Reframing racial and ethnic disparities in atopic dermatitis in Black and Latinx populations

Race science without racists: how bigoted paradigms persist in allergy research

In the wake of the murder of George Floyd and the massacre in Buffalo, the editorial boards of the prominent scientific publication companies formally apologized for their journals' historical role in advancing race science and promised to improve their standards. However, flowery commentaries cannot undo the consistent pattern of endorsing biologic differences between ethnic groups, even when discussing diseases or traits that are not considered politically charged. In this report, an exemplar is made of a recent publication claiming to identify phenotypes of atopic dermatitis that are distinct between European Americans, Asians, and African Americans. The insufficiency of the evidence and logic underlying these claims are discussed. Although devoid of malice, numerous publications continue to demonstrate how claims of biological differences between races is mainstreamed in modern scientific publications. Overall, the goal of this work is to challenge the scientific community, particularly the publication companies, to evaluate how assumptions of innate biologic disadvantage have clouded assessments of racial disparities in disease beyond the topics that are more stereotypical of race science.

Study of Genetic Mutations and Their Association With the Development of Atopic Dermatitis and Other Skin Diseases

The purpose of this study was to identify the heterogeneity of atopic dermatitis and to identify key genetic factors. This can lead to new approaches and personalized treatment strategies. I conducted a literature review of three scientific publication platforms (i.e., PubMed, Cochrane Library, Scopus) for records published between July 2011 and July 2023 using key words related to the genetics of atopic dermatitis. The high heritability and genetic pleiotropia of atopic dermatitis emphasize the importance of its genetic predisposition and interaction with concomitant diseases. The study also shows the role of various genes associated with immunity and inflammatory reactions, as well as the high heritability of atopic dermatitis, particularly among twins. Genetic mutations, specifically polymorphisms of genes encoding immune factors and inflammatory responses, determine an individual's predisposition to atopic dermatitis. Research findings also point to genetic aspects associated with other skin conditions such as psoriasis and vitiligo, confirming the existence of common genetic mechanisms between these diseases. Specifically, polymorphisms of the filaggrin gene have been found to be key genetic determinants of atopic dermatitis. I analyzed the genetic basis of atopic dermatitis, emphasizing the importance of genetic determinants and their interaction with the immune system and extracellular matrix. This study contributes to the understanding of the mechanisms of atopic dermatitis and opens new perspectives for individualized treatments.

Sociodemographic factors linked to food allergy diagnosis among high-risk children with atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is a known risk factor for the development of food allergy (FA). Prior work has suggested disparities in diagnosis/management of FA in urban populations.

OBJECTIVE

To determine whether socioeconomic conditions, as measured by the area deprivation index and insurance status, or racial/ethnic self-identity was associated with risk of FA diagnosis (DFA), evaluation by an allergist, or objective FA testing among high-risk children with AD.

METHODS

This is a retrospective cohort study of pediatric patients with physician-diagnosed AD who had received primary care at a single urban academic tertiary care center between 2009 and 2022. Statistical analysis in SPSS (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0, Armonk, NY) used χ2, analysis of variance, and logistic regression.

RESULTS

In a total of 3365 pediatric subjects, 41.3% identified as non-Hispanic Black, 33.9% Hispanic, 6.9% Asian, and 14.9% non-Hispanic White. Hispanic children with AD and DFA were significantly less likely to be evaluated by an allergist than White or Asian children (65.9% vs 82.8% and 80.3%, P = .001 and P = .02). Non-Hispanic Black children with AD and DFA were more likely to have no objective FA testing than White children (20.9% vs 12.1%, P = .04). The White and Asian children were more likely to undergo the thorough combination of both blood and skin testing for DFA than Black or Hispanic children (15.5% and 22.4% vs 7.1% and 7.9%, respectively, P = .007, P = .00005, P = .03, P = .0008).

CONCLUSION

Labeling at-risk young children with FA without thorough objective testing can affect their nutrition and quality of life. Barriers to equitable evaluation of DFA should be further investigated and addressed.

Are behavioral interventions a better choice for atopic dermatitis patients? A meta-analysis of 6 randomized controlled trials

BACKGROUND

The treatment for atopic dermatitis (AD) has been the focus of clinical research, and behavioral intervention is considered an indispensable treatment method. To our knowledge, no relevant meta-analysis has evaluated the effects of behavioral interventions on atopic dermatitis.

OBJECTIVES

To evaluate the effects of behavioral interventions on atopic dermatitis.

METHODS

The authors searched PubMed, EMBASE, and Cochrane CENTRAL to retrieve relevant RCTs (up to Feb 2022). The search strategy involved a combination of related keywords. The Cochrane Q and I2 statistics were used to assess heterogeneity.

RESULTS

Six RCTs involving seven reports with 246 patients were included. The results suggested that behavioral interventions could relieve eczema severity (correlation coefficient [r = -0.39]; p < 0.001) and scratching severity significantly (r = -0.19; p = 0.017), while not affect itching intensity (r = -0.02; p = 0.840). A sensitivity analysis confirmed the robustness of the results.

STUDY LIMITATIONS

An important limitation of this study was the insufficient number of RCTs and the limited sample size. In addition, the study lacked a control group receiving a type of intervention other than the experimental protocol. Another limitation was the short duration of follow-up.

CONCLUSIONS

This study suggests that behavioral interventions could be effective in treating atopic dermatitis by reducing eczema and scratching severity. Additionally, habit-reversal behavioral therapy may be more effective for treating atopic dermatitis.

Prurigo Nodularis: Pathogenesis and the Horizon of Potential Therapeutics

Chronic pruritus that lasts for over 6 weeks can present in various forms, like papules, nodules, and plaque types, with prurigo nodularis (PN) being the most prevalent. The pathogenesis of PN involves the dysregulation of immune cell-neural circuits and is associated with peripheral neuropathies, possibly due to chronic scratching. PN is a persistent and challenging condition, involving complex interactions among the skin, immune system, and nervous system. Lesional skin in PN exhibits the infiltration of diverse immune cells like T cells, eosinophils, macrophages, and mast cells, leading to the release of inflammatory cytokines and itch-inducing substances. Activated sensory nerve fibers aggravate pruritus by releasing neurotransmitters, perpetuating a vicious cycle of itching and scratching. Traditional treatments often fail, but recent advancements in understanding the inflammatory and itch transmission mechanisms of PN have paved the way for innovative therapeutic approaches, which are explored in this review.

Specialty drug use for autoimmune conditions varies by race and wage among employees with employer-sponsored health insurance

BACKGROUND

The relationship between race and ethnicity, wage status, and specialty medication (SpRx) use among employees with autoimmune conditions (AICs) is poorly understood. Insight into sociodemographic variations in use of these medications can inform health equity improvement efforts.

OBJECTIVE

To assess the association of race and ethnicity and wage status on SpRx use and adherence patterns among employees with AICs enrolled in employer-sponsored health insurance.

METHODS

In this observational, retrospective cohort analysis, data were obtained from the IBM Watson MarketScan database for calendar year 2018. Employees were separated into race and ethnicity subgroups based on employer-provided data. Midyear employee wage data were used to allocate employees into the following annual income quartiles: $47,000 or less, $47,001-$71,000, $71,001-$106,000, and $106,001 or more. The lowest quartile was further divided into 2 groups ($35,000 or less and $35,001-$47,000) to better evaluate subgroup differences. Outcomes included monthly days SpRx-AIC supply, proportion of days covered (PDC), and medication discontinuation rates. Generalized linear regressions were used to assess differences while adjusting for patient and other characteristics.

RESULTS

From a sample of more than 2,000,000 enrollees, race and ethnicity data were available for 617,117 (29.8%). Of those, 47,839 (7.8%) were identified as having an AIC of interest, with prevalence rates of AICs differing by race within wage categories. Among those with AICs, 5,358 (11.2%) had filled at least 1 SpRx-AIC prescription. Following adjustment, except for the highest wage category, prevalence of SpRx-AIC use was significantly less among Black and Hispanic subpopulations. Black patients had significantly lower SpRx-AIC use rates than White patients (≤$35,000: 4.9 vs 9.4%, >$35,000-$47,000: 5.5 vs 10.6%, >$47,000-$71,000: 8.5 vs 11.1%, and >$71,000-$106,000: 9.1 vs 12.7%; P <0.001 for all). For Hispanic patients, prevalence rates were significantly lower than White patients in 3 different wage categories (≤$35,000: 4.5 vs 9.4%, >$35,000-$47,000: 6.1 vs 10.6%, and >$71,000-$106,000: 8.6 vs 12.7%; P < 0.001). PDC and 90-day discontinuation rates did not differ among race and ethnicity groups within the respective wage bands.

CONCLUSIONS

Race and ethnicity and wage-related disparities exist in SpRx use, but not PDC or discontinuation rates for treatment of AICs among non-White and low-income populations with employer-sponsored insurance, and may adversely impact clinical outcomes.

Lower socioeconomic status may help explain racial disparities in asthma and atopic dermatitis prevalence: A mediation analysis

BACKGROUND

Racial disparities in atopic disease (atopic dermatitis [AD], asthma, and allergies) prevalence are well documented. Despite strong associations between race and socioeconomic deprivation in the United States, and socioeconomic status (SES) and atopic diseases, the extent to which SES explains these disparities is not fully understood.

OBJECTIVE

We sought to identify racial disparities in childhood atopic disease prevalence and determine what proportion of those disparities is mediated by SES.

METHODS

This study used the National Health Interview Survey (2011-2018) to investigate AD, asthma, and respiratory allergy prevalence in Black and White children and the extent to which measures of SES explain any identified disparities.

RESULTS

By race, prevalences were as follows: AD, White 11.8% (95% CI: 11.4%, 12.2%) and Black 17.4% (95% CI: 16.6%, 18.3%); asthma prevalence, White 7.4% (95% CI: 7.0%, 7.7%) and Black 14.3% (95% CI: 13.5%, 15.0%); respiratory allergy, White 11.4% (95% CI: 11.0%, 11.9%) and Black 10.9% (95% CI: 10.3%, 11.6%). The percentage of the disparity between racial groups and disease prevalence explained by a multivariable measure of SES was 25% (95% CI: 15%, 36%) for Black versus White children with AD and 47% (95% CI: 40%, 54%) for Black versus White children with asthma.

CONCLUSIONS

In a nationally representative US population, Black children had higher prevalence of AD and asthma than White children did and similar prevalence of respiratory allergy; a multivariable SES measure explained a proportion of the association between Black versus White race and AD and a much larger proportion for asthma.

Symptoms of Cognitive Impairment Among Children With Atopic Dermatitis

Importance

Previous studies suggest that atopic dermatitis (AD) is associated with cognitive impairment in children, but these studies have relied primarily on neurodevelopmental diagnoses (rather than symptoms) as proxy measures of cognitive function. It remains unknown if certain subpopulations of children with AD are at greater risk of cognitive impairment.

Objective

To examine the association of AD with symptoms of cognitive impairment (difficulty in learning or memory) among US children and whether this association varies according to the presence or absence of neurodevelopmental comorbidities (attention-deficit/hyperactivity disorder [ADHD], developmental delay, or learning disability).

Design, Setting, and Participants

This cross-sectional study used 2021 data from the US National Health Interview Survey collected on children aged 17 years or younger without intellectual disability or autism. The presence of AD was based on a parent or adult caregiver's report indicating either a current diagnosis of AD or a previous medical confirmation of AD by a health care professional.

Main Outcomes and Measures

Difficulty with learning or memory as reported by the child's caregiver.

Results

Among the weighted total of 69 732 807 participants, 9 223 013 (13.2%) had AD. Compared with children without AD, children with AD were more likely to experience difficulties with learning (10.8% [95% CI, 7.8%-15.8%] vs 5.9% [95% CI, 5.1%-6.9%]; P < .001) and difficulties with memory (11.1% [95% CI, 8.0%-15.9%] vs 5.8% [95% CI, 4.9%-6.9%]; P < .001). In multivariable logistic regression models adjusted for sociodemographic factors, asthma, food allergies, and seasonal allergies or hay fever, AD was associated with increased odds of difficulties in learning (adjusted odds ratio [AOR], 1.77; 95% CI, 1.28-2.45) and memory (AOR, 1.69; 95% CI, 1.19-2.41). In analyses stratified by neurodevelopmental comorbidities, AD was associated with 2- to 3-fold greater odds of memory difficulties among children with any neurodevelopmental disorder (AOR, 2.26; 95% CI, 1.43-3.57), including ADHD (AOR, 2.90; 95% CI, 1.60-5.24) or learning disabilities (AOR, 2.04; 95% CI, 1.04-4.00). However, AD was not associated with learning or memory difficulties among children without neurodevelopmental conditions.

Conclusions and Relevance

Results of this cross-sectional study suggest that pediatric AD was generally associated with greater odds of reported difficulties in learning and memory. However, this association was primarily limited to children with neurodevelopmental comorbidities, such as ADHD or learning disabilities. These findings may improve the risk stratification of children with AD for cognitive impairments and suggest that evaluation for cognitive difficulties should be prioritized among children with AD and neurodevelopmental disorders.

Abrocitinib efficacy and safety in moderate-to-severe atopic dermatitis by race, ethnicity, and Fitzpatrick skin type

BACKGROUND

Response to abrocitinib treatment for moderate-to-severe atopic dermatitis (AD) has not been evaluated across racial and ethnic subpopulations.

OBJECTIVE

To assess the efficacy and safety of abrocitinib on the basis of patient race, ethnicity, and Fitzpatrick skin type (FST).

METHODS

Data were pooled post hoc from patients treated with abrocitinib 200 mg, 100 mg, or placebo in 3 monotherapy trials (NCT02780167, NCT03349060, and NCT03575871). Race and ethnicity were self-reported; FST was determined by study investigators. Evaluations through Week 12 include the following: (1) Investigator's Global Assessment of clear or almost-clear skin; (2) greater than or equal to 75% improvement in Eczema Area and Severity Index or SCORing AD; (3) a greater-than-or-equal-to 4-point improvement in Peak Pruritus Numerical Rating Scale score; (4) least squares mean changes in Dermatology Life Quality Index and Patient-Oriented Eczema Measure scores; and (5) treatment-emergent adverse events.

RESULTS

The sample comprised 628 White, 204 Asian, and 83 Black patients; 37 were Hispanic or Latino; 624 had FST I to III and 320 had FST IV to VI. Treatment with either abrocitinib dose was associated with greater proportions of patients achieving Investigator's Global Assessment of clear or almost-clear skin, ≥ 75% improvement in Eczema Area and Severity Index, ≥ 75% improvement in SCORing AD, and a ≥ 4-point improvement in Peak Pruritus Numerical Rating Scale, or greater score changes from baseline in Dermatology Life Quality Index and Patient-Oriented Eczema Measure vs placebo regardless of race, ethnicity, or FST. Dose-response was most prominent in White patients. In Black patients, the effects of the 2 doses were similar. Treatment-emergent adverse events were more common in White and Black than in Asian patients.

CONCLUSION

Abrocitinib was more efficacious than placebo across the racial and ethnic groups and ranges of phototypes analyzed. Studies with increased representation of populations of color are warranted to elucidate potential variations in response across diverse populations.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02780167 (phase 2b), NCT03349060 (phase 3 MONO-1), and NCT03575871 (phase 3 MONO-2).

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).

Impact of socioeconomic factors on allergic diseases

Allergic and immunologic conditions, including asthma, food allergy, atopic dermatitis, and allergic rhinitis, are among the most common chronic conditions in children and adolescents that often last into adulthood. Although rare, inborn errors of immunity are life-altering and potentially fatal if unrecognized or untreated. Thus, allergic and immunologic conditions are both medical and public health issues that are profoundly affected by socioeconomic factors. Recently, studies have highlighted societal issues to evaluate factors at multiple levels that contribute to health inequities and the potential steps toward closing those gaps. Socioeconomic disparities can influence all aspects of care, including health care access and quality, diagnosis, management, education, and disease prevalence and outcomes. Ongoing research, engagement, and deliberate investment of resources by relevant stakeholders and advocacy approaches are needed to identify and address the impact of socioeconomics on health care disparities and outcomes among patients with allergic and immunologic diseases.

The Social and Home Environment: Impacts of Determinants of Health on Atopic Dermatitis, Pathways Toward Solutions, and Unique Considerations for Rural and Remote North American Indigenous Populations

Disparities in environmental and social determinants of health (DOH) are associated with morbidity in atopic dermatitis (AD). The socioecological model (SEM) is a framework that can be applied to better understand how such DOH impacts patients with AD. We include a case scenario of a remote Indigenous patient reflective of real-world situations of living with AD and examine relevant impact, gaps in knowledge, and further research needs. This review highlights a variety of social and environmental exposures as important DOH which must be addressed to achieve optimal management in AD. The "rainbow model" is a modified framework to help illustrate how complex environmental and social forces impact both AD presentation and therapeutic success. However, practical applications and outcome metrics for health promotion are limited. An inter- and transdisciplinary approach is paramount to address the complex challenges associated with AD care, as well as multistakeholder approach integrating culturally-competent equitable health frameworks. This review underscores the importance of expanding the focus of AD management beyond basic science and clinical trials to recognize and address health disparities and to promote optimal health and well-being in patients with AD, and contributes a working approach to mapping the complex interventions and patient-oriented research needed using a focus on remote North American Indigenous patients affected by AD.

Deep learning-aided decision support for diagnosis of skin disease across skin tones

Although advances in deep learning systems for image-based medical diagnosis demonstrate their potential to augment clinical decision-making, the effectiveness of physician-machine partnerships remains an open question, in part because physicians and algorithms are both susceptible to systematic errors, especially for diagnosis of underrepresented populations. Here we present results from a large-scale digital experiment involving board-certified dermatologists (n = 389) and primary-care physicians (n = 459) from 39 countries to evaluate the accuracy of diagnoses submitted by physicians in a store-and-forward teledermatology simulation. In this experiment, physicians were presented with 364 images spanning 46 skin diseases and asked to submit up to four differential diagnoses. Specialists and generalists achieved diagnostic accuracies of 38% and 19%, respectively, but both specialists and generalists were four percentage points less accurate for the diagnosis of images of dark skin as compared to light skin. Fair deep learning system decision support improved the diagnostic accuracy of both specialists and generalists by more than 33%, but exacerbated the gap in the diagnostic accuracy of generalists across skin tones. These results demonstrate that well-designed physician-machine partnerships can enhance the diagnostic accuracy of physicians, illustrating that success in improving overall diagnostic accuracy does not necessarily address bias.

Atopic Dermatitis and the Risk of Infection in End-Stage Renal Disease

Background and Objectives: Atopic dermatitis (AD), also known as eczema, is a common chronic inflammatory skin condition affecting 16.5 million adults in the United States. AD is characterized by an impaired epidermal barrier that can predispose individuals to infection. End-stage renal disease (ESRD) is also commonly complicated by infections due to chronic vascular access and immune-system dysfunction, possibly related to uremia. Multiple studies have reported that renal disease is a common comorbidity in adults with atopic dermatitis. The aim of this study was to determine whether AD is a risk factor for certain infections in patients with ESRD. Materials and Methods: Using the United States Renal Data System, a retrospective cohort analysis was conducted on adult ESRD patients initiating dialysis between 2004 and 2019 to investigate associations between infections and AD in this population. Results: Of 1,526,266 patients, 2290 were identified with AD (0.2%). Infectious outcomes of interest were bacteremia, septicemia, cellulitis, herpes zoster, and conjunctivitis. In all infectious outcomes except for conjunctivitis, patients with the infectious outcomes were more likely to carry a diagnosis of AD. After controlling for demographic and clinical covariates, AD was associated with an increased risk of cellulitis (adjusted relative risk (aRR) = 1.39, 95% confidence interval (CI) = 1.31-1.47) and herpes zoster (aRR = 1.67, CI = 1.44-1.94), but not with bacteremia (aRR = 0.96, CI = 0.89-1.05), septicemia (aRR = 1.02, CI = 0.98-1.08), or conjunctivitis (aRR = 0.97, CI = 0.740-1.34). Conclusions: Overall, after controlling for demographic and clinical covariates and adjusting for person-years-at-risk, AD was associated with an increased risk for some, but not all, infections within the population of patients with ESRD.

Topical treatments for atopic dermatitis (eczema): Systematic review and network meta-analysis of randomized trials

BACKGROUND

Atopic dermatitis (AD) is a common skin condition with multiple topical treatment options, but uncertain comparative effects.

OBJECTIVE

We sought to systematically synthesize the benefits and harms of AD prescription topical treatments.

METHODS

For the 2023 American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters AD guidelines, we searched MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, ICTRP, and GREAT databases to September 5, 2022, for randomized trials addressing AD topical treatments. Paired reviewers independently screened records, extracted data, and assessed risk of bias. Random-effects network meta-analyses addressed AD severity, itch, sleep, AD-related quality of life, flares, and harms. The Grading of Recommendations Assessment, Development and Evaluation approach informed certainty of evidence ratings. We classified topical corticosteroids (TCS) using 7 groups-group 1 being most potent. This review is registered in the Open Science Framework (https://osf.io/q5m6s).

RESULTS

The 219 included trials (43,123 patients) evaluated 68 interventions. With high-certainty evidence, pimecrolimus improved 6 of 7 outcomes-among the best for 2; high-dose tacrolimus (0.1%) improved 5-among the best for 2; low-dose tacrolimus (0.03%) improved 5-among the best for 1. With moderate- to high-certainty evidence, group 5 TCS improved 6-among the best for 3; group 4 TCS and delgocitinib improved 4-among the best for 2; ruxolitinib improved 4-among the best for 1; group 1 TCS improved 3-among the best for 2. These interventions did not increase harm. Crisaborole and difamilast were intermediately effective, but with uncertain harm. Topical antibiotics alone or in combination may be among the least effective. To maintain AD control, group 5 TCS were among the most effective, followed by tacrolimus and pimecrolimus.

CONCLUSIONS

For individuals with AD, pimecrolimus, tacrolimus, and moderate-potency TCS are among the most effective in improving and maintaining multiple AD outcomes. Topical antibiotics may be among the least effective.

Do socioeconomic factors impact atopic dermatitis outcome? A single-center study

BACKGROUND

Race and socioeconomic status are thought to influence the severity of atopic dermatitis (AD), but findings differ between countries and measures used. The role of social determinants of health versus biologic factors in causing these differences is poorly understood.

OBJECTIVE

We hypothesized that spatially-derived factors correlate with AD severity and patient-reported outcome (PRO) in a pediatric cohort from Chicago, USA.

METHODS

Children with AD and caregivers were enrolled from February 2018 to April 2019 in this single-site cross-sectional study. Severity was self- and physician-assessed using validated measures. Patient addresses were geocoded and linked to census tract IDs. Deprivation index (DI) was calculated using variables of the 2018 American Community Survey.

RESULTS

Among 216 children aged 5-17 years old, 111 (51.4%) lived in urban, 104 (48.1%) suburban, and one (0.5%) in rural areas. Race was self-classified as White in 31.0%, Black 24.5%, other or mixed 25.0%, and Asian 19.4%; 24.5% were Hispanic. Median DI was 0.32 (range 0.03-0.72), with higher scores indicating more deprivation. DI correlated with insurance type, family income, ethnicity, race, and parental education, and weakly with selected PRO T-scores. However, no correlations between any AD severity score and DI, race, ethnicity, income, education, or insurance type were found.

CONCLUSION

The impact of socioeconomic factors on AD severity in our study population was less pronounced than expected. This could be because of regional differences, including access to high-quality care. The role of access as a deciding factor in the impact of socioeconomic status on AD outcome deserves further investigation.

Atopic Dermatitis Across Shades of Skin

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

Prescribing Patterns of Dupilumab for Atopic Dermatitis in Adults: Retrospective, Observational Cohort Study

BACKGROUND

Atopic dermatitis (AD) is a common inflammatory disease caused by a type 2 T helper cell-mediated immune response to environmental antigens. Approximately 1 in 5 patients with AD presents with moderate to severe disease, and treatments approved by the Food and Drug Administration include emollients, topical glucocorticoids, and calcineurin inhibitors. Dupilumab, a fully human monoclonal antibody, improves AD via inhibition of interleukin-4 and interleukin-13.

OBJECTIVE

Our aim was to characterize the prescribing patterns of dupilumab for AD in adults at a large university-affiliated health system.

METHODS

A retrospective, observational cohort study was conducted using electronic data from the Observational Health Data Sciences and Informatics database, assessing data from the University of Colorado Medical Campus and its affiliates. The outcome measured was the prevalence of dupilumab prescribed for adults with AD (n=6421), between March 28, 2013, and March 28, 2021. We assessed whether the characteristics of patients who received dupilumab were different from those who did not. Each patient characteristic was assessed using a univariate logistic regression with the binary outcome of receiving or not receiving dupilumab.

RESULTS

We found a population prevalence of 5.6% (6421/114,476) for AD. In our cohort, Black patients with AD were more than twice as likely to have received dupilumab compared to White patients (odds ratio 2.352, 95% CI 1.58-3.39). Patients with a diagnosis of atopic neurodermatitis were approximately twice as likely to have received dupilumab compared to those with other diagnostic variants of AD (odds ratio 1.87, 95% CI 1.01-3.22).

CONCLUSIONS

Our results demonstrate that both patient racial characteristics and specific AD diagnoses were associated with variations in dupilumab prescription patterns.

Survey of topical exposure concerns for patients and caregivers dealing with atopic dermatitis

Background

Despite the recent expansion of treatment options in atopic dermatitis (AD), most management responsibilities fall on the patient and/or caregivers. Disease control often requires vigilance about and avoidance of common exposures, however the concerns for patients and caregivers living with AD have not been well enumerated.

Methods

An IRB approved survey was distributed to the public to evaluate the patient and caregiver concerns for topical exposures and potential triggers.

Results

323 people accessed the link to the survey with 259 providing response to at least one section of questions (response rate 80.2%). Results indicated that temperature and other weather related changes were the most common trigger. Nearly all respondents avoided at least one topical ingredient, with fragrances being the most common. Steroid exposure was common, however respondents expressed concerns about overall steroid exposure.

Conclusions

Our results attempt to enumerate the daily topical exposure concerns for patients and caregivers living with AD. While our online survey is both limited and without mechanistic insights, our results provide insight to providers by highlighting the role of temperature in AD symptoms; identifying commonly perceived triggers; indicating the value of provider insight for topical product selection; and indicating that no specific aspect of topical corticosteroid exposure may alleviate the general steroid concerns for patients or caregivers.

Prevalence of Atopic Diseases Among Sexually Diverse Adults in the US

This cross-sectional study assesses the prevalence of asthma, allergic rhinitis, or atopic dermatitis among sexually diverse adults compared with heterosexual adults in the US.

Diagnosing Atopic Dermatitis in Skin of Color

Atopic dermatitis (AD) is a pruritic inflammatory skin disease that disproportionately affects skin of color patients. African American, Asian, and Hispanic patients carry disproportionate disease burdens, with increased prevalence, disease severity, and health care utilization. AD has a unique clinical presentation in skin of color patients, often with greater extensor involvement, dyspigmentation, and papular and lichenified presentations. Erythema is also more difficult to appreciate and can result in an underappreciation of disease severity in skin of color patients. In this review, we highlight the important manifestations of AD across all skin types, including nuances in treatment.

Burden of Disease and Unmet Needs in the Diagnosis and Management of Atopic Dermatitis in Diverse Skin Types in Australia

Atopic dermatitis (AD) is a common, chronic, inflammatory skin disease affecting Australians of all ages, races, ethnicities, and social classes. Significant physical, psychosocial, and financial burdens to both individuals and Australian communities have been demonstrated. This narrative review highlights knowledge gaps for AD in Australian skin of colour. We searched PubMed, Wiley Online Library, and Cochrane Library databases for review articles, systematic reviews, and cross-sectional and observational studies relating to AD in Australia for skin of colour and for different ethnicities. Statistical data from the Australian Institute of Health and Welfare and the Australian Bureau of Statistics was collected. In recent years, there has been substantially increased awareness of and research into skin infections, such as scabies and impetigo, among various Australian subpopulations. Many such infections disproportionately affect First Nations Peoples. However, data for AD itself in these groups are limited. There is also little written regarding AD in recent, racially diverse immigrants with skin of colour. Areas for future research include AD epidemiology and AD phenotypes for First Nations Peoples and AD trajectories for non-Caucasian immigrants. We also note the evident disparity in both the level of understanding and the management standards of AD between urban and remote communities in Australia. This discrepancy relates to a relative lack of healthcare resources in marginalised communities. First Nations Peoples in particular experience socioeconomic disadvantage, have worse health outcomes, and experience healthcare inequality in Australia. Barriers to effective AD management must be identified and responsibly addressed for socioeconomically disadvantaged and remote-living communities to achieve healthcare equity.

Novel insights into atopic dermatitis

Recent research into the pathophysiology and treatment of atopic dermatitis (AD) has shown notable progress. An increasing number of aspects of the immune system are being implicated in AD, including the epithelial barrier, TH2 cytokines, and mast cells. Major advances in therapeutics were made in biologic cytokine and receptor antagonists and among Janus kinase inhibitors. We focus on these areas and address new insights into AD epidemiology, biomarkers, endotypes, prevention, and comorbidities. Going forward, we expect future mechanistic insights and therapeutic advances to broaden physicians' ability to diagnose and manage AD patients, and perhaps to find a cure for this chronic condition.

Racial and Ethnic Health Disparities in Dermatology

Health disparities are differences in health or disease incidence, prevalence, severity, or disease burden that are experienced by disadvantaged populations. Their root causes are attributed in large part to socially determined factors, including educational level of attainment, socioeconomic status, and physical and social environments. There is an expanding body of evidence documenting differences in dermatologic health status among underserved populations. In this review, the authors highlight inequities in outcomes across 5 dermatologic conditions, including psoriasis, acne, cutaneous melanoma, hidradenitis suppurativa, and atopic dermatitis.

Are There Ethnic Differences in Hand Eczema? A Review

Hand eczema is a common disease with economic and social ramifications. This study undertakes a review of certain existing literature to provide insight into contributory factors which may result in the varying prevalence and severity of hand eczema among different ethnic groups, particularly to identify modifiable risk factors, as well as to ascertain knowledge gaps for future research direction. The existing literature suggests that factors including (a) genes, (b) differing skin physiology, (c) cultural practices, (d) dietary habits and associated food preparation, (e) climate, (f) predominant occupations, (g) socioeconomic factors, and (h) dissimilar laws and regulations may account for the disparity in the risk of hand eczema among different ethnicities. Given that endogenous factors cannot be avoided, but certain exogenous aspects can be modified, especially as the environment plays an important role in hand eczema flares, it is helpful from a practical perspective to focus on addressing the modifiable risk factors. These factors pertain to unique cultural practices, customs, and food preparation methods. Healthcare professionals should be well-acquainted with such factors to tailor the treatment approach for patients of different ethnicities accordingly because, with globalization, physicians face increasingly diverse patient populations such that cultural customs no longer remain limited to particular geographic regions.

Atopic Dermatitis: Diagnosis, Disparity, and Management in Children of Color

Atopic dermatitis (AD), sometimes referred to as eczema, is the most common chronic skin condition in children. Children of color have a higher reported prevalence of AD compared with their White counterparts. The purpose of this article is to discuss the differences of AD in skin of color (SOC), including clinical findings and management, with an emphasis on early recognition to avoid more severe, persistent disease. School nurses are on the frontline for these students with their ability to guide families and help support students with AD in the school setting.

Racial and ethnic differences in barriers to care among US adults with chronic inflammatory skin diseases: A cross-sectional study of the All of Us Research Program

BACKGROUND

Research on racial and ethnic differences in barriers to care among patients with chronic inflammatory skin diseases (CISDs) is limited.

OBJECTIVE

To investigate the prevalence of a broad range of barriers to care among patients with CISDs across different racial and ethnic groups.

METHODS

A cross-sectional study was conducted using survey data from participants with CISDs in the All of Us Research Program. Multivariable regression was used to analyze the relationship between race and ethnicity and experiencing barriers to care.

RESULTS

Our study included 16,986 patients with CISDs. Compared to White patients, Black and Hispanic patients were significantly more likely to delay care because of cost and a broad range of additional structural barriers, including transportation, work, childcare, adult care, living in a rural area, and the lack of health care workforce diversity. However, associations between race and ethnicity and many barriers to care were substantially attenuated after controlling for insurance, income, and education.

LIMITATIONS

The population studied was not a representative sample of US adults, and responses were not specific to dermatologic care.

CONCLUSION

Racial and ethnic minority patients with CISDs, especially Black and Hispanic patients, are disproportionately affected by a broad range of barriers to care.

Air Pollution and Atopic Dermatitis, from Molecular Mechanisms to Population-Level Evidence: A Review

Atopic dermatitis (AD) has increased in prevalence to become the most common inflammatory skin condition globally, and geographic variation and migration studies suggest an important role for environmental triggers. Air pollution, especially due to industrialization and wildfires, may contribute to the development and exacerbation of AD. We provide a comprehensive, multidisciplinary review of existing molecular and epidemiologic studies on the associations of air pollutants and AD symptoms, prevalence, incidence, severity, and clinic visits. Cell and animal studies demonstrated that air pollutants contribute to AD symptoms and disease by activating the aryl hydrocarbon receptor pathway, promoting oxidative stress, initiating a proinflammatory response, and disrupting the skin barrier function. Epidemiologic studies overall report that air pollution is associated with AD among both children and adults, though the results are not consistent among cross-sectional studies. Studies on healthcare use for AD found positive correlations between medical visits for AD and air pollutants. As the air quality worsens in many areas globally, it is important to recognize how this can increase the risk for AD, to be aware of the increased demand for AD-related medical care, and to understand how to counsel patients regarding their skin health. Further research is needed to develop treatments that prevent or mitigate air pollution-related AD symptoms.

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

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

Efficacy of a lay community health worker (promotoras de salud) program to improve adherence to emollients in Spanish-speaking Latin American pediatric patients in the United States with atopic dermatitis: A randomized, controlled, evaluator-blinded study

BACKGROUND

Latin American patients in the United States experience significant health disparities. Community health workers (promotoras de salud) reduce disparities by providing culturally appropriate education. While educational interventions have been studied in atopic dermatitis (AD), a chronic dermatologic condition affecting children, none have evaluated the use of promotoras in Spanish-speaking pediatric patients in the United States.

OBJECTIVE

To create and evaluate a promotora-led education program for Spanish-speaking caregivers of Latin American, pediatric patients with AD through a randomized, controlled, evaluator-blinded study.

METHODS

Children with moderate/severe AD (n = 48) were recruited from the pediatric dermatology clinic at Children's Health℠ in Dallas, TX and randomized to receive clinic education (n = 26) or clinic education plus promotora home visits (n = 22). The primary outcome was overall adherence to topical emollients over the 12-week study, quantified by MEMSCap™ devices; several secondary endpoints were evaluated.

RESULTS

Intention-to-treat analysis revealed a trend toward increased overall adherence to emollients over the 12-week study period in promotora (median [interquartile range, IQR]: 43% [26%-61%]) versus non-promotora (median [IQR]: 20% [11%-49%]) (p = .09) groups. SCORAD, AD knowledge, and Spanish-language Parental Quality of Life Questionnaire for AD (Sp-PIQoL-AD) improved in both groups, although there was no statistically significant difference between groups. There was a trend toward increased AD knowledge at Week 4 (p = .06) in the promotora group.

CONCLUSIONS

A promotora-led educational intervention is a promising approach in increasing caregiver medication adherence in pediatric, Latin American patients with AD in the United States. Further research using creative and culturally appropriate strategies to increase medication adherence is necessary to reduce health disparities in other racial and ethnic minority populations in the United States.

Social disparities in early childhood prevention and management of food allergy

Food allergy (FA) affects 8% of US children. Navigating and managing FA permeates across multiple facets of childhood. In this article, we review research on social disparities in feeding practices, managing meals, and selecting childcare and schools. Key highlights include the following: (1) although preference for breast-feeding or formula feeding does not reduce FA risk, there are disparities in access to formula that may affect children with FA; (2) disparities likely exist in the early introduction to allergenic foods, though additional research is needed to identify barriers to following the most recent consensus guidelines on early introduction; (3) families with limited income face challenges in providing safe meals for their children; (4) disparities exist in early childcare options for preschool-age children, though there is a lack of research on FA practices in these settings; and (5) there is evidence that schools with different student demographics implement different types of FA policies. Further research is needed to better understand and characterize social disparities in FA prevention and management in early childhood and to develop evidence-based strategies to reduce them.

The shifting prevalence of asthma and allergic disease in US children

BACKGROUND

Asthma is a chronic lung disease that affected 5 million children. Allergy is a common comorbidity of asthma. Having both conditions is associated with unfavorable health outcomes and impaired quality of life.

OBJECTIVE

Purpose of this study was to assess allergy and its association with asthma by select characteristics among children to determine differences by populations.

METHODS

National Health Interview Survey data (2007-2018) were used to assess asthma and allergy status, trends, and the association between allergy and asthma by select characteristics among US children (aged 0-17 years).

RESULTS

Prevalence of asthma decreased among all children (slope [-] P < .001) and among those with allergy (slope [-] P = .002). More children had respiratory allergy (14.7%), followed by skin allergy (12.7%) and food allergy (6.4%). Prevalence of respiratory allergy significantly decreased among White non-Hispanic children (slope [-] P = .002), food allergy increased among White non-Hispanic (slope [+] P < .001) and Hispanic children (slope [+] P = .003), and skin allergy increased among Hispanic children (slope [+] P = .04). Depending on number and type, children with allergy were 2 to 8 times (skin allergy only and having all 3 allergies, respectively) more likely to have current asthma than were children without allergy. Among children with current asthma, having any allergy was significantly associated with missed school days (adjusted prevalence ratio, 1.33 [1.03-1.72]; P = .02) and taking preventive medication daily (adjusted prevalence ratio, 1.89 [1.32-2.71]; P < .001).

CONCLUSION

Trends in allergies across years differed by race and ethnicity. Strength of association between asthma and allergy differed by type and number of allergies, being highest among children having all 3 types of allergies. Having both asthma and allergy was associated with unfavorable asthma outcomes.

Caregiver Preferences and Barriers Toward Accessing Pediatric Dermatology Care for Childhood Atopic Dermatitis

INTRODUCTION

Atopic dermatitis (AD) is a common chronic childhood illness. It is often treated by primary care providers (PCPs) though it may require referral to a dermatology specialist.

METHOD

We administered an exploratory survey to 50 caregivers of children aged 0-17 years with AD to assess their preferences and barriers toward accessing dermatology specialty care for their child's AD.

RESULTS

Caregivers felt PCPs and specialists equally listened to their child's AD concerns. However, many felt there was a difference in the care provided and control of the AD and preferred to see a specialist for ongoing management.

DISCUSSION

Caregivers may benefit from their children being referred to dermatology specialists earlier and more often for their AD. Further work must be done to characterize preferences and barriers toward AD care across race and ethnicity.

Food Allergies in Inner-City Schools: Addressing Disparities and Improving Management

OBJECTIVE

Food allergy (FA) affects approximately 8% of children in the United States. Management comprises both preventing and treating allergic reactions, which poses unique challenges in the inner-city school setting. In this article, we review the epidemiology of FA in school-aged children and management challenges and opportunities specific to the inner-city population.

DATA SOURCES

A literature search of the PubMed database was performed to identify published literature on FA epidemiology, FA management, school policies, disparities, inner-city, race, ethnicity, and socioeconomic status.

STUDY SELECTIONS

Relevant articles on FA management best practices and challenges in schools, with a particular emphasis on inner-city schools and populations and socioeconomic, racial, and ethnic disparities, were reviewed in detail.

RESULTS

Disparities in FA prevalence, management, and treatment exist. Additional research is needed to better characterize these disparities and elucidate the mechanisms leading to them. There is a lack of evidence-based interventions for the prevention and treatment of food allergic reactions in schools and specifically in inner-city schools, in which a greater proportion of students may rely on school food.

CONCLUSION

There are opportunities for partnership among health care providers, schools, and communities to address unmet needs in FA management and disparities in the inner-city school setting.

Atopic Dermatitis: The Fate of the Fat

Atopic dermatitis (AD) is a chronic and relapsing inflammatory skin disease in which dry and itchy skin may develop into skin lesions. AD has a strong genetic component, as children from parents with AD have a two-fold increased chance of developing the disease. Genetic risk loci and epigenetic modifications reported in AD mainly locate to genes involved in the immune response and epidermal barrier function. However, AD pathogenesis cannot be fully explained by (epi)genetic factors since environmental triggers such as stress, pollution, microbiota, climate, and allergens also play a crucial role. Alterations of the epidermal barrier in AD, observed at all stages of the disease and which precede the development of overt skin inflammation, manifest as: dry skin; epidermal ultrastructural abnormalities, notably anomalies of the lamellar body cargo system; and abnormal epidermal lipid composition, including shorter fatty acid moieties in several lipid classes, such as ceramides and free fatty acids. Thus, a compelling question is whether AD is primarily a lipid disorder evolving into a chronic inflammatory disease due to genetic susceptibility loci in immunogenic genes. In this review, we focus on lipid abnormalities observed in the epidermis and blood of AD patients and evaluate their primary role in eliciting an inflammatory response.

Atopic eczema: How genetic studies can contribute to understanding this complex trait

Atopic eczema is an itchy inflammatory skin disease. This complex trait results from multiple genetic and environmental factors, but atopic eczema also shows great complexity in its heterogenous presentation, clinical signs and longitudinal trajectory, with or without co-morbid conditions. The past 50 years have produced substantial improvements in the management of atopic eczema, but many patients still suffer a burden of disease affecting personal, social and family life. Genetic research refocused interest on skin barrier function, but effective targeting of this central pathomechanism remains elusive. This Perspective highlights progress in understanding molecular mechanisms and translational opportunities for the future.