Atopic dermatitis is associated with osteoporosis and osteopenia in older adults

The Fracture Risk of Elderly Patients With Atopic Dermatitis

Background: A higher fracture risk has been reported previously in patients with atopic Dermatitis (AD). The bone mineral density (BMD) was not accounted for in these studies. Objective: To investigate the fracture risk in AD patients after adjustment for factors including BMD. Methods: We retrospectively analyzed AD patients (≥45 years) who underwent BMD examination at our hospital from July 2010 to February 2023. Individuals who received BMD examinations during a health checkup were identified as the controls. We documented their clinical characteristics, BMD, 10-year risk for a major fracture based on FRAX (Fracture Risk Assessment Tool), and development of osteoporotic fractures. Patients were followed until development of new onset fracture or the end of the study period. A cross-sectional comparison of BMD between AD patients and controls at baseline was performed using the Mann-Whitney U test after propensity score matching (PSM). Their fracture risks were compared using the multivariate Cox regression model. BMD and fracture risk were also compared between AD patients who received systemic therapy and those who did not. Results: A total of 50 AD patients and 386 controls were enrolled. The median age was older in AD patients when compared with controls (70 years vs 60 years). Their BMD at all sites was similar after PSM. After a median follow-up of 1.7-2.0 years, 13 osteoporotic fractures were identified. In the multivariate Cox regression analysis, AD was not associated with new onset fractures of all sites (adjusted hazard ratio [aHR] 2.55, 95% confidence interval [CI] 0.72-9.01) but was significantly associated with new onset vertebral fractures (aHR 6.80, 95% CI 1.77-26.17). The BMD and incidence of fractures were similar between AD who received systemic therapy and those who did not. Conclusions: Elderly AD patients had similar BMD but a higher short-term risk for vertebral fractures when compared with the controls.

Association Between Atopic Dermatitis and Aging: Clinical Observations and Underlying Mechanisms

As one of the most prevalent chronic inflammatory skin diseases, atopic dermatitis (AD) increasingly affects the aging population. Amid the ongoing global aging trend, it's essential to recognize the intricate relationship between AD and aging. This paper reviews existing knowledge, summarizing clinical observations of associations between AD and aging-related diseases in various systems, including endocrine, cardiovascular, and neurological. Additionally, it discusses major theories explaining the correlation, encompassing skin-mucosal barriers, systemic inflammation and stress, genes, signal transduction, and environmental and behavioral factors. The association between AD and aging holds significant importance, both in population and basic perspectives. While further research is warranted, this paper aims to inspire deeper exploration of inflammation/allergy-aging dynamics and the timely management of elderly patients with AD.

Considerations for managing elderly patients with atopic dermatitis

INTRODUCTION

Atopic dermatitis (AD) diagnosis in elderly is challenging, due to its clinical polymorphism and the lack of diagnostic biomarkers. Moreover, the chronicity of the disease and the complex pathogenetic mechanism, make elderly AD management challenging.

AREAS COVERED

A narrative review of the current literature was performed using the PubMed, Medline, Embase, and Cochrane Skin databases, by researching the following terms: 'atopic dermatitis,' 'clinical phenotypes,' 'eczema,' 'elderly patients,' 'elderly type atopic dermatitis,' 'eczema clinical presentation.' The aim was to report the current knowledge on pathogenesis, clinical presentation, and treatment options of elderly AD.

EXPERT OPINION

Elderly type AD has recently been identified as a separate entity, with an increasing prevalence. With aging, both immunosenescence and barrier alterations can cause or modify AD presentation. Moreover, a chronic proinflammatory state (so-called 'inflammaging') is often present in elderly subjects. Older patients with AD may present with peculiar immunophenotypic profile, making AD diagnosis challenging. Similarly, the chronicity of the disease and the complex pathogenetic mechanism, make AD management a challenge. Indeed, systemic therapies for AD are often contraindicated or not tolerated and the management of elderly type AD is often burdened with numerous difficulties, leading to undertreated disease. Even if dupilumab and tralokinumab represent a valuable therapeutic weapon, more data on safety of JAK inhibitors are required.

Fracture risks and their mechanisms in atopic dermatitis, focusing on receptor activator of nuclear factor kappa-B ligand

Recent multiple studies have shown that the long-term consequences of atopic dermatitis (AD) include an increased risk of osteoporosis and fracture, especially an increase in hip, pelvic, spinal and wrist fractures. AD is very common worldwide, and some kinds of fractures, such as hip fractures, are associated with increased mortality, which has a substantial socioeconomic impact; however, the precise mechanisms for this remain unclear. Receptor activator of nuclear factor kappa-Β (RANK) ligand (RANKL) and osteoprotegerin (OPG) are members of the tumour necrosis factor ligand and receptor family, members of which also are known as bone biomarkers. Alterations in the RANKL/RANK/OPG system and the balance among these factors (represented by the RANKL/OPG ratio) are central to the pathogenesis of bone loss from osteoporosis, and it is postulated that there is a potential association between the serum levels of RANKL and OPG, and bone density or fracture. Recently, our research group demonstrated that the serum RANKL/OPG ratio positively correlated with AD severity and suggests fracture risk in older women with AD. This review summarizes and discusses the risk and mechanisms of osteoporotic fracture in AD. RANKL may be involved in the pathogenesis of AD, regarding not only bone abnormality but also inflammation. Although further investigation will be needed to verify the hypotheses, recent findings may provide new insights into the pathogenesis of AD and therapeutic targets.

Single-cell RNA-Seq analysis of diabetic wound macrophages in STZ-induced mice

The crucial role of macrophages in the healing of chronic diabetic wounds is widely known, but previous in vitro classification and marker genes of macrophages may not be fully applicable to cells in the microenvironment of chronic wounds. The heterogeneity of macrophages was studied and classified at the single-cell level in a chronic wound model. We performed single-cell sequencing of CD45 + immune cells within the wound edge and obtained 17 clusters of cells, including 4 clusters of macrophages. One of these clusters is a previously undescribed population of macrophages possessing osteoclast gene expression, for which analysis of differential genes revealed possible functions. We also analysed the differences in gene expression between groups of macrophages in the control and diabetic wound groups at different sampling times. We described the differentiation profile of mononuclear macrophages, which has provided an important reference for the study of immune-related mechanisms in diabetic chronic wounds.

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.

Association of Adult Atopic Dermatitis Severity With Decreased Physical Activity: A Cross-sectional Study

BACKGROUND

Atopic dermatitis (AD) is associated with chronic pruritus, skin pain, sleep deprivation, depression, and anxiety, which may lead to decreased physical activity (PA).

OBJECTIVE

The aim of the study is to elucidate the impact of disease and itch severity on PA in adult AD.

METHODS

This is a prospective dermatology practice-based study of 955 AD patients (ages 18-97 years).

RESULTS

In multivariable logistic regression models controlling for age, sex, race/ethnicity, and asthma history, patient-reported global AD severity (PtGA), Patient-Oriented Eczema Measure, Eczema Area and Severity Index (EASI), and Investigator's Global Assessment (IGA) were associated with itch impairing light PA, moderate PA, and vigorous PA, as well as higher Patient-Reported Outcomes Measurement Information System Itch Questionnaire PA T-scores. Higher objective Scoring AD (O-SCORAD) was associated with itch impairing moderate PA. In bivariable analyses, performing greater than or equal to 30 minutes of light PA greater than or equal to 1 day a week was decreased with higher PtGA, Patient-Oriented Eczema Measure, and EASI; greater than or equal to 30 minutes of moderate PA greater than or equal to 1 day a week was decreased with PtGA, EASI, O-SCORAD, and IGA; and greater than equal to 30 minutes of vigorous PA was decreased with patient-reported AD severity, EASI, O-SCORAD, and IGA. In multivariable logistic regression models, the impact of itch on PA was inversely associated with light PA, moderate PA, and vigorous PA.

CONCLUSION

Adult AD patients with more severe disease have decreased levels of PA secondary to itch.

Evaluating the Longitudinal Course of Atopic Dermatitis: Implications for Clinical Practice

Atopic dermatitis (AD) is characterized by a heterogenous longitudinal course with varying severity, flares, and persistence. However, AD course is not routinely assessed in clinical practice or controlled trials. Our objective was to review the longitudinal course of AD in children and adults and discuss implications for routine practice and clinical trials. We conducted a focused review of the published literature, including retrospective, prospective, and interventional studies, clinical trials, and consensus guidelines. Estimates of AD persistence varied widely across studies but suggested that AD can indeed persist through childhood and into adulthood. Predictors of persistence are broad and include both disease-intrinsic and disease-extrinsic (i.e., environmental) factors. In real-world practice, most individuals with AD experience fluctuations in the signs and symptoms over time and do not experience persistent clearance of skin lesions. Clinical trials use mainly static measurements that do not take into account fluctuations in course, which may confound treatment effects. The heterogenous temporal pattern of AD can be incorporated into routine practice to better set expectations and offer a realistic prognosis. AD course should be routinely incorporated into clinical decision making. Future studies are needed to develop a standardized approach to AD assessment and treatment that includes longitudinal course.

Bone mineral density and osteoporosis risk in young adults with atopic dermatitis

Atopic dermatitis (AD) has been increasing worldwide over the past few decades. AD has been reported to be associated with an increased risk of osteoporosis and fractures in adult AD patients. The aim of this study was to investigate the bone mineral density (BMD) to evaluate osteoporosis risk in young adults with AD by sex. This was a case-control cohort study using a national dataset from the Korea National Health and Nutrition Examination Survey 2007-2009. We included young adult AD patients (men aged 19 ≤ and < 50 years, premenopausal women aged 19 ≤ and < 50 years) and 1:5 propensity score weighting controls by age, sex, body mass index (BMI), vitamin D level, and alcohol/smoking status. BMD was measured by double energy X-ray absorptiometry at the lumbar spine, femur neck, and total femur. The prevalence of low BMD, defined by a Z-score ≤  - 2.0, was compared between AD and without AD. We analyzed 311 (weighted n = 817,014) AD patients and 8,972 (weighted n = 20,880,643) controls. BMD at the lumbar spine was significantly lower in the male AD group than in the male control group (mean ± SE, 0.954 ± 0.016 vs. 0.989 ± 0.002, P = 0.03). The prevalence of low BMD (Z-score) did not significantly differ between AD and non-AD subjects in both men (3.8% vs. 2.7%, P = 0.56) and women (6.4% vs. 3.3%, P = 0.40). Among AD patients, early age at diagnosis of AD, longer duration of AD, lower BMI, rural residence (for men), less education, low vitamin D level, late menarche, and more pregnancies (for women) were associated with low BMD. In conclusion, low BMD did not occur more frequently in young adults with AD than in non-AD controls. However, early-onset/longer AD duration and lower BMI were associated with low BMD among young adult patients with AD.

Fracture risks in patients with atopic dermatitis: A nationwide matched cohort study

BACKGROUND

The risk of osteoporosis has been explored in atopic dermatitis (AD). The long-term risk of fractures in patients with AD and the effects of various AD treatments on bone health remain to be elucidated.

OBJECTIVE

To evaluate the long-term risk of fractures in patients with AD.

METHODS

This nationwide matched cohort study was conducted using the National Health Insurance Research Database of Taiwan for the period 1997 to 2013. A total of 36,855 patients with AD and 147,420 reference subjects without AD were identified. Demographic characteristics and comorbidities were compared, and cumulative incidence of fractures was evaluated. Adjusted hazard ratios for fracture risks of AD and various AD treatments were calculated using the Cox proportional hazards model.

RESULTS

A total of 1518 patients (4.12%) in the AD cohort and 5579 patients (3.78%) in the reference cohort had fractures (P = .003). The mean ages were 22.6 years in both groups. The 16-year cumulative incidence of fractures in the AD cohort (8.043%) was significantly higher than that in the reference cohort (7.366%) (P = .002). Severe AD (adjusted hazard ratio [aHR], 1.31; 95% confidence interval [CI], 1.08-1.59) was independently associated with fractures. Other independent risk factors included exposure to topical (aHR, 1.21; 95% CI, 1.05-1.39) or systemic (≥10 mg/d; aHR, 1.62; 95% CI, 1.38-1.91) corticosteroids. Use of disease-modifying antirheumatic drugs (aHR, 0.71; 95% CI, 0.53-0.90) and phototherapy (aHR, 0.73; 95% CI, 0.56-0.95) was associated with a lower risk of fractures. The results were consistent across sensitivity analyses.

CONCLUSION

Patients with AD have a higher incidence of fractures. Severe AD is independently associated with fractures.

Reversal of alopecia areata, osteoporosis follow treatment with activation of Tgr5 in mice

BACKGROUND

Alopecia areata is an autoimmune hair loss disease with infiltration of pro-inflammatory cells into hair follicles. The role of Tgr5 in dermatitis has attracted considerable attention. The present study aimed to investigate the effect of Tgr5 in the development of Alopecia areata.

METHODS

The study utilized a comparison control group design with four groups of wild-type group, wild-type+INT777 group, Tgr5-/- group, and Tgr5-/-+INT777 group. The mice were treated with INT777 (30 mg/kg/day) or the carrier solution (DMSO) intraperitoneally for 7 weeks, and the back skin was collected and analyzed by histology and immunohistochemistry staining. The lumbar vertebrae 4 has also been analyzed by DXA and Micro-CT.

RESULTS

Tgr5-/- mice displayed the decreasingly significant in hair area and length, skin thickness, and the ratio of anagen and telogen, collagen, and mast cell number and loss the bone mass than WT group. After treating with INT777, the appearance of alopecia areata and bone microstructure has improved. Immunohistochemistry and qPCR analysis showed that activation of Tgr5 can down-regulate the express of JAK1, STAT3, IL-6, TNF-α, and VEGF.

CONCLUSION

These findings indicate that activation of Tgr5 mediated amelioration of alopecia areata and osteoporosis by down-regulated JAK1-STAT3 signaling pathway.

Atopic dermatitis and bone health: a systematic review

Atopic dermatitis (AD) is associated with systemic inflammation and systemic corticosteroid use which can lead to poor bone health. The aim of this systematic review is to investigate the relationship between AD and bone mineral density (BMD), osteoporosis and fractures. We searched Web of Science, Cochrane Database of Systematic Reviews, MEDLINE and Embase. Title, abstract and full-text screening, and data extraction were done in duplicate. Quality appraisal was performed using the Agency for Healthcare Research and Quality Methodology Checklist (cross-sectional studies) and Newcastle-Ottawa Scale (cohort studies). We screened 3800 abstracts and included fifteen studies (twelve cross-sectional, three cohort). In cross-sectional studies, AD was associated with decreased BMD and increased fractures. In cross-sectional studies and a cohort study, AD was associated with a higher prevalence of osteoporosis compared to controls. There was inconsistency across studies, with some finding no association. In a large cohort study, AD was associated with increased risk of fractures of the hip (HR: 1.06, 95% CI: 1.02 to 1.11), spine (HR: 1.14, 95% CI: 1.06 to 1.23) and wrist (HR: 1.06, 95% CI: 1.01 to 1.10), with further increased risk with more severe AD. Differences between studies precluded quantitative synthesis. There is some evidence supporting an association between AD and poor bone health. Research is needed to clarify this association, underlying mechanisms and develop strategies to improve bone health of individuals with AD.

Bone mineral density, osteopenia, osteoporosis, and fracture risk in patients with atopic dermatitis: a systematic review and meta-analysis

BACKGROUND

The relationship between atopic dermatitis (AD) and abnormal bone metabolism remains unclear. We performed a systematic review and meta-analysis to determine whether patients with AD were associated with increased risks of low bone mineral density (BMD), osteopenia, osteoporosis, and related fractures.

METHODS

We searched PubMed, Embase, and the Cochrane Library through December 2019 to identify studies that investigated the association between AD and abnormal bone metabolism (including BMD, osteopenia, osteoporosis, and related fractures). The predefined primary outcome was related fractures; secondary outcomes included osteoporosis, osteopenia, and BMD. We calculated the summary odds ratios (ORs) and 95% confidence intervals (CIs) using a random-effects model.

RESULTS

Ten studies were included in this systematic review. In children and adolescents, four studies investigated the association between AD and BMD; three studies indicated that children and adolescents with AD were associated with an increased risk of low BMD; one study found similar BMD between AD and control groups. In adults, three studies assessed the risk of fracture and were included in the meta-analysis, comprising 562,405 AD patients among 3,171,268 participants. Adults with AD were associated with an increased risk of fracture (OR 1.13; 95% CI, 1.05-1.22; P=0.001). Three studies investigated the association between AD and osteoporosis, which suggested that patients with AD were associated with an increased risk of osteoporosis (OR 1.95; 95% CI, 1.18-3.23; P=0.009). Further, patients with AD were associated with increased risks of osteopenia (OR 1.90; 95% CI, 1.51-2.38; P<0.001) and low BMD at the femur and spine.

CONCLUSIONS

Patients with AD were associated with increased risks of low BMD, osteopenia, osteoporosis, and related fractures. Both clinical studies and basic research are needed to clarify the mechanisms of association between AD and abnormal bone metabolism.

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.

Inflammatory Skin-Derived Cytokines Accelerate Osteoporosis in Mice with Persistent Skin Inflammation

Secondary osteoporosis can also be caused by chronic inflammatory skin disease as well as rheumatoid arthritis or inflammatory bowel disease. However, the exact role of osteoporosis in inflammatory skin conditions has not been elucidated. Using a mouse model of dermatitis, we investigated the pathophysiology of osteoporosis in inflammatory skin conditions and the therapeutic impact of osteoporosis medication on inflammatory skin disease. We employed model mice of spontaneous skin inflammation, specifically overexpressing human caspase-1 in the epidermis. Bone density and the expression of various mRNAs in the femur were examined by micro CT and RT-PCR. The effects of minodronate and anti-RANKL antibody on bone structure, histology, and femur blood flow were studied. The mouse model of skin inflammation showed a marked decrease in bone density compared to wild-type littermates with abnormalities in both bone resorption and formation. Minodronate improved bone density by decreasing osteoclasts, but anti-RANKL antibody did not improve. In the dermatitis model, the blood flow in the bone marrow was decreased, and minodronate restored this parameter. A model of persistent dermatitis exhibited marked osteoporosis, but the impact of chronic dermatitis on osteoporosis has not been thoroughly investigated. We should explore the pathogenesis of osteoporosis in skin inflammatory diseases.

Atopic Dermatitis in Older Adults: A Review of Treatment Options

Atopic dermatitis (AD) in older adults (elderly AD) has recently emerged as a newly defined subgroup of AD. When selecting treatment options, clinical characteristics of elderly AD and age-specific factors of older patients must be considered. As in other age groups, regular application of moisturizers in combination with topical corticosteroids and calcineurin inhibitors, adjunctive administration of oral antihistamines/anti-allergic drugs, and avoidance of exacerbating factors comprise basic treatments for elderly AD. For moderate-to-severe cases and/or in those with a decreased ability to use topical treatments, powerful anti-inflammatory treatments may become necessary as additional treatment options. While low-dose oral corticosteroids may be useful for cases of elderly AD, careful attention should be paid to adverse effects. Oral cyclosporine (ciclosporin) is less commonly used due to the increased risk of malignancy and organ toxicity in older patients with AD. Narrow-band ultraviolet B phototherapy may also be useful for older patients, although the necessity of frequent hospital visits for irradiation therapy may become a burden of disease for such patients. As a biologic, dupilumab therapy markedly improves skin lesions and itch in older patients with AD, with a rapid response and non-serious adverse effects. Nevertheless, injection pain, expensive medical care, and regular follow-up every 2 weeks are disadvantages of dupilumab therapy. Therefore, clinicians must prioritize individualized treatment options that will reduce the burden of disease for cases of elderly AD.

Association of pemphigus and pemphigoid with osteoporosis and pathological fractures

Patients with pemphigus and bullous pemphigoid (BP) have potential risk factors for osteoporosis and/or fractures. To determine whether pemphigus and BP are associated with osteoporosis and fractures in the US, a cross-sectional study of 198,102,435 adults was performed, including 4506 with pemphigus and 8864 with BP from the 2006-2012 National Emergency Department Sample, a 20% sample of emergency care visits throughout the US. Pemphigus was associated with higher odds (multivariate logistic regression; adjusted odds ratio [95% confidence intervals]) of osteopenia (2.20 [1.59-3.05]), osteoporosis (2.54 [2.16-2.98]), osteomalacia (29.70 [4.05-217.83]), and pathological fractures (2.04 [1.42-2.91]). BP was associated with osteoporosis (1.55 [1.39-1.73]) and pathological fractures (1.52 [1.22-1.88]). When compared to BP, pemphigus was associated with higher odds of osteopenia (1.59 [1.06-2.41]), osteoporosis (1.38 [1.18-1.63]), and fractures (1.26 [1.04-1.53]), particularly of the ulna and radius (3.17 [1.23-8.17]). Patients with pemphigus or BP as well as long-term systemic corticosteroid use had highest odds of osteoporosis and fractures. No data were available on treatments for pemphigus or BP. Pemphigus and BP were associated with osteopenia, osteoporosis, and pathologic fractures. Patients with PEM and BP may benefit from increased screening for osteoporosis and interventions to prevent fractures.