Randomized controlled trial of vitamin D supplementation for winter-related atopic dermatitis in Boston: a pilot study

Pathogenesis of food allergy in the pediatric patient

In the US and other developed countries, food allergy is a growing epidemic in pediatric populations with a substantial impact on health-related quality of life. As such, there are great efforts underway to unravel the mechanisms of oral mucosal tolerance and to better define the factors related to host and allergen exposure that contribute to the aberrant immune response leading to sensitization and clinical food allergy. Although more research is needed to eventually develop targeted treatment and prevention strategies, this review highlights our current understanding of the pathogenesis of IgE-mediated food allergy.

Latitude, sunlight, vitamin D, and childhood food allergy/anaphylaxis

Vitamin D is widely known for its role in bone metabolism, but this sterol hormone also has important immunomodulatory properties. Vitamin D is produced by the conversion of D3 in the skin following UVB exposure, or after ingestion of D2 or D3. At the extremes of latitude, there is insufficient UVB intensity in the autumn and winter months for adequate synthesis of vitamin D to occur. Growing evidence implicates vitamin D deficiency in early life in the pathogenesis of nonskeletal disorders (e. g., type 1 diabetes and multiple sclerosis) and, more recently, atopic disorders. Several studies have reported higher rates of food allergy/anaphylaxis or proxy measures at higher absolute latitudes. Although causality remains to be determined, these studies suggest a possible role for sunlight and/or vitamin D in the pathogenesis of food allergy/anaphylaxis.

Correlation between serum vitamin d level and the severity of atopic dermatitis associated with food sensitization

Purpose

A growing body of literature has linked vitamin D deficiency with allergic diseases, particularly atopic dermatitis (AD). In this study, we investigated the association between serum vitamin D status and the clinical manifestation of AD. We also developed an analytical method for the simultaneous determination of 25-hydroxy vitamin D₃ (25(OH)D₃), using liquid chromatography (LC) coupled with tandem mass spectrometry (MS/MS).

Methods

This study included 157 patients (79 males and 78 females) with AD, aged 4 months to 56 years. We evaluated disease severity using the SCORing Atopic Dermatitis (SCORAD) index. Serum levels of 25(OH)D₃ were determined by LC coupled with MS/MS. Total IgE and specific IgE levels were assayed using the immunoCAP system. ANOVA was used for statistical evaluation.

Results

We found mild, moderate, and severe AD in 30 (11.1%), 87 (55.4%), and 40 (25.5%) patients, respectively. There was no significant correlation between serum levels of 25(OH)D₃ and AD severity. However, among the 36 patients with food sensitization, the mean±SD serum levels of 25(OH)D₃ were significantly higher (P<0.05) in patients with mild disease (21.2±5.18 ng/mL) compared with the levels in patients with moderate (17.9±4.02 ng/mL) or severe AD (13.3±5.11 ng/mL) disease.

Conclusions

These results suggest that vitamin D deficiency is related to the severity of AD associated with food sensitization. Thus, these data suggest a role for vitamin D in a select group of AD patients.

Serum 25-hydroxyvitamin D concentration does not correlate with atopic dermatitis severity

BACKGROUND

An inverse correlation between serum 25-hydroxyvitamin D concentration and atopic dermatitis (AD) severity has been suggested.

OBJECTIVE

To determine if a statistically significant relationship exists between serum 25-hydroxyvitamin D concentration and AD severity.

METHODS

A cross-sectional study was conducted of patients with AD who were 1 to 18 years of age. An objective Severity Scoring of Atopic Dermatitis (SCORAD) and a serum 25-hydroxyvitamin D concentration were measured for each subject. Statistical analysis was performed using appropriate univariate tests and multivariable models.

RESULTS

Ninety-four of 97 enrolled subjects were included in the analysis. Vitamin D deficiency (25-hydroxyvitamin D <20 ng/mL) was present in 37 subjects (39%), insufficiency (25-hydroxyvitamin D 21-29 ng/mL) in 33 (35%), and sufficiency (25-hydroxyvitamin D ≥30 ng/mL) in 24 (26%). The correlation between 25-hydroxyvitamin D concentration and SCORAD was not significant (r = -0.001; P = .99). A multivariate model showed that a lower serum 25-hydroxyvitamin D concentration was significantly associated with age 3 years or older (P < .0001), black race (P < .0001), and winter season (P = .0084).

LIMITATIONS

Limitations of this study include the inability to control for natural sunlight exposure, vitamin D intake, and AD treatment; in addition, only a single time point was captured.

CONCLUSIONS

Serum 25-hydroxyvitamin D concentration is not significantly correlated with AD severity in our pediatric population.

Vitamin d, the cutaneous barrier, antimicrobial peptides and allergies: is there a link?

Atopic diseases such as atopic dermatitis (AD) are very common in industrialized countries. Up to 15%-30% of all children and 2%-10% of all adults suffer from AD. Already in early disease stages, a defective epidermal barrier is known to contribute to the pathogenesis of AD. Central elements in the epidermal barrier are antimicrobial peptides (AMPs), which are secreted by keratinocytes, sweat gland cells but also infiltrating immune cells. AMPs function as endogenous antibiotics and are able to kill bacteria, viruses, and fungi. Furthermore AMPs act as immune modulators with effects on the innate and adaptive immune system. The probably best studied AMPs in human skin are the defensins and cathelicidin. In atopic diseases the functions of AMPs such as cathelicidin might be impaired and microbial superinfections could serve as cofactors for allergic sensitization. Hence, induction of AMPs could be beneficial in these patients. Cathelicidin which is often referred to its peptide form hCAP18 or LL-37 can be induced by ultraviolet light B (UVB) irradiation and is upregulated in infected and injured skin. The cathelicidin gene carries a vitamin D response element and the vitamin D pathway could therefore be targeted for cathelicidin regulation. As the development and course of atopic diseases might be influenced by vitamin D signaling these pathomechanisms could explain the growing evidence connecting vitamin D to allergic diseases, including AD, allergic rhinitis, food allergies and asthma. In this review the role of vitamin D and the AMP cathelicidin in the pathogenesis of atopic diseases with impaired barrier function will be discussed.

Guidelines for treatment of atopic eczema (atopic dermatitis) Part II

The existing evidence for treatment of atopic eczema (atopic dermatitis, AE) is evaluated using the national standard Appraisal of Guidelines Research and Evaluation. The consensus process consisted of a nominal group process and a DELPHI procedure. Management of AE must consider the individual symptomatic variability of the disease. Basic therapy is focused on hydrating topical treatment, and avoidance of specific and unspecific provocation factors. Anti-inflammatory treatment based on topical glucocorticosteroids and topical calcineurin inhibitors (TCI) is used for exacerbation management and more recently for proactive therapy in selected cases. Topical corticosteroids remain the mainstay of therapy, but the TCI tacrolimus and pimecrolimus are preferred in certain locations. Systemic immune-suppressive treatment is an option for severe refractory cases. Microbial colonization and superinfection may induce disease exacerbation and can justify additional antimicrobial treatment. Adjuvant therapy includes UV irradiation preferably with UVA1 wavelength or UVB 311 nm. Dietary recommendations should be specific and given only in diagnosed individual food allergy. Allergen-specific immunotherapy to aeroallergens may be useful in selected cases. Stress-induced exacerbations may make psychosomatic counselling recommendable. 'Eczema school' educational programs have been proven to be helpful. Pruritus is targeted with the majority of the recommended therapies, but some patients need additional antipruritic therapies.

Vitamin D deficiency as a risk factor for childhood allergic disease and asthma

PURPOSE OF REVIEW

Over the past 2 years, the number of studies relating vitamin D deficiency and asthma and allergies has increased significantly. The purpose of this review is to update the last review in this journal and examine the evidence of the relationship between vitamin D deficiency and childhood asthma and allergies.

RECENT FINDINGS

In the past 2 years since the last review, there have been many studies, both cross-sectional and prospective, that have investigated the effects of vitamin D on the inception and severity of asthma and allergies. Most, but not all, studies have shown that low vitamin D levels increase the risk for asthma and allergies, but a few suggest an increased risk with high levels. Results from small trials of short duration suggest that vitamin D supplementation decreases severity of eczema and decreases the risk for asthma exacerbations.

SUMMARY

Data that vitamin D deficiency results in increased risks for asthma and allergies continues to accumulate. However, the optimal level of vitamin D that decreases both the risk for development and severity of these disorders remains elusive. Results of ongoing clinical trials of vitamin D supplementation will be needed before recommendations can be firmly established.

Potential mechanisms for the association between fall birth and food allergy

BACKGROUND

Season of birth has been reported as a risk factor for food allergy, but the mechanisms by which it acts are unknown.

METHODS

Two populations were studied: 5862 children from the National Health and Nutrition Examination Survey (NHANES) III and 1514 well-characterized food allergic children from the Johns Hopkins Pediatric Allergy Clinic (JHPAC). Food allergy was defined as self-report of an acute reaction to a food (NHANES), or as milk, egg, and peanut allergy. Logistic regression compared fall or nonfall birth between (i) food allergic and nonallergic subjects in NHANES, adjusted for ethnicity, age, income, and sex, and (ii) JHPAC subjects and the general Maryland population. For NHANES, stratification by ethnicity and for JHPAC, eczema were examined.

RESULTS

Fall birth was more common among food allergic subjects in both NHANES (OR, 1.91; 95% CI, 1.31-2.77) and JHPAC/Maryland (OR, 1.31; 95% CI, 1.18-1.47). Ethnicity interacted with season (OR, 2.34; 95% CI, 1.43-3.82 for Caucasians; OR, 1.19; 95% CI, 0.77-1.86 for non-Caucasians; P = 0.04 for interaction), as did eczema (OR, 1.47; 95% CI, 1.29-1.67 with eczema; OR, 1.00; 95% CI, 0.80-1.23 without eczema; P = 0.002 for interaction).

CONCLUSIONS

Fall birth is associated with increased risk of food allergy, and this risk is greatest among those most likely to have seasonal variation in vitamin D during infancy (Caucasians) and those at risk for skin barrier dysfunction (subjects with a history of eczema), suggesting that vitamin D and the skin barrier may be implicated in seasonal associations with food allergy.

The role of vitamin D in the immunopathogenesis of allergic skin diseases

Vitamin D plays key roles in innate and adaptive immunity through the stimulation of Toll-like receptors, increasing pro-inflammatory cytokine production, and possibly enhancing T helper type 2 responses. These mechanisms may explain the growing body of evidence connecting vitamin D to allergic diseases, including asthma, food allergies, and allergic rhinitis. The data relating vitamin D to allergic skin diseases are equivocal with studies linking both high and low vitamin D levels to an increased risk of developing atopic dermatitis. In this paper, we describe the role of vitamin D in the immunopathogenesis of atopic dermatitis and other allergic skin diseases.

Dietary supplements for established atopic eczema

BACKGROUND

Many people with atopic eczema are reluctant to use the most commonly recommended treatments because they fear the long-term health effects. As a result, many turn to dietary supplements as a possible treatment approach, often with the belief that some essential ingredient is 'missing' in their diet. Various supplements have been proposed, but it is unclear whether any of these interventions are effective.

OBJECTIVES

To evaluate dietary supplements for treating established atopic eczema/dermatitis.Evening primrose oil, borage oil, and probiotics are covered in other Cochrane reviews.

SEARCH METHODS

We searched the following databases up to July 2010: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE (from 2005), EMBASE (from 2007), PsycINFO (from 1806), AMED (from 1985), LILACS (from 1982), ISI Web of Science, GREAT (Global Resource of EczemA Trials) database, and reference lists of articles. We searched ongoing trials registers up to April 2011.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of dietary supplements for the treatment of those with established atopic eczema/dermatitis.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the titles and abstracts, read the full text of the publications, extracted data, and assessed the risk of bias.

MAIN RESULTS

We included 11 studies with a total of 596 participants. Two studies assessed fish oil versus olive oil or corn oil placebo. The following were all looked at in single studies: oral zinc sulphate compared to placebo, selenium versus selenium plus vitamin E versus placebo, vitamin D versus placebo, vitamin D versus vitamin E versus vitamins D plus vitamin E together versus placebo, pyridoxine versus placebo, sea buckthorn seed oil versus sea buckthorn pulp oil versus placebo, hempseed oil versus placebo, sunflower oil (linoleic acid) versus fish oil versus placebo, and DHA versus control (saturated fatty acids of the same energy value). Two small studies on fish oil suggest a possible modest benefit, but many outcomes were explored. A convincingly positive result from a much larger study with a publicly-registered protocol is needed before clinical practice can be influenced.

AUTHORS' CONCLUSIONS

There is no convincing evidence of the benefit of dietary supplements in eczema, and they cannot be recommended for the public or for clinical practice at present. Whilst some may argue that at least supplements do not do any harm, high doses of vitamin D may give rise to serious medical problems, and the cost of long-term supplements may also mount up.

Vitamin D serum levels in allergic rhinitis: any difference from normal population?

Background

Recently it has been suggested that, the worldwide increase in allergic diseases such as asthma, allergic rhinitis and food allergy is associated with low vitamin D intake.

Objective

This study measured the vitamin D levels in patients with allergic rhinitis and compared the results with the general population.

Methods

Vitamin D levels were assessed in 50 patients with allergic rhinitis diagnosed clinically by Allergic Rhinitis and its Impact on Asthma 2008 criteria and the result of skin prick test for aeroallergens. There was no control group, and the study results were compared with the results of another study evaluating vitamin D status in the 5,329 people of normal population of Iran.

Results

The prevalence of severe vitamin D deficiency was significantly higher in patients with allergic rhinitis than the normal population, 30% and 5.1% respectively (p = 0.03). Also women with allergic rhinitis had lower vitamin D levels.

Conclusion

Measuring vitamin D serum levels could be helpful in the routine assessment of patients with allergic rhinitis in Iran.

Randomized trial of fortified milk and supplements to raise 25-hydroxyvitamin D concentrations in schoolchildren in Mongolia

BACKGROUND

The optimal public health strategy for maintaining 25-hydroxyvitamin D [25(OH)D] concentrations in schoolchildren in Mongolia is unknown.

OBJECTIVE

The objective was to compare the effectiveness of different supplement and fortified milk regimens to increase 25(OH)D concentrations in Mongolian schoolchildren.

DESIGN

Twenty-one classrooms of 579 children aged 9-11 y were randomized to interventions with an equivalent content of vitamin D(3): 1) a one-time seasonal supplement of 13,700 IU, 2) 300 IU/d from supplements, 3) 300 IU/d from fortified ultra-high-temperature pasteurized milk from the United States, 4) 300 IU/d from fortified pasteurized Mongolian milk, or 5) unfortified pasteurized Mongolian milk (control).

RESULTS

In January, the mean (±SD) serum 25(OH)D concentration was 8 ± 4 ng/mL (20 ± 10 nmol/L), and 98% of the children had a concentration <20 ng/mL (50 nmol/L). In March, concentrations were 8 ± 4 ng/mL after unfortified milk, 20 ± 6 ng/mL after fortified Mongolian milk, 29 ± 10 ng/mL after fortified US milk, 21 ± 6 ng/mL after daily supplements, and 12 ± 4 ng/mL after seasonal supplements (each greater than unfortified milk, P < 0.01). Seasonal supplementation was less effective than was daily supplementation (P < 0.0001). Despite consuming daily supplements or fortified milk, 41% of the children still had concentrations <20 ng/mL (50 nmol/L). Children with lower baseline 25(OH)D concentrations experienced slightly larger 25(OH)D responses to intervention than did children with higher concentrations (P = 0.002).

CONCLUSIONS

In this population with extremely low vitamin D concentrations, delivery of 300 IU vitamin D/d via supplements or in fortified milk improved 25(OH)D concentrations but failed to raise concentrations uniformly to >20 ng/mL (50 nmol/L). The daily low-dose intervention was superior to the seasonal larger-dose intervention. Higher doses may be needed to prevent deficiency in schoolchildren in Mongolia and at other northern latitudes. This trial is registered at clinicaltrials.gov as NCT00886379.

Vitamin D supplementation for prevention of mortality in adults

BACKGROUND

The available evidence on vitamin D and mortality is inconclusive.

OBJECTIVES

To assess the beneficial and harmful effects of vitamin D for prevention of mortality in adults.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, LILACS, the Science Citation Index Expanded, and Conference Proceedings Citation Index-Science (to January 2011). We scanned bibliographies of relevant publications and asked experts and pharmaceutical companies for additional trials.

SELECTION CRITERIA

We included randomised trials that compared vitamin D at any dose, duration, and route of administration versus placebo or no intervention. Vitamin D could have been administered as supplemental vitamin D (vitamin D(3) (cholecalciferol) or vitamin D(2) (ergocalciferol)) or an active form of vitamin D (1α-hydroxyvitamin D (alfacalcidol) or 1,25-dihydroxyvitamin D (calcitriol)).

DATA COLLECTION AND ANALYSIS

Six authors extracted data independently. Random-effects and fixed-effect model meta-analyses were conducted. For dichotomous outcomes, we calculated the risk ratios (RR). To account for trials with zero events, meta-analyses of dichotomous data were repeated using risk differences (RD) and empirical continuity corrections. Risk of bias was considered in order to minimise risk of systematic errors. Trial sequential analyses were conducted to minimise the risk of random errors.

MAIN RESULTS

Fifty randomised trials with 94,148 participants provided data for the mortality analyses. Most trials included elderly women (older than 70 years). Vitamin D was administered for a median of two years. More than one half of the trials had a low risk of bias. Overall, vitamin D decreased mortality (RR 0.97, 95% confidence interval (CI) 0.94 to 1.00, I(2) = 0%). When the different forms of vitamin D were assessed separately, only vitamin D(3) decreased mortality significantly (RR 0.94, 95% CI 0.91 to 0.98, I(2) = 0%; 74,789 participants, 32 trials) whereas vitamin D(2), alfacalcidol, or calcitriol did not. Trial sequential analysis supported our finding regarding vitamin D(3), corresponding to 161 individuals treated to prevent one additional death. Vitamin D(3) combined with calcium increased the risk of nephrolithiasis (RR 1.17, 95% CI 1.02 to 1.34, I(2) = 0%). Alfacalcidol and calcitriol increased the risk of hypercalcaemia (RR 3.18, 95% CI 1.17 to 8.68, I(2) = 17%). Data on health-related quality of life and health economics were inconclusive.

AUTHORS' CONCLUSIONS

Vitamin D in the form of vitamin D(3) seems to decrease mortality in predominantly elderly women who are mainly in institutions and dependent care. Vitamin D(2), alfacalcidol, and calcitriol had no statistically significant effect on mortality. Vitamin D(3) combined with calcium significantly increased nephrolithiasis. Both alfacalcidol and calcitriol significantly increased hypercalcaemia.

Atopic dermatitis - from new pathophysiologic insights to individualized therapy

Recently, important novel insights into the complex pathophysiology of atopic dermatitis (AD) have been gained. However, in most cases the therapy of AD is limited to base line therapy with emollients combined with symptomatic, rather general immunosuppressive treatment approaches of the flare-ups. Latest research findings together with experiences from daily clinical practice, which support the concept that a combination of general disease features together with specific trigger factors in the individual patients drive the disease, might be helpful for a subclassification of patients with AD based on the most relevant pathophysiologic modifications. Subclassification of patients with AD seems indispensable to introduce rationale-based, individualized treatment approaches of AD, which target specific modified pathways. In this review, we provide an overview about a selection of pathophysiologic pathways, which hold promise to represent targets of such therapeutic approaches in the near future.

Atopic dermatitis: a disease of altered skin barrier and immune dysregulation

Atopic dermatitis (AD) is an important chronic or relapsing inflammatory skin disease that often precedes asthma and allergic disorders. New insights into the genetics and pathophysiology of AD point to an important role of structural abnormalities in the epidermis as well as immune dysregulation not only for this skin disease but also for the development of asthma and allergies. Patients with AD have a unique predisposition to colonization or infection by microbial organisms, most notably Staphylococcus aureus and herpes simplex virus. Measures directed at healing and protecting the skin barrier and addressing the immune dysregulation are essential in the treatment of patients with AD, and early intervention may improve outcomes for both the skin disease as well as other target organs.

Correlation between serum 25-hydroxyvitamin D levels and severity of atopic dermatitis in children

BACKGROUND

Vitamin D deficiency could be associated with the prevalence of atopic dermatitis (AD).

OBJECTIVES

We carried out a study to see whether deficient/insufficient levels of vitamin D correlate with the severity of atopic skin disease.

METHODS

Using the SCORAD index, we evaluated the severity of disease in 37 children (17 girls and 20 boys) aged between 8 months and 12 years with AD, consecutively enrolled in the study. Serum levels of 25-hydroxyvitamin D [25(OH)D] were determined by a chemiluminescent method. Specific IgE (sIgE) to Staphylococcus aureus enterotoxins and sIgE to Malassezia furfur were assayed by the ImmunoCAP system. anova and the Pearson correlation test were used for statistical evaluation.

RESULTS

We found severe, moderate and mild AD in nine (24%), 13 (35%) and 15 (41%) children, respectively. Mean ± SD serum levels of 25(OH)D were significantly higher (P < 0·05) in patients with mild disease (36·9 ± 15·7 ng mL(-1)) compared with those with moderate (27·5 ± 8·3 ng mL(-1)) or severe AD (20·5 ± 5·9 ng mL(-1)). The prevalence of patients with sIgE to microbial antigens increased in relation to vitamin D deficiency and AD severity.

CONCLUSIONS

These data suggest that vitamin D deficiency may be related to the severity of AD and advocate the need for studies evaluating the use of vitamin D as a potential treatment in patients with this disease.

Can food allergy be prevented? The current evidence

Food allergy is a recognized public health concern, for which preventative strategies are required. Although an intervention that adequately protects against the development of food allergy has still to be identified, limited benefits have been shown for the prevention of related allergic conditions such as eczema, and to a lesser extent asthma and rhinitis; these benefits are usually limited to at-risk populations. Prevention strategies need to be tested using randomized controlled study designs that account for the numerous methodological challenges, safety concerns, and necessary ethical limitations.

Vitamin D: emerging roles in infection and immunity

In the preantibiotic era, TB of the skin was treated successfully with UV light. By the 1920s, pulmonary TB was being treated with regular sun exposure. During the last decade, basic laboratory research into the antimicrobial actions of vitamin D has provided new insights into these historical observations. Vitamin D has a critical role in the innate immune system through the production of antimicrobial peptides - particularly cathelicidin. Vitamin D would appear to have an important role in respiratory tract, skin and potentially gut health. A number of autoimmune diseases, including multiple sclerosis, Type I diabetes, systemic lupus erythematosus and rheumatoid arthritis, are associated with vitamin D deficiency. Vitamin D could have an important role in the prevention and possible treatment of these conditions; however, much of the current evidence relates to basic science and epidemiological research. In many situations, appropriate double-blind, randomized controlled trial data to guide clinicians treating infectious and autoimmune disease is still lacking.

Vitamin D in atopic dermatitis, asthma and allergic diseases

This review examines the scientific evidence behind the hypothesis that vitamin D plays a role in the pathogenesis of allergic diseases, along with a focus on emerging data regarding vitamin D and atopic dermatitis. Elucidated molecular interactions of vitamin D with components of the immune system and clinical data regarding vitamin D deficiency and atopic diseases are discussed. The rationale behind the sunshine hypothesis, laboratory evidence supporting links between vitamin D deficiency and allergic diseases, the clinical evidence for and against vitamin D playing a role in allergic diseases, and the emerging evidence regarding the potential use of vitamin D to augment the innate immune response in atopic dermatitis are reviewed.

Vitamin D levels and food and environmental allergies in the United States: results from the National Health and Nutrition Examination Survey 2005-2006

BACKGROUND

Previous research supports a possible link between low vitamin D levels and atopic disease. However, the association between low vitamin D levels and total and allergen-specific IgE levels has not been studied.

OBJECTIVE

We sought to test the association between serum 25-hydroxyvitamin D (25[OH]D) deficiency (<15 ng/mL) and insufficiency (15-29 ng/mL) and allergic sensitization measured by serum IgE levels in a US nationally representative sample of 3136 children and adolescents and 3454 adults in the National Health and Nutrition Examination Survey 2005-2006.

METHODS

The association of 25(OH)D deficiency with 17 different allergens was assessed after adjustment for potential confounders, including age; sex; race/ethnicity; obesity, low socioeconomic status; frequency of milk intake; daily hours spent watching television, playing videogames, or using a computer; serum cotinine levels; and vitamin D supplement use.

RESULTS

In children and adolescents allergic sensitization to 11 of 17 allergens was more common in those with 25(OH)D deficiency. Compared with sufficient vitamin D levels of greater than 30 ng/mL, after multivariate adjustment, 25(OH)D levels of less than 15 ng/mL were associated with peanut (odds ratio [OR], 2.39; 95% CI, 1.29-4.45), ragweed (OR, 1.83; 95% CI, 1.20-2.80), and oak (OR, 4.75; 95% CI, 1.53-4.94) allergies (P < .01 for all). Eight other allergens were associated with 25(OH)D deficiency, with P values of less than .05 but greater than .01. There were no consistent associations seen between 25(OH)D levels and allergic sensitization in adults.

CONCLUSION

Vitamin D deficiency is associated with higher levels of IgE sensitization in children and adolescents. Further research is needed to confirm these findings.

Randomized controlled trial using vitamins E and D supplementation in atopic dermatitis

BACKGROUND

Atopic dermatitis is a chronically relapsing, highly pruritic and inflammatory skin disease. This study was done to assess the effects of vitamins D and E supplementation on the clinical manifestation of atopic dermatitis.

METHODS

Forty-five atopic dermatitis patients were included in a randomized, double-blind, placebo-controlled trial. They were randomly divided into four groups and treated for 60 days: group P (n = 11), vitamins D and E placebos; group D (n = 12), 1600 IU vitamin D(3) plus vitamin E placebo; group E (n = 11), 600 IU synthetic all-rac-α-tocopherol plus vitamin D placebo; and group DE (n = 11), 1600 IU vitamin D(3) plus 600 IU synthetic all-rac-α-tocopherol. Serum 25(OH) vitamin D and plasma α-tocopherol were determined before and after the trial. The clinical improvement was evaluated with SCORing Atopic Dermatitis (SCORAD). Data were analyzed by analysis of variance (ANOVA) and Kruskal-Wallis tests.

RESULTS

SCORAD was reduced after 60 days in groups D, E and DE by 34.8%, 35.7% and 64.3%, respectively (p = 0.004). Objective SCORAD also showed significant improvement. There was a positive correlation between SCORAD and intensity, objective, subjective and extent (p < 0.001). We found a significant negative association between plasma α-tocopherol and SCORAD, intensity, objective and extent (p = 0.02).

CONCLUSION

This study supports the contributing and beneficial effects of vitamins D and E in the treatment of atopic dermatitis.

North-south differences in US emergency department visits for acute allergic reactions

BACKGROUND

In a previous study, latitude was positively associated with EpiPen prescription rates.

OBJECTIVE

To determine whether a similar geographic difference exists for emergency department (ED) visits for acute allergic reactions (including anaphylaxis).

METHODS

We combined National Hospital Ambulatory Medical Care Survey data for ED visits to noninstitutional hospitals from 1993 to 2005. Acute allergic reactions were identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes 995.0, 995.60-995.69, 995.1, 995.2, 995.3, 989.5, and 693.1, and visit rates were compared across standardized geographic divisions.

RESULTS

Between 1993 and 2005, there were 17.3 million ED visits for acute allergic reactions, representing 1.3% (95% confidence interval [CI], 1.2%-1.3%) of all ED visits. Per 1000 population, the Northeast had 5.5 visits (95% CI, 4.7-6.2 visits) and the South had 4.9 visits (95% CI, 4.3-5.6 visits). In a multivariable model, the Northeast had a higher odds ratio (OR) than the South (1.13; 95% CI, 1.01-1.27; P = .04). The association was stronger when restricting the analysis to visits for food-related allergic reactions (OR, 1.33; 95% CI, 1.14-1.56; P < .001).

CONCLUSIONS

The ED visit rates for acute allergic reactions are higher in northeastern vs southern regions. These observational data are consistent with the hypothesis that vitamin D may play an etiologic role in anaphylaxis, especially food-induced anaphylaxis.

Season of birth and food allergy in children

BACKGROUND

The prevalence of food allergy is rising, and etiologic factors remain uncertain. Evidence implicates a role for vitamin D in the development of atopic diseases. Based on seasonal patterns of UV-B exposure (and consequent vitamin D status), we hypothesized that patients with food allergy are more often born in fall or winter.

OBJECTIVE

To investigate whether season of birth is associated with food allergy.

METHODS

We performed a multicenter medical record review of all patients presenting to 3 Boston emergency departments (EDs) for food-related acute allergic reactions between January 1, 2001, and December 31, 2006. Months of birth in patients with food allergy were compared with that of patients visiting the ED for reasons other than food allergy.

RESULTS

We studied 1002 patients with food allergy. Of younger children with food allergy (age < 5 years), but not older children or adults, 41% were born in spring or summer compared with 59% in fall or winter (P = .002). This approximately 40:60 ratio differed from birth season in children treated in the ED for non-food allergy reasons (P = .002). Children younger than 5 years born in fall or winter had a 53% higher odds of food allergy compared with controls. This finding was independent of the suspected triggering food and allergic comorbidities.

CONCLUSIONS

Food allergy is more common in Boston children born in the fall and winter seasons. We propose that these findings are mediated by seasonal differences in UV-B exposure. These results add support to the hypothesis that seasonal fluctuations in sunlight and perhaps vitamin D may be involved in the pathogenesis of food allergy.

Vitamin D status of newborns in New Zealand

Recognition of the important non-skeletal health effects of vitamin D has focused attention on the vitamin D status of individuals across the lifespan. To examine the vitamin D status of newborns, we measured serum levels of 25-hydroxyvitamin D (25(OH)D) in the cord blood of 929 apparently healthy newborns in a population-based study in New Zealand, a country at 41 °S latitude, with strong anti-skin cancer (sun avoidance) campaigns and without vitamin D food fortification. Randomly selected midwives in two regions recruited children. The median cord blood level of 25(OH)D was 44 nmol/l (interquartile range, 29-78 nmol/l). Overall, 19 % of newborns had 25(OH)D levels < 25 nmol/l and 57 % had levels < 50 nmol/l; only 27 % had levels of 75 nmol/l or higher, which are levels associated with optimal health in older children and adults. A multivariable ordinal logistic regression model showed that the strongest determinants of low vitamin D status were winter month of birth and non-European ethnicity. Other determinants of low cord blood 25(OH)D included longer gestational age, younger maternal age and a parental history of asthma. In summary, low levels of vitamin D are common among apparently healthy New Zealand newborns, and are independently associated with several easily identified factors. Although the optimal timing and dosage of vitamin D supplementation require further study, our findings may assist future efforts to correct low levels of 25(OH)D among New Zealand mothers and their newborn children.

Nonclassical vitamin D action

It is becoming increasingly clear that vitamin D has a broad range of actions in the human body. Besides its well-known effects on calcium/phosphate homeostasis, vitamin D influences muscle function, cardiovascular homeostasis, nervous function, and the immune response. Vitamin D deficiency/insufficiency has been associated with muscle weakness and a high incidence of various chronic diseases such as cardiovascular disease, cancer, multiple sclerosis, and type 1 and 2 diabetes. Most importantly, low vitamin D status has been found to be an independent predictor of all-cause mortality. Several recent randomized controlled trials support the assumption that vitamin D can improve muscle strength, glucose homeostasis, and cardiovascular risk markers. In addition, vitamin D may reduce cancer incidence and elevated blood pressure. Since the prevalence of vitamin D deficiency/insufficiency is high throughout the world, there is a need to improve vitamin D status in the general adult population. However, the currently recommended daily vitamin D intake of 5-15 µg is too low to achieve an adequate vitamin D status in individuals with only modest skin synthesis. Thus, there is a need to recommend a vitamin D intake that is effective for achieving adequate circulating 25-hydroxyvitamin D concentrations (>75 nmol/L).

Topical calcitriol restores the impairment of epidermal permeability and antimicrobial barriers induced by corticosteroids

BACKGROUND

The active form of vitamin D(3) , calcitriol, is widely used for the treatment of psoriasis, with or without topical corticosteroids. Topical corticosteroids are known to disrupt permeability and antimicrobial barriers, even with short-term use. Yet, the effect of topical calcitriol on epidermal permeability and antimicrobial barriers disrupted by topical corticosteroids has not been determined.

OBJECTIVES

To examine the effect of calcitriol on epidermal permeability and antimicrobial barrier function that has been impaired by corticosteroids, as well as to elucidate the mechanism of improvement.

MATERIAL AND METHODS

Topical calcitriol or the control vehicle was applied to each flank of hairless mice 20 min after treatment with topical clobetasol propionate and repeated every 12 h for 3·5 days. Barrier function assessment, Nile red staining, electron microscopy, immunohistochemistry, Western blotting, and real-time reverse transcriptase-polymerase chain reaction studies were performed 24 h after the last application.

RESULTS

Epidermis co-treated with topical calcitriol showed an improvement of stratum corneum integrity and barrier recovery, more intense fluorescence staining with Nile red, and an increase in lamellar body (LB) maturation and density, as well as upregulation of major epidermal lipid synthesis-related enzymes (3-hydroxy-3-methylglutaryl-CoA, serine-palmitoyl transferase and fatty acid synthase), mouse beta-defensin 3, cathelin-related antimicrobial peptide and vitamin D receptor.

CONCLUSIONS

We found that topical calcitriol restored both the epidermal permeability and antimicrobial barrier that had been impaired by corticosteroids. This restoration was mediated by both an activation of the cutaneous vitamin D pathway and an increase of epidermal lipids and antimicrobial peptides, promoted by the formation of the LB and the activity of epidermal lipid synthesis-related enzymes.

Recent insights into atopic dermatitis and implications for management of infectious complications

Atopic dermatitis (AD) is a common complex disease that frequently follows a chronic relapsing course and affects the quality of life of patients and families in a significant manner. New insights into the pathophysiology of AD point to an important role of structural abnormalities in the epidermis combined with immune dysregulation. Patients with AD have a unique predisposition to colonization or infection by a number of microbial organisms, most notably Staphylococcus aureus and herpes simplex virus. A multipronged approach directed at healing or protecting the skin barrier and addressing the immune dysregulation is necessary to improve the likelihood of successful outcomes.

Allergic skin disease: major highlights and recent advances

AD, urticaria, and ACD account for a large percentage of the skin disorders that present at medical offices and emergency departments. With a high degree of morbidity, these diseases can be extremely difficult to manage. Consequently, these diseases continue to be the focus of much of the new research in the field. Recent studies have furthered the understanding of the complex relationship between immune and nonimmune factors in the pathogenesis of these disorders. This research has quickly led to the development of new treatment modalities and protocols for patient care, especially for AD. However, further discovery will be necessary to optimize the management of these often-vexing conditions.

Atopic dermatitis and alternative management strategies

PURPOSE OF REVIEW

To discuss the significance of studies published over the previous year regarding the pathogenesis and treatment of atopic dermatitis, including prevention, skin care, environmental modifications, nutrition, education, and anti-inflammatory medications.

RECENT FINDINGS

Recent evidence shows that 42.5% of the caregivers of children with atopic dermatitis had used alternative therapies, most commonly due to fears of topical steroid side-effects and dissatisfaction with conventional treatment. Common questions, such as the potential utility of prenatal probiotics for prevention of atopic dermatitis, as well as the interplay of food allergies and eczema will be discussed in detail. New research continues to show the efficacy and safety of topical calcineurin inhibitors and atopiclair. We will review advances in the understanding of the pathogenesis of atopic dermatitis, and the latest research on therapies available to clinicians to aid them in discussions with their patients.

SUMMARY

Atopic dermatitis impacts negatively the quality of life of both patients and their families. General pediatricians play a pivotal role in the management of this chronic condition. Management should focus on providing sound advice and easing fears regarding topical steroids, as well as pursuing conservative treatments that have the potential to prevent flares.

Cellular and molecular mechanisms in atopic dermatitis

Atopic dermatitis (AD) is a pruritic inflammatory skin disease associated with a personal or family history of allergy. The prevalence of AD is on the rise and estimated at approximately 17% in the USA. The fundamental lesion in AD is a defective skin barrier that results in dry itchy skin, and is aggravated by mechanical injury inflicted by scratching. This allows entry of antigens via the skin and creates a milieu that shapes the immune response to these antigens. This review discusses recent advances in our understanding of the abnormal skin barrier in AD, namely abnormalities in epidermal structural proteins, such as filaggrin, mutated in approximately 15% of patients with AD, epidermal lipids, and epidermal proteases and protease inhibitors. The review also dissects, based on information from mouse models of AD, the contributions of the innate and adaptive immune system to the pathogenesis of AD, including the effect of mechanical skin injury on the polarization of skin dendritic cells, mediated by keratinocyte-derived cytokines such as thymic stromal lymphopoietin (TSLP), IL-6, and IL-1, that results in a Th2-dominated immune response with a Th17 component in acute AD skin lesions and the progressive conversion to a Th1-dominated response in chronic AD skin lesions. Finally, we discuss the mechanisms of susceptibility of AD skin lesions to microbial infections and the role of microbial products in exacerbating skin inflammation in AD. Based on this information, we discuss current and future therapy of this common disease.