Increasing Comorbidities Suggest that Atopic Dermatitis Is a Systemic Disorder

Comorbidity Patterns in Patients with Atopic Dermatitis Using Network Analysis in the EpiChron Study

Background: Atopic dermatitis (AD) is associated with different comorbidities. Methods: Retrospective, observational study based on clinical information from the individuals of the EpiChron Cohort Study (Aragon, Spain) with a diagnosis of AD between 1 January 2010 and 31 December 2018. We calculated the tetrachoric correlations of each pair of comorbidities to analyze the weight of the association between them. We used a cut-off point for statistical significance of p-value < 0.01. Results: The prevalence of AD in the EpiChron Cohort was 3.83%. The most frequently found comorbidities were respiratory, cardio-metabolic, cardiovascular, and mental health disorders. Comorbidities were combined into 17 disease patterns (15 in men and 11 in women), with some sex and age specificities. An infectious respiratory pattern was the most consistently described pattern across all ages and sexes, followed by a cardiometabolic pattern that appeared in patients over 18 years of age. Conclusions: Our study revealed the presence of different clinically meaningful comorbidity patterns in patients with AD. Our results can help to identify which comorbidities deserve special attention in these types of patients and to better understand the physio-pathological mechanisms underlying the disease associations identified. Further studies are encouraged to validate the results obtained in different clinical settings and populations.

Burden of Atopic Dermatitis in Adults in Greece: Results from a Nationwide Survey

The objective was to describe the AD burden in terms of quality of life (QoL), sleep, social life, work productivity, and resource utilization in Greece and assess the impact of disease severity. A nationwide cross-sectional survey was conducted. The questionnaire consisted of socioeconomic factors, medical history, AD screening, AD severity, QoL, sleep difficulties, social activities, and work productivity questions. AD was defined using the UK Working Party criteria (UKWP cohort) and a patient-reported AD diagnosis from a physician (Expert Diagnosis cohort). Self-reported moderate/severe AD was estimated using the Patient-Oriented Eczema Measure (POEM). In the UKWP cohort, the AD effect on QoL was moderate/extremely large in 84.3% of moderate/severe AD (vs. 55.7% in mild; p = 0.016), while in the Expert Diagnosis cohort, it was 72.2% (vs. 22.8%; p < 0.001). Disease severity was associated with a higher impact on sleep and social activities. Overall work impairment was high in both mild (32.7%) and moderate/severe (48.5%) AD of the UKWP cohort, while among the Expert Diagnosis cohort, it was significantly higher among those with moderate/severe (31.2%) versus mild AD (11.9%; p < 0.001). The AD burden in Greece is significant, especially for those in moderate/severe AD stages. Acknowledging this burden is the first step toward applying healthcare decisions that will benefit patients and the community.

Association of Adult Atopic Dermatitis Severity With Decreased Physical Activity: A Cross-sectional Study

BACKGROUND

Atopic dermatitis (AD) is associated with chronic pruritus, skin pain, sleep deprivation, depression, and anxiety, which may lead to decreased physical activity (PA).

OBJECTIVE

The aim of the study is to elucidate the impact of disease and itch severity on PA in adult AD.

METHODS

This is a prospective dermatology practice-based study of 955 AD patients (ages 18-97 years).

RESULTS

In multivariable logistic regression models controlling for age, sex, race/ethnicity, and asthma history, patient-reported global AD severity (PtGA), Patient-Oriented Eczema Measure, Eczema Area and Severity Index (EASI), and Investigator's Global Assessment (IGA) were associated with itch impairing light PA, moderate PA, and vigorous PA, as well as higher Patient-Reported Outcomes Measurement Information System Itch Questionnaire PA T-scores. Higher objective Scoring AD (O-SCORAD) was associated with itch impairing moderate PA. In bivariable analyses, performing greater than or equal to 30 minutes of light PA greater than or equal to 1 day a week was decreased with higher PtGA, Patient-Oriented Eczema Measure, and EASI; greater than or equal to 30 minutes of moderate PA greater than or equal to 1 day a week was decreased with PtGA, EASI, O-SCORAD, and IGA; and greater than equal to 30 minutes of vigorous PA was decreased with patient-reported AD severity, EASI, O-SCORAD, and IGA. In multivariable logistic regression models, the impact of itch on PA was inversely associated with light PA, moderate PA, and vigorous PA.

CONCLUSION

Adult AD patients with more severe disease have decreased levels of PA secondary to itch.

Skin Dialogues in Atopic Dermatitis

Atopic dermatitis (AD) is a chronic skin disorder associated with significant quality-of-life impairment and increased risk for allergic and non-allergic comorbidities. The aim of this review is to elucidate the connection between AD and most common comorbidities, as this requires a holistic and multidisciplinary approach. Advances in understanding these associations could lead to the development of highly effective and targeted treatments.

Anti-Inflammatory microRNAs for Treating Inflammatory Skin Diseases

Skin inflammation occurs due to immune dysregulation because of internal disorders, infections, and allergic reactions. The inflammation of the skin is a major sign of chronic autoimmune inflammatory diseases, such as psoriasis, atopic dermatitis (AD), and lupus erythematosus. Although there are many therapies for treating these cutaneous inflammation diseases, their recurrence rates are high due to incomplete resolution. MicroRNA (miRNA) plays a critical role in skin inflammation by regulating the expression of protein-coding genes at the posttranscriptional level during pathogenesis and homeostasis maintenance. Some miRNAs possess anti-inflammatory features, which are beneficial for mitigating the inflammatory response. miRNAs that are reduced in inflammatory skin diseases can be supplied transiently using miRNA mimics and agomir. miRNA-based therapies that can target multiple genes in a given pathway are potential candidates for the treatment of skin inflammation. This review article offers an overview of the function of miRNA in skin inflammation regulation, with a focus on psoriasis, AD, and cutaneous wounds. Some bioactive molecules can target and modulate miRNAs to achieve the objective of inflammation suppression. This review also reports the anti-inflammatory efficacy of these molecules through modulating miRNA expression. The main limitations of miRNA-based therapies are rapid biodegradation and poor skin and cell penetration. Consideration was given to improving these drawbacks using the approaches of cell-penetrating peptides (CPPs), nanocarriers, exosomes, and low-frequency ultrasound. A formulation design for successful miRNA delivery into skin and target cells is also described in this review. The possible use of miRNAs as biomarkers and therapeutic modalities could open a novel opportunity for the diagnosis and treatment of inflammation-associated skin diseases.

Burden of Moderate to Severe Atopic Dermatitis in Adults from France, Italy, and the UK: Patient-Reported Outcomes and Treatment Patterns

Introduction

Moderate to severe atopic dermatitis (AD) is associated with a significant disease burden, impacting sleep, quality of life, and treatment needs. The aim of this study was to characterize disease burden and treatment patterns for adults with moderate to severe AD in three European countries: France, Italy, and the UK.

Methods

This retrospective analysis of adult patients with moderate to severe AD in Europe used medical records and physician/patient survey data collected in August 2019 to April 2020. Demographic and baseline disease characteristics, information on current comorbidities, disease flares, and current and previous treatments were collected by the physician. Patient-perceived burden was assessed using patient-reported outcome (PRO) questionnaires, which were completed on a voluntary basis and included the following instruments: Patient-Oriented Eczema Measure (POEM), Dermatology Life Quality Index (DLQI), EuroQol five-dimensional (EQ-5D), and Work Productivity and Activity Impairment (WPAI). Disease severity was subjectively assessed by physicians and was based on their own definition of the terms mild, moderate, and severe. Data were analyzed descriptively.

Results

The physician-reported sample included 912 patients with moderate to severe disease from France (n = 314), Italy (n = 309), and the UK (n = 289); approximately 30% of patients provided PRO data. Across these countries, 22–41% of patients reported current flares; mean POEM and DLQI scores were 10.6–13.1 and 9.5–11.1, respectively, indicating a high disease burden. However, systemic therapy use was low (e.g., conventional systemics were used by 18–24% of patients). Physician-assessed disease severity did not fully align with EASI scores, indicating that factors in addition to skin signs are impacting AD severity.

Conclusion

Patients with moderate to severe AD report significant disease burden, highlighting unmet treatment needs, particularly with respect to the underuse of systemic treatments despite AD being a systemic disease and the associated disease burden.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-022-00777-z.

Adult atopic eczema and the risk of dementia: A population-based cohort study

BACKGROUND

Chronic inflammatory conditions have been linked to dementia, but little is known about the role of atopic eczema, an inflammatory condition recently recognized to be common among older adults.

OBJECTIVE

To determine whether active atopic eczema is associated with incident dementia.

METHODS

A longitudinal cohort study of 1,767,667 individuals aged 60 to 99 years registered with The Health Improvement Network, a primary care cohort in the United Kingdom. The diagnoses of atopic eczema and dementia were identified using medical record codes.

RESULTS

The incidence of dementia was 57 per 10,000 person-years among those with atopic eczema during follow-up (12.1% of the population) compared with 44 per 10,000 person-years in the control group. This translated to a 27% increased risk of dementia (hazard ratio, 1.27; 95% CI, 1.23-1.30) in adjusted Cox proportional hazard models. Similar associations were observed in subgroup analyses of vascular dementia and Alzheimer's disease. The association persisted after additionally adjusting for the use of systemic corticosteroids (hazard ratio, 1.29; 95% CI, 1.26-1.33) and potential mediators (hazard ratio, 1.19; 95% CI, 1.16-1.22). More severe eczema was associated with a higher risk of dementia.

LIMITATIONS

Lack of detailed data on severity.

CONCLUSION

Atopic eczema was associated with a small but increased risk of incident dementia. The association increased with the severity of atopic eczema.

Characterizing real world safety profile of oral Janus kinase inhibitors among adult atopic dermatitis patients: evidence transporting from the rheumatoid arthritis population

OBJECTIVE

To address potential safety concerns of Janus Kinase Inhibitors (JAK-Is), we characterized their safety profile in the atopic dermatitis (AD) patient population.

METHODS

In this retrospective observational study, we used propensity score-based methods and a Poisson modeling framework to estimate the incidence of health outcomes of interest (HOI) for the AD patient. To that end, two mutually exclusive cohorts were created using a real world data resource: a rheumatoid arthritis (RA) cohort, where we directly quantify the safety risk of JAK-Is on HOIs, and an AD cohort, that comprises the target population of interest and to whom we transport the results obtained from the RA cohort. The RA cohort included all adults who filled at least one prescription for a JAK-I (tofacitinib, baricitinib, or upadacitinib) between 1 January 2017 and 31 January 2020. The AD cohort consisted of all adults diagnosed with AD during the same period. We first estimated the incidence rate of each HOI in the RA cohort, and then transported the results to the AD population.

RESULTS

The RA and AD cohorts included 5,296 and 261,855 patients, respectively. On average, patients in the AD cohort were younger, more often male, more likely to be Asian, and had higher household income. They also had a lower prevalence of several comorbid conditions including hypertension, chronic kidney disease, obesity, and depression. Overall, the transported incidence rates of the HOIs to the AD cohort were lower than those obtained in the RA cohort by 13-50%.

CONCLUSION

We applied transportability methods to characterize the risk of the HOIs in the AD population and found absolute risks higher than that of the general population. Future work is needed to validate these conclusions in comparable populations.

Unmet Medical Needs in Chronic, Non-communicable Inflammatory Skin Diseases

An estimated 20-25% of the population is affected by chronic, non-communicable inflammatory skin diseases. Chronic skin inflammation has many causes. Among the most frequent chronic inflammatory skin diseases are atopic dermatitis, psoriasis, urticaria, lichen planus, and hidradenitis suppurativa, driven by a complex interplay of genetics and environmental factors. Autoimmunity is another important cause of chronic skin inflammation. The autoimmune response may be mainly T cell driven, such as in alopecia areata or vitiligo, or B cell driven in chronic spontaneous urticaria, pemphigus and pemphigoid diseases. Rare causes of chronic skin inflammation are autoinflammatory diseases, or rheumatic diseases, such as cutaneous lupus erythematosus or dermatomyositis. Whilst we have seen a significant improvement in diagnosis and treatment, several challenges remain. Especially for rarer causes of chronic skin inflammation, early diagnosis is often missed because of low awareness and lack of diagnostics. Systemic immunosuppression is the treatment of choice for almost all of these diseases. Adverse events due to immunosuppression, insufficient therapeutic responses and relapses remain a challenge. For atopic dermatitis and psoriasis, a broad spectrum of innovative treatments has been developed. However, treatment responses cannot be predicted so far. Hence, development of (bio)markers allowing selection of specific medications for individual patients is needed. Given the encouraging developments during the past years, we envision that many of these challenges in the diagnosis and treatment of chronic inflammatory skin diseases will be thoroughly addressed in the future.

(-)-α-Bisabolol Alleviates Atopic Dermatitis by Inhibiting MAPK and NF-κB Signaling in Mast Cell

(-)-α-Bisabolol (BIS) is a sesquiterpene alcohol derived mostly from Matricaria recutita L., which is a traditional herb and exhibits multiple biologic activities. BIS has been reported for treatment of skin disorders, but the effect of BIS on anti-atopic dermatitis (AD) remains unclear. Therefore, we investigated the effects of BIS on 2,4-dinitrochlorobenzene (DNCB)-induced AD in BALB/c mice and the underlying mechanism in Bone Marrow-Derived Mast Cells (BMMCs). Topical BIS treatment reduced AD-like symptoms and the release of interleukin (IL)-4 without immunoglobulin (Ig)-E production in DNCB-induced BALB/c mice. Histopathological examination revealed that BIS reduced epidermal thickness and inhibited mast cells in the AD-like lesions skin. Oral administration of BIS effectively and dose-dependently suppressed mast-cell-mediated passive cutaneous anaphylaxis. In IgE-mediated BMMCs, the levels of β-hexosaminidase (β-hex), histamine, and tumor necrosis factor (TNF)-α were reduced by blocking the activation of nuclear factor-қB (NF-қB) and c-Jun N-terminal kinase (JNK) without P38 mitogen activated protein (P38) and extracellular regulated protein kinases (Erk1/2). Taken together, our experimental results indicated BIS suppresses AD by inhibiting the activation of JNK and NF-κB in mast cells. BIS may be a promising therapeutic agent for atopic dermatitis and other mast-cell-related diseases.

From Skin Barrier Dysfunction to Systemic Impact of Atopic Dermatitis: Implications for a Precision Approach in Dermocosmetics and Medicine

: Atopic dermatitis (AD) affects up to 20% of children and is considered the starting point of the atopic march with the development of food allergy, asthma, and allergic rhinitis. The heterogeneous phenotype reflects distinct and/or overlapping pathogenetic mechanisms with varying degrees of epidermal barrier disruption, activation of different T cell subsets and dysbiosis of the skin microbiome. Here, we review current evidence suggesting a systemic impact of the cutaneous inflammation in AD together with a higher risk of asthma and other comorbidities, especially in severe and persistent AD. Thus, early therapy of AD to restore the impaired skin barrier, modified microbiome, and target type 2 inflammation, depending on the (endo)phenotype, in a tailored approach is crucial. We discuss what we can learn from the comorbidities and the implications for preventive and therapeutic interventions from precision dermocosmetics to precision medicine. The stratification of AD patients into biomarker-based endotypes for a precision medicine approach offers opportunities for better long-term control of AD with the potential to reduce the systemic impact of a chronic skin inflammation and even prevent or modify the course, not only of AD, but possibly also the comorbidities, depending on the patient’s age and disease stage.

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.

Prescription Market Share and Treatment Patterns in Atopic Dermatitis: A Retrospective Observational Study Using US Insurance Claims

INTRODUCTION

There is limited real-world evidence on the treatments for atopic dermatitis (AD) since dupilumab was approved in 2017. The objective of this study was to assess market share of drugs commonly prescribed for the treatment of AD and describe treatment patterns in patients diagnosed with AD.

METHODS

This was a retrospective, observational study in adult patients with an ICD-10 diagnosis of AD between 2017 and 2019 using insurance claims data in the US population.

RESULTS

Market share cohorts consisted of 75,794 (2017) and 89,618 (2018) patients. Treatment patterns cohort had 68,588 patients with 63.56% female, mean (SD) age 43.54 (15.96) years, and mean (SD) Quan CCI 0.31 (0.85). Topicals had two-thirds market share by prescription volume (2017 = 65.56%; 2018 = 63.63%). Corticosteroids were the most prescribed topical (2017 = 71.94%; 2018 = 72.04%) and systemic (2017 = 30.59%; 2018 = 30.23%) drug class. Dupilumab had the highest medication adherence (proportion of days covered [PDC] ≥ 80%; 60.74%) and persistence (17.39%), lowest discontinuation rate (23.32%), and longest mean (SD) days on therapy 148.20 (101.77).

CONCLUSION

Topicals are the primary treatment for patients with AD, even though systemic users have higher medication adherence (PDC). Systemics provide a treatment alternative to topicals.

Comorbidity Identification and Referral in Atopic Dermatitis: a Consensus Document

BACKGROUND

Atopic dermatitis (AD) is associated with different comorbidities.

OBJECTIVE

To develop evidence-based and practical recommendations for comorbidity detection in patients with AD in daily practice.

METHODS

We employed a modified RAND/UCLA methodology, including a systematic literature review (SLR). A group of six experts on AD was established. We conducted a comprehensive search strategy on Medline, Embase, and Cochrane Library up to June 2020. The selection criteria included studies with AD patients with any comorbidity reporting data on comorbidity prevalence, burden, and management. The included studies quality was assessed. The SLR results were discussed in a nominal group meeting, and several recommendations were generated. The recommendation agreement grade was tested on additional experts through a Delphi process.

RESULTS

The recommendations cover the following issues: 1) Which comorbidities should be investigated at the first and subsequent visits; 2) How and when should comorbidities be investigated (screening); 3) How should patients with specific comorbidities be referred to confirm their diagnosis and initiate management; 4) Specific recommendations to ensure an integral care approach for AD patients with any comorbidity.

CONCLUSIONS

These recommendations seek to guide dermatologists, patients, and other stakeholders in regard to early comorbidity identification and AD patient referral to improve decision-making.

The suitability of treating atopic dermatitis with Janus kinase inhibitors

INTRODUCTION

Atopic dermatitis (AD) is a chronic inflammatory skin disease with significant morbidity and reduced quality of life, especially in patients with moderate-severe AD. Recently, topical and oral Janus kinase (JAK)-inhibitors were investigated as potential treatments for mild-moderate and moderate-severe AD. However, rare serious adverse-events observed with JAK-inhibitor therapy in AD, rheumatoid arthritis, and other immune-mediated disorders warrant careful consideration.

AREAS COVERED

This review examines the efficacy and safety of topical and oral JAK-inhibitors for treatments in AD, and reviews potential treatment applications in patients with moderate-severe AD.

EXPERT OPINION

JAK-inhibitors have rapid-onset and robust and durable efficacy, which give them considerable versatility for treating the gamut of AD patients. While the U.S. Food and Drug Administration has only approved upadacitinib and abrocitinib to treat moderate-severe AD refractory to treatment with other systemic medications including biologics, or when use of those therapies is not recommended, oral JAK-inhibitors have the potential to be used both as first-line or second-line systemic therapies in moderate-severe AD. However, oral JAK-inhibitors can lead to laboratory anomalies and rare serious adverse events. All of these important characteristics should be addressed in shared-decision making conversations, patient counseling, choosing appropriate therapies for patients, and monitoring patients in clinical practice.

Association Between Atopic Dermatitis, Asthma, and Serum Lipids: A UK Biobank Based Observational Study and Mendelian Randomization Analysis

Background

Both atopic diseases and dysregulation of serum lipids (SLs) add to significant health burden, but evidences about their association are inconsistent.

Objective

This work is to evaluate the association between asthma/atopic dermatitis (AD) and SLs and investigate the potential causal relationship.

Methods

A large-scale cross-sectional study based on the UK Biobank (UKB) and then examined the casual relationships between SLs with asthma/AD based on a Mendelian randomization (MR) analysis.

Results

A total of 502,505 participants were included in analysis. After full adjustment, AD was associated with lower TG (β = −0.006; 95%CI, −0.010 to −0.002; P = 0.006), lower LDL (β = −0.004; 95%CI, −0.006 to −0.002, P < 0.001), and lower TC (β = −0.004; 95%CI, −0.005 to −0.002; P < 0.001) but insignificantly correlated to HDL (P = 0.794). Asthma was also inversely correlated to TG (β = −0.005; 95%CI, = −0.007 to −0.003; < 0.001), LDL (β = −0.003; 95%CI, −0.004 to −0.002; P < 0.001), and TC (β = −0.002; 95%CI, −0.003 to −0.002; P < 0.001), but was positively correlated to HDL (β = 0.004; 95%CI, 0.003 to 0.005; P < 0.001), respectively. In subsequent MR analysis, both allergic diseases and asthma showed a protective effect on TC. Allergic diseases, asthma, and AD all showed a negative effect on LDL.

Conclusion

Collectively, we identify a protective causal effect of allergic diseases on serum lipids, as well as a potentially positive association of HDL with asthma. Owing to the largest sample size and the application of IVs in causal inference, this study will provide a robust evidence for the management of asthma and AD and the prevention of dyslipidemia.

Multiple Roles for Cytokines in Atopic Dermatitis: From Pathogenic Mediators to Endotype-Specific Biomarkers to Therapeutic Targets

Atopic dermatitis (AD) is one of the most common chronic inflammatory skin diseases, which generally presents with intense itching and recurrent eczematous lesions. AD affects up to 20% of children and 10% of adults in high-income countries. The prevalence and incidence of AD have increased in recent years. The onset of AD mostly occurs in childhood, although in some cases AD may persist in adult life or even manifest in middle age (adult-onset AD). AD pathophysiology is made of a complex net, in which genetic background, skin barrier dysfunction, innate and adaptive immune responses, as well as itch contribute to disease development, progression, and chronicization. One of the most important features of AD is skin dehydration, which is mainly caused by filaggrin mutations that determine trans-epidermal water loss, pH alterations, and antigen penetration. In accordance with the “outside-inside” theory of AD pathogenesis, in a context of an altered epidermal barrier, antigens encounter epidermal antigen presentation cells (APCs), such as epidermal Langerhans cells and inflammatory epidermal dendritic cells, leading to their maturation and Th-2 cell-mediated inflammation. APCs also bear trimeric high-affinity receptors for immunoglobulin E (IgE), which induce IgE-mediated sensitizations as part of pathogenic mechanisms leading to AD. In this review, we discuss the role of cytokines in the pathogenesis of AD, considering patients with various clinical AD phenotypes. Moreover, we describe the cytokine patterns in patients with AD at different phases of the disease evolution, as well as in relation to different phenotypes/endotypes, including age, race, and intrinsic/extrinsic subtypes. We also discuss the outcomes of current biologics for AD, which corroborate the presence of multiple cytokine axes involved in the background of AD. A deep insight into the correlation between cytokine patterns and the related clinical forms of AD is a crucial step towards increasingly personalized, and therefore more efficient therapy.

Blood transcriptome profiling identifies 2 candidate endotypes of atopic dermatitis

BACKGROUND

Few studies have analyzed the blood transcriptome in atopic dermatitis (AD).

OBJECTIVE

We explored blood transcriptomic features of moderate to severe AD.

METHODS

Blood messenger RNA sequencing on 60 adults from the TREATgermany registry including 49 patients before and after dupilumab treatment, as well as from an independent cohort of 31 patients and 43 controls was performed. Patient clustering, differential expression, correlation and coexpression network analysis, and unsupervised learning were conducted.

RESULTS

AD patients showed pronounced inflammatory expression signatures with increased myeloid and IL-5-related patterns, and clearly segregated into 2 distinct clusters, with striking differences in particular for transcripts involved in eosinophil signaling. The eosinophil-high endotype showed a more pronounced global dysregulation, a positive correlation between disease activity and signatures related to IL-5 signaling, and strong correlations with several target proteins of antibodies or small molecules under development for AD. In contrast, the eosinophil-low endotype showed little transcriptomic dysregulation and no association between disease activity and gene expression. Clinical improvement with receipt of dupilumab was accompanied by a decrease of innate immune responses and an increase of lymphocyte signatures including B-cell activation and natural killer cell composition and/or function. The proportion of super responders was higher in the eosinophil-low endotype (32% vs 11%). Continued downregulation of IL18RAP, IFNG, and granzyme A in the eosinophil-high endotype suggests a residual disturbance of natural killer cell function despite clinical improvement.

CONCLUSION

AD can be stratified into eosinophilic and noneosinophilic endotypes; such stratification may be useful when assessing stratified trial designs and treatment strategies.

Drug survival of systemic immunosuppressive treatments for atopic dermatitis in a long-term pediatric cohort

Background

: Systemic immunosuppressive treatments are central in the treatment of severe atopic dermatitis (AD). Yet, comparative data are sparse on the performance of such immunosuppressive treatments in pediatric cohorts with severe AD.

Objective

: This study aimed to examine the drug survival of systemic immunosuppressive treatments in a cohort of children with severe AD.

Methods

: A retrospective pediatric cohort was identified using diagnosis and treatment codes registered in medical charts. In total, 135 cases were identified; of these, 36 were excluded. All information was obtained through examination of clinical records. Drug survival was analyzed with Kaplan–Meier plots, and a log-rank test was used to test for differences in drug survival.

Results

: First-line treatment was primarily methotrexate (MTX; n = 63) and azathioprine (AZA; n = 32). For MTX, the drug survival rates were 69%, 50%, and 18% after 1, 2, and 4 years, respectively, with a median drug survival time of 1.58 years. For AZA, these rates were 63%, 53%, and 21%, respectively, with a median drug survival time of 1.14 years. There was no significant difference in drug survival between the treatments. The main reason for discontinuation was adverse effects (MTX: 25%; AZA: 41%). Despite this, a majority of patients experienced a good effect at the moment of discontinuation or data-lock (MTX: 60%; AZA: 53%), and treatment effect assessed as improvement in sleep quality was highly significant (p = .001). Second-line treatments included MTX (n = 12), AZA (n = 7), and cyclosporine (n = 5). These showed a median drug survival time of 1.8, 0.2, and 0.885 years, respectively.

Conclusion

: MTX and AZA were the dominant first-line treatments prescribed and were safe and equally valuable treatment options for severe childhood AD with similar drug survival outcomes. MTX was the most used second-line treatment.

A Review of Safety Outcomes from Clinical Trials of Baricitinib in Rheumatology, Dermatology and COVID-19

Baricitinib is an oral, selective inhibitor of Janus kinase (JAK)1/JAK2 that transiently and reversibly inhibits many proinflammatory cytokines. This mechanism is a key mediator in a number of chronic inflammatory diseases; accordingly, baricitinib has been studied and approved for the treatment of several rheumatological and dermatological disorders, as well as COVID-19. This narrative review summarises and discusses the safety profile of baricitinib across these diseases, with special focus on adverse events of special interest (AESI) for JAK inhibitors, using integrated safety data sets of clinical trial data, and puts findings into context with the underlying risk in the respective disease populations, using supporting literature. We show that rates of infection with baricitinib generally reflected the inherent risk of the disease populations being treated, with serious infections and herpes zoster being more frequent in rheumatic diseases than in dermatological disorders, and herpes simplex being reported particularly in atopic dermatitis. Similarly, rates of major adverse cardiovascular events (MACE), venous thromboembolism (VTE) and malignancies were generally within or below the ranges reported for the respective disease populations, thereby reflecting the underlying risk; these events were therefore more frequent in patients with rheumatic diseases than in those with dermatological disorders, the latter of whom generally had low absolute risk. AESI were usually more common in patients with risk factors specific for each event. When a population similar to that of ORAL Surveillance was considered, the incidence rate of MACE with baricitinib was numerically lower than that reported with tofacitinib and similar to that of tumour necrosis factor inhibitors. No safety concerns were observed in hospitalised patients with COVID-19 who received baricitinib for up to 14 days. Identifying the patterns and likelihoods of AEs that occur during treatment in large groups of patients with different diseases can help the physician and patient better contextualise the benefit-to-risk ratio for the individual patient.

The causal association of polyunsaturated fatty acids with allergic disease: A two-sample Mendelian randomization study

Objectives

Previous studies have reported a potential association of polyunsaturated fatty acids (PUFAs) levels with allergic disease risk and the possible benefit of PUFAs supplementation on allergic disease prevention. This study was performed to estimate the genetic association between PUFAs and allergic diseases using the method of both univariable and multivariable two-sample Mendelian randomization (MR).

Methods

As indicators of the PUFAs levels, we included the omega-3, omega-6, docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA), linoleic acid (LA), and the ratio of omega-6 to omega-3 (omega-6:3). Summarized statistics of genome-wide association studies (GWASs) for these PUFAs were obtained from the United Kingdom Biobank and the Twins United Kingdom cohort. Genetic data relating to allergic diseases, including atopic dermatitis (AD), allergic rhinitis (AR), allergic conjunctivitis (AC), allergic urticaria (AU) and asthma, were accessed from the FinnGen biobank analysis. Odds ratios and 95% CIs were used to express the impact.

Results

The MR results denoted a genetic association between the genetically determined increase in omega-3 levels and the decreased risk of some allergic diseases including AD (OR: 0.863; 95% CI: 0.785 to 0.949; p = 3.86E-03), AC (OR:0.720; 95% CI: 0.547 to 0.947; p = 1.87E-02) and AU (OR:0.821; 95% CI: 0.684 to 0.985; p = 3.42E-02), while omega-6 and DHA level was only found to have negatively correlation with risk of AC with ORs of 0.655 (95% CI: 0.445 to 0.964; p = 3.18E-02) and 0.671 (95% CI 0.490 to 0.918; p = 1.25E-02), respectively. Omega-6:3 were causally significantly associated with the increased risk of AD (OR:1.171; 95% CI: 1.045 to 1.312; p = 6.46E-03) and AC (IVW: OR:1.341; 95% CI: 1.032 to 1.743; p = 2.83E-02). After adjustment of age, economic level, BMI, smoking and alcohol behaviors in the multivariable MR analysis, a direct causal protective effect of omega-3 on AD and AC, as well as a direct causal association between DHA and AD were observed. Omega-6:3 was also found to be directly associated with an increased risk of AD and AC. No association was found of EPA or LA with allergic diseases.

Conclusion

Higher PUFA concentrations (omega-3, omega-6, DHA) and lower omega-6:3 ratios were genetically associated with a lower risk of some allergic diseases.

Association between atopic dermatitis and COVID-19 infection: A case-control study in the All of Us research program

BACKGROUND

There is an incomplete understanding of the risk of COVID-19 infection in atopic dermatitis (AD) patients.

OBJECTIVE

To evaluate the risk of COVID-19 infection in AD patients in a large, diverse cohort.

METHODS

A case-control study of the All of Us cohort to analyze the association between AD and COVID-19. Comorbidities and risk factors were compared between cases and controls using multivariable analyses.

RESULTS

In a cohort of 11,752 AD cases with 47,008 matched controls, AD patients were more likely to have a COVID-19 diagnosis (4.2% vs 2.8%, P < .001). AD remained significantly associated with COVID-19 in multivariable analysis (odds ratio, 1.29; P < .001) after adjusting for demographic factors and comorbidities.

LIMITATIONS

Ascertainment of AD and COVID-19 cases using electronic health records and lack of clinical data on AD severity or therapy and COVID-19 outcomes.

CONCLUSION

AD is associated with increased odds of COVID-19 infection even after controlling for common comorbidities.

Epidemiology, Comorbidities, and Prescription Patterns of Korean Prurigo Nodularis Patients: A Multi-Institution Study

Prurigo nodularis (PN) is a chronic dermatosis typified by extraordinarily itchy nodules. However, little is known of the nature and extent of PN in Asian people. This study aimed to describe the epidemiology, comorbidities, and prescription pattern of PN in Koreans based on a large dermatology outpatient cohort. Patients with PN were identified from the Catholic Medical Center (CMC) clinical data warehouse. Anonymized data on age, sex, diagnostic codes, prescriptions, visitation dates, and other relevant parameters were collected. Pearson correlation analysis was used to calculate the correlation between PN prevalence and patient age. Conditional logistic regression modeling was adopted to measure the comorbidity risk of PN. A total of 3591 patients with PN were identified at the Catholic Medical Center Health System dermatology outpatient clinic in the period 2007–2020. A comparison of the study patients with age- and sex-matched controls (dermatology outpatients without PN) indicated that PN was associated with various comorbidities including chronic kidney disease (adjusted odds ratio (aOR), 1.48; 95% confidence interval (CI), 1.29–1.70), dyslipidemia (aOR, 1.88; 95% CI, 1.56–2.27), type 2 diabetes mellitus (aOR, 1.37; 95% CI, 1.22–1.54), arterial hypertension (aOR, 1.50; 95% CI, 1.30–1.73), autoimmune thyroiditis (aOR, 2.43; 95% CI, 1.42–4.16), non-Hodgkin’s lymphoma (aOR, 1.95; 95% CI, 1.23–3.07), and atopic dermatitis (aOR, 2.16, 95% CI, 1.91–2.45). Regarding prescription patterns, topical steroids were most favored, followed by topical calcineurin inhibitors; oral antihistamines were the most preferred systemic agent for PN. PN is a relatively rare but significant disease among Korean dermatology outpatients with a high comorbidity burden compared to dermatology outpatients without PN. There is great need for breakthroughs in PN treatment.

Can crowdsourced data help to optimize atopic dermatitis treatment? Comparing web search data and environmental data in Germany

BACKGROUND

Atopic dermatitis (AD) is one of the most common chronic skin diseases worldwide, showing various manifestations and having a severe impact on quality of life. As previous studies demonstrated, internet search analysis can help identify public interest in diseases and possible influencing factors on search behavior.

OBJECTIVE

To identify AD-related topics of interest in Germany using internet search volume.

METHODS

Google Ads Keyword Planner was used to identify AD-related search terms including their search volume in Germany on a national level as well as in 16 selected cities from January 2016 to December 2019. Identified keywords were qualitatively analyzed, and temporal trends as well as the influence of seasonal and environmental factors on search volume were assessed.

RESULTS

Overall, 1222 AD-related search terms with a search volume of 8 842 360 searches were identified. An increase from 2016 to 2019 and seasonal peaks from January to April of each year were observed. Nationwide, the search volume correlated with mean monthly temperature and sun duration. With increasing temperature and sun duration, a significant decrease in search queries was observed. The most populated cities showed the lowest number of searches per 100 000 inhabitants (Berlin, Hamburg, and Munich). In the eight categories formed (comorbidities, general, influential factors, localization, stage of life, symptoms/severity, therapy/information, and questions on AD), the highest proportion of search queries were assigned to the category "therapy/information" in most cities. In this category, a focus on the topics of "alternative medicine" and "home remedies" could be observed.

CONCLUSION

The overall high and increasing search volume indicates a high interest in AD-related topics, especially regarding treatment and disease education. Information provided by internet search volume analyses can optimize AD therapy and patient-centered care by providing insight into patient needs and predicting potential climatic trigger factors.

The Atopic Dermatitis Control Tool: A High-Performance Tool for Optimal Support

The evaluation of global atopic dermatitis control is key to minimizing disease burden. The Atopic Dermatitis Control Tool (ADCT) has been developed for this purpose. Participants (diagnosed by a physician) were recruited to this observational cross-sectional study using real-life methodology and completed a questionnaire on sociodemographic and personal information. The ADCT algorithm, described by Pariser, was used to categorize patients as having controlled or uncontrolled atopic dermatitis. Data were collected for 1,606 patients. Median age of the patients was 40 years , and 1,023 (63.7%) patients were women. A total of 1,146 (71.4%) patients had uncontrolled atopic dermatitis according to the ADCT score. Patients with uncontrolled disease were at significantly higher risk of a high stress level and were more likely to be absent from work than those with controlled disease. In conclusion, a key factor for predicting disease burden in atopic dermatitis is patient self-assessed disease control in terms of multiple dimensions: stress, sleep, quality of life, work absenteeism and loss of productivity.

Persistent eczema leads to both impaired growth and food allergy: JECS birth cohort

Skin inflammation leads to altered cytokine/chemokine production and causes systemic inflammation. The systemic mechanism of atopic dermatitis (AD) is recognized to affect systemic metabolism. This study aimed to examine the relationship between early-onset persistent eczema and body weight, height, and body mass index (BMI), in addition to food allergy in a birth cohort among infants. This study design was a nationwide, multicenter, prospective birth cohort study-the Japan Environment and Children's Study (JECS). Generalized linear models were fitted for z scores of weight, height, BMI, and food allergy to evaluate the relationship between eczema and these outcomes for infants at age1, 2, and 3 years. Persistent eczema was negatively associated with height at the age of 2 years (estimated coefficient, -0.127; 95% confidence interval [CI], -0.16 to -0.095) and 3 years (-0.177; 95% CI, -0.214 to -0.139). The same tendency was also observed with weight and BMI. Early disease onset at younger than 1 year and persistent eczema had the strongest association with development of food allergy at age 3 years (OR, 11.794; 95% CI, 10.721-12.975). One phenotype of eczema with early-onset and persistent disease creates a risk of both physical growth impairment and development of food allergy. Infants who present with the early-onset and persistent type of eczema should be carefully evaluated daily for impaired physical growth and development of food allergy.

Melatonin and sleep disorders in patients with severe atopic dermatitis

Introduction

Many atopic dermatitis (AD) patients suffer from insomnia. Out of numerous factors associated with sleep disorders, melatonin seems to play a significant role.

Aim

To assess the relation between melatonin concentration and sleep disorders in adult patients with severe and very severe AD.

Material and methods

The study included 36 adult patients with severe and very severe AD and 20 healthy Caucasian volunteers. The severity of skin lesions was assessed by the EASI scale. Skin itch was evaluated by a visual-analogue scale (VAS), and sleep disorders were assessed by the Polish version of the Athens Insomnia Scale (AIS). Serum melatonin concentration of patients and controls was determined by ELISA.

Results

Melatonin concentration in patients with very severe AD was significantly (p < 0.001) lower than in patients with severe AD, however, melatonin concentration in the group of AD patients did not differ significantly (p = 0.33) from that observed in the control group. There was a significant negative correlation between the concentration of melatonin in the study group and the severity of itching (R = -0.54, p < 0.001). The intensity of sleep disorders was significantly higher (p < 0.001) in patients with a very severe form of AD compared to patients with severe AD. Moreover, there was a significant negative correlation between melatonin concentration and sleep disorders (R = -0.67, p < 0.001).

Conclusions

Our results clearly showed that sleep disturbances are more expressed in very severe AD patients compared to subjects suffering from severe disease. We also suggest that melatonin serum concentration could play a role in the pathogenesis of sleep disturbances in AD patients.

Pullulan film incorporated with nanocapsules improves pomegranate seed oil anti-inflammatory and antioxidant effects in the treatment of atopic dermatitis in mice

This study aimed to prepare pullulan films containing pomegranate seeds oil (PSO) based nanocapsules, and evaluate the formulation efficacy in the treatment of atopic dermatitis (AD)-like lesions induced by 2,4-dinitrochlorobenzene (DNCB). The Eudragit RS 100® nanocapsules (PSONC) were prepared by the interfacial precipitation of preformed polymer, whereas the films were produced by the solvent casting method. Pomegranate seed oil nanoemulsions (PSONE) were prepared by the spontaneous emulsification method for comparative reasons. Both nanosystems presented adequate mean diameter (248 ± 16 nm for PSONE and 181 ± 6 nm for PSONC), polydispersity index (below 0.2), zeta potential (-25.63 ± 1.1 mV for PSONE and + 43.13 ± 0.7 mV for PSONC) and pH in the acid range (6.77 ± 0.27 and 5.31 ± 0.17, PSONE and PSONC). By a pre-formulation study, sorbitol (6.5%) and PEG 400 (1.5%) were considered the most suitable plasticizers for developing pullulan films (6%) intending topical application. In general, pullulan films were classified as flexible and hydrophilic, with high occlusive properties, 57.6 ± 0.8%, 64.6 ± 0.8% for vehicle, PSONCF (pullulan film containing PSONC), respectively. All formulations (films and nanocarriers) presented no irritant potential in the chorioallantoic membrane test. In the in vivo model, the treatments with free PSO and PSONCF attenuated the skin injury as well as the mechanical hypernociceptive behavioral induced by DNCB exposure to mice. Importantly, the biochemical analyses provided evidence that only the treatment with PSONCF modulated the inflammatory and the oxidative stress parameters evaluated in this study. In conclusion, these data lead us to believe that PSONC incorporation into a pullulan film matrix improved the biological properties of the PSO in this AD-model.

Real-world comorbidities of atopic dermatitis in the U.S. adult ambulatory population

BACKGROUND

Atopic dermatitis (AD) is a pruritic inflammatory skin disease associated with various comorbidities. However, comprehensive analyses of real-world comorbidities in adult AD patients are limited.

OBJECTIVE

To characterize the real-world comorbidities associated with adult AD in an ambulatory population.

METHODS

We queried the MarketScan Commercial Claims and Encounters database from January 1, 2017 to December 31, 2017. Multivariable logistic regressions were performed to compare comorbidities in adult AD patients vs. age- and sex-matched controls.

RESULTS

A total of 39,779 AD patients and 353,743 controls were identified. Increased odds of psychiatric conditions including anxiety (OR 1.44) and mood disorders (OR 1.31) were observed in AD. AD patients had higher likelihood of autoimmune diseases including vitiligo (OR 4.44) and alopecia areata (OR 6.01). Adult AD was also associated with infections including impetigo (OR 9.72), MRSA (OR 3.92), and cellulitis (OR 2.52). AD patients were more likely to have systemic conditions including lymphoid/hematopoietic malignancy (OR 1.91), atherosclerosis (OR 1.69), and metabolic syndrome (OR 1.47). For all the above, p<0.001.

LIMITATIONS

Retrospective analysis of healthcare claims data CONCLUSIONS: Adult AD is associated with various psychiatric and systemic comorbidities, emphasizing the systemic nature of AD and the need for collaborative management of these patients.

Attenuation of experimentally induced atopic dermatitis in mice by sulforaphane: effect on inflammation and apoptosis

Atopic dermatitis (AD) is characterized by progressive skin inflammation. In addition, sulforaphane is an isothiocyanate organosulfur compound from cruciferous vegetables. Sulforaphane was reported to ameliorate inflammatory responses. Therefore, this study was conducted to evaluate the protective effects of sulforaphane in AD through affecting the balance between pro-inflammatory and anti-inflammatory cytokines and to evaluate its effect on AD-induced activation of the apoptotic pathway. The method of repeated rubbing of 2,4-dinitrochlorobenzene (DNCB) on shaved dorsal skin and ears of mice was used for induction of AD. After the development of AD, part of the mice was injected with 1 mg/kg sulforaphane, subcutaneously three times weekly. Samples of skin were isolated for assessment of gene and protein expression of 8-hydroxy2'-deoxyguanosine, IgE, NFκB, TNF-α, IL-1β, IL-4, IL-10, Nrf2, and caspase-3. In addition, skin sections from different groups were stained with anti-caspase-3 antibodies. Mice in the AD group were characterized by increased gene and protein expression of 8-hydroxy2'-deoxyguanosine, IgE, NFκB, TNF-α, IL-1β, and caspase-3 associated with reduced expression of Nrf2, IL-4, and IL-10. Treatment of AD mice with sulforaphane significantly reduced the number of scratches, dermatitis score, and ear thickness. In addition, sulforaphane significantly attenuated the gene and protein expressions produced by AD. Therefore, sulforaphane alleviated AD induced in mice through inhibition of oxidative stress, oxidative DNA damage, inflammation, and apoptosis. HIGHLIGHTSAtopic dermatitis is a chronic relapsing inflammatory disease.Sulforaphane is an isothiocyanate organosulfur compound obtained from cruciferous vegetables.Sulforaphane alleviated AD induced in mice.Sulforaphane inhibits oxidative stress, oxidative DNA damage, inflammation, and apoptosis.

What are the highest yielding search strategy terms for systematic reviews in atopic dermatitis? A systematic review

The impact of search strategies on systematic reviews (SR) of atopic dermatitis (AD) is unknown. The purpose of this review was to evaluate search strategies used in SR of AD and their impact on the frequency of manuscripts identified. MEDLINE and EMBASE were searched for SR related to AD. Simulations were performed by running combinations of search terms in MEDLINE and EMBASE. Overall, 250 SR met inclusion criteria, of which 225 specified search strategies. SR using 5-6 terms (20.0% to 12.1%) or ≥ 7 (40.0% to 18.8%) terms decreased, whereas SR using 3-4 terms numerically increased (18.8% to 30.2%) and 1-2 terms remained similar (37.5% to 38.9%) from 1999-2009 to 2015-2019. The most commonly searched terms were "atopic dermatitis" (n = 166), followed by "eczema" (n = 156), "dermatitis atopic'" (n = 81), "atopic eczema" (n = 74), "neurodermatitis" (n = 59), "Besniers prurigo" (n = 29), "infantile eczema" (n = 27), and "childhood eczema" (n = 19). Simulations revealed that "eczema" and "atopic dermatitis" yielded the most hits. The number of search terms that maximized hits in MEDLINE and EMBASE was 5 and 4, respectively. Search strategies for AD were heterogeneous, with high proportions of search strategies providing few search hits. Future studies should use standardized and optimized search terms.

Perception and Experience of Biologic Therapy in Atopic Dermatitis: A Qualitative Focus Group Study of Physicians and Patients in Europe and Canada

INTRODUCTION

The Biologics in Atopic Dermatitis: Experiences & Learnings (BADEL) project aims to improve real-life understanding of how, where, and when biologics can play a role in the treatment of atopic dermatitis (AD) from the perspective of healthcare professionals (HCPs) and patients.

METHODS

Individual experiences of 24 patients with moderate-to-severe AD and who had been treated with biologic therapy (dupilumab) for ≥ 3-6 months, and 20 HCPs with a sub-specialty interest in AD were collected by means of focus groups held in Canada, Germany, France, Italy and the United Kingdom. Dupilumab was the only biologic therapy available at the time of the study.

RESULTS

Most patients had suffered from AD for many years, particularly from itch and psychosocial issues, with AD negatively impacting all aspects of their life. They had experienced a long treatment journey and seen many dermatologists, enduring treatment delays and failures. They had been prescribed various therapies without long-term success. Biologics provided symptom improvement, offering many patients a near-normal quality of life. Side effects, especially conjunctivitis, were the greatest drawback, and there were a few issues with incomplete or unreliable efficacy. HCPs agreed that biologic therapy for AD in the majority of patients demonstrated rapid onset, good efficacy and tolerability, and are a viable option in patients who had exhausted all other treatment options. However, those patients who failed to sufficiently respond or developed intolerable adverse effects, particularly ocular symptoms, require alternative therapeutic options.

CONCLUSION

Biologics can provide a near-normal quality of life for many patients with AD. Patients with AD who have failed conventional therapies should be offered all such novel therapies. Education and good patient-HCP communication will enable patients to manage their disease and treatment expectations. Patients and HCPs alike eagerly await alternative targeted therapies, which will offer greater choice and flexibility.

Prevalence of type 2 inflammatory diseases in pediatric patients with atopic dermatitis: real-world evidence

BACKGROUND

Patients with atopic dermatitis (AD) are considered at increased risk of developing other type 2 inflammatory diseases. However, real-world evidence based on large US commercially insured pediatric populations is scarce.

OBJECTIVE

To use a large US claims database (IBM® MarketScan® 2013-2017) to assess prevalence and incidence of type 2 inflammatory diseases in pediatric AD patients.

METHODS

Pediatric AD patients were matched 1:1 to non-AD patients. Prevalence was assessed for conjunctivitis, rhinitis, urticaria, asthma, eosinophilic esophagitis and chronic rhinosinusitis/nasal polyps, 12 months post-index date (first AD diagnosis date for AD patients; a randomly selected outpatient visit for control patients). Incidence of other type 2 inflammatory diseases post-index was assessed among patients 0-2 years old.

RESULTS

244,776 AD and matched non-AD patients were selected. The prevalence and incidence of type 2 inflammatory diseases were higher among AD patients. Overall, the prevalence more than doubled for asthma, eosinophilic esophagitis, urticaria, and rhinitis, and increased with AD severity.

LIMITATIONS

AD identification based on billing diagnoses; observation period of only 12 months; limited to commercially insured patients CONCLUSION: The burden of type 2 inflammatory diseases in pediatric AD patients is substantial, highlighting the need to optimize management of AD and its numerous associated morbidities.

Insulin Resistance and Metabolic Syndrome in Patients with Seborrheic Dermatitis: A Case-Control Study

Background: Our knowledge of the systemic effects of seborrheic dermatitis (SD) as a chronic inflammatory skin disease remains limited. We aimed to evaluate metabolic syndrome (MS) and glucose metabolism disorders in patients with SD. Methods: The study includes 53 patients over the age of 18 diagnosed with SD and 50 age-, gender-, and body mass index-matched healthy controls. Demographic data, anthropometric measurements, blood pressure levels, family history of SD and metabolic disorder, smoking history, and severity of the disease in SD patients were obtained. Fasting plasma glucose, insulin, hemoglobin A1c, lipid profile levels, and two-hour plasma glucose in the oral glucose tolerance test (OGTT 2-h PG), homeostasis model assessment of insulin resistance (HOMA-IR), and presence of MS were determined. Results: Weight, waist circumference, family history of SD, family history of metabolic disorder, and smoking status were significantly higher in the SD group compared with the control group (P = 0.04, P = 0.007, P = 0.004, P = 0.004, and P = 0.048, respectively). The levels of fasting plasma insulin and triglyceride, HOMA-IR and OGTT 2-h PG were also significantly higher in the SD group than in the control group (P = 0.0001, P = 0.033, P = 0.0001, and P = 0.049, respectively). In addition, the number of those with insulin resistance was significantly higher in the group with SD (n = 31, 58.49%) than in the control group (n = 11, 22%) (P = 0.0001). Although the rate of MS was higher in patients with SD (n = 12, 22.64%) than the controls (n = 6, 12%), the difference was not significant (P = 0.155). Conclusion: Our findings suggest an association between SD and insulin resistance, which may be due to their common inflammatory pathogenesis. This may be an indicator of susceptibility to diabetes, and these patients can be followed up for conditions associated with insulin resistance and encouraged to adopt a healthy lifestyle.

New Insights and Treatments in Atopic Dermatitis

Atopic dermatitis is a complex, chronic inflammatory skin disorder with significant morbidity. It is often a frustrating condition for both children and parents due to chronic and relapsing course. There is now an increasing understanding of the disease pathogenesis resulting in discovery of much wanted newer therapeutics and targeted therapies after a long time. Whether these interventions will result in sustained benefits or long term cure remains to be seen.

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.

Local and Systemic Changes in Lipid Profile as Potential Biomarkers for Canine Atopic Dermatitis

Lipids play a critical role in the skin as components of the epidermal barrier and as signaling and antimicrobial molecules. Atopic dermatitis in dogs is associated with changes in the lipid composition of the skin, but whether these precede or follow the onset of dermatitis is unclear. We applied rapid lipid-profiling mass spectrometry to skin and blood of 30 control and 30 atopic dogs. Marked differences in lipid profiles were observed between control, nonlesional, and lesional skin. The lipid composition of blood from control and atopic dogs was different, indicating systemic changes in lipid metabolism. Female and male dogs differed in the degree of changes in the skin and blood lipid profiles. Treatment with oclacitinib or lokivetmab ameliorated the skin condition and caused changes in skin and blood lipids. A set of lipid features of the skin was selected as a biomarker that classified samples as control or atopic dermatitis with 95% accuracy, whereas blood lipids discriminated between control and atopic dogs with 90% accuracy. These data suggest that canine atopic dermatitis is a systemic disease and support the use of rapid lipid profiling to identify novel biomarkers.

Cardiovascular comorbidities of atopic dermatitis: using National Health Insurance data in Korea

Background

It is well known that atopic dermatitis (AD) is associated with other allergic diseases. Recentely, links to diseases other than allergic disease have also been actively studied. Among them, the results of studies regarding AD comorbidities, especially cardiovascular disease (CVD), have varied from country to country.

Objective

To analyze whether the risk of CVD is different between AD patients and healthy controls using Korean National Health Insurance Data.

Methods

We obtained data from 2005 to 2016 from the Korean National Health Insurance Research Database. Patients with one AD code and two AD-related tests codes were selected as AD patients, and age-and sex-matched controls to the AD patients were selected from among those without AD (1:5). Each group was investigated for accompanying metabolic syndrome (which contains hypertension, type 2 diabetes, and hyperlipidemia) and CVD (angina, myocardial infarction, peripheral vascular disease, and stroke) using ICD 10 codes.

Results

The incidence of metabolic diseases and CVD were significantly different between the AD and control groups. Using multivariable Cox regression, differences were adjusted for sex, age, and other CVD and metabolic diseases. As a result, not only metabolic disease, but also the CVD risk of AD patients was significantly higher than that of the control group. Patients with AD had as significantly higher risk of hyperlipidemia (hazard ratio [HR] = 33.02, p < 0.001), hypertension (HR = 4.86, p < 0.001), and type 2 diabetes (HR = 2.96, p < 0.001). AD patients also had a higher risk of stroke (HR = 10.61, p < 0.001), myocardial infarction (HR = 9.43, p < 0.001), angina (HR = 5.99, p < 0.001), and peripheral vascular disease (HR = 2.46, p < 0.001). Besides hyperlipidemia, there was no difference in risk according to AD severity.

Conclusion

Patients with AD have a greater risk of CVD than those without AD.

Fracture risks in patients with atopic dermatitis: A nationwide matched cohort study

BACKGROUND

The risk of osteoporosis has been explored in atopic dermatitis (AD). The long-term risk of fractures in patients with AD and the effects of various AD treatments on bone health remain to be elucidated.

OBJECTIVE

To evaluate the long-term risk of fractures in patients with AD.

METHODS

This nationwide matched cohort study was conducted using the National Health Insurance Research Database of Taiwan for the period 1997 to 2013. A total of 36,855 patients with AD and 147,420 reference subjects without AD were identified. Demographic characteristics and comorbidities were compared, and cumulative incidence of fractures was evaluated. Adjusted hazard ratios for fracture risks of AD and various AD treatments were calculated using the Cox proportional hazards model.

RESULTS

A total of 1518 patients (4.12%) in the AD cohort and 5579 patients (3.78%) in the reference cohort had fractures (P = .003). The mean ages were 22.6 years in both groups. The 16-year cumulative incidence of fractures in the AD cohort (8.043%) was significantly higher than that in the reference cohort (7.366%) (P = .002). Severe AD (adjusted hazard ratio [aHR], 1.31; 95% confidence interval [CI], 1.08-1.59) was independently associated with fractures. Other independent risk factors included exposure to topical (aHR, 1.21; 95% CI, 1.05-1.39) or systemic (≥10 mg/d; aHR, 1.62; 95% CI, 1.38-1.91) corticosteroids. Use of disease-modifying antirheumatic drugs (aHR, 0.71; 95% CI, 0.53-0.90) and phototherapy (aHR, 0.73; 95% CI, 0.56-0.95) was associated with a lower risk of fractures. The results were consistent across sensitivity analyses.

CONCLUSION

Patients with AD have a higher incidence of fractures. Severe AD is independently associated with fractures.

Transient and reversible reduction of stratum corneum filaggrin degradation products after allergen challenge in experimentally mite-sensitised atopic dogs

BACKGROUND

A defective skin barrier occurs in dogs with atopic dermatitis, and there is controversy over whether this defect pre-exists, or is secondary to allergic inflammation.

OBJECTIVES

To study if an allergen challenge decreases the natural moisturising factor (NMF), which contains the main filaggrin degradation products.

ANIMALS

Four house dust mite (HDM)-sensitised adult atopic dogs from a research colony.

METHODS AND MATERIALS

Dogs were challenged epicutaneously with HDMs on the right lateral abdomen while the left thorax served as control. We swabbed the skin surface before, and at days (D)1, D2, D3, D7 and D28 after challenge, on both selected sites; swabs were soaked in detergent and frozen until assayed. The NMF components were measured by liquid chromatography-tandem mass spectrometry (LC/MS-MS).

RESULTS

The allergen challenge induced moderate skin lesions at the application sites, and also mild erythema at the control areas. The allergen provocation led to significant decreases in the total NMF and its components trans-urocanic acid (t-UCA), pyrrolidone carboxylic acid (PCA) and serine on both sites. Lesion scores abated by D7 and the NMF concentrations had re-increased by D28. Skin lesion scores correlated negatively with the total NMF, t-UCA and PCA concentrations.

CONCLUSIONS AND CLINICAL IMPORTANCE

In this experimental model, a single epicutaneous allergen challenge led to a transient and reversible decrease in skin surface NMF and its components, and concentrations were negatively correlated with skin lesion scores. These observations suggest that some of the skin barrier anomalies seen in atopic dogs likely develop secondarily to the underlying cutaneous allergic inflammation.

The Use of Real-World Data to Evaluate the Association Between Atopic Dermatitis and Cardiovascular Disease: A Retrospective Claims Analysis

INTRODUCTION

Atopic dermatitis (AD) is a systemic inflammatory condition that may increase the risk of cardiovascular disease (CVD); however, ongoing debate exists surrounding its direct association. We aimed to elucidate whether AD contributes to a higher incidence of CVD and major adverse cardiovascular events (MACE) in adult patients with AD, independent of metabolic disorders.

METHODS

We retrospectively analyzed a large US-based population of patients with AD (≥ 18 years of age). Logistic regression estimated the risk of CVD and MACE in adult patients with AD, independent of metabolic disorders (including diabetes, hypertension, and obesity).

RESULTS

The odds ratio (OR; 95% confidence interval [CI]) for patients without metabolic disorders was 1.25 (1.13, 1.39) for CVD and 1.22 (1.01, 1.47) for MACE. The OR (95% CI) for AD patients with metabolic disorders was 1.09 (1.07, 1.12) for CVD and 1.14 (1.09, 1.18) for MACE. This trend was even more pronounced after long-term follow-up (≥ 3 years). Lifestyle and health behavioral factors of the subjects were not available in the dataset. The lack of control for these factors could potentially confound our results.

CONCLUSIONS

Atopic dermatitis may contribute to the risk of developing CVD and MACE in adults, independent of metabolic disorders.

Optimization of approaches to the management of adult patients with severe atopic dermatitis: analysis of real clinical practice outcomes

Atopic dermatitis (AD) is a multifactorial genetically determined immune-mediated skin disease. It is difficult to treat and significantly affects patients quality of life. The development of an integrated approach focusing on atopic multimorbidity, implementation of validated control tools and distinction of clinical parameters specific for different phenotypes of severe forms of disease is especially relevant to patients resistant to standard therapy techniques. Dupilumab, a biologic, is approved for the treatment of the resistant group of patients with moderate to severe AD in the Russian Federation. Dupilumab inhibits the functions of two key cytokines of T2-mediated inflammation IL-4 and IL-13. The article presents personal experience of the authors concerning individual approach to the choice of therapy for the management of this cohort of patients in routine clinical practice. The disease aggravating criteria were determined, which are fundamental for the formation of individual patient portrait for the biologic (dupilumab) treatment for severe AD.

Mimics of Dermatitis

Dermatitis is a common condition frequently encountered by dermatologists. The diagnosis of dermatitis can be challenging because this condition is often multifactorial, and many skin diseases that can mimic dermatitis should be considered in the differential diagnosis. It is important to recognize and be familiar with these conditions because some of them can represent signs of systemic disease or malignancies and misdiagnosis can lead to mismanagement and adverse outcomes for the patient.

Association between Atopic Dermatitis and Hypertension: A Systematic Review and Meta-Analysis

BACKGROUND

Previous studies found conflicting results about the association of atopic dermatitis (AD) with hypertension.

OBJECTIVES

Determine whether AD and AD severity are associated with hypertension.

METHODS

A systematic review was performed of published studies in MEDLINE, EMBASE, Scopus, Web of Science, and GREAT databases. At least 2 reviewers conducted title/abstract, full-text review, and data extraction. Quality of evidence was assessed using the Newcastle-Ottawa Scale.

RESULTS

Fifty-one studies met inclusion criteria; 19 had sufficient data for meta-analysis. AD was associated with higher odds of hypertension compared to healthy controls (increased in 9 of 16 studies; pooled prevalence: 16.4% vs 13.8%; random-effects regression, pooled unadjusted odds ratio [OR][95% confidence interval <CI95>]: 1.16 [1.04-1.30]), but lower odds of hypertension compared to psoriasis (decreased in 5 of 8 studies; 15.4% vs 24.8%; 0.53 [0.37-0.76]). In particular, moderate-severe AD were associated with hypertension compared to healthy controls (increased in 4 of 6 studies; 24.9% vs 14.7%; 2.33 [1.10-4.94]). Hypertension was commonly reported as an adverse-event secondary to AD treatments, particularly systemic cyclosporine A. Limitations include lack of longitudinal studies or individual-level data and potential confounding.

CONCLUSIONS

AD, particularly moderate-to-severe disease, was associated with increased hypertension compared to healthy controls, but lower odds than psoriasis.

DNA Methylation Array Identifies Golli-MBP as a Biomarker for Disease Severity in Childhood Atopic Dermatitis

In this study, we investigated the changes in global methylation status and its functional relevance in childhood atopic dermatitis (AD). Differences in epigenome-scale methylation events in peripheral blood associated with childhood AD were screened using DNA methylation arrays of 24 patients with AD compared with 24 control subjects. Of the 16,840 differentially methylated CpG regions between AD and control subjects, >97% CpG loci revealed hypomethylation in patients with childhood AD. Among the globally hypomethylated loci, we identified two CpG clusters within the golli-mbp locus of the MBP gene, which was functionally enriched by subnetwork enrichment analysis as an orchestrator among associated genes. The differential hypomethylation of the top-ranked cg24700313 cluster in the golli-mbp locus was validated by pyrosequencing in an independent cohort of 224 children with AD and 44 control subjects. DNA methylation was found to be negatively correlated with disease severity but showed no significant correlation with IgE levels after age adjustment. The multivariate correlation analysis represents a higher score in AD intensity with significantly increased IgE levels and decreased methylation levels in cg27400313. We concluded that methylation loss in the golli-mbp locus is an epigenetic factor associated with disease severity of childhood AD.

So close, and yet so far away: The dichotomy of the specific immune response and inflammation in psoriasis and atopic dermatitis

Characterization of the complex interplay between cytokines, chemokines and microorganisms has led to a better understanding of the pathogenesis of both psoriasis and AD and resulted in new therapeutics targeting distinct immune responses. Psoriasis and AD share many characteristics: they are highly prevalent, chronic, cause primarily skin inflammation, but are associated with comorbidities, and come with a devastating quality of life due to itch and stigmatization. However, the pathogenesis of psoriasis and AD is opposing - psoriasis is dominated by a Th17 immune response that causes neutrophil migration, induction of innate immunity and exaggerated epithelial metabolism. Leading cytokines of this Th17 immune response are IL-17A and F, IL-22 and TNF-a. AD is characterized by Th2 immunity characterized by the signature cytokines IL-4 and IL-13 leading to an impaired epidermal barrier, dampened innate immunity and eosinophil migration. This review compares genetics, microbiome and T-cell infiltrate and resulting epithelial response in psoriasis and AD. Whilst the antagonistic course of psoriasis and AD is confirmed by response to specific biologics targeting the key cytokines of inflammation in psoriasis and AD, respectively, clinically overlapping phenotypes are challenging in our daily clinical practice. We conclude this review by summarizing what is known about these mixed phenotypes and how the identification of clinically relevant endotypes and molecular-driven decision-making is the next step in the field of dermato-immunology.