Role of primary and secondary prevention in atopic dermatitis

Systemic inflammatory proteins in offspring following maternal probiotic supplementation for atopic dermatitis prevention

BACKGROUND

Maternal probiotic supplementation has a promising effect on atopic dermatitis (AD) prevention in infancy. In the randomised controlled study, Probiotics in the Prevention of Allergy among Children in Trondheim (ProPACT), maternal probiotics reduced the cumulative incidence of AD in their offspring by 40% at 2 years of age. However, our understanding on how probiotics prevented AD is still limited, and the role of inflammatory proteins in infants following maternal probiotic supplementation is unclear. We hypothesised that maternal probiotics lowered pro-inflammatory proteins and increased anti-inflammatory proteins in their 2-year-old children as a mechanism of AD prevention. We aimed to explore this hypothesis and the association between these proteins and the presence of AD, severity of AD, and the degree of preventive effect of probiotics.

METHODS

Plasma samples were collected from 2-year-old children (n = 202) during the ProPACT study, a randomised placebo-controlled trial of maternal probiotic supplementation. These samples were analysed for 92 inflammatory proteins using a multiplex proximity extension assay. Associations between inflammatory proteins and the presence and severity of AD, and the degree of preventive effect, was estimated individually using regression analysis and then collectively using unsupervised cluster analysis.

RESULTS

Several proteins were observed to differ between the groups. The probiotic group had lower CCL11 and IL-17C, while children with AD had higher IL-17C, MCP-4, uPA, and CD6. Cytokine CCL20 and IL-18 had moderate correlation (r = 0.35 and r = 0.46) with the severity of AD. The cluster analysis revealed that children in the cluster of samples with the highest value of immune checkpoint receptors and inflammatory suppressor enzymes showed the greatest AD preventive effect from probiotics.

CONCLUSIONS

The proteins associated with both maternal probiotic supplementation and the presence and severity of AD warrant attention because of their potential biological relevance. Cluster analysis may provide a new insight when considering which subgroups benefit from probiotic supplementation. Larger studies are needed to confirm the results.

TRIAL REGISTRATION NUMBER

The study was retrospectively registered at ClinicalTrials.gov (NCT00159523) on 12nd September 2005.

Evaluating the Effect of Eicosapentaenoic Acid in Children With Atopic Dermatitis: A Randomized Triple-Blind Clinical Trial

OBJECTIVE

To evaluate the effects of dietary eicosapentaenoic acid (EPA) in children with atopic dermatitis.

METHODS

Forty-eight children with atopic dermatitis were randomly allocated to receive either 250 mg twice daily EPA (n = 24) or placebo (n = 24) for 4 weeks. The absolute improvement in the SCORing Atopic Dermatitis (SCORAD) index and the necessity to use topical corticosteroids was evaluated.

RESULTS

Based on an intention-to-treat analysis, after 2 weeks the scores decreased to 30.50 ± 8.91 and 38.34 ± 10.52 in the EPA and placebo groups, respectively (p = 0.015). Per-protocol analysis showed a decrease in scores to 18.01 ± 10.63 in the EPA group and to 30.11 ± 9.58 in the placebo group (p = 0.001). After 2 weeks, corticosteroid was needed in 11 (50.0%) patients in the EPA group and 14 (58.3%) patients in the placebo group (p = 0.571), and after 4 weeks, it was needed in 7 (33.3%) patients in the EPA group and 14 (63.6%) patients in the placebo group, respectively (p = 0.047).

CONCLUSIONS

Our results show significant favorable effects of EPA on the SCORAD scale and with regard to the necessity for corticosteroid readministration. Few adverse effects were reported in the 2 groups. We conclude that EPA supplementation is a well-tolerated and effective add-on strategy for reducing the severity of atopic dermatitis in children.

Recommendations for dermatologists treating patients with atopic dermatitis during the Covid-19 pandemic: a look into the past for a conscious vaccination management

Atopic dermatitis (AD) is a chronic inflammatory skin disease that affects approximately 20% of children and 10% of adults. The implication of vaccines as a trigger for the de novo onset of AD in children or as a cause of exacerbation in individuals with a history of AD has long been debated. We present a brief review of the literature on AD and traditional vaccinations, proposing in addition the main recommendations for the management of patients with AD undergoing the vaccine against the SARS-COV-2 virus. Live attenuated vaccines seem to be associated with a relapse of AD and/or complications, such as eczema vaccinatum. For non-live vaccines, no adverse events are noted in atopic subjects. Since the Covid-19 vaccine is mRNA or viral vectored vaccine and there are no other currently used vaccines of this type, the same recommendations are applied as for all other non-live vaccines.

Molecular IgE sensitization profiles of urban and rural children in South Africa

BACKGROUND

Allergens can act as disease-triggering factors in atopic dermatitis (AD) patients. The aim of the study was to elucidate the molecular IgE sensitization profile in children with and without AD living in urban and rural areas of South Africa.

METHODS

Specific IgE reactivity was assessed in 166 Black South African children aged 9-38 months using a comprehensive panel of microarrayed allergens. According to clinical characterization children fell in four groups, urban AD cases (n = 32), urban controls (non-AD, n = 40), rural cases (n = 49) and rural controls (non-AD, n = 45).

RESULTS

IgE reactivity to at least one of the allergens was detected in 94% of urban and 86% of rural AD children. House dust mite (HDM; 81% urban, 74% rural AD) and animal-derived allergens (50% urban, 31% rural AD) were the most frequently recognized respiratory allergens, whereas IgE to pollen allergens was almost absent. Urban AD children showed significantly higher frequency of IgE reactivity (50%) to mouse lipocalin, Mus m 1, than rural AD children (12%). The most frequently recognized food allergens were from egg (63% urban, 43% rural AD), peanut (31% vs 41%), and soybean (22% vs 27%), whereas milk sensitization was rare. α-gal-specific IgE almost exclusively occurred in rural children (AD: 14%, non-AD: 49%).

CONCLUSION

Molecular allergy diagnosis detects frequent IgE sensitization to HDM, animal but not pollen allergens and to egg, peanut, and soy, but not milk allergens in African AD children. Urban AD children reacted more often to Mus m 1, whereas α-gal sensitization is more common in rural children likely due to parasite exposure.

Frequency and Clinical Features Associated With Eczema Herpeticum in Hospitalized Children With Presumed Atopic Dermatitis Skin Infection

BACKGROUND

Atopic dermatitis (AD) predisposes to viral skin infections, such as eczema herpeticum (EH), and to bacterial skin infections, such as those caused by Staphylococcus aureus (SA) and group A streptococcus (GAS). This study evaluated clinical features of EH and its frequency of codetection with SA or GAS in children hospitalized for presumed AD skin infection.

METHODS

We retrospectively reviewed clinical data for children ≤18 years of age admitted to a large hospital system for AD with presumed skin infection from January 2004 to December 2018. Those with an alternate primary diagnosis or missing microbiologic data were excluded. Encounters with herpes simplex virus testing were identified as AD with EH (ADEH+) or without (ADEH-). Encounters with bacterial skin culture growth were identified as SA or GAS.

RESULTS

Among 180 AD encounters with suspected skin infection, 133 (74%) were tested for herpes simplex virus. Clinical findings associated with ADEH+ status (n = 61) included fever on admission (59% vs. 32% in ADEH-; P = 0.002), rash on the neck (30% vs. 13%; P = 0.015) and vesicular rash (70% vs. 49%; P = 0.011). Encounters in the ADEH+ group had a longer hospital length of stay compared with encounters in the ADEH- group [median 4 days (interquartile range 3-5 days) vs. 3 days (interquartile range 2-3 days); P < 0.001]. GAS was identified in only 1 ADEH+ encounter (2%) versus 15 ADEH- encounters (26%), P < 0.001.

CONCLUSIONS

Providers should maintain a high index of suspicion for EH in children admitted for presumed AD skin infection. GAS was more commonly associated with ADEH- encounters.

Atopic Dermatitis and Comorbidity

Atopic dermatitis is the most common chronic inflammatory skin disease. It is often the first indicator of allergic diseases, and a certain percentage of patients are affected by allergic rhinitis and/or asthma as a consequence. The study aimed to investigate the link between atopic dermatitis and comorbidity in family medicine. In the specialist family medicine practice Osijek, a retrospective study was conducted in the period from January 1, 2016 to July 1, 2017 on the percentage of patients with atopic dermatitis in the total number of patients, and their comorbid diseases. The data source was the E-chart. The results showed that 195 (10.53%) out of 2056 patients had atopic dermatitis, 80 (41%) patients had atopic dermatitis and allergic rhinitis, 34 (17.4%) asthma, 132 (67.7%) infections, 59 (30.3%) gastrointestinal disturbances, and 68 (34.3%) had mental disorders. Patients up to 18 years old were more likely to have infections, and adult patients were exposed to chronic stress. The most commonly used drug was loratadine (60.5%), while mometasone was the most commonly administered topical drug (40%). The result of this research showed the steps of the ˝atopic march˝. Atopic dermatitis is followed by changes in the skin and its progression to other organ systems in most of the patients.

Changing perspectives in atopic dermatitis

Atopic dermatitis (AD) is a multifaceted disease that involves a complex interplay between the skin and the immune system. The course of the disease depends strongly on the genetic background of the patient and on yet poorly-defined environmental factors. Changes in lifestyle could be behind the dramatic rise in the prevalence of AD across continents; including hygienic conditions, food, social habits, skin microbiome or exposure to a number of allergens. Although AD typically develops in childhood and disappears after a few years, in a relatively large number of patients it continues into adulthood. Adult AD can also appear de novo but it is often underdiagnosed and its treatment can be challenging. New, highly effective drugs are being developed to manage moderate and severe forms of the disease in adults. In this review, we highlight the most recent developments in diagnostic tools, current insights into the mechanistic basis of this disease, and therapeutic innovations.

Novel concepts of prevention and treatment of atopic dermatitis through barrier and immune manipulations with implications for the atopic march

Skin barrier abnormalities have been suggested to play an essential role in initiation of early atopic dermatitis (AD). Antigen penetration through a compromised barrier likely leads to increased innate immune responses, antigen-presenting cell stimulation, and priming of overt cutaneous disease. In a T_H2-promoting environment, T-cell/B-cell interactions occurring in regional lymph nodes lead to excessive IgE switch. Concurrent redistribution of memory T cells into the circulation not only leads to exacerbation of AD through T-cell skin infiltration but also spreads beyond the skin to initiate the atopic march, which includes food allergy, asthma, and allergic rhinitis. Possible primary interventions to prevent AD are focusing on improving skin barrier integrity, including supplementing barrier function with moisturizers. As for secondary prophylaxis in children with established AD, this can be stratified into prevention of disease exacerbations by using proactive approaches (with either topical corticosteroids or topical calcineurin inhibitors) in mild AD cases or the prevention of other atopic disorders that will probably mandate systemic immunosuppression in severe AD cases.