Typical and atypical clinical appearance of atopic dermatitis

The Role of the Microbiota in the Pathogenesis and Treatment of Atopic Dermatitis-A Literature Review

Atopic dermatitis (AD) is a chronic inflammatory skin condition with a high prevalence worldwide. AD pathogenesis is complex and consists of immune system dysregulation and impaired skin barrier, influenced by genetic and environmental factors. The purpose of the review is to show the complex interplay between atopic dermatitis and the microbiota. Human microbiota plays an important role in AD pathogenesis and the course of the disease. Dysbiosis is an important factor contributing to the development of atopic diseases, including atopic dermatitis. The gut microbiota can influence the composition of the skin microbiota, strengthening the skin barrier and regulating the immune response via the involvement of bacterial metabolites, particularly short-chain fatty acids, in signaling pathways of the gut-skin axis. AD can be modulated by antibiotic intake, dietary adjustments, hygiene, and living conditions. One of the promising strategies for modulating the course of AD is probiotics. This review offers a summary of how the microbiota influences the development and treatment of AD, highlighting aspects that warrant additional investigation.

Dupilumab induced ocular surface disease: A prospective case series

PURPOSE

To identify the incidence, risk factors, demographics, and clinical profile of dupilumab-induced ocular surface disease (DIOSD) in patients with atopic dermatitis (AD), propose a standardised treatment protocol (STP) and evaluate the response.

METHODS

Prospective case series of AD patients treated in the Dermatology Department, Royal Victoria Infirmary, Newcastle upon Tyne, UK developing ocular symptoms after commencing Dupilumab between September 2018 and February 2020. A standard history and examination protocol were used including subjective symptom severity grading and Ocular Surface Disease Index (OSDI) questionnaire on each visit. Standard treatment was prescribed, and response evaluated.

RESULTS

32 of 113 included patients (28.31%) developed DIOSD, of which 20 (62.5%) were referred to the Cornea Service. Median age was 38.0 years (IQR 26.8; range 19-74). Male to female ratio was 1:1. Average time to onset of ocular symptoms from starting dupilumab was 9.2 weeks (IQR 8.8; range 0.1-40). 90% patients had bilateral conjunctival inflammation and blepharitis at presentation. Significant improvement in the subjective severity scale and the median OSDI score (from 34.0 to 10.2) was noted in response to topical eye treatment. Dupilumab was discontinued in none.

CONCLUSIONS

DIOSD is not uncommon although, with timely referral and appropriate topical treatment better clinical outcome and patient satisfaction can be achieved without the need to discontinue Dupilumab. Prior allergic conjunctivitis did not affect the incidence or severity of DIOSD. Further prospective studies with longer follow-up and more focus on possible disease mechanism such as goblet cell related changes and immune response are needed.

Skin biomarkers predict the development of food allergy in early life

BACKGROUND

Food allergy (FA) often occurs in early childhood with and without atopic dermatitis (AD). FA can be severe and even fatal. For primary prevention, it is important to find early biomarkers to predict the future onset of FA before any clinical manifestations.

OBJECTIVE

Our aim was to find early predictors of future onset of FA in the stratum corneum (SC).

METHODS

Skin tape strips were collected from the forearm of newborns (n = 129) at age 2 months, before any signs of clinical FA or AD. Children were clinically monitored until they reached age 2 years to confirm the presence or absence of FA and AD. Skin tape strips were subjected to lipidomic analyses by liquid chromatography-tandem mass spectrometry and cytokine determination by Meso Scale Discovery U-Plex assay.

RESULTS

Overall, 9 of 129 infants (7.0%) developed FA alone and 9 of 129 infants (7.0%) developed FA concomitantly with AD. In the stratum corneum of children with future FA and concomitant AD and FA, absolute amounts of unsaturated (N24:1)(C18-sphingosine)ceramide and (N26:1)(C18-sphingosine)ceramide and their relative percentages within the molecular group were increased compared with the amounts and percentages in healthy children, with P values ranging from less than .01 to less than .05 according to ANOVA. The children with future AD had normal levels of these molecules. IL-33 level was upregulated in those infants with future FA but not in those with future AD, whereas thymic stromal lymphopoietin was upregulated in those with future AD but not in those with future FA. Logistic regression analysis revealed strong FA predicting power for the combination of dysregulated lipids and cytokines, with an odds ratio reaching 101.4 (95% CI = 5.4-1910.6).

CONCLUSION

Noninvasive skin tape strip analysis at age 2 months can identify infants at risk of FA in the future.

Decreasing prevalence of atopic dermatitis in Swedish schoolchildren: three repeated population-based surveys

BACKGROUND

The prevalence of atopic dermatitis (AD) has increased over several decades and now affects about one-fifth of all children in high-income countries (HICs). While the increase continues in lower-income countries, the prevalence of AD might have reached a plateau in HICs.

OBJECTIVES

To investigate trends in the prevalence of AD and atopic comorbidity in schoolchildren in Sweden.

METHODS

The study population consisted of three cohorts of children (median age 8 years) in Norrbotten, Sweden, for 1996 (n = 3430), 2006 (n = 2585) and 2017 (n = 2785). An identical questionnaire that included questions from the International Study of Asthma and Allergies in Childhood (ISAAC) protocol was used in all three cohorts. Trends in AD prevalence were estimated, as well as trends in atopic comorbidity. AD prevalence was estimated both according to the ISAAC definition of AD and by adding the reported diagnosis by a physician (D-AD).

RESULTS

The prevalence of AD decreased in the last decade, from 22.8% (1996) and 21.3% (2006) to 16.3% (2017; P < 0.001). The prevalence of D-AD was lower, but the same pattern of decrease was seen, from 9.3% (1996) and 9.4% (2006) to 5.7% (2017; P < 0.001). In all three cohorts, AD was more common among girls than boys (18.9% vs. 13.8% in 2017; P < 0.001). Children from the mountain inlands had a higher prevalence of AD than children from coastal cities (22.0% vs. 15.1% in 2017; P < 0.001). In comparing D-AD, there were no significant differences between the sexes or between inland or coastal living. Concomitant asthma increased over the years from 12.2% (1996) to 15.8% (2006) to 23.0% (2017; P < 0.001). Concomitant allergic rhinitis and allergic sensitization increased from 1996 (15.0% and 27.5%) to 2006 (24.7% and 49.5%) but then levelled off until 2017 (21.0% and 46.7%).

CONCLUSIONS

The prevalence of AD among schoolchildren in Sweden decreased over the study period, whereas atopic comorbidity among children with AD increased. Although a decrease was seen, AD is still common and the increase in atopic comorbidity among children with AD, especially the increase in asthma, is concerning.

The dichotomy of regulatory B cells in cancer versus allergic disease

Regulatory B cells (Bregs) are an immunosuppressive cell phenotype that affects the immune system by limiting the inflammatory cascade. Dysregulation of Bregs can interestingly play a dichotomous role in the pathophysiology of many diseases and is especially highlighted when examining cancer pathology compared to allergic disease. This study reviews the existing literature on Bregs and compares their role in allergic disease in contrast to cancer development. Upregulation of Bregs in cancer states has been associated with poor prognostic outcomes across various cancer types, and Breg proliferation was associated with chronic interferon signaling, activation of the BCR-BTK (B cell receptor-Bruton's tyrosine kinase) pathway, and release of C-X-C motif ligand 13. In contrast, Breg dysfunction has been identified as a key mechanism in many allergic diseases, such as allergic asthma, allergic rhinitis, atopic dermatitis, and contact dermatitis. Development of Breg-targeted immunotherapies is currently at the preclinical level, but strategies differentially focus on Breg depletion in cancer versus Breg stimulation in allergy. Our review highlights the divergent functions that Bregs play in cancer compared to allergy. We conclude that natural homeostasis hinges on a fine balance between the dichotomous role of Bregs-over or underactivation can result in a pathological state.

Which Clinical Measurement Tools for Atopic Dermatitis Severity Make the Most Sense in Clinical Practice?

Assessment of atopic dermatitis (AD) severity is essential for therapeutic decision making and monitoring treatment progress. However, there are a myriad of clinical measurement tools available, some of which are impractical for routine clinical use despite being recommended for clinical trials in AD. For measurement tools to be used in clinical practice, they should be valid, reliable, rapidly completed, and scored, and easily incorporated into existing clinic workflows. This narrative review addresses content, validity, and feasibility, and provides a simplified repertoire of assessments for clinical assessment of AD based on prior evidence and expert opinion. Tools that may be feasible for clinical practice include patient-reported outcomes (eg, dermatology life quality index, patient-oriented eczema measure, numerical rating scales for itch, pain, and sleep disturbance, AD Control Tool, and patient-reported global assessment), and clinician-reported outcomes (eg, body surface area and investigator's global assessment). AD is associated with variable clinical signs, symptoms, extent of lesions, longitudinal course, comorbidities, and impacts. Any single domain is insufficient to holistically characterize AD severity, select therapy, or monitor treatment response. A combination of these tools is recommended to balance completeness and feasibility.

AtopyReg®, the Prospective Italian Patient Registry for Moderate-to-Severe Atopic Dermatitis in Adults: Baseline Demographics, Disease Characteristics, Comorbidities, and Treatment History

BACKGROUND AND OBJECTIVE

AtopyReg® is a multicenter, prospective, observational, non-profit cohort study on moderate-to-severe atopic dermatitis in adults promoted in 2018 by the Italian Society of Dermatology and Venereology (SIDeMaST). We aimed to describe baseline demographics, disease characteristics, comorbidities, and therapeutic data of adult patients affected by moderate-to-severe atopic dermatitis.

METHODS

Patients were selected based on the following inclusion criteria: age ≥ 18 years; Eczema Area and Severity Index score ≥ 16 or localization in visible or sensitive areas (face, neck, hands, or genitalia), or a Numeric Rating Scale itch score ≥ 7 or a Numeric Rating Scale sleep loss score ≥ 7, or a Dermatology Life Quality Index score ≥ 10. Demographic and clinical data at baseline were recorded and analyzed.

RESULTS

A total of 1170 patients (male 51.1%; mean age: 44.7 years; range 18-90 years) were enrolled by 12 Italian Dermatology Units between January 2019 and November 2022. Skin lesions were eczematous in 83.2% of patients, the most involved site were the flexures (53.9%), face (50.9%), and neck (48.0%). Mean Eczema Area and Severity Index score was 22.3, mean Dermatology Life Quality Index value was 17.6, mean Patient Oriented Eczema Measure score was 13.1, and mean Numeric Rating Scale itch and sleep loss scores were 7.6 and 5.9, respectively. Previous systemic therapies were corticosteroids in 77.7% of patients, antihistamines in 50.3% of patients, and cyclosporine A in 42.6% of patients.

CONCLUSIONS

This baseline data analysis deriving from AtopyReg® provides real-life evidence on patients with moderate-to-severe atopic dermatitis in Italy confirming the high burden of atopic dermatitis with a significant impact on patients' quality of life.

Efficacy and Safety of Dupilumab in Older Patients (Aged 80 Years and Above) with Atopic Dermatitis: A Prospective Study

BACKGROUND

Atopic dermatitis presents unique challenges in the older population owing to age-related changes in skin barrier function and immune regulation. However, there is limited evidence on the efficacy and safety of dupilumab, an anti-interleukin-4Rα monoclonal antibody, in patients with atopic dermatitis aged 80 years and above.

OBJECTIVE

We aimed to assess the clinical efficacy and safety of dupilumab treatment in patients with atopic dermatitis aged 80 years and above.

METHODS

Twenty-eight older patients received dupilumab and were evaluated based on several clinical parameters, including the Eczema Area and Severity Index (EASI), Numeric Rating Scale (NRS), Dermatology Life Quality Index (DELI), and AD Control Tool (ACT). Safety assessments and monitoring of concomitant medication use were conducted.

RESULTS

Twenty-six patients completed 16 weeks of treatment, 13 completed 28 weeks, and two completed more than 36 weeks. Dupilumab treatment resulted in a significant improvement in atopic dermatitis symptoms after 16 weeks as demonstrated by reduced EASI, NRS, DLQI, and ADCT scores. Dupilumab had no significant impact on underlying diseases or medication use. No common adverse reactions, such as conjunctivitis and erythema of the face and neck, were identified. Among the 26 patients receiving dupilumab treatment during the COVID-19 pandemic, 17 remained uninfected or experienced milder COVID-19 symptoms than experienced in the general population.

CONCLUSIONS

Dupilumab treatment showed significant efficacy in improving atopic dermatitis symptoms in patients aged 80 years and above with a high level of safety. Larger long-term clinical trials are needed to validate these results and provide further evidence for the use of dupilumab in older patients with atopic dermatitis.

Burgers, Fast Foods, and Increased Associated Risk for Atopic Dermatitis: A Cross-Sectional Study of Dietary Habits among Young Chinese Adults in Singapore/Malaysia

BACKGROUND

We see increasing evidence that dietary and nutrients factors play a pivotal role in allergic diseases and recent global findings suggest that dietary habits influence the pathogenesis of atopic dermatitis (AD). Frequent consumption of fast food diets is associated with AD development. Despite the rising prevalence of AD in Asia, efforts in investigating the role of dietary habits and AD in adults are still lacking.

METHODS

We evaluated the association between the dietary intake of 16 food types and AD manifestations using our Singapore/Malaysia Cross-sectional Genetics Epidemiology Study (SMCGES) population. Dietary habits profiles of 11,494 young Chinese adults (1,550 AD cases/2,978 non-atopic controls/6,386 atopic controls) were assessed by an investigator-administered questionnaire. AD cases were further evaluated for their chronicity (550 chronic) and severity (628 moderate-to-severe). Additionally, we derived a novel food index, Quality of Diet based on Glycaemic Index Score (QDGIS), to examine the association between dietary intake of glycaemic index (GI) and various AD phenotypes.

RESULTS

The majority of AD subjects are distributed in the good (37.1%) and moderate (36.2%) QDGIS classes. From the multivariable analyses for age and gender, a moderate QDGIS class was significantly associated with a lower odds of AD (adjusted odds ratio (AOR): 0.844; 95% confidence interval (CI): 0.719-0.991; p < 0.05) and moderate-to-severe AD (AOR: 0.839; 95% CI: 0.714-0.985; p < 0.05). A good QDGIS class was only significantly associated with a lower odds of chronic AD (AOR: 0.769; 95% CI: 0.606-0.976; p < 0.05). Among high GI foods, frequent consumption of burgers/fast food was strongly associated with an increased risk of chronic and moderate-to-severe AD. Among low GI foods, increased intake frequencies of fruits, vegetables, and pulses decreased the odds of AD. Finally, we identified significant associations between frequent seafood, margarine, butter, and pasta consumption with an increased odds of AD despite them having little GI values.

CONCLUSION

While genetic components are well-established in their risks associated with increased AD prevalence, there is still a lack of a focus epidemiology study associating dietary influence with AD. Based on the first allergic epidemiology study conducted here in Singapore and Malaysia, it laid the groundwork to guide potential dietary interventions from changing personal dietary habits.

Atopic Dermatitis Across Shades of Skin

Atopic dermatitis (AD) is a chronic, heterogeneous inflammatory skin disease that is associated with immense patient burden globally. There is increasing appreciation of disparities among patients identified as having skin of color (SOC), which often refers to patients of non-White race or non-European ancestry, but can broadly include individuals from a number of different racial, ethnic, ancestral, and skin pigmentation groups based on definition. In this narrative review, we discuss key terminology as it relates to AD across shades of skin, including modern definitions of 'race', 'ethnicity', and 'SOC'. We then synthesize the current literature describing disparities in AD prevalence, disease recognition, and burden alongside current data regarding genetic and immunologic findings across SOC populations. In the context of these findings, we highlight key concomitant social determinants of health, including environmental factors, socioeconomic status, and access to care, for which race often serves as a proxy for true biological and genetic differences. Finally, we discuss future efforts to shift to a more inclusive understanding of AD to encompass all shades of skin, to ensure equitable representation of diverse populations in high impact research, and intensify efforts to address the critical upstream factors driving observed disparities.

Burden of Disease; the Current Status of the Diagnosis and Management of Atopic Dermatitis in China

Atopic dermatitis (AD) is now a global health problem and has been attracting extensive attention from both academic and public society in China. This review aimed to present the current status of the prevalence, disease burden, clinical features, diagnosis, and management of AD in China. The prevalence of AD has been increasing rapidly in China during the past decades, partially due to the increased recognition of the disease; there are still substantial amounts of over-diagnosed eczema and under-diagnosed AD. Chinese dermatologists see many AD patients with atypical manifestation, which poses a challenge to the diagnosis. The Chinese diagnostic criteria for adults and pediatric patients with AD have been proposed respectively and validated with high sensitivity and specificity. International and Chinese guidelines for management of AD have been popularized; however, there are still many practices that need verification through randomized case-control study. Dupilumab and JAK inhibitors have demonstrated favorable efficacy for AD patients in China, and a multidimensional approach is needed for selection of the patients and evaluation of the efficacy and safety. Patient education and long-term management for AD are just beginning in China, and need to be strengthened in the future.

Managing Atopic Dermatitis in Patients With Skin of Color

Managing atopic dermatitis (AD) in patients with skin of color presents unique challenges for the clinician. There is increasing evidence that AD has higher prevalence, persistence, and severity among skin of color populations. This is likely to be partly related to differences in living conditions and exposure to irritants and allergens, among other factors. Assessment of AD severity in patients with darker skin can be challenging, in particular the assessment of erythema, leading to the potential for underscoring AD severity. Variations in disease have also been described, with the potential for a greater risk of inflammation-induced nodularity and hyper- or hypopigmentation. Management challenges include variable adherence to treatment, potential disparities in access to health care, and differences in the metabolism of cyclosporine. Optimal management of AD in patients with skin of color requires a tailored approach. Here, we review approaches to diagnosing AD, evaluating extent and severity with subjective and objective measures, considering treatment options for patients with skin of color, and highlighting areas for improvement in AD care for skin of color populations.

Emerging Systemic Treatments for Atopic Dermatitis

Atopic dermatitis (AD) is a chronic or chronically relapsing inflammatory skin disease which results from a complex, multifaceted interaction between environmental factors in genetically predisposed patients. Epidermal barrier impairment, alteration of the cutaneous microbiota, effect of external antigens, neurosensory dysfunction, and inflammatory and immune dysregulation all play a pivotal role in inducing and maintaining AD lesions. AD significantly impacts the patient's quality of life and general well-being and is often associated with anxiety and/or depressive symptoms. Classical treatment options include topical corticosteroids and calcineurin inhibitors, phototherapy, and systemic immunosuppression with oral corticosteroids, cyclosporine, methotrexate, and azathioprine in more severe cases. A turning point in facing AD was accomplished when the efficacy and safety of dupilumab, a monoclonal antibody targeting the interleukin (IL)-4 receptor α subunit, led to its approval for the treatment of moderate-to-severe or severe AD in children, adolescents, and adults. Subsequently, a more extensive understanding of AD etiology and pathogenesis has allowed the development of several topical and systemic novel therapy options. Most of these drugs are monoclonal antibodies which interfere with the type 2 inflammatory cascade, especially its key cytokines IL-4 and IL-13, or its downstream Janus kinase signaling pathway. However, considering the relevance of other subtypes of T helper (Th) cells, such as Th1 and Th22, and the important role of specific cytokines (IL-31) in generating pruritus, the horizon of potential therapeutic targets has widened extremely. In this review, we aim to present the most promising systemic agents currently under investigation and illustrate the most significant aspects of their efficacy, safety, and tolerability.

Comparison of real-world treatment outcomes of systemic immunomodulating therapy in atopic dermatitis patients with dark and light skin types

Background

Few data exist on differences in treatment effectiveness and safety in atopic dermatitis patients of different skin types.

Objective

To investigate treatment outcomes of dupilumab, methotrexate, and ciclosporin, and morphological phenotypes in atopic dermatitis patients, stratified by Fitzpatrick skin type.

Methods

In an observational prospective cohort study, pooling data from the Dutch TREAT (TREatment of ATopic eczema) NL (treatregister.nl) and UK-Irish A-STAR (Atopic eczema Systemic TherApy Register; astar-register.org) registries, data on morphological phenotypes and treatment outcomes were investigated.

Results

A total of 235 patients were included (light skin types [LST]: Fitzpatrick skin type 1-3, n = 156 [Ethnicity, White: 94.2%]; dark skin types [DST]: skin type 4-6, n = 68 [Black African/Afro-Caribbean: 25%, South-Asian: 26.5%, and Hispanics: 0%]). DST were younger (19.5 vs 29.0 years; P < .001), more often had follicular eczema (22.1% vs 2.6%; P < .001), higher baseline Eczema Area and Severity Index (EASI) scores (20.1 vs 14.9; P = .009), less allergic contact dermatitis (30.9% vs 47.4%; P = .03), and less previous phototherapy use (39.7% vs 59.0%; P = .008). When comparing DST and LST corrected for covariates including baseline EASI, DST showed greater mean EASI reduction between baseline and 6 months with only dupilumab (16.7 vs 9.7; adjusted P = .032). No differences were found for adverse events for any treatments (P > .05).

Limitations

Unblinded, non-randomized.

Conclusion

Atopic dermatitis differs in several characteristics between LST and DST. Skin type may influence treatment effectiveness of dupilumab.

Stratum corneum lipid and cytokine biomarkers at age 2 months predict the future onset of atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) commonly occurs in children and can progress into severe phenotypes or atopic march, causing significant impairment in quality of life. It is important to find early biomarkers of future onset of AD before any clinical manifestations.

OBJECTIVE

We sought to find early predictors of future onset of AD in skin stratum corneum (SC).

METHODS

Skin tape strips were collected from the forearm of newborns (n = 111) with and without family history of atopic diseases at the age of 2 months before any signs of clinical AD. Children were clinically monitored until they reached age 2 years to ensure the presence or absence of AD. Skin tape strips were subjected to lipidomic analyses by the liquid chromatography electrospray ionization tandem mass spectrometry and cytokine determination by Meso Scale Discovery U-Plex assay.

RESULTS

Overall, 22 of 74 (29.7%) and 5 of 37 (13.5%) infants developed AD in the risk group and the control group, respectively. In the SC of future AD children, protein-bound ceramides were decreased (P < .001), whereas unsaturated sphingomyelin species (P < .0001) and "short-chain" nonhydroxy fatty acid sphingosine and alpha-hydroxy fatty acid sphingosine ceramides were elevated (P < .01 and .05, respectively) as compared with healthy children. Thymic stromal lymphopoietin and IL-13 levels were increased in the SC of future AD subjects (by 74.5% and 78.3%, P = .0022 and P < .0001, respectively). Multivariable logistic regression analysis revealed strong AD predicting power of the combination of family history, type 2 cytokines, and dysregulated lipids, with an odds ratio reaching 54.0 (95% CI, 9.2-317.5).

CONCLUSIONS

Noninvasive skin tape strip analysis at age 2 months can identify asymptomatic children at risk of future AD development with a high probability.

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.

Immunopathogenesis of Atopic Dermatitis: Focus on Interleukins as Disease Drivers and Therapeutic Targets for Novel Treatments

Atopic dermatitis is a chronic, recurrent inflammatory skin disorder manifesting by eczematous lesions and intense pruritus. Atopic dermatitis develops primarily as a result of an epidermal barrier defect and immunological imbalance. Advances in understanding these pathogenetic hallmarks, and particularly the complex role of interleukins as atopic dermatitis drivers, resulted in achieving significant therapeutic breakthroughs. Novel medications involve monoclonal antibodies specifically blocking the function of selected interleukins and small molecules such as Janus kinase inhibitors limiting downstream signaling to reduce the expression of a wider array of proinflammatory factors. Nevertheless, a subset of patients remains refractory to those treatments, highlighting the complexity of atopic dermatitis immunopathogenesis in different populations. In this review, we address the immunological heterogeneity of atopic dermatitis endotypes and phenotypes and present novel interleukin-oriented therapies for this disease.

Immunological Parameters in Patients Suffering from Atopic Dermatitis and Either Treated or Non-Treated with Dupilumab

OBJECTIVE

The aim of the study is to analyze the absolute count of leukocytes, neutrophils, monocytes, eosinophils, T cells, natural killer cells, B cells and to evaluate the expression of functionally important CD23 and CD200 molecules on B cells in patients suffering from atopic dermatitis (AD), (with and without dupilumab therapy).

MATERIALS AND METHODS

We examined 45 patients suffering from AD - 32 patients without dupilumab treatment (10 men, 22 women, average age 35.0 years), 13 patients with dupilumab treatment (7 men, 6 women, average age 43.4 years) and 30 healthy control (10 men, 20 women, average age 44.7 years). Immunophenotype was examined by flow cytometry (Navios Flow Cytometer - Beckman Coulter). The blood count was examined with a Sysmex XN 3000, Sysmex SP10, microscope DI60 for digital morphology evaluating cell division and microscope Olympus BX40. We compared the absolute count of leukocytes and their subsets, T cells (CD4, CD8), natural killers cells, absolute and relative count of B lymphocytes and expression of surface molecules CD23 and CD200 on B cells in AD patients and in control group. Non-parametric Kruskal-Wallis one-factor analysis of variance with post-hoc (follow-up multiple comparison) and Dunn's test with Bonferroni modification of significance level were used for statistical analysis.

RESULTS

We confirmed the significantly higher number of neutrophils, monocytes and eosinophils and higher expression of CD23 and CD200 on B cells in peripheral blood of AD patients (either with or without dupilumab) therapy. We demonstrated the lower number of CD8+ T cells.

CONCLUSION

We demonstrated the difference in the count of white blood cells populations in patients suffering from AD compared with healthy control. There were a differences in the expression of immunoregulatory molecules CD23 and CD200 on B cells in AD patients (either with or without dupilumab therapy) in comparison to healthy controls.

Novel Therapeutic Strategies in the Topical Treatment of Atopic Dermatitis

Topical agents that are currently available for the treatment of atopic dermatitis may represent a valid approach in the management of mild or mild-moderate cases, whereas they are often supplemented with systemic therapies for handling more complex or unresponsive cases. The most used compounds include topical corticosteroids and calcineurin inhibitors, although their use might be burdened by side effects, poor response, and low patient compliance. Consequently, new innovative drugs with higher efficacy and safety both in the short and long term need to be integrated into clinical practice. A deeper understanding of the complex pathogenesis of the disease has led to identifying new therapeutic targets and to the development of innovative therapeutics. This narrative review aims to collect data on selected promising topical drugs that are in an advanced stage of development.

Atopic Dermatitis: Clinical Aspects and Unmet Needs

Atopic dermatitis is a common chronic-relapsing, inflammatory and itchy eczematous skin disorder which occurs in both children and adults. AD pathogenesis is complex and several factors are implicated. Pruritus plays a pivotal role in disease's burden, significantly worsening atopic patient quality of life by limiting productivity and daily activities. AD diagnosis relies still on the experience of the healthcare professional and there are several unmet needs as for the diagnostic criteria, the management and the recognition of the burden of the disease. In this paper we present an indeep focus on the main clinical features of AD and the major unmet needs that should be addressed in the next research.

Annoying Psoriasis and Atopic Dermatitis: A Narrative Review

Skin is an important organ that mainly functions as a barrier. Skin diseases can damage a person's self-confidence and reduce their willingness to socialize, as well as their social behavior and willingness. When the skin appearance is abnormal, in addition to affecting the quality of life, it often leads to personal, social, and psychological dysfunction and even induces depression. Psoriasis and atopic dermatitis are common chronic skin diseases. Their prevalence in the world is 3-10%, and there is an increasing trend year by year. These congenital or acquired factors cause the dysfunction of the immune system and then destroy the barrier function of the skin. Because these patients are flooded with a variety of inflammatory mediators, this causes skin cells to be in chronic inflammation. Therefore, psoriasis and atopic dermatitis are also considered systemic chronic inflammatory diseases. In the healthcare systems of developed countries, it is unavoidable to spend high costs to relieve symptoms of psoriasis and atopic dermatitis patients, because psoriasis and atopic dermatitis have a great influence on individuals and society. Giving a lot of attention and developing effective treatment methods are the topics that the medical community must work on together. Therefore, we used a narrative review manuscript to discuss pathogenesis, clinical classification, incidence, and treatment options, including topical medication, systemic therapeutics, immunosuppressive medication for psoriasis, and atopic dermatitis, as well as also comparing the differences between these two diseases. We look forward to providing readers with comprehensive information on psoriasis and atopic dermatitis through this review article.

Characterization of Classical Flexural and Nummular Forms of Atopic Dermatitis in Childhood with Regard to Anamnestic, Clinical and Epidermal Barrier Aspects

Nummular (coin-shaped) and classical (flexural) atopic dermatitis differ morphologically, but no other distinguishing features are known. The aim of this study was to determine differences and similarities of both variants in children. Detailed interviews, clinical examinations, biophysical measurements and electron microscopic analyses were performed on 10 children with nummular atopic dermatitis, 14 with classical atopic dermatitis and 10 healthy controls. Nummular atopic dermatitis affected more boys than girls and manifested less frequently within the first year of life than classical atopic dermatitis. Localization, distribution and morphology of the eczema varied more over time, and expression of keratosis pilaris was more severe in children with nummular atopic dermatitis. Both disease groups showed reduced hydration, increased transepidermal water loss and reduced intercellular lipid lamellae in lesional skin areas compared with non-lesional areas. These findings underline the separate classification of both variants. Further research is necessary to investigate the potential of diverging therapeutic approaches.

Atopic dermatitis in psychodermatology: a concise review for dermatologists

Atopic Dermatitis (AD) is a chronic disease of the skin with significant pruritus and phases of exacerbation and remission. The hallmarks of AD are changes in the epithelial barrier and chronic inflammation. This condition is associated with an increased risk of developing mental disorders such as depression, anxiety, and suicidal ideation. It has been proposed that psychological stress may impact on immunological factors with an up-regulation of mediating neuropeptides at the level of central nervous system and secondary involvement of endocrine glands, peripheral nervous system, and immune resident skin cells. This article provides a concise review for dermatologists on the psychodermatology of AD, in order to highlight the putative common pathways between the dermatologic and mental health issues in this illness.

Review article: Emerging issues in pediatric skin of color, Part 2

Dermatology for pediatric skin of color is the application of dermatology to the genetically diverse and distinctive segment of the pediatric population that includes children of non-White racial and ethnic groups with increased pigmentation including individuals of Asian, Hispanic/LatinX, African, Native American, Pacific Island descent, indigenous people among others with overlap in particular individuals, and mixtures thereof. The discipline of pediatric skin of color can be challenging with difficulty in diagnosis of common conditions due to underlying pigmentation, variations in common hair styling practices, and differences in demographics of cutaneous disease. Whereas some conditions are more common in children of color, other conditions have nuances in clinical appearance and therapeutics with regard to skin color. This article, the second of the series, focuses on inflammatory skin disease nuances, melanocytic disorders, and hypopigmented mycosis fungoides.

Localized hair loss in infancy: a review

PURPOSE OF REVIEW

The current review will address the different causes of localized hair loss in infancy. The data presented here will provide clinicians with the latest understanding of different disorders leading to localized hair loss and will provide recommendations for further management of infants who present with alopecia.

RECENT FINDINGS

Localized hair loss in infancy is common, but its underlying causes vary greatly. Alopecia in infants can be categorized into congenital, genetic, inflammatory, mechanical, and physiologic causes. Decisions regarding further management are complex, as they often involve not only cosmetic concerns, but also work-up of possible systemic medical issues related to hair loss.

SUMMARY

Clinicians must be able to distinguish between the different causes of infantile hair loss so that appropriate work-up and further management can be pursued. Factors such as physical appearance, timing of presentation, dermoscopic exam, histopathology, and associated systemic features can help lead clinicians to the correct diagnosis in the case of an infant with localized alopecia.

Current Status of Pediatric Formulations for Chronic and Acute Children' Diseases: Applications and Future Perspectives

Infants and other children can be affected by various acute, chronic and many of them rare illnesses. Developing drugs for children is very challenging since they cannot intake tablets or hard oral solid dosage forms. Besides, most of the prescribed pediatric medications are unlicensed. The biggest issue that clinicians have to solve is that dosing in children is not based on weight or surface area of the body, as it happened in adults but is related to age variations in drug absorption, distribution, metabolism, and elimination. Thus, for pediatric patients, various therapeutic approaches have been proposed so as to develop suitable formulations such as liquid dosage forms, flexible capsules, milk-based products, etc. In addition, the administration of current pharmaceutical products to children might lead to some serious side effects which can also happen in adults but with a lower risk. Especially, infants are at high risk of getting poisoned by taking drugs used for adults. Moreover, children are very sensitive to the taste and smell of some pharmaceutical vehicles and can resist to intake them and this situation leads parents to search for tasteless and odorless medications. In this study, the current formulations for various diseases intended to be used in pediatric patients as well as various chronic and acute diseases of childhood are summarized. Authors believe that this review can help professionals who want to work with pediatric formulations to design more efficient and child-friendly drug delivery systems.

A clinico-pathological approach to management of atopic dermatitis

Recent research in atopic dermatitis (AD) has identified it to be a heterogeneous inflammatory skin disorder of different endotypes (immune polarisation of T-cell subsets and genetic mutations) underlying various phenotypes (age of onset, ethnicity, disease severity, etc.). The corresponding heterogeneity in underlying patho-mechanisms of the disease has resulted in an impetus towards an endotype-driven management of AD. We propose a practical approach that is based on classifying AD patients into intrinsic and extrinsic phenotypes and their corresponding underlying endotypes. This approach aims to provide a practical method that integrates recent understanding of AD pathogenesis for a targeted endotype-driven management of AD.

Skin immune cell characterization in juvenile and adult Göttingen Minipigs

The skin hosts a sophisticated immune system involving responses from both innate and adaptive immune cell populations. Swine skin is close to human skin by its structure, composition and function. In addition, the minipig is considered the model of choice in toxicology studies for drugs applied by the dermal route and developed for both the adult and paediatric indications. However, knowledge on the skin immune system in minipigs, particularly in Göttingen Minipigs, is still limited. The objective of our work was first to characterize the main skin immune populations (Langerhans cells, dermal dendritic cells, macrophages and T lymphocytes) in Göttingen Minipigs. In parallel, we compared the skin immune populations from healthy and immunocompromised piglets following oral treatment with cyclosporin A (CsA) at 10 mg/kg/day. We also explored other pathological conditions using a contact dermatitis model in minipigs challenged with a sensitizer, 2,4-dinitrochlorobenzene (DNCB). Langerhans cells and dermal MHCII^lowCD163⁺ cells were increased one month after oral treatment with CsA at 10 mg/kg/day. The contact dermatitis model in Göttingen Minipigs challenged by DNCB suggested migration of Langerhans cells and dermal dendritic cells as well as T cell recruitment into the skin. These data bring new information in skin immunotoxicology in Göttingen Minipigs and could contribute to a better understanding of the effects of new therapeutic drugs on the developing immune system.

Hidradenitis suppurativa and atopic dermatitis: A 2-way association

BACKGROUND

The coexistence of hidradenitis suppurativa (HS) and atopic dermatitis (AD) had been reported but, to our knowledge, was not investigated in controlled studies.

OBJECTIVE

To evaluate the bidirectional association between HS and AD.

METHODS

A population-based retrospective cohort study was conducted to compare the incidence rate of AD among patients with HS (n = 6779) and age-, sex-, and ethnicity-matched control individuals (n = 33,260). Adjusted hazard ratios (HRs) and adjusted odds ratios were estimated.

RESULTS

The incidence of AD was 2.51 (95% confidence interval [CI], 2.07-3.02) and 1.24 (95% CI, 1.10-1.40) per 1000 person-years among patients with HS and control individuals, respectively. Patients with HS were twice as likely to develop AD as control individuals (HR, 2.06; 95% CI, 1.64-2.58). Furthermore, the prevalence of pre-existing AD was higher in patients with HS than in control individuals (2.5% vs 1.8%, respectively; P < .001). A history of AD was associated with a 40% increase in the odds of HS (odds ratio, 1.41; 95% CI, 1.19-1.67). Relative to patients with isolated HS, those with a dual diagnosis of HS and AD were younger and had a female predominance, lower prevalence of smoking, and lower body mass index.

LIMITATIONS

Retrospective data collection.

CONCLUSIONS

A bidirectional association between HS and AD was observed. Dermatologists should be aware of this association.

Risk Factors in Outpatients with Dermatitis and Eczema in Tertiary Hospitals of China Who Have Clinically Suspected Bacterial Infection

Skin bacterial infections are often observed in eczema patients, but the risk factors are not fully understood. The current study evaluated the prevalence of clinically suspected bacterial infection and its associated risk factors. Moreover, we investigated the practice of skin infection diagnosis in China. A hospital-based, multicenter, cross-sectional epidemiologic survey of bacterial infection was performed in a total of 6208 outpatients diagnosed with dermatitis and eczema from 39 tertiary hospitals of 15 provinces and municipalities in China. All patients completed a specific questionnaire regarding their demographic characteristics, disease duration, distribution of lesions, severity of itching, and medical history. Univariate analysis and multivariate analysis were used to evaluate risk factors associated with bacterial infection in patients with different types of eczema. The prevalence of clinically suspected bacterial infection was 47.0% in patients with eczema. Compared to atopic dermatitis, widespread eczema (OR = 1.50, P < 0.001) and other eczema (OR = 1.42, P < 0.001) were more likely to suffer bacterial infection. The itching grade was positively associated with the infection (OR = 2.11, 7.04, and 12.3 in patients with mild, moderate, and severe itching, respectively; P < 0.001). Lesion distribution in the cubital fossa, popliteal fossa, ear, shoulder and back, axillary, foot, and pudendum was positively associated with bacterial infection (all OR > 1.0, P < 0.05). In contrast, the face and abdomen were reversely associated with bacterial infection (OR < 1.0, P < 0.005). History of asthma, allergic rhinitis, allergic conjunctivitis, atopic dermatitis, infantile eczema, and flexion dermatitis was positively associated with bacterial infection (all OR > 1.0, P < 0.005), while the history of dry skin was reversely associated with bacterial infection (OR = 0.76, 95% CI: 0.64-0.90; P = 0.002). Patients with eczema were easily infected with bacteria. Widespread eczema and other eczema were more likely to have bacterial infection than atopic dermatitis. The high rate of infection may attribute to the lack of corresponding bacterial detection, suggesting the need of guideline development in China to prevent overuse of topical antibiotics.

A Rare Case of Lichen Planus-Like Atopic Dermatitis Involving the Hands

Lichen planus-like atopic dermatitis clinically mimics lichen planus and can pose a diagnostic challenge. We report a case of a 55-year-old African American woman who developed intensely pruritic papules and plaques on bilateral hands. Histological examination demonstrated acute spongiotic dermatitis with lymphocyte exocytosis into the epidermis. Taken together, a diagnosis of lichen planus-like atopic dermatitis was made. This case serves to highlight that lichen planus-like atopic dermatitis can develop on hands and that it presents as spongiotic dermatitis with lymphocyte exocytosis into the epidermis. Correlating the clinical presentation with histopathological findings will assist in establishing the diagnosis and guiding appropriate management.

Topographic Differential Diagnosis of Chronic Plaque Psoriasis: Challenges and Tricks

BACKGROUND

Psoriasis is an inflammatory skin disease presenting with erythematous and desquamative plaques with sharply demarcated margins, usually localized on extensor surface areas.

OBJECTIVE

To describe the common differential diagnosis of plaque psoriasis classified according to its topography in the scalp, trunk, extremities, folds (i.e., inverse), genital, palmoplantar, nail, and erythrodermic psoriasis.

METHODS

A narrative review based on an electronic database was performed including reviews and original articles published until 1 September 2020, assessing the clinical presentations and differential diagnosis for psoriasis.

RESULTS

Several differential diagnoses could be considered with other inflammatory, infectious, and/or neoplastic disorders. Topographical differential diagnosis may include seborrheic dermatitis, tinea capitis, lichen planopilaris in the scalp; lupus erythematosus, dermatomyositis, cutaneous T-cell lymphomas, atopic dermatitis, syphilis, tinea corporis, pityriasis rubra pilaris in the trunk and arms; infectious intertrigo in the inguinal and intergluteal folds and eczema and palmoplantar keratoderma in the palms and soles.

CONCLUSIONS

Diagnosis of psoriasis is usually straightforward but may at times be difficult and challenging. Skin cultures for dermatophytes and/or skin biopsy for histological examination could be required for diagnostic confirmation of plaque psoriasis.

Baricitinib: therapeutic potential for moderate to severe atopic dermatitis

INTRODUCTION

Atopic dermatitis (AD) is a chronic inflammatory skin disease mediated by multiple signals including janus kinase (JAK)/signal transducer and activator of transcription (STAT) pathway. Current therapeutic armamentarium consists of a limited number of drugs which may result in the insufficient management of AD. Preclinical evidence regarding inhibition of JAK/STAT led to the development of a promising class of therapeutics, namely, JAK inhibitors. Baricitinib, a novel JAK1/JAK2 inhibitor is currently under investigation in AD clinical trials.

AREAS COVERED

This review offers an overview of Baricitinib and examines clinical efficacy and safety data in patients with moderate-to-severe AD.

EXPERT OPINION

Baricitinib showed promising preliminary data in terms of efficacy in phase II and III trials, with a very rapid onset of response and great improvements of itch and sleep disturbances. These aforementioned aspects combined with the advantage of an oral formulation have reduced drug production costs compared to biologic agents and could lead to consideration of baricitinib as a first line systemic treatment. Also, in some countries, it could be a therapeutic option in the case of contraindication or failure of conventional systemic drugs prior to biologic therapies. Data related to long-term safety and efficacy will be important to refine the place-in-therapy of this drug.

Role of B cells in immune-mediated dermatoses

Although T cells are considered as the central component in immune-mediated diseases, supportive evidence has demonstrated that B cells also contribute to the progression of these diseases. B cells are divided into various subsets according to their secreted cytokines. Different B cell subsets play diverse roles in immune-mediated dermatoses. Regulatory B cells (Bregs) are defined functionally by their ability to secrete IL-10, which has been revealed to contribute to immunological tolerance. Drugs that deplete B cells, such as rituximab, are now used for the treatment of several immune-mediated dermatoses. In this review, we present and discuss the current knowledge on the roles of B cells in several immune-mediate dermatoses including psoriasis, pemphigus, bullous pemphigoid, and dermatomyositis, atopic dermatitis.

The relationship of prenatal antibiotic exposure and infant antibiotic administration with childhood allergies: a systematic review

Background

Early antibiotic exposure may be contributing to the onset of childhood allergies. The main objective of this study was to conduct a systematic review on the relationship between early life antibiotic exposure and childhood asthma, eczema and hay fever.

Methods

Pubmed and Embase were searched for studies published between 01-01-2008 and 01-08-2018, examining the effects of (1) prenatal antibiotic exposure and (2) infant antibiotic administration (during the first 2 years of life) on childhood asthma, eczema and hay fever from 0 to 18 years of age. These publications were assessed using the Newcastle Ottawa Scale (NOS) and analysed narratively.

Results

(1) Prenatal antibiotics: Asthma (12 studies): The majority of studies (9/12) reported significant relationships (range OR 1.13 (1.02–1.24) to OR 3.19 (1.52–6.67)). Three studies reported inconsistent findings. Eczema (3 studies): An overall significant effect was reported in one study and in two other studies only when prenatal antibiotic exposure was prolonged. (2) Infant antibiotics: Asthma (27 studies): 17/27 studies reported overall significant findings (range HR 1.12 (1.08–1.16) to OR 3.21 (1.89–5.45)). Dose-response effects and stronger effects with broad-spectrum antibiotic were often reported. 10/27 studies reported inconsistent findings depending on certain conditions and types of analyses. Of 19 studies addressing reverse causation or confounding by indication at least somewhat, 11 reported overall significant effects. Eczema (15 studies): 6/15 studies reported overall significant effects; 9 studies had either insignificant or inconsistent findings. Hay fever (9 studies): 6/9 reported significant effects, and the other three insignificant or inconsistent findings. General: Multiple and broad-spectrum antibiotics were more strongly associated with allergies. The majority of studies scored a 6 or 7 out of 9 based on the NOS, indicating they generally had a medium risk of bias. Although most studies showed significant findings between early antibiotic exposure and asthma, the actual effects are still unclear as intrapartum antibiotic administration, familial factors and confounding by maternal and child infections were often not addressed.

Conclusions

This review points to a moderate amount of evidence for a relationship between early life antibiotics (especially prenatal) and childhood asthma, some evidence for a relationship with hay fever and less convincing evidence for a relationship with eczema. More studies are still needed addressing intra-partum antibiotics, familial factors, and possible confounding by maternal and childhood infections. Children exposed to multiple, broad-spectrum antibiotics early in life appear to have a greater risk of allergies, especially asthma; these effects should be investigated further.

Distinct clinical features and serum cytokine pattern of elderly atopic dermatitis in China

BACKGROUND

Elderly atopic dermatitis (AD) is a newly defined subtype of AD stratified by age-related clinical pictures.

OBJECTIVES

To analyse the clinical features and molecular profile of elderly AD patients in China, comparing with infantile, childhood and adolescent/adult AD.

METHODS

A total of 1312 patients diagnosed by Hanifin and Rajka diagnostic criteria of AD from Huashan Hospital, Shanghai, China, were divided into four groups by age (2-18, 19-40, 41-60 and >60 years), and clinical features were evaluated by questionnaire and physical examination. Serum total IgE, eosinophil counts and various cytokines were further analysed in some of the patients and healthy controls.

RESULTS

Elderly AD showed significantly higher male/female ratio and rural/urban ratio than other age groups, and more than half of elderly AD first appeared after 60 years old. Skin lesions of elderly AD were more often seen in the trunk and extensor sites of the extremities. Level of serum IgE and eosinophil counts were significantly lower in elderly AD than those in other age groups. Serum levels of IL-4, TARC, IL-17A, IL-6, IL-22, IL-33 and TSLP were significantly higher in elderly AD patients than those of healthy controls, indicating a mixed Th2/Th17/Th22 inflammation.

CONCLUSIONS

Elderly AD demonstrated unique clinical characteristics compared with other age groups and showed mixed Th2/Th17/Th22 skewing, indicating a unique pathogenesis for elderly AD.

Something to Sweat About: Two Cases of Dupilumab-Induced Hyperhidrosis and Bromhidrosis

Introduction

Atopic dermatitis (AD, eczema) is familial chronic inflammatory skin disease of complex etiology and increasing prevalence. Dupilumab is an IL-4 receptor subunit alpha (IL-4Rα) antagonist that is the first Food and Drug Administration-approved biological therapy for moderate-to-severe adult AD inadequately controlled with topical therapies. Adverse effects reported in the literature include injection site reactions, conjunctivitis, headache, and nasopharyngitis.

Objective

We report the first cases of hyperhidrosis and bromhidrosis as side effects from dupilumab (Dupixent®) for the treatment of AD.

Case Reports

Case 1 is a 20-year-old woman with controlled allergic rhinitis and severe AD reported axillary hyperhidrosis with bromhidrosis, comparable to sweat from high-intensity exercise, with no relief from several different over-the-counter antiperspirants. Case 2 is a 61-year-old woman with history of chronic asthma, allergic contact dermatitis, allergic rhinitis, and AD noticed markedly increased sweating with bromhidrosis that was reminiscent of her menopausal symptomology, about 3 months after initiating dupilimab.

Discussion

Traditional immunosuppressive agents and corticosteroids have limited efficacy, numerous side effects, and increased risk of infection. The safety profile and efficacy of the newly approved IL-4Rα antagonist dupilumab may be favorable to oral immunosuppressants, but its use remains limited to severe recalcitrant cases, due to financial implications and lack of long-term safety data and comparative head-to-head trials.

Conclusion

We report improved outcomes with dupilumab, in addition to unpublished cases of bromhidrosis and hyperhidrosis in 2 patients with AD. This report of additional complications may inspire further clinical research and assist clinicians in considering the option of dupilumab for uncontrolled AD, despite aggressive traditional treatment.

Annular lichenoid dermatitis of youth-Recurrent case of rare skin disease treated with cyclosporine

Annular lichenoid dermatitis of youth (ALDY), first described in 2003, represents an uncommon entity whose etiopathogenesis is still debated. Futhermore, the optimal treatment for ALDY is yet to be established. We report a 9-year-old girl who presented with annular and oval erythematous lesions mostly on her trunk, with several lesions on the neck, groin, flanks, and upper extremities. The lesions had histological and immunohistochemical features characteristic for ALDY. Treatment with H1-antihistamines, topical corticosteroid, and UVB therapy was unsuccessful, while systemic treatment with cyclosporine induced complete remission.

Malassezia (Pityrosporum) Folliculitis Incognito: Malessezia-associated Folliculitis Masked by Topical Corticosteroid Therapy

Malassezia (Pityrosporum) folliculitis usually appears as pruritic monomorphous papules and pustules on the upper back, chest, extensor arms and face. Acne vulgaris, bacterial folliculitis, eosinophilic folliculitis and systemic corticosteroid-induced acne can clinically mimic the fungal-caused acneiform condition. The designation incognito is used to describe tinea or scabies when the characteristic presentation is masqueraded by the application of topical corticosteroid treatment. Application of corticosteroid cream altered the morphology of the skin lesions in a man with Malassezia folliculitis. His cutaneous findings-localized areas of post-inflammatory hyperpigmentation with flattened or completely resolved follicular papules-raised the possibility of partially treated follicular eczema or follicular contact dermatitis. Pathognomonic findings from biopsies of the skin lesions established the diagnosis of Malassezia folliculitis; the condition completely resolved after treatment with topical antifungal shampoo and cream. Similar to tinea incognito and scabies incognito, folliculitis caused by Malassezia yeast in which the cutaneous morphology has been concealed by management with topical corticosteroids should be referred to as Malassezia (Pityrosporum) folliculitis incognito. 

The role of bacterial skin infections in atopic dermatitis: expert statement and review from the International Eczema Council Skin Infection Group

Patients with atopic dermatitis (AD) have an increased risk of bacterial skin infections, which cause significant morbidity and, if untreated, may become systemic. Staphylococcus aureus colonizes the skin of most patients with AD and is the most common organism to cause infections. Overt bacterial infection is easily recognized by the appearance of weeping lesions, honey‐coloured crusts and pustules. However, the wide variability in clinical presentation of bacterial infection in AD and the inherent features of AD – cutaneous erythema and warmth, oozing associated with oedema, and regional lymphadenopathy – overlap with those of infection, making clinical diagnosis challenging. Furthermore, some features may be masked because of anatomical site‐ and skin‐type‐specific features, and the high frequency of S. aureus colonization in AD makes positive skin swab culture of suspected infection unreliable as a diagnostic tool. The host mechanisms and microbial virulence factors that underlie S. aureus colonization and infection in AD are incompletely understood. The aim of this article is to present the latest evidence from animal and human studies, including recent microbiome research, to define the clinical features of bacterial infections in AD, and to summarize our current understanding of the host and bacterial factors that influence microbial colonization and virulence.

Patient impact and economic burden of mild-to-moderate atopic dermatitis

OBJECTIVE

To present a systematic review of studies conducted to evaluate patient impact and economic burden of mild-to-moderate atopic dermatitis.

METHODS

A MEDLINE (via PubMed), Excerpta Medica database (Embase), and Cochrane Library search for English-language articles published January 1, 1996-December 31, 2016 was performed. Abstracts were manually reviewed from 2015-2016 from 10 leading conferences and congresses associated with atopic dermatitis. Manuscripts were reviewed for inclusion in two main categories within the review: patient impact of mild-to-moderate atopic dermatitis and economic burden of atopic dermatitis. Excluded from this dataset were any patients in these studies who had severe atopic dermatitis, moderate-to-severe atopic dermatitis, or atopic dermatitis of unspecified severity.

RESULTS

In total, 222 studies qualified for inclusion in the analysis; this report focuses on the 76 studies that reported results stratified by disease severity. Measured by general and specific instruments, even mild-to-moderate atopic dermatitis reduces the overall quality-of-life of patients and their caregivers/families. Disease severity assessed by validated severity instruments directly correlated with quality-of-life. Treatment of atopic dermatitis can improve the quality-of-life of patients and their caregivers/families by alleviation of symptoms and reduction in severity. In general, total costs increased as disease severity increased; even mild atopic dermatitis imposed substantial costs.

CONCLUSIONS

The results emphasize the impact of atopic dermatitis, especially mild atopic dermatitis, on patient lives and finances, including education of clinicians, payers, and patients regarding benefits associated with treatment adherence.

Eyelash length for the diagnosis of atopic dermatitis and ichthyosis vulgaris in children-a case control study

Eyelash trichomegaly (ET) is increased length (≥ 12 mm), curling, pigmentation, or thickness of eyelashes. Among acquired causes, allergic diseases and atopic dermatitis (AD) have been found to be associated with eyelash trichomegaly especially in children; however, to date, this claim has not been studied in detail. To compare the eyelash lengths of AD and ichthyosis vulgaris (IV) patients with those of age- and sex-matched patients with unrelated skin disorders, we measured (with a digital Vernier caliper) and compared the eyelash lengths of AD (n = 58) and IV (n = 31) patients to those of age- and sex-matched patients with unrelated skin disorders (n = 178). The eyelashes of the AD and male IV patients were found to be significantly longer than those of the controls (p < 0.05). The severity of atopic dermatitis, i.e., SCORAD of > 50, hyperlinearity of palms and soles, and high IgE levels significantly correlated with the long eyelashes. The limitations of study are single-center study and filaggrin gene mutation in patients of IV could not be studied.

CONCLUSION

Thus, long eyelashes may act as surrogate marker of severe AD and serve as a cutaneous marker of IV patients. What is Known: • Among acquired causes, allergic diseases and atopic dermatitis have been found to be associated with eyelash trichomegaly especially in children. What is New: • The severity of atopic dermatitis, i.e., SCORAD of > 50, hyperlinearity of palms and soles, and high IgE levels significantly correlate with the long eyelashes; thus, long eyelashes may act as surrogate marker of severe atopic dermatitis. • It may also serve as a cutaneous marker of ichthyosis vulgaris especially in male patients and patients with palmoplantar hyperlinearity.

The impact of pediatric skin disease on self-esteem

Background

Pediatric skin disorders can affect children's self-esteem, relationships with caregivers and peers, and performance in school and activities.

Objective

This review describes common pediatric congenital and acquired dermatologic disorders and the impact that these disorders can have on children's self-esteem.

Methods

A review of current, English-language literature was conducted with use of the PubMed database. Search terms included atopic dermatitis, acne, infantile hemangiomas, port wine stains, congenital melanocytic nevi, hidradenitis suppurativa, and self-esteem.

Results

During infancy and toddlerhood, skin disorders such as infantile hemangiomas primarily affect the attachment between child and caregiver. School-aged children with port wine stains and atopic dermatitis report increased bullying, teasing, and social isolation. Acne and hidradenitis typically affect older children and teens and these conditions are associated with increased risks of depression and suicidal ideation. Effective management of these conditions has been shown to increase patients' self-esteem.

Conclusion

Pediatric dermatologic disorders impact self-esteem throughout childhood. In addition to the surgical and medical management of these disorders, clinicians can also take an active role in the assessment and improvement of the psychosocial impact of these skin disorders.