Effect of mattress encasings on atopic dermatitis outcome measures in a double-blind, placebo-controlled study: the Dutch mite avoidance study

The Role of Inhalant Allergens on the Clinical Manifestations of Atopic Dermatitis

BACKGROUND

Inhalant allergens provide a source of environmental factors that contribute to the development of clinical symptoms in patients with atopic dermatitis (AD).

OBJECTIVE

To review the relationship between inhalant allergens and AD.

METHODS

A literature review was conducted using three databases: PubMed/MEDLINE, ClinicalKey, and Web of Science. Search terms, including "atopic dermatitis," "atopic eczema," and "eczema," were used in combination with "inhalant allergen," "inhaled allergen," and "aeroallergen" to identify relevant published manuscripts that highlight the relationship between AD and exposures to inhalant allergens.

RESULTS

Fifteen articles were suitable for review. The studies included in the review investigated the effect of inhalant allergens on the clinical manifestations of AD through bronchial provocation, direct skin contact, and allergen sensitization.

CONCLUSION

There is a significant relationship between exposures to inhalant allergens and AD. Inhalant allergens may aggravate AD symptoms by either bronchial provocation or direct skin contact. Sensitization of inhalant allergens, mainly house dust mites, follows a specific age-related pattern.

English Version of Clinical Practice Guidelines for the Management of Atopic Dermatitis 2021

This is the English version of the Clinical Practice Guidelines for the Management of Atopic Dermatitis 2021. Atopic dermatitis (AD) is a disease characterized by relapsing eczema with pruritus as a primary lesion. In Japan, from the perspective of evidence-based medicine, the current strategies for the treatment of AD consist of three primary measures: (i) use of topical corticosteroids, tacrolimus ointment, and delgocitinib ointment as the main treatment of the inflammation; (ii) topical application of emollients to treat the cutaneous barrier dysfunction; and (iii) avoidance of apparent exacerbating factors, psychological counseling, and advice about daily life. In the present revised guidelines, descriptions of three new drugs, namely, dupilumab, delgocitinib, and baricitinib, have been added. The guidelines present recommendations to review clinical research articles, evaluate the balance between the advantages and disadvantages of medical activities, and optimize medical activity-related patient outcomes with respect to several important points requiring decision-making in clinical practice.

Aeroallergens in Atopic Dermatitis and Chronic Urticaria

PURPOSE OF REVIEW

While aeroallergens are a well-established trigger of asthma and allergic rhinitis, their role in allergic skin diseases such as atopic dermatitis and chronic urticaria remains controversial. This paper reviews the pathophysiology and clinical evidence for aeroallergens in these allergic skin diseases and summarizes current strategies for evaluation and management.

RECENT FINDINGS

Current evidence implicates aeroallergens as triggers of cutaneous reactions in atopic dermatitis. Direct skin contact is the likely route of trigger. Aeroallergens may also trigger chronic urticaria, though mechanistic studies are limited. These allergens may cross the skin barrier and directly trigger neurons to release substance P, resulting in mast cell degranulation and dumping of histamine and prostaglandin D2. Many studies link aeroallergen sensitization to chronic urticaria, and case reports suggest the utility of avoidance strategies. The role of aeroallergens as a trigger is clear in atopic dermatitis and becoming emergent in chronic urticaria. Skin prick testing or serum-specific immunoglobulin E testing may be used to determine sensitivities. Management at this time centers on avoidance, and further studies are necessary to evaluate the efficacy of aeroallergen immunotherapy for both conditions.

[Allergen immunotherapy for atopic dermatitis]

Seit dem ersten Bericht über die Allergenimmuntherapie (AIT) durch Noon et al. vor 110 Jahren wurden zahlreiche klinische und grundlagenwissenschaftliche Studien durchgeführt, um die Effekte der einzigen kurativen Behandlung von Allergien zu untersuchen. Bei der atopischen Dermatitis (AD) findet sie jedoch nur selten Anwendung, obwohl es Evidenz dafür gibt, dass Aeroallergene zu Exazerbationen der Erkrankung beitragen können. Dieser Übersichtsbeitrag umfasst die aktuelle Studienlage, Metaanalysen und Leitlinienempfehlungen zur AIT bei AD-Patienten. Es zeigt sich eine große Heterogenität hinsichtlich Studiendesigns, Patientenkohorten, Allergenen, Applikationsformen und Endpunkten, wodurch die Vergleichbarkeit der Studien erschwert wird. Mehrere Untersuchungen zeigen eine positive Wirkung der AIT auf den Schweregrad der AD, was darauf hindeutet, dass zumindest eine Untergruppe von Patienten von der Behandlung profitieren kann. Weitere Entwicklungen auf dem Gebiet der AIT könnten dazu beitragen, dass die Therapie einen breiteren Einsatz bei AD-Patienten findet.

Secondary and Tertiary Prevention: Medical Rehabilitation

Allergies are a major public health burden, and targeted measures are required in terms of prevention and treatment. The most common allergic conditions encompass atopic dermatitis (AD), food allergy (FA), allergic asthma (AA), and allergic rhino-conjunctivitis (AR). Primary prevention aims at preventing the onset of allergic disease, before the disease process begins. Secondary prevention aims at preventing progression and exacerbation of allergic disease whereas tertiary prevention aims at reducing disease burden in patients with established disease, by allergen immunotherapy (AIT) or medical rehabilitation. Rehabilitation programs are used for treatment of AA and AD and usually consist of extensive patient assessment, optimization of treatment management, patient education, and behavioral interventions, ideally involving a multidisciplinary treatment team and sometimes provided in a specific climate, usually alpine or maritime. Similarly, prevention of occupational skin diseases requires interdisciplinary approaches on the level of secondary and tertiary preventive intervention; if this is provided, then prevention programs have proven highly (cost-) effective. Unfortunately, the recently published Minimal Standards of Prevention of these dermatoses, underlining especially the importance of meticulous allergological diagnosis and subsequent multidisciplinary patient education, are so far being adhered to only in very few European countries.

Medical devices in allergy practice

Medical devices provide people with some health benefits in terms of diagnosis, prevention, treatment, and monitoring of disease processes. Different medical specialties use varieties of medical devices more or less specific for them. Allergology is an interdisciplinary field of medical science and teaches that allergic reactions are of systemic nature but can express themselves at the level of different organs across the life cycle of an individual. Subsequently, medical devices used in allergology could be regarded as: 1) general, servicing the integral diagnostic and management principles and features of allergology, and 2) organ specific, which are shared by organ specific disciplines like pulmonology, otorhinolaryngology, dermatology, and others. The present position paper of the World Allergy Organization (WAO) is meant to be the first integral document providing structured information on medical devices in allergology used in daily routine but also needed for sophisticated diagnostic purposes and modern disease management. It is supposed to contribute to the transformation of the health care system into integrated care pathways for interrelated comorbidities.

Atopic Dermatitis: Identification and Management of Complicating Factors

Atopic dermatitis (AD) is a chronic relapsing inflammatory skin disease, associated with impaired skin barrier function and an atopic background. Various complicating factors, such as irritants, aeroallergens, food, microbial organisms, contact allergens, sweat, and scratching can induce the development of AD symptoms. Irritants, including soap/shampoo and clothes, can cause itching and eczematous lesions. In addition, young children with AD tend to become sensitized to eggs, milk, or peanuts, while older children and adults more often become sensitized to environmental allergens, such as house dust mites (HDM), animal dander, or pollen. Serum-specific IgE levels and skin prick test reactions to food tend to show high negative predictive values and low specificity and positive predictive values for diagnosing food allergy. On the other hand, AD adult patients tend to have severe skin symptoms and exhibit high HDM-specific IgE levels. Microbial organisms, e.g., Staphylococcus aureus and Malassezia furfur, might contribute to the pathogenetic mechanisms of AD. While sweat plays a major role in maintaining skin homeostasis, it can become an aggravating factor in patients with AD. Furthermore, scratching often exacerbates eczematous lesions. Several patient-specific complicating factors are seen in most cases. The identification and management of complicating factors are important for controlling AD.

Clinical practice guidelines for the management of atopic dermatitis 2018

Atopic dermatitis (AD) is a disease characterized by relapsing eczema with pruritus as a primary lesion. The current strategies to treat AD in Japan from the perspective of evidence-based medicine consist of three primary measures: (i) the use of topical corticosteroids and tacrolimus ointment as the main treatment for the inflammation; (ii) topical application of emollients to treat the cutaneous barrier dysfunction; and (iii) avoidance of apparent exacerbating factors, psychological counseling and advice about daily life. The guidelines present recommendations to review clinical research articles, evaluate the balance between the advantages and disadvantages of medical activities, and optimize medical activity-related patient outcomes with respect to several important points requiring decision-making in clinical practice.

Tips and Tricks for Controlling Eczema

Eczema is a chronic, relapsing, and remitting disease that can affect patients from infancy through adulthood. Severity of eczema ranges from mild to severe and can be plagued with recurrent flares. These flares can be difficult to treat and may require use of different strategies to address the issue. In this article, the author addresses different therapeutic options that can be used in those patients with difficult-to-treat eczema.

Diagnosis and Management of Atopic Dermatitis: A Review

GENERAL PURPOSE

The purpose of this learning activity is to provide information about the diagnosis and management of atopic dermatitis (AD).

TARGET AUDIENCE

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

LEARNING OBJECTIVES/OUTCOMES

After completing this continuing education activity, you should be able to:1. Recall the diagnostic process of AD.2. Identify nonpharmacologic therapies for skin care in patients with AD.3. Explain the pharmacologic management of AD.

ABSTRACT

Atopic dermatitis is a chronic, relapsing, intensely pruritic inflammatory skin disease that affects both children and adults. This article provides an overview of the epidemiology, clinical features, pathophysiology, complications, and specific investigations of atopic dermatitis. The current and novel therapies for the treatment of atopic dermatitis will be discussed.

Clinical Practice Guidelines for the Management of Atopic Dermatitis 2016

Atopic dermatitis (AD) is a disease characterized by relapsing eczema with pruritus as a primary lesion. Most patients have an atopic predisposition. The definitive diagnosis of AD requires the presence of all three features: (i) pruritus; (ii) typical morphology and distribution of the eczema; and (iii) chronic and chronically relapsing course. The current strategies to treat AD in Japan from the perspective of evidence-based medicine consist of three primary measures: (i) the use of topical corticosteroids and tacrolimus ointment as the main treatment for the inflammation; (ii) topical application of emollients to treat the cutaneous barrier dysfunction; and (iii) avoidance of apparent exacerbating factors, psychological counseling and advice about daily life. The guidelines present recommendations to review clinical research articles, evaluate the balance between the advantages and disadvantages of medical activities, and optimize medical activity-related patient outcomes with respect to several important points requiring decision-making in clinical practice.

In-vitro diagnostic in atopic dermatitis: Options and limitations

Atopic dermatitis is a chronic inflammatory skin disease with a complex pathogenesis and different exogenous and endogenous trigger factors. One important factor is the sensitization to inhalant and/or food allergens. The detection of total IgE and specific IgE antibodies to inhalant and/or food allergens is one central aspect in diagnosing atopic dermatitis, especially if skin prick tests are not feasible. Many patients are polysensitized, but not all sensitizations are of clinical relevance. The challenge is to identify the sensitizations with clinical relevance and to initiate suitable therapeutic options. In this article we go into detail for the allergens house dust mite, pollen, food, and Malassezia sympodialis. Furthermore, the authors comment on the impact of the detection of specific IgG/IgG4 antibodies in the diagnosis of food allergy in atopic dermatitis. Moreover, new options in the in-vitro diagnostic will be explained briefly and their actual diagnostic significance in patients with atopic dermatitis will be highlighted. These options are the detection of specific IgE antibodies to recombinant allergens and the allergen chip.

Scoping systematic review of treatments for eczema

Background

Eczema is a very common chronic inflammatory skin condition.

Objectives

To update the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) systematic review of treatments for atopic eczema, published in 2000, and to inform health-care professionals, commissioners and patients about key treatment developments and research gaps.

Data sources

Electronic databases including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Skin Group Specialised Register, Latin American and Caribbean Health Sciences Literature (LILACS), Allied and Complementary Medicine Database (AMED) and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched from the end of 2000 to 31 August 2013. Retrieved articles were used to identify further randomised controlled trials (RCTs).

Review methods

Studies were filtered according to inclusion criteria and agreed by consensus in cases of uncertainty. Abstracts were excluded and non-English-language papers were screened by international colleagues and data were extracted. Only RCTs of treatments for eczema were included, as other forms of evidence are associated with higher risks of bias. Inclusion criteria for studies included availability of data relevant to the therapeutic management of eczema; mention of randomisation; comparison of two or more treatments; and prospective data collection. Participants of all ages were included. Eczema diagnosis was determined by a clinician or according to published diagnostic criteria. The risk of bias was assessed using the Cochrane Collaboration risk-of-bias tool. We used a standardised approach to summarising the data and the assessment of risk of bias and we made a clear distinction between what the studies found and our own interpretation of study findings.

Results

Of 7198 references screened, 287 new trials were identified spanning 92 treatments. Trial reporting was generally poor (randomisation method: 2% high, 36% low, 62% unclear risk of bias; allocation concealment: 3% high, 15% low, 82% unclear risk of bias; blinding of the intervention: 15% high, 28% low, 57% unclear risk of bias). Only 22 (8%) trials were considered to be at low risk of bias for all three criteria. There was reasonable evidence of benefit for the topical medications tacrolimus, pimecrolimus and various corticosteroids (with tacrolimus superior to pimecrolimus and corticosteroids) for both treatment and flare prevention; oral ciclosporin; oral azathioprine; narrow band ultraviolet B (UVB) light; Atopiclair™ and education. There was reasonable evidence to suggest no clinically useful benefit for twice-daily compared with once-daily topical corticosteroids; corticosteroids containing antibiotics for non-infected eczema; probiotics; evening primrose and borage oil; ion-exchange water softeners; protease inhibitor SRD441 (Serentis Ltd); furfuryl palmitate in emollient; cipamfylline cream; andMycobacterium vaccaevaccine. Additional research evidence is needed for emollients, bath additives, antibacterials, specialist clothing and complementary and alternative therapies. There was no RCT evidence for topical corticosteroid dilution, impregnated bandages, soap avoidance, bathing frequency or allergy testing.

Limitations

The large scope of the review coupled with the heterogeneity of outcomes precluded formal meta-analyses. Our conclusions are still limited by a profusion of small, poorly reported studies.

Conclusions

Although the evidence base of RCTs has increased considerably since the last NIHR HTA systematic review, the field is still severely hampered by poor design and reporting problems including failure to register trials and declare primary outcomes, small sample size, short follow-up duration and poor reporting of risk of bias. Key areas for further research identified by the review include the optimum use of emollients, bathing frequency, wash products, allergy testing and antiseptic treatments. Perhaps the greatest benefit identified is the use of twice weekly anti-inflammatory treatment to maintain disease remission. More studies need to be conducted in a primary care setting where most people with eczema are seen in the UK. Future studies need to use the same core set of outcomes that capture patient symptoms, clinical signs, quality of life and the chronic nature of the disease.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

A Comprehensive Review of the Treatment of Atopic Eczema

Atopic eczema (AE) is a chronic, inflammatory skin disorder which usually develops in early childhood. In spite of intensive investigations, the causes of AE remain unclear, but are likely to be multifactorial in nature. Environmental factors or genetic-environmental interactions seem to play a key role in disease progression. Among various measures of AE managment, cutaneous hydration, which improves barrier function and relieve itchiness, may be helpful to reduce the need for topical steroid use and therefore should be used as a basic treatment. Avoiding aggravating factors is also a basic treatment of AE. Standard medical treatment with a pharmacologic approach may be necessary if basic treatment fails to control symptoms satisfactorily. Recently, more attention is given to a proactive therapeutic by regular intermittent application of low potency steroids or topical calcineurin inhibitors to prevent new flares. Furthermore, various targeted biologics are being introduced for AE control and are proposed as promising therapies. This paper provides a summary of the recent literature on the manangement of AE and a treatment guideline.

Consensus Guidelines for the Treatment of Atopic Dermatitis in Korea (Part I): General Management and Topical Treatment

Background

Since the treatment guidelines for atopic dermatitis (AD) were released by the Korean Atopic Dermatitis Association (KADA) work group in 2006, there have been several advances in AD management.

Objective

We aimed to establish updated evidence- and experience-based treatment guidelines for Korean AD.

Methods

We collected a database of references from relevant systematic AD reviews and guidelines regarding general AD management such as bathing and skin care, avoidance of exacerbating factors, education and psychosocial support, and the use of moisturizers and topical anti-inflammatory and antipruritic drugs. Evidence for each statement was graded and the strength of the recommendation for each statement classified. Thirty-nine KADA council members participated in three rounds of voting to establish an expert consensus of recommendations.

Results

Basic AD treatment includes proper bathing and skin care, avoidance of exacerbating factors, proper education and psychosocial support, and use of moisturizers. The regular use of moisturizer has a steroid-sparing effect and reduces relapse episodes. The short- and long-term use of topical corticosteroids and calcineurin inhibitors improves AD symptoms and should be encouraged to use in an active and proactive treatment. Wet-wrap therapy can be used for rapid recovery of acute exacerbation. Topical antipruritic drugs cannot be recommended for the treatment of AD.

Conclusion

This report provides up-to-date evidence- and experience-based treatment guidelines for AD regarding general management and topical treatment. In addition, the average agreement scores obtained by a panel of experts based on the Korean healthcare system and patient adherence are presented.

Personalized Immunomodulatory Therapy for Atopic Dermatitis: An Allergist's View

The current standard medical therapy for atopic dermatitis (AD) mainly focuses on symptomatic relief by controlling skin inflammation with topical corticosteroids and/or topical calcineurin inhibitors. However, the clinical efficacy of pharmacological therapy is often disappointing to both patients and physicians. The terminology of AD contains a historical meaning of eczematous dermatitis caused by hypersensitivity reaction to environmental inhalant or food allergen. Complex interrelationships among genetic abnormalities, environmental triggers, skin barrier defects, and immune dysfunction resulting in a vicious domino-circle seem to be involved in the development and maintenance of AD. In the viewpoint of AD as an allergic disease, complete avoidance of clinically relevant allergen or induction of specific immune tolerance through administrations of allergen (allergen immunotherapy) can provide clinical remission by breaking the vicious domino-circle maintaining a chronic disease state. In recent clinical studies, monoclonal antibodies including the anti-interleukin-4 receptor antibody and anti-B cell antibody induced significant clinical improvements in patients with AD. The detailed characteristics of immune dysfunction are heterogeneous among patients with AD. Therefore, a personalized combination of immunomodulatory therapies to reduce hypersensitivity (allergen immunotherapy) and correct immune dysfunction (monoclonal antibody therapy) could be a reasonable therapeutic approach for patients with AD. Future immunomodulatory therapies for AD should be developed to achieve long-term treatment-free clinical remission by induction of immune tolerance.

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.

Historic overview of allergy research in the Netherlands

Research in allergy has a long history in the Netherlands, although the relation with immunology has not always been appreciated. In many aspects Dutch researchers have made major contribution in allergy research. This ranges from the first characterization of house dust mite as an important allergen, the first characterization of human Th2 and Th1 T cell clones, to the development of diagnostic test systems. In this overview Aalberse and Knol have made an overview of the major contributions of Dutch immunologists in allergy.

Guidelines of care for the management of atopic dermatitis: Section 4. Prevention of disease flares and use of adjunctive therapies and approaches

Atopic dermatitis is a common, chronic inflammatory dermatosis that can affect all age groups. This evidence-based guideline addresses important clinical questions that arise in its management. In this final section, treatments for flare prevention and adjunctive and complementary therapies and approaches are reviewed. Suggestions on use are given based on available evidence.

The diagnosis and graded therapy of atopic dermatitis

BACKGROUND

Atopic dermatitis is the most common skin disease in children, with a prevalence of 10% to 15%, and is common in adults as well. Close coordination between primary care physicians and specialists is essential for the adequate treatment of chronically and severely affected patients.

METHOD

This article is a review of pertinent publications that were retrieved by a selective search in Pubmed, with additional consideration of the guidelines of the Association of Medical Scientific Societies in Germany (AWMF) and the European Dermatology Forum.

RESULTS

Trigger factors such as skin irritants, allergens, microbial pathogens, and psychological factors can affect the condition of the skin differently in individual patients and should be individually assessed. The use of skin moisturising creams or emollients along with avoidance of specific and unspecific irritants is of great importance, as these patients have an impaired cutaneous barrier. Topical anti-inflammatory treatment with glucocorticoids or calcineurin inhibitors is a central part of the management of atopic dermatitis; in exceptional cases, severely affected patients are treated with systemic anti-inflammatory drugs. Interdisciplinary patient education has been found to be an effective tool in the complex management of this disease. Chronically and severely affected patients present special challenges for diagnosis and treatment.

CONCLUSION

Recent advances in the understanding of the molecular basis of cutaneous barrier disorders and of congenital and acquired immune disorders have led to new approaches to the treatment of atopic dermatitis.

Impermeable dust mite covers in the primary and tertiary prevention of allergic disease: a meta-analysis

BACKGROUND

Up to 40% of the world's population has been diagnosed with an allergic disease. The most prevalent allergy is to house dust mites. Impermeable mattress covers are often the first treatment in the prevention and decrease of symptoms of allergic disease.

OBJECTIVE

To perform a meta-analysis evaluating the effectiveness of impermeable mattress covers in the primary prevention of allergic disease and as a single intervention in the tertiary prevention of allergic disease symptoms.

METHODS

MEDLINE, Embase, Web of Science, and CINAHL were systematically searched for relevant publications. Seven primary prevention trials (n = 3,461) and 17 tertiary prevention trials (n = 1,671) met the inclusion criteria and were included in the review. All article reviews and abstractions were performed in duplicate.

RESULTS

No significant pooled relative risks were found for the prevention of allergic disease. The pooled relative risks were 0.97 (95% confidence interval [CI] 0.62-1.51) for house dust mite sensitization, 0.92 (95% CI 0.81-1.05) for wheeze, 0.85 (95% CI 0.70-1.02) for asthma, 1.03 (95% CI 0.90-1.19) for allergic rhinitis, and 1.05 (95% CI 0.84-1.32) for allergic dermatitis. Likewise, no significant pooled standardized mean differences were found in the tertiary prevention of symptoms. The pooled standardized mean differences were -0.03 (95% CI -0.15 to 0.09) for peak flow, -0.06 (95% CI -0.32 to 0.20) for asthma symptom score, and -0.39 (95% CI -0.88 to 0.11) for nasal symptom score. A significant effect was seen in the decrease of house mite dust level in the mattress (-0.79, 95% CI -0.98 to -0.60).

CONCLUSION

No evidence was found to support the use of impermeable mattress covers in the primary prevention of allergic disease or in the tertiary prevention of allergic disease symptoms.

Evaluation of the adult patient with atopic dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disease with a large impact on quality of life of the patients and their families. In most cases, the diagnosis of AD can easily be made based on (family) history and clinical examination. If necessary, a practical set of diagnostic criteria such as the UK diagnostic criteria can be used. During the diagnostic phase, it is important to pay attention to atopic comorbidity, such as allergic airway disease (allergic asthma and/or rhinitis), allergic eye disease (atopic (kerato) conjunctivitis) and immediate-type food allergy. This will not have direct consequences for the treatment of AD, but may be important for the overall well-being of the patient. Psychological factors, such as family circumstances, work/school performance and lifestyle factors should also be explored. Severity scoring using properly validated scoring lists may not be necessary for the diagnosis, however, is recommended for monitoring therapy. Simple scoring systems, such as TIS and IGA are easy to perform in daily practice. Several flare factors in AD, such as exposure to irritants or UV light, can be identified by history and clinical examination: in individual cases, additional diagnostic tests may sometimes be useful to confirm clinical suspicion. There is only limited evidence that allergen exposure to aeroallergens and/or food allergens influences AD severity. Therefore, routine allergen testing is not necessary for diagnosis and treatment of AD. The decision to perform allergen tests mainly depends on atopic comorbidity.

Atopic dermatitis: a practice parameter update 2012

This parameter was developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "Atopic dermatitis: a practice parameter update 2012." This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma & Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion. Published practice parameters of the Joint Task Force on Practice Parameters for Allergy & Immunology are available online at http://www.jcaai.org.

Management of difficult-to-treat atopic dermatitis

Atopic dermatitis is a complex disorder caused by the interplay between multiple genetic and environmental factors. Particularly in patients with severe disease, the effect is not just an itchy rash but also the secondary effects on the psychological well-being of the patient and their carers, particularly disturbed sleep. The aim of this review is to provide health care professionals with a holistic approach to the management of difficult-to-treat atopic dermatitis, defined as atopic dermatitis seemingly unresponsive to simple moisturizers and mild potency (classes VI and VII) topical corticosteroids. The critical importance of education and advice is emphasized, as is the seminal role of secondary bacterial infection and polyclonal T-cell activation in causing acute flares in patients with severe, generalized disease. In atypical cases or those that do not respond to treatment, alternative diagnoses should be considered.

Surveillance of home environment in children with atopic dermatitis: a questionnaire survey

BACKGROUND

The increasing prevalence of atopic dermatitis (AD) suggests a role for environmental factors in triggering a genetic predisposition in sufferers.

OBJECTIVE

The purpose of this study was to investigate home environmental factors related to AD severity.

METHODS

We conducted a questionnaire survey about the home environmental factors in 380 children from two daycare centers and the Samsung Medical Center outpatient clinic. AD was diagnosed by Hanifin and Rajka's criteria and its severity was assessed by the Severity Scoring of Atopic Dermatitis index. Children were divided into normal control group, mild AD group and severe AD group. Home environmental factors were compared among the three groups and were statistically analyzed using analysis of variance, Chi-square test, Fisher's exact test, and multiple logistic analysis.

RESULTS

Indoor remodeling activities, such as painting (p = 0.004), floor covering (p = 0.001) and wallpaper changing (p = 0.002) were associated with severity of AD. Those in the severe AD group were more likely to live in an apartment (p < 0.001). Severe AD was observed more frequently when the monthly income of household (p = 0.027) and final educational status of mother (p = 0.001) were higher.

CONCLUSION

Some home environmental factors were associated with AD severity, but its causal relationship is not clear. Further research is needed to confirm these associations and to clarify whether they are causative.

Allergic triggers in atopic dermatitis

Food or environmental allergens play a significant pathogenic role in a subgroup of patients with atopic dermatitis (AD) and can trigger eczema flares. This review focuses on when and which diagnostic and allergen-avoidance measures are beneficial. Diagnosis of allergic triggers may be aided by skin-prick tests measuring serum-specific IgE and/or atopy patch tests (APT) based on the patient's history, and when necessary, oral food challenges (OFC). In a subset of patients, therapeutic measures, such as elimination of the incriminated allergen(s), can lead to marked improvement of AD; this is especially true for food allergens, but can also apply to inhalant allergens.

Useful tools for the management of atopic dermatitis

Eczema, frequently named atopic dermatitis, is the most frequent chronic skin disease of early childhood, with a high prevalence in industrialized countries and a relapsing-remitting course that is responsible for a serious burden on affected children and their families. Even though most facets of this disease are nowadays well known and numerous guidelines are available, some confusion still exists regarding certain aspects. First, several names have been proposed for the disorder. We suggest that the name and definition adopted by the World Allergy Organization should be used: 'eczema,' divided into 'atopic,' when an allergic sensitization can be demonstrated, and 'non-atopic,' in the absence of sensitization. Several diagnostic criteria have been proposed, but at present the two most reliable are the 2003 revision by the American Academy of Dermatology of the Hanifin-Rajka criteria, and those by Williams revised in 2005. To date, 20 different clinical scores have been published to assess the severity; however, only the EASI (Eczema Area and Severity Index), the SCORAD (SCORing Atopic Dermatitis), and the POEM (Patient-Oriented Eczema Measure) seem to have been adequately validated and are recommended for use in clinical practice and trials. The diagnostic tests to identify associated allergy or sensitization include skin-prick tests, determination of the specific IgE in serum using different assays, and atopy patch tests; in the case of suspected food allergy, a food challenge may be necessary to define the diagnosis. To evaluate quality of life, tools exist that allow both the child's and family's impairment to be considered. In addition, several algorithms exist to help decide therapy on a step-wise basis. However, such guidelines and algorithms represent only an aid to the physician and not an obligatory directive, since the ultimate judgment regarding any therapy must be performed by the physician and tailored to individual needs. A clear and validated definition of eczema control would permit better monitoring of the disease, similar to the situation with asthma in recent years. Finally, the review examines the role of special textiles in diminishing Staphylococcus aureus skin superinfection, of house dust-mite avoidance measures, and of educational programs for patients and their families, which may all help improve eczema.

The role of leukocytes, keratinocytes, and allergen-specific IgE in the development of atopic dermatitis

This review provides an overview of the inflammatory mechanisms and immunological aspects specific to atopic dermatitis. The review discusses publications on the roles of different T-cell subsets (that is, T helper 1 (Th1), Th2, T-regulatory, and Th17 cells), myeloid and plasmacytoid dendritic cells, and eosinophils. A further focus lies on keratinocyte-T-cell interactions, which may be of particular relevance in eczema. Mechanisms in innate and adaptive immunity that result in susceptibility to skin infections and in hyperreactivity to environmental stimuli, influencing the course and severity of atopic dermatitis, are summarized. Because the Journal of Investigative Dermatology has recently published reviews of specific features of barrier defects, defects in innate immunity, and, in this issue, genetics, these topics are only briefly discussed here in the context of immunology of atopic dermatitis.

The immune system and atopic dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disease with a complex pathogenesis. It is clinically well-defined and represents one manifestation of the atopic state, along with asthma, food allergy and/or allergic rhinitis. Within the last several decades, there has been much evidence to support the contribution of immune mechanisms in the pathogenesis of AD. It has also been documented that the prevalence of all atopic disease, including AD, has been increasing, although the environmental factors that may be contributing to this increase are not clearly defined. A better understanding of the underlying immunopathogenesis of AD should aid in better clinical management and development of new treatment options.

Clinical improvement and immunological changes in atopic dermatitis patients undergoing subcutaneous immunotherapy with a house dust mite allergoid: a pilot study

BACKGROUND

House dust mites (HDMs) represent significant indoor allergen sources for patients with atopic dermatitis (AD). Subcutaneous allergen-specific immunotherapy (SCIT) has been shown to be successful in patients with allergic rhinitis and mild asthma and might represent an attractive therapeutic option for the long-term treatment of HDM sensitizations in AD patients. However, only a few studies have been conducted on the effectiveness of HDM SCIT in AD, resulting in controversial clinical results. Data on immunological changes induced by SCIT in AD patients are rare.

OBJECTIVES

We performed an open pilot study to assess clinical changes and objective laboratory parameters and evaluate the benefit of HDM SCIT in 25 AD patients with IgE-mediated sensitization against HDM.

METHODS

The severity of AD was evaluated by the severity scoring of atopic dermatitis system (SCORAD). Specific IgE and IgG4 against HDM and serum levels of TARC/CCL17, MDC/CCL22, IL-16, IL-4, IFN-gamma, IL-10 and TGF-beta1 were measured during SCIT.

RESULTS

Subjective and objective SCORAD improved significantly within only 4 weeks of treatment. The level of the tolerogenic cytokine IL-10 increased, whereas CCL17 and IL-16 decreased in the sera of the patients during SCIT. Allergen specific IgE decreased, while IgG4 increased during SCIT.

CONCLUSION

In this open-label pilot study, SCIT with an HDM extract in patients with AD led to a significant improvement of AD mirrored by a reduction of SCORAD as well as serological and immunological changes, which might serve as valuable parameters to estimate the therapeutic effect of SCIT.

Home environment and suspected atopic eczema in Japanese infants: the Osaka Maternal and Child Health Study

Atopic eczema is most commonly diagnosed in children under the age of 5 yr. Environmental factors during pregnancy or in early life may confer risk for childhood atopic eczema. The present prospective study examined the relationship of the perinatal home environment and the risk of suspected atopic eczema among Japanese infants under the age of 1. Study subjects were 865 parent-child pairs. The term 'suspected atopic eczema' was used to define an outcome based on our questionnaire at 2-9 months postpartum. Adjustment was made for maternal age, gestation, family income, maternal and paternal education, maternal and paternal history of asthma, atopic eczema, and allergic rhinitis, time of delivery before the second survey, baby's older siblings, baby's sex, and baby's birth weight. A high mite allergen level from maternal bedclothes and mold in the kitchen during pregnancy were significantly associated with an increased risk of suspected atopic eczema. Frequent vacuuming practices during pregnancy and giving the infant a bath or shower at least once a day were significantly inversely related to the risk of suspected atopic eczema. Maternal smoking, maternal use of a synthetic duvet and pillow, carpet use in the living room and maternal bedroom, indoor domestic pets, no ducted heating appliance, and gas use for cooking during pregnancy and household smoking in the same room as the infant, infant's synthetic duvet, carpet use in the infant's room, or vacuuming the infant's room were not related to the risk of suspected atopic eczema. High house dust mite allergen levels and mold in the kitchen during pregnancy may increase the risk of infantile atopic eczema, whereas frequent vacuuming practices during pregnancy and giving the infant a bath or shower at least once a day may protect against infantile atopic eczema.

Prevention of allergic diseases

The prevalence of asthma and allergic diseases has increased in recent years, particularly in the industrialized world. Allergic disease begins to manifest in the first years of life. The disorder usually manifests initially in the form of food allergy and atopic dermatitis, followed in later stages by respiratory allergy with rhinitis and/or asthma. This has led to the adoption of preventive measures in those children with a high risk of atopy, based on the following considerations: 1) A family history of allergic diseases (asthma, eczema, and/or allergic rhinitis); 2) A personal history of atopy such as atopic dermatitis, particularly when associated to food allergy; and 3) The existence of allergic sensitization, particularly to pneumoallergens, of early or late onset, but persistent during childhood. Prevention is established at three different levels: primary prevention, avoiding sensitization; secondary prevention, avoiding appearance of the disease; and tertiary prevention, avoiding the symptoms. The present study discusses current knowledge of prevention and its efficacy, with mention of the importance of breastfeeding and the use of pre- and probiotics for securing adequate prevention.

The nursing programme ?Coping with itch?: a promising intervention for patients with chronic pruritic skin diseases

AIMS AND OBJECTIVE

To examine the feasibility of the nursing programme 'Coping with Itch' and the effect of the programme on the frequency and intensity of itching and scratching, itch-related coping, skin-related psychosocial morbidity and quality of life.

BACKGROUND

Itch is a major symptom of many chronic skin diseases and has a considerable impact on the quality of life. Therefore, the nursing programme 'Coping with Itch' has been developed and implemented at the outpatient departments of dermatology of one university and one general hospital in the Netherlands. The programme is intended to reduce itch and to help the patient cope with his or her itch.

DESIGN AND METHODS

The feasibility of the programme has been determined by interviewing the nurses who carried out the programme, dermatologists and one medical social worker and by counting the number of visits and specific interventions. The effect of the nursing care programme 'Coping with Itch' was evaluated in 32 patients with pruritic skin diseases. Paired t-tests were used to determine its effect after three and nine months.

RESULTS

The nursing programme 'Coping with Itch' proved to be practically feasible. It leads to a significant reduction of the frequency and intensity of itching and scratching, to a significant reduction of catastrophizing and helpless coping and to a significant reduction of skin-related psychosocial morbidity in the short term. These results stabilized at nine months. No changes were found in the quality of life.

CONCLUSION

The nursing programme 'Coping with Itch' is a promising intervention for patients with chronic pruritic skin diseases.

Prevalence and predictors of psychosocial morbidity in patients with chronic pruritic skin diseases

BACKGROUND

Itch is a major symptom of many skin diseases and causes patients considerable distress, adversely affecting quality of life. Feelings of helplessness and lack of control can influence the perceived itch and psychosocial complaints.

OBJECTIVES

To determine the prevalence of psychosocial morbidity among patients with pruritic skin diseases, and the influence of itch-related variables, coping strategies, and demographic variables on psychosocial morbidity.

PATIENTS AND METHODS

One hundred and sixty-eight patients with pruritic skin diseases from five hospitals in the Netherlands participated in the study. Skin-related psychosocial morbidity was measured with the Adjustment to Chronic Skin Diseases questionnaire (ACS); general psychosocial morbidity was measured with the Symptom Checklist-90 (SCL-90). The frequency and intensity of itching and scratching was recorded in diaries. Itch-related coping was measured with the Itching Cognitions Questionnaire (ICQ). Multiple regression analyses were used.

RESULTS

Patients with pruritic skin diseases had higher SCL-90 scores than a healthy Dutch population. All patients had psychosocial complaints as measured with the ACS. Thirty-nine per cent of the variance in skin-related psychosocial morbidity was explained by 'catastrophizing and helpless coping'; another 11% was explained by itching and scratching. Age and sex together explained another 10%. The frequency of itching and scratching (11%), 'catastrophizing and helpless coping' (19%) and skin-related psychosocial morbidity (10%) explained the variance in general psychosocial morbidity.

CONCLUSIONS

Patients with a pruritic skin disease have a high level of psychosocial morbidity. Catastrophizing and helpless coping are the most important predictors of psychosocial morbidity, with itching, scratching and demographic variables having a limited influence.

Atopic eczema: what's new?

Atopic eczema (AE) is a chronic inflammatory skin disease characterized by recurrent intense pruritus and a typical age-related distribution of skin lesions. Several new aspects with regard to the pathogenetic background as well as strategies for prevention, diagnosis and treatment of AE have emerged. There are ongoing studies on genetic susceptibility loci, as well as environmental and nutritional factors associated with an increase or a decrease of AE lesions. The atopy patch test is now available for identification of allergens in aeroallergen-triggered AE. New topical therapies, such as the calcineurin inhibitors, have broadened the therapeutic armamentarium substantially. In order to increase knowledge and coping strategies, patient education programs have been launched. Learning objective Upon completing this paper, the reader should be aware of new developments in AE, especially on nomenclature, prevention strategies, diagnostic tests, as well as therapeutic options.

What causes worsening of eczema? A systematic review

BACKGROUND

Flares of eczema are attributed to many factors, often with minimal scientific evidence.

OBJECTIVES

Systematically to search, summarize and critically appraise the scientific evidence to support the roles of individual 'flare factors' in eczema.

METHODS

We searched Medline from 1966 until 20 April 2005 to identify relevant articles for inclusion in this review. No language restrictions were imposed. All study designs were included and were ranked according to the strength of evidence. Experimental and provocation studies were restricted to those using a double-blind design. We included randomized controlled trials if they were provocation studies. Meta-analysis was not possible due to differences in study populations and methodology. The studies are therefore described qualitatively.

RESULTS

The roles of foodstuffs (13 studies), house dust mite (three), other aeroallergens (two), seasonality (two), bacterial infections (one), textiles (three), detergents (one), sunlight (one) and stress (two) were assessed in different study populations, using a variety of study designs. All studies were performed on selected groups and only four were longitudinal in design. Collectively, these studies provide some evidence that certain foods, house dust mite, stress and seasonal factors are relevant causes of disease worsening in certain subgroups with eczema. No good evidence could be found to support the role of detergents, textiles and irritants in causing worsening of eczema.

CONCLUSIONS

Despite anecdotal lists in textbooks and review articles, very little good evidence exists for 'flare factors' in eczema. The focus of all of the included studies was on disease worsening rather than clinically relevant flares. Studies of longitudinal design are required to clarify the roles of these and other putative flare factors in eczema.

[Atopy patch testing with aeroallergens and food]

The atopy patch test (APT), a patch test employing allergens known to elicit IgE-mediated reactions which is assessed by evaluating eczematous skin lesions after 24 h to 72 h, was developed as a diagnostic tool for characterizing patients with aeroallergen-triggered atopic eczema (AE, atopic dermatitis). Positive APT reactions are associated with allergen-specific T-cell responses. The specificity of APT is higher than the specificity of skin prick tests or RAST. More studies for the standardization of APT methods are necessary, especially with regard to food APT.

How is the indoor environment related to asthma?: literature review

AIMS

This paper reports a review conducted to identify the factors in the indoor environment that have an evidence-based link with the exacerbation or development of asthma and to identify measures that healthcare professionals can promote to reduce exposure to these risk factors in the home.

BACKGROUND

The indoor environment, particularly at home, has been recognized as a major source of exposure to allergens and toxic chemicals. Exposure to allergens and toxins is thought to exacerbate respiratory conditions, in particular, asthma.

METHODS

Searches were made of health and indoor environment databases, including Cochrane Library, National Health Services Centre for Reviews and Assessment Reports, British Medical Journal, CINAHL and Ovid library, MEDSCAPE/MEDLINE, EMBASE, INGENTA, Science Citation Index, Web of Science. Searches were also made of other Internet-based resources, including those of international and government bodies. The following keywords were used: allergens, allergen avoidance, asthma, asthma prevention, cat, damp, Der p 1, dog, environmental control, house dust mites, indoor air quality, indoor environment, meta analysis, mould, pets, remedial actions, respiratory illnesses and systematic reviews.

FINDINGS

There is evidence of a link between asthma and a small number of indoor environmental factors. There is currently only reasonable evidence for one causative factor for asthma in the indoor environment and that is house dust mite allergen. Although there are many studies of different remedial actions that can be taken in the home, often these give evidence of reduced risk of exposure but not clinical improvement in asthma. Although there is a lack of medical evidence for the reduction of known sensitizers such as mould, this is because of a dearth of research rather than evidence of no association.

CONCLUSIONS

There is some evidence of a link between the indoor environment and asthma. There are measures, which could be promoted by healthcare professionals to alleviate asthmatic symptoms.