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Yamamoto-Hanada K, Ohya Y. Management of Infant Atopic Eczema to Prevent Severe Eczema and Food Allergy. Clin Exp Allergy 2024. [PMID: 38866599 DOI: 10.1111/cea.14515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 06/14/2024]
Abstract
Early intervention and active management of infant atopic eczema may play a crucial role in limiting eczema severity and preventing the onset of immediate-type food allergy. Eczema management involves education, skincare and medications targeting skin inflammation and barrier repair. Topical corticosteroids are the mainstay of anti-inflammatory therapy, with nonsteroidal options available for some infants. Proactive therapy, addressing subclinical inflammation, is useful for preventing eczema flares, especially in infants with recurrent eczema flares despite reactive therapy. In clinical practice, holistic consideration of overall infant and family health is essential. Providing advice on maternal stress management, nutritional guidance and recommendations for proper sleep and lifestyle is crucial for the well-being of children and their families, not limited to eczema treatment alone.
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Affiliation(s)
| | - Yukihiro Ohya
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
- Department of Occupational and Environmental Health, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
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2
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Hultsch T. The long road to atopic disease modification in infants with atopic dermatitis. J Eur Acad Dermatol Venereol 2024; 38:627-628. [PMID: 38523505 DOI: 10.1111/jdv.19815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 01/22/2024] [Indexed: 03/26/2024]
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3
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Jacobson ME, Seshadri RS, Morimoto R, Grinich E, Haag C, Nguyen K, Simpson EL. Early intervention and disease modification in atopic dermatitis-the current state of the field and barriers to progress. J Eur Acad Dermatol Venereol 2024; 38:665-672. [PMID: 38063244 DOI: 10.1111/jdv.19699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/24/2023] [Indexed: 03/26/2024]
Abstract
Atopic dermatitis (AD) is a highly prevalent chronic inflammatory skin disease representing a major source of global disability burden. Disease-modifying therapies are showing promise in chronic inflammatory disorders such as rheumatoid arthritis and Crohn's disease with method and timing of initial treatment impacting long-term disease outcomes. Whether disease-modifying therapies, specifically those used as an early interventional approach, impacts disease course and comorbidity development in AD is not well-understood. We reviewed the progress in disease modification strategies, emphasizing early intervention approaches in common (or proto-typical) inflammatory diseases. Although more common in other fields, disease modification approaches are becoming increasingly investigated in dermatology, though studies in AD are lacking. Despite significant limitations in ongoing and completed studies, early data are promising and suggest that both the choice and timing of early intervention approach can affect long-term disease course and comorbidity development. To best improve AD patient outcomes, more research is needed to further explore the impact of early disease-modifying therapies. Future studies should focus on identifying the most effective approaches and extend the early results to a more inclusive set of comorbidities and longer-term outcomes.
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Affiliation(s)
- M E Jacobson
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon, USA
| | - R S Seshadri
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon, USA
| | - R Morimoto
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon, USA
| | - E Grinich
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon, USA
| | - C Haag
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon, USA
| | - K Nguyen
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon, USA
| | - E L Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon, USA
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4
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Wang M, Gao XH, Zhang L. A Review of Dupilumab in the Treatment of Atopic Dermatitis in Infants and Children. Drug Des Devel Ther 2024; 18:941-951. [PMID: 38560522 PMCID: PMC10981892 DOI: 10.2147/dddt.s457761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/18/2024] [Indexed: 04/04/2024] Open
Abstract
Atopic dermatitis (AD), a common pruritic and chronic inflammatory skin disease, has a major impact on a patient's quality of life. It is characterized by dry, itchy, and eczema-like rashes. AD is more prevalent in young children and has been linked to a variety of other allergy disorders. Traditional drug therapy has certain limitations for treating young children with AD. However, biologics have good clinical application prospects in the medical treatment of young patients. Dupilumab, a fully human monoclonal antibody, specifically binds to the IL-4 Rα subunit, inhibiting IL-4 and IL-13 signaling and blocking the occurrence of type 2 inflammatory response. It has a good effect on treating infants and children with moderate-to-severe AD. This review explores the safety and efficacy of dupilumab in the treatment of AD in infants and children and the impact of early intervention on AD progression, with the aim of informing clinical practice in the use of dupilumab for the treatment of young patients with AD.
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Affiliation(s)
- Mingyue Wang
- Department of Dermatology, the First Hospital of China Medical University, Shenyang, 110001, People’s Republic of China
- NHC Key Laboratory of Immunodermatology, China Medical University, Shenyang, People’s Republic of China
- Key Laboratory of Immunodermatology, China Medical University, Ministry of Education, Shenyang, People’s Republic of China
- National and Local Joint Engineering Research Center of Immunodermatological Theranostics, Shenyang, People’s Republic of China
| | - Xing-Hua Gao
- Department of Dermatology, the First Hospital of China Medical University, Shenyang, 110001, People’s Republic of China
- NHC Key Laboratory of Immunodermatology, China Medical University, Shenyang, People’s Republic of China
- Key Laboratory of Immunodermatology, China Medical University, Ministry of Education, Shenyang, People’s Republic of China
- National and Local Joint Engineering Research Center of Immunodermatological Theranostics, Shenyang, People’s Republic of China
| | - Li Zhang
- Department of Dermatology, the First Hospital of China Medical University, Shenyang, 110001, People’s Republic of China
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5
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Weins AB, Kerzel S, Schnopp C. Schwere atopische Dermatitis im frühen Kindesalter: Besonderheiten, Herausforderungen und neue Perspektiven in der Versorgung. J Dtsch Dermatol Ges 2024; 22:350-356. [PMID: 38451004 DOI: 10.1111/ddg.15344_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 11/22/2023] [Indexed: 03/08/2024]
Abstract
ZusammenfassungDie atopische Dermatitis ist die häufigste chronische Hauterkrankung im Kindesalter mit einer Prävalenz von 10% bei Kleinkindern unter 2 Jahren, wovon etwa 15% einen hohen Schweregrad aufweisen. „Kinder sind keine kleinen Erwachsenen“, dies trifft für die schwere frühkindliche atopische Dermatitis in besonderem Maße zu. Innerhalb dieser sensiblen Lebensphase zeigen sich alterstypische Facetten der Erkrankung (psychosozial, neurokognitiv, klinisch‐morphologisch), die Unterschiede im Management mit sich bringen.Besondere Bedeutung hat die Identifikation von Säuglingen und Kleinkindern mit früh‐persistierendem, schwerem Verlauf mit Blick auf eine erstmals für diese Altersgruppe zugelassene Systemtherapie: sowohl für die unmittelbare Versorgung der Hauterkrankung als auch unter dem Aspekt einer möglichen Prävention von Begleiterkrankungen. Da der „atopische Phänotyp“ klinische Überlappungen zum Spektrum der Immundefekte aufweist, ist die korrekte Einordnung des Hautbefundes bei therapierefraktärem Ekzem essenziell. In dieser Arbeit beschreiben wir eine alltagstaugliche Strategie, um anhand anamnestischer Warnhinweise, dermatologischer Leitbefunde und Labordiagnostik eine Abgrenzung von ekzematösen Hauterscheinungen bei primären Immundefekten vorzunehmen. Dazu geben wir aktuelle Empfehlungen zum Management des schweren frühkindlichen atopischen Ekzems, auch in Bezug auf die Indikation zur Systemtherapie.
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Affiliation(s)
- Andreas Benedikt Weins
- Klinik für Kinder- und Jugendmedizin, Universitätsklinik Augsburg
- KIDZ SKIN | Praxis für Kinder- und Jugenddermatologie, Ulm
| | - Sebastian Kerzel
- Krankenhaus Barmherzige Brüder, Klinik und Poliklinik für Kinder- und Jugendmedizin, Abteilung für Pädiatrische Pneumologie und Allergologie, Regensburg
| | - Christina Schnopp
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Technische Universität München
- Praxis Burgstraße, München
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6
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Weins AB, Kerzel S, Schnopp C. Severe atopic dermatitis in early infancy: characteristics, challenges and new perspectives in clinical practice. J Dtsch Dermatol Ges 2024; 22:350-355. [PMID: 38450908 DOI: 10.1111/ddg.15344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 11/22/2023] [Indexed: 03/08/2024]
Abstract
Atopic dermatitis (AD) is the most common skin disease in infants and children with a prevalence of 10% in the first two years of life. In this age group up to 15% are severely affected. "Children are not little adults" - this applies in particular to infants with severe atopic dermatitis. Age-specific clinical aspects (psychosocial, neurocognitive, morphological) of the disease require an adjusted disease management. Considering recent approval of systemic treatment options, early identification of infants and children with severe and early persistent disease is of particular importance also in view of possible prevention of atopic comorbidity. As several inborn errors of immunity (IEI) share features of the atopic phenotype, it is essential for clinicians to distinguish signs of immunodeficiency from severe AD. Here, we describe a practical approach on the basis of clinical history and key dermatological and laboratory findings. Furthermore, this paper is aimed at providing an update on general management of severe AD in early infancy, including recommendations for systemic treatment.
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Affiliation(s)
- Andreas Benedikt Weins
- Department of Pediatrics, University Hospital Augsburg, Augsburg, Germany
- KIDZ SKIN | Practice for Pediatric Dermatology, Ulm, Germany
| | - Sebastian Kerzel
- Barmherzige Brüder Hospital, Department of Pediatrics, Section for Pediatric Pneumonology and Allergology, Regensburg, Germany
| | - Christina Schnopp
- Department of Dermatology and Allergology am Biederstein, Technical University Munich, Munich, Germany
- Practice Burgstraße, Munich, Germany
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7
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Miyaji Y, Yamamoto-Hanada K, Yang L, Fukuie T, Narita M, Ohya Y. Effectiveness and safety of low-dose oral immunotherapy protocols in paediatric milk and egg allergy. Clin Exp Allergy 2023; 53:1307-1309. [PMID: 37771064 DOI: 10.1111/cea.14400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/29/2023] [Accepted: 09/11/2023] [Indexed: 09/30/2023]
Affiliation(s)
- Yumiko Miyaji
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
- Medical Support Center for the Japan Environment and Children's Study (JECS), National Center for Child Health and Development, Tokyo, Japan
| | - Kiwako Yamamoto-Hanada
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
- Medical Support Center for the Japan Environment and Children's Study (JECS), National Center for Child Health and Development, Tokyo, Japan
| | - Limin Yang
- Medical Support Center for the Japan Environment and Children's Study (JECS), National Center for Child Health and Development, Tokyo, Japan
| | - Tatsuki Fukuie
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
| | - Masami Narita
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yukihiro Ohya
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
- Medical Support Center for the Japan Environment and Children's Study (JECS), National Center for Child Health and Development, Tokyo, Japan
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8
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Zhang Q, Zhang C, Zhang Y, Liu Y, Wang J, Gao Z, Sun J, Li Q, Sun J, Cui X, Wang Y, Fu L. Early-life risk factors for food allergy: Dietary and environmental factors revisited. Compr Rev Food Sci Food Saf 2023; 22:4355-4377. [PMID: 37679957 DOI: 10.1111/1541-4337.13226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 07/21/2023] [Accepted: 07/27/2023] [Indexed: 09/09/2023]
Abstract
There appears a steep increase in the prevalence of food allergy worldwide in the past few decades. It is believed that, rather than genetic factors, the recently altered dietary and environmental factors are the driving forces behind the rapid increase of this disease. Accumulating evidence has implied that external exposures that occurred in prenatal and postnatal periods could affect the development of oral tolerance in later life. Understanding the potential risk factors for food allergy would greatly benefit the progress of intervention and therapy. In this review, we present updated knowledge on the dietary and environmental risk factors in early life that have been shown to impact the development of food allergy. These predominantly include dietary habits, microbial exposures, allergen exposure routes, environmental pollutants, and so on. The key evidence, conflicts, and potential research topics of each theory are discussed, and associated interventional strategies to prevent the disease development and ameliorate treatment burden are included. Accumulating evidence has supported the causative role of certain dietary and environmental factors in the establishment of oral tolerance in early life, especially the time of introducing allergenic foods, skin barrier function, and microbial exposures. In addition to certain immunomodulatory factors, increasing interest is raised toward modern dietary patterns, where adequately powered studies are required to identify contributions of those modifiable risk factors. This review broadens our understanding of the connections between diet, environment, and early-life immunity, thus benefiting the progress of intervention and therapy of food allergy.
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Affiliation(s)
- Qiaozhi Zhang
- Food Safety Key Laboratory of Zhejiang Province, School of Food Science and Biotechnology, Zhejiang Gongshang University, Hangzhou, China
| | - Chi Zhang
- Food Safety Key Laboratory of Zhejiang Province, School of Food Science and Biotechnology, Zhejiang Gongshang University, Hangzhou, China
| | - Yong Zhang
- Nutrition Department of the First Medical Centre of PLA General Hospital, Beijing, China
| | - Yinghua Liu
- Nutrition Department of the First Medical Centre of PLA General Hospital, Beijing, China
| | - Jin Wang
- Key Laboratory of Environmental Medicine and Engineering, Ministry of Education, and Department of Nutrition and Food Hygiene, School of Public Health, Southeast University, Nanjing, China
- Department of Bioresource Engineering, Faculty of Agricultural and Environmental Sciences, McGill University, Sainte-Anne-de-Bellevue, QC, Canada
| | - Zhongshan Gao
- Allergy Research Center, Zhejiang University, Hangzhou, China
| | - Jinlyu Sun
- Allergy Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qianqian Li
- Food Safety Key Laboratory of Zhejiang Province, School of Food Science and Biotechnology, Zhejiang Gongshang University, Hangzhou, China
| | - Jiachen Sun
- Food Safety Key Laboratory of Zhejiang Province, School of Food Science and Biotechnology, Zhejiang Gongshang University, Hangzhou, China
| | - Xin Cui
- Food Safety Key Laboratory of Zhejiang Province, School of Food Science and Biotechnology, Zhejiang Gongshang University, Hangzhou, China
| | - Yanbo Wang
- Food Safety Key Laboratory of Zhejiang Province, School of Food Science and Biotechnology, Zhejiang Gongshang University, Hangzhou, China
| | - Linglin Fu
- Food Safety Key Laboratory of Zhejiang Province, School of Food Science and Biotechnology, Zhejiang Gongshang University, Hangzhou, China
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Yamamoto-Hanada K, Kobayashi T, Mikami M, Williams HC, Saito H, Saito-Abe M, Sato M, Irahara M, Miyaji Y, Ishikawa F, Tsuchiya K, Tamagawa-Mineoka R, Takaoka Y, Takemura Y, Sato S, Wakiguchi H, Hoshi M, Natsume O, Yamaide F, Seike M, Ohya Y. Enhanced early skin treatment for atopic dermatitis in infants reduces food allergy. J Allergy Clin Immunol 2023; 152:126-135. [PMID: 36963619 DOI: 10.1016/j.jaci.2023.03.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/20/2023] [Accepted: 03/07/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Early-onset atopic dermatitis is a strong risk factor for food allergy, suggesting that early effective treatment may prevent transcutaneous sensitization. OBJECTIVES This study tested whether enhanced treatment of atopic dermatitis to clinically affected and unaffected skin is more effective in preventing hen's egg allergy than reactive treatment to clinically affected skin only. METHODS This was a multicenter, parallel-group, open-label, assessor-blind, randomized controlled trial (PACI [Prevention of Allergy via Cutaneous Intervention] study). This study enrolled infants 7-13 weeks old with atopic dermatitis and randomly assigned infants in a 1:1 ratio to enhanced early skin treatment or conventional reactive treatment using topical corticosteroids (TCSs). The primary outcome was the proportion of immediate hen's egg allergy confirmed by oral food challenge at 28 weeks of age. RESULTS This study enrolled 650 infants and analyzed 640 infants (enhanced [n = 318] or conventional [n = 322] treatment). Enhanced treatment significantly reduced hen's egg allergy compared with the conventional treatment (31.4% vs 41.9%, P = .0028; risk difference: -10.5%, upper bound of a 1-sided CI: -3.0%), while it lowered body weight (mean difference: -422 g, 95% CI: -553 to -292 g) and height (mean difference: -0.8 cm, 95% CI: -1.22 to -0.33 cm) at 28 weeks of age. CONCLUSIONS This study highlighted the potential of well-controlled atopic dermatitis management as a component of a hen's egg allergy prevention strategy. The enhanced treatment protocol of this trial should be modified before it can be considered as an approach to prevent hen's egg allergy in daily practice to avoid the adverse effects of TCSs. After remission induction by TCSs, maintenance therapy with lower potency TCSs or other topical therapies might be considered as alternative proactive treatments to overcome the safety concerns of TCSs.
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Affiliation(s)
| | - Tohru Kobayashi
- National Center for Child Health and Development, Tokyo, Japan
| | - Masashi Mikami
- National Center for Child Health and Development, Tokyo, Japan
| | - Hywel C Williams
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Hirohisa Saito
- National Center for Child Health and Development, Tokyo, Japan
| | | | - Miori Sato
- National Center for Child Health and Development, Tokyo, Japan
| | - Makoto Irahara
- National Center for Child Health and Development, Tokyo, Japan
| | - Yumiko Miyaji
- National Center for Child Health and Development, Tokyo, Japan
| | - Fumi Ishikawa
- National Center for Child Health and Development, Tokyo, Japan
| | | | | | | | | | - Sakura Sato
- National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan
| | | | - Miyuki Hoshi
- National Hospital Organization Mie National Hospital, Mie, Japan
| | - Osamu Natsume
- Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Fumiya Yamaide
- Chiba University Graduate School of Medicine, Chiba, Japan
| | - Miwako Seike
- National Center for Child Health and Development, Tokyo, Japan
| | - Yukihiro Ohya
- National Center for Child Health and Development, Tokyo, Japan.
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10
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Giovannini M, Bolis M, Barni S, Liccioli G, Sarti L, Morelli S, Pontone M, Pessina B, Tomei L, Valleriani C, Novembre E, Mori F. Pearls and Pitfalls of Weaning an Infant with Severe Atopic Dermatitis and Sensitization/Allergy to Food. J Clin Med 2023; 12:3889. [PMID: 37373584 DOI: 10.3390/jcm12123889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/21/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023] Open
Abstract
Atopic dermatitis (AD) is a common chronic inflammatory skin disorder in childhood. Skin barrier impairment exposes infants to food allergens, potentially causing sensitization followed by IgE-mediated food allergy. We describe the case of an infant with severe AD in whom several sensitizations to foods are detected, with consequently difficult weaning, and a history of anaphylaxis to cashew nut. Foods for which skin tests were negative were introduced into the infant's diet. Then, when AD control was managed, oral food challenges (OFCs) for foods to which the patient was sensitized, with the exception of cashew nut, were performed. The simultaneous presence of sensitization toward multiple foods made it difficult to introduce them using classic OFC. Therefore, it was decided to perform the low-dose, gradual controlled OFC. This led to an introduction of sensitized foods into the infant's diet, with the exception of cashew nut, avoiding allergic reactions. Absolute recommendations on how, when, and where to perform OFCs with allergenic food to which the child with AD is sensitized are lacking so far. In our opinion, OFCs and the subsequent ntroduction of allergenic foods should be individualized, evaluating some factors such as their social and nutritional importance, the patient's age and clinical phenotype (including the history of anaphylaxis), and the sensitization profile. There is agreement on the fact that the dietary approach in children with moderate-severe AD should no longer include a strict elimination diet. We believe that an early, gradual controlled introduction of all allergenics to identify the amount of food tolerated in the absence of reactions, even if low dose, may improve patients' and families' quality of life. However, even if discussing a vast relevant literature, the limitation of our work is that we describe the management of a single patient. Extensive and high-quality research is needed in this field to improve the available evidence in the area.
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Affiliation(s)
- Mattia Giovannini
- Allergy Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
- Department of Health Sciences, University of Florence, 50139 Florence, Italy
| | - Marta Bolis
- Pediatrics Clinic, ASST-Spedali Civili of Brescia, 25123 Brescia, Italy
| | - Simona Barni
- Allergy Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - Giulia Liccioli
- Allergy Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - Susanna Morelli
- Allergy Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - Matteo Pontone
- Allergy Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
- Department of Health Sciences, University of Florence, 50139 Florence, Italy
| | - Benedetta Pessina
- Allergy Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
- Department of Health Sciences, University of Florence, 50139 Florence, Italy
| | - Leonardo Tomei
- Allergy Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
- Department of Health Sciences, University of Florence, 50139 Florence, Italy
| | - Claudia Valleriani
- Immunology Laboratory, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - Elio Novembre
- Department of Health Sciences, University of Florence, 50139 Florence, Italy
| | - Francesca Mori
- Allergy Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
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11
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Yamamoto-Hanada K, Saito-Abe M, Shima K, Fukagawa S, Uehara Y, Ueda Y, Iwamura M, Murase T, Kuwano T, Inoue T, Ohya Y. mRNAs in skin surface lipids unveiled atopic dermatitis at 1 month. J Eur Acad Dermatol Venereol 2023. [PMID: 36897437 DOI: 10.1111/jdv.19017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 02/07/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND The molecular pathogenesis of atopic dermatitis (AD), presenting skin barrier dysfunction and abnormal inflammations around 1-2 months, is unreported. OBJECTIVE We aimed to examine the molecular pathogenesis of very early-onset AD by skin surface lipid-RNA (SSL-RNA) using a non-invasive technology in infants aged 1 and 2 months from a prospective cohort. METHODS We collected sebum by oil-blotting film of infants aged 1 and 2 months and analysed RNAs in their sebum. We diagnosed AD according to the United Kingdom Working Party's criteria. RESULTS Infants with AD aged 1 month showed lower expression of genes related to various lipid metabolism and synthesis, antimicrobial peptides, tight junctions, desmosomes and keratinization. They also had higher expression of several genes involved in Th2-, Th17- and Th22-type immune responses and lower expression of negative regulators of inflammation. In addition, gene expressions related to innate immunity were higher in AD infants. Infants aged 1 month with neonatal acne and diagnosed with AD aged 2 months already had gene expression patterns similar to AD aged 1 month in terms of redox, lipid synthesis, metabolism and barrier-related gene expression. CONCLUSION We identified molecular changes in barrier function and inflammatory markers that characterize the pathophysiology of AD in infants aged 1 month. We also revealed that neonatal acne at 1 month could predict the subsequent development of AD by sebum transcriptome data.
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Affiliation(s)
| | - Mayako Saito-Abe
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kyoko Shima
- Biological Science Research, Kao Corporation, Tochigi, Japan
| | - Satoko Fukagawa
- Biological Science Research, Kao Corporation, Tochigi, Japan
| | - Yuya Uehara
- Biological Science Research, Kao Corporation, Tochigi, Japan
| | - Yui Ueda
- Biological Science Research, Kao Corporation, Tochigi, Japan
| | - Maeko Iwamura
- Biological Science Research, Kao Corporation, Tochigi, Japan
| | | | - Tetsuya Kuwano
- Biological Science Research, Kao Corporation, Tochigi, Japan
| | - Takayoshi Inoue
- Biological Science Research, Kao Corporation, Tochigi, Japan
| | - Yukihiro Ohya
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
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12
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Morita E, Matsuo H, Kohno K, Yokooji T, Yano H, Endo T. A Narrative Mini Review on Current Status of Hypoallergenic Wheat Development for IgE-Mediated Wheat Allergy, Wheat-Dependent Exercise-Induced Anaphylaxis. Foods 2023; 12:foods12050954. [PMID: 36900471 PMCID: PMC10000922 DOI: 10.3390/foods12050954] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 02/08/2023] [Accepted: 02/16/2023] [Indexed: 02/26/2023] Open
Abstract
Immunoglobulin E (IgE)-mediated food allergies to wheat that develop after school age typically shows a type of wheat-dependent exercise-induced anaphylaxis (WDEIA). At present, avoidance of wheat products or postprandial rest after ingesting wheat is recommended for patients with WDEIA, depending on the severity of the allergy symptoms. ω5-Gliadin has been identified as the major allergen in WDEIA. In addition, α/β-, γ-, and ω1,2-gliadins, high and low molecular weight-glutenins, and a few water-soluble wheat proteins have been identified as IgE-binding allergens in a small proportion of patients with IgE-mediated wheat allergies. A variety of approaches have been manufactured to develop hypoallergenic wheat products that can be consumed by patients with IgE-mediated wheat allergies. In order to analyze such approaches, and to contribute to the further improvement, this study outlined the current status of these hypoallergenic wheat productions, including wheat lines with a reduced allergenicity that are mostly constructed for the patients sensitized to ω5-gliadin, hypoallergenic wheat by enzymic degradation/ion exchanger deamidation, and hypoallergenic wheat by thioredoxin treatment. The wheat products obtained by these approaches significantly reduced the reactivity of Serum IgE in wheat-allergic patients. However, either these were not effective on some populations of the patients, or low-level IgE-reactivity to some allergens of the products was observed in the patients. These results highlight some of the difficulties faced in creating hypoallergenic wheat products or hypoallergenic wheat lines through either traditional breeding or biotechnology approaches in developing hypoallergenic wheat completely safe for all the patients allergic to wheat.
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Affiliation(s)
- Eishin Morita
- Department of Dermatology, Shimane University Faculty of Medicine, Izumo 693-8501, Japan
- Correspondence: ; Tel.: +81-853-20-2210
| | - Hiroaki Matsuo
- Department of Pharmaceutical Services, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan
| | - Kunie Kohno
- Department of Dermatology, Shimane University Faculty of Medicine, Izumo 693-8501, Japan
- Department of Clinical Trial Management, Clinical Research Center, Shimane University Hospital, Izumo 693-8501, Japan
| | - Tomoharu Yokooji
- Department of Frontier Science for Pharmacotherapy, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan
| | - Hiroyuki Yano
- National Food Research Institute, National Agriculture and Food Research Organization, Tsukuba 305-8642, Japan
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13
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Epicutaneous Sensitization and Food Allergy: Preventive Strategies Targeting Skin Barrier Repair-Facts and Challenges. Nutrients 2023; 15:nu15051070. [PMID: 36904070 PMCID: PMC10005101 DOI: 10.3390/nu15051070] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/16/2023] [Accepted: 02/18/2023] [Indexed: 02/25/2023] Open
Abstract
Food allergy represents a growing public health and socio-economic problem with an increasing prevalence over the last two decades. Despite its substantial impact on the quality of life, current treatment options for food allergy are limited to strict allergen avoidance and emergency management, creating an urgent need for effective preventive strategies. Advances in the understanding of the food allergy pathogenesis allow to develop more precise approaches targeting specific pathophysiological pathways. Recently, the skin has become an important target for food allergy prevention strategies, as it has been hypothesized that allergen exposure through the impaired skin barrier might induce an immune response resulting in subsequent development of food allergy. This review aims to discuss current evidence supporting this complex interplay between the skin barrier dysfunction and food allergy by highlighting the crucial role of epicutaneous sensitization in the causality pathway leading to food allergen sensitization and progression to clinical food allergy. We also summarize recently studied prophylactic and therapeutic interventions targeting the skin barrier repair as an emerging food allergy prevention strategy and discuss current evidence controversies and future challenges. Further studies are needed before these promising strategies can be routinely implemented as prevention advice for the general population.
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14
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Zhang X, Lu C, Li Y, Norbäck D, Murthy P, Sram RJ, Deng Q. Early-life exposure to air pollution associated with food allergy in children: Implications for 'one allergy' concept. ENVIRONMENTAL RESEARCH 2023; 216:114713. [PMID: 36347392 DOI: 10.1016/j.envres.2022.114713] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/23/2022] [Accepted: 10/30/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The rapid increase of food allergy (FA) has become the "second wave" of allergy epidemic and is now a major global public health concern. Mounting evidence indicates that early life exposure to air pollution is associated with the "first wave" of allergy epidemic (including asthma, allergic rhinitis and eczema) in children, but little is known about its association with FA. OBJECTIVES We hypothesize FA has triple exposure pathways, gut-skin-airway, and investigate the effects of airway exposure to outdoor and indoor air pollution on childhood FA. METHODS A cohort study of 2598 preschool children aged 3-6 years old was conducted in Changsha, China. The prevalence of FA was surveyed using a standard questionnaire by International Study of Asthma and Allergies in Childhood (ISAAC). Exposure to indoor air pollution was assessed by four indicators: new furniture, redecoration, mold or dampness, and window condensation. Exposure to outdoor air pollution was evaluated by the concentrations of PM10, SO2 and NO2, which were obtained from the monitored stations. Both prenatal and postnatal exposure windows were considered. The association between exposure to outdoor/indoor air pollution and childhood FA was estimated by multiple logistic regression models using odds ratio (OR) and a 95% confidence interval (CI). RESULTS A total of 14.9% children reported FA. The prevalence was significantly associated with exposure to indoor air pollution, OR (95% CI) = 1.93 (1.35-2.75) for prenatal exposure to mold/dampness and 1.49 (1.07-2.10) and 1.41 (1.04-1.89) respectively for postnatal exposure to new furniture and window condensation. The prevalence of FA was also associated with prenatal and postnatal exposure to outdoor air pollution, particularly the traffic-related air pollutant NO2, with adjusted ORs (95% Cls) respectively 1.24 (1.00-1.54) and 1.38 (1.03-1.85) per interquartile range (IQR) increase. Sensitivity analysis showed that the association between outdoor/indoor air pollution and childhood FA was significant only in young children aged 3-4 years. CONCLUSION Early-life exposure to high levels of outdoor and indoor air pollution in China due to the rapid economic growth and fast urbanization in the past decades may contribute to the rapid increase of food allergy (FA) in children. Our study indicates that, in addition to gut and skin, airway may be a new route of food sensitization. Air pollution leads to the first and second waves of allergy epidemics, suggesting a concept of 'one allergy' disease.
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Affiliation(s)
- Xin Zhang
- School of Energy Science and Engineering, Central South University, Changsha 410083, China
| | - Chan Lu
- XiangYa School of Public Health, Central South University, Changsha 410078, China
| | - Yuguo Li
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, China
| | - Dan Norbäck
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Padmini Murthy
- Department of Public Health, School of Health Sciences and Practice, New York Medical College, Hawthorne NY 10532, USA
| | - Radim J Sram
- Department of Genetic Toxicology and Epigenetics, Institute of Experimental Medicine, Academy of Sciences of the Czech Republic, Prague, Czech Republic
| | - Qihong Deng
- School of Public Health, Zhengzhou University, Zhengzhou 450001, China.
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15
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Miyaji Y, Yamamoto-Hanada K, Fukuie T, Narita M, Ohya Y. Risk factors of admission in school children with severe atopic dermatitis. J Dermatol 2023; 50:72-81. [PMID: 36258264 DOI: 10.1111/1346-8138.16612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/06/2022] [Accepted: 09/28/2022] [Indexed: 01/04/2023]
Abstract
There are no data about risk factor of admission and long-term (>1 year) prognosis of proactive therapy using topical corticosteroids (TCSs) in school children. This study aims to identify the prognosis of school children over 3 years treated with proactive therapy after hospitalization due to atopic dermatitis (AD). This retrospective cohort study used electronic medical record data of schoolchildren (aged 5-19 years) with a long-term admission program for AD at the National Center for Child Health and Development from January 2008 to December 2013. Long-term prognosis at 1 and 3 years after discharge were retrospectively identified from their medical records. The most common exacerbation factor was poor adherence (51.8%). At 1 and 3 years after hospitalization, 87.3% and 74.3%, respectively, of the children used TCSs on their trunk and limbs less than twice a week. Investigator's Global Assessment of AD scores were ≤1 for 81.0%and 75.7% at 1 and 3 years after discharge, respectively. AD was well-controlled during follow-up. Rehospitalization due to AD was observed in 11.8% children. Poor adherence was biggest risk factor for admission. Children with severe AD could achieve well-controlled AD with a long-term admission AD program and home-based proactive therapy using TCSs for 3 years after discharge. Maintaining good adherence for AD treatment is required to prevent exacerbation and improve future prognosis in school children. However, we need to engage for the children who required rehospitalization.
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Affiliation(s)
- Yumiko Miyaji
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
| | | | - Tatsuki Fukuie
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
| | - Masami Narita
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yukihiro Ohya
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
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16
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Eczema phenotypes and IgE component sensitization in adolescents: A population-based birth cohort. Allergol Int 2023; 72:107-115. [PMID: 35781407 DOI: 10.1016/j.alit.2022.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/14/2022] [Accepted: 05/22/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Eczema patients are commonly immunoglobulin (Ig)E polysensitized. Although atopic dermatitis (AD) phenotypes have been recognized, IgE sensitization patterns based on AD phenotypes have not been well illustrated. We aimed to investigate how eczema phenotypes impact IgE component sensitization patterns. METHODS This birth cohort study investigated a general population in the Tokyo Children's Health, Illness, and Development Study (T-Child Study) until children reached the age of 13 years. Eczema was assessed using the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire. Allergen component specific IgE antibody titers were measured using a multiplex array ImmunoCAP ISAC. RESULTS Persistent eczema phenotype until adolescence was strongly associated with allergic march symptoms, such as wheezing and hay fever, and oral allergy symptoms, and IgE component sensitizations of airborne (Japanese cedar, house dust mite, Timothy, cat, and dog) and cross-reactive allergens (Bet v 1 family) compared to early-remission and late-onset eczema. On the other hand, late-onset eczema did not show any strong associations with allergic symptoms and IgE sensitization. Adolescents with persistent eczema have high comorbidity of symptoms of pollen-food allergy syndrome. CONCLUSIONS Early-onset eczema is deeply connected with the later allergic march, and late-onset eczema differs from the phenotype of allergic march. Early-onset eczema characterizing IgE sensitization was likely to be an extrinsic type, and late-onset eczema, which was not related to IgE sensitization, was likely an intrinsic type. Pollen-Food Allergy Syndrome is one of the allergic features in allergic march.
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17
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Saeki H, Ohya Y, Furuta J, Arakawa H, Ichiyama S, Katsunuma T, Katoh N, Tanaka A, Tsunemi Y, Nakahara T, Nagao M, Narita M, Hide M, Fujisawa T, Futamura M, Masuda K, Matsubara T, Murota H, Yamamoto-Hanada K. English Version of Clinical Practice Guidelines for the Management of Atopic Dermatitis 2021. J Dermatol 2022; 49:e315-e375. [PMID: 35996152 DOI: 10.1111/1346-8138.16527] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/03/2022] [Accepted: 06/17/2022] [Indexed: 11/29/2022]
Abstract
This is the English version of the Clinical Practice Guidelines for the Management of Atopic Dermatitis 2021. Atopic dermatitis (AD) is a disease characterized by relapsing eczema with pruritus as a primary lesion. In Japan, from the perspective of evidence-based medicine, the current strategies for the treatment of AD consist of three primary measures: (i) use of topical corticosteroids, tacrolimus ointment, and delgocitinib ointment as the main treatment of the inflammation; (ii) topical application of emollients to treat the cutaneous barrier dysfunction; and (iii) avoidance of apparent exacerbating factors, psychological counseling, and advice about daily life. In the present revised guidelines, descriptions of three new drugs, namely, dupilumab, delgocitinib, and baricitinib, have been added. The guidelines present recommendations to review clinical research articles, evaluate the balance between the advantages and disadvantages of medical activities, and optimize medical activity-related patient outcomes with respect to several important points requiring decision-making in clinical practice.
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Affiliation(s)
- Hidehisa Saeki
- Department of Dermatology, Nippon Medical School, Tokyo, Japan
| | - Yukihiro Ohya
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
| | - Junichi Furuta
- Medical Informatics and Management, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hirokazu Arakawa
- Kitakanto Allergy Research Institute, Kibounoie Hospital, Midori, Japan
| | - Susumu Ichiyama
- Department of Dermatology, Nippon Medical School, Tokyo, Japan
| | - Toshio Katsunuma
- Department of Pediatrics, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Norito Katoh
- Department of Dermatology, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Akio Tanaka
- Department of Dermatology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuichiro Tsunemi
- Department of Dermatology, Saitama Medical University, Saitama, Japan
| | - Takeshi Nakahara
- Department of Dermatology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mizuho Nagao
- Allergy Center, National Hospital Organization Mie National Hospital, Tsu, Japan
| | - Masami Narita
- Department of Pediatrics, Faculty of Medicine, Kyorin University, Tokyo, Japan
| | - Michihiro Hide
- Department of Dermatology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.,Department of Dermatology, Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Takao Fujisawa
- Allergy Center, National Hospital Organization Mie National Hospital, Tsu, Japan
| | - Masaki Futamura
- Division of Pediatrics, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Koji Masuda
- Department of Dermatology, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Tomoyo Matsubara
- Department of Pediatrics, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Hiroyuki Murota
- Department of Dermatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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18
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How primary care providers can help prevent food allergies. Curr Opin Pediatr 2022; 34:430-437. [PMID: 35797492 DOI: 10.1097/mop.0000000000001145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW IgE-mediated food allergy rates have increased in recent decades, yet treatment options remain limited. Prevention strategies are thus essential. We will review recent research and consensus guidelines for food allergy prevention. RECENT FINDINGS Research has continued to support that early introduction of allergens via the gastrointestinal tract induces tolerance and prevents development of food allergy. In contrast, allergen sensitization may occur via transcutaneous allergen exposure. This is supported by research that shows a decreased risk of food allergy with aggressive treatment of atopic dermatitis. More recent research suggests that transcutaneous sensitization could also be facilitated by frequent emollient use in the absence of atopic dermatitis but definitive research is lacking. Murine models have shown a likely role of dysbiosis, or disruption of the body's normal healthy microbiome, in development of food allergy, yet human studies have yet to show a conclusive benefit of probiotics in the prevention of food allergy. SUMMARY Important approaches for food allergy prevention are: introduction of peanut and cooked egg at 4-6 months, early introduction of other allergenic foods, and early diagnosis and treatment of atopic dermatitis (because of a predisposition to food sensitization through the damaged skin barrier). More research is needed to clarify the role, if any, of emollient use and probiotics.
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19
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Appiah MM, Haft MA, Kleinman E, Laborada J, Lee S, Loop L, Geng B, Eichenfield LF. Atopic dermatitis. Ann Allergy Asthma Immunol 2022; 129:142-149. [PMID: 35609746 DOI: 10.1016/j.anai.2022.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/08/2022] [Accepted: 05/12/2022] [Indexed: 11/25/2022]
Abstract
Atopic dermatitis (AD) is a very common skin disease associated with substantial burdens on patient health and quality of life. Knowledge regarding the pathogenesis of AD has expanded within recent years, leading to novel and efficacious therapeutic agents. Similarly, our knowledge of the impact of AD on patient's mental and physical health has also expanded. This review summarizes updates on the evolution, comorbidities, and therapeutic options of AD. AD is associated with increased cardiovascular risk, allergic diseases, and adverse mental health outcomes. Topical and systemic therapeutics have drastically altered the landscape of AD therapy in recent years.
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Affiliation(s)
- Margaret M Appiah
- Departments of Dermatology and Pediatrics, University of California San Diego, San Diego, California; Rady Children's Hospital, San Diego, California
| | - Michael A Haft
- Departments of Dermatology and Pediatrics, University of California San Diego, San Diego, California; Rady Children's Hospital, San Diego, California; University of Rochester School of Medicine, New York, New York
| | | | | | - Stephanie Lee
- Departments of Dermatology and Pediatrics, University of California San Diego, San Diego, California; Rady Children's Hospital, San Diego, California
| | - Lauren Loop
- Rady Children's Hospital, San Diego, California
| | - Bob Geng
- Rady Children's Hospital, San Diego, California; Division of Allergy and Immunology, University of California San Diego, San Diego, California
| | - Lawrence F Eichenfield
- Departments of Dermatology and Pediatrics, University of California San Diego, San Diego, California; Rady Children's Hospital, San Diego, California.
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20
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Katibi OS, Cork MJ, Flohr C, Danby SG. Moisturizer therapy in prevention of atopic dermatitis and food allergy: To use or disuse? Ann Allergy Asthma Immunol 2022; 128:512-525. [PMID: 35235817 DOI: 10.1016/j.anai.2022.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/19/2022] [Accepted: 02/22/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To critically appraise the evidence for the role of regular moisturizer application in early life to prevent atopic dermatitis (AD) and food allergy (FA). DATA SOURCES Primary peer-reviewed literature. STUDY SELECTIONS Original research articles based on systematic reviews, interventional studies, retrospective studies, case-control studies, and cohort studies related to the subject matter. RESULTS There is good evidence to show that epicutaneous sensitization through a defective skin barrier is important in the development of AD and FA. This supports moisturizer use in prevention because some of them have been proven to restore skin barrier with clear benefits in AD, whereas there is some limited evidence that these products may reduce allergic sensitization. However, moisturizers have varied effects depending on ingredients and formulation, some of which are paradoxical, such as increasing transepidermal water loss and enhancing penetration of substances in the skin. These effects may be responsible for some of the conflicting outcomes of prevention studies, some of which suggest that moisturizers are not useful in prevention of AD and FA, whereas others show a positive trend. Interestingly, there is some suggestion that moisturizers may increase the risk for allergy development perhaps through these paradoxical effects. CONCLUSION Although moisturizer use is beneficial in the management of AD, current evidence suggests that it may be ineffective in prevention of AD and FA. Further studies are needed to determine the effects of moisturization on allergic sensitization and inflammation and to investigate whether moisturizer type, frequency, duration, and age of application substantially affect the prevention and development of these allergies.
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Affiliation(s)
- Oludolapo Sherifat Katibi
- Sheffield Dermatology Research, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom; Dermatology Unit, Department of Paediatrics & Child Health, College of Health Sciences, University of Ilorin, Ilorin, Nigeria.
| | - Michael John Cork
- Sheffield Dermatology Research, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Carsten Flohr
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
| | - Simon Geoffrey Danby
- Sheffield Dermatology Research, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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21
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Shima K, Inoue T, Uehara Y, Iwamura M, Fukagawa S, Kuwano T, Tanida K, Takada N, Saito‐Abe M, Yamamoto‐Hanada K, Ohya Y, Murase T. Non‐invasive transcriptomic analysis using
mRNAs
in skin surface lipids obtained from children with mild‐to‐moderate atopic dermatitis. J Eur Acad Dermatol Venereol 2022; 36:1477-1485. [PMID: 35462437 PMCID: PMC9545805 DOI: 10.1111/jdv.18173] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/23/2022] [Indexed: 11/29/2022]
Abstract
Background Specimens for analysing the molecular pathology of skin disease are generally obtained through invasive methods, such as biopsy. However, less burdensome methods are desirable for paediatric patients. We recently established a method that comprehensively analyses RNA present in sebum (skin surface lipid–RNAs: SSL‐RNAs) using a next‐generation sequencer. Using this method, biological information can be obtained from the skin in a completely non‐invasive manner. Objectives To verify the applicability of the SSL‐RNA method for analysis of paediatric skin and analyse the molecular pathology of mild‐to‐moderate atopic dermatitis (AD) in children. Methods We collected sebum specimens from the whole faces of 23 healthy children and 16 children with mild‐to‐moderate AD (eczema area and severity index (EASI) score: 5.9 ± 2.6) ranging in age from 6 months to 5 years, using an oil‐blotting film. We then extracted SSL‐RNAs from the samples and performed an AmpliSeq transcriptomic analysis. Results The expressions of genes related to keratinization (LCE, PSORS1C2, IVL and KRT17), triglyceride synthesis and storage (PLIN2, DGAT2 and CIDEA), wax synthesis (FAR2), ceramide synthesis (GBA2, SMPD3 and SPTLC3), antimicrobial peptides (DEFB1) and intercellular adhesion (CDSN), all of which are related to the skin barrier, are lower in children with AD than in healthy children. The children with AD also have higher expression of CCL17, a Th2‐cytokine and an increased Th2‐immune response as demonstrated by a gene set variation analysis. Moreover, KRT17 and CCL17 expression levels are significantly correlated with the EASI score. Conclusions Molecular changes associated with abnormal immune responses and the epidermal barrier in children with mild‐to‐moderate AD can be determined using the SSL‐RNA method. This non‐invasive method could therefore be a useful means for understanding the molecular pathology of paediatric AD.
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Affiliation(s)
- K. Shima
- Biological Science Research, Kao Corporation Tochigi Japan
| | - T. Inoue
- Biological Science Research, Kao Corporation Tochigi Japan
| | - Y. Uehara
- Biological Science Research, Kao Corporation Tochigi Japan
| | - M. Iwamura
- Biological Science Research, Kao Corporation Tochigi Japan
| | - S. Fukagawa
- Biological Science Research, Kao Corporation Tochigi Japan
| | - T. Kuwano
- Biological Science Research, Kao Corporation Tochigi Japan
| | - K. Tanida
- Biological Science Research, Kao Corporation Tochigi Japan
| | - N. Takada
- Biological Science Research, Kao Corporation Tochigi Japan
| | - M. Saito‐Abe
- Allergy Center, National Center for Child Health and Development Tokyo Japan
| | - K. Yamamoto‐Hanada
- Allergy Center, National Center for Child Health and Development Tokyo Japan
| | - Y. Ohya
- Allergy Center, National Center for Child Health and Development Tokyo Japan
| | - T. Murase
- Biological Science Research, Kao Corporation Tochigi Japan
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22
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Winslow A, Keet CA. Preventing allergies through the skin. Ann Allergy Asthma Immunol 2022; 129:276-285. [PMID: 35470039 DOI: 10.1016/j.anai.2022.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 03/17/2022] [Accepted: 04/07/2022] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To inform readers of the current and forthcoming skin barrier interventions that have clinically relevant implications in the prevention of allergic sensitization and atopic diseases. DATA SOURCES Peer-reviewed journal articles indexed on PubMed and clinical trials referenced on clinicaltrials.gov were analyzed. STUDY SELECTIONS Literature searches from PubMed and clinicaltrials.gov were performed using combinations of the following search terms: prevention, allergy, atopy, skin, cutaneous, microbiome, microbiota, Staphylococcus aureus, atopic dermatitis, eczema, food allergy, and asthma. RESULTS The skin barrier represents an entry point for allergic sensitization and TH2-mediated allergic disorders. Results from clinical trials designed to improve microbiome complexity and reduce S aureus colonization, provide skin barrier enhancement, and deliver epicutaneous immunotherapy are summarized and discussed in the context of primary, secondary, and tertiary prevention of allergic disease. CONCLUSION The skin barrier is a promising target for prevention of allergic disease, though clinical trial results thus far have been mixed, at best.
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Affiliation(s)
- Andrew Winslow
- Division of Allergy and Immunology, Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Corinne Allison Keet
- Division of Allergy and Immunology, Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
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23
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Egg Allergy in Children and Weaning Diet. Nutrients 2022; 14:nu14081540. [PMID: 35458102 PMCID: PMC9025129 DOI: 10.3390/nu14081540] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/02/2022] [Accepted: 04/03/2022] [Indexed: 02/01/2023] Open
Abstract
Eggs are a fundamental food in the human diet, and together with cow’s milk, they are the most common food allergen. This work highlights the main nutritional characteristics of eggs to show how their absence from a child’s diet can constitute a serious deficiency. We then analyze the risk factors that facilitate the onset of egg allergy. The third part of the paper reports possible interventions to lower the appearance of food allergy that have been occurred in trials. The last part of the paper is a synthesis of this research study that has been taken from several of the latest guidelines or from position papers.
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Singh AM, Anvari S, Hauk P, Lio P, Nanda A, Sidbury R, Schneider L. Atopic Dermatitis and Food Allergy: Best Practices and Knowledge Gaps-A Work Group Report from the AAAAI Allergic Skin Diseases Committee and Leadership Institute Project. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:697-706. [PMID: 35101439 DOI: 10.1016/j.jaip.2021.12.037] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/20/2022]
Abstract
Allergists are often asked to evaluate children with atopic dermatitis (AD) for allergen triggers to disease. Testing, particularly for food triggers, often leads to elimination diets in an effort to improve AD control. However, the dual exposure hypothesis suggests that oral tolerance to food antigens is promoted through high-dose oral exposure, where sensitization occurs through lower dose cutaneous exposure. This suggests that strict elimination diets may pose some risks in children with AD. In addition, emerging evidence suggests an important role of skin inflammation in further allergic disease and the importance of dietary exposure to maintain oral tolerance. This work group report reviews current guidelines-based management for children with moderate-to-severe AD, the evidence for current recommendations for the evaluation and management of these children, provides a nuanced examination of these studies, and addresses current knowledge gaps in the care of these children.
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Affiliation(s)
- Anne Marie Singh
- Department of Pediatrics, Division of Allergy, Immunology and Rheumatology, Departments of Dermatology and Medical Microbiology and Immunology, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, Wisconsin.
| | - Sara Anvari
- Department of Pediatrics, Division of Immunology, Allergy, and Retrovirology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Pia Hauk
- Department of Pediatrics, Section of Allergy/Immunology, University of Colorado School of Medicine, Colorado Children's Hospital, Aurora, Colorado
| | - Peter Lio
- Medical Dermatology Associates of Chicago and Department of Dermatology, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Anil Nanda
- Asthma and Allergy Center, Lewisville and Flower Mound, Texas and Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Robert Sidbury
- Department of Pediatrics, Division of Dermatology, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Lynda Schneider
- Boston Children's Hospital, Department of Pediatrics, Division of Immunology, Harvard Medical School, Boston, Massachusetts
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25
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Brough HA, Lanser BJ, Sindher SB, Teng JMC, Leung DYM, Venter C, Chan SM, Santos AF, Bahnson HT, Guttman‐Yassky E, Gupta RS, Lack G, Ciaccio CE, Sampath V, Nadeau KC, Nagler CR. Early intervention and prevention of allergic diseases. Allergy 2022; 77:416-441. [PMID: 34255344 DOI: 10.1111/all.15006] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/09/2021] [Indexed: 12/12/2022]
Abstract
Food allergy (FA) is now one of the most common chronic diseases of childhood often lasting throughout life and leading to significant worldwide healthcare burden. The precise mechanisms responsible for the development of this inflammatory condition are largely unknown; however, a multifactorial aetiology involving both environmental and genetic contributions is well accepted. A precise understanding of the pathogenesis of FA is an essential first step to developing comprehensive prevention strategies that could mitigate this epidemic. As it is frequently preceded by atopic dermatitis and can be prevented by early antigen introduction, the development of FA is likely facilitated by the improper initial presentation of antigen to the developing immune system. Primary oral exposure of antigens allowing for presentation via a well-developed mucosal immune system, rather than through a disrupted skin epidermal barrier, is essential to prevent FA. In this review, we present the data supporting the necessity of (1) an intact epidermal barrier to prevent epicutaneous antigen presentation, (2) the presence of specific commensal bacteria to maintain an intact mucosal immune system and (3) maternal/infant diet diversity, including vitamins and minerals, and appropriately timed allergenic food introduction to prevent FA.
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Affiliation(s)
- Helen A. Brough
- Department Women and Children’s Health (Pediatric Allergy) School of Life Course Sciences Faculty of Life Sciences and Medicine King’s College London London UK
- Peter Gorer Department of Immunobiology School of Immunology and Microbial Sciences King’s College London London UK
- Children’s Allergy Service Evelina Children’s Hospital Guy’s and St. Thomas’s NHS Foundation Trust London UK
| | - Bruce Joshua Lanser
- Division of Pediatric Allergy‐Immunology Department of Pediatrics National Jewish Health Denver CO USA
| | - Sayantani B. Sindher
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University Stanford University Stanford CA USA
- Division of Pulmonary and Critical Care Medicine Department of Medicine Stanford University Stanford CA USA
- Division of Allergy, Immunology and Rheumatology Department of Medicine Stanford University Stanford CA USA
| | - Joyce M. C. Teng
- Department of Dermatology Lucile Packard Children's Hospital at the Stanford University School of Medicine Palo Alto CA USA
| | - Donald Y. M. Leung
- Division of Pediatric Allergy‐Immunology Department of Pediatrics National Jewish Health Denver CO USA
| | - Carina Venter
- Section of Allergy & Immunology School of Medicine University of Colorado DenverChildren's Hospital Colorado Aurora CO USA
| | - Susan M. Chan
- Department Women and Children’s Health (Pediatric Allergy) School of Life Course Sciences Faculty of Life Sciences and Medicine King’s College London London UK
- Peter Gorer Department of Immunobiology School of Immunology and Microbial Sciences King’s College London London UK
- Children’s Allergy Service Evelina Children’s Hospital Guy’s and St. Thomas’s NHS Foundation Trust London UK
| | - Alexandra F. Santos
- Department Women and Children’s Health (Pediatric Allergy) School of Life Course Sciences Faculty of Life Sciences and Medicine King’s College London London UK
- Peter Gorer Department of Immunobiology School of Immunology and Microbial Sciences King’s College London London UK
- Children’s Allergy Service Evelina Children’s Hospital Guy’s and St. Thomas’s NHS Foundation Trust London UK
- Asthma UK Centre in Allergic Mechanisms of Asthma London UK
| | - Henry T. Bahnson
- Benaroya Research Institute and Immune Tolerance Network Seattle WA USA
| | - Emma Guttman‐Yassky
- Department of Dermatology and the Immunology Institute Icahn School of Medicine at Mount Sinai New York NY USA
- Laboratory for Investigative Dermatology The Rockefeller University New York NY USA
| | - Ruchi S. Gupta
- Center for Food Allergy and Asthma Research Northwestern University Feinberg School of Medicine Chicago IL USA
- Ann & Robert H. Lurie Children's Hospital of Chicago Chicago IL USA
| | - Gideon Lack
- Department Women and Children’s Health (Pediatric Allergy) School of Life Course Sciences Faculty of Life Sciences and Medicine King’s College London London UK
- Peter Gorer Department of Immunobiology School of Immunology and Microbial Sciences King’s College London London UK
- Children’s Allergy Service Evelina Children’s Hospital Guy’s and St. Thomas’s NHS Foundation Trust London UK
| | | | - Vanitha Sampath
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University Stanford University Stanford CA USA
| | - Kari C. Nadeau
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University Stanford University Stanford CA USA
- Division of Pulmonary and Critical Care Medicine Department of Medicine Stanford University Stanford CA USA
- Division of Allergy, Immunology and Rheumatology Department of Medicine Stanford University Stanford CA USA
| | - Cathryn R. Nagler
- Department of Pathology and Pritzker School of Molecular Engineering University of Chicago Chicago IL USA
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26
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Kojima R, Miyake K, Shinohara R, Kushima M, Horiuchi S, Otawa S, Yokomichi H, Akiyama Y, Ooka T, Yamagata Z. Association of egg protein levels in dust with allergy status and related factors. Pediatr Int 2022; 64:e15372. [PMID: 36168729 DOI: 10.1111/ped.15372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 09/06/2022] [Accepted: 09/20/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Levels of peanut protein in dust have been reported to be associated with sensitization and allergy to it, so controlling food protein in dust may help prevent food allergy. However, studies of factors associated with egg protein levels in dust are scarce. This study aimed to determine the factors contributing to egg protein levels in dust. METHODS This cross-sectional study included 159 participants in the Sub-Cohort Study of the Japan Environment and Children's Study in Yamanashi Prefecture at a 6 year follow up. House dust at 6 years was collected and egg protein concentrations were measured for whole egg protein. Household factors, including the maternal frequency of egg consumption, were assessed by questionnaires. A linear regression model was used to analyze the effect of household environmental factors on egg protein in dust. RESULTS In multivariate analysis, frequent maternal egg consumption (≥5 times a week) was associated with higher egg protein concentrations in house dust (β = 0.96, P = 0.01). The egg protein load was significantly associated with a higher number of cohabitants (≥5, β = 0.85, P = 0.02) in addition to frequent maternal egg consumption. Among the participants, 140 (88.1%) had no egg allergy, 15 (9.4%) were egg tolerant, and 4 (2.5%) had an egg allergy at 6 years old. There was no significant association between the current egg allergy status and egg protein concentrations in dust. CONCLUSIONS The frequency of maternal egg consumption and the number of inhabitants are contributing factors to egg protein levels in dust.
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Affiliation(s)
- Reiji Kojima
- Department of Health Sciences, School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Kunio Miyake
- Department of Health Sciences, School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Ryoji Shinohara
- Center for Birth Cohort Studies, University of Yamanashi, Yamanashi, Japan
| | - Megumi Kushima
- Center for Birth Cohort Studies, University of Yamanashi, Yamanashi, Japan
| | - Sayaka Horiuchi
- Center for Birth Cohort Studies, University of Yamanashi, Yamanashi, Japan
| | - Sanae Otawa
- Center for Birth Cohort Studies, University of Yamanashi, Yamanashi, Japan
| | - Hiroshi Yokomichi
- Department of Health Sciences, School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Yuka Akiyama
- Department of Health Sciences, School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Tadao Ooka
- Department of Health Sciences, School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Zentaro Yamagata
- Department of Health Sciences, School of Medicine, University of Yamanashi, Yamanashi, Japan.,Center for Birth Cohort Studies, University of Yamanashi, Yamanashi, Japan
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27
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Sabouraud-Leclerc D, Bradatan E, Moraly T, Payot F, Larue C, Chabbert AB, Nemni A, Pontcharraud R, Juchet A, Divaret-Chauveau A, Morisset M. Primary prevention of food allergy in 2021: Update and proposals of French-speaking pediatric allergists. Arch Pediatr 2021; 29:81-89. [PMID: 34955309 DOI: 10.1016/j.arcped.2021.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 07/28/2021] [Accepted: 11/30/2021] [Indexed: 12/12/2022]
Abstract
During the past years, there has been an alarming increase in cases of food allergy and anaphylaxis in ever-younger children. Often, these children have multiple food allergies and food sensitizations, involving allergens with high anaphylactic potential, such as peanuts and nuts, which have a major influence on their quality of life and future. After reviewing the current epidemiological data, we discuss the main causes of the increase in food allergies. We analyze data from studies on the skin barrier and its fundamental role in the development of sensitization and food allergies, data on the tolerogenic digestive tract applied in particular to hen eggs and peanuts, as well as data on the prevention of allergy to cow milk proteins. In light of these studies, we propose a practical guide of recommendations focused on infants and the introduction of cow milk, the management of eczema, and early and broad dietary diversification including high-risk food allergens, such as peanut and nuts while taking into account the food consumption habits of the family.
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Affiliation(s)
- D Sabouraud-Leclerc
- American Memorial Hospital, Pediatrics Department, Reims University Hospital, 47 rue Cognacq Jay 51100 Reims, France.
| | - E Bradatan
- Namur Regional Hospital Center, Pediatrics Department, Pneumology and Allergology Unit, 185, Avenue Albert 1er, 5000, Namur, Belgium
| | - T Moraly
- Saint-Vincent de Paul Hospital, Group of Hospitals of Lille Catholic Institute, Allergology Unit, 59000 Lille, France
| | - F Payot
- Femme-Mère-Enfant Hospital, Allergology Unit, Lyon University Hospital, 69000 Lyon, France
| | - C Larue
- G.H.E.F. Meaux Hospital, Allergology Unit, 6-8 rue Saint Fiacre, 77100 Meaux, France
| | - A Broué Chabbert
- Pediatric Pulmonology and Allergology Office, 1 rue de la Paderne, 31170 Tournefeuille, France
| | - A Nemni
- Allergology Unit, Robert Ballanger Hospital, 93600 Aulnay-Sous-Bois, France
| | - R Pontcharraud
- Toulouse University Hospital, Dietician Unit, 31000 Toulouse, France
| | - A Juchet
- Clinique Rive Gauche, 49 Allées Charles de Fitte, 31076 Toulouse Cedex 03, France
| | - A Divaret-Chauveau
- Pediatric Allergy Department, Children's Hospital, Nancy University Hospital, 54500 Vandoeuvre les Nancy, France; EA 3450 DevAH-Department of Physiology, Faculty of Medicine, University of Lorraine, 54500 Vandoeuvre les Nancy, France; UMR/CNRS 6249 Chrono-Environnement, University of Franche Comté, Besançon, France
| | - M Morisset
- Angers University Hospital, Allergology Unit, 49000 Angers, France
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28
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Mortz CG, Toit G, Beyer K, Bindslev‐Jensen C, Brockow K, Brough HA, Comberiati P, Eiwegger T, Santos A, Worm M, Ballmer‐Weber BK. When and how to evaluate for immediate type food allergy in children with atopic dermatitis. Allergy 2021; 76:3845-3848. [PMID: 34157156 DOI: 10.1111/all.14982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/19/2021] [Accepted: 06/05/2021] [Indexed: 01/22/2023]
Affiliation(s)
- Charlotte G. Mortz
- Department of Dermatology and Allergy Center Odense Research Center for Anaphylaxis (ORCA) Odense University Hospital Odense Denmark
| | - George Toit
- Children's Allergy Service Evelina London Children's Hospital Guy's and St Thomas' NHS Foundation Trust Paediatric Allergy Group School of Life Course Sciences & School of Immunology and Microbial Sciences King's College London London UK
| | - Kirsten Beyer
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine Charite Universitatsmedizin Berlin Berlin Germany
| | - Carsten Bindslev‐Jensen
- Department of Dermatology and Allergy Center Odense Research Center for Anaphylaxis (ORCA) Odense University Hospital Odense Denmark
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein School of Medicine Technical University Munich Munich Germany
| | - Helen Annaruth Brough
- Children's Allergy Service Evelina London Children's Hospital Guy's and St Thomas' NHS Foundation Trust Paediatric Allergy Group School of Life Course Sciences & School of Immunology and Microbial Sciences King's College London London UK
| | - Pasquale Comberiati
- Department of Clinical and Experimental Medicine Section of Pediatrics University of Pisa Pisa Italy
- Department of Clinical Immunology and Allergology I.M. Sechenov First Moscow State Medical University Moscow Russia
| | - Thomas Eiwegger
- Translational Medicine Program Research Institute Hospital for Sick Children Toronto ON Canada
- Division of Immunology and Allergy Food Allergy and Anaphylaxis Program The Department of Pediatrics Hospital for Sick Children Toronto ON Canada
- Department of Immunology Faculty of Medicine University of Toronto Toronto ON Canada
| | - Alexandra Santos
- Children's Allergy Service Evelina London Children's Hospital Guy's and St Thomas' NHS Foundation Trust Paediatric Allergy Group School of Life Course Sciences & School of Immunology and Microbial Sciences King's College London London UK
- Asthma UK Centre in Allergic Mechanisms of Asthma London UK
| | - Margitta Worm
- Allergy and Immunology Deprtment of Dermatology, Venerology and Allergy Charité‐Universitätsmedizin Berlin Berlin Germany
| | - Barbara K. Ballmer‐Weber
- Allergy Unit Department of Dermatology University Hospital Zürich Zürich Switzerland
- Allergy Unit Clinic for Dermatology and Allergology Kantonsspital St. Gallen St. Gallen Switzerland
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29
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Current Insights into Atopic March. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8111067. [PMID: 34828780 PMCID: PMC8620020 DOI: 10.3390/children8111067] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/10/2021] [Accepted: 11/16/2021] [Indexed: 11/20/2022]
Abstract
The incidence of allergic diseases is increasing, and research on their epidemiology, pathophysiology, and the prevention of onset is urgently needed. The onset of allergic disease begins in infancy with atopic dermatitis and food allergy and develops into allergic asthma and allergic rhinitis in childhood; the process is defined as “atopic march”. Atopic march is caused by multiple immunological pathways, including allergen exposure, environmental pollutants, skin barrier dysfunction, type 2 inflammation, and oxidative stress, which promote the progression of atopic march. Using recent evidence, herein, we explain the involvement of allergic inflammatory conditions and oxidative stress in the process of atopic march, its epidemiology, and methods for prevention of onset.
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30
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Mancuso JB, Lee SS, Paller AS, Ohya Y, Eichenfield LF. Management of Severe Atopic Dermatitis in Pediatric Patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1462-1471. [PMID: 33838839 DOI: 10.1016/j.jaip.2021.02.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/05/2021] [Accepted: 02/05/2021] [Indexed: 12/13/2022]
Abstract
Atopic dermatitis is a common, chronic inflammatory skin disorder, present in about 12% of children worldwide. Optimizing management of severe atopic dermatitis in pediatric patients is critical to reduce signs of inflammation, alleviate pruritus and sleep disturbance, minimize the development and/or impact of comorbidities, and improve the patient and caregiver's quality of life. Evaluating the longitudinal severity of pediatric atopic dermatitis is an important component of measuring therapeutic response and long-term management, and is different in clinical practice versus clinical trials. This article describes when and how to use different treatments for pediatric patients with severe atopic dermatitis, including topical medications, phototherapy, and systemic medical therapies (traditional immunosuppressants, biologics, and small molecule inhibitors). It also provides recommendations useful in clinical practice for nonpharmacologic interventions for pediatric patients with severe atopic dermatitis.
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Affiliation(s)
- Jennifer B Mancuso
- Department of Dermatology, University of Michigan Medical School, Ann Arbor, Mich
| | - Stephanie S Lee
- Departments of Dermatology and Pediatrics, University of California San Diego, San Diego, Calif; Pediatric and Adolescent Dermatology, Rady Children's Hospital San Diego, San Diego, Calif
| | - Amy S Paller
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Yukihiro Ohya
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
| | - Lawrence F Eichenfield
- Departments of Dermatology and Pediatrics, University of California San Diego, San Diego, Calif; Pediatric and Adolescent Dermatology, Rady Children's Hospital San Diego, San Diego, Calif.
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31
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Perkin MR, Logan K, Marrs T, Radulovic S, Craven J, Boyle RJ, Chalmers JR, Williams HC, Versteeg SA, van Ree R, Lack G, Flohr C. Association of frequent moisturizer use in early infancy with the development of food allergy. J Allergy Clin Immunol 2021; 147:967-976.e1. [PMID: 33678253 PMCID: PMC9393761 DOI: 10.1016/j.jaci.2020.10.044] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/23/2020] [Accepted: 10/27/2020] [Indexed: 12/20/2022]
Abstract
Background Objectives Methods Results Conclusions
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Affiliation(s)
- Michael R Perkin
- Population Health Research Institute, St George's, University of London, London, United Kingdom.
| | - Kirsty Logan
- Paediatric Allergy Research Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom
| | - Tom Marrs
- Paediatric Allergy Research Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom
| | - Suzana Radulovic
- Paediatric Allergy Research Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom
| | - Joanna Craven
- Paediatric Allergy Research Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom
| | - Robert J Boyle
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, United Kingdom
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, United Kingdom
| | - Serge A Versteeg
- Department of Experimental Immunology, Academic Medical Center, Amsterdam, The Netherlands
| | - Ronald van Ree
- Department of Experimental Immunology, Academic Medical Center, Amsterdam, The Netherlands; Department of Otorhinolaryngology, Academic Medical Center, Amsterdam, The Netherlands
| | - Gideon Lack
- Paediatric Allergy Research Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom
| | - Carsten Flohr
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
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32
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Leung DYM, Berdyshev E, Goleva E. Cutaneous barrier dysfunction in allergic diseases. J Allergy Clin Immunol 2021; 145:1485-1497. [PMID: 32507227 DOI: 10.1016/j.jaci.2020.02.021] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 01/08/2023]
Abstract
The fundamental defect(s) that drives atopic dermatitis (AD) remains controversial. "Outside in" proponents point to the important association of filaggrin gene mutations and other skin barrier defects with AD. The "inside out" proponents derive support from evidence that AD occurs in genetic animal models with overexpression of type 2 immune pathways in their skin, and humans with gain-of-function mutations in their type 2 response develop severe AD. The observation that therapeutic biologics, targeting type 2 immune responses, can reverse AD provides compelling support for the importance of "inside out" mechanisms of AD. In this review, we propose a central role for epithelial cell dysfunction that accounts for the dual role of skin barrier defects and immune pathway activation in AD. The complexity of AD has its roots in the dysfunction of the epithelial barrier that allows the penetration of allergens, irritants, and microbes into a cutaneous milieu that facilitates the induction of type 2 immune responses. The AD phenotypes and endotypes that result in chronic skin inflammation and barrier dysfunction are modified by genes, innate/adaptive immune responses, and different environmental factors that cause skin barrier dysfunction. There is also compelling evidence that skin barrier dysfunction can alter the course of childhood asthma, food allergy, and allergic rhinosinusitis. Effective management of AD requires a multipronged approach, not only restoring cutaneous barrier function, microbial flora, and immune homeostasis but also enhancing skin epithelial differentiation.
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Affiliation(s)
| | | | - Elena Goleva
- Department of Pediatrics, National Jewish Health, Denver, Colo
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33
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McAleer MA, Jakasa I, Stefanovic N, McLean WHI, Kezic S, Irvine AD. Topical corticosteroids normalize both skin and systemic inflammatory markers in infant atopic dermatitis. Br J Dermatol 2020; 185:153-163. [PMID: 33269467 PMCID: PMC8359435 DOI: 10.1111/bjd.19703] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2020] [Indexed: 12/13/2022]
Abstract
Background Atopic dermatitis (AD) is the most common inflammatory skin disease. It is highly heterogeneous in clinical presentation, treatment response, disease trajectory and associated atopic comorbidities. Immune biomarkers are dysregulated in skin and peripheral blood. Aims We used noninvasive skin and peripheral biomarkers to observe the effects of real‐world topical corticosteroid (TCS) treatment in infants with AD, by measuring skin and blood biomarkers before and after therapy. Methods Seventy‐four treatment‐naïve infants with AD underwent 6 weeks of TCS treatment. Stratum corneum (SC) and plasma blood biomarkers as well as SC natural moisturizing factor (NMF) were measured before and after TCS therapy. Immune markers included innate, T helper (Th)1 and Th2 immunity, angiogenesis, and vascular factors. AD severity was assessed by the Scoring Atopic Dermatitis index, and skin barrier function by transepidermal water loss (TEWL). Twenty healthy infants were recruited as controls. Results TCS therapy predictably led to improvement in disease severity. Levels of immune markers in the skin and in the peripheral blood showed significant change from baseline, though most did not reach healthy control levels. The most prominent change from baseline in the SC was in markers of innate immune activation, interleukin (IL)‐18, IL‐8 and IL‐1α, and the Th2 chemokines C‐C motif chemokine (CCL)17 and CCL22. In blood, the largest changes were in Th2‐skewed biomarkers: CCL17, IL‐13, CCL22, IL‐5, and CCL26. TEWL decreased after therapy; no significant changes from baseline were found for NMF. Conclusions The profound impact of topical therapy on systemic biomarkers suggests that the skin compartment generates a major component of dysregulated systemic cytokines in infant AD. There may be long‐term beneficial effects of correcting systemic immune dysregulation through topical therapy.
What is already known about this topic?
Atopic dermatitis (AD) is a clinically heterogeneous condition with multiple clinical manifestations and a complex pathogenesis. Noninvasive sampling of the stratum corneum has yielded significant insights into cytokine profiles of this compartment in AD. Peripheral blood signatures have distinct cytokine profiles in childhood AD.
What does this study add?
We show the effects of topical corticosteroid (TCS) therapy on both skin‐derived and peripheral blood biomarkers. TCS therapy had an effect on the cutaneous compartment but also substantially normalized the peripheral blood compartment cytokine signatures. The long‐term effects of normalizing peripheral immune signatures are unknown but could potentially be beneficial.
What is the translational message?
TCS therapy can normalize systemic immune dysregulation in infant AD.
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Affiliation(s)
- M A McAleer
- Paediatric Dermatology, Children's Health Ireland at Crumlin, Dublin, Ireland.,National Children's Research Centre, Crumlin, Dublin, Ireland.,Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - I Jakasa
- Laboratory for Analytical Chemistry, Department of Chemistry and Biochemistry, Faculty of Food Technology and Biotechnology, University of Zagreb, Croatia
| | - N Stefanovic
- Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - W H I McLean
- Dermatology and Genetic Medicine, School of Life Sciences, University of Dundee, Dundee, UK
| | - S Kezic
- Coronel Institute of Occupational Health, Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, the Netherlands
| | - A D Irvine
- Paediatric Dermatology, Children's Health Ireland at Crumlin, Dublin, Ireland.,National Children's Research Centre, Crumlin, Dublin, Ireland.,Laboratory for Analytical Chemistry, Department of Chemistry and Biochemistry, Faculty of Food Technology and Biotechnology, University of Zagreb, Croatia
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34
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Sindher S, Alkotob SS, Shojinaga MN, Brough HA, Bahnson HT, Chan S, Lack G, Leung DYM, Nadeau KC. Pilot study measuring transepidermal water loss (TEWL) in children suggests trilipid cream is more effective than a paraffin-based emollient. Allergy 2020; 75:2662-2664. [PMID: 32176320 DOI: 10.1111/all.14275] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/20/2020] [Accepted: 02/23/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Sayantani Sindher
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University School of Medicine Stanford CA USA
- Division of Pulmonary and Critical Care Medicine Department of Medicine Stanford University Stanford CA USA
| | - Shifaa S. Alkotob
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University School of Medicine Stanford CA USA
- Division of Pulmonary and Critical Care Medicine Department of Medicine Stanford University Stanford CA USA
| | - Melanie N. Shojinaga
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University School of Medicine Stanford CA USA
- Division of Pulmonary and Critical Care Medicine Department of Medicine Stanford University Stanford CA USA
| | - Helen A. Brough
- Paediatric Allergy Group Department of Women and Children's Health School of Life Course Sciences King's College LondonSt. Thomas' Hospital London UK
- Paediatric Allergy Group Peter Gorer Department of Immunobiology School of Immunology & Microbial Sciences King's College London Guys' Hospital London UK
- Children's Allergy Service Evelina Children's Hospital Guy's and St. Thomas' Hospital NHS Foundation Trust London UK
| | - Henry T. Bahnson
- Immune Tolerance Network Benaroya Research Institute Seattle WA USA
| | - Susan Chan
- Paediatric Allergy Group Department of Women and Children's Health School of Life Course Sciences King's College LondonSt. Thomas' Hospital London UK
- Paediatric Allergy Group Peter Gorer Department of Immunobiology School of Immunology & Microbial Sciences King's College London Guys' Hospital London UK
- Children's Allergy Service Evelina Children's Hospital Guy's and St. Thomas' Hospital NHS Foundation Trust London UK
| | - Gideon Lack
- Paediatric Allergy Group Department of Women and Children's Health School of Life Course Sciences King's College LondonSt. Thomas' Hospital London UK
- Paediatric Allergy Group Peter Gorer Department of Immunobiology School of Immunology & Microbial Sciences King's College London Guys' Hospital London UK
- Children's Allergy Service Evelina Children's Hospital Guy's and St. Thomas' Hospital NHS Foundation Trust London UK
| | - Donald Y. M. Leung
- Department of Pediatrics National Jewish Health Denver CO USA
- Department of Pediatrics University of Colorado at Denver Health Sciences Center Aurora CO USA
| | - Kari C. Nadeau
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University School of Medicine Stanford CA USA
- Division of Pulmonary and Critical Care Medicine Department of Medicine Stanford University Stanford CA USA
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35
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Brough HA, Nadeau KC, Sindher SB, Alkotob SS, Chan S, Bahnson HT, Leung DYM, Lack G. Epicutaneous sensitization in the development of food allergy: What is the evidence and how can this be prevented? Allergy 2020; 75:2185-2205. [PMID: 32249942 PMCID: PMC7494573 DOI: 10.1111/all.14304] [Citation(s) in RCA: 137] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/26/2020] [Accepted: 03/28/2020] [Indexed: 12/14/2022]
Abstract
There is increasing evidence regarding the importance of allergic sensitization through the skin. In this review, we provide an overview of the atopic march and immune mechanism underlying the sensitization and effector phase of food allergy. We present experimental models and human data that support the concept of epicutaneous sensitization and how this forms one half of the dual-allergen exposure hypothesis. We discuss specific important elements in the skin (FLG and other skin barrier gene mutations, Langerhans cells, type 2 innate lymphoid cells, IL-33, TSLP) that have important roles in the development of allergic responses as well as the body of evidence on environmental allergen exposure and how this can sensitize an individual. Given the link between skin barrier impairment, atopic dermatitis, food allergy, allergic asthma, and allergic rhinitis, it is logical that restoring the skin barrier and prevention or treating atopic dermatitis would have beneficial effects on prevention of related allergic diseases, particularly food allergy. We present the experimental and human studies that have evaluated this approach and discuss various factors which may influence the success of these approaches, such as the type of emollient chosen for the intervention, the role of managing skin inflammation, and differences between primary and secondary prevention of atopic dermatitis to achieve the desired outcome.
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Affiliation(s)
- Helen A Brough
- Paediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, St. Thomas' Hospital, London, UK
- Paediatric Allergy Group, Peter Gorer Department of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guys' Hospital, London, UK
- Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, UK
| | - Kari C Nadeau
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, CA, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA
- Department of Medicine, Division of Allergy, Immunology and Rheumatology, Stanford University, Stanford, CA, USA
| | - Sayantani B Sindher
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, CA, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA
| | - Shifaa S Alkotob
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, CA, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA
| | - Susan Chan
- Paediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, St. Thomas' Hospital, London, UK
- Paediatric Allergy Group, Peter Gorer Department of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guys' Hospital, London, UK
- Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, UK
| | - Henry T Bahnson
- Benaroya Research Institute and Immune Tolerance Network, Seattle, WA, USA
| | - Donald Y M Leung
- Department of Pediatrics, Division of Pediatric Allergy-Immunology, National Jewish Health, Denver, CO, USA
| | - Gideon Lack
- Paediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, St. Thomas' Hospital, London, UK
- Paediatric Allergy Group, Peter Gorer Department of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guys' Hospital, London, UK
- Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, UK
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36
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Berdyshev E, Goleva E, Bronova I, Bronoff AS, Hoffman BC, Ramirez-Gama MA, Garcia SL, Crumrine D, Elias PM, Cho CB, Leung DYM. Unique skin abnormality in patients with peanut allergy but no atopic dermatitis. J Allergy Clin Immunol 2020; 147:361-367.e1. [PMID: 32615171 DOI: 10.1016/j.jaci.2020.06.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 06/15/2020] [Accepted: 06/22/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND The nonlesional skin of children with atopic dermatitis (AD) with peanut allergy (PA) is associated with increased transepidermal water loss; low urocanic acid (UCA) and pyrrolidone carboxylic acid (PCA), both of which are filaggrin breakdown products; and a reduced ratio of esterified ω-hydroxy fatty acid sphingosine ceramides (EOS-CERs) to nonhydroxy fatty acid sphingosine ceramides (NS-CERs) in the skin. The skin barrier of subjects with PA without AD (AD-PA+) has not been studied. OBJECTIVE Our aim was to explore whether AD-PA+ is associated with skin barrier abnormalities. METHODS A total of 33 participants were enrolled, including 13 AD-PA+, 9 AD+PA+, and 11 nonatopic (NA) participants. RESULTS The PCA content in the stratum corneum of AD-PA+ subjects was significantly reduced versus that in NA subjects (median level, 67 vs 97 μg/mg protein [P = .028]). The ratio between cis- and trans-UCA decreased significantly from being highest in the NA group (1.62) to lowest in AD+PA+ group (0.07 [P < .001 vs in the NA group; P = .006 vs in the AD-PA+ group]), with the AD-PA+ group having an intermediate cis/trans-UCA ratio (1.17 [P = .024 vs in the NA group]). The TEWL in AD-PA+ subjects did not differ from that in the group with NA skin. Interestingly, AD-PA+ subjects had an increased EOS/NS-CER ratio versus that in the group of subjects with NA skin (1.9 vs 1.3 [P = .008]), whereas the AD+PA+ group had a decreased proportion of EOS-CERs (0.8 [P = .001] vs in the AD-PA+ group). CONCLUSION Our data demonstrate that irrespective of AD, PA is associated with decreased skin cis-UCA and PCA content. An increase in skin EOS-CER/NS-CER ratio separates the AD-PA+ group from the AD+PA+ and NA groups.
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Affiliation(s)
| | - Elena Goleva
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | - Irina Bronova
- Department of Medicine, National Jewish Health, Denver, Colo
| | | | - Bryce C Hoffman
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | | | | | - Debra Crumrine
- Department of Dermatology, VA Medical Center/University of California San Francisco, San Francisco, Calif
| | - Peter M Elias
- Department of Dermatology, VA Medical Center/University of California San Francisco, San Francisco, Calif
| | - Christine B Cho
- Department of Pediatrics, National Jewish Health, Denver, Colo; Department of Pediatrics, University of Colorado, Denver, Colo
| | - Donald Y M Leung
- Department of Pediatrics, National Jewish Health, Denver, Colo; Department of Pediatrics, University of Colorado, Denver, Colo.
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