New insights into the epidemiology of childhood atopic dermatitis

Diagnostic Models for Atopic Dermatitis Based on Serum Microbial Extracellular Vesicle Metagenomic Analysis: A Pilot Study

PURPOSE

Associations between a wide variety of diseases and the microbiome have been extensively verified. Recently, there has been a rising interest in the role the microbiome plays in atopic dermatitis (AD). Furthermore, metagenomic analysis of microbe-derived extracellular vesicles (EVs) has revealed the importance and relevance of microbial EVs in human health.

METHODS

We compared the diversity and proportion of microbial EVs in the sera of 24 AD patients and 49 healthy controls, and developed a diagnostic model. After separating microbial EVs from serum, we specifically targeted the V3-V4 hypervariable regions of the 16S rDNA gene for amplification and subsequent sequencing.

RESULTS

Alpha and beta diversity between controls and AD patients both differed, but only the difference in beta diversity was significant. Proteobacteria, Firmicutes, and Bacteroidetes were the dominant phyla in healthy controls and AD patients, accounting for over 85% of the total serum bacterial EVs. Also, Proteobacteria, Firmicutes, Actinobacteria, Verrucomicrobia, and Cyanobacteria relative abundances were significantly different between the AD and control groups. At the genus level, the proportions of Escherichia-Shigella, Acinetobacter, Pseudomonas, and Enterococcus were drastically altered between the AD and control groups. AD diagnostic models developed using biomarkers selected on the basis of linear discriminant analysis effect size from the class to genus levels all yielded area under the receiver operating characteristic curve, sensitivity, specificity, and accuracy of value 1.00.

CONCLUSIONS

In summary, microbial EVs demonstrated the potential in their use as novel biomarkers for AD diagnosis. Therefore, future work should investigate larger case and control groups with cross-sectional or longitudinal clinical data to explore the utility and validity of serum microbiota EV-based AD diagnosis.

Genetic predisposition and environmental factors associated with the development of atopic dermatitis in infancy: a prospective birth cohort study

The influence of environmental factors on atopic dermatitis (AD) has been investigated in many cross-sectional studies. It remains however unclear if they could influence AD development early in life. This prospective birth cohort study aimed to monitor aspects of family lifestyle and child's nutrition within a Caucasian population and to assess its association with AD development over the first 2 years of life. Genetic predisposition was evaluated based on family history and profilaggrin genotyping. Of 149 included children, 36 developed AD. Infants with a family history of atopy developed AD 2.6 times more frequently (30 of 97) than infants without atopic predisposition (6 of 52). Genotyping was carried out on 50% of the children included. Profilaggrin mutations (R501X, 2282del4, R2447X, and S3247X) were infrequent in our population. Lower incidence of AD was observed in infants exposed to a damp housing environment, lower household income, and smoking mothers with a higher but not with a lower education level.Conclusion: Family history of atopy was a significant risk factor for AD regardless of the most common, currently defined, FLG mutations. Humidity at home and passive smoking seem associated with AD development in infancy. What is Known: • Atopic dermatitis (AD) is associated with mutations in various genes of the immune system and the epidermal barrier complex in particular filaggrin (FLG) mutation. • Inherited factors alone cannot explain the rising AD; environmental factors are therefore likely to play a decisive role in this rise but the exact role that these factors may play in increasing AD risk in infancy remains unclear. Moreover, the relationship between environmental factors and AD has been the focus of mostly cross-sectional studies and not prospective studies. What is New: • This prospective birth cohort study demonstrates that family history of atopy is a significant risk factor for AD regardless of the most common, currently defined, FLG mutations. • A lower incidence of AD was observed in infants exposed to a moist housing environment, lower household income, and smoking of mothers with a higher but not with a lower education level.

Analisi costo-utilità di dupilumab per il trattamento della dermatite atopica grave negli adulti in Italia

Background:

Atopic dermatitis (AD) is a chronic, multifactorial, inflammatory skin disease with significant impact on patients’ quality of life.

Objective:

The objective of this analysis was to estimate the incremental cost-utility ratio (ICUR) of dupilumab, administered every other week, plus supportive care (SC), vs SC, in the Italian adult population with severe AD, for whom ciclosporin treatment is contraindicated, ineffective or not tolerated.

Methods:

Simulation of outcomes and costs was conducted using a 1-year decision tree, followed by a lifetime horizon Markov model. Clinical data were derived from a pooled analysis of two studies. The analysis was conducted adopting the Italian National Health Service (NHS) perspective. In the model, the following costs were considered: i) Drug acquisition costs; ii) Disease management costs; iii) Costs of adverse events. Robustness of findings was tested using both one-way deterministic and probabilistic sensitivity analyses.

Results:

In the base case, dupilumab plus SC was more effective than SC (+2.42 quality adjusted life years, QALYs). The total lifetime cost per patient treated with dupilumab was higher than SC (€ 137,267 and € 56,744, respectively). Dupilumab plus SC was cost-effective vs. SC, with an ICUR of € 33,263 per QALY gained. The ICUR fell in the informal range of ICUR acceptability proposed for Italy (range: € 25,000-€ 40,000 per QALY gained). Sensitivity analyses confirmed robustness and reliability of base case results.

Conclusions:

Dupilumab plus SC is a cost-effective option for the treatment of patients with severe AD in Italy, compared with SC, when NHS perspective is considered.

Associations of ambient air pollutants with airway and allergic symptoms in 13,335 preschoolers in Shanghai, China

Findings are inconsistent in studies for impacts of outdoor air pollutants on airway health in childhood. In this paper, we collected data regarding airway and allergic symptoms in the past year before a survey in 13,335 preschoolers from a cross-sectional study. Daily averaged concentrations of ambient sulphur dioxide (SO₂), nitrogen dioxide (NO₂), and particulate matter with an aerodynamic diameter ≤10 μm (PM₁₀) in the past year before the survey were collected in the kindergarten-located district. We investigated associations of 12-month average concentrations of these pollutants with childhood airway and allergic symptoms. In the two-level (district-child) logistic regression analyses, exposure to higher level of NO₂ and of PM₁₀ increased odds of wheeze symptoms (adjusted OR, 95%CI: 1.03, 1.01-1.05 for per 3.0 μg/m³ increase in NO₂; 1.22, 1.09-1.39 for per 7.6 μg/m³ increase in PM₁₀), wheeze with a cold (1.03, 1.01-1.06; 1.22, 1.08-1.39), dry cough during night (1.05, 1.03-1.08; 1.23, 1.09-1.40), rhinitis symptoms (1.11, 1.08-1.13; 1.32, 1.07-1.63), rhinitis on pet (1.11, 1.05-1.18; 1.37, 0.95-1.98) and pollen (1.12, 1.03-1.21; 1.23, 0.84-1.82) exposure, eczema symptoms (1.09, 1.05-1.12; 1.22, 0.98-1.52), and lack of sleep due to eczema (1.12, 1.07-1.18; 1.58, 1.25-1.98). Exposures to NO₂ and PM₁₀ were also significantly and positively associated with the accumulative score of airway symptoms. Similar positive associations were found of NO₂ and of PM₁₀ with the individual symptoms and symptom scores among preschoolers from different kindergarten-located district. These results indicate that ambient NO₂ and PM₁₀ likely are risk factors for airway and allergic symptoms in childhood in Shanghai, China.

Maternal prenatal stress and infantile wheeze and asthma: The Osaka Maternal and Child Health Study

OBJECTIVE

Some recent studies suggest that maternal prenatal stress (MPS) increases allergic diseases in the children. However, knowledge on this issue in Asian children are lacking. We investigated the association between MPS and the risks of wheeze and asthma in Japanese infants aged 16-24 months.

METHODS

The present subjects were 763 Japanese mother-child pairs. The first, second, and third surveys based on self-administered questionnaires were performed during pregnancy, between 2 and 9 months postpartum, and from 16 to 24 months postpartum, respectively. Data on MPS was obtained in the first survey, using the Stress Inventory (SI), which constructs 12 specific behavioral patterns as response styles to stressors. Data on wheeze and asthma was obtained in the third survey, where wheeze was based on the International Study of Asthma and Allergies in Childhood criteria and asthma was based on doctors' diagnosis.

RESULTS

There were 169 infants with wheeze (22.1%) and 33 infants with asthma (4.3%), at the time of the third survey. Multiple logistic regression analyses found that a maternal behavioral pattern characterized by chronic irritation and anger was associated with the risk of childhood asthma (adjusted odds ratio [OR] = 1.56, 95% confidence interval [CI]: 1.11 to 2.22), but not wheeze (adjusted OR = 1.02, 95%CI: 0.88 to 1.19), while there was no appreciable association between the other SI scales and the risk of childhood wheeze or asthma.

CONCLUSIONS

The results partly supported the hypothesis that MPS might increase the risk of asthma in their infants in Japanese.

Influence of mouth breathing on atopic dermatitis risk and oral health in children: A population-based cross-sectional study

Background/purpose

Previous studies have suggested that mouth breathing has harmful effects on atopic dermatitis (AD) and oral health in children, but the evidence has been insufficient. To investigate the association of mouth breathing with AD and oral health in Korean schoolchildren aged 8–11 years.

Materials and methods

Cross-sectional data were obtained from March to April 2016. A questionnaire was used to investigate children's mouth breathing habits and personal/family histories related to allergic disease. Oral health status was determined through a clinical oral examination. Data were analyzed with multivariable logistic regression.

Results

In total, 1507 children were included. A moderate relationship was observed between mouth breathing and AD (adjusted odds ratio, 1.05; 95% confidence interval, 1.00–1.10; p-value, 0.035), whereas no association was found between mouth breathing and dental caries in children. Mouth breathing during sleep (MBS) was closely related to allergic diseases and other respiratory diseases. Furthermore, mouth breathing was associated with child's tonsillitis and was identified as a possible risk factor for class II dental malocclusion.

Conclusion

We confirmed the positive association between mouth breathing (especially during sleep) and allergic diseases, including the AD in school-aged children. The influence of mouth breathing on dental caries remains uncertain. An intervention trial is required to evaluate whether the prevention of mouth breathing can reduce the risk of allergic diseases.

A comparative case-control study of diagnostic criteria for atopic dermatitis and proposal of new diagnostic criteria from Tunisia

BACKGROUND

Atopic dermatitis (AD) is a heterogeneous disease. Thus, it is difficult to set up standard diagnostic criteria that cover the entire spectrum of AD patients. Our objectives were to study the epidemiologic characteristics of AD in Tunisia and to evaluate five diagnostic criteria (Hanifin and Rajka, Williams, Taieb and Boralevi, REACH and ISAAC questionnaire).

METHODS

This prospective case-control study was carried out in our Dermatology Department in Tunisia. The cases and controls were collected over a period of one year (January 3, 2017, to January 2, 2018).

RESULTS

We collected 101 patients with AD and 101 controls. Patients and controls were comparable by age and gender. The mean age of patients was 9 years and 9 months with sex ratio 1.02. Children accounted for more than half of the patients (61.39%). The sensitivity and specificity of the criteria were, respectively: 90.1% and 90.1% for the Hanifin and Rajka criteria, 53.47% and 96.04% for the Williams criteria, 62.50% and 92.3% for the Taieb and Boralevi criteria, 41.58% and 92.08% for ISAAC questionnaire, 49.5% and 91.09% for REACH questionnaire. A new version of AD diagnostic criteria has been proposed. By applying these new criteria retrospectively to our patients, the sensitivity rises to 90.1%.

CONCLUSION

The new version of AD criteria is a practical diagnostic tool compared to the Hanifin and Rajka criteria and seems to correct the problem of low sensitivity of the Williams criteria. Large validation studies are needed.

Systemic Immunomodulatory Treatments for Patients With Atopic Dermatitis: A Systematic Review and Network Meta-analysis

Importance

Most clinical trials assessing systemic immunomodulatory treatments for patients with atopic dermatitis are placebo-controlled.

Objective

To compare the effectiveness and safety of systemic immunomodulatory treatments for patients with atopic dermatitis in a systematic review and network meta-analysis.

Data Sources

The Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Latin American and Caribbean Health Science Information database, Global Resource of Eczema Trials database, and clinical trial registries were searched from inception to October 28, 2019.

Study Selection

English-language randomized clinical trials of 8 weeks or more of treatment with systemic immunomodulatory medications for moderate to severe atopic dermatitis were included. Titles, abstracts, and articles were screened in duplicate. Of 10 324 citations, 39 trials were included.

Data Extraction and Synthesis

Data were extracted in duplicate, and the review adhered to Preferred Reporting Items for Systematic Reviews and Meta-analyses for Network Meta-Analyses guidelines. Random-effects bayesian network meta-analyses were performed and certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation criteria.

Main Outcomes and Measures

Prespecified outcomes were change in signs of disease, symptoms, quality of life, itch, withdrawals, and serious adverse events.

Results

A total of 39 trials with 6360 patients examining 20 medications and placebo were included. Most trials were conducted for adults receiving up to 16 weeks of therapy. Dupilumab, 300 mg every 2 weeks, was associated with improvement in the Eczema Area and Severity Index score vs placebo (mean difference, 11.3-point reduction; 95% credible interval [CrI], 9.7-13.1 [high certainty]). Cyclosporine (standardized mean difference, -1.1; 95% CrI, -1.7 to -0.5 [low certainty]) and dupilumab (standardized mean difference, -0.9; 95% CrI, -1.0 to -0.8 [high certainty]) were similarly effective vs placebo in clearing clinical signs of atopic dermatitis and may be superior to methotrexate (standardized mean difference, -0.6; 95% CrI, -1.1 to 0.0 [low certainty]) and azathioprine (standardized mean difference, -0.4; 95% CrI, -0.8 to -0.1 [low certainty]). Several investigational medications for atopic dermatitis are promising, but data to date are limited to small early-phase trials. Safety analyses were limited by low event rates.

Conclusions and Relevance

Dupilumab and cyclosporine may be more effective for up to 16 weeks of treatment than methotrexate and azathioprine for treating adult patients with atopic dermatitis. More studies directly comparing established and novel treatments beyond 16 weeks are needed and will be incorporated into future updates of this review.

Effects of gut microbiome and environment on the development of eczema in Chinese infants

BACKGROUND

Eczema is a relapsing and persistent inflammatory skin disease affecting about one-fifth of children worldwide. As in other developed countries, the prevalence of this chronic disease in Hong Kong is approximately 30%. Moreover, the number of local cases reported has been on a rising trend since 1995. Eczema frequently starts in early infancy. A total of 45% of all cases begin within the first six months of life, 60% during the first year and 85% before the age of 5. The pathophysiology of eczema is multi-factorial and is a complex inter-relationship between skin barrier, genetic predisposition, immunologic development, microbiome, environment, nutrition, and pharmacological and psychological factors.

OBJECTIVE

To characterize the longitudinal changes of gut microbial profile in early childhood and to examine the association between gut microbiome diversity, environmental factors and the development of eczema in early childhood.

METHOD

We will conduct a longitudinal cohort study that follows 1250 Hong Kong Chinese infants for 2 years and assess the gut microbiome and other potential environmental factors in the aetiology of eczema. Parents will be asked to provide demographic data, their infant birth data, allergy condition, diet, environmental conditions as well as the data on maternal stress. Stool specimen will be collected for gut microbiome diversity analysis. We will examine newborn infants at enrollment, at 4 months, 1 year and 2 years after birth.

EXPECTED RESULTS

This study will evaluate the association between gut microbiome, environmental factors and the development of eczema in Chinese infants. Findings from this study may be used to develop a predictive path model to guide effective health promotion, disease prevention and management.

Crisaborole Ointment, 2%, for Treatment of Patients with Mild-to-Moderate Atopic Dermatitis: Systematic Literature Review and Network Meta-Analysis

Introduction

There is a need to compare efficacy and safety profiles of crisaborole ointment, 2%, versus other topical treatments across randomized clinical trials (RCTs). We performed this review/network meta-analysis to evaluate the comparative efficacy and safety of crisaborole versus other topical pharmacologic therapies for mild-to-moderate atopic dermatitis (AD) among patients aged ≥ 2 years.

Methods

Searches were conducted in MEDLINE, Embase, the Cochrane Collection Central Register of Clinical Trials, and the Database of Abstracts of Reviews of Effects using Ovid to identify English language articles reporting RCTs of topical anti-inflammatory agents in patients aged ≥ 2 years with mild-to-moderate AD published between inception and 10 March 2020. This review used a prespecified protocol with eligibility criteria for population, interventions, comparisons, outcomes, and study design. Efficacy was evaluated using the Investigator’s Static Global Assessment (ISGA) of clear (0) or almost clear (1) and expressed by hazard ratios (HR) with 95% credible intervals.

Results

Patients treated with crisaborole or tacrolimus ointment, 0.1% or 0.03%, versus vehicle alone were significantly more likely to achieve ISGA 0/1 at 28–42 days, with the greatest point estimate observed for the crisaborole comparison (hazard ratio: 2.07; 95% credible interval 1.76 to − 2.36; probability HR above 1 [p better]: 100.0%). Patients were also more likely to achieve ISGA 0/1 with crisaborole than with pimecrolimus cream, 1% (HR: 1.62; 95% credible interval 1.04–2.48; p better: 98.3%). While network meta-analysis for safety was not feasible because of data limitations, crisaborole pivotal studies (AD-301/AD-302) showed crisaborole was well tolerated.

Conclusions

Crisaborole was shown to be superior to vehicle and pimecrolimus and comparable to tacrolimus, 0.1% or 0.03%, with respect to ISGA 0/1 at 28–42 days in patients aged ≥ 2 years with mild-to-moderate AD. This evaluation of comparative efficacy of crisaborole further supports use of crisaborole as an effective therapeutic option in this population.

Electronic supplementary material

The online version of this article (10.1007/s13555-020-00389-5) contains supplementary material, which is available to authorized users.

Fiction, Falsehoods, and Few Facts: Cross-Sectional Study on the Content-Related Quality of Atopic Eczema-Related Videos on YouTube

Background

In recent years, YouTube has become a recognized source of medical information for health care consumers. Although YouTube has advantages in this context, there are potential dangers as videos may contain nonscientific, misleading, or even harmful information.

Objective

As little is known about YouTube as a source of information on atopic dermatitis (AD), we investigated the content-related quality of AD videos and their perception among YouTube users.

Methods

The quality of the 100 most viewed AD videos was assessed by using the Global Quality Scale (GQS) and the DISCERN instrument. Videos were classified as “useful,” “misleading,” and “potentially harmful,” and the correlations of viewers’ ratings (likes) with the GQS and DISCERN scores were assessed.

Results

Among the 100 videos, 68.0% (68/100) and 62.0% (62/100) were of poor and very poor scientific quality, respectively. Additionally, 32.0% (32/100) of the videos were classified as useful, 48.0% (48/100) were classified as misleading, and 34.0% (34/100) were classified as potentially harmful. Viewers’ ratings did not correlate with the GQS and DISCERN scores. Overall, 50.0% (50/100) of the videos were posted by private individuals and promoters of complementary/alternative treatments, 42.0% (42/100) by therapeutical advertisers, and only 8.0% (8/100) by nonprofit organizations/universities.

Conclusions

Our study demonstrated that two-thirds of the videos analyzed were below acceptable medical quality standards and that many videos were disseminating misleading or even dangerous content. Subjective and anecdotal content was overrepresented, and viewers did not appear to be able to distinguish between high- and low-quality videos. Health promotion strategies by professional medical organizations are needed to improve their presence and visibility on YouTube.

Skin Microbiome Differences in Atopic Dermatitis and Healthy Controls in Egyptian Children and Adults, and Association with Serum Immunoglobulin E

Atopic dermatitis (AD) is a complex, multifactorial, chronic pruritic inflammatory skin disease. We report the first microbiome study and new insights on the relationship between skin microbiota variation and AD susceptibility in a population sample from Egypt. We characterized the skin microbiome in 75 patients with AD and 20 healthy controls using Illumina MiSeq sequencing of 16S rRNA gene. Overall, bacterial diversity of skin microbiome in patients with AD was less than those of the healthy subjects. Genus level analysis revealed significant abundance variations by age, disease severity, locality, or immune response. Among these genera, Streptococcus, Cutibacterium, and Corynebacterium appeared to be specific signatures for AD in children, adolescents, and adults, respectively, while Staphylococcus was noted as a potential biomarker candidate for AD. Additionally, functional potential of metagenomes shifted the overall metabolic pathways to participate in the exacerbation of disease. Total immunoglobulin E (IgE) levels were positively correlated with relative enrichment of certain Staphylococcus aureus subspecies. Finally, AD-related differences in skin bacterial diversity appeared to be in part linked to the serum IgE level. These new observations attest to the promise of microbiome science and metagenomic analysis in AD specifically, and clinical dermatology broadly.

Lower vitamin D levels in the breast milk is associated with atopic dermatitis in early infancy

BACKGROUND

Our previous study showed that the discontinuation of breastfeeding could improve atopic dermatitis (AD) symptoms in exclusively breastfed infants. As vitamins A and D are influential on the immune system, we aimed to analyze the association of vitamin A and D levels in breast milk (BM) with AD.

METHODS

We enrolled two- to four-month-old exclusively breastfed infants. The objective SCORing Atopic Dermatitis (objSCORAD) was evaluated. The lipid layer of BM was extracted and analyzed by liquid chromatography for vitamin A and D levels. Medical charts were reviewed for the clinical course of AD.

RESULTS

Forty-five AD patients and 45 healthy controls were enrolled. The objSCORAD was 20.54 ± 1.73 (shown as mean ± SEM) in the AD group. The sex, parental atopy history, nutrient intake of mothers, and vitamin A levels in BM were not significantly different between the two groups. The 25-(OH) D₃ level in BM was significantly lower in the AD group than in the control group (1.72 ± 0.30 and 3.95 ± 0.64 ng/mL, respectively; P = .001). The 25-(OH) D₃ level negatively correlated with objSCORAD (P = .003). The only factor that is significantly associated with persistent AD is the objSCORAD in infancy (P = .003) after adjusting for age, sex, parental atopy history, and 25-(OH) D₃ level by multiple regression.

CONCLUSION

Vitamin D levels in BM for exclusively breastfed infants were negatively associated with objSCORAD. Lower vitamin D levels in BM might be a risk factor for infantile AD.

Memory Buttons in Combination with Mobile Application-Induced Objective and Subjective Effects in Patients with Atopic Dermatitis

BACKGROUND

Atopic dermatitis (AD) is a chronic skin condition where nonadherence often results in lack of disease control.

OBJECTIVE

We wanted to determine whether the combination of an electronic memory button and a supportive application (app) would affect the Quality of Life and subjective and objective severity measures among AD patients over one month following the patient's normal schedules of treatment.

METHODS

A randomized, investigator-blinded, prospective observational feasibility study for one month where patients diagnosed with AD were randomized based on POEM severity score and divided into 3 groups. The 3 groups were (1) the control group with two consultations, (2) in addition to group 1, patients also received electronic memory buttons to click every time they used their topical products, and (3) in addition to group 2, patients also received an app to track their treatment schedules. At both consultations, patients were evaluated using SCORAD, EASI, POEM, and DLQI.

RESULTS

96 patients were enrolled and randomized, of which 83 patients completed the study. EASI and SCORAD scores were lower in all groups at 2nd consultation (p < 0.05); however, these were highly significant for group 3 (p < 0.05); however, these were highly significant for group 3 (p < 0.05); however, these were highly significant for group 3 (p < 0.05); however, these were highly significant for group 3 (.

CONCLUSION

A reduction in severity following objective assessments of the AD was observed for all groups and was highly significant for patients offered a memory button and the corresponding app. Furthermore, patients reported a significant subjective beneficial effect if they used the memory button and app. This indicates that digital solutions may have a benefit in clinical practice and may reduce nonadherence and increase the wellbeing of the patients.

A Calm, Dispassionate Look at Skin Microbiota in Atopic Dermatitis: An Integrative Literature Review

Atopic dermatitis (AD) is a chronic common inflammatory skin disorder with clinical characteristics of pruritic, dry, and recurrent flares that involve the whole body. Recent studies have demonstrated that the skin microbiota, characterized by an overgrowth of Staphylococcus aureus (S. aureus), plays a critical role in the manifestation of AD. There is striking evidence that skin microbiota can modulate the development and progression of AD. Therefore, more and more therapeutic approaches are adopted for modifying skin microbiota. Here we discuss the role of skin microbiota in the etiology and maintenance of AD; furthermore, we summarize the effects of therapeutic treatments on skin microbiota in AD based on published literature. With the help of the theoretical guidance suggested by microbial metagenome analysis, the reconstitution of microbiota should be a promising way to harness the pathogens of AD and could be used as a brand-new therapeutic strategy in clinical trials. We believe that the targeted therapy of dysbiosis in AD may possibly become a unique approach to an integrated treatment program in the near future.

Epidemiology and direct costs of atopic dermatitis in Poland based on the National Health Fund register (2008-2017)

Introduction

Epidemiological data indicate significant differences in atopic dermatitis (AD) prevalence between countries.

Aim

The purpose of this study is to (i) analyse the recorded prevalence of atopic dermatitis (diagnoses of AD reported to the Polish National Health Fund (NHF)) and to (ii) estimate direct costs of medical care for AD incurred by the NHF.

Material and methods

The analysis was based on data reported to the database of the public payer (NHF). The prevalence rates were calculated using the NHF data and population estimates were obtained from the Central Statistical Office of Poland (GUS).

Results

In 2017, the annual prevalence rate of AD in the Polish population was 32.5 per 10,000 inhabitants (34.7/10,000 for women and 30.1/10,000 for men). The highest prevalence was observed in the youngest age groups (300/10,000 in children up to 4 years of age and 141/10,000 in 5–9-year-olds). The prevalence rate decreased with age and AD was the least prevalent in patients over 85 years of age (4/10,000). In 2008–2017, NHF expenditure on AD treatment varied between PLN 19.9 million (EUR 5.6 million) in 2008 and PLN 28.4 million (EUR 6.5 million) in 2016.

Conclusions

The prevalence rates of AD in Poland estimated on the basis of NHF data are significantly lower than those reported in previous epidemiological studies conducted in Poland and worldwide. This may indicate that the prevalence of AD in the Polish population is underestimated or that there are no adequate disease control measures in patients with a confirmed diagnosis.

Experimental atopic dermatitis is dependent on the TWEAK/Fn14 signaling pathway

Tumor necrosis factor (TNF)-like weak inducer of apoptosis (TWEAK) acts through its receptor fibroblast growth factor inducible 14 (Fn14), and participates in skin inflammation. Both TWEAK and Fn14 are highly expressed in skin lesions of patients with atopic dermatitis. The purpose of this study was to further explore the effect of Fn14 inhibition on experimental atopic dermatitis. Experimental atopic dermatitis was induced in the wild-type and Fn14 knock-out BALB/c mice. The effect of TWEAK/Fn14 interaction on keratinocytes was studied in an in-vitro model of atopic dermatitis. Fn14 deficiency ameliorates skin lesions in the mice model, accompanied by less infiltration of inflammatory cells and lower local levels of proinflammatory cytokines, including TWEAK, TNF-α and interleukin (IL)-17. Fn14 deficiency also attenuates the up-regulation of TNFR1 in skin lesions of atopic dermatitis. Moreover, topical TWEAK exacerbates skin lesion in the wild-type but not in the Fn14 knock-out mice. In vitro, TWEAK enhances the expressions of IL-17, IL-18 and IFN-γ in keratinocytes under atopic dermatitis-like inflammation. These results suggest that Fn14 deficiency protects mice from experimental atopic dermatitis, involving the attenuation of inflammatory responses and keratinocyte apoptosis. In the context of atopic dermatitis-like inflammation, TWEAK modulates keratinocytes via a TNFR1-mediated pathway.

The exposome in atopic dermatitis

Atopic dermatitis (AD) is a complex inflammatory disorder with multiple interactions between genetic, immune and external factors. The sum of external factors that an individual is exposed to throughout their lifetime is termed the exposome. The exposome spans multiple domains from population to molecular levels and, in combination with genetic factors, holds the key to understanding the phenotypic diversity seen in AD patients. Exposomal domains are categorized into nonspecific (human and natural factors affecting populations), specific (eg humidity, ultraviolet radiation, diet, pollution, allergens, water hardness) and internal (cutaneous and gut microbiota and host cell interaction) exposures. The skin, as the organ that most directly interacts with and adapts to the external environment, is a prime target for exploration of exposomal influences on disease. Given the well-recognized physical environmental influences on AD, this condition could be much better understood through insightful exposomal research. In this narrative review, we examine each domain in turn, highlighting current understanding of the mechanisms by which exposomal influences modulate AD pathogenesis at distinct points in time. We highlight current approaches to exposome modification in AD and other allergic disease and propose future directions for exposome characterization and modification using novel research techniques.

Association Between Maternal Perceived Stress in All Trimesters of Pregnancy and Infant Atopic Dermatitis: A Prospective Birth Cohort Study

Background: Currently, most studies indicate that there is a potential link between maternal psychologic stress and the risk of atopic dermatitis (AD) in offspring. However, it is unknown which trimester of pregnancy is most sensitive to maternal stress in terms of risk of infant AD and whether the changes of maternal stress level in different trimesters of pregnancy may be associated with infant AD. In this study, we aimed to investigate the association between maternal perceived stress across three trimesters of pregnancy and AD in infants at 6 months. Methods: A total of 1,638 pregnant women participated in the population-based birth cohort study. Maternal prenatal stress was assessed by self-report questionnaires during each trimester. Infant AD was diagnosed at age 6 months, according to the UK Working Party diagnostic criteria. Univariate and multivariate logistic regression models were used to analyze the association between maternal prenatal stress in each trimester of pregnancy and infant AD. Results: Maternal perceived stress in the 2nd trimester was associated with AD in infants at 6 months (aOR 1.56; 95% CI 1.08-2.25, P = 0.019). Furthermore, increased level of perceived stress from the 1st to the 2nd trimester (aOR 2.05, 95% CI 1.33-3.15, P = 0.001) and from the 1st to the 3rd trimester (aOR 1.92, 95% CI 1.22-3.00, P = 0.004) were also associated with the risk of infant AD at 6 months. Conclusion: A high level of maternal perceived stress in the 2nd trimester and increased level of perceived stress from the 1st to the 2nd and 3rd trimesters of pregnancy may increase the risk of offspring developing AD at 6 months.

Relationship Between Atopic Dermatitis and Food Allergy

Consistent evidence has been found on the relationship between food allergy (FA) and atopic dermatitis (AD) in some children. Food sensitization can be often found in these patients. Allergy should be confirmed, though, with a food challenge test (FC) before advising a restrictive diet which could be harmful for the patient. Younger children with AD frequently show sensitization to egg, milk or peanut, while older ones and adults are more often sensitized to environmental allergens such as house dust mites, moulds, animal dander or pollens. It is well known that a barrier disturbance plays a main role in the development of sensitization and allergy. Therefore, due to the early appearance of AD, preventive newborn skincare with emollients and early introduction of food appear to be very important to determine food tolerance.

Taeumjowi-tang, a Traditional Korean Sasang Remedy, Improves Obesity-Atopic Dermatitis Comorbidity by Regulating Hypoxia-Inducible Factor 1 Alpha

Atopic dermatitis (AD) is an inflammatory disease of the skin, resulting from an immune dysfunction, that often occurs as a comorbidity of obesity. This investigation evaluated the capacity of Taeumjowi-tang (TJT), a Korean herbal formulation from the Sasang medical tradition to influence prognostic features of AD and obesity in a mouse model. Here, obesity and AD were induced by a high-fat diet (HFD) and 1-fluoro-2,4-dinitrobenzene (DNFB). Following an 8-week HFD regimen and 4 weeks of DNFB administration, the comorbid (CO) group manifested increased body weight and AD-like lesions, as compared to normal control (NC) mice, while TJT administration diminished these symptoms of obesity and AD. Specifically, TJT treatment reduced epidermal thickness and eosinophil/mast cell infiltration, along with reduction in immunoglobulin E, interleukin (IL)-4, IL-6, and tumor necrosis factor-alpha (TNF-α). It was additionally demonstrated that TJT suppresses HFD/DNFB-associated increase of the inflammation-related nuclear factor-kappa beta (NF-κB) and mitogen activated protein kinase. Moreover, significantly increased levels of hypoxia inducible factor-1 alpha (HIF-1α) protein was observed in CO group versus controls, an increase significantly down-regulated by TJT-treatment. These outcomes suggest that TJT may prove useful in clinical management of obesity-AD comorbidity treatment, an effect that may be due to regulation of HIF-1α expression.

Association of frequent intake of fast foods, energy drinks, or convenience food with atopic dermatitis in adolescents

PURPOSE

Specific food consumption, besides food allergy, may aggravate atopic dermatitis (AD). However, previous reports on the association between AD and food intake in adolescents are scarce. The aim of this study was to determine the relationship between AD and specific food consumption frequency in adolescents.

METHODS

A cross-sectional analysis using data from the Korea Youth Risk Behavior Web-based Survey 2017 was performed. The frequency of food consumption in the recent-diagnosed AD group (AD diagnosed within 12 months) compared to those in the previous-diagnosed AD (AD diagnosed more than 12 months ago) or control group were investigated.

RESULTS

A total of 53,373 participants were eligible for this study. The weighted prevalence of the recent-diagnosed AD and the previous-diagnosed AD was 7.39% and 18.00%, respectively. When compared with subjects with the previous-diagnosed AD, those with the recent-diagnosed AD were significantly more likely to frequently consume fast foods (odds ratio OR 1.405; 95% CI 1.150-1.717), energy drinks (OR 1.457; 95% CI 1.175-1.807), or convenience food (OR 1.304; 95% CI 1.138-1.495). Patients of the recent-diagnosed AD were significantly more likely to frequently consume fast foods (OR 1.374; 95% CI 1.155-1.634) than the control group. The differences in the frequency of specific food consumption among groups were more pronounced in high school students than in middle school students.

CONCLUSIONS

Frequent intake of fast foods, energy drinks, and convenience food was related to the recent-diagnosed AD in adolescents. Prospective cohort and interventional studies are needed to identify causal relationships.

The Microbiome and Atopic Dermatitis: A Review

The microbiome is defined as the sum of microbes, their genomes, and interactions in a given ecological niche. Atopic dermatitis is a multifactorial chronic inflammatory skin disease leading to dryness and itchiness of the skin. It is often associated with comorbidities such as allergic rhinoconjunctivitis and asthma. Today, culture-free techniques have been established to define microbes and their genomes that may be both detrimental and beneficial for their host. There are signs that microbes, both on skin and in the gut, may influence the course of atopic dermatitis. Antiseptic treatment has been used for decades, however now, with the help of traditional culture-based methods and modern metagenomics, we are beginning to understand that targeted treatment of dysbiosis may possibly become part of an integrated therapy plan in the future.

Challenging a paradigm: skin sensitivity to sodium lauryl sulfate is independent of atopic diathesis

BACKGROUND

Sodium lauryl sulfate (SLS) is the best-studied detergent in irritant contact dermatitis. In atopic dermatitis, the two major pathophysiological abnormalities concern skin barrier function and regulation of cutaneous immune responses. The probability of atopic skin diathesis can be assessed by comprehensive analysis of patient history, as well as clinical and laboratory findings, resulting in the Erlangen Atopy Score (EAS).

OBJECTIVES

To investigate the impacts of (i) atopic skin diathesis according to the EAS and (ii) the physician-assessed diagnoses 'atopic dermatitis', 'allergic rhinitis' and 'allergic asthma' on SLS skin reactions.

METHODS

This is a retrospective analysis of data from 2030 consecutive patients patch tested with SLS (0·25% aqueous) from two tertiary referral centres in Germany, from 2008 to 2014.

RESULTS

Patients with a high probability of atopic skin diathesis showed no significant increase in positive SLS reactions compared with patients without atopic skin diathesis (14·2% vs. 16·8%). The grading of positive SLS skin reactions (1-4) revealed no differences in patients with or without atopic skin diathesis. Furthermore, diagnoses of atopic dermatitis, allergic rhinitis or allergic asthma had no impact on positive SLS skin reactions in multivariate logistic regression analysis.

CONCLUSIONS

We found no association of increased skin irritability to SLS with atopic skin diathesis, atopic dermatitis, allergic rhinitis or allergic asthma in a large patient cohort. It therefore seems that the test of skin irritability with SLS, which is currently common practice in many centres, does not allow prediction of susceptibility to irritant eczematous inflammation in atopic vs. nonatopic individuals. What's already known about this topic? Irritant contact dermatitis and atopic skin diathesis share impaired skin barrier function as a pathophysiological pattern. Sodium lauryl sulfate (SLS) is tested at 0·25% aqueous as an irritant control in patch testing, and hence the results might be affected by atopic skin diathesis. What does this study add? Challenging a long-standing paradigm, we found no association of increased reactivity to SLS patch tests in individuals with atopic skin diathesis, atopic dermatitis, allergic rhinitis or allergic asthma in a large patient cohort. Thus, irritant control testing with SLS, which is useful in interpreting doubtful allergen patch test results, does not depend on individual atopy status.

Breastfeeding duration modifies the effect of smoking during pregnancy on eczema from early childhood to adolescence

BACKGROUND

Cigarette smoke contains compounds similar to coal tar, an ancient remedy of eczema. Some studies have reported protective effects of maternal gestational smoking on offspring eczema; however, others have shown no or increased risks. Similarly, studies linking breastfeeding duration and eczema have demonstrated contradictory findings. No study has yet investigated combined effects of these two factors on eczema.

OBJECTIVE

Since tobacco compounds can pass to offspring via breast milk, we investigated their combined effects on eczema development from childhood to adolescence.

METHODS

We obtained information regarding gestational smoking, exclusive breastfeeding duration, and eczema at ages 1-or-2, 4, 10, and 18 years from the Isle of Wight (IOW) birth cohort, UK. Using generalized estimating equations, we assessed the interaction of gestational smoking and residual exclusive breastfeeding duration (Resid-BF-duration, obtained by regressing the latter on maternal smoking) on eczema over time adjusting for confounders. For the three transition periods of 1-or-2 to 4 years, 4-10, and 10-18 years, we estimated risks of persistent, incident, and remitting eczema associated with the interaction using repeated measurements.

RESULTS

If the mother smoked during gestation, longer Resid-BF-duration was associated with a lower risk of eczema, compared to if she did not smoke. The risk ratios (95% CI) if the mother smoked during gestation and exclusively breastfed for at least 3, 9, 15, 21 weeks are 0.7 (0.6, 1.7), 0.6 (0. 4, 0.9), 0.5 (0.3, 0.8), and 0.4 (0.2, 0. 8), respectively. Additionally, in all three transition periods, the risk of persistent eczema was lower with longer Resid-BF-duration if the mother smoked during gestation.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest a protective effect of gestational smoking combined with longer duration of exclusive breastfeeding on early-onset persistent eczema. Future studies should examine underlying biological mechanisms. Prolonged breastfeeding should be encouraged even if the mother smoked during gestation.

Frequent Versus Infrequent Bathing in Pediatric Atopic Dermatitis: A Randomized Clinical Trial

BACKGROUND

Studies evaluating bathing frequency in pediatric atopic dermatitis (AD) are limited. Parents of children with AD often receive conflicting information, leading to frustration and confusion.

OBJECTIVE

To evaluate efficacy of twice-daily soaking baths, followed by immediate application of an occlusive moisturizer (ie, soak-and-seal [SS]), versus twice-weekly SS baths, in the acute management of pediatric AD.

METHODS

We conducted a randomized, single-blind, crossover-controlled trial comparing frequent versus infrequent SS baths, in children 6 months to 11 years of age with moderate-to-severe AD. Children were randomized 1:1 into 2 groups: group 1 underwent twice-weekly SS baths, for 10 minutes or less, over 2 weeks ("dry method" [DM]) followed by twice-daily SS baths, for 15 to 20 minutes, over 2 weeks ("wet method" [WM]). Group 2 did the inverse. Patients received the same moisturizer, cleanser, and low-potency topical corticosteroid (TCS). Primary outcome was AD severity evaluated using the SCORing Atopic Dermatitis (SCORAD) index. Caregiver assessment of AD severity (Atopic Dermatitis Quickscore [ADQ]), quality of life, Staphylococcal aureus colonization, skin hydration, moisturizer, and TCS usage were assessed.

RESULTS

Of the 63 children screened, 42 fulfilled inclusion criteria and were randomized. Forty (95%) completed the study. WM decreased SCORAD by 21.2 compared with DM (95% confidence interval [CI], 14.9-27.6; P < .0001). Secondary analysis showed a greater than 30% SCORAD improvement for WM versus DM (McNemar's χ² = 8.83, df = 1, P = .0030). SCORAD correlated with ADQ (r = 0.66), and ADQ also showed significant improvement with WM decreasing ADQ by 5.8 (95% CI, 1.8-9.7). No other secondary endpoints showed significance.

CONCLUSIONS

As an acute treatment intervention, WM is superior to DM at improving disease severity in moderate-to-severe pediatric AD.

The innate immune perspective of autoimmune and autoinflammatory conditions

Innate immunity is one of two immune defence system arms. It is present at birth and does not require 'learning' through exposure to foreign organisms. It activates various mechanisms collectively to eliminate pathogens and hold an infection until the adaptive response are mounted. The innate immune system consists of four elements: the epithelial barrier, cells (e.g. macrophages, NK cells), plasma proteins (e.g. complement) and cytokines. These components act in concert to induce complex processes, as well as recruitment, activation and differentiation of adaptive responses. The innate response is more than just the 'first line of defence', as it essentially withholds the vast majority of any intruder, has a complex interplay with the adaptive arm and is crucial for survival of the host. Finally, yet importantly, a myriad of diseases has been linked with innate immune dysregulation. In this mini-review we will shed some light on these conditions, particularly regarding autoinflammatory ones.

Application of lipidomics to reveal differences of facial skin surface lipids between atopic dermatitis and healthy infants

BACKGROUND

The current knowledge about potential risk factors for atopic dermatitis (AD) is primarily based on the structure and function of the stratum corneum, which is characterized by osmotic defects and abnormal antibacterial function. There are no studies on the difference between facial lipids in infants with AD and healthy infants.

AIMS

We sought to explore significantly different lipid markers for infants with AD presenting with lesions and healthy infants aged 0-2 years to guide treatment strategies.

METHODS

Twenty-eight patient infants with AD and 32 healthy infants were recruited. Each infant received its surface skin lipids (SSL) on the right cheek. The components of skin lipids were measured by ultra-performance liquid chromatography-quadrupoletime-of-flight mass spectrometry (UPLC-Q-TOF-MS) to explore significantly different lipid markers by analyzing the detection results using orthogonal partial least squares analysis(OPLS-DA).

RESULTS

There were clear distinctions in the components of SSL between the two groups. Twenty-nine significantly different lipid markers (P ≤ .05) were found.

CONCLUSION

This study confirmed that there were significant differences in the components of the SSL between AD infants with lesions and healthy infants, but also found lipid types, lipid contents, and lipid structures as AD-related risks.

The role of filaggrin in atopic dermatitis and allergic disease

OBJECTIVE

To provide an overview of filaggrin biology and the role of filaggrin variants in atopic dermatitis (AD) and allergic disease.

DATA SOURCES

We performed a PubMed literature review consisting mainly of studies relating to filaggrin in the last 5 years.

STUDY SELECTIONS

We selected articles that were found in PubMed using the search terms filaggrin, atopic dermatitis, skin barrier, and atopy.

RESULTS

Filaggrin plays an important role in the development of AD and allergic disease. Novel methods in measuring filaggrin expression and identifying filaggrin mutations aid in stratifying this patient cohort. We review new insights into understanding the role of filaggrin in AD and allergic disease.

CONCLUSION

Filaggrin remains a very important player in the pathogenesis of atopic dermatitis and allergic disease. This review looks at recent studies that aid our understanding of this crucial epidermal protein.

Protocol for an outcome assessor-blinded pilot randomised controlled trial of an ion-exchange water softener for the prevention of atopic eczema in neonates, with an embedded mechanistic study: the Softened Water for Eczema Prevention (SOFTER) trial

INTRODUCTION

Atopic eczema affects 20% of UK children, and environmental factors are important in its aetiology. Several observational studies suggest an increased risk of atopic eczema in children living in hard water areas. The Softened Water for Eczema Prevention pilot trial tests the feasibility of installing domestic ion-exchange water softeners around the time of birth to reduce the risk of atopic eczema in children with a family history of atopy. A further aim is to explore the pathophysiological mechanisms for this in an embedded mechanistic study.

METHODS AND ANALYSIS

Multicentre parallel group assessor-blinded randomised controlled pilot trial. Participants are newborn babies (n=80) living in a hard water (>250 mg/L calcium carbonate) area at risk of developing atopic eczema because of a family history of atopy. Participants will be randomised prior to birth in a 1:1 ratio. The intervention group will have an ion-exchange water softener installed prior to birth. The control group will receive their usual domestic hard water supply. Follow-up will be until 6 months of age. Data will be collected at birth (baseline), 1, 3 and 6 months of age. The main outcome is the proportion of eligible families screened who are willing and able to be randomised. Several secondary feasibility and clinical endpoints will also be evaluated, alongside mechanistic outcomes. Data will be analysed on an intention-to-treat basis. There will be no hypothesis testing for the clinical outcomes. Study acceptability will be evaluated through semistructured interviews.

ETHICS AND DISSEMINATION

This study has been reviewed and given a favourable opinion by the North West-Liverpool East Research Ethics Committee (Ref: 17/NW/0661). The results of the study will be reported at international conferences and in peer-reviewed scientific journals. We will send participating families a summary of the pilot trial results.

TRIAL REGISTRATION NUMBER

NCT03270566.

Therapeutic Potential of Hematopoietic Prostaglandin D2 Synthase in Allergic Inflammation

Worldwide, there is a rise in the prevalence of allergic diseases, and novel efficient therapeutic approaches are still needed to alleviate disease burden. Prostaglandin D₂ (PGD₂) has emerged as a central inflammatory lipid mediator associated with increased migration, activation and survival of leukocytes in various allergy-associated disorders. In the periphery, the hematopoietic PGD synthase (hPGDS) acts downstream of the arachidonic acid/COX pathway catalysing the isomerisation of PGH₂ to PGD₂, which makes it an interesting target to treat allergic inflammation. Although much effort has been put into developing efficient hPGDS inhibitors, no compound has made it to the market yet, which indicates that more light needs to be shed on potential PGD₂ sources and targets to determine which particular condition and patient will benefit most and thereby improve therapeutic efficacy. In this review, we want to revisit current knowledge about hPGDS function, expression in allergy-associated cell types and their contribution to PGD₂ levels as well as beneficial effects of hPGDS inhibition in allergic asthma, rhinitis, atopic dermatitis, food allergy, gastrointestinal allergic disorders and anaphylaxis.

Phenotypic analysis of atopic dermatitis in children aged 1-12 months: elaboration of novel diagnostic criteria for infants in China and estimation of prevalence

BACKGROUND

Atopic dermatitis (AD) is the most common skin disorder in infancy. However, the diagnosis and definite significance of infantile AD remains a debated issue.

OBJECTIVE

To analyse the phenotypes of AD in infancy, to establish diagnostic criteria and to estimate the prevalence of this condition in China.

METHODS

This is a multicentric study, in which 12 locations were chosen from different metropolitan areas of China. Following careful and complete history-taking and skin examination, the definite diagnosis of AD was made and the severity based on the SCORAD index was determined by local experienced dermatologists. Based on the detailed phenotyping, the major and representative clinical features of infantile AD were selected to establish the diagnostic criteria and evaluate their diagnostic efficacy.

RESULTS

A total of 5967 infants were included in this study. The overall point prevalence of AD was 30.48%. The infantile AD developed as early as at the second month of life, and its incidence peaked in the third month of life at 40.81%. The proportion of mild, moderate and severe AD was 67.40%, 30.57% and 2.03%, respectively. The most commonly seen manifestations in the infantile AD were facial dermatitis (72.07%), xerosis (42.72%) and scalp dermatitis (27.93%). We established the novel diagnostic criteria of infants, which included: (i) onset after 2 weeks of birth; (ii) pruritus and/or irritability and sleeplessness comparable with lesions; and (iii) all two items above with one of the following items can reach a diagnosis of AD: (i) eczematous lesions distributed on cheeks and/or scalp and/or extensor limbs, and (ii) eczematous lesions on any other parts of body accompanied by xerosis.

CONCLUSIONS

In China, the prevalence of AD in infancy is 30.48% according to clinical diagnosis of dermatologists. The novel Chinese diagnostic criteria for AD in infants show a higher sensitivity and comparable specificity.

Efficacy and safety of Soshiho-tang in patients with atopic dermatitis and gastrointestinal disorders: Study protocol for a double-blind, randomized, and placebo-controlled clinical trial

BACKGROUND

Atopic dermatitis (AD) is a chronically relapsing inflammatory skin disease that affects the quality of life in patients with AD. Since there is limitation of conventional treatment of AD, complementary treatment is required to treat AD symptoms more effectively and safely Soshiho-tang (SSHT) is a traditional herbal medicine that exhibits anti-inflammatory and anti-ulcer effects and improves the immune function. In this clinical trial, we will evaluate the efficacy and safety of SSHT in patients with AD and gastrointestinal disorders in comparison with placebo.

METHODS/DESIGN

This study is a single-center, randomized, double-blind, placebo-controlled, and investigator-initiated clinical trial. A total of 60 patients aged 3 to 18 years with AD and gastrointestinal disorders and who received a diagnosis of AD by Hanifin & Rajka criteria with a Scoring Atopic Dermatitis (SCORAD) index between 15 and 49 will be enrolled. Participants will be randomly assigned to the SSHT or placebo group in a ratio of 1:1. Additionally, they will have a visit schedule comprising 4 visits including a screening visit during 8 to 10 weeks. The participants will be administered SSHT or placebo 3 times a day for 4 weeks. The primary outcome will be measured by a change of the SCORAD index. The secondary outcome measures include the following: survey questionnaires for the perception of gastrointestinal disorders, amount and frequency of ointment usage for AD, dermatology quality of life index, itchiness and sleep disability score in visual analog scale, percutaneous water loss, skin surface temperature, Hamilton anxiety rating scale, and children's depression inventory.

DISCUSSION

In our knowledge, this will be the first clinical trial to assess the efficacy and safety of SSHT in patients with AD and gastrointestinal disorders. The findings of this study will provide new treatment options for patients with AD and gastrointestinal disorders.

TRIAL REGISTRATION

Korean National Clinical Trial Registry, Clinical Research Information Service. (KCT0003713) https://cris.nih.go.kr/cris/search/search_result_st01_en.jsp?seq=13489<ype=&rtype=.

The impact of airborne pollution on skin

Indoor and outdoor airborne pollutants modify our environment and represent a growing threat to human health worldwide. Airborne pollution effects on respiratory and cardiac health and diseases have been well established, but its impact on skin remains poorly described. Nonetheless, the skin is one of the main targets of pollutants, which reach the superficial and deeper skin layers by transcutaneous and systemic routes. In this review, we report the outcomes of basic and clinical research studies monitoring pollutant levels in human tissues including the skin and hair. We present a current understanding of the biochemical and biophysical effects of pollutants on skin metabolism, inflammatory processes and oxidative stress, with a focus on polyaromatic hydrocarbons and ground-level ozone that are widespread outdoor pollutants whose effects are mostly studied. We reviewed the literature to report the clinical effects of pollutants on skin health and skin ageing and their impact on some chronic inflammatory skin diseases. We also discuss the potential interactions of airborne pollutants with either ultraviolet radiation or human skin microbiota and their specific impact on skin health.

The Role of the Environmental Risk Factors in the Pathogenesis and Clinical Outcome of Atopic Dermatitis

Atopic dermatitis (AD) prevalence is rising worldwide. Literature data suggest the incidence of AD in developing countries is gradually getting close to that of developed ones, in which AD affects 20% of the paediatric population. Such an increment, associated with significant variations in prevalence among the various countries, underlines the importance of environmental factors in the disease onset. Among these, great importance is given to hygiene, intestinal microbiota, exposure to bacterial endotoxins, outdoor living with contact to animals, atmospheric pollution, weather, and diet. Genetic (alteration of the skin barrier function) as well as immunologic factors concur with the environmental ones. Only the systematical study of all these elements can best elucidate AD epidemiology.

Clinical Insights About Topical Treatment of Mild-to-Moderate Pediatric and Adult Atopic Dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin condition, also referred to as atopic eczema, that is identified by itching and recurrent eczematous lesions. It often starts in infancy where it affects up to 20% of children but is also highly prevalent in adults. AD inflicts a significant psychosocial burden on patients and their families and increases the risk of other immune-mediated inflammatory conditions, such as asthma and allergic rhinitis, food allergy, and mental health disorders. It is a lifelong condition associated with epidermal barrier dysfunction and altered immune function. Through the use of emollients and anti-inflammatory agents, current prevention and treatment therapies attempt to restore epidermal barrier function. Acute flares are treated with topical corticosteroids. Topical calcineurin inhibitors (TCIs) and topical corticosteroids (TCSs) are used for proactive treatment to prevent remission. There remains a need and opportunity to improve AD care through future research directed toward an improved understanding of the heterogeneity of the disease and its subtypes, the role of autoimmunity in its pathogenesis, the mechanisms behind disease-associated itch and response to specific allergens, and the comparative effectiveness and safety of therapies.

Early immunologic changes during the onset of atopic dermatitis

OBJECTIVE

Atopic dermatitis (AD), which is commonly called eczema, is the most common chronic inflammatory skin disease. The pipeline of new targeted treatments is currently expanding, a development that is largely based on our increasing understanding of disease mechanisms. Mechanistic insights have long been based on long-standing adult AD. Recently, studies also investigated early pediatric AD at disease onset, and revealed several differences in barrier and immune properties when compared with long-standing adult AD. This review focuses on immunological changes very early in life that predispose to the development of AD, and summarizes characteristics of the molecular AD phenotype in this age group.

DATA SOURCES

Review of published literature.

STUDY SELECTIONS

Studies investigating human AD at disease onset in newborns, toddlers, and young children, in comparison with adults with long-standing disease.

RESULTS

Already in cord blood, increased Th2 and decreased Th1 levels were found to increase the risk of AD development. Both pediatric and adult AD share Th2/Th22 activation and defects in lipid barrier deposition and tight junction formation, but Th1 activation and epidermal differentiation complex defects are largely absent in pediatric AD.

CONCLUSION

Immune changes predisposing to AD development are present very early in life. During the first months of disease, AD shows various differences in immune and barrier properties from long-standing adult AD, which might necessitate tailored treatment approaches depending on the age of the patient.

The prevalence and risk factors of atopic dermatitis in 6-8 year-old first graders in Taipei

BACKGROUND

Despite the advance in the understanding of etiology, pathophysiology and diagnosis of atopic dermatitis (AD), its prevalence has increased annually in Taiwan.

PURPOSES

The purpose of this study is to explore the prevalence, and personal and environmental risk factors of AD.

METHODS

A cross-sectional survey was conducted via health centers of elementary schools in Taipei city. We used the Chinese version of ISAAC questionnaire to examine possible personal and environmental risk factors of AD. Questionnaires were completed by parents or guardians of first graders (6-8 year-old) who agreed to participate in this study. Logistic regression was conducted to examine possible personal and environmental factors related to AD (in early life and currently).

RESULTS

The 12-month prevalence of AD (in the past 12 months) was 10.7% (2683/24,999) among 6- to 8-year-old first graders in Taipei. Forty-five percent of first graders with AD had their first episode of AD symptoms before the age of two. Children with asthma history were 1.65 times (95% CI: 1.51-1.79, p < 0.001) and children with rhinitis were 2.57 times (95% CI: 2.34-2.84, p < 0.001) more likely to have AD than those without the conditions. Compare to their counterarts, children who used antibiotics during their first year of life (OR = 1.37, 95% CI: 1.22-1.53, p < 0.001) and who had bronchiolitis before the age of two (OR = 1.47, 95% CI: 1.33-1.63, p < 0.001) had a higher chance to have AD during the last 12 months of the study. However, receiving breastfeeding for less than 4 months (OR = 0.75, 95% CI: 0.67-0.83, p < 0.001) and having older siblings (OR = 0.83, 95% CI: 0.76-0.92, p < 0.001) had 25% and 17% reduced risks for AD in the 12 months before this study, respectively.

CONCLUSION

Our study verified personal and environmental risk factors of AD in children in Taiwan. Based on the results, we propose that avoiding bronchiolitis before the age of two, using antibiotics properly in babies, and providing diet counseling for breastfeeding mothers may be good prevention strategies of AD.

A new phototherapy regimen during winter as an add-on therapy, coupled with oral vitamin D supplementation, for the long-term control of atopic dermatitis: study protocol for a multicentre, randomized, crossover, pragmatic trial - the PRADA trial

Background

Atopic dermatitis is a highly prevalent, chronic, relapsing disease in both adults and children. On the severity spectrum, lower-end patients benefit from small amounts of topical anti-inflammatory treatments (TAT), whereas higher-end patients need systemic immunosuppressants; in-between patients are treated with TAT and phototherapy. The major therapeutic challenge in this population is the long-term control of disease activity, and the current TAT-based pro-active strategy does not meet all their needs. Immunosuppressants are used as long-term control add-on treatments, but they are restricted to the most severely affected patients because of safety concerns. In addition, neither immunosuppressants nor other strategies have been properly evaluated in the long term despite long-term control having been acknowledged as one of the most important core outcome domains to be targeted in atopic dermatitis trials. Safe add-on therapies, rigorously evaluated for long-term control of the disease, are therefore needed. Phototherapy and vitamin D supplementation are both good candidates.

Methods

This is a multicenter, national, randomized, superiority, crossover trial testing add-on phototherapy (one winter under spaced sessions of phototherapy and one winter under observation) among subjects receiving standard care (i.e., TAT). On the same population, we will test the long-term control provided by oral supplementation of vitamin D versus placebo in a randomized, superiority, double-blind, parallel-group trial. The primary outcomes are (1) repeat measures of the PO-SCORAD severity score over 1 year and (2) cumulate consumption of TAT (number of tubes) during the winter. They will be tested following a hierarchical testing procedure. The secondary outcomes will be measures repeated over 2 years of investigator-based severity scores, patient-reported severity and quality of life scores, serum vitamin D levels, weeks during which the disease is well-controlled, inter-visit cumulate consumption of TAT, and synthetic patient-reported satisfaction at the end of each winter.

Discussion

This study includes two separate 2-year pragmatic trials designed to evaluate the efficacy of vitamin D supplementation and pro-active phototherapy for primary care atopic dermatitis patients receiving TAT on long-term control of disease activity. The experimental design enables the study of both interventions and exploration of the interaction between vitamin D and phototherapy. A pragmatic trial is particularly suited to the assessment of long-term control. This study explores the possibility of new and safe therapeutic strategies for the control of long-term atopic dermatitis, and is an example of efficacy research that is unlikely to be sponsored by industrialists. A potentially effective low-cost therapeutic strategy for long-term control is essential for patients and public health.

Trial registration

ClinicalTrials.gov Identifier: NCT02537509, first received: 1 September 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3276-9) contains supplementary material, which is available to authorized users.