Stress and atopic dermatitis

Atopic Dermatitis and Atopic Keratoconjunctivitis: New Insights in the Analyses of Microbiota and Probiotic Effect

Atopy is defined as a predisposition to hypersensitivity reactions against a range of antigens. It is characterized by the activation of CD4+ T helper type 2 (Th2) cells and an increased production of immunoglobulin E (IgE). The most common atopic conditions are atopic dermatitis, asthma, allergic rhinitis, food allergies, and atopic ocular diseases. Atopic keratoconjunctivitis (AKC) is a chronic, bilateral inflammatory condition affecting the ocular surface, frequently occurring in conjunction with atopic dermatitis. It is not uncommon for patients to present with multiple conditions simultaneously or in a sequential manner. A comprehensive understanding of the underlying mechanisms of atopic diseases is essential for the effective clinical evaluation and treatment. Recent research has underscored the pivotal role of the microbiota in the pathogenesis of atopic dermatitis and atopic eye diseases, with alterations in microbial composition (dysbiosis) being linked to a spectrum of atopic conditions. Probiotics are currently being investigated as a potential treatment option for restoring microbial balance and alleviating disease symptoms. This review examines the relationship between atopic dermatitis, atopic keratoconjunctivitis, and the microbiota, evaluating the current evidence and exploring the potential of probiotics as a novel therapeutic approach.

Integrative Treatment Approaches with Mind-Body Therapies in the Management of Atopic Dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disease with a complex pathophysiology characterized by intense pruritus, often associated with psychological stress and atopic and non-atopic comorbidities that significantly reduce quality of life. The psychological aspects of AD and the interaction between the mind and body via the skin-brain axis have led to an interest in mind-body therapies (MBT). The aim of this article is, therefore, to reinforce the importance of psychodermatological care in AD. We performed a focused literature review on holistic practices or integrative MBT in AD, including education, cognitive behavioral therapy, habit reversal, meditation, mindfulness, hypnotherapy, eye movement desensitization and reprocessing, biofeedback, progressive muscle relaxation, autonomous sensory meridian response, music therapy, massage, and touch therapy. A multidisciplinary holistic approach with MBT, in addition to conventional pharmacologic antipruritic therapies, to break the itch-scratch cycle may improve AD outcomes and psychological well-being. Although there is a paucity of rigorously designed trials, evidence shows the potential benefits of an integrative approach on pruritus, pain, psychological stress, anxiety, depressive symptoms, and sleep quality. Relaxation and various behavioral interventions, such as habit reversal therapy for replacing harmful scratching with massaging with emollient 'plus', may reduce the urge to scratch, while education may improve adherence to conventional therapies.

Effects of Psychological Stress on Spontaneous Itch and Mechanical Alloknesis of Atopic Dermatitis

Atopic dermatitis (AD), a chronic inflammatory skin disease, manifests as an intractable itch. Psychological stress has been suggested to play a role in the onset and worsening of AD symptoms. However, the pathophysiological relationships between psychological stressors and cutaneous manifestations remain unclear. To elucidate the mechanisms underlying the stress-related exacerbation of itch, we investigated the effects of water stress, restraint stress and repeated social defeat stress on itch-related scratching behaviour, mechanical alloknesis and dermatitis in male NC/Nga mice with AD-like symptoms induced by the repeated application of ointment containing Dermatophagoides farina body. NC/Nga mice with AD-like symptoms were subjected to water stress, restraint stress and repeated social defeat stress, and their scratching behaviour, sensitivity to mechanical stimuli (mechanical alloknesis) and severity of  dermatitis were evaluated. Social defeat stress+ Dermatophagoides farina body-treated mice exposed to stress showed slower improvements in or the exacerbation of AD-like symptoms, including dermatitis and itch. In the mechanical alloknesis assay, the mechanical alloknesis scores of social defeat stress+ Dermatophagoides farina body-treated mice exposed to stress were significantly higher than those of non-exposed social defeat stress+ Dermatophagoides farina body- and social defeat stress-treated mice. These results suggest that psychological stress delays improvements in dermatitis by exacerbating itch hypersensitivity in AD.

Classification of psychodermatological disorders: Proposal of a new international classification

INTRODUCTION

Several classifications of psychodermatology disorders have been proposed, with most of them based on two to four main disorder category groups. However, there is, to date, no classification that has resulted from a consensus established by psychodermatology experts. The DSM-5-TR (Diagnostic and statistical manual of mental disorders (5th ed.), Text Revision) and the ICD-11 (International classification of diseases (11th revision)) also do not provide a systematized approach of psychodermatology disorders. Taking into consideration that classifications are a key pillar for a comprehensive approach to the pathologies of each branch of medicine, the proposal of a classification in psychodermatology appeared as a central need for the recognition of psychodermatological disorders, in an attempt to improve their recognition and, in that sense, to find a common language for the development of this subspecialty that crosses dermatology and psychiatry.

METHODS

Previously published classifications in psychodermatology were critically reviewed and discussed by expert opinion from an international multidisciplinary panel of 16 experts in psychodermatology and a new classification system is proposed, considering classical concepts in general dermatology and psychopathology.

RESULTS

Two main categories of disorders are presented (a main group related to primary mental health disorders and another main group related to primary skin disorders), which are subsequently subdivided into subgroups considering pathophysiological and phenomenological similarities, including key aspects of dermatological examination, namely the presence of visible skin lesions (primary and secondary skin lesions) and psychopathological correlates.

CONCLUSION

This new classification aims to unify previous classifications, systematize the disorders that belong to psychodermatology and highlight their tenuous boundaries, to improve their management. It has been built and approved by the Psychodermatology Task Force of the European Academy of Dermatology and Venereology (EADV), the European Society for Dermatology and Psychiatry (ESDaP) and the Association for Psychoneurocutaneous Medicine of North America (APMNA).

Integrative Multiomics Approach to Skin: The Sinergy between Individualised Medicine and Futuristic Precision Skin Care?

The skin is a complex ecosystem colonized by millions of microorganisms, the skin microbiota, which are crucial in regulating not only the physiological functions of the skin but also the metabolic changes underlying the onset of skin diseases. The high microbial colonization together with a low diversity at the phylum level and a high diversity at the species level of the skin is very similar to that of the gastrointestinal tract. Moreover, there is an important communication pathway along the gut-brain-skin axis, especially associated with the modulation of neurotransmitters by the microbiota. Therefore, it is evident that the high complexity of the skin system, due not only to the genetics of the host but also to the interaction of the host with resident microbes and between microbe and microbe, requires a multi-omics approach to be deeply understood. Therefore, an integrated analysis, with high-throughput technologies, of the consequences of microbial interaction with the host through the study of gene expression (genomics and metagenomics), transcription (transcriptomics and meta-transcriptomics), and protein production (proteomics and meta-proteomics) and metabolite formation (metabolomics and lipidomics) would be useful. Although to date very few studies have integrated skin metabolomics data with at least one other 'omics' technology, in the future, this approach will be able to provide simple and fast tests that can be routinely applied in both clinical and cosmetic settings for the identification of numerous skin diseases and conditions. It will also be possible to create large archives of multi-omics data that can predict individual responses to pharmacological treatments and the efficacy of different cosmetic products on individual subjects by means of specific allotypes, with a view to increasingly tailor-made medicine. In this review, after analyzing the complexity of the skin ecosystem, we have highlighted the usefulness of this emerging integrated omics approach for the analysis of skin problems, starting with one of the latest 'omics' sciences, metabolomics, which can photograph the expression of the genome during its interaction with the environment.

Expression of calcitonin gene-related peptide in atopic dermatitis and correlation with distress

BACKGROUND

Atopic dermatitis (AD) is a chronic, inflammatory, often severely itching skin disorder. It may worsen due to stress, depression, or anxiety. Calcitonin gene-related peptide (CGRP) may be involved in inflammation signaling. CGRP has also been suggested in relation to stress, depression, and anxiety. This study aimed to investigate the expression of CGRP in the skin of patients with AD.

METHODS

Twenty-seven adult patients with AD, characterized with clinical and psychodemographic parameters, were investigated regarding CGRP expression in skin biopsies, using an immunohistochemical technique.

RESULTS

The total number of CGRP-positive nerve-like fibers was found to be higher in lesional skin than in non-lesional skin. Moreover, more inflammatory cells of dendritic shape intruded into the epidermis in lesional skin compared to non-lesional skin. Keratinocytes showing expression of CGRP were also found in lesional skin. Interestingly, the number of CGRP-positive nerve-like fibers in lesional skin correlated with depressive and anxiety scores. Correlation with depressive score was also found for round CGRP-positive inflammatory cells in the epidermis.

CONCLUSIONS

CGRP may have a role in both the inflammatory process and distress, in AD.

Causal relationships between atopic dermatitis and psychiatric disorders: a bidirectional two-sample Mendelian randomization study

BACKGROUND

Observational studies have suggested the potential associations between atopic dermatitis (AD) and psychiatric disorders. However, the causal relationship between them remains uncertain. This study aimed to evaluate the potential bidirectional causal relationship between AD and psychiatric disorders, including autism spectrum disorder (ASD), major depressive disorder (MDD), attention deficit hyperactivity disorder (ADHD), bipolar disorder (BD), anorexia nervosa (AN), Tourette syndrome (TS), schizophrenia, and anxiety.

METHODS

Bidirectional two-sample Mendelian randomization (MR) was employed to elucidate the causality between AD and psychiatric disorders, using summary statistics from the most comprehensive genome-wide association studies conducted on AD (Ncases = 60,653, Ncontrols = 804,329). Psychiatric disorders were derived from the Psychiatric Genomics Consortium and were independent of AD data sources. The MR analysis entailed the implementation of multiple methods, including the inverse variance weighted method, MR-Egger regression method, weighted median method, simple mode method, and weighted mode method.

RESULTS

Bidirectional two-sample MR analysis uncovered significant causal associations between AD and severe psychiatric disorders. Specifically, liability to AD was associated with increased risk of ADHD (OR = 1.116; 95% CI: [1.009, 1.234]; P = 0.033) and ASD (OR = 1.131; 95% CI: [1.023, 1.251]; P = 0.016). Additionally, evidence suggested that liability to ADHD (OR = 1.112; 95% CI: [1.094, 1.130]; P = 9.20e-40), liability to AN (OR = 1.1; 95% CI: [1.068, 1.134]; P = 4.45e-10) and liability to BD (OR = 1.067; 95% CI: [1.009, 1.128]; P = 0.023) were associated with an increased risk of AD. Only the causal association between AD and ASD was independent of the reverse effect bias. These causal associations were robust and not affected by biases of heterogeneity and horizontal pleiotropy.

CONCLUSIONS

Our study emphasizes the significant causal association between AD and an increased risk of ASD, and also identifying BD and AN as risk factors for AD.

Stressors in Atopic Dermatitis

As with other inflammatory skin disorders, atopic dermatitis has a tendency to cause stress and also be exacerbated by it. Patients with atopic dermatitis have several disease-associated stressors, some of which include physical discomfort due to itching and altered appearance due to flare-ups. These stressors have been shown to effect patients psychosocially by altering sleep patterns, decreasing self-esteem, and interfering with interpersonal relationships. In combination with its direct effect on patients, atopic dermatitis also causes stress for parents and caregivers. Studies suggest that atopic dermatitis is strongly correlated with co-sleeping habits, which can negatively impact the health and mood of parents or caregivers. It has also been reported to interfere with the formation of a strong mother-child relationship. In order to optimize treatment for patients with atopic dermatitis, it is important to note the impact that it has on quality of life. By implementing patient counseling, sleep-targeted therapies, and the use of quality of life (QoL) indices, atopic dermatitis patients and caregivers have the potential to experience greater satisfaction with treatment.

The Mind Body Connection in Dermatologic Conditions: A Literature Review

Psychodermatology pertains to the relationship between the skin and brain. This review aims to summarize the evidence of the mind body connection in four psychophysiological conditions: rosacea, atopic dermatitis (AD), acne vulgaris (AV), and psoriasis. A literature search was conducted using several English language databases. All four conditions share similar psychiatric co-morbidities, including but not limited to anxiety, depression, and suicidality. In rosacea, the upregulation of transient receptor potential vanilloid type 1, Toll like receptor 2, and Th17 cells releases downstream products that are simultaneously implicated in mood disorders. Stress exacerbates AV through the hypothalamic-pituitary-adrenal (HPA) system, which alters functioning of sebocytes and Cutibacterium acnes. In AD and psoriasis, the HPA axis influences Th1, Th2, Th22, and Th1, Th17 immune mediated responses, respectively. This leads to the secretion of pro-inflammatory cytokines which are also involved in the pathogenesis of anxiety and depression. Neurotransmitters implicated in mental illness, such as gamma-aminobutyric acid and serotonin, may also play a role in the development of AD and psoriasis. The management of cutaneous disease may mitigate psychological distress, and future research may show the corollary to also be true.

Psychological Stress and Atopic Dermatitis: A Focus Group Study

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disorder. It is often reported to be worsened by psychological stress.

OBJECTIVE

To explore the role of psychological stress and related triggers in AD, and its connection to worsening of this disease, focusing on patients' perspectives.

METHODS

In total, 28 patients with AD were included in focus groups. Topics regarding psychological stress and psychological triggers were discussed.

RESULTS

The hypothesis that psychological stress may have impact on eczema and its pruritus was supported by all of the patients. Distinguishing the worsening effect of psychological stress from effects of physiological triggers, such as infection, climate and allergic factors, was claimed to be difficult by many patients. Most of the patients thought that chronic stress affected the AD more when compared to acute stress. Family problems, financial problems, work overload, school exam periods, lack of structure at work, and unforeseen events were identified as important psychological triggers. Conventional treatment/therapy with topical corticosteroids and emollients, UV light treatment, were suggested as possible treatments, as well as psychological intervention and physical exercise.

CONCLUSION

Psychological stress is an important factor to consider in the management of patients with AD. In particular, chronic stress tends to worsen AD. The type of stress can possibly also affect the quality of the pruritus experienced by the patients. Unforeseen events and decision making were frequently mentioned as important triggers. Furthermore, physical exercise was reported to provide beneficial effects.

Prevalence of Atopic Diseases Among Sexually Diverse Adults in the US

This cross-sectional study assesses the prevalence of asthma, allergic rhinitis, or atopic dermatitis among sexually diverse adults compared with heterosexual adults in the US.

Atopic Dermatitis: Disease Features, Therapeutic Options, and a Multidisciplinary Approach

The latest findings regarding AD pathogenesis point to an impaired function of the epidermal barrier, changed immune response, colonization of the skin by microorganisms, and certain psychological factors among other causes/triggers. The inflammatory response of AD patients is mainly associated with the activation of T cells (Th2 cells predominate), dendritic cells, macrophages, keratinocytes, mast cells, and eosinophils. Therapy usually involves medical evaluations and adequate management including treatment of concomitant diseases (e.g., allergies and infections), patient education and nursing care, psychological support, and nutritional consultations, which are organized through specific programs and structured educational groups. Systemic AD therapy includes conventional systemic treatment (cyclosporine, methotrexate, azathioprine) and new, specific drugs, interleukin inhibitors (e.g., dupilumab) and JAK inhibitors (baricitinib, abrocitinib, upadacitinib, etc.). Since many AD patients are affected by various psychological factors and comorbidities, they should be assessed and managed through a multidisciplinary approach, involving different professions (psychologists, ear-nose-throat specialists, pulmonologists, allergologists, immunologists, nutritionists, pediatricians, gastroenterologists, psychiatrists (when necessary), and others). A multidisciplinary approach provides better coping strategies and improves control over the disease, patient adherence to therapy, and quality of life. It also has a positive influence on family quality of life while at the same time making more efficient use of dermatology healthcare resources, reducing the economic burden on both patients and society.

Investigation of possible relationship between atopic dermatitis and salivary biomarkers, stress, and sleep disorders

Atopic dermatitis (AD) is a chronic, relapsing, multifactorial inflammatory disease with genetic, environmental, and immunological characteristics. The quality of life and sleep of patients and their families are affected by AD, which triggers stress, described as one of the factors that worsens AD. Salivary biomarkers such as cortisol, alpha-amylase, chromogranin A, and melatonin have been associated with stress and sleep disturbances. Therefore, the evaluation of stress and sleep disorders using salivary biomarkers in AD patients is important. This review aims to describe the possible relationship between atopic dermatitis and stress, sleep disorders, and salivary biomarkers, seeking to contribute to better understanding and clinical management of AD. This descriptive study is characterized as a narrative literature review. A literature search was conducted of studies published in English and Portuguese between January 2012 and October 2022 that are available in electronic media from various databases, such as Scientific Electronic Library Online, Latin American and Caribbean Literature on Health Sciences, and PubMed. AD is associated with different degrees of impact on the lives of individuals who present with the disease. Psychological stress may induce changes in saliva composition and worsen AD; at the same time, the severity of the disease may be associated with emotional impact. Further studies are needed to assess and correlate AD severity, stress, and sleep disturbances with salivary biomarkers in order to better understand this association.

Atopic dermatitis in a chimpanzee (pan troglodytes verus)-A diagnostic and therapeutic challenge

Diagnosis and treatment of atopic dermatitis (AD) in chimpanzees are challenging. Validated allergy tests specific for chimpanzees are not available. A multifactorial management of atopic dermatitis is important. Successful management of AD has, to the best knowledge of the authors, not been described in chimpanzees.

Work-related stress and atopic dermatitis: Results from the study on occupational allergy risks

Chronic stress at work is ubiquitous in modern societies. However, its influence on atopic dermatitis (AD) has hardly been investigated. This study aimed to elucidate the association between work-related stress and AD via a longitudinal study. The analysis comprised data from three phases (2002-2003, 2007-2009, 2017-2018) of the prospective Study on Occupational Allergy Risks (SOLAR), including 1,240 young adults aged 16 to 18 years at baseline (61% female) who were originally recruited for the International Study of Asthma and Allergies in Childhood Phase II in 1995-1996. AD was assessed at all three phases based on self-reports of a physician's diagnosis and symptoms. Work-related stress was measured at all three periods using the work discontent and work overload scales from the Trier Inventory for the Assessment of Chronic Stress with adaptions to school and university. Generalized estimating equations were used to analyze the association between stress and AD, treating work discontent and work overload first as continuous and then as categorical exposure variables. We observed 50 AD cases (4%) at SOLAR I, 48 (4%) at SOLAR II, and 42 (3%) at SOLAR III. A one-point increase in the work discontent score was associated with an odds ratio (OR) for AD of 1.05 (95% confidence interval [CI], 1.00-1.10). The respective increase in the work overload score led to an OR of 1.03 (95% CI, 0.99-1.06). In the categorical analysis, there was no clear indication of elevated odds of AD in the highest vs. lowest exposure group (4th vs. 1st quartile: OR, 1.53; 95% CI, 0.92-2.53 for work discontent; OR, 1.38, 95% CI, 0.83-2.27 for work overload). Altogether, we observed limited to no evidence for an association between work-related stress and AD. Our study's ability to detect stronger evidence may have been compromised by shortcomings such as nondifferential misclassification of the outcome or insufficient statistical precision due to small numbers of AD cases. Another explanation could be that AD predominantly becomes evident in childhood, not in adulthood.

Questionnaire-Based Study Evaluating the Hand Hygiene Practices and the Impact of Disinfection in the COVID-19 Pandemic on Hand Skin Conditions in Poland

During the COVID-19 pandemic, disinfection became an integral part of everybody's life in order to avoid spreading the coronavirus. In 2021, an original anonymous online survey was carried out. The questions concerned the usage of disinfectants. The study population included 56 subjects diagnosed by a physician with hand eczema (HE-derm group) and 114 subjects with no hand skin disease diagnosed by a specialist (non-derm). The HE and non-HE groups were distinguished. Nearly 80% of the HE group, and 10% of the non-HE group, experienced worsening of hand skin lesions caused by increased skin disinfection. HE-group respondents more often declared the occurrence of new hand skin symptoms, over 80% of the subjects of this group had more than 1 new symptom (compared to nearly 40% of the non-HE group). Exacerbations of the skin disease were more frequently observed by the HE group during the pandemic. There was a statistically significant decrease of the quality of life in the HE group compared to the non-HE group during the pandemic. The COVID-19 pandemic caused an increase in the prevalence of hand skin symptoms and deterioration of the skin condition. Education on appropriate disinfection techniques and skincare, as well as early dermatological intervention, might allow us to limit the development of hand skin diseases.

Seungmagalgeun-Tang, a Traditional Herbal Formula, Alleviates Skin Inflammation and Depression-Like Behavior in Atopic Dermatitis Mice under Sleep Deprivation Conditions

Atopic dermatitis (AD) is a common inflammatory skin disease, which can be worsened under sleep deprivation (SD) conditions. This study investigated the efficacy and the mechanism of action of the traditional herbal formula Seungmagalgeun-tang (SMGGT) on the inflammation and behavioral changes in a mouse model of AD exposed to SD. SMGGT decreased levels of IgE, TNF-α, IL-4, IL-13, and mast cell infiltration and reduced the expression of CD3 in the mouse skin. SMGGT also reversed the SD-induced increase in corticosterone and decrease in melatonin level. Furthermore, SMGGT reduced the immobility time in the tail suspension test significantly. HaCaT cells and HMC-1 cells were used to investigate the effects of SMGGT on cell signaling pathways. In TNF-α/IFN-γ (TI) treated HaCaT cells, SMGGT reduced production of TARC/CCL17 and MDC/CCL22 and suppressed the p38 MAPK, STAT1, and NF-κB pathways. In substance P (SP)/CRH-stimulated HMC-1 cells, SMGGT decreased VEGF production and inhibited ERK phosphorylation. Network pharmacology and molecular docking analysis revealed that puerarin and paeoniflorin might contribute to the effects of SMGGT by targeting several AD-related molecules and pathways. Puerarin and paeoniflorin exerted anti-inflammatory effects by decreasing production of MDC/CCL22 and IL-6 in TI-treated HaCaT cells and VEGF production in SP/CRH-stimulated HMC-1 cells. This study suggests that SMGGT with puerarin and paeoniflorin as main bioactive components alleviates skin inflammation and depression-like behavior in a sleep-deprived mouse model of AD.

[Impact of COVID-19 Pandemic on Patients with Atopic Dermatitis]

Atopic dermatitis (AD) is a chronic skin disease that may be triggered by psychological conditions and several allergens. Patients with AD may be experienced disease exacerbation due to the COVID-19 pandemic lifestyle including home-quarantine and increased stress. We obtained the electronic data of 100 AD patients admitted to our hospital from 2016 to 2019 and called them with specific phone line.Out of 100 patients, 43 were male, and 57 were female (mean age ± SD: 45.85 ± 16.90). Sixty patients (37 females and 23males; mean age: 42.22± 14.71) confronted disease flare-up during the COVID-19 era. Exacerbation of AD was correlated with treatment dose alteration, a lengthy history of atopic dermatitis, eczema duration, self-isolation, frequent handwashing, hand disinfection, and POEM scoring (P < 0.05). Regarding the POEM scoring, 61 patients with moderate to severe AD experienced higher anxiety than 39 patients with silent to mild AD (p = 0.013).In this study, most patients experienced disease exacerbation and perceived mild anxiety in this pandemic.

Impact of COVID-19 Pandemic on Patients with Atopic Dermatitis

Atopic dermatitis (AD) is a chronic skin disease that may be triggered by psychological conditions and several allergens. Patients with AD may be experienced disease exacerbation due to the COVID-19 pandemic lifestyle including home-quarantine and increased stress. We obtained the electronic data of 100 AD patients admitted to our hospital from 2016 to 2019 and called them with specific phone line.

Out of 100 patients, 43 were male, and 57 were female (mean age ± SD: 45.85 ± 16.90). Sixty patients (37 females and 23males; mean age: 42.22 ± 14.71) confronted disease flare-up during the COVID-19 era. Exacerbation of AD was correlated with treatment dose alteration, a lengthy history of atopic dermatitis, eczema duration, self-isolation, frequent handwashing, hand disinfection, and POEM scoring (P < 0.05). Regarding the POEM scoring, 61 patients with moderate to severe AD experienced higher anxiety than 39 patients with silent to mild AD (P = 0.013).

In this study, most patients experienced disease exacerbation and perceived mild anxiety in this pandemic.

Potential of Tamanu (Calophyllum inophyllum) Oil for Atopic Dermatitis Treatment

Tamanu oil, derived from the nut of Calophyllum inophyllum L., has been traditionally used to treat various skin-related ailments. In recent years, this oil is increasingly gaining popularity as researchers continue to search for novel natural alternative therapies for various skin diseases. There have been a number of in vitro and in vivo studies investigating various skin-active properties of tamanu oil, and it has been proven to have potent anti-inflammatory, antioxidant, antimicrobial, analgesic, and even wound-healing abilities. These properties make tamanu oil an especially interesting candidate for the treatment of atopic dermatitis (AD). This multifaceted disease is marked by the disruption of the skin barrier function, chronic inflammation, and skin microbiome dysbiosis with limited treatment options, which is free from adverse events and inexpensive, making it desperate for a new treatment option. In this review, we examine previous in vitro and in vivo studies on AD-relevant pharmacological properties of tamanu oil in order to evaluate the potential of tamanu oil as a novel treatment option for AD.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Flare management in atopic dermatitis: from definition to treatment

Atopic dermatitis (AD) is a skin immune-mediated inflammatory disease with a chronic-recurrent course. Acute exacerbations or flares are an integral part of the AD course and are generally defined as disease worsening, requiring escalation/intensification of treatment. Management of flares is crucial since their prevention is a key aim of long-term disease control. Nevertheless, difficulties related to this aspect are several, starting from the definition of flare itself, which is not always satisfactory or unambiguous, and needs clarification. Indeed, this hurdle may reduce clarity on treatment choice and generate difficulties when comparing data between studies. Deepening our knowledge on flares could be highly relevant to both clinicians and patients to provide adequate control of the disease through patient education and appropriate treatment. This review aims to summarize current knowledge on the management of AD flares from definition to treatment, highlighting aspects that are still unclear, and identifying any necessary unmet needs to better manage AD.

Serum-Derived Neuronal Exosomal microRNAs as Stress-Related Biomarkers in an Atopic Dermatitis Model

Chronic allergic inflammatory skin disease—atopic dermatitis (AD)—is characterized by eczema, pruritus, xeroderma, and lichenification. Psychological stress is one cause of this disease; however, psychological stress will also result from the presence of AD symptoms. Previous studies have shown that psychological stress triggers neuroinflammation in the brain, where microRNAs (miRNAs) in the neuronal exosomes (nEVs) were analyzed to identify the composition of the miRNAs in the nEVs and how they were altered by AD. In this study, the AD model was induced by treatment with 2,4-dinitrochlorobenzene (DNCB). The expression patterns of neuroinflammation markers, such as brain-derived neurotrophic factor, cyclooxygenase-2, and glial fibrillary acidic protein, were subsequently evaluated over time. Among these groups, there was a significant difference in DNCB 14 days expression compared with the control; therefore, nEVs were isolated from serum and next-generation sequencing was performed. The results demonstrate that 9 miRNAs were upregulated and 16 were downregulated in the DNCB 14 days compared with the control. Previous studies have shown that some of these miRNAs are associated with stress and stress-induced depression, which suggests that the miRNAs in nEVs may also be stress-related biomarkers.

Common and discrete mechanisms underlying chronic pain and itch: peripheral and central sensitization

Normally, an obvious antagonism exists between pain and itch. In normal conditions, painful stimuli suppress itch sensation, whereas pain killers often generate itch. Although pain and itch are mediated by separate pathways under normal conditions, most chemicals are not highly specific to one sensation in chronic pathologic conditions. Notably, in patients with neuropathic pain, histamine primarily induces pain rather than itch, while in patients with atopic dermatitis, bradykinin triggers itch rather than pain. Accordingly, repetitive scratching even enhances itch sensation in chronic itch conditions. Physicians often prescribe pain relievers to patients with chronic itch, suggesting common mechanisms underlying chronic pain and itch, especially peripheral and central sensitization. Rather than separating itch and pain, studies should investigate chronic itch and pain including neuropathic and inflammatory conditions. Here, we reviewed chronic sensitization leading to chronic pain and itch at both peripheral and central levels. Studies investigating the connection between pain and itch facilitate the development of new therapeutics against both chronic dysesthesias based on the underlying pathophysiology.

Association between chronic pruritus, depression, and insomnia: A cross-sectional study

Background

Skin diseases that cause chronic pruritus can have negative effects on a patient's quality of life.

Objective

We evaluated the associations between chronic pruritus and psychological conditions including insomnia and depression.

Methods

This study included responses from 91 participants with chronic pruritus (response rate: 74.6%). A survey including questionnaires regarding data on demographic characteristics, intensity of pruritus using the visual analog scale (VAS) and the 4-item itch questionnaire, and the degrees of insomnia and depression measured by the Insomnia Severity Index and Beck Depression Inventory, respectively.

Results

Patients with symptoms of insomnia or depression had significantly more intense pruritus than patients without psychological symptoms (insomnia, VAS median [interquartile range]: 7.0 [5.0-8.25] vs. 5.0 [3.0-7.5]; depression, VAS median [interquartile range]: 7.5 [5.0-8.25] vs. 5.0 [3.0-7.0]). Multivariable analyses revealed that patients with moderate to severe pruritus were more likely to have depression than those with mild pruritus (odds ratio: 10.95; 95% confidence interval: 2.24-53.06). There were no differences in the severity of insomnia and depression among skin diseases.

Limitations

This study had a cross-sectional design and limited generalizability.

Conclusion

Chronic pruritus is significantly associated with insomnia and depression, regardless of the etiology.

New Pathways for the Skin's Stress Response: The Cholinergic Neuropeptide SLURP-1 Can Activate Mast Cells and Alter Cytokine Production in Mice

Background: The alpha7 nicotinic acetylcholine receptor (Chrna7) plays an essential anti-inflammatory role in immune homeostasis and was recently found on mast cells (MC). Psychosocial stress can trigger MC hyperactivation and increases pro-inflammatory cytokines in target tissues such as the skin. If the cholinergic system (CS) and Chrna7 ligands play a role in these cascades is largely unknown.

Objective: To elucidate the role of the CS in the response to psychosocial stress using a mouse-model for stress-triggered cutaneous inflammatory circuits.

Methods: Key CS markers (ACh, Ch, SLURP-1, SLURP-2, Lynx1, Chrm3, Chrna7, Chrna9, ChAT, VAChT, Oct3, AChE, and BChE) in skin and its MC (sMC), MC activation, immune parameters (TNFα, IL1β, IL10, TGFβ, HIF1α, and STAT3) and oxidative stress were analyzed in skin from 24 h noise-stressed mice and in cultured MC (cMC) from C57BL/6 or Chrna7-Knockout mice.

Results: First, Chrna7 and SLURP-1 mRNA were exclusively upregulated in stressed skin. Second, histomorphometry located Chrna7 and SLURP-1 in nerves and sMC and demonstrated upregulated contacts and increased Chrna7+ sMC in stressed skin, while 5 ng/mL SLURP-1 degranulated cMC. Third, IL1β+ sMC were high in stressed skin, and while SLURP-1 alone had no significant effect on cMC cytokines, it upregulated IL1β in cMC from Chrna7-KO and in IL1β-treated wildtype cMC. In addition, HIF1α+ sMC were high in stressed skin and Chrna7-agonist AR-R 17779 induced ROS in cMC while SLURP-1 upregulated TNFα and IL1β in cMC when HIF1α was blocked.

Conclusions: These data infer that the CS plays a role in the regulation of stress-sensitive inflammatory responses but may have a surprising pro-inflammatory effect in healthy skin, driving IL1β expression if SLURP-1 is involved.

Utilization of health services for skin disorders during military operations. A population- based study

In addition to the immediate casualties of armed conflicts, their indirect impact may bring even more damage by causing malfunctioning of health systems and impaired access to diagnosis and treatment. We conducted a population-based study, to assess the utilization rates of health services due to skin disorders, among civilians exposed to missile attacks and siren alarms during three military operations in Israel. The study was designed as a natural experiment, whereas periods of military operations were compared to the non-military times. During the military operations, when sirens and missiles were an everyday experience, the number of visits to dermatologists was 1.07-1.16 times lower [Relative Risk (RR)=0.86-0.92] as compared to the non-military periods, especially evident for patients residing closer to the military zone, where it dropped almost 2- folds (RR=0.52). Although perceived nonurgent in their majority, the routine care should not be delayed to prevent more serious skin conditions.

The global, regional, and national burden of atopic dermatitis in 195 countries and territories: An ecological study from the Global Burden of Disease Study 2017

Introduction

Numerous population-based studies have focused on the global prevalence of atopic dermatitis (AD), but there are few studies on the global trends of the burden associated with AD.

Methods

We analyzed the global AD trends in 2017 in 195 countries worldwide using the Global Burden of Disease (GBD) Study database, including prevalence rates, age and sex patterns, and AD burden, using disability-adjusted life years (DALYs). Age-standardized DALYs were also compared to the sociodemographic index values of all the countries in 2017.

Results

The age-specific DALYs in 2017 showed a right-skewed distribution, with the highest DALYs between 1 and 5 years of age. Females had a higher burden of AD throughout all age groups and geographic regions. The GBD super region with the greatest burden of DALYs caused by AD was high income (178.63 DALYs per 100,000 males, 231.8 for females), and the country with the highest DALYs was Sweden (326.91). The GBD super region with the lowest age-standardized DALY burden caused by AD was south Asia (84.51 DALYs per 100,000 males, 100.54 for females).

Conclusion

There is a large GBD caused by AD. The observed burden is the greatest in resource-rich countries, females, and young children.

Associations between Stress and Physical Activity in Korean Adolescents with Atopic Dermatitis Based on the 2018-2019 Korea Youth Risk Behavior Web-Based Survey

This study aimed to confirm the associations between stress and physical activity (PA) in Korean adolescents with atopic dermatitis (AD) based on data from the 2018-2019 Korea Youth Risk Behavior Web-Based Survey. The AD groups were divided into adolescents who were not diagnosed with AD, adolescents who were diagnosed with AD more than one year ago, and adolescents who were diagnosed with AD within one year. We defined the regular PA group and the non-PA group using the American College of Sports Medicine guidelines for children and adolescents: moderate to vigorous PA ≥5 times per week, including vigorous PA ≥3 days per week and muscle strengthening exercises ≥3 times per week. We performed logistic regression analysis to calculate the stress odds ratio (OR) and 95% confidence interval (CI) by group using model 1, adjusted for age, sex, and body mass index, and model 2, additionally adjusted for drinking, smoking, economic statuses, academic achievement, asthma, and rhinitis. In the group diagnosed with AD within one year, stress was 41% and 32% higher according to models 1 (1.41 (1.31-1.52)) and 2 (1.34 (1.20-1.50)), respectively. However, the stress OR was 30% lower in adolescents who completed regular PA than in the non-PA group (model 1: 0.71 (0.58-0.87); model 2: 0.68 (0.57-0.84)), even if diagnosed with AD within one year. In conclusion, the stress of adolescents with AD was significantly higher than that of adolescents without AD. The stress was significantly lower in the group with regular PA, and it was more robust in adolescents diagnosed with AD within one year.

Health-related behaviors and mental health states of South Korean adolescents with atopic dermatitis

Atopic dermatitis (AD) is a common chronic skin disease with a negative influence on adolescent mental health state. We aimed to identify the influencing factors for mental health in adolescents with AD. We used data from the 13th Korean Youth Risk Behavior Web-based Survey (KYRBS) conducted in 2017. KYRBS data were obtained from a stratified, multistage, clustered sample. Participants responded to the question "have you ever been diagnosed with AD by a doctor?" and several yes/no questions about stress, depressive symptoms and suicidal ideation. Among 62 276 participants, the proportion of adolescents with AD was 25.0%. Compared with adolescents without AD, those with AD were significantly more likely to experience stress, depressive symptoms and suicidal ideation (P < 0.001) at rates of 59.1%, 27.8% and 13.9%, respectively. In the multivariate logistic regression model, subjective unhappiness was most strongly associated with stress in subjects with AD (adjusted odds ratio [aOR], 7.34; 95% confidence interval [CI], 5.87-9.18), while depression (aOR, 9.83; 95% CI, 7.85-11.32) and suicidal ideation (aOR, 5.70; 95% CI, 5.01-6.48) were reciprocally the most important risk factors in adolescents with AD. AD in adolescents is associated with a higher prevalence of stress, depressive symptoms and suicidal ideation. It is important for pediatricians to watch for these risks and to screen for suicidality in adolescents with AD.

Piperine Ameliorates Trimellitic Anhydride-Induced Atopic Dermatitis-Like Symptoms by Suppressing Th2-Mediated Immune Responses via Inhibition of STAT6 Phosphorylation

Atopic dermatitis (AD) is a common inflammatory skin disease predominately related to Type 2 helper T (Th2) immune responses. In this study, we investigated whether piperine is able to improve AD symptoms using a trimellitic anhydride (TMA)-induced AD-like mouse model. Topical treatment with piperine reduced ear swelling (ear thickness and epidermal thickness) induced by TMA exposure. Furthermore, piperine inhibited pro-inflammatory cytokines such as TNF-α and IL-1β in mouse ears, compared with the TMA-induced AD group. In measuring allergic immune responses in draining lymph nodes (dLNs), we found that IL-4 secretion, GATA3 mRNA level, and STAT6 phosphorylation were suppressed by piperine treatment. In an ex vivo study, piperine also inhibited the phosphorylation of STAT6 on the CD4⁺ T cells isolated from splenocytes of BALB/c mice, and piperine suppressed IL-4-induced CCL26 mRNA expression and STAT6 phosphorylation in human keratinocytes resulting in the inhibition of infiltration of CCR3⁺ cells into inflammatory lesions. These results demonstrate that piperine could ameliorate AD symptoms through suppression of Th2-mediated immune responses, including the STAT6/GATA3/IL-4 signaling pathway. Therefore, we suggest that piperine is an excellent candidate as an inhibitor of STAT6 and may help to improve AD symptoms.

Biological Sex and IgE Sensitization Influence Severity of Depression and Cortisol Levels in Atopic Dermatitis

BACKGROUND

Depression is a common comorbid condition with atopic dermatitis (AD), particularly during the active disease cycle. Controversial results regarding the contribution of biological sex, immunoglobulin E (IgE) sensitization, and cortisol on AD severity and comorbid depression justify further investigation.

OBJECTIVE AND METHODS

To explore the influence of sex and IgE sensitization on biochemical and psychological parameters, and severity of AD, a case-control study of 105 volunteers (56 AD, 49 healthy controls (HC); 50 males, 55 females) was conducted over 10 weeks, starting at dermatological symptom onset. Disease severity, serum IgE, cortisol and testosterone levels, and depression scores were assessed at study baseline and after 10 weeks of conventional treatment.

RESULTS

Dermatological severity differed among AD males by IgE sensitization and was elevated in males with extrinsic atopic dermatitis (EAD). Hamilton Depression Rating Scale (HAMD) scores were elevated in all patients at study baseline and improved with symptom reduction to HC levels, except female EAD. Severity of depression and dermatitis were correlated in EAD males at baseline and at week 10. Serum cortisol was elevated in male EAD at baseline, in contrast to males with intrinsic atopic dermatitis (IAD) at week 10. In addition, cortisol levels were found negatively correlated with SCORAD and HAMD scores in EAD males at week 10.

CONCLUSION

Pathophysiological features of AD and depression are likely related to different inflammation-based effects and appear to be biological sex-dependent. Cortisol levels depend on biological sex and IgE sensitization in AD and increase in males with EAD at exacerbation and IAD males at resolution. Biological sex-related disease triggers, IgE sensitization, and cortisol levels are important for the understanding of the mechanisms underlying AD and comorbid depression.

The influence of autogenic training on the physical properties of skin and cardiac autonomic activity in postmenopausal women: an exploratory study

BACKGROUND

Autogenic training (AT) is a major relaxation training technique whose clinical efficacy has been verified in dermatology. Many reports demonstrate ameliorated skin conditions in AT-treated subjects with reduced psychological stress. However, no studies have examined the effects of AT on the skin of postmenopausal women.

OBJECTIVES

We examine the influences of AT on the physical properties of skin and cardiac autonomic activity in postmenopausal women.

METHODS

Postmenopausal women were classed into an AT group and a control one. The women in the AT group were mentored by a professional to practice AT twice a day for 7 weeks. The women in the control group were instructed to close their eyes for 3 minutes instead of AT. Hydration of the stratum corneum (SC), transepidermal water loss (TEWL), skin elasticity and heart-rate variability (HRV) were measured before and after the study period to examine how they changed.

RESULTS

SC hydration and skin elasticity of the cheek, increased in both groups, and the increase was significantly higher in the AT group (n = 14) than in the control group (n = 12) (P < 0.05, Cohen's d = 1.03; P < 0.05, Cohen's d = 0.99; respectively). TEWL did not change in either group. LF/HF was lower in the AT group than in the control group (P < 0.05, Cohen's d = 0.91).

CONCLUSION

AT increased SC hydration and skin elasticity with changes in the balance of autonomic nervous system activity in postmenopausal women, implying that AT may have improvement effects on aged skin by menopause.

The exposome in atopic dermatitis

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

Maternal Depression and Atopic Dermatitis in American Children and Adolescents

Atopic dermatitis (AD) is a chronic, inflammatory skin disease associated with considerable burden and mental health symptoms. We sought to determine the association of maternal depression in the postpartum period and maternal and paternal depression in later childhood with AD prevalence and persistence in US children. Data were analyzed from the Fragile Families and Child Wellbeing Study, a prospective cohort study of 4898 children born in 20 metropolitan US cities. History of postpartum depression was associated with childhood AD overall (multivariable logistic regression; adjusted odds ratio [aOR], 1.32; 95% confidence interval [CI], 1.06-1.64), and particularly at ages 5 years (aOR, 1.34; 95% CI, 1.04-1.73) and 9 years (aOR, 1.37; 95% CI, 1.10-1.70). Postpartum depression was associated with more persistent AD (present at 2 years: aOR, 1.58; 95% CI, 1.12-2.22; 3 years: aOR, 1.73; 95% CI, 1.15-2.60). Maternal depression in the past year was associated with significantly higher odds of AD at age 5 years (aOR, 1.54; 95% CI, 1.20-1.99), 9 years (aOR, 1.36; 95% CI, 1.10-1.71), and 15 years (aOR, 1.43; 95% CI, 1.13-1.80). Maternal depression was associated with higher odds of AD during 1 year (aOR, 1.50; 95% CI, 1.16-1.94), 2 years (aOR, 1.60; 95% CI, 1.16-2.19), or all 3 years of interviews (aOR, 1.61; 95% CI, 1.06-2.45). In conclusion, maternal depression in the postpartum period and beyond is associated with AD throughout childhood and adolescence.

Does age influence the quality of life in children with atopic dermatitis?

BACKGROUND

Atopic dermatitis (AD) is one of the most common childhood skin diseases that can affect the quality of life (QoL) of children. The QoL of Montenegrin children with AD has not been sufficiently explored. The aim of this study was to assess their QoL with special emphasize on age differences.

METHODS

This cross-sectional study included children with AD seen at the Clinic of Dermatology and Venereology, Clinical Center of Montenegro (CCM) in Podgorica between August 2017 and July 2018. The QoL was assessed with the Infants' Dermatitis Quality of Life Index (IDQOL) and the Children's Dermatology Life Quality Index (CDLQI). Disease severity was measured by the Three Item Severity (TIS) score.

RESULTS

A total of 386 children with AD aged from newborn to 16 years took part in this study. The mean total score of the QoL was 14.7 in infants (0-4 years old), 19.4 in younger children (5-9 years old), and 16.6 in older children (10-16 years old). Age was in negative correlation with the CDLQI score, leisure domain of the CDLQI and CDLQI sleep, and in positive correlation with the IDQOL child mood. TIS score was in positive correlation with both the IDQOL and CDLQI score.

CONCLUSIONS

The QoL measured by CDLQI was more impaired in younger children, whilst IDQOL child mood was more impaired in older infants. The most impaired QoL was seen in children in the age group 5-9 years. Regardless of disease severity, treatment and counseling of children suffering from AD should be tailored specifically to their age.

Complementary and Integrative Therapies for Childhood Atopic Dermatitis

Background: Childhood atopic dermatitis is a chronic inflammatory skin condition that causes significant psychological and financial costs to the individual and society. Treatment regimens may require long-term medication adherence and can be associated with poor patient satisfaction. There is considerable interest in complementary and integrative medicine (CIM) approaches for childhood atopic dermatitis. Objective: To assess the effects of CIM approaches on childhood atopic dermatitis outcomes as defined by randomized, controlled clinical trials. Methods: A PubMed review of CIM-related treatments for pediatric atopic dermatitis was performed, and data related to age, study population, efficacy, treatment regimen, length of treatment, and sample size were included. Results: The search yielded 20 trials related to probiotic/prebiotic treatments for atopic dermatitis, three on the effects of vitamins on children with atopic dermatitis, and two on the effects of Chinese herbal treatments for atopic dermatitis in children and adolescents. The strongest evidence was for supplementation with the probiotics L. fermentum and L. plantarum. Conclusions: Certain strains of probiotics, specifically L. plantarum and L. fermentum, may improve clinical severity scores in children with atopic dermatitis. However, additional trials are needed to more thoroughly delineate the effects of additional integrative therapies on childhood atopic dermatitis.

Gene-environment interactions in primary atopic disorders

Environmental factors modify disease presentation and severity in allergic disorders. Primary atopic disorders (PADs) are a heterogenous group of single gene disorders that lead to significant atopic and allergic disease manifestations. However, a number of these monogenic diseases have variable penetrance suggesting that gene-gene and/or gene-environment interactions could modulate the clinical phenotype. Environmental factors such as diet, the microbiome at the epithelial-environment interface, the presence and/or extent of infection, and psychologic stress can alter disease phenotypic expression of allergic diseases, and PADs provide discrete contexts in which to understand these influences. We outline how gene-environment interactions likely contribute to a variable penetrance and expressivity in PADs. Dietary modifications of both macronutrients and/or micronutrients alter T-cell metabolism and may influence effector T-cell function. The mucosal microbiome may affect local inflammation and may remotely influence regulatory elements, while psychologic stress can affect mast cell and other allergic effector cell function. Understanding gene-environment interactions in PADs can hopefully provide a foundation for interrogating gene-environment interactions to common allergic disorders, and also present opportunities for personalized interventions based on the altered pathways and environmental influences in affected individuals.

Synergistic Effect of H1-Antihistamines on Topical Corticosteroids for Pruritus in Atopic Dermatitis: A Systematic Review and Meta-Analysis

Background

Although oral antihistamines (H1-histamine receptor antagonists) are the main treatment option for pruritus in general skin dermatosis, their effect in treating pruritus of atopic dermatitis (AD) has not yet been established.

Objective

We conducted a systematic review and meta-analysis to evaluate the effectiveness of combined therapy of H1-antihistamines and topical steroids.

Methods

We systematically searched MEDLINE, Embase, and CENTRAL databases for articles published from 1967 to 2015. We identified 1,206 studies and assessed their titles, abstract, and full-text. Random effects meta-analysis was used to calculate mean differences (MD) with 95% confidence intervals (CI).

Results

Two studies satisfying the inclusion criteria of antihistamine therapy with mandatory topical steroid use were selected. Comparing antihistamine monotherapy with combination therapy, patients treated with the addition of antihistamine to topical corticosteroids showed a statistically significant clinical improvement (standard MD, −0.24; 95% CI, −0.42 to −0.05; p=0.01).

Conclusion

H1-antihistamines may have a synergistic effect when combined with topical steroids by influencing various associative factors of chronic pruritus in AD.

Current Concepts on 6-sulfo LacNAc Expressing Monocytes (slanMo)

The human mononuclear phagocytes system consists of dendritic cells (DCs), monocytes, and macrophages having different functions in bridging innate and adaptive immunity. Among the heterogeneous population of monocytes the cell surface marker slan (6-sulfo LacNAc) identifies a specific subset of human CD14^- CD16⁺ non-classical monocytes, called slan⁺ monocytes (slanMo). In this review we discuss the identity and functions of slanMo, their contributions to immune surveillance by pro-inflammatory cytokine production, and cross talk with T cells and NK cells. We also consider the role of slanMo in the regulation of chronic inflammatory diseases and cancer. Finally, we highlight unresolved questions that should be the focus of future research.

Guidelines on Management of Atopic Dermatitis in India: An Evidence-Based Review and an Expert Consensus

BACKGROUND

Atopic dermatitis (AD) is a common and chronic, pruritic inflammatory skin condition that affects all age groups. There was a dearth of consensus document on AD for Indian practitioners. This article aims to provide an evidence-based consensus statement for the management of AD with a special reference to the Indian context. This guideline includes updated definition, etiological factors, classification, and management of atopic dermatitis.

METHODOLOGY

The preparation of guidelines was done in multiple phases. Indian Dermatology Expert Board Members (DEBM), recommended by the Skin Allergy Society of India, prepared 26 evidence-based recommendations for AD. An extensive literature search was done in MEDLINE, Google scholar, Cochrane, and other resources. Articles published in the past 10 years were reviewed and recommendations were graded based on the quality of evidence as per GRADE. After forming the initial structure, DEBM met in Mumbai and gave their decisions on an agree and disagree scale with an Indian perspective. Finally, their suggestions were compiled for preparing the article. After DEBM finalized the draft, a treatment algorithm was formulated for the management of AD.

RESULTS

DEBM suggested a working definition for AD. The panel agreed that moisturizers should be used as mainstay of therapy and should be continued in all lines of therapy and in maintenance phase. Topical corticosteroids and topical calcineurin inhibitors should be considered as the first line of treatment. Among systemic therapies, cyclosporin should be considered first line, followed by azathioprine, methotrexate, and mycophenolate mofetil. Phototherapy can be an effecive alternative. Empirical food restriction was recommended against.

CONCLUSION

These guidelines should form a reference for the management of patients with AD in an evidence-based manner.

The impact of lifestyle factors on evolution of atopic dermatitis: An alternative approach

Atopic dermatitis (AD) is a multifactorial chronic inflammatory disease with an incompletely understood etiopathogenesis. With a significant impact on the quality of life of patients, AD has attracted the interest of many research studies aiming to investigate the complex cellular and molecular mechanisms and to identify new therapeutic pathways. Various studies have focused on psycho-immunology, emphasizing the involvement of stress, defined as a general response of the body to external or internal challenges to the AD pathology. Factors like lifestyle and leisure activities may change the behavior of immune cells in AD with a strong impact on the evolution of the disease. Moreover, the poor adherence of AD patient to standard treatment approach has led to the necessity to combine different therapies in the field of complementary and alternative medicine. Although there are still not enough data to conclude that adjuvant therapies are effective in a conventional sense, there are already promising results suggesting that alternative therapeutic strategies could be a main subject of further research.

Associations of unsafe, unsupportive, and underdeveloped neighborhoods with atopic dermatitis in US children

BACKGROUND

Atopic dermatitis (AD) is influenced by multiple emotional and environmental factors. Yet, little is known about the impact of neighborhood environment characteristics on AD.

OBJECTIVE

To determine the association of neighborhood characteristics with AD prevalence and severity in US children.

METHODS

We analyzed data from the 2007-2008 National Survey of Children's Health, including a representative sample of 79,667 children and adolescents (age 0-17 years) in the United States. Multivariable weighted logistic regression models that adjusted for sociodemographics were constructed to determine the associations of neighborhood characteristics with AD prevalence and severity.

RESULTS

Atopic dermatitis prevalence or severity were significantly increased in children residing in neighborhoods where people reportedly definitely do not help each other out (adjusted odds ratio [95% confidence interval]: 1.32 [1.15-1.52]), watch out for each other's children (1.26 [1.10-1.45] and 1.66 [1.14-2.41], respectively), have people to count on (1.28 [1.13-1.45]), and trusted adults to help the child (1.16 [1.01-1.32] and 1.54 [1.05-2.27], respectively). Children also had increased odds of AD if their caregiver felt that the child was never (1.52 [1.27-1.82]) or sometimes (1.23 [1.12-1.36]) safe in his/her neighborhood. Severe AD was less common in children residing in a neighborhood with a bookmobile or library (0.68 [0.52-0.90]).

CONCLUSION

US children residing in unsafe, unsupportive, or underdeveloped neighborhoods have higher prevalence and severity of AD.

Impact of acute stress on itch sensation and scratching behaviour in patients with atopic dermatitis and healthy controls

BACKGROUND

Patients with atopic dermatitis (AD) often report that stress aggravates their itch. However, no study has investigated if and how acute stress influences itch sensation and scratching behaviour in these patients.

OBJECTIVES

We evaluated the impact of acute stress on experimentally induced cowhage itch perception and scratching behaviour in 16 healthy subjects and 15 patients with AD.

METHODS

The Trier Social Stress Test (TSST) was used to induce acute stress. The itch sensation, provoked by applying cowhage to the forearms, and off-site scratching behaviour (not directed at the cowhage application site) were compared before and after performing the TSST or the control condition (watching a video of landscape scenes).

RESULTS

In patients with AD, stress induced by TSST caused a significant reduction of cowhage-evoked itch but significantly increased off-site scratching behaviour. Such changes in itch perception and scratching behaviour were not observed in healthy controls. In addition, a significant positive correlation was noted between stress induced by TSST and clinical severity of eczema.

CONCLUSIONS

We speculate that psychological stress increases spontaneous scratching in patients with AD, which may enhance the vicious cycle of itching and scratching, resulting in aggravation of the skin eczema. These results provide new insights on the mechanism of acute stress-related exacerbation of itch in patients with AD.

Epidemiology of adult atopic dermatitis

Atopic dermatitis (AD) is driven by a complex gene-environment interaction. Many of the risk factors and genetic underpinning previously observed for pediatric AD may not apply to adult atopic dermatitis, suggesting that these may largely be different disorders. Whereas AD is classically thought of as a pediatric disease, recent studies have shown high rates of disease in adults as well. Risk factors for persistence of childhood-onset AD, as well as adult-onset AD, are reviewed. Adults with AD are particularly vulnerable to exogenous insults from the outside environment, including climate, ultraviolet exposure, pollution, irritants and pruritogens, and microbes. Finally, adult AD is associated with a substantial health care burden, with increased utilization, direct and indirect costs of care, and lost work productivity.

Introduction

Atopic dermatitis (AD) is a chronic relapsing condition that is characterized by itching and redness of the skin. Our modern usage of atopic dermatitis dates back to 1933, when Wise and Sulzberger first coined the term to signify the disease's close association with other respiratory atopy, such as bronchial asthma and allergic rhinitis. A recent systematic review of 69 cross-sectional and cohort studies has confirmed that AD is now a worldwide phenomenon with lifetime AD prevalences of well over 20% in many affluent country settings. Although there is no obvious consistent overall global trend in the prevalence of AD, studies have shown that climate, urbanization, lifestyle, and socioeconomic class influence the prevalence of atopic dermatitis. Despite the pervasiveness of the disease, an understanding of atopic dermatitis has been hampered by a number of factors. Data suggests that extrinsic environmental factors work in concert with intrinsic immune mechanism and genetic factors to drive disease progression. With such a complex etiology, management of atopic dermatitis currently at best achieves symptomatic control rather than cure. This approach poses a significant burden on healthcare resources, as well as patients' quality of life. Current management methods of AD often involves a combination of non-pharmacologic modalities and prescription medications. Though they can be effective when employed, there are significant barriers to treatment for patients including time, costs, and medication side effects. Our aim, throughout this text, is to explore the complexities of AD, providing the healthcare provider with tips and tricks to improve patient care and satisfaction and the most current trends and treatment approaches on the horizon.