Epidemiology of atopic dermatitis

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).

A Review of Anti-Inflammatory Phytoconstituents Used in Herbal Cosmeceuticals for the Treatment of Atopic Dermatitis

Skin diseases such as atopic dermatitis affect babies, children, and adults and are characterized by red skin/spots, severe itching that appears on the face, head, legs, neck, and hands, and various causes of illness caused by various external and internal factors. AD is a type IIgE-mediated hypersensitivity reaction. Herbal preparations treat various dermatological diseases like dry skin, melasma, acne, and eczema. Cosmeceuticals are the connection between cosmetics and medicine, one of the world's most used forms of medicine. Cosmeceuticals products are beneficial in treating AD. Herbal cosmetics play a major role in curing various skin diseases. Today, various herbs used in cosmeceuticals have anti-inflammatory, antioxidant, antibacterial, and antiseptic effects. Compared to synthetic preparations, herbal preparations have fewer side effects. This review paper introduces Atopic dermatitis, cosmeceutical, and various phytoconstituents like gallic acid, ferulic acid, boswellic acid, quercetin, and naringenin tetra hydroxyl flavanol glycoside, glycyrrhizic acid, epigallocatechin gallate, etc., used in atopic dermatitis.

The Acari Hypothesis, III: Atopic Dermatitis

Atopic dermatitis is a chronic relapsing dermatopathology involving IgE against allergenic materials present on mammalian epithelial surfaces. Allergens are as diverse as pet danders, and polypeptides expressed by microbes of the mammalian microbiome, e.g., Malassezia spp. The Acari Hypothesis posits that the mammalian innate immune system utilizes pathogen-bound acarian immune effectors to protect against the vectorial threat posed by mites and ticks. Per The Hypothesis, IgE-mediated allergic disease is a specious consequence of the pairing of acarian gastrointestinal materials, e.g., allergenic foodstuffs, with acarian innate immune effectors that have interspecies operability. In keeping with The Hypothesis, the IgE profile of atopic patients should include both anti-acarian antibodies and specious antibodies responsible for specific allergy. Further, the profile should inform on the diet and/or environment of the acarian vector. In this regard, the prevalence of Demodex and Dermatophagoides on the skin of persons suffering from atopic dermatitis is increased. Importantly, the diets of these mites correspond well with the allergens of affected patients. In this report, roles for these specific acarians in the pathogenesis of atopic dermatitis are proposed and elaborated.

Understanding immunological origins of atopic dermatitis through multi-omic analysis

BACKGROUND

The pathophysiology of atopic dermatitis (AD) is multifactorial, impacted by individual medical, demographic, environmental, and immunologic factors. This study used multi-omic analyses to assess how host and microbial factors could contribute to infant AD development.

METHODS

This longitudinal cohort study included 129 term infants, identified as AD (n = 37) or non-AD (n = 92) using the Infant Feeding Practices-II survey and review of medical records. Standardized surveys were used to assess medical and demographic traits (gestational age, sex, race, maternal AD, and atopy family history), and environmental exposures (delivery method, maternal tobacco use, pets, breastfeeding duration, and timing of solid food introduction). Saliva was collected at 6 months for multi-omic assessment of cytokines, microRNAs, mRNAs, and the microbiome. The contribution of each factor to AD status was assessed with logistic regression.

RESULTS

Medical, demographic, and environmental factors did not differ between AD and non-AD infants. Five "omic" factors (IL-8/IL-6, miR-375-3p, miR-21-5p, bacterial diversity, and Proteobacteria) differed between groups (p < .05). The severity of AD was positively associated with levels of miR-375-3p (R = .17, p = .049) and Proteobacteria (R = .22, p = .011), and negatively associated with levels of miR-21-5p (R = .20, p = .022). Multi-omic features accounted for 17% of variance between groups, significantly improving an AD risk model employing medical, demographic, and environmental factors (X²  = 32.47, p = .006).

CONCLUSION

Interactions between the microbiome and host signaling may predispose certain infants to AD by promoting a pro-inflammatory environment.

HautTief Multidisciplinary Educational Program for Patients with Psoriasis or Atopic Dermatitis: A Randomized Controlled Study

Background

Improving health-related quality of life (HRQoL), disease severity, and treatment adherence through patient education is an increasingly important, yet relatively new area in dermatology. This randomized controlled trial aims to contribute to this growing area of research by exploring the effects of a 9-week educational program for patients with chronic skin diseases.

Objective

The aim of the study was to evaluate the effect of a multidisciplinary educational program on HRQoL and disease severity in patients with psoriasis or atopic dermatitis (AD).

Methods

Sixty-four patients with diagnosed psoriasis or AD were recruited from University Hospital Zurich and randomized (1:1) to the intervention or control group. To assess HRQoL, the following self-reported questionnaires were used: Dermatology Life Quality Index (DLQI), Skindex-29, EuroQol-5D (EQ-5D), RAND 36-Item Short Form Survey (SF-36), and Beck Depression Inventory (BDI) to measure depression symptoms. Psoriasis Area and Severity Index (PASI) and the Eczema Area and Severity Index (EASI) were used to capture disease extent. These scores were assessed at four study visits, which were performed at baseline and 3, 6, and 9 months after the start of the program.

Results

At month 6, an improvement of at least 25% in BDI was recorded in 15 (68.2%) of 22 patients in the intervention group and 6 (27.3%) of 22 patients in the control group (difference 40.9%, p = 0.016). 53.3% (16 of 30) of patients achieved an improvement in one subdomain of the SF-36 score (role limitations due to emotional problems) at 6-month follow-up, compared with 23.1% (6 of 26) of those not attending the educational program (difference 30.2%; p = 0.042). No significant differences in DLQI, Skindex-29, EQ-5D, PASI, and EASI between both groups at the three time points were found.

Conclusion

An educational program may improve HRQoL and depression status of patients with psoriasis or AD.

Atopic dermatitis: molecular, cellular, and clinical aspects

Atopic dermatitis (AD) is a complicated, inflammatory skin disease, which numerous genetic and environmental factors play roles in its development. AD is categorized into different phenotypes and stages, although they are mostly similar in their pathophysiological aspects. Immune response alterations and structural distortions of the skin-barrier layer are evident in AD patients. Genetic makeup, lifestyle, and environment are also significantly involved in contextual factors. Genes involved in AD-susceptibility, including filaggrin and natural moisturizing, cause considerable structural modifications in the skin's lipid bilayer and cornified envelope. Additionally, the skin's decreased integrity and altered structure are accompanied by biochemical changes in the normal skin microflora's dysbiosis. The dynamic immunological responses, genetic susceptibilities, and structural modifications associated with AD's pathophysiology will be extensively discussed in this review, each according to the latest achievements and findings.

Validation and reproducibility of the International Study of Asthma and Allergies in Childhood (ISAAC) Written Atopic Eczema Questionnaire for telephone survey in children aged 6-7 years

BACKGROUND

The prevalence of atopic eczema is unknown in many countries. The International Study of Asthma and Allergies in Childhood (ISAAC) is an epidemiological landmark in the study of allergic diseases.

OBJECTIVE

To validate and assess the reproducibility of the ISAAC Written Atopic Eczema Questionnaire (WAEQ) for children aged between 6 and 7 years by telephone contact.

METHODS

Observational study through interviews with guardians of children aged 6 to 7 years using the ISAAC atopic eczema module questionnaire in three different phases separated by 2 weeks: telephone interviews in the first and third contacts and in-person interviews under supervision in the second contact. Reproducibility was estimated using the Kappa index and validation using the sensitivity and specificity coefficients.

RESULTS

Data from 88 children (32 from the atopic eczema group) were analyzed. Reproducibility showed almost perfect agreement for the questions "Recurrent pruritic lesions" and "Lesions in typical locations" (Kappa between 0.81-0.82), while a substantial agreement was observed for all other indicators (Kappa variation between 0.66 and 0.78). The validation showed high specificity (≥ 80.4%) and sensitivity (≥ 87.5%) for all questions, except those related to chronicity and medical diagnosis (34.4% and 40.6%, respectively).

STUDY LIMITATIONS

Non-random selection, no sample size calculation, participants from a tertiary hospital and study period coincident with the Coronavirus pandemic.

CONCLUSIONS

Our results showed that the ISAAC atopic eczema module questionnaire by telephone interviews has good reproducibility and high agreement with the clinical diagnosis of atopic eczema. It may be an appropriate alternative tool in epidemiological studies of childhood atopic eczema, especially in periods of social isolation.

Cynanchi atrati and Its Phenolic Constituent Sinapic Acid Target Regulator of Calcineurin 1 (RCAN1) to Control Skin Inflammation

Atopic dermatitis (AD) is a common inflammatory skin disorder, and numerous pharmacological approaches are employed to reduce symptoms. Natural products of plant-derived materials have been accepted as complementary therapy for the treatment of a wide range of inflammatory diseases. Cynanchi atrati (CA) is an oriental medicinal herb used in the treatment of acute urinary infection, febrile diseases, and laryngopharyngitis. However, the role of CA root extract in skin inflammation such as AD has not been explored yet. In this study, we examined the possible effect of CA root extract on skin inflammation and evaluated the underlying signaling mechanism using in vitro and in vivo modeling systems. Raw264.7 macrophages were used for in vitro experiments, and an oxazolone-induced AD mouse model was used to evaluate in vivo effects. CA extract significantly inhibited the expression levels of lipopolysaccharide (LPS)-induced pro-inflammatory cytokines such as interleukin-6 (IL-6) and interleukin-1β (IL-1β) in RAW264.7 macrophages. The CA root extract mediated suppression of pro-inflammatory cytokine expression and was associated with the decreased nuclear factor kappa B (NF-κB) gene transcriptional activation. Moreover, CA root extract attenuated the in vivo expression of IL-6 and tumor necrosis factor-α (TNF-α) and ear swelling in the AD mouse models. We also observed that the inhibitory effect of CA root extract on skin inflammation was accompanied by the upregulation of calcineurin 1 (RCAN1) expression, which functions in the inflammatory pathways by suppressing NF-κB signaling. We consistently observed that the immunosuppressive effect of CA root extract in AD was significantly perturbed in the RCAN1 knockout mice. In addition, we isolated a phenolic acid compound, sinapic acid (SA), from the CA root extract and found that SA consistently exerted an immunosuppressive effect in RAW264.7 macrophages by inducing RCAN1 expression. Our results provide the first evidence that CA root extract and its phenolic acid constituent, SA, modulate NF-κB signaling pathways by inducing RCAN1 expression in the skin inflammation process. Thus, we suggest that CA root extract has a therapeutic value for the treatment of AD by targeting endogenous immune regulators.

Prospective, comparative clinical pilot study of cold atmospheric plasma device in the treatment of atopic dermatitis

Cold atmospheric plasma generates free radicals through the ionization of air at room temperature. Its effect and safety profile as a treatment modality for atopic dermatitis lesions have not been evaluated prospectively enough. We aimed to investigate the effect and safety of cold atmospheric plasma in patients with atopic dermatitis with a prospective pilot study. Cold atmospheric plasma treatment or sham control treatment were applied respectively in randomly assigned and symmetric skin lesions. Three treatment sessions were performed at weeks 0, 1, and 2. Clinical severity indices were assessed at weeks 0, 1, 2, and 4 after treatment. Additionally, the microbial characteristics of the lesions before and after treatments were analyzed. We included 22 patients with mild to moderate atopic dermatitis presented with symmetric lesions. We found that cold atmospheric plasma can alleviate the clinical severity of atopic dermatitis. Modified atopic dermatitis antecubital severity and eczema area and severity index score were significantly decreased in the treated group. Furthermore, scoring of atopic dermatitis score and pruritic visual analog scales significantly improved. Microbiome analysis revealed significantly reduced proportion of Staphylococcus aureus in the treated group. Cold atmospheric plasma can significantly improve mild and moderate atopic dermatitis without safety issues.

Long-chain saturated fatty acids in breast milk are associated with the pathogenesis of atopic dermatitis via induction of inflammatory ILC3s

Breastfeeding influences the immune system development in infants and may even affect various immunological responses later in life. Breast milk provides a rich source of early nutrition for infant growth and development. However, the presence of certain compounds in breast milk, related to an unhealthy lifestyle or the diet of lactating mothers, may negatively impact infants. Based on a cohort study of atopic dermatitis (AD), we find the presence of damage-associated molecular patterns (DAMPs) activity in the mother's milk. By non-targeted metabolomic analysis, we identify the long-chain saturated fatty acids (LCSFA) as a biomarker DAMPs (+) breast milk samples. Similarly, a mouse model in which breastfed offspring are fed milk high in LCSFA show AD onset later in life. We prove that LCSFA are a type of damage-associated molecular patterns, which initiate a series of inflammatory events in the gut involving type 3 innate lymphoid cells (ILC3s). A remarkable increase in inflammatory ILC3s is observed in the gut, and the migration of these ILC3s to the skin may be potential triggers of AD. Gene expression analysis of ILC3s isolated from the gut reveal upregulation of genes that increase ILC3s and chemokines/chemokine receptors, which may play a role in ILC migration to the skin. Even in the absence of adaptive immunity, Rag1 knockout mice fed a high-LCSFA milk diet develop eczema, accompanied by increased gut ILC3s. We also present that gut microbiota of AD-prone PA milk-fed mice is different from non-AD OA/ND milk-fed mice. Here, we propose that early exposure to LCSFAs in infants may affect the balance of intestinal innate immunity, inducing a highly inflammatory environment with the proliferation of ILC3s and production of interleukin-17 and interleukin-22, these factors may be potential triggers or worsening factors of AD.

From Dysbiosis to Healthy Skin: Major Contributions of Cutibacterium acnes to Skin Homeostasis

Cutibacterium acnes is the most abundant bacterium living in human, healthy and sebum-rich skin sites, such as the face and the back. This bacterium is adapted to this specific environment and therefore could have a major role in local skin homeostasis. To assess the role of this bacterium in healthy skin, this review focused on (i) the abundance of C. acnes in the skin microbiome of healthy skin and skin disorders, (ii) its major contributions to human skin health, and (iii) skin commensals used as probiotics to alleviate skin disorders. The loss of C. acnes relative abundance and/or clonal diversity is frequently associated with skin disorders such as acne, atopic dermatitis, rosacea, and psoriasis. C. acnes, and the diversity of its clonal population, contributes actively to the normal biophysiological skin functions through, for example, lipid modulation, niche competition and oxidative stress mitigation. Compared to gut probiotics, limited dermatological studies have investigated skin probiotics with skin commensal strains, highlighting their unexplored potential.

Identification of oral symptoms associated with atopic dermatitis in adolescents: Results from the Korea national representative survey 2009-2017

The relationship between oral health and atopic dermatitis (AD) remains unclear. Here we investigated the association between oral health status and AD using data from 634,299 subjects in the Korean Youth Risk Behavior Survey (KYRBS). Participants with oral symptoms were defined as those with any of following: sensitive teeth, toothache, bleeding gums or gum pain, and dry mouth. Current AD was determined by the question if participant had been diagnosed with AD from doctor within the past 12 months. We estimated the odds ratio (OR) for AD diagnosis according to the presence of oral symptoms. The OR for current AD, which is a dependent variable, was significantly increased in participants with oral symptoms, which are independent variables, in an adjusted model (OR, 1.27; 95% confidence interval [CI], 1.26–1.29; P < 0.001). In detailed analyses, all four oral symptoms were significantly associated with AD diagnosis: sensitive teeth (OR, 1.21; CI, 1.19–1.23; P < 0.001), bad breath (OR, 1.18; CI, 1.17–1.20; P < 0.001), toothache (OR, 1.18; CI, 1.16–1.20; P < 0.001), and bleeding gums (OR, 1.14; CI, 1.12–1.16; P < 0.001). In the presence of oral symptoms, the ORs for having two or more allergic diseases (AD, allergic rhinitis, and/or asthma) were higher than that of AD alone. In this study, oral symptoms appeared to be associated with AD in Korean adolescences.

Effects of conditioned media from human umbilical cord blood-derived mesenchymal stem cells in the skin immune response

Atopic dermatitis (AD) is an inflammatory skin disease in which type 2 allergic inflammation plays a critical role. In this study, the anti-inflammatory effect of conditioned media from human umbilical cord blood-derived mesenchymal stem cells (USC-CM) was investigated in order to apply it as an effective treatment with a low risk of side effects that can overcome the limitations of AD treatment which is currently in use. We found that USC-CM has various growth factors and cytokines associated with anti-inflammatory effect. RT-PCR and ELISA analysis showed that USC-CM inhibited the levels of type 2 cytokine and chemokine Thymus and activation-regulated chemokine (TARC), TNF-α and IL-6 in TNF-α/IFN-γ-stimulated HaCaT cells. In addition, USC-CM inhibited IL-4 and IL-13 levels in Th2 cells. Therefore, the results of our study demonstrated that USC-CM has anti-inflammatory effect in TNF-α/IFN-γ-stimulated HaCaT cells which associated with the inhibition of the immunoglobulin (IgE) secretion by activating B cell line. Our In vivo results showed that when the USC-CM was applied to lesions of patients with the mild AD for 4 weeks, the skin barrier was strengthened by increasing the level of Corneometer and decreasing the value of transepidermal water loss (TEWL). In conclusion, the results suggest that USC-CM may have therapeutic effect for AD as cosmetics and drug materials.

Atopic Dermatitis and Comorbidity

Atopic dermatitis is the most common chronic inflammatory skin disease. It is often the first indicator of allergic diseases, and a certain percentage of patients are affected by allergic rhinitis and/or asthma as a consequence. The study aimed to investigate the link between atopic dermatitis and comorbidity in family medicine. In the specialist family medicine practice Osijek, a retrospective study was conducted in the period from January 1, 2016 to July 1, 2017 on the percentage of patients with atopic dermatitis in the total number of patients, and their comorbid diseases. The data source was the E-chart. The results showed that 195 (10.53%) out of 2056 patients had atopic dermatitis, 80 (41%) patients had atopic dermatitis and allergic rhinitis, 34 (17.4%) asthma, 132 (67.7%) infections, 59 (30.3%) gastrointestinal disturbances, and 68 (34.3%) had mental disorders. Patients up to 18 years old were more likely to have infections, and adult patients were exposed to chronic stress. The most commonly used drug was loratadine (60.5%), while mometasone was the most commonly administered topical drug (40%). The result of this research showed the steps of the ˝atopic march˝. Atopic dermatitis is followed by changes in the skin and its progression to other organ systems in most of the patients.

Enhancement of Chemokine mRNA Expression by Toll-Like Receptor 2 Stimulation in Human Peripheral Blood Mononuclear Cells of Patients with Atopic Dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disease which is often associated with Staphylococcus aureus (S. aureus) colonization. S. aureus ingredients are potential ligands to activate the Toll-like receptor 2 (TLR2) and drive inflammatory cytokine or chemokine production. However, the role of TLR2-mediated chemokine expression in AD development has not been systematically investigated. In this study, we sought to determine the mode of TLR2-mediated chemokine expression in AD patients. Human peripheral blood mononuclear cells (PBMCs) were isolated from AD patients and healthy controls. Upon incubation with TLR2 ligands Pam3CSK4 and PGN, mRNA expression of chemokines, including CCL1, CCL5, CCL8, CCL13, CCL17, CCL18, CCL22, and CCL27, were determined by quantitative real-time polymerase chain reaction (qRT-PCR) analysis. The results showed that basal mRNA expression of CCL17 in PBMCs from AD patients was upregulated compared with healthy controls, while those of CCL8 and CCL13 were downregulated. When stimulated with TLR2 ligands, the mRNA expression of CCL5, CCL8, CCL13, CCL18, and CCL22 in PBMCs from AD patients was significantly higher than those from healthy controls. The different basal chemokine mRNA expression profiles indicate the different immune status in patients with AD compared with healthy controls. Excessive chemokine mRNA expression induced by TLR2 activation is associated with the development of AD.

Contact Allergy in Children with Atopic Dermatitis: A Retrospective Study

Background:

The relationship between atopic dermatitis and allergic contact dermatitis is frequently debated, particularly in children. The impaired skin barrier of atopic subjects can facilitate the penetration of exogenous agents and its mutations in the filaggrin gene might be implicated in an increased risk to develop contact dermatitis. Moreover, atopic children are protractedly exposed to chemical substances contained in skin care products from an early age.

Patients And Methods:

The aim of this retrospective study is to determine if atopic children are more prone to allergic contact dermatitis and which substances are more frequently related to this disease. From 2014 to 2016, a total of 268 children under 14 years with a history of eczematous dermatitis, of whom 141 (52.6%) were affected, and 127 (47.4%) were not affected by AD, underwent patch testing with the baseline S.I.D.A.P.A standard series.

Results:

Based on the results of our study, the prevalence of contact allergy in atopic children is comparable to that noted in non-atopic children. The most frequent causes of contact allergy in children are fragrances, and their prevalence is significantly higher in atopic children (19.9%) than in non-atopic ones, (11.8%; p < .05).

Conclusion:

Our study highlights the importance of patch testing in atopic children for continuously monitoring the trends and changes of contact allergies that are a common disease and is even significantly increasing for some allergens, as fragrances. We may speculate that the protracted use of skincare products, associated with the impaired skin barrier of atopic children, enhances the risk of sensitization to the ingredients of these products.

Different potencies of topical corticosteroids for a better treatment strategy in children with atopic dermatitis (the Rotterdam Eczema study): protocol for an observational cohort study with an embedded randomised open-label controlled trial

INTRODUCTION

Topical corticosteroids (TCS) of different potencies are the main treatment to control atopic dermatitis (AD). The Dutch guideline on AD for general practitioners (GPs) recommends a stepwise approach in which treatment steps are tailored to the severity of the disease, starting with the lowest possible potency of TCS. However, it remains unclear whether the recommended stepwise approach is most efficient. This randomised open-label controlled trial aims to determine whether a potent TCS is more effective than a low-potency TCS in the initial treatment of children with a moderate flare-up of AD in primary care. In the observational cohort, the overall aim is to determine the frequency, burden and determinants of flare-ups of AD during follow-up.

METHODS AND ANALYSIS

The study is an observational cohort study with an embedded pragmatic randomised controlled, open-label trial. Eligible are patients diagnosed with AD (aged 12 weeks to 18 years) who visited the GP for AD or received repeated prescriptions for AD in the previous 12 months; follow-up of the cohort is 1 year. Children are enrolled in the trial if they have a flare-up of AD during follow-up in the cohort. Eligible children are randomised to the intervention group (with a potent TCS once daily) or to the GP guideline group (with a low potency TCS once daily). Primary outcome is the difference in average subjective disease severity over 24 weeks follow-up in the trial, measured with the patient-oriented eczema measure. As secondary outcome, the Eczema Area and Severity Index is measured.

ETHICS AND DISSEMINATION

This study tests the hypothesis that immediate treatment with a potent TCS during a flare-up of AD leads to faster and more efficacious results as compared with starting with a TCS with low potency with less overall use of TCS. The study protocol is approved by the Medical Ethics Committee (MEC) of the Erasmus Medical Center Rotterdam, the Netherlands (MEC-2017-328). The results of the study will be published in international peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NTR: 6679; Pre-results.

'High dose' vs. 'medium dose' UVA1 phototherapy in italian patients with severe atopic dermatitis

BACKGROUND

The current evidences attest UVA1 phototherapy as effective in the treatment of severe atopic dermatitis (AD). Furthermore, in this indication, 'medium dose' is as effective as 'high dose' regimen. To date, a randomized comparison study evaluating the effectiveness as well as safety of different UVA1 protocols in different skin types in the treatment of adult patients with severe AD is still lacking.

OBJECTIVE

The aim of the present study was to compare the safety and the efficacy of medium and high dose UVA1 either in fair or in dark skin types.

METHODS

Twenty-seven adult patients with severe AD were consecutively included in a randomized, controlled, open, two arms trial Severity of AD was determined by means of SCORAD index and clinical improvement was also monitored. A total of 13 out of 27 patients were treated with high dose (130 J/cm2 ) UVA1 protocol while 14 out of 27 patients received medium dose (60 J/cm2 ) UVA1 protocol. Phototherapy was performed five times weekly up to 3 weeks. Before and after UVA1 treatment each patient was evaluated for skin pigmentation through Melanin Index (MI) quantitative evaluation.

RESULTS

Skin status improved in all patients resulting in a reduction of SCORAD index in all groups. Our results demonstrated that among patients with darker skin types and higher MI, high dose UVA1 was significantly more effective than medium dose (P < 0.0001) while within the groups with skin type II, no significant differences between high and medium dose protocols were observed.

CONCLUSION

Our study, confirms previous observations that UVA1 phototherapy should be considered among the first approaches in the treatment of patients with severe generalized AD and also demonstrates that in darker skin types, high dose UVA1 phototherapy is more effective than medium dose in the treatment of adult patients with severe AD.

Atopic dermatitis

Atopic dermatitis (AD) is a common, chronic skin disorder that can significantly impact the quality of life of affected individuals as well as their families. Although the pathogenesis of the disorder is not completely understood, it appears to result from the complex interplay between defects in skin barrier function, environmental and infectious agents, and immune dysregulation. There are no diagnostic tests for AD; therefore, the diagnosis is based on specific clinical criteria that take into account the patient's history and clinical manifestations. Successful management of the disorder requires a multifaceted approach that involves education, optimal skin care practices, anti-inflammatory treatment with topical corticosteroids and/or topical calcineurin inhibitors, the management of pruritus, and the treatment of skin infections. Systemic immunosuppressive agents may also be used, but are generally reserved for severe flare-ups or more difficult-to-control disease. Topical corticosteroids are the first-line pharmacologic treatments for AD, and evidence suggests that these agents may also be beneficial for the prophylaxis of disease flare-ups. Although the prognosis for patients with AD is generally favourable, those patients with severe, widespread disease and concomitant atopic conditions, such as asthma and allergic rhinitis, are likely to experience poorer outcomes.

Oral Aspects Identified in Atopic Dermatitis Patients: A Literature Review

Introduction:

Atopic dermatitis is a chronic inflammatory skin condition that is more prevalent in children (10-20% of the world's population) than in adults. As its etiology is multifactorial, it is important to know the most frequent oral manifestations in atopic dermatitis patients.

Methodology:

In the last decades, the correlation between atopic dermatitis and conditions and/or changes in the oral cavity has been demonstrated by several studies. The objective of this paper was to describe, through a review of the literature, the oral health conditions and/or oral aspects identified in patients with atopic dermatitis.

Search Strategy:

A descriptive literature review was carried out through a bibliographical survey based on the last 10 years, in order to answer the study questions.

Results:

As a result, we found six studies with different sample sizes, ranging from 43 to 468 patients, and the majority of them were of cross-sectional study design.

Discussion:

Two studies performed their analysis through dental exams and reported that patients with atopic dermatitis tend to have a greater frequency of carious lesions, and two studies correlated Candida with atopic dermatitis through mycological analyzes.

Conclusion:

There are a few studies in the literature that identify the oral aspects of atopic dermatitis. More investigations are needed in order to contribute to the knowledge of such oral aspects and the approach to treat these patients regarding oral health.

Infectious Complications in Atopic Dermatitis

Atopic dermatitis is characterized by the interplay of skin barrier defects with the immune system and skin microbiome that causes patients to be at risk for infectious complications. This article reviews the pathogenesis of atopic dermatitis and the mechanisms through which patients are at risk for infection from bacterial, viral, and fungal pathogens. Although these complications may be managed acutely, prevention of secondary infections depends on a multipronged approach in the maintenance of skin integrity, control of flares, and microbial pathogens.

Dioscorea quinqueloba Ameliorates Oxazolone- and 2,4-Dinitrochlorobenzene-induced Atopic Dermatitis Symptoms in Murine Models

Dioscorea quinqueloba has been used for food substances, as well as in herbal medicines for allergic diseases such as asthma. This study aimed to investigate the anti-atopic dermatitis (AD) effects of the total extract of D. quinqueloba rhizomes and active fractionson murine oxazolone- and 2,4-dinitrochlorobenzene-induced models of AD. Specific AD symptoms, such as erythema, ear swelling, and epidermis thickening, were significantly reduced in the oxazolone-mediated AD BALB/c mice upon topical application of D. quinqueloba rhizomes 95% EtOH extract (DQ). DQEA (D. quinqueloba rhizomes EtOAc fraction) was beneficial for protecting the skin barrier against AD in DNCB-sensitized SKH-1 hairless mice. Decreased total serum IgE and IL-4 levels could be observed in atopic dorsal skin samples of the DQEA-treated group. On the basis of the phytochemical analysis, DQEA was found to contain dioscin and gracillin as its main compounds. Therapeutic applications with D. quinqueloba might be useful in the treatment of AD and related inflammatory skin diseases.

Predicting the atopic march: Results from the Canadian Healthy Infant Longitudinal Development Study

BACKGROUND

The atopic march describes the progression from atopic dermatitis during infancy to asthma and allergic rhinitis in later childhood. In a Canadian birth cohort we investigated whether concomitant allergic sensitization enhances subsequent development of these allergic diseases at age 3 years.

METHODS

Children completed skin prick testing at age 1 year. Children were considered sensitized if they produced a wheal 2 mm or larger than that elicited by the negative control to any of 10 inhalant or food allergens. Children were also assessed for atopic dermatitis by using the diagnostic criteria of the UK Working Party. At age 3 years, children were assessed for asthma, allergic rhinitis, food allergy, and atopic dermatitis. Data from 2311 children were available.

RESULTS

Atopic dermatitis without allergic sensitization was not associated with an increased risk of asthma at age 3 years after adjusting for common confounders (relative risk [RR], 0.46; 95% CI, 0.11-1.93). Conversely, atopic dermatitis with allergic sensitization increased the risk of asthma more than 7-fold (RR, 7.04; 95% CI, 4.13-11.99). Atopic dermatitis and allergic sensitization had significant interactions on both the additive (relative excess risk due to interaction, 5.06; 95% CI, 1.33-11.04) and multiplicative (ratio of RRs, 5.80; 95% CI, 1.20-27.83) scales in association with asthma risk. There was also a positive additive interaction between atopic dermatitis and allergic sensitization in their effects on food allergy risk (relative excess risk due to interaction, 15.11; 95% CI, 4.19-35.36).

CONCLUSIONS

Atopic dermatitis without concomitant allergic sensitization was not associated with an increased risk of asthma. In combination, atopic dermatitis and allergic sensitization had strong interactive effects on both asthma and food allergy risk at age 3 years.

An Atopic Dermatitis Management Algorithm for Primary Care Providers and Assessment of Its Usefulness as a Clinical Tool

BACKGROUND/OBJECTIVES

There is a lack of primary care provider (PCP) understanding of atopic dermatitis (AD) treatments and topical steroid use. We designed an AD management algorithm for pediatric PCPs. We hypothesized that the algorithm would improve pediatric PCPs' knowledge of AD diagnosis and management.

METHODS

Pediatric primary care resident and attending physicians at three residency programs were invited to participate in an electronic AD algorithm survey that contained demographic and 19 knowledge-based questions. Participants were randomized to intervention and control groups, with the intervention group receiving a short lecture and copy of our algorithm to use in an inpatient or outpatient setting for 2 months. Changes in scores between preintervention and postintervention surveys were compared.

RESULTS

Of the 54 participants, those in the intervention group (n = 26) performed significantly better than those in the control group (n = 28) after controlling for pretest scores (β = 1.19 [95% confidence interval 0.07, 2.32], p = 0.04). The intervention group had a higher average score on the posttest knowledge questions (71% correct) than the control group (65% correct) (p = 0.06). The majority of physicians who received the algorithm agreed or strongly agreed that they liked using the algorithm.

CONCLUSION

The use of a management algorithm improved physician knowledge about the diagnosis and treatment of AD and was well accepted by physicians. Use of this management algorithm may lead to better recognition and management of AD, particularly earlier recognition of and therapy for superinfection, improving treatment outcomes and quality of life for patients and families.

Multidisciplinary interventions in the management of atopic dermatitis

Atopic dermatitis (AD) is the most common pediatric skin disease. AD has a significant effect on patient and family quality of life caused by intense pruritus, sleep disruption, dietary and nutritional concerns, and psychological stress associated with the disease and its management. Multidisciplinary approaches to AD care have been developed in appreciation of the complex interplay among biological, psychological, behavioral, and dietary factors that affect disease control and the wide range of knowledge, skills, and support that patients and families require to effectively manage and cope with this condition. Common components of multidisciplinary treatment approaches include medical evaluation and management by an AD specialist, education and nursing care, psychological and behavioral support, and nutritional assessment and guidance. Models of care include both clinical programs and structured educational groups provided as adjuncts to standard clinical care. Available evidence suggests beneficial effects of multidisciplinary interventions in improving disease severity and quality of life, particularly for patients with moderate-to-severe disease. Additional research is needed to identify the best candidates for the various multidisciplinary approaches and evaluate the cost-effectiveness of these programs.

Expression levels of transcription factor PU.1 and interleukin-9 in atopic dermatitis and their relation to disease severity and eruption types

BACKGROUND

The role of immunological factors in atopic dermatitis (AD) pathogenesis is well established. T-helper (TH) cells are central in AD pathogenesis. A relatively new subset of T cells, Th9 cells, was shown to be involved in the development of allergic asthma and allergic rhinitis, while its role in AD is still to be investigated. This study aimed to measure gene expression levels of interleukin-9 (IL-9) and PU.1, and to examine relationships with disease severity, serum IgE, and eruption types in AD patients.

METHODS

The study enrolled 30 AD patients, 30 psoriasis patients, and 30 healthy subjects. The severity of AD was assessed using the SCORAD index. IL-9 and PU.1 expressions were measured by using real-time quantitative polymerase chain reaction (RQ-PCR). Serum IgE was measured by IgE (human) enzyme-linked immunosorbent assay (ELISA) Kit.

RESULTS

IL-9 and PU.1 gene expressions were significantly higher in AD patients than in controls (P1 = 0.007, P2 < 0.001, respectively). In the atopic dermatitis patients, expression of IL-9 and PU.1 were significantly positively correlated with SCORAD index (P1 = 0.004, P2 = 0.002) and clinically with erythema and edema scores. IL-9 and PU.1 expressions were positively significantly correlated (P = 0.005) and positively correlated with serum IgE in the AD group (P1 = 0.017, P2 = 0.023). No significant difference was noted between AD patients with or without histories of other atopies regarding expression levels of IL-9 and PU.1 (P1 = 0.677, P2 = 0.135).

CONCLUSIONS

PU.1 and IL-9 may play a role in AD pathogenesis and relate to disease severity and clinical eruption types.

Assessment of IgE-mediated food allergies in children with atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is an inflammatory disease of the skin, which is characterised by a chronic relapsing course.

AIM

The aim of the study was to assign the prevalence of clinically active food allergies among a group of children between 3 months and 7 years of age, with AD.

METHODS

Eighty-eight children with AD were screened for specific IgE antibodies to food proteins. All patients with AD and specific IgE antibodies to food proteins were subjected to Oral Food Challenges (OFCs) with the relevant foods.

RESULTS

Food-sensitised patients with moderate levels of sIgE had clinically active food allergy to milk (39.28%) and egg (42.34%) on the basis of positive OFCs. High IgE and eosinophilia had a prevalence of almost 80% and 25%, regardless of concomitant food sensitisation and disease severity.

CONCLUSIONS

In this study, clinically active food allergies were recognised in 26.13% of children with AD. Nevertheless, no association was confirmed between food sensitisation and AD severity. High IgE and peripheral eosinophilia have not been found more prevalent among children with severe AD nor among children with food sensitisation. Infants and younger children with AD should be screened for an underlying food allergy, regardless of disease severity.

Prevalence of non-food allergies among non-immigrants, long-time immigrants and recent immigrants in Canada

OBJECTIVES

The prevalence of allergic conditions has been increasing worldwide, with the highest rates seen in Western countries like Canada. The development of allergies is known to be related to both genetic and environmental factors, but the causal pathways remain unclear. Studies on immigrants provide a unique opportunity to disentangle these two factors and provide a better understanding of the disease aetiology. The aim of this study was to investigate the relationship between immigration status and prevalence of non-food allergies in a population-based study of Canadians.

METHODS

Data of 116,232 respondents from the Canadian Community Health Survey (Cycle 3.1, 2005) were used in a multivariable logistic regression to assess the association between immigration status (non-immigrant, long-time immigrant [&gt;10 years] and recent immigrant [≤10 years]) and self-reported doctor-diagnosed non-food allergies, adjusting for potential confounders.

RESULTS

The highest prevalence of non-food allergies was found among non-immigrants (29.6%), followed by long-time immigrants (23.9%) and then recent immigrants (14.3%). The odds of non-food allergies were reduced by 60% (OR = 0.40, 95% CI: 0.35, 0.45) among recent immigrants and 25% (OR = 0.75, 95% CI: 0.70, 0.80) among long-time immigrants, compared with non-immigrants, after adjusting for sex, age, socio-economic status and rurality.

CONCLUSION

This study finds a distinctly lower prevalence of non-food allergies among immigrants compared with non-immigrants, with the difference diminishing with longer duration of residence in Canada. The findings highlight the potential of environmental determinants of allergy development that warrant further investigation, and demonstrate the need for multicultural strategies to manage the public health burden of allergic conditions.

Psychiatry outpatient visits by atopic dermatitis patients varying in the complexity of their prescriptions: A nationwide cohort study conducted from 2005 to 2013

The uncomfortable symptoms of atopic dermatitis (AD) often trigger psychological stress.We investigated the association between AD severity and outpatient visits to psychiatrists using Korean National Health Insurance claims data from 2004 to 2013.This was a retrospective cohort analysis; we estimated hazard ratios (HRs).Of the 266,182 subjects, 18,290 (6.9%) had a history of visiting a psychiatrist, and 25,419 (9.5%) were diagnosed with AD. Compared with the subjects without AD, subjects with AD had a higher HR for visiting a psychiatrist (3.70, 95% confidence interval [CI]:48 3.43-3.98), and this significantly increased as the complexity of the AD medications increased. Subjects who received topical treatments plus a systematic steroid (HR: 4.88, 95% CI: 4.51-5.27) and those who received topical treatments plus a systematic steroid plus a systematic calcineurin inhibitor (HR: 9.56, 95% CI: 4.29-21.28) had higher HRs compared with those without AD.Severe AD patients exhibited greater psychological stress than those without AD or with mild AD symptoms. Moreover, medication diversity may represent an efficient and low-cost method by which to identify a vulnerable population.

Biphasic increase in scratching behaviour induced by topical application of Dermatophagoides farinae extract in NC/Nga mice

Atopic dermatitis (AD) is a chronic inflammatory skin disease accompanied by severe itching and eczematous lesion. In this study, we applied an ointment containing Dermatophagoides farinae body (Dfb) extract repeatedly on the dorsal skin of NC/Nga mice with barrier disruption to investigate the characteristics of this murine model of human AD. Following repeated topical application of Dfb ointment twice weekly for 2 weeks, the dermatitis score increased gradually, accompanied by an elevation of total immunoglobulin E level in plasma. Topical application of Dfb ointment also caused epidermal hyperplasia and accumulation of inflammatory cells in the lesional skin and increased expression of T-helper (Th) 1/Th2/Th17 cytokines in axillary lymph node cells. Furthermore, increased sprouting of intraepidermal nerve fibres was observed with an increase in the content of nerve growth factor and decrease in that of semaphorin 3A in the lesional skin. These findings suggest that the characteristics in this model were similar to those observed in patients with AD. Interestingly, it was observed for the first time that scratching behaviour increased in a biphasic fashion by topical application of Dfb ointment in addition to an increase in spontaneous scratching behaviour in this model. It is also suggested that further clarifying the underlying mechanisms of scratching behaviour in this model leads not only to elucidating the pathogenesis of AD but also to discovering novel therapeutic drugs for AD.

The role of vitamin D in atopic dermatitis

Vitamin D has been suggested to have an important impact on a much wider aspects on human health than calcium homeostasis and mineral metabolism, specifically in the field of human immunology. It has been reported that vitamin D influences the regulation of both innate and adaptive immune systems, which makes the association between vitamin D and allergic diseases a field of interest. Although many studies have sought to determine whether vitamin D has an influence on progression of allergic disease, the impact of vitamin D on atopic dermatitis development and severity remains unclear. In this review, we summarize recent studies relating vitamin D to atopic dermatitis and discuss its possible role in the pathogenesis of allergic skin diseases, emphasizing the need for well-designed, prospective trials on vitamin D supplementation in the context of prevention and treatment for allergic conditions.

Health effects of probiotics on the skin

Skin is the largest organ of the body and is constantly exposed to physical, chemical, bacterial, and fungal challenges. It is well known that probiotics are helpful for specific disorders and different clinical studies have indicated that probiotics have special effects in cutaneous apparatus directly or indirectly that can be considerable from versatile aspects. Probiotic bacteriotherapy can have great potential in preventing and treating the skin diseases including eczema, atopic dermatitis, acne, and allergic inflammation or in skin hypersensitivity, UV-induced skin damage, wound protection, and as a cosmetic product. The current paper comprehensively reviews the different health effects of probiotics on the skin.

Vitamin D and atopic dermatitis: A systematic review and meta-analysis

OBJECTIVES

Despite the evidence supporting the use of vitamin D supplements for managing atopic dermatitis (AD), no meta-analysis providing definite conclusions in this field has been reported. The purpose of the present study was to conduct a systematic review and meta-analysis of all controlled studies of vitamin D for treating AD to elucidate the efficacy of vitamin D for alleviating the symptoms of AD.

METHODS

Literature searches were conducted using Ovid-MEDLINE, EMBASE, Web of Science, Cochrane Library, and Korean and Chinese databases. Search terms used were "vitamin D", "atopic dermatitis", "randomized", "controlled trial", and "clinical trial". Random effects models were used to calculate the mean difference, with 95% confidence intervals to analyze the effects of vitamin D supplementation for severity of AD.

RESULTS

Initial searches yielded 266 citations. Of these original results, nine met specific selection criteria. Four of the randomized controlled trials compared the efficacy of vitamin D with a placebo on severity of AD and were included in the meta-analysis. The vitamin D supplementation interventions showed a higher mean difference in severity of AD symptoms (mean difference = -5.81, 95% CI: -9.03 to -2.59, P = 0.0004, I(2) = 50%).

CONCLUSIONS

Vitamin D has a potentially significant role for improving the symptoms of AD. The results from this study suggest that vitamin D supplementation may help ameliorate the severity of AD, and can be considered as a safe and tolerable therapy. However, larger-scale studies over a longer duration of treatment are needed to confirm this conclusion.

The Association Between Bathing Habits and Severity of Atopic Dermatitis in Children

BACKGROUND

Atopic dermatitis is an inflammatory skin disease that frequently affects children. The current recommendations on management using lifestyle modification are highly variable, leading to confusion and uncertainty among patients.

AIM

To determine current bathing behaviors and the subsequent impact on disease severity.

METHODS

This was an observational cross-sectional study conducted at an urban pediatric emergency department. Parents were asked to fill out a questionnaire concerning the patient's bathing habits. The results were correlated with the atopic dermatitis severity determined by the SCORAD (SCORing Atopic Dermatitis) tool.

RESULTS

No difference between variables was found to be significant for bathing frequency, time spent bathing, or use of moisturizers. Multivariate analysis showed that atopic dermatitis severity increased with age greater than 2 years (P = .0004) and with greater bathing duration (P = .001).

CONCLUSION

Atopic dermatitis severity may be associated with a longer duration of bathing. The frequency of bathing does not appear to affect atopic dermatitis severity.

A Review of Multidisciplinary Interventions in Atopic Dermatitis

Multidisciplinary interventions have been developed for patients with atopic dermatitis (AD) and their families, with the aim of improving outcomes such as disease control, adherence, and quality of life. We reviewed the content of different multidisciplinary approaches to intervention for AD and evidence for their impact on key outcome measures. We also provided data from our multidisciplinary outpatient program for pediatric AD. Studies included in the review suggest benefits of multidisciplinary interventions as models of treatment or adjuncts to standard medical care, with a positive impact on outcomes including disease severity and itching/scratching. There were limitations to existing studies, including heterogeneous methods used to assess quality of life outcomes across studies and lack of controlled studies assessing the outcome of clinical care programs. Further research will be useful in assessing the impact of multidisciplinary interventions on important outcomes such as treatment adherence and sleep, identifying the elements of multidisciplinary interventions that are most critical for improved outcomes, and identifying the best candidates for multidisciplinary intervention approaches.

The use of biologicals in cutaneous allergies - present and future

PURPOSE OF REVIEW

Up-to-date biologicals in cutaneous allergies play - unfortunately - only a minor role. However, this situation might change. Recently, omalizumab was licensed for chronic urticaria; this article reviews recent advances in the use of biologicals in cutaneous allergies.

RECENT FINDINGS

Interestingly, the mechanism of omalizumab appears to be different in urticaria and allergic asthma for which the drug has been licensed previously. In urticaria dosage is not dependent on serum IgE-levels and response is seen very often after only 12 h. Other indications in cutaneous allergy in which biologicals have been investigated, at least in case reports or small studies, are TNF-α-antagonists and rituximab in chronic urticaria, omalizumab, rituximab and TNF-α-antagonists in atopic dermatitis as well as mepolizumab in this disease. However, all these studies appear to show a benefit for individual patients but not a clear breakthrough for the whole group of patients involved. This, however, might also be one of the future approaches that sub-groups of patients who have different responses to biologicals may be identified, as apparently different cytokine patterns are predominantly involved in the individual patient.

SUMMARY

In conclusion, although currently only one biological is approved in chronic urticaria, there is hope that a rapid better understanding of individual disease factors will support the development of other novel drugs in this field.

Molecular biology of atopic dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disease with specific genetic and immunological mechanisms. The rapid development of new techniques in molecular biology had ushered in new discoveries on the role of cytokines, chemokines, and immune cells in the pathogenesis of AD. New polymorphisms of AD are continually being reported in different populations. The physical and immunological barrier of normal intact skin is an important part of the innate immune system that protects the host against microbials and allergens that are associated with AD. Defects in the filaggrin gene FLG may play a role in facilitating exposure to allergens and microbial pathogens, which may induce Th2 polarization. Meanwhile, Th22 cells also play roles in skin barrier impairment through IL-22, and AD is often considered to be a Th2/Th22-dominant allergic disease. Mast cells and eosinophils are also involved in the inflammation via Th2 cytokines. Release of pruritogenic substances by mast cells induces scratching that further disrupts the skin barrier. Th1 and Th17 cells are mainly involved in chronic phase of AD. Keratinocytes also produce proinflammatory cytokines such as thymic stromal lymphopoietin (TSLP), which can further affect Th cells balance. The immunological characteristics of AD may differ for various endotypes and phenotypes. Due to the heterogeneity of the disease, and the redundancies of these mechanisms, our knowledge of the pathophysiology of the disease is still incomplete, which is reflected by the absence of a cure for the disease.