Triggers of atopic dermatitis

Atopic Dermatitis: Clinical Aspects and Treatments

GENERAL PURPOSE

To review issues related to atopic dermatitis, including its classification, clinical presentation, potential triggers, and treatment options.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and registered nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Synthesize a differential diagnosis for atopic dermatitis (AD).2. Explain the classification of AD cases.3. Select triggers or exacerbating factors for AD.4. Explain pharmacologic and nonpharmacologic treatment options for patients with AD.

A Comprehensive Review of Therapeutic Approaches Available for the Treatment of Dermatitis

BACKGROUND

Dermatitis or eczema is a prevalent skin disorder worldwide and is also very common as a pediatric inflammatory skin disorder. Its succession gets worse with the multiple comorbidities which exhibit mechanisms that are poorly understood. Its management further becomes a challenge due to the limited effective treatment options available. However, the Novel Drug Delivery Systems (NDDS) along with new targeting strategies can easily bypass the issues associated with dermatitis management. If we compare the active constituents against phytoconstituents effective against dermatitis then phytoconstituents can be perceived to be more safe and gentle.

OBJECTIVE

Administration of NDDS of plant extract or actives displays improved absorption behavior, which helps them to permeate through lipid-rich biological membrane leading to increased bioavailability. The newer efficient discoveries related to eczema can face various exploitations. This can be intervened by the subjection of patent rights, which not only safeguard the novel works of individual(s) but also give them the opportunity to share details of their inventions with people globally.

CONCLUSION

The present review focuses on the available research about the use of nanoformulations in the topical delivery. It further elaborates the use of different animal models as the basis to characterize the different features of dermatitis. The review also highlights the recent nanoformulations which have the ability to amplify the delivery of active agents through their incorporation in transfersomes, ethosomes, niosomes or phytosomes, etc.

Position document: IgE-mediated cow's milk allergy

The present document offers an update on the recommendations for managing patients with cow's milk allergy - a disorder that manifests in the first year of life, with an estimated prevalence of 1.6-3% in this paediatric age group. The main causal allergens are the caseins and proteins in lactoserum (beta-lactoglobulin, alpha-lactoalbumin), and the clinical manifestations are highly variable in terms of their presentation and severity. Most allergic reactions affect the skin, followed by the gastrointestinal and respiratory systems, and severe anaphylaxis may occur. The diagnosis of cow's milk allergy is based on the existence of a suggestive clinical history, a positive allergy study and the subsequent application of controlled exposure testing, which constitutes the gold standard for confirming the diagnosis. The most efficient treatment for cow's milk allergy is an elimination diet and the use of adequate substitution formulas. The elimination diet must include milk from other mammals (e.g., sheep, goat, etc.) due to the risk of cross-reactivity with the proteins of cow's milk. Most infants with IgE-mediated cow's milk allergy become tolerant in the first few years of life. In those cases where cow's milk allergy persists, novel treatment options may include oral immunotherapy, although most authors do not currently recommend this technique in routine clinical practice. Enough evidence is not there to confirm the efficacy of elimination diets in the mother and infant for preventing the appearance of cow's milk allergy. Likewise, no benefits have been observed with prebiotic and probiotic dietetic supplements in infants for preventing food allergy.

Absence of clinical symptoms upon introduction of egg into the diet of milk-allergic infants not previously sensitised to egg

BACKGROUND

It is unclear how many children suffering from IgE mediated cow's milk allergy are sensitised to egg in early life and what the clinical implication of this sensitisation is. It is also unclear if those not sensitised to egg in early life, do later on develop sensitisation and clinical allergy to egg.

METHODS

This study examines the prevalence of egg sensitisation among infants with allergy to cow's milk, prior to and following the introduction of egg and what this sensitisation clinically means.

RESULTS

The percentage of egg-sensitised children seen among the group of children with cow's milk allergy was 43.2%, and predictive factors for egg sensitisation are discussed. 81.8% of the sensitised patients presented with symptoms when exposed to egg in at least one of its forms, although up to 54.5% of patients tolerated boiled egg and egg-based products. Of the non-sensitised patients, the vast majority (92.5%) did not present with symptoms after the introduction of egg in their diet.

CONCLUSIONS

Coexistence of allergy to egg and milk allergy is common, and it is recommended that these patients be monitored, since children who are sensitised to egg despite having never been exposed to it in their diet, may present with symptoms immediately following first ingestion. Most children who are initially non-sensitised to egg do not require special care, and it is not generally recommended to delay or monitor these children, although a small number may have subsequently reacted to egg.

Predicting risk for early infantile atopic dermatitis by hereditary and environmental factors

BACKGROUND

Hereditary and environmental factors contribute to the occurrence of atopic dermatitis (AD). However, the interaction of these two factors is not totally understood.

OBJECTIVES

To evaluate the early risk factors for infantile AD at the age of 6 months and to develop a predictive model for the development of AD.

METHODS

In 2005, a representative sample of mother and newborn pairs was obtained by multistage, stratified systematic sampling from the Taiwan national birth register. Information on hereditary and environmental risk factors was collected by home interview when babies were 6 months old. Multivariate regression analysis was applied to determine the risk factors for AD in the infants.

RESULTS

A total of 20 687 pairs completed the study satisfactorily. AD was diagnosed in 7.0% of 6-month-old infants by physicians. Parental asthma, atopic dermatitis and allergic rhinitis, and maternal education levels were risk factors for AD in infants. Among environmental factors, fungus on walls at home and renovation/painting in the house during pregnancy were significantly associated with early infantile AD. Using these factors, the probability of having infantile AD was estimated and grouped into low, high and very high. With five runs of tests in mutually exclusive subsets of this population, the likelihood of AD for 6-month-old infants was consistent in all the groups with the predictive model. The highest predicted probability of AD was 70.1%, among boys with maternal education levels > 12 years, both parents with AD, renovation and painting of the house during pregnancy and fungus on walls at home. The lowest probability was 3.1%, among girls with none of the above factors.

CONCLUSIONS

This investigation provides a technique for predicting the risk of infantile AD based on hereditary and environmental factors, which could be used for developing a preventive strategy against AD, especially among those children with a family history of atopy.

Pediatric asthma and related allergic and nonallergic diseases: patient-oriented evidence-based essentials that matter

Asthma is the most common medical diagnosis among hospitalized children. In the USA, asthma has accounted for approximately 15% of nonsurgical admissions to hospital in the pediatric age group. Asthma is also one of the leading causes for emergency care requirements, one of the leading causes for missed school, and a cause for considerable morbidity, disability and occasional mortality at all ages. Despite these discouraging statistics, convincing data indicate that this failure of asthma management is not the result of inadequate therapeutic potential, but instead represents ineffective delivery of medical care. Management of asthma and its major co-morbidities, allergic and nonallergic rhinitis, and atopic dermatitis requires a knowledge of the alternative therapies, natural history, and educational techniques for providing patients and families with the ability to manage these troublesome chronic disorders.

Atopic dermatitis

Atopic dermatitis (AD) is commonly associated with immunoglobulin E (IgE) antibody-related mechanisms, which are the focus of this article. The vast majority of patients with AD exhibit hyperproduction of IgE, particularly during disease onset or flare. IgE-dependent late-phase reactions may influence the chronic inflammatory response in AD. Clearly, genetics plays a major role in determining who develops AD. However, the recent increase in AD prevalence suggests that a complex interaction between environmental factors and susceptibility genes results in clinical expression of the disorder. These immunologic "triggers" differ among individuals and include various foods, airborne allergens, irritants and contactants, hormones, stress, climate, and microorganisms. Although much about AD remains to be elucidated, our current understanding of its pathophysiology has provided clinicians with the ability to construct more rational therapeutic interventions, including multiple-agent regimens that provide both immediate relief and effective long-term management. Future advances will come from identification of the genes causing this disease and further elucidation of the immunoregulatory mechanisms involved in the pathogenesis of AD.

A clinician's paradigm in the treatment of atopic dermatitis

Successful management of atopic dermatitis requires a multipronged approach that includes skin barrier function care, use of topical or systemic agents, and identification and elimination of precipitating or exacerbating factors. Because the origin of atopic dermatitis is multifactorial and trigger factors differ among patients, treatment plans must be specific to the individual patient. This article offers an example of a permutational, or flexible, treatment paradigm. The approach utilizes 4 topical regimens--high-potency topical corticosteroids, lowest effective potency topical corticosteroids, topical calcineurin inhibitors (TCIs), or topical corticosteroid/TCI combinations--as initial therapy in a variety of induction protocols, as determined by the severity of a patient's condition and history. The paradigm permits treatment to progress from a chosen induction therapy to maintenance therapy. During the patient's induction therapy, as soon as an acceptable level of clearance is achieved, therapy should be adjusted to a maintenance regimen, such as monotherapy with either a TCI or a lowest effective potency topical corticosteroid (the latter used intermittently) or an alternation of the two agents. If there is no clearance or positive response with the initial induction protocol, the clinician should move to one of the alternative regimens.

Immunoglobulin E- (IgE) and non-IgE-mediated reactions in the pathogenesis of atopic eczema/dermatitis syndrome (AEDS)

AEDS is a chronic, relapsing, highly pruritic inflammatory skin disease that commonly begins in childhood. Two forms of this disorder exist, i.e. an allergic (extrinsic) form and a nonallergic (intrinsic) form. There are clear genetic, humoral and cellular differences between the allergic and nonallergic forms of AEDS. The allergic variants express local IgE production in affected tissue and both allergic and nonallergic triggers play a major role in the expression of disease. The role of allergens is very important in the immunopathogenesis of AEDS. Nonimmunological triggers play a secondary modulatory role often hampering treatment effort and optimal response to therapeutic efforts.