Atopic dermatitis: an update

Antihistamines in the Treatment of Atopic Dermatitis

Background:

Atopic dermatitis (AD) is an inflammatory skin disorder that is exceedingly challenging to treat. A prominent feature of AD is chronic pruritus. Early evidence suggested that pruritus in AD was partially due to mast cell release of histamine. Conversely, recent studies do not validate the role of histamine in the pathogenesis of pruritus. Conventional management continues to include the wide use of antihistamines to treat the persistent itch, however, there is an urgent need for therapy which will reduce the severity of pruritus for these patients.

Objective:

To review the evidence in the literature for the use of antihistamines in the treatment of atopic dermatitis.

Methods:

A MEDLINE search (1966–2002) was performed to obtain studies examining the use of antihistamines in the treatment of atopic dermatitis. Search terms included: atopic dermatitis; eczema; antihistamines; azatadine; brompheniramine; cetirizine; chlorpheniramine; clemastine; cyclizine; cyproheptadine; desloratadine; diphenhydramine; fexofenadine; hydroxyzine; loratadine; meclizine; promethazine; trimeprazine. Further references were gathered from these publications.

Results:

Historically, antihistamines have been used in the treatment of AD. However, this review shows that the evidence for its use is inconclusive. At present, several antihistamines continue to provide relief of pruritus by central sedation, and they can also be used therapeutically for concomitant allergic conditions associated with AD. More clinical trials examining the therapeutic efficacy of antihistamines, especially with the newer nonsedating antihistamines, are necessary to elucidate their role in the treatment of AD.

Conclusion:

Dermatologists require additional evidence regarding the efficacy of antihistamines and their mechanism of action in the treatment of AD to enhance patient care.

Risk of developing major depressive disorder and anxiety disorders among adolescents and adults with atopic dermatitis: a nationwide longitudinal study

BACKGROUND

Previous cross-sectional studies have suggested a comorbid association between atopic dermatitis (AD) and depressive disorder as well as anxiety disorders, but the temporal relationship was not determined.

METHODS

Using the Taiwan National Health Insurance Research Database, 8208 AD patients aged 12 and older without psychiatric history and age-/sex-matched (1:1) controls between 1998 and 2008 were enrolled in our study and followed to the end of 2011. Subjects who developed major depression, any depressive disorder, and anxiety disorders during the follow-up were identified.

RESULTS

The Cox regression analysis after adjusting for demographic data and atopic comorbidities demonstrated that patients with AD had an elevated risk of developing major depression (hazard ratio [HR]: 6.56, 95% confidence interval [CI]: 3.64-11.84), any depressive disorder (HR: 5.44, 95% CI: 3.99-7.44), and anxiety disorders (HR: 3.57, 95% CI: 2.55-4.98). Stratified by age group, both adolescents and adults with AD were prone to developing major depression (HR: 4.26, 95% CI: 1.39-13.13; HR: 7.56, 95% CI: 3.75-15.23), any depressive disorder (HR: 4.38, 95% CI: 2.09-9.18; HR: 5.66, 95% CI: 4.01-7.99), and anxiety disorders (HR: 5.40, 95% CI: 2.02-14.39; HR: 3.36, 95% CI: 2.38-4.80).

CONCLUSIONS

AD in both adolescence and adulthood increased the risk of developing major depression, any depressive disorder, and anxiety disorders in later life. Further studies would be required to clarify the possible underlying mechanism between AD and depression as well as anxiety disorders.

Dermatosis neglecta in schizophrenia: a rare case report

Dermatosis neglecta is a chronic, dermatologic disorder results in ignored, neglected body parts due to chronic disability or painful conditions. There is scarcity of literature supporting the existence of dermatosis neglecta in the context of psychiatric illnesses. In this case report, we attempts to highlight, dermatosis neglecta in a homeless patient suffering from schizophrenia.

Colonization by S. aureus increases the EASI and the number of appointments by patients with atopic dermatitis: cohort with 93 patients

BACKGROUND

Atopic dermatitis leads to epidermal barrier dysfunction and bacteria colonization. The relationship of the last factor with the severity of the disease and the frequency of exacerbation is not fully known.

OBJECTIVES

Verify the severity of the atopic dermatitis and the number of appointments generated by dermatosis, comparing patients colonized with patients not colonized by S. aureus. Verify the frequency of colonization by methicillin resistant Staphylococcus aureus acquired in the community.

METHODS

Cohort study with a 12 months follow-up, in a sample of patients from Porto Alegre, RS public network. Cultures in active injuries and nasal cavities were carried out as well as methicillin sensitivity tests to S. aureus. The severity of atopic dermatitis was defined by Eczema Area and Severity Index (EASI).

RESULTS

We included 93 patients, 43% female and 56% male, 26 colonized by S. aureus in the nasal orifices, 56 in the skin damage. The mean of initial Eczema Area and Severity Index was 5.5 and final 3.9. The initial Eczema Area and Severity Index of patients colonized by S. aureus in the skin and nasal cavity was larger than the number of patients without colonization(p< 0.05). During the period of one year, in average, there were six appointments/patient. There was linear correlation between the number of appointments during one year and the inicial Eczema Area and Severity Index (r = 0,78). There were no patients with methicillin resistant Staphylococcus aureus acquired in the community.

CONCLUSION

There is a relevant influence of staphylococcal colonization on the severity of atopic dermatitis and the number of appointments required by its exacerbation. Methicillin resistance among those affected by S. aureus does not seem to be an emergent problem, in this Brazilian sample.

Prevalence of community-acquired methicillin-resistant Staphylococcus aureus and antibiotic resistance in patients with atopic dermatitis in Porto Alegre, Brazil

BACKGROUND

Atopic dermatitis (AD) is a skin manifestation of atopy caused by hyperreactivity to various antigens. Studies have shown that 60-100% of patients with this condition present with colonization by Staphylococcus aureus. Given increasing rates of antimicrobial resistance, the sensitivity to antimicrobials of S. aureus colonizing atopic patients has been investigated. Cross-sectional studies worldwide suggest that the prevalence of methicillin-resistant S. aureus infection (MRSA) in the AD population varies from 0% to 30.8%.

OBJECTIVES

The objectives of this study were to determinate the prevalence of S. aureus and MRSA in patients with AD in two dermatologic centers in Porto Alegre, Brazil.

METHODS

A total of 91 patients with AD attending two dermatologic centers in Porto Alegre were enrolled in this study from December 2009 to July 2011. Two skin swabs were taken from each patient, one from the nares and the other from a non-infected eczematous skin lesion. The swabs were sent to the laboratory, where standard procedures to isolate bacteria and identify S. aureus, antimicrobial resistance, and sensitivity patterns were carried out. The severity of AD was defined using the Eczema Area and Severity Index (EASI).

RESULTS

Of the 91 patients sampled, 67 (73.6%) patients were found to be positive for S. aureus colonization. Nasal swabs were positive in 55 (60.4%) patients, lesional swabs in 44 (48.4%) patients, and both lesional and nasal swabs were positive in 32 (35.2%) patients. Patients with positive swabs had a higher mean ± standard deviation EASI score [mean (9.1 ± 8.8)] compared with patients with negative swabs (3.9 ± 3.6) (P = 0.002). None of the 91 patients showed any evidence of MRSA infection. Overall, nearly 32% of the S. aureus isolated from nasal swabs and 36.40% of the S. aureus isolated from lesional swabs was resistant to erythromycin.

CONCLUSIONS

The results of this study confirm a high rate of S. aureus colonization in pediatric patients with AD and indicate a relevant association between colonization and high EASI score. No MRSA was found in cultures from this sample of patients in southern Brazil. Nearly one-third of isolates were identified as resistant to erythromycin, an antibiotic that is commonly used in pediatric patients.

Compensation of cATSCs-derived TGFβ1 and IL10 expressions was effectively modulated atopic dermatitis

In this study, we found an effective and novel therapeutic approach to atopic dermatitis (AD) therapy via treatment with a canine adipose tissue stem cell (cATSC) extract. We determined that the therapeutic application of cATSC-derived interleukin 10 (IL10) and transforming growth factor β1 (TGFβ1) effectively modulated the overloaded immune response after the induction of AD. In addition, we investigated the molecular role of the cATSC extract during AD treatment. Dogs with naturally occurring AD that was treated at Seoul National University Veterinary Teaching Hospital was enrolled in this study. Owner consent was obtained for privately owned dogs before enrollment. We prepared a primary fat-derived cATSC extract that contained various functional factors, including IL10 and TGFβ1, as a treatment for AD. We found that the cATSC extract significantly ameliorated the pathological symptoms of canine AD. The cATSC extract secreted the immunomodulatory cytokines IL10 and TGFβ1, which modulated the overloaded immune response after the induction of AD. Moreover, these immunomodulatory cytokines modulated AD-induced inflammation and inactivated the pathological signals IL6, INFγ, iNOS, eNOS and Nox4. Additionally, these cytokines protected against apoptotic keratinocyte degeneration. This study demonstrated the novel therapeutic efficacy of the cATSC extract during successive AD treatments, which suggests a potential therapeutic use for human AD patients.

Bacterial skin colonization and infections in patients with atopic dermatitis

Atopic Dermatitis is a chronic inflammatory skin disease that affects a large number of children and adults. The disease results from an interaction between genetic predisposition, host environment, skin barrier defects, and immunological factors. A major aggravating factor associated with Atopic Dermatitis is the presence of microorganisms on the patient's skin surface. Staphylococcus aureus and Streptococcus pyogenes, for instance, can exacerbate chronic skin inflammation. As a result, antimicrobials have often been prescribed to control the acute phase of the disease. However, increased bacterial resistance to antimicrobial agents has made it difficult for dermatologists to prescribe appropriate medication. In the presence of disseminated dermatitis with secondary infection, systemic antibiotics need to be prescribed; however, treatment should be individualized, in an attempt to find the most effective antibiotic with fewer side effects. Also, the medication should be used for as short as possible in order to minimize bacterial resistance.

Prevalence of allergic diseases in a sample of Taif citizens assessed by an original Arabic questionnaire (phase I) A pioneer study in Saudi Arabia

BACKGROUND

In recent decades, the prevalence of allergic diseases has markedly increased worldwide; however, there are still many cases which remain undiagnosed. Epidemiological studies have the potential to elucidate the prevalence and risk factors for these diseases.

OBJECTIVES

This study aimed at evaluating the capability of a new original non-translated questionnaire in Arabic language to determine the prevalence and severity of these diseases in a sample from Taif citizens. Thus, it could provide a framework as an initial step towards accomplishing the first national questionnaire-based survey study determining the actual prevalence of various allergic diseases in Saudi Arabia.

METHODS

A detailed seven-section questionnaire including 143 closed questions covering almost all of the usual and unusual symptoms of various allergic diseases, in Arabic language, was handed out to 1050 subjects, from whom 877 (83.52%) questionnaires were completed; however, 23 questionnaires were discarded as they were not accurately filled in. Thus, 854 (81.33%) were enrolled in this study.

RESULTS

Urticaria, allergic rhinitis with or without other co-morbidities, and atopic dermatitis were the most prevalent allergic morbidities, however, other allergic diseases could be diagnosed by the aid of the questionnaire. Likelihood ratio-evidenced agreement between diagnosis reached by the questionnaire and that reached by doctor occurred in 50 sample cases (p<0.0001).

CONCLUSIONS

The questionnaire proved its capability in aiding the diagnosis of various allergic morbidities. It evidenced a high prevalence of allergic diseases in Taif city. This is an important health issue which requires strategic application of primary health care facilities to achieve adequate control.

Increased transepidermal water loss and decreased ceramide content in lesional and non-lesional skin of dogs with atopic dermatitis

This study evaluated changes in transepidermal water loss (TEWL), skin hydration and intercorneal lipid content in dogs with atopic dermatitis (AD). TEWL and skin hydration were measured in the inguinal skin of 10 dogs with AD and 30 normal dogs. TEWL was significantly higher in both lesional skin (94.3 +/- 38.8 g/m(2)/h) and non-lesional skin (28.8 +/- 9.5) of dogs with AD than healthy controls (12.3 +/- 2.3) (P < 0.05). Water content in the lesional skin of dogs with AD (15.8 +/- 7.0 AU) was significantly lower than that of controls (24.2 +/- 8.8) (P < 0.05), whereas no significant differences were recognized in water content between non-lesional skin of dogs with AD and controls. To compare the lipid content between lesional and non-lesional skin of dogs with AD and controls, intercorneal lipids, extracted from the stratum corneum, were quantified by thin-layer chromatography. The relative amounts of ceramides in the lesional skin (24.4 +/- 5.6%) and non-lesional skin (25.6 +/- 3.8%) of dogs with AD were significantly lower than those in controls (31.4 +/- 6.9%) (P < 0.05). Conversely, no significant differences were recognized in the relative amounts of cholesterols and free fatty acids (FFA) between dogs with AD and controls. Moreover, there are statistical correlations between TEWL and the relative amounts of ceramides, but not those of cholesterols and FFA, in both lesional and non-lesional skin of dogs with AD. These results strongly suggest that decreased ceramide content accelerates TEWL in dogs with AD, similar to the situation seen in the corresponding human disease.

Eczema and sleep and its relationship to daytime functioning in children

Chronic childhood eczema has significant morbidity characterised by physical discomfort, emotional distress, reduced child and family quality-of-life and, of particular note, disturbed sleep characterised by frequent and prolonged arousals. Sleep disturbance affects up to 60% of children with eczema, increasing to 83% during exacerbation. Even when in clinical remission, children with eczema demonstrate more sleep disturbance than healthy children. Notably, disturbed sleep in otherwise healthy children is associated with behavioural and neurocognitive deficits. Preliminary evidence suggests that disturbed sleep in children with eczema is also associated with behavioural deficits while the impact on neuropsychological functioning remains unexplored. In conclusion, a disease which affects up to 20% of children in some countries and may produce long-term behavioural and neurocognitive deficits merits further evaluation using standardised tests of sleep, behaviour and neurocognition.

A review of allergen-specific immunotherapy in human and veterinary medicine

This article reviews allergen-specific immunotherapy in human and veterinary medicine. Current hypotheses of possible mechanisms of actions are outlined. Indications, success rates, adverse effects and factors influencing outcome of therapy are discussed in humans, dogs, cats and horses.

Familiar and environmental factors influencing atopic dermatitis in the childhood

BACKGROUND

The increase in the incidence of atopic dermatitis (AD) in developed countries has been related to familiar and environmental factors. This survey was undertaken to investigate the family background, birthweight and the home environment of children suffering from AD in order to point out the possible factors that provoke the development of the disease.

METHODS

The study uses data collected by means of self-administered questionnaires and discusses 461 cases of children (age 0-12) with active skin signs of AD. The control group comprised of 343 children (age 0-12) with no skin signs or positive lifetime history of AD. Associations between familiar and various home environmental factors and the risk of AD were calculated by means of odds ratios.

RESULTS

There were statistically significant positive associations between atopic eczema symptoms and higher birthweight, small households, wall-to-wall carpets, as well as indoor-kept pets. Day-nursery attendance, heating system and indoor smoking, however, did not significantly alter the risk of the disease.

CONCLUSIONS

Because of the limitations of a retrospective questionnaire study, further research is needed to confirm these associations and clarify whether they are causative.

Stress and Psychoneuroimmunologic Factors in Dermatology

There is clinical and experimental evidence that the brain can start, influence, and stop biologic skin events. Studies suggest that the skin, as a relevant part of the "diffuse brain," can modify the quality of perceptions and feelings. The immune and the endocrine systems seem to represent the protagonists of the modulation of those events and, in this context, psychosocial stressors and interventions can lead to global health changes of great interest for dermatologists.

Prevalence of atopic dermatitis and serum IgE values in nursery school children in Ishigaki Island, Okinawa, Japan

There have been many studies of the prevalence of atopic dermatitis (AD), but few population-based epidemiologic studies measure the prevalence in Japan among children aged 5 years and younger. We examined the prevalence of AD, serum total IgE levels and specific IgE antibodies to 10 common allergens among children in Ishigaki Island, Okinawa, Japan in 2001. We also obtained information on the predictability of the U.K. Working Party diagnostic questionnaire criteria for AD in this population. Five hundred and sixty five children aged 5 years and younger were enrolled in this study with informed consent from their parents. The questionnaire of the U.K. Working Party diagnostic criteria for AD was translated into Japanese, and the parents completed the questionnaire sheet. Physical examination and blood sampling were done for all children. Thirty-nine out of the 565 (6.9%) children were diagnosed with AD by physical examination. The total and specific IgE levels were significantly higher in the children with AD than in those without AD. High levels of total IgE were found in 33.3% of the children with AD. A specific IgE to one or more allergens was detected in 64.1% of children with AD. However, a substantial population of children without AD also had high levels of total IgE (12.7%) and a specific IgE to one or more allergens (30.2%), and the increment of total and specific IgE levels was significantly associated with age. The percentage of positive answers to the questionnaire of the U.K. Working Party diagnostic criteria for AD was significantly higher in children with AD (59.0%) than in children without AD (5.3%) (P<0.0001). Its specificity was 94.7%. The false negative rate was 41%. In conclusion, the prevalence of AD was relatively low in children in Ishigaki Island. High levels of total IgE were found in only one third of children with AD under 5 years of age. The Japanese translated form of the questionnaire of the U.K. Working Party diagnostic criteria for AD should be refined to improve its sensitivity.

Effect of immunotherapy in myelitis with atopic diathesis

OBJECTIVE

A recent nationwide survey of myelitis with atopic diathesis in Japan disclosed that the disease frequently shows a chronic persistent course. A neuropathological study of the spinal cord also revealed chronic active inflammation. Since the effects of various immunotherapies have not been studied extensively in this condition, we evaluated the efficacies of various immunotherapies in patients with myelitis with atopic diathesis.

PATIENTS AND METHODS

Forty-two treatments in 26 patients with myelitis with atopic diathesis were retrospectively analyzed. One of the following therapies was administered: (1) corticosteroids (CS) (pulse therapy followed by oral administration with gradual tapering); (2) intravenous immunoglobulin (IVIG) (400 mg/kg/day for 5 consecutive days); (3) plasma exchanges (PE); or (4) PE followed by IVIG or CS (PE+IVIG/CS). The therapeutic efficacies were evaluated by thorough neurological examination and laboratory tests including MRI, somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs).

RESULTS

Objective neurological findings improved in 89% of the PE group and 90% of the PE+IVIG/CS group, compared with only 72% of the CS and 60% of the IVIG groups. Improvement determined by laboratory tests was seen in 57% of the PE and 57% of the PE+IVIG/CS groups, compared with only 15% of the CS and none of the IVIG groups. Thus, the improvement rate determined by laboratory tests was significantly greater for therapies including PE than for those without PE (p=0.0187).

CONCLUSIONS

These data suggest that immunotherapy is effective in myelitis with atopic diathesis despite a chronic persistent course, and that PE is the most beneficial immunotherapy.

Allergen-specific immunotherapy induces Th1 shift in dogs with atopic dermatitis

Allergen-specific immunotherapy has been applied to canine atopic dermatitis. Despite the accumulated clinical evidence of its effect for atopic dogs, the basic immunologic mechanisms were not fully understood. In this study, the cytokine profile ex vivo in canine atopic dermatitis before and after allergen-specific immunotherapy was characterized using competitive reverse transcription-polymerase chain reaction (RT-PCR). Blood samples were collected from 10 dogs with atopic dermatitis and peripheral blood mononuclear cells were stimulated with house dust mite antigen. The levels of IFN-gamma and IL-4 mRNA were lower in atopic dogs compared with non-atopic controls. The ratio of IFN-gamma/IL-4 was low in atopic dogs indicating a cytokine profile polarized to Th2. The level of IFN-gamma after immunotherapy was significantly higher than that before (P < 0.05) whereas that of IL-4 mRNA was not changed. Consequently, the ratio of IFN-gamma/IL-4 after immunotherapy was significantly higher than that before immunotherapy (P < 0.05). These results indicate a Th2 cytokine bias is the dominant state in atopic dogs and allergen-specific immunotherapy causes a shift to wards a Th1 bias by enhancing IFN-gamma expression.

Increased responsiveness of the hypothalamus-pituitary-adrenal (HPA) axis to stress in newborns with atopic disposition

In previous studies, atopic patients showed attenuated cortisol responses to psychosocial stress which is suggestive of a hyporeactive hypothalamus-pituitary-adrenal (HPA) axis in this patient group. Regarding the anti-inflammatory role of glucocorticoids, reduced responsiveness of the HPA axis under stress may be one potential explanation of stress-induced exacerbation of atopic symptoms. The present study evaluated whether hyporeactivity of the HPA axis is a feature related to the disposition of atopy rather than a consequence of an ongoing chronic allergic inflammatory process. Newborns with an atopic disposition (parental atopy; n=31) and without atopic disposition (no parental atopy; n=20) were recruited. To further assess atopic disposition, total IgE levels were determined in the cord blood of the neonates. Three days after birth, a blood sample was obtained by a heel prick which is part of a standard pediatric examination. Blood sampling by heel prick is well known to be a significant stressor resulting in activation of the HPA axis in newborns. Analysis of salivary cortisol indicated a significant increase of cortisol levels in the newborns after the stressor with a trend towards an elevated cortisol response in babies with a family history of atopy or with elevated levels of cord IgE (> or = 0.5 kU/l). Neonates with a positive parental atopic heritage and elevated cord IgE were found to show significantly elevated cortisol responses to the heel prick stress when compared to newborns without a parental atopic history and normal cord IgE values. Moreover, cord IgE levels were significantly correlated with basal cortisol levels and the cortisol response to the stressor. These findings suggest that atopic disposition in neonates is associated with altered responsiveness of the HPA axis to stress which may increase the vulnerability to develop manifestation of atopy in later life.

Complementary therapy for atopic eczema and other allergic skin diseases

Atopic eczema is one of the most common chronic inflammatory skin diseases, with a prevalence of at least 10% in children and 0.5-1% in adults. The disease shows a drastically increasing tendency. This article provides an overview of the pathophysiology, pathomechanisms, prevention, and treatment of atopic eczema. We present a therapeutic concept that integrates all aspects of the complex pathophysiology that is a prerequisite for individualized and successful treatment. This is based on intervention in the pathophysiology of atopic eczema and elimination of exogenous provocation factors. Particular attention is given to unconventional therapy options such as phytotherapy, which are attracting patients in many countries, and possible effects, side effects, and interactions with other drugs are discussed.

Myelitis with atopic diathesis: a nationwide survey of 79 cases in Japan

We recently reported the occurrence of myelitis in patients with atopic disorders and its pathology to be eosinophilic inflammation. Because similar cases have been reported, we conducted a nationwide epidemiological survey (NES) of myelitis with atopy in Japan. We compared the clinicolaboratory features of the 30 NES cases with the 49 cases at Kyushu University Hospital (KU). Although the NES cases were distributed throughout Japan, the NES and KU cases shared common characteristics. We therefore combined all of the cases identified. The average onset age was 35.8+/-13.4 years, and the male/female ratio was 1:0.65. The onset mode was subacute/chronic in half the patients, and stepwise progression or symptom fluctuation was frequent (69.6%). The most common lesion site was determined clinically and by MRI to be the cervical cord, and paresthesia and/or dysesthesia were the most common symptoms initially (74.7%) and throughout the entire course (83.5%). Cerebrospinal fluid (CSF) abnormalities were infrequent and mild. These findings suggest that myelitis associated with atopy has mild but prolonged symptoms and occurs throughout Japan.

Managing childhood atopic dermatitis

Atopic dermatitis, a chronic inflammatory skin disorder that affects up to 20% of school-aged children, can profoundly influence quality of life. Basic therapy consists of avoidance of triggering factors and optimal skin care. Until now, corticosteroids have been the usual treatment for acute flares. Short-term safety profiles are reasonable, but long-term use of corticosteroids may involve significant adverse effects. Topical immunomodulators (tacrolimus and pimecrolimus) are beneficial and safe for adults and children and represent a major new alternative to chronic corticosteroid use, especially in children.

Tratamento da alopecia areata com corticóide tópico: estudo prospectivo randomizado duplo cego em crianças

FUNDAMENTOS: Na alopecia areata há perda súbita e assintomática de pêlos em qualquer área pilosa do corpo. A etiologia é desconhecida, e os tratamentos propostos não costumam alterar o curso natural e imprevisível da doença. Atinge as crianças, menos responsivas às terapêuticas e mais susceptíveis às formas mais extensas. O estado atópico é considerado fator de pior prognóstico; é provável que a relação entre as duas doenças se deva às origens imunológicas, embora sejam desconhecidos seus pontos de intersecção. OBJETIVOS: Avaliar a eficácia do dipropionato de betametasona em creme a 0,05% na alopecia areata da criança e a influência da atopia na resposta terapêutica. MÉTODO: Estudo prospectivo controlado duplo cego em 35 crianças de até 12 anos portadoras de alopecia areata, atendidas no Ambulatório de Dermatologia do Instituto de Puericultura e Pediatria Martagão Gesteira - UFRJ e do Hospital Municipal Jesus, ambos no Rio de Janeiro, RJ, no período de 1996 a 1998. RESULTADOS: Das 35 crianças estudadas, 30 (85,7%) evoluíram com resposta positiva ao final de seis meses de acompanhamento. Os percentuais de resposta foram semelhantes nas terapias utilizadas - dipropionato de betametasona e placebo (p= 0,47). Dos 29 atópicos, 26 (89,6%) tiveram resposta positiva aos tratamentos. Não foi estabelecida correlação estatisticamente significativa entre a resposta terapêutica e a condição atópica (p= 0,19). CONCLUSÃO: Não houve diferença entre as respostas terapêuticas nos grupos estudados; a atopia não influenciou a resposta ao tratamento efetuado.

Prevalence of atopic dermatitis in Japanese adults

BACKGROUND

Adult atopic dermatitis (AD) in Japan has become a significant social problem, with as many as one-third of adult patients with severe AD absenting themselves from work or classes due to aggravation of the disease. Reports of such patients have become increasingly common in recent years. Despite the pressing need for epidemiological studies to clarify the prevalence and distribution of AD and to determine its aetiology, no previous research has been carried out on the prevalence of AD within the adult population in Japan.

OBJECTIVES

To clarify the prevalence of adult AD in Japan, using the U.K. Working Party's diagnostic criteria.

METHODS

The subjects of this study were mostly government officials or their family members visiting the Medical Center of Health Science, Toranomon Hospital in Tokyo for annual health check-ups in the period from September 1997 to August 1998. Questionnaires completed by 10 762 persons (8076 men and 2686 women) aged 30 years or above were analysed. The questionnaire consisted of 14 questions on allergic disease. The U.K. Working Party's diagnostic criteria were used after translation into Japanese. Three types of prevalence were used as indicators of prevalence: point, 1-year and lifetime prevalence.

RESULTS

The point prevalence, 1-year prevalence and lifetime prevalence of AD in Japanese adults were 2.9%, 3.0% and 3.3%, respectively. No significant statistical differences were observed between the sexes or among age groups within each sex. The survey indicated that 88.6% of those who had ever had AD were currently affected by active AD, while 93.4% of those who had had at least one episode of AD in the past had experienced an episode over the previous year.

CONCLUSIONS

This study gives the first indication of the prevalence of adult AD among the Japanese, based on the U.K. criteria. Both the internal and external validity of this study are believed to be high; it would be safe to conclude that the 1-year prevalence of AD in Japanese adult populations living in urban areas is 3.0%.

Assessment of epidermal barrier function by photoacoustic spectrometry in relation to its importance in the pathogenesis of atopic dermatitis

With the use of the photoacoustic spectrometry system, in which a mixture of lipid- and water-soluble dyes is applied to the skin and then irradiated with light from a xenon lamp (425 nm and 550 nm), we measured photoacoustic signals of both dyes within the stratum corneum and their disappearance rate through the stratum corneum. The signal intensity was higher and dyes penetrated faster in clinically normal skin of patients with atopic dermatitis (AD) compared with healthy subjects, indicating an impairment of the in vivo cutaneous permeability barrier function against both lipophilic and hydrophilic chemicals. Furthermore, penetration rates of the hydrophilic dyes tended to increase in proportion to the severity of AD and significantly correlated with serum IgE levels in the severe AD group. Thus, abnormal barrier functions of clinically normal skin in AD may predispose inflammatory processes evoked by irritants and allergens, especially their water-soluble elements.

T-helper 1, T-helper 2 and immunosuppressive cytokines in canine atopic dermatitis

Atopic dermatitis is a common inflammatory skin disease of humans and dogs. Human atopic dermatitis is associated with T-helper (Th) 2 type responses, although Th1 cytokines are present in chronic lesions. This study used semi-quantitative reverse transcriptase polymerase chain reactions to determine the expression of gene transcripts for immunosuppressive cytokines (transforming growth factor beta [TGFbeta] and interleukin [IL]-10), Th2 type cytokines (IL-4 and IL-6) and Th1 type cytokines (interferon gamma [IFNgamma], tumour necrosis factor alpha [TNFalpha], IL-2 and IL-12) in lesional atopic, non-lesional atopic and healthy canine skin. Canine atopic dermatitis was associated with over-expression of IL-4 mRNA and reduced transcription of TGFbeta compared to healthy skin (ANOVA, p<0.05). Higher levels of IFNgamma, TNFalpha and IL-2 mRNA were seen in lesional compared to non-lesional and healthy skin (p<0.05). There were no significant differences in IL-10, IL-6 or IL-12 transcription. This is the first report to demonstrate that canine atopic dermatitis is associated with over-production of IL-4 and under expression of TGFbeta.

Modulation of cathepsin G expression in severe atopic dermatitis following medium-dose UVA1 phototherapy

BACKGROUND

During the last decade, medium-dose UVA1 phototherapy (50 J/cm2) has achieved great value within the treatment of severe atopic dermatitis (AD). The purpose of our study was to investigate to what extent UVA1 irradiation is able to modulate the status of protease activity by the use of a monoclonal antibody labeling cathepsin G.

METHODS

In order to further elucidate the mechanisms by which medium-dose UVA1 irradiation leads to an improvement of skin status in patients with AD, biopsy specimens from 15 patients before and after treatment were analyzed immunohistochemically for proteolytic activation.

RESULTS

Compared to lesional skin of patients with AD before UVA1 irradiation, the number of cells positive for cathepsin G within the dermal infiltrate decreased significantly after treatment. The decrease of cathepsin G+ cells was closely linked to a substantial clinical improvement in skin condition.

CONCLUSIONS

In summary, our findings demonstrated that medium-dose UVA1 irradiation leads to a modulation of the expression of cathepsin G in the dermal inflammatory infiltrate in patients with severe AD. Cathepsin G may attack laminin, proteoglycans, collagen I and insoluble fibronectin, to provoke proinflammatory events, to degrade the basement membrane, to destroy the tissue inhibitor of metalloproteinases and to increase the endothelial permeability. Therefore, its down-regulation by UVA1 phototherapy may induce the reduction of skin inflammation as well as improvement of the skin condition.

The incidence of atopic dermatitis in school entrants is associated with individual life-style factors but not with local environmental factors in Hannover, Germany

BACKGROUND

Atopic dermatitis (AD) is a common skin disease in childhood. Micro- and macro-environmental factors have not yet been studied simultaneously in a large cohort of the same area in detail.

OBJECTIVES

The incidence of AD was investigated in 97% of all school entrants (n = 4219) in the city of Hannover, Germany, with regard to the influence of individual and environmental factors.

METHODS

A standardized questionnaire based on the criteria of Hanifin and Rajka that has the sensitivity and specificity of 97% compared with the clinical diagnosis of a dermatologist and a logistic regression model were used. Multiple local-based environmental factors were analysed for all 49 city quarters.

RESULTS

Of all children studied, 10.5% suffered from AD at some time in their lives. The frequency of AD was significantly increasing with more privileged socio-economic status (P < 0.01). Independent factors that were associated with a higher frequency of AD were German nationality (12.4% AD compared with 2.1% in non-German), higher paternal socio-economic status (i.e. father's profession), higher daily duration of the fathers' professional work and the lack of paternal shift work. In contrast, there was no significant association between the frequency of AD and local environmental factors such as the biological effective level of air pollution and urbanization.

CONCLUSIONS

In conclusion, we confirm an association between a privileged life-style and a higher incidence of AD in a large number of investigated children between 5 and 9 years of age (97.6% of children were 6 or 7 years old) for the German city of Hannover. We propose the socio-economic status as a marker for different life-styles and social micro-environments in further studies as there were multiple significant correlations between individual social and environmental factors. The macro-environment seems to be less important for the disease outcome in this context.

Expression of Th1, Th2 and immunosuppressive cytokine gene transcripts in canine atopic dermatitis

BACKGROUND

Atopic dermatitis is a common inflammatory skin disease of humans and dogs. Human atopic dermatitis is associated with Th2-type responses, although Th1 cytokines can be identified in chronic lesions. In contrast, tolerance to environmental allergens in healthy individuals is mediated by regulatory T cells.

OBJECTIVE

This study examined the expression of the immunosuppressive cytokines TGF-beta and IL-10, the Th2-type cytokines IL-4 and IL-6, and the Th1-type cytokines IFN-gamma, TNF-alpha, IL-2, IL-12p35 and IL-12p40, in canine atopic dermatitis.

MATERIALS AND METHODS

RNA was isolated from lesional atopic, non-lesional atopic and healthy canine skin samples. Semi-quantitative reverse transcriptase polymerase chain reactions (RT-PCRs) were carried out using specific primers and one-way analyses of variance used to compare cytokine expression in each group.

RESULTS

Canine atopic dermatitis was associated with over-expression of IL-4 mRNA and reduced transcription of TGF-beta compared with healthy skin (P < 0.05). Higher levels of IFN-gamma, TNF-alpha and IL-2 mRNA were seen in lesional compared with non-lesional and healthy skin (P < 0.05). There were no significant differences in IL-10, IL-6, IL-12p35 or IL-12p40 transcription between the three groups.

CONCLUSIONS

This is the first report to demonstrate that canine atopic dermatitis is associated with over-production of IL-4. Clinical tolerance in healthy individuals appears to be associated with TGF-beta, although it is unclear if this reflects an active mechanism or simply non-responsiveness of the immune system. Th1 cytokines may be induced by subsequent self-trauma and secondary infections in atopic skin. We believe that these results better characterize spontaneously occurring canine atopic dermatitis. We further propose that this should be investigated as a possible animal model of human atopic dermatitis.

Overactivation of IL-4-induced activator protein-1 in atopic dermatitis

Atopic dermatitis is regarded as mediated by Th2-type immunity. In fact, it frequently coincides with the elevation of immunoglobulin (Ig)-E in patients' sera. Due to the pivotal role of interleukin (IL)-4 in regulation of IgE, we hypothesized if atopic dermatitis represents a hyper-reactive condition in response to IL-4 when it coincides the higher serum level of IgE. To address this possibility, peripheral blood mononuclear cells (PBMC) isolated from patients with atopic dermatitis with the high serum IgE level, from those with psoriasis or from healthy volunteers were stimulated with recombinant IL-4 and analyzed for activation of transcription factors including activator protein (AP)-1 or signal transducers and activators of transcription (STAT)-6 by employing electrophoretic mobility shift assays. Although no significant difference between atopy patients and other groups was observed in the STAT-6 binding activity in IL-4-stimulated PBMC, it over-activated the binding of AP-1 in PBMC of the patients with atopic dermatitis. The AP-1 binding was interfered by the use of an antibody directed against JunB. This is the indication that IL-4-overactivated AP-1 is composed of JunB. Furthermore, semi-quantitative RT-PCR analyses revealed marked down-modulation of a Th1 cytokine, interferon (IFN)-gamma, in IL-4-stimulated PBMC derived from atopy patients, but not that from healthy individuals. Together, our present study indicates that AP-1 is over-activated by IL-4 in PBMC of the atopic patients with the higher IgE level, thereby implying that IL-4-induced over-activation of AP-1 might be one of pathogenic factors in atopic dermatitis.

Peripheral blood mononuclear cell responses to major and minor Dermatophagoides allergens in canine atopic dermatitis

Atopic dermatitis is a chronic inflammatory and pruritic skin disease commonly seen in dogs and humans. Most cases involve hypersensitivity to the house dust mites (HDM) Dermatophagoides farinae and Dermatophagoides pteronyssinus. Human atopic dermatitis is associated with the HDM derived allergens Der f 1 and 2, and Der p 1 and 2. Serological data, however, suggest that a 98/104kD protein is the most important allergen in dogs with atopic dermatitis. The aim of this study was to characterise the specificity of circulating T-cells in canine atopic dermatitis for HDM derived allergens. Peripheral blood mononuclear cells (PBMCs) from dogs with atopic dermatitis that were skin test positive for D. farinae and D. pteronyssinus were cultured with crude extracts of D. farinae, D. pteronyssinus and D. microceras, a 98/104kD allergen purified from D. farinae, Der f 1 and Der f 2. There was significantly greater responsiveness of PBMCs to the D. farinae and D. pteronyssinus extracts compared to the D. microceras extract, and similarly to the purified 98/104kD allergen compared to Der f 1 and Der f 2. The close association between serological findings and PBMC proliferation implies that the 98/104kD HDM protein is a major target of immune recognition and that T-cells also participate in the pathogenesis of canine atopic dermatitis by supporting IgE production.

Trends in the prevalence of atopic dermatitis in school children: longitudinal study in Osaka Prefecture, Japan, from 1985 to 1997

BACKGROUND

The authors have carried out questionnaire surveys of health symptoms in school children (aged 7-12 years) in Osaka Prefecture, Japan. In this study, the geographical distribution of and trends in the prevalence of atopic dermatitis were evaluated.

OBJECTIVES

To assess the relationship between the prevalence of atopic dermatitis in children and the environmental factors, and to estimate future changes of the prevalence of atopic dermatitis.

METHODS

A total of seven population surveys were carried out at 2-year intervals between 1985 and 1997 in a total of about 4 million primary school children (460 000-740 000 per survey).

RESULTS

The lifetime prevalence of atopic dermatitis increased from 15.0% in 1985 to 24.1% in 1993 but levelled off thereafter. According to the school year, the prevalence was higher in lower-year pupils. However, the prevalence stopped rising earlier in lower-year pupils and began to decrease in 1997 in first- to third-year pupils. The prevalence according to areas was significantly correlated negatively with air pollution and positively with the income index. According to the income classes, the prevalence increased until 1993 but levelled off thereafter in all classes, which reduced the differences among the classes.

CONCLUSIONS

The increase of the prevalence of atopic dermatitis in school children stopped in 1993 in Osaka Prefecture, Japan. It is conceivable that the prevalence had reached the saturation level.

Atopic eczema and the home environment

BACKGROUND

There is strong evidence to suggest that the prevalence of atopic eczema is increasing in developed countries. Environmental factors have been implicated in the disease.

OBJECTIVES

This descriptive case-control study sheds light on the possible association between atopic eczema in school children and various home environmental factors, and generates hypotheses for further studies.

METHODS

The study uses data on reported atopic eczema symptoms collected via a cross-sectional parental postal survey (n = 1350) in Nottingham, U.K. Estimates of the risk of reported eczema associated with various home environmental factors were calculated by means of odds ratios (OR), along with population attributable risk percentages.

RESULTS

The study showed statistically significant associations between atopic eczema symptoms and dampness in the home [OR 1.40; 95% confidence interval (CI) 1.00-1.97], the use of a radiator to heat the child's bedroom (OR 1.50; 95% CI 1.05-2.16) and the use of synthetic pillows (OR 1.51; 95% CI 1.01-2.28). Frequent vacuuming in the home was associated with a decreased prevalence of atopic eczema (OR 0.74; 95% CI 0.58-0.94). The associations with dampness in the home, synthetic pillows and frequency of vacuuming were not altered significantly after adjustment for age, sex and socio-economic status. Population attributable risk percentages for the use of a radiator and synthetic pillows indicate that although the relative risk estimates for these factors may be small, the population impact of these factors is considerable (26% and 28%, respectively), owing to the high prevalence of exposure to these factors among this group of school children.

CONCLUSIONS

Further research is needed to confirm these associations and additional research is needed to see whether they might be causative. Practical public health advice about the importance of controlling the home environment may then be targeted at families with atopic eczema.

Peripheral blood mononuclear cell responses to Dermatophagoides farinae in canine atopic dermatitis

Atopic dermatitis is a chronic inflammatory and pruritic skin disease commonly seen in dogs and humans that is characterised by the presence of allergen-specific IgE. Data from skin tests and serological analysis suggest that the house dust mite Dermatophagoides farinae is the most important allergen in dogs with atopic dermatitis. The aim of this study was to determine if D. farinae specific peripheral blood mononuclear cell (PBMC) responses could be detected in dogs with atopic dermatitis. PBMCs were isolated by the density centrifugation from dogs with atopic dermatitis that were skin test positive for D. farinae, dogs with atopic dermatitis that were skin test negative for D. farinae, and healthy dogs. Cells were cultured with increasing concentrations of the D. farinae extract, no antigen, vaccine antigens or concanavalin A (ConA). There was significantly greater responsiveness of PBMCs from the D. farinae positive dogs than from either the D. farinae negative or healthy dogs (ANOVA, P<0.05). In contrast, no significant differences were observed in the control responses between the three groups. This is the first study to demonstrate that D. farinae specific circulating memory cells are involved in the pathogenesis of canine house dust mite hypersensitivity.

Characterisation of major and minor Dermatophagoides allergens in canine atopic dermatitis

Atopic dermatitis is a well-recognised chronic inflammatory skin disease of humans and dogs. Most atopic dogs are sensitised to Dermatophagoides mites. The aim of this study was to characterise allergens in different Dermatophagoides species using polyclonal and monoclonal antibodies to canine IgE. Western blots were prepared from crude extracts of D farinae, D pteronyssinus and D microceras, and purified group 1 and 2 allergens under reducing and non-reducing conditions. They were probed with sera from atopic (n = 33) and healthy (n = 27) dogs. There was no significant difference in the sensitivity or specificity between the polyclonal and monoclonal sera in detecting Dermatophagoides -specific IgE. Major allergens common to both D farinae and D pteronyssinus were detected at 97-98 kDa, 103-104 kDa and 134-139 kDa on both reducing and non-reducing blots. Major allergens at 84-85 kDa, 65-69 kDa and 44-45 kDa were only recognised on reducing blots, suggesting that these are fragments of the larger allergens. Only a few sera recognised group 1 or 2 allergens on blots of crude extracts or purified allergens. These results confirm that, in atopic dogs, high molecular weight allergens are the most important Dermatophagoides allergens, rather than the low molecular weight group 1 and 2 proteins.

Atopic dermatitis. How to incorporate advances in management

Atopic dermatitis is a common, genetically determined skin disease that most likely results from an immunologic imbalance. In the majority of patients, conservative topical steroid treatment along with patient education suffices.

Spinal cord lesions of myelitis with hyperIgEemia and mite antigen specific IgE (atopic myelitis) manifest eosinophilic inflammation

We report the neuropathological findings of spinal cord specimens obtained from two patients who had localized myelitis with hyperIgEemia and mite antigen specific IgE (atopic myelitis). Both cases showed mild spinal cord dysfunction, and the gadolinium-enhanced area of the isolated spinal cord lesion observed on MRI was biopsied, respectively. Neuropathologically, both cases showed many perivascular lymphocyte cuffings associated with disrupted vessels, and the infiltration of eosinophils in the spinal cord lesions. Both myelin and axons were lost in the lesions, which were associated with astrogliosis. These findings suggest that an allergic mechanism may play a role in this condition.

Pattern of skin disease at the Ethio-Swedish pediatric hospital, Addis Ababa, Ethiopia

Although skin diseases are common in children, only a very few prospective studies are available, in the literature, mainly from developed countries. This work reports the pattern of skin diseases in a tertiary referral hospital in Addis Ababa, Ethiopia, from June 1995 to July 1997. A total of 1000 consecutive new pediatric patients, ages 0-12 years, were studied. The male:female ratio was 1:1. Allergic skin diseases were most frequently found (55%), followed by infections (33%) and photodermatosis (8%). Of the allergic skin diseases, atopic dermatitis was the most prevalent (47%), followed by seborrheic dermatitis (17.4%).

Effect of house dust mite avoidance measures in children with atopic dermatitis

BACKGROUND

House dust mite allergens are associated with atopic dermatitis (AD).

OBJECTIVES

The aim of our study was to verify if house dust mite allergen avoidance measures can improve the clinical manifestations of AD in children.

METHODS

Forty-one children (mean age 3.9 years) affected by AD associated with high total and/or specific IgE serum levels ('extrinsic' AD) were recruited. Clinical evaluation was performed utilizing the Severity Scoring of AD (SCORAD) index; dust was sampled from the children's beds and tested using an enzyme-linked immunosorbent assay. The study was planned in two parts. In the first part, a placebo-controlled trial of 2 months duration, mite allergen avoidance measures (encasing mattresses and pillows; a weekly hot wash of bedding; frequent vacuum cleaning of living room and bedroom; soft toys and carpets regularly cleaned or removed; no pets allowed) were recommended to group A patients, but not to group B. In the second part of the study, environmental avoidance measures were recommended to initial control group B patients also. One year after the start of the study the amounts of mite allergen in the home and clinical score of AD were measured in both groups.

RESULTS

At the end of the first part of the study, significant decreases in major allergens of Dermatophagoides pteronyssinus (Der p1) and D. farinae (Der f1) load (from 393 to 94 ng m-2) and concentration (from 1.84 to 0.73 microg g-1 of dust) in children's beds were observed in treatment group A. At the same time, in this group the mean SCORAD index improved significantly (from 33 to 26; P = 0.022). After 12 months, when all patients had used allergen avoidance measures, Der p1 + Der f1 load, concentration and clinical score had improved, reaching similar values in both groups.

CONCLUSIONS

Simple mite allergen avoidance measures should be recommended to families with children affected by extrinsic AD in order to control the clinical manifestations and prevent mite sensitization.

Atopic dermatitis in infants and children. An update

The goal in treating patients with atopic dermatitis is to maintain adequate hydration while decreasing pruritus and inflammation. It is also important to recognize factors that are responsible for flares. Although the etiology of atopic dermatitis remains unknown, therapies are being developed targeting immunologic defects in this disease.

The natural history of sensitizations to food and aeroallergens in atopic dermatitis: a 4-year follow-Up

The natural history of atopic dermatitis (AD) is variable. Generally the dermatitis disappears during the first years of life, but it is often followed by the appearance of allergic respiratory diseases (ARDs). Our aim was to establish the risk factors for developing an ARD in children with AD. We followed up for 4 years 78 children (51 boys, 27 girls) with mild (26%), moderate (48%), and severe (26%) AD (clinical score proposed by Rajka and Langeland). In all the patients IgE serum levels were checked and skin prick tests (SPTs) were performed at the first examination. The SPTs were repeated in 68 children at the end of the study. The children with severe AD had significantly higher IgE serum levels than those with mild or moderate AD. SPTs at the first observation were positive in 47% of cases, mostly in patients with severe AD, with a prevalence of food allergens, particularly in younger patients. At the second observation, SPTs were positive in 65% of cases, including 100% of children with severe AD. Inhalants were the most common allergens. An ARD appeared in 38% of all patients: in 75% of those with severe AD and in 54% of those with a positive first SPT. Allergic screening should be carried out at an early age, especially in severe AD, since SPT positivity to food allergens, associated with severe clinical AD symptoms and a high IgE serum level, identifies those children ages 0-3 years at high risk of development of ARD.

Th1 dominance in HAM/TSP and the optico-spinal form of multiple sclerosis versus Th2 dominance in mite antigen-specific IgE myelitis

To clarify the Th1/Th2 balance in spinal cord inflammation, we used ELISA to measure the total and allergen-specific IgE in 69 patients with clinically definite multiple sclerosis (MS), including 24 patients with the optico-spinal form of MS, 45 with HAM/TSP, 30 HTLV-I carriers without HAM/TSP, 40 patients with acute myelitis, 43 with neurodegenerative disorders, and 42 healthy subjects, and flow cytometry to study the intracellular IFNgamma-positive versus IL-4-positive cell ratio (intracellular IFNgamma/IL-4 ratio) in peripheral blood CD4(+) T cells in 40 patients with MS, including 17 patients with the optico-spinal form of MS, 23 with HAM/TSP, 22 with acute myelitis, 23 with neurodegenerative disorders, and 36 healthy subjects. Patients with HAM/TSP showed a significantly higher intracellular IFNgamma/IL-4 ratio, lower IL-4(+)/IFN-gamma(-) cell percentages, lower total IgE level, and lower frequency of cedar pollen-specific IgE than did the controls. The patients with optico-spinal MS showed a significantly higher intracellular IFNgamma/IL-4 ratio and higher IL-4(-)/IFN-gamma(+) cell percentages than the controls even at remission or in the convalescence phase. In contrast, in the patients with acute myelitis, the total serum IgE level and the frequency of mite antigen-specific IgE were significantly elevated in comparison to the controls, while those having mite antigen-specific IgE myelitis showed a significantly lower IFNgamma/IL-4 ratio in the CD4(+) T cells in comparison to the controls. These findings suggest that the Th1 cell response is predominant in HAM/TSP and optico-spinal MS, whereas the Th2 cell response is predominant in mite antigen-specific IgE myelitis.

Managing pediatric atopic dermatitis

Although atopic dermatitis is a very common inflammatory skin condition in children and results in many pediatric healthcare visits, its exact cause is unknown. No single laboratory test can reliably diagnose atopic dermatitis, but a relatively simple set of diagnostic criteria was recently validated for use by practicing physicians. Because existing remedies for atopic dermatitis do not cure the disorder, a program of disease control and management should be pursued. Patients and their caregivers should be advised that current therapies are primarily preventive and palliative. However, a comprehensive plan that includes routine general skin care, medical management of symptoms, identification and avoidance of aggravating factors (including psychological factors), and attention to quality-of-life issues can reduce the occurrence of skin flares. Successful treatment of acute flare-ups can be achieved with appropriate use of topical corticosteroids, but occasionally children afflicted with severe atopic dermatitis require more intensive therapies (e.g., ultraviolet light exposure systemic corticosteroids, and cyclosporine) that need close physician monitoring. Physicians must remain mindful of the psychological and quality-of-life burdens imposed on children with atopic dermatitis and their families and tailor treatments to the needs of each individual patient.

Climatotherapy of atopic dermatitis at the Dead Sea: demographic evaluation and cost-effectiveness

BACKGROUND

About 21% of the patients coming yearly to the DMZ Clinic at the Dead Sea for climatotherapy suffer from atopic dermatitis. This is a common, chronic, and relapsing disease which necessitates drug treatment (topical corticosteroids, antimicrobials, antihistamines, or immunomodulators), phototherapy, or climatotherapy. Objective and methods As the improvement in the condition of patients after 4 weeks of climatotherapy at the Dead Sea is remarkable, we undertook to evaluate the demographic factors that have the strongest impact on this beneficial effect, in adults and children. The major factors studied were: gender, previous medical history, previous stays at the Dead Sea, skin type, skin involvement, age, and duration of treatment. Results A retrospective study of 1718 patients revealed that previous treatments at the Dead Sea and stays longer than 4 weeks caused a clearance greater than 95%, the length of sun exposure was no longer than 5 h daily, and there was no impact of the percentage of skin involvement on the clearance of patients staying more than 4 weeks.

CONCLUSION

s Climatotherapy of atopic dermatitis at the Dead Sea is a highly effective modality for treating this disease. It is also a highly cost-effective method, as the patients take no medications and experience no side-effects. Successful climatotherapy of atopic dermatitis requires strict medical supervision throughout the whole length of the patient's stay on shore.

Clinical aspects, epidemiology, and prognosis of atopic dermatitis

OBJECTIVE

This review article examines the clinical aspects, epidemiology, and prognosis of atopic dermatitis.

DATA SOURCES

These are studies and review articles from textbooks of dermatitis and allergy in general, as well as more recent epidemiologic surveys published in specialist journals of allergy and dermatology.

STUDY SELECTION

Included studies meet the criteria of being a survey of the prevalence of atopic dermatitis published recently in a respected peer-reviewed journal. Particular emphasis is placed on those that examine both the prevalence of the problem and significant causative and associated factors.

RESULTS

Atopic dermatitis is frequently a severe illness that develops in early infancy. It can persist beyond the childhood years and is often found in association with significant respiratory complications. The exact pathogenesis is unclear but it appears that it has a complex immunologic origin. Early surveys lack the methodologic refinements of more recent data from the mid-1990s, including the SCARPOL study. Collectively, these point to a high current prevalence rate of 10% to 15%, a figure that has risen steadily in the preceding decades. The most common associations of atopic dermatitis are a risk of developing respiratory disorders, such as allergic rhinitis and asthma (40% to 60%), and a persistence rate after puberty (40% to 60%), which is indeed much higher than previously suspected.

CONCLUSIONS

A clear recognition of the various disease subgroups along with intervention studies that evaluate reduction of risk are needed before more precise treatment strategies can be devised.

Effect of stress on atopic dermatitis: investigation in patients after the great hanshin earthquake

BACKGROUND

Although a variety of factors are responsible for atopic dermatitis (AD), very little is known about the effect of stress caused by a natural disaster on AD symptoms.

OBJECTIVE

This study was conducted to assess the effect of stress or trauma on the symptoms of AD.

METHODS

One thousand four hundred fifty-seven patients with AD (745 males and 712 females), diagnosed by using the criteria of the Japanese Dermatology Association, were enrolled in the study. The data were obtained from a self-administered questionnaire given to patients with AD after experiencing the Great Hanshin Earthquake. The data were analyzed by multivariate logistic regression analysis. Patients were divided into 3 groups: area A, severe damage to buildings and houses; area B, mild damage; and control area, no damage.

RESULTS

Exacerbation of skin symptoms was found in 38% and 34% of patients in areas A and B, respectively, whereas similar exacerbation was seen in 7% of control patients. Nine percent and 5% of the patients in areas A and B, respectively, showed improvement in their symptoms compared with 1% in the control group. The earthquake caused stress in 63% and 48% of the patients in areas A and B, respectively, but fewer patients felt stress in undamaged areas (19%). Multiple logistic regression analysis revealed that of the factors examined here, subjective distress is the factor that is most responsible for the exacerbation of skin symptoms (odds ratio, 2.98; 95% confidence interval, 2.25-3.96).

CONCLUSION

The results presented here strongly suggest that stress caused by a natural disaster influences AD symptoms.