The socioeconomic impact of atopic dermatitis in the United States: a systematic review

Unveiling the mechanism of essential oil action against skin pathogens: from ancient wisdom to modern science

Essential oils are among the most well-known phyto-compounds, and since ancient times, they have been utilized in medicine. Over 100 essential oils have been identified and utilized as therapies for various skin infections and related ailments. While numerous commercial medicines are available in different dosage forms to treat skin diseases, the persisting issues include their side effects, toxicity, and low efficacy. As a result, researchers are seeking novel classes of compounds as substitutes for synthetic drugs, aiming for minimal side effects, no toxicity, and high efficacy. Essential oils have shown promising antimicrobial activity against skin-associated pathogens. This review presents essential knowledge and scientific information regarding essential oil's antimicrobial capabilities against microorganisms that cause skin infections. Essential oils mechanisms against different pathogens have also been explored. Many essential oils exhibit promising activity against various microbes, which has been qualitatively assessed using the agar disc diffusion experiment, followed by determining the minimum inhibitory concentration for quantitative evaluation. It has been observed that Staphylococcus aureus and Candida albicans have been extensively researched in the context of skin-related infections and their antimicrobial activity, including established modes of action. In contrast, other skin pathogens such as Staphylococcus epidermidis, Streptococcus pyogens, Propionibacterium acnes, and Malassezia furfur have received less attention or neglected. This review report provides an updated understanding of the mechanisms of action of various essential oils with antimicrobial properties. This review explores the anti-infectious activity and mode of action of essential against distinct skin pathogens. Such knowledge can be valuable in treating skin infections and related ailments.

Association of maternal ultra-processed food consumption during pregnancy with atopic dermatitis in infancy: Korean Mothers and Children's Environmental Health (MOCEH) study

BACKGROUND

Maternal diet during pregnancy might influence the development of childhood allergic disorders. There are few studies on the association between processed food intake and infant atopic dermatitis (AD) during pregnancy. The aim of the present study was to investigate the association of ultra-processed food (UPF) intake during pregnancy with infantile AD.

METHODS

This study involved 861 pairs of pregnant women and their offspring from the Mothers' and Children's Environmental Health (MOCEH) study, a multi-center birth cohort project conducted in Korea. Dietary intake was estimated using a 24-h recall method at 12-28 weeks gestation. The NOVA classification was used to identify UPF, and UPF intake was calculated as the percentage of total energy consumption and categorized into quartiles. Infantile AD was assessed based on medical history and the criteria of the International Study of Asthma and Allergies in Childhood (ISAAC). Associations were assessed by logistic regression with adjustment for confounding factors.

RESULTS

Children born to mothers in the highest quartile of UPF consumption (15.5% or more of the total energy) compared to the lowest quartile (6.8% or less) showed a higher risk of AD within 12 months [odds ratio (OR) = 1.69; 95% confidence interval (CI): 1.07-2.66, P for trend 0.0436]. After adjustment for the confounding factors under study, the association was strengthened; the adjusted OR between extreme quartiles was 2.19 (95% CI: 1.11-4.32, P for trend = 0.0418). This association was maintained even after an additional adjustment based on the Korean Healthy Eating Index (KHEI), an indicator of diet quality.

CONCLUSIONS

Higher maternal consumption of UPF during pregnancy was associated with a greater risk of infantile AD within the first year of life.

Trends in occupational and work-related contact dermatitis attributed to nickel, chromium and cobalt in the UK: findings from The Health and Occupation Research network 1996-2019

BACKGROUND

Occupational exposure to metals such as nickel, chromium and cobalt can be associated with contact dermatitis, which can adversely affect an individual's health, finances and employment. Despite this, little is known about the incidence of metal-related occupational contact dermatitis over prolonged periods of time.

OBJECTIVES

To investigate the medically reported trends in the incidence of work-related contact dermatitis attributed to nickel, chromium and cobalt in the UK.

METHODS

Incidence and trends in cases of occupational contact dermatitis caused by nickel, chromium or cobalt between 1996 and 2019 (inclusive), reported to the EPIDERM surveillance scheme, were investigated and compared with trends in the incidence of occupational contact dermatitis attributed to agents other than the aforementioned metals. A sensitivity analysis restricting the study cohort to cases attributed to only one type of metal was also conducted.

RESULTS

Of all cases reported to EPIDERM during the study period, 2374 (12%) were attributed to nickel, chromium or cobalt. Cases predominantly comprised females (59%), with a mean (SD) age (males and females) of 38 (13) years. Cases were most frequently reported in manufacturing, construction, and human health and social activity industries. The most frequently reported occupations were hairdressing, and sales and retail (assistants, cashiers and checkout operators). The highest annual incidence rate of contact dermatitis was observed in females (2.60 per 100 000 persons employed per year), with the first and second peak seen in those aged 16-24 and ≥ 65 years, respectively. A statistically significant decrease in the incidence of occupational contact dermatitis attributed to metals over the study period was observed for all occupations (annual average change -6.9%, 95% confidence interval -7.8 to -5.9), with much of the decrease occurring between 1996 and 2007. Similar findings were obtained in the sensitivity analyses.

CONCLUSIONS

Over a period of 24 years, there has been a statistically significant decline in the incidence of metal-related occupational contact dermatitis in the UK. This could be attributed not only to improvements in working conditions, which have reduced metal exposure, but could also be due to the closure of industries in the UK that might have generated cases of contact dermatitis owing to metal exposure.

Atopic Dermatitis in Children

Atopic dermatitis (AD) is extremely common in the pediatric population, and most children with AD will first present to their primary care provider (PCP). The PCP can recognize AD by its clinical features, including itch, a chronic relapsing course, and the characteristic eruption. The cornerstone of AD therapy is dry skin care, typically a short daily bath/shower followed by an emollient applied to all skin. Most children with AD will also require topical medications, such as topical corticosteroids and/or topical nonsteroidal therapies. For children with more severe disease, systemic agents, including several novel therapies, may be required. In managing AD, the clinician must monitor for side effects of medications as well as complications of the AD itself, the most common of which is secondary infection. An understanding of the pathogenesis, treatments, and complications of AD is essential for the PCP, as untreated (or undertreated) AD has a significant impact on the quality of life of affected children and their caregivers. [Pediatr Ann. 2024;53(4):e121-e128.].

Association between CCL5, CCL11, and CCL17 polymorphisms and atopic dermatitis risk: A systematic review and meta-analysis

BACKGROUND

Atopic dermatitis (AD) is a common and recurrent inflammatory disease with strong genetic susceptibility. The abnormal production of chemokines plays an important role in the occurrence and development of AD.

METHODS

A comprehensive online literature search was performed in databases of China National Knowledge Infrastructure, Wanfang, VIP China Science and Technology Journal Database, China Biomedical Literature Database, PubMed, Embase and Cochrane Library to retrieve relevant articles published from January 2000 to October 2022. The odds ratio (OR) with its 95% confidence interval (CI) was employed to calculate this relationship.

RESULTS

A total of 7 studies were finally screened out, including 1316 AD patients and 1099 controls. There were 3 studies for CC chemokine ligand 5 (CCL5) polymorphisms, 2 for CCL11 polymorphisms, and 2 for CCL17 polymorphisms, respectively. The meta-analysis revealed a significant association between the CCL5 - 403G/A polymorphism and AD under the allelic model (A vs G: OR = 1.25, 95% CI = 1.02-1.52, P = .03), heterozygous model (AG vs GG: OR = 1.40, 95% CI = 1.08-1.80, P = .01) and dominant model (AA + AG vs GG: OR = 1.38, 95% CI = 1.08-1.76, P = .01) in a fixed-effect model. The allelic model (G vs C: OR = 1.46, 95% CI = 1.07-1.98, P < .01) and dominant model (GG + GC vs CC: OR = 1.74, 95% CI = 1.23-2.47, P < .001) of the CCL5 - 28C/G polymorphism were also associated with an increased risk of AD. However, this significant association was not found in other alleles and genotypes (P > .05).

CONCLUSION

Our results show that the A allele, AG and AA + AG genotypes of the CCL5 - 403G/A polymorphism, the G allele and GG + GC genotype of the CCL5 - 28C/G polymorphism are risk factors for AD. Future studies with large population are still needed to further explore those correlations.

The Economic Impact of Atopic Dermatitis

Atopic dermatitis (AD) is a chronic inflammatory disorder that affects over 30 million people in the United States. Given the large and growing prevalence of AD, the associated economic burden is significant. It has been estimated that AD costs over $5 billion dollars annually. These costs include both direct and indirect costs. Direct costs include prescription medicines, visits to health-care providers, hospitalizations, and transportation. Indirect costs include missed days or lost productivity at work or school, career modification, and reduced quality of life. Understanding and measuring these costs can be accomplished through rigorous economic evaluation, which is the organized process of considering inputs and outcomes of various activities. Economic evaluation has been used to contextualize the burden of AD in society. It has also been used to inform patients, providers, and other stakeholders on how to deliver the most evidence-based, efficient way possible. Understanding the economic impact of atopic dermatitis is an important aspect of delivering high-quality care.

Patient education in atopic dermatitis: a scoping review

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease that affects children and adults. Poor treatment adherence in AD requires interventions to promote self-management; patient education in chronic diseases is key to self-management. Many international AD management guidelines published to date include a recommendation for educating patients as part of their treatment but there are no formal recommendations on how to deliver this knowledge. MAIN: We performed a scoping review to map the existing literature on patient education practices in AD and to highlight the clinical need for improved patient education in AD. The literature search was performed with the online databases MEDLINE, Embase, Grey Matters, ClinicalTrails.gov and the International Clinical Trials Registry Platform (ICTRP). The search strategy yielded 388 articles. Of the 388 articles screened, 16 studies met the eligibility criteria, and the quantitative data was summarized by narrative synthesis. The majority of studies were randomized controlled trials conducted in Europe, Asia and North America. Since 2002, there have been limited studies evaluating patient education in the treatment of AD. Frequent education methods used included group-based educational programs, educational pamphlets, individual consultations and online resources. Education was most commonly directed at caregivers and their children. Only one study compared the efficacy of different education methods. In all included studies, the heterogenous nature of outcome measures and study design limited the consistency of results. Despite the heterogeneity of studies, patient education was shown to improve quality of life (QoL), disease severity and psychological outcomes in AD patients.

CONCLUSION

This scoping review highlights that patient education is effective in a variety of domains relevant to AD treatment. Further comparative studies and randomized trials with longer-term follow-up are needed to provide validated and consistent patient education recommendations for AD; these may depend on age and population.

Chitosan hydrogels with MK2 inhibitor peptide-loaded nanoparticles to treat atopic dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disorder that lacks ideal long-term treatment options due to a series of side effects, such as skin atrophy, related to the most common treatment prescribed to manage moderate-to-severe AD. In this study, a cell-penetrating MK2 inhibitor peptide YARA (YARAAARQARAKALNRQGLVAA) was loaded into hollow thermo-responsive pNIPAM nanoparticles (NP), which were further incorporated into chitosan hydrogels (H-NP-YARA) to promote local drug delivery, improve moisture and the anti-inflammatory activity. The NPs exhibited high loading efficiency (>50%) and the hydrogel remained porous following NP incorporation as observed by scanning electron microscopy (SEM). Both nanoparticles and hydrogels were able to improve the release of YARA and sustained release to up to 120 h. The hydrogels and NPs delivered 2 and 4-fold more YARA into viable skin layers of porcine skin in vitro at 12 h post-application than the non-encapsulated compound in intact and impaired barrier conditions. Furthermore, the YARA-loaded NPs (NP-YARA) and H-NP-YARA treatment decreased the levels of inflammatory cytokines up to 20 time-fold compared with the non-treated group of human keratinocytes under inflammatory conditions. Consistent with the results in cell culture, the loading of YARA in NP reduced the levels of IL-1β, IL-6, and TNF-α up to 3.3 times in an ex vivo skin culture model after induction of inflammation. A further decrease of up to 17 times-fold was observed with H-NP-YARA treatment compared to the drug in solution. Our data collectively suggest that chitosan hydrogel containing YARA-loaded nanoparticles is a promising new formulation for the topical treatment of AD.

The evolving landscape of immunotherapy for the treatment of allergic conditions

Allergic conditions, such as asthma, chronic urticaria, atopic dermatitis (AD), and eosinophilic esophagitis, have long been treated with oral and topical steroids which resulted in negative off-target effects. However, newer biologic medications are increasingly being developed and approved for treatment of these conditions. These medications have a variety of mechanisms of action to target pathophysiology specific to these diseases. As biologics become more targeted, fewer off-target effects are seen improving tolerability for patients as well as expanded options for treatment of these conditions. This review discusses monoclonal antibody therapies (omalizumab, mepolizumab, reslizumab, benralizumab, dupilumab, tezepelumab, and tralokinumab) including their safety and use in asthma, chronic urticaria, AD, and eosinophilic esophagitis.

Healthcare utilization for atopic dermatitis: An analysis of the 2010-2018 health insurance review and assessment service national patient sample data

This cross-sectional, retrospective, observational study aimed to analyze the distribution and healthcare usage patterns of patients with atopic dermatitis using the 2010-2018 Health Insurance Review and Assessment Service data. Patients diagnosed with atopic dermatitis in Korea between January 2010 and December 2018 and registered in the Health Insurance Review and Assessment national database were identified, and 270,008 patients who used healthcare services at least once during this period were evaluated to ascertain the healthcare usage patterns and treatment methods for atopic dermatitis. The number of patients with atopic dermatitis plateaued during the study period, while the number of claims and total expenses increased by a small margin. Atopic dermatitis prevalence was the highest among patients aged <5 years (31.4%), followed by those aged 5-14 years (23.53%) and 15-24 years (15.33%). However, the prevalence in these age groups showed a decreasing trend over time. The most used Western medicine treatments were injections and oral medications involving topical corticosteroids, antihistamine agents, and oral steroids, while it was acupuncture therapy in Korean medicine. The frequency of the most frequently prescribed medication, topical corticosteroid, showed a decreasing trend over time. The findings in this study will inform healthcare policy makers and clinicians across different countries on the usage trends of Western medicine and Korean medicine treatment.

Economic and Humanistic Burden in Paediatric Patients with Atopic Dermatitis

Data concerning the economic and humanistic burden in patients with paediatric atopic dermatitis (AD) and their families are scarce. This retrospective study investigated these burdens in paediatric patients with AD using maintenance treatment with topical corticosteroids and/or conventional systemic immunosuppressants. Patient-reported outcomes regarding quality of life, AD severity, and parental work-related impairment were completed at inclusion. Data on healthcare resource utilization and medication prescription were collected retrospectively over the previous 12 months. Patients were categorized into mild, moderate or severe AD, based on Eczema Area and Severity Index score and medication use. Costs per patient per year per AD severity category were calculated. A total of 101 patients (median age 11.0 years (interquartile range 7.5-14.0), 47.5% men) were included, of whom 38 had mild AD, 37 moderate AD, and 26 severe AD. Mean ± standard deviation (SD) total costs patient per year for mild, moderate and severe AD were €1,812 ± €1,280, €2,680 ± €3,127, and €5,861 ±  €3,993, respectively. Highest total direct and indirect costs were found in patients with severe AD, mainly due to higher healthcare and medication costs. Highest humanistic burden was found in patients with moderate AD. For example, the median (interquartile range) Patient-Oriented Eczema Measure score was significantly higher in these patients compared with mild and severe AD (19.0 (15.0-24.0) vs 12.0 (8.8-15.0) and 17.0 (9.5-22.0), respectively). AD in paediatric patients incurs considerable direct and indirect costs, especially in patients with severe AD. The high humanistic burden in patients with moderate AD underlines the need for effective and safe new treatment options for children with AD.

Allergen immunotherapy for atopic dermatitis: Systematic review and meta-analysis of benefits and harms

BACKGROUND

Atopic dermatitis (AD, eczema) is driven by a combination of skin barrier defects, immune dysregulation, and extrinsic stimuli such as allergens, irritants, and microbes. The role of environmental allergens (aeroallergens) in triggering AD remains unclear.

OBJECTIVE

We systematically synthesized evidence regarding the benefits and harms of allergen immunotherapy (AIT) for AD.

METHODS

As part of the 2022 American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters AD Guideline update, we searched the MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, Global Resource for Eczema Trials, and Web of Science databases from inception to December 2021 for randomized controlled trials comparing subcutaneous immunotherapy (SCIT), sublingual immunotherapy (SLIT), and/or no AIT (placebo or standard care) for guideline panel-defined patient-important outcomes: AD severity, itch, AD-related quality of life (QoL), flares, and adverse events. Raters independently screened, extracted data, and assessed risk of bias in duplicate. We synthesized intervention effects using frequentist and Bayesian random-effects models. The GRADE approach determined the quality of evidence.

RESULTS

Twenty-three randomized controlled trials including 1957 adult and pediatric patients sensitized primarily to house dust mite showed that add-on SCIT and SLIT have similar relative and absolute effects and likely result in important improvements in AD severity, defined as a 50% reduction in SCORing Atopic Dermatitis (risk ratio [95% confidence interval] 1.53 [1.31-1.78]; 26% vs 40%, absolute difference 14%) and QoL, defined as an improvement in Dermatology Life Quality Index by 4 points or more (risk ratio [95% confidence interval] 1.44 [1.03-2.01]; 39% vs 56%, absolute difference 17%; both outcomes moderate certainty). Both routes of AIT increased adverse events (risk ratio [95% confidence interval] 1.61 [1.44-1.79]; 66% with SCIT vs 41% with placebo; 13% with SLIT vs 8% with placebo; high certainty). AIT's effect on sleep disturbance and eczema flares was very uncertain. Subgroup and sensitivity analyses were consistent with the main findings.

CONCLUSIONS

SCIT and SLIT to aeroallergens, particularly house dust mite, can similarly and importantly improve AD severity and QoL. SCIT increases adverse effects more than SLIT. These findings support a multidisciplinary and shared decision-making approach to optimally managing AD.

Clinical Implication of Serum Adiponectin Levels in Adult Patients with Atopic Dermatitis

Atopic dermatitis (AD) is characterized by chronic, relapsing, pruritic inflammatory skin disease. Adiponectin has been reported to have anti-inflammatory effects not only on metabolic disorders but also on various inflammatory disorders. The study aimed to validate adiponectin as a potential biomarker for AD disease severity and treatment response. Seventy-five patients with AD and 28 healthy volunteers were enrolled in the study. Patient information, including Eczema Area and Severity Index (EASI) scores and pruritus numeric rating scales (NRSs), were collected. An enzyme linked immunosorbent assay (ELISA) was conducted to measure levels of serum adiponectin. Additionally, sera of patients treated with dupilumab were collected and measured at 16 and 52 weeks from baseline. Serum adiponectin levels were significantly lower in moderate and severe AD patients than in the control and mild AD patients. Serum adiponectin level was negatively correlated with the EASI score and pruritus NRS. However, no significant changes were observed according to biologic treatment for AD. Low serum adiponectin levels are associated with moderate to severe AD, suggesting a potential role for adiponectin as a biomarker for severity assessment of AD.

An evaluation of abrocitinib for moderate-to-severe atopic dermatitis

INTRODUCTION

Atopic dermatitis (AD) is a common itchy inflammatory skin condition that affects many individuals. For many years, the landscape of AD treatment remained unchanged; however, there has been developing therapies that directly target the underlying immunological mechanism of AD. Janus kinase (JAK) inhibitors are small molecules that have shown anti-inflammatory and anti-itch effects in AD. Recently, abrocitinib, an oral JAK 1 inhibitor, was approved by the Food and Drug Administration for atopic dermatitis.

AREAS COVERED

By downregulating the immune cascade, abrocitinib has demonstrated the ability to curb symptoms of AD, including rapidly reducing pruritus in 2-3 days, and is safe and well-tolerated overall despite a low increased risk in infection. The data discussed was obtained from a comprehensive literature review utilizing PubMed.

EXPERT OPINION

Abrocitinib has strong efficacy, likely due to its broader mechanism of action provided by the inhibition of key regulatory molecule, JAK. Results have demonstrated that it is more efficacious at curbing symptoms of AD than dupilumab, the current treatment of choice for refractory, moderate-to-severe AD. While abrocitinib provides a great alternative treatment, particularly for non-responders and AD subtypes, it also demonstrates a stronger side effect profile that must be considered.

Managing Atopic Dermatitis with Lebrikizumab - The Evidence to Date

Atopic dermatitis is a prevalent, inflammatory skin disease that presents with an eczematous, itchy rash. As of late, there have been many emerging monoclonal antibody inhibitor and small molecule therapies that have changed the course of eczema treatment. One of the treatments in the pipeline for atopic dermatitis is interleukin 13 monoclonal antibody inhibitor, lebrikizumab. As interleukin 13 has been identified as a pro-inflammatory cytokine in the immunological cascade of eczema, it is thought that lebrikizumab can be a great treatment choice for patients with atopic dermatitis. Lebrikizumab is currently being investigated in several studies. Thus far, lebrikizumab for the treatment of eczema has been found to be efficacious; in particular, a rapid response of pruritus improvement has been demonstrated in as early as 2 days. Additionally, it is well tolerated and has an acceptable safety profile, with reports suggesting that are decreased risks of infection when compared to dupilumab. In this review, we aim to summarize the current understanding of lebrikizumab in terms of the mechanism of action, preclinical pharmacology, pharmacokinetics and metabolism, efficacy and safety, and drug indications.

Association of Probiotics with Atopic Dermatitis among Infant: A Meta-analysis of Randomized Controlled Trials

Background. Previous studies have explored the relationship between probiotics and risk of atopic dermatitis among infant; however, the results are still inconclusive. We aimed to assess the abovementioned association. Methods. PubMed, Web of Science, Embase, and China National Knowledge Infrastructure were retrieved for association between probiotics and atopic dermatitis with randomized controlled trials (RCTs) until Nov 20, 2021. The effect size was pooled by using random or fixed effect models according to the heterogeneity. Stata 12.0 was used for meta-analysis, sensitivity analysis, and bias analysis. Results. At the end of the screening article, 2575 infants were extracted from 8 trials and finally met the qualification criteria. In comparison to placebo, probiotics dramatically reduced incidence of childhood atopic dermatitis ( $\text{RR}=0.86$ , 95% $\text{CI}=0.78$ -0.95). However, probiotics did not exhibit benefit over placebo in preventing the development of either IgE-associated infant AD ( $\text{RR}=0.98$ , 95% $\text{CI}=0.79$ -1.22) or sensitive constitution ( $\text{RR}=0.93$ , 95% $\text{CI}=0.81$ -1.08). From the results of sensitivity and publication bias, we found that these results were robust with little publication bias. Conclusion. During the late stages of pregnancy, women taking probiotics could lower the risk of infantile atopic dermatitis, but not for IgE-associated infant AD or sensitive constitution. The results could provide evidence for the fibrosis. Future studies are needed to confirm the results.

Serum Ceruloplasmin as a Potential Clinical Biomarker in Atopic Dermatitis

Background

Although the discovery of new biomarkers in atopic dermatitis (AD) is challenging, it is valuable in diagnosis, assessment of severity, and evaluation of treatment response.

Objective

This study was designed to identify and validate new candidate protein biomarkers of AD via proteomic analysis.

Methods

Comparison of protein expression in the patients’ serum before- and after-treatment and in patients without AD was performed via two-dimensional gel electrophoresis (2-DE), followed by image analysis. Spots showing differential expression in 2-DE image analysis were identified subsequently via nanoscale liquid chromatography-tandem mass spectrometry (LC-MS/MS) experiments. Blood tests were conducted to validate the results obtained by measuring the levels of candidate proteins.

Results

Based on LC-MS/MS analysis and database search, we identified ceruloplasmin (Cp) as a candidate protein. Serum Cp levels were significantly decreased in in pre-treated AD group than in control group. Additionally, the serum Cp level was higher in the mild group than in the moderate group of AD based on the Eczema Area and Severity Index (EASI) score.

Conclusion

Low serum Cp levels are associated with AD, suggesting the potential role of Cp as a biomarker for diagnosis and severity assessment of AD.

What are the highest yielding search strategy terms for systematic reviews in atopic dermatitis? A systematic review

The impact of search strategies on systematic reviews (SR) of atopic dermatitis (AD) is unknown. The purpose of this review was to evaluate search strategies used in SR of AD and their impact on the frequency of manuscripts identified. MEDLINE and EMBASE were searched for SR related to AD. Simulations were performed by running combinations of search terms in MEDLINE and EMBASE. Overall, 250 SR met inclusion criteria, of which 225 specified search strategies. SR using 5-6 terms (20.0% to 12.1%) or ≥ 7 (40.0% to 18.8%) terms decreased, whereas SR using 3-4 terms numerically increased (18.8% to 30.2%) and 1-2 terms remained similar (37.5% to 38.9%) from 1999-2009 to 2015-2019. The most commonly searched terms were "atopic dermatitis" (n = 166), followed by "eczema" (n = 156), "dermatitis atopic'" (n = 81), "atopic eczema" (n = 74), "neurodermatitis" (n = 59), "Besniers prurigo" (n = 29), "infantile eczema" (n = 27), and "childhood eczema" (n = 19). Simulations revealed that "eczema" and "atopic dermatitis" yielded the most hits. The number of search terms that maximized hits in MEDLINE and EMBASE was 5 and 4, respectively. Search strategies for AD were heterogeneous, with high proportions of search strategies providing few search hits. Future studies should use standardized and optimized search terms.

Phototherapy for atopic eczema

BACKGROUND

Atopic eczema (AE), also known as atopic dermatitis, is a chronic inflammatory skin condition that causes significant burden. Phototherapy is sometimes used to treat AE when topical treatments, such as corticosteroids, are insufficient or poorly tolerated.

OBJECTIVES

To assess the effects of phototherapy for treating AE.

SEARCH METHODS

We searched the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and ClinicalTrials.gov to January 2021.

SELECTION CRITERIA

We included randomised controlled trials in adults or children with any subtype or severity of clinically diagnosed AE. Eligible comparisons were any type of phototherapy versus other forms of phototherapy or any other treatment, including placebo or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology. For key findings, we used RoB 2.0 to assess bias, and GRADE to assess certainty of the evidence. Primary outcomes were physician-assessed signs and patient-reported symptoms. Secondary outcomes were Investigator Global Assessment (IGA), health-related quality of life (HRQoL), safety (measured as withdrawals due to adverse events), and long-term control.

MAIN RESULTS

We included 32 trials with 1219 randomised participants, aged 5 to 83 years (mean: 28 years), with an equal number of males and females. Participants were recruited mainly from secondary care dermatology clinics, and study duration was, on average, 13 weeks (range: 10 days to one year). We assessed risk of bias for all key outcomes as having some concerns or high risk, due to missing data, inappropriate analysis, or insufficient information to assess selective reporting. Assessed interventions included: narrowband ultraviolet B (NB-UVB; 13 trials), ultraviolet A1 (UVA1; 6 trials), broadband ultraviolet B (BB-UVB; 5 trials), ultraviolet AB (UVAB; 2 trials), psoralen plus ultraviolet A (PUVA; 2 trials), ultraviolet A (UVA; 1 trial), unspecified ultraviolet B (UVB; 1 trial), full spectrum light (1 trial), Saalmann selective ultraviolet phototherapy (SUP) cabin (1 trial), saltwater bath plus UVB (balneophototherapy; 1 trial), and excimer laser (1 trial). Comparators included placebo, no treatment, another phototherapy, topical treatment, or alternative doses of the same treatment. Results for key comparisons are summarised (for scales, lower scores are better): NB-UVB versus placebo/no treatment There may be a larger reduction in physician-assessed signs with NB-UVB compared to placebo after 12 weeks of treatment (mean difference (MD) -9.4, 95% confidence interval (CI) -3.62 to -15.18; 1 trial, 41 participants; scale: 0 to 90). Two trials reported little difference between NB-UVB and no treatment (37 participants, four to six weeks of treatment); another reported improved signs with NB-UVB versus no treatment (11 participants, nine weeks of treatment). NB-UVB may increase the number of people reporting reduced itch after 12 weeks of treatment compared to placebo (risk ratio (RR) 1.72, 95% CI 1.10 to 2.69; 1 trial, 40 participants). Another trial reported very little difference in itch severity with NB-UVB (25 participants, four weeks of treatment). The number of participants with moderate to greater global improvement may be higher with NB-UVB than placebo after 12 weeks of treatment (RR 2.81, 95% CI 1.10 to 7.17; 1 trial, 41 participants). NB-UVB may not affect rates of withdrawal due to adverse events. No withdrawals were reported in one trial of NB-UVB versus placebo (18 participants, nine weeks of treatment). In two trials of NB-UVB versus no treatment, each reported one withdrawal per group (71 participants, 8 to 12 weeks of treatment). We judged that all reported outcomes were supported with low-certainty evidence, due to risk of bias and imprecision. No trials reported HRQoL. NB-UVB versus UVA1 We judged the evidence for NB-UVB compared to UVA1 to be very low certainty for all outcomes, due to risk of bias and imprecision. There was no evidence of a difference in physician-assessed signs after six weeks (MD -2.00, 95% CI -8.41 to 4.41; 1 trial, 46 participants; scale: 0 to 108), or patient-reported itch after six weeks (MD 0.3, 95% CI -1.07 to 1.67; 1 trial, 46 participants; scale: 0 to 10). Two split-body trials (20 participants, 40 sides) also measured these outcomes, using different scales at seven to eight weeks; they reported lower scores with NB-UVB. One trial reported HRQoL at six weeks (MD 2.9, 95% CI -9.57 to 15.37; 1 trial, 46 participants; scale: 30 to 150). One split-body trial reported no withdrawals due to adverse events over 12 weeks (13 participants). No trials reported IGA. NB-UVB versus PUVA We judged the evidence for NB-UVB compared to PUVA (8-methoxypsoralen in bath plus UVA) to be very low certainty for all reported outcomes, due to risk of bias and imprecision. There was no evidence of a difference in physician-assessed signs after six weeks (64.1% reduction with NB-UVB versus 65.7% reduction with PUVA; 1 trial, 10 participants, 20 sides). There was no evidence of a difference in marked improvement or complete remission after six weeks (odds ratio (OR) 1.00, 95% CI 0.13 to 7.89; 1 trial, 9/10 participants with both treatments). One split-body trial reported no withdrawals due to adverse events in 10 participants over six weeks. The trials did not report patient-reported symptoms or HRQoL. UVA1 versus PUVA There was very low-certainty evidence, due to serious risk of bias and imprecision, that PUVA (oral 5-methoxypsoralen plus UVA) reduced physician-assessed signs more than UVA1 after three weeks (MD 11.3, 95% CI -0.21 to 22.81; 1 trial, 40 participants; scale: 0 to 103). The trial did not report patient-reported symptoms, IGA, HRQoL, or withdrawals due to adverse events. There were no eligible trials for the key comparisons of UVA1 or PUVA compared with no treatment. Adverse events Reported adverse events included low rates of phototoxic reaction, severe irritation, UV burn, bacterial superinfection, disease exacerbation, and eczema herpeticum.

AUTHORS' CONCLUSIONS

Compared to placebo or no treatment, NB-UVB may improve physician-rated signs, patient-reported symptoms, and IGA after 12 weeks, without a difference in withdrawal due to adverse events. Evidence for UVA1 compared to NB-UVB or PUVA, and NB-UVB compared to PUVA was very low certainty. More information is needed on the safety and effectiveness of all aspects of phototherapy for treating AE.

Increased expression of Filaggrin and Claudin-1 in the ocular surface of patients with atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is an itchy, chronic and inflammatory skin condition, with dysfunctional immune response and skin barrier defects. Reduction of filaggrin (FLG) and tight junctions (TJ) proteins, such as claudin-1 (CLDN-1), expression in cutaneous epithelial barrier is remarkable in AD pathogenesis. Ocular involvement occurs in approximately 40% of AD patients leading to changes in the structure of the conjunctiva.

OBJECTIVES

We aimed to evaluate the expression of FLG and CLDN-1 in the ocular surface of adults with AD, analysing bulbar conjunctival cells collected by a novel non-invasive cellular imprint.

METHODS

Bulbar conjunctival epithelial cells were collected by cellular imprint technique, and FLG and CLDN-1 expression were assessed by immunofluorescence (IF) and real-time polymerase chain reaction (RT-PCR).

RESULTS

We detected increased expression of FLG and CLDN-1, as well as their transcript levels in AD patients compared with healthy controls (HC). There was a positive correlation between tear film break-up time (TBUT) and FLG expression. Fluorescein staining was inversely associated with FLG expression.

CONCLUSIONS

Our results may reflect a reactive response of the ocular surface to AD-related ocular inflammation and associated dry eye disease. Further investigations focusing on the role of FLG and TJ expression in the ocular surface of AD patients may increment the understanding of the pathophysiology of extracutaneous AD and developing future targeted therapies.

Systemic toxicity induced by topical application of heptafluorobutyric acid (PFBA) in a murine model

Heptafluorobutyric acid (PFBA) is a synthetic chemical belonging to the per- and polyfluoroalkyl substances (PFAS) group that includes over 5000 chemicals incorporated into numerous products. PFBA is a short-chain PFAS (C4) labeled as a safer alternative to legacy PFAS which have been linked to numerous health effects. Despite the high potential for dermal exposure, occupationally and environmentally, dermal exposure studies are lacking. Using a murine model, this study analyzed serum chemistries, histology, immune phenotyping, and gene expression to evaluate the systemic toxicity of sub-chronic dermal PFBA 15-day (15% v/v or 375 mg/kg/dose) or 28-day (3.75-7.5% v/v or 93.8-187.5 mg/kg/dose) exposures. PFBA exposure produced significant increases in liver and kidney weights and altered serum chemistries (all exposure levels). Immune-cell phenotyping identified significant increases in draining lymph node B-cells (15%) and CD11b + cells (3.75-15%) and skin T-cells (3.75-15%) and neutrophils (7.5-15%). Histopathological and gene expression changes were observed in both the liver and skin after dermal PFBA exposure. The findings indicate PFBA induces liver toxicity and alterations of PPAR target genes, suggesting a role of a PPAR pathway. These results demonstrate that sustained dermal exposure to PFBA induces systemic effects and raise concerns of short-chain PFAS being promoted as safer alternatives.

Cytokines and apoptosis in atopic dermatitis

Atopic dermatitis (AD) is the most common chronic inflammatory skin disease. AD affects 10-20% of children worldwide and persists into adulthood in a minority of cases, affecting approximately 2-3% of the adult population, with an increased prevalence over the past decades in developed countries. Atopy is a genetic tendency to overproduce IgE class antibodies in response to common antigens found in the environment. Concurrence of different atopy such as allergic rhinitis or asthma in children with AD is estimated at 80%. AD is characterized by a vicious cycle of an allergic immune response. The emerging picture of the AD is a complex disorder with barrier dysfunction, immunological, genetic and environmental factors all playing key roles. Patients with severe or persistent disease and their families experience significant impairment in their quality of life, and in addition, AD places a heavy economic burden on society as a whole. Pathogenesis, the role of the epidermal barrier, mechanisms of cells apoptosis, the role of T cells and cytokines in AD are discussed in this article.

Halting the March: Primary Prevention of Atopic Dermatitis and Food Allergies

Atopic dermatitis (AD) is one of the most common inflammatory skin conditions, affecting 15% to 30% of children and 2% to 10% of adults. Population-based studies suggest that having AD is associated with subsequent development of other atopic diseases, in what is known as the "atopic march." We will provide an overview of studies that investigate primary prevention strategies for the first 2 diseases in the march, namely, AD and food allergies (FA). These strategies include emollients, breastfeeding, microbial exposures, probiotics, vitamin D and UV light, water hardness, and immunotherapy. Some studies, including randomized controlled trials on emollients and microbial supplementation, have found encouraging results; however, the evidence remains limited and contradictory. With regard to breastfeeding, microbial and lifestyle exposures, vitamin D and UV light, water hardness, and immunotherapy, the lack of randomized controlled trials makes it difficult to draw definitive conclusions. Current American Academy of Pediatrics guidelines support the idea that breastfeeding for 3 to 4 months can decrease AD incidence in children less than 2 years old. Recommendations regarding a direct relationship between breastfeeding on FA, however, cannot be made because of insufficient data. Regarding microbial supplementation, most guidelines do not recommend probiotics or prebiotics for the purpose of preventing allergic diseases because of limited evidence. Before definitive conclusions can be made regarding these interventions, more well-designed, longitudinal, and randomized controlled trials, particularly in at-risk populations, are required.

Health, educational and employment outcomes among children treated for a skin disorder: Scotland-wide retrospective record linkage cohort study of 766,244 children

BACKGROUND

To compare health, educational and employment outcomes of schoolchildren receiving medication for a skin disorder with peers.

METHODS

This retrospective population cohort study linked eight Scotland-wide databases, covering dispensed prescriptions, hospital admissions, maternity records, death certificates, annual pupil census, school examinations, school absences/exclusions and unemployment to investigate educational (absence, exclusion, special educational need, academic attainment), employment, and health (admissions and mortality) outcomes of 766,244 children attending local authority run primary, secondary and special schools in Scotland between 2009 and 2013.

RESULTS

After adjusting for sociodemographic and maternity confounders the 130,087 (17.0%) children treated for a skin disorder had increased hospitalisation, particularly within one year of commencing treatment (IRR 1.38, 95% CI 1.35-1.41, p<0.001) and mortality (HR 1.50, 95% CI 1.18-1.90, p<0.001). They had greater special educational need (OR 1.19, 95% CI 1.17-1.21, p<0.001) and more frequent absences from school (IRR 1.07, 95% CI 1.06-1.08, p<0.001) but did not exhibit poorer exam attainment or increased post-school unemployment. The associations remained after further adjustment for comorbid chronic conditions.

CONCLUSIONS

Despite increased hospitalisation, school absenteeism, and special educational need, children treated for a skin disorder did not have poorer exam attainment or employment outcomes. Whilst findings relating to educational and employment outcomes are reassuring, the association with increased risk of mortality is alarming and merits further investigation.

Traditional Chinese medicine for food allergy and eczema

OBJECTIVE

To summarize the recent evidence of traditional Chinese medicine (TCM) for food allergy and eczema.

DATA SOURCES

Published literature from PubMed database and abstract conference presentations.

STUDY SELECTIONS

Studies relevant to TCM for food allergy and eczema were included.

RESULTS

TCM is the main component of complementary and alternative medicine in the United States. Food Allergy Herbal Formula 2 (FAHF-2) (derived from the classical formula Wu Mei Wan) prevented systemic anaphylaxis in murine models and was found to have safety and preliminary immunomodulatory effects on T cells and basophils. The phase II trial of combined TCM with oral immunotherapy and omalizumab for multiple food allergy is ongoing. Retrospective practice-based evidence study revealed that comprehensive TCM therapy effectively prevented frequent and severe food anaphylaxis triggered by skin contact or protein inhalation. The traditional Japanese herbal medicine Kakkonto suppressed allergic diarrhea and decreased mast cells in intestinal mucosa in a murine model. The active compounds from TCM were found to have potent inhibition of immunoglobulin (Ig) E, mast cell activation, and proinflammatory cytokine or signaling pathway (tumor necrosis factor alpha, interleukin 8, NF-κB) suggesting value for both IgE and non-IgE-mediated food allergy. Triple TCM therapy including ingestion, bath, and cream markedly improved skin lesion, itching, and sleep loss in patients with corticosteroid dependent, recalcitrant, or topical steroid withdrawal. Xiao Feng San and Japanese and Korean formulas were found to have effectiveness in eczema. Furthermore, acupuncture reduced wheal size, skin itching, and basophil activation in atopic dermatitis. Moreover, TCM is generally safe.

CONCLUSION

TCM has potential as safe and effective therapy for food allergy and eczema. Further research is needed for botanical drug development and to further define the mechanisms of actions.

TRIAL REGISTRATION

FAHF-2: https://ichgcp.net/clinical-trials-registry/NCT00602160; ethyl acetate and butanol purified FAHF-2: https://clinicaltrials.gov/ct2/show/NCT02879006.

Creating a Smartphone App for Caregivers of Children With Atopic Dermatitis With Caregivers, Health Care Professionals, and Digital Health Experts: Participatory Co-Design

Background

Smartphone apps could support patients and caregivers in disease self-management. However, as patients’ experiences and needs might not always align with clinical judgments, the eliciting and engaging of perspectives of all stakeholders in the smartphone app design process is of paramount importance.

Objective

The aims of this study are to better understand the needs of and challenges facing caregivers and health care professionals (HCPs) who care for children with atopic dermatitis (AD) and to explore the desirable features and content of a smartphone app that would support AD self-management.

Methods

This study adopted a qualitative participatory co-design methodology involving 3 focus group discussions: workshop one focused on caregivers; workshop two engaged with HCPs; and in the last workshop, caregivers and digital health experts were asked to design the wireframe prototype. The participants completed a sociodemographic questionnaire, a technology acceptance questionnaire, and a workshop evaluation form.

Results

Twelve caregivers participated in the first workshop, and 10 HCPs participated in the second workshop. Eight caregivers and 4 digital health experts attended the third workshop. Three superordinate themes that reflected caregivers’ and HCPs’ challenges and needs were identified: empowerment by education, confusion over treatment, and emotional impact. Workshop participants also raised a series of suggestions on the features and contents of the AD self-management app, which informed the last co-design workshop, and described their needs and challenges. In the last workshop, the participants developed a wireframe prototype of the app following the identified requirements and recommendations.

Conclusions

The co-design approach was found to be a successful way of engaging with the participants, as it allowed them to express their creativity and helped us to articulate the root of the clinical problems. The co-design workshop was successful in creating and generating new ideas and solutions for smartphone app development.

Effectiveness and adverse events of topical and allergen immunotherapy for atopic dermatitis: a systematic review and network meta-analysis protocol

BACKGROUND

Atopic dermatitis (AD) is an inflammatory chronic condition that affects the skin of children and adults and has an important impact on the quality of life. Treatments for AD are based on environmental controls, topical and systemic therapies, and allergen-specific immunotherapy (AIT). However, it remains unclear the effectiveness and adverse events of AIT and all conventional topical treatments compared with placebo and each other for AD.

METHODS

We will search five electronic databases [Central Cochrane register of controlled trials (CENTRAL), MEDLINE, EMBASE, CINAHL, and LILACS] from inception until November 2019 with no language restriction, and we will include experimental studies [randomized controlled trials (RCTs), and quasi-RCTs]. The primary outcome is global and specific skin symptoms assessment. Secondary outcomes are hospital length of stay, quality of life, and adverse events. Reviewers independently will extract data from the studies that meet our inclusion criteria and will assess the risk of bias of individual primary studies. We will conduct random effects pairwise meta-analyses for the observed pairwise comparisons with at least two trials. Then, we will perform random-effects Bayesian network meta-analysis (NMA) to obtain treatment effects for all possible comparisons and to provide a hierarchy of all interventions for each outcome. Possible incoherence between direct and indirect sources of evidence will be investigated locally (if possible) and globally. To investigate sources of statistical heterogeneity, we will perform a series of meta-regression analyses based on pre-specified important effect modifiers. Two authors will appraise the certainty of the evidence for each outcome applying the GRADE's framework for NMA.

DISCUSSION

The findings of this systematic review will shed the light on the effectiveness and adverse events of all possible comparisons for treating AD and on the quality of the collated evidence for recommendations. It will also provide critical information to health care professionals to comprehend and manage this disease at different age stages, treatment type, duration, and severity of atopic dermatitis.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO Protocol ID CRD42019147106.

Systemic treatments for eczema: a network meta-analysis

BACKGROUND

Eczema is a common and chronic, relapsing, inflammatory skin disorder. It seriously impacts quality of life and economic outcomes, especially for those with moderate to severe eczema. Various treatments allow sustained control of the disease; however, their relative benefit remains unclear due to the limited number of trials directly comparing treatments.

OBJECTIVES

To assess the comparative efficacy and safety of different types of systemic immunosuppressive treatments for moderate to severe eczema using NMA and to generate rankings of available systemic immunosuppressive treatments for eczema according to their efficacy and safety.

SEARCH METHODS

We searched the following databases up to August 2019: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of systemic immunosuppressive agents for moderate to severe atopic eczema when compared against placebo or any other eligible eczema treatment.

DATA COLLECTION AND ANALYSIS

We synthesised data using pair-wise analysis and NMA to compare treatments and rank them according to their effectiveness. Effectiveness was assessed primarily by determining the proportion of participants who achieved at least 75% improvement in the Eczema Area and Severity Index (EASI75) and improvement in the Patient-Oriented Eczema Measure (POEM). Safety was evaluated primarily by considering the proportion of participants with serious adverse events (SAEs) and infection. We deemed short-term follow-up as ≤ 16 weeks and long-term follow-up as > 16 weeks. We assessed the certainty of the body of evidence from the NMA for these primary outcomes using six domains of CiNEMA grading.

MAIN RESULTS

We included a total of 74 studies, with 8177 randomised participants. Approximately 55% of participants were male, with average age of 32 years (range 2 to 84 years), although age and gender were unreported for 419 and 902 participants, respectively. Most of the included trials were placebo controlled (65%), 34% were head-to-head studies (15% assessed the effects of different doses of the same drug), and 1% were multi-armed studies with both an active comparator and a placebo. All trials included participants with moderate to severe eczema, but 62% of studies did not separate data by severity; 38% of studies assessed only severe eczema. The total duration of included trials ranged from 2 weeks to 60 months, whereas treatment duration varied from a single dose (CIM331, KPL-716) to 60 months (methotrexate (MTX)). Seventy studies were available for quantitative synthesis; this review assessed 29 immunosuppressive agents from three classes of interventions. These included (1) conventional treatments, with ciclosporin assessed most commonly; (2) small molecule treatments, including phosphodiesterase (PDE)-4 inhibitors, tyrosine kinase inhibitors, and Janus kinase (JAK) inhibitors; and (3) biological treatments, including anti-CD31 receptors, anti-interleukin (IL)-22, anti-IL-31, anti-IL-13, anti-IL-12/23p40, anti-OX40, anti-TSLP, anti-CRTH2, and anti-immunoglobulin E (IgE) monoclonal antibodies, but most commonly dupilumab. Most trials (73) assessed outcomes at a short-term duration ranging from 2 to 16 weeks, whereas 33 trials assessed long-term outcomes, with duration ranging from 5 to 60 months. All participants were from a hospital setting. Fifty-two studies declared a source of funding, and of these, pharmaceutical companies funded 88%. We rated 37 studies as high risk; 21, unclear risk, and 16, low risk of bias, with studies most commonly at high risk of attrition bias. Network meta-analysis suggests that dupilumab ranks first for effectiveness when compared with other biological treatments. Dupilumab is more effective than placebo in achieving EASI75 (risk ratio (RR) 3.04, 95% confidence interval (CI) 2.51 to 3.69) and improvement in POEM score (mean difference 7.30, 95% CI 6.61 to 8.00) at short-term follow-up (high-certainty evidence). Very low-certainty evidence means we are uncertain of the effects of dupilumab when compared with placebo, in terms of the proportion of participants who achieve EASI75 (RR 2.59, 95% CI 1.87 to 3.60) at longer-term follow-up. Low-certainty evidence indicates that tralokinumab may be more effective than placebo in achieving short-term EASI75 (RR 2.54, 95% CI 1.21 to 5.34), but there was no evidence for tralokinumab to allow us to assess short-term follow-up of POEM or long-term follow-up of EASI75. We are uncertain of the effect of ustekinumab compared with placebo in achieving EASI75 (long-term follow-up: RR 1.17, 95% CI 0.40 to 3.45; short-term follow-up: RR 0.91, 95% CI 0.28 to 2.97; both very low certainty). We found no evidence on ustekinumab for the POEM outcome. We are uncertain whether other immunosuppressive agents that targeted our key outcomes influence the achievement of short-term EASI75 compared with placebo due to low- or very low-certainty evidence. Dupilumab and ustekinumab were the only immunosuppressive agents evaluated for longer-term EASI75. Dupilumab was the only agent evaluated for improvement in POEM during short-term follow-up. Low- to moderate-certainty evidence indicates a lower proportion of participants with SAEs after treatment with QAW039 and dupilumab compared to placebo during short-term follow-up, but low- to very low-certainty evidence suggests no difference in SAEs during short-term follow-up of other immunosuppressive agents compared to placebo. Evidence for effects of immunosuppressive agents on risk of any infection during short-term follow-up and SAEs during long-term follow-up compared with placebo was of low or very low certainty but did not indicate a difference. We did not identify differences in other adverse events (AEs), but dupilumab is associated with specific AEs, including eye inflammation and eosinophilia.

AUTHORS' CONCLUSIONS

Our findings indicate that dupilumab is the most effective biological treatment for eczema. Compared to placebo, dupilumab reduces eczema signs and symptoms in the short term for people with moderate to severe atopic eczema. Short-term safety outcomes from clinical trials did not reveal new safety concerns with dupilumab. Overall, evidence for the efficacy of most other immunosuppressive treatments for moderate to severe atopic eczema is of low or very low certainty. Given the lack of data comparing conventional with newer biological treatments for the primary outcomes, there remains high uncertainty for ranking the efficacy and safety of conventional treatments such as ciclosporin and biological treatments such as dupilumab. Most studies were placebo-controlled and assessed only short-term efficacy of immunosuppressive agents. Further adequately powered head-to-head RCTs should evaluate comparative long-term efficacy and safety of available treatments for moderate to severe eczema.

Association of atopic dermatitis with suicide risk among 788,411 adolescents: A Korean cross-sectional study

BACKGROUND

Atopic dermatitis (AD) is known to negatively influence the mental health of patients. However, only a few studies have explored the influencing factors for psychiatric problems among adolescents with AD.

OBJECTIVE

To assess the association of AD and suicidal behaviors among adolescents by analyzing data from the 3rd through the 13th annual Korean Youth Risk Behavior Web-based Surveys (completed from 2007 to 2017).

METHODS

Survey data were obtained from a stratified, multistage, clustered sample. Students self-reported AD if they had received a diagnosis of AD by a physician. Influencing factors for suicidal behaviors were tested by logistic regression models.

RESULTS

A total of 788,411 adolescents completed the survey. The proportion of participants with AD was 22.2%. Those reporting suicide ideation and suicide attempts were 19.0%, and 4.5%, respectively. Compared with adolescents without AD, those with AD were more likely to be female, to skip breakfast less frequently, to exercise less frequently, to drink less alcohol, and to not be current smokers and were statistically significantly more likely to have negative mental health states. In the multivariable model, perceived unhappiness and suicidal ideation were the strongest influencing factors for suicidal ideation (adjusted odds ratio, 4.90; 95% CI, 4.31-5.57) and for suicidal attempts (adjusted odds ratio, 48.01; 95% CI, 42.69-53.09), respectively.

CONCLUSION

Adolescents with AD had a meaningful prevalence of suicidal behaviors. Although further research is needed to clarify this association, adolescents with AD with influencing factors for negative mental health state may need intervention from practitioners who use a multidisciplinary team approach to prevent suicide.

Atopic Dermatitis: Update on Pathogenesis and Therapy

Atopic dermatitis (AD) is the most common inflammatory skin condition in pediatric patients. AD has long been associated with comorbidities including food allergies, asthma, and allergic rhinitis, but recent literature has expanded this list to include attention-deficit/hyperactivity disorder and depression. AD has tremendous impact on quality of life for both affected children and their families. Improved understanding of AD pathogenesis, particularly regarding skin barrier dysfunction, the role of the cutaneous microbiome, and immune dysregulation, has spawned exciting new therapeutic directions. Although good skin care and appropriate use of topical corticosteroids remain first-line treatment, more precisely targeted treatments hold great promise. A recently approved topical phosphodiesterase inhibitor, crisaborole, and a subcutaneously administered interleukin-4/interleukin-13 blocker, dupilumab, are the first of what will likely be many new treatment options for patients with AD. [Pediatr Ann. 2020;49(3):e140-e146.].

Impact of atopic dermatitis treatment on child and parent sleep, daytime functioning, and quality of life

BACKGROUND

Atopic dermatitis (AD) is a common childhood disorder that is associated with a variety of negative health outcomes in children and parents, including poor sleep and daytime functioning. Despite this, few studies have examined the impact of treatment for AD on sleep, and even fewer have included validated sleep questionnaires, child report of sleep disturbance, or objective measures of sleep.

OBJECTIVE

To address limitations in the literature by examining objective and subjective reports of sleep, as well as measures of daytime functioning before and after admission to an intensive treatment program for AD.

METHODS

Twenty-nine parent-child dyads who presented to an intensive day treatment program participated in this study. Sleep was objectively measured with 1 week of actigraphy both 1 week before admission and 1 month after discharge. Subjective questionnaires of sleep, daytime functioning, and quality of life were completed by children and parents at admission, discharge, 1 month after discharge, and 3 months after discharge.

RESULTS

Study results highlight the benefit of the treatment program on reducing AD severity, as well as improvements in objectively measured sleep duration and efficiency, self-reported measures of sleep, daytime functioning, and quality of life in children and parents up to 3 months after discharge.

CONCLUSION

This study highlights the importance of treatment for child AD on both child and parent health outcomes.

Does age influence the quality of life in children with atopic dermatitis?

BACKGROUND

Atopic dermatitis (AD) is one of the most common childhood skin diseases that can affect the quality of life (QoL) of children. The QoL of Montenegrin children with AD has not been sufficiently explored. The aim of this study was to assess their QoL with special emphasize on age differences.

METHODS

This cross-sectional study included children with AD seen at the Clinic of Dermatology and Venereology, Clinical Center of Montenegro (CCM) in Podgorica between August 2017 and July 2018. The QoL was assessed with the Infants' Dermatitis Quality of Life Index (IDQOL) and the Children's Dermatology Life Quality Index (CDLQI). Disease severity was measured by the Three Item Severity (TIS) score.

RESULTS

A total of 386 children with AD aged from newborn to 16 years took part in this study. The mean total score of the QoL was 14.7 in infants (0-4 years old), 19.4 in younger children (5-9 years old), and 16.6 in older children (10-16 years old). Age was in negative correlation with the CDLQI score, leisure domain of the CDLQI and CDLQI sleep, and in positive correlation with the IDQOL child mood. TIS score was in positive correlation with both the IDQOL and CDLQI score.

CONCLUSIONS

The QoL measured by CDLQI was more impaired in younger children, whilst IDQOL child mood was more impaired in older infants. The most impaired QoL was seen in children in the age group 5-9 years. Regardless of disease severity, treatment and counseling of children suffering from AD should be tailored specifically to their age.

Breastfeeding and Atopic Dermatitis Risk: A Systematic Review and Meta-Analysis of Prospective Cohort Studies

OBJECTIVES

The effect of breastfeeding on atopic dermatitis (AD) remains controversial. To determine the association -between breastfeeding and AD, we conducted an updated meta-analysis of prospective cohort studies.

METHODS

A comprehensive search of PubMed, EMBASE, MEDLINE and Cochrane Library was conducted. Studies meeting the predetermined criteria were evaluated by 2 authors independently. The pooled relative risk (RR) adjusted for confounders with its 95% CI was calculated by a random-effects model. Heterogeneity was explored by subgroup analysis and meta-regression.

RESULTS

A total of 27 studies were included for meta-analysis. The pooled estimates for the effect of total and exclusive breastfeeding on AD were 1.01 (95% CI 0.93-1.10) and 0.99 (95% CI 0.88-1.11), respectively. Heterogeneity was substantial across studies (total: p < 0.01 or I2 = 65.2%; exclusive: p < 0.01 or I2 = 72.3%). There was a weak evidence for a protective effect of breastfeeding against AD in cohorts with atopic heredity (total: RR 0.85, 95% CI 0.74-0.98; exclusive: RR 0.83, 95% CI 0.70-0.97). In cohorts without atopic heredity, the effect shifted to the risk side when limited to exclusive breastfeeding (RR 1.19, 95% CI 1.02-1.40) while it dropped towards null when limited to total breastfeeding (RR 1.11, 95% CI 0.94-1.31).

CONCLUSIONS

There is no association between AD and breastfeeding, regardless of total or exclusive breastfeeding patterns. There is some evidence for a protective function of exclusive and total breastfeeding in a cohort with atopic heredity. The effect shifts to the risk side in cohorts without atopic heredity. However, these findings should be interpreted with caution because heterogeneity is evident.

Factors influencing quality of life in children with atopic dermatitis and their caregivers: a cross-sectional study

Better understanding of atopic dermatitis' effect on quality of life could enhance current management and therapeutic strategies. Studies investigating factors related to the health-related quality of life (HRQOL) of children with atopic dermatitis and their caregivers are limited. This cross-sectional study included 559 children (<16 years) with atopic dermatitis and their caregivers. Disease severity was associated with infants' HRQOL (moderate: IRR: 1.42, 95% CI 1.20-1.67; severe: IRR: 1.72, 95% CI 1.32-2.24). Age and disease severity were associated with children's HRQOL (age: IRR: 0.99, 95% CI 0.98-1.00; moderate: IRR: 1.08, 95% CI 1.02-1.14). Quality of life subdomains itching/scratching, emotional distress and sleep disturbance were most reported and increased with higher disease severity. Both caregivers' mental and physical health were negatively affected by children's HRQOL (physical: IRR: 0.99, 95% CI 0.99-1.00; mental: IRR: 0.98, 95% CI 0.97-0.99). Sociodemographic characteristics (gender, ethnicity, educational attainment of carers, number of children) did not demonstrate significance in children's HRQOL model. In conclusion, current atopic dermatitis diagnostics and treatment have to be extended to the factors influencing both children' as their caregivers' quality of life and adapting management accordingly. Itching/scratching, emotional distress and sleep disturbance deserve attention. Sociodemographic characteristics in children's HRQOL models also merit attention in further research.

Dupilumab for atopic dermatitis: evidence to date

INTRODUCTION

Atopic dermatitis (AD) is a common chronic, pruritic inflammatory dermatosis. The inflammatory response is characterized by a T helper 2 (Th2) immune response phenotype.

EVIDENCE ACQUISITION

To assess current available data on dupilumab, the writers of this article did a comprehensive search in different databases, including Medline, EMBASE, SCOPUS, and clinical trial registries. All relevant articles identified were then manually reviewed. Information regarding dupilumab mechanism of action, pharmacokinetics, clinical efficacy, safety, and future trends was then summarized.

EVIDENCE SYNTHESIS

Topical therapy is the main treatment in mild-to-moderate AD, but many cases of moderate-to-severe require systemic treatments. Dupilumab is the first biologic approved for the treatment of adults with moderate-to-severe AD. It inhibits IL-4 and IL-13 signaling pathways and reduces Th2 response. Clinical trials have demonstrated significantly improved clinical and patient-reported outcomes. The addition of application of topical corticosteroids results in a more significant improvement in signs and symptoms of AD than with use of dupilumab in monotherapy. The vast majority of patients improves under dupilumab, and almost 40% of patients achieve clear or nearly clear skin. In addition to its effectiveness, dupilumab also has a favorable safety profile. Frequent adverse events reported in the clinical trials were mostly mild-to-moderate and included nasopharyngitis, upper respiratory tract infection, injection site reactions, and conjunctivitis.

CONCLUSIONS

In general, rates of adverse events occurred with similar frequency between the treatment and placebo groups. Conjunctivitis seems to be a dupilumab-specific side effect and so far has only been observed in atopic dermatitis patients (not in asthma or nasal polyposis). There were no major serious safety concerns identified in phase III clinical trials. Trials in the pediatric population are ongoing and are highly awaited.

Efficacy and safety of Soshiho-tang in patients with atopic dermatitis and gastrointestinal disorders: Study protocol for a double-blind, randomized, and placebo-controlled clinical trial

BACKGROUND

Atopic dermatitis (AD) is a chronically relapsing inflammatory skin disease that affects the quality of life in patients with AD. Since there is limitation of conventional treatment of AD, complementary treatment is required to treat AD symptoms more effectively and safely Soshiho-tang (SSHT) is a traditional herbal medicine that exhibits anti-inflammatory and anti-ulcer effects and improves the immune function. In this clinical trial, we will evaluate the efficacy and safety of SSHT in patients with AD and gastrointestinal disorders in comparison with placebo.

METHODS/DESIGN

This study is a single-center, randomized, double-blind, placebo-controlled, and investigator-initiated clinical trial. A total of 60 patients aged 3 to 18 years with AD and gastrointestinal disorders and who received a diagnosis of AD by Hanifin & Rajka criteria with a Scoring Atopic Dermatitis (SCORAD) index between 15 and 49 will be enrolled. Participants will be randomly assigned to the SSHT or placebo group in a ratio of 1:1. Additionally, they will have a visit schedule comprising 4 visits including a screening visit during 8 to 10 weeks. The participants will be administered SSHT or placebo 3 times a day for 4 weeks. The primary outcome will be measured by a change of the SCORAD index. The secondary outcome measures include the following: survey questionnaires for the perception of gastrointestinal disorders, amount and frequency of ointment usage for AD, dermatology quality of life index, itchiness and sleep disability score in visual analog scale, percutaneous water loss, skin surface temperature, Hamilton anxiety rating scale, and children's depression inventory.

DISCUSSION

In our knowledge, this will be the first clinical trial to assess the efficacy and safety of SSHT in patients with AD and gastrointestinal disorders. The findings of this study will provide new treatment options for patients with AD and gastrointestinal disorders.

TRIAL REGISTRATION

Korean National Clinical Trial Registry, Clinical Research Information Service. (KCT0003713) https://cris.nih.go.kr/cris/search/search_result_st01_en.jsp?seq=13489<ype=&rtype=.

Alternative Treatments for Atopic Dermatitis: An Update

Atopic dermatitis (AD) is a chronic pruritic inflammatory skin disease in which management with topical anti-inflammatory agents during exacerbations remains the mainstay of treatment. With no cure in sight, a significant proportion of patients elect to incorporate complementary and alternative medicine (CAM) as an adjunct to conventional treatment. Many clinicians find it difficult to provide recommendations as the field covers an extensive number of very disparate therapies, with limited quality evidence to indicate efficacy. Since publication of the last review on this topic in the Journal that compiled and analyzed randomized controlled trials (RCTs) on CAMs in 2015, several new studies have surfaced. This update aims to aggregate and review these new data. A literature search was conducted in the PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Global Resource for EczemA Trials (GREAT) databases for RCTs on complementary and alternative therapies in AD from March 2015 through May 2018, resulting in 15 studies being included in this review. The preliminary results for many treatments such as vitamin E, East Indian Sandalwood Oil (EISO), melatonin, L-histidine, and Manuka honey show positive clinical effects, but there is currently not enough evidence to recommend their use in AD therapy. Future investigative efforts should focus on reproducing some of these studies with a larger sample size whose clinical characteristics and demographics are more reflective of the general AD population, and standardizing the process to produce reliable data.

Association between atopic dermatitis and serious cutaneous, multiorgan and systemic infections in US adults

BACKGROUND

Atopic dermatitis (AD) is associated with barrier disruption, immune dysregulation, and immunosuppressing treatments that can increase the association with an unusual number of infections.

OBJECTIVE

To determine whether adults with AD have an unusually large number of serious infections and related outcomes.

METHODS

Data from the 2002 to 2012 National Inpatient Sample were analyzed, including an approximately 20% sample of all US hospitalizations (n = 72,108,077 adults). Prevalence of serious infections in hospitalized patients with vs without AD, length of stay, cost of care, and inpatient mortality secondary to serious infections were determined.

RESULTS

The prevalence of serious infections expressed as a percentage (95% confidence interval) was higher in adults hospitalized with than in those without AD (42.1% [41.6-42.6] vs 25.4% [25.2-25.6]; P = .0002). In logistic regression models with multiple predictors (multivariable logistic regression models), AD was associated with 32 of 38 infections examined. Associated cutaneous infections included eczema herpeticum (odds ratio [95% confidence interval] adjusted for other predictors: 67.93 [47.93-96.28]), erysipelas (11.15 [9.47-13.1]), and cellulitis (4.53 [4.42-4.64]). Associated respiratory infections included aspergillosis (1.51 [1.21-1.88]) and tuberculosis (1.57 [1.41-1.76]). AD was associated with extracutaneous, multiorgan, and systemic infections, including infectious arthropathy (2.01 [1.84-2.20]), endocarditis (1.25 [1.12-1.39]), encephalitis (1.65 [1.40-1.96]), and methicillin-resistant Staphylococcus aureus infections (3.29 [3.17-3.42]). Patients with AD hospitalized with vs without any serious infection had an increased geometric mean cost of inpatient care ($8,273 [8,126-8,423] vs $7,179 [7,052-7,307]) and length of stay (5.3 days [5.2-5.3] vs 3.9 [3.9-4.0]; P = .0002), with $11 to $228 million excess annual costs from hospitalization with serious infections in adults with AD.

CONCLUSION

Adults with AD had increased cutaneous, respiratory, multiorgan, and systemic infections, which were associated with a considerable cost burden.

Probiotics for treating eczema

BACKGROUND

Eczema is a common chronic skin condition. Probiotics have been proposed as an effective treatment for eczema; their use is increasing, as numerous clinical trials are under way. This is an update of a Cochrane Review first published in 2008, which suggested that probiotics may not be an effective treatment for eczema but identified areas in which evidence was lacking.

OBJECTIVES

To assess the effects of probiotics for treating patients of all ages with eczema.

SEARCH METHODS

We updated our searches of the following databases to January 2017: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library, the Global Resource of Eczema Trials (GREAT) database, MEDLINE, Embase, PsycINFO, the Allied and Complementary Medicine Database (AMED), and Latin American Caribbean Health Sciences Literature (LILACS). We searched five trials registers and checked the reference lists of included studies and relevant reviews for further references to relevant randomised controlled trials (RCTs). We also handsearched a number of conference proceedings. We updated the searches of the main databases in January 2018 and of trials registries in March 2018, but we have not yet incorporated these results into the review.

SELECTION CRITERIA

Randomised controlled trials of probiotics (live orally ingested micro-organisms) compared with no treatment, placebo, or other active intervention with no probiotics for the treatment of eczema diagnosed by a doctor.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane. We recorded adverse events from the included studies and from a separate adverse events search conducted for the first review. We formally assessed reporting bias by preparing funnel plots, and we performed trial sequential analysis for the first primary outcome - eczema symptoms at the end of active treatment.We used GRADE to assess the quality of the evidence for each outcome (in italic font).

MAIN RESULTS

We included 39 randomised controlled trials involving 2599 randomised participants. We included participants of either gender, aged from the first year of life through to 55 years (only six studies assessed adults), who had mild to severe eczema. Trials were undertaken in primary and secondary healthcare settings, mainly in Europe or Asia. Duration of treatment ranged from four weeks to six months, and duration of follow-up after end of treatment ranged from zero to 36 months. We selected no standard dose: researchers used a variety of doses and concentrations of probiotics. The probiotics used were bacteria of the Lactobacillus and Bifidobacteria species, which were taken alone or combined with other probiotics, and were given with or without prebiotics. Comparators were no treatment, placebo, and other treatments with no probiotics.For all results described in this abstract, the comparator was no probiotics. Active treatment ranged from six weeks to three months for all of the following results, apart from the investigator-rated eczema severity outcome, for which the upper limit of active treatment was 16 weeks. With regard to score, the higher the score, the more severe were the symptoms. All key results reported in this abstract were measured at the end of active treatment, except for adverse events, which were measured during the active treatment period.Probiotics probably make little or no difference in participant- or parent-rated symptoms of eczema (13 trials; 754 participants): symptom severity on a scale from 0 to 20 was 0.44 points lower after probiotic treatment (95% confidence interval (CI) -1.22 to 0.33; moderate-quality evidence). Trial sequential analysis shows that target sample sizes of 258 and 456, which are necessary to demonstrate a minimum mean difference of -2 and -1.5, respectively, with 90% power, have been exceeded, suggesting that further trials with similar probiotic strains for this outcome at the end of active treatment may be futile.We found no evidence suggesting that probiotics make a difference in QoL for patients with eczema (six studies; 552 participants; standardised mean difference (SMD) 0.03, 95% CI -0.36 to 0.42; low-quality evidence) when measured by the participant or the parent using validated disease-specific QoL instruments.Probiotics may slightly reduce investigator-rated eczema severity scores (24 trials; 1596 participants). On a scale of 0 to 103 for total Severity Scoring of Atopic Dermatitis (SCORAD), a score combining investigator-rated eczema severity score and participant scoring for eczema symptoms of itch and sleep loss was 3.91 points lower after probiotic treatment than after no probiotic treatment (95% CI -5.86 to -1.96; low-quality evidence). The minimum clinically important difference for SCORAD has been estimated to be 8.7 points.We noted significant to extreme levels of unexplainable heterogeneity between the results of individual studies. We judged most studies to be at unclear risk of bias; six studies had high attrition bias, and nine were at low risk of bias overall.We found no evidence to show that probiotics make a difference in the risk of adverse events during active treatment (risk ratio (RR) 1.54, 95% CI 0.90 to 2.63; seven trials; 402 participants; low-quality evidence). Studies in our review that reported adverse effects described gastrointestinal symptoms.

AUTHORS' CONCLUSIONS

Evidence suggests that, compared with no probiotic, currently available probiotic strains probably make little or no difference in improving patient-rated eczema symptoms. Probiotics may make little or no difference in QoL for people with eczema nor in investigator-rated eczema severity score (combined with participant scoring for eczema symptoms of itch and sleep loss); for the latter, the observed effect was small and of uncertain clinical significance. Therefore, use of probiotics for the treatment of eczema is currently not evidence-based. This update found no evidence of increased adverse effects with probiotic use during studies, but a separate adverse events search from the first review revealed that probiotic treatment carries a small risk of adverse events.Results show significant, unexplainable heterogeneity between individual trial results. Only a small number of studies measured some outcomes.Future studies should better measure QoL scores and adverse events, and should report on new probiotics. Researchers should also consider studying subgroups of patients (e.g. patients with atopy or food allergies, adults) and standardising doses/concentrations of probiotics given.

Atopic dermatitis: the skin barrier and beyond

BACKGROUND

Atopic dermatitis is the most common chronic inflammatory skin disorder, affecting up to 20% of children and 10% of adults in industrialized countries. This highly debilitating condition poses a considerable burden to both the individual and society at large. The pathophysiology of atopic dermatitis is complex, encompassing both genetic and environmental risk factors.

METHODS

This is a narrative review based on a systematic literature search.

CONCLUSIONS

Dysregulation of innate and adaptive immunity plays a key role; however, recent epidemiological, genetic and molecular research has focused interest on skin barrier dysfunction as a common precursor and pathological feature. Current understanding of the aetiology of atopic dermatitis highlights disruption of the epidermal barrier leading to increased permeability of the epidermis, pathological inflammation in the skin, and percutaneous sensitization to allergens. Thus, most novel treatment strategies seek to target specific aspects of the skin barrier or cutaneous inflammation. Several studies have also shown promise in preventing atopic dermatitis, such as the early use of emollients in high-risk infants. This may have broader implications in terms of halting the progression to atopic comorbidities including food allergy, hay fever and asthma.

Dupilumab in atopic dermatitis: rationale, latest evidence and place in therapy

Atopic dermatitis (AD) is one of the most common chronic inflammatory skin diseases. The prevalence of AD is increasing and is currently estimated at 10-20% in adults worldwide. In the majority of patients, AD can be adequately controlled with topical treatment or ultraviolet light therapy, but there is a high unmet need for effective and safe therapeutics in patients with more severe or difficult to treat AD. During the past decade, new advances in the understanding of the underlying immune pathogenesis of AD have led to the development of new, more targeted therapies. Dupilumab, a fully human monoclonal antibody targeting the interleukin (IL)-4 receptor α, thereby blocking the IL-4 and IL-13 pathway, is one of the first biologics that has been developed for AD. Dupilumab has shown promising results in phase III trials and has recently been approved by the US Food and Drug Administration and the European Commission for the treatment of moderate to severe AD. With the approval of dupilumab, we are entering a new era of biological therapeutics in AD management. The place of dupilumab should be established in the current treatment standards. Based on current treatment guidelines and experts' opinions in the management of AD, we have built a proposal for a treatment algorithm for systemic treatment of AD in European countries.

Severe Atopic Dermatitis in Children

PURPOSE OF REVIEW

Severe atopic dermatitis (AD) in childhood leads to significant morbidity including psychosocial problems and infectious complications. There are only a few approved treatment options for these patients. These include topical corticosteroids and tacrolimus ointment, which are associated with potential side effects.

RECENT FINDINGS

In order to find better and safer treatments, further understanding of AD mechanisms is needed. Primary skin barrier defects play an important role in the pathogenesis of AD. In addition, the suppression of skin barrier functions by Th2 inflammation also plays an important role in the persistence and recurrence of AD. Cytokines in the Th2 pathway, which includes IL-4, IL-13, TSLP, IL-25, IL-31, and IL-33, are potential therapeutic targets in AD. Other potential targets of AD are Janus kinase, phospholipase A2, aryl hydrocarbon receptor, and skin microbiota. A better understanding of the pathogenesis of AD will provide future direction for treatment.

Significance of Skin Barrier Dysfunction in Atopic Dermatitis

The epidermis contains epithelial cells, immune cells, and microbes which provides a physical and functional barrier to the protection of human skin. It plays critical roles in preventing environmental allergen penetration into the human body and responsing to microbial pathogens. Atopic dermatitis (AD) is the most common, complex chronic inflammatory skin disease. Skin barrier dysfunction is the initial step in the development of AD. Multiple factors, including immune dysregulation, filaggrin mutations, deficiency of antimicrobial peptides, and skin dysbiosis contribute to skin barrier defects. In the initial phase of AD, treatment with moisturizers improves skin barrier function and prevents the development of AD. With the progression of AD, effective topical and systemic therapies are needed to reduce immune pathway activation and general inflammation. Targeted microbiome therapy is also being developed to correct skin dysbiosis associated with AD. Improved identification and characterization of AD phenotypes and endotypes are required to optimize the precision medicine approach to AD.