Association between childhood atopic dermatitis and cutaneous, extracutaneous and systemic infections

Efficacy and Risk Stratification of Janus Kinase Inhibitors in the Treatment of Moderate-to-Severe Atopic Dermatitis

Recently, 3 oral Janus kinase (JAK) inhibitors-abrocitinib, baricitinib, and upadacitinib-were approved in many regions around the world for the treatment of moderate-severe atopic dermatitis (AD). These JAK inhibitors generally have rapid onset of action and short half-life. Higher doses of abrocitinib and upadactinib even demonstrated superior efficacy to dupilumab. However, JAK inhibitors can be associated with rare serious and potentially life-threatening adverse events. Heterogeneity in study designs and lack of head-to-head studies make safety comparison between JAK inhibitors difficult. Dose reduction and patient selection are the most important considerations for risk mitigation. This narrative review examines the efficacy data for abrocitinib, baricitinib, and upadacitinib from large phase III double-blinded randomized controlled trials in AD and discusses risk stratification for oral JAK inhibitors in AD patients.

Association of Adult Atopic Dermatitis Severity With Bacterial, Viral, and Fungal Skin Infections

Background: Little is known about the relationship of atopic dermatitis (AD) severity, phenotype, and persistence on different types of skin infections. Objective: To evaluate the relationship of AD characteristics and skin infections over time in adults. Methods: We performed a prospective dermatology practice-based study (n = 559). History of infection was assessed using questionnaires. AD severity was evaluated using Scoring Atopic Dermatitis (SCORAD), Eczema Area and Severity Index (EASI), Investigator's Global Assessment (IGA), and Patient-reported Global Assessment (PtGA). Results: At baseline, 160 (21.4%) patients reported history of ≥1 skin infection, including 14.3% with bacterial infections. In multivariable repeated measures logistic regression models, ≥1 cutaneous infection was associated with moderate (adjusted odds ratio [95% confidence interval]: 2.67 [1.67-4.28]) and severe (6.35 [3.36-12.01]) versus mild SCORAD; as well as severe SCORAD-itch; moderate and severe versus clear-mild EASI; moderate and severe versus clear-mild PtGA; mild, moderate, and severe versus clear-almost clear IGA. Cutaneous infections were not associated with ichthyosis, palmar hyperlinearity, nummular eczema, cheilitis, or hand eczema. Specific infections varied by AD severity and body site. Persistent moderate-severe disease was associated with higher odds of skin infection. Conclusion: Skin infections were associated with AD severity but not phenotype, and may be mitigated by improved AD severity.

Dermatology for the internist: optimal diagnosis and management of atopic dermatitis

Internists are front-line health care providers that commonly provide the first encounter to patients for dermatological conditions, especially atopic dermatitis (AD). Internists need to be comfortable with managing mild-moderate AD in their practices. Criteria and guidelines established in dermatology literature are available to help the general practitioner diagnose and treat AD. AD is a systemic disease associated with multiple cutaneous and extra-cutaneous comorbidities that warrant screening by internists, especially mental health conditions. Environmental factors may play a role in the development or worsening of AD; however, there is currently no strong evidence to guide specific population- or clinic-based interventions for their avoidance. While food allergies are common in AD patients, the role of food allergens as an exacerbating factor for AD is controversial. Before starting any dietary modifications, careful evaluation should be performed by an allergist. If the patient is not well-controlled despite adequate topical therapies or is experiencing severe/worsening disease, early referral to dermatology is warranted to rule out confounding diagnoses and/or escalation to systemic therapies. Finally, it is important to recognise the racial disparities present in AD and address these when formulating treatment plans.Key messages:Confounding dermatoses, either instead of or in addition to AD, should be considered in treatment-refractory AD, and the appropriate workup may be initiated while awaiting dermatology referral.AD patients have multiple cutaneous and extra-cutaneous comorbidities that warrant screening by internists, especially mental health conditions.

DESCRIBE-AD: A novel classification framework for atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is a chronic, inflammatory skin disease associated with heterogeneous morphology, distribution, symptoms, severity, extent, longitudinal courses, quality of life burden, comorbidities, and treatment responses. This heterogeneity contributes to challenges in diagnosis, the characterization of disease activity, and therapeutic stratification.

OBJECTIVE

To develop a framework to standardize AD assessment.

METHODS

We propose a novel framework to assess AD based on a literature review and clinical experience.

RESULTS

DESCRIBE-AD is a framework that can effectively capture the clinical domains contributing to AD heterogeneity and includes both patient- and clinician-reported perspectives. DESCRIBE-AD includes assessments of Dermatitis morphology and phenotype, Evolution of disease, Symptom severity, Comorbid health disorders, Response to therapy, Intensity of lesions, Burden of disease, and Extent of lesions. Rather than placing the focus on any single, specific aspect of AD, DESCRIBE-AD allows for a comprehensive approach to the assessment and clinical management of AD.

CONCLUSIONS

DESCRIBE-AD is a novel framework that can be used to better describe the heterogeneity of AD and guide treatment decisions.

Risk of herpesvirus, serious, and opportunistic infections in atopic dermatitis: a population-based cohort study

BACKGROUND

Staphylococcal and herpes simplex virus (HSV) infections are commonly recognized in atopic dermatitis (AD) but less is known about other types of infections.

OBJECTIVES

To determine the risk of herpesvirus infections, serious infections, and opportunistic infections in patients with AD.

METHODS

We conducted a population-based cohort study using UK-based electronic medical records data. Patients with AD were each matched to up to 5 unaffected patients on age, practice, and index date. AD severity was defined using treatments. The outcomes were incident herpesvirus infections (cytomegalovirus [CMV], Epstein-Barr virus [EBV], HSV, or varicella zoster virus [VZV]), serious infections, and opportunistic infections.

RESULTS

409,431 children and 625,083 adults with AD were matched to 1,809,029 children and 2,678,888 adults without AD, respectively. In adjusted Cox regression models, children and adults with AD had 50-52% greater risk of HSV and 18-33% greater risk of VZV, with risk increasing in parallel with AD severity. CMV risk was elevated among children with AD (HR 2.50 [1.38-4.54]) and adults with severe AD (4.45 [1.76-11.25]). Patients with AD had 26-40% increase in risk of serious infections, with severe AD carrying greatest risk. Although rare, opportunistic infections were not associated with AD in children but were associated with all severities of AD in adults (overall HR 1.31 [1.20-1.42]). All estimates remained consistent after excluding patients receiving immunosuppressive treatments for AD.

CONCLUSIONS

AD is significantly associated with herpesvirus infections, serious infections, and opportunistic infections in a dose-responsive manner with severity. AD may increase susceptibility to infections exclusive of immunosuppressive medications.

Association between Atopic Dermatitis and Hypertension: A Systematic Review and Meta-Analysis

BACKGROUND

Previous studies found conflicting results about the association of atopic dermatitis (AD) with hypertension.

OBJECTIVES

Determine whether AD and AD severity are associated with hypertension.

METHODS

A systematic review was performed of published studies in MEDLINE, EMBASE, Scopus, Web of Science, and GREAT databases. At least 2 reviewers conducted title/abstract, full-text review, and data extraction. Quality of evidence was assessed using the Newcastle-Ottawa Scale.

RESULTS

Fifty-one studies met inclusion criteria; 19 had sufficient data for meta-analysis. AD was associated with higher odds of hypertension compared to healthy controls (increased in 9 of 16 studies; pooled prevalence: 16.4% vs 13.8%; random-effects regression, pooled unadjusted odds ratio [OR][95% confidence interval <CI95>]: 1.16 [1.04-1.30]), but lower odds of hypertension compared to psoriasis (decreased in 5 of 8 studies; 15.4% vs 24.8%; 0.53 [0.37-0.76]). In particular, moderate-severe AD were associated with hypertension compared to healthy controls (increased in 4 of 6 studies; 24.9% vs 14.7%; 2.33 [1.10-4.94]). Hypertension was commonly reported as an adverse-event secondary to AD treatments, particularly systemic cyclosporine A. Limitations include lack of longitudinal studies or individual-level data and potential confounding.

CONCLUSIONS

AD, particularly moderate-to-severe disease, was associated with increased hypertension compared to healthy controls, but lower odds than psoriasis.

Association of pediatric atopic dermatitis and psoriasis with school absenteeism and parental work absenteeism: A cross-sectional United States population-based study

BACKGROUND

The impact of childhood atopic dermatitis (AD) and psoriasis on school absenteeism is not fully elucidated.

OBJECTIVE

To determine the burden and predictors of chronic school absenteeism in children with AD and psoriasis.

METHODS

Data were analyzed from the 1999-2015 Medical Expenditure Panel Surveys, cross-sectional, population-based studies of health status and function in the United States.

RESULTS

Among 3132 and 200 children with AD and psoriasis, respectively, 1544 (67.7%) and 97 (62.5%) missed ≥1 day, and 120 (3.9%) and 5 (3.6%) missed ≥15 days (chronically absent) per year due to illness. AD was associated with chronic absenteeism overall (logistic regression; adjusted odds ratio 1.42, 95% CI [1.13-1.78]) and with more severe disease (mild-moderate: 1.33 [1.04-1.70], severe: 2.00 [1.21-3.32]). No statistical difference in chronic absenteeism was found for children with versus those without psoriasis (1.26 [0.51-3.12]). Parents of children with AD were more likely to miss work for caregiving versus those of children without AD, whereas parents of children with psoriasis had similar rates of work absenteeism versus those of children without psoriasis.

LIMITATIONS

The severity of AD and psoriasis was assessed by treatment pattern.

CONCLUSION

Children in the United States with AD had increased chronic school absenteeism. Further interventions are warranted to prevent school absenteeism in childhood AD.

Association of Atopic Dermatitis With Bacterial, Fungal, Viral, and Sexually Transmitted Skin Infections

BACKGROUND

Atopic dermatitis (AD) is associated with altered skin barrier, microbiome, and immune dysregulation that may increase risk of skin infections.

OBJECTIVE

The aim of the study was to determine whether AD is associated with skin infections and related outcomes.

METHODS

Data from the 2006 to 2012 National Emergency Department Sample were analyzed, including an approximately 20% sample of all US emergency department (ED) visits (N = 198,102,435 adults or children).

RESULTS

Skin infections were increased in ED visits of adults (7.14% vs 3.76%) and children (5.15% vs 2.48%) with AD. In multivariable logistic regression models, AD was associated with significantly higher odds of skin infection in adults (adjusted odds ratio [95% confidence interval] = 1.93 [1.89-1.97]) and children (2.23 [2.16-2.31]). Pediatric and adult AD were associated with significantly higher odds of carbuncle/furuncles, impetigo, cellulitis, erysipelas, methicillin-resistant and methicillin-sensitive Staphylococcus aureus infections, molluscum contagiosum, cutaneous warts, herpes simplex and zoster viruses, eczema herpeticum, dermatophytosis, and candidiasis of skin/nails and vulva/urogenitals. Adults with AD had significantly higher odds of genital warts (1.51 [1.36-1.52]) and herpes (1.23 [1.11-1.35]). Skin infections were associated with US $19 million excess annual costs of ED care in persons with AD.

CONCLUSIONS

Atopic dermatitis patients had higher odds of multiple bacterial, viral, fungal, and sexually transmitted skin infections.

Risk of systemic infections in adults with atopic dermatitis: A nationwide cohort study

BACKGROUND

Atopic dermatitis (AD) has been linked to systemic infections in adulthood, but large-scale studies are few, and potential associations are unclear.

OBJECTIVE

To examine whether adults with AD have increased risk of developing systemic infections leading to hospital-based management.

METHODS

Nationwide register-based cohort study including all Danish adults from 1995 through 2017. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated by using Cox models.

RESULTS

A total of 10,602 adults with AD (median age, 29.8 y; interquartile range, 22.6-44.8) and 106,020 reference individuals were included. The overall incidence rate per 10,000 person-years of systemic infections was 180.6 (95% CI, 172.6-189.0) among adults with AD compared with 120.4 (95% CI, 118.3-122.5) among reference adults. The association between AD and systemic infections was observed for musculoskeletal (adjusted HR [aHR], 1.81; 95% CI, 1.42-2.31), heart (aHR, 1.75; 95% CI, 1.21-2.53), and upper (aHR, 1.42; 95% CI, 1.15-1.73) and lower respiratory tract infections (aHR, 1.21; 95% CI, 1.10-1.33). The risk of sepsis (aHR, 1.19; 95% CI, 1.01-1.44) and skin infections (aHR, 2.30; 95% CI, 2.01-2.62) was also increased.

LIMITATIONS

The findings cannot be generalized to adults with milder AD seen outside the hospital system.

CONCLUSION

We found an increased risk of systemic infections among adults with hospital managed AD.

A real-world study of the longitudinal course of adult atopic dermatitis severity in clinical practice

BACKGROUND

Little is known about the longitudinal course of adult atopic dermatitis (AD) lesional severity and extent in clinical practice.

OBJECTIVE

To determine the longitudinal course of AD in clinical practice.

METHODS

A prospective, dermatology practice-based study was performed (n = 400). Patients were assessed at baseline and approximately 6, 12, 18, and 24 months by eczema area and severity index (EASI) and objective-scoring atopic dermatitis (objective-SCORAD). Multivariable repeated measures linear regression models were constructed to evaluate AD severity over time.

RESULTS

Overall, 36.2% and 18.2% of patients had moderate (6.0-22.9) or severe (23.0-72.0) EASI scores at any visit, respectively. Similarly, 29.0% and 26.4% of patients had moderate (24.0-37.9) or severe (38.0-83.0) objective-SCORAD scores at any visit, respectively. Among patients with baseline moderate (6.0-22.9) or severe (23.0-72.0) EASI scores, 25.0% and 18.6% continued to have moderate or severe scores at 1 or more follow-up visits, respectively. Similarly, among patients with baseline moderate (24.0-37.9) or severe (38.0-83.0) objective-SCORAD scores, 22.6% and 24.5% continued to have moderate or severe scores at 1 or more follow-up visits, respectively. In longitudinal regression models, EASI was significantly associated with body surface area (adjusted β [95% confidence interval]: 0.16 [0.09-0.23]) and edema/papulation (2.31 [0.19-4.43]). In addition, objective-SCORAD was significantly associated with body surface area (0.12 [0.04-0.21]), edema/papulation (4.69 [2.05-7.32]), and scratch (3.34 [0.45-6.24]) over time.

CONCLUSION

AD lesional severity has a heterogeneous longitudinal course. Many patients had fluctuating lesional severity scores over time. A minority of patients had persistently moderate or severe lesions over time. Most patients with moderate-severe disease at baseline were unable to achieve persistent lesional clearance.

Osteomyelitis complicating secondarily infected atopic eczema: two case reports and a narrative literature review

BACKGROUND

Atopic eczema is a relapsing, itchy chronic cutaneous inflammatory disease that commonly affects children. The disease is often complicated by cutaneous infections such as eczema herpeticum, eczema vaccinatum and a varied number of bacterial infections - impetigo, cellulitis and erysipelas. However, rare case reports of infective endocarditis, otitis media and osteo-articular infections have been associated with atopic eczema. These associations possibly represent the extracutaneous infectious complications of atopic eczema.

CASE PRESENTATION

Here we present two cases of osteomyelitis in HIV negative children with habitual scratching of poorly managed and/or uncontrolled atopic eczema respectively. Both cases presented to the orthopaedic surgeons and were admitted as acute phalangeal osteomyelitis and acute - on - chronic tibial osteomyelitis respectively. The first case was an 8 year old girl who had moderate-severe poorly-controlled atopic eczema and contiguously spread phalangeal osteomyelitis. The second case was an 11 year old pre-pubertal boy who had untreated atopic eczema and tibial osteomyelitis possibly from haematogenously spread Staphylococcus aureus infection. Both were successfully discharged from hospital and currently have well controlled eczema. The 11 year old patient is also being reviewed monthly by the orthopaedic surgeons and is chronic suppressive antibiotics. He may require sequestrectomy, should it be needed.

CONCLUSIONS

Invasive staphylococcal and streptococcal osteo-articular (OA) infection can arise as an extra-cutaneous infectious complication of poorly controlled atopic eczema. It is more common in the 3 to 15 year age group and especially in boys with a septic arthritis to osteomyelitis ratio of around 29:5. Clinicians should maintain a high index of suspicion in patients with moderate-severe atopic eczema and they ought to promptly manage these OA infections with intravenous antibiotics to avoid further complications.

Predictors of hospital readmission in US children and adults with atopic dermatitis

BACKGROUND

Decreasing readmissions is a health care priority in the United States. However, little is kanown about the determinants of hospital readmissions for atopic dermatitis (AD).

OBJECTIVE

To determine readmission rates among inpatients hospitalized for AD in the United States.

METHODS

We analyzed the 2012-2014 Nationwide Readmission Database, including a representative, cross-sectional sample of hospital readmissions in the United States.

RESULTS

Overall, 17.0% of inpatients with AD were readmitted within 1 year for all causes, including 12.5% with only a single readmission and 4.6% for AD. In multivariable Cox proportional hazards regression models, hospital readmission for AD was associated with below-median household income, being uninsured, having a prolonged initial hospitalization, but inversely associated with older age and a diagnosis of infection. Inpatients admitted for AD on a weekend, in the summer, or in autumn were more likely to be readmitted for AD. Hospital characteristics associated with readmission for AD included nonmetropolitan hospital location and hospital teaching status.

CONCLUSION

One in 5 inpatients with AD are readmitted within 1 year for all causes. There are socioeconomic and health care disparities in readmission rates for AD.

Association between atopic dermatitis and autoimmune disorders in US adults and children: A cross-sectional study

BACKGROUND

Little is known about the risk and predictors of autoimmune diseases in children and adults.

OBJECTIVE

To determine the prevalence, predictors, and excess costs of autoimmune disease in atopic dermatitis (AD) patients.

METHODS

Cross-sectional study of the 2002-2012 National Inpatient Sample, which includes a ∼20% sample of all US hospitalizations (n = 87,053,155 adults and children).

RESULTS

The prevalence of autoimmune disease was higher in adults with AD (7.9%, 95% confidence interval [95% CI] 7.3-8.5%) than without AD (5.7%, 95% CI 5.7%-5.8%) and higher in children with AD (2.0%, 95% CI 1.7%-2.3%) than without AD (1.0%, 95% CI 0.9%-1.1%). In multivariable logistic regression models controlling for sociodemographics, adult (adjusted odds ratio 1.45, 95% CI 1.32-1.58) and pediatric (adjusted odds ratio 2.08, 95% CI 1.73-2.50) AD were associated with any autoimmune disorder. In particular, AD was associated with 18 of 32 autoimmune disorders examined in adults and 13 of 24 examined in children, including disorders of the skin, endocrine, gastrointestinal, hematologic, and musculoskeletal systems. AD patients hospitalized with any autoimmune disorder had a higher cost of inpatient care, with $2.5-$50 million excess annual costs.

CONCLUSIONS

Adults and children with AD had increased cutaneous and extracutaneous autoimmune disorders, which were associated with a considerable cost burden.