Validation of the Patient-Oriented SCORing for Atopic Dermatitis tool for black skin

Diagnosis of Allergic Dermatoses in Skin of Color

PURPOSE OF REVIEW

This review aims to deliver a comprehensive report of the most recent knowledge on diagnosing allergic dermatoses in skin of color (SOC) patients.

RECENT FINDINGS

Allergic dermatoses can affect populations of all backgrounds. However, racial/ethnic variations in epidemiology, clinical features, and associated allergens have been reported. Nuances in the approach to diagnosis, including the assessment of erythema and interpretation of patch tests, are important considerations when treating patients with SOC. In this review, we outline various manifestations of allergic dermatoses in SOC with a focus on important clinical presentations and diagnostic tools, aiming to support clinicians in accurate recognition of diseases, thereby opening avenues to improve outcomes across diverse skin types.

Topical Steroid Withdrawal is a Targetable Excess of Mitochondrial NAD

Background

Topical corticosteroids (TCS) are first-line therapies for numerous skin conditions. Topical Steroid Withdrawal (TSW) is a controversial diagnosis advocated by patients with prolonged TCS exposure who report severe systemic reactions upon treatment cessation. However, to date there have been no systematic clinical or mechanistic studies to distinguish TSW from other eczematous disorders.

Methods

A re-analysis of a previous survey with eczematous skin disease was performed to evaluate potential TSW distinguishing symptoms. We subsequently conducted a pilot study of 16 patients fitting the proposed diagnostic criteria. We then performed: tissue metabolomics, transcriptomics, and immunostaining on skin biopsies; serum metabolomics and cytokine assessments; shotgun metagenomics on microbiome skin swabs; genome sequencing; followed by functional, mechanistic studies using human skin cell lines and mice.

Results

Clinically distinct TSW symptoms included burning, flushing, and thermodysregulation. Metabolomics and transcriptomics both implicated elevated NAD+ oxidation stemming from increased expression of mitochondrial complex I and conversion of tryptophan into kynurenine metabolites. These abnormalities were induced by glucocorticoid exposure both in vitro and in a cohort of healthy controls (N=19) exposed to TCS. Targeting complex I via either metformin or the herbal compound berberine improved outcomes in both cell culture and in an open-label case series for patients with TSW.

Conclusion

Taken together, our results suggest that TSW has a distinct dermatopathology. While future studies are needed to validate these results in larger cohorts, this work provides the first mechanistic evaluation into TSW pathology, and offers insights into clinical identification, pharmacogenomic candidates, and directed therapeutic strategies.

Infantile atopic dermatitis - increasing severity predicts negative impacts on maternal and infant sleep: a mixed methods study

BACKGROUND

While the impacts of atopic dermatitis (AD) on maternal and child sleep outcomes have been previously explored, less is known about the associations between infantile AD and sleep quality and quantity.

OBJECTIVE

To describe the perceived causes of AD-associated maternal sleep disturbances and the association between AD severity and infant sleep outcomes.

METHODS

Mothers with infants aged < 19 months old with a diagnosis of AD were recruited from social media and medical clinics in Winnipeg, Canada between October 2021 and May 2022. Infant AD severity was classified using maternal-reported data on the Patient-Oriented Scoring Atopic Dermatitis tool (PO-SCORAD). Quantitative data were collected via a series of questionnaires with a subset of mothers subsequently completing semi-structured interviews. Quantitative and qualitative data were integrated in the discussion.

RESULTS

Mothers of infants with moderate/severe AD (6/12) were more likely to report their infant suffering from a higher degree of sleeplessness (i.e., ≥ 5 on a scale of 0-10) over the past 48 h compared to mothers of infants with mild AD (0/18). This was supported by qualitative findings where mothers described how their infant's sleep quality and quantity worsened with AD severity. Additionally, 7/32 mothers reported that their child's AD, regardless of severity, disturbed their sleep. Maternal sleep loss was most commonly attributed to infant itching (6/7), followed by worry (4/7).

CONCLUSION

Infantile AD severity was associated with worse sleep outcomes for both mothers and infants. We propose that maternal and infantile sleep quality and quantity can be improved by reducing AD severity through adherence to topical treatments.

Abrocitinib efficacy and safety in moderate-to-severe atopic dermatitis by race, ethnicity, and Fitzpatrick skin type

BACKGROUND

Response to abrocitinib treatment for moderate-to-severe atopic dermatitis (AD) has not been evaluated across racial and ethnic subpopulations.

OBJECTIVE

To assess the efficacy and safety of abrocitinib on the basis of patient race, ethnicity, and Fitzpatrick skin type (FST).

METHODS

Data were pooled post hoc from patients treated with abrocitinib 200 mg, 100 mg, or placebo in 3 monotherapy trials (NCT02780167, NCT03349060, and NCT03575871). Race and ethnicity were self-reported; FST was determined by study investigators. Evaluations through Week 12 include the following: (1) Investigator's Global Assessment of clear or almost-clear skin; (2) greater than or equal to 75% improvement in Eczema Area and Severity Index or SCORing AD; (3) a greater-than-or-equal-to 4-point improvement in Peak Pruritus Numerical Rating Scale score; (4) least squares mean changes in Dermatology Life Quality Index and Patient-Oriented Eczema Measure scores; and (5) treatment-emergent adverse events.

RESULTS

The sample comprised 628 White, 204 Asian, and 83 Black patients; 37 were Hispanic or Latino; 624 had FST I to III and 320 had FST IV to VI. Treatment with either abrocitinib dose was associated with greater proportions of patients achieving Investigator's Global Assessment of clear or almost-clear skin, ≥ 75% improvement in Eczema Area and Severity Index, ≥ 75% improvement in SCORing AD, and a ≥ 4-point improvement in Peak Pruritus Numerical Rating Scale, or greater score changes from baseline in Dermatology Life Quality Index and Patient-Oriented Eczema Measure vs placebo regardless of race, ethnicity, or FST. Dose-response was most prominent in White patients. In Black patients, the effects of the 2 doses were similar. Treatment-emergent adverse events were more common in White and Black than in Asian patients.

CONCLUSION

Abrocitinib was more efficacious than placebo across the racial and ethnic groups and ranges of phototypes analyzed. Studies with increased representation of populations of color are warranted to elucidate potential variations in response across diverse populations.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02780167 (phase 2b), NCT03349060 (phase 3 MONO-1), and NCT03575871 (phase 3 MONO-2).

Solving the health disparity of eczema assessment: A role for skin tape soluble protein?

Background

The assessment of erythema in patients with atopic dermatitis (AD) is based on clinical examination. The difficulty of perceiving erythema in Black patients with AD has led to underestimation of AD severity in these patients.

Objective

In this study, we analyzed the concentration of skin tape soluble protein of AD lesions against common AD clinical signs.

Method

A total of 50 children with AD were included. Skin tape total soluble protein was extracted from AD lesions and analyzed against validated AD clinical signs, including erythema, excoriation, edema, oozing, and lichenification.

Results

Concentration of skin tape soluble protein is positively correlated with acute signs of AD, especially erythema.

Conclusion

Determination of concentration of skin tape protein is a potential tool for grading erythema of AD lesions, and it may have an application in improving the health disparity of assessment of eczema severity in Black patients with AD.

Phenotypes, endotypes and genotypes of atopic dermatitis and allergy in populations of African ancestry on the continent and diaspora

Atopic dermatitis is a complex inflammatory condition characterized by synergist interactions between epidermal and immune related genotypes, skin barrier defects and immune dysregulation as well as microbial dysbiosis. Ethnicity-specific variations in clinical presentation, immune endotypes and genetic susceptibility have been described in diverse populations. We summarize available data with specific consideration of AD in populations of African ancestry. Some highlights include the observation of AD lesions on extensor surfaces, lichen planus-like AD, prurigo type AD and follicular AD in African populations. In addition, a consistent absence of dominant filaggrin gene defects has been reported. The detection of normal filaggrin protein content in AD skin implicates the contribution of alternative mechanisms in the pathogenesis of AD in African patients. Markedly high IgE has been described in paediatric and adult African AD. While Th2, Th22 and Th17 activation in African AD skin shares the same direction as with other populations, it has been noted that the magnitude of activation is dissimilar. Reduced Th17 cytokines have been observed in the circulation of moderate to severe paediatric AD.

Advancements in Allergen Immunotherapy for the Treatment of Atopic Dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin condition that affects individuals of all age groups, manifesting as a spectrum of symptoms varying from mild to severe. Allergen immunotherapy (AIT) involves the administration of allergen extracts and has emerged as a potential treatment strategy for modifying immune responses. Its pathogenesis involves epidermal barrier dysfunction, microbiome imbalance, immune dysregulation, and environmental factors. Existing treatment strategies encompass topical steroids to systemic agents, while AIT is under investigation as a potential immune-modifying alternative. Several studies have shown reductions in the severity scoring of atopic dermatitis (SCORAD) scores, daily rescue medication use, and visual analog scale (VAS) scores following AIT. Biomarker changes include increased IgG4 levels and decreased eosinophil counts. This review provides valuable insights for future research and clinical practice, exploring AIT as a viable option for the management of AD.

Which Clinical Measurement Tools for Atopic Dermatitis Severity Make the Most Sense in Clinical Practice?

Assessment of atopic dermatitis (AD) severity is essential for therapeutic decision making and monitoring treatment progress. However, there are a myriad of clinical measurement tools available, some of which are impractical for routine clinical use despite being recommended for clinical trials in AD. For measurement tools to be used in clinical practice, they should be valid, reliable, rapidly completed, and scored, and easily incorporated into existing clinic workflows. This narrative review addresses content, validity, and feasibility, and provides a simplified repertoire of assessments for clinical assessment of AD based on prior evidence and expert opinion. Tools that may be feasible for clinical practice include patient-reported outcomes (eg, dermatology life quality index, patient-oriented eczema measure, numerical rating scales for itch, pain, and sleep disturbance, AD Control Tool, and patient-reported global assessment), and clinician-reported outcomes (eg, body surface area and investigator's global assessment). AD is associated with variable clinical signs, symptoms, extent of lesions, longitudinal course, comorbidities, and impacts. Any single domain is insufficient to holistically characterize AD severity, select therapy, or monitor treatment response. A combination of these tools is recommended to balance completeness and feasibility.

Assessment of infant outgrowth of cow's milk allergy in relation to the faecal microbiome and metaproteome

Previous studies provide evidence for an association between modifications of the gut microbiota in early life and the development of food allergies. We studied the faecal microbiota composition (16S rRNA gene amplicon sequencing) and faecal microbiome functionality (metaproteomics) in a cohort of 40 infants diagnosed with cow's milk allergy (CMA) when entering the study. Some of the infants showed outgrowth of CMA after 12 months, while others did not. Faecal microbiota composition of infants was analysed directly after CMA diagnosis (baseline) as well as 6 and 12 months after entering the study. The aim was to gain insight on gut microbiome parameters in relation to outgrowth of CMA. The results of this study show that microbiome differences related to outgrowth of CMA can be mainly identified at the taxonomic level of the 16S rRNA gene, and to a lesser extent at the protein-based microbial taxonomy and functional protein level. At the 16S rRNA gene level outgrowth of CMA is characterized by lower relative abundance of Lachnospiraceae at baseline and lower Bacteroidaceae at visit 12 months.

Pro-Inflammatory versus Anti-Inflammatory cytokines in atopic dermatitis patients: A case control study

Atopic dermatitis (AD) is a chronic relapsing inflammatory skin disorder with significant morbidity and impairment of life quality. Prevalence is increasing around the world; therefore, intensive research is ongoing to understand the mechanisms of development of AD and offer new treatment options for AD patients.

AIMS

To investigate the association between Inflammatory (IL-17, TNF-α, IFN-γ) versus anti-Inflammatory Cytokines (IL-35, TGF-β) in AD patients.

PATIENTS AND METHODS

A case control study included 40 AD patients and 20 age- and sex-matched healthy subjects. Cases were subjected to full history taking and full dermatological examination. The assessment of disease severity was conducted by using SCORAD score. Assessment of inflammatory (IL-17, TNF-α, IFN-γ) and anti-Inflammatory Cytokines (IL-35, TGF-β) was performed by using ELISA technique.

RESULTS

The mean level of TNF-α, IL-17 was statistically significantly higher in the AD cases as compared with the control group. The mean level of TGF-β, Il-35, and IFN-γ was statistically significantly lower in the Atopic dermatitis cases as compared with the control group. There was statistically significant strong positive correlation between TNF-α with SCORAD score and IL-17 while there was statistically significant strong negative correlation between TNF-α with TGF-β and IL-35. There was statistically significant strong positive correlation between IL-17 with SCORAD score and TNF-α while there was statistically significant strong negative correlation between IL-17 with TGF-β and IL-35.

CONCLUSION

The current results could be used as a clue for the utilization of inflammatory (IL-17, TNF-α, IFN-γ) versus anti-inflammatory Cytokines (IL-35, TGF-β) in AD as a diagnostic biomarker for severity of cases with Atopic dermatitis. IL-17 plays an important role in the pathogenesis of AD, and IL-17 blocker may be used as a potential future treatment of AD.

Differences in Psychometric Properties of Clinician- and Patient-Reported Outcome Measures for Atopic Dermatitis by Race and Skin Tone: A Systematic Review

The psychometric validity and reliability of widely used atopic dermatitis (AD) outcome measures across different races and ethnicities are unclear. We describe the rates of reporting race, ethnicity, and skin tone in studies testing the psychometric properties of AD outcome measures and compare the psychometric analyses across race, ethnicity, and skin tone. We systematically reviewed MEDLINE and EMBASE for studies reporting psychometric properties of clinician-reported or patient-reported outcome measures in AD (International Prospective Register of Systematic Reviews: CRD42021239614). Overall, 16,100 nonduplicate articles were screened; 165 met inclusion criteria. Race and/or ethnicity were reported in 55 (33.3%) studies; of those, race was assessed by self-report in 10 studies (6.1%) or was unspecified in 45 (27.3%). A total of 16 studies (9.7%) evaluated psychometric property differences by race, and only five (4.4%) of those did not recognize it as a limitation. Properties assessed across race, ethnicity, or skin tone were differential item functioning, convergent validity feasibility, inter-rater reliability, intrarater reliability, test‒retest reliability, and known-groups validity. Multiple instruments demonstrated performance differences across ethnoracial groups. This review highlights the paucity of race/ethnicity consideration for psychometric property testing in AD outcome measurement instruments. More AD outcomes instruments should be validated in diverse populations.

House dust microbiota and atopic dermatitis; effect of urbanization

BACKGROUND

Previous studies have shown that a child's risk of developing atopic disease is impacted by both genetic and environmental factors. Because small children spend the majority of their time in their homes, exposure to microbial factors in their home environment may be protective or risk factors for development of atopic diseases, such as atopic dermatitis.

METHODS

Dust samples from the homes of 86 Black South African children 12 to 36 months old were collected for analysis of the bacterial microbiome. This case-control study design included children with and without atopic dermatitis from rural and urban environments.

RESULTS

Significant differences in bacterial composition and diversity were found when comparing children with and without atopic dermatitis. Furthermore, house dust microbiota was significantly different in rural and urban areas. Differences were best accounted for by higher relative abundance of Ruminococcaceae, Lachnospiraceae, and Bacteroidaceae families in rural compared with urban houses. Levels of Ruminococcaceae were also found to be significantly depleted in the house dust of rural children with atopic dermatitis as compared to control children.

CONCLUSIONS

House dust composition may be an important risk factor for the development of atopic disease, and this association may be driven in part by the gut microbiome. Low levels of the Ruminococcaceae family from Clostridia class in particular may explain the association between urban living and atopy. However, further research is needed to elucidate these links.

Measuring Atopic Dermatitis Disease Severity: The Potential for Electronic Tools to Benefit Clinical Care

Severity of atopic dermatitis (AD) correlates with impact on health-related quality of life (HRQoL), work productivity, and burden on health systems. Tools to measure severity inform regulatory approval, drug access, and value- or measurement-based care. A core set of instruments for measuring AD has been established. Clinician-reported tools are divided broadly into multi-item global estimates or precise calculators that also weigh affected corporeal surfaces. Increasingly, subjective patient-reported outcomes are valued, with the potential to capture vast amounts of health-related data. Patient-reported outcomes can be disease-agnostic, skin-related, or AD-specific, and evaluate global disease, itch severity, long-term control, or overall HRQoL. Patient-reported outcomes are expansive in number; therefore, item banks and adaptive digital user interfaces will be increasingly needed, along with capacity to store and analyze data. Technologies for AD include tools for communication, severity assessment, or data exchange, as well as electronic health records (EHRs). For clinicians, a limited number of applications exist, with relatively poor interoperability with EHRs to date. For patients, a growing number of mobile health (mHealth) applications exhibit variable compliance with international guidelines for self-management. Data privacy and information security governance are key considerations in the development of information technologies for AD. Integrated and streamlined digital operational processes for disease measurements may build capacity for high value and efficient care of patients with AD across the globe.

Beneficial Effects of Paraffin Bath Therapy as Additional Treatment of Chronic Hand Eczema: A Randomized, Single-Blind, Active-Controlled, Parallel-Group Study

Objective: Chronic hand eczema (CHE) is a common inflammatory skin disease with a major psychological and socioeconomic impacts on patients' quality of life (QoL) and work ability. To the best of knowledge, this study is the first randomized-controlled trial conducted to evaluate the effect of paraffin bath therapy in management of hand eczema and its related symptoms. Design: This study was a parallel-group, active-control, randomized clinical trial with measures at pretreatment, 6th week, and 12th week of treatment. Settings: The study took place at the Outpatient Clinic of Faculty of Physical Therapy, Cairo University, and some licensed rehabilitation centers in Cairo for a 1-year period. Subjects: Sixty patients with moderate to severe CHE were randomly assigned into two groups of equal number; the paraffin bath therapy group and the control group. Interventions: The paraffin group received paraffin bath therapy for 5 days a week for 12 weeks, in addition to the routine skin care program, while the control group only received the routine skin care program. Outcome measures: SCORing Atopic Dermatitis (SCORAD) was used to assess the severity of atopic dermatitis and dermatology life quality index (DLQI) to assess the effect of CHE on quality of patients' life. All measurements were obtained before, at the 6th week, and at the 12th week of treatment. Results: Marked improvement in the severity of the disease symptoms was observed, reflected by a highly decrease in objective SCORAD score in the paraffin group over time more than the control group. The percentage of reduction was 28.6% in paraffin group versus 0.41% in control group. Subjective item score (itching and sleepiness) was reduced in the paraffin group more than the control group with a percentage of improvement (47% and 5.5%), respectively. Regarding QoL measure, there were highly positive changes in DLQI in paraffin group more than the control group. The percentage of improvement was 60% in paraffin group and 3.8% in control group. Conclusions: Paraffin bath therapy applied for a 12-week duration seems to be effective, both in reducing severity of eczema symptoms and improving QoL in patients with CHE.

Comparison of Patient-Oriented Eczema Measure and Patient-Oriented Scoring Atopic Dermatitis vs Eczema Area and Severity Index and other measures of atopic dermatitis: A validation study

BACKGROUND

Little is known about the measurement properties of Patient-Oriented Scoring Atopic Dermatitis (PO-SCORAD) in adults with atopic dermatitis (AD). Even less is known about how PO-SCORAD performs compared with the Patient-Oriented Eczema Measure (POEM).

OBJECTIVE

To examine the measurement properties of PO-SCORAD and compare them with those of POEM.

METHODS

A prospective dermatology practice-based study of 291 patients with AD (age range, 18-72 years).

RESULTS

PO-SCORAD and POEM were moderately correlated with each other (Spearman ρ = 0.56) and had weak-moderate correlations with the Numeric Rating Scale (NRS) worst itch and average itch, Dermatology Life Quality Index (DLQI), ItchyQOL, Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance (SD) and Sleep-Related Impairment (SRI), Patient Health Questionnaire-9 (PHQ-9), and Eczema Area and Severity Index (EASI) (P < .001). POEM had significantly stronger correlations with DLQI, ItchyQOL, and EASI than did PO-SCORAD. PO-SCORAD and POEM had fair discriminant validity. Changes from baseline in PO-SCORAD and POEM were moderately correlated with each other; were weakly to strongly correlated with NRS worst itch and average itch, DLQI, ItchyQOL, PROMIS SD, PROMIS SRI, PHQ-9, and EASI; and had good test-retest reliability. There was no differential item functioning of items or floor or ceiling effects for PO-SCORAD or POEM. The thresholds for meaningful change for PO-SCORAD and POEM were -15.5 and -5.0, respectively. Median completion times for PO-SCORAD and POEM were 3 minutes and 1 minute, respectively.

CONCLUSION

PO-SCORAD and POEM had good construct and cross-cultural validity, reliability, and responsiveness in adults with AD and were feasible for use in clinical trials and practice. However, POEM had better measurement properties than PO-SCORAD.