Assessment of major comorbidities in adults with atopic dermatitis using the Charlson comorbidity index

Comprehensive Ophthalmological Evaluation in Atopic Dermatitis

INTRODUCTION

Atopic dermatitis (AD), a chronic type 2 inflammatory skin disease, is frequently associated with ocular surface diseases (OSD) which may appear or worsen under anti-type 2-targeted treatments. However, the exact prevalence of OSD and the ophthalmology referral criteria remain ill-defined in AD patients before initiating such biotherapies. We aimed to characterize the prevalence, the nature and the factors related to OSD development in AD that may justify an ophthalmological management.

METHODS

A total of 98 consecutive AD inpatients without biological treatment were retrospectively included. These were systematically evaluated by an ophthalmologist during their dermatological care. Clinical and laboratory data were analysed to characterize OSD and their risk factors.

RESULTS

OSD were found in 83/98 AD patients (85%); mainly dry eye syndrome (64%, 63/98), allergic conjunctivitis (42%, 41/98), posterior (33%, 32/98), and anterior blepharitis (27%, 26/98). In AD patients without ocular symptoms, OSDs were also frequently found (63%, 12/19) and were mostly mild. Risk factors for OSD were history of allergic rhinitis, allergic sensitization, head and neck AD, ocular symptoms (foreign body sensation in the eye, burning, itching, photophobia), and total IgE level >3,000 kU/L.

CONCLUSION

The prevalence of OSD was high, even in asymptomatic patients. The risk factors identified may indicate the need for ophthalmological examination for therapeutic management, especially when biological agents targeting type 2 inflammation are considered.

Are Antimicrobial Peptides a 21st-Century Solution for Atopic Dermatitis?

Atopic dermatitis (AD) is a chronic inflammatory skin disorder that is the result of various environmental, bacterial and genetic stimuli, which culminate in the disruption of the skin's barrier function. Characterized by highly pruritic skin lesions, xerosis and an array of comorbidities among which skin infections are the most common, this condition results in both a significant loss of quality of life and in the need for life-long treatments (e.g., corticosteroids, monoclonal antibodies and regular antibiotic intake), all of which may have harmful secondary effects. This, in conjunction with AD's rising prevalence, made the development of alternative treatment strategies the focus of both the scientific community and the pharmaceutical industry. Given their potential to both manage the skin microbiome, fight infections and even modulate the local immune response, the use of antimicrobial peptides (AMPs) from more diverse origins has become one of the most promising alternative solutions for AD management, with some being already used with some success towards this end. However, their production and use also exhibit some limitations. The current work seeks to compile the available information and provide a better understanding of the state of the art in the understanding of AMPs' true potential in addressing AD.

Assessment of Subclinical Atherosclerosis in Children with Atopic Dermatitis

INTRODUCTION

Data from studies conducted to date have evaluated clinical atherosclerotic conditions in adult patients with atopic dermatitis (AD). Subclinical atherosclerotic changes that are a precursor of atherosclerotic conditions may begin in childhood. The aim of this study was to investigate the presence of subclinical atherosclerosis in pediatric patients with AD and to determine the associated risk factors.

METHODS

A total of 59 patients who were referred to our department over a 6-month period and diagnosed with AD, and 53 healthy controls with a similar age and gender were included in the study. Subclinical atherosclerosis markers (carotid intima media thickness [CIMT], distensibility, stiffness, and strain) were measured using conventional echocardiography. The patients' age, SCORAD index, and duration of symptoms were recorded. Serum total immunoglobulin E, C-reactive protein (CRP), blood lipid profile, and complete blood count markers were measured.

RESULTS

The median age of the patients was 61 (10-103) months, and 59.3% of them were male. The patients with AD had a higher CIMT (1.60 ± 0.35 vs. 1.30 ± 0.50 mm) and a lower distensibility (0.006 ± 0.009 vs. 0.01 ± 0.008) and strain (0.10 ± 0.14 vs. 0.19 ± 0.14) than the healthy controls (p < 0.01 for all), but there was no significant difference with regard to stiffness (10.16 ± 21.75 vs. 8.99 ± 12.66). Significant correlations between CIMT and disease duration, age, and the SCORAD index were found (p < 0.01, p < 0.01, and p < 0.05, respectively). No correlation between the subclinical atherosclerosis markers and the other laboratory results was found (p > 0.05 for all).

CONCLUSION

This study demonstrates that pediatric patients with AD may express subclinical atherosclerosis markers. The evaluation of subclinical atherosclerosis in these patients revealed that CIMT may be the most important marker, as it displayed positive correlations with symptom duration, age, and disease severity.

Disease modification in inflammatory skin disorders: opportunities and challenges

Progress in understanding of the mechanisms underlying chronic inflammatory skin disorders, such as atopic dermatitis and psoriasis vulgaris, has led to new treatment options with the primary goal of alleviating symptoms. In addition, this knowledge has the potential to inform on new strategies aimed at inducing deep and therapy-free remission, that is, disease modification, potentially impacting on associated comorbidities. However, to reach this goal, key areas require further exploration, including the definitions of disease modification and disease activity index, further understanding of disease mechanisms and systemic spillover effects, potential windows of opportunity, biomarkers for patient stratification and successful intervention, as well as appropriate study design. This Perspective article assesses the opportunities and challenges in the discovery and development of disease-modifying therapies for chronic inflammatory skin disorders.

Comorbidities of atopic dermatitis-what does the evidence say?

Atopic dermatitis (AD) is a common disease that is associated with atopic and nonatopic comorbidities. There has been a growing interest in this area of AD, because presence or risk of comorbidities can in many ways impact the management of patients with AD. Thus, some treatments for AD may improve its comorbidities as well, whereas others may increase their risk. In this review article, we discuss various comorbidities of AD mostly on the basis of the results of recent multiple systematic reviews and meta-analyses to update readers about this rapidly developing area of dermatology. We emphasize the important information provided by studies presenting both relative risk and absolute risk, and show that AD is associated with, among others, atopic comorbidities such as asthma, rhinitis, and food allergy, nonatopic comorbidities such as ocular, psychiatric, infectious, endocrine, autoimmune, and cardiovascular diseases, and certain cancers. Clinicians need to be aware of these and be cognizant about positive and negative effects of existing and new treatments for AD.

Systemic Therapy for Atopic Dermatitis in Older Adults and Adults With Comorbidities: A Scoping Review and International Eczema Council Survey

BACKGROUND

Clinical trials of systemic therapies for atopic dermatitis (AD) often exclude patients based on age and comorbidities.

OBJECTIVES

We conducted a scoping review of observational studies and survey of International Eczema Council (IEC) members on the treatment of AD in patients with liver disease, renal disease, viral hepatitis, HIV, or history of malignancy.

METHODS

We searched MEDLINE via Ovid, Embase via Ovid, and Web of Science from inception to September 14, 2020. We mapped the available evidence on the use of cyclosporine, methotrexate, azathioprine, mycophenolate, systemic corticosteroids, and dupilumab for AD in older adults (≥65 years) and adults with the previously mentioned comorbidities. We surveyed IEC members on their preferred systemic medications for each patient population.

RESULTS

We identified 25 studies on the use of systemic medications in special populations of adults with AD. Although IEC members preferred dupilumab as the first-line systemic agent across all special populations, many could not identify viable third-line systemic therapy options for some populations.

CONCLUSIONS

Data on systemic therapy for AD for older adults and adults with comorbidities are limited. Although IEC members' access to systemic therapies differs geographically, expert opinion suggests that dupilumab is preferred for those patients.

Cardiovascular comorbidities of atopic dermatitis: using National Health Insurance data in Korea

Background

It is well known that atopic dermatitis (AD) is associated with other allergic diseases. Recentely, links to diseases other than allergic disease have also been actively studied. Among them, the results of studies regarding AD comorbidities, especially cardiovascular disease (CVD), have varied from country to country.

Objective

To analyze whether the risk of CVD is different between AD patients and healthy controls using Korean National Health Insurance Data.

Methods

We obtained data from 2005 to 2016 from the Korean National Health Insurance Research Database. Patients with one AD code and two AD-related tests codes were selected as AD patients, and age-and sex-matched controls to the AD patients were selected from among those without AD (1:5). Each group was investigated for accompanying metabolic syndrome (which contains hypertension, type 2 diabetes, and hyperlipidemia) and CVD (angina, myocardial infarction, peripheral vascular disease, and stroke) using ICD 10 codes.

Results

The incidence of metabolic diseases and CVD were significantly different between the AD and control groups. Using multivariable Cox regression, differences were adjusted for sex, age, and other CVD and metabolic diseases. As a result, not only metabolic disease, but also the CVD risk of AD patients was significantly higher than that of the control group. Patients with AD had as significantly higher risk of hyperlipidemia (hazard ratio [HR] = 33.02, p < 0.001), hypertension (HR = 4.86, p < 0.001), and type 2 diabetes (HR = 2.96, p < 0.001). AD patients also had a higher risk of stroke (HR = 10.61, p < 0.001), myocardial infarction (HR = 9.43, p < 0.001), angina (HR = 5.99, p < 0.001), and peripheral vascular disease (HR = 2.46, p < 0.001). Besides hyperlipidemia, there was no difference in risk according to AD severity.

Conclusion

Patients with AD have a greater risk of CVD than those without AD.

Atopic dermatitis: an expanding therapeutic pipeline for a complex disease

Atopic dermatitis (AD) is a common chronic inflammatory skin disease with a complex pathophysiology that underlies a wide spectrum of clinical phenotypes. AD remains challenging to treat owing to the limited response to available therapies. However, recent advances in understanding of disease mechanisms have led to the discovery of novel potential therapeutic targets and drug candidates. In addition to regulatory approval for the IL-4Ra inhibitor dupilumab, the anti-IL-13 inhibitor tralokinumab and the JAK1/2 inhibitor baricitinib in Europe, there are now more than 70 new compounds in development. This Review assesses the various strategies and novel agents currently being investigated for AD and highlights the potential for a precision medicine approach to enable prevention and more effective long-term control of this complex disease.

Recent advances in understanding of the complex phenotype and mechanisms underlying atopic dermatitis (AD) have revealed multiple new potential targets for pharmacological intervention. Here, Bieber reviews therapeutic strategies and assesses the expanding pipeline for the therapy of AD, highlighting the potential for a precision medicine approach to the management of this complex disorder.

Association of pediatric atopic dermatitis and psoriasis with school absenteeism and parental work absenteeism: A cross-sectional United States population-based study

BACKGROUND

The impact of childhood atopic dermatitis (AD) and psoriasis on school absenteeism is not fully elucidated.

OBJECTIVE

To determine the burden and predictors of chronic school absenteeism in children with AD and psoriasis.

METHODS

Data were analyzed from the 1999-2015 Medical Expenditure Panel Surveys, cross-sectional, population-based studies of health status and function in the United States.

RESULTS

Among 3132 and 200 children with AD and psoriasis, respectively, 1544 (67.7%) and 97 (62.5%) missed ≥1 day, and 120 (3.9%) and 5 (3.6%) missed ≥15 days (chronically absent) per year due to illness. AD was associated with chronic absenteeism overall (logistic regression; adjusted odds ratio 1.42, 95% CI [1.13-1.78]) and with more severe disease (mild-moderate: 1.33 [1.04-1.70], severe: 2.00 [1.21-3.32]). No statistical difference in chronic absenteeism was found for children with versus those without psoriasis (1.26 [0.51-3.12]). Parents of children with AD were more likely to miss work for caregiving versus those of children without AD, whereas parents of children with psoriasis had similar rates of work absenteeism versus those of children without psoriasis.

LIMITATIONS

The severity of AD and psoriasis was assessed by treatment pattern.

CONCLUSION

Children in the United States with AD had increased chronic school absenteeism. Further interventions are warranted to prevent school absenteeism in childhood AD.

Treatment Patterns in Danish Patients with Atopic Dermatitis Before and After Hospital Referral

Introduction

A number of treatments for atopic dermatitis (AD) are available; however, long-term treatment patterns and healthcare consumption in patients with AD are poorly described.

Methods

We conducted a registry-based longitudinal drug utilization study among Danish patients with AD that were referred to their first-ever visit at hospital-based dermatology clinics. Their first visit was in the period between 1 January 2005 and 31 December 2012, and patients were followed up to 5 years after their first visit.

Results

In total, 8213 people with a first-time hospital dermatologist contact for AD were included in the study (3514 aged 0–9 years, 1501 aged 10–19 years, 3198 aged 20 years or older). At first visit, a baseline history of moderately potent topical corticosteroid (TCS) use was seen among 46.6% of children (0–9 years), whereas potent or very potent TCS use was more frequently among older individuals (e.g., 51.1% and 25.6% of people aged 50 years or older had used potent and very potent TCS, respectively). The median (interquartile range) annual number of visits to general practitioners was 4 (2–7) for children and 5 (2–8) for adults, in the 12 months prior to referral. Three years after referral, these numbers had decreased to 2 (1–4) and 3 (1–6), respectively. In the first year after referral, 6% of patients were prescribed systemic corticosteroids, whereas other systemic therapies were used in 5% or less.

Conclusions

After referral, low proportions of patients received systemic treatment, or potent TCS. These findings highlight considerable differences in treatment patterns between general practitioners and private practice dermatologists, compared with hospital-based dermatologists, and emphasize the need for better adherence to evidence-based treatment guidelines.

Mental Health Symptoms and Functional Impairment in Children With Atopic Dermatitis

BACKGROUND

The impact of childhood atopic dermatitis (AD) on social and behavioral issues is not well understood.

OBJECTIVE

This study sought to determine the prevalence and predictors of social and behavioral symptoms and functional impairment among US children with AD.

METHODS

The 1996 to 2015 Medical Expenditure Panel Surveys were analyzed, including a representative, cross-sectional study of 2553 US children with AD. Behavioral and functional issues were examined using Columbia Impairment Scale (CIS) scores.

RESULTS

Childhood AD was associated with behavioral and functional problems, particularly nervousness (odds ratio [OR], 1.18; 95% confidence interval [95% CI], 1.06-1.31), home behavior (OR, 1.18; 95% CI, 1.06-1.32), staying out of trouble (OR, 1.18; 95% confidence interval, 1.06-1.31), and relationships with other kids (OR, 1.17; 95% CI, 1.05-1.31) and with siblings (OR, 1.14; 95% CI, 1.02-1.28). Higher CIS scores were present in children with AD versus without AD (adjusted β, 0.62; 95% CI, 0.22-1.02) and with psoriasis (adjusted β, 0.86; 95% CI, 0.22-1.49). Among children with AD, higher CIS scores were notably associated with male sex, older age, lower household income, public insurance, and comorbid depression and anxiety.

CONCLUSIONS

AD was associated with behavioral and functional impairment, similar to psoriasis and other common chronic conditions. There are significant sociodemographic differences in CIS scores.

Association of Childhood Atopic Dermatitis With Atopic and Nonatopic Multimorbidity

BACKGROUND

Little is known about the impact of multimorbidity in childhood atopic dermatitis (AD).

OBJECTIVE

We sought to determine the likelihood and predictors of chronic disease multimorbidity in childhood AD.

METHODS

Data were examined for children (<18 years) in the 1996-2015 Medical Expenditure Panel Survey, an annual, representative sample of United States households. Multimorbidity was assessed using Charlson Comorbidity Index (CCI), Healthcare Utilization Project Chronic Comorbidity Indicator (HCUP-CCI) and frequency of atopic comorbidities.

RESULTS

Young children with mild-moderate and severe AD, and adolescents with mild-moderate AD had higher CCI scores. Similarly, young children and adolescents with mild-moderate and severe AD had increased HCUP-CCI scores. Children with AD and atopic disease had higher CCI and HCUP-CCI scores than children with either alone. Young children and adolescents with mild-moderate and severe AD had more atopic comorbidities.

CONCLUSIONS

Pediatric AD is associated with increased atopic and non-atopic multimorbidity. Comorbid atopic disease may identify a subset of children with AD who particularly benefit from enhanced screening and management of multimorbidity.

Risk of systemic infections in adults with atopic dermatitis: A nationwide cohort study

BACKGROUND

Atopic dermatitis (AD) has been linked to systemic infections in adulthood, but large-scale studies are few, and potential associations are unclear.

OBJECTIVE

To examine whether adults with AD have increased risk of developing systemic infections leading to hospital-based management.

METHODS

Nationwide register-based cohort study including all Danish adults from 1995 through 2017. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated by using Cox models.

RESULTS

A total of 10,602 adults with AD (median age, 29.8 y; interquartile range, 22.6-44.8) and 106,020 reference individuals were included. The overall incidence rate per 10,000 person-years of systemic infections was 180.6 (95% CI, 172.6-189.0) among adults with AD compared with 120.4 (95% CI, 118.3-122.5) among reference adults. The association between AD and systemic infections was observed for musculoskeletal (adjusted HR [aHR], 1.81; 95% CI, 1.42-2.31), heart (aHR, 1.75; 95% CI, 1.21-2.53), and upper (aHR, 1.42; 95% CI, 1.15-1.73) and lower respiratory tract infections (aHR, 1.21; 95% CI, 1.10-1.33). The risk of sepsis (aHR, 1.19; 95% CI, 1.01-1.44) and skin infections (aHR, 2.30; 95% CI, 2.01-2.62) was also increased.

LIMITATIONS

The findings cannot be generalized to adults with milder AD seen outside the hospital system.

CONCLUSION

We found an increased risk of systemic infections among adults with hospital managed AD.

Comorbidités de la dermatite atopique

Atopic dermatitis is associated with an increased risk of asthma (10 to 30% according to age), allergic rhinitis and conjunctivitis and food allergy. Other comorbidiies are globally lest frequent than in psoriasis. There is no increased risk of solid cancer. Smoking is a major confounding factor that has to be taken into account. Obesity and metabolic syndrome are more frequent and there is a moderately increased cardiovascular risk in severe forms of atopic dermatitis. There is a clear-cut increased risk of vitiligo and alopecia areata and a lower risk of other auto-immune diseases, including type I diabetes in children. There is a higher risk of cutaneous but not extra-cutaneous bacterial and viral infections, and increased frequency of contact dermatitis and urticaria. Severe atopic dermatitis is associated with psychiatric comorbidities, like attention disorders/hyperactivity, depression and suicidal ideas. © 2019 Elsevier Masson SAS. All rights reserved.

Association between parental autoimmune disease and atopic dermatitis in their offspring: a matched case-control study

BACKGROUND

Atopic dermatitis (AD) is associated with many autoimmune diseases, in part due to overlapping genetic risk loci. While parental atopic disease is an important risk for AD in the offspring, little is known on the putative associations between parental autoimmune disease and AD in their children.

MATERIALS AND METHODS

All children born between 1996 and 2011 who received a diagnosis of AD in the hospital system before their fifth birthday were matched 1 : 10 with children from the general population. Maternal and paternal autoimmune diseases were assessed using registry-based data. Conditional logistic regression was performed on the relationships between parental autoimmune diseases and AD in their children.

RESULTS

A total of 8589 children with AD were matched with controls. One or more autoimmune disease was identified in 5.89% (506/8589) of mothers to AD children and 3.67% (315/8589) of fathers to AD children compared to 4.85% (4163/85 890) and 3.28% (2816/85 890) in parents of control children. Maternal autoimmune disease but not paternal autoimmune disease was associated with AD in the offspring (odds ratio [OR] 1.20 [95% confidence interval (CI) 1.20-1.32] and OR 1.08 [0.96-1.22], respectively), Two or more maternal autoimmune diseases, maternal dermatologic autoimmune disease and maternal digestive autoimmune disease were all also associated with AD development in her children (1.96 [95% CI 1.36-2.84], OR 1.60 [95% CI 1.24-2.07] and OR 1.24 [95% CI 1.06-1.45], respectively).

CONCLUSIONS

The risk of AD is influenced by many factors including atopy status and filaggrin gene mutations. In this matched case-control study, maternal autoimmune disease was associated with AD diagnosis in the offspring. Maternal dermatologic and digestive autoimmune diseases were most closely associated with subsequent AD diagnosis in the offspring.

Atopic dermatitis and risk of hypertension, type 2 diabetes, myocardial infarction and stroke in a cross-sectional analysis from the Canadian Partnership for Tomorrow Project

BACKGROUND

Atopic dermatitis (AD) has been associated with cardiovascular risk factors and diseases, but epidemiological studies to date have found conflicting results.

OBJECTIVES

To determine the associations of AD with hypertension, type 2 diabetes (T2D), myocardial infarction (MI) and stroke.

METHODS

We conducted a cross-sectional analysis of baseline data from the Canadian Partnership for Tomorrow Project, which includes Canadian residents aged 30-74 years living in British Columbia, Alberta, Ontario, Quebec and the Atlantic Provinces. We excluded participants with incomplete data on AD, hypertension, T2D, MI or stroke, who had type 1 or gestational diabetes or who developed any of the outcomes at an age prior to a diagnosis of AD. This left 259 119 participants in our analysis. We used logistic regression to calculate age- and sex-, and multivariable-adjusted odds ratios (ORs) and 95% confidence intervals (CIs) between AD and subsequent hypertension, T2D, MI and stroke.

RESULTS

AD was reported by 21 379 (8·4%) participants. In total, 52 787 cases of hypertension, 12 739 cases of T2D, 4390 cases of MI and 2235 cases of stroke were reported by participants at enrolment. In the multivariable-adjusted model, AD was associated with decreased odds of hypertension (OR 0·87, 95% CI 0·83-0·90), T2D (OR 0·78, 95% CI 0·71-0·84), MI (OR 0·87, 95% CI 0·75-1·00) and stroke (OR 0·79, 95% CI 0·66-0·95).

CONCLUSIONS

We did not find evidence of a positive association between AD and subsequent hypertension, T2D, MI or stroke; AD was inversely associated with these outcomes in our study. Given our findings and the conflicting literature, AD is likely not a major risk factor for cardiovascular disease.