Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema

Cross-condition risk and protective factors for psychosocial distress in parents and carers of children and young people with appearance-affecting conditions and injuries

Alongside typical parenting challenges, initial condition-specific research suggests thadifferent experiences and support needs.t parents of children with different visible differences may experience similar psychosocial difficulties. Despite this, large-scale cross-condition research to identify risk and protective factors for parental distress and psychosocial adjustment has been lacking. Two hundred and nine parents and carers of children with a range of visible differences completed an online survey comprised of standardised outcome measures, study-specific measures, and open-ended questions. Multiple regression modelling identified possible risk and protective factors, and data collected via open-ended questions were analysed using content analysis. Findings support themes previously identified in small-scale cross-condition qualitative research with parents of children with visible differences. Risk factors for parental negative affect and stress included parental reports of the noticeability of their child's visible difference and teasing. Protective factors included good parent-child communication, self-compassion, knowledge of their child's condition and satisfaction with treatment. The risk and protective factors identified provide important insight into the experiences of this parent population and indicate possible avenues for psychosocial intervention.

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.

Superantigen Encoding Genes in Staphylococcus aureus Isolated from Lesional Skin, Non-Lesional Skin, and Nares of Patients with Atopic Dermatitis

Patients with atopic dermatitis (AD) are more likely than healthy individuals to harbour Staphylococcus aureus on their skin. Superantigens (SAgs) produced by specific S. aureus strains may contribute to AD-associated skin inflammation. The present study compared the prevalence and types of SAg-encoding genes between S. aureus isolated from patients with AD and from  controls, and within the AD group between isolates from different sampling sites (lesional skin, non-lesional skin, and nares). This retrospective case-control study extracted data from 2 previous studies that examined S. aureus using whole-genome sequencing. The 138 S. aureus isolates obtained from 71 AD patients contained 349 SAg-encoding genes; 22 (6.3%) were found in isolates from nares (0.4 ± 0.6 genes per isolate), 99 (28.4%) in isolates from non-lesional skin (3.7 ± 3.9), and 228 (65.3%) in isolates from lesional skin (4.2 ± 4.5). S. aureus (n = 101) from the control group contained 594 SAg-encoding genes (5.9 ± 4.2). Of the S. aureus isolated from lesional AD skin, 69% carried at least 1 gene encoding SAg compared with 33% of AD nasal isolates. SAg could be a factor in the pathogenesis of a subset of AD patients.

Patient and family burden in pediatric atopic dermatitis and its treatment pattern in Japan

BACKGROUND

This study evaluated the level of burden in pediatric and adolescent atopic dermatitis (AD) patients in Japan, the associated burden on caregivers/families, and whether this burden varied with age.

METHODS

Data were drawn from the Adelphi Pediatric AD Disease Specific Programme (DSP)™, a cross-sectional survey of physicians and their patients conducted in Japan between July and December 2022. Physicians reported patient demographics, clinical characteristics, disease burden, and current/previous therapies. Patients and/or caregivers reported perceived disease severity and impact of AD, including the Children's Dermatology Life Quality Index (CDLQI) and Dermatitis Family Impact questionnaire (DFI).

RESULTS

Overall, 55 physicians provided data for 537 AD patients aged ≤17. Mean (SD) overall scores for CDLQI, POEM, and DFI were 9.3 (6.3), 8.3 (6.8), and 11.7 (7.2), respectively. Age was associated with higher patient and/or caregiver-reported CDLQI scores, which increased by 0.543 points per year of age (P = 0.01). Patients with severe disease reported a more significant impact on quality of life factors compared with mild patients (P < 0.001). Age was associated with higher caregiver-reported burden, with DFI scores increasing by 0.325 per year (P = 0.01). Physician-reported impact on caregivers showed that age was significantly associated with increased burden on sleep, daily activities, work, and mood (P < 0.05), with disease severity associated with impact across all factors (P < 0.01).

CONCLUSIONS

Both increasing age and disease severity were associated with the increased impact of AD on patients and their caregivers. Disease control/modification through appropriate therapeutic intervention at a younger age may relieve the burden of pediatric AD on patients and their families.

Real-world outcomes of children treated with dupilumab for moderate-to-severe atopic dermatitis: a single-centre retrospective observational UK study

BACKGROUND

Dupilumab is licensed for the treatment of moderate-to-severe atopic dermatitis (AD) in patients aged ≥ 6 months.

OBJECTIVES

The aim of this study was to examine real-world outcomes and safety of dupilumab in British children with moderate-to-severe AD attending a tertiary referral paediatric centre.

METHODS

Skin and quality of life scores, adverse events and discontinuation rates were assessed. Patients aged ≤ 18 years with moderate-to-severe AD were included if they had skin scores recorded at baseline and at least one follow-up visit. Efficacy and safety were assessed using descriptive statistics.

RESULTS

In this retrospective observational survey, 72 children/teenagers, with a median age of 14 years (range 7-18) were included. Oral systemic immunosuppressants had failed to control AD in 88% of children recruited. All patients commenced on dupilumab had pretreatment eczema skin scores consistent with moderate-to-severe disease, with a median Eczema Area and Severity Index (EASI) score of 25 [interquartile range (IQR) 20-31]. EASI scores decreased by a median of 94% (IQR 82-100) and remained consistently low over 10-52 months of the study, with a median EASI score at final follow-up of 2 (IQR 0-6). Of the 72 children, 8 (11%) were able to discontinue dupilumab as they were in remission. Nineteen (26%) experienced adverse events, most commonly conjunctivitis (12 patients; 17%). Eight (11%) discontinued dupilumab (six with ongoing inflammatory skin flares, one with severe allergic conjunctivitis, one with intercurrent Wilson disease).

CONCLUSIONS

Dupilumab was highly effective in treating most children with moderate-to-severe AD with good safety outcomes in the real world. However, 10% of children may need alternative therapy because of drug ineffectiveness or side-effects.

Tapinarof cream 1% once daily: Significant efficacy in the treatment of moderate to severe atopic dermatitis in adults and children down to 2 years of age in the pivotal phase 3 ADORING trials

BACKGROUND

Tapinarof cream 1% once daily (QD), a topical aryl hydrocarbon receptor agonist, downregulates pro-inflammatory Th2 cytokines, upregulates skin-barrier components, and reduces oxidative stress.

OBJECTIVE

To assess tapinarof efficacy and safety in adults and children down to 2 years of age with atopic dermatitis (AD).

METHODS

Eight hundred and thirteen patients were randomized to tapinarof or vehicle QD in two 8-week phase 3 trials.

RESULTS

The primary efficacy endpoint, Validated Investigator Global Assessment for Atopic Dermatitis score of 0 or 1 and ≥2-grade improvement from baseline at Week 8, was met with statistical significance in both trials: 45.4% versus 13.9% and 46.4% versus 18.0% (tapinarof vs vehicle; both P < .0001). Significantly superior Eczema Area and Severity Index 75 (EASI75) responses were also observed with tapinarof versus vehicle at Week 8: 55.8% versus 22.9% and 59.1% versus 21.2% (both P < .0001). Rapid improvements in patient-reported pruritus were also significant with tapinarof versus vehicle. Common adverse events (≥5%) of folliculitis, headache, and nasopharyngitis were mostly mild or moderate, with lower discontinuations due to adverse events in the tapinarof groups than with vehicle.

LIMITATIONS

Long-term efficacy was not assessed.

CONCLUSION

Tapinarof demonstrated highly significant efficacy and favorable safety and tolerability in a diverse population of patients with AD down to 2 years of age.

Efficacy and safety of dupilumab with concomitant topical corticosteroids in Japanese pediatric patients with moderate-to-severe atopic dermatitis: A randomized, double-blind, placebo-controlled phase 3 study

BACKGROUND

We investigated the efficacy and safety of dupilumab in Japanese patients aged ≥6 months to <18 years old with moderate-to-severe atopic dermatitis not adequately controlled with existing therapies.

METHODS

In this randomized, double-blind, phase 3 study, patients received dupilumab (n = 30) or placebo (n = 32) with concomitant topical corticosteroids for 16 weeks, then all patients received dupilumab from 16 to 52 weeks. The primary endpoint was the proportion of patients with ≥75% improvement in Eczema Area and Severity Index (EASI) score from baseline (EASI-75) to Week 16. Key secondary endpoints included changes in EASI score, proportion of patients with investigator global assessment (IGA) scores of 0/1, and changes in worst daily itch numerical rating scale (NRS) scores (evaluated in patients aged ≥6 to <12 years [n = 35]).

RESULTS

At Week 16, more patients achieved EASI-75 with dupilumab than placebo (43.3% vs 18.8%; P = 0.0304), and the least squares mean (LSM) difference in percent change in EASI scores at Week 16 of dupilumab vs placebo was -39.4% (P = 0.0003). However, no significant difference in the proportion of patients achieving IGA scores of 0/1 at Week 16 with dupilumab versus placebo were seen (10.0% vs 9.4%; P = 0.8476). The percent change in worst daily itch NRS scores at Week 16 was higher with dupilumab (LSM difference: -33.3%; nominal P = 0.0117). Dupilumab was well tolerated; no new safety signals were identified.

CONCLUSIONS

Dupilumab showed consistent efficacy and was well tolerated in Japanese patients aged ≥6 months to <18 years with moderate-to-severe atopic dermatitis previously insufficiently controlled with existing therapies.

Effect of Therapeutic Gardening Program in Urban Gardens on the Mental Health of Children and Their Caregivers with Atopic Dermatitis

This study was conducted to identify the physical and psychological difficulties of children with atopic dermatitis and their caregivers, and to investigate the effects of participation in a novel therapeutic gardening program based on psychological intervention on their physical and mental health. The program, consisting of 15 sessions, was conducted for approximately 4 months in urban gardens in Seoul and involved 30 children with atopic dermatitis and their caregivers. Additionally, a control group of 30 non-participating caregivers was recruited for comparative analysis. The psychological and emotional changes in caregivers were assessed using six self-report scales (depression, anxiety, stress, vitality, life satisfaction, parenting efficacy) before and after participation in the program. Additionally, the depression index (CDI) and atopic dermatitis index (SCORAD, TEWL) were measured for the children with atopic dermatitis. The research results indicate that the therapeutic gardening program utilizing psychological intervention had a positive impact on the physiological and psychological health of participants. These results are significant as they demonstrate the clinical application of the professionally developed therapeutic gardening program through active intervention and operation. This study suggests that this program can serve as an effective intervention in improving the mental health of both children with atopic dermatitis and their caregivers.

Distinct T cell signatures are associated with Staphylococcus aureus skin infection in pediatric atopic dermatitis

Atopic dermatitis (AD) is an inflammatory skin condition with a childhood prevalence of up to 25%. Microbial dysbiosis is characteristic of AD, with Staphylococcus aureus the most frequent pathogen associated with disease flares and increasingly implicated in disease pathogenesis. Therapeutics to mitigate the effects of S. aureus have had limited efficacy and S. aureus-associated temporal disease flares are synonymous with AD. An alternative approach is an anti-S. aureus vaccine, tailored to AD. Experimental vaccines have highlighted the importance of T cells in conferring protective anti-S. aureus responses; however, correlates of T cell immunity against S. aureus in AD have not been identified. We identify a systemic and cutaneous immunological signature associated with S. aureus skin infection (ADS.aureus) in a pediatric AD cohort, using a combined Bayesian multinomial analysis. ADS.aureus was most highly associated with elevated cutaneous chemokines IP10 and TARC, which preferentially direct Th1 and Th2 cells to skin. Systemic CD4+ and CD8+ T cells, except for Th2 cells, were suppressed in ADS.aureus, particularly circulating Th1, memory IL-10+ T cells, and skin-homing memory Th17 cells. Systemic γδ T cell expansion in ADS.aureus was also observed. This study suggests that augmentation of protective T cell subsets is a potential therapeutic strategy in the management of S. aureus in AD.

Schwere atopische Dermatitis im frühen Kindesalter: Besonderheiten, Herausforderungen und neue Perspektiven in der Versorgung

Die atopische Dermatitis ist die häufigste chronische Hauterkrankung im Kindesalter mit einer Prävalenz von 10% bei Kleinkindern unter 2 Jahren, wovon etwa 15% einen hohen Schweregrad aufweisen. „Kinder sind keine kleinen Erwachsenen“, dies trifft für die schwere frühkindliche atopische Dermatitis in besonderem Maße zu. Innerhalb dieser sensiblen Lebensphase zeigen sich alterstypische Facetten der Erkrankung (psychosozial, neurokognitiv, klinisch‐morphologisch), die Unterschiede im Management mit sich bringen.

Besondere Bedeutung hat die Identifikation von Säuglingen und Kleinkindern mit früh‐persistierendem, schwerem Verlauf mit Blick auf eine erstmals für diese Altersgruppe zugelassene Systemtherapie: sowohl für die unmittelbare Versorgung der Hauterkrankung als auch unter dem Aspekt einer möglichen Prävention von Begleiterkrankungen. Da der „atopische Phänotyp“ klinische Überlappungen zum Spektrum der Immundefekte aufweist, ist die korrekte Einordnung des Hautbefundes bei therapierefraktärem Ekzem essenziell. In dieser Arbeit beschreiben wir eine alltagstaugliche Strategie, um anhand anamnestischer Warnhinweise, dermatologischer Leitbefunde und Labordiagnostik eine Abgrenzung von ekzematösen Hauterscheinungen bei primären Immundefekten vorzunehmen. Dazu geben wir aktuelle Empfehlungen zum Management des schweren frühkindlichen atopischen Ekzems, auch in Bezug auf die Indikation zur Systemtherapie.

Severe atopic dermatitis in early infancy: characteristics, challenges and new perspectives in clinical practice

Atopic dermatitis (AD) is the most common skin disease in infants and children with a prevalence of 10% in the first two years of life. In this age group up to 15% are severely affected. "Children are not little adults" - this applies in particular to infants with severe atopic dermatitis. Age-specific clinical aspects (psychosocial, neurocognitive, morphological) of the disease require an adjusted disease management. Considering recent approval of systemic treatment options, early identification of infants and children with severe and early persistent disease is of particular importance also in view of possible prevention of atopic comorbidity. As several inborn errors of immunity (IEI) share features of the atopic phenotype, it is essential for clinicians to distinguish signs of immunodeficiency from severe AD. Here, we describe a practical approach on the basis of clinical history and key dermatological and laboratory findings. Furthermore, this paper is aimed at providing an update on general management of severe AD in early infancy, including recommendations for systemic treatment.

Efficacy and Safety of Dupilumab Treatment with Concomitant Topical Corticosteroids in Children Aged 6 Months to 5 Years with Severe Atopic Dermatitis

INTRODUCTION

Treatment options for children younger than 6 years with severe atopic dermatitis (AD) are limited, as systemic immunosuppressants may present safety concerns in this young age group. Dupilumab is the first systemic treatment option approved for infants and young children with severe AD in the European Union. This study reports the efficacy and safety of dupilumab with concomitant low-potency corticosteroids in children aged 6 months to 5 years with severe AD.

METHODS

This was a pre-specified subgroup analysis of data for patients aged 6 months to 5 years with severe AD at baseline (Investigator's Global Assessment [IGA] = 4) from a randomised, double-blind, placebo-controlled, phase III trial of dupilumab. Patients were randomised to either subcutaneously administered dupilumab (200/300 mg) or matched placebo every 4 weeks, plus low-potency topical corticosteroids for 16 weeks. Co-primary endpoints at week 16 were the proportion of patients with IGA ≤ 1 (clear or almost clear skin) and the proportion of patients with ≥ 75% improvement from baseline in Eczema Area and Severity Index (EASI-75). Secondary endpoints at week 16 included mean changes in EASI, pruritus, skin pain, sleep loss and quality of life.

RESULTS

The analysis included 125 patients (63 receiving dupilumab vs. 62 placebo). At week 16, significantly more patients receiving dupilumab vs. placebo had achieved IGA ≤ 1 (14.3% vs. 1.6%; P = 0.0085) and EASI-75 (46.0% vs. 6.6%; P < 0.0001). Significant improvements with dupilumab were observed in all secondary endpoints, including a least squares mean 48.9% reduction in pruritus. The overall incidence of adverse events (AEs) was similar between the dupilumab and placebo groups (66.7% vs. 73.8%). No dupilumab-related AEs were serious or led to treatment discontinuation.

CONCLUSION

Dupilumab significantly improved AD signs, symptoms and quality of life in children aged 6 months to 5 years with severe AD with acceptable safety.

TRIAL REGISTRATION

The trial was registered with ClinicalTrials.gov with ID number NCT03346434, part B.

Erigeron annuus Extract Improves DNCB-Induced Atopic Dermatitis in a Mouse Model via the Nrf2/HO-1 Pathway

Atopic dermatitis (AD) is a persistent inflammatory skin condition resulting from an intricate interplay among genetic, immunological, and environmental factors. Erigeron annuus (EA), an annual winter plant belonging to the family Asteraceae, possesses anti-inflammatory, cytoprotective, and antioxidant activities. In this study, we hypothesized that Erigeron annuus extract (EAE) could be an effective agent for ameliorating AD-like symptoms. To confirm this hypothesis in vitro, we used H2O2-stimulated human keratinocytes (HaCaT cells) to demonstrate that pre-treatment with EAE protected against oxidative stress. HaCaT cells pretreated with EAE and stimulated with H2O2 showed decreased intracellular malondialdehyde content, increased superoxide dismutase activity, and reduced intracellular reactive oxygen species accumulation. To verify the in vivo hypothesis based on the intracellular results, an AD disease mouse model was induced with 1-chloro-2,4-dinitrobenzene (DNCB), and EAE was orally administered at a non-toxic concentration according to the toxicity evaluation results. The results showed that AD disease models in BALB/c mice exhibited reduced ear epidermal thickness, scratching behavior, and mast cell infiltration. In conclusion, our results indicate that EAE has the potential to improve AD by upregulating the nuclear factor erythroid 2-related factor 2 (Nrf2)/heme oxygenase-1 (HO-1) signaling pathway.

Defining and Measuring the Scope of Atopic Dermatitis

Atopic dermatitis (AD) has no definitive diagnostic test and has a large range of phenotypes, making it a difficult disease to assess and define. However, an agreed-upon definition of AD is important for clinical trials, population-based studies, and clinical practice. Several diagnostic criteria systems have been proposed to fill these needs, with none considered the gold standard. To further aid in standardized assessment of AD patients, numerous disease severity and quality-of-life measurement tools have been proposed. There is similarly no gold standard and efforts are ongoing to develop a single consensus scale. Finally, assessment of AD-associated comorbidities, including allergic/immunologic conditions, psychiatric disorders, and metabolic/cardiac conditions, is important when evaluating this patient population.

Stressors in Atopic Dermatitis

As with other inflammatory skin disorders, atopic dermatitis has a tendency to cause stress and also be exacerbated by it. Patients with atopic dermatitis have several disease-associated stressors, some of which include physical discomfort due to itching and altered appearance due to flare-ups. These stressors have been shown to effect patients psychosocially by altering sleep patterns, decreasing self-esteem, and interfering with interpersonal relationships. In combination with its direct effect on patients, atopic dermatitis also causes stress for parents and caregivers. Studies suggest that atopic dermatitis is strongly correlated with co-sleeping habits, which can negatively impact the health and mood of parents or caregivers. It has also been reported to interfere with the formation of a strong mother-child relationship. In order to optimize treatment for patients with atopic dermatitis, it is important to note the impact that it has on quality of life. By implementing patient counseling, sleep-targeted therapies, and the use of quality of life (QoL) indices, atopic dermatitis patients and caregivers have the potential to experience greater satisfaction with treatment.

Roles of Parental Psychological Flexibility, Self-Compassion, and Self-Efficacy in Affecting Mental Health and Quality of Life in Parents of Children with Eczema

Parents of young children with eczema often experience adverse mental health consequences, including depression, anxiety, stress, and a reduced health-related quality of life (HRQoL), due to the unpredictable nature of flare-ups and exacerbations. This study investigated the roles of psychological flexibility, self-compassion, and self-efficacy in fostering parental mental health outcomes and HRQoL while caring for children diagnosed with eczema. Baseline data from an ongoing clinical trial examining the effects of a family acceptance-and-commitment-therapy-based eczema management program (FACT-EMP) on parent-child dyads affected by eczema (N = 110 dyads, 75.5% mothers; 66.4% boys) were analyzed using adjusted hierarchical regression analyses. The findings indicate that psychological inflexibility was significantly associated with symptoms of anxiety, depression, stress, and HRQoL. Self-compassion was significantly linked to all assessed mental health outcomes, whereas self-efficacy showed a significant association only with symptoms of depression. These results underscore the significance of promoting parental psychological flexibility and self-compassion through acceptance and commitment therapy and compassion-based approaches to enhance mental health and quality of life while managing children's eczema.

Comparison of lotions, creams, gels and ointments for the treatment of childhood eczema: the BEE RCT

Background

Emollients are recommended for children with eczema (atopic eczema/dermatitis). A lack of head-to-head comparisons of the effectiveness and acceptability of the different types of emollients has resulted in a 'trial and error' approach to prescribing.

Objective

To compare the effectiveness and acceptability of four commonly used types of emollients for the treatment of childhood eczema.

Design

Four group, parallel, individually randomised, superiority randomised clinical trials with a nested qualitative study, completed in 2021. A purposeful sample of parents/children was interviewed at ≈ 4 and ≈ 16 weeks.

Setting

Primary care (78 general practitioner surgeries) in England.

Participants

Children aged between 6 months and 12 years with eczema, of at least mild severity, and with no known sensitivity to the study emollients or their constituents.

Interventions

Study emollients sharing the same characteristics in the four types of lotion, cream, gel or ointment, alongside usual care, and allocated using a web-based randomisation system. Participants were unmasked and the researcher assessing the Eczema Area Severity Index scores was masked.

Main outcome measures

The primary outcome was Patient-Oriented Eczema Measure scores over 16 weeks. The secondary outcomes were Patient-Oriented Eczema Measure scores over 52 weeks, Eczema Area Severity Index score at 16 weeks, quality of life (Atopic Dermatitis Quality of Life, Child Health Utility-9 Dimensions and EuroQol-5 Dimensions, five-level version, scores), Dermatitis Family Impact and satisfaction levels at 16 weeks.

Results

A total of 550 children were randomised to receive lotion (analysed for primary outcome 131/allocated 137), cream (137/140), gel (130/135) or ointment (126/138). At baseline, 86.0% of participants were white and 46.4% were female. The median (interquartile range) age was 4 (2-8) years and the median Patient-Oriented Eczema Measure score was 9.3 (SD 5.5). There was no evidence of a difference in mean Patient-Oriented Eczema Measure scores over the first 16 weeks between emollient types (global p = 0.765): adjusted Patient-Oriented Eczema Measure pairwise differences - cream-lotion 0.42 (95% confidence interval -0.48 to 1.32), gel-lotion 0.17 (95% confidence interval -0.75 to 1.09), ointment-lotion -0.01 (95% confidence interval -0.93 to 0.91), gel-cream -0.25 (95% confidence interval -1.15 to 0.65), ointment-cream -0.43 (95% confidence interval -1.34 to 0.48) and ointment-gel -0.18 (95% confidence interval -1.11 to 0.75). There was no effect modification by parent expectation, age, disease severity or the application of UK diagnostic criteria, and no differences between groups in any of the secondary outcomes. Median weekly use of allocated emollient, non-allocated emollient and topical corticosteroids was similar across groups. Overall satisfaction was highest for lotions and gels. There was no difference in the number of adverse reactions and there were no significant adverse events. In the nested qualitative study (n = 44 parents, n = 25 children), opinions about the acceptability of creams and ointments varied most, yet problems with all types were reported. Effectiveness may be favoured over acceptability. Parents preferred pumps and bottles over tubs and reported improved knowledge about, and use of, emollients as a result of taking part in the trial.

Limitations

Parents and clinicians were unmasked to allocation. The findings may not apply to non-study emollients of the same type or to children from more ethnically diverse backgrounds.

Conclusions

The four emollient types were equally effective. Satisfaction with the same emollient types varies, with different parents/children favouring different ones. Users need to be able to choose from a range of emollient types to find one that suits them.

Future work

Future work could focus on how best to support shared decision-making of different emollient types and evaluations of other paraffin-based, non-paraffin and 'novel' emollients.

Trial registration

This trial is registered as ISRCTN84540529 and EudraCT 2017-000688-34.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (HTA 15/130/07) and will be published in full in Health Technology Assessment; Vol. 27, No. 19. See the NIHR Journals Library website for further project information.

Psychological Stress and Atopic Dermatitis: A Focus Group Study

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disorder. It is often reported to be worsened by psychological stress.

OBJECTIVE

To explore the role of psychological stress and related triggers in AD, and its connection to worsening of this disease, focusing on patients' perspectives.

METHODS

In total, 28 patients with AD were included in focus groups. Topics regarding psychological stress and psychological triggers were discussed.

RESULTS

The hypothesis that psychological stress may have impact on eczema and its pruritus was supported by all of the patients. Distinguishing the worsening effect of psychological stress from effects of physiological triggers, such as infection, climate and allergic factors, was claimed to be difficult by many patients. Most of the patients thought that chronic stress affected the AD more when compared to acute stress. Family problems, financial problems, work overload, school exam periods, lack of structure at work, and unforeseen events were identified as important psychological triggers. Conventional treatment/therapy with topical corticosteroids and emollients, UV light treatment, were suggested as possible treatments, as well as psychological intervention and physical exercise.

CONCLUSION

Psychological stress is an important factor to consider in the management of patients with AD. In particular, chronic stress tends to worsen AD. The type of stress can possibly also affect the quality of the pruritus experienced by the patients. Unforeseen events and decision making were frequently mentioned as important triggers. Furthermore, physical exercise was reported to provide beneficial effects.

Atopic Dermatitis in Italian Pre-School Children: Literature Review of Epidemiological Data with a Focus on Disease Prevalence and Severity

Atopic dermatitis (AD) is one of the most common diseases worldwide. Severe AD has a major impact on the quality of life of patients. We performed a systematic literature review on the epidemiology of AD in Italian pre-school children (age 0-5 years) and we assessed the available data on the severity of AD. In August 2022, we performed a bibliographic search using PubMed/Medline and EMBASE. We identified 10 studies with Italian data on the prevalence and/or incidence of AD in pre-school children. The period (12 months) prevalence of AD varied widely across studies, ranging between 4.0% and 42.2%, with median estimates of 14.3% among all studies and 11.8% among studies from 2010 onwards. Applied to the Italian population, this leads to a prevalence of 309,000-375,000 pre-school AD cases. Only one study computed the incidence of AD, reporting rates of 9 cases per 100 person-years in children aged 0-1 year, and 2.5 cases per 100 person-years in children aged 1-4 years. Severity data from Italy were also reviewed, across three identified three studies. A point estimate found 8.4% of cases were considered severe in one study based on the Patient-Oriented Eczema Measure (POEM), with an overall range of 7.8-11% across different Italian studies and according to various severity score types.

Quality of life in children with skin disease: A Spanish sample

INTRODUCTION

The impact of skin diseases on quality of life varies widely, and some can have an impact similar to that of asthma or cystic fibrosis.

MATERIAL AND METHODS

We conducted a cross-sectional, observational and descriptive study with the aim of describing the degree to which quality of life was affected in paediatric patients managed in a dermatology clinic by means of the Children's Dermatology Life Quality Index (CDLQI).

RESULTS

In our study, the skin disease with the greatest impact on quality of life was atopic dermatitis, chiefly on account of symptoms like pruritus and insomnia. It was followed by acne, mainly due to the associated negative feelings (shame, sadness, etc.). Quality of life in patients with viral warts and molluscum contagiosum was mostly affected by the treatment, chiefly based on cryotherapy. Most patients with nevi or café-au-lait spots did not have a decreased quality of life, although up to one third of them had negative feelings in relation to their skin disease.

DISCUSSION

Atopic dermatitis was the common skin disease that caused the greatest impairment in quality of life in our sample, although other diseases also had an impact on different dimensions of quality of life. We ought to underscore the recommendation to use less painful treatments than cryotherapy for viral warts and molluscum contagiosum, as the impairment in quality of life in paediatric patients with these conditions was mainly due to the treatment.

Investigation of Quality of Life of Patients with Atopic Dermatitis and Quality of Life, Psychiatric Symptomatology, and Caregiver Burden of Their Mothers

BACKGROUND

The purpose of the present research was to evaluate the quality of life of patients with atopic dermatitis (AD), and that of their mothers. We compared the anxiety and depression scores and caregiving burden of mothers of patients with AD with the same scores of mothers of healthy children.

MATERIALS AND METHODS

A total of 153 patients between the ages of 2 months and 16 years with AD in our clinic, and their mothers, were contained in the patient group. An additional 141 healthy cases between the ages of 2 months and 16 years, and their mothers, were included as the control group. The Children's Dermatology Life Quality Index (CDLQI) was completed according to the children's opinions, and the Infant's Dermatitis Quality of Life Index (IDLQI), Family Dermatology Life Quality Index (FDLQI), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire, and Zarit Caregiver Burden (ZCB) scale were completed based on the mothers' opinions.

RESULTS

We detected a positive relationship between the SCORAD index and the IDLQI, CDLQI, and FDLQI scores of children with AD. We found that anxiety, depression, and caregiving burden in mothers of AD cases increased when mothers of AD cases were compared with mothers of healthy children (p < 0.0001, p < 0.0001, and p < 0.002, respectively). Also, based on the mothers' responses, we noted a positive correlation among the BDI, BAI, ZCB, and SCORAD index scores.

CONCLUSIONS

Our study found that the quality of life of patients with AD, and that of their mothers, was negatively affected by the disease. We also found that anxiety, depression levels (not at the clinical diagnosis level, and the caregiving burden in mothers of AD cases increased when mothers of AD cases were compared with mothers of healthy children.

The skin is no barrier to mixtures: Air pollutant mixtures and reported psoriasis or eczema in the Personalized Environment and Genes Study (PEGS)

BACKGROUND

Autoimmune (AI) diseases appear to be a product of genetic predisposition and environmental triggers. Disruption of the skin barrier causes exacerbation of psoriasis/eczema. Oxidative stress is a mechanistic pathway for pathogenesis of the disease and is also a primary mechanism for the detrimental effects of air pollution.

METHODS

We evaluated the association between autoimmune skin diseases (psoriasis or eczema) and air pollutant mixtures in 9060 subjects from the Personalized Environment and Genes Study (PEGS) cohort. Pollutant exposure data on six criteria air pollutants are publicly available from the Center for Air, Climate, and Energy Solutions and the Atmospheric Composition Analysis Group. For increased spatial resolution, we included spatially cumulative exposure to volatile organic compounds from sites in the United States Environmental Protection Agency Toxic Release Inventory and the density of major roads within a 5 km radius of a participant's address from the United States Geological Survey. We applied logistic regression with quantile g-computation, adjusting for age, sex, diagnosis with an autoimmune disease in family or self, and smoking history to evaluate the relationship between self-reported diagnosis of an AI skin condition and air pollution mixtures.

RESULTS

Only one air pollution variable, sulfate, was significant individually (OR = 1.06, p = 3.99E-2); however, the conditional odds ratio for the combined mixture components of PM2.5 (black carbon, sulfate, sea salt, and soil), CO, SO2, benzene, toluene, and ethylbenzene is 1.10 (p-value = 5.4E-3).

SIGNIFICANCE

While the etiology of autoimmune skin disorders is not clear, this study provides evidence that air pollutants are associated with an increased prevalence of these disorders. The results provide further evidence of potential health impacts of air pollution exposures on life-altering diseases.

SIGNIFICANCE AND IMPACT STATEMENT

The impact of air pollution on non-pulmonary and cardiovascular diseases is understudied and under-reported. We find that air pollution significantly increased the odds of psoriasis or eczema in our cohort and the magnitude is comparable to the risk associated with smoking exposure. Autoimmune diseases like psoriasis and eczema are likely impacted by air pollution, particularly complex mixtures and our study underscores the importance of quantifying air pollution-associated risks in autoimmune disease.

Effects of infant feeding with goat milk formula or cow milk formula on atopic dermatitis: protocol of the randomised controlled Goat Infant Formula Feeding and Eczema (GIraFFE) trial

INTRODUCTION

Atopic dermatitis (AD) is a chronic, inflammatory skin condition significantly affecting quality of life. A small randomised trial showed an approximately one-third lower incidence of AD in goat milk formula-fed compared with cow milk formula-fed infants. However, due to limited statistical power, AD incidence difference was not found to be significant. This study aims to explore a potential risk reduction of AD by feeding a formula based on whole goat milk (as a source of protein and fat) compared with a formula based on cow milk proteins and vegetable oils.

METHODS AND ANALYSIS

This two-arm (1:1 allocation), parallel, randomised, double-blind, controlled nutritional trial shall enrol up to 2296 healthy term-born infants until 3 months of age, if parents choose to start formula feeding. Ten study centres in Spain and Poland are participating. Randomised infants receive investigational infant and follow-on formulas either based on whole goat milk or on cow milk until the age of 12 months. The goat milk formula has a whey:casein ratio of 20:80 and about 50% of the lipids are milk fat from whole goat milk, whereas the cow milk formula, used as control, has a whey:casein ratio of 60:40 and 100% of the lipids are from vegetable oils. The energy and nutrient levels in both goat and cow milk formulas are the same. The primary endpoint is the cumulative incidence of AD until the age of 12 months diagnosed by study personnel based on the UK Working Party Diagnostic Criteria. The secondary endpoints include reported AD diagnosis, measures of AD, blood and stool markers, child growth, sleep, nutrition and quality of life. Participating children are followed until the age of 5 years.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the ethical committees of all participating institutions.

TRIAL REGISTRATION NUMBER

NCT04599946.

The association between atopic dermatitis, cognitive function and school performance in children and young adults

BACKGROUND

Children with atopic dermatitis (AD) may have disturbed sleep, affected self-esteem and decreased quality of life, likely interfering with performance in school.

OBJECTIVES

To examine the association between hospital-managed paediatric AD, school performance and cognitive function.

METHODS

In this cross-sectional study we linked data from the Danish national registers and identified three populations between 2001 and 2019. Population 1 comprised children with graduation grades registered from lower secondary school, population 2 comprised adolescents with registration of an upper secondary graduation mean, and population 3 comprised male conscripts with registration of an IQ test score. AD was defined as a hospital diagnostic code (inpatient or outpatient) prior to the exam or conscription date, and was stratified according to severity, activity and atopic comorbidity. Outcomes included graduation mean from lower and upper secondary school, special educational assistance in primary and lower secondary school, and IQ at conscription.

RESULTS

In total, 770 611 (12 137 with AD), 394 193 (6261 with AD) and 366 182 (4539 with AD) children and adolescents were included in populations 1 (lower secondary graduation), 2 (upper secondary graduation) and 3 (conscription), respectively. In lower secondary school, children with severe AD had significantly lower overall, written and oral graduation grade means compared with children with mild AD: respectively, difference -0.29 [95% confidence interval (CI) -0.45 to -0.13, P < 0.001], difference -0.26 (95% CI -0.42 to -0.10, P = 0.0016) and difference -0.30 (95% CI -0.49 to -0.11, P = 0.0018). In upper secondary school, adolescents with AD performed similarly to their peers without AD. Young men with AD scored significantly lower IQ test means at conscription examination than male conscripts without AD: difference -0.60 (95% CI -0.87 to -0.32, P < 0.001).

CONCLUSIONS

AD, in particular when severe, is associated with lower school performance in childhood and IQ in young men, which can interfere with academic achievements in life. Optimization of treatment of children with AD and specific educational support to children with severe AD could be needed.

Targeting Interleukin 13 for the Treatment of Atopic Dermatitis

Atopic dermatitis (AD) is a common chronic inflammatory skin condition that has a significant impact on a patient's quality of life and requires ongoing management. Conventional topical and systemic therapies do not target specific components of AD pathogenesis and, therefore, have limited efficacy and may be associated with long-term toxicity. Thus, AD management is challenging, with a significant proportion of patients not achieving clear skin or a reduction in pruritus. There remains a large unmet need for effective therapeutic strategies with favorable safety profiles that can be used long-term in patients with refractory AD. The emergence of targeted biological and small molecule therapies has effectively broadened available treatment options for moderate-to-severe AD. Most recently, interleukin 13 (IL-13) inhibitors were shown to be efficacious and well-tolerated, with tralokinumab already approved for use in this patient population. It is important for dermatologists to be aware of the evidence behind this emerging class of biologic agents to guide treatment choices and improve outcomes in patients with AD. The main objective of this paper is to review the current literature regarding the efficacy and safety of current and emerging anti-IL-13 monoclonal antibodies, including tralokinumab, lebrikizumab, cendakimab, and eblasakimab, for the treatment of moderate-to-severe AD.

The positive effect of mother-performed infant massage on infantile eczema and maternal mental state: A randomized controlled trial

Objective

To observe the influence of MPIM on infantile eczema, quality of life, growth and maternal mental state.

Methods

This trial was a randomized controlled study. Sixty-six full-term infants with eczema were randomly divided into eczema control group (EC group, n = 33) and eczema with MPIM group (EM group, n = 33), along with healthy full-term infants in the healthy control group (HC group, n = 31). The mothers in the EC group received the instruction of routine care, while the mothers in the EM group applied massage on the infants plus receiving the same instruction of the routine care. HC group received none of any specific intervention. Data were collected in the three groups at the baseline and at the end of 2- and 5-month intervention. Before and at the end of 2-month intervention, the following indexes were investigated in infants including the growth indexes, eczema area severity index (EASI), infantile dermatitis quality of life index (IDQOL). And the scores of self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were investigated in mothers at the same timepoints. At the end of 5-month intervention, the infants' growth and relapse condition of eczema were observed.

Results

Overall, 31 cases in HC group, 31 in EC group and 32 in EM group were included for data analysis. There were no significant differences in the indexes of infantile growth among the three groups (all P >0.05). The scores of EASI and IDQOL significantly lowered (both P < 0.001) in EC group following the instruction of routine care, along with reduced maternal scores of SAS and SDS (both P < 0.05). Compared with the EC group, the EM group showed significantly lower scores of EASI and IDQOL (both P < 0.001) and lower relapse rate (P < 0.01) in infants with eczema, along with significantly lower scores of SAS and SDS in mothers (both P < 0.01). Moreover, none of obvious adverse reaction was reported following MPIM, to which most of the mothers could adhere.

Conclusion

MPIM could effectively promote the remission of infantile eczema and reduce its relapse, along with relieving maternal anxiety and depression mood.

Clinical trial registration

Identifier: ChiCTR2200066246.

The relationship between atopic dermatitis and atopic itch in children and the psychosocial functioning of their mothers: A cross-sectional study

Atopic dermatitis is a chronic inflammatory skin disease significantly affecting patients' and their parents' lives. Mothers are mostly responsible for the long-term treatment and their wellbeing is essential. The major objective of this cross-sectional study was to investigate the relationship between atopic dermatitis in children, especially concomitant itch, and the quality of life, stress, sleep quality, anxiety, and depression of their mothers. The study included 88 mothers of children with atopic dermatitis and 52 mothers of children without atopic dermatitis. All mothers completed sociodemographic questionnaire, the Perceived Stress Scale, the Athens Insomnia Scale and the Hospital Anxiety and Depression Scale. Additionally, mothers of children with atopic dermatitis filled in the Family Dermatology Life Quality Index. The severity of atopic dermatitis and pruritus intensity were evaluated by the Scoring Atopic Dermatitis Index and the Numerical Rating Scale, respectively. The severity of atopic dermatitis and itch significantly correlated with the quality of life, insomnia, and perceived stress of the mothers. Mothers whose children had had atopic dermatitis for more than 6 months had significantly higher scores of anxiety and depression. The results highlight the importance of screening mothers for functional impairment to provide adequate support. More attention should be directed to the standardization of stepped care interventions addressing factors resulting in the impaired functioning of mothers.

Implications of Atopic Dermatitis on the Quality of Life of 6-11 Years Old Children and Caregivers (PEDI-BURDEN)

Purpose

Atopic dermatitis (AD) is a chronic, relapsing and remitting inflammatory skin disease characterized by intense itch. The disease burden includes physical limitations, psychosocial discomfort, and a reduced quality of life (HRQoL). This study presents the results of a parent-reported survey on the psychosocial impact of AD on Italian pre-adolescent children (6-11 years old), with a specific focus on bullying, self-isolation, absenteeism, and presenteeism.

Methods

An online questionnaire was sent to 3067 random recipients and 160 matched the inclusion criteria for age, self-reported AD diagnosis, localizations (according to ISAAC), and disease severity (POEM ≥8). 100 children, with comparable ages, not matching the inclusion criteria for AD, were recruited as a control group.

Results

Children with AD and their caregivers had a significantly lower quality of sleep (QoS) compared to the control group. The presence of AD was directly responsible for many restless nights, both in children and caregivers (58.9 and 55.4 respectively). Children with AD and their parents also experienced significantly more daytime drowsiness (43.6 and 54.6 days, respectively). Children with AD were more frequently victims of bullying at school (20.0% vs 9.0%; p≤0.05) or in other social environments (16.9% vs 3.0%; p≤0.05). AD caused 17.7 days of absenteeism and 20.1 days of presenteeism per student over the previous 12 months, accounting for 37.8 days of study impairment overall. Severe/very severe AD had a significantly greater impact on presenteeism than moderate AD (25.1 vs 17.5 days; p≤0.05). Presenteeism, which was more pronounced among bullied students, was positively correlated with absenteeism only in the AD cohort.

Conclusion

AD has a detrimental impact on the HRQoL of pediatric patients, causing stigmatization and social isolation. Functional distress was also reported by caregivers. Our study might inform the public and policymakers about the disease burden of AD at a young age.

Efficacy and Safety of Upadacitinib for Management of Moderate-to-Severe Atopic Dermatitis: An Evidence-Based Review

Atopic dermatitis (AD) is a common skin condition characterized by inflammation that presents with erythematous and pruritic skin. Its chronic relapse-remitting nature has a significant impact on the quality of life, and often requires ongoing management. Given the limited treatments available for AD, there remains a large need for effective and safe alternative therapies for long-term use. Janus kinase (JAK) inhibitors are a new class of agents that target the JAK-STAT pathway, which plays an important role in the production of proinflammatory cytokines involved in AD pathogenesis. Phase II and III clinical trials revealed that JAK inhibitors, such as upadacitinib, are effective and well-tolerated agents for the treatment of moderate-to-severe AD. As a result, upadacitinib was approved for use in patients with moderate-to-severe AD by the European Medicines Agency (2021), Health Canada (2021) and the FDA (2022) in the last year. It is important for dermatologists to be aware of the clinical evidence to continue incorporating the use of upadacitinib into the treatment algorithm for AD, which will ultimately lead to improved patient outcomes. Therefore, this review is an up-to-date summary of the clinical data available on the efficacy and safety of upadacitinib treatment for AD.

Systemic treatment of children and adolescents with atopic dermatitis aged ≥2 years: a Delphi consensus project mapping expert opinion in Northern Europe

BACKGROUND

Paediatric atopic dermatitis (AD) can be burdensome, affecting mental health and impairing quality of life for children and caregivers. Comprehensive guidelines exist for managing paediatric AD, but practical guidance on using systemic therapy is limited, particularly for new therapies including biologics and Janus kinase (JAK) inhibitors, recently approved for various ages in this indication.

OBJECTIVES

This expert consensus aimed to provide practical recommendations within this advancing field to enhance clinical decision-making on the use of these and other systemics for children and adolescents aged ≥2 years with moderate-to-severe AD.

METHODS

Nineteen physicians from Northern Europe were selected for their expertise in managing childhood AD. Using a two-round Delphi process, they reached full or partial consensus on 37 statements.

RESULTS

Systemic therapy is recommended for children aged ≥2 years with a clear clinical diagnosis of severe AD and persistent disease uncontrolled after optimizing non-systemic therapy. Systemic therapy should achieve long-term disease control and reduce short-term interventions. Recommended are cyclosporine A for short-term use (all ages) and dupilumab or methotrexate for long-term use (ages ≥6 years). Consensus was not reached on the best long-term systemics for children aged 2-6 years, although new systemic therapies will likely become favourable: New biologics and JAK inhibitors will soon be approved for this age group, and more trial and real-world data will become available.

CONCLUSIONS

This article makes practical recommendations on the use of systemic AD treatments for children and adolescents, to supplement international and regional guidelines. It considers the systemic medication that was available for children and adolescents with moderate-to-severe AD at the time this consensus project was done: azathioprine, cyclosporine A, dupilumab, methotrexate, mycophenolate mofetil and oral glucocorticosteroids. We focus on the geographically similar Northern European countries, whose healthcare systems, local preferences for AD management and reimbursement structures nonetheless differ significantly.

Unsettling experiences: A qualitative inquiry into young peoples’ narratives of diagnosis for common skin conditions in the United Kingdom

Skin conditions such as eczema and psoriasis are relatively prevalent health concerns in children, adolescents and young adults. Experiences of these dermatology diagnoses in adolescence have hitherto not been the focus of research, perhaps owing to assumptions that these diagnoses are not particularly impactful or intricate processes, events or labels. We draw on a thematic secondary analysis of in-depth interviews with 42 adolescents and young people living in the United Kingdom and, influenced by the sociologies of diagnosis and time, highlight the psychological, emotional, social and temporal complexities involved in their diagnosis experiences. Firstly, we describe how participants remembered, re- and co-constructed their diagnosis experiences during the interview. Secondly, we explore the pace and rhythm of diagnosis, including mis-diagnoses, highlighting the jarring potential for adolescents on being diagnosed, even for conditions typically deemed minor. Thirdly, we consider the ways in which these diagnoses have the capacity to reformulate notions of past, present and future, including projecting into imagined futures and reinterpreting past bodily sensations. Finally, we examine how memories about and the meaning of diagnosis are revisited, revised and potentially replaced as a child or adolescent grows older, and increases their management of their condition and encounters with healthcare professionals. In unsettling an assumption that diagnosis experiences for adolescents of common skin conditions is unproblematic or straightforward, our qualitative analysis critically engages with and contribute to tenets of health research that are of interest to quantitative and qualitative researchers, clinicians and patients.

Docosahexaenoic Acid Effect on Prenatal Exposure to Arsenic and Atopic Dermatitis in Mexican Preschoolers

Childhood atopic dermatitis (AD) is a chronic and recurrent health problem that involves multiple factors, particularly immunological and environmental. We evaluated the impact of docosahexaenoic acid (DHA) supplementation on prenatal arsenic exposure on the risk of atopic dermatitis in preschool children as part of the POSGRAD (Prenatal Omega-3 fatty acid Supplements, GRowth, And Development) clinical trial study in the city of Morelos, Mexico. Our study population included 300 healthy mother-child pairs. Of these, 146 were in the placebo group and 154 in the supplement group. Information on family history, health, and other variables was obtained through standardized questionnaires used during follow-up. Prenatal exposure to arsenic concentrations, which appear in maternal urine, was measured by inductively coupled plasma optical emission spectrometry. To assess the effect of prenatal arsenic exposure on AD risk, we ran a generalized estimating equation model for longitudinal data, adjusting for potential confounders, and testing for interaction by omega-3 fatty acid supplementation during pregnancy. The mean and SD (standard deviation) of arsenic concentration during pregnancy was 0.06 mg/L, SD (0.04 mg/L). We found a marginally significant association between prenatal arsenic exposure and AD (OR = 1.12, 95% CI: 0.99, 1.26); however, DHA supplementation during pregnancy modified the effect of arsenic on AD risk (p < 0.05). The results of this study strengthen the evidence that arsenic exposure during pregnancy increases the risk of atopic dermatitis early in life. However, supplementation with omega-e fatty acids during pregnancy could modify this association.

Topical anti‐inflammatory treatments for eczema: network meta‐analysis

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To compare the efficacy and safety of topical anti‐inflammatory treatments for reducing eczema symptoms or signs or improving eczema‐related quality of life in children and adults with eczema, by undertaking a network meta‐analysis. To provide a clinically useful ranking of these treatments according to their efficacy and safety.

Unveiling the true costs and societal impacts of moderate-to-severe atopic dermatitis in Europe

Atopic dermatitis (AD) is a chronic, auto-immune condition that imposes a high burden on individuals, society, and the healthcare system. Approximately 4.4% of adults and up to 18.6% of children/adolescents have AD in Europe, with 20% of all cases accounting for moderate-to-severe forms. This form of the condition in adults results in annual societal costs across Europe of an estimated €30 billion; €15.2 billion related to missed workdays or reduced work productivity, €10.1 billion related to direct medical costs and €4.7 billion related to personal expenditure of patients/families. AD can also substantially impact physical, emotional, and social quality-of-life. Several studies have shown the debilitating itch-scratch cycle is the main cause of the multifaceted burden, as it causes substantial sleep deprivation and stigmatisation due to the physical appearance of the skin, and confidence issues. These factors lead to psychosocial issues and can cumulate over time and prohibit patients reaching their 'full life potential'. Despite this, many patients with the condition are undertreated, resulting in uncontrolled symptoms and a further strain placed on patients, society, and the economy. The authors of this White Paper comprise the European Atopic Dermatitis Working Group, which is a network of international specialists with expertise in dermatology and healthcare policy decisions. Their programme of action is focused on harnessing their expertise to build consensus, advance research, share knowledge, and ultimately seek to improve AD care outcomes through achieving long-term symptom control. This White Paper presents a systematic evaluation of the overall financial and humanistic burden of moderate-to-severe AD and the current challenges that exist with AD care. It introduces recommendations for how, collaboratively, key stakeholders and policy makers can support improvements in AD management to achieve better disease control, thus reducing the costs and associated burden placed on individuals, society, and the economy.

Study protocol: assessing SleeP IN infants with early-onset atopic Dermatitis by Longitudinal Evaluation (The SPINDLE study)

BACKGROUND

Atopic dermatitis (AD) is the most common chronic inflammatory skin condition in childhood. Most (50-60%) children with AD report sleep disturbance, which is secondary to itch, dry skin, inflammation, and abnormal circadian rhythm. Sleep is essential for brain development, learning, and growth. Sleep disruption in early life is associated with cognitive and psychological dysfunction in later life. The aim of this study is to describe in detail the sleep architecture of infants with early-onset atopic dermatitis (AD), compared to controls, by using EEG polysomnography, sleep actigraphy, and parental reporting.

METHODS

This observational study will recruit six- to eight-month old infants with moderate to severe AD and age-matched control infants who do not have AD. At six-eight months diurnal sleep electroencephalography and polysomnography will be performed in our research center. Nocturnal sleep actigraphy will be performed at home for five consecutive nights at six-eight months and 12 months. Between six and 12 months, monthly questionnaires will capture data on quantitative sleep and parental sleep. Skin barrier and immune profiles will be captured at six-eight and 12 months. AD will be assessed using standardized severity assessment tools and treated according to protocol. A neurodevelopmental assessment will be performed at 18 months to assess cognition and behaviour. An estimated sample size of 50 participants in each group is required to power the primary outcome of disturbed macrostructure of sleep and secondary outcomes of disturbed microstructure of sleep, and disturbed parental sleep, assuming an attrition rate of 60%. Potential confounding factors which will be controlled for in the data analysis will include parental educational level, parental depression, feeding practice, and number of siblings.

DISCUSSION

This study will provide a rich analysis of sleep in infants with AD in the first year of life using detailed electroencephalography, novel actigraphy techniques, and longitudinal parent-reported data. It may provide guidance on the optimal treatment of AD to prevent or reduce sleep disruption.

TRIAL REGISTRATION

clinicaltrials.gov NCT05031754 , retrospectively registered on September 2nd, 2021.

How parents and children evaluate emollients for childhood eczema: a qualitative study

BACKGROUND

Eczema affects one in five children in the UK. Regular application of emollients is routinely recommended for children with eczema. There are four main emollient types, but no clear evidence of which is best. The current 'trial and error' approach to find suitable emollients can be frustrating for parents, children, and clinicians.

AIM

To identify how parents and children experience and evaluate emollients.

DESIGN AND SETTING

Qualitative interview study, nested within a primary care trial of emollients (Best Emollients for Eczema [BEE] trial).

METHOD

Semi-structured interviews with children with eczema and their parents were conducted. Participants were purposively sampled on emollient type (lotion, cream, gel, or ointment), age, and eczema severity.

RESULTS

Forty-four parents were interviewed, with children participating in 24 of those interviews. There was no clear preference for any one emollient type. The strongest theme was the variation of experience in each of the four types. Participants focused on thickness and absorbency, both positively and negatively, to frame their evaluations. Effectiveness and acceptability were both considered when evaluating an emollient but effectiveness was the primary driver for continued use. For some, participating in the trial had changed their knowledge and behaviour of emollients, resulting in use that was more regular and for a longer duration.

CONCLUSION

There is no one emollient that is suitable for everyone, and parents/children prioritise different aspects of emollients. Future research could evaluate decision aids and/or tester pots of different types, which could enable clinicians and parents/children to work collaboratively to identify the best emollient for them.

Quality of Life Among Family of Patients with Atopic Dermatitis and Psoriasis

BACKGROUND

Chronic inflammatory skin diseases like atopic dermatitis (AD) and psoriasis can severely impact patients' quality of life (QOL). However, the effect of these diseases can diminish the QOL of patients' family members as well. The objective of this study was to understand the impact on QOL for family members of patients diagnosed with AD or psoriasis.

METHODS

We conducted focus groups and interviews with 23 individuals; 12 had a family member with AD, and 11 had a family member with psoriasis. After investigators independently coded the transcripts, thematic analysis was conducted.

RESULTS

Three major themes emerged: (1) lifestyle consequences-many daily activities for family members, including but not limited to leisure activities, sleep, and cleaning, were affected by AD or psoriasis; (2) emotional consequences-family members felt frustrated, worried, or embarrassed, among other concerns, because of their loved ones' AD or psoriasis; (3) relationships-relationships between family members and their loved ones with AD or psoriasis could become strained, and though family members might try to be sympathetic, doing so could be difficult because of their lack of understanding of how these diseases feel and personally affect their loved ones.

CONCLUSIONS

This study highlights the impacts of AD and psoriasis on the whole family. Clinicians should be mindful of the effects on QOL not only for patients but also for family members who live with and care about these patients. Especially when family members assist with treatments, it is important to understand family members' experiences when making treatment decisions.

Linker-Improved Chimeric Endolysin Selectively Kills Staphylococcus aureus In Vitro, on Reconstituted Human Epidermis, and in a Murine Model of Skin Infection

Staphylococcus aureus causes a broad spectrum of diseases in humans and animals. It is frequently associated with inflammatory skin disorders such as atopic dermatitis, where it aggravates symptoms. Treatment of S. aureus-associated skin infections with antibiotics is discouraged due to their broad-range deleterious effect on healthy skin microbiota and their ability to promote the development of resistance. Thus, novel S. aureus-specific antibacterial agents are desirable. We constructed two chimeric cell wall-lytic enzymes, Staphefekt SA.100 and XZ.700, which are composed of functional domains from the bacteriophage endolysin Ply2638 and the bacteriocin lysostaphin. Both enzymes specifically killed S. aureus and were inactive against commensal skin bacteria such as Staphylococcus epidermidis, with XZ.700 proving more active than SA.100 in multiple in vitro activity assays. When surface-attached mixed staphylococcal cultures were exposed to XZ.700 in a simplified microbiome model, the enzyme selectively removed S. aureus and retained S. epidermidis. Furthermore, XZ.700 did not induce resistance in S. aureus during repeated rounds of exposure to sublethal concentrations. Finally, we demonstrated that XZ.700 formulated as a cream is effective at killing S. aureus on reconstituted human epidermis and that an XZ.700-containing gel significantly reduces bacterial numbers compared to an untreated control in a mouse model of S. aureus-induced skin infection.

Air Pollution and Weather Conditions Are Associated with Daily Outpatient Visits of Atopic Dermatitis in Shanghai, China

BACKGROUND

Non-optimum weather conditions and air pollution have the potential to increase the risk of atopic dermatitis (AD), but the associations are rarely evaluated, especially in developing countries.

OBJECTIVE

To investigate the independent influence and interaction effects of meteorological factors and air pollutants on the onset of AD.

METHODS

Daily data on outpatient visits of AD were obtained from Shanghai Dermatology Hospital and comprised 34,633 patients during the period from January 2013 to December 2018. Meteorological conditions and air pollutant concentrations in Shanghai, China, during the 6-year period were collected. We applied the overdispersed generalized additive model and the distributed lag model to explore the short-term cumulative effects of environmental factors on AD.

RESULTS

AD symptoms were aggravated by extreme low temperature (1st percentile, 0.5°C) (RR = 1.32, 95% CI: 1.16-1.51) and per 10 unit decrease of humidity (RR = 1.10, 95% CI: 1.12-2.47). The increased concentration of air pollutants except ozone (O3) contributed to the increased risk of AD outpatients. A 10 μg/m3 increase in sulfur dioxide (SO2) and nitrogen dioxide (NO2) were associated with 6.03% (95% CI: 2.29%, 9.91%), and 1.96% (95% CI: 0.46%, 3.48%) increase of AD outpatients. AD patients in the 8- to 17-year-old group were most susceptible to extreme low temperature, and patients in the 0- to 7-year-old group were most susceptible to air pollutants, including particulate matter (PM10), SO2, and NO2. Men were more sensitive to the effects of extreme low temperature than women, while women were more vulnerable to air pollutants. The adverse effects of SO2 and NO2 on AD can be enhanced significantly by the warm season or other pollutants.

CONCLUSION

Exposure to a lower temperature, lower humidity, and higher levels of air pollutants is significantly associated with increased risks of AD incidence. These impacts were more pronounced in children less than 7 years old, women, and warm seasons.

Experts' Consensus on the Use of Pimecrolimus in Atopic Dermatitis in China: A TCS-Sparing Practical Approach

Introduction

Atopic dermatitis (AD) is a chronic, pruritic, inflammatory skin disease with rising prevalence. Topical corticosteroids (TCS) are recommended as first-line therapy for patients with AD in China; however, corticophobia is a widespread concern, which can manifest as noncompliance: in a previous Chinese study, almost all parents whose children had AD were very concerned about the side effects of TCS and, as a result, nearly half did not use it in the event of recurrence. We propose a TCS-sparing treatment algorithm for the management of infants, children, adolescents, and adults with mild-to-moderate AD, to guide clinical practice in China.

Methods

A panel of eight experts in AD from China and one expert from Germany formed to develop a practical algorithm for the management of mild-to-moderate AD, focusing on pimecrolimus.

Results

Irrespective of body location, all patients with mild AD (including acute flares) and infants with moderate AD should apply the topical calcineurin inhibitor (TCI) pimecrolimus twice daily to the affected area until symptoms disappear. For children, adolescents, and adults with moderate AD, pimecrolimus should be applied twice daily to sensitive skin areas, and a TCI (either pimecrolimus or tacrolimus) should be applied twice daily to other body locations. Short-term administration of TCS, followed by TCI twice daily, is recommended for most patients with moderate AD experiencing acute flares, regardless of lesion site. Emollients should be used regularly.

Conclusions

The algorithm presented intends to simplify treatment of AD in China and guide clinical decision-making.

Association of Atopic Dermatitis with Depression and Suicide: A Two-Sample Mendelian Randomization Study

Background

Atopic dermatitis (AD) has long been hypothesized to be associated with risk of depression and suicide, but the causal relationship between them is still unclear.

Objective

To evaluate the causality between AD, depression, and suicide using a Mendelian randomization (MR) approach.

Method

We extracted summary-level data for AD, major depression, and suicidal ideation or attempt from published, nonoverlapping genome-wide association studies (GWAS). Inverse variance-weighted (IVW) analysis was used as the primary analysis. Alternate methods, including weighted median, MR Egger, MR pleiotropy residual sum and outlier, weighted mode, and leave-out analysis, were performed to assess pleiotropy.

Results

13 SNPs (13,287 cases and 41,345 controls) were selected as instrumental variables (IVs). The IVW analysis indicated a statistically significant but small causal effect of AD on major depression (OR = 1.027, 95% CI 1.004-1.050; p = 0.020). No significant evidence was observed for a causal effect of AD on suicide. No significant effect of pleiotropy was found.

Conclusion

AD has a significant but small effect on major depression, but not on suicide.

Topical Melatonin Exerts Immunomodulatory Effect and Improves Dermatitis Severity in a Mouse Model of Atopic Dermatitis

Oral melatonin supplement has been shown to improve dermatitis severity in children with AD, but the mechanism of the effect is unclear, and it is uncertain whether melatonin has a direct immunomodulatory effect on the dermatitis. Topical melatonin treatment was applied to DNCB-stimulated Balb/c mice, and gross and pathological skin findings, serum IgE, and cytokine levels in superficial lymph nodes were analyzed. Secretion of chemokines and cell proliferative response after melatonin treatment in human keratinocyte HaCaT cells were also studied. We found that in DNCB-stimulated Balb/c mice, topical melatonin treatment improved gross dermatitis severity, reduced epidermal hyperplasia and lymphocyte infiltration in the skin, and decreased IP-10, CCL27, IL-4, and IL-17 levels in superficial skin-draining lymph nodes. Melatonin also reduced cytokine-induced secretion of AD-related chemokines IP-10 and MCP-1 and decreased IL-4-induced cell proliferation in HaCaT cells. Melatonin seems to have an immunomodulatory effect on AD, with IP-10 as a possible target, and topical melatonin treatment is a potentially useful treatment for patients with AD.

Family burden of hospital-managed pediatric atopic dermatitis: A nationwide registry-based study

BACKGROUND

Parents of children with atopic dermatitis (AD) report reduced quality of life and higher stress level, which could increase risk of psychiatric and pain disorders, and medication use.

METHODS

By use of Danish national registries, we identified family members of all first-born Danish children born between 1 January 1995 and 31 December 2013 with a hospital diagnosis of AD, matched them 1:10 with family members of children without AD, and followed the cohorts over time.

RESULTS

Mothers of children with hospital-managed AD had higher risk of filling a prescription for medications for depression, anxiety, pain and sleep problems, and of consulting a psychologist, but most associations disappeared after full adjustment. Siblings had higher risk of receiving a diagnosis for adjustment disorder, and fathers showed increased risk of filling a prescription for pain medication and of divorce, in crude but not adjusted models.

CONCLUSIONS

The increased risk of study endpoints seen in mothers of children with hospital-managed AD was not explained by pediatric AD alone. Rather, the total burden in these families including parent and child morbidity and socioeconomic resources seems to explain these observations. The burden in families of children with AD may potentially affect the overall management of their child's AD.

Characterization of Classical Flexural and Nummular Forms of Atopic Dermatitis in Childhood with Regard to Anamnestic, Clinical and Epidermal Barrier Aspects

Nummular (coin-shaped) and classical (flexural) atopic dermatitis differ morphologically, but no other distinguishing features are known. The aim of this study was to determine differences and similarities of both variants in children. Detailed interviews, clinical examinations, biophysical measurements and electron microscopic analyses were performed on 10 children with nummular atopic dermatitis, 14 with classical atopic dermatitis and 10 healthy controls. Nummular atopic dermatitis affected more boys than girls and manifested less frequently within the first year of life than classical atopic dermatitis. Localization, distribution and morphology of the eczema varied more over time, and expression of keratosis pilaris was more severe in children with nummular atopic dermatitis. Both disease groups showed reduced hydration, increased transepidermal water loss and reduced intercellular lipid lamellae in lesional skin areas compared with non-lesional areas. These findings underline the separate classification of both variants. Further research is necessary to investigate the potential of diverging therapeutic approaches.

Negative perceptions and emotional impact of striae gravidarum among pregnant women

Background

The impact of striae gravidarum (SG), or stretch marks of pregnancy, on quality of life (QoL) is unclear.

Objective

The purpose of this study was to investigate how SG affect QoL in pregnant women.

Methods

In this cross-sectional survey study of healthy pregnant women who developed SG during their current pregnancy, we asked about the impact of lesions on emotional, psychological, and life-quality facets. Spearman product-moment correlation coefficients were generated to determine the strength of relationships between variables.

Results

We analyzed 116 valid surveys. Participants reported permanency of SG as the top physical concern (n = 87; 75%). With regard to severity, nearly three-quarters of participants rated their lesions as very prominent (n = 24; 21%) or moderate (n = 57; 49%). Among the life-quality facets queried, embarrassment/self-consciousness was the most frequently associated with SG, with over one-third of participants reporting “a lot” (n = 19; 16%) or a “moderate” (n = 26; 22%) amount of embarrassment/self-consciousness related to having SG. Lesion severity significantly correlated with the degree of embarrassment/self-consciousness (r = .543), as well as the impact of SG on other life-quality facets, including overall QoL (r = .428), clothing choice (r = .423), self-image/self-esteem (r = .417), feelings of anxiety/depression (r = .415), and social activities (r = .313; all p ≤ .001). Nearly one-quarter of participants believed that emotional distress related to SG was similar or greater than that caused by other skin problems, such as acne, psoriasis, or eczema.

Conclusion

SG can be associated with a host of negative reactions reflecting increased psychological and emotional distress, including embarrassment and decreased QoL. These consequences may compound the emotional stress of pregnancy, potentially warranting psychological support and adjustment strategies.

What Do We Know about Pruritus in Very Young Infants? A Literature Review

In infants, pruritus is frequently considered as absent because they do not scratch themselves. Because pruritus could induce severe adverse effects in this vulnerable population, we aimed to review existing evidence on the ability of young infants to experience itch and on how to assess itch-related discomfort in this population. A literature review was performed (Pubmed, Google Scholar). Neurological itch pathways are well described. Skin development starts early during gestation. At 34 weeks of gestation, skin is almost complete while skin adaptations occur after birth. Newborn skin is neurologically functional, including the ability for young infants to feel pain. Similarities and interactions between pain and pruritus support the hypothesis that infants could feel pruritus. However, the existence of pruritus in infants has never been evidenced. Many itchy conditions can affect them, suggesting non-negligible prevalence of infant pruritus among which atopic dermatitis (AD) is the most studied disease. Studies reported a negative impact of AD on children and their families. There is no existing validated method to assess pruritus in infants, although they may feel pruritus and chronic pruritus can lead to serious adverse effects. To appropriately diagnose pruritus appears of great interest among young infants. Development of a method is required to this aim.

Cross-Sectional Study to Identify Potential Risk Factors for Eczema within the Common Household Environment in Taiwan

Background

Much attention has been focused on environmental risk factors and their roles in eczema development. In this regard, the specific eczema risk factors in Taiwan were relatively unknown. As such, this study investigated the common indoor risk factors present in Taiwanese households.

Aims

To discuss the effects of several indoor risk factors on the prevalence of atopic eczema in Taiwan.

Materials and Methods

A cross-sectional, population-based study was performed in Kaohsiung, Taiwan, using both survey investigation and fungal culturing. A total of 998 participants were enrolled in the survey, with 513 participants selected for fungal culture. Risks of atopic eczema were calculated as odds ratios for various risk factors using logistic regression. The correlation between potential risk factors and the fungal level was analyzed with linear regression.

Results

Pet and house plants have an adjusted odds ratio of 1.434 (95% CL: 1.011-2.033) and 1.820 (95% CL: 1.229-2.696), respectively. Additionally, smoking was shown to possess an odds ratio of 1.461 (95% CL: 1.064-2.006). Wood wall has an adjusted odds ratio of 2.143 (95% CL: 1.235-3.658). Frequent bedroom shower use (β = 0.254) and hours of opened windows (β = 0.106) have shown significant positive associations with indoor fungal level.

Conclusion

Pets, house plants, and smoking were concluded to be major risk factors for atopic eczema. Wood wall remained controversial due to its limited sample size and possible confounders. Bedroom shower and window-opening have been shown to increase mold growth, but the lack of association with eczema suggested other allergens besides mold to be the primary eczema trigger.

Safety of Janus kinase (JAK) inhibitors in the short-term treatment of atopic dermatitis

Atopic dermatitis (AD) is a chronic heterogeneous condition characterized by erythematous, pruritic, and inflamed skin. Janus kinase (JAK) inhibitors are a new class of drugs that target proteins in the Janus kinase-signal transducer and activator of transcription (JAK-STAT) pathway. These drugs can be administered orally or topically to inhibit signaling of the JAK-STAT pathway and minimize the production of proinflammatory cytokines. The efficacy and safety of JAK inhibitors have been investigated in phase 2 and 3 clinical trials for AD. The safety of new medications, which are immunosuppressive by nature, is of utmost concern for the prescriber and patient alike. Herein we summarize the safety results of clinical trials using oral abrocitinib, upadacitinib, and baricitinib, as well as topical ruxolitinib and delgocitinib for the treatment of AD. The most prevalent (2-5% occurrence rate) treatment-emergent adverse events from oral JAK inhibitor use in AD were nausea, upper respiratory tract infection, headache, herpes zoster, herpes simplex, acne, increased blood creatine phosphokinase levels, and decreased platelet counts. Topical JAK inhibitors were not associated with systemic effects. All studies reported that JAK inhibitors were well tolerated in patients with AD in comparison with the control group. While the use of JAK inhibitors in patients suffering from AD is very promising, trials reported to date are of short duration (maximum 16 weeks), and more information on the long-term safety of these novel agents is required.