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Influence of climate factors on pediatric alopecia areata flares in Philadelphia, Pennsylvania. Sci Rep 2021; 11:21034. [PMID: 34702837 PMCID: PMC8548540 DOI: 10.1038/s41598-021-00433-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 09/15/2021] [Indexed: 11/13/2022] Open
Abstract
Patients with alopecia areata (AA) may experience episodic disease flares characterized by increasing hair loss that follow a seasonal pattern. However, no studies have examined whether specific climate factors contribute to the seasonal pattern of AA flares. Using Spearman rank correlation analyses, we assessed the association between climate variables and AA flare frequency per month in 336 children with AA in Philadelphia, Pennsylvania. Region-specific monthly values for average ambient temperature, air pressure, cloudiness, hours of sunlight, relative humidity, number of days with sun, number of days with rain, volume of precipitation, wind gust, wind speed, and UV index from January 2015 to December 2017 were obtained from World Weather Online. We found significant (P < 0.05) correlations between AA flare frequency and UV index (R = − 0.66), precipitation (R = − 0.66), number of days with rain (R = − 0.70), number of days with sun (R = 0.62), and air pressure (R = 0.80). Stratified analyses showed even stronger associations with UV index and precipitation in patients with an atopic comorbidity. New significant correlations appeared with temperature, wind speed, and UV index of the prior month. However, in patients who did not have atopic comorbidities, we generally observed weaker and non-significant correlations between climate and AA flare frequency. This study suggests that certain climate factors may mediate the seasonal pattern of AA flares and may contribute to AA pathogenesis. Atopic AA patients may be more susceptible to the influence of climate compared to those with no history of atopy.
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Shi H, Wan G, Wang T, Zhu J, Jiang L, Ma S, Yao J, Yin Z, Maimaiti M, Dong H. Prevalence and influencing risk factors of eczema among preschool children in Urumqi city: a cross-sectional survey. BMC Pediatr 2021; 21:347. [PMID: 34399722 PMCID: PMC8365957 DOI: 10.1186/s12887-021-02819-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 07/22/2021] [Indexed: 12/17/2022] Open
Abstract
Background Eczema is a chronic inflammatory disease associated with impaired quality of life. We identified indoor environmental risk factors, to provide strong evidence for the prevention and control of eczema in preschool children. Methods Using a cross-sectional study with stratified random cluster sampling, we conducted a self-administered questionnaire survey among 8153 parents of children aged 2–8 years in 60 kindergartens in six districts of Urumqi city during August 2019. Results Among 8153 preschool children, 12.0% of the children have been diagnosed with eczema. Multivariate logistic regression analysis showed that caesarean section (odds ratio [OR] = 1.18, 95% confidence interval [CI]: 1.03–1.36), being an only child (OR = 1.36, 95% CI: 1.18–1.57), presence of mould or moisture in the mother’s home before pregnancy (OR = 1.53, 95% CI: 1.17–2.00), presence of flies or mosquitoes in the dwelling currently (OR = 1.31, 95% CI: 1.10–1.55), pets kept in the child’s home currently (OR = 1.23, 95% CI: 1.01–1.51), presence of pets during child’s first year (OR = 1.45, 95% CI: 1.14–1.85), and family history of eczema (OR = 3.53, 95% CI: 2.98–4.19) are the risk factors for the development of eczema, whereas ethnicity other than the Han Chinese (OR = 0.77, 95% CI: 0.61–0.96) is a protective factor for eczema. Conclusion Preschool children in Urumqi are at a high risk of eczema, particularly those of the Han Chinese ethnicity. Parents should be attentive to the indoor living environment of children and take actions to reduce indoor humidity, pest control and elimination, and avoid raising pets to reduce the risk of development of eczema in children. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02819-5.
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Affiliation(s)
- Haonan Shi
- School of Public Health, Xinjiang Medical University, Urumqi, 830011, China
| | - Guangsheng Wan
- School of Nursing & Health Management, Shanghai University of Medicine & Health Sciences, No.279, Zhouzhu Highway, Pudong New District, Shanghai, 201318, China
| | - Tingting Wang
- School of Nursing & Health Management, Shanghai University of Medicine & Health Sciences, No.279, Zhouzhu Highway, Pudong New District, Shanghai, 201318, China.
| | - Jia Zhu
- Cadre Health Center, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, 830001, China
| | - Lan Jiang
- Department of Laboratory Medicine, Xinjiang Uyghur Autonomous Region Maternal and Child Health Hospital, Urumqi, 830002, China
| | - Shaowei Ma
- School of Public Health, Xinjiang Medical University, Urumqi, 830011, China
| | - Jian Yao
- School of Public Health, Xinjiang Medical University, Urumqi, 830011, China
| | - Zhe Yin
- School of Public Health, Xinjiang Medical University, Urumqi, 830011, China
| | - Murizhati Maimaiti
- School of Public Health, Xinjiang Medical University, Urumqi, 830011, China
| | - Huijuan Dong
- School of Public Health, Xinjiang Medical University, Urumqi, 830011, China
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Stefanovic N, Irvine AD, Flohr C. The Role of the Environment and Exposome in Atopic Dermatitis. CURRENT TREATMENT OPTIONS IN ALLERGY 2021; 8:222-241. [PMID: 34055570 PMCID: PMC8139547 DOI: 10.1007/s40521-021-00289-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW Atopic dermatitis (AD) is a chronic inflammatory skin disorder affecting up to 20% of children and up to 5% of adults worldwide, contributing to significant disease-related morbidity in this patient cohort. Its aetiopathogenesis is underpinned by multiple factors, including genetic susceptibility, skin barrier defects, a skewed cutaneous immune response and microbiome perturbation in both the skin and the gut. In this review, we aim to examine the biological effects of key environmental exposures (the sum of which is termed the "exposome") at the population, community and individual levels in order to describe their effect on AD pathogenesis. RECENT FINDINGS It is now understood that as well as considering the type of environmental exposure with regard to its effect on AD pathogenesis, the dosage and timing of the exposure are both critical domains that may lead to either exacerbation or amelioration of disease. In this review, we consider the effects of population-wide exposures such as climate change, migration and urbanization; community-specific exposures such as air pollution, water hardness and allergic sensitisation; and individual factors such as diet, microbiome alteration, psychosocial stress and the impact of topical and systemic therapy. SUMMARY This review summarises the interaction of the above environmental factors with the other domains of AD pathogenesis, namely, the inherent genetic defects, the skin barrier, the immune system and the cutaneous and gut microbiota. We specifically emphasise the timing and dosage of exposures and its effect on the cellular and molecular pathways implicated in AD.
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Affiliation(s)
| | - Alan D. Irvine
- Department of Paediatric Dermatology, Children’s Health Ireland at Crumlin, Dublin, Ireland
- National Children’s Research Centre, Crumlin and Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - 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, UK
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Piquero-Casals J, Carrascosa JM, Morgado-Carrasco D, Narda M, Trullas C, Granger C, Fabbrocini G. The Role of Photoprotection in Optimizing the Treatment of Atopic Dermatitis. Dermatol Ther (Heidelb) 2021; 11:315-325. [PMID: 33582977 PMCID: PMC8019014 DOI: 10.1007/s13555-021-00495-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 01/23/2021] [Indexed: 01/31/2023] Open
Abstract
Atopic dermatitis (AD) is a chronic inflammatory skin disease with an estimated prevalence of 10-15% in children and 2-10% in adults. Clinically, there is notable phenotypic variability driven by a complex interaction between genetics, immune function, and the environment. Impairment of the skin barrier plays a significant role in the pathogenesis of AD. The apparent beneficial effect of sunlight in patients with atopic eczema is questioned due to its capacity to disrupt the skin barrier and generate free radicals that can damage proteins, lipids, and DNA. The sum of the external factors that an individual is exposed to throughout their lifetime is termed the exposome. Environmental factors such as sun exposure, temperature, and humidity contribute to both AD flares and regional prevalence variation. Literature on photoprotection in atopic dermatitis is very scarce. The use of adequate sunscreens in atopic dermatitis can ensure the level of photoprotection required to prevent skin photoaging and skin cancer and to mitigate skin barrier dysfunction, decrease inflammation, and neutralize facial redness. Herein we discuss and review the role of UV radiation and the exposome in the etiology of AD, as well as the role of adequate photoprotection.
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Affiliation(s)
| | - José Manuel Carrascosa
- Department of Dermatology, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma of Barcelona, IGTP, Badalona, Spain
| | - Daniel Morgado-Carrasco
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | | | | | | | - Gabriella Fabbrocini
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Napoli, Italy
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de Lusignan S, Alexander H, Broderick C, Dennis J, McGovern A, Feeney C, Flohr C. The epidemiology of eczema in children and adults in England: A population-based study using primary care data. Clin Exp Allergy 2021; 51:471-482. [PMID: 33179341 PMCID: PMC7984097 DOI: 10.1111/cea.13784] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/12/2020] [Accepted: 11/04/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Whilst eczema is a common inflammatory skin condition, we lack contemporary estimates of disease incidence and prevalence across the lifespan. OBJECTIVE To estimate the incidence and prevalence of eczema in children and adults in England and variation by sociodemographic factors (sex, socio-economic status, ethnicity, and geography). METHODS We used the Royal College of General Practitioners Research and Surveillance Centre primary care research database of 3.85 million children and adults registered with participating general practitioner practices between 2009 and 2018 inclusive. Eczema incidence was defined as the first-ever diagnosis of eczema recorded in the primary care record, and eczema prevalence was defined as fulfilment of criteria for active eczema (two eczema records appearing in the primary care record within any one-year period). RESULTS Eczema incidence was highest in infants younger than 1 year (15.0 per 100 person-years), lowest in adults aged 40-49 (0.35 p/100 person-years), and increased from middle age to a second smaller peak in people 80 years or older (0.79 p/100 person-years). Eczema prevalence was highest in children aged 2 (16.5%) and lowest in adults aged 30-39 (2.8%). Eczema incidence was higher in male infants (<2) and male adults older than 70; for all other ages, incidence was higher in females. Eczema was more common in Asian and black ethnic groups than in people of white ethnicity. Higher socio-economic status was associated with a greater incidence of eczema in infants younger than 2, but the reverse was seen for all other age groups. Both incidence and prevalence of eczema were greater in urban settings and in North-West England. CONCLUSIONS AND CLINICAL RELEVANCE Eczema has a bimodal distribution across the lifespan. We observed differences in incidence and prevalence of eczema by ethnicity, geography, sex, and socio-economic status, which varied in magnitude throughout life.
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Affiliation(s)
- Simon de Lusignan
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
- Royal College of General Practitioners Research and Surveillance CentreLondonUK
| | - Helen Alexander
- Unit for Population‐Based Dermatology Research, St John's Institute of Dermatology, Guy's & Thomas' NHS Foundation Trust and King's College LondonLondonUK
| | - Conor Broderick
- Unit for Population‐Based Dermatology Research, St John's Institute of Dermatology, Guy's & Thomas' NHS Foundation Trust and King's College LondonLondonUK
| | | | | | | | - Carsten Flohr
- Unit for Population‐Based Dermatology Research, St John's Institute of Dermatology, Guy's & Thomas' NHS Foundation Trust and King's College LondonLondonUK
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The Role of Environmental Exposures in Atopic Dermatitis. Curr Allergy Asthma Rep 2020; 20:74. [PMID: 33047271 DOI: 10.1007/s11882-020-00971-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Although genetic factors clearly play a role in the development of atopic dermatitis (AD), the recent dramatic increase in the prevalence of AD in low- and middle-income countries is not consistent with only a role of genetic factors. These findings strongly suggest that environmental factors may play an important role in the pathogenesis of AD. RECENT FINDINGS We reviewed the role of gene-environment studies; in utero exposures including tobacco smoke, alcohol, maternal stress, various digestive supplements, and gestational diabetes; early-life exposures including diet, gut microbiota, antibiotics, and breastfeeding; climate including temperature, ultraviolet radiation exposure, and air pollution; and household products, indoor allergens, water hardness, pH, and skin microbiota and their effects on AD. Environmental factors definitely play a role in the pathogenesis of AD. However, identifying definitive factors continues to be difficult in the setting of conflicting evidence and the complex interactions between genotypes and the environment resulting in a multitude of AD phenotypes. All of the different environmental interactions discussed highlight the importance of intervening on multiple levels in a patient's environment to improve or even prevent AD symptoms. Further, the importance of modifying environmental factors early on in a person's life is demonstrated. When possible, all of these environmental factors should be considered in treating a patient with AD and the appropriate modifications should be made at population and individual levels.
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Stefanovic N, Flohr C, Irvine AD. The exposome in atopic dermatitis. Allergy 2020; 75:63-74. [PMID: 31194890 PMCID: PMC7003958 DOI: 10.1111/all.13946] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 05/27/2019] [Accepted: 06/05/2019] [Indexed: 12/14/2022]
Abstract
Atopic dermatitis (AD) is a complex inflammatory disorder with multiple interactions between genetic, immune and external factors. The sum of external factors that an individual is exposed to throughout their lifetime is termed the exposome. The exposome spans multiple domains from population to molecular levels and, in combination with genetic factors, holds the key to understanding the phenotypic diversity seen in AD patients. Exposomal domains are categorized into nonspecific (human and natural factors affecting populations), specific (eg humidity, ultraviolet radiation, diet, pollution, allergens, water hardness) and internal (cutaneous and gut microbiota and host cell interaction) exposures. The skin, as the organ that most directly interacts with and adapts to the external environment, is a prime target for exploration of exposomal influences on disease. Given the well-recognized physical environmental influences on AD, this condition could be much better understood through insightful exposomal research. In this narrative review, we examine each domain in turn, highlighting current understanding of the mechanisms by which exposomal influences modulate AD pathogenesis at distinct points in time. We highlight current approaches to exposome modification in AD and other allergic disease and propose future directions for exposome characterization and modification using novel research techniques.
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Affiliation(s)
| | - Carsten Flohr
- Unit for Population‐Based Dermatology Research, St John's Institute of DermatologyGuy's & St Thomas’ NHS Foundation Trust and King's College LondonLondonUK
| | - Alan D. Irvine
- Department of Paediatric DermatologyOur Lady’s Children’s Hospital CrumlinDublinIreland
- National Children’s Research Centre, Crumlin and Clinical MedicineTrinity College DublinDublinIreland
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Calov M, Alinaghi F, Hamann CR, Silverberg J, Egeberg A, Thyssen JP. The Association Between Season of Birth and Atopic Dermatitis in the Northern Hemisphere: A Systematic Review and Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:674-680.e5. [PMID: 31678290 DOI: 10.1016/j.jaip.2019.10.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/08/2019] [Accepted: 10/10/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Cold and dry climate negatively affects skin barrier functions. This could explain the higher incidence of atopic dermatitis (AD) in Northern countries distant from the equator, as well as the general worsening of AD in Northern European winter months. Although it has been suggested that fall and winter birth is associated with AD, this remains unknown. OBJECTIVES To examine whether the prevalence of AD is associated with season of birth. METHODS We conducted a systematic review and meta-analysis. Two reviewers independently searched 3 databases. Study quality was assessed using a Newcastle-Ottawa scale. Study heterogeneity was assessed with Cochrane Q and I2 statistics. Odds ratios with 95% CIs were calculated. Publication bias was assessed using funnel plots. RESULTS The systematic review identified 23 relevant articles of which 9 articles were included in the meta-analysis. Among a total of 726,378 children aged 0 to 12 years, the overall pooled prevalence of AD was 12.9%. The pooled prevalence of AD was 15.4% (95% CI, 12.1%-19.1%), 14.9% (95% CI, 12.0%-18.1%), 12.7% (95% CI, 10.2%-15.4%), and 13.7% (95% CI, 10.8%-17.0%), among children born in the fall, winter, spring, and summer, respectively. AD was significantly associated with fall (odds ratio, 1.16; 95% CI, 1.06-1.28; P = .0018) and winter (odds ratio, 1.15; 95% CI, 1.04-1.27; P = .0076) birth compared with spring birth. CONCLUSIONS Although a positive and significant association was observed between being born in fall and winter and developing AD on the Northern hemisphere, there is a need for additional and better-designed studies to understand the effect of seasonal changes on the risk of AD.
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Affiliation(s)
- Monika Calov
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark; Copenhagen Research Group for Inflammatory Skin (CORGIS), Hellerup, Denmark
| | - Farzad Alinaghi
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark; Copenhagen Research Group for Inflammatory Skin (CORGIS), Hellerup, Denmark
| | - Carsten Robert Hamann
- Copenhagen Research Group for Inflammatory Skin (CORGIS), Hellerup, Denmark; Section of Dermatology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jonathan Silverberg
- Departments of Dermatology, Preventive Medicine and Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Alexander Egeberg
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark; Copenhagen Research Group for Inflammatory Skin (CORGIS), Hellerup, Denmark
| | - Jacob Pontoppidan Thyssen
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark; Copenhagen Research Group for Inflammatory Skin (CORGIS), Hellerup, Denmark.
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Tsakok T, Woolf R, Smith CH, Weidinger S, Flohr C. Atopic dermatitis: the skin barrier and beyond. Br J Dermatol 2018; 180:464-474. [PMID: 29969827 DOI: 10.1111/bjd.16934] [Citation(s) in RCA: 150] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Atopic dermatitis is the most common chronic inflammatory skin disorder, affecting up to 20% of children and 10% of adults in industrialized countries. This highly debilitating condition poses a considerable burden to both the individual and society at large. The pathophysiology of atopic dermatitis is complex, encompassing both genetic and environmental risk factors. METHODS This is a narrative review based on a systematic literature search. CONCLUSIONS Dysregulation of innate and adaptive immunity plays a key role; however, recent epidemiological, genetic and molecular research has focused interest on skin barrier dysfunction as a common precursor and pathological feature. Current understanding of the aetiology of atopic dermatitis highlights disruption of the epidermal barrier leading to increased permeability of the epidermis, pathological inflammation in the skin, and percutaneous sensitization to allergens. Thus, most novel treatment strategies seek to target specific aspects of the skin barrier or cutaneous inflammation. Several studies have also shown promise in preventing atopic dermatitis, such as the early use of emollients in high-risk infants. This may have broader implications in terms of halting the progression to atopic comorbidities including food allergy, hay fever and asthma.
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Affiliation(s)
- T Tsakok
- St John's Institute of Dermatology, King's College London, London, U.K
| | - R Woolf
- St John's Institute of Dermatology, King's College London, London, U.K
| | - C H Smith
- St John's Institute of Dermatology, King's College London, London, U.K
| | - S Weidinger
- Department of Dermatology and Allergy, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - C Flohr
- St John's Institute of Dermatology, King's College London, London, U.K
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Hamann C, Andersen Y, Engebretsen K, Skov L, Silverberg J, Egeberg A, Thyssen J. The effects of season and weather on healthcare utilization among patients with atopic dermatitis. J Eur Acad Dermatol Venereol 2018; 32:1745-1753. [DOI: 10.1111/jdv.15023] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 03/05/2018] [Indexed: 12/17/2022]
Affiliation(s)
- C.R. Hamann
- Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
- Copenhagen Research Group for Inflammatory Skin (CORGIS); Herlev and Gentofte Hospital; Hellerup Denmark
- School of Health and Medical Science; Graduate Programme in Public Health and Epidemiology; University of Copenhagen; Copenhagen Denmark
| | - Y.M.F. Andersen
- Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
- Copenhagen Research Group for Inflammatory Skin (CORGIS); Herlev and Gentofte Hospital; Hellerup Denmark
- School of Health and Medical Science; Graduate Programme in Public Health and Epidemiology; University of Copenhagen; Copenhagen Denmark
| | - K.A. Engebretsen
- Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
- Copenhagen Research Group for Inflammatory Skin (CORGIS); Herlev and Gentofte Hospital; Hellerup Denmark
- National Allergy Research Centre; Herlev and Gentofte Hospital; Hellerup Denmark
| | - L. Skov
- Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
- Copenhagen Research Group for Inflammatory Skin (CORGIS); Herlev and Gentofte Hospital; Hellerup Denmark
- National Allergy Research Centre; Herlev and Gentofte Hospital; Hellerup Denmark
| | - J.I. Silverberg
- Departments of Dermatology, Preventive Medicine, and Medical Social Sciences; Feinberg School of Medicine; Northwestern University; Chicago IL USA
| | - A. Egeberg
- Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
- Copenhagen Research Group for Inflammatory Skin (CORGIS); Herlev and Gentofte Hospital; Hellerup Denmark
| | - J.P. Thyssen
- Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
- Copenhagen Research Group for Inflammatory Skin (CORGIS); Herlev and Gentofte Hospital; Hellerup Denmark
- National Allergy Research Centre; Herlev and Gentofte Hospital; Hellerup Denmark
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