What is "high risk?" a systematic review of atopy risk and implications for primary prevention

A programme of research to set priorities and reduce uncertainties for the prevention and treatment of skin disease

Background

Skin diseases are very common and can have a large impact on the quality of life of patients and caregivers. This programme addressed four diseases: (1) eczema, (2) vitiligo, (3) squamous cell skin cancer (SCC) and (4) pyoderma gangrenosum (PG).

Objective

To set priorities and reduce uncertainties for the treatment and prevention of skin disease in our four chosen diseases.

Design

Mixed methods including eight systematic reviews, three prioritisation exercises, two pilot randomised controlled trials (RCTs), three feasibility studies, two core outcome initiatives, four funding proposals for national RCTs and one completed national RCT.

Setting

Secondary care, primary care and the general population.

Participants

Patients (and their caregivers) with eczema, vitiligo, SCC and PG, plus health-care professionals with an interest in skin disease.

Interventions

Our three intervention studies included (1) barrier enhancement using emollients from birth to prevent eczema (pilot RCT); (2) handheld narrowband ultraviolet light B therapy for treating vitiligo (pilot RCT); and (3) oral ciclosporin (Neoral®, Novartis Pharmaceuticals) compared with oral prednisolone for managing PG (pragmatic national RCT).

Results

Systematic reviews included two overarching systematic reviews of RCTs of treatments for eczema and vitiligo, an umbrella review of systematic reviews of interventions for the prevention of eczema, two reviews of treatments for SCC (one included RCTs and the second included observational studies), and three reviews of outcome measures and outcome reporting. Three prioritisation partnership exercises identified 26 priority areas for future research in eczema, vitiligo and SCC. Two international consensus initiatives identified four core domains for future eczema trials and seven core domains for vitiligo trials. Two pilot RCTs and three feasibility studies critically informed development of four trial proposals for external funding, three of which are now funded and one is pending consideration by funders. Our pragmatic RCT tested the two commonly used systemic treatments for PG (prednisolone vs. ciclosporin) and found no difference in their clinical effectiveness or cost-effectiveness. Both drugs showed limited benefit. Only half of the participants’ ulcers had healed by 6 months. For those with healed ulcers, recurrence was common (30%). Different side effect profiles were noted for each drug, which can inform clinical decisions on an individual patient basis. Three researchers were trained to PhD level and a dermatology patient panel was established to ensure patient involvement in all aspects of the programme.

Conclusions

Findings from this programme of work have already informed clinical guidelines and patient information resources. Feasibility studies have ensured that large national pragmatic trials will now be conducted on important areas of treatment uncertainty that address the needs of patients and the NHS. There is scope for considerable improvement in terms of trial design, conduct and reporting for RCTs of skin disease, which can be improved through wider collaboration, registration of trial protocols and complete reporting and international consensus over core outcome sets. Three national trials have now been funded as a result of this work. Two international initiatives to establish how best to measure the core outcome domains for eczema and vitiligo are ongoing.

Trial registration

Current Controlled Trials Barrier Enhancement for Eczema Prevention (BEEP) (ISRCTN84854178 and NCT01142999), Study of Treatments fOr Pyoderma GAngrenosum Patients (STOP GAP) (ISRCTN35898459) and Hand Held NB-UVB for Early or Focal Vitiligo at Home (HI-Light Pilot Trial) (NCT01478945).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 18. See the NIHR Journals Library website for further project information.

Birch pollen influence the severity of atopic eczema - prospective clinical cohort pilot study and ex vivo penetration study

There is little clinical evidence for a correlation between the severity of atopic eczema (AE) and pollen exposition. To obtain more data, we performed a clinical cohort pilot study about the influence of pollen on AE between sensitized and nonsensitized subjects and an experimental study addressing the cutaneous penetration of pollen into the skin. Fifty-five patients were monitored during birch pollen season. To study the cutaneous penetration, grass pollen allergens were applied on excised skin and the uptake in CD1c-expressing dendritic cells was investigated. The correlation between environmental pollen load and severity of the Scoring Atopic Dermatitis (SCORAD) score and pruritus was observed, regardless of the status of sensitization. The sensitized group recovered significantly worse after the birch pollen season. Remarkably higher amounts of pollen allergens taken up by CD1c cells were detected in epidermal cells derived from skin explants with a disturbed epidermal barrier. These findings suggest an exacerbating role of pollen in AE utilizing the epidermal route.

Cohort study for prevention of atopic dermatitis using hair mineral contents

We undertook a cohort study to determine the association between hair mineral content and the onset of atopic dermatitis (AD) in infants. Eight hundred and thirty-four mother-infant pairs, who donated hair samples during one and ten-month health checkups, had their samples analyzed by proton induced X-ray emission (PIXE) for 32 mineral concentrations, and these mineral concentration data together with their AD family history were statistically examined for any relationships between them. Results indicated that of all minerals, only selenium (Se) and strontium (Sr) showed statistically significant associations for infants, while the same two elements were only marginally significant for mothers. Se deficiency in either infant or mother increased the AD risk. A Sr deficiency in infants increased AD risk, while the same deficiency in mothers decreased the risk. To predict the probability of AD development using this data, we performed logistic regression analysis, which provided a sensitivity of 65.9%, a specificity of 70.5%, a positive predictive value (PPV) of 10.3%, a negative predictive value (NPV) of 97.6% and a relative risk (RR) of 4.2, all far better than any corresponding figures explicitly mentioned in previously published papers.

How should an incident case of atopic dermatitis be defined? A systematic review of primary prevention studies

BACKGROUND

Eczema prevention is now an active area of dermatologic and allergy research. Defining an incident case is therefore a prerequisite for such a study.

OBJECTIVE

We sought to examine how an incident case of atopic dermatitis was defined in previous atopic dermatitis prevention studies in order to make recommendations on a standard definition of new atopic dermatitis cases for use in future prevention trials.

METHODS

We conducted a systematic review of controlled interventional atopic dermatitis prevention studies by using searches of MEDLINE and Cochrane databases for studies published from 1980 to the end of January 2011. Studies that included atopic dermatitis as a secondary outcome, such as asthma prevention trials, were included.

RESULTS

One hundred two studies were included in the final analysis, of which 27 (26.5%) did not describe any criteria for defining an incident case of atopic dermatitis. Of the remaining 75 studies with reported disease criteria, the Hanifin-Rajka criteria were the most commonly used (28 studies). A disease definition unique to that particular study (21 studies) was the second most commonly used disease definition, although the sources for such novel definitions were not cited.

CONCLUSIONS

The results from this systematic review highlight the need for improved reporting and standardization of the definition used for an incident case in atopic dermatitis prevention studies. Most prevention studies have used disease definitions such as the Hanifin-Rajka criteria that include disease chronicity. While acceptable for cumulative incidence outcomes, inclusion of disease chronicity precludes the precise measurement of disease onset. We propose a definition based on existing scientific studies that could be used in future prospective studies.

Hypersensitivity to Pollen of Olea Europea in Patients with Pollen Allergy in Zadar County, Croatia

Preosjetljivost na pelud masline važan je uzrok peludnih alergija u mediteranskim zemljama. Cilj ovoga rada bio je utvrditi učestalost preosjetljivosti na pelud masline među bolesnicima s peludnom alergijom u Zadru i Zadarskoj županiji. Dobivene rezultate usporedili smo s ranijim ispitivanjem preosjetljivosti na pelud masline u Dalmaciji.

Ukupno je obrađen 671 ispitanik s preosjetljivosti na peludne alergene. Od toga broja 61 % ispitanika bilo je muškog spola, a 39 % je bilo ženskog spola. Od ukupno ispitanih 53.5 % činila su djeca u dobi od 4 do 14 godina, a preostalih 46.5 % bili su odrasli u dobi od 15 do 59 godina života. Svim ispitanicima uzeta je detaljna obiteljska i osobna anamneza, napravljen klinički pregled te učinjeno kožno prick-testiranje i enzimatsko-imunološki UniCAP-test za određivanje specifičnih IgE-protutijela. Statistička obrada podataka učinjena je χ2-testom.

Preosjetljivost na pelud masline dokazana je u 8.8 % bolesnika s peludnom alergijom. Najveći broj bolesnika s preosjetljivosti na pelud masline boluje od alergijskog rinitisa, 58 % bolesnika. Postoji statistički značajna razlika u broju bolesnika između dvije ispitivane sredine, gradske i seoske. Samo 3 % bolesnika stanovnici su otoka.

Preosjetljivost na pelud masline u našem ispitivanju najniža je u odnosu na ispitivanja provedena u drugim mediteranskim zemljama. Najčešće se očituje kliničkom slikom alergijskog rinitisa, a statistički je značajno češća u gradskoj sredini. Usporedba preosjetljivosti na pelud masline tijekom dvaju ispitivanih razdoblja u našoj zemlji nije pokazala porast broja bolesnika s preosjetljivosti na pelud masline.

Partially hydrolyzed 100% whey protein infant formula and reduced risk of atopic dermatitis: a meta-analysis

OBJECTIVE

A reduced risk of atopic dermatitis (AD) among healthy infants who received 100% whey protein partially hydrolyzed formula (PHF-W) compared with intact protein cow's milk formula (CMF), has been reported in several studies. To validate these observations and estimate the magnitude of this potential association with greater statistical precision, we conducted a meta-analysis of clinical trial and intervention studies.

MATERIALS AND METHODS

A total of 18 articles representing 12 independent study populations met our inclusion criteria.

RESULTS

A statistically significant 44% (summary relative risk estimate [SRRE] = 0.56, 95% confidence interval 0.40-0.77) reduced risk of atopic manifestations, which included AD, was found among infants receiving PHF-W compared with infants receiving CMF. In a subanalysis of 4 studies that reported results specifically for AD and that were considered of superior methodological quality, the incidence of AD was reduced by 55% (SRRE = 0.45, 95% confidence interval 0.30-0.70).

CONCLUSIONS

Regardless of study design, infant population, follow-up time, or study location, individual study findings were consistent because a reduced incidence of AD was reported in all of the reviewed studies. Exclusive breast-feeding should be encouraged as the standard for infant nutrition in the first months of life. For infants who are not exclusively breast-fed, feeding with PHF-W instead of CMF reduces the risk of AD in infants, particularly in infants with a family history of allergy.