Atopic Eczema in Adulthood and Risk of Depression and Anxiety: A Population-Based Cohort Study

Biomarkers associated with the development of comorbidities in patients with atopic dermatitis: A systematic review

Biomarkers associated with the development of comorbidities in atopic dermatitis (AD) patients have been reported, but have not yet been systematically reviewed. Seven electronic databases were searched, from database inception to September 2021. English language randomized controlled trials, prospective and retrospective cohort, and case-control studies that investigated the association between a biomarker and the development of comorbidities in AD patients were included. Two authors independently screened the records for eligibility, one extracted all data, and critically appraised the quality of studies and risk of bias. Fifty six articles met the inclusion criteria, evaluating 146 candidate biomarkers. The most frequently reported biomarkers were filaggrin mutations and allergen specific-IgE. Promising biomarkers include specific-IgE and/or skin prick tests predicting the development of asthma, and genetic polymorphisms predicting the occurrence of eczema herpeticum. The identified studies and biomarkers were highly heterogeneous, and associated with predominately moderate-to-high risk of bias across multiple domains. Overall, findings were inconsistent. High-quality studies assessing biomarkers associated with the development of comorbidities in people with AD are lacking. Harmonized datasets and independent validation studies are urgently needed.

Factors associated with depression, anxiety and severe mental illness among adults with atopic eczema or psoriasis: a systematic review and meta-analysis

BACKGROUND

Evidence suggests an association between atopic eczema (AE) or psoriasis and mental illness; however, the factors associated with mental illness are unclear.

OBJECTIVES

To synthesize and evaluate all available evidence on factors associated with depression, anxiety and severe mental illness (SMI) among adults with AE or psoriasis.

METHODS

We searched electronic databases, grey literature databases and clinical trial registries from inception to February 2022 for studies of adults with AE or psoriasis. Eligible studies included randomized controlled trials (RCTs), cohort, cross-sectional or case-control studies where effect estimates of factors associated with depression, anxiety or SMI were reported. We did not apply language or geographical restrictions. We assessed risk of bias using the Quality in Prognosis Studies tool. We synthesized results narratively, and if at least two studies were sufficiently homogeneous, we pooled effect estimates in a random effects meta-analysis.

RESULTS

We included 21 studies (11 observational, 10 RCTs). No observational studies in AE fulfilled our eligibility criteria. Observational studies in people with psoriasis mostly investigated factors associated with depression or anxiety - one cross-sectional study investigated factors associated with schizophrenia. Pooled effect estimates suggest that female sex and psoriatic arthritis were associated with depression [female sex: odds ratio (OR) 1.62, 95% confidence interval (CI) 1.09-2.40, 95% prediction intervals (PIs) 0.62-4.23, I2 = 24.90%, τ2 = 0.05; psoriatic arthritis: OR 2.26, 95% CI 1.56-3.25, 95% PI 0.21-24.23, I2 = 0.00%, τ2 = 0.00] and anxiety (female sex: OR 2.59, 95% CI 1.32-5.07, 95% PI 0.00-3956.27, I2 = 61.90%, τ2 = 0.22; psoriatic arthritis: OR 1.98, 95% CI 1.33-2.94, I2 = 0.00%, τ2 = 0.00). Moderate/severe psoriasis was associated with anxiety (OR 1.14, 95% CI 1.05-1.25, I2 0.00%, τ2 = 0.00), but not depression. Evidence from RCTs suggested that adults with AE or psoriasis given placebo had higher depression and anxiety scores compared with comparators given targeted treatment (e.g. biologic agents).

CONCLUSIONS

Our review highlights limited existing research on factors associated with depression, anxiety and SMI in adults with AE or psoriasis. Observational evidence on factors associated with depression or anxiety in people with psoriasis was conflicting or from single studies, but some identified factors were consistent with those in the general population. Evidence on factors associated with SMIs in people with AE or psoriasis was particularly limited. Evidence from RCTs suggested that AE and psoriasis treated with placebo was associated with higher depression and anxiety scores compared with skin disease treated with targeted therapy; however, follow-up was limited. Therefore, long-term effects on mental health are unclear.

Novel multimorbidity clusters in people with eczema and asthma: a population-based cluster analysis

Eczema and asthma are allergic diseases and two of the commonest chronic conditions in high-income countries. Their co-existence with other allergic conditions is common, but little research exists on wider multimorbidity with these conditions. We set out to identify and compare clusters of multimorbidity in people with eczema or asthma and people without. Using routinely-collected primary care data from the U.K. Clinical Research Practice Datalink GOLD, we identified adults ever having eczema (or asthma), and comparison groups never having eczema (or asthma). We derived clusters of multimorbidity from hierarchical cluster analysis of Jaccard distances between pairs of diagnostic categories estimated from mixed-effects logistic regressions. We analysed 434,422 individuals with eczema (58% female, median age 47 years) and 1,333,281 individuals without (55% female, 47 years), and 517,712 individuals with asthma (53% female, 44 years) and 1,601,210 individuals without (53% female, 45 years). Age at first morbidity, sex and having eczema/asthma affected the scope of multimorbidity, with women, older age and eczema/asthma being associated with larger morbidity clusters. Injuries, digestive, nervous system and mental health disorders were more commonly seen in eczema and asthma than control clusters. People with eczema and asthma of all ages and both sexes may experience greater multimorbidity than people without eczema and asthma, including conditions not previously recognised as contributing to their disease burden. This work highlights areas where there is a critical need for research addressing the burden and drivers of multimorbidity in order to inform strategies to reduce poor health outcomes.

A Molecular Basis Approach of Eczema and Its Link to Depression and Related Neuropsychiatric Outcomes: A Review

"What about my eczema do I love the most? The hurt? A scratch? The humiliation of the public? Oh, there are so many options available!" Studies have shown an association between atopic eczema (AE), a common inflammatory skin condition, and an increased risk of mental health problems. Despite this, experts are still examining the causes of the links between common mental diseases (such as depression and anxiety) and skin conditions. We collected studies that were published in the past 10 years. We searched the following databases: PubMed, PubMed Central, Science Direct, and Google Scholar. Further relevant research was assessed by examining the bibliographies of eligible studies and related ones. Two reviewers looked at the titles and abstracts of the studies to see if they were eligible, and then they read the full texts. We went through eczema and depression relationships, their etiopathogenesis, molecular basis, immune response, the role of genetic factors, and possible interactions between neurons and the immune system. Another possible contributing factor could be a change in cutaneous microbiota in eczema patients. Part of the initial connection could be explained by psychological stress, which further leads to depression in eczema patients. Healthcare professionals treating eczema patients must be aware of the comorbidity of mental problems and the potential that people with poor mental health may need social or emotional support. Patients with eczema, especially youngsters, can benefit from routine health checks since they can help identify neuropsychiatric issues like depression early and lessen the burden of both physical sickness and poor mental health. Given that AE is a condition that appears to be related to depression and anxiety, more research with larger samples is needed to determine a potential role for targeted mental health screening in people with AE, as well as the possibility of mental health modification through improved AE control (e.g., using new biologic agents).

Involvement of Atopic Dermatitis in the Development of Systemic Inflammatory Diseases

The skin is recognized as a peripheral lymphoid organ that plays an essential defensive action against external environmental stimuli. However, continuous stimulation of these factors causes chronic inflammation at the local site and occasionally causes tissue damage. Chronic inflammation is recognized as a trigger for systemic organ inflammation. Atopic dermatitis (AD) is a chronic inflammatory skin disease that is influenced by various external environmental factors, such as dry conditions, chemical exposure, and microorganisms. The pathogenesis of AD involves various Th2 and proinflammatory cytokines. Recently updated studies have shown that atopic skin-derived cytokines influence systemic organ function and oncogenesis. In this review, we focus on AD’s influence on the development of systemic inflammatory diseases and malignancies.

Increased Knowledge-based Care is Indicated for Patients with Atopic Dermatitis

Abstract is not missing (Guest Editorial)

NLRP3 neuroinflammatory factors may be involved in atopic dermatitis mental disorders: an animal study

Background: Numerous clinical studies have shown that atopic dermatitis (AD) is often associated with mental disorders. This could contribute to the overall burden of atopic dermatitis. However, the underlying mechanism of mental health symptoms in AD has not been fully elucidated. Methods: An AD mouse was induced by 2,4-dinitrofluorobenzene (DNFB), which was repeatedly applied to the back skin of the BALB/C mice to establish an atopic dermatitis mental disorder model. The role of neuroinflammation in the pathogenesis of atopic dermatitis mental disorders was then explored. Results: After the stimulation of DNFB for 35 days, the skin lesions, the HE staining of skin lesions, and the behavioral experiments (including elevated plus maze assay and tail suspension test) suggested that the AD mental disorder mouse model was successfully replicated. The expression of neuroinflammatory factors in the hippocampus was then investigated through Western blotting. The results showed a significant increase in the protein expression of NLRP3, caspase-1, and IL-1β. Conclusion: Mental disorders in AD might be related to the neuroinflammatory response in the hippocampus. An alternative yet essential approach to promoting AD recovery could be through reducing neuroinflammation and improving mental disorders.

The link between cutaneous inflammation and cognitive impairment

Cognitive impairment is a symptom of neurological disorders, including dementia and Alzheimer's disease; and mild cognitive impairment can be a precursor of both disorders. Aged humans and animal models with other systemic disorders, such as cardiovascular diseases and diabetes, display a higher incidence of cognitive decline. Epidemiological studies have shown that the incidence of cognitive impairment also is higher in subjects with certain inflammatory skin disorders, including psoriasis and chronic eczematous dermatitis. Chronologically aged individuals exhibit increased cutaneous inflammation and elevated circulating cytokine levels, linked to alterations in epidermal function, which itself can induce cutaneous inflammation. Conversely, strategies that improve epidermal function can lower cytokine levels in both the skin and circulation. Thus, it seems likely that epidermal dysfunction could contribute, at least in part, to the development of chronic low-grade inflammation, also termed 'inflammaging', in the elderly. The evidence of cognitive impairment in patients with inflammatory dermatoses suggests a link between cutaneous inflammation and cognitive impairment. Because of the pathogenic role of epidermal dysfunction in ageing-associated cutaneous inflammation, improvements in epidermal function could be an alternative approach for mitigation of the ageing-associated decline in cognitive function.

Identification of Effective Diagnostic Biomarkers and Immune Cell Infiltration in Atopic Dermatitis by Comprehensive Bioinformatics Analysis

Background: Atopic dermatitis (AD) is a dermatological disorder characterized by symptoms such as chronically inflamed skin and frequently intolerable itching. The mechanism underlying AD development is still unclear. Our study aims to identify the diagnostic and therapeutic biomarkers for AD and provide insight into immune mechanisms at the molecular level through bioinformatics analysis.

Methods: The GSE6012, GSE32924, and GSE36842 gene expression profiles were obtained for analysis from the Gene Expression Omnibus database. Differentially expressed genes (DEGs) were segregated using the “Batch correction” and “RobustRankAggreg” methods. Weighted gene co-expression network analysis (WGCNA) was performed to screen for module genes with AD traits. Then, common DEGs (co-DEGs) were screened out via combined differential expression analysis and WGCNA. Functional enrichment analysis was performed for these co-DEGs using Gene Ontology (GO) and the Kyoto Encyclopedia of Genes and Genomes (KEGG), followed by protein-protein interaction network analysis. Candidate hub genes were identified using the “cytoHubba” plugin in Cytoscape, and their value for AD diagnosis was validated using receiver operating characteristic curve analysis in the external database GSE120721. Immunohistochemical staining was performed for further validation. The CIBERSORT algorithm was used to evaluate skin samples obtained from healthy controls (HCs) and lesions of AD patients, to determine the extent of immune cell infiltration. The association between the identified hub genes and significant differential immune cells was analyzed using Pearson correlation analysis.

Results: A total of 259 DEGs were acquired from the intersection of DEGs obtained by the two independent procedures, and 331 AD-trait module genes were separated out from the blue module via WGCNA analysis. Then, 169 co-DEGs arising from the intersection of the 259 DEGs and the 331 AD-trait module genes were obtained. We found that co-DEGs were significantly enhanced in the type I interferon and IL-17 signal transduction pathways. Thirteen potential hub genes were identified using Cytoscape. Five hub genes (CCR7, CXCL10, IRF7, MMP1, and RRM2) were identified after screening via external dataset validation and immunohistochemical analysis. We also identified four significant differential immune cells, i.e., activated dendritic cells, plasma cells, resting mast cells, and CD4+ naïve T cells, between AD patients and HCs. Moreover, the relationship between the identified hub genes and significant differential immune cells was analyzed. The results showed that the CCR7 expression level was positively correlated with the number of CD4+ naïve T cells (R = 0.42, p = 0.011).

Conclusion: CCR7, CXCL10, IRF7, MMP1, and RRM2 could be potential diagnostic and therapeutic biomarkers for AD. CCR7 expression level was positively correlated with the number of CD4+ naïve T cells in AD. These findings need to be corroborated in future studies.

Unveiling the true costs and societal impacts of moderate-to-severe atopic dermatitis in Europe

Atopic dermatitis (AD) is a chronic, auto-immune condition that imposes a high burden on individuals, society, and the healthcare system. Approximately 4.4% of adults and up to 18.6% of children/adolescents have AD in Europe, with 20% of all cases accounting for moderate-to-severe forms. This form of the condition in adults results in annual societal costs across Europe of an estimated €30 billion; €15.2 billion related to missed workdays or reduced work productivity, €10.1 billion related to direct medical costs and €4.7 billion related to personal expenditure of patients/families. AD can also substantially impact physical, emotional, and social quality-of-life. Several studies have shown the debilitating itch-scratch cycle is the main cause of the multifaceted burden, as it causes substantial sleep deprivation and stigmatisation due to the physical appearance of the skin, and confidence issues. These factors lead to psychosocial issues and can cumulate over time and prohibit patients reaching their 'full life potential'. Despite this, many patients with the condition are undertreated, resulting in uncontrolled symptoms and a further strain placed on patients, society, and the economy. The authors of this White Paper comprise the European Atopic Dermatitis Working Group, which is a network of international specialists with expertise in dermatology and healthcare policy decisions. Their programme of action is focused on harnessing their expertise to build consensus, advance research, share knowledge, and ultimately seek to improve AD care outcomes through achieving long-term symptom control. This White Paper presents a systematic evaluation of the overall financial and humanistic burden of moderate-to-severe AD and the current challenges that exist with AD care. It introduces recommendations for how, collaboratively, key stakeholders and policy makers can support improvements in AD management to achieve better disease control, thus reducing the costs and associated burden placed on individuals, society, and the economy.

Atopic dermatitis: pathomechanisms and lessons learned from novel systemic therapeutic options

Atopic dermatitis (AD) is a chronic, heterogenous, inflammatory skin disorder associated with a high skin-related health burden, typically starting in childhood and often persisting into adulthood. AD is characterized by a wide range of clinical phenotypes, reflecting multiple underlying pathophysiological mechanisms and interactions between genetics, immune system dysregulation, and environmental factors. In this review, we describe the diverse cellular and molecular mechanisms involved in AD, including the critical role of T cell-driven inflammation, primarily via T helper (Th) 2- and Th17-derived cytokines, many of which are mediated by the Janus kinase (JAK) signaling pathway. These local inflammatory processes interact with sensory neuronal pathways, contributing to the clinical manifestations of AD, including itch, pain, and sleep disturbance. The recent elucidation of the molecular pathways involved in AD has allowed treatment strategies to evolve from broad-acting systemic immunosuppressive therapies to more targeted agents, including JAK inhibitors and cytokine-specific biologic agents. Evidence from the clinical development of these targeted therapies has reinforced and expanded our understanding of the pathophysiological mechanisms underlying AD and holds promise for individualized treatment strategies tailored to specific AD subtypes.

Living with Atopic Dermatitis as a Young Adult in Relation to Health-related Quality of Life and Healthcare Contacts: A Population-based Study

Most studies of health-related quality of life (HRQoL) and atopic dermatitis are based on data from dermatology clinics. The aim of this study was to determine whether atopic dermatitis affects HRQoL in adolescence and young adulthood, based on data from the population-based cohort BAMSE (Children, Allergy, Environmental, Stockholm, Epidemiology). A further aim was to determine if the use of topical corticosteroids and healthcare contacts affect HRQoL. Participants with data from birth to young adulthood (n=3,064) were included. Two generic instruments were used to measure HRQoL:General Health at age 12, 16 and 24 years and EQ-5D-3L, including EQ-visual analogue scale (EQ-VAS) at age 24 years. In addition, the disease-specific Dermatology Quality Life Index (DLQI) was used at 24 years. Healthcare consultations for atopic dermatitis were obtained from Stockholm Regional Healthcare Data Warehouse (n = 1,944). Participants with atopic dermatitis had an increased odds ratio (OR) of not feeling completely healthy (adjusted OR 1.50; 95% confidence interval (95% CI): 1.30–1.73). Participants with persistent atopic dermatitis, fulfilling atopic dermatitis criteria in the 12- and/or 16- and 24-year follow-ups reported worse EQ-VAS value 70.0 (95% CI 67.3–72.7) in the 25^th percentile, than peers without atopic dermatitis. Over an 8-year period, contact with healthcare was limited (mean number 0.96). In conclusion, atopic dermatitis had a negative impact on HRQoL in young adults from adolescence to adulthood and healthcare consultations were few.

Eczema is a shared risk factor for anxiety and depression: A meta-analysis and systematic review

Globally, anxiety and depression are the most common psychiatric disorders that add large burdens to individuals and society; however, the mechanisms underlying these disorders are unclear. Several studies have found that eczema is a shared risk factor for both these conditions. We identified and evaluated eligible observational studies from EMBASE and PubMed. In total, 20 relevant cohort and case-control studies comprising 141,910 patients with eczema and 4,736,222 control participants fulfilled our established criteria. Information extracted included study design, location, sample size, sex distribution of cases and controls or reference cohorts, measurements of outcomes, odds ratio (OR) with 95% confidence interval (CI), and adjusted factors for exposure associated with outcome risk. The meta-analysis was performed by calculating the pooled OR with 95% CI, and heterogeneity was assessed using Cochrane Q and I2 statistics. The pooled effect showed a positive association (n = 4,896,099, OR = 1.63, 95% CI [1.42-1.88], p<0.001) between eczema and depression or anxiety, with positive associations also observed in the depression (n = 4,878,746, OR = 1.64, 95% CI [1.39-1.94], p<0.001) and anxiety (n = 4,607,597, OR = 1.68, 95% CI [1.27-2.21], p<0.001) groups. Subgroup and sensitivity analyses confirmed that these findings were stable and reliable. This study suggests that eczema is associated with an increased risk of developing depression and anxiety, which may assist clinicians in the prevention or treatment of these disorders.

Asthma and early smoking associated with high risk of panic disorder in adolescents and young adults

PURPOSE

Studies have reported a strong link between asthma and panic disorder. We conducted a 17-year community-based large cohort study to examine the relationship between asthma, early smoking initiation, and panic disorder during adolescence and early adulthood.

METHODS

A total of 162,766 participants aged 11-16 years were categorized into asthma and nonasthma groups at baseline and compared within the observation period. Covariates during late childhood or adolescence included parental education, cigarette smoking by family members of participants, and participant's gender, age, alcohol consumption, smoking, and exercise habits. Data for urbanicity, prednisone use, allergic comorbidity, and Charlson comorbidity index were acquired from the National Health Insurance Research Database. The Cox proportional-hazards model was used to evaluate the association between asthma and panic disorder.

RESULTS

Our findings revealed that asthma increased the risk of panic disorder after adjustment for key confounders in the Cox proportional hazard regression model (adjusted HR: 1.70, 95% CI 1.28-2.26). Hospitalizations or visits to the emergency department for asthma exhibited a dose-response effect on the panic disorder (adjusted HR: 2.07, 95% CI 1.30-3.29). Patients with asthma with onset before 20 years of age who smoked during late childhood or adolescence had the greatest risk for panic disorder (adjusted HR: 4.95, 95% CI 1.23-19.90).

CONCLUSIONS

Patients newly diagnosed with asthma had a 1.7-times higher risk of developing panic disorder. Smoking during late childhood or adolescence increased the risk for developing the panic disorder in patients with asthma.

Classifying atopic dermatitis: a systematic review of phenotypes and associated characteristics

Atopic dermatitis is a heterogeneous disease, accompanied by a wide variation in disease presentation and the potential to identify many phenotypes that may be relevant for prognosis and treatment. We aimed to systematically review previously reported phenotypes of atopic dermatitis and any characteristics associated with them. Ovid EMBASE, Ovid MEDLINE and Web of Science were searched from inception till the 12th of February 2021 for studies attempting to classify atopic dermatitis. Primary outcomes are atopic dermatitis phenotypes and characteristics associated with them in subsequent analyses. A secondary outcome is the methodological approach used to derive them. In total, 8,511 records were found. By focusing only on certain clinical phenotypes, 186 studies were eligible for inclusion. The majority of studies were hospital-based (59%, 109/186) and cross-sectional (76%, 141/186). The number of included patients ranged from seven to 526,808. Data-driven approaches to identify phenotypes were only used in a minority of studies (7%, 13/186). Ninety-one studies (49%) investigated a phenotype based on disease severity. A phenotype based on disease trajectory, morphology and eczema herpeticum was investigated in 56 (30%), 22 (12%) and 11 (6%) studies, respectively. Thirty-six studies (19%) investigated morphological characteristics in other phenotypes. Investigated associated characteristics differed between studies. In conclusion, we present an overview of phenotype definitions used in literature for severity, trajectory, morphology and eczema herpeticum, including associated characteristics. There is a lack of uniform and consistent use of atopic dermatitis phenotypes across studies.

Association of Atopic Dermatitis with Depression and Suicide: A Two-Sample Mendelian Randomization Study

Background

Atopic dermatitis (AD) has long been hypothesized to be associated with risk of depression and suicide, but the causal relationship between them is still unclear.

Objective

To evaluate the causality between AD, depression, and suicide using a Mendelian randomization (MR) approach.

Method

We extracted summary-level data for AD, major depression, and suicidal ideation or attempt from published, nonoverlapping genome-wide association studies (GWAS). Inverse variance-weighted (IVW) analysis was used as the primary analysis. Alternate methods, including weighted median, MR Egger, MR pleiotropy residual sum and outlier, weighted mode, and leave-out analysis, were performed to assess pleiotropy.

Results

13 SNPs (13,287 cases and 41,345 controls) were selected as instrumental variables (IVs). The IVW analysis indicated a statistically significant but small causal effect of AD on major depression (OR = 1.027, 95% CI 1.004-1.050; p = 0.020). No significant evidence was observed for a causal effect of AD on suicide. No significant effect of pleiotropy was found.

Conclusion

AD has a significant but small effect on major depression, but not on suicide.

Salivary Cortisol Values and Personality Features of Atopic Dermatitis Patients: A Prospective Study

BACKGROUND

Atopic dermatitis (AD) patients commonly experience psychological stress and impaired psychosocial functioning.

OBJECTIVE

The aim of this study was to compare patients' salivary cortisol levels with AD severity and other associated stress-related psychological measures/parameters.

METHODS

This prospective study analyzed salivary cortisol levels (enzyme-linked immunosorbent assay) in 84 AD patients (42 symptomatic patients and 42 asymptomatic patients). Each subject filled out the Perceived Stress Scale (PSS), Brief Illness Perception Questionnaire, and the Crown-Crisp Experiential Index, which concerns personality features.

RESULTS

Increased cortisol values were found in both groups and were not dependent on disease severity (Scoring Atopic Dermatitis [SCORAD]) and PSS. Patients with severe AD had significantly lower cortisol levels than those with moderate and mild AD (P = 0.042). The PSS levels were not dependent on SCORAD but correlated with the perceived effect of AD on emotional states (Illness Perception Questionnaire 8), personality traits, anxiety, and depression (P < 0.001).

CONCLUSIONS

The severity of perceived stress in AD patients is not adequately measured by salivary cortisol levels nor SCORAD; it does, however, correlate with the impact of AD on patients' emotional states and personality features (anxiety, depression). All AD patients, regardless of disease severity, should be assessed for impacts of stress, and a multidisciplinary approach should address mental wellness.

Atopic Eczema-Associated Fracture Risk and Oral Corticosteroids: A Population-Based Cohort Study

BACKGROUND

Evidence suggests adults with atopic eczema have increased fracture risk. However, it is unclear whether oral corticosteroids explain the association.

OBJECTIVE

To assess to what extent oral corticosteroids mediate the relationship between atopic eczema and fractures.

METHODS

We conducted a cohort study using English primary care (Clinical Practice Research Datalink) and hospital admissions (Hospital Episode Statistics) records (1998-2016) including adults (18 years old and older) with atopic eczema matched (age, sex, and general practice) with up to 5 adults without atopic eczema. We used Cox regression to estimate hazard ratios (HRs) for specific major osteoporotic fractures (hip, spine, pelvis, or wrist) and for any-site fracture comparing individuals with atopic eczema with those without, adjusting for 6 different definitions of time-updated oral corticosteroid use (ever any prescription, ever high-dose, and recent, cumulative, current, or peak dose).

RESULTS

We identified 526,808 individuals with atopic eczema and 2,569,030 without. We saw evidence of an association between atopic eczema and major osteoporotic fractures (eg, spine HR 1.15, 99% CI 1.08-1.22; hip HR 1.11, 99% CI 1.08-1.15) that remained after additionally adjusting for oral corticosteroids (eg, cumulative corticosteroid dose: spine HR 1.09, 99% CI 1.03-1.16; hip HR 1.09, 99% CI 1.06-1.12). Fracture rates were higher in people with severe atopic eczema than in people without even after adjusting for oral corticosteroids (eg, spine HR [99% CI]: confounder-adjusted 2.31 [1.91-2.81]; additionally adjusted for cumulative dose 1.71 [1.40-2.09]).

CONCLUSIONS

Our findings suggest that little of the association between atopic eczema and major osteoporotic fractures is explained by oral corticosteroid use.

Dermatology for the internist: optimal diagnosis and management of atopic dermatitis

Internists are front-line health care providers that commonly provide the first encounter to patients for dermatological conditions, especially atopic dermatitis (AD). Internists need to be comfortable with managing mild-moderate AD in their practices. Criteria and guidelines established in dermatology literature are available to help the general practitioner diagnose and treat AD. AD is a systemic disease associated with multiple cutaneous and extra-cutaneous comorbidities that warrant screening by internists, especially mental health conditions. Environmental factors may play a role in the development or worsening of AD; however, there is currently no strong evidence to guide specific population- or clinic-based interventions for their avoidance. While food allergies are common in AD patients, the role of food allergens as an exacerbating factor for AD is controversial. Before starting any dietary modifications, careful evaluation should be performed by an allergist. If the patient is not well-controlled despite adequate topical therapies or is experiencing severe/worsening disease, early referral to dermatology is warranted to rule out confounding diagnoses and/or escalation to systemic therapies. Finally, it is important to recognise the racial disparities present in AD and address these when formulating treatment plans.Key messages:Confounding dermatoses, either instead of or in addition to AD, should be considered in treatment-refractory AD, and the appropriate workup may be initiated while awaiting dermatology referral.AD patients have multiple cutaneous and extra-cutaneous comorbidities that warrant screening by internists, especially mental health conditions.

Mediating Effects of Emotional Support Reception and Provision on the Relationship between Group Interaction and Psychological Well-Being: A Study of Young Patients

While it is well-established that mutual aid groups are effective in the psychological rehabilitation of vulnerable individuals, few studies have thoroughly investigated the dynamic mechanism of how psychological well-being improves through mutual aid groups of young patients with chronic health conditions. In connection with several existing theories (i.e., the helper therapy principle, equity theory, the norm of reciprocity, and the concept of communal relationships), this study aims to: (1) evaluate whether emotional support exchanges (i.e., emotional support reception and provision) mediate the relationship between group interaction and psychological well-being; and (2) compare three potential underlying mechanisms—the mediating role of emotional support provision, equitable reciprocity (i.e., a balance of receiving and providing emotional support, where no party over-benefits or under-benefits), and sequential reciprocity (i.e., repaying the helper or a third party in the future after receiving help)—through a path analysis model. A stratified random sampling procedure with chronic health conditions as the stratifying criterion was used to recruit 391 individuals aged 12–45 years from mutual aid groups in Hong Kong, who completed both the baseline and follow-up surveys over a 12-month interval. The results of the path model revealed significant mediating roles of emotional support provision and sequential reciprocity, not equitable reciprocity. The present study offers theoretical and practical implications for promoting the psychological well-being of young patients with chronic health conditions.

Factors Associated with Affective Symptoms and Quality of Life in Patients with Atopic Dermatitis

The aim of this study was to detect demographic and clinical factors associated with affective symptoms and quality of life in patients with severe atopic dermatitis. First, one-way analyses of variance and correlations were performed to compare a large set of qualitative and quantitative clinical variables. Three final multivariable regression models were performed, with depression/anxiety subscales and Dermatology Life Quality Index scores as dependent variables, and the factors that were statistically significant on univariate analyses as independent ones. More severe anxiety symptoms and poorer quality of life (p < 0.01) were significantly associated with more severe depressive symptoms. Female sex and disturbed sleep (p = 0.03) were significantly associated with more severe anxiety. Finally, previous treatment with cyclosporine (p = 0.03) or methotrexate (p = 0.04), more severe depressive symptoms (p < 0.01), itch (p = 0.03), impaired sleep (p < 0.01) and perceived severity of dermatological illness (p < 0.01) were significant predictors of low quality of life. This study shows a complex interplay between the severity of atopic dermatitis, poor quality of life and presence of clinically relevant affective symptoms. These results will help dermatologists to identify patients who need psychiatric consultation within the framework of a multidisciplinary approach.

The epidemiology of atopic dermatitis in older adults: A population-based study in the United Kingdom

Background

Atopic dermatitis is known to be common among children, but there are few studies examining the epidemiology across the life course. In particular, there is a paucity of data on atopic dermatitis among older adults.

Objective

To evaluate participant characteristics, patterns of disease activity and severity, and calendar trends in older adult atopic dermatitis in comparison to other age groups in a large population-based cohort.

Methods

This was a cohort study of 9,154,936 individuals aged 0–99 years registered in The Health Improvement Network, a database comprised of electronic health records from general practices in the United Kingdom between 1994 and 2013. Atopic dermatitis was defined by a previously validated algorithm using a combination of at least one recorded atopic dermatitis diagnostic code in primary care and two atopic dermatitis therapies recorded on separate days. Cross-sectional analyses of disease prevalence were conducted at each age. Logistic mixed effect regression models were used to identify predictors of prevalent disease over time among children (0–17 years), adults (18–74 years), and older adults (75–99 years).

Results

Physician-diagnosed atopic dermatitis was identified in 894,454 individuals with the following proportions in each age group: 18.3% of children, 7.7% of adults, and 11.6% of older adults. Additionally, atopic dermatitis prevalence increased across the 2-decade period (beta from linear regression test for trend in the change in proportion per year = 0.005, p = 0.044). In older adults, atopic dermatitis was 27% less common among females (adjusted OR 0.73, 95% CI 0.70–0.76) and was more likely to be active (59.7%, 95% CI 59.5–59.9%) and of higher severity (mean annual percentage with moderate and severe disease: 31.8% and 3.0%, respectively) than in other age groups.

Conclusion

In a large population-based cohort, the prevalence of physician-diagnosed atopic dermatitis has increased throughout adulthood and was most common among males age 75 years and above. Compared to children ages 0–17 and adults ages 18–74, older adult atopic dermatitis was more active and severe. Because the prevalence of atopic dermatitis among older adults has increased over time, additional characterization of disease triggers and mechanisms and targeted treatment recommendations are needed for this population.

Association of Atopic Dermatitis and Mental Health Outcomes Across Childhood: A Longitudinal Cohort Study

IMPORTANCE

Research has highlighted associations between atopic dermatitis (AD) and mental health conditions in adults. However, literature on the development of mental health comorbidities in children is limited despite the large burden of pediatric AD worldwide.

OBJECTIVE

To examine the association between AD and internalizing behaviors and symptoms of depression at multiple points across childhood and adolescence and to explore potential mediating factors, including asthma/rhinitis, sleep, and inflammation.

DESIGN, SETTING, AND PARTICIPANTS

This longitudinal, population-based birth cohort study included children followed up from birth for a mean (SD) duration of 10.0 (2.9) years from the UK Avon Longitudinal Study of Parents and Children. Data were collected from September 6, 1990, to December 31, 2009. Data were analyzed from August 30, 2019, to July 30, 2020.

EXPOSURES

Annual period prevalence of AD assessed at 11 points from 6 months to 18 years of age, measured by standardized questions about flexural dermatitis.

MAIN OUTCOMES AND MEASURES

Symptoms of depression, measured using child-reported responses to the Short Moods and Feelings Questionnaire at 5 points from 10 to 18 years of age and internalizing behaviors, measured by maternal report of the Emotional Symptoms subscale of the Strength and Difficulties Questionnaire at 7 points from 4 to 16 years of age.

RESULTS

Among the 11 181 children included in the analysis (5721 male [51.2%]), the period prevalence of symptoms of depression ranged from 6.0% to 21.6%; for internalizing behaviors, from 10.4% to 16.0%. Although mild to moderate AD was not associated with symptoms of depression, it was associated with internalizing behaviors as early as 4 years of age (mean increased odds of 29%-84% across childhood in adjusted models). Severe AD was associated with symptoms of depression (adjusted odds ratio, 2.38; 95% CI, 1.21-4.72) and internalizing symptoms (adjusted odds ratio, 1.90; 95% CI, 1.14-3.16). Sleep quality mediated some of this association, but it was not explained by differences in sleep duration, asthma/rhinitis, or levels of inflammatory markers (interleukin 6 and C-reactive protein).

CONCLUSIONS AND RELEVANCE

Within this population-based birth cohort study in the UK, severe AD was associated with symptoms of depression and internalizing behaviors throughout childhood and adolescence. Risk of internalizing symptoms was increased even for children with mild AD beginning early in childhood, highlighting the importance of behavioral and mental health awareness in this population.

Shared Genetic Liability Between Major Depressive Disorder and Atopic Diseases

Objectives

Deciphering the genetic relationships between major depressive disorder (MDD) and atopic diseases (asthma, hay fever, and eczema) may facilitate understanding of their biological mechanisms as well as the development of novel treatment regimens. Here we tested the genetic correlation between MDD and atopic diseases by linkage disequilibrium score regression.

Methods

A polygenic overlap analysis was performed to estimate shared genetic variations between the two diseases. Causal relationships between MDD and atopic diseases were investigated using two-sample bidirectional Mendelian randomization analysis. Genomic loci shared between MDD and atopic diseases were identified using cross-trait meta-analysis. Putative functional genes were evaluated by fine-mapping of transcriptome-wide associations.

Results

The polygenic analysis revealed approximately 15.8 thousand variants causally influencing MDD and 0.9 thousand variants influencing atopic diseases. Among these variants, approximately 0.8 thousand were shared between the two diseases. Mendelian randomization analysis indicates that genetic liability to MDD has a causal effect on atopic diseases (b = 0.22, p = 1.76 × 10^-6), while genetic liability to atopic diseases confers a weak causal effect on MDD (b = 0.05, p = 7.57 × 10^-3). Cross-trait meta-analyses of MDD and atopic diseases identified 18 shared genomic loci. Both fine-mapping of transcriptome-wide associations and analysis of existing literature suggest the estrogen receptor β-encoding gene ESR2 as one of the potential risk factors for both MDD and atopic diseases.

Conclusion

Our findings reveal shared genetic liability and causal links between MDD and atopic diseases, which shed light on the phenotypic relationship between MDD and atopic diseases.

Shared Genetic Liability Between Major Depressive Disorder and Atopic Diseases

OBJECTIVES

Deciphering the genetic relationships between major depressive disorder (MDD) and atopic diseases (asthma, hay fever, and eczema) may facilitate understanding of their biological mechanisms as well as the development of novel treatment regimens. Here we tested the genetic correlation between MDD and atopic diseases by linkage disequilibrium score regression.

METHODS

A polygenic overlap analysis was performed to estimate shared genetic variations between the two diseases. Causal relationships between MDD and atopic diseases were investigated using two-sample bidirectional Mendelian randomization analysis. Genomic loci shared between MDD and atopic diseases were identified using cross-trait meta-analysis. Putative functional genes were evaluated by fine-mapping of transcriptome-wide associations.

RESULTS

The polygenic analysis revealed approximately 15.8 thousand variants causally influencing MDD and 0.9 thousand variants influencing atopic diseases. Among these variants, approximately 0.8 thousand were shared between the two diseases. Mendelian randomization analysis indicates that genetic liability to MDD has a causal effect on atopic diseases (b = 0.22, p = 1.76 × 10^-6), while genetic liability to atopic diseases confers a weak causal effect on MDD (b = 0.05, p = 7.57 × 10^-3). Cross-trait meta-analyses of MDD and atopic diseases identified 18 shared genomic loci. Both fine-mapping of transcriptome-wide associations and analysis of existing literature suggest the estrogen receptor β-encoding gene ESR2 as one of the potential risk factors for both MDD and atopic diseases.

CONCLUSION

Our findings reveal shared genetic liability and causal links between MDD and atopic diseases, which shed light on the phenotypic relationship between MDD and atopic diseases.

Impact of Althaea Officinalis extract in patients with atopic eczema: a double-blind randomized controlled trial

Background

Althaea Officinalis introduced as an emerging anti-inflammatory agent with immunomodulatory effects that may suppress the symptoms of atopic eczema. In this study, we aimed to investigate the impact of liposomal formulation of Althaea Officinalis flower extract compared with steroids for atopic eczema treatment.

Methods

In this randomized, double-blind controlled trial phase II, forty patients with moderate to severe allergic atopic eczema confirmed by skin prick test were enrolled in the study from October 2018 to January 2019. Steroids on the lesions of the left side of the body and topical Althaea Officinalis extract (intervention) or eucerin as a topical placebo on the lesions of the right side of the body were tested. SCORAD (SCORing Atopic Dermatitis) was assessed at the baseline, and two, and four weeks after completing the trial. Data were analyzed by SPSS version 22.

Results

In the active treatment group, after two weeks, the SCORAD was significantly lower in the left side (recovery with steroid treatment) (p < 0.001), and after 4 weeks the SCORAD was lower on both sides, and there were no significant differences between two sides (similarity between Althaea Officinalis and steroid effects). In the control group, the SCORAD score was significantly lower on the left side (steroid) after two and four weeks (p < 0.001). There was no side effect and reaction to drugs.

Conclusions

Considering the potential side effects of steroids, and the similar efficacy of Althaea Officinalis flower extract, using this component may be accompanied by higher benefits in patients with atopic eczema.

Trial registration

IRCT2016102323235N5.

Efficacy and Safety of Janus Kinase Inhibitors for the Treatment of Atopic Dermatitis: A Systematic Review and Meta-Analysis

BACKGROUND

Current therapeutic options for atopic dermatitis (AD) are limited. Janus kinase (JAK) inhibitors may be viable alternatives.

OBJECTIVES

To assess the efficacy and safety of JAK inhibitors for AD treatment.

METHODS

We searched PubMed, Embase, the Cochrane Controlled Register of Trials, Web of Science, Global Resource of Eczema Trials database, and ClinicalTrials.gov from inception to September 1, 2020. Randomized clinical trials (RCTs) comparing JAK inhibitors with placebo/vehicle treatment for AD patients were included. The primary study outcomes included (1) the change (%) from the Eczema Area and Severity Index (EASI) baseline expressed as weighted mean difference (WMD) and 95% confidence interval (95% CI), and (2) the Investigator's Global Assessment (IGA) response and safety outcomes expressed as relative risk (RR) and 95% CI.

RESULTS

We included 14 RCTs published in 13 studies (3,822 patients). Treatment with JAK inhibitors significantly improved IGA response (RR 2.83, 95% CI 2.25-3.56, p < 0.001) and EASI score (WMD -28.82, 95% CI -34.48 to -23.16, p < 0.001). JAK inhibitor treatment achieved the largest improvement in both IGA response (RR 3.59, 95% CI 2.66-4.84, p < 0.001) and EASI score (WMD -42.00, 95% CI -48.64 to -35.36, p < 0.001) by week 4 of treatment. Topical JAK inhibitors were significantly more efficacious than oral inhibitors. Upadacitinib treatment for 4 weeks was most effective in reducing EASI score (WMD -53.92, 95% CI -69.26 to -38.58, p < 0.001), while abrocitinib for 4 weeks led to the most effective IGA response (RR 5.47, 95% CI 2.74-10.93, p < 0.001). There was no difference in the frequency of adverse events (AEs) leading to discontinuation; however, JAK inhibitors use, especially abrocitinib, led to a higher incidence of treatment-emergent AEs (RR 1.25, 95% CI 1.10-1.42, p = 0.001).

CONCLUSION

Our results imply that JAK inhibitors are an effective and safe AD treatment. Nevertheless, further trials with longer duration and head-to-head comparisons of different JAK inhibitors are needed.

Association of atopic dermatitis with an increased risk of systemic lupus erythematosus: A systematic review and meta-analysis

Context:

Previous studies on the association between atopic dermatitis (AD) and systemic lupus erythematosus (SLE) have yielded inconsistent results.

Aims:

To investigate the relationship between atopic dermatitis and systemic lupus erythematosus.

Settings and Design:

Systematic review and meta-analysis.

Materials and Methods:

A systematic review was conducted on EMBASE and MEDLINE databases from inception to March 2020 using a search strategy that consisted of terms related to AD and SLE. Eligible study must be either cohort or case-control study. For cohort studies, they must include patients with AD and comparators without AD, then follow them for incident SLE. For case-control studies, they must include cases with SLE and controls without SLE and examine their prior history of AD.

Statistical Analysis Used:

Meta-analysis of the studies was performed using a random-effect, generic inverse variance method to combine effect estimate and standard error. Funnel plot was used to assess publication bias.

Results:

A total of 21,486 articles were retrieved. After two rounds of review by three investigators, six case-control studies were qualified for the meta-analysis. The case-control study meta-analysis found a significantly increased odds of SLE among patients with AD with the pooled odds ratio of 1.46 (95% CI, 1.05–2.04).

Conclusions:

A significant association between AD and increased odds of SLE was observed by this systematic review and meta-analysis.

Illness perceptions of adults with eczematous skin diseases: a systematic mixed studies review

BACKGROUND

Eczematous skin diseases, e.g., atopic dermatitis or contact dermatitis, are associated with a high disease burden, a significant impact on quality of life and a higher risk for anxiety and depression. Therefore, coping strategies are of interest. In order to understand coping processes, it is necessary to examine the patients' perspectives on their illness. The aim of this systematic mixed studies review is to investigate the illness perceptions of patients with eczematous skin diseases to get a better understanding of their coping processes.

METHODS

We performed a systematic literature search in PubMed, The Cochrane Library, PsycInfo, PSYNDEX, CINAHL, Web of Science, and Scopus until February 20, 2019. Both qualitative and quantitative studies were included in the review. Two independent reviewers conducted data extraction and carried out a narrative synthesis. We assessed study quality with the Mixed Methods Appraisal Tool.

RESULTS

Three qualitative and four quantitative studies were included in the systematic review. We found different methodological approaches for investigating illness perceptions: guided interviews, focus group interviews as well as standardized questionnaires, e.g., the Brief Illness Perception Questionnaire. All studies report suspected causes of the skin disease, such as endogenous and exogenous causes (namely, psychological or occupational factors). We found long timeline beliefs as well as various perceived and experienced social, economic, and psychological consequences. Our analysis reveals complex emotional representations in patients with eczematous skin diseases, in particular impairment of emotional well-being, and feelings of shame or helplessness. Qualitative and quantitative data were predominantly complementary and convergent.

CONCLUSION

Patients with eczematous skin diseases have complex illness representations regarding their disease. These representations interrelate with the coping behavior of patients. Therefore, medical professionals should consider them for counseling and treatment.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2018 CRD42018109217 .

Predictors and age-dependent pattern of psychologic problems in childhood atopic dermatitis

BACKGROUND/OBJECTIVES

Little is known about the predictors and trends of psychological comorbidities in childhood atopic dermatitis (AD), or whether they occur in an age-dependent pattern. We hypothesized racial/ethnic and socioeconomic disparities lead to increased psychological problems among children with AD and psychological comorbidities occur in an age-dependent manner.

METHODS

We analyzed cross-sectional data on 228 898 children aged 2-17 years from the 1997-2018 National Health Interview Survey.

RESULTS

Children with AD had higher proportions of depression/sadness (17.2% vs 12.6%; odds ratio [95% confidence interval]: 1.44 [1.37-1.51]), attention deficit (hyperactivity) disorder (ADD/ADHD) (10.0% vs 7.1%; 1.46 [1.38-1.55]), emotional/behavioral difficulties (29.9% vs 23.5%; 1.77 [1.69-1.84]), feelings of frequent worry (38.8% vs 23.5%; 1.66 [1.58-1.74]), and autism (1.9% vs 0.9%; 2.00 [1.75-2.29]). Among children with AD, psychologic comorbidity was associated with atopic comorbidities and multimorbidity and white race, households with lower income and education, and no insurance coverage. In children with or without AD, the prevalence of autism peaked during pre-adolescence; ADD/ADHD and emotional/behavioral difficulties peaked in adolescence; and depression/sadness and feelings of frequent worry increased steadily throughout childhood without plateau.

CONCLUSION

Atopic dermatitis was associated with multiple psychologic disorders, particularly among those with atopic comorbidities, white race, and low household income. Psychologic comorbidities increased in an age-dependent pattern, though similar to children without AD.

Prevalence of Skin Reactions and Self-Reported Allergies in 5 Countries with Their Social Impact Measured through Quality of Life Impairment

Background: The prevalence of allergies increases worldwide. Allergies may increase the risk of skin reactions. Objective: To evaluate the prevalence of allergies and skin reactions in the adult population, the strength of their relationship, and their impact on the quality of life. Methods: An online survey was conducted in a representative population of 11,067 adults from China, USA, Brazil, Russia, and France. Results: Overall, 35.6% of respondents reported having allergies, they were predominantly fair-skinned women, and younger than responders reporting no allergy. Among patients reporting allergies, 68.6% declared that their allergy makes their skin reacts. A strong association between allergy and major skin reactions was observed, which were associated with skin discomforts such as itching, burning, and pain. Skin discomforts were associated with an increased risk of quality of life alteration. Conclusions: Quantifying the prevalence and the association of allergies with skin reactions and discomfort sensations is critical to evaluating the impact on quality of life. Since skin barrier alteration is hypothesized as a risk factor and a route of sensitization for allergy development, the daily use of topical treatments, such as moisturizers, could help prevent allergic skin reactions, discomfort and impaired quality of life in individuals with an altered skin barrier.

Clinical and Economic Burden of Mild-to-Moderate Atopic Dermatitis in the UK: A Propensity-Score-Matched Case-Control Study

Introduction

The burden of mild-to-moderate atopic dermatitis (AD) in the United Kingdom (UK) is not well understood. Long-lasting AD flares may lead to systemic inflammation resulting in reversible progression from mild to more severe AD. This study aimed to assess the clinical and economic burden of mild-to-moderate AD in the UK.

Methods

AD patients were identified in the Health Improvement Network (THIN) from 2013 to 2017 and propensity score matched to non-AD controls by demographics. Patients were identified based on continuous disease activity using validated algorithms and sufficient patient status to fully validate data integrity for the entire period. Mild-to-moderate AD patients were identified by using treatment as a surrogate. Demographics, clinical characteristics and healthcare resource use (HCRU) were obtained from THIN. Literature reviews were conducted to obtain additional outcomes. A cost-of-illness model was developed to extrapolate the burden in 2017 to the UK population and in subsequent years (2018–2022).

Results

In 2017, the prevalence of mild-to-moderate AD in THIN was 1.28%. These patients reported higher comorbidity rates and significantly higher (p < 0.0001) HCRU, encompassing mean general practitioner visits (5.57 versus 3.59), AD-related prescriptions (5.85 versus 0.68) and total referrals (0.97 versus 0.82) versus matched non-AD controls. The model projected total HCRU and drug excess costs of €462.99M over the 5 years. The excess cost decreased to €417.35M after excluding patients on very potent topical corticosteroids, who most likely had at least moderate disease. The excess costs increased to €1.21B and €7.06B when considering comorbidity burden and productivity losses, respectively.

Conclusion

Mild-to-moderate AD patients had higher comorbidity burden, HCRU and cost compared with matched non-AD controls. Overall, UK country-based economic burden was high given partly the high prevalence of this disease. Moreover, productivity burden and comorbidities had considerable impact on the economic burden, which further suggests the importance of optimal disease management.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-021-00519-7.

Efficacy and Safety of Runzao Zhiyang Capsule as an Add-On Therapy for Chronic Eczema: A Systematic Review and Meta-Analysis

Background

Runzao Zhiyang capsule (RZC), an oral Chinese herbal medicine, has been widely used for chronic eczema in China for many years. This study aims to evaluate the efficacy and safety of RZC as an add-on therapy to conventional treatment for chronic eczema.

Methods

Randomized controlled trials (RCTs) assessing the efficacy and safety of RZC as an add-on therapy for chronic eczema were retrieved from eight literature databases from their inception to 31 August, 2020, including CNKI, WanFang, VIP, Sinomed, PubMed, Cochrane Library, Web of Science, and Embase. The Cochrane risk of bias tool was used to assess the methodological quality of the included studies. The data were analyzed by RevMan5.3 software.

Results

A total of 18 RCTs involving 1896 patients with chronic eczema were included. Compared with no oral treatment, RZC was superior on the total efficacy rate (TER) (RR = 1.45, 95% CI: 1.23 to 1.72, P < 0.0001), Eczema Area and Severity Index (EASI) (MD = -0.73, 95% CI: -0.90 to -0.56, P < 0.00001), and Visual Analogue Scale (VAS) for pruritus (MD = -2.76, 95%CI: -4.53 to -0.99, P=0.002). Similar results were also seen in a randomized, placebo-controlled trial. Compared with the antihistamine (AH) group, TER in the RZC combined with AH group was significantly higher (RR = 1.32, 95% CI: 1.21 to 1.43, P < 0.00001), and the EASI score (MD = -0.29, 95% CI: -0.38 to -0.20, P < 0.001), the VAS score (MD = -0.19, 95% CI: -0.23 to -0.15, P < 0.00001), and the level of serum total IgE (MD = -9.83 ng/ml, 95% CI: -11.66 to -8.00 ng/ml, P < 0.00001) decreased more significantly in the RZC combined with AH group. In terms of safety, mild gastrointestinal diseases occurred more frequently in the RZC group, and no serious adverse effect was reported.

Conclusions

RZC as an add-on therapy to conventional treatment shows good effects on chronic eczema, and there is no severe side effect from short-term use of RZC. However, due to suboptimal quality of the included studies, more large-sample and high-quality RCTs are needed to improve the evidence quality.

Relationship between atopic dermatitis, depression and anxiety: a two-sample Mendelian randomization study

BACKGROUND

Growing evidence suggests that atopic dermatitis (AD) is associated with an increased risk of depressive disorders and anxiety. However, existing studies were observational and may have uncovered correlations but could not easily disentangle noncausal or reverse-causal associations because these associations could be confounded and may not reflect true causal relationships.

OBJECTIVES

To examine, in a two-sample Mendelian randomization study, the potential effect of AD on the risk of depressive disorders and anxiety.

METHODS

Genetic instruments from the largest available genome-wide association study (GWAS) for AD (10 788 cases and 30 047 controls) were used to investigate the relationship to broad depression (170 756 cases and 329 443 controls), major depressive disorder (MDD; 30 603 cases and 143 916 controls) and anxiety (5580 cases and 11 730 controls). A set of complementary approaches were carried out to assess horizontal pleiotropy and related potential caveats occurring in MR studies.

RESULTS

We observed no causal impact of AD on the risk of depressive disorders and anxiety, with close-to-zero effect estimates. The inverse weighted method revealed no associations of AD on broad depression [odds ratio (OR) 1·014; P = 0·431], probable MDD (OR 1·002; P = 0·568), International Classification of Diseases, Ninth/Tenth Revision-based MDD (OR 1·001; P = 0·466) or anxiety (OR 1·097; P = 0·180).

CONCLUSIONS

This MR study does not support a causal effect of AD on depression and anxiety.

The global burden of atopic dermatitis: lessons from the Global Burden of Disease Study 1990-2017

BACKGROUND

The Global Burden of Disease (GBD) Study provides an annually updated resource to study disease-related morbidity and mortality worldwide.

OBJECTIVES

Here we present the burden estimates for atopic dermatitis (AD), including data from inception of the GBD project in 1990 until 2017.

METHODS

Data on the burden of AD were obtained from the GBD Study.

RESULTS

Atopic dermatitis (AD) ranks 15th among all nonfatal diseases and has the highest disease burden among skin diseases as measured by disability-adjusted life-years (DALYs). Overall, the global DALY rate for AD in 1990 was 121 [95% uncertainty interval (UI) 65·4-201] and remained similar in 2017 at 123 (95% UI 66·8-205). The three countries with the highest DALY rates of AD were Sweden (327, 95% UI 178-547), the UK (284, 95% UI 155-478) and Iceland (277, 95% UI 149-465), whereas Uzbekistan (85·1, 95% UI 45·2-144), Armenia (85·1, 95% UI 45·8-143) and Tajikistan (85·1, 95% UI 46·1-143) ranked lowest.

CONCLUSIONS

The global prevalence rate of AD has remained stable from 1990 to 2017. However, the distribution of AD by age groups shows a bimodal curve with the highest peak in early childhood, decreasing in prevalence among young adults, and a second peak in middle-aged and older populations. We also found a moderate positive correlation between a country's gross domestic product and disease burden. GBD data confirm the substantial worldwide burden of AD, which has remained stable since 1990 but shows significant geographical variation. Lifestyle factors, partially linked to affluence, are likely important disease drivers. However, the GBD methodology needs to be developed further to incorporate environmental risk factors, such as ultraviolet exposure, to understand better the geographical and age-related variations in disease burden.

Bone mineral density, osteopenia, osteoporosis, and fracture risk in patients with atopic dermatitis: a systematic review and meta-analysis

BACKGROUND

The relationship between atopic dermatitis (AD) and abnormal bone metabolism remains unclear. We performed a systematic review and meta-analysis to determine whether patients with AD were associated with increased risks of low bone mineral density (BMD), osteopenia, osteoporosis, and related fractures.

METHODS

We searched PubMed, Embase, and the Cochrane Library through December 2019 to identify studies that investigated the association between AD and abnormal bone metabolism (including BMD, osteopenia, osteoporosis, and related fractures). The predefined primary outcome was related fractures; secondary outcomes included osteoporosis, osteopenia, and BMD. We calculated the summary odds ratios (ORs) and 95% confidence intervals (CIs) using a random-effects model.

RESULTS

Ten studies were included in this systematic review. In children and adolescents, four studies investigated the association between AD and BMD; three studies indicated that children and adolescents with AD were associated with an increased risk of low BMD; one study found similar BMD between AD and control groups. In adults, three studies assessed the risk of fracture and were included in the meta-analysis, comprising 562,405 AD patients among 3,171,268 participants. Adults with AD were associated with an increased risk of fracture (OR 1.13; 95% CI, 1.05-1.22; P=0.001). Three studies investigated the association between AD and osteoporosis, which suggested that patients with AD were associated with an increased risk of osteoporosis (OR 1.95; 95% CI, 1.18-3.23; P=0.009). Further, patients with AD were associated with increased risks of osteopenia (OR 1.90; 95% CI, 1.51-2.38; P<0.001) and low BMD at the femur and spine.

CONCLUSIONS

Patients with AD were associated with increased risks of low BMD, osteopenia, osteoporosis, and related fractures. Both clinical studies and basic research are needed to clarify the mechanisms of association between AD and abnormal bone metabolism.

Risk factors for mental illness in adults with atopic eczema or psoriasis: protocol for a systematic review

INTRODUCTION

Evidence indicates that people with the common inflammatory skin diseases atopic eczema or psoriasis are at increased risk of mental illness. However, the reasons for the relationship between skin disease and common mental disorders (ie, depression and anxiety) or severe mental illnesses (ie, schizophrenia, bipolar disorder and other psychoses) are unclear. Therefore, we aim to synthesise the available evidence regarding the risk factors for mental illness in adults with atopic eczema or psoriasis.

METHODS AND ANALYSIS

We will conduct a systematic review of randomised controlled trials, cohort, case-control and cross-sectional studies. We will search the following databases from inception to March 2020: Medline, Embase, Global Health, Scopus, the Cochrane Library, Web of Science, Base, PsycInfo, the Global Resource of Eczema Trials, and the grey literature databases Open Grey, PsycExtra and the New York Academy of Medicine Grey Literature Report. We will also search the bibliographies of eligible studies and relevant systematic reviews to identify additional relevant studies. Citation searching of large summary papers will be used to further identify relevant publications. Two reviewers will initially review study titles and abstracts for eligibility, followed by full text screening. We will extract data using a standardised data extraction form. We will assess the risk of bias of included studies using the Quality in Prognosis Studies tool. We will synthesise data narratively, and if studies are sufficiently homogenous, we will consider a meta-analysis. We will assess the quality of the evidence using the Grading of Recommendations, Assessment, Development and Evaluation framework.

ETHICS AND DISSEMINATION

Ethical approval is not required for a systematic review. Results of the review will be published in a peer-reviewed journal and disseminated through conferences.

PROSPERO REGISTRATION NUMBER

CRD42020163941.

Hidradenitis suppurativa and atopic dermatitis: A 2-way association

BACKGROUND

The coexistence of hidradenitis suppurativa (HS) and atopic dermatitis (AD) had been reported but, to our knowledge, was not investigated in controlled studies.

OBJECTIVE

To evaluate the bidirectional association between HS and AD.

METHODS

A population-based retrospective cohort study was conducted to compare the incidence rate of AD among patients with HS (n = 6779) and age-, sex-, and ethnicity-matched control individuals (n = 33,260). Adjusted hazard ratios (HRs) and adjusted odds ratios were estimated.

RESULTS

The incidence of AD was 2.51 (95% confidence interval [CI], 2.07-3.02) and 1.24 (95% CI, 1.10-1.40) per 1000 person-years among patients with HS and control individuals, respectively. Patients with HS were twice as likely to develop AD as control individuals (HR, 2.06; 95% CI, 1.64-2.58). Furthermore, the prevalence of pre-existing AD was higher in patients with HS than in control individuals (2.5% vs 1.8%, respectively; P < .001). A history of AD was associated with a 40% increase in the odds of HS (odds ratio, 1.41; 95% CI, 1.19-1.67). Relative to patients with isolated HS, those with a dual diagnosis of HS and AD were younger and had a female predominance, lower prevalence of smoking, and lower body mass index.

LIMITATIONS

Retrospective data collection.

CONCLUSIONS

A bidirectional association between HS and AD was observed. Dermatologists should be aware of this association.

Atopic dermatitis and psychosocial comorbidities - What's new?

Atopic dermatitis (AD) is a chronic inflammatory disease. During the last years, researchers have focused on a variety of associated comorbidities, especially psychosocial disease. This article aims at giving an overview over recent data. A systematic literature research was performed in PubMed including data from the time period January 1, 2018 until March 1, 2020. Patients with AD frequently suffer from cocomitant depression, anxiety, and attention deficit hyperactivity disorder. There is less evidence about the relation between AD and schizophrenia, eating disorder, and obsessive compulsive disorder. There is still great need for research in the connection between AD and psychosocial disease, particularly about the pathogenesis and the influence of new therapies.

Atopic dermatitis

Atopic dermatitis is a common inflammatory skin disorder characterised by recurrent eczematous lesions and intense itch. The disorder affects people of all ages and ethnicities, has a substantial psychosocial impact on patients and relatives, and is the leading cause of the global burden from skin disease. Atopic dermatitis is associated with increased risk of multiple comorbidities, including food allergy, asthma, allergic rhinitis, and mental health disorders. The pathophysiology is complex and involves a strong genetic predisposition, epidermal dysfunction, and T-cell driven inflammation. Although type-2 mechanisms are dominant, there is increasing evidence that the disorder involves multiple immune pathways. Currently, there is no cure, but increasing numbers of innovative and targeted therapies hold promise for achieving disease control, including in patients with recalcitrant disease. We summarise and discuss advances in our understanding of the disease and their implications for prevention, management, and future research.

Association of atopic dermatitis with suicide risk among 788,411 adolescents: A Korean cross-sectional study

BACKGROUND

Atopic dermatitis (AD) is known to negatively influence the mental health of patients. However, only a few studies have explored the influencing factors for psychiatric problems among adolescents with AD.

OBJECTIVE

To assess the association of AD and suicidal behaviors among adolescents by analyzing data from the 3rd through the 13th annual Korean Youth Risk Behavior Web-based Surveys (completed from 2007 to 2017).

METHODS

Survey data were obtained from a stratified, multistage, clustered sample. Students self-reported AD if they had received a diagnosis of AD by a physician. Influencing factors for suicidal behaviors were tested by logistic regression models.

RESULTS

A total of 788,411 adolescents completed the survey. The proportion of participants with AD was 22.2%. Those reporting suicide ideation and suicide attempts were 19.0%, and 4.5%, respectively. Compared with adolescents without AD, those with AD were more likely to be female, to skip breakfast less frequently, to exercise less frequently, to drink less alcohol, and to not be current smokers and were statistically significantly more likely to have negative mental health states. In the multivariable model, perceived unhappiness and suicidal ideation were the strongest influencing factors for suicidal ideation (adjusted odds ratio, 4.90; 95% CI, 4.31-5.57) and for suicidal attempts (adjusted odds ratio, 48.01; 95% CI, 42.69-53.09), respectively.

CONCLUSION

Adolescents with AD had a meaningful prevalence of suicidal behaviors. Although further research is needed to clarify this association, adolescents with AD with influencing factors for negative mental health state may need intervention from practitioners who use a multidisciplinary team approach to prevent suicide.