Sleep disturbance in children with moderate/severe atopic dermatitis: A case-control study

Burden of atopic dermatitis in paediatric patients: an international cross-sectional study

BACKGROUND

Few large-scale international studies have broadly characterized the burden of atopic dermatitis (AD) across age groups among children and adolescents.

OBJECTIVES

To better characterize the AD burden in paediatric patients by disease severity.

METHODS

This cross-sectional, web-based survey of paediatric patients (6 months to < 18 years old) was conducted in 18 countries representing North America, Latin America, Europe, Middle East/Eurasia and East Asia. Patients with diagnosed AD were identified based on the International Study of Asthma and Allergies in Childhood criteria and self-/parent-report of ever being told by a physician that they or their child had eczema. AD severity was assessed using the Patient-Oriented Eczema Measure and Patient Global Assessment. Outcomes included measures of itch, skin pain, sleep, health-related quality of life (HRQoL), missed school days and atopic comorbidities.

RESULTS

The survey included 1489 children aged 6 months to < 6 years; 2898 children aged 6 to < 12 years; and 3078 adolescents aged 12 to < 18 years diagnosed with AD. Although the burden of mild AD was substantial, paediatric patients with moderate or severe AD had more itch, skin pain, sleep problems and impaired HRQoL, and missed more school days relative to those with mild AD; greater burden was observed among those with severe relative to moderate AD. At least one atopic comorbidity was present in 92.5% of all respondents.

CONCLUSIONS

These results highlight the burden of AD in paediatric patients, especially those with moderate-to-severe disease, and suggest the need for assessments that include the impact of AD on function and daily life.

Epidemiology of mental health comorbidity in patients with atopic dermatitis: An analysis of global trends from 1998 to 2022

The prevalence rates of attention deficit hyperactivity disorder (ADHD), depression, anxiety and suicide are increasing in patients with atopic dermatitis (AD), although no research has systematically examined these trends yet. Here, we explore the prevalence of the occurrence of comorbidities, such as ADHD, depression, anxiety and suicide with AD. We searched seven electronic databases from inception to October 2022 to identify relevant studies, and the Agency for Healthcare Research and Quality (AHRQ) and Newcastle-Ottawa Scale (NOS) tools were used to assess the quality of observational studies. Statistical analysis was performed using R software. Publication bias was evaluated using Egger's and Begg's linear tests. The global prevalence rates of ADHD, depression, anxiety and suicidal ideation in patients with AD were 7%, 17%, 21% and 13%, respectively, between 1998 and October 2022. Among children (aged <18 years), North American children with AD had the highest prevalence rates of ADHD (10%), depression (13%) and anxiety (20%). Among the adult (aged ≥18 years) population, patients with AD in Africa had the highest prevalence rates of depression (36%) and anxiety (44%), while Asian adults with AD had the highest prevalence rates of ADHD (7%) and suicidal ideation (20%). These results highlight the high prevalence and comorbidity rates of mental illnesses with AD, which should be brought to the attention of patients with AD and their physicians.

Sleep and allergic diseases among young Chinese adults from the Singapore/Malaysia Cross-Sectional Genetic Epidemiology Study (SMCGES) cohort

BACKGROUND AND OBJECTIVE

Sleep disruption has been shown to affect immune function and thus influence allergic disease manifestation. The specific effects of sleep on allergic diseases, however, are less well-established; hence, in a unique population of young Chinese adults, we investigated the association between sleep and allergic disease.

METHODS

Young Chinese adults recruited from Singapore in the Singapore/Malaysia Cross-Sectional Genetic Epidemiology Study (SMCGES) were analyzed. We used the International Study of Asthma and Allergies in Childhood (ISAAC) protocol and a skin prick test to determine atopic dermatitis (AD), allergic rhinitis (AR), and asthma status. Information regarding total sleep time (TST) and sleep quality (SQ) was also obtained.

RESULTS

Of 1558 participants with a mean age of 25.0 years (SD = 7.6), 61.4% were female, and the mean total sleep time (TST) was 6.8 h (SD = 1.1). The proportions of AD, AR, and asthma were 24.5% (393/1542), 36.4% (987/1551), and 14.7% (227/1547), respectively. 59.8% (235/393) of AD cases suffered from AD-related sleep disturbances, 37.1% (209/564) of AR cases suffered from AR-related sleep disturbances, and 25.1% (57/227) of asthma cases suffered from asthma-related sleep disturbances. Only asthma cases showed a significantly lower mean TST than those without asthma (p = 0.015). Longer TST was significantly associated with lower odds of AR (OR = 0.905, 95% CI = 0.820-0.999) and asthma (OR = 0.852, 95% CI = 0.746-0.972). Linear regression analyses showed that lower TST was significantly associated with asthma (β =  - 0.18, SE = 0.076, p-value = 0.017), and AR when adjusted for AR-related sleep disturbances (β =  - 0.157, SE = 0.065, p-value = 0.016). Only sleep disturbances due to AR were significantly associated with a poorer SQ (OR = 1.962, 95% CI = 1.245-3.089).

CONCLUSIONS

We found that sleep quality, but not sleep duration was significantly poorer among AD cases, although the exact direction of influence could not be determined. In consideration of the literature coupled with our findings, we posit that TST influences allergic rhinitis rather than vice versa. Finally, the association between TST and asthma is likely mediated by asthma-related sleep disturbances, since mean TST was significantly lower among those with nighttime asthma symptoms. Future studies could consider using objective sleep measurements coupled with differential expression analysis to investigate the pathophysiology of sleep and allergic diseases.

Severe atopic dermatitis, sleep disturbance, and low light exposure

STUDY OBJECTIVES

Atopic dermatitis (AD) is a chronic inflammatory skin disorder in children. AD worsens at night, particularly in severe disease. Low light exposure contributes to inflammation, poor sleep, and misalignment between circadian (24-hour) rhythms (biological clocks) and social clocks (weekday vs. weekend sleep timing), but has not been evaluated in AD. Our objective was to perform a cross-sectional study to determine whether there is an association between AD severity, recorded light exposure (RLE), and sleep measures in participants with AD and healthy controls.

METHODS

Secondary data analysis from two prospective observational studies of 74 participants ages 5-17 years old with severe AD compared to others (healthy controls and mild/moderate AD). Participants wore actigraphy watches for at least 1 weekday and one weekend. Rest/activity and RLE (lux) were obtained from the watches and were analyzed to estimate duration and quality of sleep/light exposure.

RESULTS

Participants (n = 74) were on average 10.9 ± 3.6 years old, with 45% female, 17% no AD, 27% mild, 32% moderate, and 24% severe AD. On weekends, severe AD participants versus others fell asleep at a similar time (23:52 ± 1:08 vs. 23:40 ± 1:29 mean clock-time hours ± SD; p = 0.23), had similar sleep-onset latency (8.2 ± 8.7 vs. 12.7 ± 16.9 minutes; p = 0.28), but woke later (09:12 ± 1:04 vs. 08:13 ± 1:14 minutes; p < 0.01) resulting in a later sleep-midpoint (04:32 ± 0:53 vs. 03:49 ± 1:08 minutes; p = 0.02). Severe AD participants had lower levels of daytime RLE than others (mean-over-all-days: 1948.4 ± 2130.0 vs. 10341.3 ± 13453.8 lux; p = 0.01) and throughout seasons, weekdays, or weekend, yet had similar nighttime RLE.

CONCLUSION

Severe AD is characterized by low RLE and sleep disturbance. Low RLE could potentially induce circadian misalignment, contributing to inflammation and worse disease in severe AD. Low RLE can also reflect altered lifestyle and behavior due to atopic disease impacts. Prospective studies are needed to test causality and the potential of bright light as an adjuvant therapy for severe AD.

Mind and skin: Exploring the links between inflammation, sleep disturbance and neurocognitive function in patients with atopic dermatitis

Atopic dermatitis (AD) is a chronic, pruritic and inflammatory, dry skin condition with many known comorbidities. These include airway disease, food allergies, atopic eye disease and autoimmune conditions. Furthermore, there is often significant sleep disturbance as well as increased psychological distress and mental health problems. Severe AD therefore often has a significant impact on the quality of life of both patients and their families. In this review we discuss recent findings on the putative links between AD, its association with itch, sleep disturbance and neuropsychiatric morbidity, including the role of inflammation in these conditions. Itch was thought to predominantly drive sleep disruption in AD. We now understand changes in sleep influence immune cell distribution and the associated inflammatory cytokines, which suggests a bidirectional relationship between AD and sleep. We also increasingly recognize inflammation as a key driver in psychological symptoms and disorders. The link between cutaneous, systemic and possible brain inflammation could at least in part be driven by the sleep deprivation and itch-driven neuronal proliferation seen in AD.

Assessment and Management of Sleep Disturbances in Atopic Dermatitis: A Review

Atopic dermatitis (AD) is a chronic burdensome inflammatory skin disease with well-established cutaneous and systemic comorbidities and disease burden. AD particularly has profound impacts on sleep in individuals of all ages. Sleep disturbances (SDs) affect 6.2% of school-age children and 33-87.1% of adults with AD. This narrative review addresses the burden of SD in AD patients, as well as biological mechanisms of SD in AD, including biological clocks influencing sleep, inflammation, and behavior. Approaches for early detection, diagnosis, objective quantification, patient education, and management are reviewed. It is imperative to break the itch-scratch cycle to reduce SDs and improve quality of life in individuals with AD.

Association of Sleep Duration and Weekend Catch-Up Sleep with Suicidal Ideation among Adolescents with Atopic Dermatitis

Atopic dermatitis (AD) is a prevalent allergic disease in children that often causes sleep disturbance and which is associated with diminished quality of life and heightened susceptibility to depression and suicidality. In this study, we investigate the relationship between weekend catch-up sleep (WCUS) and mental health in a sample of 71,434 adolescents with AD and 221,057 without AD using multivariate logistic regression analysis. We hypothesized that adolescents with AD experience shorter total and daytime sleep due to pruritus, with compensatory longer WCUS. We found that the lifetime prevalence of AD was 24.4%, and that adolescents with AD slept less overall, with significantly shorter weekday and weekend sleep durations but longer weekend catch-up sleep (WCUS). Sleep dissatisfaction was markedly higher in the AD group. Interestingly, our results suggest that prolonged WCUS is a protective factor against suicidal ideation in adolescents with AD. The study highlights the importance of addressing sleep patterns in adolescents with AD to enhance mental health. Overall, our findings indicate a need for increased awareness and intervention strategies to ensure sufficient sleep and reduce the risk of suicidal ideation in this population.

Changing Trends in School Absenteeism and Identification of Associated Factors in Adolescents with Atopic Dermatitis

Atopic dermatitis (AD) has a negative influence on school attendance. We aimed to identify factors associated with school absenteeism in adolescents with AD. We used data from the 3rd to 11th annual Korean Youth Risk Behavior Web-based Survey completed from 2007 to 2015. Survey data were obtained from a stratified, multistage, clustered sample. Participants responded to the question "have you ever been diagnosed with AD?" Factors associated with AD-related school absenteeism (ADSA), which is defined as at least one school absence due to AD, were evaluated. Among the 141,899 subjects, the prevalence of AD increased (17.3% to 24.2%), while that of ADSA decreased (7.3% to 2.6%) from 2007 to 2015. Compared to adolescents without ADSA, those with ADSA were more likely to be male, middle school students, and have negative mental health states, including suicidality. In the multivariate logistic regression model, the association of sleep dissatisfaction and depression with ADSA was high (adjusted odds ratio, 6.12; 95% confidence intervals, 4.61-7.95; and 5.44; 5.23-5.67, respectively). The prevalence of ADSA has decreased despite an increase in the prevalence of AD in Korean adolescents; however, it is important for pediatricians to screen for factors associated with ADSA to improve school attendance in adolescents with AD.

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

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

Sleep Disturbances in Children With Atopic Dermatitis: A Scoping Review

Atopic dermatitis (AD) is associated with various quality of life concerns including poor sleep. Sleep impairments in children with AD are associated with increased risk of short stature, metabolic syndrome, mental illness and neurocognitive dysfunction. Although the association between AD and sleep disturbance is well established, the specific types of sleep disturbance in pediatric AD patients and their underlying mechanisms are not fully understood. A scoping literature review was performed to characterize and summarize the types of sleep disturbance in children (less than 18 years of age) with AD. 31 papers met inclusion criteria and extracted data were analyzed in an iterative manner. Two types of sleep disturbances were found to be more prevalent in pediatric AD patients in comparison to controls. One category was related to loss of sleep (increased frequency or duration of awakenings, increased sleep fragmentation, delayed sleep onset, decreased total sleep duration, and decreased sleep efficiency). Another category was associated with unusual behaviors during sleep (restlessness/limb movement/scratching, sleep-disordered breathing including obstructive sleep apnea and snoring, nightmares, nocturnal enuresis and nocturnal hyperhidrosis). Some mechanisms underlying these sleep disturbances include pruritus and induced scratching and increased proinflammatory markers induced by sleep loss. Sleep disturbance appears to be associated with AD. We recommend clinicians to consider interventions that may reduce sleep disturbances in children with AD. Further investigation of these sleep disturbances is needed to elucidate pathophysiology, develop additional treatments, and reduce negative impacts on the health outcomes and quality of life in pediatric AD patients.

Objective Sleep in Atopic Dermatitis: A Meta-Analysis

Background: The evidence regarding objective sleep especially for the sleep architecture in atopic dermatitis (AD) was limited and not well summarized. Objective: To determine the objective sleep in AD patients as well as its confounders. Methods: We searched PubMed/Medline, Embase, and PsycInfo up to May 2021. Case-control studies or cohort studies that recruited AD patients and healthy controls and reported objective sleep parameters assessed by polysomnography or actigraphy were included. Results: A total of 7 studies with 173 AD patients and 122 controls were analyzed. Specifically, AD patients have significantly decreased total sleep time (TST, -13.797 minutes) and sleep efficiency (SE, -5.589%) accompanied by prolonged wake time after sleep onset (WASO, 29.972 minutes) and rapid eye movement sleep latency (31.894 minutes, all P < 0.05). Furthermore, subgroup analyses showed more WASO in severe AD subgroup compared with nonsevere AD subgroup (51.323 minutes vs 20.966 minutes, P = 0.032), less SE in male-majority subgroup compared with female-majority subgroup (-9.443% vs -4.997%, P = 0.018), and less TST in adult subgroup compared with child subgroup (-41.045 vs -4.016 minutes, P = 0.037). Conclusion: Objective sleep was worse in AD patients, especially among patients with severe AD, males, and adults. AD appears to more predispose difficulty in sleep maintenance rather than falling asleep.

Impact of Crisaborole on Sleep Outcomes in Pediatric Patients with Mild-to-Moderate Atopic Dermatitis

INTRODUCTION

Using data from three clinical trials, the effect of crisaborole treatment on sleep outcomes for pediatric patients with atopic dermatitis (AD) and their families was examined.

METHODS

This analysis comprised patients aged 2 to < 16 years from the double-blind phase 3 CrisADe CORE 1 (NCT02118766) and CORE 2 (NCT02118792) studies, families of patients aged 2 to < 18 years from CORE 1 and CORE 2, and patients aged 3 months to < 2 years from the open-label phase 4 CrisADe CARE 1 study (NCT03356977), all with mild-to-moderate AD who received crisaborole ointment 2% twice daily for 28 days. Sleep outcomes were assessed via the Children's Dermatology Life Quality Index and Dermatitis Family Impact questionnaires in CORE 1 and CORE 2 and the Patient-Oriented Eczema Measure questionnaire in CARE 1.

RESULTS

In CORE 1 and CORE 2, a significantly lower proportion of crisaborole-treated patients than vehicle-treated patients reported sleep disruption at day 29 (48.5% versus 57.7%, p = 0.001). The proportion of families whose sleep was affected by their child's AD in the preceding week was also significantly lower in the crisaborole group (35.8% versus 43.1%, p = 0.02) at day 29. At day 29 in CARE 1, the proportion of crisaborole-treated patients who experienced ≥ 1 night of disturbed sleep in the previous week decreased by 32.1% from baseline.

CONCLUSION

These results suggest that crisaborole improves sleep outcomes in pediatric patients with mild-to-moderate AD and their families.

Patient-reported outcomes for measuring sleep disturbance in pediatric atopic dermatitis: Cross-sectional study of the Patient Reported Outcomes Measurement Information System pediatric sleep measures and actigraphy

BACKGROUND

Most children with atopic dermatitis (AD) experience sleep disturbance, but reliable and valid assessment tools are lacking.

OBJECTIVES

To test the Patient-Reported Outcomes Measurement Information System (PROMIS) sleep measures in pediatric AD and to develop an algorithm to screen, assess, and intervene to reduce sleep disturbance.

METHODS

A cross-sectional study was conducted with children with AD ages 5 to 17 years and 1 parent (n = 61), who completed sleep, itch, and AD-specific questionnaires; clinicians assessed disease severity. All children wore actigraphy watches for a 1-week objective sleep assessment.

RESULTS

PROMIS sleep disturbance parent proxy reliability was high (Cronbach α = 0.90) and was differentiated among Patient-Oriented Eczema Measure (POEM)-determined disease severity groups (mean ± standard deviation in mild vs moderate vs severe was 55.7 ± 7.5 vs 59.8 ± 10.8 vs 67.1 ± 9.5; P < .01). Sleep disturbance correlated with itch (numeric rating scale, r = 0.48), PROMIS sleep-related impairment (r = 0.57), and worsened quality of life (Children's Dermatology Life Quality Index, r = 0.58), with all P values less than .01. Positive report on the POEM sleep disturbance question has high sensitivity (95%) for PROMIS parent proxy-reported sleep disturbance (T-score ≥ 60). An algorithm for screening and intervening on sleep disturbance was proposed.

LIMITATIONS

This was a local sample.

CONCLUSIONS

Sleep disturbance in pediatric AD should be screened using the POEM sleep question, with further assessment using the PROMIS sleep disturbance measure or objective sleep monitoring if needed.

Microbial derived antimicrobial peptides as potential therapeutics in atopic dermatitis

Atopic dermatitis (AD) is a common chronic inflammatory skin disease that significantly affects the patient's quality of life. A disrupted skin barrier, type 2 cytokine-dominated inflammation, and microbial dysbiosis with increased Staphylococcus aureus colonization are critical components of AD pathogenesis. Patients with AD exhibit decreased expression of antimicrobial peptides (AMPs) which is linked to increased colonization by Staphylococcus aureus. The skin microbiome itself is a source of several AMPs. These host- and microbiome-derived AMPs define the microbial landscape of the skin based on their differential antimicrobial activity against a range of skin microbes or their quorum sensing inhibitory properties. These are particularly important in preventing and limiting dysbiotic colonization with Staphylococcus aureus. In addition, AMPs are critical for immune homeostasis. In this article, we share our perspectives about the implications of microbial derived AMPs in AD patients and their potential effects on overlapping factors involved in AD. We argue and discuss the potential of bacterial AMPs as therapeutics in AD.

Reflectance Confocal Microscopy in Monitoring Atopic Dermatitis Treated with Topical Calcineurin Inhibitors

Atopic dermatitis is a chronic inflammatory skin disease associated with multiple allergies in the atopic march. It has a complex pathogenesis, related to genetic, immune, and environmental factors. Its incidence and prevalence are increasing in the last decades, especially in developed countries. It affects the quality of life due to the recurrent lesions and the associated pruritus. Thus, it is very important to use non-invasive techniques to manage and follow-up the patients with such a heterogenous disease that can have a high impact on some of them. The reflectance confocal microscope is a modern device for in vivo visualization of the epidermis and the upper dermis which could replace in some cases the cutaneous biopsy. We report a case of a patient with atopic dermatitis investigated with the confocal reflectance microscope at the beginning of the topical treatment with calcineurin inhibitors and three weeks after, with favorable evolution. Reflectance confocal microscopy allows the assessment of the dynamic changes in the skin during treatment. Moreover, it can be useful for highlighting discrete changes even in the subclinical stages of the inflammatory process. Future developments, which will lead to the definition and validation of reflectance confocal microscopy criteria for the diagnosis and staging of atopic dermatitis, could help to improve the treatment and prevention strategies of the disease.

Shedding Light on the Lifestyle and Participation of Portuguese Adolescents with Chronic Conditions—Data from the HBSC 2018 Study

Variables associated with lifestyle can constitute either risk or protective factors for the development and progression of chronic conditions (CC). This study intends to explore the differences between adolescents with and without CC and between adolescents whose school participation is affected/not affected by the existing CC with regard to variables related to lifestyle (i.e., sleep, physical activity, BMI, and leisure). In addition, it also intends to analyze the influence of these variables (i.e., CC and lifestyle) regarding the adolescents’ quality of life (QoL). This work is part of the Portuguese HBSC 2018 study. A total of 8215 adolescents participated (52.7% female), with an average age of 14.36 years (SD = 2.28). The results showed that the adolescents with CC and whose school attendance and participation are affected by their CC exhibit more sleep difficulties (i.e., they experience lower sleep quality and have a higher degree of sleepiness), higher BMI levels (i.e., higher values of overweight and obesity), less participation in leisure activities, and a lower perception of QoL. A higher perception of QoL is associated with school participation unaffected by the existing CC, sleeping well, a low level of sleepiness, a more frequent practice of physical activity, a lower BMI, and a greater involvement in leisure activities. Adolescent health and well-being are a prominent issue in terms of public policies, with behavior and lifestyle playing a significant role in this domain. This message needs to be reinforced in regard to families, educators, healthcare professionals, and public sector policies, particularly concerning students with CC.

Effects of Residential Environment and Lifestyle on Atopic Eczema Among Preschool Children in Shenzhen, China

Eczema, one of the most prevalent inflammatory skin diseases among children, is potentially influenced by genetic, environmental and social factors. However, few studies have investigated the effect of residential environment and lifestyle on childhood eczema. Therefore, this study conducted a cross-sectional study based on 2,781 preschool children in Shenzhen, China, during 2015–2016. Logistic regression models were employed to analyze the associations between residential/household environment, lifestyle, dietary habits and eczema in children. The prevalence of eczema among children in Shenzhen was 24.6%. Significant associations (increased odds >50%, P < 0.05) were found between childhood eczema and the factors of using composite wood floors (adjusted OR = 1.777 for doctor-diagnosed eczema, 1.911 for eczema-like symptoms), living in a villa/townhouse (aOR = 3.102, 2.156), the presence of mold or damp stains in the child's room (aOR = 1.807, 2.279), and rarely cleaning the child's room (aOR = 1.513, 1.540). In addition, watching TV/playing computer games for more than one hour per day was significantly associated with eczema (aOR = 1.172, 1.174). Notably, we found that eating rice/pasta one to three times per week may elevate the risk of eczema-like symptoms (aOR = 1.343), which warrants further investigation. In addition, ambient air pollution, in the covariates, may also affect childhood eczema. Therefore, avoiding these adverse factors and creating a low-risk environment are crucial to prevent childhood eczema.

Dupilumab Provides Rapid and Sustained Improvement in SCORing Atopic Dermatitis Outcomes in Paediatric Patients with Atopic Dermatitis

This post hoc analysis examined SCORing Atopic Dermatitis (SCORAD) outcomes in 471 paediatric patients (children age 6–<12 years, n = 304; adolescents age 12–<18 years, n = 167) with atopic dermatitis treated with dupilumab, ± topical corticosteroids, in two 16-week phase 3 randomized controlled trials and a 1-year interim data cut of a subsequent open-label extension study. Paediatric patients treated with dupilumab (± topical corticosteroids) had significantly lower SCORAD, objective SCORAD (o-SCORAD), and individual SCORAD components from week 3 to 16 compared with placebo (± topical corticosteroids) in the randomized controlled trials. The results were sustained or continuously improved over 1 year of open-label treatment with dupilumab ± topical corticosteroids. SCORAD-50 was achieved in almost all patients (91.3–91.8%) by week 52 with continued dupilumab treatment across age groups. Almost all (> 86%) patients achieved mild or absent pruritus and sleep loss at week 52. In conclusion, dupilumab ± topical corticosteroids resulted in rapid and significant improvements in all aspects of SCORAD analysed, and the results were sustained over 1 year.

Association between Serum Total and Specific Immunoglobulin E Levels and Body Height: A Cross-Sectional Study of Children and Adolescents

Background: The atopy rate in children has increased significantly. Atopy and growth are connected in a multifactorial manner and are important health issues for children around the world. The principal research question in this cross-sectional investigation concerned the association between serum total, specific immunoglobulin E (IgE) levels, and body height (BH)/weight (BW)/body mass index (BMI). Methods: A total of 993 subjects were enrolled for analysis retrospectively with allergic diseases and aged from 6 months to 18 years during the years 2015−2016. A complete panel of 36 allergen-specific IgE was taken from each participant using the MAST allergen test as well as their BH, BW, BMI, and total IgE levels. Results: There was a statistically significant positive association between the total IgE levels with BH (N = 348) and BW (N = 623) in the preschool age group (<6 years old, p-values of 0.009 and 0.034, respectively). In the preschool group, the total IgE levels showed a positive association with house dust (p < 0.001), cockroach mix (p < 0.001), Dermatophagoides farina (p < 0.001), and Dermatophagoides pteronyssinus (p < 0.001). After performing a general linear model followed by a backward selection of variables with age, sex, specific IgE, and total IgE, egg white sensitization demonstrated a significant negative association with BH (p = 0.009), and Dermatophagoides farina sensitization showed a significant positive association with BH (p = 0.006). The analysis showed that, in this model, the level of total IgE was not associated with BH. Conclusions: The results of this study indicate that the level of total IgE was not associated with BH in the preschool age group. Future studies are needed to replicate the results in outcome with follow-up allergic cohorts.

Sexual Dysfunction and Atopic Dermatitis: A Systematic Review

Atopic dermatitis (AD) is a chronic inflammatory disease of the skin whose main symptom is pruritus and may affect all age ranges. Regarding the prevalence, it has been estimated at around 10% of the world population. Many concomitant diseases have been associated with AD, but the causal relationship between AD and psychological impairment has not been clearly established. Scientific literature studying the probable association between male or female sexual dysfunction and dermatological pathology is limited, even more so in AD. This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines and the Cochrane Collaboration methodology for systematic reviews. All relevant articles in English were identified through a search from inception to 10 December 2020, including the following databases: Medline (via PubMed), Scopus, Web of Science Core Collection, and SciELO. The results of the search were compiled using the COVIDENCE software for systematic reviews. The methodological quality of the included studies was done using the “Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies” and the “Quality Assessment of Case-Control Studies” developed by the National Heart, Lung, and Blood Institute, National Institutes of Health (NIH). Our search yielded potentially relevant studies. Five studies that evaluated the prevalence of sexual dysfunction in atopic dermatitis were retrieved after applying the selection criteria. The present systematic review achieved data from 8088 patients with atopic dermatitis from four articles. Sample sizes for atopic dermatitis patients ranged from 266 to 3997. We identified one cohort study with four years of follow-up, three studies with a cross-sectional design, and one case-control study. Three studies reported data disaggregated by the severity of atopic dermatitis. Two studies included healthy controls with a total sample size of 1,747,755 subjects. Two studies compared data with other dermatological conditions such as psoriasis. In conclusion, we can establish that unlike other psychological comorbidities such as anxiety and depression, sexual dysfunction is a field scarcely explored in the literature. This sexual dysfunction focuses on the male sex in large population studies and in clinical diagnoses without exploring it through specific and validated questionnaires in this regard. Further studies focused on both genders are needed. It is important to correlate this sexual dysfunction with the severity of the disease, previous treatments, and cardiovascular comorbidities.

IGAxBSA composite for assessing disease severity and response in patients with atopic dermatitis

BACKGROUND

Accurate assessment of atopic dermatitis (AD) severity is critical when initiating and monitoring therapy. Use of existing research tools such as the Eczema Area and Severity Index (EASI) and the SCORing Atopic Dermatitis (SCORAD) is complex and time-consuming in clinical practice. A previous analysis found the product of validated Investigator Global Assessment (vIGA) and affected body surface area (BSA) to be an accurate and practical tool for routine assessment of paediatric AD.

OBJECTIVE

To evaluate IGAxBSA composite as an alternative to EASI or SCORAD for assessment of AD disease severity and disease responsiveness.

METHODS

The relationship between IGAxBSA, EASI, and SCORAD was assessed in a post-hoc analysis of pooled data from the dupilumab clinical trial programme in adult and paediatric patients with moderate-to-severe AD who had received dupilumab or placebo (with/without topical corticosteroids [TCS]).

RESULTS

Using datapoints from pooled dupilumab randomized controlled trials (n = 3473) and open-label extension (OLE) trials (n = 3045), we found that IGAxBSA correlated well with EASI and SCORAD, irrespective of treatment group and race (White/Asian/Black). IGAxBSA correlated better with objective measures (EASI, SCORAD) than with patient/caregiver-reported subjective measures. IGAxBSA correlated strongly with EASI and SCORAD in assessing disease change over time (r = 0.8973; r = 0.7649, respectively; P < 0.0001) and concordance between IGAxBSA-50/75/90 and EASI-50/75/90 was excellent (88-94%).

CONCLUSIONS

IGAxBSA is a valid alternative for assessment of AD disease severity and response over time, compared with EASI or SCORAD in patients with AD, irrespective of race.

Retrospective analysis of adverse events with dupilumab reported to the United States Food and Drug Administration

BACKGROUND

Atopic dermatitis (AD) is one of the most common inflammatory skin diseases and has aesthetic, physical, and emotional-social sequelae when left untreated.

OBJECTIVE

To classify the most common adverse reactions associated with dupilumab treatment in patients with AD.

METHODS

The United States Food and Drug Administration Adverse Event Reporting (FAERS) database was analyzed for common adverse reactions associated with dupilumab, topical pimecrolimus, and topical tacrolimus. Phase III clinical trial data were used to compare the rate of herpes infections between the treatment group and placebo group.

RESULTS

The most common adverse reaction associated with dupilumab was ocular complications. Herpes infections were extremely rare in the patients with AD being treated with dupilumab.

LIMITATIONS

Prescribing information for dupilumab, topical pimecrolimus, and topical tacrolimus is not available. Adverse effects are reported by patients, health care providers, and pharmaceutical companies, they have not been corroborated.

CONCLUSIONS

Ocular complications are the most common complication associated with dupilumab. The rate of herpes infection is low in patients being treated with dupilumab, topical pimecrolimus, and topical tacrolimus. There is no significant difference for the rate of herpes infection between, placebo, dupilumab, topical pimecrolimus, and the topical tacrolimus treatment group, suggesting that dupilumab does not affect herpes infection rates.

Risk factors for allergic diseases: a cross-sectional survey of 9,501 Chinese preschool-aged children

BACKGROUND

Childhood allergic diseases are increasing worldwide with unprecedented complexity and severity, and they cause a major burden on health and healthcare costs. We aimed to identify potential factors, both in isolation and in combination, associated with allergic diseases among preschool-aged children, and to construct a nomogram prediction model based on significant factors.

METHODS

We cross-sectionally recruited 9,501 preschool-aged children from 30 kindergartens in Beijing and Tangshan. Allergic diseases were ascertained according to the "International Study of Asthma and Allergies in Childhood" questionnaire. Risk for allergic diseases is quantified by odds ratio (OR) with 95% confidence interval (CI).

RESULTS

Four factors were identified to be independently, consistently, and significantly associated with the risk for allergic diseases overall and by four clinical manifestations separately, including bedtime (per 1 hour late) (taking asthma/wheezing as an example, OR, 95% CI, P: 1.21, 1.08 to 1.35, 0.001), outdoor activities ≤1.5 h per day (1.45, 1.26 to 1.68, 3.77E-07), family history of allergic diseases (2.23, 1.92 to 2.60, 0.00E+00), and antibiotic use during childhood (3.64, 2.44 to 5.42, 1.66E-10). Further analyses revealed that family history of allergic diseases acted with antibiotic use during childhood in an additive manner. For practical reasons, risk prediction nomogram models were constructed for allergic diseases respectively in Beijing and Tangshan based on significant and conventional factors, and the prediction accuracy was good, with the C-index 69% in Tangshan and 68% in Beijing (both P=0.00E+00).

CONCLUSIONS

Our findings identified four factors in significant association with the risk for allergic diseases, and in particular family history of allergic diseases and antibiotic use during childhood acted additively.

Sleep Disturbance in School-Aged Children with Atopic Dermatitis: Prevalence and Severity in a Cross-Sectional Sample

BACKGROUND

Atopic dermatitis (AD) causes sleep disturbance but the epidemiology is not known.

OBJECTIVE

To estimate the US prevalence of sleep disturbance and its impact on psychological and neurocognitive function.

METHODS

We conducted a cross-sectional survey of 180 parent-child dyads with AD using stratified sampling based on disease severity (Patient Oriented Eczema Measure: mild [n = 30), moderate (n = 75) or severe (n = 75]), age, and race (White or Black or African American or other). Symptoms of sleep and psychologic health were assessed using the Patient-Reported Outcome Measurement Information System. To estimate the prevalence of sleep disturbance, we calculated weights using poststratification adjustment making marginal frequencies of AD severity, race, and age similar to marginal frequencies in the 2007 National Survey of Children's Health. Unweighted regression models examined associations with sleep disturbance.

RESULTS

In children age 5 to 17 years with AD, we estimated that sleep disturbance occurred in 66.9% (95% confidence interval, 53.3% to 80.5%; 3,116,305 children). The odds of severe sleep disturbance (worse than 95% of US children) were highest in moderate to severe versus mild AD (2.03 [1.00-4.10]; P = .0495; compared with 8.68 [1.82-41.49]; P = .0068). Predictors of parent proxy-reported sleep disturbance were itch intensity (adjusted β [95% confidence interval] 1.33 [0.62-2.04]) and low income (<$50,000: 6.64 [2.05-11.23]; and $50,000 to less than 100,000: 4.75 [0.35-9.14]). Controlling for disease severity, itch intensity, and significant sociodemographics-parent-proxy, reported sleep disturbance was associated with increased severity of sleep-related impairment, depression, fatigue, and anxiety, in addition to worse inattention and impulsivity. In fully adjusted models, children who self-reported sleep disturbance (T-score ≥60) had increased odds of sleep-related impairment (1.20 [1.11-1.29]), depression (1.13 [1.03, 1.24]), fatigue (1.28 [1.06-1.54]), and anxiety (1.16 [1.02-1.31]).

CONCLUSIONS

Sleep disturbance is a common symptom of AD. It affects about 3 million US children and is associated with neuropsychiatric impairment, including depression, anxiety, and inattention. Clinicians should screen for these symptoms in school-aged children, particularly those with moderate to severe AD.

Characteristics associated with clinical response to Comano thermal spring water balneotherapy in pediatric patients with atopic dermatitis

BACKGROUND

Several studies have investigated the efficacy of balneotherapy in atopic dermatitis (AD), including a pediatric open randomized clinical trial conducted at the Comano thermal spring water center, which showed a significant reduction in AD severity and an improvement of the quality of life. However, so far many studies on balneotherapy in pediatric AD have included relatively small populations without identifying patients' characteristics associated with their response. The aim of the present study was to identify any features associated with the clinical response to the Comano thermal spring water balneotherapy in a large cohort of pediatric AD patients.

METHODS

An observational study was conducted on 867 children aged ≤16 years (females 50.5%, mean patient's age 5.9 years, standard deviation ±3.6 years) with mild to severe AD who underwent balneotherapy at the Comano thermal spring water center (Comano, Trentino, Italy) from April to October 2014. Patients were stratified according to their disease severity, which was evaluated using five SCORing Atopic Dermatitis (SCORAD) categories before and immediately after a thermal spring water balneotherapy course. Potential characteristics associated with the patients' clinical response to Comano thermal spring water balneotherapy were investigated.

RESULTS

A statistically significant improvement in AD severity was observed after Comano thermal spring water balneotherapy (p < 0.0001). A significantly higher percentage of patients achieving improvement in AD severity was reported among children ≤4 years old (p < 0.0001) with early-onset AD (p < 0.0001), severe AD (p < 0.0001) or coexistent reported food allergies (p < 0.01). The therapy was well tolerated, and no relevant adverse effects were reported during the treatment course.

CONCLUSIONS

Comano thermal spring water balneotherapy is a safe complementary treatment for pediatric patients with AD, as it was able to reduce the disease severity, especially in children ≤4 years old, with early onset AD, severe AD or concomitant food allergies.

A skin-conformable wireless sensor to objectively quantify symptoms of pruritus

Itch is a common clinical symptom and major driver of disease-related morbidity across a wide range of medical conditions. A substantial unmet need is for objective, accurate measurements of itch. In this article, we present a noninvasive technology to objectively quantify scratching behavior via a soft, flexible, and wireless sensor that captures the acousto-mechanic signatures of scratching from the dorsum of the hand. A machine learning algorithm validated on data collected from healthy subjects (n = 10) indicates excellent performance relative to smartwatch-based approaches. Clinical validation in a cohort of predominately pediatric patients (n = 11) with moderate to severe atopic dermatitis included 46 sleep-nights totaling 378.4 hours. The data indicate an accuracy of 99.0% (84.3% sensitivity, 99.3% specificity) against visual observation. This work suggests broad capabilities relevant to applications ranging from assessing the efficacy of drugs for conditions that cause itch to monitoring disease severity and treatment response.

Sleep Disturbances and Atopic Dermatitis: Relationships, Methods for Assessment, and Therapies

Atopic dermatitis is one of the most common chronic inflammatory skin conditions and is associated with sleep disturbances in 47% to 80% of children and 33% to 90% of adults. Herein, we review the literature on sleep disturbances experienced by patients with atopic dermatitis, as well as the mechanisms that may underlie this. We present subjective and objective methods for measuring sleep quantity and quality and discuss strategies for management. Unfortunately, the literature on this topic remains sparse, with most studies evaluating sleep as a secondary outcome using subjective measures. The development of portable, at-home methods for more objective measures offers new opportunities to better evaluate sleep disturbances in atopic dermatitis research studies and in clinical practice.

Sleep and Limb Movement Characteristics of Children With Atopic Dermatitis Coincidentally Undergoing Clinical Polysomnography

STUDY OBJECTIVES

Atopic dermatitis (AD) is a prevalent, chronic, itchy skin condition. Children undergoing polysomnography (PSG) may coincidentally have AD. Many children with AD have sleep disturbances. Our study aimed to characterize limb movements in children with AD and their effect on sleep.

METHODS

A retrospective chart review was conducted for children who underwent comprehensive attended PSG and had AD. PSG sleep parameters were compared to published normative data. A subset of patients with markedly elevated total limb movements was further compared to a matched group of patients with a diagnosis of periodic limb movement disorder (PLMD) and no history of AD.

RESULTS

There were 34 children with AD 6.36 ± 3.21 years (mean ± standard deviation), 50% female and with mild to moderate AD. There was increased wake after sleep onset (WASO = 46.0 ± 37.8 minutes), sleep onset latency (46.5 ± 53.0 minutes) and total limb movement index (13.9 ± 7.5 events/h) compared to normative values. Although our cohort was mostly mild AD, 7 of the 34 children with AD (20%) had a total limb movement index during sleep > 15 events/h. Increased total limb movements in PLMD versus patients with AD was most notable during stage N2 sleep (38 ± 17 versus 22 ± 7, P = .01, respectively).

CONCLUSIONS

We found altered PSG parameters in children with AD, suggesting that clinicians should consider the diagnosis when affected children undergo PSG. Although our AD cohort was mild, we still determined a need to consider AD when diagnosing PLMD given the presence of elevated total limb movements in children with AD.

CITATION

Treister AD, Stefek H, Grimaldi D, Rupani N, Zee P, Yob J, Sheldon S, Fishbein AB. Sleep and limb movement characteristics of children with atopic dermatitis coincidentally undergoing clinical polysomnography. J Clin Sleep Med. 2019;15(8):1107-1113.

Sleep Apnea and Skin

Purpose of the Review

Skin disease is associated with obstructive sleep apnea (OSA) both epidemiologically and mechanistically. In this review we highlight conditions which have a well-established link to obstructive sleep apnea, such as psoriasis and atopic dermatitis.

Recent findings

We describe putative mechanistic links between OSA and skin disease involving inflammatory pathways, obesity, mechanical upper airways obstruction, and hypoxia. In the context of these mechanisms we describe specific skin conditions, and other conditions which are associated with both skin manifestations (including hair/nail findings) and OSA. The risks/ benefits of CPAP in the context of skin disease are also reviewed.

Summary

We conclude that further research is needed to understand the mechanisms behind the associations between OSA and skin disease. Given the frequent co-occurrence of OSA and skin conditions, there would be great benefit for OSA clinical trials to consider improvement in skin disease as an outcome measure.

Ameliorative and Synergic Effects of Derma-H, a New Herbal Formula, on Allergic Contact Dermatitis

Allergic contact dermatitis (ACD) is characterized by itching, skin inflammation, and allergic responses caused by release of immunoglobulin E and T helper 2-specific cytokines. The aim of this study is to investigate the ameliorative and synergic effects of herbal formula, Derma-H, containing Astragalus membranaceus Fisch. ex Bunge (AM) and Nepeta tenuifolia Benth (NT) which have been used as traditional medicinal herbs for the cure of dryness, edema, and pruritus. 2,4-Dinitrochlorobenzene (DNCB) was applied for ACD induction. AM, NT, and a mixture of AM and NT was topically applied to skin lesions for 11 days. Dermatitis score and number of scratches were significantly diminished in AM, NT, and AM + NT (Derma-H)-treated groups. Especially, Derma-H was more effective than single treatment of AM and NT on skin hyperplasia and mast cell infiltration. Also, NGF expression decreased by NT and a mixture of AM and NT. Additionally, series of TrkA, Raf-1, MEK, and ERK were significantly inhibited by topical AM and NT application. Those findings suggested AM and NT treatment has a synergic effect on DNCB-induced ACD in mice.

Unraveling the Relationship Between Itching, Scratch Scales, and Biomarkers in Children With Alagille Syndrome

Pruritus is a debilitating symptom for patients with Alagille syndrome (ALGS). In a previously reported trial of maralixibat, an investigational antipruritic agent, itching was assessed using a digital diary based on twice‐daily caregiver observation of itching severity (Itch Reported Outcome, ItchRO[Observer]). The goal of this study was to characterize pruritus in participants with ALGS at baseline in this trial, as assessed by the ItchRO instrument and the physician‐observed clinician scratch scale (CSS), relative to biomarkers putatively associated with pruritus and health‐related quality of life assessment. Thirty‐seven participants with ALGS (median age of 6 years; range 1‐17 years) were enrolled. No association was identified between CSS and ItchRO(Obs) (r = 0.22, P = 0.2). Neither CSS nor ItchRO were associated with serum bile acids (r = −0.08, P = 0.6 for both) or autotaxin (r = 0.22, P = 0.2; r = 0.28, P = 0.12). There was no significant association between Pediatric Quality of Life Inventory total parent scores and CSS or ItchRO (r = −0.23, P = 0.2; r = −0.16, P = 0.36). There was a significant association between ItchRO and Multidimensional Fatigue Scale and Family Impact Module total scores (Pearson correlation coefficient −0.575, P = 0.0005; 0.504, P = 0.002). In exploratory analysis, selected questions relating to fatigue and sleep disturbance (n = 12) from Pediatric Quality of Life Inventory, Multidimensional Fatigue Scale, and Family Impact Module were correlated with pruritus scores; positive associations were identified. Conclusion: Itching scores did not correlate with each other, nor with putative serum biomarkers of pruritus, and further, did not correlate with quality of life. Hypothesis‐generating analyses implicate sleep disturbance and fatigue as key associations with caregiver observations of itching. This is highly relevant to the selection of surrogate endpoints for clinical trials of pruritus therapies.

Product of Investigator Global Assessment and Body Surface Area (IGAxBSA): A practice-friendly alternative to the Eczema Area and Severity Index to assess atopic dermatitis severity in children

BACKGROUND

Accurately documenting pediatric atopic dermatitis (AD) severity is important, but research tools, such as Eczema Area and Severity Index (EASI), are too time consuming for clinical settings. Product of the Physician Global Assessment and affected percentage of body surface area (PGA×BSA) is a new, rapid measure of psoriasis severity.

OBJECTIVE

To evaluate an Investigator Global Assessment and body surface area product (IGA×BSA) as an easy-to-use severity measure for pediatric AD.

METHODS

Patient-reported and objective disease severity measures were collected from 195 caretaker/child dyads (child age range, 5-17 years) with almost clear (Validated Investigator Global Assessment for AD [vIGA] of 1) to severe (vIGA of 4) AD. Data were assessed with Spearman coefficients and plots. Severity strata were proposed by using an anchoring approach based on the EASI.

RESULTS

IGA×BSA correlates better with the EASI than IGA alone (r = 0.924 vs r = 0.757, P < .001). Bland-Altman plot indicates high and consistent agreement between IGA×BSA and the EASI. Suggested severity strata for IGA×BSA are 0-30, mild; 30.1-130, moderate; and 130.1-400, severe (κ = 0.760).

LIMITATIONS

The patient cohort was predominantly from the midwestern United States.

CONCLUSIONS

IGA×BSA (using the vIGA) is a simple measure that correlates well with the EASI in patients with mild to severe pediatric AD. Future work is needed to affirm reliability across IGA scales and responsiveness to change.

Allergic Disease, Short Sleep Duration, and Suicidal Ideation and Plans Among Korean Adolescents

The purpose of the study is to identify the relationships between allergic disease, suicidal ideation, and plans among Korean adolescents. Additionally, we examined the mediating role of short sleep duration. We analyzed nationally representative cross-sectional data from the 12th to 14th Korea Youth Risk Behavior Web-Based Survey; the final sample included 164,725 middle school-aged and high school-aged adolescents (mean age = 15.17 years, standard deviation = .13; 51.1% male). Allergic disease was a statistically significant risk factor for suicidal ideation (crude odds ratio [COR] = 1.284, 95% confidence interval [CI] = [1.246, 1.323]) and suicide plans (COR = 1.165, 95% CI = [1.108, 1.224]). Short sleep duration was a statistically significant mediator (p < .001). We advised school nurses to assess warning signs of poor sleep-including irritability, depression, sleep problems, poor concentration, and poor academic achievement-and that programs be created to improve sleep and mental health in adolescents with allergic disease.

Evaluation of factors that may affect disease development and severity in childhood atopic dermatitis

BACKGROUND

Atopic dermatitis is a chronic, relapsing, inflammatory disease. Data concerning the role of perinatal conditions in the development of the disease are few and inconsistent. The purpose of this study was to investigate the effects of skin care on the severity of the disease, also to evaluate the relations of perinatal conditions with disease development and severity.

METHODS

Seventy-five patients with atopic dermatitis aged 2-10 years, their parents and 65 healthy age-compatible volunteers and their parents were included in the study. The Scoring Atopic Dermatitis (SCORAD) score was used to assess the severity of the disease.

RESULTS

Emollient use (regular/irregular) was higher in patients with severe disease compared to those with mild and moderate disease, but no significant difference was determined in regular use rates (P=0.029, and P=0.504, respectively). Topical corticosteroid use and sleep disturbance rates in the previous three months in the subjects regularly using emollients were low (P=0.032, and P=0.005, respectively). The incidence of severe disease was higher in the patients born in the winter (P=0.033). Severe disease rates were significantly high in the subjects in the patient group with advanced maternal age, a history of cesarean delivery and incubator use (P=0.017, P=0.046, and P=0.025, respectively).

CONCLUSIONS

Low topical corticosteroid requirement and sleep disturbance rates in the subjects regularly using moisturizers emphasize the importance of emollient use in treatment. The association of cesarean delivery, history of incubator, and birth in winter with severe disease suggests that disease severity is related to less exposure to environmental allergens in the hygiene hypothesis.

Update on Atopic Dermatitis: Diagnosis, Severity Assessment, and Treatment Selection

Atopic dermatitis (AD) is one of the most common inflammatory skin diseases affecting children and adults. The intense pruritus and rash can be debilitating, significantly impairing quality of life. Until recently, treatment was largely nonspecific and, in severe disease, sometimes ineffective and/or fraught with many side effects. Now, multiple agents targeting specific disease pathways are available or in development. Two new therapies, crisaborole and dupilumab, have become available since 2016, and dupilumab has dramatically improved outcomes for adults with severe AD. This article provides an overview of AD, including strategies for differential diagnosis and assessment of disease severity to guide treatment selection. Key clinical trials for crisaborole and dupilumab are reviewed, and other targeted treatments now in development are summarized. Two cases, representing childhood-onset and adult-onset AD, are discussed to provide clinical context for diagnosis, severity assessment, and treatment selection and outcomes.

Approach to the Assessment and Management of Pediatric Patients With Atopic Dermatitis: A Consensus Document. Section I: Overview of Pediatric Atopic Dermatitis

Pediatric atopic dermatitis (AD) is one of the most common dermatoses encountered by health-care providers treating children. Diagnosis of AD is clinical, with no universally accepted biomarkers or assessment tools. Patient-reported outcomes and subjective assessments of quality of life in both the patient and family are important considerations when treating pediatric AD. Here, we provide an overview of pediatric AD epidemiology, its clinical presentation, burden, diagnosis, and assessment, with a focus on implications for patient counseling in order to optimize care.

Mental health impairment among children with atopic dermatitis: A United States population-based cross-sectional study of the 2013-2017 National Health Interview Survey

BACKGROUND

Atopic dermatitis (AD) is associated with mental health disorders, but its impact on global mental health symptoms is less clear.

OBJECTIVE

To determine the association between pediatric AD and mental health impairment.

METHODS

In a cross-sectional study using 2013-2017 United States National Health Interview Survey data, children with and without AD were assessed for mental disorder with impairment (MDI) using a validated behavioral screening questionnaire. Mental health services utilization was also reported.

RESULTS

The prevalence of any MDI was 26.7% (95% confidence interval [CI], 25.1-28.3) among children with AD and 17.7% (95% CI, 17.2-18.2) among those without AD, with severe MDI being present in 10.9% (95% CI 9.9-12.1) and 6.2% (95% CI 5.9-6.5), respectively. Adjusted for sociodemographic factors, AD was associated with higher odds of MDI (odds ratio, 1.52; 95% CI, 1.39-1.67), including impairments in conduct, emotions, peer relationships, and attention. Among children with AD, 19.9% (95% CI, 16.6-23.8) and 53.5% (95% CI, 48.5-58.5) of those with mild or severe MDI, respectively, had seen a mental health professional in the last year.

LIMITATIONS

Misclassification bias may arise from self-reported data.

CONCLUSION

AD is associated with clinically significant mental health symptoms, but many affected children may not seek or receive care for their symptoms.

Systematic Review and Meta-analysis Comparing Topical Corticosteroids With Vehicle/Moisturizer in Childhood Atopic Dermatitis

PROBLEM

To determine the safety and efficacy of topical corticosteroid versus vehicle/moisturizer in children under 2 years old (<2 y).

ELIGIBILITY CRITERIA

A systematic review and meta-analysis searching PubMed MEDLINE, Embase, Web of Science, Cochrane Database of Controlled Trials, Cochrane Database of Systematic Reviews, DARE, NHS Economic Evaluation, CINAHL, GREAT, and Clinicaltrials.gov. We selected randomized controlled trials (RCTs) comparing topical corticosteroids to vehicle/moisturizer and included children <2 y. Two authors extracted data.

SAMPLE

Only one study limited analyses to children <2 y, so our review included participants older than 2 years. Twelve RCTs were included with 2224 participants. Ten studies were industry-sponsored.

RESULTS

The proportion of responders to topical corticosteroid across studies was 0.65 (95% CI, 0.54-0.74), as compared to vehicle/moisturizer 0.32 (95% confidence interval (CI), 0.20-0.48). The proportion of adverse events were similar between groups (topical steroids 0.17 (95% CI, 0.08-0.33) vs. vehicle/moisturizer 0.12 (CI 0.02-0.42)). High heterogeneity in treatment response occurred across studies that could not be explained by potential moderators. Mild adrenal suppression occurred in 4 of 157 measured participants (3%) receiving topical corticosteroids. Limitations include the few RCTs on this topic, the inclusion of participants >2 y and outcome measures and reporting methods rarely met CONSORT guidelines.

CONCLUSIONS

Topical corticosteroids trended to being more effective and equally safe to vehicle/moisturizers, but generalizability is limited given the dearth of well-designed studies focused on children <2 y. Adverse events from vehicle/moisturizer may be greater than topical corticosteroid due to under treatment.

IMPLICATIONS

Further work is needed in this age group.

Association of Atopic Dermatitis With Sleep Quality in Children

Importance

Pruritus, a hallmark of atopic dermatitis (AD), is thought to disrupt sleep, yet little is known about how variations in disease activity and severity of this common childhood condition may be associated with sleep patterns over time.

Objective

To determine whether children with active AD have impaired sleep duration and quality at multiple time points throughout childhood and whether disease severity affects sleep outcomes.

Design, Setting, and Participants

This longitudinal cohort study used data of children enrolled in the Avon Longitudinal Study of Parents and Children, a population-based birth cohort in Avon, United Kingdom. Participants were children (N = 13 988) alive at 1 year and followed up with repeated measures of self-reported AD and sleep through 16 years of age. This study was based on data collected from 1990 to 2008. Data analysis was performed from September 2017 to September 2018.

Main Outcomes and Measures

Standardized measure of sleep duration and composite measure of sleep quality, including nighttime awakenings, early morning awakenings, difficulty falling asleep, and nightmares, were repeated at multiple time points between 2 and 16 years of age.

Results

The study sample comprised 13 988 children (7220 male [51.6%]) followed up for a median (interquartile range [IQR]) duration of 11 (5-14) years. Of this total, 4938 children (35.3%) met the definition of having atopic dermatitis between 2 and 16 years of age. Total sleep duration was similar between children with active AD and without AD at all ages, and the average estimated difference across childhood was a clinically negligible difference of 2 minutes less per day for children with AD (95% CI, -4 to 0 minutes). In contrast, children with active AD were more likely to report worse sleep quality at all time points, with a nearly 50% higher odds of experiencing more sleep-quality disturbances (adjusted odds ratio [aOR], 1.48; 95% CI, 1.33 to 1.66). Children with more severe active disease (quite bad or very bad AD: aOR, 1.68; 95% CI, 1.42 to 1.98) and with comorbid asthma or allergic rhinitis (aOR, 1.79; 95% CI, 1.54 to 2.09) had worse sleep quality. However, even children with mild AD (OR, 1.40; 95% CI, 1.27 to 1.54) or inactive AD (OR, 1.41; 95% CI, 1.28 to 1.55) had statistically significantly increased odds of impaired sleep quality.

Conclusions and Relevance

Atopic dermatitis appeared to be associated with impaired sleep quality throughout childhood; thus, it is suggested that clinicians should consider sleep quality among all children with AD, especially those with comorbid asthma or allergic rhinitis and severe disease, and that interventions to improve sleep quality are needed.

Neurocognitive function in moderate-severe pediatric atopic dermatitis: A case-control study

BACKGROUND/OBJECTIVES

Epidemiological studies have shown an increased prevalence of attention deficit hyperactivity disorder (ADHD) in children with atopic dermatitis (AD), but many of the features of ADHD may occur as a result of the poor sleep and itch distraction associated with AD.

METHODS

A case-control study was performed in children aged 6-17 years with moderate/severe AD compared with age-/sex-matched healthy controls. Participants were screened for ADHD using Vanderbilt assessments.

RESULTS

Seventeen patients with AD and 18 controls completed the study. Two children with AD (11.7%) and one control (5.56%) met screening criteria for ADHD via parent-completed Vanderbilt assessments; AD patients were not significantly more likely to screen positive for ADHD (P = 0.47), or comorbid behavior disorders (P = 0.23). However, AD patients were more likely than controls to exhibit ADHD-associated behaviors, most significantly inattention.

CONCLUSIONS

Our AD cohort did not have a significantly increased prevalence of ADHD. Certain neurocognitive symptoms are increased in children with moderate-to-severe AD compared to controls.

Associations of Eczema Severity and Parent Knowledge With Child Quality of Life in a Pediatric Primary Care Population

We investigated factors associated with quality of life (QOL) in children with eczema. We conducted a cross-sectional analysis of survey data from 224 parents of children with eczema attending a large, hospital-based pediatric clinic. Parents completed a validated eczema severity scale (Patient-Oriented Eczema Measure), a QOL scale (Infants' Dermatitis QOL Index or Children's Dermatology Life Quality Index), and a knowledge and understanding questionnaire. In adjusted multivariate analyses, worse eczema severity was associated with worse overall QOL (β = 0.5; 95% confidence interval [CI] = [0.5, 0.6]), while a higher knowledge score was associated with better QOL (β = -3.4; 95% CI = [-6.6, -0.2]). Similarly, even after adjustment for eczema severity, greater understanding of a child's individual treatment plan was associated with better QOL (β = -0.7; 95% CI = [-1.4, -0.08]), while increased frequency of worrying about a child's eczema was associated with worse QOL (β = 0.7; 95% CI = [0.03, 1.1]). These results suggest primary care providers may be able to influence QOL through optimal eczema management and family education.

Recent Developments in Atopic Dermatitis

Atopic dermatitis (AD) is a bothersome and common skin disease affecting ∼10.7% of children in the United States. This skin condition significantly decreases quality of life in not only patients, but in their families as well. Pediatricians are often the first physicians to diagnose and manage these patients and thus are relied on by families to answer questions about this disease. AD is complex, multifactorial, and has historically had limited therapeutic options, but the landscape of this disease is now rapidly changing. Pathways contributing to the pathogenesis of this disease are continually being discovered, and new therapies for AD are being developed at an unprecedented rate. With this article, we will review the current guidelines regarding the management of AD, outline updates in the current understanding of its pathophysiology, and highlight novel developments available for the treatment of this burdensome disease.