Early intervention for the prevention of atopic dermatitis

Shedding light on key pharmacological knowledge and strategies for pediatric atopic dermatitis

INTRODUCTION

Atopic dermatitis (AD) is an inflammatory disease affecting over 20% of the pediatric population, with 85% of cases presenting before the age of five. Recently, therapeutic options in pediatric patients have evolved rapidly, following extensive development in adult treatments.

AREAS COVERED

This review will encompass relevant molecular drivers, along with an overlook on treatment modalities in pediatric AD, as well as a summary of pipeline treatments in clinical trials for pediatric patients from PubMed, Google Scholar, and Clinicaltrials.gov up to July 2022. Topical corticosteroids are the mainstay for AD flares in adults and children. Topical approved agents in pediatric AD are calcineurin inhibitors, crisaborolecrisaborole, and ruxolitinib. Dupilumab is the only FDA approved biologic for patients with AD from six months of age. A Janus kinase inhibitor, upadacitinib, is a systemic treatment approved for pediatric AD patients (age >12 years). Systemic immunosuppressants used in pediatric AD include methotrexate, azathioprine, cyclosporinecyclosporine, and mycophenolate mofetil.

EXPERT OPINION

Data regarding disease prevention are conflicting, however, an abundance of research has transpired regarding amelioration of symptoms and induction of disease clearance by targeting numerous pathological mechanisms. Understanding the pediatric AD phenotype will further advance the field and the development of improved therapeutics.

Novel concepts of prevention and treatment of atopic dermatitis through barrier and immune manipulations with implications for the atopic march

Skin barrier abnormalities have been suggested to play an essential role in initiation of early atopic dermatitis (AD). Antigen penetration through a compromised barrier likely leads to increased innate immune responses, antigen-presenting cell stimulation, and priming of overt cutaneous disease. In a T_H2-promoting environment, T-cell/B-cell interactions occurring in regional lymph nodes lead to excessive IgE switch. Concurrent redistribution of memory T cells into the circulation not only leads to exacerbation of AD through T-cell skin infiltration but also spreads beyond the skin to initiate the atopic march, which includes food allergy, asthma, and allergic rhinitis. Possible primary interventions to prevent AD are focusing on improving skin barrier integrity, including supplementing barrier function with moisturizers. As for secondary prophylaxis in children with established AD, this can be stratified into prevention of disease exacerbations by using proactive approaches (with either topical corticosteroids or topical calcineurin inhibitors) in mild AD cases or the prevention of other atopic disorders that will probably mandate systemic immunosuppression in severe AD cases.

Therapeutic modalities for cow's milk allergy

OBJECTIVE

To discuss current therapeutic modalities for cow's milk allergy and its prevention.

DATA SOURCES AND STUDY SELECTION

The sources of data include original clinical studies carried out at Ste. Justine Hospital, as well as a systematic search of the published English and French language scientific literature restricted to human subjects using computerized searches (National Public Library of Medicine, Cochrane Database Systems Review) from 1997 to 2002. Search terms for article retrieval included food allergy, milk allergy, therapy, and prevention.

CONCLUSIONS

The therapy of food allergies depends upon an accurate diagnosis, which remains a challenge in non--IgE-mediated cases. Dietary exclusion remains the mainstay of therapy, with medications reserved for exceptional patients. Preliminary evidence suggests that pancreatic enzyme supplementation may be of benefit for cases with multiple food allergies and severe eczema. Hydrolysate formula use is currently recommended for dietary allergy prevention in infants at an increased risk when maternal milk is insufficient or unavailable. The use of partially hydrolyzed formulas to prevent allergic disorders, including atopic dermatitis, is supported by clinical studies, but cannot be used in the already sensitized, milk-allergic child. Probiotics show enormous potential in preventing food allergic disorders as well.

Atopic dermatitis in 5-6-year-old Swedish children: cumulative incidence, point prevalence, and severity scoring

BACKGROUND

This study aimed to evaluate the cumulative incidence, point prevalence, and severity of atopic dermatitis (AD) in a pediatric population. We also aimed to identify differential diagnoses relevant to AD in this population.

METHODS

Children scheduled for a health visit at 5.5 years of age were selected consecutively during the period October 1997-March 1998 from two cities in southern Sweden (Göteborg and Kristianstad). Schultz Larsen's questionnaire was used to evaluate the cumulative incidence of AD. Clinical examination was performed by dermatologists (A.B. and A.S.) for those children with active eczema. The UK working party's criteria were used for the clinical diagnosis of AD. The SCORAD index was used to evaluate the severity of eczema. This index includes evaluation of extent, intensity, and subjective symptoms to a maximum score of 103 points.

RESULTS

In Göteborg 1219 and in Kristianstad 742 questionnaires were answered regarding 1961 children, 1004 boys and 957 girls. The response rate was 89%. According to the answers to Schultz Larsen's questionnaire, the cumulative incidence of AD in the whole material was 20.7% (406/1961) (CI 95% 18.9-22.5). In Göteborg, 104 of the examined children fulfilled the UK working party's criteria, equivalent to a point prevalence of 8.5% (CI 95% 7.0-10.1). In Kristianstad, the corresponding point prevalence was 11.5% (CI 95% 9.2-13.8). The severity of AD was evaluated in all children with visible eczema. SCORAD evaluation was performed in 155 of the 157 children with visible eczema. The majority of children had mild or moderate eczema; mean value 20.5 (CI 95% 18.7-22.3), median 19.6. Of the 96 children who did not fulfil the criteria of AD, other skin disorders were diagnosed in 51 at the clinical examination. Dry skin was by far the most common differential diagnosis.

CONCLUSIONS

We have used validated protocols to evaluate the cumulative incidence, point prevalence, and severity of AD in a population-based study in southern Sweden The present study, involving a rural and urban pediatric population, shows that AD is common, usually classified as mild or moderate, and seems to increase over time.

Is allergy prevention realistic and beneficial?

Allergic diseases among children have shown a marked increase during the last two or three decades, despite increased awareness of possible preventive measures. Preventive efforts have focused on new-borns and infants with a biparental history of allergy as they are at particularly high risk of developing allergic disease (40-60%). No good intervention studies have been performed in the general population, only in high-risk families. Unfortunately, so far known risk factors can only explain a small part of the recent increase in allergic diseases. The most important recommendation for everyone is not to smoke during pregnancy and when living/working with young children. Breast milk is the best for every baby, even from an immunologic aspect. Humidity problems should be reduced in homes, day-care centres and schools. It is probably wise not to keep furred pets indoors in homes when babies have a family history of allergy. However, the effect of such advice should be assessed, including the acceptability, compliance, costs and effectiveness. There is no doubt that we should go on with preventive measures both in babies at high risk of allergy and also in the general population. At the same time, research should try to find even more efficient ways to reduce the current "allergy epidemic".