Guidelines for Diagnosis and Treatment of Atopic Dermatitis in China (2020)#

A systematic review of guidelines for the management of atopic dermatitis in children

Atopic dermatitis (AD) is a chronic disease that is increasing in prevalence, particularly in children and people with skin of colour. Current management involves topical treatments, phototherapy and immunosuppressants, as well as newer therapies like dupilumab. Health professionals should also be aware of the specific management considerations for AD in people with skin of colour. This systematic review was conducted to examine global guidelines for the management of AD in children, compare management recommendations, examine specific recommendations for children with skin of colour, and assess the quality of the guidelines. The databases Medline, Embase, CINAHL, Scopus, Guidelines International Network, and Emcare Nursing and Allied Health were searched to identify guidelines or articles relating to the management of AD in children from 1990 to 2023. A grey literature search was also undertaken. The recommendations from the guidelines were extracted and compared, and the quality of the guidelines was assessed using the Appraisal Guidelines for Research and Evaluation (AGREE) II tool. A total of 1644 articles were identified from the initial search. Title and abstract screening, full text screening, and reference checking yielded 28 guidelines for the final appraisal and data extraction. The main variations in management recommendations were the timing of emollients, bleach baths, bath additives, oral antihistamines, and the age cut-offs for topical calcineurin inhibitors. Many guidelines were not updated to reflect newer therapies like dupilumab and topical phosphodiesterase-4 (PDE4) inhibitors. There were minimal recommendations regarding management of skin of colour. Only 12/28 guidelines met the satisfactory cut-off score for the AGREE II appraisal, largely due to a lack of well-documented methodology. This review showed that the recommendations for AD management in skin of colour were consistently lacking. Despite generally consistent management strategies over the last 5 years, less than half of the guidelines met high-quality criteria, emphasising the importance of using tools like AGREE II in future guideline development.

Gut microbiota profile and atopic dermatitis in the first year of life

The connection between the immune response and the composition of gut microbiota has been associated with an increased prevalence of atopic dermatitis in the first year of life. The study aimed to investigate gut microbiota characteristics in infants with atopic dermatitis compared to healthy infants to better understand the link between early-life microbiota composition and the development of atopic dermatitis. The study analyzed the intestinal microbiota of 121 infants with clinical signs of atopic dermatitis, divided into Group I (infants with atopic dermatitis) and Group II (healthy controls). The study showed that infants with atopic dermatitis presented increased values of proteolytic bacteria mainly represented by Enterobacter species (P = 0.041), Klebsiella species (P = 0.038), and Escherichia coli (P = 0.013), with significantly decreased levels of acidifying bacteria represented by Enterococcus species, Lactobacillus and Bifidobacterium (P < 0.05) and normal levels of Clostridium species, Candida albicans, Mould fungi and Geotrichum species. This study highlights distinct differences in the gut microbiota of infants with atopic dermatitis, providing insights into the dynamic intestinal ecosystem during early life for future personalized therapeutic strategies.

Long-Term Efficacy and Safety of Stapokibart in Adults with Moderate-to-Severe Atopic Dermatitis: An Open-Label Extension, Nonrandomized Clinical Trial

BACKGROUND

Stapokibart/CM310, a humanized monoclonal antibody targeting the interleukin-4 receptor α chain, has shown promising treatment benefits in patients with moderate-to-severe atopic dermatitis in previous phase II clinical trials.

OBJECTIVE

We aimed to evaluate the long-term efficacy and safety of stapokibart in adults with moderate-to-severe atopic dermatitis.

METHODS

Enrolled patients who previously completed parent trials of stapokibart received a subcutaneous stapokibart 600-mg loading dose, then 300 mg every 2 weeks up to 52 weeks. Efficacy outcomes included the proportions of patients with ≥ 50%/75%/90% improvements from baseline of parent trials in the Eczema Area and Severity Index, Investigator's Global Assessment, and weekly average of the daily Peak Pruritus Numerical Rating Scale.

RESULTS

In total, 127 patients were enrolled, and 110 (86.6%) completed the study. At week 52, the Eczema Area and Severity Index-50/75/90 response rates were 96.3%, 87.9%, and 71.0%, respectively. An Investigator's Global Assessment 0/1 with a ≥ 2-point reduction was achieved in 39.3% of patients at week 16, increasing to 58.9% at week 52. The proportions of patients with ≥ 3-point and ≥ 4-point reductions in the weekly average of daily Peak Pruritus Numerical Rating Scale scores were 80.2% and 62.2%, respectively, at week 52. Improvement in patients' quality of life was sustained over a 52-week treatment period. Treatment-emergent adverse events occurred in 88.2% of patients, with an exposure-adjusted event rate of 299.2 events/100 patient-years. Coronavirus disease 2019, upper respiratory tract infection, and conjunctivitis were the most common treatment-emergent adverse events.

CONCLUSIONS

Long-term treatment with stapokibart for 52 weeks showed high efficacy and good safety profiles, supporting its use as a continuous long-term treatment option for atopic dermatitis.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04893707 (15 May, 2021).

TRPV3-Activated PARP1/AIFM1/MIF Axis through Oxidative Stress Contributes to Atopic Dermatitis

TRPV3 is a temperature-sensitive calcium-permeable channel. In previous studies, we noticed prominent TUNEL-positive keratinocytes in patients with Olmsted syndrome and Trpv3+/G568V mice, both of which carry gain-of-function variants in the TRPV3 gene. However, it remains unclear how the keratinocytes die and whether this process contributes to more skin disorders. In this study, we showed that gain-of-function variant or pharmacological activation of TRPV3 resulted in poly(ADP-ribose) polymerase 1 (PARP1)/AIFM1/macrophage migration inhibitory factor axis-mediated parthanatos, which is an underestimated form of cell death in skin diseases. Chelating calcium, scavenging ROS, or inhibiting nitric oxide synthase effectively rescued the parthanatos, indicating that TRPV3 regulates parthanatos through calcium-mediated oxidative stress. Furthermore, inhibiting PARP1 downregulated TSLP and IL33 induced by TRPV3 activation in HaCaT cells, reduced immune cell infiltration, and ameliorated epidermal thickening in Trpv3+/G568V mice. Marked parthanatos was also detected in the skin of MC903-treated mice and patients with atopic dermatitis, whereas inhibiting PARP1 largely alleviated the MC903-induced dermatitis. In addition, stimulating parthanatos in mouse skin with methylnitronitrosoguanidine recapitulated many features of atopic dermatitis. These data demonstrate that the TRPV3-regulated parthanatos-associated PARP1/AIFM1/macrophage migration inhibitory factor axis is a critical contributor to the pathogenesis of Olmsted syndrome and atopic dermatitis, suggesting that modulating the PARP1/AIFM1/macrophage migration inhibitory factor axis is a promising therapy for these conditions.

Heterogeneous Regulation of StaphylococcusAureus by Different StaphylococcusEpidermidisagr Types in Atopic Dermatitis

The skin commensal Staphylococcus epidermidis exhibits a protective role in skin inflammation; however, the exact functions of S. epidermidis and their mechanisms in atopic dermatitis (AD) are not fully understood. Here, whole-genome sequencing was conducted on strains of S. epidermidis isolated from pediatric patients with AD and revealed significant strain-level heterogeneity in functional genes. Specific sequence analysis of S. epidermidis identified four types of accessory gene regulator (agr) according to locus variations in the agr operon, which was consistent with the metagenomic data of the contextual microbiota. The number of S. epidermidisagr type I was slightly decreased among AD isolates, whereas agr type IV was hardly detected in AD isolates. Functional experiments showed that strains of S. epidermidisagr types I and IV, but not types II and III, inhibited the expression of S. aureusagr-mediated virulence factors in vitro, suppressed S. aureus epidermal colonization, and attenuated skin inflammation in a mouse model. The delineation of genome signatures of S. epidermidis at the strain level in AD and the quorum-sensing interference between S. epidermidisagr type IV and S. aureus provide a foundation for the modulation of the skin microbiota and the treatment of AD.

Burden of Disease; the Current Status of the Diagnosis and Management of Atopic Dermatitis in China

Atopic dermatitis (AD) is now a global health problem and has been attracting extensive attention from both academic and public society in China. This review aimed to present the current status of the prevalence, disease burden, clinical features, diagnosis, and management of AD in China. The prevalence of AD has been increasing rapidly in China during the past decades, partially due to the increased recognition of the disease; there are still substantial amounts of over-diagnosed eczema and under-diagnosed AD. Chinese dermatologists see many AD patients with atypical manifestation, which poses a challenge to the diagnosis. The Chinese diagnostic criteria for adults and pediatric patients with AD have been proposed respectively and validated with high sensitivity and specificity. International and Chinese guidelines for management of AD have been popularized; however, there are still many practices that need verification through randomized case-control study. Dupilumab and JAK inhibitors have demonstrated favorable efficacy for AD patients in China, and a multidimensional approach is needed for selection of the patients and evaluation of the efficacy and safety. Patient education and long-term management for AD are just beginning in China, and need to be strengthened in the future.

A Web-Based Instrument for Infantile Atopic Dermatitis Identification (Electronic Version of the Modified Child Eczema Questionnaire): Development and Implementation

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory cutaneous disease that affects 30.48% of young children; thus, there is a need for epidemiological studies in community settings. Web-based questionnaires (WBQs) are more convenient, time-saving, and efficient than traditional surveys, but the reliability of identifying AD through WBQs and whether AD can be identified without the attendance of doctors, especially in community or similar settings, remains unknown.

OBJECTIVE

This study aimed to develop and validate a web-based instrument for infantile AD identification (electronic version of the modified Child Eczema Questionnaire [eCEQ]) and to clarify the possibility of conducting WBQs to identify infantile AD without the attendance of doctors in a community-representative population.

METHODS

This study was divided into 2 phases. Phase 1 investigated 205 children younger than 2 years to develop and validate the eCEQ by comparison with the diagnoses of dermatologists. Phase 2 recruited 1375 children younger than 2 years to implement the eCEQ and verify the obtained prevalence by comparison with the previously published prevalence.

RESULTS

In phase 1, a total of 195 questionnaires were analyzed from children with a median age of 8.8 (IQR 4.5-15.0) months. The identification values of the eCEQ according to the appropriate rules were acceptable (logic rule: sensitivity 89.2%, specificity 91.5%, positive predictive value 97.1%, and negative predictive value 72.9%; statistic rule: sensitivity 90.5%, specificity 89.4%, positive predictive value 96.4%, and negative predictive value 75%). In phase 2, a total of 837 questionnaires were analyzed from children with a median age of 8.4 (IQR 5.2-14.6) months. The prevalence of infantile AD obtained by the eCEQ (logic rule) was 31.9% (267/837), which was close to the published prevalence (30.48%). Based on the results of phase 2, only 20.2% (54/267) of the participants identified by the eCEQ had previously received a diagnosis from doctors. Additionally, among the participants who were not diagnosed by doctors but were identified by the eCEQ, only 6.1% (13/213) were actually aware of the possible presence of AD.

CONCLUSIONS

Infantile AD can be identified without the attendance of doctors by using the eCEQ, which can be easily applied to community-based epidemiological studies and provide acceptable identification reliability. In addition, the eCEQ can also be applied to the field of public health to improve the health awareness of the general population.

Association of IL-4 and IL-18 genetic polymorphisms with atopic dermatitis in Chinese children

Background

Atopic dermatitis (AD) is a common chronic inflammatory skin disease, adversely affecting nearly 20% of the pediatric population worldwide. Interleukin-4 (IL-4) and interleukin-18 (IL-18) are considered to be involved in the pathogenesis and development of AD. The aim of this study was to investigate the association of IL-4 and IL-18 gene polymorphisms with the susceptibility and severity of AD in Chinese children.

Methods

Six candidate single nucleotide polymorphisms (SNPs) in IL-4 and IL-18 genes were genotyped through multi-PCR combined with next-generation sequencing in 132 AD children and 100 healthy controls, and all the analyses were performed on blood genome DNA.

Results

The frequencies of G allele, CG genotype and CG + GG genotype of IL-4 rs2243283, as well as the haplotype IL-4/GTT (rs2243283-rs2243250-rs2243248) were all significantly decreased in AD patients compared with the controls [G vs. C: P = 0.033, OR = 0.59; CG vs. CC: P = 0.024, OR = 0.47; CG + GG vs. CC: P = 0.012, OR = 0.49; GTT vs. CCT: P = 0.011, OR = 0.65]. Moreover, the frequencies of A allele, AA genotype and AG + AA genotype of IL-18 rs7106524, along with the haplotype IL-18/CAA (rs187238-rs360718-rs7106524) were statistically increased in the severe AD patients (A vs. G: P < 0.001, OR = 2.79; AA vs. GG: P = 0.003, OR = 5.51; AG + AA vs. GG: P = 0.036, OR = 2.93; CAA vs. CAG: P = 0.001, OR = 2.86).

Conclusions

Our findings suggested that genetic variation in IL-4 rs2243283 such as G allele, CG genotype and CG + GG genotype might confer the reduced susceptibility to AD in Chinese children. Furthermore, A allele, AA genotype and AG + AA genotype of IL-18 rs7106524 explored the strong association with severity in Chinese AD children.

Use patterns of systemic immunomodulators in the United States before and after dupilumab approval in adults with atopic dermatitis

PURPOSE

The patterns of dupilumab use, the first systemic drug approved for the treatment of atopic dermatitis (AD), is not well understood in the context of off-label systemic medications.

OBJECTIVE

To describe patterns of prescribing, switching and discontinuing systemic AD drugs, before and after the approval of dupilumab and understand variables associated with dupilumab prescription.

METHODS

Using longitudinal claims data, we identified patients with AD who initiated a systemic therapy (dupilumab, cyclosporine, methotrexate, azathioprine, mycophenolate) from March 2015 to February 2021, with a washout period of 1 year. We used Sankey plots to visualize longitudinal patterns of use at 3, 6, and 12 months and logistic regression to determine associates of dupilumab prescription.

RESULTS

The number of patients starting systemic treatment increased from 319 before dupilumab approval to 1358 after. Dupilumab use increased from 72% to 84%. In 2019-2020, 36% of patients discontinued systemic treatment within a year compared to 62% in 2015-2016. 92% of patients who started dupilumab in 2020-2021 had received no other systemic treatment before. Patients <60 years and those who used steroid-sparing topical treatments were more likely to receive dupilumab.

CONCLUSION

Among new users of a systemic treatment for AD, dupilumab was most used treatment by far.

Efficacy and safety of dupilumab in pediatric patients with moderate to severe atopic dermatitis: a real-world study

Dupilumab is the first human monoclonal antibody that treats atopic dermatitis (AD) by blocking interleukin 4 (IL-4) and interleukin 13 (IL-13), which can suppress the Th2 inflammatory reaction. Effective treatments for pediatric AD patients are limited; therefore, we aimed to assess the efficacy and safety of dupilumab in pediatric AD patients. Fifteen pediatric patients diagnosed with moderate to severe AD and treated with dupilumab were enrolled in this study. SPSS was used to analyze data and obtain the average values of Eczema Area and Severity Index (EASI), SCORing AD (SCORAD), and Children's Dermatology Life Quality Index (CDLQI). GRAPHPAD was used to analyze and plot the statistics. The average EASI values were 19.23 ± 3.03 and 1.69 ± 0.54 at baseline and at following up for 6 months after standardized treatment protocol, respectively. The average SCORAD values were 43.27 ± 4.63 and 6.13 ± 1.41 at baseline and at following up for 6 months after standardized treatment protocol, respectively. The average CDLQI value at baseline was 13.53 ± 2.88 and following up for 6 months after standardized treatment protocol was 1.60 ± 0.63. The most frequent adverse event was conjunctivitis. No serious adverse events occurred during the treatment period. Dupilumab could reduce symptoms and improve pruritus in pediatric AD patients, and the frequent adverse events were reversible. It has a definite therapeutic effect on AD; nevertheless, further studies should be conducted to obtain information on its the long-term efficacy and safety.

Use of Dexpanthenol for Atopic Dermatitis-Benefits and Recommendations Based on Current Evidence

BACKGROUND

Atopic dermatitis (AD) is an inflammatory skin disease of multiple phenotypes and endotypes, and is highly prevalent in children. Many people of all ages, including active adolescents, pregnant women, and the elderly, suffer from AD, experiencing chronicity, flares, and unexpected relapse. Dexpanthenol has multiple pharmacological effects and has been employed to treat various skin disorders such as AD. We aimed to summarize the up-to-date evidence relating to dexpanthenol and to provide a consensus on how to use dexpanthenol effectively for the treatment of AD.

METHODS

The evidence to date on the application and efficacy of dexpanthenol in AD was reviewed. The literature search focused on dexpanthenol use and the improvement of skin barrier function, the prevention of acute flares, and its topical corticosteroid (TCS) sparing effects. Evidence and recommendations for special groups such as pregnant women, and the effects of dexpanthenol and emollient plus in maintenance therapy, were also summarized.

RESULTS

Dexpanthenol is effective and well-tolerated for the treatment of AD. Dexpanthenol improves skin barrier function, reduces acute and frequent flares, has a significant TCS sparing effect, and enhances wound healing for skin lesions.

CONCLUSION

This review article provides helpful advice for clinicians and patients on the proper maintenance treatment of AD. Dexpanthenol, as an active ingredient in ointments or emollients, is suitable for the treatment and maintenance of AD. This paper will guide dermatologists and clinicians to consider dexpanthenol as a treatment option for mild to moderate AD.