Atopic dermatitis in adults: clinical and epidemiological considerations

Methotrexate for refractory adult atopic dermatitis leads to alterations in cutaneous IL-31 and IL-31RA expression

BACKGROUND

Methotrexate (MTX) is an alternative treatment for patients with moderate/severe atopic dermatitis (AD).

OBJECTIVE

The authors evaluated the effect of MTX on the cutaneous expression of cytokines and chemokines that are involved in the inflammatory response in adult AD patients who received treatment with methotrexate for 24 weeks.

METHODS

The authors conducted a prospective single-institution cohort study with 12 adults with moderate/severe AD who received oral MTX (15 mg/wk for 24 wks) and 10 non-atopic matched controls. The comparison was made of skin biopsies of lesional and non-lesional skin, pre- and post MTX treatment. The authors analyzed mean epidermal thickness and expression of IL-31, IL-31RA, OSMR, TSLP, Ki67, IL-4 mRNA, IL-6, IL-10, TNF-α, IFN-γ, TARC, and CCL-22.

RESULTS

There was a reduction in mean epidermal thickness (p = 0.021), an increase in IL-31RA expression (immunohistochemistry) in the epidermis (p = 0.016) and a decrease in IL-31 gene expression (p = 0.019) on lesional AD skin post-MTX treatment. No significant changes in the cutaneous expression of the other evaluated markers were identified.

STUDY LIMITATIONS

Small sample size and limited length of follow-up.

CONCLUSIONS

Treatment with MTX in adults with moderate/severe AD reduced epidermal hyperplasia and changed the cutaneous expression of inflammatory cytokines and receptors that are mainly related to pruritus, including IL-31 and IL-31RA.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03327116.

Atopic Dermatitis in Latin America: Considerations on Epidemiology, Clinical and Laboratory Features, Ethnic/Racial Variations, and Therapeutic Management

Latin America (LA) encompasses about 8.5% of the world's population, exhibits ethnic/racial heterogeneity and social inequality. We hereby present a 20-year literature review (2004-2023) on epidemiology, diagnosis, clinical and laboratory features, quality of life and management of atopic dermatitis (AD) in LA. Highest AD prevalence for children aged 6-7 years was reported in Ecuador (22.5%) and Colombia (20.9%), for adolescents in Colombia (24.6%) and for all ages, in Brazil (20.1%). Regions with a predominantly Black population in LA varied significantly, ranging from 4.4% in Northern Brazil to 10.1% in Cuba, indicating genetic variation among African subgroups. Filaggrin loss-of-function mutations showed variants seen in Europeans in 9.3% of Chilean patients and studies in Brazil revealed impaired expression of filaggrin and claudin-1 in the skin but increased expression in conjunctival epithelia of AD patients. The most reported AD features included erythema, pruritus, and dry skin, with marked lichenification. Severe pruritus was reported by 54.4% of patients and a high impact on quality of life was detected in 50% of adults with AD. In Brazilian referral hospitals, 65.6% of patients were classified as having severe AD, and 56% had one or more hospitalizations during their lifetime, indicating a need for better disease control. Diagnosing AD is challenging due to broad clinical features, ethnoracial variations and lack of universal diagnostic criteria. Furthermore, lack of physician training, barriers to medication access, and socioeconomic inequalities hinder effective disease management in LA.

Atopic Dermatitis in Latin America: A Roadmap to Address Data Collection, Knowledge Gaps, and Challenges

BACKGROUND

Atopic dermatitis (AD) is a systemic, multifactorial disease that causes significant morbidity and health care burden in Latin America (LA). Data on AD are scarce in LA. Lack of disease registries and non-standardized study methodologies, coupled with region-specific genetic, immunological, and environmental factors, hamper data collection. A panel of LA experts in AD was given a series of relevant questions to address before a conference. Each narrative was discussed and edited through numerous rounds of deliberation until achieving consensus. Identified knowledge gaps in AD research were updated prevalence, adult-disease epidemiology, local phenotypes and endotypes, severe-disease prevalence, specialist distribution, and AD public health policy. Underlying reasons for these gaps include limited funding for AD research, from epidemiology and public policy to clinical and translational studies. Regional heterogeneity requires that complex interactions between race, ethnicity, and environmental factors be further studied. Informed awareness, education, and decision making should be encouraged.

Atopic dermatitis in adults: A cross-sectional study in the department of dermatology, Antananarivo, Madagascar

Background

Although atopic dermatitis (AD) is becoming a pressing public health concern in the world, Madagascar is underrepresented in the AD literature.

Objective

We aimed to study the demographic and clinical pattern of AD in adult dermatology outpatients.

Methods

A cross-sectional study was conducted in the Department of Dermatology, University Hospital, Antananarivo, Madagascar. Patients >15 years old with a registered diagnosis of AD, from January 2010 to February 2019, were included. AD was diagnosed by a dermatologist according to Hanifin and Rajka criteria. The severity of AD was assessed using scoring atopic dermatitis (SCORAD).

Results

Forty-two cases of AD were included. The prevalence was 0.5%. The median patient age was 37 years. The age of onset of AD was before the age of 15 years in 38% of the patients and after the age of 15 years in 61.9% of the patients. There was a female preponderance (female to male ratio, 2:1), but no correlation was found between sex and the severity of AD. People living in urban areas were the most affected. According to SCORAD, 37 cases presented moderate AD and 2 cases presented severe AD.

Conclusion

The prevalence of AD in adult dermatology outpatients is still low, and moderate AD is the most frequent form, according to SCORAD.

Characterization of CD19+ CD24hi CD38hi B cells in Chinese adult patients with atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease. Human interleukin-10⁺ B cells (B10 cells) is one of regulatory B cells and is enriched in CD19⁺ CD24^hi CD38^hi B cells. A little is known about these cells in atopic dermatitis.

OBJECTIVE

To study CD19⁺ CD24^hi CD38^hi B cells and their clinical significance in Chinese adult patients with atopic dermatitis.

METHODS

Thirty-two adult patients with AD and nineteen healthy controls were enrolled. Peripheral blood mononuclear cells (PBMCs) were isolated and stained with fluorescein-conjugated monoclonal antibodies for CD19, CD24, CD27, CD38 and Annexin V. The stained PBMCs were analysed by flow cytometry. B10 cells were prepared by stimulating PBMCs with CpG, LPS and CD40L followed by restimulation with phorbol12-myristate 13-acetate (PMA) and ionomycin. Serum IL-10, B-cell-activating factor (BAFF) and a proliferation-inducing ligand (APRIL) levels were measured by using the ELISA. Apoptosis and proliferation of CD19⁺ CD24^hi CD38^hi B cells were measured by flow cytometry. 4/P-signal transducer and activator of transcription 3 (STAT3) and extracellular signal-regulated kinase 1/2 (Erk) phosphorylation were also studied.

RESULTS

The number of CD19⁺ CD24^hi CD38^hi B cells in patients with AD was similar to that in healthy controls. However, B10 cells were decreased in patients with AD. The proportion of B10 cells was negatively associated with blood basophil counts but not associated with disease activity. CD19⁺ CD24^hi CD38^hi B cells from AD patients were more susceptible to apoptosis upon stimulation with CpG, LPS and CD40L. B cells from AD patients showed lower STAT3 and Erk phosphorylation.

CONCLUSIONS

CD19⁺ CD24^hi CD38^hi B cells were unchanged in atopic dermatitis while B10 cells were decreased. The increased B-cell apoptosis, decreased STAT3 and Erk phosphorylation might contribute to these changes.

Investigation of oral atopic diseases: Correlation between geographic tongue and fungiform papillary glossitis

INTRODUCTION

The correlation between oral lesions and atopy is not new, but few studies have investigated the prevalence of mucosal changes in diseases within the atopic spectrum, leading to conflicting data. Some studies found a possible relationship between geographic tongue, transient lingual papillitis and atopic diseases.

AIM

To investigate the frequency of geographic tongue and fungiform papillary glossitis in patients with atopic diseases, and its correlation with serum IgE levels and skin test results.

MATERIAL AND METHODS

The sample was comprised of participants with atopic diseases paired with participants who received negative puncture skin tests. All were submitted to stomatological and medical evaluations, prick test and oral cytopathological.

RESULTS

The female sex was more numerous in both groups. Mean age was 21 years. A total of 60 diagnoses of atopic diseases were obtained, with allergic rhinitis being the most prevalent. Fungiform papillary glossitis was the most frequent oral lesion in both groups, while geographic tongue was present in 2 cases (2%) in the test group and 2 (2%) in the control group. Atopic patients with fungiform papillary glossitis presented high serum IgE levels. In atopic patients with geographic tongue, the prick test positively identified extracts of Dermatophagoides pteronyssinus (100%) and Dermatophagoides farinae (100%).

CONCLUSION

Due to the low frequency of geographic tongue lesions found in the study, it is no possible to conclude if that could be an oral manifestation of atopy. However fungiform papillary glossitis is a common alteration in atopic and non-atopic patients and has a relationship with high IgE serum levels. However, the consolidation of this result requires a larger sample size.

Optimizing a clinical guidance for diagnosis of atopic dermatitis in adults: joint recommendations of the Italian Society of Dermatology and Venereology (SIDeMaST), Italian Association of Hospital Dermatologists (ADOI), and Italian Society of Allergological, Occupational and Environmental Dermatology (SIDAPA)

Atopic dermatitis (AD) places significant burden not only on quality of life, but is also associated with considerable costs to healthcare systems. Diagnosis of AD may be challenging when it starts in adolescence or adulthood, and is further complicated as its manifestations are different from those generally seen in children. Accordingly, better definition of diagnostic criteria for adult onset AD is needed to avoid misdiagnosis and undertreatment in adult patients. To provide practical guidance for clinicians to reliably diagnose AD in adult patients, representatives from three Italian dermatology scientific societies (Italian Society of Dermatology and Venereology [SIDeMaST], Italian Association of Hospital Dermatologists [ADOI], Italian Society of Allergological, Occupational and Environmental Dermatology [SIDAPA]) carried out a joint consensus meeting to develop useful indications for improving diagnosis of moderate to severe AD in adult patients in routine clinical practice. The most representative criteria for morphological criteria, localization, clinical history, and differential diagnosis were identified by the experts. The most frequent clinical presentations are those on the flexural areas, hands, face/neck, and trunk, with itch and eczema as key manifestations. The diagnostic path defined herein can form a sort of "check list" for physicians to adopt when evaluating patients with suspected AD, which can help in refining a diagnosis and refer the patient for specialist dermatological care. It is hoped that the practical guidance developed by the consensus group will help to improve outcomes, lower overall costs of care, and ameliorate the patient's quality of life, even though validation in a large cohort of patients is still needed.

Determinants of disease severity among patients with atopic dermatitis: association with components of the atopic march

We aimed to explore the association of key clinical characteristics with disease severity in atopic dermatitis (AD) and its relation to components of the atopic march in a large hospital cohort. Outpatients with AD referred to the Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark, between January 2012 and December 2017, were compared based on disease severity (SCORAD); mild (< 25), moderate (25-50) and severe (> 50). A total of 470 AD patients were included: 122 small children (< 4 years of age), 103 children/adolescents (age 4-15 years) and 245 adults (> 15 years of age). A significant difference between severity groups in small children was observed for FLG mutation carrier status (16.7 vs. 30.2 vs. 60.0% mutation carriers among patients with mild, moderate and severe AD, respectively, p = 0.012) and self-rated health (3.2 vs. 2.7 vs. 2.8 with 4 being excellent health, p = 0.022). A significant difference between severity groups in adults was observed for male sex (24.4 vs. 39.8 vs. 52.9%, p = 0.003), serum total IgE (577 vs. 1269 vs. 2379 × 10³ IU/L, p < 0.001), blood eosinophil count (0.28 vs. 0.39 vs. 0.61 × 10⁹/L, p < 0.001) and asthma (42.9 vs. 38.8 vs. 72.0%, p < 0.001). Early onset of AD (< 1 year of age) and FLG mutation was associated with more severe disease and high serum total IgE levels. In conclusion, the distribution of key clinical characteristics varies significantly according to the severity of AD measured by SCORAD. Sub-typing of AD patients related to determinants of disease severity may be helpful in establishing prognosis and targeted treatment of AD.

Clinical Diversity of Atopic Dermatitis: A Review of 5,000 Patients at a Single Institute

PURPOSE

Atopic dermatitis (AD) is a chronic eczematous dermatitis that has a high prevalence and diverse clinical features. Although several hypotheses about its multifactorial pathogenesis have been suggested, the cause is not yet fully understood. A better understanding of the clinical features may helpful inelucidating the pathogenesis of AD.

METHODS

This retrospective study analyzed the questionnaires, medical charts, and laboratory examination results of 5,000 patients diagnosed with AD at a single tertiary hospital in Korea.

RESULTS

The demographics, allergic comorbidities, family history, severity, and treatment experiences of the patients were analyzed. Most of the patients were adults, 76.3% of whom were classified as havingan extrinsic type of AD. The mean eczema area and severity index (EASI) score was found to be 13.68, and adult patients were found to have higher severity than the other age groups. The anatomical involvements were different among the age groups, with more involvements of the head and neck in adults. The patients reported seasonal changes and stress as the factors that aggravated their symptoms the most. Topical steroids and oral cyclosporine were the most used medications at our clinic, whereas 10.1% of the patients underwent allergen-specific immunotherapy.

CONCLUSIONS

This analysis of 5,000 patients would lead to a better understanding of various subtypes and diverse clinical features of AD in Koreans. Distinct characteristics were observed among different age groups; thus, treatment strategies may need to be differentiated accordingly.

Association of Perceived Stress with Atopic Dermatitis in Adults: A Population-Based Study in Korea

Atopic dermatitis (AD) is a widely prevalent skin disease that affects both children and adults. The aim of the study was to assess the association of perceived stress (single-item, self-reported) with AD (self-reported) in a sample of Korean adults using a cross-sectional research design. A cross-sectional study was conducted using data from 33,018 adults aged 20 years and older collected in the 2007-2012 Korea National Health and Nutrition Examination Surveys (KNHANES). An increased level of self-reported stress was positively associated with an increased prevalence of AD in Korean adults (p for trend <0.001). After adjusting for covariates, the odds ratios (ORs) of AD among participants reporting high and very high levels of stress were 1.81 (95% confidence interval (CI): 1.22, 2.67) and 2.17 (95% CI: 1.38, 3.42), respectively, compared with those who reported low levels of stress. This study found a statistically significant association between perceived stress and AD among Korean adults.

Prevalence of rhinitis among 6 and 7-year old students in Fortaleza

OBJECTIVE

to evaluate the prevalence of rhinitis symptoms among 6 and 7-year old schoolchildren in Fortaleza, Brazil.

METHODS

a cross-sectional study using the rhinitis module of the ISAAC (International Study of Asthma and Allergies in Childhood) questionnaire. The sample included 2,020 students from public and private schools, in 2010.

RESULTS

the prevalence of cumulative rhinitis, active rhinitis, allergic rhinoconjunctivitis and physician-diagnosed rhinitis was 49.9%, 42%, 15.4% and 28.1%, respectively, being significantly more prevalent among private school students (OR = 0.55, 95CI: 0.46 - 0.66, p < 0.001; OR = 0.50, 95CI: 0.41 - 0.60, p < 0.001; OR = 0.67, 95CI: 0.52 - 0.85, p < 0.001; OR = 0.15, 95CI: 0.12 - 0.19, p < 0.001, respectively), without differences between genders. Interference with daily activities was reported by 25.3%, while 5.7% reported to be moderately or severely affected, without a difference between genders.

CONCLUSION

the prevalence of rhinitis symptoms and associated morbidity among 6-7-year old schoolchildren in Fortaleza was above the Brazilian average, with predominance among private school students, without difference between genders. It was observed that rhinitis was underdiagnosed in this population.

Profile of skin barrier proteins (filaggrin, claudins 1 and 4) and Th1/Th2/Th17 cytokines in adults with atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) in adults and profile of skin barrier proteins and inflammatory cytokines.

OBJECTIVE

Evaluation of the expression of skin barrier proteins such as filaggrin, claudins 1 and 4 and of circulating inflammatory cytokines (Th1/Th2/Th17) in adults with AD.

METHODS

Thirty-three adult patients with AD diagnosed according to the Hanifin & Rajkacriteria, and 25 healthy controls were enrolled in the study. AD severity was measured by Eczema Area and Severity Index (EASI). Laboratory assays included immunohistochemistry analysis of skin barrier proteins, such as filaggrin, claudins 1 and 4 and interleukin-17 (IL-17) from skin samples and determination of circulating cytokine levels (IL-2, 4, 5, 6, 10, 17A, TNF and IFN-γ) by flow cytometry (Cytometric Bead Array).

RESULTS

We observed a reduced expression of filaggrin and claudin 1 in lesional skin of AD patients, when compared to controls. There was an inverse correlation of filaggrin expression and disease severity. In addition, IL-17 expression was enhanced in AD patients. Similarly, higher levels of inflammatory cytokines (IL-2, 5, 6, 10, 17A and IFN-γ) were found in AD patients.

CONCLUSION

Our data reinforce the role of an altered skin barrier in the pathogenesis of AD. Our results show not only reduced expression of filaggrin and claudin 1 in lesional atopic skin but also inverse correlation of filaggrin expression and disease severity. Moreover, elevation of in situ IL-17 and of circulating interleukin levels in AD emphasize the systemic, inflammatory profile of this defective skin barrier dermatosis.