march in pediatric AD patients versus conventional immunomodulators.

METHODS

This retrospective cohort study utilized data from the TriNetX US Collaborative Network (2011-2024). Pediatric AD patients (≤18 years) were categorized into DUPI-cohort (newly prescribed dupilumab) or CONV-cohort (prescribed conventional immunomodulators without dupilumab). After 1:1 propensity-score matching, we analyzed atopic march progression, defined by the incident asthma or allergic rhinitis (AR). Cumulative incidence was plotted using Kaplan-Meier, with risk assessment via Cox regression.

RESULTS

The study included 2192 patients in each cohort. The 3-year cumulative incidence of atopic march progression was lower in the DUPI-cohort than the CONV-cohort (20.09% vs 27.22%; P < .001). The DUPI-cohort demonstrated significant risk reduction in atopic march progression (hazard ratio [HR] 0.68, 95% CI 0.55-0.83), individual asthma (HR 0.60, 0.45-0.81), and individual AR (HR 0.69, 0.54-0.88). Younger patients on dupilumab exhibited a greater risk reduction for atopic march progression and individual asthma, contrasting with the opposite age-related pattern for individual AR.

LIMITATIONS

Observational study.

CONCLUSION

Among pediatric AD patients, dupilumab was associated with reduced risk of atopic march progression compared with conventional therapies.

[Mental disorders from climate and environmental changes using the example of dermatology]

BACKGROUND

Global climate and environmental changes impose a significant impact on human health by increasing prevalences of chronic and acute skin diseases. Climate-associated environmental changes can also trigger or intensify mental illnesses independently of a skin disease.

AIM

Discussion of the effects of the climate and environmental changes on dermatological diseases applying the biopsychosocial model.

MATERIALS AND METHODS

A selective literature search in the PubMed database and other sources was conducted.

RESULTS

The biopsychosocial model considers complex interactions between biological, psychological, and social factors. In view of the consequences of climate and environmental changes, an extension of the model is proposed for the first time in order to address new challenges. The modified presentation supports the understanding of the dynamics and underscores that in dermatological care not only direct health effects of climate and environmental changes have to be dealt with, but also with an increasing number of mental illnesses, which in turn are to be regarded as direct and indirect health effects.

CONCLUSION

Coping with the predicted increase in the burden of disease and the decline in the available labor force associated with demographic change poses a major challenge. In order to maintain the functionality of the healthcare system, the prompt implementation of resource-efficient, sustainable measures in all areas of society is essential. The integrative consideration of dermatological and psychological complaints in the context of climate and environmental changes requires the adaptation of content for the education, training, and continuing education of specialists.

Correlation between disease severity indices and quality of life measurement tools in atopic dermatitis patients

INTRODUCTION

Reports regarding the correlation and effect size of change of the full spectrum of quality of life and disease severity measures applied in-person to patients with atopic dermatitis are scarce.

OBJECTIVES

To assess quality-of-life with 3 different instruments and to evaluate disease severity indices and to determine their correlation and effect size of change between two measurements.

MATERIALS AND METHODS

Patient-level data were obtained through two in-person visits. Sociodemographic information and data related to disease distribution, severity (through the BSA, EASI, SCORAD, POEM, and itching scales), and the impact of atopic dermatitis on quality of life using the DLQI and Skindex-29, and EQ-5D, were assessed. The correlation between change in quality-of-life scores and disease severity scores in addition to the standardized effect size were also evaluated.

RESULTS

Only 139 out of 212 patients completed the follow-up visit. BSA highly correlated with SCORAD and EASI, and the lowest correlation was found with POEM. The best correlation of pruritus VAS was found with sleep disturbance. The SCORAD score highly correlated with EASI, and the lowest correlation was found with POEM. The magnitude of the effect at initiation of the study vs follow-up was in average moderate to important.

CONCLUSIONS

Patients with atopic dermatitis experience a substantial burden on quality of life. Disease activity correlates better with quality-of-life measurements when the disease is less severe after starting therapy. POEM and Skindex-29 seem to be optimal to determine disease severity and quality of life in adults with atopic dermatitis.

Causal relationships between dietary antioxidant vitamin intake and atopic dermatitis: A two-sample Mendelian randomization study

OBJECTIVE

Oxidative stress is strongly associated with atopic dermatitis (AD), and increased antioxidant intake could potentially reduce the risk of or alleviate its symptoms. However, the argument is disputed. Therefore, we conducted a Mendelian randomization (MR) analysis to explore the causal relationship between dietary antioxidant vitamin intake and AD.

METHODS

We applied MR analysis to examine the causative association between dietary antioxidant vitamin intake (vitamin C, vitamin E, carotene, and retinol) and AD. The genome-wide association study (GWAS) summary data for antioxidant vitamins intake and AD were obtained from the IEU OpenGWAS database and the UK biobank. Our study consisted of two major parts, MR analysis to detect the causal relationship between exposure and outcome, and sensitivity analysis as supplemental evidence to verify the robustness of the results.

RESULT

The results revealed a suggestive causal relationship between vitamin E intake and AD (p = 0.038, OR 95% CI = 0.745-0.992). However, there was no causal relationship between the other three vitamins (vitamin C, carotene, and retinol) and AD (p = 0.507, OR 95% CI = 0.826-1.099) (p = 0.890, OR 95% CI = 0.864-1.184) (p = 0.492, OR 95% CI = 0.893-1.264). None of the single nucleotide polymorphisms (SNPs) were detected as heterogeneous and pleiotropy in the sensitivity analysis (p > 0.05).

CONCLUSION

The analysis suggested that dietary intake of vitamin E may potentially lower the risk of AD. Conversely, intake of vitamin C, retinol, and carotene is not causally related to AD. Although vitamin E intake could be protective against AD, intake of dietary antioxidant vitamins to prevent or treat AD is not necessary.

Successful treatment of severe atopic dermatitis and alopecia universalis with upadacitinib in a 29-year-old male patient

A 29-year-old male patient had severe atopic dermatitis (AD) and alopecia universalis (AU) that could not be controlled by using classic therapy. He started taking upadacitinib and achieved an excellent response for both his AD and AU. Thus, upadacitinib represents a promising therapeutic approach for patients with severe AD and alopecia areata.

Biologics and small molecules treatment for moderate-to-severe atopic dermatitis patients with comorbid conditions and special populations: an Italian perspective

This comprehensive review offers a detailed look at atopic dermatitis (AD) treatment in Italy, focusing primarily on the use of biologics and small molecules. In response to advancing knowledge of AD's causes and treatments, there's a global need for updated guidelines to provide physicians with a more comprehensive clinical perspective, facilitating personalized treatment strategies. Dupilumab, a groundbreaking biologic, gained approval as a significant milestone. Clinical trials demonstrated its ability to significantly reduce AD severity scores, with an impressive 37% of patients achieving clear or nearly clear skin within just 16 weeks of treatment. Real-world studies further support its efficacy across various age groups, including the elderly, with a safety profile akin to that of younger adults. Tralokinumab, a more recent approval, shows promise in clinical trials, particularly among younger populations. However, its real-world application, especially in older individuals, lacks comprehensive data. Janus Kinases inhibitors like Upadacitinib, Baricitinib, and Abrocitinib hold substantial potential for AD treatment. Nevertheless, data remains limited for patients over 75, with older adults perceived to carry a higher risk profile. Integrated safety analyses revealed individuals aged 60 and above experiencing major adverse cardiovascular events and malignancies, underscoring the need for cautious consideration. While these therapies offer promise, especially among younger patients, further research is essential to determine their safety and efficacy in various populations, including pediatric, geriatric, and those with comorbidities. Biologics and small molecules are improving AD treatment, as shown in this review.

A Multidisciplinary Approach Is Beneficial in Atopic Dermatitis

Atopic dermatitis (AD) is a highly heterogeneous chronic inflammatory skin disorder that is frequently associated with a plethora of comorbidities. AD is, therefore, considered a systemic disease impacted by a considerable burden and leading to poor quality of life, especially in patients with moderate-to-severe disease. Since atopic and non-atopic comorbidities can further worsen the disease course, accurate establishment of the patient's individual intrinsic risk profile and needs is crucial and may help in guiding the selection of the best treatment option. Better quality of care for patients with AD can be delivered through a multidisciplinary team led by a dermatologist, for comprehensive patient management. The implementation of a multidisciplinary approach for AD could enhance the delivery of optimised and safe treatments, improve the standard of care and patient outcomes in the short and long term, and prevent or delay the lifelong impact of uncontrolled AD. Understanding the unmet needs, assessing correctly the patient risk profile and enhancing the shared patient-physician decision-making process can lead to disease control and quality-of-life improvement, especially in the context of the introduction of newer treatment for AD. This narrative review is a call for more data to establish standardised patient profiles and multidisciplinary strategies in AD management. In view on the fast-evolving treatments for AD, this review aims at highlighting the importance of a multidisciplinary approach to a comprehensive assessment and holistic care in patients with moderate-to-severe AD.

Association Between Atopic Dermatitis and Aging: Clinical Observations and Underlying Mechanisms

As one of the most prevalent chronic inflammatory skin diseases, atopic dermatitis (AD) increasingly affects the aging population. Amid the ongoing global aging trend, it's essential to recognize the intricate relationship between AD and aging. This paper reviews existing knowledge, summarizing clinical observations of associations between AD and aging-related diseases in various systems, including endocrine, cardiovascular, and neurological. Additionally, it discusses major theories explaining the correlation, encompassing skin-mucosal barriers, systemic inflammation and stress, genes, signal transduction, and environmental and behavioral factors. The association between AD and aging holds significant importance, both in population and basic perspectives. While further research is warranted, this paper aims to inspire deeper exploration of inflammation/allergy-aging dynamics and the timely management of elderly patients with AD.

Prevalence of Severe Atopic Dermatitis and Comorbid Chronic Systemic Diseases Is Increasing in Korean Children and Adolescents

Severe atopic dermatitis (AD) is not a localized cutaneous disease, but a systemic disease that often accompanies comorbidities. In this nationwide population-based study, we aimed to analyze the prevalence of severe AD and chronic systemic diseases in Koreans aged ≤ 20 years between 2011 and 2019 using the data from the Korean Health Insurance Review and Assessment Service. Total AD and severe AD were defined according to the International Classification of Diseases-10 code L20. In children aged 6-20 years, the prevalence of severe AD significantly increased from 0.02% in 2011 to 0.04% in 2019 (P for trend < 0.001), with the ratio of severe AD to total AD increasing from 0.76% in 2011 to 1.10% in 2019 (P for trend < 0.001). The prevalence rates of severe AD significantly increased between 2011 and 2019 in children aged 6-12 years (P for trend < 0.05) and 13-18 years (P for trend < 0.001). Severe AD was more frequently found in males than in females each year (all P < 0.001, from 2011 to 2019). During the period from 2011 to 2019, the prevalence rate of chronic systemic diseases was higher in subjects with severe AD than in those without AD (P < 0.001) or with mild-to-moderate AD (P < 0.001). In conclusion, our results suggest that the prevalence of severe AD is increasing in Korean children and adolescents and is higher in males and older age groups. Moreover, severe AD is associated with chronic systemic diseases. Therefore, more attention should be paid to managing severe AD.

Effects of abrocitinib on pruritus and eczema symptoms and tolerance in patients with moderate‑to‑severe atopic dermatitis in randomized, double‑blind and placebo‑controlled trials: A systematic review and a meta‑analysis

Abrocitinib is a highly selective Janus kinase 1 (JAK1) inhibitor that can block a multitude of inflammatory signaling pathways that underlie atopic dermatitis (AD). In addition, abrocitinib inhibits JAK1 signaling in sensory neurons to alleviate acute and chronic pruritus during AD. However, substantial variations in efficacy and safety risks remain due to variations in doses applied in clinical use. Therefore for the present study, differences in the efficacy and tolerability of 100 and 200 mg abrocitinib for treating pruritus and eczema symptoms in patients with moderate-to-severe AD were evaluated compared with placebo. Specifically, randomized controlled trials (RCTs) of abrocitinib compared with placebo for the treatment of moderate-to-severe AD were searched on Pubmed, E.B. Stephens Company, China National Knowledge Infrastructure, Wanfang Medical network, Web of Science and related Clinical Trials Registry up to November 2023. In total, two researchers evaluated the quality of the included literature according to the Cochrane Handbook of Systematic Reviews. RevMan 5.3 software was used to conduct a meta-analysis of the efficacy and safety indicators in a cross-comparison of the effects exerted by placebo and 100 and 200 mg abrocitinib. A total of 1,825 patients with moderate-to-severe AD were included across five double-blind, placebo RCTs. Compared with the placebo group, during the double-blind trial period, significant improvements were observed in the investigator's global assessment score, response rate of eczema area and severity index (EASI)-50, EASI-75, EASI-90 and pruritus numerical rating scale (P-NRS) in the 100 and 200 mg abrocitinib groups (P<0.05). However, pairwise control analysis of the 100 and 200 mg group yielded significant differences (P<0.05) in all of the aforementioned therapeutic indicators except for the P-NRS score. In terms of safety, compared with the placebo group, there were significantly higher incidence of nausea, upper respiratory tract viral infection, infections and infestations in the 100 mg abrocitinib group (P<0.05). In addition, there were significantly higher incidence of nausea, gastrointestinal disorder, headache and dizziness in the 200 mg group (P<0.05). There were also significant differences in the incidence of nausea, gastrointestinal disorder and dizziness between the 100 and 200 mg groups (P<0.05). For patients with moderate-to-severe AD, oral administration of 100 or 200 mg abrocitinib once/day was concluded to ameliorate skin pruritus and eczema symptoms to varying degrees, with the efficacy significantly superior at the 200 mg dose. However, the risk of a number of adverse reactions, such as headache, dizziness, nausea and gastrointestinal dysfunction, is also significantly increased. Therefore, patients should be made aware of the risk of adverse drug effects prior to the administration of long-term high abrocitinib doses. Furthermore, large-scale, multi-center, rigorous clinical trials remain necessary to validate the findings from the present study.

Pruritus and Pain Constitute the Main Negative Impact of Atopic Dermatitis® From the Patient's Perspective: A Systematic Review

Atopic Dermatitis® (AD) is an inflammatory skin disease characterized by intense itching and highly visible signs, representing a great burden to the patient. Despite its straightforward diagnosis, AD severity and burden can be underestimated in routine clinical practice. This review aims to determine the impact of AD on patients' lives, establish which domains of life are most affected, and identify symptom drivers of AD burden. A systematic literature review was conducted in Pubmed/Medline, Web of Science, and Scopus following Cochrane and PRISMA recommendations. Observational studies published in English or Spanish between January 1, 2018, and August 31, 2022, evaluating the impact of AD and its symptoms from the patient's perspective, were included. Reviewed studies were assessed for quality following the STrengthening the Reporting of OBservational studies in Epidemiology Checklist. A total of 28 observational studies evaluating the impact of AD and its symptoms from the patient's perspective were included in the review. All domains of the AD patient's life were found to be greatly affected, including health-related quality of life (HRQoL), emotional health, sleep disorders, work impairment, health care resource utilization, cognitive function, and development of comorbidities. The more severe the disease, the greater the impact, worsening in patients with moderate and severe AD. Pruritus and pain are reported to be the disease symptoms with the greatest impact. In conclusion, AD impacts several domains of patients' lives, especially HRQoL and mental health. Pruritus and pain are identified as the main drivers of AD impact, suggesting that optimal symptom control may reduce the burden and improve disease management.

Patient-reported assessment of medical care for chronic inflammatory skin diseases: an enterprise-based survey

Background

Chronic inflammatory skin diseases (CISDs) are among the most common diseases in the Western world. Current estimates of medical care for CISDs are primarily based on surveys among patients in medical care facilities and on health insurance data.

Aim

Survey-based examination to what extent CISD patients in health-aware environment consider their skin disease to be controlled.

Methods

The survey of CISD patients was carried out in 2022 among the employees of a pharmaceutical company located in Germany and Switzerland. Software-based, anonymous, self-reported questionnaires were used.

Results

The number of employees, who answered the questionnaire, was 905. Of these, 222 participants (24.5%) reported having at least one CISD. 28.7% of participants with CISD described their disease as being hardly or not controlled. Regarding the nature of disease, more than one third of participants suffering from hidradenitis suppurativa (HS) or psoriasis fell into the hardly/not controlled category. In contrast, the largest proportion of participants with chronic spontaneous urticaria (43%) or atopic dermatitis (42%) considered their CISD to be completely or well controlled. Only 35.5% of CISD sufferers stated that they were currently under medical care for their skin condition. Being under medical care, however, had no influence on the extent CISD sufferers considered their skin disease to be controlled. The number of active CISD episodes but not the total number of symptomatic days per year was negatively associated with poor disease control (p = 0.042 and p = 0.856, respectively). Poor disease control had a negative effect on the personal and professional lives of those affected, as deduced from its positive association with the extent of daily activity impairment and presenteeism (p = 0.005 and p = 0.005, respectively). Moreover, 41.4 and 20.7% of participants with hardly/not controlled disease stated that their CISD had a moderate and severe or very severe impact on their overall lives (p < 0.001), respectively. A severe or very severe impact of their CISD on their overall life was most commonly reported by participants with HS.

Conclusion

Medical care for CISDs, even in an environment with high socio-economic standard and high health-awareness, still appears to be limited and has a negative impact on individuals and society.

Risk of atopic dermatitis and the atopic march paradigm in children of mothers with atopic illnesses: A birth cohort study from the United Kingdom

BACKGROUND

Atopic dermatitis (AD) is thought to precede the onset of other allergic illness (OAI) in a temporal progression (ie, atopic march), yet the timing and progression has been questioned. It is also unclear how parental allergic illness impacts the development of these illnesses in offspring.

OBJECTIVE

(1) Explore risk of incident AD and (2) timing of allergic disease onset in children of mothers with AD compared with mothers without AD from the United Kingdom.

METHODS

We created a birth cohort of mother-child pairs using IQVIA Medical Research Data database and developed Cox proportional models to examine the above associations (hazard ratio, HR [95% confidence interval, CI]).

RESULTS

Among 1,224,243 child-mother pairs, mean child (standard deviation) follow-up time was 10.8 (8.3) years and 50.1% were males (N = 600,905). Children were 59% (HR = 1.59 [1.57, 1.60]) more likely to have AD if their mothers had AD compared with no AD with mean age of first AD diagnosis at 3.3 (4.8) years. Most children with any diagnosis of AD present with AD first (91.0%); however, in those with asthma, only 67.8% developed AD first.

CONCLUSION

Children born to mothers with AD are more prone to develop AD and some develop OAI first, suggesting that not all follow the same sequential pathway.

A critical evaluation of suitability of tralokinumab for treatment of moderate-to-severe atopic dermatitis in adolescents and adults

INTRODUCTION

Atopic dermatitis (AD) is a chronic, intensely pruritic disease associated with significant patient burden. Recent advancements in AD pathogenesis have expanded its therapeutics pipeline. Tralokinumab is a fully human monoclonal antibody that binds specifically Interleukin (IL)-13, inhibiting the downstream IL-13 signaling. Phase 3 clinical trials and some real-world studies showed that tralokinumab, as monotherapy or in combination with topical corticosteroids, is efficacious and safe in adult patients with moderate-to-severe AD. Similar results were reported in a phase 3 trial in adolescents (aged ≥12 years).

AREAS COVERED

We review the role of IL-13 in AD and discuss the value of tralokinumab for treating moderate-to-severe AD, comparing efficacy and safety results derived from clinical trials and real-life data.

EXPERT OPINION

The role of IL-13 in AD supports a targeted therapeutic approach. Tralokinumab has proven efficacious and well-tolerated in a large proportion of patients confirming its value for treating moderate-to-severe AD from age 12 years onwards; it quickly improves itching and can maintain a high-level of response over time; it can be administered with flexible dosing schedules. Future studies will further clarify the role of IL-13 pathway and which patients would be best suited to tralokinumab, shifting AD treatment into an era of precision medicine.

Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations

BACKGROUND

Guidance addressing atopic dermatitis (AD) management, last issued in 2012 by the American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force, requires updating as a result of new treatments and improved guideline and evidence synthesis methodology.

OBJECTIVE

To produce evidence-based guidelines that support patients, clinicians, and other decision-makers in the optimal treatment of AD.

METHODS

A multidisciplinary guideline panel consisting of patients and caregivers, AD experts (dermatology and allergy/immunology), primary care practitioners (family medicine, pediatrics, internal medicine), and allied health professionals (psychology, pharmacy, nursing) convened, prioritized equity, diversity, and inclusiveness, and implemented management strategies to minimize influence of conflicts of interest. The Evidence in Allergy Group supported guideline development by performing systematic evidence reviews, facilitating guideline processes, and holding focus groups with patient and family partners. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach informed rating the certainty of evidence and strength of recommendations. Evidence-to-decision frameworks, subjected to public comment, translated evidence to recommendations using trustworthy guideline principles.

RESULTS

The panel agreed on 25 recommendations to gain and maintain control of AD for patients with mild, moderate, and severe AD. The eAppendix provides practical information and implementation considerations in 1-2 page patient-friendly handouts.

CONCLUSION

These evidence-based recommendations address optimal use of (1) topical treatments (barrier moisturization devices, corticosteroids, calcineurin inhibitors, PDE4 inhibitors [crisaborole], topical JAK inhibitors, occlusive [wet wrap] therapy, adjunctive antimicrobials, application frequency, maintenance therapy), (2) dilute bleach baths, (3) dietary avoidance/elimination, (4) allergen immunotherapy, and (5) systemic treatments (biologics/monoclonal antibodies, small molecule immunosuppressants [cyclosporine, methotrexate, azathioprine, mycophenolate, JAK inhibitors], and systemic corticosteroids) and UV phototherapy (light therapy).