Comparison of different activity parameters in atopic dermatitis: correlation with clinical scores

Atopic Dermatitis Biomarkers and the Movement Toward Personalized Treatment

Atopic dermatitis (AD) is a heterogeneous disorder with varying phenotypes. Although AD has long been associated with barrier dysfunction, the pathogenesis of this disease is more complex, involving many molecular markers in different functional domains. Biomarkers can be helpful in different ways, including predicting prognosis, measuring treatment response, and gauging disease severity. With the advent of targeted immunomodulators, biomarkers have the potential to take on new significance in terms of selecting appropriate therapies for patients. In this review, we have summarized the key findings related to biomarkers and AD, including the specific subtype differences. Clinicians will use this information to better understand the potential of biomarkers in AD and have a guide because more specific treatments are developed that are tailored toward individual molecular profiles.

Effects of Angelica gigas Nakai as an Anti-Inflammatory Agent in In Vitro and In Vivo Atopic Dermatitis Models

We investigated the cellular and molecular mechanisms mediating the effects of Angelica gigas Nakai extract (AGNE) through the mitogen-activated protein kinases (MAPKs)/NF-κB pathway using in vitro and in vivo atopic dermatitis (AD) models. We examined the effects of AGNE on the expression of proinflammatory cytokines and chemokines in human mast cell line-1 (HMC-1) cells. Compound 48/80-induced pruritus and 2,4-dinitrochlorobenzene- (DNCB-) induced AD-like skin lesion mouse models were also used to investigate the antiallergic effects of AGNE. AGNE reduced histamine secretion, production of proinflammatory cytokines including interleukin- (IL-) 1β, IL-4, IL-6, IL-8, and IL-10, and expression of cyclooxygenase- (COX-) 2 in HMC-1 cells. Scratching behavior and DNCB-induced AD-like skin lesions were also attenuated by AGNE administration through the reduction of serum IgE, histamine, tumor necrosis factor-α (TNF-α), IL-6 levels, and COX-2 expression in skin tissue from mouse models. Furthermore, these inhibitory effects were mediated by the blockade of the MAPKs and NF-κB pathway. The findings of this study proved that AGNE improves the scratching behavior and atopy symptoms and reduces the activity of various atopy-related mediators in HMC-1 cells and mice model. These results suggest the AGNE has a therapeutic potential in anti-AD.

Specific immunotherapy in atopic dermatitis

Allergen specific immunotherapy (SIT) using house dust mite (HDM) extracts has been performed mainly with patients of asthma and allergic rhinitis. In the meanwhile, there has been a long debate on the efficacy of SIT in atopic dermatitis (AD) with only a few double-blind placebo-controlled trials. However, several randomized controlled trials of SIT in AD revealed significant improvement of clinical symptoms and also, positive result was shown by a following meta-analysis study of these trials. In order to predict and evaluate the treatment outcome, finding a biomarker that can predict treatment responses and treatment end-points is critical but it is very challenging at the same time due to the complexity of causes and mechanisms of AD. Other considerations including standardization of the easiest and safest treatment protocol and optimizing the treatment preparations should be studied as well. This review summarizes the basics of SIT in AD including the brief mechanisms, treatment methods and schedules, and also highlights the clinical efficacy of SIT in AD along with mild, controllable adverse reactions. Immunologic effects and studies of various biomarkers are also introduced and finally, future considerations with upcoming studies on SIT were discussed.

Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis

Atopic dermatitis (AD) is a chronic, pruritic, inflammatory dermatosis that affects up to 25% of children and 2% to 3% of adults. This guideline addresses important clinical questions that arise in the management and care of AD, providing updated and expanded recommendations based on the available evidence. In this first of 4 sections, methods for the diagnosis and monitoring of disease, outcomes measures for assessment, and common clinical associations that affect patients with AD are discussed. Known risk factors for the development of disease are also reviewed.

The Self-administered Eczema Area and Severity Index in children with moderate to severe atopic dermatitis: better estimation of AD body surface area than severity

The Self-Administered Eczema Area and Severity Index (SA-EASI) is one of the few patient based atopic dermatitis (AD) disease activity scores and was found to be highly correlated with the EASI. Correlation with other frequently used scoring methods has not been investigated. The aim of this study was to evaluate the relation of the SA-EASI with two physician-based disease activity scores (objective SCORAD and SASSAD score) and with a serum marker for AD (Thymus and Activation-Regulated Cytokine [TARC]) in children with AD. Sixty children with moderate to severe AD were included. The SA-EASI was completed by caregivers, and the objective SCORAD and SASSAD scores were measured successively on the same day by a trained investigator. Blood for serum TARC measurement was drawn. The correlation between the SA-EASI and the objective SCORAD was high (ρ = 0.61, p = <0.001), mainly based on high correlation between the body surface area (BSA) measurements of both scores (ρ = 0.50, p = <0.001). The correlation with the SASSAD score (only severity measurement) was 0.43 (p = <0.001). The correlation with serum TARC levels was 0.46; p = <0.001, mainly based on the BSA score of the SA-EASI (ρ = 0.42, p = <0.001). Parents may have more difficulty in scoring severity of AD than scoring BSA involved. Educating parents in severity scoring of AD may improve agreement of the SA-EASI and the objective SCORAD, TARC, and SASSAD score. Additional use of the SA-EASI in routine clinical practice or in trials may then facilitate more frequent but still accurate assessment of AD.

Elevated serum levels of S100 calcium binding protein A8 (S100A8) reflect disease severity in canine atopic dermatitis

A monoclonal antibody to canine S100 calcium binding protein A8 (S100A8) was developed to determine the association between S100A8 and the disease severity of canine atopic dermatitis. Serum S100A8 concentrations were studied in dogs with canine atopic dermatitis (n=213) and healthy dogs (n=213). Statistical correlations between these indices and atopic dermatitis activity were established, and dermatitis severity was assessed according to the CADESI score. Serum S100A8 concentrations were measured with an enzyme-linked immunosorbent assay (ELISA). S100A8 serum levels were significantly higher in canine atopic dermatitis patients than in healthy dogs. A strong positive correlation was identified between S100A8 levels and canine atopic dermatitis patients. Our findings suggested that S100A8 is actively involved in the pathogenesis and clinical picture of canine atopic dermatitis.

Assessment of atopic eczema: clinical scoring and noninvasive measurements

BACKGROUND

Clinical scoring systems are widely used in clinical trials of atopic eczema (AE), while noninvasive methods are more often used for research purposes. Positive correlations between the two types of methods may be used in support of the validity of both in a clinical context. Few studies are available of the association between clinical scores and instrumental assessment of disease severity obtained with noninvasive instruments.

OBJECTIVES

To compare clinical scores in AE with biometric data in AE.

METHODS

Transepidermal water loss, stratum corneum hydration, erythema, scaling and subepidermal oedema were measured. 'Scoring of Atopic Dermatitis (SCORAD)', 'Eczema Area and Severity Index (EASI)' and 'Atopic Dermatitis Severity Index (ADSI)' were used for clinical scores. Two assessments at 6-month intervals at the antecubital fossa, dorsal forearm and popliteal fossa in 101 patients with AE and 30 controls were carried out.

RESULTS

Significant correlations were found within the clinical scores (P < 0.0001 and r = 0.85-0.91) and between instruments and clinical scores (P < 0.0001 and r = 0.61-0.79).

CONCLUSIONS

The various instruments and clinical scores showed internal agreement and noninvasive methods correlated significantly with the three different clinical scorings systems. This observation suggests that both methods provide data of clinical (scores) and biological (instrumental measures) relevance, and may be useful in future studies of AE. It is speculated that combined measures including scores and selected instruments may be particularly useful.

Effect of climatic change in children with atopic eczema

BACKGROUND

Climate and sunlight (ultraviolet radiation) influence activity of atopic eczema.

OBJECTIVE

To evaluate the effect of moving from a subarctic/temperate climate to a sunny subtropical climate on children's atopic eczema.

METHODS

Children, 4-13 years, with severe atopic eczema were randomized to stay 4 weeks in Gran Canary (index patients = 30) and home in Norway (controls = 26), with a follow up of 3 months. SCORing of Atopic Dermatitis (SCORAD) was primary variable, and secondary were Children's Dermatology Life Quality Index (CDLQI), Staphylococcus aureus skin colonization and pharmacological skin treatment.

RESULTS

SCORing of Atopic Dermatitis decreased from 37.2 (29.4-44.9) to 12.2 (9.0-15.4) [mean (95% confidence intervals)] after 4 weeks and 21.2 (17.2-25.1) 3 months thereafter in index patients (P < 0.0005), much less in controls.Children's Dermatology Life Quality Index in the index group improved from 8.7 to 2.2 and 4.5 after 4 weeks and 3 months (P < 0.0005), not in controls. Bacterial skin colonization with S. aureus decreased in the index group from 23/30 (77%) to 12/30 (40%; P = 0.001) and 12/30 (40%; P = 0.005) after 1 month and 3 months, and the use of local steroids decreased in index patients but not in controls.

CONCLUSIONS

The change from a subartic/temperate to a subtropical climate for 4 weeks improved significantly skin symptoms (SCORAD) and quality of life, even for 3 months after return.

Increased serum thymus and activation-regulated chemokine and cutaneous T cell-attracting chemokine levels in children with atopic dermatitis

BACKGROUND

Thymus and activation-regulated chemokine (TARC) and cutaneous T cell-attracting chemokine (CTACK) are responsible for the trafficking of T helper type 2 lymphocytes into sites of allergic inflammation.

OBJECTIVE

We tested whether these cytokines are useful markers for childhood atopic dermatitis (AD), and evaluated age-related differences in the levels of these chemokines.

METHODS

Serum TARC and CTACK levels, total serum IgE levels, total eosinophil counts, and specific IgE levels were measured in 401 children. The patients were characterized as having atopic eczema (n=157), non-atopic eczema (n=107), or as healthy control subjects (n=137).

RESULTS

Both TARC and CTACK levels in children with AD were significantly higher than those in healthy control subjects. Serum TARC and CTACK levels significantly correlated with disease severity both in children with atopic eczema and in children with non-atopic eczema. Serum TARC levels in children with AD significantly correlated with their serum CTACK levels. Serum TARC and CTACK levels decreased in accordance with their ages.

CONCLUSION

Serum TARC and CTACK levels might be useful markers for disease severity both in children with atopic eczema and with non-atopic eczema. Serum TARC and CTACK levels decreased in accordance with their ages.

Characteristics of extrinsic vs. intrinsic atopic dermatitis in infancy: correlations with laboratory variables

BACKGROUND

Atopic dermatitis (AD) has been divided into the extrinsic type (ADe) and the intrinsic type (ADi) according to the serum IgE levels and the presence or absence of allergen-specific IgE. Although previous studies have demonstrated differences in the various immunological parameters, the characteristics of AD in infancy have rarely been reported.

OBJECTIVES

Our study was performed to analyse the correlations between the laboratory parameters of infantile ADe and ADi.

METHODS

We recruited 237 infants with AD and checked the SCORAD index, the number of peripheral blood eosinophils, the serum eosinophil cationic protein (ECP) levels, the total serum IgE levels and the specific serum IgE levels in all the patients. We also checked the serum interleukin (IL)-4 and IL-5 levels in 20 patients with ADe and in 20 with ADi.

RESULTS

This study showed many peculiar characteristics of infantile AD. In infancy, ADi was more prevalent than ADe. The eosinophil count, the ECP level and the SCORAD in ADi were lower than in ADe. Furthermore, a group of patients without characteristics of ADi or ADe could be identified. We tentatively classify this group as indeterminate type (ADind) and propose it as a separate entity. The clinical severity was well correlated with the eosinophil count and the serum ECP levels in ADe and ADi. Therefore these two parameters could be used as clinical severity markers in infancy. Infants are more allergic to food, and the variety of specific allergenic responses was connected with clinical severity. A higher eosinophil count, a higher ECP level and a higher detection rate of IL-5 in the peripheral blood of infants with ADe means that eosinophils have a more prominent role in ADe than in ADi.

CONCLUSIONS

Infantile AD has many distinctive features in its laboratory variables as compared with AD in other age groups. Clinicians should recognize these facts when they deal with infants with AD, and further studies are warranted on the natural course of infantile AD.

The objective severity assessment of atopic dermatitis (OSAAD) score: validity, reliability and sensitivity in adult patients with atopic dermatitis

BACKGROUND

The Objective Severity Assessment of Atopic Dermatitis (OSAAD) score is a recently developed scale for evaluation of severity of atopic dermatitis, constructed from the assessment of epidermal barrier function, and properties using noninvasive bioengineering methods and computer-assisted estimates of disease extent. The method has been validated for use in infants and children with atopic dermatitis and compared with a referent scoring system.

OBJECTIVES

The aim of the present study was to test the validity, reliability and sensitivity of the OSAAD score as an objective tool for the assessment of the severity of atopic dermatitis in adult patients.

METHODS

Thirty-two adult patients with atopic dermatitis were included in the study. To assess the validity of the OSAAD score we tested it against the Severity Scoring of Atopic Dermatitis (SCORAD) index of the European Task Force on Atopic Dermatitis as a referent clinical severity scale, and the serum levels of interleukin (IL)-16 as a laboratory variable for monitoring the activity of atopic dermatitis. Responsiveness to change was assessed in a longitudinal study comparing OSAAD, SCORAD and serum levels of IL-16 before and after treatment. To test the reliability of the OSAAD score we studied the interobserver variability of the score recorded by three independent board-certified dermatologists in 16 patients and compared it with SCORAD.

RESULTS

We report a significant correlation between the OSAAD and the SCORAD index as an acknowledged referent severity scale. The OSAAD score correlated significantly with the serum levels of IL-16 in the acute stage of atopic dermatitis. In a longitudinal study, the OSAAD score decreased significantly, parallel with improvement of the skin findings and a significant decrease in the SCORAD score and IL-16 serum levels. We report improved interobserver variability for the OSAAD score compared with SCORAD.

CONCLUSIONS

This is the first study validating the OSAAD score as a sensitive and reliable tool for the assessment of the severity of atopic dermatitis in adult patients.

Bicentre experience in the treatment of severe generalised atopic dermatitis with extracorporeal photochemotherapy

Pilot studies have shown an improvement of atopic dermatitis in approximately 65% of patients during extracorporeal photopheresis (ExP) therapy. The purpose of the present clinical trial was to investigate the response to ExP by controlling clinical and laboratory parameters during short term ExP therapy in patients with severe generalised atopic dermatitis. Thirty-five patients with severe, therapy-resistant atopic dermatitis were treated with ExP in an open clinical trial at two week intervals over a period of 6 to 10 cycles. Disease activity was measured before each cycle by SCORAD index together with a standardized protocol for blood samples. ExP led to a significant decrease (p < 0.05) in SCORAD from 74.4 +/- 15.5 before to 36.8 +/- 16.8 after ExP therapy (mean 10 cycles). Approximately 70% (24/33 patients = responder) of patients had a favourable response to ExP requiring at least 6 cycles. The decrease in SCORAD was accompanied by a significant decrease of eosinophil cationic protein (27%), sE-selectin (37%) and sIL-2R (53%) levels in serum (p < 0.05). No significant correlation between a decrease in these levels and values of blood eosinophils or lymphocytes was found (p > 0.05). In comparison to responders, most non-responders were characterised by very high levels of total IgE before and during therapy (p < 0.05). The present clinical trial confirms that short term ExP is an effective treatment for certain patients with severe atopic dermatitis based on anti-inflammatory mechanisms. Total IgE could be a predictor of outcome in ExP treatment.

Dietary treatment of childhood atopic eczema/dermatitis syndrome (AEDS)

OBJECTIVE

This review summarizes the research and clinical evidence in favour of dietary intervention aimed at eliminating allergenic foods in the management of atopic eczema/dermatitis syndrome (AEDS).

DATA SOURCES

The data source was PubMed, using a search algorithm selecting for clinical studies of AEDS, diet therapy and food allergy in all children to October 2003. Also included is a commentary based on the authors' clinical experience in the allergy unit of a university hospital in Italy.

RESULTS

Fourteen prospective studies matched the entry criteria. Diverse trial designs, diagnostic criteria, types of dietary intervention and length of observation periods precluded meta-analytic methods. Allergenic food exclusion claimed efficacy in 13 of the 14 studies and was most useful in infants, in patients with elevated immunoglobulin E levels and/or multiple food sensitization and in patients with a diagnosis of food allergy.

CONCLUSION

Dietary intervention in the form of an elimination diet is efficacious in children with AEDS when a specific diagnosis of food allergy has been made. Diagnostic evaluation of food allergy should be performed in all children with eczema, particularly in younger children and those with severe forms of the disease.

Consensus guidelines in diagnosis and treatment of atopic dermatitis

Atopic dermatitis is a common condition of great health significance. Consensus-driven guidelines of care or specific practice parameters may be useful, as are treatment algorithms based upon disease severity. Development of consensus guidelines on diagnosis and treatment of atopic dermatitis are discussed, and disease-severity-based guidelines of care proposed.