Evaluation of the adult patient with atopic dermatitis

Follicular conjunctivitis in dogs: A retrospective study (2007-2022)

OBJECTIVE

To evaluate the incidence, clinical features, treatment, and outcome of canine follicular conjunctivitis (CFC).

PROCEDURE

Medical records of dogs diagnosed with CFC were reviewed. Data recorded included signalment, duration of clinical signs and treatment details prior to presentation, concurrent ocular/systemic diseases, ocular clinical signs, cytology, treatment, follow-up, and outcome. Blepharospasm, signs of self-trauma, hyperemia, chemosis, ocular discharge, and follicle location and severity (0.5-4) were retrospectively evaluated. Based on severity, treatment consisted of topical 0.1% diclofenac or 0.1% dexamethasone sodium eyedrops. Dogs were classified into young (YD < 18 months) and adult (AD ≥ 18 months).

RESULTS

One hundred and fifty-three dogs (276 eyes) were included in the study: 83YD (54%) and 70AD (46%). Males and bilateral disease were over-represented in both groups. Severity was associated with young age (p = .032) and bilaterality (p = .025), and not with dermatological diseases (p > .05). No differences in follicular location were observed except for more frequent involvement of the nictitating membrane (MN) in YD (p = .02). Response to treatment was faster in AD (p = .001), with complete resolution in 80.6% of the eyes (100/124) at 1 month. YD treated with diclofenac showed faster resolution than those treated with 0.1% dexamethasone (p = .009).

CONCLUSIONS

Although CFC is a bilateral ocular disease occurring at any age, the clinical presentation is influenced by age. Follicular conjunctivitis in adult dogs is less sever, less commonly affects the NM, and responds more quickly to topical treatment. One month of topical diclofenac may be adequate for mild cases, and 1 month of topical 0.1% dexamethasone is recommended as initial therapy for moderate to severely affected cases.

Renal Cystinuria and Immune Cells (T Lymphocytes) Dysfunction: What We Know about?

INTRODUCTION

Cystinuria (CYS) is the most common monogenic kidney stone disease.

METHODS

Starting from an unusual case of CYS associated to primary sclerosing cholangitis, inflammatory bowel disease (IBD), and autoimmune hepatitis in a young male, we carefully review the literature and propose here a working hypothesis regarding the potential risk of cystinuric patients to develop conditions due to immune system dysregulation. To corroborate this hypothesis, we retrospectively evaluate the frequency of dysimmunity in a monocentric cohort including 36 cystinuric patients compared to healthy and disease controls.

RESULTS

CYS patients have an increased prevalence of atopic disease compared to disease controls (p = 0.03) and 16.7% of CYS subjects were diagnosed with allergic disease to a variety of antigens.

CONCLUSION

Further studies are needed to define the relationship between proximal tubular transport defect of CYS and dysregulated immunity.

Diagnostic approach and grading scheme for canine allergic conjunctivitis

BACKGROUND

In humans, allergic conjunctivitis is a well described disease. In contrast, allergic conjunctivitis has not received much attention from the veterinary community so far. Canine allergic conjunctivitis (cAC) is one of the possible manifestations associated with canine atopic dermatitis (cAD), being often underdiagnosed and undertreated. Our aim is to contribute to disease characterization and clinical stagingfor cAC severity.

RESULTS

A retrospective observational study including 122 dogs that underwent a complete ophthalmological and dermatological examinations and diagnosed with allergic conjunctivitis was conducted. A total of six ophthalmic clinical signs were considered for disease characterization and clinical staging: conjunctival hyperemia, chemosis, ocular pruritus, epiphora, seromucoid to mucopurulent discharge and keratitis, classified from 0 (absent) to 3 (severe). Scores comprised between 1-5 were considered mild, 6-10 moderate and 11-18 severe. The majority of dogs (64%) presented with moderate cAC followed by 24% of mild stages and only 12% of severe presentations. The severity of allergic conjunctivitis was not correlated to sex or age at the time of diagnosis and all presented with a bilateral form of the disease. Chemosis (84%), hyperemia (83%) and ocular pruritus (79%) was observed in 55% of the cases. Seromucoid to mucopurulent discharge (62%) and epiphora (69%) were less frequent, with keratitis being the least encountered clinical sign (15%). The degree of keratitis showed a positive correlation with both severity and chronicity of cAC (rho = 0.21-0.29, p ≤ 0.02)). Severity of cAD and cAD were not significantly correlated (p-value = 0.4).

DISCUSSION AND CONCLUSION

The triad hyperemia, chemosis and ocular pruritus, already known in human medicine to be a reliable way of diagnosing human allergic conjunctivitis, also proved to be important in cAC Mild forms of the disease may pass unnoticed, ocular pruritus being hard to assess in canine patients.The proposed standardized diagnostic approach and novel grading scheme for cAC may be of value for both veterinary ophthalmologists and dermatologists, as well as general practitioners.

Assessment of serum concentrations of matrix metalloproteinase 1, matrix metalloproteinase 2 and tissue inhibitors of metalloproteinases 1 in atopic dermatitis in correlation with disease severity and epidermal barrier parameters

Introduction

Matrix metalloproteinases (MMPs) are a group of proteolytic enzymes, conditioning the integrity of skin cells, however, their role in the inflammatory process of atopic dermatitis (AD) and the direct effect on the epidermal barrier parameters remain unexplained.

Aim

To assess MMP-1, MMP-2, tissue inhibitors of metalloproteinases (TIMP)-1 concentrations in blood serum in the context of transepidermal water loss (TEWL) and stratum corneum hydration in AD. Moreover, serum levels of MMPs and TIMP-1 were analysed in relation to the Eczema Area and Severity Index (EASI).

Material and methods

Forty-three AD patients and 22 control group subjects have been investigated. Serum concentrations of MMP-1, MMP-2, and TIMP-1 have been evaluated with ELISA. TEWL and stratum corneum hydration have been assessed with a TM300 Tewameter and a CM825 Corneometer. Skin lesions in patients with AD have been evaluated with the Eczema Area and Severity Index.

Results

MMP-1 and MMP-2 serum concentrations were significantly higher in the AD group. The results of TIMP-1 serum concentration were similar for both groups. The correlation between the serum concentration and the EASI was demonstrated only for MMP-2 for patients with severe and moderate AD. Patients with AD and TIMP-1 serum concentration greater than MMP-1 presented lower TEWL and higher epidermal hydration.

Conclusions

The results of this study warrant further investigation. The predominance of TIMP-1 over MMP-1 in blood serum can potentially limit TEWL and maintain the proper water content of the epidermis. Future work is necessary to establish how reliable the role of MMP-2 concentration is as an indicator of the severity of AD.

Atopic dermatitis induces anxiety- and depressive-like behaviors with concomitant neuronal adaptations in brain reward circuits in mice

Clinically, it has been reported that atopic dermatitis (AD) has been linked with negative emotional problems such as depression and anxiety, thereby reducing the quality of life, but little is known about the molecular mechanism that underlies AD-associated emotional impairments. We sought to determine whether AD could induce anxiety- and depressive-like symptoms in mice and to identify pertinent signaling changes in brain reward circuitry. AD-like lesions were induced by the repeated intradermal application of MC903 into the cheek of the mouse. We assessed dermatitis severity with scratching behavior, histopathological changes, anxiety- and depressive-like behaviors using the elevated plus maze, open field and tail suspension tests, and serum corticosterone levels. In the nucleus accumbens (NAc), dorsal striatum (DS) and ventral tegmental area (VTA), protein levels of dopamine- and plasticity-related signaling molecules were determined by Western immunoblotting assay. Intradermal administration of MC903 into mouse cheek provoked a strong hind limb scratching behavior as well as the robust skin inflammation with epidermal thickening. MC903-treated mice also displayed markedly increased anxiety- and depressive-like behaviors, along with elevated serum corticosterone levels. Under these conditions, enhanced cAMP response element binding protein (CREB) and dopamine and cAMP-regulated phosphoprotein, 32 kDa (DARPP32) phosphorylation, significantly higher brain-derived neurotrophic factor (BDNF) and ΔFosB, but reduced tyrosine hydroxylase (TH) and dopamine D1 receptor (D1R) protein expression were found in the NAc, DS and VTA. Striatal BDNF, phospho-DARPP32 and phospho-CREB levels were significantly associated with the levels of depressive-like behavior in these mice. Taken together, these findings demonstrate that AD-like skin lesion elicits anxiety- and depressive-like phenotypes that are associated with neuroplasticity-related changes in reward circuitry, providing a better understanding of AD-associated emotional impairments.

Approach to the Assessment and Management of Adult Patients With Atopic Dermatitis: A Consensus Document. Section III: Evaluation of Atopic Dermatitis Patients for Comorbidities

Atopic dermatitis (AD) is often associated with other atopic diseases, including asthma, allergic rhinitis, atopy-associated eye disorders, and eosinophilic esophagitis. Depression and anxiety are also comorbidities to AD that significantly affect quality of life and should be screened for in patients with AD. Links to other comorbidities such as cardiovascular disease and malignancy are considered inconclusive, but patient counselling and screening may be appropriate in some patients. This article highlights practical recommendations for the recognition and management of atopic and nonatopic comorbidities commonly associated with AD.

Allergic phenotypes in adult patients with atopic dermatitis, determined with the ISAC test (ImmunoCAP ISAC)

Introduction

Atopic dermatitis (AD) is a chronic inflammatory dermatosis, often with a concomitant allergy. The ImmunoCAP ISAC (Immuno Solid-Phase Allergen Chip) test is a novel method to determine the allergenic phenotype in a given patient.

Aim

In this study, we used the ImmunoCAP ISAC test to analyze allergic phenotypes in adult patients with AD.

Material and methods

The study included 19 adult patients with AD. The severity of AD was assessed using SCORAD index. Serum concentrations of total IgE were determined by means fluoro-enzyme immunoassay (FEIA). The levels of asIgE were measured with the ImmunoCAP ISAC kits.

Results

Positive results of the ISAC test were documented in 84.2% of the study subjects. All patients synthesized asIgE against species-specific respiratory allergens; major components of animal allergens (57.87%), tree pollen allergens (47.3%), grass pollen allergens (42.1%), dust mite allergens (26.3%) and major allergen of mugwort (26.3%). 47.3% of the subjects were sensitive to cross-reactive allergenic components, most often proteins of the lipocalin family (57.8%), followed by PR-10 (26.3%), PR-14 (21%) and PR-5 proteins (21%). asIgE against species-specific allergens were found in 10.5% of the study subjects. No statistically significant relationships were observed between the severity or duration of AD and the prevalence and levels of asIgE against the allergens included in the ISAC panel. However, duration of AD correlated significantly with the serum concentration of total IgE.

Conclusions

The ISAC test is suitable for determination of the allergenic phenotype in a given patient, and as such has an unquestioned diagnostic and therapeutic value.

Changing perspectives in atopic dermatitis

Atopic dermatitis (AD) is a multifaceted disease that involves a complex interplay between the skin and the immune system. The course of the disease depends strongly on the genetic background of the patient and on yet poorly-defined environmental factors. Changes in lifestyle could be behind the dramatic rise in the prevalence of AD across continents; including hygienic conditions, food, social habits, skin microbiome or exposure to a number of allergens. Although AD typically develops in childhood and disappears after a few years, in a relatively large number of patients it continues into adulthood. Adult AD can also appear de novo but it is often underdiagnosed and its treatment can be challenging. New, highly effective drugs are being developed to manage moderate and severe forms of the disease in adults. In this review, we highlight the most recent developments in diagnostic tools, current insights into the mechanistic basis of this disease, and therapeutic innovations.

Patch Test Negative Generalized Dermatitis

Allergic contact dermatitis is a common condition in dermatology. Patch testing is the criterion standard for diagnosis. However, dermatitis is not always caused by an allergen, and patch testing does not identify a culprit in every patient. Generalized dermatitis, defined as eczematous dermatitis affecting greater than 3 body sites, is often encountered in dermatology practice, especially patch test referral centers. Management for patients with generalized dermatitis who are patch test negative is challenging. The purpose of this article is to outline an approach to this challenging scenario and summarize the paucity of existing literature on patch test negative generalized dermatitis.

Osteoporosis in adult patients with atopic dermatitis: A nationwide population-based study

The aim of this study was to investigate osteoporosis risk in atopic dermatitis (AD) patients. This study included patients in the Taiwan National Health Insurance Research dataset. The population-based study included all patients aged 20–49 years who had been diagnosed with AD during 1996–2010. In total, 35,229 age and gender-matched patients without AD in a 1:1 ratio were randomly selected as the non-AD group. Cox proportional-hazards regression and Kaplan–Meier analyses were used to measure the hazard ratios and the cumulative incidences of osteoporosis, respectively. During the follow-up period, 360(1.02%) AD patients and 127(0.36%) non-AD patients developed osteoporosis. The overall incidence of osteoporosis was4.72-fold greater in the AD patients compared to the non-AD patients (1.82 vs. 0.24 per 1,000 person-years, respectively) after adjusting for potential confounding factors. Osteoporosis risk factors included female gender, age, advanced Charlson Comorbidity Index, depression and use of corticosteroids. The dataset analysis showed that AD was significantly associated with subsequent risk of osteoporosis.

Atopic dermatitis: Kids are not just little people

The approach to children and adults with atopic dermatitis is similar. In both age groups, failure to respond to conventional therapy should prompt evaluation for complicating factors such as secondary infection and secondary ACD. Immunologic, metabolic, genetic, and nutritional disorders should be considered in the differential diagnosis of refractory pediatric atopic dermatitis. Cutaneous T cell lymphoma (CTCL), cutaneous drug reactions, other spongiotic dermatoses, psoriasis, dermatomycosis, and infestations should be considered in the differential of refractory atopic dermatitis in adults. Systemic therapies prescribed to both children and adults with severe atopic dermatitis include oral corticosteroids, cyclosporine, methotrexate, azathioprine, and mycophenolate mofetil.

Chitosan Coated Textiles May Improve Atopic Dermatitis Severity by Modulating Skin Staphylococcal Profile: A Randomized Controlled Trial

BACKGROUND

Atopic dermatitis (AD) patients may benefit from using textiles coated with skin microbiome-modulating compounds. Chitosan, a natural biopolymer with immunomodulatory and antimicrobial properties, has been considered potentially useful.

OBJECTIVE

This randomized controlled trial assessed the clinical utility of chitosan-coated garment use in AD.

METHODS

Of the 102 patients screened, 78 adult and adolescents were randomly allocated to overnight use of chitosan-coated or uncoated cotton long-sleeved pyjama tops and pants for 8 weeks. The primary outcome was change in disease severity assessed by Scoring Atopic dermatitis index (SCORAD). Other outcomes were changes in quality of life, pruritus and sleep loss, days with need for rescue medication, number of flares and controlled weeks, and adverse events. Changes in total staphylococci and Staphylococcus aureus skin counts were also assessed. Comparisons were made using analysis of variance supplemented by repeated measures analysis for the primary outcome. Interaction term between time and intervention was used to compare time trends between groups.

RESULTS

Chitosan group improved SCORAD from baseline in 43.8%, (95%CI: 30.9 to 55.9), P = 0.01, placebo group in 16.5% (-21.6 to 54.6); P = 0.02 with no significant differences between groups; Dermatology Quality of life Index Score significantly improved in chitosan group (P = 0.02) and a significant increase of skin Coagulase negative Staphylococci (P = 0.02) was seen.

CONCLUSIONS

Chitosan coated textiles may impact on disease severity by modulating skin staphylococcal profile. Moreover, a potential effect in quality of life may be considered.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01597817.

Developments in the field of allergy in 2013 through the eyes of Clinical and Experimental Allergy

2013 was another exciting year for allergy in general and Clinical and Experimental Allergy in particular. In the field of asthma and rhinitis, there continued to be a focus on heterogeneity and phenotypes with increasing use of biostatistical techniques to determine clusters of similar populations. Obesity- and aspirin-associated disease are intriguing associations with asthma which were explored in a number of papers. We published a number of excellent papers on mechanisms of airway inflammation and how this relates to physiology, pathology, genetics and biomarkers in both human and experimental model systems. In terms of mechanisms, there is less on individual cell types in allergic disease at the moment, but the immunology of allergic disease continued to fascinate our authors. Another area that was popular both in the mechanisms and in the epidemiology sections was early life events and how these lead to allergic disease, with an increasing focus on the role of the microbiome and how this influences immune tolerance. In the clinical allergy section, oral immunotherapy for food allergy is clearly a major topic of interest at the moment as was in vitro testing to distinguish between sensitization and allergic disease. There was less on inhalant allergy this year, but a good representation from the drug allergy community including some interesting work on non-IgE-mediated mechanisms. In the allergen section, important new allergens continue to be discovered, but the major focus as in the last couple of years was on working out how component-resolved approaches can improve diagnosis and management of food and venom allergy.

Danggui buxue tang inhibits 2,4-dinitrochlorobenzene: induced atopic dermatitis in mice

Danggui Buxue Tang (DBT) is a herbal decoction that has been used in Chinese medicine to enhance qi and blood circulation. Previously, we found that DBT can suppress allergy-related asthma in mice, leading us to hypothesize that DBT might ameliorate allergy disease. In this study, we evaluated whether DBT can attenuate atopic dermatitis (AD) symptoms and have an anti-inflammatory effect on AD-like mice. The dorsal skin of female mice was shaved and sensitized cutaneously (skin smear) with 1-chloro-2,4-dinitrobenzene. Mice were then given various doses of DBT from days 14 to 29 cutaneously. DBT treatment suppressed ear swelling and skin inflammation and decreased mast cell and eosinophil infiltration into skin and ear tissue. DBT also inhibited levels of IgE and Th2-associated cytokine levels in serum. These results demonstrate that cutaneous administration of DBT reduced the development of AD-like skin lesions in mice.

Therapeutic strategies in extrinsic atopic dermatitis: focus on inhibition of IL-4 as a new pharmacological approach

INTRODUCTION

Recent data about atopic dermatitis (AD) pathogenesis postulate that T cells and their related cytokines and chemokines are primarily responsible for the inflammatory responses.

AREAS COVERED

AD, the primary complex disease associated with filaggrin deficiency, is characterized by cutaneous inflammation driven by type 2 helper T (TH2) cells. TH2-related molecules, such as IL-4, IL-13, dominate the immune infiltrate. Experimental evidences suggest that these cytokines may be considered attractive therapeutic targets in AD, particularly in extrinsic AD with IgE overproduction. Recently, a fully human monoclonal antibody directed against the IL-4 receptor α subunit blocking IL-4 and IL-13 signaling has been evaluated in Phase I and Phase II clinical trials in patients with moderate-to-severe AD with significant improvement in disease severity. Phase III trials are ongoing.

EXPERT OPINION

Treatment of AD represents a therapeutic challenge. TH2 cytokine-targeted therapies represent promising treatment options that could improve the therapeutic armamentarium for AD. These therapies are likely to become future therapeutic options in AD, particularly in the extrinsic AD.

Frequency of bathing in the management of atopic dermatitis: to bathe or not to bathe?

BACKGROUND

Atopic dermatitis prevalence has increased in the developed world in recent decades, and effective management is vital to improve patients' quality of life.

METHODS

A prospective, randomized, case-control study with a purposive sample of 28 children, aged 6 months to 10 years, diagnosed with atopic dermatitis. Participants received bathing instructions to be followed either daily or twice a week, with a follow-up duration of 2 weeks. Improvement of symptoms over time was measured using the SCORAD (SCORing Atopic Dermatitis) tool.

RESULTS

Overall symptoms decreased significantly at follow-up compared with baseline (difference = 5.0938, confidence interval = 0.2116 to 9.9759) but the differences in scores before and after interventions were not statistically significant between the groups (difference = -1.0937, confidence interval = -5.9759 to 3.7884).

CONCLUSIONS

The frequency of bathing did not seem to play an important role in the management of atopic dermatitis. Clinicians should focus on the need for adequate skin hydration.