Atopic dermatitis in 5-6-year-old Swedish children: cumulative incidence, point prevalence, and severity scoring

Decreasing prevalence of atopic dermatitis in Swedish schoolchildren: three repeated population-based surveys

BACKGROUND

The prevalence of atopic dermatitis (AD) has increased over several decades and now affects about one-fifth of all children in high-income countries (HICs). While the increase continues in lower-income countries, the prevalence of AD might have reached a plateau in HICs.

OBJECTIVES

To investigate trends in the prevalence of AD and atopic comorbidity in schoolchildren in Sweden.

METHODS

The study population consisted of three cohorts of children (median age 8 years) in Norrbotten, Sweden, for 1996 (n = 3430), 2006 (n = 2585) and 2017 (n = 2785). An identical questionnaire that included questions from the International Study of Asthma and Allergies in Childhood (ISAAC) protocol was used in all three cohorts. Trends in AD prevalence were estimated, as well as trends in atopic comorbidity. AD prevalence was estimated both according to the ISAAC definition of AD and by adding the reported diagnosis by a physician (D-AD).

RESULTS

The prevalence of AD decreased in the last decade, from 22.8% (1996) and 21.3% (2006) to 16.3% (2017; P < 0.001). The prevalence of D-AD was lower, but the same pattern of decrease was seen, from 9.3% (1996) and 9.4% (2006) to 5.7% (2017; P < 0.001). In all three cohorts, AD was more common among girls than boys (18.9% vs. 13.8% in 2017; P < 0.001). Children from the mountain inlands had a higher prevalence of AD than children from coastal cities (22.0% vs. 15.1% in 2017; P < 0.001). In comparing D-AD, there were no significant differences between the sexes or between inland or coastal living. Concomitant asthma increased over the years from 12.2% (1996) to 15.8% (2006) to 23.0% (2017; P < 0.001). Concomitant allergic rhinitis and allergic sensitization increased from 1996 (15.0% and 27.5%) to 2006 (24.7% and 49.5%) but then levelled off until 2017 (21.0% and 46.7%).

CONCLUSIONS

The prevalence of AD among schoolchildren in Sweden decreased over the study period, whereas atopic comorbidity among children with AD increased. Although a decrease was seen, AD is still common and the increase in atopic comorbidity among children with AD, especially the increase in asthma, is concerning.

Prevalence and Characteristics of Dupilumab-Induced Ocular Surface Disease in Adults With Atopic Dermatitis

PURPOSE

Dupilumab-induced ocular surface disease (DIOSD) is a common reaction among patients treated for atopic dermatitis. This study aimed to identify the clinical characteristics, associated risk factors, treatment strategies, and long-term outcomes of DIOSD.

METHODS

We conducted a multicenter retrospective cohort study of consecutive adult outpatients treated with dupilumab for moderate-to-severe atopic dermatitis from 2017 through 2021 at 2 tertiary care centers. We used stepwise multivariable logistic regression to assess the association between patient characteristics and development of DIOSD.

RESULTS

Among 210 patients treated with dupilumab, 37% (n = 78) developed DIOSD over the 52-week follow-up period. Vision-threatening complications including corneal scarring and cicatricial ectropion were noted in 1% (n = 3) of patients. Clinical features were blepharoconjunctivitis (68%, n = 53), burning/stinging/dryness (14%, n = 29), epiphora (13%, n = 10), pruritus (13%, n = 10), blurred vision (3%, n = 2), and photophobia (1%, n = 1). DIOSD was associated with a history of asthma (odds ratio: 2.94, 95% confidence interval: 1.26-6.87, P = 0.01) and a family history of atopic dermatitis (odds ratio: 2.58, 95% confidence interval: 1.08-6.17, P = 0.03). Interventions were initiated for 63% of patients with DIOSD, with artificial tears (56%) and corticosteroid drops (29%) most commonly used. Dupilumab was discontinued because of DIOSD in 4% of patients.

CONCLUSIONS

DIOSD is a common adverse event that is usually mild but may lead to treatment interruption and vision-threatening complications. A personal history of asthma and family history of atopic dermatitis may be associated with a higher risk of developing DIOSD.

Validation of Patient Identification Algorithms for Atopic Dermatitis Using Healthcare Databases

INTRODUCTION

The use of real-world data offers a possibility to perform large-scale epidemiological studies in actual clinical settings. Despite their many advantages, administrative databases were not designed to be used in research, and the validation of diagnoses and treatments in administrative databases is needed. The primary objective of this study was to validate an existing algorithm based on dispensed prescriptions and diagnoses of skin conditions to identify pediatric patients with atopic dermatitis (AD), using a diagnosis of AD in primary care as a gold standard.

METHODS

Retrospective observational data were collected from nation-wide secondary care and pharmacy-dispensed medication databases and two regional primary care databases in Sweden. An existing algorithm and a Modified algorithm, using skin-specific diagnoses from secondary care and/or pharmacy-dispensed prescriptions to identify patients with AD, were assessed. To verify the presence of AD, diagnoses from primary care were used in the base case and complemented with diagnoses from secondary care in a sensitivity analysis.

RESULTS

The sensitivity (30.0%) and positive predictive value (PPV) (40.7%) of the existing algorithm were low in the pediatric patient population when using primary care data only but increased when secondary care visits were also included in the Modified algorithm (sensitivity, 62.1%; PPV, 66.3%). The specificity of the two algorithms was high in both the base case and sensitivity analysis (95.1% and 94.1%). In the adult population, sensitivity and PPV were 20.4% and 8.7%, respectively, and increased to 48.3% and 16.9% when secondary care visits were also included in the Modified algorithm.

CONCLUSION

The Modified algorithm can be used to identify pediatric AD populations using primary and secondary administrative data with acceptable sensitivity and specificity, but further modifications are needed to accurately identify adult patients with AD.

PREVALENCE FOR THE ATOPIC DERMATITIS DEVELOPMENT AT PRE-SCHOOL CHILDREN OF ALTAI KRAI

Aim of research: to evaluate the prevalence of atopic dermatitis at 3–6-year-old children by applying russified version of ISAAC questionnaire (International Study of Asthma and Allergies in Childhood) and to determine risk factors.Materials and Methods. Cross-section research was carried out in five places of Altai Territory (2015–2016). The prevalence of AD was determined with the help of the russified ISAAC Manual filled in by parents of the 3–5-year-old children. The ISAAC definition for current atopic dermatitis (cAD) was used in studies. Patient considered suffering from cAD if respondents’ parents pointed «YES»  on three questions: «Have you ever had an itchy rash which was coming and going for at least six months?», «Have you had this itchy rash at any time in the last 12 months?», «Has this itchy rash at any time affected any of the following places: the folds of the elbows, behind the knees, under the buttocks, or around the neck, ears or eyes?».Results. The research covered 3205 children of 3–6-year-old age. The prevalence of cAD was 12.3 % (n = 393). Medically confirmed diagnosis of AD was stated only at 7.9 % (n = 254) from 393 children. It was established in logistic-regression analysis that burdened familial allergologic history increases 4,6 times the risk of the cAD development at preschool age (OR = 4.62; 95 % CI = 3.69–5.77; p 0,01). Little duration of breastfeeding (less than six months) increases the risk of cAD development 1,6 times (OR = 1.62; 95 % CI = 1.26–2.09; p 0.05. The prematurity, tobacco smoking at parents or the contact with pets on the first year age were not found to enhance the risk of cAD development at preschool children.Conclusion. The cAD prevalence markedly exceeds the rates of the medically confirmed diagnoses. The burdened familial history of allergic diseases and little duration of breastfeeding enhance the risk of cAD development at preschool age.

Review of Atopic Dermatitis and Topical Therapies

Atopic dermatitis is one of the most common skin disorders in the developed world, affecting up to 20% of children and 1% to 3% of adults. This review concisely explains the pathophysiology and epidemiology of atopic dermatitis, as well as potential challenges facing its successful treatment. Furthermore, mainstay topical treatment modalities are evaluated, such as emollients, topical corticosteroids, and topical calcineurin inhibitors. The use of topical corticosteroids and topical calcineurin inhibitors in combination is discussed, as studies have indicated encouraging results. The proactive use of topical corticosteroids and topical calcineurin inhibitors is also investigated, in order to bring attention to a new possibility in long-term management of atopic dermatitis. Last, new and upcoming topical medications are described, including Janus kinase inhibitors, phosphodiesterase-4 inhibitors, and benvitimod. Although topical corticosteroids and topical calcineurin inhibitors can be very effective in the treatment of atopic dermatitis, it is important that practitioners are aware of mechanistically unique and new treatments for patients for whom more traditional topical therapies have failed. Overall, this review article hopes to serve as a comprehensive overview of currently available topical treatments for atopic dermatitis, while shedding light on new treatments coming in the future.

Preconceptional and perinatal exposure to traffic-related air pollution and eczema in preschool children

BACKGROUND

Evidence linking prenatal exposure to outdoor air pollution with eczema in early childhood is scare, and the role of components of air pollution and exposure timing remains unclear.

OBJECTIVES

We investigated the association between exposure to air pollution during preconceptional and perinatal period and the risk of eczema in preschool children.

METHODS

We conducted a prospective cohort study of 2598 children aged 3-6 years in Changsha, China. The prevalence of eczema was assessed by a standardized health questionnaire administered by the parents. Individual exposures to nitrogen dioxide (NO₂), sulfur dioxide (SO₂) and particulate matter with an aerodynamic diameter≤10μm (PM₁₀) during the 4th-6th and 1st-3rd month before pregnancy, entire pregnancy, and three trimesters were estimated by an inverse distance weighted (IDW) method based on concentrations measured at monitoring stations. Association between childhood eczema and exposure to air pollution was examined by logistic regression models in terms of odds ratio (OR) and 95% confidence interval (CI) for an interquartile range (IQR) increase in exposure.

RESULTS

Life-time prevalence of eczema in preschool children in Changsha was 28.6%. Childhood eczema was associated with traffic-related air pollutant NO₂ during 3 months before pregnancy and entire pregnancy with adjusted ORs=1.19 (95% CI: 1.04-1.37) and 1.21 (95% CI: 1.03-1.42) respectively. The highest risk of eczema was observed for the 1st trimester exposure to NO₂ [OR=1.26 (95% CI: 1.09-1.46)]. However, no association was detected for SO₂ and PM₁₀ exposure during any window. High-level exposure to NO₂ during the whole time period significantly increased the effect of NO₂ in all windows on eczema risk as compared with low-level exposure. Sensitivity analysis indicated that the association between both preconceptional and perinatal exposure to NO₂ and childhood eczema was consistent and robust, and this association was modified by some personal, parental hereditary and indoor environmental factors.

CONCLUSION

Our findings support the hypothesis that early childhood eczema is associated with exposure to traffic-related air pollutant during both preconceptional and perinatal period, especially at a high level of exposure.

Children with Dry Skin and Atopic Predisposition: Outcome Measurement with Validated Scores for Atopic Dermatitis

BACKGROUND

Dry skin is a common skin condition in childhood. Few studies exist investigating the influence of daily skin care on dry skin in infants at risk of developing atopic dermatitis (AD). We aimed to assess the effect of skin care on dry skin in this special cohort using validated scores for AD and analysis of skin microtopography.

METHODS

43 children were randomized to group 1 (G1) and group 2 (G2) and 22 infants to group 3 (G3). During 16 weeks, G1 and G3 applied daily a plant-based emollient and G2 a petrolatum-based emollient. The core outcome was assessed by Severity Scoring of Atopic Dermatitis (SCORAD) and Patient-Oriented SCORing Atopic Dermatitis (PO-SCORAD). The influence on the parents' life was evaluated by a questionnaire and microtopography by Visioscan® VC 98.

RESULTS

The SCORAD index declined significantly until week (W) 16 in all groups (p ≤ 0.041). The sleeplessness score analyzed by PO-SCORAD was highly reduced after W12 in G1 and after W16 in G2 (p ≤ 0.030). The influence on the parents' anxiety was reduced in G3 at W12 and W16 (p = 0.016). The Visioscan parameter scaliness strongly diminished at W4 (p ≤ 0.049) and W16 (p ≤ 0.013) in all groups.

CONCLUSIONS

This trial demonstrates improved skin conditions and sleep following daily emollient application in infants and children having dry skin and being at risk of AD. Especially parents of infants showed a reduced fear that their children might develop AD. Further studies are required to investigate the preventive effect of daily emollient therapy in this special cohort evaluating the outcome measures used in this trial.

Sensitization pattern to inhalant and food allergens in symptomatic children at first evaluation

Background

Data on specific IgE sensitization prevalence in children with allergy-like symptoms seen in the primary care setting are rare. Early diagnosis of allergic diseases is important to prevent clinical manifestations, exacerbations or expansion of allergic diseases to other organ systems. The present study aims to assess the usefulness of early serological diagnosis in children with common allergic symptoms.

Methods

532 children (<15 years of age), with at least one of ten allergy-like symptoms, from 21 primary care centers in two geographic areas of Italy and Spain were included in the study. Patients were tested with, either Phadiatop® Infant (0–5 years of age) or Phadiatop® and food mix (fx5e) (>5 years of age) to discriminate atopic from non-atopic subjects. A blood sample of atopic subjects was taken for additional 6–26 specific IgE antibody determinations from a predefined panel using the ImmunoCAP^® System.

Results

267 children (50.2 %) were positive in the initial test and were classified as atopic. 14 % were mono-sensitized, 37 % were sensitized to 2–3 allergens and 49 % to more than 3 allergens. The average number of symptoms in the atopic group was 3.3 vs 2.8 in the non-atopic group. The prevalence of sensitization to single allergens was highest for grass and ragweed pollen and house-dust mites (19–28 %). Sensitization to tree allergens was highest for olive tree (16.5 %). Cow’s milk and egg white were the most sensitizing foods (~15 %). Food allergen sensitization predominated in younger children (OR = 2.8) whereas the inverse occurred with inhalant allergens (OR = 2.5 to 5.6). A significant positive correlation between patient age and the number of sensitizations was found.

Conclusions

Specific IgE sensitization in children with allergy-like symptoms is common. Multiple sensitization is predominating. Number of clinical symptoms was higher in the atopic group compared to the non-atopic without a correlation with the number of positive allergens. Age seems to play a crucial role in the development of sensitization with a significant positive correlation between patient age and the number of sensitizations.

Atopic diathesis in patients with Kawasaki disease

OBJECTIVE

To determine the association between Kawasaki disease (KD) and atopic diathesis (atopic dermatitis [AD], allergic rhinitis, and asthma) in children younger than 5 years of age.

STUDY DESIGN

In this nationwide study, we aimed to analyze the association and temporal relationship between KD and atopic diathesis. Data were obtained from the National Health Insurance Research Database of Taiwan from 1997 to 2010. In total, 200 patients with KD younger than 5 years of age and 800 age- and sex-matched control subjects were enrolled.

RESULTS

In the whole study population, an increased risk of any concomitant atopic diseases was observed in patients with KD (OR 1.61, 95% CI 1.15-2.26). The risk of AD was increased in male patients between 1 and 5 years of age (OR 3.02, 95% CI 1.22-7.50). More than 60% of the patients developed atopic diseases after the diagnosis of KD.

CONCLUSION

There appears to be an association between KD and risk of AD. Most of the atopic diseases occurred after the episode of KD.

Celiac disease and dermatologic manifestations: many skin clue to unfold gluten-sensitive enteropathy

Cutaneous manifestations of intestinal diseases are increasingly reported both in the adult and in the children, and this association cannot longer be considered a simple random. Besides the well-known association between celiac disease (CD) and dermatitis herpetiformis (DH), considered as the cutaneous manifestation of gluten-dependent enteropathy, is more frequently reported also the association with other mucocutaneous diseases. Among these there are both autoimmune, allergic, and inflammatory diseases, but also a more heterogeneous group called miscellaneous. The knowledge about pathogenic, epidemiological, clinical, and diagnostic aspects of CD is increasing in recent years as well as those about DH, but some aspects still remain to be defined, in particular the possible pathogenetic mechanisms involved in the association between both CD and DH and CD and other immunological skin diseases. The aim of this paper is to describe the skin diseases frequently associated with CD, distinguishing them from those which have a relationship probably just coincidental.

A shorter and more specific oral sensitization-based experimental model of food allergy in mice

Cow's milk protein allergy (CMPA) is one of the most prevalent human food-borne allergies, particularly in children. Experimental animal models have become critical tools with which to perform research on new therapeutic approaches and on the molecular mechanisms involved. However, oral food allergen sensitization in mice requires several weeks and is usually associated with unspecific immune responses. To overcome these inconveniences, we have developed a new food allergy model that takes only two weeks while retaining the main characters of allergic response to food antigens. The new model is characterized by oral sensitization of weaned Balb/c mice with 5 doses of purified cow's milk protein (CMP) plus cholera toxin (CT) for only two weeks and posterior challenge with an intraperitoneal administration of the allergen at the end of the sensitization period. In parallel, we studied a conventional protocol that lasts for seven weeks, and also the non-specific effects exerted by CT in both protocols. The shorter protocol achieves a similar clinical score as the original food allergy model without macroscopically affecting gut morphology or physiology. Moreover, the shorter protocol caused an increased IL-4 production and a more selective antigen-specific IgG1 response. Finally, the extended CT administration during the sensitization period of the conventional protocol is responsible for the exacerbated immune response observed in that model. Therefore, the new model presented here allows a reduction not only in experimental time but also in the number of animals required per experiment while maintaining the features of conventional allergy models. We propose that the new protocol reported will contribute to advancing allergy research.

Evaluation of a parental questionnaire to identify atopic dermatitis in infants and preschool children

Aim. To develop and validate a questionnaire for detecting atopic dermatitis in infants and small children from the age of 2 months. Methods. Parents to 60 children answered a written questionnaire prior to a physical examination and individual semistructured interview. Qualitative and quantitative analyses of validity, sensitivity, specificity, and predictive values of the questionnaire were performed. Results. A total of 27 girls and 33 boys, aged 2 to 71 months, 35 with and 25 without physician-diagnosed eczema, participated. Validation of the questionnaire by comparisons with physicians' diagnoses showed a sensitivity of 0.91 (95% CI 0.77–0.98) and a specificity of 1 (95% CI 0.86–1). Conclusions. Three questions in a parental questionnaire were sufficient for diagnosing eczema in infants and small children.

Dermatology in public health - a model for surveillance of common skin diseases

Aims: The aim was to establish a baseline prevalence of skin conditions of public health importance in the general population and taking the validity of the questions into account. Our model is intended for future surveillance of skin conditions. Methods: The suggested questions have for the first time been used in Swedish population surveys. A random sample was taken from the general population aged 16 to 84 years of the participating areas. Results: During the past 12 months, hand eczema was reported by 9.4%, childhood eczema by 15.7% and nickel allergy by 13.7% of the population. Hand and childhood eczema questions have previously been validated. Taking the validity into account, the actual population prevalence of hand eczema (11.7%) is underestimated, and the prevalence of atopic childhood eczema (10.0%) is overestimated based on the results of the questionnaire. In addition to presenting prevalence, population survey results can be used for risk analyses. A 10-fold risk of hand eczema in individuals with childhood eczema and self-reported nickel sensitivity is shown in our study. Conclusions: Questionnaires can be used for epidemiologic surveillance so long as the questions are validated and that the validity is taken into account when estimating the occurrence of the conditions. Public health surveys such as this one lay the basis for future epidemiological surveillance of skin conditions that can be subject to interventions. We propose that these, or similar, questions should be used regularly in population surveys and supplemented by questions on skin exposure.

Early exposure to antibiotics and infections and the incidence of atopic eczema: a population-based cohort study

It has been suggested that infants exposed to antibiotics are at increased risk for atopic eczema (AE), whereas the early exposure to infections might be protective. This study describes the complex relationship between early exposure to infections, anti-infectious treatment with antibiotics, and incident AE. Using a German population-based administrative health-care and prescription database, we established a cohort of 370 children not diagnosed as having AE during their first year of life. For each individual child we identified all infections and prescriptions of antibiotics within the first year as well as incident AE within the second year of life. Crude analyses suggested that early infections and exposure to antibiotics are risk factors for AE. However, stratified analyses indicated that early infections were only associated with a higher rate of AE when treated with broad-spectrum antibiotics such as cephalosporines or macrolides. The risk ratio (RR) of children with early respiratory tract infections not treated with antibiotics was 0.69 [95% confidence interval (95% CI) 0.39 to 1.24], whereas respiratory tract infections treated with macrolides (RR: 2.15, 95% CI: 1.18-3.91) or cephalosporines (RR: 1.93, 95% CI: 1.07-3.49) significantly increased the risk for AE. The results for other common childhood infections tended to be similar. Antibiotic treatment appears to modify the association between early infections and subsequent AE. We found no evidence that infections per se significantly alter the likelihood for subsequent AE.

Development of atopic dermatitis in the DARC birth cohort

The aim was to describe the relapsing pattern, sensitization and prognosis of atopic dermatitis (AD) in the first 6 yr in a population-based, prospective birth cohort. The DARC cohort includes 562 children with clinical examinations, specific-IgE and skin prick test at all follow-ups. All children were examined for the development of AD using Hanifin-Rajka criteria and for food hypersensitivity by oral challenges. Severity of AD was measured by objective SCORing Atopic Dermatitis (SCORAD). Point-prevalence of AD peaked at 18 months of age (10%) and decreased at 36 and 72 months to slightly below 7%. The 6-yr cumulative incidence was 22.8% and sensitization was found in 43% of children with AD. It was predominately sensitization to foods, however shifting toward inhalant allergens with age. Sensitization at >or=2 follow-ups affected severity, whereas short-term sensitization at one follow-up does not. Children with early, non-IgE mediated (intrinsic) AD outgrew more often their eczema; however if they develop persistent AD, they remain intrinsic. Early long-term sensitization worsens the prognosis, but 38% of all children have a debut later than 18 months of age. Boys had earlier onset of AD than girls. The large number of follow-ups gives a detailed picture of the relapsing pattern and shows that the relapses occur independently of time of onset. We could not establish any clear correlation between elimination diets and AD duration nor severity.

Systemic therapy of atopic dermatitis in children

Atopic dermatitis (AD) is a common disease in childhood that is a serious burden on patients and their families. Most AD is mild and can be managed with the use of emollients and standard therapy consisting of topical corticosteroids or topical calcineurin inhibitors. However, in a subgroup of patients with moderate to severe AD, the disease is recalcitrant to topical therapy and systemic treatments become necessary. Short courses of systemic corticosteroids are often used in clinical practice, but their use is controversial. International guidelines suggest that in the case of acute flare-ups, patients might benefit from a short course of systemic corticosteroids, but long-term use and use in children should be avoided. Ciclosporin is an immunosuppressant agent that acts directly on cells of the immune system, with an inhibitory effect on T cells. When AD cannot be controlled by standard topical therapies, ciclosporin significantly decreases symptom scores, disease extent, pruritus and sleep deprivation, and improves quality of life. The most frequent adverse effects associated with the use of ciclosporin are hypertension and renal dysfunction, but they are usually reversible after drug discontinuation. Ciclosporin has been found to be safely used, effective and well tolerated in children with severe AD. However, studies to assess the long-term effectiveness and safety of ciclosporin in AD are lacking. In patients for whom ciclosporin is not suitable, or when there is a lack of response, alternative drugs should be considered, such as azathioprine or interferon-gamma. Intravenous immunoglobulins and the monoclonal antibody infliximab only have a place in the systemic therapy of AD when other drugs have failed. Mycophenolate mofetil has recently been introduced in the treatment of recalcitrant AD. Efalizumab and omalizumab are monoclonal antibodies with a possible future role in the treatment of AD, but further studies are needed.

Childhood eczema and asthma incidence and persistence: a cohort study from childhood to middle age

BACKGROUND

The association between eczema and asthma is well documented, but the temporal sequence of this association has not been closely examined.

OBJECTIVES

To examine the association between childhood eczema and asthma incidence from preadolescence to middle age, and between childhood eczema and asthma persisting to middle age. A further aim was to examine any effect modification by nonallergic childhood exposures on the association between childhood eczema and both childhood asthma and later life incident asthma.

METHODS

Data were gathered from the 1968, 1974, and 2004 surveys of the Tasmanian Longitudinal Health Study. Multivariable logistic regression examined the association between childhood eczema and childhood asthma. Cox regression examined the association between childhood eczema and asthma incidence in preadolescence, adolescence, and adult life. Binomial regression examined the association between childhood eczema and childhood asthma persisting to age 44 years.

RESULTS

Childhood eczema was significantly associated with childhood asthma and with incident asthma in preadolescence (hazard ratio [HR], 1.70; 95% CI, 1.05-2.75), adolescence (HR, 2.14; 95% CI, 1.33-3.46), and adult life (HR, 1.63; 95% CI, 1.28-2.09). Although childhood eczema was significantly associated with asthma persisting from childhood to middle age (relative risk, 1.54; 95% CI, 1.17-2.04), this association was no longer evident when adjusted for allergic rhinitis.

CONCLUSION

Childhood eczema increased the likelihood of childhood asthma, of new-onset asthma in later life and of asthma persisting into middle age.

Atopic dermatitis among 2-year olds; high prevalence, but predominantly mild disease--the PACT study, Norway

Atopic dermatitis is often the first and most prevalent manifestation of atopic disease in preschool children. The objectives of the present study were to determine the prevalence and severity of atopic dermatitis in 2-year-old children. Questionnaire data from a total population of 4784 two-year olds and data from a clinical investigation of a sub-sample of 390 children were obtained from a comprehensive prospective study (Prevention of Atopy among Children in Trondheim). The severity of the atopic dermatitis was scored both according to the Nottingham Eczema Severity Score and the Severity Scoring of Atopic Dermatitis. In the total population the prevalence of this disease, defined as any eczema and itchy rash was 16.5% (95% CI: 15.5-17.6). In the subsample, the corresponding prevalence was 20.6% (95% CI: 16.6-24.6) and 15.9% (95% CI: 12.3-19.5) when diagnosed by the UK Working Party's Criteria. More than 70% of the children with UK-diagnosed atopic dermatitis had mild disease according to both the Nottingham Eczema Severity Score and the Severity Scoring of Atopic Dermatitis. The prevalence of atopic dermatitis among 2-year olds was high. However, more than two-thirds of the children had mild disease, which may imply that the impact of atopic dermatitis as a risk factor for future atopic disease is limited.

Remembering childhood atopic dermatitis as an adult: factors that influence recollection

BACKGROUND

Atopic dermatitis (AD) is common in the population, and studies have shown that the disease is on the increase. Studies based on hospital records reflect selected populations and may miss less severe cases of AD, and the use of self-reported questionnaires has the drawback of recall bias.

OBJECTIVES

To investigate some possible factors influencing recall bias when questionnaires are used to establish the prevalence of childhood eczema in an adult population.

METHODS

A questionnaire regarding past and present eczema was sent to 557 cases (with signs suggesting the diagnosis AD) and 554 matched controls (subjects lacking signs of AD) born during 1960-1969 and identified in school health medical records. Cases and controls were aged 31-42 years at the time of the study and 70.5% returned the questionnaire.

RESULTS

Of 403 cases, 29% did not report childhood eczema in the questionnaire. There was a difference between those who did recall their childhood AD (remembering group, RG), and those who did not (forgetful group, FG) in who had documented the diagnostic signs in the school health records. In the RG the signs were reported by both parents and school health personnel in 51% of cases, and in the FG this was true of only 16%. The RG had a higher prevalence of eczema after 15 years of age and of hand eczema. The RG also reported more visits to physicians after the age of 15 years and more time taken as sick leave due to eczema.

CONCLUSIONS

Several factors influence how well people remember their AD in childhood. These factors include disease activity in adult life, disease severity, and who noticed the eczema in childhood.

Increased expression of aquaporin 3 in atopic eczema

BACKGROUND

Dry skin in atopic eczema depends on increased water loss. The mechanisms behind this are poorly understood. The aim of this work was to identify genes that may contribute to water loss in eczema.

METHODS

Affymetrix DNA microarrays U133A were used to analyse gene expression in skin biopsies from 10 patients with atopic eczema and 10 healthy controls.

RESULTS

DNA microarray analysis showed up-regulation of 262 genes and down-regulation of 129 genes in atopic eczema. The known functions of these genes were analysed using Gene Ontology to identify genes that could contribute to increased water loss. This led to identification of aquaporin 3 (AQP3), which has a key role in hydrating healthy epidermis. Increased expression of AQP3 was found in eczema compared with healthy skin. This was confirmed with real-time polymerase chain reaction (P<0.001). In healthy skin, epidermal AQP3 immunoreactivity was weak and mainly found in the stratum basale. A gradient was formed with decreasing AQP3 staining in the lower layers of the stratum spinosum. By contrast, in acute and chronic atopic eczema strong AQP3 staining was found in both the stratum basale and the stratum spinosum.

CONCLUSIONS

Aquaporin 3 is the predominant aquaporin in human skin. Increased expression and altered cellular distribution of AQP3 is found in eczema and this may contribute to water loss.

[Risk factors for atopic dermatitis and familial prevalence in Spain (ELIHO study)]

INTRODUCTION

Atopic dermatitis (AD) is a cutaneous disease of unknown etiology. It shows a clear genetic predisposition with probable environmental modulation. This study evaluated risk factors associated with diagnosis and flares of AD in Spanish children.

PATIENTS AND METHODS

We performed an observational, multicenter, retrospective case-control study that included 4243 children aged less than 14 years old with AD and 978 controls matched for age and sex. Family history of disease and environmental variables were collected in both groups and clinical history of AD was recorded in the case group.

RESULTS

Significant risk factors for AD were: a family history of the disease and concomitant cutaneous infections. The prevalence of AD in first degree relatives was 39 % and that in second degree relatives was 19 % (higher in maternal than paternal lines). The mean age of children with AD was 4.2 (SD 3.4) years and the mean age at diagnosis was 1.5 (SD 2.2) years, with a mean of 2.9 (SD 2.6) flares during the previous year. Cold weather (Cantabrian and Continental Iberian Peninsula areas) was related to a greater number of flares. Children with AD had a greater number of concomitant cutaneous diseases and infections than children in the control group.

CONCLUSIONS

AD is mainly a genetic disease, with climatic factors involved in severity modulation, and with important immunological alterations. In contrast, this study found no domestic environmental factors that were associated with disease onset.

Margarine and butter consumption, eczema and allergic sensitization in children. The LISA birth cohort study

It has been hypothesized that margarine intake is associated with allergic diseases. However, the epidemiological evidence in children is limited. The aim of the present study was to assess the relationship between dietary intake of margarine and butter with eczema and allergic sensitization in 2-yr-old children. Data of 2582 children at the age of 2 yr with complete information on exposure to diet and allergic outcome were analyzed in a German prospective birth cohort study (LISA). Margarine and butter intake were estimated from a semiquantitative food frequency questionnaire about general fat use at home combined with questions on the child's spread intake. Multiple logistic regression analysis was applied comparing predominant margarine and predominant butter intake with consumption of both butter and margarine. Predominant margarine intake was positively associated with lifetime prevalence of symptomatic eczema (aOR: 1.71; 95% CI: 1.12-2.61) and doctor-diagnosed eczema (aOR: 2.10; 95% CI: 1.36-3.25) and allergic sensitization against inhalant allergens (aOR: 2.10; 95% CI: 1.01-4.41) at the age of 2 yr. No statistically significant associations were found for butter intake. Stratification for parental history of atopic diseases indicated that children at high risk of atopic diseases have higher effect estimates for margarine intake compared to children without parental history of atopic diseases. Stratification for sex also showed higher effect estimates in boys. Children with predominant margarine consumption had an increased risk for eczema and allergic sensitization, while butter intake was no predictor for allergic diseases. However, we could not determine whether margarine is a causal risk factor or whether other lifestyle factors have influenced this association.

Stable incidence of atopic dermatitis among children in Denmark during the 1990s

An increase in the prevalence of atopic dermatitis (AD) has been reported since the 1960s. The increase could be due to many factors including a genuine increase of incidence or duration of AD. We decided to study if the increasing trend persisted during the 1990s by comparing the cumulative incidence of AD in 1993 and 1998. Further, we studied the severity and management of AD among children. Two samples of children born in Denmark were drawn from the Danish Medical Birth Register. In the 1993 and 1998 studies a mailed questionnaire with identical questions concerning AD was sent out. In the 1998 follow-up study the questionnaire included a severity score and questions concerning management of AD. In the 1993 study the cumulative incidence of AD at age 7 was 18.9% and in 1998 it was 19.6%. There was no difference in the age-adjusted AD incidence in the 5-year observation period. In the 1998 study, 81% had mild to moderate AD, 90% had been seen by a doctor at least once, 36% had mainly been treated by a dermatologist, and 2% had been hospitalized. It should be kept in mind that we base most of our common knowledge of the disease on AD patients selected for management in dermatology clinics and departments.

Swedish patients' perceptions of a preoperative skin test

PREOPERATIVE PREPARATION is an important aspect of creating a safe and pleasant hospital experience for surgical patients. Evaluating patient satisfaction, however, also depends on determining patients' perceptions of the care they receive. THIS STUDY used a descriptive, qualitative method with a phenomenographic approach to determine how patients perceived undergoing a preoperative skin test that was developed to ascertain what substances might result in intraoperative reactions in patients with allergies, asthma, or eczema. OVERALL, the patients had positive perceptions of the skin test; however, the results indicate a need for improved and individualized preoperative instruction that focuses on patients from a holistic perspective.

The Occurrence of Atopic Dermatitis in Greenland

Until recently there was no information available on the prevalence of atopic dermatitis in Greenland. Our objective was to determine the prevalence of atopic dermatitis in younger schoolchildren in Greenland. In the autumn of 2000 we used our previously elaborated questionnaire in a cross-sectional study of 954 schoolchildren aged 7-8 years, who lived in five Greenlandic towns. The findings were compared to data on atopic dermatitis from Denmark. The response rate was 65% (622). The lifetime prevalence of atopic dermatitis was calculated to be 14.0% (95% confidence interval 11.3-16.7) using our standard score criteria with an absolute lower limit estimate of 4.5%. Taking the response rate of 65% into consideration this study indicates that in 2000 the lifetime prevalence of atopic dermatitis among younger schoolchildren in Greenland was in the range of 10-15%.

Goat milk is less immunogenic than cow milk in a murine model of atopy

OBJECTIVES

Cow milk protein allergy occurs in 2% to 6% of infants population. Goat milk has been used as an alternative to cow milk, but there is probably some cross-reactivity between the milks. Little is known about the allergenicity of goat milk per se. The aim of this study is to compare cow and goat milk allergenicity in a mouse atopy model.

METHODS

Balb/C mice were intragastrically sensitized to cow or goat milk by five doses administrated weekly. Six weeks after the first dose mice were killed, sera were collected and spleens removed for analysis.

RESULTS

The number of mice with diarrhea was significantly higher in the cow milk-sensitized group than in the goat milk-sensitized group. Serum cow milk-specific immunoglobulin G1 and histamine levels were also significantly higher in cow milk-sensitized mice. Cytokine production by spleen derived T cells showed a Th2 response with high levels of interleukin-4 production and low levels of interferon-gamma in cow milk-sensitized mice. In addition, goat milk induced a lower lymphocyte sensitization as a result of a significant decrease in the specific proliferation ratio of these cells.

CONCLUSION

Goat milk, when used as the first source of protein after a breast-feeding period, is less allergenic than cow milk in mice. Further studies are needed to clarify if goat milk is suitable as an alternative to cow milk in milk based formulas for infant nutrition.

Role of topical emollients and moisturizers in the treatment of dry skin barrier disorders

Emollients and moisturizing creams are used to break the dry skin cycle and to maintain the smoothness of the skin. The term 'moisturizer' is often used synonymously with emollient, but moisturizers often contain humectants in order to hydrate the stratum corneum. Dryness is frequently linked to an impaired barrier function observed, for example, in atopic skin, psoriasis, ichthyosis, and contact dermatitis. Dryness and skin barrier disorders are not a single entity, but are characterized by differences in chemistry and morphology in the epidermis. Large differences also exist between moisturizing creams. Moisturizers have multiple functions apart from moistening the skin. Similar to other actives, the efficacy is likely to depend on the dosage, where compliance is a great challenge faced in the management of skin diseases. Strong odor from ingredients and greasy compositions may be disagreeable to the patients. Furthermore, low pH and sensory reactions, from lactic acid and urea for example, may reduce patient acceptance. Once applied to the skin, the ingredients can stay on the surface, be absorbed into the skin, be metabolized, or disappear from the surface by evaporation, sloughing off, or by contact with other materials. In addition to substances considered as actives, e.g. fats and humectants, moisturizers contain substances conventionally considered as excipients (e.g. emulsifiers, antioxidants, preservatives). Recent findings indicate that actives and excipients may have more pronounced effects in the skin than previously considered. Some formulations may deteriorate the skin condition, whereas others improve the clinical appearance and skin barrier function. For example, emulsifiers may weaken the barrier. On the other hand, petrolatum has an immediate barrier-repairing effect in delipidized stratum corneum. Moreover, one ceramide-dominant lipid mixture improved atopic dermatitis and decreased transepidermal water loss (TEWL) in an open-label study in children. In double-blind studies moisturizers with urea have been shown to reduce TEWL in atopic and ichthyotic patients. Urea also makes normal and atopic skin less susceptible against irritation to sodium laurilsulfate. Treatments improving the barrier function may reduce the likelihood of further aggravation of the disease. In order to have optimum effect it is conceivable that moisturizers should be tailored with respect to the epidermal abnormality. New biochemical approaches and non-invasive instruments will increase our understanding of skin barrier disorders and facilitate optimum treatments. The chemistry and function of dry skin and moisturizers is a challenging subject for the practicing dermatologist, as well as for the chemist developing these agents in the pharmaceutical/cosmetic industry.

Prevalence of self-reported eczema in relation to living environment, socio-economic status and respiratory symptoms assessed in a questionnaire study

BACKGROUND

Potential links between eczema and obstructive pulmonary diseases have been postulated. Previously we have reported the prevalence of upper and lower respiratory diseases and the relation to environmental and socio-economic factors in a randomly selected adult population in southern Sweden using a postal questionnaire. In the present study we wanted to analyse the prevalence of eczema and its relation to socio-economic status, heredity factors and environmental factors in an adult population.

METHODS

Self-reported eczema, upper and lower respiratory symptoms, asthma and Chronic Bronchitis Emphysema (CBE) were examined in 12,071 adults, aged 20-59 years, living in southern Sweden by using a postal questionnaire. There were comparable numbers of males and females in all age groups. Multiple logistic regression analysis (forward conditional) was applied to estimate the association between the proposed risk factors (heredity, self-reported asthma and CBE, nasal symptoms, socio-economic group, environmental factors, age, gender and smoking habits) and self-reported eczema.

RESULTS

The response rate was 70.1%. In all, 1240 subjects (14.6%) stated that they had eczema. In all age cohorts self-reported eczema was more frequently reported by women than by men (p < 0.05). The prevalence of self-reported eczema among the economically active population varied from 17.1% to 8.2% with the highest rates among assistant non-manual employees. However, when controlling for age, gender and risk occupation there was no association between low social position and eczema. Living close to heavy traffic (OR = 1.45, 95% CI 1.25-1.67) and living seaside (OR = 1.17, 95% CI 1.01-1.35) but not urban/suburban living was associated with eczema. Heredity of eczema (OR = 5.77, 95% CI 5.02-6.64), self reported allergic rhinitis (OR = 2.31, 95% CI 2.00-2.68), self reported asthma (OR = 1.98, 95% CI 1.56-2.51) and self reported CBE (OR = 1.42, 95% CI 1.08-1.87) were all associated with eczema.

CONCLUSIONS

In this epidemiological study we see that self-reported eczema is a common disease in an adult population especially among women. Eczema seems to be linked to environment factors, obstructive pulmonary diseases and rhinitis.

Use of the Self-Administered Eczema Area and Severity Index by parent caregivers: results of a validation study

BACKGROUND

The Eczema Area and Severity Index (EASI) is used by dermatological investigators world-wide to assess eczema disease severity. EASI measures are, however, time-consuming and require trained personnel, thereby limiting its application to large-scale epidemiological studies. Additionally, the use of self-assessed severity indices in dermatology is restricted to adult subjects and conditions, thereby not addressing the needs of paediatric patients.

OBJECTIVES

To develop and validate an instrument for a caregiver's self-assessment of the severity of his/her child's atopic dermatitis (AD), the Self-Administered EASI (SA-EASI).

METHODS

Trained investigators performed a modified EASI assessment on the same day as an SA-EASI was obtained from 47 caregivers of children with AD.

RESULTS

The SA-EASI was found to be a valid measure of the severity of AD. Total, acute and chronic SA-EASI scores predicted total, acute and chronic modified EASI scores (P < 0.0001). SA-EASI body surface area (BSA) scores predicted EASI BSA scores (P < 0.0001). SA-EASI pruritus scores correlated with the acute, chronic and total EASI scores (P = 0.0001).

CONCLUSIONS

The SA-EASI may provide caregivers the means to report the severity of their child's skin disease objectively. The high correlation with the EASI score observed in this sample implies that statistical inferences with the SA-EASI will be valid for large populations. In future studies, this will permit analysis of the relationship of skin disease severity to such measures as quality of life, disability, patient satisfaction and the costs of various therapies. Moreover, this SA-EASI instrument may allow older children, over 12 years old, to assess the severity of their AD.