Emerging drugs for the treatment of atopic dermatitis: a focus on phase 2 and phase 3 trials

INTRODUCTION

Atopic dermatitis (AD) is an inflammatory skin condition that affects millions of pediatric and adult patients with well-studied impact on morbidity and quality of life. Management occurs in a stepwise fashion beginning with preventative measures before immunomodulators are introduced. However, challenges remain in treatment of moderate-to-severe atopic dermatitis that is refractory to first- and second-line treatments and there are only few topical anti-inflammatory options, especially for pediatric patients.

AREAS COVERED

New medications are required to address these gaps as lesions may persist despite treatment or patients may discontinue treatment due to actual or anticipated adverse effects of mainstay medications. Emerging research into the pathophysiology of AD and the immune system at large has provided opportunities for novel interventions aimed at stopping AD mechanisms at new checkpoints. Clinical trials for 36 agents currently in phase 2 or phase 3 are evaluated with particular focus on the studies for, B244, CBP-201, tapinarof, lebrikizumab, nemolizumab, amlitelimab, and rocatinlimab as they explore novel pathways and have some of the most promising results.

EXPERT OPINION

These clinical trials contribute to the evolution of AD treatment toward greater precision based on salient pathways with a particular focus on moderate-to-severe AD to enhance efficacy and minimize adverse effects.

Comparison of Old and New Systemic Treatments for Moderate to Severe Atopic Dermatitis

PURPOSE OF REVIEW

Historically, systemic treatments for atopic dermatitis (AD) primarily consisted of immunosuppressive agents such as corticosteroids and Disease Modifying Antirheumatic Drugs (DMARDS), which provided symptomatic relief but often had long-term adverse effects. Newer treatments have shown significant efficacy with less side effects in clinical trials. This review discusses and compares conventional and newer systemic treatments for AD.

RECENT FINDINGS

Newer medications for AD including dupilumab, tralokinumab, lebrikizumab, and oral JAK inhibitors have been shown to be safe and efficacious. High dose cyclosporine and dupilumab were more effective than methotrexate and azathioprine in improving clinical signs of AD. High-dose upadacitinib was shown in another meta-analysis to be most effective in the measured outcomes but had the highest frequency of adverse events. Targeted biologic treatments are increasingly favored over traditional immunosuppressive treatments of AD. Treatment can be individualized based on potency, adverse side effects, mechanism of action, and administration preference. Ongoing research continues to expand treatment options for AD.

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).

Constant vigilance! Managing threats to the skin barrier

OBJECTIVE

Skin barrier defects are one of the primary causes of atopic dermatitis (AD). The basis of skin barrier defects in AD is due to a deficiency in various barrier proteins including filaggrin, involucrin, claudins, and lipids such as ceramide, fatty acids, and cholesterol. This review updates a more detailed lipid dysregulation in the skin barrier of AD based on recent lipidomic analysis. The clinical implications, treatments, prevention, and predictive capability of skin barrier defects are also reviewed.

DATA SOURCES

Published literature obtained through PubMed searches.

STUDY SELECTIONS

Studies relevant to the mechanisms, clinical implications, treatments, prevention, and predictors of AD development.

RESULTS

Skin barrier defects contribute to transepidermal water loss, infections, IgE sensitizations, and cutaneous inflammation in AD. Preventive treatments include daily hydration and application of moisturizers. Because skin barrier defects precede the development of AD, they provide an opportunity for prediction and intervention.

CONCLUSION

Skin barrier defects play an important role in the comorbidities of AD including infectious complications, disease flare, and allergic diathesis. Current research focuses on prevention and prediction of AD development.

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.

Patients' and Caregivers' Preferences for Mental Health Care and Support in Atopic Dermatitis

Background: Atopic dermatitis (AD) has large mental health impacts for patients and caregivers, yet their preferences regarding how to relieve these impacts are poorly understood. Objective: To understand patients' and caregivers' preferences for AD-related mental health care and support. Methods: We surveyed 279 adult AD patients and 154 caregivers of children with AD across 26 countries regarding their AD-related mental health burden, preferred strategies for improving AD-related mental health, and experiences with mental health care in AD. Results: Caregivers reported significantly worse overall mental health (P = 0.01) and anxiety (P = 0.03) than adult patients when controlling for AD severity. Among adult patients, 58% selected treating the AD, 51% managing itch, 44% wearing clothing to cover up skin, 43% avoiding social situations, and 41% spending time alone, as strategies they felt would improve their own AD-related mental health. Caregivers selected managing itch and treating the AD most frequently for both their own (76% and 75%, respectively) and their children's (75% and 61%) mental health. Adult patients were less satisfied with mental health care from mental health providers versus nonmental health providers (P < 0.001). Conclusions: Effective AD management is the preferred method for improving mental health among patients as well as caregivers, who may experience the greatest mental health impacts. Self-care strategies should be considered in a shared decision-making approach.

Topical treatments for atopic dermatitis (eczema): Systematic review and network meta-analysis of randomized trials

BACKGROUND

Atopic dermatitis (AD) is a common skin condition with multiple topical treatment options, but uncertain comparative effects.

OBJECTIVE

We sought to systematically synthesize the benefits and harms of AD prescription topical treatments.

METHODS

For the 2023 American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters AD guidelines, we searched MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, ICTRP, and GREAT databases to September 5, 2022, for randomized trials addressing AD topical treatments. Paired reviewers independently screened records, extracted data, and assessed risk of bias. Random-effects network meta-analyses addressed AD severity, itch, sleep, AD-related quality of life, flares, and harms. The Grading of Recommendations Assessment, Development and Evaluation approach informed certainty of evidence ratings. We classified topical corticosteroids (TCS) using 7 groups-group 1 being most potent. This review is registered in the Open Science Framework (https://osf.io/q5m6s).

RESULTS

The 219 included trials (43,123 patients) evaluated 68 interventions. With high-certainty evidence, pimecrolimus improved 6 of 7 outcomes-among the best for 2; high-dose tacrolimus (0.1%) improved 5-among the best for 2; low-dose tacrolimus (0.03%) improved 5-among the best for 1. With moderate- to high-certainty evidence, group 5 TCS improved 6-among the best for 3; group 4 TCS and delgocitinib improved 4-among the best for 2; ruxolitinib improved 4-among the best for 1; group 1 TCS improved 3-among the best for 2. These interventions did not increase harm. Crisaborole and difamilast were intermediately effective, but with uncertain harm. Topical antibiotics alone or in combination may be among the least effective. To maintain AD control, group 5 TCS were among the most effective, followed by tacrolimus and pimecrolimus.

CONCLUSIONS

For individuals with AD, pimecrolimus, tacrolimus, and moderate-potency TCS are among the most effective in improving and maintaining multiple AD outcomes. Topical antibiotics may be among the least effective.

Systemic treatments for atopic dermatitis (eczema): Systematic review and network meta-analysis of randomized trials

BACKGROUND

Atopic dermatitis (AD) is an inflammatory skin condition with multiple systemic treatments and uncertainty regarding their comparative impact on AD outcomes.

OBJECTIVE

We sought to systematically synthesize the benefits and harms of AD systemic treatments.

METHODS

For the 2023 American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters AD guidelines, we searched MEDLINE, EMBASE, CENTRAL, Web of Science, and GREAT databases from inception to November 29, 2022, for randomized trials addressing systemic treatments and phototherapy for AD. Paired reviewers independently screened records, extracted data, and assessed risk of bias. Random-effects network meta-analyses addressed AD severity, itch, sleep, AD-related quality of life, flares, and harms. The Grading of Recommendations Assessment, Development and Evaluation approach informed certainty of evidence ratings. This review is registered in the Open Science Framework (https://osf.io/e5sna).

RESULTS

The 149 included trials (28,686 patients with moderate-to-severe AD) evaluated 75 interventions. With high-certainty evidence, high-dose upadacitinib was among the most effective for 5 of 6 patient-important outcomes; high-dose abrocitinib and low-dose upadacitinib were among the most effective for 2 outcomes. These Janus kinase inhibitors were among the most harmful in increasing adverse events. With high-certainty evidence, dupilumab, lebrikizumab, and tralokinumab were of intermediate effectiveness and among the safest, modestly increasing conjunctivitis. Low-dose baricitinib was among the least effective. Efficacy and safety of azathioprine, oral corticosteroids, cyclosporine, methotrexate, mycophenolate, phototherapy, and many novel agents are less certain.

CONCLUSIONS

Among individuals with moderate-to-severe AD, high-certainty evidence demonstrates that high-dose upadacitinib is among the most effective in addressing multiple patient-important outcomes, but also is among the most harmful. High-dose abrocitinib and low-dose upadacitinib are effective, but also among the most harmful. Dupilumab, lebrikizumab, and tralokinumab are of intermediate effectiveness and have favorable safety.

Recent advances in immunomodulators for atopic dermatitis

PURPOSE OF REVIEW

Conventional treatments of atopic dermatitis have been inadequate, especially in patients with moderate-to-severe disease.

RECENT FINDINGS

In the past 5 years, four immunomodulators have been approved for the treatment of atopic dermatitis in children. These include dupilumab, ruxolitinib, upadacitinib, and abrocitinib. The review summarizes the pivotal phase 3 trials of these medications.

SUMMARY

The newer immunomodulators have transformed the treatment of atopic dermatitis, particularly in patients with moderate-to-severe disease. Dupilumab targets IL-4 and IL-13, which are the main causes of allergic inflammation, resulting in great efficacy and few side effects. Upadacitinib and abrocitinib are alternative systemic medications for adolescents who have failed or are unable to tolerate dupilumab. Ruxolitinib cream is the latest addition to the current topical therapy. It is indicated for children 12 years and older with mild-to-moderate atopic dermatitis. Further studies are needed to confirm its safety and efficacy for younger children and for patients with more severe disease.

Rapid reduction in Staphylococcus aureus in atopic dermatitis subjects following dupilumab treatment

BACKGROUND

Atopic dermatitis (AD) is an inflammatory disorder characterized by dominant type 2 inflammation leading to chronic pruritic skin lesions, allergic comorbidities, and Staphylococcus aureus skin colonization and infections. S aureus is thought to play a role in AD severity.

OBJECTIVES

This study characterized the changes in the host-microbial interface in subjects with AD following type 2 blockade with dupilumab.

METHODS

Participants (n = 71) with moderate-severe AD were enrolled in a randomized (dupilumab vs placebo; 2:1), double-blind study at Atopic Dermatitis Research Network centers. Bioassays were performed at multiple time points: S aureus and virulence factor quantification, 16s ribosomal RNA microbiome, serum biomarkers, skin transcriptomic analyses, and peripheral blood T-cell phenotyping.

RESULTS

At baseline, 100% of participants were S aureus colonized on the skin surface. Dupilumab treatment resulted in significant reductions in S aureus after only 3 days (compared to placebo), which was 11 days before clinical improvement. Participants with the greatest S aureus reductions had the best clinical outcomes, and these reductions correlated with reductions in serum CCL17 and disease severity. Reductions (10-fold) in S aureus cytotoxins (day 7), perturbations in TH17-cell subsets (day 14), and increased expression of genes relevant for IL-17, neutrophil, and complement pathways (day 7) were also observed.

CONCLUSIONS

Blockade of IL-4 and IL-13 signaling, very rapidly (day 3) reduces S aureus abundance in subjects with AD, and this reduction correlates with reductions in the type 2 biomarker, CCL17, and measures of AD severity (excluding itch). Immunoprofiling and/or transcriptomics suggest a role for TH17 cells, neutrophils, and complement activation as potential mechanisms to explain these findings.

History of S. aureus Skin Infection Significantly Associates with History of Eczema Herpeticum in Patients with Atopic Dermatitis

INTRODUCTION

Patients with atopic dermatitis (AD) are uniquely susceptible to a number of serious viral skin complications, including eczema herpeticum (EH), caused by herpes simplex virus. This study explored the associations between biomarkers of epithelial barrier dysfunction, type 2 immunity, Staphylococcus aureus infection, and S. aureus-specific immunoglobulin responses in a cohort of AD subjects with and without a history of EH (EH+ and EH-, respectively).

METHODS

A total of 112 subjects with AD (56 EH+, 56 EH-), matched by age and AD severity, were selected from a registry of over 3000 AD subjects. Logistic regression was used to test the association between history of S. aureus skin infection and history of EH, while controlling for a number of confounders.

RESULTS

Compared to those without a history of S. aureus skin infection, subjects with a history of S. aureus skin infection were found to have more than sixfold increased odds of having a history of EH (6.60, 95% confidence interval [CI]: 2.00-21.83), after adjusting for history of other viral skin infections (molluscum contagiosum virus, human papillomavirus), serum total IgE, and IgG against the S. aureus virulence factor SElX.

CONCLUSIONS

These findings indicate an important relationship between S. aureus skin infections and EH.

Phenotypic and Endotypic Determinants of Atopic Dermatitis Severity From the Atopic Dermatitis Research Network (ADRN) Registry

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin condition with a highly variable clinical phenotype.

OBJECTIVE

This study aimed to identify historical and clinical features and biomarkers associated with AD severity.

METHODS

A US registry of extensively phenotyped AD participants (aged 0.73-80 years) were enrolled at 9 academic centers. Information on family and personal medical history, examination, skin swabs (culture), and serum biomarkers was collected to evaluate their association with AD severity.

RESULTS

Participants with AD (N = 2862) whose disease was categorized as mild (11.6%), moderate (58.0%), or severe (30.4%) based on Rajka-Langeland scoring were enrolled. The trend test, when adjusting for gender, race, and age, demonstrated that severity was strongly (P ≤ .04) associated with a personal/family history of allergic disorders, history of alopecia, exposure to passive smoke, ocular herpes infection, skin bacterial and viral infections, and history of arrhythmia. Features observed more frequently (P ≤ .002), as a function of severity, included skin infections (impetigo, human papillomavirus, and molluscum contagiosum virus), Staphylococcus aureus colonization, excoriations, hyperlinear palms, ichthyosis, blepharitis, conjunctivitis, ectropion, and wheezing. Serum IgE, allergen and food (≤6 years) Phadiatop, and eosinophilia were strongly linked to severity (P < .001).

CONCLUSIONS

In a diverse US AD population, severity was associated with a history of atopic disorders, skin and extracutaneous bacterial and viral infections (by history and physical examination), higher IgE, eosinophilia and allergen sensitization, atopic skin manifestations (ie, excoriation, hyperlinear palms, and ichthyosis), and atopic ocular features (ie, blepharitis, conjunctivitis, and ectropion) as well as asthma findings (ie, wheezing). Data from our prospective registry significantly advance our understanding of AD phenotypes and endotypes, which is critical to achieve optimal management.

Values and Preferences of Patients and Caregivers Regarding Treatment of Atopic Dermatitis (Eczema): A Systematic Review

Importance

Patient values and preferences can inform atopic dermatitis (AD) care. Systematic summaries of evidence addressing patient values and preferences have not previously been available.

Objective

To inform American Academy of Allergy, Asthma & Immunology (AAAAI)/American College of Allergy, Asthma and Immunology (ACAAI) Joint Task Force on Practice Parameters AD guideline development, patient and caregiver values and preferences in the management of AD were systematically synthesized.

Evidence Review

Paired reviewers independently screened MEDLINE, Embase, PsycINFO, and CINAHL databases from inception until March 20, 2022, for studies of patients with AD or their caregivers, eliciting values and preferences about treatment, rated risk of bias, and extracted data. Thematic and inductive content analysis to qualitatively synthesize the findings was used. Patients, caregivers, and clinical experts provided triangulation. The GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative Research) informed rating of the quality of evidence.

Findings

A total of 7780 studies were identified, of which 62 proved eligible (n = 19 442; median age across studies [range], 15 years [3-44]; 59% female participants). High certainty evidence showed that patients and caregivers preferred to start with nonmedical treatments and to step up therapy with increasing AD severity. Moderate certainty evidence showed that adverse effects from treatment were a substantial concern. Low certainty evidence showed that patients and caregivers preferred odorless treatments that are not visible and have a minimal effect on daily life. Patients valued treatments capable of relieving itching and burning skin and preferred to apply topical corticosteroids sparingly. Patients valued a strong patient-clinician relationship. Some studies presented varied perspectives and 18 were at high risk for industry sponsorship bias.

Conclusions and Relevance

In the first systematic review to address patient values and preferences in management of AD to our knowledge, 6 key themes that may inform optimal clinical care, practice guidelines, and future research have been identified.

321 Cancer risk with topical pimecrolimus and tacrolimus for atopic dermatitis: systematic review and Bayesian meta-analysis

Atopic dermatitis affects millions worldwide and is effectively managed by topical treatments, including topical calcineurin inhibitors, pimecrolimus and tacrolimus. In 2005 and 2011, the FDA released reviews associating topical calcineurin inhibitors with a theoretical cancer risk, albeit an uncertain association. We systematically reviewed the risk of cancer in patients with atopic dermatitis exposed to topical calcineurin inhibitors. We systematically identified randomized controlled trials, comparative, and non-comparative non-randomized studies from database inception to 6 June 2022, from MEDLINE, EMBASE, GREAT, LILACS, ICTRP, FDA, EMA, company registers and relevant citations. We included studies in any language addressing the risk of cancer in patients with atopic dermatitis exposed to topical calcineurin inhibitors for greater than 3 weeks. We excluded split-body studies. We conducted a Bayesian meta-analysis and used the GRADE approach to determine the certainty of the evidence. A multidisciplinary panel including patients, advocacy groups and care providers, set an a priori threshold of 1 in 1000 risk difference as a clinically important effect. We analysed 121 studies (52 randomized controlled trials and 69 non-randomized studies) including 3.4 million patents followed for a mean of 11 months (range: 0.7–120). The absolute risk of any cancer with topical calcineurin inhibitor exposure was neither different from controls (absolute risk 4.70 per 1000 with topical calcineurin inhibitor exposure vs. 4.56 per 1000 without; odds ratio 1.03 [95% credible interval 0.94–1.11], moderate-certainty evidence) nor the general US population (4.6 per 1000). Findings were similar in infants, children, and adults, and were robust to trial sequential, subgroup and sensitivity analyses. Among infants, children and adults with atopic dermatitis, moderate-certainty evidence shows that topical calcineurin inhibitors do not increase the risk of cancer. These findings support the safe use of topical calcineurin inhibitors in the management of patients with atopic dermatitis. Our findings provide actional information to inform updated clinical practice guidelines, product labels and continuing education for care providers, to clarify the safe usage of topical calcineurin inhibitors.

Skin Antiseptics for Atopic Dermatitis: Dissecting Facts From Fiction

Staphylococcus aureus is a known trigger and cause of infectious complications in atopic dermatitis (AD). Various antiseptics have been used in an attempt to decrease the burden of S. aureus in AD. In this Commentary, we present the evidence for and against some of the commonly used antiseptics in clinical and research settings. These agents remain attractive as an adjunct therapy for AD owing to their relative low cost and potential benefits of reducing S. aureus. Although a number of studies have evaluated the use of dilute bleach, its mechanisms remain controversial. A higher concentration of bleach than the commonly used 0.005% is likely needed for its anti-S. aureus effect. Silver-coated textiles have demonstrated anti-S. aureus effects in various studies; however, their efficacy and side effects in AD remain to be confirmed. Other antiseptics including chlorhexidine, triclosan, and triclocarban are also discussed. Variables that may affect the outcomes of these studies include length of use, concurrent application of moisturizers, and anti-inflammatory medications.

Elevated serum total IgE is associated with eczema exacerbation in children hospitalized for atopic dermatitis

BACKGROUND/OBJECTIVES

Atopic dermatitis (AD) can be a debilitating skin condition, often leading to hospitalization due to severe AD exacerbations or infectious complications. As both AD exacerbations and infectious complications can present similarly, it can be difficult to distinguish the two conditions. Thus, we aimed to evaluate if there is any difference in serum IgE levels in children with AD who were hospitalized for AD exacerbation and for AD-associated infectious complications.

METHODS

A retrospective chart review was performed on hospitalized children with AD exacerbations and AD-associated infectious complications over a 17-year span. Data including length of stay, primary diagnosis, systemic antibiotics, laboratory, and bacterial culture results were collected. Serum total immunoglobulin E (IgE) levels were adjusted by age. Age, length of stay, total IgE levels, and age-adjusted IgE levels were compared using t-test. Logistic regression was used for age-adjusted IgE levels.

RESULTS

The mean serum total IgE level in subjects with AD exacerbation was 9603 ± 15,873 kU/L, which was significantly higher than that of subjects with infectious complications at 3167 ± 5486 kU/L (p = .029). Logistic regression revealed that subjects with an age-adjusted IgE of >4 had more than 3-fold odds of having AD exacerbation than infectious complications.

CONCLUSIONS

Our results suggest that total IgE levels are higher in children who were hospitalized for AD exacerbation than those with AD-associated infectious complications.

Allergen immunotherapy for atopic dermatitis: Systematic review and meta-analysis of benefits and harms

BACKGROUND

Atopic dermatitis (AD, eczema) is driven by a combination of skin barrier defects, immune dysregulation, and extrinsic stimuli such as allergens, irritants, and microbes. The role of environmental allergens (aeroallergens) in triggering AD remains unclear.

OBJECTIVE

We systematically synthesized evidence regarding the benefits and harms of allergen immunotherapy (AIT) for AD.

METHODS

As part of the 2022 American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters AD Guideline update, we searched the MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, Global Resource for Eczema Trials, and Web of Science databases from inception to December 2021 for randomized controlled trials comparing subcutaneous immunotherapy (SCIT), sublingual immunotherapy (SLIT), and/or no AIT (placebo or standard care) for guideline panel-defined patient-important outcomes: AD severity, itch, AD-related quality of life (QoL), flares, and adverse events. Raters independently screened, extracted data, and assessed risk of bias in duplicate. We synthesized intervention effects using frequentist and Bayesian random-effects models. The GRADE approach determined the quality of evidence.

RESULTS

Twenty-three randomized controlled trials including 1957 adult and pediatric patients sensitized primarily to house dust mite showed that add-on SCIT and SLIT have similar relative and absolute effects and likely result in important improvements in AD severity, defined as a 50% reduction in SCORing Atopic Dermatitis (risk ratio [95% confidence interval] 1.53 [1.31-1.78]; 26% vs 40%, absolute difference 14%) and QoL, defined as an improvement in Dermatology Life Quality Index by 4 points or more (risk ratio [95% confidence interval] 1.44 [1.03-2.01]; 39% vs 56%, absolute difference 17%; both outcomes moderate certainty). Both routes of AIT increased adverse events (risk ratio [95% confidence interval] 1.61 [1.44-1.79]; 66% with SCIT vs 41% with placebo; 13% with SLIT vs 8% with placebo; high certainty). AIT's effect on sleep disturbance and eczema flares was very uncertain. Subgroup and sensitivity analyses were consistent with the main findings.

CONCLUSIONS

SCIT and SLIT to aeroallergens, particularly house dust mite, can similarly and importantly improve AD severity and QoL. SCIT increases adverse effects more than SLIT. These findings support a multidisciplinary and shared decision-making approach to optimally managing AD.

Safety, pharmacokinetics, and efficacy of ruxolitinib cream in children and adolescents with atopic dermatitis

BACKGROUND

Therapies for children with atopic dermatitis (AD) have safety and tolerability concerns that may limit long-term use. Ruxolitinib cream, a Janus kinase (JAK) inhibitor, is effective and well tolerated in adolescents and adults with AD.

OBJECTIVE

To analyze the safety and tolerability of ruxolitinib cream in pediatric patients. Pharmacokinetics and efficacy were also evaluated in this phase 1 study (NCT03257644).

METHODS

Patients aged 2 to 17 years with AD (affected body surface area 8%-20%; Investigator's Global Assessment score ≥2) were enrolled stepwise in 6 age-descending, strength-increasing cohorts to apply 0.5%, 0.75%, or 1.5% ruxolitinib cream twice daily for 28 days. Safety, pharmacokinetics, and efficacy were analyzed at baseline, week 2 (day 10), and week 4 (day 29).

RESULTS

Among 71 patients, 44 (62.0%) had a baseline Investigator's Global Assessment score of 3; median (range) body surface area affected at baseline was 12.2% (1.7%-20.4%). Ruxolitinib cream was well tolerated, with 4 patients (5.6%) experiencing treatment-related adverse events (all grades 1/2). No clinically meaningful changes in mean chemistry or hematology values were observed, and no consistent pattern of change in bone biomarkers was detected. Mean plasma ruxolitinib levels within each cohort (range, 23.1-97.9 nM) were well below the half-maximal inhibitory concentration for thrombopoietin phosphorylation of STAT3 (281 nM). All cohorts experienced improvements in exploratory efficacy end points.

CONCLUSION

Ruxolitinib cream was well tolerated in pediatric patients with AD, with no effect on blood counts or bone biomarkers. Mean plasma concentration was low. Efficacy was consistent with data from previous studies in adolescents and adults.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03257644.

Genetic/Environmental Contributions and Immune Dysregulation in Children with Atopic Dermatitis

Atopic dermatitis (AD) is one of the most common skin conditions in humans. AD affects up to 20% of children worldwide and results in morbidity for both patients and their caregivers. The basis of AD is an interplay between genetics and the environment characterized by immune dysregulation. A myriad of mutations that compromise the skin barrier and/or immune function have been linked to AD. Of these, filaggrin gene (FLG) mutations are the most evidenced. Many other mutations have been implicated in isolated studies that are often unreplicated, creating an archive of genes with potential but unconfirmed relevance to AD. Harnessing big data, polygenic risk scores (PRSs) and genome-wide association studies (GWAS) may provide a more practical strategy for identifying the genetic signatures of AD. Epigenetics may also play a role. Staphylococcus aureus is the most evidenced microbial contributor to AD. Cutaneous dysbiosis may result in over-colonization by pathogenic strains and aberrant skin immunity and inflammation. Aeroallergens, air pollution, and climate are other key environmental contributors to AD. The right climate and/or commensals may improve AD for some patients.

Dietary Elimination for the Treatment of Atopic Dermatitis: A Systematic Review and Meta-Analysis

BACKGROUND

The influence of diet on atopic dermatitis (AD) is complex, and the use of dietary elimination as a treatment has conflicting views.

OBJECTIVE

To systematically review the benefits and harms of dietary elimination for the treatment of AD.

METHODS

We searched MEDLINE, Embase, AMED, PsycINFO, and the Cochrane Central Register of Controlled Trials from inception to January 18, 2022, without language restrictions, for randomized controlled trials (RCTs) and observational studies comparing dietary elimination and no dietary elimination for the treatment of AD. We conducted random-effects meta-analyses of eczema outcomes. We used the grading of recommendations, assessment, development, and evaluation approach to assess certainty of evidence (CRD42021237953).

RESULTS

Ten RCT (n = 599; baseline median of study mean age, 1.5 years; median of study mean SCOring Atopic Dermatitis index, 20.7, range, 3.5-37.6) were included in the meta-analysis. Compared with no dietary elimination, low-certainty evidence showed that dietary elimination may slightly improve eczema severity (50% with vs 41% without dietary elimination improved the SCOring Atopic Dermatitis index by a minimally important difference of 8.7 points, risk difference of 9% [95% CI, 0-17]), pruritus (daytime itch score [range, 0-3] mean difference, -0.21 [95% CI, -0.57 to 0.15]), and sleeplessness (sleeplessness score [range, 0-3] mean difference, -0.47 [95% CI, -0.80 to -0.13]). There were no credible subgroup differences based on elimination strategy (empiric vs guided by testing) or food-specific sensitization. Insufficient data addressed harms of elimination diets among included RCTs, although indirect evidence suggests that elimination diets may increase the risk for developing IgE-mediated food allergy.

CONCLUSIONS

Dietary elimination may lead to a slight, potentially unimportant improvement in eczema severity, pruritus, and sleeplessness in patients with mild to moderate AD. This must be balanced against potential risks for indiscriminate elimination diets including developing IgE-mediated food allergy and withholding more effective treatment options for AD.

Atopic dermatitis: Is innate or adaptive immunity in control? A clinical perspective

Atopic dermatitis (AD) is a chronic inflammatory skin disease with barrier defects and immune dysregulations. The pathogenesis of AD involves the physical barrier as well as epithelial cells, which are considered a vital part of the innate immunity of the skin. The importance of filaggrin mutations in the pathogenesis of AD has also been well-established with reproducible results around the world in multiple studies and ethnic groups. This protein plays an important role in skin barrier functions and further reaffirms barrier defects as one of the primary causes of AD. The main epithelial cells, keratinocytes, function as a major sentinel for the skin in detecting danger signals or microbial pathogens, and trigger downstream immune responses. In AD, these cells express TSLP, IL-33 and IL-25, which lead to downstream systemic production of type 2 cytokines. In spite of major advances in our understanding of the innate immunity of AD, recent success in the systemic therapeutics of AD have focused on targeting the products of the adaptive immunity, particularly cytokines produced by T cells. In addition to type 2 cytokines, type 17 cytokines have also been implicated in the pathogenesis of AD. The current review examines the implications of these cytokines in AD from clinical perspectives.

Bleach baths for atopic dermatitis: A systematic review and meta-analysis including unpublished data, Bayesian interpretation, and GRADE

BACKGROUND

Bleach bathing is frequently recommended to treat atopic dermatitis (AD), but its efficacy and safety are uncertain.

OBJECTIVE

To systematically synthesize randomized controlled trials (RCTs) addressing bleach baths for AD.

METHODS

We searched MEDLINE, EMBASE, CENTRAL, and GREAT from inception to December 29, 2021, for RCTs assigning patients with AD to bleach vs no bleach baths. Paired reviewers independently and in duplicate screened records, extracted data, and assessed risk of bias (Cochrane version 2) and GRADE quality of evidence. We obtained unpublished data, harmonized individual patient data and did Frequentist and Bayesian random-effects meta-analyses.

RESULTS

There were 10 RCTs that enrolled 307 participants (median of mean age 7.2 years, Eczema Area Severity Index baseline mean of means 27.57 [median SD, 10.74]) for a median of 6 weeks (range, 4-10). We confirmed that other trials registered globally were terminated. Bleach baths probably improve AD severity (22% vs 32% improved Eczema Area Severity Index by 50% [ratio of means 0.78, 95% credible interval 0.59-0.99]; moderate certainty) and may slightly reduce skin Staphylococcal aureus colonization (risk ratio, 0.89 [95% confidence interval, 0.73-1.09]; low certainty). Adverse events, mostly dry skin and irritation, along with itch, patient-reported disease severity, sleep quality, quality of life, and risk of AD flares were not clearly different between groups and of low to very low certainty.

CONCLUSION

In patients with moderate-to-severe AD, bleach baths probably improve clinician-reported severity by a relative 22%. One in 10 will likely improve severity by 50%. Changes in other patient-important outcomes are uncertain. These findings support optimal eczema care and the need for additional large clinical trials.

TRIAL REGISTRATION

PROSPERO Identifier: CRD42021238486.

Aeroallergens in Atopic Dermatitis and Chronic Urticaria

PURPOSE OF REVIEW

While aeroallergens are a well-established trigger of asthma and allergic rhinitis, their role in allergic skin diseases such as atopic dermatitis and chronic urticaria remains controversial. This paper reviews the pathophysiology and clinical evidence for aeroallergens in these allergic skin diseases and summarizes current strategies for evaluation and management.

RECENT FINDINGS

Current evidence implicates aeroallergens as triggers of cutaneous reactions in atopic dermatitis. Direct skin contact is the likely route of trigger. Aeroallergens may also trigger chronic urticaria, though mechanistic studies are limited. These allergens may cross the skin barrier and directly trigger neurons to release substance P, resulting in mast cell degranulation and dumping of histamine and prostaglandin D2. Many studies link aeroallergen sensitization to chronic urticaria, and case reports suggest the utility of avoidance strategies. The role of aeroallergens as a trigger is clear in atopic dermatitis and becoming emergent in chronic urticaria. Skin prick testing or serum-specific immunoglobulin E testing may be used to determine sensitivities. Management at this time centers on avoidance, and further studies are necessary to evaluate the efficacy of aeroallergen immunotherapy for both conditions.

EAACI Biologicals Guidelines-Omalizumab for the treatment of chronic spontaneous urticaria in adults and in the paediatric population 12-17 years old

Chronic spontaneous urticaria (CSU) imposes a significant burden on patients, families and healthcare systems. Management is difficult, due to disease heterogeneity and insufficient efficacy of classical drugs such as H₁ R-antihistamines. Better understanding of the mechanisms has enabled a stratified approach to the management of CSU, supporting the use of targeted treatment with omalizumab. However, many practical issues including selection of responders, the definition of response, strategies to enhance the responder rate, the duration of treatment and its regimen (in the clinic or home-based) and its cost-effectiveness still require further clarification. The EAACI Guidelines on the use of omalizumab in CSU follow the GRADE approach in formulating recommendations for each outcome. In addition, future therapeutic approaches and perspectives as well as research priorities are discussed.

Complete blood count profiles in children with eczema herpeticum

Eczema herpeticum (EH) can be a life-threatening condition. Prompt diagnosis and treatment are crucial. In this article, we retrospectively assessed the use of screening complete blood count (CBC) to differentiate EH from bacterial skin infection and eczema exacerbation in children who were hospitalized for atopic dermatitis (AD). Children with EH had consistent leukopenia and lymphopenia, relative to the comparison groups as well as standard references.

Whole genome sequencing identifies novel genetic mutations in patients with eczema herpeticum

BACKGROUND

Eczema herpeticum (EH) is a rare complication of atopic dermatitis (AD) caused by disseminated herpes simplex virus (HSV) infection. The role of rare and/or deleterious genetic variants in disease etiology is largely unknown. This study aimed to identify genes that harbor damaging genetic variants associated with HSV infection in AD with a history of recurrent eczema herpeticum (ADEH+).

METHODS

Whole genome sequencing (WGS) was performed on 49 recurrent ADEH+ (≥3 EH episodes), 491 AD without a history of eczema herpeticum (ADEH-) and 237 non-atopic control (NA) subjects. Variants were annotated, and a gene-based approach (SKAT-O) was used to identify genes harboring damaging genetic variants associated with ADEH+. Genes identified through WGS were studied for effects on HSV responses and keratinocyte differentiation.

RESULTS

Eight genes were identified in the comparison of recurrent ADEH+to ADEH-and NA subjects: SIDT2, CLEC7A, GSTZ1, TPSG1, SP110, RBBP8NL, TRIM15, and FRMD3. Silencing SIDT2 and RBBP8NL in normal human primary keratinocytes (NHPKs) led to significantly increased HSV-1 replication. SIDT2-silenced NHPKs had decreased gene expression of IFNk and IL1b in response to HSV-1 infection. RBBP8NL-silenced NHPKs had decreased gene expression of IFNk, but increased IL1b. Additionally, silencing SIDT2 and RBBP8NL also inhibited gene expression of keratinocyte differentiation markers keratin 10 (KRT10) and loricrin (LOR).

CONCLUSION

SIDT2 and RBBP8NL participate in keratinocyte's response to HSV-1 infection. SIDT2 and RBBP8NL also regulate expression of keratinocyte differentiation genes of KRT10 and LOR.

EAACI Biologicals Guidelines-dupilumab for children and adults with moderate-to-severe atopic dermatitis

Atopic dermatitis imposes a significant burden on patients, families and healthcare systems. Management is difficult, due to disease heterogeneity, co-morbidities, complexity in care pathways and differences between national or regional healthcare systems. Better understanding of the mechanisms has enabled a stratified approach to the management of atopic dermatitis, supporting the use of targeted treatments with biologicals. However, there are still many issues that require further clarification. These include the definition of response, strategies to enhance the responder rate, the duration of treatment and its regimen (in the clinic or home-based), its cost-effectiveness and long-term safety. The EAACI Guidelines on the use of dupilumab in atopic dermatitis follow the GRADE approach in formulating recommendations for each outcome and age group. In addition, future approaches and research priorities are discussed.

Efficacy and safety of dupilumab for moderate-to-severe atopic dermatitis: A systematic review for the EAACI biologicals guidelines

This systematic review evaluates the efficacy, safety and economic impact of dupilumab compared to standard of care for uncontrolled moderate-to-severe atopic dermatitis (AD). Pubmed, EMBASE and Cochrane Library were searched for RCTs and health economic evaluations. Critical and important AD-related outcomes were considered. The risk of bias and the certainty of the evidence were assessed using GRADE. Seven RCTs including 1845 subjects >12 years treated with dupilumab 16 to 52 weeks were evaluated. For adults, there is high certainty that dupilumab decreases SCORAD (MD -30,72; 95% CI -34,65% to -26,79%) and EASI-75 (RR 3.09; 95% CI 2.45 to 3.89), pruritus (RR 2.96; 95% CI 2.37 to 3.70), rescue medication (RR 3.46; 95% CI 2.79 to 4.30), sleep disturbance (MD -7.29; 95% CI -8.23 to -6.35) and anxiety/depression (MD -3.08; 95% CI -4.41 to -1.75) and improves quality of life (MD -4.80; 95% CI -5.55 to -4.06). The efficacy for adolescents is similar. Dupilumab-related adverse events (AEs) slightly increase (low certainty). The evidence for dupilumab-related serious AE is uncertain. The incremental cost-effectiveness ratio ranged from 28 500 £ (low certainty) to 124 541 US$ (moderate certainty). More data on long-term safety are needed both for children and for adults, together with more efficacy data in the paediatric population. Registration: PROSPERO (CRD42020153645).

The infectious complications of atopic dermatitis

OBJECTIVE

Atopic dermatitis (AD) is a chronic inflammatory skin disease that is complicated by an increased risk for skin and systemic infections. Preventive therapy for AD is based on skin barrier improvement and anti-inflammatory treatments, whereas overt skin and systemic infections require antibiotics or antiviral treatments. This review updates the pathophysiology, diagnosis, management, controversy of antibiotic use, and potential treatments of infectious complications of AD.

DATA SOURCES

Published literature obtained through PubMed database searches and clinical pictures.

STUDY SELECTIONS

Studies relevant to the mechanisms, diagnosis, management, and potential therapy of infectious complications of AD.

RESULTS

Skin barrier defects, type 2 inflammation, Staphylococcusaureus colonization, and cutaneous dysbiosis are the major predisposing factors for the increased infections in AD. Although overt infections require antibiotics, the use of antibiotics in AD exacerbation remains controversial.

CONCLUSION

Infectious complications are a comorbidity of AD. Although not common, systemic bacterial infections and eczema herpeticum can be life-threatening. Preventive therapy of infections in AD emphasizes skin barrier improvement and anti-inflammatory therapy. The use of antibiotics in AD exacerbation requires further studies.

Are avoidance diets still warranted in children with atopic dermatitis?

Nearly 40% of children with moderate-to-severe atopic dermatitis (AD) have IgE-mediated food allergy (FA). This clinical observation has been extensively documented by experimental data linking skin inflammation in AD to FA, as well as by food challenges reproducing symptoms and avoidance diets improving AD. Although food avoidance may improve AD, avoidance diets do not cure AD, may even have detrimental effects such as progression to immediate-type allergy including anaphylactic reactions, and may significantly reduce the quality of life of the patient and the family. AD care should focus upon optimal medical management, rather than dietary elimination. Food allergy testing is primarily indicated when immediate-type allergic reactions are a concern. In recalcitrant AD, if food is being considered a possible chronic trigger, a limited panel of foods may be tested. An avoidance diet is only indicated in patients clearly identified as food allergic by an appropriate diagnostic food challenge, and after adequately informing the family of the limited benefits, and possible harms of an elimination diet.

Update on Atopic Dermatitis: Diagnosis, Severity Assessment, and Treatment Selection

Atopic dermatitis (AD) is one of the most common inflammatory skin diseases affecting children and adults. The intense pruritus and rash can be debilitating, significantly impairing quality of life. Until recently, treatment was largely nonspecific and, in severe disease, sometimes ineffective and/or fraught with many side effects. Now, multiple agents targeting specific disease pathways are available or in development. Two new therapies, crisaborole and dupilumab, have become available since 2016, and dupilumab has dramatically improved outcomes for adults with severe AD. This article provides an overview of AD, including strategies for differential diagnosis and assessment of disease severity to guide treatment selection. Key clinical trials for crisaborole and dupilumab are reviewed, and other targeted treatments now in development are summarized. Two cases, representing childhood-onset and adult-onset AD, are discussed to provide clinical context for diagnosis, severity assessment, and treatment selection and outcomes.

Validation of five patient-reported outcomes for atopic dermatitis severity in adults

BACKGROUND

Structured patient-reported outcomes of atopic dermatitis (AD) severity are not standardized in clinical practice.

OBJECTIVES

To determine the construct validity, internal consistency, cross-cultural validity and floor or ceiling effects of multiple AD severity assessments.

METHODS

This is a cross-sectional, population-based study of 2893 adults, including 602 adults who met a modified set of U.K. diagnostic criteria for AD. AD severity was assessed using self-reported global AD severity, Patient-Oriented Eczema Measure (POEM), Patient-Oriented Scoring Atopic Dermatitis (PO-SCORAD) and its objective and subjective components, and numerical rating scale (NRS)-itch. Quality of life was assessed using Short-Form (SF)-12 mental and physical health scores, Short-Form Six Dimensions (SF-6D) health utility scores and Dermatology Life Quality Index (DLQI). Mental health was assessed with the Hospital Anxiety and Depression Scale (HADS).

RESULTS

PO-SCORAD, PO-SCORAD objective and subjective subscores, NRS-itch and POEM all had moderate-to-strong correlations with each other and DLQI, fair-to-moderate correlations with HADS-anxiety and HADS-depression, and inverse correlations with SF-12 mental component score and SF-6D (Pearson correlations, P < 0·001). All scores showed good criterion validity as judged by anova and receiver operator characteristics. PO-SCORAD, PO-SCORAD objective subscore and POEM had similarly good internal consistency (Cronbach's alpha = 0·84, 0·82 and 0·86); the PO-SCORAD subjective subscore was less internally consistent (alpha = 0·57). All scores showed potentially poor cross-cultural validity as demonstrated by uniform and nonuniform differential item functioning by age, sex and/or race/ethnicity for multiple items. There were floor effects for POEM, but not for the other assessments.

CONCLUSIONS

PO-SCORAD, PO-SCORAD objective and subjective subscores, NRS-itch and POEM appear to be valid for assessing AD severity in clinical practice. What's already known about this topic? Few studies have demonstrated the validity of the atopic dermatitis severity assessments Patient-Oriented Scoring Atopic Dermatitis (PO-SCORAD), PO-SCORAD subscores, numerical rating scale (NRS)-itch and Patient-Oriented Eczema Measure (POEM). What does this study add? This study demonstrates that PO-SCORAD, PO-SCORAD subscores, NRS-itch and POEM all had good construct validity in the assessment of atopic dermatitis severity in adults. Only POEM demonstrated floor effects. What are the clinical implications of this work? PO-SCORAD, PO-SCORAD subscores, NRS-itch and POEM all appear to have sufficient validity to be used as assessments of atopic dermatitis severity in clinical practice.

Symptoms and diagnosis of anxiety and depression in atopic dermatitis in U.S. adults

Background

The relationship between atopic dermatitis (AD), anxiety and depression in the U.S. adult population is not well established.

Objectives

To determine the relationship of AD and its severity with symptoms and diagnosis of anxiety and depression in U.S. adults.

Methods

A cross‐sectional, population‐based study of 2893 adults was performed. AD was determined using modified U.K. Diagnostic Criteria.

Results

Adults with AD vs. those without AD had higher mean Hospital Anxiety and Depression Scale anxiety (HADS‐A) (7·7 vs. 5·6) and depression (HADS‐D) (6·0 vs. 4·3) scores and higher prevalences of abnormal (≥ 11) HADS‐A (28·6% vs. 15·5%) and HADS‐D (13·5% vs. 9·0%) scores. In multivariable linear and logistic regression models controlling for sociodemographics, AD was associated with significantly higher mean HADS‐A and HADS‐D scores (7·7 and 6·0) and higher odds of abnormal HADS‐A [odds ratio (OR) 2·19, 95% confidence interval (CI) 1·65–2·91] and HADS‐D scores (OR 1·50, 95% CI 1·04–2·17) (P ≤ 0·03 for all). Mean and abnormal HADS‐A and HADS‐D scores were increased in moderate and severe/very severe self‐reported global AD severity, Patient‐Oriented Eczema Measure (POEM), Patient‐Oriented Scoring AD (PO‐SCORAD), PO‐SCORAD itch and sleep (P < 0·0001 for all). All respondents with severe PO‐SCORAD, POEM and PO‐SCORAD itch had borderline or abnormal HADS‐A and HADS‐D scores. Adults with AD vs. those without AD had higher prevalence of self‐reported healthcare‐diagnosed anxiety or depression in the past year (40·0% vs. 17·5%). Many adults with AD who had borderline and/or abnormal HADS‐A or HADS‐D scores reported no diagnosis of anxiety or depression.

Conclusions

AD is associated with significantly increased anxiety and depression, which may go undiagnosed.

What's already known about this topic?

Previous studies found higher rates of anxiety and depression in clinical cohorts of patients with atopic dermatitis.

What does this study add?

This study found dramatically higher rates of anxiety and depression among adults with atopic dermatitis in the U.S. population, which was primarily driven by atopic dermatitis severity.

Anxiety and depression often go undiagnosed in adults with atopic dermatitis.

Linked Comment: https://doi.org/10.1111/bjd.18252.

https://doi.org/10.1111/bjd.18278 available online

https://www.bjdonline.com/article/Chronic-urticaria-and-osteoporosis-a-longitudinal-community-based-cohort-study-of-11944-patients/

Atopic dermatitis yardstick: Practical recommendations for an evolving therapeutic landscape

The implementation of treatment guidelines for atopic dermatitis is challenging, in part because of different guidance documents being used by different groups of specialists and in part because the language of guidelines often reflects the evidence base rather than the practical "how to." The Atopic Dermatitis Yardstick is part of a series developed in response to the need to proactively address the loss of disease control for atopic illnesses at all levels of severity. It presents a comprehensive update on how to conduct a sustained step-up in therapy for the patient with inadequately controlled or poorly controlled atopic dermatitis. Patient profiles, based on current guidelines and the authors' combined clinical experience, provide a practical and clinically meaningful guide to aid physicians in helping their patients achieve the goal of clear to almost clear. The intent is not to replace guidelines but to complement their recommendations incorporating the latest research and therapies.

Antibiotic choice and methicillin-resistant Staphylococcus aureus rate in children hospitalized for atopic dermatitis

BACKGROUND

Systemic antibiotics are commonly used in hospitalized patients with severe atopic dermatitis (AD) exacerbation. However, the antibiotic prescribing patterns are unclear.

OBJECTIVE

To compare the prescribing patterns of antibiotics for children who were hospitalized for AD exacerbation and infectious complications.

METHODS

Electronic medical records were reviewed for patients younger than 18 years who were hospitalized for AD exacerbation or infectious complications based on International Classification of Diseases, Ninth Revision, Clinical Modification and International Classification of Diseases, Tenth Revision, Clinical Modification codes from 2003 to 2018. The following information was obtained: history, physical examination findings, physician discharge summary, antibiotic treatments, serum tests, and wound cultures. The t test was used to compare clinical and laboratory features.

RESULTS

A total of 174 patients with AD were included. Seventy patients had AD exacerbation and 104 had infectious complications, including cellulitis, abscesses, invasive infections, and eczema herpeticum. The differences between these 2 groups of patients were further verified by length of stay, serum total IgE level, and inflammatory markers (C-reactive protein and erythrocyte sedimentation rate). A total of 56 of 70 patients (80%) with AD exacerbation were treated with a systemic antibiotic. Clindamycin and vancomycin together accounted for 88% of antibiotics on admission for both groups, whereas clindamycin and sulfamethoxazole-trimethoprim were prescribed at similar rates for both groups at discharge. Wound culture results showed that the methicillin-resistant Staphylococcus aureus (MRSA) rate was significantly lower in children with AD exacerbation (22%) vs infectious complications (39%).

CONCLUSION

Children were treated with a high frequency of anti-MRSA antibiotics for inpatient AD exacerbation and infectious complications. However, the rate of MRSA was significantly lower in children with AD exacerbation. Thus, empiric antibiotic choice for infectious complications may not be appropriate for AD exacerbation.

Content and construct validity, predictors, and distribution of self-reported atopic dermatitis severity in US adults

BACKGROUND

Atopic dermatitis (AD) is associated with skin lesions, multiple symptoms, and effect of quality of life, all of which factor into disease severity. Self-reported global AD severity may be a valid severity assessment for epidemiologic research.

OBJECTIVE

To validate self-reported global AD severity in a representative cohort of adults with AD.

METHODS

Preliminary probing-cognitive interviews were performed (n = 8). Next, a cross-sectional US population-based survey study of adults with AD was performed. AD was diagnosed using an adap/tation of the UK Working Party criteria (n = 602). AD severity was assessed using self-reported global AD severity (mild, moderate, severe), Patient-Oriented Scoring AD (PO-SCORAD), Patient-Oriented Eczema Measure (POEM), Numeric Rating Scale (NRS)-itch, NRS-sleep, NRS-pain, and Hospital Anxiety and Depression Scale (HADS).

RESULTS

Self-reported global AD severity had good content validity. Self-reported global AD severity had strong correlations with PO-SCORAD (Spearman correlation ρ = 0.61) and objective PO-SCORAD (ρ = 0.61); moderate correlations with POEM (ρ = 0.54), NRS-itch (ρ = 0.44), NRS-pain (ρ = 0.46), and HADS (ρ = 0.41); and weak correlation with NRS-sleep (ρ = .32) (P < .001 for all). Consistent and significant correlations were observed in stratified analyses by age, sex, race/ethnicity, and level of education. There were stepwise increases of PO-SCORAD, NRS-itch, NRS-sleep, NRS-pain, POEM, and HADS with increasing self-reported global AD severity (Kruskal-Wallis test, P < .01). There was weak-moderate concordance between self-reported AD severity and established severity strata for PO-SCORAD (ρ = 0.44), NRS-itch (ρ = 0.30), and POEM (ρ = 0.43). Rather, self-reported global AD severity was best predicted by a combination of PO-SCORAD, POEM, NRS-itch, NRS-pain, and HADS. No differential item reporting was found by age, sex, or race/ethnicity.

CONCLUSION

Self-reported AD severity simultaneously assesses multiple AD constructs and appears to be sufficiently valid for assessing AD severity in clinical and epidemiologic studies.

Association of atopic dermatitis with allergic, autoimmune, and cardiovascular comorbidities in US adults

BACKGROUND

Atopic dermatitis (AD) has been associated with multiple comorbid extracutaneous and systemic disorders. The relation between AD severity and disease comorbidities is complex and not fully understood.

OBJECTIVE

To determine the complex relation between AD severity and comorbidities.

METHODS

A cross-sectional US population-based study of 8,217 adults who were participants in a nationally representative internet health panel was performed using a structured questionnaire. A diagnosis of AD was determined using modified United Kingdom Working Party Criteria for AD (n = 602). AD severity was assessed using Patient-Oriented Scoring AD, Patient-Oriented Eczema Measure, Dermatology Life Quality Index, and self-reported global AD severity. Logistic regression and structural equation models were used to explore associations of AD with self-reported allergic, cardiometabolic, anxiety and depression, and autoimmune disease.

RESULTS

In multivariable regression models controlling for sociodemographics, AD was associated with higher odds of asthma (adjusted odds ratio [OR] 2.09, 95% confidence interval [CI] 1.71-2.55), hay fever (OR 4.31, 95% CI 3.27-5.69), food allergy (OR 2.07, 95% CI 1.54-2.77), anxiety and depression (OR 2.34, 95% CI 1.91-2.87), autoimmune disease (OR 3.05, 95% CI 2.31-4.03), obesity (OR 1.37, 95% CI 1.13-1.67), diabetes (OR 1.52, 95% CI 1.16-1.99), high blood pressure (OR 1.46, 95% CI 1.18-1.80), and heart disease (OR 1.94, 95% CI 1.40-2.70) compared with controls (P < .01 for all). All these associations were significant in mild and/or moderate disease, with even stronger effects in severe AD. Results of structural equation models showed direct effects of moderate to severe AD on food allergy, anxiety and depression, and diabetes, direct and indirect effects on obesity, and indirect effects on high blood pressure and heart disease.

CONCLUSION

There is a strong relation of AD severity to allergic, autoimmune, and cardiovascular comorbidities.

Atopic Dermatitis in America Study: A Cross-Sectional Study Examining the Prevalence and Disease Burden of Atopic Dermatitis in the US Adult Population

Population-based estimates on the prevalence of atopic dermatitis in adults vary widely. The objectives of this study were to determine the prevalence of atopic dermatitis in the population of the United States, the distribution of disease severity, and its impact on health-related quality of life. Among 1,278 participating adults, the prevalence (95% confidence interval) of atopic dermatitis was 7.3% (5.9-8.8). Overall, 60.1% (56.1-64.1) of participants were classified as having mild, 28.9% (25.3-32.7) as having moderate, and 11% as having severe (8.6-13.7) disease. Patients with atopic dermatitis and those with more severe disease had higher scores in the dermatology life quality index (mean [standard deviation] for AD patients = 4.71 [6.44] vs. control individuals = 0.97 [2.12]) (P < 0.001) and the hospital anxiety (mean [standard deviation] for AD patients = 7.03 [4.80] vs. control individuals = 4.73 [4.8]) and depression (mean, [standard deviation] for AD patients = 5.83 [4.54] vs. control individuals = 3.62 [3.61]) scales, indicating a worse impact on quality of life and an increased likelihood of anxiety or depression. Based on our prevalence estimates, 16.5 million adults would have a diagnosis of atopic dermatitis, with 6.6 million meeting criteria for moderate to severe disease. Our study confirms the high prevalence and disease burden of atopic dermatitis in this population.

Severity strata for POEM, PO-SCORAD, and DLQI in US adults with atopic dermatitis

BACKGROUND

Patient-Oriented Eczema Measure (POEM) is the preferred patient-reported outcome (PRO) for assessing symptoms of atopic dermatitis (AD). Dermatology Life Quality Index (DLQI) is commonly used to assess the burden of skin disease. Previous severity strata were developed for POEM and DLQI in clinical cohorts, which may be biased toward more severe disease. Severity strata were not previously examined in population-based cohorts. Patient-Oriented Scoring AD (PO-SCORAD) is another commonly used PRO for assessing AD symptoms; however, severity strata are not established.

OBJECTIVE

We sought to confirm previously developed strata for POEM and DLQI, and to develop strata for the PO-SCORAD in a population-based cohort of adults with AD.

METHODS

A cross-sectional, population-based study of 8,217 adults was performed using a structured questionnaire. A diagnosis of AD was determined using modified UK Diagnostic Criteria for AD (n = 602). AD severity was assessed using self-reported global AD severity (anchoring question), POEM, PO-SCORAD, and DLQI. Strata were selected using an anchoring approach based on patient-reported disease severity.

RESULTS

We confirmed the existing strata for DLQI (mild = 0-5, moderate = 6-10, severe = 11-30) (kappa = 0.446). However, the preferred strata for POEM was mild = 0-7, moderate = 8-19, and severe = 20-28 (kappa = 0.409) and PO-SCORAD was mild = 1-27, moderate = 28-56, severe = 57-104 (kappa = 0.444).

CONCLUSION

Existing strata for DLQI performed well in a population-based cohort of adult AD. The optimal severity strata for the POEM in our AD population varies slightly from those previously published for AD. This may suggest that different strata may be optimal in different study settings and cohorts. Finally, we proposed new strata for PO-SCORAD in adult AD.