How should an incident case of atopic dermatitis be defined? A systematic review of primary prevention studies

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Should Emollients Be Recommended for the Prevention of Atopic Dermatitis?-New Evidence and Current State of Knowledge

INTRODUCTION

Atopic dermatitis (AD) is a chronic, pruritic skin disease with complex pathogenesis, which affects about 43 million children aged 1-4 years. One of the most known methods of alleviating symptoms of AD is emollient treatment, which varies depending on formulation and additional active ingredients. There is some evidence that emollients could be used in AD prevention in high-risk children.

MATERIALS AND METHODS

A search of the literature from Cochrane Library, PubMed and Medline was conducted between August and September 2023 with the following keywords: "atopic dermatitis", "emollients", and "prevention". Only randomised clinical trials published in the last 5 years were included into the meta-analysis.

RESULTS

Considering the inclusion criteria only 11 randomized clinical trials were taken into account, and six of them proved lack of effect of emollients in the prevention of atopic dermatitis among neonates from AD risk groups.

CONCLUSIONS

Emollient treatment has a good safety profile and most of the ingredients used in formulations are nonirritant for sensitive newborn and infant skin. There is some evidence of the positive effects of emollient treatment in prevention of AD in predisposed populations. The relatively high cost of emollient treatment (vs regular infant skin-care routine) would support the necessity for further evaluation of their effectiveness in nonpredisposed populations.

Identification of eczema clusters and their association with filaggrin and atopic comorbidities: analysis of five birth cohorts

BACKGROUND

Longitudinal modelling of the presence/absence of current eczema through childhood has identified similar phenotypes, but their characteristics often differ between studies.

OBJECTIVES

To demonstrate that a more comprehensive description of longitudinal pattern of symptoms may better describe trajectories than binary information on eczema presence.

METHODS

We derived six multidimensional variables of eczema spells from birth to 18 years of age (including duration, temporal sequencing and the extent of persistence/recurrence). Spells were defined as consecutive observations of eczema separated by no eczema across 5 epochs in five birth cohorts: infancy (first year); early childhood (age 2-3 years); preschool/early school age (4-5 years); middle childhood (8-10 years); adolescence (14-18 years). We applied Partitioning Around Medoids clustering on these variables to derive clusters of the temporal patterns of eczema. We then investigated the stability of the clusters, within-cluster homogeneity and associated risk factors, including FLG mutations.

RESULTS

Analysis of 7464 participants with complete data identified five clusters: (i) no eczema (51.0%); (ii) early transient eczema (21.6%); (iii) late-onset eczema (LOE; 8.1%); (iv) intermittent eczema (INT; 7.5%); and (v) persistent eczema (PE; 11.8%). There was very-high agreement between the assignment of individual children into clusters when using complete or imputed (n = 15 848) data (adjusted Rand index = 0.99; i.e. the clusters were very stable). Within-individual symptom patterns across clusters confirmed within-cluster homogeneity, with consistent patterns of symptoms among participants within each cluster and no overlap between the clusters. Clusters were characterized by differences in associations with risk factors (e.g. parental eczema was associated with all clusters apart from LOE; sensitization to inhalant allergens was associated with all clusters, with the highest risk in the PE cluster). All clusters apart from LOE were associated with FLG mutations. Of note, the strongest association was for PE [relative risk ratio (RRR) 2.70, 95% confidence interval (CI) 2.24-3.26; P < 0.001] followed by INT (RRR 2.29, 95% CI 1.82-2.88; P < 0.001).

CONCLUSIONS

Clustering of multidimensional variables identified stable clusters with different genetic architectures. Using multidimensional variables may capture eczema development and derive stable and internally homogeneous clusters. However, deriving homogeneous symptom clusters does not necessarily mean that these are underpinned by completely unique mechanisms.

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.

Skin care interventions in infants for preventing eczema and food allergy

BACKGROUND

Eczema and food allergy are common health conditions that usually begin in early childhood and often occur in the same people. They can be associated with an impaired skin barrier in early infancy. It is unclear whether trying to prevent or reverse an impaired skin barrier soon after birth is effective for preventing eczema or food allergy.

OBJECTIVES

Primary objective To assess the effects of skin care interventions such as emollients for primary prevention of eczema and food allergy in infants. Secondary objective To identify features of study populations such as age, hereditary risk, and adherence to interventions that are associated with the greatest treatment benefit or harm for both eczema and food allergy.

SEARCH METHODS

We performed an updated search of the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase in September 2021. We searched two trials registers in July 2021. We checked the reference lists of included studies and relevant systematic reviews, and scanned conference proceedings to identify further references to relevant randomised controlled trials (RCTs).  SELECTION CRITERIA: We included RCTs of skin care interventions that could potentially enhance skin barrier function, reduce dryness, or reduce subclinical inflammation in healthy term (> 37 weeks) infants (≤ 12 months) without pre-existing eczema, food allergy, or other skin condition. Eligible comparisons were standard care in the locality or no treatment. Types of skin care interventions could include moisturisers/emollients; bathing products; advice regarding reducing soap exposure and bathing frequency; and use of water softeners. No minimum follow-up was required.

DATA COLLECTION AND ANALYSIS

This is a prospective individual participant data (IPD) meta-analysis. We used standard Cochrane methodological procedures, and primary analyses used the IPD dataset. Primary outcomes were cumulative incidence of eczema and cumulative incidence of immunoglobulin (Ig)E-mediated food allergy by one to three years, both measured at the closest available time point to two years. Secondary outcomes included adverse events during the intervention period; eczema severity (clinician-assessed); parent report of eczema severity; time to onset of eczema; parent report of immediate food allergy; and allergic sensitisation to food or inhalant allergen.

MAIN RESULTS

We identified 33 RCTs comprising 25,827 participants. Of these, 17 studies randomising 5823 participants reported information on one or more outcomes specified in this review.  We included 11 studies, randomising 5217 participants, in one or more meta-analyses (range 2 to 9 studies per individual meta-analysis), with 10 of these studies providing IPD; the remaining 6 studies were included in the narrative results only.   Most studies were conducted at children's hospitals. Twenty-five studies, including all those contributing data to meta-analyses, randomised newborns up to age three weeks to receive a skin care intervention or standard infant skin care. Eight of the 11 studies contributing to meta-analyses recruited infants at high risk of developing eczema or food allergy, although the definition of high risk varied between studies. Durations of intervention and follow-up ranged from 24 hours to three years. All interventions were compared against no skin care intervention or local standard care. Of the 17 studies that reported information on our prespecified outcomes, 13 assessed emollients. We assessed most of the evidence in the review as low certainty and had some concerns about risk of bias. A rating of some concerns was most often due to lack of blinding of outcome assessors or significant missing data, which could have impacted outcome measurement but was judged unlikely to have done so. We assessed the evidence for the primary food allergy outcome as high risk of bias due to the inclusion of only one trial, where findings varied based on different assumptions about missing data. Skin care interventions during infancy probably do not change the risk of eczema by one to three years of age (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.81 to 1.31; risk difference 5 more cases per 1000 infants, 95% CI 28 less to 47 more; moderate-certainty evidence; 3075 participants, 7 trials) or time to onset of eczema (hazard ratio 0.86, 95% CI 0.65 to 1.14; moderate-certainty evidence; 3349 participants, 9 trials). Skin care interventions during infancy may increase the risk of IgE-mediated food allergy by one to three years of age (RR 2.53, 95% CI 0.99 to 6.49; low-certainty evidence; 976 participants, 1 trial) but may not change risk of allergic sensitisation to a food allergen by age one to three years (RR 1.05, 95% CI 0.64 to 1.71; low-certainty evidence; 1794 participants, 3 trials). Skin care interventions during infancy may slightly increase risk of parent report of immediate reaction to a common food allergen at two years (RR 1.27, 95% CI 1.00 to 1.61; low-certainty evidence; 1171 participants, 1 trial); however, this was only seen for cow's milk, and may be unreliable due to over-reporting of milk allergy in infants. Skin care interventions during infancy probably increase risk of skin infection over the intervention period (RR 1.33, 95% CI 1.01 to 1.75; risk difference 17 more cases per 1000 infants, 95% CI one more to 38 more; moderate-certainty evidence; 2728 participants, 6 trials) and may increase the risk of infant slippage over the intervention period (RR 1.42, 95% CI 0.67 to 2.99; low-certainty evidence; 2538 participants, 4 trials) and stinging/allergic reactions to moisturisers (RR 2.24, 95% 0.67 to 7.43; low-certainty evidence; 343 participants, 4 trials), although CIs for slippages and stinging/allergic reactions were wide and include the possibility of no effect or reduced risk. Preplanned subgroup analyses showed that the effects of interventions were not influenced by age, duration of intervention, hereditary risk, filaggrin (FLG) mutation, chromosome 11 intergenic variant rs2212434, or classification of intervention type for risk of developing eczema. We could not evaluate these effects on risk of food allergy. Evidence was insufficient to show whether adherence to interventions influenced the relationship between skin care interventions and eczema or food allergy development.

AUTHORS' CONCLUSIONS

Based on low- to moderate-certainty evidence, skin care interventions such as emollients during the first year of life in healthy infants are probably not effective for preventing eczema; may increase risk of food allergy; and probably increase risk of skin infection. Further study is needed to understand whether different approaches to infant skin care might prevent eczema or food allergy.

Effectiveness of a standardized skin care regimen to prevent atopic dermatitis in infants at risk for atopy: a randomized, pragmatic, parallel-group study

BACKGROUND

It has been proposed that regular emollient application in early life could enhance skin barrier function and prevent atopic dermatitis (AD) especially in predisposed infants. This hypothesis was supported by evidence from exploratory and pilot trials showing protective effects in terms of reduced cumulative atopic dermatitis incidence with the use of daily emollient therapy starting immediately after birth.

OBJECTIVES

To investigate the effectiveness of a standardized skin care regimen for infants on the development of AD compared to not structured skin care regimen in infants with atopic predisposition.

METHODS

Prospective, parallel group, randomized, pragmatic, investigator-blinded intervention trial including 160 infants with 52 weeks intervention and 52 weeks follow up phase up to the age of two years. Infants were randomly assigned to receive a standardized skin care regimen including once daily leave-on product application (lipid content 21%) or skin care as preferred by the parents.

RESULTS

Using the intention to treat approach, the cumulative AD incidence was 10.6% after one year, and 19.5% after two years in the total sample. There were no statistical significant differences between intervention and control groups. Skin barrier parameters between the intervention and control groups were comparable. AD severity was higher and quality of life was more affected in the control group.

CONCLUSIONS

Regular emollient application during the first year of life does not prevent the development of atopic dermatitis. A standardized skin care regimen does not delay skin barrier development or causes side effects.

Neonatal Bacillus Calmette-Guérin Vaccination to Prevent Early-Life Eczema: A Systematic Review and Meta-analysis

ABSTRACT

Increasing evidence suggests that early-life bacillus Calmette-Guérin (BCG) vaccine could prevent atopic eczema through its beneficial off-target effects. In this meta-analysis, 3 randomized control trials with similar methods were included and enabled robust estimations with low heterogeneity, involving a total of 5655 children randomized to early-life BCG Denmark (n = 2832) or no BCG (n = 2823). Meta-analyses suggest a beneficial effect of BCG to prevent eczema (risk ratio [RR], 0.89; 95% confidence interval [CI], 0.82-0.98). In subgroup analyses, BCG was more beneficial in boys (RR, 0.84; 95% CI, 0.74-0.95) and in children born to 2 atopic parents (RR, 0.81; 95% CI, 0.68-0.97). The NNT to prevent one case of eczema among children of 1 or 2 atopic parent was 20 (95% CI, 12-50). Bacillus Calmette-Guérin Denmark leads to an 11% reduction in the risk of eczema in early life. A greater effect was observed with increasing predisposition. Given its well-established safety profile, neonatal BCG vaccination should be considered for children of atopic parents.

Discordance Between Diagnosis Tools for Assessing Eczema in Infants: A Challenge for Intervention Trials

BACKGROUND

There is no standardized definition for infant eczema, and various tools have been used across studies, precluding direct comparison.

OBJECTIVE

The aim of the study was to assess and to compare the accuracy of diagnostic tools for infant eczema using the extensive data collected in Melbourne Infant Study: BCG for Allergy and Infection Reduction (MIS BAIR), an eczema prevention trial.

METHODS

Eczema incidence was assessed by 3 questionnaire-based measures: modified UK diagnostic tool, parent-reported medically diagnosed eczema, and parent-reported use of topical corticosteroids. Agreement between the definitions was quantified using κ coefficient. Eczema severity was assessed by 3-monthly Patient-Oriented Eczema Measure (POEM) scores and a SCORing Atopic Dermatitis (SCORAD) clinical assessment at a 12-month visit (ClinicalTrial.gov: NCT01906853).

RESULTS

Among the 538 participants fulfilling at least 1 of the 3 questionnaire-based eczema definitions, only 197 participants (37%) met all 3 definitions. Agreement between the definitions was poor with κ coefficients ranging from -0.11 to 0.62. The most frequently reported symptoms were generally dry skin (483/538, 90%) and pruritus (400/538, 74%). The face (352/538, 65%) and the trunk (306/538, 57%) were more frequently affected than the creases (257/538, 48%). Participants fulfilling all 3 questionnaire-based definitions of eczema were more likely to have higher severity scores and earlier onset of symptoms.

CONCLUSIONS

There is poor agreement between currently available tools for assessing infant eczema.

Modelling trajectories of parentally reported and physician-confirmed atopic dermatitis in a birth cohort study

BACKGROUND

In a population-based birth cohort, we aimed to identify longitudinal trajectories of atopic dermatitis (AD) during childhood using data from different sources (validated questionnaires and healthcare records). We investigated the impact of different AD definitions on such trajectories and their relationships with various risk factors.

METHODS

Of the 1184 children born into the study, 1083 had information on current AD for at least three follow-ups from birth to age 11 years and were included in the analysis for parentally reported AD (PRAD). Data were transcribed from healthcare records for 916 of 1184 children for the analysis of doctor-diagnosed AD (DDAD). We also derived a composite definition of AD (CDAD) (at least two of the following: PRAD, DDAD, current use of AD treatment). Using latent class analysis (LCA), we determined longitudinal profiles of AD using the three definitions. Filaggrin (FLG) genotype data were available for 803 white participants.

RESULTS

For PRAD, LCA identified four AD classes ('no AD', 'persistent', 'early-onset remitting' and 'late-onset'). For DDAD and CDAD, the optimal number of phenotypes was three ('no AD', 'persistent' and 'early-onset remitting'). Although AD classes at population level appeared similar in different models, a considerable proportion of children (n = 485, 45%) moved between classes. The association with FLG genotype, atopic diseases and early-life risk factors was inconsistent across different definitions, but the association with oral food challenge-confirmed peanut allergy was similar, with a nine- to 11-fold increase among children in the persistent AD class. In a CDAD model, compared with the early-onset remitting class, those with persistent AD were significantly more likely to have (at age 3 years) moderate/severe AD, polysensitization and current wheeze, and were less likely to have been breastfed.

CONCLUSIONS

Standardized composite definitions of AD may help to define AD cases with more precision and identify more consistent long-term trajectories.

What are the highest yielding search strategy terms for systematic reviews in atopic dermatitis? A systematic review

The impact of search strategies on systematic reviews (SR) of atopic dermatitis (AD) is unknown. The purpose of this review was to evaluate search strategies used in SR of AD and their impact on the frequency of manuscripts identified. MEDLINE and EMBASE were searched for SR related to AD. Simulations were performed by running combinations of search terms in MEDLINE and EMBASE. Overall, 250 SR met inclusion criteria, of which 225 specified search strategies. SR using 5-6 terms (20.0% to 12.1%) or ≥ 7 (40.0% to 18.8%) terms decreased, whereas SR using 3-4 terms numerically increased (18.8% to 30.2%) and 1-2 terms remained similar (37.5% to 38.9%) from 1999-2009 to 2015-2019. The most commonly searched terms were "atopic dermatitis" (n = 166), followed by "eczema" (n = 156), "dermatitis atopic'" (n = 81), "atopic eczema" (n = 74), "neurodermatitis" (n = 59), "Besniers prurigo" (n = 29), "infantile eczema" (n = 27), and "childhood eczema" (n = 19). Simulations revealed that "eczema" and "atopic dermatitis" yielded the most hits. The number of search terms that maximized hits in MEDLINE and EMBASE was 5 and 4, respectively. Search strategies for AD were heterogeneous, with high proportions of search strategies providing few search hits. Future studies should use standardized and optimized search terms.

Impact of Atopic Dermatitis and Chronic Hand Eczema on Quality of Life Compared With Other Chronic Diseases

: The aim of this study was to conduct 3 literature reviews to examine the impact of atopic dermatitis (AD) and chronic hand eczema (CHE) on health-related quality of life (HRQoL) compared with other chronic conditions by comparing reported utility scores of 4 commonly used generic HRQoL instruments. A systematic search was performed using PubMed, ScienceDirect, MEDLINE, EMBASE, Health Technology Assessment database, and ScHARRHUD. Inclusion criteria included, but were not limited to, patients of any age, studies from any location, publications reporting utility data based on EuroQoL 5 dimensions, the EuroQoL 5-dimension Visual Analog Scale, the Short-Form Health Survey, and the Short-Form 6 Dimensions in the English language. Inclusion criteria were met by 16 articles for AD, 25 articles for chronic conditions, and 9 articles for CHE. The findings of this review highlight that the disutility and loss in HRQoL of patients with AD and CHE are similar to or higher than other chronic conditions, such as cancer or hepatitis.

Skin care interventions in infants for preventing eczema and food allergy

BACKGROUND

Eczema and food allergy are common health conditions that usually begin in early childhood and often occur together in the same people. They can be associated with an impaired skin barrier in early infancy. It is unclear whether trying to prevent or reverse an impaired skin barrier soon after birth is effective in preventing eczema or food allergy.

OBJECTIVES

Primary objective To assess effects of skin care interventions, such as emollients, for primary prevention of eczema and food allergy in infants Secondary objective To identify features of study populations such as age, hereditary risk, and adherence to interventions that are associated with the greatest treatment benefit or harm for both eczema and food allergy.

SEARCH METHODS

We searched the following databases up to July 2020: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase. We searched two trials registers and checked reference lists of included studies and relevant systematic reviews for further references to relevant randomised controlled trials (RCTs). We contacted field experts to identify planned trials and to seek information about unpublished or incomplete trials.

SELECTION CRITERIA

RCTs of skin care interventions that could potentially enhance skin barrier function, reduce dryness, or reduce subclinical inflammation in healthy term (> 37 weeks) infants (0 to 12 months) without pre-existing diagnosis of eczema, food allergy, or other skin condition were included. Comparison was standard care in the locality or no treatment. Types of skin care interventions included moisturisers/emollients; bathing products; advice regarding reducing soap exposure and bathing frequency; and use of water softeners. No minimum follow-up was required.

DATA COLLECTION AND ANALYSIS

This is a prospective individual participant data (IPD) meta-analysis. We used standard Cochrane methodological procedures, and primary analyses used the IPD dataset. Primary outcomes were cumulative incidence of eczema and cumulative incidence of immunoglobulin (Ig)E-mediated food allergy by one to three years, both measured by the closest available time point to two years. Secondary outcomes included adverse events during the intervention period; eczema severity (clinician-assessed); parent report of eczema severity; time to onset of eczema; parent report of immediate food allergy; and allergic sensitisation to food or inhalant allergen.

MAIN RESULTS

This review identified 33 RCTs, comprising 25,827 participants. A total of 17 studies, randomising 5823 participants, reported information on one or more outcomes specified in this review. Eleven studies randomising 5217 participants, with 10 of these studies providing IPD, were included in one or more meta-analysis (range 2 to 9 studies per individual meta-analysis). Most studies were conducted at children's hospitals. All interventions were compared against no skin care intervention or local standard care. Of the 17 studies that reported our outcomes, 13 assessed emollients. Twenty-five studies, including all those contributing data to meta-analyses, randomised newborns up to age three weeks to receive a skin care intervention or standard infant skin care. Eight of the 11 studies contributing to meta-analyses recruited infants at high risk of developing eczema or food allergy, although definition of high risk varied between studies. Durations of intervention and follow-up ranged from 24 hours to two years. We assessed most of this review's evidence as low certainty or had some concerns of risk of bias. A rating of some concerns was most often due to lack of blinding of outcome assessors or significant missing data, which could have impacted outcome measurement but was judged unlikely to have done so. Evidence for the primary food allergy outcome was rated as high risk of bias due to inclusion of only one trial where findings varied when different assumptions were made about missing data. Skin care interventions during infancy probably do not change risk of eczema by one to two years of age (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.81 to 1.31; moderate-certainty evidence; 3075 participants, 7 trials) nor time to onset of eczema (hazard ratio 0.86, 95% CI 0.65 to 1.14; moderate-certainty evidence; 3349 participants, 9 trials). It is unclear whether skin care interventions during infancy change risk of IgE-mediated food allergy by one to two years of age (RR 2.53, 95% CI 0.99 to 6.47; 996 participants, 1 trial) or allergic sensitisation to a food allergen at age one to two years (RR 0.86, 95% CI 0.28 to 2.69; 1055 participants, 2 trials) due to very low-certainty evidence for these outcomes. Skin care interventions during infancy may slightly increase risk of parent report of immediate reaction to a common food allergen at two years (RR 1.27, 95% CI 1.00 to 1.61; low-certainty evidence; 1171 participants, 1 trial). However, this was only seen for cow's milk, and may be unreliable due to significant over-reporting of cow's milk allergy in infants. Skin care interventions during infancy probably increase risk of skin infection over the intervention period (RR 1.34, 95% CI 1.02 to 1.77; moderate-certainty evidence; 2728 participants, 6 trials) and may increase risk of infant slippage over the intervention period (RR 1.42, 95% CI 0.67 to 2.99; low-certainty evidence; 2538 participants, 4 trials) or stinging/allergic reactions to moisturisers (RR 2.24, 95% 0.67 to 7.43; low-certainty evidence; 343 participants, 4 trials), although confidence intervals for slippages and stinging/allergic reactions are wide and include the possibility of no effect or reduced risk. Preplanned subgroup analyses show that effects of interventions were not influenced by age, duration of intervention, hereditary risk, FLG mutation,  or classification of intervention type for risk of developing eczema. We could not evaluate these effects on risk of food allergy. Evidence was insufficient to show whether adherence to interventions influenced the relationship between skin care interventions and risk of developing eczema or food allergy.

AUTHORS' CONCLUSIONS

Skin care interventions such as emollients during the first year of life in healthy infants are probably not effective for preventing eczema, and probably increase risk of skin infection. Effects of skin care interventions on risk of food allergy are uncertain. Further work is needed to understand whether different approaches to infant skin care might promote or prevent eczema and to evaluate effects on food allergy based on robust outcome assessments.

Skin emollient and early complementary feeding to prevent infant atopic dermatitis (PreventADALL): a factorial, multicentre, cluster-randomised trial

BACKGROUND

Skin emollients applied during early infancy could prevent atopic dermatitis, and early complementary food introduction might reduce food allergy in high-risk infants. The study aimed to determine if either regular skin emollients applied from 2 weeks of age, or early complementary feeding introduced between 12 and 16 weeks of age, reduced development of atopic dermatitis by age 12 months in the general infant population.

METHODS

This population-based 2×2 factorial, randomised clinical trial was done at Oslo University Hospital and Østfold Hospital Trust, Oslo, Norway; and Karolinska University Hospital, Stockholm, Sweden. Infants of women recruited antenatally at the routine ultrasound pregnancy screening at 18 weeks were cluster-randomised at birth from 2015 to 2017 to the following groups: (1) controls with no specific advice on skin care while advised to follow national guidelines on infant nutrition (no intervention group); (2) skin emollients (bath additives and facial cream; skin intervention group); (3) early complementary feeding of peanut, cow's milk, wheat, and egg (food intervention group); or (4) combined skin and food interventions (combined intervention group). Participants were randomly assigned (1:1:1:1) using computer- generated cluster randomisation based on 92 geographical living area blocks as well as eight 3-month time blocks. Carers were instructed to apply the interventions on at least 4 days per week. Atopic dermatitis by age 12 months was the primary outcome, based on clinical investigations at 3, 6 and 12 months by investigators masked to group allocation. Atopic dermatitis was assessed after completing the 12-month investigations and diagnosed if either of the UK Working Party and Hanifin and Rajka (12 months only) diagnostic criteria were fulfilled. The primary efficacy analyses was done by intention-to-treat analysis on all randomly assigned participants. Food allergy results will be reported once all investigations at age 3 years are completed in 2020. This was a study performed within ORAACLE (the Oslo Research Group of Asthma and Allergy in Childhood; the Lung and Environment). The study is registered at clinicaltrials.gov, NCT02449850.

FINDINGS

2697 women were recruited between Dec 9, 2014, and Oct 31, 2016, from whom 2397 newborn infants were enrolled from April 14, 2015, to April 11, 2017. Atopic dermatitis was observed in 48 (8%) of 596 infants in the no intervention group, 64 (11%) of 575 in the skin intervention group, 58 (9%) of 642 in the food intervention group, and 31 (5%) of 583 in the combined intervention group. Neither skin emollients nor early complementary feeding reduced development of atopic dermatitis, with a risk difference of 3·1% (95% CI -0·3 to 6·5) for skin intervention and 1·0% (-2·1 to 4·1) for food intervention, in favour of control. No safety concerns with the interventions were identified. Reported skin symptoms and signs (including itching, oedema, exanthema, dry skin, and urticaria) were no more frequent in the skin, food, and combined intervention groups than in the no intervention group.

INTERPRETATION

Neither early skin emollients nor early complementary feeding reduced development of atopic dermatitis by age 12 months. Our study does not support the use of these interventions to prevent atopic dermatitis by 12 months of age in infants.

FUNDING

The study was funded by several public and private funding bodies: The Regional Health Board South East, The Norwegian Research Council, Health and Rehabilitation Norway, The Foundation for Healthcare and Allergy Research in Sweden-Vårdalstiftelsen, Swedish Asthma and Allergy Association's Research Foundation, Swedish Research Council-the Initiative for Clinical Therapy Research, The Swedish Heart-Lung Foundation, SFO-V at the Karolinska Institute, Freemason Child House Foundation in Stockholm, Swedish Research Council for Health, Working Life and Welfare-FORTE, Oslo University Hospital, the University of Oslo, and Østfold Hospital Trust.

Daily emollient during infancy for prevention of eczema: the BEEP randomised controlled trial

BACKGROUND

Skin barrier dysfunction precedes eczema development. We tested whether daily use of emollient in the first year could prevent eczema in high-risk children.

METHODS

We did a multicentre, pragmatic, parallel-group, randomised controlled trial in 12 hospitals and four primary care sites across the UK. Families were approached via antenatal or postnatal services for recruitment of term infants (at least 37 weeks' gestation) at high risk of developing eczema (ie, at least one first-degree relative with parent-reported eczema, allergic rhinitis, or asthma, diagnosed by a doctor). Term newborns with a family history of atopic disease were randomly assigned (1:1) to application of emollient daily (either Diprobase cream or DoubleBase gel) for the first year plus standard skin-care advice (emollient group) or standard skin-care advice only (control group). The randomisation schedule was created using computer-generated code (stratified by recruiting centre and number of first-degree relatives with atopic disease) and participants were assigned to groups using an internet-based randomisation system. The primary outcome was eczema at age 2 years (defined by UK working party criteria) with analysis as randomised regardless of adherence to allocation for participants with outcome data collected, and adjusting for stratification variables. This trial is registered with ISRCTN, ISRCTN21528841. Data collection for long-term follow-up is ongoing, but the trial is closed to recruitment.

FINDINGS

1394 newborns were randomly assigned to study groups between Nov 19, 2014, and Nov 18, 2016; 693 were assigned to the emollient group and 701 to the control group. Adherence in the emollient group was 88% (466 of 532) at 3 months, 82% (427 of 519) at 6 months, and 74% (375 of 506) at 12 months in those with complete questionnaire data. At age 2 years, eczema was present in 139 (23%) of 598 infants with outcome data collected in the emollient group and 150 (25%) of 612 infants in the control group (adjusted relative risk 0·95 [95% CI 0·78 to 1·16], p=0·61; adjusted risk difference -1·2% [-5·9 to 3·6]). Other eczema definitions supported the results of the primary analysis. Mean number of skin infections per child in year 1 was 0·23 (SD 0·68) in the emollient group versus 0·15 (0·46) in the control group; adjusted incidence rate ratio 1·55 (95% CI 1·15 to 2·09).

INTERPRETATION

We found no evidence that daily emollient during the first year of life prevents eczema in high-risk children and some evidence to suggest an increased risk of skin infections. Our study shows that families with eczema, asthma, or allergic rhinitis should not use daily emollients to try and prevent eczema in their newborn.

FUNDING

National Institute for Health Research Health Technology Assessment.

Diagnosis of atopic dermatitis in children: comparison of the Hanifin-Rajka and the United Kingdom Working Party criteria

BACKGROUND

Atopic dermatitis (AD) is the most common chronic skin disease in childhood. There is no definitive test for diagnosing AD. The Hanifin-Rajka criteria (HRC) and The United Kingdom Working Party criteria (UKC) are the most used in the literature. It is aimed to evaluate the clinical efficacy of HRC and UKC in pediatric age.

METHODS

Children diagnosed AD in the pediatric allergy clinic were enrolled. Patients with skin problems other than AD were involved as controls. All participants were evaluated for HRC and UKC at the time of diagnosis. Clinical diagnosis by the pediatric allergist was determined as the gold standard.

RESULTS

200 children with AD and 90 controls were enrolled in the study. Median (interquartile range, IQR) age of AD patients was 13.5 (7-36) months. There was no significant difference in age and sex between groups (p=0.11 and p=0.34, respectively). The HRC were superior to the UKC for sensitivity, negative predictive value, kappa and accuracy rate (94% vs. 72%, 84% vs. 60%, 0.68 vs. 0.56 and 87 vs. 78, respectively). On the other hand, specificity and positive predictive value of UKC were better than those of HRC (92% vs. 71% and 95% vs. 88%, respectively).

CONCLUSION

HRC seem to be better in diagnosing AD than UKC for young children. Further studies are needed to evaluate comparableness of HRC and UKC for AD in childhood in order to generate an international consensus for clinical trials.

Different definitions of atopic dermatitis: impact on prevalence estimates and associated risk factors

Background

There is no objective test that can unequivocally confirm the diagnosis of atopic dermatitis (AD), and no uniform clinical definition.

Objectives

To investigate to what extent operational definitions of AD cause fluctuation in the prevalence estimates and the associated risk factors.

Methods

We first reviewed the operational definitions of AD used in the literature. We then tested the impact of the choice of the most common definitions of ‘cases’ and ‘controls’ on AD prevalence estimates and associated risk factors (including filaggrin mutations) among children aged 5 years in two population‐based birth cohorts: the Manchester Asthma and Allergy Study (MAAS) and Asthma in Ashford. Model performance was measured by the percentage of children within an area of clinical indecision (defined as having a posterior probability of AD between 25% and 60%).

Results

We identified 59 different definitions of AD across 45 reviewed studies. Of those, we chose four common ‘case’ definitions and two definitions of ‘controls’. The prevalence estimates using different case definitions ranged between 22% and 33% in MAAS, and between 12% and 22% in Ashford. The area of clinical indecision ranged from 32% to 44% in MAAS and from 9% to 29% in Ashford. Depending on the case definition used, the associations with filaggrin mutations varied, with odds ratios (95% confidence intervals) ranging from 1·8 (1·1–2·9) to 2·2 (1·3–3·7) in MAAS and 1·7 (0·8–3·7) to 2·3 (1·2–4·5) in Ashford. Associations with filaggrin mutations also differed when using the same ‘case’ definition but different definitions of ‘controls’.

Conclusions

Use of different definitions of AD results in substantial differences in prevalence estimates, the performance of prediction models and association with risk factors.

What's already known about this topic?

There is no objective test that can unequivocally confirm the diagnosis of atopic dermatitis (AD) and no uniform clinical definition.

This results in different definitions utilized in AD studies, raising concerns on the generalizability of the results and comparability across different studies.

What does this study add?

This study has shown that different definitions of ‘cases’ and ‘controls’ have major impacts upon prevalence estimates and associations with risk factors, including genetics, in two population‐based birth cohorts.

These findings suggest the importance of developing a consensus on AD definitions of both ‘controls’ and ‘cases’ to minimize biases in studies.

https://www.bjdonline.com/article/different-definitions-of-atopic-dermatitis-impact-on-prevalence-estimates-and-associated-risk-factors/

Linked Comment: https://doi.org/10.1111/bjd.18303.

https://doi.org/10.1111/bjd.18571 available online

Effectiveness of an antenatal maternal supplementation with prebiotics for preventing atopic dermatitis in high-risk children (the PREGRALL study): protocol for a randomised controlled trial

INTRODUCTION

Atopic dermatitis (AD) is a chronic inflammatory disease affecting 10%-15% of children in Europe. There is a need for new primary preventive therapeutic strategies in at-risk populations. Recent research has indicated that atopic diseases are associated with a disrupted gut microbial 'balance' in early life raising the possibility that interventions which yield optimal patterns of microflora could improve host's health. Prebiotics, sugars with immunomodulatory properties that stimulate the diversity of the digestive microbiota, are ideal candidates for such research. So far, most clinical trials have focused on improving infant gut colonisation postnatally. However, prenatal life is a crucial period during which different tolerance mechanisms are put in place. We aim to determine whether antenatal prebiotics supplementation prevents AD in high-risk children.

METHODS AND ANALYSIS

This is a randomised, multicentre, double-blind, trial to evaluate the effectiveness of antenatal prebiotic maternal supplementation (galacto-oligosaccharide/inulin) in pregnant women versus placebo on the occurrence of AD at 1 year of age in at-risk children (defined as having a maternal history of atopic disease). Participating women will be randomised to daily ingestion of a prebiotics or placebo (maltodextrin) from 20 weeks' gestation until delivery. The primary outcome is the prevalence of AD at 1 year of age, using the version of the UK Working Party Diagnostic Criteria optimised for preventive studies. Key secondary endpoints are AD severity, quality of life and prebiotics tolerance. The target sample size is 376 women (188 patients per group) which will provide 80% power to detect a 33% reduction of the risk of AD in the verum group (α=0.05). The primary analysis will be based on the intention-to-treat principle.

ETHICS AND DISSEMINATION

Results will be presented in peer-reviewed journals and at international conferences. Ethics approval for the study was obtained from the institutional ethical review board of 'Comité de Protection des Personnes Sud Ouest-Outre-Mer III' of the University Hospital Centre of Bordeaux (2017/13).

TRIAL REGISTRATION NUMBER

NCT03183440; Pre-results.

PEBBLES study protocol: a randomised controlled trial to prevent atopic dermatitis, food allergy and sensitisation in infants with a family history of allergic disease using a skin barrier improvement strategy

INTRODUCTION

The skin is an important barrier against environmental allergens, but infants have relatively impaired skin barrier function. There is evidence that impaired skin barrier function increases the risk of allergic sensitisation, atopic dermatitis (AD) and food allergy. We hypothesise that regular prophylactic use of emollients, particularly those that are designed to improve skin barrier structure and function, will help prevent these conditions. With the aim of determining if application of a ceramide-dominant emollient two times per day reduces the risk of AD and food allergy, we have commenced a multicentre phase III, outcome assessor blinded, randomised controlled trial of this emollient applied from birth to 6 months.

METHODS AND ANALYSIS

Infants (n=760) with a family history of allergic disease will be recruited from maternity hospitals in Melbourne. The primary outcomes are as follows: the presence of AD, assessed using the UK Working Party criteria, and food allergy using food challenge, in the first 12 months of life as assessed by a blinded study outcome assessor. Secondary outcomes are as follows: food sensitisation (skin prick test), skin barrier function, AD severity, the presence of new onset AD after treatment cessation (between 6 and 12 months) and the presence of parent reported AD/eczema. Recruitment commenced in March 2018.

ETHICS AND DISSEMINATION

The PEBBLES Study is approved by the Human Research Ethics Committees of the Royal Children's Hospital (RCH) (#37090A) and the Mercy Hospital for Women (2018-008). Parents or guardians will provide written informed consent. Outcomes will be disseminated through peer-reviewed publications and presented at scientific conferences.

TRIAL REGISTRATION NUMBERS

ACTRN12617001380381 and NCT03667651.

Incidence Trends of Atopic Dermatitis in Infancy and Early Childhood in a Nationwide Prescription Registry Study in Norway

Importance

With increasing prevalence of atopic dermatitis (AD) and its manifestation in most countries, together with the supporting evidence of the progression to other atopic phenotypes, AD has developed into a worldwide public health concern. The presence of the disease of has increased since the 1950s, but some recent studies suggest a stationary or decreasing trend.

Objective

To analyze a nationwide health register based on prescription data to determine the incidence rate (IR) of AD in an entire pediatric population.

Design, Setting, and Participants

All children resident in Norway younger than 6 years from January 1, 2009, through December 31, 2015, were included in this cohort study. Medical diagnoses and disease-specific medications were used as a proxy for identifying children with AD in this population-based prescription registry study. The prescription study was terminated in 2016. The total number of 295 286 disease-specific prescriptions was analyzed from August 2016 through December 2017. The hypothesis was formulated before, during, and after the data collection.

Main Outcomes and Measures

All children with a medical diagnosis of AD or eczema based on at least 2 prescriptions of topical corticosteroids or at least 1 prescription of topical calcineurin inhibitors. Incidence rates per person-year (PY) and IR ratios were calculated.

Results

A total of 295 286 disease-specific prescriptions were dispensed to 122 470 children, of whom 63 460 had AD and 56 009 (88.3%) had reimbursed prescriptions and associated AD diagnoses. The annual Norwegian study population (aged <6 years) increased from 357 451 children in 2009 to 373 954 in 2015. The overall IR increased from 0.028 per PY (95% CI, 0.028-0.029 per PY) in 2009 to 0.034 per PY (95% CI, 0.033-0.035 per PY) in 2014. For children younger than 1 year, the IR increased from 0.052 per PY (95% CI, 0.050-0.053 PY) in 2009 to 0.073 per PY (95% CI, 0.071-0.075 per PY) in 2014. In this age group, the IR was 53% higher in boys compared with girls (IR ratio, 1.53; 95% CI, 1.49-1.57; P < .001). The incidence proportion before the age of 6 years was 17.4% (95% CI, 17.2%-17.7%). The primary seasons for the onset of AD were winter and spring.

Conclusions and Relevance

This nationwide study suggests an increase in the IR of pediatric AD, especially among children younger than 1 year. This study's findings suggest that increase occurred with a higher IR during winter and spring seasons. Atopic dermatitis had an earlier onset in boys than in girls. During the study period, more than 1 in 6 children younger than 6 years had, at some point, been affected by AD.

Prevention of allergies in childhood - where are we now?

Allergic diseases represent an increasing health problem for children worldwide. Along with allergic airway diseases, food allergy comes to the fore and herewith closely intertwined the hypothesis that an early allergic sensitization might occur via skin barrier defect(s). The importance of the skin barrier has been documented by several studies meanwhile. Not only genetic studies screen the associations between Filaggrin loss-of-function mutations, atopic dermatitis, allergic sensitization, food allergy and even airway diseases, but also epidemiological studies cast new light on the hypothesis of the atopic march. As another focus in context of the development of an allergic phenotype, the specific microbial exposure with all its diversities has been crystallized as it shapes the immune system in (early) infancy. Studies explored both, the role of human intestinal microbiota as well as the external microbial diversity. Unfortunately suitable markers for atopic predictors are still rare. New studies point out that specific IgE antibodies (e.g., IgE to Phl p 1) in children without allergic symptoms so far, might function as a pre-clinical biomarker, which may help to identify candidates for primary (allergen non-specific) or secondary (allergen-specific) prevention in terms of specific immunoprophylaxis. These manifold research activities document a complex increase in knowledge. Nevertheless new assumptions need to be substantively confirmed in order to finally generate the urgently needed preventive strategies for allergic diseases in childhood.

The Long-Term Course of Atopic Dermatitis

Atopic dermatitis (AD) is a chronic, relapsing condition, meaning that the intensity of symptoms usually fluctuates over time. Changes in skin physiology may be evident from birth, suggesting that AD may be a lifelong condition marked by intermittent symptoms/disease activity. Methodological considerations for studying the long-term course of AD are reviewed in detail. Improved measurement of the frequency and duration of active disease periods can help to elucidate more about the clinical course AD and the role of treatment in long-term outcomes.

A programme of research to set priorities and reduce uncertainties for the prevention and treatment of skin disease

Background

Skin diseases are very common and can have a large impact on the quality of life of patients and caregivers. This programme addressed four diseases: (1) eczema, (2) vitiligo, (3) squamous cell skin cancer (SCC) and (4) pyoderma gangrenosum (PG).

Objective

To set priorities and reduce uncertainties for the treatment and prevention of skin disease in our four chosen diseases.

Design

Mixed methods including eight systematic reviews, three prioritisation exercises, two pilot randomised controlled trials (RCTs), three feasibility studies, two core outcome initiatives, four funding proposals for national RCTs and one completed national RCT.

Setting

Secondary care, primary care and the general population.

Participants

Patients (and their caregivers) with eczema, vitiligo, SCC and PG, plus health-care professionals with an interest in skin disease.

Interventions

Our three intervention studies included (1) barrier enhancement using emollients from birth to prevent eczema (pilot RCT); (2) handheld narrowband ultraviolet light B therapy for treating vitiligo (pilot RCT); and (3) oral ciclosporin (Neoral®, Novartis Pharmaceuticals) compared with oral prednisolone for managing PG (pragmatic national RCT).

Results

Systematic reviews included two overarching systematic reviews of RCTs of treatments for eczema and vitiligo, an umbrella review of systematic reviews of interventions for the prevention of eczema, two reviews of treatments for SCC (one included RCTs and the second included observational studies), and three reviews of outcome measures and outcome reporting. Three prioritisation partnership exercises identified 26 priority areas for future research in eczema, vitiligo and SCC. Two international consensus initiatives identified four core domains for future eczema trials and seven core domains for vitiligo trials. Two pilot RCTs and three feasibility studies critically informed development of four trial proposals for external funding, three of which are now funded and one is pending consideration by funders. Our pragmatic RCT tested the two commonly used systemic treatments for PG (prednisolone vs. ciclosporin) and found no difference in their clinical effectiveness or cost-effectiveness. Both drugs showed limited benefit. Only half of the participants’ ulcers had healed by 6 months. For those with healed ulcers, recurrence was common (30%). Different side effect profiles were noted for each drug, which can inform clinical decisions on an individual patient basis. Three researchers were trained to PhD level and a dermatology patient panel was established to ensure patient involvement in all aspects of the programme.

Conclusions

Findings from this programme of work have already informed clinical guidelines and patient information resources. Feasibility studies have ensured that large national pragmatic trials will now be conducted on important areas of treatment uncertainty that address the needs of patients and the NHS. There is scope for considerable improvement in terms of trial design, conduct and reporting for RCTs of skin disease, which can be improved through wider collaboration, registration of trial protocols and complete reporting and international consensus over core outcome sets. Three national trials have now been funded as a result of this work. Two international initiatives to establish how best to measure the core outcome domains for eczema and vitiligo are ongoing.

Trial registration

Current Controlled Trials Barrier Enhancement for Eczema Prevention (BEEP) (ISRCTN84854178 and NCT01142999), Study of Treatments fOr Pyoderma GAngrenosum Patients (STOP GAP) (ISRCTN35898459) and Hand Held NB-UVB for Early or Focal Vitiligo at Home (HI-Light Pilot Trial) (NCT01478945).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 18. See the NIHR Journals Library website for further project information.

Children with Dry Skin and Atopic Predisposition: Outcome Measurement with Validated Scores for Atopic Dermatitis

BACKGROUND

Dry skin is a common skin condition in childhood. Few studies exist investigating the influence of daily skin care on dry skin in infants at risk of developing atopic dermatitis (AD). We aimed to assess the effect of skin care on dry skin in this special cohort using validated scores for AD and analysis of skin microtopography.

METHODS

43 children were randomized to group 1 (G1) and group 2 (G2) and 22 infants to group 3 (G3). During 16 weeks, G1 and G3 applied daily a plant-based emollient and G2 a petrolatum-based emollient. The core outcome was assessed by Severity Scoring of Atopic Dermatitis (SCORAD) and Patient-Oriented SCORing Atopic Dermatitis (PO-SCORAD). The influence on the parents' life was evaluated by a questionnaire and microtopography by Visioscan® VC 98.

RESULTS

The SCORAD index declined significantly until week (W) 16 in all groups (p ≤ 0.041). The sleeplessness score analyzed by PO-SCORAD was highly reduced after W12 in G1 and after W16 in G2 (p ≤ 0.030). The influence on the parents' anxiety was reduced in G3 at W12 and W16 (p = 0.016). The Visioscan parameter scaliness strongly diminished at W4 (p ≤ 0.049) and W16 (p ≤ 0.013) in all groups.

CONCLUSIONS

This trial demonstrates improved skin conditions and sleep following daily emollient application in infants and children having dry skin and being at risk of AD. Especially parents of infants showed a reduced fear that their children might develop AD. Further studies are required to investigate the preventive effect of daily emollient therapy in this special cohort evaluating the outcome measures used in this trial.

Atopic dermatitis

Atopic dermatitis (also known as atopic eczema) is a chronic inflammatory skin disease that is characterised by intense itching and recurrent eczematous lesions. Although it most often starts in infancy and affects two of ten children, it is also highly prevalent in adults. It is the leading non-fatal health burden attributable to skin diseases, inflicts a substantial psychosocial burden on patients and their relatives, and increases the risk of food allergy, asthma, allergic rhinitis, other immune-mediated inflammatory diseases, and mental health disorders. Originally regarded as a childhood disorder mediated by an imbalance towards a T-helper-2 response and exaggerated IgE responses to allergens, it is now recognised as a lifelong disposition with variable clinical manifestations and expressivity, in which defects of the epidermal barrier are central. Present prevention and treatment focus on restoration of epidermal barrier function, which is best achieved through the use of emollients. Topical corticosteroids are still the first-line therapy for acute flares, but they are also used proactively along with topical calcineurin inhibitors to maintain remission. Non-specific immunosuppressive drugs are used in severe refractory cases, but targeted disease-modifying drugs are being developed. We need to improve understanding of the heterogeneity of the disease and its subtypes, the role of atopy and autoimmunity, the mechanisms behind disease-associated itch, and the comparative effectiveness and safety of therapies.

Emollient enhancement of the skin barrier from birth offers effective atopic dermatitis prevention

Background

Atopic dermatitis (atopic eczema) is a chronic inflammatory skin disease that has reached epidemic proportions in children worldwide and is increasing in prevalence. Because of the significant socioeconomic effect of atopic dermatitis and its effect on the quality of life of children and families, there have been decades of research focused on disease prevention, with limited success. Recent advances in cutaneous biology suggest skin barrier defects might be key initiators of atopic dermatitis and possibly allergic sensitization.

Objective

Our objective was to test whether skin barrier enhancement from birth represents a feasible strategy for reducing the incidence of atopic dermatitis in high-risk neonates.

Methods

We performed a randomized controlled trial in the United States and United Kingdom of 124 neonates at high risk for atopic dermatitis. Parents in the intervention arm were instructed to apply full-body emollient therapy at least once per day starting within 3 weeks of birth. Parents in the control arm were asked to use no emollients. The primary feasibility outcome was the percentage of families willing to be randomized. The primary clinical outcome was the cumulative incidence of atopic dermatitis at 6 months, as assessed by a trained investigator.

Results

Forty-two percent of eligible families agreed to be randomized into the trial. All participating families in the intervention arm found the intervention acceptable. A statistically significant protective effect was found with the use of daily emollient on the cumulative incidence of atopic dermatitis with a relative risk reduction of 50% (relative risk, 0.50; 95% CI, 0.28-0.9; P = .017). There were no emollient-related adverse events and no differences in adverse events between groups.

Conclusion

The results of this trial demonstrate that emollient therapy from birth represents a feasible, safe, and effective approach for atopic dermatitis prevention. If confirmed in larger trials, emollient therapy from birth would be a simple and low-cost intervention that could reduce the global burden of allergic diseases.

Randomized trial of vitamin D supplementation for winter-related atopic dermatitis in children

BACKGROUND

Epidemiologic and preclinical data, and a small randomized trial in Boston, suggest that vitamin D supplementation may improve winter-related atopic dermatitis (AD).

OBJECTIVE

To determine the effect of vitamin D supplementation on winter-related AD.

METHODS

We performed a randomized, double-blind, placebo-controlled trial of Mongolian children with winter-related AD (clinicaltrials.gov identifier: NCT00879424). Baseline eligibility included age 2 to 17 years, AD score 10 to 72 using the Eczema Area and Severity Index (EASI), and winter-related AD (eg, history of AD worsening during the fall-to-winter transition). Subjects were enrolled in Ulaanbaatar during winter and randomly assigned to oral cholecalciferol (1000 IU/day) versus placebo for 1 month. All children and parents received emollient and patient education about AD and basic skin care. The main outcomes were changes in EASI score and in Investigator's Global Assessment.

RESULTS

The 107 enrolled children had a mean age of 9 years (SD 5), and 59% were male. Their median age of AD onset was 3 months (interquartile range 2 months to 1 year) and mean EASI score at baseline 21 (SD 9). One-month follow-up data were available for 104 (97%) children. Compared with placebo, vitamin D supplementation for 1 month produced a clinically and statistically significant improvement in EASI score (adjusted mean change: -6.5 vs -3.3, respectively; P = .04). Moreover, change in Investigator's Global Assessment favored vitamin D over placebo (P = .03). There were no adverse effects in either group.

CONCLUSION

Vitamin D supplementation improved winter-related AD among Mongolian children, a population likely to have vitamin D deficiency in winter.

Can early skin care normalise dry skin and possibly prevent atopic eczema? A pilot study in young infants

BACKGROUND

Atopic eczema (AE) affects approximately 20% of children in Northern countries. Onset during early infancy is common and is characterised by altered skin barrier, increased water loss and defective lipid layer. Restoration of skin barrier by emollients and/or oil baths is an important part of AE treatment, but its role in preventing xerosis and AE is unknown. The present pilot study aimed to assess if xerosis, and possibly AE, could be reduced at six months of age by early introduction of frequent oil baths/facial fat cream in infants with dry skin.

METHODS

A controlled intervention pilot study included 56 six-week-old infants with xerosis, but not AE. Skin quality score ranging from 0 (normal skin) to 4 (probable AE), was assessed at inclusion, three and six months of age, with skin quality at six months as main outcome. One well baby clinic was recruited for intervention, frequent skin care (oil bath (0.5 dl) and facial fat cream, five well baby clinics recruited for observation only.

RESULTS

The intervention group (n=24) had more often normal skin (75%) at six months than the observation group (37.5%) (p<0.001), and less often probable AE (4.0 vs. 19.0%, respectively, ns). Oil baths were performed regularly, 2-4 up to 5-7 times/week in the intervention group, vs. fewer oil baths with sparse volume of oil in the observation group. No adverse reactions were reported.

CONCLUSION

Regular oil baths in infants seem to reduce xerosis and may possibly reduce atopic eczema.

Deciphering the complexities of atopic dermatitis: shifting paradigms in treatment approaches

Atopic dermatitis (AD) is the most common chronic inflammatory skin disease. It often precedes the development of food allergy and asthma. Recent insights into AD reveal abnormalities in terminal differentiation of the epidermal epithelium leading to a defective stratum corneum, which allows enhanced allergen penetration and systemic IgE sensitization. Atopic skin is also predisposed to colonization or infection by pathogenic microbes, most notably Staphylococcus aureus and herpes simplex virus. Causes of this abnormal skin barrier are complex and driven by a combination of genetic, environmental, and immunologic factors. These factors likely account for the heterogeneity of AD onset and the severity and natural history of this skin disease. Recent studies suggest prevention of AD can be achieved through early interventions to protect the skin barrier. Onset of lesional AD requires effective control of local and systemic immune activation for optimal management. Early intervention might improve long-term outcomes for AD and reduce the systemic allergen sensitization that leads to associated allergic diseases in the gastrointestinal and respiratory tract.

Persistence of mild to moderate atopic dermatitis

IMPORTANCE

Atopic dermatitis (AD) is a common illness of childhood.

OBJECTIVE

To evaluate the natural history of AD and determine the persistence of symptoms over time.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional and cohort study of a nation-wide long-term registry of children with AD enrolled in the Pediatric Eczema Elective Registry (PEER).

MAIN OUTCOMES AND MEASURES

Self-reported outcome of whether a child's skin was AD symptom-free for 6 months at 6-month intervals.

RESULTS

A total of 7157 patients were enrolled in the PEER study for a total of 22,550 person-years. At least 2 years of follow-up were observed for 4248 children and at least 5 years of follow-up were observed for 2416 children. Multiple demographic and exposure variables were associated with more persistent AD. At every age (ie, 2-26 years), more than 80% of PEER participants had symptoms of AD and/or were using medication to treat their AD. It was not until age 20 years that 50% of patients had at least 1 lifetime 6-month symptom- and treatment-free period.

CONCLUSIONS AND RELEVANCE

Based on this large longitudinal cohort study, symptoms associated with AD seem to persist well into the second decade of a child's life and likely longer. Atopic dermatitis is probably a life-long illness.

Validation of asthma and eczema in population-based Swedish drug and patient registers

PURPOSE

Validated measures of asthma and eczema at the population level remain a challenge. Our aim was to ascertain if register-based information on asthma/eczema medication can function as a proxy for an asthma/eczema diagnosis and to validate register-based asthma diagnoses.

METHODS

Information was requested on all 0-45-year-old individuals with reported asthma/eczema medication and/or diagnoses in the Swedish Prescribed Drug Register and National Patient Register, between July 2005 and December 2009 (N = 250 691). Medical records for 1952 randomly selected individuals were reviewed to estimate the proportion of individuals with the following: (1) asthma/eczema medication that fulfilled predefined criteria of asthma/eczema (positive predictive value (PPV)) and (2) a register-based asthma diagnosis verified as asthma by predefined criteria.

RESULTS

Positive predictive value for asthma by predefined criteria ranged between 0.75 (95%CI: 0.70-0.78) to 0.94 (95%CI: 0.91-0.96), depending on age group. In pre-school children, PPV for asthma in combination with obstructive bronchitis was 0.87 (95%CI: 0.83-0.90), and PPV for eczema was estimated to 0.45 (95%CI: 0.38-0.51). Eighty percent of children 0-4.5 years and 99% of children >4.5-17 years with a register-based diagnosis of asthma were verified as asthmatics.

CONCLUSION

Asthma medication is a suitable proxy for asthma in older children and adults; the same approach is insufficient for eczema. This validation study of two Swedish registers opens for future large nation-wide register-based studies on asthma.

New insights into atopic dermatitis: role of skin barrier and immune dysregulation

Atopic dermatitis (AD) is a chronic inflammatory skin disease that is often associated with the development of food allergy and asthma. New insights into AD reveals an important role for structural abnormalities in the epidermis resulting in a leaky epithelial barrier as well as chronic immune activation that contribute to the pathophysiology of this common skin disease. Patients with AD have a predisposition to colonization or infection by microbial organisms, most notably Staphylococcus aureus and herpes simplex virus (HSV). Measures directed at healing and protecting the skin barrier and controlling the immune activation are needed for effective management of AD. Early intervention may improve outcomes for AD as well as reduce the systemic allergen sensitization that may lead to associated allergic diseases in other organs.

Current issues in atopic comorbidities and preventing the atopic march

The individual, family, and public health burden of atopic dermatitis (AD) is considerable. The prevalence of AD is high, the signs and symptoms of the disease adversely affect quality of life for patients and their families, and the comorbid conditions associated with AD can increase considerably the negative impact of the disease. These comorbid conditions patients with AD are susceptible to include skin infectious, IgE-mediated diseases, and mental health disorders. New research identifies the skin barrier as not only an important initiator of atopic dermatitis but may even be a site for allergic sensitization to protein antigens. The skin barrier represents a potential new target for novel atopic prevention strategies.

Prevention of atopic dermatitis

Atopic dermatitis now affects one in five children, and may progress to asthma and hay fever. In the absence of effective treatments that influence disease progression, prevention is a highly desirable goal. The evidence for most existing disease prevention strategies, such as avoidance of allergens and dietary interventions, has been unconvincing and inconsistent. Fresh approaches to prevention include trying to induce tolerance to allergens in early life, and enhancing the defective skin barrier to reduce skin inflammation, sensitisation and subsequent allergic disease. Early and aggressive treatment of atopic dermatitis represents another possible secondary prevention strategy that could interrupt the development of autoimmunity, which may account for atopic dermatitis persistence. Large scale and long term randomized controlled trials are needed to demonstrate that these ideas result in clinical benefit.

Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects in 2012

This review highlights some of the research advances in anaphylaxis; hypersensitivity reactions to foods, drugs, and insects; and allergic skin diseases that were reported in the Journal in 2012. Studies support an increase in peanut allergy prevalence in children and exposure to the antibacterial agent triclosan and having filaggrin (FLG) loss-of-function mutations as risk factors for food sensitization. The role of specific foods in causing eosinophilic esophagitis is elucidated by several studies, and microRNA analysis is identified as a possible noninvasive disease biomarker. Studies on food allergy diagnosis emphasize the utility of component testing and the possibility of improved diagnosis through stepped approaches, epitope-binding analysis, and bioinformatics. Treatment studies of food allergy show promise for oral immunotherapy, but tolerance induction remains elusive, and additional therapies are under study. Studies on anaphylaxis suggest an important role for platelet-activating factor and its relationship to the need for prompt treatment with epinephrine. Insights on the pathophysiology and diagnosis of non-IgE-mediated drug allergy are offered, with novel data regarding the interaction of drugs with HLA molecules. Numerous studies support influenza vaccination of persons with egg allergy using modest precautions. Evidence continues to mount that there is cross-talk between skin barrier defects and immune responses in patients with atopic dermatitis. Augmentation of the skin barrier with reduction in skin inflammatory responses will likely lead to the most effective intervention in patients with this common skin disease.