Atopic dermatitis and risk of ischemic stroke: a nationwide population-based study

VINDICATE-P: A Mnemonic for the Many Comorbidities of Atopic Dermatitis

Patients with atopic dermatitis (AD) are at increased risk of atopic and non-atopic comorbidities. In fact, the Hanifin and Rajka criteria include allergic and infectious comorbidities as a minor criterion. Despite the well-recognized list of comorbidities, the past 15 years greatly expanded the list of recognized comorbidities of AD. This narrative review focuses on comorbidities of AD using a mnemonic, VINDICATE-P: vascular/cardiovascular, infectious, neoplastic and neurologic, degenerative, iatrogenic, congenital, atopic and autoimmune, traumatic, endocrine/metabolic, and psychiatric. The comorbidities of AD vary by age. More research is needed into the mechanisms of comorbidities and optimal screening strategies in AD patients.

Interplay between diabetes mellitus and atopic dermatitis

Inflammatory dermatoses such as atopic dermatitis (AD) have long been linked to the pathogenesis of diabetes mellitus. Indeed, numerous studies show an increased risk of diabetes mellitus in individuals with AD although lower prevalence of diabetes mellitus is also observed in few studies. Though the underlying mechanisms accounting for the reciprocal influence between these two conditions are still unclear, the complex interplay between diabetes mellitus and AD is attributable, in part, to genetic and environmental factors, cytokines, epidermal dysfunction, as well as drugs used for the treatment of AD. Proper management of one condition can mitigate the other condition. In this review, we summarize the evidence of the interaction between diabetes mellitus and AD, and discuss the possible underlying mechanisms by which these two conditions influence each other.

Common and distinct risk profiles of asymptomatic extra- and intracranial atherosclerosis in the Nagahama cohort

BACKGROUND AND PURPOSE

Atherosclerotic burden increases the risk of both extracranial internal carotid artery stenosis (ICS) and intracranial large artery disease (ICAD). However, the differences in risk profiles have not been thoroughly investigated.

METHODS

Participants were recruited from the Nagahama study cohort in Japan. Individuals over 60 years old who underwent 1.5-T head and neck magnetic resonance angiography (MRA) between July 2013 and February 2017 were included. ICAD was defined as WASID ≥ 50%, and ICS was defined as NSCET ≥ 30%. The prevalence and association of risk factors, including proatherogenic and proinflammatory factors, and the p.R4810K variant in the RNF213 gene, were investigated. Multivariable logistic regression analyses were performed.

RESULTS

A total of 3089 individuals participated in the study, with a mean age of 68.1 ± 5.3 years, and 36.0% were males. Among them, 52 (1.7%) had ICS, 119 (3.8%) had ICAD, and 15 (0.49%) had both conditions. Alopecia areata was an independent predictor for both ICS (Odds ratio [OR] 3.5; 95% CI 1.3-8.3) and ICAD (OR 2.1; 95% CI 1.0-3.9). Diabetes (OR 3.7; 95% CI 2.0-7.0) and older age (OR 2.4; 95% CI 1.2-4.5) were associated only with ICS, while the RNF213 variant was associated with only ICAD (OR 5.7; 95% CI 1.6-16.0). ICS and ICAD were also independently associated with each other.

CONCLUSIONS

In this MRA-based large scale study, alopecia areata, known as a systemic inflammatory disease, was shown to be a common risk factor for ICS and ICAD. While conventional atherosclerotic factors were associated with ICS, non-atherosclerotic factors appear to contribute to ICAD in Japan.

Atopy improves survival and decreases risk of brain metastasis in cutaneous melanoma

Importance

Development of new therapies in melanoma has increased survival, and as a result more patients are living to develop brain metastasis (BrM). Identifying patients at increased risk of BrM is therefore of significant public health importance.

Objective

To determine whether history of atopy is associated with improved survival or reduced incidence of BrM in cutaneous melanoma.

Design

A retrospective cohort study conducted from June 2022 to March 2024.

Setting

Population-based in states with Surveillance, Epidemiology and End Results (SEER) supported cancer registries.

Participants

Individuals (≥65 years) diagnosed with cutaneous melanoma between January 1, 2008 and December 31, 2017 that are participants in traditional Medicare.

Exposures

Individuals were compared that had history of atopy (allergic rhinitis, atopic dermatitis, asthma, and/or allergic/atopic conjunctivitis) diagnosed prior to melanoma diagnosis, ascertained using ICD-9 or ICD-10 codes in Medicare claims.

Main Outcomes and Measures

Primary endpoints were diagnosis with a BrM or death during the follow-up period. Associations between atopy and endpoints were assessed using cox proportional hazards models to estimate hazard ratios (HR) and p-values.

Results

A total of 29,956 cutaneous melanoma cases were identified (median age 76, 60% male and 97% non-Hispanic White). Overall, 7.1% developed BrM during follow up. Among the 35% that had history of atopy, the most common condition was atopic dermatitis (19%). After adjustment for demographic and prognostic factors, atopy was associated with a 16% decrease in death (HR=0.84 [95%CI:0.80-0.87], pFDR<0.001). Among those with non-metastatic disease at time of diagnosis, atopy conferred a 15% decrease in cumulative incidence BrM (HR=0.85 [95%CI: 0.76-0.94], pFDR=0.006), with a 25% decrease associated with atopic dermatitis (HR=0.75 [95%CI:0.65-0.86], pFDR<0.001). Among those with metastatic disease at diagnosis (any metastatic site), only those who received immune checkpoint inhibitors had a survival benefit associated with atopy (HR=0.31, [95%CI:0.15-0.64], p=0.001 vs HR=1.41, [95%CI:0.87-2.27], p=0.165).

Conclusions and Relevance

Atopy, particularly atopic dermatitis, was significantly associated with improved survival and decreased incidence of BrM. The improved survival associated with these conditions in the context of immunotherapy suggests that these conditions in the elderly may identify those with more robust immune function that may be more responsive to treatment.

Incidence of Cardiovascular Disease and Venous Thromboembolism in Patients With Atopic Dermatitis

BACKGROUND

Atopic dermatitis (AD) may increase risk for atherothrombotic and cardiovascular (CV) disease.

OBJECTIVE

Determine CV disease and venous thromboembolism risk among patients with AD.

METHODS

Cohort study using electronic health data from U.K. general practices in 1994 to 2015. Children (<18 y) and adults (≥18 y) with AD were matched to patients without AD on age, same practice, and encounter date. Treatments and specialist referrals served as proxies of AD severity. Outcomes were incident myocardial infarction, cerebrovascular accident (CVA), diabetes, hypertension, dyslipidemia, deep vein thrombosis (DVT), and pulmonary embolism. Cox regression analysis was used to compare outcomes in AD versus non-AD patients.

RESULTS

Comparing 409,341 children with AD (93.2% mild, 5.5% moderate, and 1.3% severe) to 1,809,029 unaffected children, AD was associated with higher risk of DVT (hazard ratio [HR] 1.23; 95% confidence interval [95% CI] 1.02-1.48) and severe AD was associated with higher risk of CVA (HR 2.43; 95% CI 1.13-5.22) and diabetes (HR 1.46; 95% CI 1.06-2.01). Comparing 625,083 adults with AD (65.7% mild, 31.4% moderate, and 2.9% severe) to 2,678,888 unaffected adults, AD, especially when severe, was associated with higher risk of DVT (HR 1.14; 95% CI 1.11-1.18; and HR 1.64; 95% CI 1.49-1.82, respectively) and small but increased risks of CVA, diabetes, and dyslipidemia. Adults with severe AD had higher risk of myocardial infarction (HR 1.27; 95% CI 1.15-1.39), CVA (HR 1.21; 95% CI 1.13-1.30), diabetes (HR 1.15; 95% CI 1.09-1.22), dyslipidemia (HR 1.11; 95% CI 1.06-1.17), and pulmonary embolism (HR 1.39; 95% CI 1.21-1.60) compared with adults without AD.

CONCLUSIONS

Atopic dermatitis, particularly when severe, is associated with small but increased risks of CV risk factors and events and significantly increased risk of venous thromboembolism.

Major adverse cardiovascular events in patients with atopic dermatitis treated with oral Janus kinase inhibitors: a systematic review and meta-analysis

BACKGROUND

On the basis of safety data for patients with inflammatory rheumatism or inflammatory bowel disease, treatment with Janus kinase (JAK) inhibitors (JAKi) has been linked to the occurrence of major adverse cardiovascular events (MACE). However, these inflammatory diseases are proatherogenic; in contrast, patients with atopic dermatitis (AD) do not usually have a high cardiovascular (CV) comorbidity burden.

OBJECTIVES

To perform a systematic review and meta-analysis of MACE in patients with AD treated with JAKi.

METHODS

We systematically searched PubMed, Embase, Cochrane Library and Google Scholar from their inception to 2 September 2022. Cohort studies, randomized controlled trials and pooled safety analyses providing CV safety data on patients taking JAKi for AD were selected. We included patients aged ≥ 12 years. We built a 'controlled-period' cohort (n = 9309; 6000 exposed to JAKi and 3309 exposed to comparators) and an 'all-JAKi' cohort (n = 9118 patients exposed to a JAKi in any of the included studies). The primary outcome was a composite of acute coronary syndrome (ACS), ischaemic stroke and CV death. The broader secondary MACE outcome encompassed ACS, stroke (whether ischaemic or haemorrhagic), transient ischaemic attack and CV death. The frequency of primary and secondary MACE was assessed in both cohorts. A fixed-effects meta-analysis using the Peto method was used to calculate the odds ratio (OR) for MACE in the 'controlled-period' cohort. Evaluation of the risk of bias was done using the Cochrane risk-of-bias tool (version 2). Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Eight per cent of the records identified initially met the selection criteria, corresponding to 23 records included in the 'all-JAKi' cohort. Patients had been exposed to baricitinib, upadacitinib, abrocitinib, ivarmacitinib, placebo or dupilumab. Four primary events (three with JAKi and one with placebo) and five secondary events (four with JAKi and one with placebo) occurred among 9309 patients in the 'controlled-period' cohort (MACE frequency 0.04% and 0.05%, respectively). Eight primary events and 13 secondary events occurred among 9118 patients in the 'all-JAKi' cohort (MACE frequency 0.08% and 0.14%, respectively). The OR for primary MACE in patients with AD treated with JAKi vs. placebo or dupilumab was 1.35 (95% confidence interval 0.15-12.21; I2 = 12%, very low certainty of evidence).

CONCLUSIONS

Our review highlights rare cases of MACE among JAKi users for AD. JAKi may have little-to-no effect on the occurrence of MACE in patients with AD vs. comparators, but the evidence is uncertain. Real-life long-term population-level safety studies are needed.

Risk of Venous Thromboembolism Among Adults With Atopic Dermatitis

Importance

The associations of atopic dermatitis (AD) with multiple cardiovascular comorbidities have been investigated because of its pathomechanisms regarding chronic systemic inflammation and potential vascular effects. Nevertheless, the association between AD and incident venous thromboembolism (VTE) in adulthood is largely unknown. This study aimed to investigate the association of AD with incident VTE.

Objective

To examine the risk of incident VTE among patients with AD.

Design, Setting, and Participants

This population-based nationwide cohort study included adults 20 years or older (adults with AD newly diagnosed between 2003 and 2017 and matched controls) from the National Health Insurance Research Database. Patients with AD were subgrouped according to the severity of the disease. A Cox regression model was used to estimate hazard ratios (HRs) for VTE. Stratified analyses according to age and sex, and a sensitivity analysis excluding systemic steroid users were performed.

Main Outcomes and Measures

Hazard ratios (HRs) for incident VTE associated with AD.

Results

This analysis included a total of 284 858 participants, with 142 429 participants each in the AD (mean [SD] age, 44.9 [18.3] years; 78 213 women) and non-AD cohorts (mean [SD] age, 44.1 [18.1] years; 79 636 women). During the follow-up, 1066 patients (0.7%) in the AD cohort and 829 patients (0.6%) in the non-AD cohort developed VTE, with incidence rates of 1.05 and 0.82 per 1000 person-years, respectively. Adults with AD had a significantly increased risk of incident VTE (HR, 1.28; 95% CI, 1.17-1.40) compared with adults without AD. Individual outcome analyses suggested that AD was associated with higher risks of deep vein thrombosis (HR, 1.26; 95% CI, 1.14-1.40) and pulmonary embolism (HR, 1.30; 95% CI, 1.08-1.57).

Conclusions and Relevance

The results of this cohort study suggest that AD in adulthood is associated with an increased risk of VTE; however, the absolute risk difference of VTE between adults with and without AD appears small. Nevertheless, cardiovascular examination and imperative management may be considered for adults with AD who present with symptoms suggestive of VTE. Future research is warranted to elucidate the pathophysiology underlying the association between AD and VTE.

Incidence of Cardiovascular Disease After Atopic Dermatitis Development: A Nationwide, Population-Based Study

PURPOSE

Despite increasing evidence for the potential association between atopic dermatitis (AD) and cardiovascular diseases (CVDs), results have still remained controversial. Therefore, this study investigated the association between AD and subsequent CVDs in adults newly diagnosed with AD.

METHODS

Datasets from the National Health Insurance Service-National Sample Cohort in South Korea from 2002 to 2015 were analyzed. The primary outcome was new-onset CVD, which included angina pectoris, myocardial infarction, stroke, or any revascularization procedure. The crude and adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated in the AD group compared with the matched control group using the Cox proportional hazards regression models.

RESULTS

A total of 40,512 individuals with AD were matched with 40,512 control subjects without AD. The overall incidence of CVDs was 2,235 (5.5%) and 1,640 (4.1%) in the AD and matched control groups, respectively. In the adjusted model, AD was associated with an increased risk of CVDs (HR, 1.42; 95% CI, 1.33-1.52), angina pectoris (adjusted HR, 1.49; 95% CI, 1.36-1.63), myocardial infarction (adjusted HR, 1.40; 95% CI, 1.15-1.70), ischemic stroke (adjusted HR, 1.34; 95% CI, 1.20-1.49), and hemorrhagic stroke (adjusted HR, 1.26; 95% CI, 1.05-1.52). Most of the subgroup and sensitivity analysis results were consistent with those of the main analysis.

CONCLUSIONS

The current study found that adult patients newly diagnosed with AD were at significantly increased risk for subsequent CVDs, suggesting the need to consider early prevention strategies for CVDs targeting patients with AD.

Neurodevelopment at 6 years of age in children with atopic dermatitis

BACKGROUND

Few studies have reported an association between atopic dermatitis and cognitive impairment in children. Therefore, we evaluated the association between atopic dermatitis (AD) and neurodevelopmental dysfunction in children.

METHODS

We analyzed 2,395,966 children born between 2008 and 2012 in Korea. All data were acquired from the databases of the Korean National Health Insurance System. AD was defined as five or more diagnoses before age 24 months. The outcome was suspected neurodevelopmental dysfunction in the gross motor skill, fine motor skill, cognition, language, sociality, and self-care domains of the Korean Developmental Screening Test for Infants and Children at age 6 years. The positive control outcome was defined as attention deficit hyperactive disorder (ADHD). The associations were assessed using ordinal logistic regression, adjusting for asthma and allergic rhinitis.

RESULTS

Among the eligible children, 89,452 and 30,557 were allocated to the control and AD groups, respectively. In the weighted data, the AD group showed a higher risk of suspected neurodevelopmental dysfunction in the total score (weighted adjusted odds ratio [95% CI] 1.10 [1.05-1.16]), gross motor skills (1.14 [1.04-1.25]), and fine motor skills (1.15 [1.06-1.25]) than the control group. The AD with steroids or hospitalization groups showed an increased risk of suspected neurodevelopmental dysfunction. In addition, the AD group showed a significant association with mental retardation, psychological development disorder, and behavioral and emotional disorders as well as ADHD.

CONCLUSIONS

AD before age 2 years may be associated with an increased risk of neurodevelopmental dysfunction including gross and fine motor skills in the young childhood period.

Rates of cardiovascular events among patients with moderate-to-severe atopic dermatitis in an integrated health care system: A retrospective cohort study

Patients with versus without atopic dermatitis may have a greater risk of cardiovascular events, and the risk increases with severity of atopic dermatitis. The incidence of cardiovascular events in the population of patients with moderate-to-severe atopic dermatitis is largely unknown. This retrospective study evaluates incidence rates of cardiovascular events in patients aged ≥12 years with moderate-to-severe atopic dermatitis in a cohort of Kaiser Permanente Northern California health care system members without recognized risk factors for adverse events. Patients with moderate-to-severe atopic dermatitis, as defined by dermatologist-rendered code and prescription history between 2007 and 2018, were included. Major adverse cardiovascular events, venous thrombotic events, deep vein thrombosis, and pulmonary embolisms were identified via International Classification of Diseases codes. Stratification variables included age, sex, race, smoking history, and diabetes. Incidence rates per 1000 person-years were calculated by the number of patients with an incident event divided by the total person-years of observation. Among 8197 patients with moderate-to-severe atopic dermatitis, incidence rates per 1000 person-years (95% confidence interval) for major adverse cardiovascular events, venous thrombotic events, deep vein thrombosis, and pulmonary embolism were: 2.6 (2.1-3.2), 2.0 (1.5-2.5), 1.6 (1.2-2.1), and 0.7 (0.5-1.0), respectively. Incidence rates for all events were higher for older versus younger patients, patients with versus without diabetes, former smokers versus patients who had never smoked, and men versus women, except for pulmonary embolisms, which were higher in women. This study estimated the incidence of cardiovascular events in patients with moderate-to-severe atopic dermatitis and provides valuable information for clinicians.

Involvement of Atopic Dermatitis in the Development of Systemic Inflammatory Diseases

The skin is recognized as a peripheral lymphoid organ that plays an essential defensive action against external environmental stimuli. However, continuous stimulation of these factors causes chronic inflammation at the local site and occasionally causes tissue damage. Chronic inflammation is recognized as a trigger for systemic organ inflammation. Atopic dermatitis (AD) is a chronic inflammatory skin disease that is influenced by various external environmental factors, such as dry conditions, chemical exposure, and microorganisms. The pathogenesis of AD involves various Th2 and proinflammatory cytokines. Recently updated studies have shown that atopic skin-derived cytokines influence systemic organ function and oncogenesis. In this review, we focus on AD’s influence on the development of systemic inflammatory diseases and malignancies.

Investigating the association of atopic dermatitis with ischemic stroke and coronary heart disease: A mendelian randomization study

Background: Atopic dermatitis (AD) is the most common chronic skin inflammatory disease. Prior observational studies have reported inconsistent results on the association of AD with ischemic stroke and coronary heart disease. In this study, we applied two-sample Mendelian randomization (MR) to evaluate the causal effect of AD on ischemic stroke and coronary heart disease.

Methods: Twelve single-nucleotide polymorphisms robustly associated with AD (p < 5 × 10^–8) were obtained from a genome-wide association study that included 10,788 cases and 30,047 controls by the EArly Genetics and Life course Epidemiology (EAGLE) Consortium (excluding the 23andMe study). The corresponding data for ischemic stroke (34,217 cases and 406,111 controls), large artery stroke (4,373 cases and 406,111 controls), cardioembolic stroke (7,193 cases and 406,111 controls), small vessel stroke (5,386 cases and 192,662 controls), coronary heart disease (122,733 cases and 424,528 controls), and myocardial infarction (43,676 cases and 128,199 controls) were obtained from the MR-Base platform. In the primary MR analyses, we applied the inverse variance weighted method to evaluate the associations. We performed a sensitivity analysis using weighted median, MR-Egger, weighted mode, simple mode, Mendelian Pleiotropy RESidual Sum and Outlier (MR-PRESSO), and leave-one-out methods.

Results: In the primary MR analyses, we found no causal association of genetically predicted AD with ischemic stroke [odds ratio (OR) = 1.00, 95% confidence interval (CI): 0.95–1.06], large artery stroke (OR = 1.02, 95% CI: 0.88–1.17), cardioembolic stroke (OR = 1.06, 95% CI: 0.94–1.18), small vessel stroke (OR = 1.05, 95% CI: 0.94–1.17), coronary heart disease (OR = 1.00, 95% CI: 0.94–1.05), and myocardial infarction (OR = 1.03, 95% CI: 0.98–1.09). The results from the primary MR analyses were supported in sensitivity analyses using the weighted median, weighted mode, simple mode, and MR-Egger methods and multivariable MR analyses adjusting for asthma and several traditional risk factors for ischemic stroke and coronary heart disease. MR-Egger intercepts provided no evidence of directional pleiotropy. The MR-PRESSO and leave-one-out analyses did not indicate any outlier instruments.

Conclusion: Our MR study does not support a causal association of genetically predicted AD with ischemic stroke, large artery stroke, cardioembolic stroke, small vessel stroke, coronary heart disease, and myocardial infarction.

Skin Dialogues in Atopic Dermatitis

Atopic dermatitis (AD) is a chronic skin disorder associated with significant quality-of-life impairment and increased risk for allergic and non-allergic comorbidities. The aim of this review is to elucidate the connection between AD and most common comorbidities, as this requires a holistic and multidisciplinary approach. Advances in understanding these associations could lead to the development of highly effective and targeted treatments.

Assessing Causal Associations of Atopic Dermatitis With Heart Failure and Other Cardiovascular Outcomes: A Mendelian Randomization Study

Background and Aims

Observational epidemiological studies have suggested that atopic dermatitis (AD) was associated with an increased risk of cardiovascular diseases (CVDs). However, causality remains to be established. In the present study, Mendelian randomization (MR) analyses were used to evaluate whether AD and CVDs are causally associated.

Methods

This study was based on summary statistics of genome-wide association studies (GWASs) for a set of cardiovascular outcomes including heart failure (HF), coronary artery disease (CAD), myocardial infarction (MI), atrial fibrillation (AF), stroke, and stroke subtypes. A total of 19 independent single nucleotide polymorphisms associated with AD were identified at a genome-wide significance threshold (P < 5 × 10^-8) based on a large GWAS meta-analysis. MR estimates were pooled using the inverse variance weighted method. Complementary analyses further evaluated the robustness of the results.

Results

Genetically determined AD was causally associated with HF [odds ratio (OR), 1.07; 95% confidence interval (CI), 1.03-1.10; P = 1.11 × 10^-4]. However, there was no causal association between AD and the risk of AF, CAD, MI, stroke, and stroke subtypes. Complementary analyses returned similar results. No horizontal pleiotropy was found.

Conclusion

This MR study provided evidence to support that AD exerted an effect contributing to HF. No significant associations were found for other cardiovascular outcomes. The study suggested that prevention and early diagnosis of AD may help prevent HF. Improved awareness of these associations is warranted for better management of CVDs in the future.

Vascular inflammation in moderate-to-severe atopic dermatitis is associated with enhanced Th2 response

BACKGROUND

In atopic dermatitis (AD), some studies have shown an association with increased cardiovascular disease in certain populations. However, other investigations found modest or no association. Despite conflicting results, molecular profiling studies in both AD skin and blood have demonstrated upregulation of atherosclerosis and cardiovascular risk-related markers. However, the underlying mechanisms connecting AD to vascular inflammation/atherosclerosis are unknown. In this study, we aim to determine factors associated with vascular inflammation/atherosclerosis in AD patients.

METHODS

We used 18-FDG PET-CT to characterize vascular inflammation in AD patients and healthy subjects. In parallel, we assessed their skin and blood immune profiles to determine AD-related immune biomarkers associated with vascular inflammation. We also assessed levels of circulating microparticles, which are known to be associated with increased cardiovascular risk.

RESULTS

We found significant correlations between vascular inflammation and Th2-related products in skin and blood of AD patients as well as atherosclerosis-related markers that were modulated by dupilumab. Circulating levels of endothelial microparticles were significantly higher in severe AD patients and tended to correlate with vascular inflammation assessed by PET-CT.

CONCLUSION

Vascular inflammation in AD is associated with enhanced Th2 response and clinical severity, which may explain cardiovascular comorbidities observed in select AD populations. Larger prospective studies are needed to further evaluate vascular inflammation and cardiovascular events and mortality in AD patients. Finally, as dupilumab treatment demonstrated significant modulation of atherosclerosis-related genes in AD patients compared to placebo, these data suggest that modulation of vascular inflammation with systemic treatment should be explored in patients with AD.

Cardiovascular comorbidities of atopic dermatitis: using National Health Insurance data in Korea

Background

It is well known that atopic dermatitis (AD) is associated with other allergic diseases. Recentely, links to diseases other than allergic disease have also been actively studied. Among them, the results of studies regarding AD comorbidities, especially cardiovascular disease (CVD), have varied from country to country.

Objective

To analyze whether the risk of CVD is different between AD patients and healthy controls using Korean National Health Insurance Data.

Methods

We obtained data from 2005 to 2016 from the Korean National Health Insurance Research Database. Patients with one AD code and two AD-related tests codes were selected as AD patients, and age-and sex-matched controls to the AD patients were selected from among those without AD (1:5). Each group was investigated for accompanying metabolic syndrome (which contains hypertension, type 2 diabetes, and hyperlipidemia) and CVD (angina, myocardial infarction, peripheral vascular disease, and stroke) using ICD 10 codes.

Results

The incidence of metabolic diseases and CVD were significantly different between the AD and control groups. Using multivariable Cox regression, differences were adjusted for sex, age, and other CVD and metabolic diseases. As a result, not only metabolic disease, but also the CVD risk of AD patients was significantly higher than that of the control group. Patients with AD had as significantly higher risk of hyperlipidemia (hazard ratio [HR] = 33.02, p < 0.001), hypertension (HR = 4.86, p < 0.001), and type 2 diabetes (HR = 2.96, p < 0.001). AD patients also had a higher risk of stroke (HR = 10.61, p < 0.001), myocardial infarction (HR = 9.43, p < 0.001), angina (HR = 5.99, p < 0.001), and peripheral vascular disease (HR = 2.46, p < 0.001). Besides hyperlipidemia, there was no difference in risk according to AD severity.

Conclusion

Patients with AD have a greater risk of CVD than those without AD.

The Use of Real-World Data to Evaluate the Association Between Atopic Dermatitis and Cardiovascular Disease: A Retrospective Claims Analysis

INTRODUCTION

Atopic dermatitis (AD) is a systemic inflammatory condition that may increase the risk of cardiovascular disease (CVD); however, ongoing debate exists surrounding its direct association. We aimed to elucidate whether AD contributes to a higher incidence of CVD and major adverse cardiovascular events (MACE) in adult patients with AD, independent of metabolic disorders.

METHODS

We retrospectively analyzed a large US-based population of patients with AD (≥ 18 years of age). Logistic regression estimated the risk of CVD and MACE in adult patients with AD, independent of metabolic disorders (including diabetes, hypertension, and obesity).

RESULTS

The odds ratio (OR; 95% confidence interval [CI]) for patients without metabolic disorders was 1.25 (1.13, 1.39) for CVD and 1.22 (1.01, 1.47) for MACE. The OR (95% CI) for AD patients with metabolic disorders was 1.09 (1.07, 1.12) for CVD and 1.14 (1.09, 1.18) for MACE. This trend was even more pronounced after long-term follow-up (≥ 3 years). Lifestyle and health behavioral factors of the subjects were not available in the dataset. The lack of control for these factors could potentially confound our results.

CONCLUSIONS

Atopic dermatitis may contribute to the risk of developing CVD and MACE in adults, independent of metabolic disorders.

High-Density Lipoprotein (HDL) in Allergy and Skin Diseases: Focus on Immunomodulating Functions

From an evolutionary perspective, lipoproteins are not only lipid transporters, but they also have important functions in many aspects of immunity. High-density lipoprotein (HDL) particles are the most abundant lipoproteins and the most heterogeneous in terms of their composition, structure, and biological functions. Despite strong evidence that HDL potently influences the activity of several immune cells, the role of HDL in allergies and skin diseases is poorly understood. Alterations in HDL-cholesterol levels have been observed in allergic asthma, allergic rhinitis, atopic dermatitis (eczema), psoriasis, urticaria, and angioedema. HDL-associated apolipoprotein (apo) A-I, apoA-IV, and apoC-III, and lyso-phosphatidylcholines potently suppress immune cell effector responses. Interestingly, recent studies provided evidence that allergies and skin diseases significantly affect HDL composition, metabolism, and function, which, in turn, could have a significant impact on disease progression, but may also affect the risk of cardiovascular disease and infections. Interestingly, not only a loss in function, but also, sometimes, a gain in function of certain HDL properties is observed. The objective of this review article is to summarize the newly identified changes in the metabolism, composition, and function of HDL in allergies and skin diseases. We aim to highlight the possible pathophysiological consequences with a focus on HDL-mediated immunomodulatory activities.

A Preliminary 18F-FDG-PET/MRI Study Shows Increased Vascular Inflammation in Moderate-to-Severe Atopic Dermatitis

BACKGROUND

Recent data suggest that patients with atopic dermatitis (AD) have increased systemic immune activation and cardiovascular risk. However, unlike psoriasis, evaluation of active vascular inflammation using state-of-the-art imaging is lacking in AD.

OBJECTIVE

To assess aortic and carotid vascular inflammation using ¹⁸F-fluorodeoxyglucose-positron emission tomography/magnetic resonance imaging (¹⁸F-FDG-PET/MRI) imaging in moderate-to-severe AD versus healthy individuals.

METHODS

A total of 27 patients with moderate-to-severe AD and 12 healthy controls were imaged using ¹⁸F-FDG-PET/MRI. Target-to-background ratio (TBR) values were calculated in multiple segments of the aorta and carotid vessels.

RESULTS

Patients with AD had elevated aortic max TBR (fold change [FCH] = 1.45, P = .057) versus healthy controls and significantly elevated mean TBR (FCH = 1.20; P < .05) in the right carotid (RC) arteries versus controls. When examining greatest focal inflammation (most diseased segment [MDS] TBR), patients with AD had higher aortic inflammation (FCH = 1.28; P = .052). AD clinical severity significantly correlated with C-reactive protein (ρ = 0.60, P < .01) and with RC mean TBR levels (ρ = 0.60, P = .04). Stratifying patients into moderate-to-severe and very severe AD showed greater RC mean TBR in patients with very severe AD versus controls (FCH = 1.31; P = .02) and versus patients with moderate/severe AD (FCH = 1.23, P = .05). Aortic inflammation was also significantly greater in patients with very severe AD versus controls (max TBR: FCH = 1.6, P = .04; MDS TBR: FCH = 1.73, P = .03).

CONCLUSIONS

This preliminary study is the first that establishes greater vascular (aorta and carotid) inflammation in moderate-to-severe AD versus healthy controls. Furthermore, very severe AD showed higher inflammation than both moderate/severe patients and healthy controls. Future studies with larger patient cohorts and evaluation before and after treatment are needed to determine the extent to which vascular inflammation in AD is modifiable.

Histoire naturelle de la dermatite atopique

Atopic dermatitis (AD) is a common frequent chronic inflammatory skin disease which begins frequently in infancy. The clinical expression of AD is a recurrent eczema on a dry skin. AD is a multifactorial disease characterized by two linked abnormalities: a skin barrier defect and a cellular inflammation, with type-2 main components. However, the pathophysiology of AD is not as simple as this description looks like. In this review, we will present a synthesis of current knowledge on natural history of AD and the involved factors, in order to clarify AD care. The evolution of AD is associated with many atopic comorbidities, following the "atopic march" scheme: IgE-mediated food allergy, allergic asthma and rhinitis occurring classically after AD. In fact, this is rarely the case, but the atopic march seems to be associated with AD severity. AD has also many neuropsychological complications which are essential to be detected. Other factors could influence the natural history of AD: genetic mutations on different genes (proteins of skin barrier, innate and adaptive immunity pathways), skin dysbiosis with colonization by Staphylococcus aureus, sensitization against environmental proteins. AD treatment is based on the restauration of the skin barrier using emollients and on anti-inflammatory drugs (notably topical corticosteroids) during the inflammatory flares. It is not recommended to treat the skin colonization by S. aureus, excepted in case of skin infection. The probiotics have no efficiency as curative treatment of AD, but could have an interest for the primary prevention, especially in at-risk populations. © 2019 Elsevier Masson SAS. All rights reserved.

Prevalence of baseline comorbidities in patients with atopic dermatitis: A population-based cohort study in Taiwan

BACKGROUND

Atopic dermatitis has been linked to increased risk of many comorbidities. However, the risks of certain comorbidities are still debated.

OBJECTIVE

To better characterize the basic demographics, treatment patterns, and associations between atopic dermatitis and comorbidities and to further investigate the influence of severity on comorbidities.

METHODS

We used a sample cohort of 999,992 people from the National Health Insurance Research Database of Taiwan to evaluate atopic dermatitis in the general population.

RESULTS

A total of 12,780 patients with atopic dermatitis in 2010 were identified. The prevalence was 1.28%. The proportions of severe and moderate cases were 7.43% and 19.26%, respectively. The most commonly used systemic treatment was corticosteroids. Compared with the general population, atopic dermatitis patients showed increased risks of all 9 groups of comorbidities, including autoimmune disorders, atopic disorders, chronic urticaria, ocular disorders, metabolic disorders, hypertensive disorders, ischemic heart disorders, cerebrovascular disorders, and psychiatric disorders. The severity and persistence of atopic dermatitis were correlated with the development of certain comorbidities.

LIMITATIONS

Miscoding and misclassification might have occurred, and only patients with active disease were enrolled.

CONCLUSION

Patients with atopic dermatitis have higher risks of various comorbidities. Comprehensive monitoring and treatment plans are needed to better manage these patients.

Comorbidities in Atopic Dermatitis: An Update and Review of Controversies

Early onset of atopic dermatitis is considered a risk factor for any atopic disease, especially when the skin manifestations are persistent, and there is sensitization to multiple allergens and a family history. Atopic dermatitis is also thought to exert a synergistic effect with inflammation present in other organs and systems, as is the case in other immune-mediated inflammatory diseases. Most studies show a statistical relationship between obesity, various cardiometabolic comorbid conditions, and atopic dermatitis; this relationship is more marked when the disease is more severe or active over a longer period of time. However, other than epidemiological assessments, few studies provide in-depth evidence of functional mechanisms. Furthermore, various confounders, such as deterioration of quality of life and the psychological aspects of atopic dermatitis, could favor unhealthy habits, including a sedentary lifestyle and smoking, which could in turn increase the risk of morbidity and mortality. Chronic inflammation with differentiation toward a type 2 helper T cell pattern and the long-term use of immunosuppressants could be risk factors for some hematologic diseases, although they could exert a protective effect in others. The presence of proinflammatory cytokines capable of crossing the blood-brain barrier could favor an increase in the frequency of psychological diseases (eg, depression, anxiety, and suicidal ideation) and attention disorders (eg, attention deficit or hyperactivity). However, other factors, such as chronic pruritus and sleep disorders, could also play roles.

Approach to the Assessment and Management of Pediatric Patients with Atopic Dermatitis: A Consensus Document. Section II: Comorbid Disease in Pediatric Atopic Dermatitis

Pediatric atopic dermatitis (AD) is one of the most common skin conditions encountered by health-care providers caring for infants, children, and adolescents. Pediatric patients with AD may present with other allergic and nonallergic comorbidities that require appropriate treatment and referral. They may also experience a trajectory of allergic diseases known as the atopic march, which depends on a complex interaction between genetic and environmental factors and likely involves early epidermal barrier dysfunction. Here we provide a review and clinical recommendations on the assessment and referral of comorbidities in pediatric AD.

[Atopic dermatitis and general medical comorbidities]

Atopic dermatitis (AD) is one of the most frequent chronic inflammatory skin diseases, characterized by pruritic eczematous lesions. Due to the fact that AD is accompanied by signs of systemic inflammation and that an increased number of novel systemic treatment options are currently emerging, research into general medical comorbidities in moderately to severely affected AD patients has received great impetus in recent years. These studies have confirmed an increased risk of atopic diseases such as allergic asthma in AD patients. Furthermore, an association between AD and dermatological diseases with autoimmune pathophysiology such as vitiligo and alopecia areata has been demonstrated. Moreover, several studies have revealed an increased risk for internal autoimmune diseases in AD patients, e.g. inflammatory bowel disease and rheumatoid arthritis. A differentiated view of the data on AD as a possible risk factor for cardiovascular disease is needed. Large cross-sectional studies in the US revealed a correlation between AD and cardiovascular comorbidities. This has not been confirmed as yet in large German, Danish and Canadian investigations. Whether diverse "coping" strategies in different countries can explain these variances remains to be discussed. In terms of microbial comorbidities, AD patients display a particular susceptibility to viral infections.

Atopic eczema and major cardiovascular outcomes: A systematic review and meta-analysis of population-based studies

BACKGROUND

Atopic eczema is a common inflammatory skin disease. Various inflammatory conditions have been linked to cardiovascular disease, a major cause of global mortality and morbidity.

OBJECTIVE

We sought to systematically review and meta-analyze population-based studies assessing associations between atopic eczema and specific cardiovascular outcomes.

METHODS

MEDLINE, Embase, and Global Health were searched from inception to December 2017. We obtained pooled estimates using random-effects meta-analyses. We used a multivariate Bayesian meta-regression model to estimate the slope of effect of increasing atopic eczema severity on cardiovascular outcomes.

RESULTS

Nineteen relevant studies were included. The effects of atopic eczema reported in cross-sectional studies were heterogeneous, with no evidence for pooled associations with angina, myocardial infarction, heart failure, or stroke. In cohort studies atopic eczema was associated with increased risk of myocardial infarction (n = 4; relative risk [RR], 1.12; 95% CI, 1.00-1.25), stroke (n = 4; RR, 1.10; 95% CI, 1.03-1.17), ischemic stroke n = 4; RR, 1.17; 95% CI, 1.14-1.20), angina (n = 2; RR, 1.18; 95% CI, 1.13-1.24), and heart failure (n = 2; RR, 1.26; 95% CI, 1.05-1.51). Prediction intervals were wide for myocardial infarction and stroke. The risk of cardiovascular outcomes appeared to increase with increasing severity (mean RR increase between severity categories, 1.15; 95% credibility interval, 1.09-1.21; uncertainty interval, 1.04-1.28).

CONCLUSION

Significant associations with cardiovascular outcomes were more common in cohort studies but with considerable between-study heterogeneity. Increasing atopic eczema severity was associated with increased risk of cardiovascular outcomes. Improved awareness among stakeholders regarding this small but significant association is warranted.

Diagnosis validation and clinical characterization of atopic dermatitis in Nurses' Health Study 2

BACKGROUND

Epidemiologic studies of atopic dermatitis (AD) are often limited by case definitions that have not been validated.

OBJECTIVE

In this study, we assessed the accuracy of self-report of AD in a large cohort of US female nurses, the Nurses' Health Study 2 (NHS2). We also provide clinical characteristics of AD in the cohort.

METHODS

We sent an electronic questionnaire to NHS2 participants who previously reported ever having a diagnosis of AD. This questionnaire was designed to confirm cases of AD using previously validated algorithms with >85% specificity. We assessed the association of AD with asthma, comparing the results when different definitions of AD were applied. We also inquired about various aspects of participants' AD.

RESULTS

Responses were received from 2509 of 5126 (49%) nurses who were sent the questionnaire, with an average age of 62. Most participants (1996/2509, 80%) reiterated their previously reported clinician diagnosis of AD. Application of the two diagnostic algorithms yielded confirmation of 1538 and 1293 prevalent cases, respectively. The association of AD with asthma was stronger when more stringent AD case definitions were applied. Participants generally reported mild disease (92% with ≤10% maximal body surface area involved) and a high proportion (57%) reported adult-onset disease.

CONCLUSIONS

Self-report of AD diagnosis has good reliability, and future analyses will be strengthened by our ability to conduct sensitivity analyses with refined confirmed AD subgroups.

Self-Reported Eczema in Relation with Mortality from Cardiovascular Disease in Japanese: the Japan Collaborative Cohort Study

Aim: Previous studies suggested a positive association between eczema and cardiovascular disease (CVD), probably through enhanced systemic inflammation. However, several studies reported null findings about eczema and CVD, so the evidence is still controversial.

Methods: We asked 85,099 participants (35,489 men and 49,610 women), aged 40 to 79 years, without a history of CVD or cancer at baseline between 1988 and 1990, to complete a lifestyle questionnaire, including information eczema frequency (seldom, sometimes or often).

Results: During the 6,389,818 person-years of follow-up, there were 1,174 deaths from coronary heart disease (CHD), 979 from heart failure, 366 from cardiac arrhythmia, 2,454 from total stroke, 1,357 from ischemic stroke, 1,013 from hemorrhagic stroke, and 201 from aortic aneurysm or dissection. The multivariable-adjusted model showed that individuals who “sometimes” or “often” had eczema had 0.82 (95%confidence interval (CI): 0.69–0.97) or 1.26 (95%CI: 1.01–1.56) times the risk of mortality from CHD, respectively, compared to those who “seldom” did. Individuals who “often” had 1.30 (95%CI: 1.05–1.61) times the risk of mortality from CHD, compared to those who “seldom or sometimes” did. There was no association of eczema with mortality from other CVD, or no interaction between eczema and sex or age, in relation to any CVD mortality risk.

Conclusions: Self-reported frequent eczema was associated with increased risk of mortality from CHD, but not other major CVD, in a Japanese general population. Since steroid usage was not considered, future studies should include it as a potential confounding factor.

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

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

Relationship of atopic dermatitis with stroke and myocardial infarction: A meta-analysis

BACKGROUND

Lots of previous reports have suggested a potential association of atopic dermatitis (AD) with stroke and myocardial infarction (MI). However, the result is still controversial, Consequently, we conducted this meta-analysis to estimate the relationship of AD with Stroke and MI.

METHODS

PubMed, Embase, and Web of Science databases were searched from inception to June 2018. Stroke and MI were considered as a composite endpoint. We calculated pooled hazard ratios (HRs) with 95% confidence intervals (CIs). Subgroup and sensitivity analysis were performed to assess the potential sources of heterogeneity of the pooled estimation.

RESULTS

A total of 12 articles with 15 studies involving 3,701,199 participants were included in this meta-analysis. Of these, 14 studies on stroke and 12 on MI. Pooled analysis showed participants with AD experienced a significant increased risk of stroke (combined HR, 1.15; 95% CI, 1.08-1.22; P = .000) and MI (combined HR, 1.13; 95% CI, 1.02-1.24; P = .014), compared with participants without AD. The risk of stroke and MI was significant both in male subjects (stroke: HR: 1.33, 95% CI: 1.14-1.56; MI: HR: 2.01, 95% CI: 1.31-3.08), but not in female subjects (HR: 1.02, 95% CI: 0.77-1.35; MI: HR: 0.98, 95% CI: 0.72-1.32). The results were more pronounced for ischemic stroke (HR: 1.16, 95% CI: 1.13-1.19) in the stratified with stroke type. Stratifying by AD type, the risk of stroke was significant in severe AD (HR: 1.29, 95% CI: 1.08-1.54) and moderate AD (HR: 1.11, 95% CI: 1.01-1.22) for MI.

CONCLUSIONS

AD is independently associated with an increased risk of stroke and MI, especially in male subjects and ischemic stroke and the risk is associated with the severity of AD.

Major Comorbidities of Atopic Dermatitis: Beyond Allergic Disorders

The consequences of atopic dermatitis reach beyond the skin and past childhood. Patients with atopic dermatitis are at risk of developing allergic comorbidities, but less is known about the associations between atopic dermatitis and non-allergic conditions. Understanding these non-allergic comorbidities has the potential to improve patient outcomes and to help mitigate the cost and burdens associated with these conditions. Atopic dermatitis is associated with cutaneous bacterial infections, more severe forms/courses of cutaneous viral infections, and extra-cutaneous infections. Atopic dermatitis is also associated with several mental health comorbidities particularly attention-deficit hyperactivity disorder, anxiety, and depression. Data are largely inconsistent for specific cancers, but atopic dermatitis appears to protect against malignancy overall; severe long-term atopic dermatitis is associated with adult lymphomas. Atopic dermatitis may also be associated with obesity, cardiovascular disease, and autoimmune disease, particularly alopecia areata and gastrointestinal immune-mediated disorders. Although the causative mechanisms underlying these associations are poorly understood, treating physicians should be aware of associations in seeking to alleviate the burden for patients with atopic dermatitis.

Association of atopic dermatitis with allergic, autoimmune, and cardiovascular comorbidities in US adults

BACKGROUND

Atopic dermatitis (AD) has been associated with multiple comorbid extracutaneous and systemic disorders. The relation between AD severity and disease comorbidities is complex and not fully understood.

OBJECTIVE

To determine the complex relation between AD severity and comorbidities.

METHODS

A cross-sectional US population-based study of 8,217 adults who were participants in a nationally representative internet health panel was performed using a structured questionnaire. A diagnosis of AD was determined using modified United Kingdom Working Party Criteria for AD (n = 602). AD severity was assessed using Patient-Oriented Scoring AD, Patient-Oriented Eczema Measure, Dermatology Life Quality Index, and self-reported global AD severity. Logistic regression and structural equation models were used to explore associations of AD with self-reported allergic, cardiometabolic, anxiety and depression, and autoimmune disease.

RESULTS

In multivariable regression models controlling for sociodemographics, AD was associated with higher odds of asthma (adjusted odds ratio [OR] 2.09, 95% confidence interval [CI] 1.71-2.55), hay fever (OR 4.31, 95% CI 3.27-5.69), food allergy (OR 2.07, 95% CI 1.54-2.77), anxiety and depression (OR 2.34, 95% CI 1.91-2.87), autoimmune disease (OR 3.05, 95% CI 2.31-4.03), obesity (OR 1.37, 95% CI 1.13-1.67), diabetes (OR 1.52, 95% CI 1.16-1.99), high blood pressure (OR 1.46, 95% CI 1.18-1.80), and heart disease (OR 1.94, 95% CI 1.40-2.70) compared with controls (P < .01 for all). All these associations were significant in mild and/or moderate disease, with even stronger effects in severe AD. Results of structural equation models showed direct effects of moderate to severe AD on food allergy, anxiety and depression, and diabetes, direct and indirect effects on obesity, and indirect effects on high blood pressure and heart disease.

CONCLUSION

There is a strong relation of AD severity to allergic, autoimmune, and cardiovascular comorbidities.

Atopic diseases/diathesis and subsequent ischemic stroke among patients with bipolar disorder: A nationwide longitudinal study

INTRODUCTION

Previous studies have suggested that both bipolar disorder and atopy are associated with an increased risk of stroke. However, the role of atopic diseases/diathesis in the risk of stroke among patients with bipolar disorder remains unclear.

METHODS

Using Taiwan's National Health Insurance Research Database, we selected 55,593 patients with bipolar disorder between 2002 and 2008, divided them into patients with atopic diseases/diathesis (n = 21,050) and patients without atopic diseases/diathesis (n = 34,543), and observed them until the end of 2011. Patients who experienced a stroke during the follow-up period were identified.

RESULTS

Patients with bipolar disorder and atopic diseases/diathesis had an elevated risk of ischemic stroke (hazard ratio [HR]: 1.44, 95% confidence interval [CI]: 1.25-1.59) compared with patients with only bipolar disorder; a dose-dependent relationship was observed between the number of allergic comorbidities and the risk of ischemic stroke (1 atopic disease, HR: 1.30, 95% CI: 1.13-1.49; 2 atopic diseases, HR: 1.59, 95% CI: 1.33-1.91; ≥ 3 atopic diseases, HR: 2.09, 95% CI: 1.50-2.91).The role of atopic diseases in the risk of hemorrhagic stroke among patients with bipolar disorder was nonsignificant (HR: 0.84, 95% CI: 0.64-1.09).

CONCLUSIONS

Patients with bipolar disorder and atopic diseases/diathesis are more prone to ischemic stroke later in life than are those without atopic diseases/diathesis. Further study is required to investigate the underlying mechanism linking atopy, bipolar disorder, and stroke.

Severe and predominantly active atopic eczema in adulthood and long term risk of cardiovascular disease: population based cohort study

OBJECTIVE

To investigate whether adults with atopic eczema are at an increased risk of cardiovascular disease and whether the risk varies by atopic eczema severity and condition activity over time.

DESIGN

Population based matched cohort study.

SETTING

UK electronic health records from the Clinical Practice Research Datalink, Hospital Episode Statistics, and data from the Office for National Statistics, 1998-2015.

PARTICIPANTS

Adults with a diagnosis of atopic eczema, matched (on age, sex, general practice, and calendar time) to up to five patients without atopic eczema.

MAIN OUTCOME MEASURES

Cardiovascular outcomes (myocardial infarction, unstable angina, heart failure, atrial fibrillation, stroke, and cardiovascular death).

RESULTS

387 439 patients with atopic eczema were matched to 1 528 477 patients without atopic eczema. The median age was 43 at cohort entry and 66% were female. Median follow-up was 5.1 years. Evidence of a 10% to 20% increased hazard for the non-fatal primary outcomes for patients with atopic eczema was found by using Cox regression stratified by matched set. There was a strong dose-response relation with severity of atopic eczema. Patients with severe atopic eczema had a 20% increase in the risk of stroke (hazard ratio 1.22, 99% confidence interval 1.01 to 1.48), 40% to 50% increase in the risk of myocardial infarction, unstable angina, atrial fibrillation, and cardiovascular death, and 70% increase in the risk of heart failure (hazard ratio 1.69, 99% confidence interval 1.38 to 2.06). Patients with the most active atopic eczema (active >50% of follow-up) were also at a greater risk of cardiovascular outcomes. Additional adjustment for cardiovascular risk factors as potential mediators partially attenuated the point estimates, though associations persisted for severe atopic eczema.

CONCLUSIONS

Severe and predominantly active atopic eczema are associated with an increased risk of cardiovascular outcomes. Targeting cardiovascular disease prevention strategies among these patients should be considered.

The association with cardiovascular disease and type 2 diabetes in adults with atopic dermatitis: a systematic review and meta-analysis

BACKGROUND

Recent studies examining the association between atopic dermatitis (AD) and cardiovascular disease (CVD) and type 2 diabetes have shown inconsistent results.

OBJECTIVES

To carry out a systematic review and meta-analysis that examines the association with cardiovascular disease and type 2 diabetes in adults with AD.

METHODS

We compared the risk of CVD and diabetes for adult patients with and without AD by searching the PubMed, Embase and Web of Science databases. Data extraction was carried out by two independent reviewers. We found a total of 2855 citations, of which 53 were considered relevant based on title and abstract. Overall, 16 publications were included in the qualitative analysis, of which 13 were also included in a quantitative meta-analysis of crude data.

RESULTS

No association was observed between AD and unspecified but suspected type 2 diabetes [pooled odds ratio (OR) 1·11; 95% confidence interval (CI) 0·87-1·42], hypertension (pooled OR 1·16; 95% CI 0·98-1·37), stroke (pooled OR 1·15; 95% CI 0·95-1·39) or myocardial infarction (pooled OR 1·14; 95% CI 0·83-1·56), but a positive association was observed with angina pectoris (OR 1·73; 95% CI 1·27-2·37). Meta-analysis of adjusted data gave similar results.

CONCLUSIONS

While adults with AD in some populations have an increased prevalence of cardiovascular risk factors, such as obesity and smoking, it is unlikely that AD represents an independent and clinically relevant risk factor for cardiometabolic disease.

Associations between atopic dermatitis and other disorders

Atopic dermatitis is a heterogeneous, chronic, and inflammatory skin disease that is associated with a profound symptom burden. Recent studies have demonstrated associations between atopic dermatitis and a number of multi-organ and systemic disorders. The origin of these comorbid conditions is likely multifactorial, with combined effects of skin-barrier disruption, immune dysregulation, intense symptoms, and iatrogenic complications. Some of these comorbid conditions appear to be related to the underlying severity of atopic dermatitis and inadequate disease control. This review will summarize recent developments in the understanding of the comorbid health disorders associated with atopic dermatitis, particularly infections, sleep disturbances, and cardiovascular disease.

Cause-specific mortality in adults with atopic dermatitis

BACKGROUND

Adult atopic dermatitis (AD) has been associated with several comorbidities, but cause-specific mortality risk is unknown.

OBJECTIVE

To examine cause-specific death rates and risk in adults with AD.

METHODS

We performed cross-linkage of nationwide health care and cause of death registers. Adult patients with AD were matched with 10 controls per study subject. We calculated incidence rates per 1000 person-years and hazard ratios (HRs) of cause-specific death with 95% confidence intervals (95% CIs) using Cox proportional hazards models.

RESULTS

A total of 8686 patients and 86,860 matched controls were studied. The risk for death due to any cause was significantly increased in patients with AD (HR 1.27, 95%CI 1.11-1.45). Significant causes included cardiovascular (HR 1.45; 95% CI 1.07-1.96), infectious (HR 3.71; 95% CI 1.43-9.60), and urogenital diseases (HR 5.51; 95% CI 1.54-19.80). No increased risk for death due to cancer, endocrine, neurologic, psychiatric, respiratory, or gastroenterologic disease was observed.

LIMITATIONS

The results might not be generalizable to patients seen exclusively by primary care physicians.

CONCLUSION

Adults with atopic dermatitis had slightly increased risk for death during follow-up. While the risk for death from cardiovascular, urogenital, and infectious diseases was slightly elevated among patients with AD, the absolute risk was very low.

Association between eczema and major cardiovascular outcomes in population-based studies: a systematic review protocol

INTRODUCTION

Chronic inflammatory diseases such as eczema (also known as atopic dermatitis) have been inconsistently linked to cardiovascular disease and stroke in both mechanistic and epidemiological studies. There is a need to review the existing epidemiological data examining the association between eczema and major cardiovascular outcomes, including angina, myocardial infarction, coronary revascularisation, heart failure, cardiac arrhythmias, stroke and cardiovascular death, in order to improve our understanding of the comorbidities of eczema.

METHODS AND ANALYSIS

We will systematically review population-based studies, including cohort, case-control and cross-sectional studies, reporting on the association between eczema and cardiovascular outcomes. We will search Medline, Embase and Global Health, from their date of inception to April 2017, using a comprehensive search strategy formulated with the help of a librarian. Two reviewers will independently screen titles and abstracts in duplicate, followed by independent data extraction and quality assessment. We will group studies by the cardiovascular outcome under study and synthesise them narratively. If sufficient numbers of homogeneous studies are returned, we will perform meta-analyses to obtain pooled effect estimates. Preferred Reporting Items for Systematic Review and Meta-Analysis will be used to inform the reporting of this study.

TRIAL REGISTRATION NUMBER

CRD42017060359.

Atopic dermatitis and risk of hypertension, type 2 diabetes, myocardial infarction and stroke in a cross-sectional analysis from the Canadian Partnership for Tomorrow Project

BACKGROUND

Atopic dermatitis (AD) has been associated with cardiovascular risk factors and diseases, but epidemiological studies to date have found conflicting results.

OBJECTIVES

To determine the associations of AD with hypertension, type 2 diabetes (T2D), myocardial infarction (MI) and stroke.

METHODS

We conducted a cross-sectional analysis of baseline data from the Canadian Partnership for Tomorrow Project, which includes Canadian residents aged 30-74 years living in British Columbia, Alberta, Ontario, Quebec and the Atlantic Provinces. We excluded participants with incomplete data on AD, hypertension, T2D, MI or stroke, who had type 1 or gestational diabetes or who developed any of the outcomes at an age prior to a diagnosis of AD. This left 259 119 participants in our analysis. We used logistic regression to calculate age- and sex-, and multivariable-adjusted odds ratios (ORs) and 95% confidence intervals (CIs) between AD and subsequent hypertension, T2D, MI and stroke.

RESULTS

AD was reported by 21 379 (8·4%) participants. In total, 52 787 cases of hypertension, 12 739 cases of T2D, 4390 cases of MI and 2235 cases of stroke were reported by participants at enrolment. In the multivariable-adjusted model, AD was associated with decreased odds of hypertension (OR 0·87, 95% CI 0·83-0·90), T2D (OR 0·78, 95% CI 0·71-0·84), MI (OR 0·87, 95% CI 0·75-1·00) and stroke (OR 0·79, 95% CI 0·66-0·95).

CONCLUSIONS

We did not find evidence of a positive association between AD and subsequent hypertension, T2D, MI or stroke; AD was inversely associated with these outcomes in our study. Given our findings and the conflicting literature, AD is likely not a major risk factor for cardiovascular disease.

Atopic dermatitis and the metabolic syndrome

Atopic dermatitis is a common chronic inflammatory skin disease affecting about 10% to 20% of the general population. Disturbances in lipid metabolism contribute to defective lipid lamellae of the stratum corneum. The relationship of the metabolic syndrome and atopic dermatitis, on the contrary, remains unclear, because there are contradictory results from various trials.

The atopic dermatitis blood signature is characterized by increases in inflammatory and cardiovascular risk proteins

Beyond classic “allergic”/atopic comorbidities, atopic dermatitis (AD) emerges as systemic disease with increased cardiovascular risk. To better define serum inflammatory and cardiovascular risk proteins, we used an OLINK high-throughput proteomic assay to analyze moderate-to-severe AD (n = 59) compared to psoriasis (n = 22) and healthy controls (n = 18). Compared to controls, 10 proteins were increased in serum of both diseases, including Th1 (IFN-γ, CXCL9, TNF-β) and Th17 (CCL20) markers. 48 proteins each were uniquely upregulated in AD and psoriasis. Consistent with skin expression, AD serum showed up-regulation of Th2 (IL-13, CCL17, eotaxin-1/CCL11, CCL13, CCL4, IL-10), Th1 (CXCL10, CXCL11) and Th1/Th17/Th22 (IL-12/IL-23p40) responses. Surprisingly, some markers of atherosclerosis (fractalkine/CX3CL1, CCL8, M-CSF, HGF), T-cell development/activation (CD40L, IL-7, CCL25, IL-2RB, IL-15RA, CD6) and angiogenesis (VEGF-A) were significantly increased only in AD. Multiple inflammatory pathways showed stronger enrichment in AD than psoriasis. Several atherosclerosis mediators in serum (e.g. E-selectin, PI3/elafin, CCL7, IL-16) correlated with SCORAD, but not BMI. Also, AD inflammatory mediators (e.g. MMP12, IL-12/IL-23p40, CXCL9, CCL22, PI3/Elafin) correlated between blood and lesional as well as non-lesional skin. Overall, the AD blood signature was largely different compared to psoriasis, with dysregulation of inflammatory and cardiovascular risk markers, strongly supporting its systemic nature beyond atopic/allergic association.

Atopic dermatitis 2017: where we were 10-15 years ago in psoriasis

Novel and innovative treatment options for atopic dermatitis (AD) are underway. The recent advancements in understanding AD are reminiscent of the progress made in psoriasis research over a decade ago.

Prevalence of comorbidity and associated risk factors in adults with atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is a common chronic skin disorder, which may persist into adulthood; however, the prevalence of comorbidities in patients with AD is not well characterized. AD is considered a systemic disorder like psoriasis, which has raised a need for data on the comorbidity profile of patients with AD, to assess the potential risks, benefits, and complications in management of patients with AD. We described the occurrence of medical and psychiatric comorbidities and associated risk factors in adults with AD compared with psoriasis and the general population.

METHODS

All Danish individuals aged ≥18 years with a hospital (inpatient or ambulatory) diagnosis of AD or psoriasis during the study period (January 1, 1995-December 31, 2012) were linked in administrative registers.

RESULTS

Overall, prevalence of smoking and alcohol abuse was higher among patients with AD than the general population, but lower than psoriasis patients. Similarly, patients with AD had more risk factors and higher prevalence of comorbidity than the general population, but lower prevalence and reduced risk compared to psoriasis patients, except for use of anxiolytics, which was higher in severe AD. Prevalence of diabetes was lower in AD than psoriasis patients as well as general population controls.

CONCLUSIONS

Despite an increased risk of various medical and psychiatric comorbidities compared to general population controls, adult patients with AD had markedly lower prevalence of cardiovascular disease than psoriasis patients. However, prevalence of psychiatric comorbidity and tobacco smoking was alarmingly high in severe patients with AD, which might be target for intervention in patient management.

An Italian multicentre study on adult atopic dermatitis: persistent versus adult-onset disease

Atopic dermatitis (AD) is a chronic, recurrent, inflammatory skin disease which predominantly affects children. However, AD may persist until adulthood (persistent AD), or directly start in adults (adult-onset AD). AD often shows a non-flexural rash distribution, and atypical morphologic variants in adults and specific diagnostic criteria are lacking. Moreover, adult AD prevalence as well as detailed data which can characterize persistent vs adult-onset subtype are scant. The aim of this study was to investigate on the main features of adult AD particularly highlighting differences between persistent vs adult-onset form. An Italian multicentre observational study was conducted between April 2015-July 2016 through a study-specific digital database. 253 adult AD patients were enrolled. Familiar history of AD was negative in 81.0%. Erythemato-desquamative pattern was the most frequent clinical presentation (74.3%). Flexural surface of upper limbs was most commonly involved (47.8%), followed by eyelid/periocular area (37.9%), hands (37.2%), and neck (32%). Hypertension (7.1%) and thyroiditis (4.3%) were the most frequent comorbidities. A subgroup analysis between persistent (59.7%) vs adult-onset AD patients (40.3%) showed significant results only regarding AD severity (severe disease was more common in persistent group, p < 0.05), itch intensity (higher in adult-onset disease), and comorbidities (hypertension was more frequent in adult-onset group, p < 0.01). Adult AD showed uncommon features such as significant association with negative AD family history and lacking of association with systemic comorbidities respect to general population. No significant differences among persistent vs adult-onset subgroup were registered except for hypertension, itch intensity, and disease severity.