The therapeutic concept of "patient management" in atopic eczema

The Future of Functional Clothing for an Improved Skin and Textile Microbiome Relationship

The skin microbiome has become a hot field of research in the last few years. The emergence of next-generation sequencing has given unprecedented insights into the impact and involvement of microbiota in skin conditions. More and more cosmetics contain probiotics or bacteria as an active ingredient, with or without scientific data. This research is also acknowledged by the textile industry. There has been a more holistic approach on how the skin and textile microbiome interacts and how they influence the pH, moisture content and odour generation. To date, most of the ingredients have a broad-spectrum antibacterial action. This manuscript covers the current research and industry developments in the field of skin and textiles. It explores the nature of antimicrobial finishing in textiles which can disrupt the skin microbiome, and the benefits of more natural and microbiome friendly therapies to combat skin conditions, malodour and skin infection.

The Effects of Fabric Containing Chamaecyparis obtusa Essential Oil on Atopic Dermatitis-Like Lesions: A Functional Clothing Possibility

BACKGROUND

Essential oil derived from Chamaecyparis obtusa (EOCO) has been used as an alternative treatment for allergy-related diseases due to its immune-modulating characteristics. Clothing has the longest and most intense contact with human skin, and functional fabrics with intrinsic properties have been increasingly implemented in medical applications. Specially designed fabrics may support atopic dermatitis (AD) treatment. In this study, the effects of fabric containing EOCO on AD were investigated using an NC/Nga mouse model.

METHODS

The fabric was applied for 6 h per day for 14 days. The therapeutic effects were evaluated according to measurements of skin lesion severity (modified SCORAD score), transepidermal water loss (TEWL), serum IgE and inflammatory cytokine levels, lesion thickness measured after hematoxylin and eosin staining, and immunohistochemical and Western blot analysis for skin epidermal differentiation protein.

RESULTS

The EOCO group exhibited significantly reduced modified SCORAD score, TEWL, and serum IgE levels. Among the inflammatory cytokines analyzed, only the mean values of regulated on activation, normal T cell expressed and secreted were observed to be decreased compared with other control groups. The histological analysis of the skin also revealed that the EOCO group expressed reduced epidermal hyperplasia and recovered filaggrin, involucrin, and loricrin expression.

CONCLUSIONS

It was confirmed that fabric containing EOCO has anti-atopic and anti-inflammatory properties. The study data show that fabric containing EOCO can be implemented as an alternative functional clothing for people suffering from AD.

Structural and clinical impact of anti-allergy agents: An overview

Allergic disorders are markedly rising in industrialized countries. The identification of compounds that trigger the immunoglobulin E (IgE)-dependent allergic reaction remain the means to improve the quality of life by limiting patient's exposure to critical allergens. Information concerning the treatment and onset of allergic disorders including atopic dermatitis, allergic rhinitis, and bronchial asthma has been provided by the research over the past decade. Recent studies also indicated that allergic inflammation is associated closely with their exacerbation and progression and indeed is the basic pathophysiology of allergic diseases. As a result of immunological and molecular biological studies our understanding of the mechanism of allergic inflammation with regard to therapeutic agents has improved. While much effort has been paid to developing a new anti-allergic agent, the allergic disease has yet to be completely conquered. The more extensive research will allow the development of new therapeutics to combat allergic diseases. Currently, with respect to mechanism of action anti-allergy drugs are classified into five types including histamine H₁ antagonists, leukotriene antagonists, Th₂ cytokine inhibitors, thromboxane A₂ inhibitors and mediator-release inhibitors. The use of two or more anti-allergy agents together is not acknowledged at present, but this will be the subject of research in the future because with different mechanisms of action anti-allergy agents used at the same time will theoretically increase their effects. This review article focuses on anti-allergy agents highlighting their applications, clinical trials and recent advancement on drugs.

Alternative, Complementary, and Forgotten Remedies for Atopic Dermatitis

Atopic dermatitis, perhaps more than other dermatologic diseases, has garnered much attention in the realm of alternative medicine. This may be because its etiopathogenesis is incompletely understood, it is increasingly common, and it waxes and wanes often without clear precipitants, opening up many opportunities for misinterpretation. Herein we explore the evidence for a number of different alternative and complementary therapies, from textiles to vitamin supplements. By definition, none have enough data to be deemed “effective” in a conventional sense, but it is hopeful that some show promising evidence that may one day lead to mainstream acceptance with further research.

Correlation between Objective SCORAD and Three-Item Severity Score Used by Physicians and Objective PO-SCORAD Used by Parents/Patients in Children with Atopic Dermatitis

<b><i>Background:</i></b> A self-assessment rating scale (SAS) is a good tool to assess the fluctuating disease severity and quality of life (QoL) in children with atopic dermatitis (AD). The European Task Force on Atopic Dermatitis created an SAS based on the Scoring Atopic Dermatitis (SCORAD) index, called the Patient-Oriented SCORAD (PO-SCORAD). <b><i>Objective:</i></b> The aim of our study was to measure the correlation between alternative systems such as the Objective SCORAD, the Three-Item Severity (TIS) score and the Objective PO-SCORAD. We also investigated the correlations between the objective severity assessments and QoL. <b><i>Methods:</i></b> In a specialized outpatient clinic, an observational prospective study was performed with children ≤16 years with AD. <b><i>Results:</i></b> Seventy-five children were included. A good and significant correlation was shown between Objective SCORAD and Objective PO-SCORAD: Spearman's &#x03C1; correlation (r_s) = 0.63 (p < 0.001). The correlation with QoL was moderate, but still significant (r_s = 0.41-0.61, p < 0.001). <b><i>Conclusion:</i></b> The Objective PO-SCORAD can be used for the evaluation of fluctuating AD and correlates significantly with the Objective SCORAD and the less time-consuming TIS score.

Non-pharmacologic therapies for atopic dermatitis

Atopic dermatitis (AD) continues to present significant therapeutic challenges, especially in severe cases. Navigating the line between risk and benefit can be difficult for more powerful medications such as immunosuppressants, but non-pharmacologic treatments are often overlooked and underutilized. Creative application of these more physical therapies can serve to minimize the pharmacologic treatments and their side effects, and possibly even create synergy between modalities, to maximize benefit to the patient.

Immunoglobulin e-mediated allergy plays a role in atopic eczema as shown in the atopy patch test

Although the pathophysiology of immunoglobulin E (IgE)-mediated allergic rhinoconjunctivitis and bronchial asthma is rather well established, the role of allergy in atopic eczema (AE) is still controversial. By a technique called atopy patch test, aeroallergens like house dust mite, animal dander, or pollen were proven as relevant trigger factors in a subgroup of patients with AE. The atopy patch test is an epicutaneous patch test with such allergens known to elicit IgE-mediated reactions, and used for the evaluation of eczematous skin reactions. In a series of single-center and multicenter studies, a method was developed, standardized, and compared with other diagnostic techniques (radioallergosorbent test, skin prick test) in AE patients. With regard to clinical history, the most specific results were obtained with the atopy patch test (allergen-dependent, 69%-92%), whereas sensitivity was higher for skin prick test (range, 69%-82%) and specific IgE (range, 65%-94%). The characterization of a patient subgroup with relevant IgE-mediated allergy may lead to more efficient avoidance and eventually even specific immunotherapy strategies in the management of AE.

The clinical efficacy, safety and functionality of anion textile in the treatment of atopic dermatitis

BACKGROUND

Several previous studies have suggested the improvement of atopic dermatitis (AD) in response to special fabrics. In particular, beneficial effects have been reported, following the use of anion textiles.

OBJECTIVE

The purpose of this study is to evaluate the effectiveness and safety of an anion textile in patients suffering from AD.

METHODS

We compared an anion textile with a pure cotton textile. Fifty-two atopic patients (n=52) were enrolled and divided into two groups. The patients in the test (n=25) and control (n=19) groups wore undergarments made of an anion textile or pure cotton over a period of 4 weeks. The overall severity of disease was evaluated using the SCORing atopic dermatitis (SCORAD) index, whereas, the treatment efficacy was measured using a Tewameter® (Courage & Khazaka, Cologne, Germany), Mexameter® (Courage & Khazaka) and Corneo meter® (Courage & Khazaka).

RESULTS

At the end of the study, a significant decrease in the SCORAD index was observed among the patients with AD in the test group (mean SCORAD decreased from 47.2 to 36.1). Similarly, improvements in the mean transepidermal water loss, skin erythema and stratum corneum hydration were significantly greater among the patients with AD in the test group than in the control group.

CONCLUSION

Anion textiles may be used to significantly improve the objective and subjective symptoms of AD, and are similar in terms of comfort to cotton textiles. The use of anion textiles may be beneficial in the management of patients with AD.

Is prevention of atopic eczema with hydrolyzed formulas cost-effective? A health economic evaluation from Germany

OBJECTIVE

The German Infant Nutritional Intervention (GINI) trial, a prospective, randomized, double-blind intervention, enrolled children with a hereditary risk for atopy. When fed with certain hydrolyzed formulas for the first 4 months of life, the risk was reduced by 26-45% in PP and 8-29% in intention-to-treat (ITT) analyses compared with children fed with regular cow's milk at age 6. The objective was to assess the cost-effectiveness of feeding hydrolyzed formulas.

PATIENTS AND METHODS

Cost-effectiveness was assessed with a decision tree model programmed in TreeAge. Costs and effects over a 6-yr period were analyzed from the perspective of the German statutory health insurance (SHI) and a societal perspective at a 3% effective discount rate followed by sensitivity analyses.

RESULTS

The extensively hydrolyzed casein formula would be the most cost-saving strategy with savings of 478 € per child treated in the ITT analysis (CI95%: 12 €; 852 €) and 979 € in the PP analysis (95%CI: 355 €; 1455 €) from a societal perspective. If prevented cases are considered, the partially whey hydrolyzed formula is cost-saving (ITT -5404 €, PP -6358 €). From an SHI perspective, the partially whey hydrolyzed formula is cost-effective, but may also be cost-saving depending on the scenario. An extensively hydrolyzed whey formula also included into the analysis was dominated in all analyses.

CONCLUSIONS

For the prevention of AE, two formulas can be cost-effective or even cost-saving. We recommend that SHI should reimburse formula feeding or at least the difference between costs for cow's milk formula and the most cost-effective formula.

What's new in atopic eczema?

IMPORTANCE OF THE FIELD

Atopic eczema (AE) is a chronic relapsing inflammatory skin condition and one of the most common, potentially debilitating diseases with increasing incidence.

AREAS COVERED IN THIS REVIEW

The complex etiology of AE with multiple systemic and local immunologic and inflammatory responses and interactions between susceptibility genes and environmental factors leading to defects in skin barrier function and eczematous skin lesions is presented. Knowledge of pathogenesis is important for understanding the more innovative treatment approaches discussed.

WHAT THE READER WILL GAIN

Basic therapy consists of hydrating topical treatment and avoidance of specific and unspecific provocation factors. For acute eczematous skin lesions, anti-inflammatory treatment consists mainly of topical glucocorticoids and topical calcineurin inhibitors (tacrolimus and pimecrolimus). Microbial colonization and superinfection may induce skin exacerbation, which can be treated by either topical or systemic antimicrobial treatment. Systemic anti-inflammatory therapy is limited to severe cases and consists of systemic steroids, cyclosporine A or mycophenolate mofetil. Novel anti-inflammatory concepts that go beyond corticosteroids are in the early phases of development. There are targeted therapeutic approaches, such as cytokine and chemokine modulators and it remains to be investigated how effective they will be and what side effects they may carry.

TAKE HOME MESSAGE

Existing treatment modalities such as barrier repair therapy, topical immunosuppressive agents, antiseptic treatment as well as systemic treatment options are discussed. The review aims to summarize the most recent findings of more innovative treatment approaches such as modulation of cytokines or chemokines, modulation of T-cell responses or anti-IgE therapy.

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.

Efficacy and functionality of silver-coated textiles in patients with atopic eczema

BACKGROUND

Microbial skin colonization with Staphylococcus aureus is known to play an important role in atopic eczema (AE). Recently, an antibacterial effect of silver-coated textiles on S. aureus colonization has been demonstrated.

OBJECTIVES

To investigate clinical efficacy and functionality of silver-coated textiles in AE, a multicentre, double-blind, placebo-controlled trial was conducted.

PATIENTS/METHODS

From November 2001 to August 2002, 68 consecutive outpatients clinically diagnosed with generalized AE were included in the study. Inclusion criteria were the clinical diagnosis of AE with a moderate severity as measured by the scoring of atopic dermatitis (SCORAD) index with at least 20. Patients were instructed to wear either silver-coated (verum, 35 patients + 2 dropouts) or cotton garments (placebo, 22 patients + 9 dropouts) directly on the skin for 2 weeks. Only basic skin care and ongoing therapy with topical steroids or oral antihistamines was permitted. Clinical severity was assessed using the 'SCORAD' before, during and at the end of study. Quality of life (QOL), wearing comfort (WC) and functionality (FU) of study clothes were measured in parallel. Patients documented their subjective and objective symptoms daily.

RESULTS

In the verum group, eczema improved significantly after 1 week with further enhancement until the end of study (P = 0.03 and P < 0.001). Silver-coated textiles were comparable to cotton in WC and FU. Pruritus and self-assigned skin condition improved significantly more than with placebo (P < 0.001 and P = 0.003).

CONCLUSIONS

In conclusion, silver-coated textiles are able to improve objective and subjective symptoms of AE significantly within 2 weeks, showing a good wearing comfort and functionality comparable to cotton.

Review of the potential photo-cocarcinogenicity of topical calcineurin inhibitors. Position statement of the European Dermatology Forum

Topical Calcineurin Inhibitors (TCIs) used for the treatment of atopic eczema modify the immune regulatory function of the skin and may have the potential to enhance immunosuppressive ultraviolet (UV) effects. Current recommendations on UV protection in eczema patients treated with PCIs are inconsistent and have given rise to uncertainty and anxiety in patients. Therefore, the European Dermatology Forum (EDF) developed a position statement which reviews critically the available data with regard to the problem, especially analysing and commenting the limitations of rodent models for the human situation. There is no conclusive evidence from rodent trials to indicate that long-term application of TCIs is photococarcinogenic. There is a need for further studies to investigate the validity of mouse models as well as long-term cohort studies in patients using TCIs. Available data suggest that long-term application of TCIs is safe, that there is no evidence of increased skin cancer risk and that it is ethical to treat patients with TCIs when indicated.

Atopic dermatitis -- topical therapy: do patients apply much too little?

BACKGROUND

The treatment of atopic dermatitis still remains a challenge. Little research has been done on the issue of the extent to which patients correctly use prescribed topical preparations under everyday conditions.

AIMS

To investigate what quantity of topical preparations is applied by outpatients in daily routine treatment over a 26-week period and to what extent this consumption is related to the course of the severity of patients' skin conditions.

METHODS

Thirty adult outpatients (20 female and 10 male) with atopic dermatitis were examined at four different times during 26 weeks. For treatment and skin care these patients were given a topical glucocorticoid preparation (prednicarbate) and the corresponding emollient.

RESULTS

The average severity rating (SCORAD) was 29.6 (before therapy 33.9, after 26 weeks 27.4). The SCORAD indices improved by a mean of 6.5 points (p<0.05).

CONCLUSION

Patients who applied the correct amount of the prednicarbate-containing preparations (not less than 90% of 0.5 g/dm(2)) to the areas of affected skin showed a significant improvement in SCORAD indices across the four measuring times.

Predictive features for persistence of atopic dermatitis in children

Allergen exposure plays an important role in atopic dermatitis (AD). Because immunological mechanisms underlying asthma and AD have great similarities, we evaluated whether features such as allergen sensitization, immune response, disease severity and duration or allergen exposure could be considered predictive for AD persistence. Seventy-one AD children (age range 14-158 months) were enrolled and followed for 3 consecutive years for AD severity using the SCORAD index (SI). At enrollment, reactivity to inhalant and food allergens using the skin prick test (SPT) and house dust mite (HDM) atopy patch test (APT), and HDM allergens in house dust were evaluated. After 3 years, 38 children outgrew their AD (AD- group), while in 33 AD persisted (AD+ group). At enrollment, AD+ children had a higher SI, higher rate of positivity to SPT and APT for mites (p = 0.001), and higher environmental exposure to HDM allergens (p = 0.035). The AD+ children developed more respiratory symptoms in comparison to AD- children (p < 0.001). None of the AD- children presented APT positivity. In our study population, positivity of SPT and APT for HDM, environmental allergen exposure levels and severity of the disease at enrollment presented a significant predictive power towards AD persistence. Subjects with positive skin reactivity to HDM should be considered at risk of AD persistence and of possible development of allergic respiratory disorders.

Atopic eczema and allergy

Although the pathomechanisms of respiratory atopy are well established, the role of IgE-mediated hypersensitivity in the elicitation and maintenance of eczematous skin lesions in atopic eczema (AE) is still controversial. There is, however, evidence for exogenous elicitation of AE by contact with aero- or food allergens (house dust mite, cat, and so forth). Recent investigations show that epidermal Langerhans' cells bind IgE via different receptors, especially the high-affinity receptor (Fc epsilon RI), which is significantly more strongly expressed in lesional skin of AE compared with other inflammatory skin diseases including allergic contact dermatitis. The clinical relevance of IgE-mediated sensitization in AE has been evaluated by the so-called atopy patch test (APT). The APT shows a much higher specificity compared with the skin prick test and radioallergosorbent test. However, allergic reactions do not play a decisive role in every case of AE. Other factors, such as nonspecific skin irritability or psychosomatic interactions, have to be considered. The concept of "extrinsic" versus "intrinsic" types of AE seems attractive. The concept of AE starting with TH2 inflammation, becoming TH1 inflammation in chronicity, and finally progressing to an autoimmune disease with IgE antibodies against autologous epidermal proteins is very attractive. Based on new knowledge, new methods in diagnosis, treatment, and prevention will develop, including more effective avoidance strategies, more potent anti-inflammatory treatment (e.g., immunomodulation or topical immunophyllins), and new ultraviolet modalities. The new findings have given rise to a possible new classification of eczema/dermatitis. The concept of "patient management," including all aspects from avoidance to therapy, has gained acceptance.

Role of staphylococcal superantigens in atopic dermatitis: from colonization to inflammation

OBJECTIVE

This review article has been prepared in order to enable the readers to understand the role of staphylococcal superantigens (SsAgs) in atopic dermatitis (AD).

DATA SOURCES

MEDLINE literature search was performed for obtaining references. Recent reviews, research articles, poster presentations, and letters (to the editor) were meticulously reviewed.

RESULTS

(1) SsAgs contribute to the pathogenesis of cutaneous inflammation in AD with five potential mechanisms: Direct stimulation of antigen presenting cells (APCs) and keratinocytes. Stimulation of T cell proliferation [superantigenic binding to T cell receptor (TCR)]. Expansion of skin-homing cutaneous lymphocyte antigen (CLA) (+) T cells. The role of superantigens as allergens. Reduction of apoptosis. (2) Effectiveness of antibiotic therapy in AD patients without signs of bacterial infection is still under discussion. If signs of skin infection are present, antibiotic therapy (topical/oral) may help exacerbations of AD. Prolonged topical/oral antibiotic therapy, however, may cause development of antibiotic-resistant strains of Staphylococcus aureus (SA).

CONCLUSIONS

Atopic dermatitis is a genetically determined, chronically relapsing, inflammatory skin disease which has many aspects and a complex immunopathogenesis involving both immediate and cellular immune responses. While the pathogenic role of SsAgs may not be of primary importance, SsAgs appear to be one of the important triggering factors that contribute to the cutaneous inflammation in AD. We suggest that staphylococcal colonization does not always mean SsAg-mediated inflammation, and anti-staphylococcal treatment should be considered in cases with signs of bacterial infection.

The management of moderate to severe atopic dermatitis in adults with topical fluticasone propionate. The Netherlands Adult Atopic DermatitisStudy Group

This study was designed to investigate a long-term therapeutic strategy for the management of recurring atopic dermatitis (AD) in adults using fluticasone propionate (FP) ointment (CutivateTM) whereby FP could help to prevent a relapse of AD once symptoms were under control. Adult patients with chronic, moderate to severe AD entered this multicentre study. All patients were initially treated with FP 0.005% (g/g) ointment in two different regimens. Patients whose AD had been completely healed by these treatments then entered a long-term treatment phase applying FP or placebo ointment once daily, two times per week for 16 weeks to 'known' healed lesions. By the end of the initial treatment period, mean SCORAD values had significantly (P < 0.0005) improved from baseline. Patients who entered the maintenance phase and were treated with intermittent FP for up to 16 weeks, demonstrated its superior efficacy (P = 0.018) over placebo, maintaining the improvements achieved after the initial treatment phase, reducing risk of relapse and delaying time to relapse (P = 0.013). No significant changes were detected in either treatment group in serum cortisol levels or in skin thickness measurements. Intermittent FP applied two times per week maintained a significant level of control, and delayed relapse of AD by comparison with placebo.

Staphylococcus aureus colonization in atopic dermatitis and its therapeutic implications

Skin colonization with Staphylococcus aureus is a characteristic feature of atopic dermatitis with more than 90% of patients being colonized. Extracellular matrix proteins are important for the adherence of S. aureus to human keratinocytes. The bacterium interferes in the inflammatory process of atopic dermatitis in various ways, among which the ability to release superantigens in a high percentage of clinical isolates is of great importance. As the colonization correlates significantly with the severity of eczema, anti-staphylococcal treatment measurements are widely used. In cases of atopic dermatitis exacerbation with wide-spread weeping lesions, a systemic antibiotic treatment is warranted, with erythromycin no longer being recommended due to an increased resistance rate. In localized superinfected lesions the topical application of an antibiotic-glucocorticoid preparation may offer advantages to the mere steroid application. Based on efficacy and resistance data, fusidic acid is the antibiotic of choice. There is evidence that phototherapy in atopic dermatitis may be even more effective when combined with anti-staphylococcal measurements. In the future new therapeutical options may be available.

Food-induced cutaneous adverse reactions

The skin is the most frequently affected target organ in allergy or intolerance of food and food additives. The most common manifestation is acute urticaria (with or without angioedema), accounting for 40-60% of patients with IgE-mediated food allergy, whereas food additives rather aggravate chronic urticaria (intolerance provocation). The role of food allergy in the pathogenesis of atopic dermatitis is still controversial; however, there is no doubt that, particularly in infants and young children, food allergens can induce atopic dermatitis or aggravate skin lesions. In adults, food allergy as a cause or a trigger of atopic dermatitis is very rare. However, in food-allergic patients with atopic dermatitis, the ingestion of the food item can provoke the whole spectrum of IgE-mediated symptoms, from oral allergy syndrome to severe anaphylaxis. Skin symptoms can also be induced not only after food ingestion in sensitized people, but also after direct skin contact, as lipophilic food allergens can penetrate the skin via the hair follicles or when the skin barrier function is defective. Immediate contact reactions of the skin are a heterogeneous group: they include not only contact urticaria (contact urticaria syndrome) on an immunologic or nonimmunologic basis, but also allergic or nonallergic eczematous reactions caused by food proteins (protein contact dermatitis). A prototype is baker's eczema in a restricted sense with immediate-type sensitization to flour. Atopic eczema provoked by direct contact of the skin with food must also be taken into consideration. Finally, very rarely, allergic contact dermatitis that is due to type IV sensitization to food or food additives (positive delayed type reaction in the patch tests) can occur. The oral ingestion of these foods may provoke in these patients a generalized eczematous rash or dyshidrosiform reactions (vesicles) of the fingers, palms, and soles.

Isolation of cDNA clones coding for IgE autoantigens with serum IgE from atopic dermatitis patients

Recently we demonstrated that a high percentage of atopic dermatitis (AD) patients displayed specific immunoglobulin E reactivity to human proteins. Here we show that IgE autoreactivity is found predominantly in AD patients with severe skin manifestations and reveal the molecular nature of four IgE autoantigens. An expression cDNA library constructed from a human epithelial cell line (A 431) was screened with serum IgE from two AD patients. DNA sequence analysis of three IgE-reactive clones identified the alpha-chain of the nascent polypeptide-associated complex, cytokeratin type II, and the BCL7B oncogen as atopy-related IgE autoantigens (ara). The fourth cDNA coded for an IgE autoantigen containing a typical calcium binding motif that occurred in histogenetically different cells and tissues (keratinocytes, muscle, brain). Recombinant Escherichia coli-expressed IgE autoantigens bound IgE from AD but not from patients with other immunologically mediated disorders (graft vs. host disease, systemic lupus erythematosus) and elicited immediate type skin reactions in AD patients. In serum samples collected from an AD patient over a period of 5 years, IgE anti-ara NAC antibody levels peaked during disease exacerbation. Our finding that ara BCL7B was detected in serum bound to IgE antibodies suggests that intracellular IgE autoantigens can become released after tissue damage and may occur as IgE immune complexes. Via binding to antigen presenting cells as well as to effector cells, IgE autoantigen immune complexes may contribute to exacerbation and/or perpetuation of severe atopic diseases even in the absence of exogenous allergens.