The epidemiology of atopic dermatitis in Italian schoolchildren

Implications of Atopic Dermatitis on the Quality of Life of 6-11 Years Old Children and Caregivers (PEDI-BURDEN)

Purpose

Atopic dermatitis (AD) is a chronic, relapsing and remitting inflammatory skin disease characterized by intense itch. The disease burden includes physical limitations, psychosocial discomfort, and a reduced quality of life (HRQoL). This study presents the results of a parent-reported survey on the psychosocial impact of AD on Italian pre-adolescent children (6-11 years old), with a specific focus on bullying, self-isolation, absenteeism, and presenteeism.

Methods

An online questionnaire was sent to 3067 random recipients and 160 matched the inclusion criteria for age, self-reported AD diagnosis, localizations (according to ISAAC), and disease severity (POEM ≥8). 100 children, with comparable ages, not matching the inclusion criteria for AD, were recruited as a control group.

Results

Children with AD and their caregivers had a significantly lower quality of sleep (QoS) compared to the control group. The presence of AD was directly responsible for many restless nights, both in children and caregivers (58.9 and 55.4 respectively). Children with AD and their parents also experienced significantly more daytime drowsiness (43.6 and 54.6 days, respectively). Children with AD were more frequently victims of bullying at school (20.0% vs 9.0%; p≤0.05) or in other social environments (16.9% vs 3.0%; p≤0.05). AD caused 17.7 days of absenteeism and 20.1 days of presenteeism per student over the previous 12 months, accounting for 37.8 days of study impairment overall. Severe/very severe AD had a significantly greater impact on presenteeism than moderate AD (25.1 vs 17.5 days; p≤0.05). Presenteeism, which was more pronounced among bullied students, was positively correlated with absenteeism only in the AD cohort.

Conclusion

AD has a detrimental impact on the HRQoL of pediatric patients, causing stigmatization and social isolation. Functional distress was also reported by caregivers. Our study might inform the public and policymakers about the disease burden of AD at a young age.

Multiple Roles for Cytokines in Atopic Dermatitis: From Pathogenic Mediators to Endotype-Specific Biomarkers to Therapeutic Targets

Atopic dermatitis (AD) is one of the most common chronic inflammatory skin diseases, which generally presents with intense itching and recurrent eczematous lesions. AD affects up to 20% of children and 10% of adults in high-income countries. The prevalence and incidence of AD have increased in recent years. The onset of AD mostly occurs in childhood, although in some cases AD may persist in adult life or even manifest in middle age (adult-onset AD). AD pathophysiology is made of a complex net, in which genetic background, skin barrier dysfunction, innate and adaptive immune responses, as well as itch contribute to disease development, progression, and chronicization. One of the most important features of AD is skin dehydration, which is mainly caused by filaggrin mutations that determine trans-epidermal water loss, pH alterations, and antigen penetration. In accordance with the “outside-inside” theory of AD pathogenesis, in a context of an altered epidermal barrier, antigens encounter epidermal antigen presentation cells (APCs), such as epidermal Langerhans cells and inflammatory epidermal dendritic cells, leading to their maturation and Th-2 cell-mediated inflammation. APCs also bear trimeric high-affinity receptors for immunoglobulin E (IgE), which induce IgE-mediated sensitizations as part of pathogenic mechanisms leading to AD. In this review, we discuss the role of cytokines in the pathogenesis of AD, considering patients with various clinical AD phenotypes. Moreover, we describe the cytokine patterns in patients with AD at different phases of the disease evolution, as well as in relation to different phenotypes/endotypes, including age, race, and intrinsic/extrinsic subtypes. We also discuss the outcomes of current biologics for AD, which corroborate the presence of multiple cytokine axes involved in the background of AD. A deep insight into the correlation between cytokine patterns and the related clinical forms of AD is a crucial step towards increasingly personalized, and therefore more efficient therapy.

Characteristics associated with clinical response to Comano thermal spring water balneotherapy in pediatric patients with atopic dermatitis

BACKGROUND

Several studies have investigated the efficacy of balneotherapy in atopic dermatitis (AD), including a pediatric open randomized clinical trial conducted at the Comano thermal spring water center, which showed a significant reduction in AD severity and an improvement of the quality of life. However, so far many studies on balneotherapy in pediatric AD have included relatively small populations without identifying patients' characteristics associated with their response. The aim of the present study was to identify any features associated with the clinical response to the Comano thermal spring water balneotherapy in a large cohort of pediatric AD patients.

METHODS

An observational study was conducted on 867 children aged ≤16 years (females 50.5%, mean patient's age 5.9 years, standard deviation ±3.6 years) with mild to severe AD who underwent balneotherapy at the Comano thermal spring water center (Comano, Trentino, Italy) from April to October 2014. Patients were stratified according to their disease severity, which was evaluated using five SCORing Atopic Dermatitis (SCORAD) categories before and immediately after a thermal spring water balneotherapy course. Potential characteristics associated with the patients' clinical response to Comano thermal spring water balneotherapy were investigated.

RESULTS

A statistically significant improvement in AD severity was observed after Comano thermal spring water balneotherapy (p < 0.0001). A significantly higher percentage of patients achieving improvement in AD severity was reported among children ≤4 years old (p < 0.0001) with early-onset AD (p < 0.0001), severe AD (p < 0.0001) or coexistent reported food allergies (p < 0.01). The therapy was well tolerated, and no relevant adverse effects were reported during the treatment course.

CONCLUSIONS

Comano thermal spring water balneotherapy is a safe complementary treatment for pediatric patients with AD, as it was able to reduce the disease severity, especially in children ≤4 years old, with early onset AD, severe AD or concomitant food allergies.

The global, regional, and national burden of atopic dermatitis in 195 countries and territories: An ecological study from the Global Burden of Disease Study 2017

Introduction

Numerous population-based studies have focused on the global prevalence of atopic dermatitis (AD), but there are few studies on the global trends of the burden associated with AD.

Methods

We analyzed the global AD trends in 2017 in 195 countries worldwide using the Global Burden of Disease (GBD) Study database, including prevalence rates, age and sex patterns, and AD burden, using disability-adjusted life years (DALYs). Age-standardized DALYs were also compared to the sociodemographic index values of all the countries in 2017.

Results

The age-specific DALYs in 2017 showed a right-skewed distribution, with the highest DALYs between 1 and 5 years of age. Females had a higher burden of AD throughout all age groups and geographic regions. The GBD super region with the greatest burden of DALYs caused by AD was high income (178.63 DALYs per 100,000 males, 231.8 for females), and the country with the highest DALYs was Sweden (326.91). The GBD super region with the lowest age-standardized DALY burden caused by AD was south Asia (84.51 DALYs per 100,000 males, 100.54 for females).

Conclusion

There is a large GBD caused by AD. The observed burden is the greatest in resource-rich countries, females, and young children.

Atopic dermatitis in schoolchildren and adolescents: a critical review of Italian epidemiological data and systemic treatments

INTRODUCTION

The epidemiology of atopic dermatitis (AD) is largely different in pre-school and schoolchildren. We summarized the available epidemiological data on schoolchildren (6-11 years) and adolescents (12-17 years) in Italy and reviewed information on systemic treatments for moderate-to-severe AD in adolescents.

EVIDENCE ACQUISITION

In January 2019, we searched for data on prevalence and/or incidence of AD and on the efficacy, effectiveness and safety of systemic AD therapies. Papers were evaluated and selected, and relevant information was extracted. Twenty papers from 17 studies reported original epidemiological information on AD in Italy.

EVIDENCE SYNTHESIS

Most studies were conducted before 2005. Though variations emerged between studies, the lifetime prevalence of AD was estimated between 15-17% in schoolchildren and between 8-13% in adolescents. The (12-months) period prevalence of AD was estimated between 8-10% in children and between 8-11% in adolescents. Up-to-date information on the prevalence of severe AD is not available. Cyclosporine A may be used in pediatric age patients (children and adolescents) with persistent or severe AD refractory to topical treatments, but its use has several limitations, and is not recommended in patients younger than 16 years. The treatment paradigm of AD is still far from being satisfactory.

CONCLUSIONS

We provided a quantitative synthesis of AD epidemiology in Italian schoolchildren and adolescents. Recent data are needed, as most information dates back to the 1990s or early 2000s, and data on the incidence of AD, the proportion of severe cases, and treatment of severe cases in the real-world setting are scanty.

How does parental history of atopic disease predict the risk of atopic dermatitis in a child? A systematic review and meta-analysis

BACKGROUND

Parental history of atopic disease is a well-established risk factor for the development of atopic dermatitis (AD), but several aspects of this association remain unclear.

OBJECTIVE

We sought to determine the association of parental history of atopic disease with AD in offspring.

METHODS

We searched PubMed and EMBASE through June 2018 for relevant records and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled odds ratios (ORs) with 95% CI were calculated using random-effects models.

RESULTS

A total of 163 records covering 149 unique studies were included. Of these, 119 studies were included in the meta-analysis. Individuals with parental history of atopic disease had increased odds of AD (OR, 1.81; 95% CI, 1.65-1.99). Parental asthma (OR, 1.56; 95% CI, 1.18-2.05) and allergic rhinitis (OR, 1.68; 95% CI, 1.34-2.11) had a smaller effect than AD (OR, 3.30; 95% CI, 2.46-4.42). The effect of maternal and paternal history was comparable for all atopic diseases. An increase in odds was observed when comparing the effect of having 1 (OR, 1.30; 95% CI, 1.15-1.47) or 2 atopic parents (OR, 2.08; 95% CI, 1.83-2.36), as well as having a parent with 1 (OR, 1.49; 95% CI, 1.28-1.74) or more atopic diseases (OR, 2.32; 95% CI, 1.92-2.81).

CONCLUSIONS

This study provides evidence-based risk estimates that may guide physicians who counsel parents with a history of atopic disease about their children's risk of AD. This information is of particular importance for future efforts toward establishing prophylactic interventions for AD on a general population level.

Asthma, Rhinoconjunctivitis, Eczema, and the Association with Perinatal Anthropometric Factors in Vietnamese Children

Few studies have investigated possible causative and protective factors associated with allergic diseases in resource-limited countries, Southeast Asia. We estimated the current prevalence of asthma, rhinoconjunctivitis, and eczema among 6-year-old children, and identified anthropometric factors associated with asthma, rhinoconjunctivitis and eczema, in South-Central Vietnam. A birth cohort study recruited 1,999 children born at a provincial hospital in Nha Trang, Vietnam between May 2009 and May 2010. A 6-year follow-up survey was conducted where clinical, familial, and environmental information was collected by interviewing caregivers using a standardized form based on the International Study of Asthma and Allergies in Childhood, Phase Three Core and Environmental Questionnaire for 6–7-year-old children. The odds ratios of asthma, rhinoconjunctivitis, and eczema for anthropometric factors were estimated using logistic regression analysis. In total, 1202 children participated in the follow-up survey. The proportions of children who had current asthma, rhinoconjunctivitis, and eczema were 5.1% (95% confidence interval [CI] 3.9–6.5%), 11.5% (9.7–13.4%), and 6.7% (5.3–8.2%), respectively. Low birthweight (adjusted odds ratio 5.12, 95% CI 1.92–13.64) was independently associated with increased risk of eczema. Further studies are necessary to understand the involved mechanism.

Faltering of prenatal growth precedes the development of atopic eczema in infancy: cohort study

Background

Infants with atopic eczema have an increased risk of impaired growth, but the origin of this impairment is unclear. The aim of this study was to examine fetal and infant growth in relation to infantile atopic eczema.

Methods

Within the UK Southampton Women's Survey, 1,759 infants with known maternal menstrual data had anthropometric measurements at 11, 19, and 34 weeks' gestation, birth, and ages 6 and 12 months, enabling derivation of growth velocity SD scores. Infantile atopic eczema at ages 6 and/or 12 months was ascertained using modified UK Working Party diagnostic criteria.

Results

Expressed per SD increase, higher femur length and abdominal circumference at 34 weeks' gestation were associated with decreased risks of atopic eczema (eczema OR/SD increase 0.81 [95% CI 0.69-0.96], P=0.017 and 0.78 [95% CI 0.65-0.93], P=0.006, respectively), while every SD increase in head to abdominal circumference ratio (indicating disproportionate growth) was associated with an increase in risk of atopic eczema (1.37 [1.15-1.63], P=0.001). Lower velocities of linear growth from 11 weeks' gestation to birth and birth to age 6 months were associated with atopic eczema (atopic eczema OR/SD increase 0.80 [0.65-0.98], P=0.034 and 0.8 [1 0.66-1.00], P=0.051, respectively). Infants with atopic eczema at age 12 months had a larger head circumference in early gestation and faltering of abdominal growth velocity from 19 to 34 weeks' gestation (atopic eczema OR/SD increase 0.67 [0.51-0.88], P=0.003).

Conclusion

Infants with atopic eczema demonstrate altered patterns of fetal growth, including faltering of linear growth in utero, prior to the clinical onset of atopic eczema. These findings suggest growth falters prior to the start of clinical atopic eczema and its treatment.

A systematic review and meta-analysis of the regional and age-related differences in atopic dermatitis clinical characteristics

BACKGROUND

Previous studies found conflicting results about the commonality of different atopic dermatitis (AD) signs and symptoms.

OBJECTIVE

To determine the prevalences of AD characteristics and differences by region and age.

METHODS

A systematic review was performed of all published studies in MEDLINE, EMBASE, SCOPUS, LILACS, Cochrane, China National Knowledge Infrastructure, Taiwan Electronic Periodical Services, and CiNii that analyzed the proportion of AD characteristics. Two reviewers performed a review study titles and/or abstracts and data abstraction.

RESULTS

In all, 101 studies reported proportion of AD features with sufficient data for meta-analysis. The most prevalent AD features were pruritus, lichenification, and xerosis. There were differences in AD characteristics by study region. Flexural involvement was less commonly reported in India, the Americas, and Iran. Studies from East Asian reported more erythroderma and truncal, extensor, scalp, and auricular involvement. Studies from Southeast Asia reported more exudative eczema, truncal involvement, lichenification, and prurigo nodularis. Studies from Iran reported more head, face, and neck involvement; pityriasis alba; and xerosis. Studies from Africa reported more papular lichenoid lesions, palmar hyperlinearity, ichthyosis, and orbital darkening.

LIMITATIONS

Heterogeneity between studies and limited reporting of certain AD clinical characteristics.

CONCLUSIONS

AD characteristics are heterogeneous and vary by region and age.

Various diagnostic criteria for atopic dermatitis (AD): A proposal of Reliable Estimation of Atopic Dermatitis in Childhood (REACH) criteria, a novel questionnaire-based diagnostic tool for AD

Atopic dermatitis (AD) is a heterogeneous disease that manifests with a wide variety of clinical symptoms and signs. Due to the lack of definitive biomarkers for AD, it is very difficult to set up standard diagnostic criteria for AD which cover the entire spectrum of AD patients. Various instruments have been proposed for AD diagnosis, and they can be classified into a hospital setting or a community setting. From the preventive medicine viewpoint, questionnaire-based diagnostic criteria in a community setting are important to detect and manage childhood AD patients properly. In this article, various diagnostic criteria for AD in hospital and community settings will be reviewed. Additionally, the Reliable Estimation of Atopic Dermatitis in Childhood (REACH), a new full questionnaire-based diagnostic tool for childhood AD, will be reviewed.

Epidemiology of Frequently Occurring Skin Diseases in Italian Children from 2006 to 2012: A Retrospective, Population-Based Study

BACKGROUND

Recent estimates indicate an increase in the prevalence of skin diseases in children. Few large epidemiologic studies have examined prevalence trends in Europe. This study evaluated the incidence and prevalence of frequently occurring pediatric skin diseases (PSDs) in Italy as seen by family pediatricians (FPs).

METHODS

Data were retrospectively extracted from the Pedianet database (2006-2012) in children ages 0 to 14 years presenting with a skin disease at their FP. The incidence and prevalence estimates were calculated per year and stratified according to sex, age, and geographic area.

RESULTS

A mean of 145,233 children (52.1% male) across five Italian regions were registered with their participating FP for a total of 913,253 person-years of follow-up. The majority of patients were from the northeast (44.6%) and 37.7% were ages 5-9 years. Incidence estimates (new cases/1,000 person-years) for most PSDs increased from 2006 to 2012, the highest being for atopic dermatitis (AD) (14.1 vs 16.5), acute urticaria (10.1 vs 11.6), and contact dermatitis (9.3 vs 10.8), whereas psoriasis remained unchanged over the 7 years (0.61 vs 0.57). In contrast, prevalence estimates (cases/100 patients) increased two to three times for several PSDs, including AD (2.7% vs 8.5%), seborrheic dermatitis (0.5% vs 1.6%), chronic urticaria (0.4% vs 0.8%), and psoriasis (0.09% vs 0.22%). Differences in prevalence according to age range and geographic area were observed for psoriasis, AD, and urticaria.

CONCLUSION

This study provides comprehensive evidence of the increasing prevalence and incidence of PSDs across Italy. Additional causality studies to address this important clinical and psychosocial problem are recommended.

Natural history and risk factors of atopic dermatitis in children

Atopic dermatitis (AD) is one of the most common inflammatory allergic diseases with pruritic skin lesions particularly in infancy. It is considered to be the first step of atopic march and has variable disease courses. Many children with AD may resolve their AD symptoms with increasing age and may develop respiratory allergies such as asthma and rhinoconjunctivitis at certain ages. Natural course of AD has been supported by many cross-sectional and longitudinal studies in many countries. In general, atopic dermatitis tends to be more severe and persistent in young children, particularly if they have some risk factors including genetic factors. It appears that approximately 40%-70% of childhood AD will get resolved when they reach the age of 6-7 years. However, it is also observed that over half of the children with AD developed respiratory allergy during late childhood.

Preliminary results on clinical effects of probiotic Lactobacillus salivarius LS01 in children affected by atopic dermatitis

GOALS

The goal of this study was to evaluate the clinical efficacy of an intake of Lactobacillus salivarius LS01 (DSM 22775) for the treatment of atopic dermatitis (AD) in children.

BACKGROUND

AD is an inflammatory and pruritic chronic relapsing skin disorder with multifactorial etiopathology. Some evidence suggests that probiotics may improve AD by modulating the immune system and the composition of intestinal microbiota.

STUDY

A total of 43 patients aged from 0 to 11 years were enrolled in the study (M/F ratio=1:1) and treated with the probiotic strain L. salivarius LS01. Clinical efficacy of probiotic treatment was assessed from baseline by changes in itch index and in the objective SCORAD/SCORAD index.

RESULTS

Patients being given probiotic treatment showed a significant improvement in clinical parameters (SCORAD and itch values) from baseline. The reduction in SCORAD and itch index observed after 4 weeks of treatment also persisted after the cessation of probiotic supplementation.

CONCLUSIONS

L. salivarius LS01 seems to be able to improve the quality of life of children affected by AD and, as a consequence, it may have promising clinical and research implications.

Prevalence of childhood eczema and food sensitization in the First Nations reserve of Natuashish, Labrador, Canada

Background

The Mushua Innu of Natuashish, Labrador, Canada seem to have a high rate of childhood eczema. Anecdotally this problem seems to be more common now than 20 years ago. There has been speculation that this could be related to food sensitization that may have arisen coincident with a move away from a traditional Innu diet. We undertook to assess the prevalence and severity of pediatric eczema in Natuashish (population 792), and investigate the level of sensitization to common food antigens.

Methods

Over a three-month period we performed a population survey of all children in the community from the ages of 2–12 inclusive. The one-year prevalence of eczema was assessed using the United Kingdom Working Party’s diagnostic criteria, and graded on the Nottingham Severity Scale. All children with eczema and twice as many age/sex matched controls were offered complete blood counts, total IgE, and food specific IgE levels for egg white, cow’s milk protein and wheat.

Results

One hundred and eighty two (95% of the eligible children) were assessed. Of the 182 children examined eczema was diagnosed in 30 (16.5%) - 22 females and 8 males. The majority of children with eczema (20/30) were classified as being in the moderate and severe category. Of the 22 with eczema and 40 controls who consented to venipuncture all but 3 had IgE levels above the lab's reference range. Food specific antibody assays showed that 32, 23, and 5 percent of children with eczema were sensitized to egg, milk, and wheat respectively. None of the controls were sensitized.

Conclusions

The children of Natuashish, Labrador have a high rate of eczema, much of it graded as moderate or severe. IgE levels were markedly elevated in children with and without eczema, with average values at least ten-fold higher than other populations. There is no evidence of an unusual amount of sensitization to egg, milk or wheat.

Active or passive exposure to tobacco smoking and allergic rhinitis, allergic dermatitis, and food allergy in adults and children: a systematic review and meta-analysis

BACKGROUND

Allergic rhinitis, allergic dermatitis, and food allergy are extremely common diseases, especially among children, and are frequently associated to each other and to asthma. Smoking is a potential risk factor for these conditions, but so far, results from individual studies have been conflicting. The objective of this study was to examine the evidence for an association between active smoking (AS) or passive exposure to secondhand smoke and allergic conditions.

METHODS AND FINDINGS

We retrieved studies published in any language up to June 30th, 2013 by systematically searching Medline, Embase, the five regional bibliographic databases of the World Health Organization, and ISI-Proceedings databases, by manually examining the references of the original articles and reviews retrieved, and by establishing personal contact with clinical researchers. We included cohort, case-control, and cross-sectional studies reporting odds ratio (OR) or relative risk (RR) estimates and confidence intervals of smoking and allergic conditions, first among the general population and then among children. We retrieved 97 studies on allergic rhinitis, 91 on allergic dermatitis, and eight on food allergy published in 139 different articles. When all studies were analyzed together (showing random effects model results and pooled ORs expressed as RR), allergic rhinitis was not associated with active smoking (pooled RR, 1.02 [95% CI 0.92-1.15]), but was associated with passive smoking (pooled RR 1.10 [95% CI 1.06-1.15]). Allergic dermatitis was associated with both active (pooled RR, 1.21 [95% CI 1.14-1.29]) and passive smoking (pooled RR, 1.07 [95% CI 1.03-1.12]). In children and adolescent, allergic rhinitis was associated with active (pooled RR, 1.40 (95% CI 1.24-1.59) and passive smoking (pooled RR, 1.09 [95% CI 1.04-1.14]). Allergic dermatitis was associated with active (pooled RR, 1.36 [95% CI 1.17-1.46]) and passive smoking (pooled RR, 1.06 [95% CI 1.01-1.11]). Food allergy was associated with SHS (1.43 [1.12-1.83]) when cohort studies only were examined, but not when all studies were combined. The findings are limited by the potential for confounding and bias given that most of the individual studies used a cross-sectional design. Furthermore, the studies showed a high degree of heterogeneity and the exposure and outcome measures were assessed by self-report, which may increase the potential for misclassification.

CONCLUSIONS

We observed very modest associations between smoking and some allergic diseases among adults. Among children and adolescents, both active and passive exposure to SHS were associated with a modest increased risk for allergic diseases, and passive smoking was associated with an increased risk for food allergy. Additional studies with detailed measurement of exposure and better case definition are needed to further explore the role of smoking in allergic diseases.

Perinatal factors and the risk of atopic dermatitis: a cohort study

OBJECTIVE

To analyze the effects of pregnancy and early events in the newborn on the risk of subsequent atopic dermatitis (AD) during the first year of life.

PATIENTS AND METHODS

This is a prospective multicenter cohort study of newborns during the first year of life. Newborns identified on random days in three obstetrics departments in the area of Bergamo, Lombardy, Northern Italy, were eligible. At baseline, the mothers were interviewed by medical staff during their stay in hospital after delivery. At 6 and 12 months after delivery, a postal questionnaire was sent to the parents. Relative risks were calculated with and without adjustment by multiple regression analysis.

RESULTS

A total of 1081 newborns entered the study: 796 (74%) parents answered the 12-month questionnaire. Hundred and thirty-eight (17%) reported a diagnosis of AD at 6 months and 222 (28%) at 12 months. Parental history of AD and/or asthma was associated with an increased risk of AD (RR 1.5, 95%CI 1.1-2.0). Birth weight was slightly associated with an increased risk of AD: RR 1.04, 95%CI 1.001-1.08 (continuous variable, increment of 100 grams). No association emerged between breast feeding, smoking, and risk of AD.

CONCLUSIONS

This study in an Italian offspring cohort points to family history of atopic diseases and body weight at birth as relevant risk factors. The study was unable to document associations with other perinatal factors particularly breast feeding and parental smoking in the perinatal period.

Asthma and frequency of wheeze: risk factors for the persistence of atopic dermatitis in children

BACKGROUND

Studies have examined the development of asthma in children with atopic dermatitis (AD); however, none have looked at the association of asthma or the frequency of wheeze with respect to persistence or difficulty in achieving AD clinical improvement in children.

OBJECTIVE

To determine whether children with AD who have asthma and increasing frequency of wheezing have more persistent AD.

METHODS

This is a cohort study using the Pediatric Eczema Elective Registry (PEER) database, which includes data obtained at enrollment and 3 years later. The AD outcome was the persistence of skin symptoms. Our covariates of interest were asthma diagnosis and wheezing symptoms, which were measured at enrollment and again at year 3 of the study. Multivariate logistic regression models assessed the magnitude of associations among AD symptoms, asthma diagnosis, and the frequency of wheeze. All models were adjusted for sex, age, and ethnicity.

RESULTS

A total of 2104 children were enrolled in the PEER study and had at least 3 years of follow-up at the time of this study. At enrollment, an asthma diagnosis decreased the likelihood of being rash free in the preceding 6 months by 30% (odds ratio, 0.70; 95% confidence interval, 0.59-0.84). At year 3, having asthma decreased the likelihood by 40% (odds ratio, 0.60; 95% confidence interval, 0.49-0.72). Increasing frequency of wheezing also decreased the likelihood that a child was rash free (P < .001).

CONCLUSION

For children with AD, a history of asthma and an increasing frequency of wheezing correlate strongly with more persistent AD.

Atopic dermatitis in adolescence

Atopic dermatitis (AD) is a chronic inflammatory skin disorder that typically occurs during childhood especially in the first year of life, with a variable frequency from 10% to 30%. Recent studies have shown that in Europe among 10-20% of children with AD suffer from this disorder also in adolescence. AD is a chronic inflammatory skin disease with a typical onset in the first years of life and with a 10-30% prevalence among young children. AD prevalence in adolescence has been estimated around 5-15% in European countries. AD persists from childhood through adolescence in around 40% of cases and some risk factors have been identified: female sex, sensitization to inhalant and food allergens, allergic asthma and/or rhinoconjunctivitis, the practice of certain jobs. During adolescence, AD mainly appears on the face and neck, often associated with overinfection by Malassezia, and on the palms and soles. AD persistence during adolescence is correlated with psychological diseases such as anxiety; moreover, adolescents affected by AD might have problems in the relationship with their peers. Stress and the psychological problems represent a serious burden for adolescents with AD and cause a significant worsening of the patients' quality of life (QoL). The pharmacological treatment is similar to other age groups. Educational and psychological approaches should be considered in the most severe cases.

Quality of life measures in Italian children with atopic dermatitis and their families

BACKGROUND

The impact of atopic dermatitis (AD) on children's quality of life (QoL) in US and European countries is relatively well known, though rarely evaluated in the Italian population. Moreover, the association between child age and QoL has not been enough investigated, even though few studies detected a worse QoL in youngest AD children. The aim of the study was to evaluate the QoL in an Italian sample of atopic children and their families, also exploring a possible association with child age.

METHODS

60 AD children aged between 1-12 years and their mothers completed specific QoL questionnaires (IDQoL/CDLQI, DFI) and a clinician completed a measure of AD severity (SCORAD).

RESULTS

AD severity (Objective SCORAD) significantly correlated with QoL measures. Severe AD children showed higher IDQoL/CDLQI and DFI scores compared to mild and moderate AD groups (P = 0.006 and P < 0.0005, respectively), but only DFI scores differed in these last two conditions (P = 0.014). DFI scores negatively correlated with children's age (P = 0.046), but did not differ when considering child age ranges. Multiple linear regression analyses revealed a significant association between Objective SCORAD and QoL measures.

CONCLUSIONS

A strong association between severe AD and poor QoL, both in children and mothers, was found in the Italian sample, in line with the international literature. Family's QoL scores were sensitively related to AD severity, more than the child's QoL, emphasising that the disease has a deep impact on the family. A significant association between age and QoL was only partially found and needs further investigation.

Molecular and immunological characterization of Staphylococcus aureus in pediatric atopic dermatitis: implications for prophylaxis and clinical management

S. aureus represents a critical cofactor in atopic dermatitis (AD). In this paper, the prevalence of S. aureus infection/colonization was evaluated in 117 children as well as in their cohabitants, in order to assess the value of S. aureus characterization in predicting disease onset and severity and in providing indications for prophylaxis. Results showed that children with AD as well as their cohabitants had a significantly greater incidence of S. aureus infection/colonization as compared to controls. The genetic characterization showed a virtual identity of the bacteria strains collected at different sites of the patients with those found in the cohabitants, suggesting both a direct transmission between the nasal reservoir and the lesions in the same atopic subject and a risk for reinfection within family cohabitants. These data stress the need of preliminary laboratory assessment and posttherapy control in both AD patients and their close contacts for effective S. aureus eradication.

Atopic dermatitis in Tunisian schoolchildren

Introduction

The prevalence of atopic dermatitis (AD) is low in North Africa. We describe the epidemiology of this atopic condition among school children in Tunisia.

Methods

We conducted a Cross-sectional survey study of 5 to 6-year-old schoolchildren from 21 primary schools of Sfax. The diagnosis of AD was based on the U.K. Working Party diagnostic criteria. A questionnaire including these criteria and some risk factors of AD was issued to the children. All children were examined by one dermatologist.

Results

Among the 1617 examined children, ten had AD giving a one-year prevalence of 0.65%. The overall sex ratio was 2.33. The disease occurred before the age of 2 years in 3 children. Pure AD without concomitant respiratory allergies was noted in 3 cases. One first-degree family member with atopy was at least noted in seven children. The strongest associated factor was the presence of AD in at least one parent and maternal age at the time of the child birth. Nor breast-feeding neither environmental characteristics of the house did correlate with AD.

Conclusion

The prevalence of AD in Tunisian schoolchildren is low but comparable to those of other developing countries. Family history of atopy and maternal age at the birth time was the most important associated factors.

Balneotherapy for atopic dermatitis in children at Comano spa in Trentino, Italy

BACKGROUND

No controlled studies have investigated whether balneotherapy is effective in atopic dermatitis (AD).

OBJECTIVES

To investigate the efficacy and safety of balneotherapy performed at Comano spa (Trentino, Italy) compared to topical corticosteroids (TCS) in the treatment of AD.

METHODS

This was an open, randomized, clinical trial including 104 children (aged 1-14 years) with mild to moderate AD who were assigned either to balneotherapy (n = 54) or TCS (n = 50) once daily for 2 weeks. AD severity and quality of life were measured using the SCORAD, investigator global assessment (IGA), patients' self global assessment (PSGA), children's dermatology life quality index (CDLQI) and family dermatitis impact questionnaire (FDIQ). Subjective measures were re-evaluated 4 months after the end of therapy.

RESULTS

Balneotherapy and TCS resulted in a significant reduction of all parameters at week 2. TCS were more effective than balneotherapy regarding SCORAD (46% ± 7.71 vs 26% ± 9.4, mean ± SD; p < 0.03). In contrast, IGA, PSGA, CDLQI and FDIQ improvement was similar. At month 4, the number and duration of relapses were less in patients treated with balneotherapy compared to those treated with TCS (p <0.0001).

CONCLUSIONS

Balneotherapy at Comano spa appears to be beneficial in children with mild to moderate AD.

Validation of epidemiological tools for eczema diagnosis in Brazilian children: the ISAAC's and UK Working Party's criteria

Background

Instruments for field diagnosis of eczema are increasingly used, and it is essential to understand specific limitations to make best use of their strengths. Our objective was to assess the validity of ISAAC and UK Working Party criteria for field diagnosis of eczema in children.

Methods

We performed a cohort study in urban Brazil. Parents/guardians of 1,419 children answered ISAAC phase II questionnaire. Children were examined for skin lesions (UKWP protocol). Two dermatologists examined most cases of eczema (according to ISAAC or UKWP), and a sample without eczema.

Results

Agreement between repeat questionnaires on the filter question was poor (kappa = 0.4). Agreement between the 2 dermatologists was fair (kappa = 0.6). False positive reports included scabies in 39% of ISAAC cases and 33% of UKWP cases. Sensitivity and PPV were low (ISAAC: 37.1% and 16.1%; UKWP: 28.6% and 23.8%). Specificity and NPV were high (ISAAC: 90.0% and 96.6%; UKWP: 95.3% and 96.2%). One-year prevalence of eczema was 11.3% (ISAAC), 5.9% (UKWP) and 4.9% (adjusted dermatologist diagnosis). Point prevalence of scabies (alone or not) was 43%, 33% and 18%, in eczemas according to ISAAC, to UKWP and to dermatologists. The reasons why children with eczema were not identified by ISAAC or UKWP were wrongly denying dry skin, itchy rash or personal history of atopic diseases. A limitation is that questionnaire was already validated in Brazil, but not field tested in this specific setting.

Conclusions

Studies using UKWP or ISAAC criteria should include a validation arm, to contribute to the understanding of potential limitations of their use in different contexts and to explore solutions. We list specific recommendations.

Prediction of the incidence, recurrence, and persistence of atopic dermatitis in adolescence: a prospective cohort study

BACKGROUND

Although it is known that atopic dermatitis (AD) can develop during adolescence, research on its course and predictors in this age group is thus far limited.

OBJECTIVE

We aimed to describe the course of AD over puberty and prospectively determine risk factors for the incidence, recurrence, and persistence of AD until adolescence in a population-based cohort study.

METHODS

German participants of the International Study of Asthma and Allergies in Childhood Phase II were followed prospectively. The final dataset comprised 2857 adolescents, of whom 2433 were unaffected by AD at baseline. Bivariate and multivariate prediction models for the incidence, recurrence, and persistence of AD using early-life factors, family history of atopic diseases, and job history as predictors were developed.

RESULTS

The incidence of AD between ages 9 to 11 and 16 to 20 years was 1.7%, and recurrence was 2.4%. AD persisted in 47.6% of adolescents with AD symptoms at baseline (n = 424). High socioeconomic status, female sex, asthma symptoms and a positive skin prick test response at baseline, parental history of rhinitis/AD, and having worked in a high-risk job were significant predictors for the course of disease. With all the factors present, the probability of the incidence of AD was 21.4% (95% CI, 1.8% to 80.2%) and increased up to 81.7% (95% CI, 47.0% to 95.8%) for recurrence of AD and 87.6% (95% CI, 63.4% to 96.6%) for persistence of AD among those affected by AD. Early-life exposures did not predict the course of AD over puberty.

CONCLUSION

Genetic factors, early allergen sensitization, and having worked in a high-risk job seem to be more important for disease development in late adolescence than other early-life exposures.

A case of polypoid clear cell acanthoma on the nipple

Clear cell acanthoma (CCA) is a rare benign epidermal tumor. It usually presents as a flat nodule or dome-shaped plaque and is often localized on the legs of the elderly. We observed an unusual case of polypoid CCA on the nipple of a 14-year-old girl. At present, a few cases of CCA on the nipple area have been reported in the literature. However, CCA presented as a polypoid tumor on the nipple area has been reported very rarely. We herein report the very rare case of polypoid CCA on the nipple and suggest that CCA should be included in the clinical differential diagnosis of polypoid lesions on the nipple.

Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three

BACKGROUND

In 1999, The International Study of Asthma and Allergies in Childhood (ISAAC) Phase One reported the prevalence of eczema symptoms in 715,033 children from 154 centers in 56 countries by using standardized epidemiologic tools.

OBJECTIVE

To update the world map of eczema prevalence after 5 to 10 years (ISAAC Phase Three) and include additional data from over 100 new centers.

METHODS

Cross-sectional surveys using the ISAAC questionnaire on eczema symptoms were completed by adolescents 13 to 14 years old and by parents of children 6 to 7 years old. Current eczema was defined as an itchy flexural rash in the past 12 months and was considered severe eczema if associated with 1 or more nights per week of sleep disturbance.

RESULTS

For the age group 6 to 7 years, data on 385,853 participants from 143 centers in 60 countries showed that the prevalence of current eczema ranged from 0.9% in India to 22.5% in Ecuador, with new data showing high values in Asia and Latin America. For the age group 13 to 14 years, data on 663,256 participants from 230 centers in 96 countries showed prevalence values ranging from 0.2% in China to 24.6% in Columbia with the highest values in Africa and Latin America. Current eczema was lower for boys than girls (odds ratio, 0.94 and 0.72 at ages 6 to 7 years and 13 to 14 years, respectively).

CONCLUSION

ISAAC Phase Three provides comprehensive global data on the prevalence of eczema symptoms that is essential for public health planning. New data reveal that eczema is a disease of developing as well as developed countries.

Climate and prevalence of atopic eczema in 6- to 7-year-old school children in Spain. ISAAC phase III

Atopic eczema (AE) is a chronic skin disease. Recent reports indicate that the worldwide prevalence of AE is increasing and that various environmental factors are implicated in its aetiology. Climatic conditions have been related with AE prevalence, and Spain has varying climatic conditions. The aim of this study is to document the possible climatic influence on the prevalence of AE in schoolchildren aged 6-7 years in three different climatic regions in Spain. We conducted a cross-sectional population-based survey of 28,394 schoolchildren aged 6-7 years from 10 Spanish centres in three different climatic regions. The mean participation rate was 76.5%. AE prevalence was assessed using the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire and the Spanish Academy of Dermatology criteria used in Spain to diagnose AE. The data, including annual temperature, precipitation, relative humidity and the annual number of sunny hours per climatic region, were obtained from the Spanish National Institute of Meteorology. Different AE prevalences were found in all three climatic regions studied: Atlantic, 32.9; Mediterranean 28.3; and Continental 31.2 per 100 children studied (p < 0.005). AE was positively associated with precipitation and humidity, and was negatively associated with temperature and the number of sunny hours. The results show that AE is significantly dependent on meteorological conditions.

Diagnostic criteria for atopic dermatitis: a systematic review

BACKGROUND

Atopic dermatitis (AD) has a wide spectrum of dermatological manifestations and despite various validated sets of diagnostic criteria that have been developed over the past decades, there is disagreement about its definition. Nevertheless, clinical studies require valid diagnostic criteria for reliable and reproducible results.

OBJECTIVE

To summarize the evidence concerning the validity of diagnostic criteria for AD.

METHODS

All data sources were identified through searches on Medline, Embase and Cochrane databases. The Quality Assessment of Diagnostic Accuracy tool (QUADAS) was used. Results are presented in a receiver operating characteristic (ROC) plot.

RESULTS

Out of the 20 articles that met the criteria, 27 validation studies were identified. In two studies concerning Hanifin and Rajka diagnostic criteria sensitivity and specificity ranged from 87.9% to 96.0% and from 77.6% to 93.8%, respectively. Nineteen validation studies of the U.K. diagnostic criteria showed sensitivity and specificity ranging from 10% to 100% and 89.3% to 99.1%, respectively. Three validation studies concerning the Schultz-Larsen criteria showed sensitivity from 88% to 94.4% and specificity from 77.6% to 95.9%. In one article concerning the criteria of Diepgen, the sensitivity ranged from 83.0% to 87.7% and the specificity from 83.9% to 87.0%. One article studied the Kang and Tian criteria and reported 95.5% sensitivity and 100% specificity. One article validating the International Study of Asthma and Allergies in Childhood (ISAAC) criteria showed a positive and negative predictive value of 48.8% and 91.1%, respectively.

CONCLUSION

With this systematic review of the existing sets of diagnostic criteria for AD a varying number of validation studies with varying methodological quality was found. The U.K. diagnostic criteria are the most extensively validated. However, improvement of methodological design for validation studies and uniformity in well-validated and applicable diagnostic criteria are needed to improve future intervention studies and to compare study results.

Prevalence and risk factors for atopic dermatitis in preschool children

BACKGROUND

Atopic dermatitis (AD) is a common condition in infancy which usually disappears by 3 years of age in a significant proportion of children. The prognosis is mostly determined by severity and presence of atopic sensitization.

OBJECTIVES

To investigate prevalence of AD, comorbidities and risk factors in a population of preschool children aged 3-5 years.

METHODS

Children in kindergartens were evaluated. The International Study of Asthma and Allergies in Childhood written questionnaire (WQ) was used, with additional questions on risk factors. Atopy was investigated by skin prick tests.

RESULTS

One thousand, four hundred and two valid WQs (92% response rate) were returned for evaluation. The prevalence of AD symptoms in the last 12 months in the whole population was 18.1% (254 cases). Seventy-two per cent of these children presented AD-specific localizations. The prevalence of eczema as a doctor's diagnosis in the total population was 15.4%. Positive atopic sensitization was present in 18.6% of the total and in 32.2% of the AD study population, respectively. Multiple sensitivities were observed in 58.2% of sensitized children. The prevalence of sensitization demonstrated that the most common sensitizing allergens in children with AD were mites and grass pollen. Rhinitis symptoms and wheezing were present in 32.2% and 24.2%, respectively, of children with AD. Allergic sensitization to egg, cat, grass pollen and mites, as well as the presence of symptoms of rhinitis, and a positive family history of atopy were all significant risk factors for AD.

CONCLUSIONS

The study demonstrates a high prevalence of AD and a close relationship with rhinitis symptoms. Significant risk factors for AD were sensitization to food or inhalant allergens as well as parental history of atopy.

Environmental factors and allergic disorders

Despite numerous studies on possible associations between environmental exposure and allergic disorders, any conclusions made remain a matter of controversy. We conducted a review of evidence in relation to environmental and nutritional determinants and wheeze, asthma, atopic dermatitis, and allergic rhinitis. Identified were 263 articles for analysis after consideration of 1093 papers that were published since 2000 and selected by electronic search of the PubMed database using keywords relevant to epidemiological studies. Most were cross-sectional and case-control studies. Several prospective cohort studies revealed inconsistent associations between various environmental factors and the risk of any allergic disorder. Therefore, the evidence was inadequate to infer the presence or absence of a causal relationship between various environmental exposures and allergic diseases. However, evidence is suggestive of positive associations of allergies with heredity. Because almost all the studies were performed in Western countries, the application of these findings to people in other countries, including Japan, may not be appropriate. Further epidemiological information gained from population-based prospective cohort studies, in particular among Japanese together with other Asians, is needed to assess causal relationships between various environmental factors and allergic diseases.

No significant increase within a 3-year interval in the prevalence of atopic dermatitis among schoolchildren in Baranya County, Hungary

BACKGROUND

The prevalence of atopic dermatitis (AD) in children has significantly increased worldwide in the past decades. Although it is well known that the number of AD patients has also been growing in Hungary, there are only a few published prevalence studies that allow international comparisons.

OBJECTIVES

The aim of this study was to estimate the prevalence of AD among schoolchildren in Baranya County in 2005 and to compare the data with those from 2002.

METHODS

The data from the 1454 children (771 girls, 683 boys) surveyed in 2002, and 1454 children (760 girls, 694 boys) surveyed in 2005, respectively, aged 7-14 years were analysed. The distinct populations of the 7- to 9-year-old age groups were separately compared in relation to their lifetime AD prevalence.

RESULTS

The prevalence of AD accounted for 15.1% in 2002, and 16.1% in 2005. In the compared distinct 7- to 9-year-old populations the prevalence rates were 17.0% in 2002 and 17.1% in 2005. There were no statistically significant differences between the data of the two surveys.

CONCLUSIONS

The results indicate the high prevalence rate of AD nearly approaching the markedly high values registered in the welfare countries, and could indicate that AD has reached a plateau in Hungary.

[Prevalence of atopic eczema and nutritional factors in 6-7 year old children]

OBJECTIVES

To describe the prevalence of atopic eczema (AE) and to find the characteristics of the diet of children with AE.

DESIGN

Descriptive, transversal study.

SETTING

Primary schools.

MAIN MEASUREMENTS

The study used the standardized and validated questionnaire of the ISAAC phase III study, which finds the prevalence of AE in children and enables inter-centre comparison to be conducted. A questionnaire about food consumption was included. The prevalence ratio (PR) of AE and food consumption (95% confidence intervals) was calculated.

RESULTS

A total of 28 448 children aged 6-7 were included in the study. The prevalence of clinically diagnosed AE was 15.35% in boys and 15.24% in girls. The foods most often consumed were: dairy and cereals, followed by rice, pasta, and eggs. The least consumed were: butter, margarine, and fast food. The PR for children who consumed pasta was (PR=1.35), seafood (PR=1.28), cereals (PR=1.26), eggs (PR=1.13), and meat (PR=1.09).

CONCLUSIONS

The prevalence of AE in Spain was 15.3%, and was associated with food consumption. The consumption of dairy products, cereals, and olive oil was appropriate. The intake of fruit, vegetables, seafood, and legumes was below the recommended amounts. Future studies on the question are needed.

Atopic eczema. What has caused the epidemic in industrialised countries and can early intervention modify the natural history of atopic eczema?

Atopic eczema (AE) has a lifetime prevalence of between 15 and 20% in industrialized countries, but a very low prevalence in rural Africa. The 'atopic eczema epidemic' has developed in industrialized countries within the last four decades. The disease has a strong genetic influence, so environmental factors must be responsible for the dramatic increase in disease prevalence. It is therefore fair to consider what interventions may change its prevalence. In this article, several factors are considered: the increased number of doctors in industrialized countries, the development of drugs like topical steroids and emollients, the 'demanding parents' and 'old mother' syndromes, introduction of vaccination programmes, allergen exposure, breastfeeding and the possible beneficial effects of probiotics. In 90% of children with AE, onset is before the age of 5. Its course runs over years. Approximately two out of three outgrow the disease between 7 and 12 years of age. Although its cause is unknown, type I allergic reactions are common and allergen avoidance has been attempted in many studies as a preventive measure in atopic dermatitis. However, results are rather disappointing. The use of probiotics, i.e. daily intake of Lactobacillus, has proven effective in preventing, or at least delaying, the development of atopic eczema. So has breastfeeding, although some studies cannot confirm its beneficial effect. Therapeutic interventions using antihistamines, desensitisation and control of skin inflammation using topical steroids have not proven successful in shortening the course of atopic eczema, although controlled studies are lacking. The use of emollients has, however, a documented effect in up to one of three children with mild atopic eczema. It will be interesting to observe if the new topical immuno-modulators, tacrolimus and pimecrolimus, may be able to shorten the natural course of the disease.

Validation of the U.K. Working Party diagnostic criteria for atopic eczema in a Xhosa-speaking African population

BACKGROUND

Reliable diagnostic criteria for eczema are important for epidemiological comparisons. Although the U.K. diagnostic criteria for atopic eczema have performed well in an English language setting, limited data are available from other countries where cultural and linguistic factors may affect their validity.

OBJECTIVES

We sought to determine the validity of the U.K. criteria for eczema in relation to clinical assessment by a dermatologist in a Xhosa-speaking South African population.

METHODS

A cross-sectional survey of 3067 children aged 3-11 years was conducted in rural, peri-urban and urban settings in South Africa. The prevalence of atopic eczema was determined using the U.K. diagnostic criteria and a clinical assessment by a dermatologist. Questions were translated into the local language (Xhosa). Trained researchers administered the questions to the children's parents or carers. The validity of the U.K. criteria was then determined by calculating the sensitivity, specificity, positive and negative predictive values, and Youden's Index in relation to the dermatologist's examination.

RESULTS

The point prevalence of atopic eczema according to a dermatologist was 1.0% [95% confidence interval (CI) 0.6-1.4], while the prevalence of visible flexural eczema according to the U.K. protocol was 1.8% (95% CI 1.3-2.2). The sensitivity and specificity of the U.K. criteria in this setting was 43.7% (95% CI 26.3-62.3) and 97.9% (97.3-98.4), respectively. The positive and negative predictive values of the U.K. criteria were 18.4% (95% CI 10.4-28.9) and 99.4% (95% CI 99.0-99.6), respectively. The presence of visible flexural eczema according to the U.K. photographic protocol was the best predictor of atopic eczema, with a sensitivity and specificity of 81.2% (95% CI 63.5-92.7) and 99.0% (95% CI 98.6-99.3), respectively, and a positive and negative predictive value of 48.1% (95% CI 34.3-62.1) and 99.8% (95% CI 99.5-99.9), respectively.

CONCLUSIONS

The validity of the full question-based version of the U.K. diagnostic criteria for atopic eczema in this South African setting is low, which may be due to a combination of translational and cultural issues. However, the one physical sign of visible flexural eczema performed well, suggesting that it alone might be a useful tool for future international comparative prevalence studies.

[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.

The association between birth size and atopy in young North-European adults

BACKGROUND

There is evidence that atopic disorders may begin in intra-uterine life; however, studies of birth characteristics and atopy show conflicting results.

METHODS

We wanted to investigate the association of birth weight and head circumference with serum total or specific IgE, allergic rhinitis or eczema while addressing the influence of demographic and geographical factors. In this historic prospective cohort study, data were collected from birth records for 1683 men and women born in 1947-1973, from six Nordic-Baltic populations participating in the European Community Respiratory Health Survey. Blood tests for the measurement of serum total and specific IgE were available for 1494 subjects. In multiple regression analyses, adjustments were made for birth length, gender, age, study centre, adult body mass index, level of education, parental and adult smoking. RESULTS There was no association of birth weight (n=1230) and head circumference (n=285) with serum total IgE, specific IgE antibodies, allergic rhinitis or eczema. There were neither significant interactions by gender or age, nor heterogeneity between the study centres in the analyses of birth weight and adult atopy.

CONCLUSION

Birth size was not associated with atopy among adults in this large Nordic-Baltic population study.

Pimecrolimus in dermatology: atopic dermatitis and beyond

Pimecrolimus is a calcineurin inhibitor developed for the topical therapy of inflammatory skin diseases, particularly atopic dermatitis (AD). Pimecrolimus selectively targets T cells and mast cells. Pimecrolimus inhibits T-cell proliferation, as well as production and release of interleukin-2 (IL-2), IL-4, interferon-gamma and tumour necrosis factor-alpha. Moreover, pimecrolimus inhibits mast cell degranulation. In contrast to tacrolimus, pimecrolimus has no effects on the differentiation, maturation and functions of dendritic cells. In contrast to corticosteroids, pimecrolimus does not affect endothelial cells and fibroblasts and does not induce skin atrophy. Given the low capacity of pimecrolimus to permeate through the skin, it has a very low risk of systemic exposure and subsequent systemic side-effects. In different randomised controlled trials, topical pimecrolimus as cream 1% (Elidel) has been shown to be effective, well tolerated and safe in both adults and children with mild to moderate AD. In addition, pimecrolimus has been successfully used in inflammatory skin diseases other than AD, including seborrheic dermatitis, intertriginous psoriasis, lichen planus and cutaneous lupus erythematosus.

CD4(+)IL-13(+) cells in peripheral blood well correlates with the severity of atopic dermatitis in children

BACKGROUND

In atopic dermatitis (AD) a Th1/Th2 imbalance has been reported, and interleukin (IL)-13 seems to play a pivotal role in the inflammatory network. We tried to assess the correlation between the immunological marker CD4(+)IL-13(+) and the clinical phase of extrinsic AD in children.

METHODS

Twenty children with AD were studied. Assessed parameters were: clinical severity (SCORAD index), total serum immunoglobulin E (IgE), blood eosinophil count, and percentage of CD4(+)IFNgamma(+), CD4(+)IL-4(+), CD4(+)IL-13(+) T cells. Determinations were carried out in the acute phase and after clinical remission were achieved. Ten nonatopic-matched children served as controls.

RESULTS

At baseline, AD was mild in 25%, moderate in 50% and severe in 25% of children. In the acute phase a significant relationship between the eosinophil count and the SCORAD index was found (P = 0.0001). Blood CD4(+)IL-4(+) were significantly higher in the AD group (median 17.0, range: 13.7-21.4) than in controls (12.6, 6.4-17.2, P < 0.0001). CD4(+)IL-13(+) cells in the AD group well correlated (P = 0.0007) with SCORAD index. At remission, a significant correlation between SCORAD index and eosinophil count was found (P < 0.03) and the percentage of CD4(+)IL-13(+) cells globally decreased (P < 0.0001), while no difference was found among SCORAD classes.

CONCLUSION

This study confirms the Th2 profile predominance in the peripheral blood of children with AD, and evidences close relationship between the number of CD4(+)IL-13(+) T cells and the disease's severity.

Atopic dermatitis exclusively localized on nipples and areolas

We present an 11-year-old girl, with celiac disease, and a 9- month history of itchy and erythemato-edematous lesions with vesicles and exudation on her nipples and areolas. No other lesions or signs of scratching were present on her face or folds. She had no specific lesions of atopic dermatitis in typical sites nor in other body surface during her life. Patch tests showed a positive reaction to nickel and thimerosal that was not significantly related to the clinical appearance. This presentation documents the clinical relevance of atopic dermatitis minor diagnostic criteria. We discuss the importance of nipple eczema in AD and its differential diagnosis.