Associations between onychomycosis and COVID-19 clinical outcomes: a retrospective cohort study from a US metropolitan center

Little is known about the relationship of COVID-19 outcomes with onychomycosis. We investigated the relationship of onychomycosis with COVID-19 outcomes. A retrospective cohort study was performed on SARS-CoV-2 positive adult outpatients or inpatients who had onychomycosis and other skin diseases. Overall, 430 adults were identified with SARS-CoV-2 and a skin disease, including 98 with diagnosed onychomycosis. In bivariable logistic regression models, onychomycosis was associated with increased hospitalization {odds ratio(OR) [95% confidence interval (CI)]: 3.56 [2.18-5.80]}, initial inpatient vs. outpatient visits (OR [95% CI]: 2.24 [1.35-3.74]), use of oxygen therapy (OR [95% CI]: 2.77 [1.60-4.79]), severe-critical vs. asymptomatic-mild severity (OR [95% CI]: 2.28 [1.32-3.94]), and death (OR [95% CI]: 7.48 [1.83-30.47]) from COVID-19, but not prolonged hospitalization (OR [95% CI]: 1.03 [0.47-2.25]). In multivariable models adjusting for socio-demographics, comorbidities, and immunosuppressant medication use, the associations with onychomycosis remained significant for hospitalization, inpatient visits, oxygen therapy, severe-critical COVID-19. Onychomycosis was a significant independent risk factor for COVID-19 severity, hospitalization, and receiving supplemental oxygen therapy.

Clinical Efficacy of a Digital Intervention for Patients with Atopic Dermatitis: a Prospective Single-Center Study

Introduction

Improving disease awareness and treatment adherence is key for the long-term management of atopic dermatitis (AD). Digital interventions can support patients in disease self-management and adopting a healthier lifestyle through behavioral modifications. We aimed to test the clinical efficacy of a digital program in patients with AD.

Methods

Adults with mild-to-severe AD were recruited for a 6-week feasibility study. The intervention was delivered through a mobile app and consisted of symptom and trigger education, treatment reminders, lifestyle coaching, and healthy lifestyle support. Here we report the secondary outcomes of intervention efficacy on clinical symptoms, as assessed by Scoring Atopic Dermatitis (SCORAD) and Patient-Oriented Eczema Measure (POEM), on health-related quality of life (HR QoL) as assessed by Dermatology Life Quality Index (DLQI), and changes in behaviors related to disease management as assessed by a six-item questionnaire.

Results

Twenty of 21 patients (95.2%) completed the program (81% female, mean age 31.4 years, mean time from diagnosis 26.8 years). Clinical symptoms and patient-reported global severity improved by 44% and 46%, respectively, while HR QoL improved by 41% (p < 0.001 for all measures). Adherence to treatments and preventive measures improved from pre- to post-intervention, including skincare, avoidance of triggers, and disease-related knowledge. A significant interaction was observed between increased treatment adherence and clinical improvement, such that larger clinical improvements were observed in patients with higher treatment adherence.

Conclusion

Patients with AD are open to and can benefit from a digitally delivered targeted intervention, as demonstrated by significant improvements in treatment adherence and related clinical outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-022-00821-y.

Phenotypic differences of atopic dermatitis stratified by age

Background

Atopic dermatitis (AD) is common across all ages. Understanding heterogeneous age-related phenotypes may improve AD management.

Objective

To determine age-related clinical phenotypes of AD.

Methods

A prospective, dermatology practice-based study was performed (n = 380). AD severity was evaluated using questionnaires and full-body examination. Phenotypes were determined using latent class analysis.

Results

There were 23 (6.1%) pediatric patients (<18 years), 176 (46.3%) young adults (18-39 years), and 181 (47.6%) older adults (≥ 40 years). Both young and older adults experienced less AD on ankles (adjusted odds ratio [95% confidence interval]: 0.41 [0.19-0.90], 0.43 [0.20-0.94]), moderate-severe AD on flexures (0.47 [0.26-0.87], 0.30 [0.16-0.56]), pityriasis alba (0.24 [0.11-0.52], 0.07 [0.03-0.18]), oozing lesions (0.44 [0.25-0.79], 0.35 [0.20-0.63]), moderate-severe excoriations (0.49 [0.28-0.85], 0.44 [0.26-0.76]), and severe itch (adjusted β [95% confidence interval], -1.46 [-2.63 to -0.29]; -1.79 [-2.94 to -0.65]) compared with pediatric patients. Young adults experienced more AD around the eyes (2.92 [1.21-7.02]). Older adults experienced more AD on elbows (0.34 [0.19-0.64]), nipples (0.40 [0.16-0.99]), knees (0.27 [0.14-0.53]), keratosis pilaris (0.38 [0.15-0.98]), and lichenification (0.47 [0.22-0.98]). Four classes were identified for distribution of AD and associated signs.

Conclusion

Distinct phenotypes exist by age with younger patients experiencing more AD signs and symptoms. Clinicians should consider them when managing AD.

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.

The Validated Investigator Global Assessment for Atopic Dermatitis (vIGA-AD™): a clinical outcome measure for the severity of atopic dermatitis

BACKGROUND

The validated Investigator Global Assessment for Atopic Dermatitis (vIGA-AD™) is a standardized severity assessment for use in clinical trials and registries for atopic dermatitis (AD).

OBJECTIVES

To investigate the reliability, validity, responsiveness and within-patient meaningful change of the vIGA-AD.

METHODS

Data were analysed from adult patients with moderate-to-severe AD in the BREEZE-AD1 (N = 624 patients; NCT03334396), BREEZE-AD2 (N = 615; NCT03334422) and BREEZE-AD5 (N = 440; NCT03435081) phase III baricitinib clinical studies.

RESULTS

Across studies, test-retest reliability for stable patients showed moderate-to-good agreement [range of Kappa values for Patient Global Impression of Severity-Atopic Dermatitis (PGI-S-AD), 0·516-0·639; for Eczema Area and Severity Index (EASI), 0·658-0·778]. Moderate-to-large correlations between vIGA-AD and EASI or body surface area (range at baseline, 0·497-0·736; Week 16, 0·716-0·893) supported convergent validity. Known-groups validity was demonstrated vs. EASI and PGI-S-AD (vIGA-AD for severe vs. moderate EASI categories at baseline, P < 0·001). Responsiveness was demonstrated vs. EASI (P < 0·001 for much improved vs. improved and improved vs. stable). Anchor- and distribution-based methods supported a vIGA-AD change of -1·0 as clinically meaningful. These findings are limited to populations defined by the studies' inclusion and exclusion criteria.

CONCLUSIONS

The vIGA-AD demonstrated sufficient reliability, validity, responsiveness and interpretation standards for use in clinical trials. What is already known about this topic? A description of the development of the validated Investigator Global Assessment for Atopic Dermatitis (vIGA-AD™) has been published previously. What does this study add? The current study validates the vIGA-AD by demonstrating appropriate test-retest reliability, convergent validity, known-groups validity and responsiveness across three baricitinib clinical studies. In addition, a 1-point change was identified as a clinically meaningful patient-perceived change minimal clinically important difference in the vIGA-AD. What are the clinical implications of the work? The vIGA-AD is a measure for investigator assessment of atopic dermatitis suitable for use in clinical research.

Tralokinumab Efficacy and Safety, with or without Topical Corticosteroids, in North American Adults with Moderate-to-Severe Atopic Dermatitis: A Subanalysis of Phase 3 Trials ECZTRA 1, 2, and 3

Introduction

In pivotal phase 3 tralokinumab monotherapy (ECZTRA 1/2) and topical corticosteroid (TCS) combination (ECZTRA 3) trials in adults with moderate-to-severe atopic dermatitis (AD), tralokinumab significantly improved signs and symptoms of AD. Geographic region may impact treatment response due to potential differences in race and ethnicity, and based on findings in other therapy areas. Here, we evaluated the efficacy and safety of tralokinumab in the ECZTRA 1/2/3 North American population at week 16, as well as maintenance of responses over time, and compared these data side-by-side with those of the ECZTRA 1/2/3 non-North American population.

Methods

Primary endpoints were Investigator’s Global Assessment score of 0 or 1 (IGA 0/1; clear or almost clear) or at least 75% improvement in Eczema Area and Severity Index (EASI-75) at week 16. At week 16, tralokinumab-treated IGA 0/1 or EASI-75 responders were re-randomized 2:2:1 to tralokinumab 300 mg q2w, or q4w, or placebo (ECZTRA 1/2) and 1:1 to tralokinumab 300 mg q2w or q4w (ECZTRA 3).

Results

Overall, 559/1596 (35%) and 160/380 (42.1%) patients randomized in ECZTRA 1/2 and ECZTRA 3 were from North America, respectively. At week 16, IGA 0/1 and EASI-75 response rates were greater with tralokinumab versus placebo in ECZTRA 1/2 (IGA 0/1: 25.3% vs 15.1%; 95% confidence interval [CI] 3.0, 17.3; p = 0.012; EASI-75, 40.1% vs 19.4%; 95% CI 12.6, 28.7; p < 0.001) and ECZTRA 3 (IGA 0/1, 40.0% vs 25.9%; 95% CI − 0.5, 28.3; p = 0.074; EASI-75: 58.1% vs 37.0%; 95% CI 4.9, 37.0; p = 0.012) and tralokinumab was well tolerated in the North American population. Patients with IGA 0/1 or EASI-75 response at week 16 demonstrated sustained responses at week 52 and week 32 in ECZTRA 1/2 and ECZTRA 3, respectively. Similar findings were observed in the non-North American trial populations.

Conclusions

Tralokinumab, with or without TCS, displayed similar efficacy and safety in patients with moderate-to-severe AD across the North American population, and was comparable to the non-North American population.

Clinical Trial Registration

NCT03131648 (registered 27-Apr-2017); NCT03160885 (registered 19-May-2017); NCT03363854 (registered 6-Dec-2017).

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-022-00805-y.

Durability of Response to Abrocitinib in Patients with Moderate-to-Severe Atopic Dermatitis After Treatment Discontinuation in a Phase 2b Trial

Introduction

Multiple clinical trials showed that 12 weeks of abrocitinib monotherapy was safe and effective for the treatment of moderate-to-severe atopic dermatitis (AD). The reversibility of pharmacologic activity after abrocitinib discontinuation was not described.

Methods

This post hoc analysis used data from a phase 2b study to evaluate maintenance of disease control during a 4-week drug-free follow-up period in patients with moderate-to-severe AD treated with once-daily abrocitinib (200 mg/100 mg) or placebo for 12 weeks. Proportions of patients who achieved and maintained 50% or 75% improvement in Eczema Area and Severity Index (EASI-50/EASI-75), an Investigator’s Global Assessment (IGA) score of 0/1, or at least a 4-point improvement in the pruritus numeric rating scale (pruritus NRS4) were determined. Biomarkers of Janus kinase inhibition and AD disease were measured in blood samples.

Results

Among week 12 responders to abrocitinib 200 mg, 77.4%, 42.3%, 21.1%, and 42.9% maintained their EASI-50, EASI-75, IGA, and pruritus NRS4 response at week 16; corresponding proportions of week 12 responders maintaining response to abrocitinib 100 mg were 51.9%, 35.0%, 33.3%, and 43.5%, respectively. Four weeks after abrocitinib discontinuation, all AD biomarkers reverted toward baseline levels, with high-sensitivity C-reactive protein and eosinophil percentage demonstrating the most complete recovery in patients treated with abrocitinib versus placebo.

Conclusion

Abrocitinib discontinuation resulted in rapid reversal of disease control consistent with reversal of suppression of pharmacodynamic and AD-specific biomarkers during the drug-free follow-up period. Maintenance of response was inversely related to the threshold of improvement. Patients with moderate-to-severe AD using continuous abrocitinib therapy would likely have the best long-term outcomes.

Trial Registration

ClinicalTrials.gov identifier NCT02780167.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-022-00764-4.

Predictors of chronic COVID-19 symptoms in a community-based cohort of adults

Background

COVID-19 can cause some individuals to experience chronic symptoms. Rates and predictors of chronic COVID-19 symptoms are not fully elucidated.

Objective

To examine occurrence and patterns of post-acute sequelae of SARS-CoV2 infection (PASC) symptomatology and their relationship with demographics, acute COVID-19 symptoms and anti-SARS-CoV-2 IgG antibody responses.

Methods

A multi-stage observational study was performed of adults (≥18 years) from 5 US states. Participants completed two rounds of electronic surveys (May-July 2020; April-May 2021) and underwent testing to anti-SARS-CoV-2 nucleocapsid protein IgG antibody testing. Latent Class Analysis was used to identify clusters of chronic COVID-19 symptoms.

Results

Overall, 390 adults (median [25%ile, 75%ile] age: 42 [31, 54] years) with positive SARS-CoV-2 antibodies completed the follow-up survey; 92 (24.7%) had ≥1 chronic COVID-19 symptom, with 11-month median duration of persistent symptoms (range: 1–12 months). The most common chronic COVID-19 symptoms were fatigue (11.3%), change in smell (9.5%) or taste (5.6%), muscle or joint aches (5.4%) and weakness (4.6%). There were significantly higher proportions of ≥1 persistent COVID-19 symptom (31.5% vs. 18.6%; Chi-square, P = 0.004), and particularly fatigue (15.8% vs. 7.3%, P = 0.008) and headaches (5.4% vs. 1.0%, P = 0.011) in females compared to males. Chronic COVID-19 symptoms were also increased in individuals with ≥6 acute COVID-19 symptoms, Latent class analysis revealed 4 classes of symptoms. Latent class-1 (change of smell and taste) was associated with lower anti-SARS-CoV-2 antibody levels; class-2 and 3 (multiple chronic symptoms) were associated with higher anti-SARS-CoV-2 antibody levels and more severe acute COVID-19 infection.

Limitations

Ambulatory cohort with less severe acute disease.

Conclusion

Individuals with SARS-CoV-2 infection commonly experience chronic symptoms, most commonly fatigue, changes in smell or taste and muscle/joint aches. Female sex, severity of acute COVID-19 infection, and higher anti-SARS-CoV-2 IgG levels were associated with the highest risk of having chronic COVID-19 symptoms.

Unbiased discovery of autoantibodies associated with severe COVID-19 via genome-scale self-assembled DNA-barcoded protein libraries

Pathogenic autoreactive antibodies that may be associated with life-threatening coronavirus disease 2019 (COVID-19) remain to be identified. Here, we show that self-assembled genome-scale libraries of full-length proteins covalently coupled to unique DNA barcodes for analysis by sequencing can be used for the unbiased identification of autoreactive antibodies in plasma samples. By screening 11,076 DNA-barcoded proteins expressed from a sequence-verified human ORFeome library, the method, which we named MIPSA (for Molecular Indexing of Proteins by Self-Assembly), allowed us to detect circulating neutralizing type-I and type-III interferon (IFN) autoantibodies in five plasma samples from 55 patients with life-threatening COVID-19. In addition to identifying neutralizing type-I IFN-α and IFN-ω autoantibodies and other previously known autoreactive antibodies in patient plasma, MIPSA enabled the detection of as yet unidentified neutralizing type-III anti-IFN-λ3 autoantibodies that were not seen in healthy plasma samples or in convalescent plasma from ten non-hospitalized individuals with COVID-19. The low cost and simple workflow of MIPSA will facilitate unbiased high-throughput analyses of protein-antibody, protein-protein and protein-small-molecule interactions.

Tralokinumab Plus Topical Corticosteroids as Needed Provides Progressive and Sustained Efficacy in Adults with Moderate-to-Severe Atopic Dermatitis Over a 32-Week Period: An ECZTRA 3 Post Hoc Analysis

Background

The efficacy and safety of tralokinumab, a fully human monoclonal antibody that specifically neutralizes interleukin-13, plus topical corticosteroids (TCS) as needed were evaluated over 32 weeks in the phase III ECZTRA 3 trial. Significantly more tralokinumab- versus placebo-treated patients achieved the primary endpoints of Investigator’s Global Assessment (IGA) score of 0/1 and 75% improvement in Eczema Area and Severity Index (EASI-75) and all confirmatory endpoints at Week 16.

Objective

This post hoc analysis investigated the impact of tralokinumab plus TCS on atopic dermatitis (AD) severity, symptoms, and health-related quality of life (QoL) over the entire 32-week treatment period of ECZTRA 3, including all patients initiated on tralokinumab irrespective of the response achieved at Week 16.

Methods

Patients were randomized 2:1 to receive subcutaneous tralokinumab 300 mg or placebo every 2 weeks (q2w) with TCS as needed for an initial 16 weeks. At Week 16, patients who achieved the clinical response criteria (IGA 0/1 and/or EASI-75) with tralokinumab were re-randomized 1:1 to tralokinumab q2w or every 4 weeks (q4w), with TCS as needed, for another 16 weeks. Patients not achieving the clinical response criteria with tralokinumab received tralokinumab q2w plus TCS from Week 16. All patients randomized to tralokinumab in the initial treatment period were pooled for this analysis, irrespective of response at Week 16 or dosing regimen beyond Week 16.

Results

Continued tralokinumab (q2w, N = 164; q4w, N = 69) plus TCS treatment provided progressive improvements from Week 16 onwards in AD signs, with 70.2% (177/252) of patients achieving EASI-75 and 50.4% (127/252) achieving EASI-90 at Week 32. Improvements in patient-reported outcomes were observed within the first few weeks of tralokinumab q2w plus TCS treatment and were sustained throughout the 32-week period. At Week 32, patients initiated on tralokinumab q2w plus TCS achieved a relative improvement versus baseline of 70.8% (standard error (SE), 2.4) in eczema-related sleep interference numeric rating scale (NRS) and 66.8% (SE, 3.1) in Dermatology Life Quality Index (DLQI). Mean TCS use during Weeks 16–32 ranged from 9.2 to 13.6 g (SE, 1.2–2.0) q2w. Most patients (89.9% (222/247)) initiated on tralokinumab q2w plus TCS achieved a meaningful improvement in at least one of the three disease domains, including AD signs (EASI-50), symptoms (pruritus NRS improvement ≥ 3), and QoL (DLQI improvement ≥ 4) at Week 16. Of patients initiated on tralokinumab q2w plus TCS, 53.4% (132/247) achieved a clinically meaningful improvement in all three domains at Week 16 (vs. placebo, 28.5% (35/123); p < 0.001).

Conclusions

Continued tralokinumab treatment plus TCS as needed provides progressive and sustained improvements in AD signs, symptoms, and health-related QoL over 32 weeks.

Clinical trial registration

NCT03363854; study start date: 22 February 2018; primary completion date: 8 March 2019; study completion date: 26 September 2019.

Infographic

Patient-oriented measures for phase 3 studies of tralokinumab for treatment of atopic dermatitis (ECZTRA 1, 2 and 3)

BACKGROUND

Tralokinumab, as monotherapy or in combination with topical corticosteroids (TCS), has demonstrated significant efficacy through 52 weeks in phase 3 trials of adults with moderate-to-severe atopic dermatitis (AD) and additional efficacy in a long-term extension trial. Early changes in patient-reported symptoms have not been communicated.

OBJECTIVE

To examine early changes in patient-reported outcomes (PROs) across the ECZTRA 1, 2, and 3 tralokinumab trials.

METHODS

Monotherapy data (ECZTRA 1+2) was pooled; ECZTRA 3 examined tralokinumab + optional TCS. PROs were assessed through the trials.

RESULTS

1596 and 380 patients were randomized in ECZTRA 1+2 and ECZTRA 3, respectively. Baseline demographics and clinical characteristics were similar between groups. Early separation from placebo was observed in percentage improvement in worst average daily pruritus numerical rating score (NRS) [week 1, ECZTRA 1+2; week 2, ECZTRA 3] and from day 2 in ECZTRA 1+2 daily data. More tralokinumab-treated patients achieved clinically meaningful improvements (≥4 points) in NRS by week 2 (ECZTRA 1+2) or week 3 (ECZTRA 3) versus placebo. Improvements in eczema-related sleep NRS were seen within 2 weeks (week 1, ECZTRA 1+2; week 2, ECZTRA 3), supported by similar improvements in other sleep measures. Meaningful changes in Dermatology Life Quality Index were observed from week 2 (ECZTRA 1+2). Results were supported by numerical differences from placebo in Patient-Orientated Eczema Measure total score (week 2, both datasets).

CONCLUSION

Tralokinumab +/- TCS demonstrated early and clinically meaningful improvements versus placebo in several PROs, which may be beneficial to patients because AD symptom relief is a key treatment concern for patients.

Patch testing with Cobalt in Children and Adolescents: North American Contact Dermatitis Group experience, 2001 to 2018

BACKGROUND

Allergic contact dermatitis (ACD) to cobalt is more common in children and adolescents than adults. However, detailed information on sites and sources of cobalt ACD are limited.

OBJECTIVES

To assess trends in positive and clinically relevant patch test reactions to cobalt in children and associated patient characteristics, common sources, and body sites affected.

METHODS

A retrospective analysis of children (<18 years) patch tested to cobalt by the North American Contact Dermatitis Group between 2001-2018.

RESULTS

Of 1,919 children patch tested, 228 (11.9%) and 127 (6.6%) had a positive/allergic or currently relevant patch test reaction to cobalt, respectively. The most common primary body sites affected were scattered generalized (30.0%), face, not otherwise specified (NOS, 10.6%), and trunk (10.1%). Patients with allergic and currently relevant allergic patch test reactions were more likely to have a primary site of trunk (P=.0160 and P=.0008) ears (P=.0005 and P<.0001). Affected body site(s) varied by cobalt source among patients with currently relevant reactions, especially for less common sources. The most commonly identified sources of cobalt included jewelry, belts, and clothing.

CONCLUSIONS

Positive patch test reactions to cobalt were common in children. Most common body site was scattered generalized and the sources of cobalt varied by body site. This article is protected by copyright. All rights reserved.

Occurrence of inflammatory bowel disease in patients with chronic inflammatory skin diseases: a cohort study

BACKGROUND

Several studies linked various chronic inflammatory skin diseases (CISDs) with inflammatory bowel disease (IBD) in a range of data sources with mixed conclusions.

OBJECTIVE

We compared the incidence of IBD-ulcerative colitis (UC) and Crohn's disease (CD)- in patients with a CISD versus similar persons without a CISD.

METHODS

In this cohort study using nationwide, longitudinal, commercial insurance claims data from the US, we identified adults and children who were seen by a dermatologist between 2004-2020, and diagnosed with either psoriasis, atopic dermatitis, alopecia areata, vitiligo, or hidradenitis suppurativa. Comparator patients were identified through risk-set sampling; they were eligible if they were seen by a dermatologist at least twice and not diagnosed with a CISD. Patient follow-up lasted until either IBD diagnosis, death, disenrollment, or end of data stream, whichever came first. IBD events, ulcerative colitis (UC) or Crohn's (CD), were identified via validated algorithms-hospitalization or diagnosis with endoscopic confirmation. Incidence rates were computed before and after adjustment via propensity-score (PS) decile stratification to account for IBD risk factors. Hazard ratios (HR) and 95% confidence intervals were estimated to compare the incidence of IBD in CISD versus non-CISD.

RESULTS

We identified patients with atopic dermatitis (n=123,614), psoriasis (n=83,049), alopecia areata (n=18,135), vitiligo (n=9,003) or hidradenitis suppurativa (n=6,806), and comparator patients without a CISD (n=2,376,120). During a median follow-up time of 718 days, and after applying PS adjustment for IBD risk factors, we observed increased risk of both UC (HR_UC =2.30; 1.61-3.28) and CD (HR_CD =2.70; 1.69-4.32) in patients with hidradenitis suppurativa, an increased risk of CD (HR_CD =1.23; 1.03-1.46) but not UC (HR_UC =1.01; 0.89-1.14) in psoriasis, and no increased risk of IBD in atopic dermatitis (HR_UC =1.02; 0.92-1.12, HR_CD =1.08; 0.94-1.23), alopecia areata (HR_UC =1.18; 0.89-1.56, HR_CD =1.26; 0.86-1.86) or vitiligo (HR_UC =1.14; 0.77-1.68, HR_CD =1.45; 0.87-2.41).

CONCLUSIONS

IBD was increased in patients with hidradenitis suppurativa. Crohn's disease alone was increased in patients with psoriasis. Neither ulcerative colitis nor Crohn's disease was increased in patients with atopic dermatitis, alopecia areata or vitiligo.

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.

Dupilumab Provides Rapid and Sustained Improvement in SCORing Atopic Dermatitis Outcomes in Paediatric Patients with Atopic Dermatitis

This post hoc analysis examined SCORing Atopic Dermatitis (SCORAD) outcomes in 471 paediatric patients (children age 6–<12 years, n = 304; adolescents age 12–<18 years, n = 167) with atopic dermatitis treated with dupilumab, ± topical corticosteroids, in two 16-week phase 3 randomized controlled trials and a 1-year interim data cut of a subsequent open-label extension study. Paediatric patients treated with dupilumab (± topical corticosteroids) had significantly lower SCORAD, objective SCORAD (o-SCORAD), and individual SCORAD components from week 3 to 16 compared with placebo (± topical corticosteroids) in the randomized controlled trials. The results were sustained or continuously improved over 1 year of open-label treatment with dupilumab ± topical corticosteroids. SCORAD-50 was achieved in almost all patients (91.3–91.8%) by week 52 with continued dupilumab treatment across age groups. Almost all (> 86%) patients achieved mild or absent pruritus and sleep loss at week 52. In conclusion, dupilumab ± topical corticosteroids resulted in rapid and significant improvements in all aspects of SCORAD analysed, and the results were sustained over 1 year.

Evaluating the Longitudinal Course of Atopic Dermatitis: Implications for Clinical Practice

Atopic dermatitis (AD) is characterized by a heterogenous longitudinal course with varying severity, flares, and persistence. However, AD course is not routinely assessed in clinical practice or controlled trials. Our objective was to review the longitudinal course of AD in children and adults and discuss implications for routine practice and clinical trials. We conducted a focused review of the published literature, including retrospective, prospective, and interventional studies, clinical trials, and consensus guidelines. Estimates of AD persistence varied widely across studies but suggested that AD can indeed persist through childhood and into adulthood. Predictors of persistence are broad and include both disease-intrinsic and disease-extrinsic (i.e., environmental) factors. In real-world practice, most individuals with AD experience fluctuations in the signs and symptoms over time and do not experience persistent clearance of skin lesions. Clinical trials use mainly static measurements that do not take into account fluctuations in course, which may confound treatment effects. The heterogenous temporal pattern of AD can be incorporated into routine practice to better set expectations and offer a realistic prognosis. AD course should be routinely incorporated into clinical decision making. Future studies are needed to develop a standardized approach to AD assessment and treatment that includes longitudinal course.

Patch testing with glucosides: The North American Contact Dermatitis Group experience, 2009-2018

BACKGROUND

Alkyl glucosides are nonionic surfactants that are increasingly used in personal care products.

OBJECTIVE

To characterize positive patch test reactions to decyl glucoside (5% petrolatum, tested 2009-2018) and lauryl glucoside (3% petrolatum, tested 2017-2018).

METHODS

Retrospective analysis of patients tested by the North American Contact Dermatitis Group.

RESULTS

Of 24,097 patients patch tested to decyl and/or lauryl glucoside, 470 (2.0%) had positive reactions. Compared with glucoside-negative patients, glucoside-positive patients had higher odds of occupational skin disease (13.4% vs 10.1%; P = .0207), history of hay fever (38.5% vs 31.6%; P = .0014), atopic dermatitis (39.0% vs 28.6%; P < .0001), and/or asthma (21.8% vs 16.5%; P = .0023). Most glucoside reactions (83.9%) were currently relevant. The most common source was personal care products (63.0%), especially hair products (16.5%) and skin cleansers (15.2%). Of 4933 patients tested to decyl and lauryl glucoside, 134 (2.7%) were positive to 1 or both; 43.4% (43 of 99) of decyl-positive patients were also positive to lauryl glucoside and 55.1% (43/78) of lauryl glucoside patients were also positive to decyl glucoside.

LIMITATIONS

The cohort predominantly reflects a referral population, and follow-up after testing was not captured.

CONCLUSION

Glucoside positivity occurred in 2.0% of the tested patients. Reactions were often clinically relevant and linked to personal care products. Cross-reactivity was >40%.

Longitudinal course and predictors of depressive symptoms in atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is associated with eczematous lesions, pruritus, pain, and sleep disturbance, which may negatively impact mental health over time.

OBJECTIVE

Determine the predictors and longitudinal course of depressive symptoms in adults with AD.

METHODS

A prospective, dermatology practice-based study was performed (n=695). AD signs, symptoms and severity and Patient Health Questionnaire (PHQ)-9 were assessed.

RESULTS

At baseline, 454 (65.32%) had minimal, 139 (20.00%) mild, 57 (8.20%) moderate, 27 (3.88%) moderately severe, and 8 (2.59%) had severe depression. Most had fluctuating levels of depressive symptoms. Feeling bad, thoughts of self-harm, difficulty concentrating, and slow movement were most persistent. Predictors of persistent depression included older age, non-white race, male sex, public or no insurance, more severe itch, skin pain, facial erythema, nipple eczema, sleep disturbance, and presence of pityriasis alba.

LIMITATIONS

Single center study.

CONCLUSION

Depressive symptoms are closely related to and fluctuate with AD severity over time. Improved control of AD signs and symptoms, particularly itch, may secondarily improve mental health.

Differences between pediatric and adult atopic dermatitis

Atopic dermatitis (AD) is a common disease with a broad spectrum of clinical manifestations. AD can manifest differently in adults than children. Core AD features are similar between children and adults overall, including lesions affecting flexural areas, presence of atopy, and xerosis. Adults have more signs of chronic disease, higher prevalence and different patterns of hand eczema, and a stronger relationship of disease activity with emotional factors, whereas children with AD have more exudative lesions, perifollicular accentuation, pityriasis alba, Dennie-Morgan folds, and seborrheic dermatitis-like presentation. These differences may be due in part to pathophysiologic differences in AD in children compared with adults. Atopic diseases commonly co-occur with AD, although most do not temporally have the "atopic march." Further research is warranted to better understand the differential roles of immune dysregulation, epidermal-barrier disruption, and dysbiosis between children and adults and determine whether such differences translate into differences in therapeutic efficacy.

Lanolin Allergic Reactions: North American Contact Dermatitis Group Experience, 2001 to 2018

BACKGROUND

Lanolin is an important cause of allergic contact dermatitis.

OBJECTIVES

The aims of this study were to describe the epidemiology of lanolin allergy and to assess trends in patch test reactions to lanolin over time.

METHODS

This study used a retrospective analysis of patients patch tested with lanolin alcohol 30% or Amerchol L-101 50% in petrolatum by the North American Contact Dermatitis Group between 2001 and 2018 (n = 43,691).

RESULTS

Overall, 1431 (3.3%) had a positive reaction, and 1238 (2.8%) were currently relevant. Prevalence of lanolin allergy was 4.63% between 2011 and 2018 (P < 0.0001). Most lanolin-allergic patients had + (52%) reactions; 18%, and 6% had ++ and +++ reactions, respectively. Common primary anatomic sites of dermatitis were the hands (20.7%), scattered/generalized distribution (19.6%), and face (17.0%). Allergic reactions to lanolin were more common in children (4.5%) than in adults (3.2%, P = 0.0018). Compared with nonallergic patients, lanolin-allergic patients were more likely to have history of eczema or hay fever, male sex, older than 40 years, or Black race (P < 0.05). Common lanolin sources were personal care products and drugs/medications. Only 2.24% of the positive reactions were linked to occupation.

CONCLUSIONS

Lanolin sensitivity was common. Reactions were often clinically relevant and linked to personal care products and medications.