Dust mite avoidance in atopic dermatitis

Mite allergy and atopic dermatitis: Is there a clear link? (Review)

Atopic dermatitis (AD) represents a widespread chronic skin disease associated with different atopic disorders and allergies. These associations, similar to overall AD pathophysiology, are entangled, multifactorial and they are yet to be clarified. IgE and non IgE mediated pathomechanisms appear to be implicated in AD. Allergens constitute key aspects in AD pathogenesis, as they may serve as trigger factors. This review emphasizes mainly house dust mites (HDM), as they are likely the most relevant airborne allergen for AD. Here we review in a concise form the mite allergens, the role of molecular diagnosis and the treatment strategies for HDM. Strategies of avoiding allergens, with a few exceptions, are not enough to control children's AD; recent studies show HDM avoidance procedures in diagnosed AD are insufficient. Regardless, some guidelines acknowledge the benefit of mattress and pillow covers in patients with dust mite sensitization that are unresponsive to optimal AD management. Most clinical trials investigating allergen-specific immunotherapy (AIT) as a potential treatment for AD were done with adult patients; a scarce number of studies looked into the efficacy of AIT as a treatment option in children suffering from AD, with conflicting data among them. One of the most feasible of these studies showed significant improvement of AD outcomes only in the mild/moderate group, but not in the severe group. Uncontrolled studies are hard to interpret, considering the natural history of remitting and relapsing of AD, in many of the patients, without clinical interventions. More AIT studies, especially pediatric studies, are required in order to either prove the reproducibility of positive results or to deny its effectiveness.

House dust mite reduction and avoidance measures for treating eczema

BACKGROUND

Eczema is an inflammatory skin disease that tends to involve skin creases, such as the folds of the elbows or knees; it is an intensely itchy skin condition, which can relapse and remit over time. As many as a third of people with eczema who have a positive test for allergy to house dust mite have reported worsening of eczema or respiratory symptoms when exposed to dust.

OBJECTIVES

To assess the effects of all house dust mite reduction and avoidance measures for the treatment of eczema.

SEARCH METHODS

We searched the following databases up to 14 August 2014: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2014, Issue 8), MEDLINE (from 1946), Embase (from 1974), LILACS (from 1982), and the GREAT database. We also searched five trials registers and checked the reference lists of included and excluded studies for further references to relevant studies. We handsearched abstracts from international eczema and allergy meetings.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of any of the house dust mite reduction and avoidance measures for the treatment of eczema, which included participants of any age diagnosed by a clinician with eczema as defined by the World Allergy Organization. We included all non-pharmacological and pharmacological interventions that sought to reduce or avoid exposure to house dust mite and their allergenic faeces. The comparators were any active treatment, no treatment, placebo, or standard care only.

DATA COLLECTION AND ANALYSIS

Two authors independently checked the titles and abstracts identified, and there were no disagreements. We contacted authors of included studies for additional information. We assessed the risk of bias using Cochrane methodology.

MAIN RESULTS

We included seven studies of 324 adults and children with eczema. Overall, the included studies had a high risk of bias. Four of the seven trials tested interventions with multiple components, and three tested a single intervention. Two of the seven trials included only children, four included children and adults, and one included only adults. Interventions to reduce or avoid exposure to house dust mite included covers for mattresses and bedding, increased or high-quality vacuuming of carpets and mattresses, and sprays that kill house dust mites.Four studies assessed our first primary outcome of 'Clinician-assessed eczema severity using a named scale'. Of these, one study (n = 20) did not show any significant short-term benefit from allergen impermeable polyurethane mattress encasings and acaricide spray versus allergen permeable cotton mattress encasings and placebo acaricide spray. One study (n = 60) found a modest statistically significant benefit in the Six Area, Six Sign Atopic Dermatitis (SASSAD) scale over six months (mean difference of 4.2 (95% confidence interval 1.7 to 6.7), P = 0.008) in favour of a mite impermeable bedding system combined with benzyltannate spray and high-filtration vacuuming versus mite permeable cotton encasings, water with a trace of alcohol spray, and a low-filtration vacuum cleaner. The third study (n = 41) did not compare the change in severity of eczema between the two treatment groups. The fourth study (n = 86) reported no evidence of a difference between the treatment groups.With regard to the secondary outcomes 'Participant- or caregiver-assessed global eczema severity score' and the 'Amount and frequency of topical treatment required', one study (n = 20) assessed these outcomes with similar results being reported for these outcomes in both groups. Four studies (n = 159) assessed 'Sensitivity to house dust mite allergen using a marker'; there was no clear evidence of a difference in sensitivity levels reported between treatments in any of the four trials.None of the seven included studies assessed our second primary outcome 'Participant- or caregiver-assessed eczema-related quality of life using a named instrument' or the secondary outcome of 'Adverse effects'.We were unable to combine any of our results because of variability in the interventions and paucity of data.

AUTHORS' CONCLUSIONS

We were unable to determine clear implications to inform clinical practice from the very low-quality evidence currently available. The modest treatment responses reported were in people with atopic eczema, specifically with sensitivity to one or more aeroallergens. Thus, their use in the eczema population as a whole is unknown. High-quality long-term trials of single, easy-to-administer house dust mite reduction or avoidance measures are worth pursuing.

Management of itch in atopic dermatitis

Atopic dermatitis is a common, pruritic, inflammatory skin disorder. Chronic, localized, or even generalized pruritus is the diagnostic hallmark of atopic dermatitis, and its management remains a challenge for physicians. The threshold for itch and alloknesis is markedly reduced in these patients, and infections can promote exacerbation and thereby increase the itch. Modern management consists of anti-inflammatory, occasionally antiseptic, as well as antipruritic therapies to address the epidermal barrier as well as immunomodulation or infection. Mild forms of atopic dermatitis may be controlled with topical therapies, but moderate-to-severe forms often require a combination of systemic treatments consisting of antipruritic and immunosuppressive drugs, phototherapy, and topical compounds. In addition, patient education and a therapeutic regimen to help the patient cope with the itch and eczema are important adjuvant strategies for optimized long-term management. This review highlights various topical, systemic, and complementary and alternative therapies, as well as provide a therapeutic ladder for optimized long-term control of itch in atopic dermatitis.

Bacterial superantigen facilitates epithelial presentation of allergen to T helper 2 cells

Although clinical and laboratory evidence support roles for both staphylococcal infection and environmental allergens in the pathogenesis of atopic dermatitis, human studies have largely considered these variables independently. We sought to test the hypothesis that staphylococcal superantigen influences the allergen-specific T cell response. We first mapped a Der p 1 epitope and used HLA DRB1*1501 class II tetramer-based cell sorted populations to show that specific CD4(+) T cells were able to recognize the peptide presented by HLA DR-matched keratinocytes. We observed that staphylococcal enterotoxin B (SEB) enhanced the IL-4 Der p 1-specific T cell response. This response was mediated by two synergistic mechanisms: first, SEB-induced IFN-gamma promoted class II and intercellular adhesion molecule-1 expression by presenting keratinocytes; and second, SEB-induced IL-4 directly amplified allergen-specific CD4(+) T cell production of many cytokines. We propose that handling of staphylococcal infection is a critical step in the amplification of the allergen-specific T cell response, linking two common disease associations and with implications for the prevention and treatment of atopic disease.

Quantitation of house dust mite allergens (Der f 1 and group 2) on the skin and hair of dogs

OBJECTIVE

To determine the concentration of house dust mite (HDM) allergens, Der f 1 and group 2, on the skin and hair of dogs and whether associations exist between the presence of Der f 1 and group 2 allergens on the skin and hair of dogs and household and dog characteristics.

ANIMALS

63 pet dogs from 50 homes.

PROCEDURE

Dogs were weighed and body surface area in square meters was determined. Skin and hair samples were obtained by vacuuming dogs. Collected dust was analyzed by use of standard ELISA techniques.

RESULTS

HDM allergen was detected in 21 of 59 skin and hair samples. Presence of group 2 allergen on skin and hair of dogs was significantly associated with long hair, compared with short or medium length hair. Median house dust sample concentrations of Der f 1 and group 2 allergens were high in homes with dogs that had skin and hair samples that were positive for Der f 1 and group 2 allergens. Dogs with skin and hair samples that were positive for Der f 1 and group 2 allergens resided in homes with a high number of house dust samples that were positive for Der f 1, group 2, or both allergens and in homes with a mean house dust sample allergen concentration of > or =2 microg/g of dust.

CONCLUSIONS AND CLINICAL RELEVANCE

Associations exist between environmental HDM allergen concentrations and HDM allergens on the skin and hair samples of dogs. Environmental allergen load is a major factor in accumulation of allergens on the skin and hair of dogs.

Quantitation of house dust mites and house dust mite allergens in the microenvironment of dogs

OBJECTIVE

To quantitate the density of Dermatophagoides farinae and D pteronyssinus and concentrations of house dust mite (HDM) allergens (Der f 1, Der p 1, and Group 2 allergens) in the indoor microenvironment of dogs. Sample Population-50 homes in Columbus, Ohio.

PROCEDURES

n each home, samples of dust were collected from 3 locations in which dogs spent most time. Whenever possible, the species of mites collected was identified. Mite density (mites/g of dust) was assessed, and allergen concentrations were assayed by standardized ELISAs. Relative humidity and temperature in each home were monitored during a 5-day period. Characteristics of homes and sample sources were evaluated.

RESULTS

Dust samples from all 50 homes contained > or = 1 HDM allergen; Der f 1 and Der p 1 were detected in 100 and 74% of homes, respectively. Fifteen homes had HDMs; compared with D pteronyssinus, D farinae was found more commonly (14/15 homes) and at a higher density. Basements, homes without central air-conditioning, and dog beds that were > or = 1 year old had high HDM allergen concentrations. Homes with > or = 2 microg of Der f 1 or Group 2 allergens/g of dust or > or = 100 mites/g of dust were significantly more likely to have a maximum relative humidity > or = 75%.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicate the presence of HDMs and HDM allergens in the specific microenvironment of dogs in homes. Factors associated with high levels of exposure were identified, which may be associated with increased risk for sensitization and development of atopic diseases.

Quantitation of house dust mites and house dust mite allergens in the microenvironment of dogs

OBJECTIVE

To quantitate the density of Dermatophagoides farinae and D pteronyssinus and concentrations of house dust mite (HDM) allergens (Der f 1, Der p 1, and Group 2 allergens) in the indoor microenvironment of dogs.

SAMPLE POPULATION

50 homes in Columbus, Ohio.

PROCEDURES

In each home, samples of dust were collected from 3 locations in which dogs spent most time. Whenever possible, the species of mites collected was identified. Mite density (mites/g of dust) was assessed, and allergen concentrations were assayed by standardized ELISAs. Relative humidity and temperature in each home were monitored during a 5-day period. Characteristics of homes and sample sources were evaluated.

RESULTS

Dust samples from all 50 homes contained > or = 1 HDM allergen; Der f 1 and Der p 1 were detected in 100 and 74% of homes, respectively. Fifteen homes had HDMs; compared with D pteronyssinus, D farinae was found more commonly (14/15 homes) and at a higher density. Basements, homes without central air-conditioning, and dog beds that were > or = 1 year old had high HDM allergen concentrations. Homes with > or = 2 microg of Der f 1 or Group 2 allergens/g of dust or > or = 100 mites/g of dust were significantly more likely to have a maximum relative humidity > or = 75%.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated the presence of HDMs and HDM allergens in the specific microenvironment of dogs in homes. Factors associated with high levels of exposure were identified, which may be associated with increased risk for sensitization and development of atopic diseases.