Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema

A programme of research to set priorities and reduce uncertainties for the prevention and treatment of skin disease

Background

Skin diseases are very common and can have a large impact on the quality of life of patients and caregivers. This programme addressed four diseases: (1) eczema, (2) vitiligo, (3) squamous cell skin cancer (SCC) and (4) pyoderma gangrenosum (PG).

Objective

To set priorities and reduce uncertainties for the treatment and prevention of skin disease in our four chosen diseases.

Design

Mixed methods including eight systematic reviews, three prioritisation exercises, two pilot randomised controlled trials (RCTs), three feasibility studies, two core outcome initiatives, four funding proposals for national RCTs and one completed national RCT.

Setting

Secondary care, primary care and the general population.

Participants

Patients (and their caregivers) with eczema, vitiligo, SCC and PG, plus health-care professionals with an interest in skin disease.

Interventions

Our three intervention studies included (1) barrier enhancement using emollients from birth to prevent eczema (pilot RCT); (2) handheld narrowband ultraviolet light B therapy for treating vitiligo (pilot RCT); and (3) oral ciclosporin (Neoral®, Novartis Pharmaceuticals) compared with oral prednisolone for managing PG (pragmatic national RCT).

Results

Systematic reviews included two overarching systematic reviews of RCTs of treatments for eczema and vitiligo, an umbrella review of systematic reviews of interventions for the prevention of eczema, two reviews of treatments for SCC (one included RCTs and the second included observational studies), and three reviews of outcome measures and outcome reporting. Three prioritisation partnership exercises identified 26 priority areas for future research in eczema, vitiligo and SCC. Two international consensus initiatives identified four core domains for future eczema trials and seven core domains for vitiligo trials. Two pilot RCTs and three feasibility studies critically informed development of four trial proposals for external funding, three of which are now funded and one is pending consideration by funders. Our pragmatic RCT tested the two commonly used systemic treatments for PG (prednisolone vs. ciclosporin) and found no difference in their clinical effectiveness or cost-effectiveness. Both drugs showed limited benefit. Only half of the participants’ ulcers had healed by 6 months. For those with healed ulcers, recurrence was common (30%). Different side effect profiles were noted for each drug, which can inform clinical decisions on an individual patient basis. Three researchers were trained to PhD level and a dermatology patient panel was established to ensure patient involvement in all aspects of the programme.

Conclusions

Findings from this programme of work have already informed clinical guidelines and patient information resources. Feasibility studies have ensured that large national pragmatic trials will now be conducted on important areas of treatment uncertainty that address the needs of patients and the NHS. There is scope for considerable improvement in terms of trial design, conduct and reporting for RCTs of skin disease, which can be improved through wider collaboration, registration of trial protocols and complete reporting and international consensus over core outcome sets. Three national trials have now been funded as a result of this work. Two international initiatives to establish how best to measure the core outcome domains for eczema and vitiligo are ongoing.

Trial registration

Current Controlled Trials Barrier Enhancement for Eczema Prevention (BEEP) (ISRCTN84854178 and NCT01142999), Study of Treatments fOr Pyoderma GAngrenosum Patients (STOP GAP) (ISRCTN35898459) and Hand Held NB-UVB for Early or Focal Vitiligo at Home (HI-Light Pilot Trial) (NCT01478945).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 18. See the NIHR Journals Library website for further project information.

The aryl hydrocarbon receptor AhR links atopic dermatitis and air pollution via induction of the neurotrophic factor artemin

Atopic dermatitis is increasing worldwide in correlation with air pollution. Various organic components of pollutants activate the transcription factor AhR (aryl hydrocarbon receptor). Through the use of AhR-CA mice, whose keratinocytes express constitutively active AhR and that develop atopic-dermatitis-like phenotypes, we identified Artn as a keratinocyte-specific AhR target gene whose product (the neurotrophic factor artemin) was responsible for epidermal hyper-innervation that led to hypersensitivity to pruritus. The activation of AhR via air pollutants induced expression of artemin, alloknesis, epidermal hyper-innervation and inflammation. AhR activation and ARTN expression were positively correlated in the epidermis of patients with atopic dermatitis. Thus, AhR in keratinocytes senses environmental stimuli and elicits an atopic-dermatitis pathology. We propose a mechanism of air-pollution-induced atopic dermatitis via activation of AhR.

Mental health associations with eczema, asthma and hay fever in children: a cross-sectional survey

OBJECTIVE

This study aimed to examine the association of eczema, asthma and hay fever with mental health in a general child population and to assess the influence of parental socioeconomic position on these associations.

METHODS

We conducted a cross-sectional health survey of children aged 3, 6, 11 and 15 years in the City of Copenhagen, Denmark. Individual questionnaire data on eczema, asthma, and hay fever and mental health problems assessed using the Strengths and Difficulties Questionnaire (SDQ) was linked to register data on demographics and parental socioeconomic position. 9215 (47.9%) children were included in the analyses.

RESULTS

Linear regression analyses showed that children with current eczema symptoms had higher SDQ scores (mean difference, 95% CI) of emotional problems (0.26, 0.12 to 0.39), conduct problems (0.19, 0.09 to 0.29) and hyperactivity problems (0.32, 0.16 to 0.48); children with current asthma symptoms had higher SDQ scores of emotional problems (0.45, 0.32 to 0.58), conduct problems (0.28, 0.18 to 0.38) and hyperactivity problems (0.52, 0.35 to 0.69); and children with current hay fever symptoms had higher SDQ scores of emotional problems (0.57, 0.42 to 0.72), conduct problems (0.22, 0.11 to 0.33), hyperactivity problems (0.44, 0.26 to 0.61) and peer problems (0.14, 0.01 to 0.26), compared with children without current symptoms of the relevant disease. For most associations, parental socioeconomic position did not modify the effect.

CONCLUSIONS

Children with eczema, asthma or hay fever had more emotional, conduct and hyperactivity problems, but not peer problems, compared with children without these diseases. Atopic diseases added equally to the burden of mental health problems independent of socioeconomic position.

Review of Systemic Treatment Options for Adult Atopic Dermatitis

Background:

Atopic dermatitis (AD) is a chronic, pruritic inflammatory skin disease resulting from defects in skin barrier and aberrant immune responses. AD significantly affects the quality of life. Not all patients respond to topical therapies, and often systemic therapy is required to control the disease.

Objective:

To review the treatment options for adult AD patients including those options for patients who do not respond adequately or have contraindications to oral systemic therapy.

Methods:

A working group of clinicians with experience managing AD was convened to review the current literature on treatment options for adult AD patients. This review is based on the best available evidence from a published systematic review and an additional literature search.

Results:

Current treatments for AD are reviewed, including options for adult AD patients who do not respond or have contraindications to current systemic therapies. A new approach with targeted therapies is reviewed based on best available evidence.

Conclusion:

Many AD patients respond satisfactorily to topical or systemic treatments, but for those patients who do not respond or have contraindications, new biologic agents appear to be promising therapies.

Topical treatment of atopic dermatitis in children: current challenges and answers

Atopic dermatitis (AD) is the most prevalent skin disease in the early childhood and is a considerable problem both for patients and members of their families and for the society on the whole. In most cases, AD requires a long-term therapy such as the use of anti-inflammatory drugs. Selective inhibitors of the synthesis and release of proinflammatory cytokines - topical calcineurin inhibitors (Tcis) - are now used to solve this problem, with pimecrolimus being one of them. Pimecrolimus has been thoroughly examined for the past decade in different clinical studies involving a total of over 4,000 infants (below 2 years of age). These studies demonstrated the efficacy and safety of pimecrolimus for AD in children provided it is used in a long-term therapy on an intermittent basis. Unlike topical corticosteroids, the long-term use of pimecrolimus is not associated with any risk of development of systemic immunosuppression, skin atrophy, skin barrier dysfunction or systemic absorption so it is safe even if applied to the most sensitive skin areas. In view of this, the authors make a conclusion that pimecrolimus used in the form of a cream is a safe and efficient drug for the treatment of infants aged over three months suffering from atopic dermatitis.

Stigmatization and self-perception in children with atopic dermatitis

Atopic dermatitis (AD) is one of the most common skin diseases. Prevalence of AD is highest in childhood. Because of chronicity and often visible lesions, AD may lead to stigmatization and problems with self-perception. However, problems of self-perception and stigmatization in AD children are poorly studied. Literature data on general tendencies of children’s development, clinical course, and epidemiologic tendencies of AD in different age groups make it possible to highlight three main periods in the formation of self-perception and stigmatization. The first period is from early infancy till 3 years of age. The child’s problems in this period depend on parental exhaustion, emotional distress, and security of the mother–child attachment. The child’s AD may form a kind of vicious circle in which severe AD causes parental distress and exhaustion that in turn lead to exacerbation of AD and psychological problems in children. The second period is from 3 till 10 years of age. During this period, development of AD children may be influenced by teasing, bullying, and avoiding by their peers. However, the majority of children in this age group are very optimistic. The third period is from 10 years till adulthood. Problems related to low self-esteem are characteristic during this period. It is important to identify children with AD and their parents who need psychological help and provide them with needs-based consultation and care. Appropriate treatment, medical consultations, and educational programs may help to reduce emotional problems in AD children and their parents.

Environmental Factors Associated with Altered Gut Microbiota in Children with Eczema: A Systematic Review

Eczema is a common skin condition that impairs children's daily life activities and quality of life. Previous research shows that gut microbiome composition plays an important role in the development of eczema. The present review summarizes evidence on environmental factors related to altered gut microbiota in children with eczema. We searched Medline, PubMed, Embase, and the Cochrane database of Systematic Reviews through October 2015. The search strategy focused on articles published in peer-reviewed, English-language journals with no publication year limit. Only original studies and review articles that reported environmental factors on gut microbiome specific to eczema were included in this review. We selected six studies (total 1990 participants) for full review and identified that the composition of gut microbiota specific to eczema could be influenced by the following environmental factors: length of gestation, mode of delivery, type of feeding, method of treatment, number of older siblings, and other lifestyle factors. There has been inconsistent empirical evidence as to the modulatory effects of gut microbiota on immunological functions in children with eczema. Further research on the environmental-host-microbial interaction is needed to develop a strong base of knowledge for the development and implementation of prevention strategies and policies for eczema.

Transplantation of human skin microbiota in models of atopic dermatitis

Atopic dermatitis (AD) is characterized by reduced barrier function, reduced innate immune activation, and susceptibility to Staphylococcus aureus. Host susceptibility factors are suggested by monogenic disorders associated with AD-like phenotypes and can be medically modulated. S. aureus contributes to AD pathogenesis and can be mitigated by antibiotics and bleach baths. Recent work has revealed that the skin microbiome differs significantly between healthy controls and patients with AD, including decreased Gram-negative bacteria in AD. However, little is known about the potential therapeutic benefit of microbiome modulation. To evaluate whether parameters of AD pathogenesis are altered after exposure to different culturable Gram-negative bacteria (CGN) collected from human skin, CGN were collected from healthy controls and patients with AD. Then, effects on cellular and culture-based models of immune, epithelial, and bacterial function were evaluated. Representative strains were evaluated in the MC903 mouse model of AD. We found that CGN taken from healthy volunteers but not from patients with AD were associated with enhanced barrier function, innate immunity activation, and control of S. aureus. Treatment with CGN from healthy controls improved outcomes in a mouse model of AD. These findings suggest that a live-biotherapeutic approach may hold promise for treatment of patients with AD.

Development of a Japanese Culturally Modified Version of the Childhood Atopic Dermatitis Impact Scale (JCMV-CADIS)

BACKGROUND

The Childhood Atopic Dermatitis Impact Scale (CADIS) was developed to measure the impact of AD on QoL in both affected children and their families. However, no scale of this kind exists in Japan. The aims of this study were to validate the Japanese Culturally Modified Version of the CADIS (JCMV-CADIS) and to describe the family impact of children with AD in a Japanese context.

METHODS

Participants included primary-caregivers for children with AD between 2 and 6 years of age. Interviews were conducted, and new items for the Japanese version were drafted. Reliability and validity were evaluated and compared with the original CADIS, and unique features of the Japanese version were analyzed.

RESULTS

Exploratory factor analysis revealed the following factors: "Symptoms" and "Activity Limitations and Behavior" in the Child domain, and "Emotions Related to Social Factors," "Emotions Related to the Child's Condition," "Family and Social Function," "Complexity of Care," and "Approaches to Management of AD in Daily Life" in the Parent domain. The latter two factors were unique to the JCMV-CADIS and were not derived from the Original. "Emotion" was split into two independent factors. All factors showed good reliability (internal consistency and stability) and validity (concurrent validity and discriminant validity), except for the concurrent validity of "Approaches to Management of AD in Daily Life." This factor seemed to reflect characteristics similar to the family-related function.

CONCLUSIONS

The JCMV-CADIS is a QoL scale developed for Japanese children with AD and their families. Further evaluation of clinical applicability is needed.

Crisaborole and its potential role in treating atopic dermatitis: overview of early clinical studies

Atopic dermatitis (AD), a chronic, relapsing, inflammatory skin disease that is characterized by intense pruritus and eczematous lesions with up to 90% of patients presenting with mild to moderate disease. Current topical treatments for AD have not changed in over 15 years and are associated with safety concerns. In AD, overactivity of phosphodiesterase 4 (PDE4), leads to inflammation and disease exacerbation. Crisaborole Topical Ointment, 2%, is a novel, nonsteroidal, topical anti-inflammatory PDE4 inhibitor currently being investigated for the treatment of mild to moderate AD. Preliminary studies in children and adults demonstrated favorable efficacy and safety profiles. Crisaborole may represent an anti-inflammatory option that safely minimizes the symptoms and severity of AD and that can be used for both acute and long-term management.

Quality of life and disease severity in patients with atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) affects quality of life (QoL) negatively in patients and their families. We examined the relationship between disease severity and QoL in patients with AD.

METHODS

Consecutive, newly referred outpatients with AD, 4 years of age or older, were assessed from January 2012 onwards by means of the dermatology life quality index (DLQI, range 0-30), the Scoring of AD (SCORAD) disease severity score (range 0-103), filaggrin gene (FLG) mutation status and paraclinical tests related to allergy.

RESULTS

A total of 250 patients with a mean age of 26.0 years were identified with complete data on DLQI; 148 (59.2%) females and 102 (40.8%) males. Of these 45.6% had asthma, 46.8% had hay fever, 22.7% had a loss-of-function mutation in FLG, and 61.9% had one or more inhalant allergic sensitizations. The correlation between SCORAD and DLQI was 0.42 (P < 0.001). After multivariate adjustment there was an increasing mean DLQI score with increasing disease severity measured by SCORAD (DLQI in mild = 5.30, moderate = 8.59 and severe = 11.94 AD), P-value for difference between groups <0.001; a higher mean DLQI among females than males (9.73 vs. 8.34), P = 0.028; and among patients reporting facial eczema (9.88 vs. 6.24), P = 0.012. No statistically significant influence on DLQI was found for hand or foot eczema, age, blood eosinophil count, allergic sensitization, asthma, hay fever, FLG mutation status and smoking. FLG null mutation status was not significantly associated with SCORAD.

CONCLUSION

AD impacts negatively on the QoL, proportional to the severity of the disease. Furthermore, female sex and facial eczema are associated with low QoL. Positive FLG null mutation status is not associated with QoL or disease severity.

Economic evidence for the prevention and treatment of atopic eczema: a protocol for a systematic review

BACKGROUND

Eczema, synonymous with atopic eczema or atopic dermatitis, is a chronic skin disease that has a similar impact on health-related quality of life as other chronic diseases. The proposed research aims to provide a comprehensive systematic assessment of the economic evidence base available to inform economic modelling and decision making on interventions to prevent and treat eczema at any stage of the life course. Whilst the Global Resource of Eczema Trials (GREAT) database collects together the effectiveness evidence for eczema, there is currently no such systematic resource on the economics of eczema. It is important to gain an overview of the current state of the art of economic methods in the field of eczema in order to strengthen the economic evidence base further.

METHODS/DESIGN

The proposed study is a systematic review of the economic evidence surrounding interventions for the prevention and treatment of eczema. Relevant search terms will be used to search MEDLINE, EMBASE, Database of Abstracts of Reviews of Effects, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, National Health Service (NHS) Economic Evaluation Database, Health Technology Assessment, Cumulative Index to Nursing and Allied Health Literature, EconLit, Scopus, Cost-Effectiveness Analysis Registry and Web of Science in order to identify relevant evidence. To be eligible for inclusion studies will be primary empirical studies evaluating the cost, utility or full economic evaluation of interventions for preventing or treating eczema. Two reviewers will independently assess studies for eligibility and perform data abstraction. Evidence tables will be produced presenting details of study characteristics, costing methods, outcome methods and quality assessment. The methodological quality of studies will be assessed using accepted checklists.

DISCUSSION

The systematic review is being undertaken to identify the type of economic evidence available, summarise the results of the available economic evidence and critically appraise the quality of economic evidence currently available to inform future economic modelling and resource allocation decisions about interventions to prevent or treat eczema. We aim to use the review to offer guidance about how to gather economic evidence in studies of eczema and/or what further research is necessary in order to inform this.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015024633.

Humoral and Cellular Autoreactivity to Epidermal Proteins in Atopic Dermatitis

Atopic dermatitis (AD), a chronic relapsing inflammatory disease of the skin, is an important public health concern affecting 10-20 % of children worldwide. The etiology and pathogenesis of AD involve the interplay of genetic and environmental factors, including abnormalities in skin integrity and a skewed immune system usually driven by a Th2 phenotype in childhood with a switch to Th1 in the chronic phase of disease. Children and adults with AD commonly have elevated IgE levels directed to multiple different antigens, including aeroallergens, food allergens, and microbial proteins. IgE targeting self-antigens from epidermal proteins have been detected in up to 91 % of patients, particularly in severe persistent AD. It has been suggested that the occurrence of autoreactivity develops in early childhood. However, it is not clear yet if autoreactive IgEs in patients with AD are pathogenic or just an epiphenomenon. The fact that these autoantibodies are associated with severity and are not present in other allergic or skin diseases favors the pathogenicity of IgE-mediated autoreactivity in AD. In this review, we evaluate the pathogenesis of AD and the emerging role of autoreactivity to various keratinocyte antigens involving both the humoral and cellular components of the immune system.

Factors associated with quality of life in children with asthma living in Scotland

INTRODUCTION

Asthma affects children's quality of life (QoL) but factors associated with QoL are not well understood. Our hypothesis was that there are factors linked to QoL which are amenable to treatment or environmental modification.

METHODS

QoL was ascertained in a study designed to link environmental exposures to asthma outcomes. Univariate and multivariate analysis were used to determine which factors are associated with QoL.

RESULTS

There were 553 children with asthma where QoL was determined, mean age 10.3 and 312 (58%) were boys. The median QoL score was 5.9 (interquartile range 4.6, 6.8). In the multivariate model, asthma severity (as evidenced by British Thoracic Society, BTS, treatment step), smoking exposure, socioeconomic status and rhinitis were associated with the QoL score. QoL score was reduced by (i) 30% [95% confidence interval 20, 39] for those on BTS step 4 compared to BTS step 1 treatment (ii) 11% [2, 19] for children with ≥ two resident smokers with reference to no resident smokers (iii) 3% [1, 5] for each quintile difference in deprivation compared to the most affluent and (iv) 9% [4, 14] for children with rhinitis compared to no rhinitis.

CONCLUSIONS

The QoL for children with asthma in the UK is generally good. Clinicians caring children with asthma should consider routinely asking about smoke exposure and hayfever symptoms in addition to assessing asthma control.

Education to improve quality of life of people with chronic inflammatory skin conditions: a systematic review of the evidence

Patient and carer education has been proposed as a way of improving health-related quality of life (HRQoL) among people with chronic inflammatory skin conditions. This systematic review aimed to assess the effects of education that specifically addresses HRQoL among people with chronic inflammatory skin conditions. We searched 12 literature databases and other sources (up to July 2014). Seven randomized controlled trials (RCTs) met the review inclusion criteria. Data from these RCTs were extracted and critically appraised. Two RCTs showed that for psoriasis in adults, group-based and text message education (as adjuncts to usual care) resulted in better HRQoL and disease severity outcomes than comparators, respectively. One RCT found that group-based education for children with eczema (atopic dermatitis) and their parents resulted in greater improvements in parents' HRQoL and in the children's disease severity than no education at 12 months. The remaining RCTs evaluated an educational session for psoriasis, a website for carers of children with eczema, information on skincare and make-up use given to women with acne, and an itch-coping programme for a range of conditions, all as adjuncts to usual care. None of these RCTs found statistically significant effects on HRQoL or disease severity compared with usual care. Common features of the effective interventions were long delivery (over 6 weeks to 3 months) and delivery by a multidisciplinary team. Overall, the evidence base is currently limited and generally has an unclear risk of bias. There is a need for more large RCTs evaluating piloted and theory-based interventions.

Atopic dermatitis in children. A current algorithm for the disease treatment and control

The article discusses key aspects of the pathogenesis of atopic dermatitis and issues of the selection of pathogenetically substantiated therapy methods. The authors provide data on the efficient use of basic drugs used to treat dermatosis in children - topical glucocorticosteroids and calcineurin inhibitors. The authors also describe a current algorithm for using topical calcineurin inhibitors during the period of an exacerbation of atopic dermatitis and to prevent relapses.

Quality of Life in Patients with Atopic Dermatitis: Disease Burden, Measurement, and Treatment Benefit

Health-related quality of life (HRQoL) is often markedly impaired in both adults and children with atopic dermatitis. The quality of life of the parents of infants or children with this chronic disease is also affected owing to problems such as itch-induced sleeping problems and treatment effort. As HRQoL is only partly associated with disease severity, both parameters should be evaluated in research and clinical practice. For the measurement of HRQoL, both skin- and disease-specific questionnaires are available in addition to generic instruments. In randomized controlled trials on atopic dermatitis, HRQoL is most commonly evaluated with the Dermatology Life Quality Index for use in adults and related questionnaires for children and families, such as the Children's Dermatology Life Quality Index. There is evidence that different treatment modalities may be effective in improving HRQoL in adults, children, and parents, which is supported by the patients' own evaluation of treatment benefit in an observational study.

Mechanism of Sleep Disturbance in Children with Atopic Dermatitis and the Role of the Circadian Rhythm and Melatonin

Sleep disturbance is common in children with atopic dermatitis (AD). It is a major factor leading to impaired quality of life in these patients and could have negative effects on neurocognitive function and behavior. However, the pathophysiology of sleep disturbance in children with AD is poorly understood, and there is no consensus on how to manage sleep problems in these patients. Pruritus and scratching could lead to sleep disruption but is unlikely the sole etiology. The circadian rhythm of cytokines, the immune system, and skin physiology such as transcutaneous water loss and skin blood flow might also play a role. Recent studies have suggested that melatonin could also be involved due to its multiple effects on sleep, immunomodulation, and anti-oxidant ability. Environmental factors should also be considered. In this review, we summarize the current understanding of the pathophysiology of sleep disturbance in children with AD, and discuss possible therapeutic implications.

Quality of life impact of childhood skin conditions measured using the Children's Dermatology Life Quality Index (CDLQI): a meta-analysis

BACKGROUND

The Children's Dermatology Life Quality Index (CDLQI) is the most widely used instrument for measuring the impact of skin disease on quality of life (QoL) in children.

OBJECTIVES

To provide a meta-analysis of all published QoL scores for a range of childhood skin conditions.

METHODS

Studies using the CDLQI questionnaire to measure QoL in skin conditions were identified by searching Medline and Embase from January 1995 (CDLQI creation) to December 2014. Studies were grouped according to condition and baseline scores were combined using meta-analysis.

RESULTS

Sixty-seven studies using the CDLQI met the inclusion criteria. The overall estimated CDLQI scores for conditions reported more than once were [point estimate (95% confidence interval, CI), number of studies (n), score range]: atopic eczema [8·5 (7·1-9·8), n = 38, 0-29], acne [5·3 (1·9-8·5), n = 5, 0-30], alopecia [3·1 (0-7·7), n = 2, 0-6], molluscum contagiosum [3·5 (0·6-6·7), n = 5, 0-27], psoriasis [8·0 (3·9-12·1), n = 6, 0-29], scabies [9·2 (0·0-20·3), n = 2, 1-26], urticaria [7·1 (0-15·4), n = 2, 0-22], vitiligo [6·5 (0·7-12·2), n = 2, 0-20] and warts [2·9 (0-5·8), n = 4, 0-16]. Overall, the mean effect on QoL [weighted average CDLQI score 4·6 (95% CI 3·9-5·4)] for children with these conditions was small. However, many children were found to experience a very large impact on QoL (34% of children with atopic eczema, 10% with molluscum contagiosum and 1-5% with acne) in studies where the distributions of scores were provided.

CONCLUSIONS

Most skin conditions in children have a 'small' mean effect on QoL. However, the range is large and a significant proportion of children with many common skin conditions will experience a very large effect on quality of life.

Effects of oral vitamin E on treatment of atopic dermatitis: A randomized controlled trial

BACKGROUND

The pathogenesis of atopic dermatitis (AD) remains to be determined; recently a possible change in the immune system with production of immunoglobulins is proposed. As vitamin E is a potent antioxidant, with the ability to decrease the serum levels of immunoglobulin E (IgE) in atopic patients, we aimed to evaluate the effect of oral vitamin E on treatment of AD.

MATERIALS AND METHODS

This randomized, double-blind, placebo-controlled trial comprised seventy participants with mild-to-moderate AD, based on the Hanifin and Rajka diagnostic criteria. The patients were randomly selected from teaching skin clinics in Isfahan, Iran. They were randomly assigned to two groups of equal number, receiving vitamin E (400 IU/day) and placebo for four 4 months. Each month, the extent, severity, and subjective symptoms including itch and sleeplessness were measured by SCORAD index. Three months after the end of intervention, the recurrence rate was assessed.

RESULTS

The improvement in all symptoms, except sleeplessness, was significantly higher in the group receiving vitamin E than in controls (-1.5 vs. 0.218 in itching, -10.85 vs. -3.54 in extent of lesion, and -11.12 vs. -3.89 in SCORAD index, respectively, P < 0.05). Three months after the end of intervention, the recurrence rate of AD was evaluated. Recurrence rate between all 42 individuals, who remained in the study, was 18.6%. Recurrence ratio of the group receiving vitamin E compared to the placebo group was 1.17, without significant differences between the two groups (P > 0.05).

CONCLUSION

This study suggests that vitamin E can improve the symptoms and the quality of life in patients with AD. As vitamin E has no side effects with a dosage of 400 IU/day, it can be recommended for the treatment of AD.

A randomised placebo-controlled trial of oral and topical antibiotics for children with clinically infected eczema in the community: the ChildRen with Eczema, Antibiotic Management (CREAM) study

BACKGROUND

Secondary skin infection is common during eczema exacerbations and many children are treated with antibiotics when this is suspected, although there is little high-quality evidence to justify this practice.

OBJECTIVE

To determine the clinical effectiveness of oral and topical antibiotics, in addition to standard treatment with emollients and topical corticosteroids, in children with clinically infected eczema.

DESIGN

Multicentre randomised, double-blind, placebo-controlled trial.

SETTING

General practices and dermatology clinics in England, Wales and Scotland.

PARTICIPANTS

Children (aged 3 months to < 8 years) with a diagnosis of eczema (according to U.K. Working Party definition) and clinical suspicion of infection.

INTERVENTIONS

(1) Oral flucloxacillin and topical placebo; (2) topical fusidic acid (Fucidin(®), Leo Laboratories Limited) and oral placebo; and (3) oral and topical placebos, all for 1 week.

MAIN OUTCOME MEASURES

Patient-Orientated Eczema Measure (POEM) at 2 weeks (assessing subjective severity in the week following treatment).

RESULTS

We randomised 113 children (36 to oral antibiotic, 37 to topical antibiotic and 40 to placebo), which was fewer than our revised target sample size of 282. A total of 103 (92.0%) children had one or more clinical features suggestive of infection and 78 (69.6%) children had Staphylococcus aureus cultured from a skin swab. Oral and topical antibiotics resulted in a 1.52 [95% confidence interval (CI) -1.35 to 4.40] and 1.49 (95% CI -1.55 to 4.53) increase (worse subjective severity) in POEM score at 2 weeks, relative to placebo and controlling for baseline POEM score. Eczema Area and Severity Index (objective severity) scores were also higher (worse) in the intervention groups, at 0.20 (95% CI -0.12 to 0.52) and 0.42 (95% CI 0.09 to 0.75) for oral and topical antibiotics, respectively, at 2 weeks. Analyses of impact on the family, quality of life, daily symptom scores, and longer-term outcomes were all consistent with the finding of no or limited difference and a trend towards worse outcomes in the intervention groups. Sensitivity analyses, including adjusting for compliance and imputation for missing data, were consistent with the main findings.

CONCLUSIONS

Our data suggest that oral and topical antibiotics have no effect, or a harmful effect, on subjective eczema severity in children with clinically infected eczema in the community. The CIs around our estimates exclude a meaningful beneficial effect (published minimal clinically important difference for POEM is 3.4). Although most patients in this trial had features suggestive of infection and S. aureus on their skin, participants primarily had mild-moderate eczema and those with signs of more severe infection were often excluded. Clinicians should consider avoiding oral and topical antibiotic use in children with suspected infected eczema in the community who do not have signs of 'severe infection'. Further research should seek to understand how best to encourage the use of topical steroids and limit use of antibiotics in those with eczema flares without signs of severe infection, as well as developing tools to better phenotype eczema flares, in order to better define a population that may benefit from antibiotic treatment.

TRIAL REGISTRATION

European Union Drug Regulating Authorities Clinical Trials (EudraCT) number 2011-003591-37 and Current Controlled Trials ISRCTN96705420.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Do early-life exposures explain why more advantaged children get eczema? Findings from the U.K. Millennium Cohort Study

Background

Atopic dermatitis (eczema) in childhood is socially patterned, with higher incidence in more advantaged populations. However, it is unclear what factors explain the social differences.

Objectives

To identify early‐life risk factors for eczema, and to explore how early‐life risk factors explain any differences in eczema.

Methods

We estimated odds ratios (ORs) for ever having had eczema by age 5 years in 14 499 children from the U.K. Millennium Cohort Study (MCS), with a focus on maternal, antenatal and early‐life risk factors and socioeconomic circumstances (SECs). Risk factors were explored to assess whether they attenuated associations between SECs and eczema.

Results

Overall 35·1% of children had ever had eczema by age 5 years. Children of mothers with degree‐level qualifications vs. no educational qualifications were more likely to have eczema (OR 1·52, 95% confidence interval 1·31–1·76), and there was a gradient across the socioeconomic spectrum. Maternal atopy, breastfeeding (1–6 weeks and ≥ 6 months), introduction of solids under 4 months or cow's milk under 9 months, antibiotic exposure in the first year of life and grime exposure were associated with an increased odds of having eczema. Female sex, Pakistani and Bangladeshi ethnicity, smoking during pregnancy, exposure to environmental tobacco smoke and having more siblings were associated with reduced odds for eczema. Controlling for maternal, antenatal and early‐life characteristics (particularly maternal smoking during pregnancy, breastfeeding and number of siblings) reduced the OR for eczema to 1·26 (95% confidence interval 1·03–1·50) in the group with the highest educational qualifications compared with the least.

Conclusions

In a representative U.K. child cohort, eczema was more common in more advantaged children. This was explained partially by early‐life factors including not smoking during pregnancy, breastfeeding and having fewer siblings.

What's already known about this topic?

Previous studies have suggested that atopic dermatitis (eczema) in childhood is socially patterned, with higher incidence in more advantaged populations.

It is unclear what explains these differences.

What does this study add?

This large longitudinal study confirmed a significant excess of atopic dermatitis in more advantaged children born in 2000.

This could be explained partially by maternal and early‐life factors including less maternal smoking in pregnancy, prolonged breastfeeding and fewer siblings.

Plain language summary available online

Measurement properties of quality of life measurement instruments for infants, children and adolescents with eczema: protocol for a systematic review

BACKGROUND

Eczema is a common chronic or chronically relapsing, inflammatory skin disease that exerts a substantial negative impact on quality of life (QoL). The Harmonising Outcome Measures for Eczema (HOME) initiative has used a consensus-based process which identified QoL as one of the four core outcome domains to be assessed in all eczema clinical trials. A number of measurement instruments exist to measure QoL in infants, children, and adolescents with eczema, and there is a great variability in both content and quality of the instruments used. Therefore, the objective of the proposed research is to comprehensively and systematically assess the measurement properties of the existing measurement instruments that were developed and/or validated for the measurement of patient-reported QoL in infants, children, and adolescents with eczema.

METHODS/DESIGN

This study is a systematic review of the measurement properties of patient-reported measures of QoL developed and/or validated for infants, children, and adolescents with eczema. A systematic literature search will be carried out in MEDLINE via PubMed and EMBASE using a selection of relevant search terms. Eligible studies will be primary empirical studies evaluating, describing, or comparing measurement properties of QoL instruments for infants, children, and adolescents with eczema. Two reviewers will independently perform eligibility assessment and data abstraction. Evidence tables will be used to record study characteristics, instrument characteristics, measurement properties, and interpretability. The adequacy of the measurement properties will be assessed using predefined criteria. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist will be used to evaluate the methodological quality of included studies. A best evidence synthesis will be undertaken if more than one study has examined a particular measurement property.

DISCUSSION

The proposed systematic review will yield a comprehensive assessment of measurement properties of existing QoL instruments in infants, children, and adolescents with eczema. The results will serve as a basis to recommend a QoL measurement instrument for infants, one for children, and one for adolescents for use in future clinical trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015023483.

The Association Between Bathing Habits and Severity of Atopic Dermatitis in Children

BACKGROUND

Atopic dermatitis is an inflammatory skin disease that frequently affects children. The current recommendations on management using lifestyle modification are highly variable, leading to confusion and uncertainty among patients.

AIM

To determine current bathing behaviors and the subsequent impact on disease severity.

METHODS

This was an observational cross-sectional study conducted at an urban pediatric emergency department. Parents were asked to fill out a questionnaire concerning the patient's bathing habits. The results were correlated with the atopic dermatitis severity determined by the SCORAD (SCORing Atopic Dermatitis) tool.

RESULTS

No difference between variables was found to be significant for bathing frequency, time spent bathing, or use of moisturizers. Multivariate analysis showed that atopic dermatitis severity increased with age greater than 2 years (P = .0004) and with greater bathing duration (P = .001).

CONCLUSION

Atopic dermatitis severity may be associated with a longer duration of bathing. The frequency of bathing does not appear to affect atopic dermatitis severity.

The march from early life food sensitization to allergic disease: a systematic review and meta-analyses of birth cohort studies

BACKGROUND

There is growing evidence for an increase in food allergies. The question of whether early life food sensitization, a primary step in food allergies, leads to other allergic disease is a controversial but important issue. Birth cohorts are an ideal design to answer this question.

OBJECTIVES

We aimed to systematically investigate and meta-analyse the evidence for associations between early food sensitization and allergic disease in birth cohorts.

METHODS

MEDLINE and SCOPUS databases were searched for birth cohorts that have investigated the association between food sensitization in the first 2 years and subsequent wheeze/asthma, eczema and/or allergic rhinitis. We performed meta-analyses using random-effects models to obtain pooled estimates, stratified by age group.

RESULTS

The search yielded fifteen original articles representing thirteen cohorts. Early life food sensitization was associated with an increased risk of infantile eczema, childhood wheeze/asthma, eczema and allergic rhinitis and young adult asthma. Meta-analyses demonstrated that early life food sensitization is related to an increased risk of wheeze/asthma (pooled OR 2.9; 95% CI 2.0-4.0), eczema (pooled OR 2.7; 95% CI 1.7-4.4) and allergic rhinitis (pooled OR 3.1; 95% CI 1.9-4.9) from 4 to 8 years.

CONCLUSION

Food sensitization in the first 2 years of life can identify children at high risk of subsequent allergic disease who may benefit from early life preventive strategies. However, due to potential residual confounding in the majority of studies combined with lack of follow-up into adolescence and adulthood, further research is needed.

Breastfeeding and asthma and allergies: a systematic review and meta-analysis

AIM

To systematically review the association between breastfeeding and childhood allergic disease.

METHODS

Predetermined inclusion/exclusion criteria identified 89 articles from PubMed, CINAHL and EMBASE databases. Meta-analyses performed for categories of breastfeeding and allergic outcomes. Meta-regression explored heterogeneity.

RESULTS

More vs. less breastfeeding (duration) was associated with reduced risk of asthma for children (5-18 years), particularly in medium-/low-income countries and with reduced risk of allergic rhinitis ≤5 years, but this estimate had high heterogeneity and low quality. Exclusive breastfeeding for 3-4 months was associated with reduced risk of eczema ≤2 years (estimate principally from cross-sectional studies of low methodological quality). No association found between breastfeeding and food allergy (estimate had high heterogeneity and low quality). Meta-regression found differences between study outcomes may be attributable to length of breastfeeding recall, study design, country income and date of study inception. Some of the protective effect of breastfeeding for asthma may be related to recall bias in studies of lesser methodological quality.

CONCLUSION

There is some evidence that breastfeeding is protective for asthma (5-18 years). There is weaker evidence for a protective effect for eczema ≤2 years and allergic rhinitis ≤5 years of age, with greater protection for asthma and eczema in low-income countries.

Assessment of Quality of Life in Patients With Skin Disorders Undergoing Ayurvedic Panchakarma (Biopurification) as Management

BACKGROUND

Chronic skin conditions can have a negative impact on one's quality of life, affecting their physical, functional, and emotional well-being. Whereas biopurifactory measures (panchakarma) of Ayurveda claims to provide better quality of life after treatment. Hence current study is planned to provide evidence in patients with skin disorders, undergoing Ayurvedic treatment.

METHODOLOGY

Sixty patients with skin disorder, who underwent purification therapies like therapeutic emesis and therapeutic purgation, were randomly placed in 2 groups to assess quality of life. Quality of life assessment was done with the help of Skindex-29 among the patients before and after Ayurvedic purification therapy. Thereafter, the quality of life assessment was done on the first follow-up.

RESULTS

A statistically significant improvement in the quality of life domains-emotions, functioning, and symptoms-after the Ayurvedic management was observed with P value <.001.

CONCLUSION

Study concludes that there is improvement in quality of life among patients with skin disease after undergoing Ayurveda purification therapies.

Environmental tobacco smoke and the risk of eczema symptoms among school children in South Africa: a cross-sectional study

OBJECTIVE

The aim of this study was to investigate the association between eczema ever (EE) and current eczema symptoms (ES) in relation to exposure to environmental tobacco smoke (ETS).

DESIGN

A cross-sectional study using the International Study of Asthma and Allergies in Childhood questionnaire.

SETTING

16 schools were randomly selected from two neighbourhoods situated in Ekurhuleni Metropolitan Municipality, Gauteng Province, South Africa.

PARTICIPANTS

From a total population of 3764 school children aged 12-14 years, 3468 completed the questionnaire (92% response rate). A total of 3424 questionnaires were included in the final data analysis.

PRIMARY OUTCOME

The prevalence of EE and current ES was the primary outcome in this study.

RESULTS

Data were analysed using Multilevel Logistic Regression Analysis (MLRA). The likelihood of EE was increased by exposure to ETS at home (OR 1.30 95% CI 1.01 to 1.67) and at school (OR 1.26 95% CI 1.00 to 1.60). The likelihood of EE was lower for males (OR 0.66 95% CI 0.51 to 0.84). The likelihood of ES was increased by ETS at home (OR 1.93 95% CI 1.43 to 2.59) and school (1.44 95% CI 1.09 to 1.90). The likelihood of ES was again lower for males (OR 0.56 95% CI 0.42 to 0.76). Smoking by mother/female guardian increased the likelihood of EE and ES, however, this was not significant in the multivariate analysis.

CONCLUSIONS

Symptoms of eczema were positively associated with exposure to ETS at home and school. The results support the hypothesis that ETS is an important factor in understanding the occurrence of eczema.

Пимекролимус в лечении атопического дерматита у детей. Вопросы безопасности и эффективности. Опыт пятилетнего применения

A growth in the incidence rate for atopic dermatitis (AD) in infants has been observed for this decade. Early formation of AD (at the age of 3-6 months) is observed in 45% of infants, and in 60% of infants - during the first year of life. As many as 65% of children (by the age of 7) and 74% of children (by the age of 16) suffering from AD have a spontaneous remission of the disease. As many as 20-43% of children suffering from AD further develop bronchial asthma, and the incidence rate of allergic rhinitis is twice as high. In spite of the fact that topical corticosteroids (TCS) are prescribed frequently enough, there is a need in the non-hormonal therapy due to poor compliance with the TCS treatment regimen in connection with side effects. Treatment of AD is often complicated by the colonization with Staphylococcus aureus and inefficacy of the external therapy with topical corticosteroids because many patients with AD have a high level of IgE against the superantigen of Staphylococcus. 1% pimecrolimus cream (PIM) and TCS were compared in a long-term large-scale study involving younger children suffering from mild to moderate AD. Materials and methods. The five-year open-label study involved 2,418 children, who were randomized into groups receiving PIM (n = 1205; in case of an aggravation - short-term administration of TCS) or TCS (n = 1213). The main goal of the study was to compare the safety of these two methods of treatment; an auxiliary goal was to confirm the long-term efficacy of PIM. Treatment was considered to be successful if the score based on the IGA scale was 0 (clean skin) or 1 (almost clean). Results. The effect in both groups of the drugs - PIM and TCS - was fast, and the success of treatment was recorded for >50% of patients by Week 3. In both groups, treatment was determined to be successful after 5 years in >85% of patients, and treatment of manifestations of AD on the face was efficient in 95% of all subjects. In the PIM group, the need in steroids was considerably lower than in the TCS group (7 days of administration vs. 178 days in the TCS group). In both groups, there were adverse events similar by their nature and frequency, and no disorders of humoral or cellular immunity were revealed. Conclusions. The long-term administration of PIM in case of mild to moderate AD in children was revealed to be safe and had no effect on the immune system. When PIM was used, the need in corticosteroids was considerably reduced (steroid-preserving effect). These data confirm that PIM is as efficient as TCS and can be used as the first-line therapy for mild to moderate AD in infants and younger children.

Atopic dermatitis: current treatment guidelines. Statement of the experts of the Dermatological Section, Polish Society of Allergology, and the Allergology Section, Polish Society of Dermatology

Atopic dermatitis (AD) is a condition frequently encountered in medical practices across the country. More than 60% of children with AD are at risk to develop allergic rhinitis or asthma (the atopic march). Patients with AD have a unique predisposition to colonization or infection by Staphylococcus aureus. Treatments for AD need to rapidly control symptoms of the disease, improve quality of life and prevent exacerbations. Given the chronic and relapsing nature of the disease, therapies need to encourage good compliance and be well tolerated.

Child Allergic Symptoms and Well-Being at School: Findings from ALSPAC, a UK Cohort Study

Background

Eczema and asthma are common conditions in childhood that can influence children’s mental health. Despite this, little is known about how these conditions affect the well-being of children in school. This study examines whether symptoms of eczema or asthma are associated with poorer social and mental well-being in school as reported by children and their teachers at age 8 years.

Methods

Participants were from the Avon Longitudinal Study of Parents and Children. Measures of child well-being in school were child-reported (n = 6626) and teacher reported (n = 4366): children reported on their enjoyment of school and relationships with peers via a self-complete questionnaire; teachers reported child mental well-being using the Strengths and Difficulties Questionnaire [binary outcomes were high ‘internalizing’ (anxious/depressive) and ‘externalizing’ (oppositional/hyperactive) problems (high was >90th percentile)]. Child rash and wheeze status were maternally reported and symptoms categorised as: ‘none’; ‘early onset transient’ (infancy/preschool only); ‘persistent’ (infancy/preschool and at school age); and ‘late onset’ (school age only).

Results

Children with persistent (OR 1.29, 95% CI 1.02 to 1.63) and late onset (OR 1.48, 95% CI 1.02 to 2.14) rash were more likely to report being bullied, and children with persistent wheeze to feel left out (OR 1.42, 95% CI 1.10 to 1.84). Late onset rash was associated with high teacher-reported internalising behaviours (OR 1.61, 95% CI 1.02 to 2.54), and persistent rash with high externalising behaviours (OR 1.37, 95% CI 1.02 to 1.84). Child sleep and maternal mental health explained some of the associations with teacher-reported mental well-being.

Conclusion

Symptoms of eczema or asthma can adversely affect a child’s social and mental well-being at primary school. This suggests interventions, such as additional support or education of peers, should begin at early stages in schooling.

Choice of Moisturiser for Eczema Treatment (COMET): study protocol for a randomized controlled trial

BACKGROUND

Eczema is common in children and in the UK most cases are managed in primary care. The foundation of all treatment is the regular use of leave-on emollients to preserve and restore moisture to the skin. This not only improves comfort but may also reduce the need for rescue treatment for 'flares', such as topical corticosteroids. However, clinicians can prescribe many different types of emollient and there is a paucity of evidence to guide this choice. One reason for this may be the challenges of conducting a clinical trial: are parents or carers of young children willing to be randomly allocated an emollient and followed up for a meaningful amount of time?

DESIGN

This is a single-centre feasibility study of a pragmatic, four-arm, single-masked, randomized trial. Children with eczema who are eligible (from 1 month to less than 5 years of age, not known to be sensitive or allergic to any of study emollients or their constituents) are recruited via their general practices. Participants are allocated Aveeno® lotion, Diprobase® cream, Doublebase® gel or Hydromol® ointment via a web-based system, using a simple randomization process in a 1:1:1:1 fashion. Researchers are masked to the study emollient. Participants are assessed at baseline and followed up for 3 months. Data are collected by daily diaries, monthly researcher visits and review of electronic medical records. Because this is a feasibility study, a formal sample size calculation for the estimation of treatment effectiveness has not be made but we aim to recruit 160 participants.

DISCUSSION

Recruitment is on-going. At the end of the study, as well as being able to answer the question, 'Is it is possible to recruit and retain children with eczema from primary care into a four-arm randomized trial of emollients?', we will also have collected important data on the acceptability and effectiveness of four commonly used emollients.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN21828118 and Clinical Trials Register EudraCT2013-003001-26.

Pimecrolimus in atopic dermatitis: consensus on safety and the need to allow use in infants

Atopic dermatitis (AD) is a distressing dermatological disease, which is highly prevalent during infancy, can persist into later life and requires long-term management with anti-inflammatory compounds. The introduction of the topical calcineurin inhibitors (TCIs), tacrolimus and pimecrolimus, more than 10 yr ago was a major breakthrough for the topical anti-inflammatory treatment of AD. Pimecrolimus 1% is approved for second-line use in children (≥2 yr old) and adults with mild-to-moderate AD. The age restriction was emphasized in a boxed warning added by the FDA in January 2006, which also highlights the lack of long-term safety data and the theoretical risk of skin malignancy and lymphoma. Since then, pimecrolimus has been extensively investigated in short- and long-term studies including over 4000 infants (<2 yr old). These studies showed that pimecrolimus effectively treats AD in infants, with sustained improvement with long-term intermittent use. Unlike topical corticosteroids, long-term TCI use does not carry the risks of skin atrophy, impaired epidermal barrier function or enhanced percutaneous absorption, and so is suitable for AD treatment especially in sensitive skin areas. Most importantly, the studies of pimecrolimus in infants provided no evidence for systemic immunosuppression, and a comprehensive body of evidence from clinical studies, post-marketing surveillance and epidemiological investigations does not support potential safety concerns. In conclusion, the authors consider that the labelling restrictions regarding the use of pimecrolimus in infants are no longer justified and recommend that the validity of the boxed warning for TCIs should be reconsidered.

Advances in the diagnosis and therapeutic management of atopic dermatitis

Atopic dermatitis is a very prevalent disease that affects children as well as adults. The disease has a severe impact on quality of life for the patients and their families. The skin in atopic dermatitis patients is a site of both a severe inflammatory reaction dominated by lymphocytes and decreased skin barrier function. The treatment of the disease is mainly aimed at reducing the inflammation in the skin and/or restoring the skin barrier function. However, most of the treatments used today singularly aim at reducing the inflammation in the skin. Depending on the severity of the disease, the anti-inflammatory treatment may be topical or systemic, but basic treatment, no matter the severity, should always be emollients. In addition, new studies have shown good effects of psychosocial interventions, such as eczema schools, for patients and their families. This review covers the latest trends in the treatment of atopic dermatitis.

Extended implementation of educational programs for atopic dermatitis in childhood

Children with atopic dermatitis (AD) suffer from chronic relapsing inflammatory skin lesions accompanied by insatiable itching, dryness, excoriated skin, or even (super-)infections. This burden impairs the quality of life of affected children and their families. Due particularly to the recurrent course of the disease, patients often lose confidence in treatment and fear side effects of steroids. Family education programs for AD have been established in the last decades to provide appropriate education and psychosocial support. However, the need for long-lasting strategies in treatment and prevention has even increased. Recent findings not only underline the importance of an intact skin barrier in regard to acute therapy but also suggest that an impairment of skin barrier integrity promotes the development of subsequent atopic diseases in the course of the atopic march. Moreover, in addition to the psychosocial burden due to stigmatized appearance or sleep disturbance, new observations document an increased presence of psychosomatic comorbidities in patients with AD. We reviewed recent educational interventions regarding the theoretical background and here will discuss the heterogeneous approaches of existing programs in childhood. Despite high variations of educational strategies, an overriding aim should be the broader integration of supporting programs in the treatment of children with AD to empower the affected child and its caregiver's to obtain the best possible care, quality of life, and to promote (secondary) prevention.

Educational background of nurses and their perceptions of the quality and safety of patient care

Background

International health systems research confirms the critical role that nurses play in ensuring the delivery of high quality patient care and subsequent patient safety. It is therefore important that the education of nurses should prepare them for the provision of safe care of a high quality. The South African healthcare system is made up of public and private hospitals that employ various categories of nurses. The perceptions of the various categories of nurses with reference to quality of care and patient safety are unknown in South Africa (SA).

Objective

To determine the relationship between the educational background of nurses and their perceptions of quality of care and patient safety in private surgical units in SA.

Methods

A descriptive correlational design was used. A questionnaire was used for data collection, after which hierarchical linear modelling was utilised to determine the relationships amongst the variables.

Results

Both the registered- and enrolled nurses seemed satisfied with the quality of care and patient safety in the units were they work. Enrolled nurses (ENs) indicated that current efforts to prevent errors are adequate, whilst the registered nurses (RNs) obtained high scores in reporting incidents in surgical wards.

Conclusion

From the results it was evident that perceptions of RNs and ENs related to the quality of care and patient safety differed. There seemed to be a statistically-significant difference between RNs and ENs perceptions of the prevention of errors in the unit, losing patient information between shifts and patient incidents related to medication errors, pressure ulcers and falls with injury.

Economic value of atopic dermatitis prevention via infant formula use in high-risk Malaysian infants

Background

Breastfeeding is best for infants and the World Health Organization recommends exclusive breastfeeding for at least the first 6 months of life. For those who are unable to be breastfed, previous studies demonstrate that feeding high-risk infants with hydrolyzed formulas instead of cow's milk formula (CMF) may decrease the risk of atopic dermatitis (AD).

Objective

To estimate the economic impact of feeding high-risk, not exclusively breastfed, urban Malaysian infants with partiallyhydrolyzed whey-based formula (PHF-W) instead of CMF for the first 17 weeks of life as an AD risk reduction strategy.

Methods

A cohort Markov model simulated the AD incidence and burden from birth to age 6 years in the target population fed with PHF-W vs. CMF. The model integrated published clinical and epidemiologic data, local cost data, and expert opinion. Modeled outcomes included AD-risk reduction, time spent post AD diagnosis, days without AD flare, quality-adjusted life years (QALYs), and costs (direct and indirect). Outcomes were discounted at 3% per year. Costs are expressed in Malaysian Ringgit (MYR; MYR 1,000 = United States dollar [US $]316.50).

Results

Feeding a high-risk infant PHF-W vs. CMF resulted in a 14% point reduction in AD risk (95% confidence interval [CI], 3%-23%), a 0.69-year (95% CI, 0.25-1.10) reduction in time spent post-AD diagnosis, additional 38 (95% CI, 2-94) days without AD flare, and an undiscounted gain of 0.041 (95% CI, 0.007-0.103) QALYs. The discounted AD-related 6-year cost estimates when feeding a high-risk infant with PHF-W were MYR 1,758 (US $556) (95% CI, MYR 917-3,033) and with CMF MYR 2,871 (US $909) (95% CI, MYR 1,697-4,278), resulting in a per-child net saving of MYR 1,113 (US $352) (95% CI, MYR 317-1,884) favoring PHF-W.

Conclusion

Using PHF-W instead of CMF in this population is expected to result in AD-related costs savings.

Parents' experience of childhood atopic eczema in the public health sector of Gauteng

Background

The World Allergy Organization found that 20% – 30% of the world's population suffers from an allergic disease. Most allergic patients are seen by non-allergy-trained healthcare workers. The public primary healthcare (PHC) management of childhood atopic eczema (CAE) in the central Gauteng district was the focus of the overall study. The focus of this article is the parents’ experience of CAE and the management thereof. The research question was: What is the experience of parents living with a child with atopic eczema (AE)?

Objectives

The overall purpose was to develop validated PHC management guidelines for CAE. One of the objectives was to explore and describe the experiences of parents regarding the AE of their children and the management thereof.

Method

An embedded single case study design using a qualitative, explorative, descriptive and contextual strategy was employed. Data was collected through semi-structured individual interviews from a purposively selected sample and field notes. Ten parents were interviewed, after which data saturation occurred. Data were analysed according to Tesch's steps of descriptive data analysis. Lincoln and Guba's model was used to ensure trustworthiness.

Results

Three main themes were identified. This article focuses on theme one: The physical, emotional and social impact of CAE. Theme two identified the management challenges and theme three indicated recommendations regarding the management of CAE.

Conclusion

The facilitation of management of CAE focuses on developing PHC guidelines and addressing management challenges in order to achieve better controlled CAE.

Atopic dermatitis: global epidemiology and risk factors

Atopic dermatitis (AD) is a chronic inflammatory skin disease posing a significant burden on health-care resources and patients' quality of life. It is a complex disease with a wide spectrum of clinical presentations and combinations of symptoms. AD affects up to 20% of children and up to 3% of adults; recent data show that its prevalence is still increasing, especially in low-income countries. First manifestations of AD usually appear early in life and often precede other allergic diseases such as asthma or allergic rhinitis. Individuals affected by AD usually have genetically determined risk factors affecting the skin barrier function or the immune system. However, genetic mutations alone might not be enough to cause clinical manifestations of AD, and it is merely the interaction of a dysfunctional epidermal barrier in genetically predisposed individuals with harmful effects of environmental agents which leads to the development of the disease. AD has been described as an allergic skin disease, but today, the contribution of allergic reactions to the initiation of AD is challenged, and it is proposed that allergy is rather a consequence of AD in subjects with a concomitant underlying atopic constitution. Treatment at best achieves symptom control rather than cure; there is thus a strong need to identify alternatives for disease prevention.

The Impact of Atopic Dermatitis on Quality of Life

Approximately 5-20% of children worldwide suffer from atopic dermatitis (AD), a kind of dermatitis characterized as an inflammatory, relapsing, noncontagious and itchy skin disorder. Children often develop AD during their first year of life. An increased rate of sensitization to both food and aeroallergens has been shown to coexist in patients with AD. Sensitization to well-known allergens such as cow's milk protein can occur on average in 50% of children with AD. In general, quality of life (QoL) is perceived as the quality of an individual's daily life, that is, an assessment of their well-being or lack thereof. QoL is a broad concept that includes such things as standard of living, community, and family life. Patients with skin diseases experience a wide range of symptoms ranging from trivial problems to major handicaps which affect their lives. The misery of living with AD cannot be overstated for it may have a profoundly negative effect on the health-related QoL of children and their families in many cases. Physicians taking care of children with AD should consult parents on how their child's illness has impacted their lifestyle and recommend professional intervention if deemed necessary.

Cost-effectiveness of partially hydrolyzed whey protein formula in the primary prevention of atopic dermatitis in high-risk urban infants in Southeast Asia

BACKGROUND

Atopic dermatitis (AD) is one of the most common skin conditions among infants. Proteins found in cow's milk formula (CMF) have been found to be attributable to heightened AD risk, particularly in infants with familial AD heredity. Previous studies have suggested that intervention with partially hydrolyzed formula in nonexclusively breastfed infants can have a protective effect against AD development.

OBJECTIVE

The aim of the present study was to compare the estimates of the economic impact of reducing the AD incidence by feeding a partially hydrolyzed whey-based formula (PHF-W) instead of a standard CMF to high-risk nonexclusively breastfed urban infants for the first 17 weeks of life in the Philippines, Malaysia, and Singapore.

METHODS

In each country, a mathematical model simulated AD incidence and burden from birth to 6 years of age of using PHF-W versus CMF in the target population using data from the German Infant Nutritional Intervention study. The models integrated literature, current cost and market data, and expert clinician opinion. Modeled outcomes included AD risk reduction, time spent after AD diagnosis, AD symptom-free days, quality-adjusted life years (QALYs), and costs (direct and indirect). Outcomes were discounted at 3% per year. Costs were expressed in USD.

RESULTS

Feeding high-risk infants PHF-W instead of CMF resulted in an estimated absolute 14% (95% CI 1-24) AD risk reduction, a 0.69-year (95% CI 0.25-1.13) reduction in the time spent after AD diagnosis per child, reductions of 16-38 AD days, and gains in 0.02-0.04 QALYs, depending on the country. The per-child AD-related 6-year cost-saving estimates of feeding high-risk infants with PHF-W versus CMF were USD 739 in Singapore, USD 372 in Malaysia, and USD 237 in the Philippines.