The infectious complications of atopic dermatitis

The role of microRNAs in atopic dermatitis

Atopic dermatitis (AD), known as eczema, is a chronic inflammatory skin condition affecting millions worldwide. This abstract provides an overview of the clinical features and underlying pathogenesis of AD, highlighting the role of specific microRNAs (miRNAs) in its development and progression. AD presents with distinct clinical manifestations that evolve with age, starting in infancy with dry, itchy skin and red patches, which can lead to sleep disturbances. In childhood, the rash spreads to flexural areas, resulting in lichenification. In adulthood, lesions may localize to specific areas, including the hands and eyelids. Pruritus (itchiness) is a hallmark symptom, often leading to excoriations and increased vulnerability to skin infections. The pathogenesis of AD is multifaceted, involving genetic, immunological, and environmental factors. Skin barrier dysfunction, immune dysregulation, genetic predisposition, microbiome alterations, and environmental triggers contribute to its development. Recent research has uncovered the role of miRNAs, such as miR-10a-5p, miR-29b, miR-124, miR-143, miR-146a-5p, miR-151a, miR-155, and miR-223, in AD pathogenesis. These microRNAs play crucial roles in regulating various aspects of immune responses, keratinocyte dynamics, and inflammation. MicroRNA-10a-5p orchestrates keratinocyte proliferation and differentiation, while miR-29b regulates keratinocyte apoptosis and barrier integrity. MicroRNA-124 exhibits anti-inflammatory effects by targeting the NF-κB signaling pathway. MicroRNANA-143 counters allergic inflammation by modulating IL-13 signaling. MicroRNA-146a-5p regulates immune responses and correlates with IgE levels in AD. MicroRNA-151a shows diagnostic potential and modulates IL-12 receptor β2. MicroRNA-155 plays a central role in immune responses and Th17 cell differentiation, offering diagnostic and therapeutic potential. MicroRNA-223 is linked to prenatal smoke exposure and immune modulation in AD. Understanding these microRNAs' intricate roles in AD pathogenesis promises more effective treatments, personalized approaches, and enhanced diagnostic tools. Further research into these molecular orchestrators may transform the landscape of AD management, improving the quality of life for affected individuals.

Recurrent skin and soft tissue infections (SSTIs) in three family members caused by methicillin-resistant Staphylococcus aureus (MRSA) with Panton-Valentine leukocidin (PVL) exotoxin

Three family members attended their general practice and emergency department over a 3-month period with recurrent skin and soft tissue infections (SSTIs) such as paronychia, submandibular carbuncle and groin and gluteal abscess requiring surgical drainage. Only when two family members were concurrently admitted with abscesses requiring drainage under general anaesthetic was the definitive diagnosis reached. The wound swabs identified methicillin-resistant Staphylococcus aureus (MRSA) and subsequent identification of the exotoxin Panton-Valentine leukocidin (PVL). Following MRSA decolonisation therapy with mupirocin and octenidine, only one family member has had one recurrence of an SSTI with MRSA isolated from the wound. When patients present with a history of recurrent SSTIs or a family all have had similar presentations, the clinician should consider MRSA with PVL exotoxin infection. Then patients must be referred for confirmation to ensure management is effective for the SSTI and prescribe MRSA decolonisation therapy concurrently to reduce recurrence.

Antibacterial and Immunosuppressive Effects of a Novel Marine Brown Alga-Derived Ester in Atopic Dermatitis

Atopic dermatitis (AD) is a chronic skin condition that is characterized by dysregulated immune responses and a heightened risk of Staphylococcus aureus infections, necessitating the advancement of innovative therapeutic methods. This study explored the potential of (6Z,9Z,12Z,15Z)-(2R,3R,4R,5R)-2,3,4,5,6-pentahydroxyhexyl octadeca-6,9,12,15-tetraenoate (HSN-S1), a compound derived from the marine alga Hizikia fusiformis, which shows anti-inflammatory, antimicrobial, and immunomodulatory properties. HSN-S1 was isolated and characterized using advanced chromatographic and spectroscopic methods. Its efficacy was evaluated via in vitro assays with keratinocytes, macrophages, and T cells to assess cytokine suppression and its immunomodulatory effects; its antibacterial activity against S. aureus was quantified. The in vivo effectiveness was validated using a 2,4-dinitrochlorobenzene-induced AD mouse model that focused on skin pathology and cytokine modulation. HSN-S1 significantly reduced pro-inflammatory cytokine secretion, altered T-helper cell cytokine profiles, and showed strong antibacterial activity against S. aureus. In vivo, HSN-S1 alleviated AD-like symptoms in mice and reduced skin inflammation, transepidermal water loss, serum immunoglobulin-E levels, and Th2/Th17 cytokine outputs. These findings suggest HSN-S1 to be a promising marine-derived candidate for AD treatment, as it offers a dual-target approach that could overcome the limitations of existing therapies, hence warranting further clinical investigation.

Atopic Dermatitis Complicated by Recurrent Eczema Herpeticum Is Characterized by Multiple, Concurrent Epidermal Inflammatory Endotypes

A subgroup of patients with atopic dermatitis (AD) suffers from recurrent, disseminated herpes simplex virus skin infection, termed eczema herpeticum. To determine the transcriptional mechanisms of the skin and immune system pathobiology that underlie development of AD with eczema herpeticum (ADEH), we performed RNA-sequencing analysis of nonlesional skin (epidermis, dermis) from AD patients with and without a history of ADEH (ADEH+, n = 15; ADEH-, n = 13) along with healthy controls (n = 15). We also performed RNA sequencing on participants' plasmacytoid dendritic cells infected in vitro with herpes simplex virus 1. ADEH+ patients exhibited dysregulated gene expression, limited in the dermis (14 differentially expressed genes) and more widespread in the epidermis (129 differentially expressed genes). ADEH+-upregulated epidermal differentially expressed genes were enriched in type 2 cytokine (IL4R , CCL22, CRLF2, IL7R), interferon (CXCL10, ICAM1, IFI44, IRF7), and IL-36γ (IL36G) inflammatory gene pathways. All ADEH+ participants exhibited type 2 cytokine and inteferon endotypes, and 87% were IL36G-high. In contrast, these endotypes were more variably expressed among ADEH- participants. ADEH+ skin also had dysregulated epidermal differentiation complex gene expression of the late-cornified envelope, S100A, and small proline-rich gene families, which are involved in skin barrier function and antimicrobial activities. Plasmacytoid dendritic cell transcriptional responses to herpes simplex virus 1 infection were unaltered by ADEH status. The study concluded that the pathobiology underlying ADEH+ risk is associated with a unique, multifaceted epidermal inflammation that accompanies dysregulation of epidermal differentiation complex genes. These findings will help direct future studies that define how these inflammatory patterns may drive risk of eczema herpeticum in AD.

Secondary Bacterial Infections in Patients with Atopic Dermatitis or Other Common Dermatoses

Secondary bacterial infections of common dermatoses such as atopic dermatitis, ectoparasitosis, and varicella zoster virus infections are frequent, with Staphylococcus aureus and Streptococcus pyogenes being the bacteria most involved. There are also Gram-negative infections secondary to common dermatoses such as foot dyshidrotic eczema and tinea pedis. Factors favoring secondary bacterial infections in atopic dermatitis, ectoparasitosis, and varicella zoster virus infections mainly include an epidermal barrier alteration as well as itch. Mite-bacteria interaction is also involved in scabies and some environmental factors can promote Gram-negative bacterial infections of the feet. Furthermore, the bacterial ecology of these superinfections may depend on the geographical origin of the patients, especially in ectoparasitosis. Bacterial superinfections can also have different clinical aspects depending on the underlying dermatoses. Subsequently, the choice of class, course, and duration of antibiotic treatment depends on the severity of the infection and the suspected bacteria, primarily targeting S. aureus. Prevention of these secondary bacterial infections depends first and foremost on the management of the underlying skin disorder. At the same time, educating the patient on maintaining good skin hygiene and reporting changes in the primary lesions is crucial. In the case of recurrent secondary infections, decolonization of S. aureus is deemed necessary, particularly in atopic dermatitis.

Role of antioxidants supplementation in the treatment of atopic dermatitis: a critical narrative review

Atopic dermatitis (AD) is a chronic inflammatory skin disease characterized by itching, epidermal barrier dysfunction, and an unbalanced inflammatory reaction. AD pathophysiology involves a dysregulated immune response driven by T helper-2 cells. Many factors, including reactive oxygen species (ROS), are involved in AD pathogenesis by causing cellular damage and inflammation resulting in skin barrier dysfunction. This narrative review aims to provide a comprehensive overview of the role of natural molecules and antioxidant compounds, highlighting their potential therapeutic value in AD prevention and management. They include vitamin D, vitamin E, pyridoxine, Vitamin C, carotenoids, and melatonin. Some studies report a statistically significant association between antioxidant levels and improvement in AD, however, there are conflicting results in which antioxidant supplementation, especially Vitamin D, did not result in improvement in AD. Therefore, the clinical efficacy of these dietary nutritional factors in the treatment of AD needs to be further evaluated in clinical trials. Meanwhile, antioxidants can be incorporated into the management of AD patients in a personalized manner, tailored to the severity of the disease, comorbidities, and individual needs.

Constant vigilance! Managing threats to the skin barrier

OBJECTIVE

Skin barrier defects are one of the primary causes of atopic dermatitis (AD). The basis of skin barrier defects in AD is due to a deficiency in various barrier proteins including filaggrin, involucrin, claudins, and lipids such as ceramide, fatty acids, and cholesterol. This review updates a more detailed lipid dysregulation in the skin barrier of AD based on recent lipidomic analysis. The clinical implications, treatments, prevention, and predictive capability of skin barrier defects are also reviewed.

DATA SOURCES

Published literature obtained through PubMed searches.

STUDY SELECTIONS

Studies relevant to the mechanisms, clinical implications, treatments, prevention, and predictors of AD development.

RESULTS

Skin barrier defects contribute to transepidermal water loss, infections, IgE sensitizations, and cutaneous inflammation in AD. Preventive treatments include daily hydration and application of moisturizers. Because skin barrier defects precede the development of AD, they provide an opportunity for prediction and intervention.

CONCLUSION

Skin barrier defects play an important role in the comorbidities of AD including infectious complications, disease flare, and allergic diathesis. Current research focuses on prevention and prediction of AD development.

Impact of climate change on atopic dermatitis: A review by the International Eczema Council

Atopic dermatitis (AD), the most burdensome skin condition worldwide, is influenced by climatic factors and air pollution; however, the impact of increasing climatic hazards on AD remains poorly characterized. Leveraging an existing framework for 10 climatic hazards related to greenhouse gas emissions, we identified 18 studies with evidence for an impact on AD through a systematic search. Most climatic hazards had evidence for aggravation of AD the impact ranged from direct effects like particulate matter-induced AD exacerbations from wildfires to the potential for indirect effects like drought-induced food insecurity and migration. We then created maps comparing the past, present, and future projected burden of climatic hazards to global AD prevalence data. Data are lacking, especially from those regions most likely to experience more climatic hazards. We highlight gaps important for future research: understanding the synergistic impacts of climatic hazards on AD, long-term disease activity, the differential impact on vulnerable populations, and how basic mechanisms explain population-level trends.

Bacterial microbiota and proinflammatory cytokines in the anal sacs of treated and untreated atopic dogs: Comparison with a healthy control group

The pathogenesis of anal sacculitis has not been extensively investigated, although atopic dogs seem to be predisposed to the disease. The aim of this study was therefore to characterize and compare the bacterial microbiota and pro-inflammatory cytokines in the anal sacs of dogs from three groups (healthy dogs, untreated atopic dogs and atopic dogs receiving antipruritic treatment or allergen-specific immunotherapy) in order to determine whether changes could be at the origin of anal sacculitis in atopic dogs. Bacterial populations of anal sac secretions from fifteen healthy dogs, fourteen untreated and six treated atopic dogs were characterized by sequencing the V4 region of the 16S rRNA gene using Illumina technology. Proinflammatory cytokines were analyzed with the Luminex multiplex test. Community membership and structure were significantly different between the anal sacs of healthy and untreated atopic dogs (P = 0.002 and P = 0.003, respectively) and between those of untreated and treated atopic dogs (P = 0.012 and P = 0.017, respectively). However, the community structure was similar in healthy and treated atopic dogs (P = 0.332). Among the proinflammatory cytokines assessed, there was no significant difference between groups, except for interleukin 8 which was higher in the anal sacs of untreated atopic dogs compared to treated atopic dogs (P = 0.02), and tumor necrosis factor-alpha which was lower in the anal sacs of healthy dogs compared to treated atopic dogs (P = 0.04). These results reveal a dysbiosis in the anal sacs of atopic dogs, which may partially explain the predisposition of atopic dogs to develop bacterial anal sacculitis. Treatments received by atopic dogs (oclacitinib, desloratadine and allergen-specific immunotherapy) shift the microbiota of the anal sacs towards that of healthy dogs. Further studies are required to identify significant cytokines contributing to anal sacculitis in atopic dogs.

Mendelian Randomization Studies in Atopic Dermatitis: A Systematic Review

Prior studies have found associations between atopic dermatitis (AD) and comorbidities, including depression, obesity, asthma, and allergic rhinitis. Although observational studies often cannot establish robust causality between potential risk factors and AD, Mendelian randomization minimizes confounding when exploring causality by relying on random allelic assortment at birth. In this study, we systematically reviewed 30 Mendelian randomization studies in AD. Body mass index, gut microbial flora, the IL-18 signaling pathway, and gastroesophageal reflux disease were among the causal factors for AD, whereas AD was causal for several medical conditions, including heart failure, rheumatoid arthritis, and conjunctivitis. These insights may improve preventive counseling in AD.

The use of essential oils in atopic dermatitis: a review

Atopic dermatitis (AD) has become a common childhood disease that affects a large number of children worldwide and has become a chronic skin disease that causes huge economical and psychological damage to the whole family. Despite the use of steroids, immunosuppressants, and various topical preparation, the prognosis is still poor. Hence, this review aimed to explore the potential of using essential oils (EO) as an active ingredient in managing AD. The review was completed by using Pubmed, Scopus, and Medline to search for relevant articles that study the pathophysiology of AD, the properties of EO, the use of EO in managing AD, and the suitable advanced formulation to incorporate EO. From the review conducted, it was concluded that EO have huge potential in managing AD and can be used as complimentary therapeutic agents in AD treatment. Scientists and industries should venture into commercializing more topical products with EO to help manage AD more effectively.

Differentiation of keratinocytes or exposure to type 2 cytokines diminishes S. aureus internalization

Staphylococcus aureus is a leading cause of skin and soft tissue infections. Colonization by this bacterium is increased in individuals with chronic cutaneous diseases such as atopic dermatitis, psoriasis, and bullous pemphigoid. The greater abundance of S. aureus on the skin of subjects with atopic dermatitis in particular has been linked to recurrent cutaneous infections. The primary cell type of the epidermal layer of the skin is the keratinocyte, and it is thought that S. aureus internalized in keratinocytes associates with an increased incidence of skin infections. This study addresses whether keratinocyte differentiation and/or inflammation, two important characteristics altered in cutaneous diseases, influence bacterial internalization. To do this, S. aureus internalization was measured in immortalized and primary keratinocytes that were differentiated using high Ca2+-containing media and/or exposed to cytokines characteristic of atopic dermatitis (IL-4 and IL-13) or psoriasis (IL-17A and IL-22) skin. Our results indicate that S. aureus internalization is uniquely decreased upon keratinocyte differentiation, since this was not observed with another skin-resident bacterium, S. epidermidis. Additionally, treatment with IL-4 + IL-13 diminished bacterial internalization. We interpret this decrease as a mechanism of keratinocyte-based bacterial killing since a similar number of bacterial genomes were detected in cytokine-treated cells, but less viable internalized S. aureus was recovered. Finally, of the receptors reported for S. aureus binding/internalizing into keratinocytes, expression of the α5 component of the α5β1 integrin was in greatest accordance with the number of internalized bacteria in the context of keratinocyte differentiation.IMPORTANCEIndividuals with chronic cutaneous diseases demonstrate heightened susceptibility for severe and recurrent infections from Staphylococcus aureus. What drives this altered susceptibility remains poorly understood. Previous publications have detected S. aureus as deep as the dermal layer of skin in subjects with atopic dermatitis, suggesting that the cutaneous environment of this disease enables deeper bacterial infiltration than occurs in healthy individuals. This observation indicates that S. aureus has greater opportunity to interact with multiple skin cell types in individuals with chronic inflammatory skin diseases. Identifying the characteristics of the skin that influence bacterial internalization, a common method to establish reservoirs and evade the immune response, is critical for our understanding of S. aureus pathogenesis. The significance of this research is the novel identification of epidermal characteristics that influence S. aureus internalization. With this knowledge, methods can be developed to identify patient populations at greater risk for cutaneous infections.

Atopic Dermatitis in Children

Atopic dermatitis (AD) is extremely common in the pediatric population, and most children with AD will first present to their primary care provider (PCP). The PCP can recognize AD by its clinical features, including itch, a chronic relapsing course, and the characteristic eruption. The cornerstone of AD therapy is dry skin care, typically a short daily bath/shower followed by an emollient applied to all skin. Most children with AD will also require topical medications, such as topical corticosteroids and/or topical nonsteroidal therapies. For children with more severe disease, systemic agents, including several novel therapies, may be required. In managing AD, the clinician must monitor for side effects of medications as well as complications of the AD itself, the most common of which is secondary infection. An understanding of the pathogenesis, treatments, and complications of AD is essential for the PCP, as untreated (or undertreated) AD has a significant impact on the quality of life of affected children and their caregivers. [Pediatr Ann. 2024;53(4):e121-e128.].

Updates in atopic dermatitis for the primary care physician: A review of advances in the understanding and treatment of atopic dermatitis

Atopic dermatitis (AD) is a common inflammatory skin condition occurring in both pediatric and adult patients. Pruritus is a clinical hallmark of the disease, and patients with AD often experience disruptions to their quality of life. The pathogenesis of AD is a complex and multifactorial interplay between genetic factors, epidermal barrier disruption, and immune dysregulation. Clinically, AD is characterized by pruritus, eczematous skin changes, and age-specific lesion distribution patterns. Infants and young children tend to have AD lesions on their face and extensor surfaces of their extremities while older children and adults tend to have AD lesions on flexural surfaces of their extremities. Many patients also experience a chronic and relapsing disease course. Due to the chronicity and severe pruritus, lesions often undergo secondary changes like lichenification. Patients with AD can experience a number of comorbidities including other atopic disease (i.e. allergic rhinitis, asthma), skin infections, cardiovascular, and neuropsychiatric illnesses. Management of AD depends on the severity of the disease as well as the distribution of the disease. Traditionally, treatment of AD included the use of moisturizers / emollients, topical corticosteroids or topical calcineurin inhibitors, or systemic therapy with non-selective immunosuppressants such as corticosteroids, cyclosporine, azathioprine, or similar. However, in the past decade, new biologic and small molecule drugs, both topical and systemic, have become important therapeutic options for AD patients, especially for those with moderate-to-severe disease. The development of these medications, following decades of research to better understand AD, are designed to specifically target various components of immune dysregulation and inflammation implicated in the pathogenesis of AD. Their successful development and deployment now allow for an exciting new era of treatment for individuals suffering from atopic dermatitis.

Interplay of cytokines in the pathophysiology of atopic dermatitis: insights from Murin models and human

The pathogenesis of atopic dermatitis (AD) is understood to be crucially influenced by three main factors: dysregulation of the immune response, barrier dysfunction, and pruritus. In the lesional skin of AD, various innate immune cells, including Th2 cells, type 2 innate lymphoid cells (ILC2s), and basophils, produce Th2 cytokines [interleukin (IL)-4, IL-5, IL-13, IL-31]. Alarmins such as TSLP, IL-25, and IL-33 are also produced by epidermal keratinocytes, amplifying type 2 inflammation. In the chronic phase, not only Th2 cells but also Th22 and Th17 cells increase in number, leading to suppression of filaggrin expression by IL-4, IL-13, and IL-22, which further deteriorates the epidermal barrier function. Dupilumab, which targets IL-4 and IL-13, has shown efficacy in treating moderate to severe AD. Nemolizumab, targeting IL-31RA, effectively reduces pruritus in AD patients. In addition, clinical trials with fezakinumab, targeting IL-22, have demonstrated promising results, particularly in severe AD cases. Conversely, in murine models of AD, several cytokines, initially regarded as promising therapeutic targets, have not demonstrated sufficient efficacy in clinical trials. IL-33 has been identified as a potent activator of immune cells, exacerbating AD in murine models and correlating with disease severity in human patients. However, treatments targeting IL-33 have not shown sufficient efficacy in clinical trials. Similarly, thymic stromal lymphopoietin (TSLP), integral to type 2 immune responses, induces dermatitis in animal models and is elevated in human AD, yet clinical treatments like tezepelumab exhibit limited efficacy. Therapies targeting IL-1α, IL-5, and IL-17 also failed to achieve sufficient efficacy in clinical trials. It has become clear that for treating AD, IL-4, IL-13, and IL-31 are relevant therapeutic targets during the acute phase, while IL-22 emerges as a target in more severe cases. This delineation underscores the necessity of considering distinct pathophysiological aspects and therapeutic targets in AD between mouse models and humans. Consequently, this review delineates the distinct roles of cytokines in the pathogenesis of AD, juxtaposing their significance in human AD from clinical trials against insights gleaned from AD mouse models. This approach will improve our understanding of interspecies variation and facilitate a deeper insight into the pathogenesis of AD in humans.

Unraveling the skin; a comprehensive review of atopic dermatitis, current understanding, and approaches

Atopic dermatitis, also known as atopic eczema, is a chronic inflammatory skin disease characterized by red pruritic skin lesions, xerosis, ichthyosis, and skin pain. Among the social impacts of atopic dermatitis are difficulties and detachment in relationships and social stigmatization. Additionally, atopic dermatitis is known to cause sleep disturbance, anxiety, hyperactivity, and depression. Although the pathological process behind atopic dermatitis is not fully known, it appears to be a combination of epidermal barrier dysfunction and immune dysregulation. Skin is the largest organ of the human body which acts as a mechanical barrier to toxins and UV light and a natural barrier against water loss. Both functions face significant challenges due to atopic dermatitis. The list of factors that can potentially trigger or contribute to atopic dermatitis is extensive, ranging from genetic factors, family history, dietary choices, immune triggers, and environmental factors. Consequently, prevention, early clinical diagnosis, and effective treatment may be the only resolutions to combat this burdensome disease. Ensuring safe and targeted drug delivery to the skin layers, without reaching the systemic circulation is a promising option raised by nano-delivery systems in dermatology. In this review, we explored the current understanding and approaches of atopic dermatitis and outlined a range of the most recent therapeutics and dosage forms brought by nanotechnology. This review was conducted using PubMed, Google Scholar, and ScienceDirect databases.

Interprofessional Collaboration: Differentiating Netherton Syndrome and Atopic Dermatitis in an African American Infant

Netherton syndrome is a rare, autosomal recessive disorder that clinically presents with a triad of congenital ichthyosiform erythroderma, hair shaft abnormalities, and immune dysregulation, which is confirmed with genetic testing for mutations in the serine protease inhibitor Kazal-type 5 (SPINK5) gene. This diagnosis was included in our differential due to the patient's recurring and unimproving rash with desquamating skin. While eczema was included in our differential diagnoses, the patient's systemic symptoms, including failure to thrive, prompted our team to consider other diagnoses. This patient endured numerous treatments and diagnostic tests to eliminate underlying immunodeficiencies and autoinflammatory diseases. In this case report, we present a two-month-old male who was originally brought into the outpatient pediatric clinic for severe eczema, periorbital swelling, and failure to thrive. The patient returned with a continuing exudative rash after amoxicillin suspension treatment and was ultimately hospitalized for IV antibiotic treatment. The patient was then transferred to multiple hospitals for treatment and final diagnosis of severe seborrheic dermatitis and atopic dermatitis. Multiple inpatient hospitals and outpatient clinics had to collaborate and communicate effectively to reach a diagnosis. The diagnosis for this patient was found after a true display of the value of interdisciplinary collaboration as several outpatient clinics and inpatient hospitals worked together for this outcome.

Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations

BACKGROUND

Guidance addressing atopic dermatitis (AD) management, last issued in 2012 by the American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force, requires updating as a result of new treatments and improved guideline and evidence synthesis methodology.

OBJECTIVE

To produce evidence-based guidelines that support patients, clinicians, and other decision-makers in the optimal treatment of AD.

METHODS

A multidisciplinary guideline panel consisting of patients and caregivers, AD experts (dermatology and allergy/immunology), primary care practitioners (family medicine, pediatrics, internal medicine), and allied health professionals (psychology, pharmacy, nursing) convened, prioritized equity, diversity, and inclusiveness, and implemented management strategies to minimize influence of conflicts of interest. The Evidence in Allergy Group supported guideline development by performing systematic evidence reviews, facilitating guideline processes, and holding focus groups with patient and family partners. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach informed rating the certainty of evidence and strength of recommendations. Evidence-to-decision frameworks, subjected to public comment, translated evidence to recommendations using trustworthy guideline principles.

RESULTS

The panel agreed on 25 recommendations to gain and maintain control of AD for patients with mild, moderate, and severe AD. The eAppendix provides practical information and implementation considerations in 1-2 page patient-friendly handouts.

CONCLUSION

These evidence-based recommendations address optimal use of (1) topical treatments (barrier moisturization devices, corticosteroids, calcineurin inhibitors, PDE4 inhibitors [crisaborole], topical JAK inhibitors, occlusive [wet wrap] therapy, adjunctive antimicrobials, application frequency, maintenance therapy), (2) dilute bleach baths, (3) dietary avoidance/elimination, (4) allergen immunotherapy, and (5) systemic treatments (biologics/monoclonal antibodies, small molecule immunosuppressants [cyclosporine, methotrexate, azathioprine, mycophenolate, JAK inhibitors], and systemic corticosteroids) and UV phototherapy (light therapy).

Nanozyme-Engineered Hydrogels for Anti-Inflammation and Skin Regeneration

Inflammatory skin disorders can cause chronic scarring and functional impairments, posing a significant burden on patients and the healthcare system. Conventional therapies, such as corticosteroids and nonsteroidal anti-inflammatory drugs, are limited in efficacy and associated with adverse effects. Recently, nanozyme (NZ)-based hydrogels have shown great promise in addressing these challenges. NZ-based hydrogels possess unique therapeutic abilities by combining the therapeutic benefits of redox nanomaterials with enzymatic activity and the water-retaining capacity of hydrogels. The multifaceted therapeutic effects of these hydrogels include scavenging reactive oxygen species and other inflammatory mediators modulating immune responses toward a pro-regenerative environment and enhancing regenerative potential by triggering cell migration and differentiation. This review highlights the current state of the art in NZ-engineered hydrogels (NZ@hydrogels) for anti-inflammatory and skin regeneration applications. It also discusses the underlying chemo-mechano-biological mechanisms behind their effectiveness. Additionally, the challenges and future directions in this ground, particularly their clinical translation, are addressed. The insights provided in this review can aid in the design and engineering of novel NZ-based hydrogels, offering new possibilities for targeted and personalized skin-care therapies.

Comorbidities in childhood atopic dermatitis: A population-based study

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease that is associated with allergic comorbidities. However, studies examining comorbidities in childhood AD are incomplete, which may contribute to suboptimal care.

OBJECTIVE

The objective was to compare the risk of developing different allergic and non-allergic comorbidities among children with AD to that of a matched non-AD reference cohort in Sweden.

METHODS

This was a nationwide population-based cohort study using longitudinal data from primary and specialist care registers. Patients with AD were identified by confirmed diagnosis in primary or specialist care. The non-AD reference cohort was randomly drawn from the general population and matched 1:1 with the AD patients. The risk of developing the following conditions was evaluated: hypersensitivity and allergic disorders, neurological disorders, psychiatric disorders, infections, immunological and inflammatory disorders, Type 1 diabetes (T1D), endocrine and metabolic disorders, skeletal disorders, ocular disorders and malignancies.

RESULTS

This study included 165,145 patients with AD (mild-to-moderate [n = 126,681] and severe [n = 38,464]) and an equally sized reference cohort. Patients with AD displayed a higher risk of developing comorbid conditions for all investigated categories, except for T1D and skeletal disorders, compared with the reference cohort. The highest risk compared with the reference cohort was observed for hypersensitivity and allergic disorders (hazard ratio [HR]: 3.87), followed by malignancies (HR: 2.53) and immunological and inflammatory disorders (HR: 2.36). Patients with AD also had higher risk of developing multiple comorbidities (≥2). The risk of comorbidity onset increased alongside AD severity and patients with active AD were associated with increased risk of comorbidity onset compared with patients in remission.

CONCLUSIONS

The clinical burden of AD is substantial for children with AD and patients are at an increased risk of developing several comorbid conditions extending beyond the atopic march. Our results also showed a positive association between worsening severity of AD and an increased risk of comorbidity onset.

Atopic Dermatitis and the Risk of Infection in End-Stage Renal Disease

Background and Objectives: Atopic dermatitis (AD), also known as eczema, is a common chronic inflammatory skin condition affecting 16.5 million adults in the United States. AD is characterized by an impaired epidermal barrier that can predispose individuals to infection. End-stage renal disease (ESRD) is also commonly complicated by infections due to chronic vascular access and immune-system dysfunction, possibly related to uremia. Multiple studies have reported that renal disease is a common comorbidity in adults with atopic dermatitis. The aim of this study was to determine whether AD is a risk factor for certain infections in patients with ESRD. Materials and Methods: Using the United States Renal Data System, a retrospective cohort analysis was conducted on adult ESRD patients initiating dialysis between 2004 and 2019 to investigate associations between infections and AD in this population. Results: Of 1,526,266 patients, 2290 were identified with AD (0.2%). Infectious outcomes of interest were bacteremia, septicemia, cellulitis, herpes zoster, and conjunctivitis. In all infectious outcomes except for conjunctivitis, patients with the infectious outcomes were more likely to carry a diagnosis of AD. After controlling for demographic and clinical covariates, AD was associated with an increased risk of cellulitis (adjusted relative risk (aRR) = 1.39, 95% confidence interval (CI) = 1.31-1.47) and herpes zoster (aRR = 1.67, CI = 1.44-1.94), but not with bacteremia (aRR = 0.96, CI = 0.89-1.05), septicemia (aRR = 1.02, CI = 0.98-1.08), or conjunctivitis (aRR = 0.97, CI = 0.740-1.34). Conclusions: Overall, after controlling for demographic and clinical covariates and adjusting for person-years-at-risk, AD was associated with an increased risk for some, but not all, infections within the population of patients with ESRD.

Effects of Sodium Salts of Fatty Acids and Their Derivatives on Skin Permeation of Cromolyn Sodium

Atopic dermatitis is a chronic inflammatory disorder with rising prevalence. The safety concerns over usually used steroids are driving the need for developing an effective atopic dermatitis treatment. The use of therapeutic agents such as cromolyn sodium (CS) is suggested. However, due to its physicochemical properties, CS permeation across the skin is a challenge. The aim of this study was to investigate the effect of sodium salts of fatty acids or their derivatives with varied carbon chain lengths as potential enhancers on the skin permeation of CS. These included sodium caprylate, salcaprozate sodium, sodium decanoate, sodium palmitate, and sodium oleate dissolved in propylene glycol along with CS (4% w/w). In vitro permeation of the formulations across the dermatomed porcine ear skin was investigated over 24 h using Franz Diffusion cells. The amount of CS permeation from propylene glycol was 5.54 ± 1.06 µg/cm2 after 24 h. Initial screening of enhancers (enhancer: drug::1:1) showed enhancement in permeation of CS using sodium oleate and sodium caprylate, which were then investigated in higher ratio of drug: enhancer (1:2). Among all the formulations tested, sodium oleate (enhancer: drug::1:2) was observed to significantly (p < 0.05) enhance the permeation of CS with the highest total delivery of 359.79 ± 78.92 µg/cm2 across skin in 24 h and higher drug retention in the skin layers (153.0 ± 24.93 µg/cm2) as well. Overall, sodium oleate was found to be the most effective enhancer followed by sodium caprylate for improving the topical delivery of CS.

Rapid reduction in Staphylococcus aureus in atopic dermatitis subjects following dupilumab treatment

BACKGROUND

Atopic dermatitis (AD) is an inflammatory disorder characterized by dominant type 2 inflammation leading to chronic pruritic skin lesions, allergic comorbidities, and Staphylococcus aureus skin colonization and infections. S aureus is thought to play a role in AD severity.

OBJECTIVES

This study characterized the changes in the host-microbial interface in subjects with AD following type 2 blockade with dupilumab.

METHODS

Participants (n = 71) with moderate-severe AD were enrolled in a randomized (dupilumab vs placebo; 2:1), double-blind study at Atopic Dermatitis Research Network centers. Bioassays were performed at multiple time points: S aureus and virulence factor quantification, 16s ribosomal RNA microbiome, serum biomarkers, skin transcriptomic analyses, and peripheral blood T-cell phenotyping.

RESULTS

At baseline, 100% of participants were S aureus colonized on the skin surface. Dupilumab treatment resulted in significant reductions in S aureus after only 3 days (compared to placebo), which was 11 days before clinical improvement. Participants with the greatest S aureus reductions had the best clinical outcomes, and these reductions correlated with reductions in serum CCL17 and disease severity. Reductions (10-fold) in S aureus cytotoxins (day 7), perturbations in TH17-cell subsets (day 14), and increased expression of genes relevant for IL-17, neutrophil, and complement pathways (day 7) were also observed.

CONCLUSIONS

Blockade of IL-4 and IL-13 signaling, very rapidly (day 3) reduces S aureus abundance in subjects with AD, and this reduction correlates with reductions in the type 2 biomarker, CCL17, and measures of AD severity (excluding itch). Immunoprofiling and/or transcriptomics suggest a role for TH17 cells, neutrophils, and complement activation as potential mechanisms to explain these findings.

Systemic Type 2 Inflammation-Associated Atopic Dermatitis Exacerbates Periodontitis

INTRODUCTION

Atopic dermatitis (AD) is a prevalent and chronic inflammatory skin disease characterized by Th2 cell-mediated type 2 inflammation. Emerging evidence indicated that AD patients exhibit an increased incidence of oral disorders. In the present study, we sought mechanistic insights into how AD affects periodontitis.

METHODS

Onset of AD was induced by 2,4-dinitrochlorobenzene (DNCB). Furthermore, we induced periodontitis (P) in AD mice. The effect of AD in promoting inflammation and bone resorption in gingiva was evaluated. Hematoxylin and eosin staining, tartrate-resistant acid phosphatase staining, immunofluorescence assay, and flow cytometry were used to investigate histomorphology and cytology analysis, respectively. RNA sequencing of oral mucosa is used tissues to further understand the dynamic transcriptome changes. 16S rRNA microbial analysis is used to profile oral microbial composition.

RESULTS

Compared to control group, mice in AD group showed inflammatory signatures and infiltration of a proallergic Th2 (Th2A)-like subset in oral mucosa but not periodontitis, as identified by not substantial changes in mucosa swelling, alveolar bone loss, and TRAP+ osteoclasts infiltration. Similarly, more Th2A-like cell infiltration and interleukin-4 levels were significantly elevated in the oral mucosa of DNCB-P mice compared to P mice. More importantly, AD exacerbates periodontitis when periodontitis has occurred and the severity of periodontitis increased with aggravation of dermatitis. Transcriptional analysis revealed that aggravated periodontitis was positively correlated with more macrophage infiltration and abundant CCL3 secreted. AD also altered oral microbiota, indicating the re-organization of extracellular matrix.

CONCLUSIONS

These data provide solid evidence about exacerbation of periodontitis caused by type 2 dermatitis, advancing our understanding in cellular and microbial changes during AD-periodontitis progression.

Bacterial Metabolites and Inflammatory Skin Diseases

The microbiome and gut-skin axis are popular areas of interest in recent years concerning inflammatory skin diseases. While many bacterial species have been associated with commensalism of both the skin and gastrointestinal tract in certain disease states, less is known about specific bacterial metabolites that regulate host pathways and contribute to inflammation. Some of these metabolites include short chain fatty acids, amine, and tryptophan derivatives, and more that when dysregulated, have deleterious effects on cutaneous disease burden. This review aims to summarize the knowledge of wealth surrounding bacterial metabolites of the skin and gut and their role in immune homeostasis in inflammatory skin diseases such as atopic dermatitis, psoriasis, and hidradenitis suppurativa.

Phenotypic and Endotypic Determinants of Atopic Dermatitis Severity From the Atopic Dermatitis Research Network (ADRN) Registry

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin condition with a highly variable clinical phenotype.

OBJECTIVE

This study aimed to identify historical and clinical features and biomarkers associated with AD severity.

METHODS

A US registry of extensively phenotyped AD participants (aged 0.73-80 years) were enrolled at 9 academic centers. Information on family and personal medical history, examination, skin swabs (culture), and serum biomarkers was collected to evaluate their association with AD severity.

RESULTS

Participants with AD (N = 2862) whose disease was categorized as mild (11.6%), moderate (58.0%), or severe (30.4%) based on Rajka-Langeland scoring were enrolled. The trend test, when adjusting for gender, race, and age, demonstrated that severity was strongly (P ≤ .04) associated with a personal/family history of allergic disorders, history of alopecia, exposure to passive smoke, ocular herpes infection, skin bacterial and viral infections, and history of arrhythmia. Features observed more frequently (P ≤ .002), as a function of severity, included skin infections (impetigo, human papillomavirus, and molluscum contagiosum virus), Staphylococcus aureus colonization, excoriations, hyperlinear palms, ichthyosis, blepharitis, conjunctivitis, ectropion, and wheezing. Serum IgE, allergen and food (≤6 years) Phadiatop, and eosinophilia were strongly linked to severity (P < .001).

CONCLUSIONS

In a diverse US AD population, severity was associated with a history of atopic disorders, skin and extracutaneous bacterial and viral infections (by history and physical examination), higher IgE, eosinophilia and allergen sensitization, atopic skin manifestations (ie, excoriation, hyperlinear palms, and ichthyosis), and atopic ocular features (ie, blepharitis, conjunctivitis, and ectropion) as well as asthma findings (ie, wheezing). Data from our prospective registry significantly advance our understanding of AD phenotypes and endotypes, which is critical to achieve optimal management.

Topical Janus kinase inhibitors in atopic dermatitis: a safety network meta-analysis

BACKGROUND

Topical Janus kinase (JAK) inhibitors are being developed for the treatment of mild to moderate atopic dermatitis. However, comparative evidence on their safety profiles is still limited.

AIM

This study aimed to compare the relative safety of topic JAK inhibitors in patients with atopic dermatitis.

METHOD

Phase 2 and 3 clinical trials (RCTs) evaluating the efficacy and safety of topical JAK inhibitors in atopic dermatitis were searched on Medline, EMBASE and clinicaltrials.gov. The following outcomes were considered: any adverse event (AE), serious AEs, AEs leading to treatment discontinuation, any infection, any application site reaction.

RESULTS

Ten RCTs were included in this network meta-analysis. Tofacitinib was associated with a reduced risk of any AE when compared with ruxolitinib (OR 0.18, 95% CrI 0.03-0.92). The analyses for the remaining outcomes did not identify other statistically significant risk differences between the topical JAK inhibitors.

CONCLUSION

Although tofacitinib seems to present a reduced risk of any adverse event compared with ruxolitinib, this was the only statistically significant result found between JAK inhibitors. Therefore, such findings should be interpreted with caution considering the scarce data available and the heterogeneity between the studies, and there is no robust evidence allowing pointing out clinically important differences between the safety profiles of the existing topical JAK inhibitors. Further pharmacovigilance activities are needed to confirm the safety profile of these drugs.

Atopic Dermatitis: A Common Pediatric Diagnosis That Is Not Just Another Rash

Emergency nurse practitioners are expected to assess and manage a variety of patients. These patients may present with urgent care-type complaints to severe life-threatening illnesses or injuries. For some, dermatological problems can sometimes be just as challenging as a critically ill patient. Atopic dermatitis (AD) is one, if not, the most common chronic inflammatory disease. Its presentation can vary depending on the age of the patient, the patient's skin tone, and other comorbidities. Patients often seek emergency care related to the condition itself or associated complications. This article includes a review of the pathophysiology, clinical manifestations, and standard management of AD. Finally, the potential complications of AD are discussed. A better understanding of AD will allow emergency nurse practitioners to properly identify and treat this chronic condition, as well as its complications.

JAK1 inhibitors for the treatment of atopic dermatitis: a focus on pharmacokinetic considerations

INTRODUCTION

Atopic dermatitis (AD) is associated with reduced quality of life, depression, and anxiety, making efficacious and safe treatments a priority. We will focus on the safety, efficacy, and pharmacokinetics of JAK1 inhibitors used in the treatment of AD.

AREAS COVERED

In this review, the pharmacodynamics, pharmacokinetics, safety, and efficacy of JAK1 inhibitors for the treatment of atopic dermatitis are discussed. The data was obtained by searching ClinicalTrials.gov, PubMed, and Google Scholar. Articles between January 2012 and March 2023 were considered for inclusion.

EXPERT OPINION

Given the rare, but serious black box warnings with JAK inhibitors, patients and providers may be weary of initiating treatment. In these instances, clinicians may weigh the risks and benefits of treatment with this class. Risk is relative, and while there are risks to treating AD with JAK inhibitors, there are also risks to untreated or undertreated AD, including infection and impairments in mental, physical, and psychosocial function. While JAK1 inhibitors appear to be safe, they were only recently approved for AD in January 2022, and more long-term safety data is needed. We expect to see additional FDA approval of these drugs, new formulations, and more safety and efficacy data in the future.

Peristomal Skin Complications: Detailed Analysis of a Web-Based Survey and Predictive Risk Factors

Patients with a stoma are at risk of developing peristomal skin complications (PSCs) that can negatively impact their quality of life. This study aims to identify potential risk factors for dermatitis, pruritis/xerosis, infections, and ulcerations among patients with a stoma and evaluate preventive measures. This cross-sectional study involved data regarding 232 Italian patients with a stoma. A questionnaire was used to collect patient characteristics, comorbidities, and stoma management data. The most frequent PSCs observed were dermatitis and pruritis/xerosis in approximately 60% of patients. Psoriasis was strongly correlated with dermatitis, while being overweight or obese increased the risk of pruritis/xerosis. Class 2 obesity and atopic dermatitis were associated with an increased risk of infections. Being underweight, completely nonautonomous, and having inflammatory bowel disease were associated with a higher risk of ulcerations, while radiotherapy was a strong risk factor for ulceration. Preventive measures such as using hydrocolloid barriers, TNT gauze cleansing, and low pH detergent were effective in preventing dermatitis. Appropriate stoma care and maintenance, including the use of protective film and careful monitoring of weight and comorbidities, are crucial in minimizing the risk of complications associated with a stoma.

Crisaborole efficacy in murine models of skin inflammation and Staphylococcus aureus infection

Phosphodiesterase 4 (PDE4) is highly expressed in keratinocytes and immune cells and promotes pro-inflammatory responses upon activation. The activity of PDE4 has been attributed to various inflammatory conditions, leading to the development and approval of PDE4 inhibitors as host-directed therapeutics in humans. For example, the topical PDE4 inhibitor, crisaborole, is approved for the treatment of mild-to-moderate atopic dermatitis and has shown efficacy in patients with psoriasis. However, the role of crisaborole in regulating the immunopathogenesis of inflammatory skin diseases and infection is not entirely known. Therefore, we evaluated the effects of crisaborole in multiple mouse models, including psoriasis-like dermatitis, AD-like skin inflammation with and without filaggrin mutations, and Staphylococcus aureus skin infection. We discovered that crisaborole dampens myeloid cells and itch in the skin during psoriasis-like dermatitis. Furthermore, crisaborole was effective in reducing skin inflammation in the context of filaggrin deficiency. Importantly, crisaborole reduced S. aureus skin colonization during AD-like skin inflammation. However, crisaborole was not efficacious in treating S. aureus skin infections, even as adjunctive therapy to antibiotics. Taken together, we found that crisaborole reduced itch during psoriasis-like dermatitis and decreased S. aureus skin colonization upon AD-like skin inflammation, which act as additional mechanisms by which crisaborole dampens the immunopathogenesis in mouse models of inflammatory skin diseases. Further examination is warranted to translate these preclinical findings to human disease.

The impact of climate change on atopic dermatitis and mental health comorbidities: a review of the literature and examination of intersectionality

Climate change, fueled by increasing concentrations of greenhouse gases, is associated with rising temperatures, extreme weather events, increased aeroallergen production, and air pollution. Our understanding that many inflammatory cutaneous diseases carry important mental health comorbidities is expanding. Simultaneously, the detrimental impacts of climate change on human health are now widely recognized as a global public health crisis. Importantly, these climate-associated phenomena exacerbate the environmental triggers of atopic dermatitis (AD) and are also associated with amplification of comorbid mental health conditions in AD including depression, anxiety, trauma-related disorders, and psychotic spectrum disorders. This review is the first to examine the nexus of climate change, atopic dermatitis, and mental health comorbidities and emphasizes the disproportionate impacts of climate change in vulnerable and marginalized populations.

Acute bacterial skin and skin structure infections in pediatric patients: potential role of dalbavancin

INTRODUCTION

Acute bacterial skin and skin structure infections (ABSSSIs) are a subtype of skin and soft tissue infections (SSTI), usually sustained by Gram-positive bacteria, whose incidence is high among children. ABSSSIs are responsible for a considerable number of hospitalizations. Moreover, as multidrug resistant (MDR) pathogens become widespread, the pediatric category seems burdened with an increased risk of resistance and treatment failure.

AREAS COVERED

To obtain a view on the status of the field, we describe the clinical, epidemiological, and microbiological aspects of ABSSSI in children. Old and new treatment options were critically revised with a focus on the pharmacological characteristics of dalbavancin. Evidence on the use of dalbavancin in children was collected, analyzed, and summarized.

EXPERT OPINION

Many of the therapeutic options available at the moment are characterized by the need for hospitalization or repeated intravenous infusions, safety issues, possible drug-drug interactions, and reduced efficacy on MDRs. Dalbavancin, the first long-acting molecule with strong activity against methicillin-resistant and also many vancomycin-resistant pathogens represents a game changer for adult ABSSSI. In pediatric settings, the available literature is still limited, but a growing body of evidence supports dalbavancin use in children with ABSSSI, demonstrating this drug to be safe and highly efficacious.

Effect of Disease Severity on Comorbid Conditions in Atopic Dermatitis: Nationwide Registry-Based Investigation in Finnish Adults

The majority of registry studies on atopic dermatitis include only patients and diagnoses from specialized healthcare. The aim of this retrospective, real-world cohort study was to evaluate the effect of atopic dermatitis severity on comorbidities and total morbidity, with comprehensive data from both primary and specialty healthcare registries covering the entire Finnish adult population. In total, 124,038 patients were identified (median age 46 years; 68% female) and stratified by disease severity. All regression analyses (median follow-up 7.0 years) were adjusted at a minimum for age, sex, obesity, and educational level. Compared with mild atopic dermatitis, severe atopic dermatitis was significantly associated with multiple morbidities, including neurotic, stress-related and somatoform disorders, abscesses, erysipelas/cellulitis, impetigo, herpes zoster, extragenital herpes, bacterial conjunctivitis, septicaemia, lymphomas, alopecia areata, urticaria, other dermatitis, contact allergy, osteoporosis, and intervertebral disc disorders (p < 0.001). In addition, there were significant associations with alcohol dependence, depression, condylomas, rosacea, migraine, sleep apnoea, hypertension, enthesopathies, atherosclerosis, and drug-induced cataract (p < 0.05). Odds ratios were modest and mostly were between 1.10 and 2.75. Furthermore, patients with severe atopic dermatitis had lower incidences of prostate cancer, cystitis, and anogenital herpes than patients with mild atopic dermatitis (p < 0.05). These results suggest that severe atopic dermatitis results in significant overall morbidity.

Atopic dermatitis complicated by recurrent eczema herpeticum is characterized by multiple, concurrent epidermal inflammatory endotypes

BACKGROUND

A subgroup of atopic dermatitis (AD) patients suffer from recurrent, disseminated herpes simplex virus (HSV) skin infections, termed eczema herpeticum (EH), which can be life-threatening and contribute to AD morbidity. The pathobiology underlying ADEH is unknown.

OBJECTIVE

To determine transcriptional mechanisms of skin and immune system pathobiology that underlie ADEH disease.

METHODS

We performed whole transcriptome RNA-sequencing of non-lesional skin samples (epidermis, dermis) of AD patients with (ADEH + , n=15) and without (ADEH - , n=13) recurrent EH history, and healthy controls (HC, n=15). We also performed RNA-sequencing on plasmacytoid dendritic cells (pDCs) collected from these participants and infected in vitro with HSV-1. Differential expression, gene set enrichment, and endotyping analyses were performed.

RESULTS

ADEH + disease was characterized by dysregulation in skin gene expression, which was limited in dermis (differentially expressed genes [DEGs]=14) and widespread in epidermis (DEGs=129). ADEH + -upregulated epidermal DEGs were enriched in type 2 cytokine (T2) ( IL4R, CCL22, CRLF2, IL7R ), interferon ( CXCL10, ICAM1, IFI44 , and IRF7) , and IL-36γ ( IL36G ) inflammatory pathway genes. At a person-level, all ADEH + participants exhibited T2 and interferon endotypes and 87% were IL36G-high. In contrast, these endotypes were more variably expressed among ADEH - participants. ADEH + patient skin also exhibited dysregulation in epidermal differentiation complex (EDC) genes within the LCE, S100 , and SPRR families, which are involved in skin barrier function, inflammation, and antimicrobial activities. pDC transcriptional responses to HSV-1 infection were not altered by ADEH status.

CONCLUSIONS

ADEH + pathobiology is characterized by a unique, multi-faceted epidermal inflammation that accompanies dysregulation in the expression of EDC genes.

Key Messages

AD patients with a history of recurrent EH exhibit molecular skin pathobiology that is similar in form, but more severe in degree, than in AD patients without this complication. Non-lesional skin of ADEH + patients concurrently exhibits excessive type 2 cytokine, interferon, and IL-36γ-driven epidermal inflammation. Expression of these inflammatory skin endotypes among ADEH + patients is associated with dysregulation in expression of epidermal differentiation complex genes involved in barrier function, inflammation, and antimicrobial activity.

Capsule Summary

AD patients with a history of recurrent disseminated HSV-1 skin infections form a unique molecular skin endotype group that concurrently exhibits type 2 cytokine, interferon, and IL-36γ-driven skin inflammation, accompanied by dysregulation in expression of epidermal differentiation complex genes involved in barrier function, inflammation, and antimicrobial activity.

Elevated serum total IgE is associated with eczema exacerbation in children hospitalized for atopic dermatitis

BACKGROUND/OBJECTIVES

Atopic dermatitis (AD) can be a debilitating skin condition, often leading to hospitalization due to severe AD exacerbations or infectious complications. As both AD exacerbations and infectious complications can present similarly, it can be difficult to distinguish the two conditions. Thus, we aimed to evaluate if there is any difference in serum IgE levels in children with AD who were hospitalized for AD exacerbation and for AD-associated infectious complications.

METHODS

A retrospective chart review was performed on hospitalized children with AD exacerbations and AD-associated infectious complications over a 17-year span. Data including length of stay, primary diagnosis, systemic antibiotics, laboratory, and bacterial culture results were collected. Serum total immunoglobulin E (IgE) levels were adjusted by age. Age, length of stay, total IgE levels, and age-adjusted IgE levels were compared using t-test. Logistic regression was used for age-adjusted IgE levels.

RESULTS

The mean serum total IgE level in subjects with AD exacerbation was 9603 ± 15,873 kU/L, which was significantly higher than that of subjects with infectious complications at 3167 ± 5486 kU/L (p = .029). Logistic regression revealed that subjects with an age-adjusted IgE of >4 had more than 3-fold odds of having AD exacerbation than infectious complications.

CONCLUSIONS

Our results suggest that total IgE levels are higher in children who were hospitalized for AD exacerbation than those with AD-associated infectious complications.

Advances in Current Drugs and Formulations for the Management of Atopic Dermatitis

Atopic dermatitis (AD) is a chronic, relapsing inflammatory skin disease with a complex pathophysiology. Treatment of AD remains challenging owing to the presence of a wide spectrum of clinical phenotypes and limited response to existing therapies. However, recent genetic, immunological, and pathophysiological insights into the disease mechanism resulted in the invention of novel therapeutic drug candidates. This review provides a comprehensive overview of current therapies and assesses various novel drug delivery strategies currently under clinical investigation. Further, this review majorly emphasizes on various topical treatments including emollient therapies, barrier repair agents, topical corticosteroids (TCS), phosphodiesterase 4 (PDE4) inhibitors, calcineurin inhibitors, and Janus kinase (JAK)-signal transducer and activator of transcription (STAT) pathway inhibitors. It also discusses biological and systemic therapies, upcoming treatments based on ongoing clinical trials. Additionally, this review scrutinized the use of pharmaceutical inactive ingredients in the approved topical dosage forms for AD treatment.

Children atopic dermatitis: Diagnosis, mimics, overlaps, and therapeutic implication

Atopic dermatitis (AD) is a chronic inflammatory, itching skin with a significant psychosocial impact on patients and relatives. In adults and adolescents besides flexural eczema, head and neck eczema, and hand eczema, which are the most frequent clinical phenotypes (84.9% and 84.2%, respectively), there are also other possible presentation such as, portrait-like dermatitis (20.1%), diffuse eczema (6.5%), eczema nummulare-like (5.8%), prurigo nodularis-like (2.1%) and erythrodermia (0.7%). Diagnosis can be easy due to the typically distributed eczematous lesions, albeit with age-related differences, However, it is also extremely heterogeneous in severity, course, and sometimes particular clinical features. Currently, there are no better diagnostic criteria than an experienced dermatologist for the diagnosis of AD. Misdiagnosis and delayed treatment will have an impact not only on the child's physical health, but also and especially on the child's psychological health. The aim of our review was to group the main differential diagnoses in pediatric age where the diagnosis can often hide many pitfalls.

Mechanisms regulating neutrophil responses in immunity, allergy, and autoimmunity

Neutrophil granulocytes, or neutrophils, are the most abundant circulating leukocytes in humans and indispensable for antimicrobial immunity, as exemplified in patients with inborn and acquired defects of neutrophils. Neutrophils were long regarded as the foot soldiers of the immune system, solely destined to execute a set of effector functions against invading pathogens before undergoing apoptosis, the latter of which was ascribed to their short life span. This simplistic understanding of neutrophils has now been revised on the basis of insights gained from the use of mouse models and single-cell high-throughput techniques, revealing tissue- and context-specific roles of neutrophils in guiding immune responses. These studies also demonstrated that neutrophil responses were controlled by sophisticated feedback mechanisms, including directed chemotaxis of neutrophils to tissue-draining lymph nodes resulting in modulation of antimicrobial immunity and inflammation. Moreover, findings in mice and humans showed that neutrophil responses adapted to different deterministic cytokine signals, which controlled their migration and effector function as well as, notably, their biologic clock by affecting the kinetics of their aging. These mechanistic insights have important implications for health and disease in humans, particularly, in allergic diseases, such as atopic dermatitis and allergic asthma bronchiale, as well as in autoinflammatory and autoimmune diseases. Hence, our improved understanding of neutrophils sheds light on novel therapeutic avenues, focusing on molecularly defined biologic agents.

Initiation of hydroxychloroquine therapy during pregnancy can cause adverse effects and alter pregnancy outcomes: a case of acute generalized exanthematous pustulosis induced by hydroxychloroquine in a patient with systemic lupus erythematosus

Hydroxychloroquine is effective for treating a number of autoimmune diseases, including systemic lupus erythematosus. Hydroxychloroquine is generally safe and may be prescribed to pregnant women. Although current guidelines recommend initiating hydroxychloroquine when considering pregnancy, the drug can cause adverse effects such as acute generalized exanthematous pustulosis, which should be carefully evaluated. A 30-year-old pregnant woman with systemic lupus erythematosus at 16+5 gestational weeks was referred to our tertiary centre for persistent proteinuria and alopecia. Tacrolimus was initiated and the dose of prednisone was increased. At 20+3 weeks of gestation, hydroxychloroquine was administered to allow for a dose reduction of prednisolone. Proteinuria gradually improved as the pregnancy course stabilized. At 27+1 weeks of gestation, generalized pustular exanthema developed, presumably due to hydroxychloroquine. After analysis of the clinical course and skin lesions, she was considered to have either acute generalized exanthematous pustulosis or generalized pustular psoriasis. Despite discontinuing hydroxychloroquine, the skin lesions worsened dramatically, and infliximab therapy was required. After one course of infliximab treatment, exanthema gradually subsided. The final diagnosis was acute generalized exanthematous pustulosis, based on the clinical course and pathological findings. At 30 weeks, the pyothorax developed because of the pyogenic skin lesion and the compromised immune system, and long-term antibiotic therapy was required until 32+4 weeks, after which, she underwent caesarean section. Although introducing hydroxychloroquine is occasionally necessary during pregnancy, it is preferable to initiate hydroxychloroquine in the preconception period and not after pregnancy because of the possible adverse effect which can alter perinatal prognosis. Rheumatologists should consider the potential risks of hydroxychloroquine.

The Impact of Global Health Disparities on Atopic Dermatitis in Displaced Populations: Narrowing the Health Equity Gap for Patients with Skin of Color

Atopic dermatitis (AD) is a relatively common inflammatory skin disease marked by eczematous lesions and pruritus often leading to significant morbidity and quality of life impairment for those affected. Recent studies have shown that patients with skin of color (SOC) carry a larger disease burden than patients of European descent. In the USA, these disparities are partly due to structural, environmental, and interpersonal racism. From a global perspective, there is a paucity of research on the burden of atopic dermatitis and other inflammatory skin diseases experienced by the record numbers of refugees, migrants, and asylum seekers around the world. Although it is still unclear whether the true prevalence of AD in displaced communities is higher compared with the general population, those who are displaced suffer from unique risk factors that render them especially vulnerable. In this review, we outline a number of factors contributing to AD susceptibility and/or aggravation in displaced communities. These include poor living conditions, climate change events, psychological stress, and lack of access to medical care and health-related behaviors.

Risk factors for group A streptococcal pharyngitis and skin infections: A case control study

Background

Group A streptococcal (GAS) infections can trigger an immune-mediated response resulting in acute rheumatic fever (ARF). The role of social and environmental risk factors for GAS pharyngitis and skin infections are not well understood. This study aimed to identify factors associated with GAS pharyngitis and skin infections, and to determine if these are the same as those for ARF.

Methods

A case-control study, including 733 children aged 5-14 years, was undertaken between March 2018 and October 2019 in Auckland, New Zealand. Healthy controls (n = 190) and symptomatic cases including GAS pharyngitis (n = 210), GAS seronegative carriers (n = 182), and GAS skin infections (n = 151) were recruited. Trained interviewers administered a comprehensive, pre-tested, face-to-face questionnaire.

Findings

Multivariable analysis identified strong associations between barriers to accessing primary healthcare and having GAS pharyngitis (adjusted OR 3·3; 95% CI 1·8-6·0), GAS carriage (aOR 2·9; 95% CI 1·5-6·0) or a GAS skin infection (aOR 3·5; 95% CI 1·6-7·6). Children who had GAS skin infections were more likely than all other groups to report living in a crowded home (aOR 1·9; 95% CI 1·0-3·4), have Māori or Pacific grandparents (aOR 3·0; 95% CI 1·2-7·6), a family history of ARF (aOR 2·2; 95% CI 1·1-4·3), or having a previous diagnosis of eczema (aOR 3·9; 95% CI 2·2-6·9).

Interpretation

Reducing barriers to accessing primary healthcare (including financial restrictions, the inability to book an appointment, lack of transport, and lack of childcare for other children) to treat GAS pharyngitis and skin infections could potentially reduce these infections and lead to a reduction in their sequelae, including ARF. These strategies should be co-designed and culturally appropriate for the communities being served and carefully evaluated.

Funding

This work was supported by the Health Research Council of New Zealand (HRC), award number 16/005.

Signaling sphingolipids are biomarkers for atopic dermatitis prone to disseminated viral infections

BACKGROUND

Life-threatening viral diseases such as eczema herpeticum (EH) and eczema vaccinatum (EV) occur in <5% of individuals with atopic dermatitis (AD). The diagnosis of AD, however, excludes all individuals with AD from smallpox vaccination.

OBJECTIVES

We sought to identify circulatory and skin lipid biomarkers associated with EH and EV.

METHODS

Stratum corneum and plasma samples from 15 subjects with AD and a history of EH, 13 age- and gender-matched subjects with AD and without EH history, and 13 healthy nonatopic (NA) controls were analyzed by liquid chromatography tandem mass spectrometry for sphingolipid content. Sphingosine-1-phosphate (S1P) and ceramide levels were validated in plasma samples from the Atopic Dermatitis Vaccinia Network/Atopic Dermatitis Research Network repository (12 NA, 12 AD, 23 EH) and plasma from 7 subjects with EV and 7 matched subjects with AD. S1P lyase was downregulated in human primary keratinocytes to evaluate its effect on herpes simplex virus 1 (HSV-1) replication in vitro.

RESULTS

The stratum corneum of patients with EH demonstrated significantly higher levels of free sphingoid bases than those in patients who were NA, indicating enhanced sphingolipid turnover in keratinocytes (P < .05). Plasma from 2 independent cohorts of patients with EH had a significantly increased S1P/ceramide ratio in subjects with EH versus those with AD and or who were NA (P < .01). The S1P level in plasma from subjects with EV was twice the level in plasma from subjects with AD (mean = 1,533 vs 732 pmol/mL; P < .001). Downregulation of S1P lyase expression with silencing RNA led to an increased S1P level and doubled HSV-1 titer in keratinocytes.

CONCLUSIONS

Our data point to long-term abnormalities in the S1P signaling system as a biomarker for previous disseminated viral diseases and a potential treatment target in recurring infections.

Skin Dialogues in Atopic Dermatitis

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

Unveiling the true costs and societal impacts of moderate-to-severe atopic dermatitis in Europe

Atopic dermatitis (AD) is a chronic, auto-immune condition that imposes a high burden on individuals, society, and the healthcare system. Approximately 4.4% of adults and up to 18.6% of children/adolescents have AD in Europe, with 20% of all cases accounting for moderate-to-severe forms. This form of the condition in adults results in annual societal costs across Europe of an estimated €30 billion; €15.2 billion related to missed workdays or reduced work productivity, €10.1 billion related to direct medical costs and €4.7 billion related to personal expenditure of patients/families. AD can also substantially impact physical, emotional, and social quality-of-life. Several studies have shown the debilitating itch-scratch cycle is the main cause of the multifaceted burden, as it causes substantial sleep deprivation and stigmatisation due to the physical appearance of the skin, and confidence issues. These factors lead to psychosocial issues and can cumulate over time and prohibit patients reaching their 'full life potential'. Despite this, many patients with the condition are undertreated, resulting in uncontrolled symptoms and a further strain placed on patients, society, and the economy. The authors of this White Paper comprise the European Atopic Dermatitis Working Group, which is a network of international specialists with expertise in dermatology and healthcare policy decisions. Their programme of action is focused on harnessing their expertise to build consensus, advance research, share knowledge, and ultimately seek to improve AD care outcomes through achieving long-term symptom control. This White Paper presents a systematic evaluation of the overall financial and humanistic burden of moderate-to-severe AD and the current challenges that exist with AD care. It introduces recommendations for how, collaboratively, key stakeholders and policy makers can support improvements in AD management to achieve better disease control, thus reducing the costs and associated burden placed on individuals, society, and the economy.

Integrative transcriptome-wide analysis of atopic dermatitis for drug repositioning

Atopic dermatitis (AD) is one of the most common inflammatory skin diseases, which significantly impact the quality of life. Transcriptome-wide association study (TWAS) was conducted to estimate both transcriptomic and genomic features of AD and detected significant associations between 31 expression quantitative loci and 25 genes. Our results replicated well-known genetic markers for AD, as well as 4 novel associated genes. Next, transcriptome meta-analysis was conducted with 5 studies retrieved from public databases and identified 5 additional novel susceptibility genes for AD. Applying the connectivity map to the results from TWAS and meta-analysis, robustly enriched perturbations were identified and their chemical or functional properties were analyzed. Here, we report the first research on integrative approaches for an AD, combining TWAS and transcriptome meta-analysis. Together, our findings could provide a comprehensive understanding of the pathophysiologic mechanisms of AD and suggest potential drug candidates as alternative treatment options.

Integrative genomic and transcriptomic analyses on publicly available data-sets together with in silico drug repositioning identifies alternative therapeutic options to treat atopic dermatitis.

Narrative review on the management of moderate-severe atopic dermatitis in pediatric age of the Italian Society of Pediatric Allergology and Immunology (SIAIP), of the Italian Society of Pediatric Dermatology (SIDerP) and of the Italian Society of Pediatrics (SIP)

Currently, there are a few detailed guidelines on the overall management of children and adolescents with moderate-severe atopic dermatitis. AD ​​is a complex disease presenting with different clinical phenotypes, which require an individualized and multidisciplinary approach. Therefore, appropriate interaction between primary care pediatricians, pediatric allergists, and pediatric dermatologists is crucial to finding the best management strategy. In this manuscript, members of the Italian Society of Pediatric Allergology and Immunology (SIAIP), the Italian Society of Pediatric Dermatology (SIDerP), and the Italian Society of Pediatrics (SIP) with expertise in the management of moderate-severe atopic dermatitis have reviewed the latest scientific evidence in the field. This narrative review aims to define a pathway to appropriately managing children and adolescents with moderate-severe atopic dermatitis.