Atopic Dermatitis

SAN FRANCISCO – A peanut or egg allergy diagnosed when infants were 1 year of age often resolved by the time they turned 6, in a longitudinal, population-based study of more than 5,000 Australian children.

Mitchel L. Zoler/MDedge News

Among 131 infants diagnosed with a peanut allergy when they were 1 year old and then followed with repeat testing 5 years later, 41 (31%) had complete resolution of their peanut allergy, while the allergy persisted in the other 90 children, Rachel L. Peters, PhD, said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. The study also followed 404 infants diagnosed with an egg allergy at 1 year of age and found that by age 6 the allergy had resolved in 368 (91%), while persisting in 36 children, said Dr. Peters, an epidemiologist at Murdoch Children’s Research Institute in Parkville, Australia.


The analysis also identified risk factors that linked with an increased rate of allergy persistence. For peanut allergy persistence beyond the first year, the correlating factors were early-onset eczema, tree nut allergy, and a stronger peanut allergy identified by a greater than 4-mm reaction to a peanut skin-prick test. Factors that linked with an increased rate of persistent egg allergy were eczema, peanut allergy, gastrointestinal or respiratory reaction symptoms to milk, and reaction on an oral food challenge elicited by a low dose (less than 0.5 mL) of milk.

A consequence of the frequent resolution of these food allergies was that a positive skin-prick test reaction to either peanut or egg at 1 year old was poorly predictive of allergy status at age 6, while skin-prick tests at age 6 worked well for identifying a persistent food allergy at that age.

The analyses that Dr. Peters and her associates ran used data collected in the HealthNuts study, a comprehensive, prospective, population-based study of food allergies in children that enrolled 5,276 infants at 1 year old. The HealthNuts researchers enrolled infants at immunization clinics in the Melbourne area, with enrollment stratified to represent the people who live in that region (Clin Exp Allergy. 2010 Oct;40[10]:1516-22).

mzoler@mdedge.com

On Twitter @mitchelzoler

SOURCE: Peters R et al. J Allergy Clin Immunol. 2019 Feb;143[2]:AB421.

SAN FRANCISCO – A peanut or egg allergy diagnosed when infants were 1 year of age often resolved by the time they turned 6, in a longitudinal, population-based study of more than 5,000 Australian children.

Mitchel L. Zoler/MDedge News

Among 131 infants diagnosed with a peanut allergy when they were 1 year old and then followed with repeat testing 5 years later, 41 (31%) had complete resolution of their peanut allergy, while the allergy persisted in the other 90 children, Rachel L. Peters, PhD, said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. The study also followed 404 infants diagnosed with an egg allergy at 1 year of age and found that by age 6 the allergy had resolved in 368 (91%), while persisting in 36 children, said Dr. Peters, an epidemiologist at Murdoch Children’s Research Institute in Parkville, Australia.


The analysis also identified risk factors that linked with an increased rate of allergy persistence. For peanut allergy persistence beyond the first year, the correlating factors were early-onset eczema, tree nut allergy, and a stronger peanut allergy identified by a greater than 4-mm reaction to a peanut skin-prick test. Factors that linked with an increased rate of persistent egg allergy were eczema, peanut allergy, gastrointestinal or respiratory reaction symptoms to milk, and reaction on an oral food challenge elicited by a low dose (less than 0.5 mL) of milk.

A consequence of the frequent resolution of these food allergies was that a positive skin-prick test reaction to either peanut or egg at 1 year old was poorly predictive of allergy status at age 6, while skin-prick tests at age 6 worked well for identifying a persistent food allergy at that age.

The analyses that Dr. Peters and her associates ran used data collected in the HealthNuts study, a comprehensive, prospective, population-based study of food allergies in children that enrolled 5,276 infants at 1 year old. The HealthNuts researchers enrolled infants at immunization clinics in the Melbourne area, with enrollment stratified to represent the people who live in that region (Clin Exp Allergy. 2010 Oct;40[10]:1516-22).

mzoler@mdedge.com

On Twitter @mitchelzoler

SOURCE: Peters R et al. J Allergy Clin Immunol. 2019 Feb;143[2]:AB421.

SAN FRANCISCO – A peanut or egg allergy diagnosed when infants were 1 year of age often resolved by the time they turned 6, in a longitudinal, population-based study of more than 5,000 Australian children.

Mitchel L. Zoler/MDedge News

Among 131 infants diagnosed with a peanut allergy when they were 1 year old and then followed with repeat testing 5 years later, 41 (31%) had complete resolution of their peanut allergy, while the allergy persisted in the other 90 children, Rachel L. Peters, PhD, said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. The study also followed 404 infants diagnosed with an egg allergy at 1 year of age and found that by age 6 the allergy had resolved in 368 (91%), while persisting in 36 children, said Dr. Peters, an epidemiologist at Murdoch Children’s Research Institute in Parkville, Australia.


The analysis also identified risk factors that linked with an increased rate of allergy persistence. For peanut allergy persistence beyond the first year, the correlating factors were early-onset eczema, tree nut allergy, and a stronger peanut allergy identified by a greater than 4-mm reaction to a peanut skin-prick test. Factors that linked with an increased rate of persistent egg allergy were eczema, peanut allergy, gastrointestinal or respiratory reaction symptoms to milk, and reaction on an oral food challenge elicited by a low dose (less than 0.5 mL) of milk.

A consequence of the frequent resolution of these food allergies was that a positive skin-prick test reaction to either peanut or egg at 1 year old was poorly predictive of allergy status at age 6, while skin-prick tests at age 6 worked well for identifying a persistent food allergy at that age.

The analyses that Dr. Peters and her associates ran used data collected in the HealthNuts study, a comprehensive, prospective, population-based study of food allergies in children that enrolled 5,276 infants at 1 year old. The HealthNuts researchers enrolled infants at immunization clinics in the Melbourne area, with enrollment stratified to represent the people who live in that region (Clin Exp Allergy. 2010 Oct;40[10]:1516-22).

mzoler@mdedge.com

On Twitter @mitchelzoler

SOURCE: Peters R et al. J Allergy Clin Immunol. 2019 Feb;143[2]:AB421.

The connection between diet and physical beauty has been an area of increasing interest in popular culture as well as in the scientific community. Numerous supplements, plant derivatives, and antioxidants have been proposed to help improve skin conditions and prevent signs of aging.¹ Clinical and basic research has played an important role in confirming or debunking these claims, leading to new insight into oral supplements that may play a role in improving signs of photoaging, as well as symptoms of common skin diseases such as acne vulgaris (AV), atopic dermatitis (AD), and psoriasis. This article reviews some of the vitamins, supplements, and antioxidants that have been studied in the improvement of these conditions.

Photoaging

Recently, there has been increased interest among researchers in the role of antioxidants in combatting photoaging. The main determinants of photoaging are chronic sunlight exposure and melanin density. Photoaging presentation includes deep rhytides, pigmentary changes, dryness, loss of skin tone, leathery appearance, and actinic purpura.^2-4

Beta-carotene is a fat-soluble derivative of vitamin A, which has retinol activity and has an inhibitory effect on free radicals. It has been used to decrease the effect of UV light on the skin as well as to treat erythropoietic porphyria.^5-7 One study evaluated the efficacy of low-dose and high-dose beta-carotene in improving facial rhytides and elasticity in a cohort of 30 women older than 50 years.⁸ Participants were given 30 or 90 mg of beta-carotene once daily for 90 days, and the final results were compared to baseline. Those who received the 30-mg dose showed improvements in facial rhytides and elasticity, increased type I procollagen messenger RNA levels, decreased UV-induced thymine dimer staining, and decreased 8-hydroxy-2′-deoxyguanosine staining. The lower dose of beta-carotene was found to prevent photoaging and was superior to the higher dose, which actually significantly decreased the minimal erythema dose (indicating a deleterious effect)(P=.025).⁸

Another study compared the role of a 25-mg carotenoid supplement vs a combination of carotenoid and vitamin E (335 mg [500 IU] RRR-α-tocopherol) supplements in preventing erythema development on the back.⁹ Using a blue light solar stimulator for illumination, erythema on the dorsal back skin was significantly reduced after week 8 (P<.01). The erythema was lower in the combination group than the carotenoid group alone, but the difference was not statistically significant. Furthermore, after 12 weeks, yellowing of the skin was observed in both groups, especially the skin of the palms and face.⁹

Collagen peptides also have been used in the prevention and repair of photoaging. Proksch et al¹⁰ conducted a double-blind, placebo-controlled trial to investigate the role of collagen peptides on skin elasticity in 69 women aged 35 to 55 years. At 4 weeks, oral supplementation of collagen hydrolysate (2.5 g once daily or 5 g once daily for 8 weeks) showed significant (P<.05) improvement of skin elasticity in both the low-dose and high-dose groups in women older than 50 years; however, collagen peptides did not lead to statistically significant improvement in skin hydration or transepidermal water loss. No known side effects were reported; thus, collagen peptides may be both efficacious and safe in improving signs of photoaging in elderly patients.¹⁰ Thus, these studies have shown potentially positive effects of beta-carotene, vitamin E, and collagen peptides in improving the signs of photoaging.

Acne Vulgaris

Acne vulgaris is a common dermatologic condition seen in the western hemisphere, with 40 to 50 million affected individuals in the United States annually.^11,12 A landmark study that examined 1200 Kitavans from Papua New Guinea and 115 Aché individuals from a hunter-gatherer community in Paraguay found no cases of AV in either group.¹² These findings have led to the speculation that AV may be associated with environmental factors, particularly the Western diet.

An investigator-blinded randomized clinical trial (RCT) explored the role of a low-glycemic diet compared to a carbohydrate-dense diet on improvement of AV lesions after 12 weeks.¹³ The results yielded a significant decrease in lesions in the low-glycemic group (mean [SEM], −23.5 [−3.9]) vs the control group (−12.0 [−3.0])(P=.03). Furthermore, the results indicated a significant decrease in weight (P<.001) and body mass index (P=.001) with an improvement in insulin sensitivity in the low-glycemic group vs the control group.¹³ Kwon et al¹⁴ conducted a similar investigator-blinded parallel study with 32 participants receiving either a low-glycemic diet or continuing their normal diet for 10 weeks. Participants in the low-glycemic group demonstrated a significant reduction in mean noninflammatory lesions (−27.6% [P=.04]) and mean inflammatory lesions (−70.9% [P<.05]). Histologic image analysis showed a significant decrease in the mean (SEM) area of sebaceous glands in the low-glycemic group (0.32 [0.03] mm²) compared to baseline (0.24 [0.03] mm²)(P=.03). At 10 weeks, immunohistochemical specimens showed reduction in IL-8 (P=.03) and sterol regulatory element-binding protein 1 (P=.03), which regulates the synthesis of lipids.¹⁴ Thus, both studies concluded that a reduction in glycemic load may improve acne overall.^13,14

Another study attempted to investigate the role of additional dietary supplements in improving acne. A double-blinded RCT explored the efficacy of omega-3 fatty acids or γ-linoleic acid compared to a control group in improving mild to moderate AV lesions through clinical and histological evaluations.¹⁵ The 10-week prospective study included 45 patients who were allocated to 3 matched groups and randomized to 3 treatment arms. They were given omega-3 fatty acids (1000 mg each of eicosapentaenoic acid and docosahexaenoic acid) or γ-linoleic acid (borage oil with 400 mg of γ-linoleic acid) or no intervention. After treatment completion, patients in both treatment groups showed significant reduction in mean inflammatory acne lesions, mean noninflammatory acne lesions, and mean acne severity (all P<.05), while the control group showed no significant reduction in acne lesions or acne severity. Furthermore, hematoxylin and eosin and IL-8 immunohistochemical staining of biopsies from the affected areas showed significant reduction of inflammation in both treatment groups (P<.05) but not in the control group. Therefore, the authors concluded that both omega-3 fatty acids and γ-linoleic acid could be used as adjuvant therapies in AV treatment.¹⁵

Atopic Dermatitis

The prevalence of atopic dermatitis (AD) in children ranges from approximately 9% to 18% across the United States.¹⁶ Pyridoxine, or vitamin B₆, is an important water-soluble vitamin and a cofactor for numerous biochemical processes including carbohydrate and amino acid metabolism pathways and glucocorticoid receptor regulation.^17,18 However, a double-blinded, placebo-controlled RCT failed to show efficacy of once-daily pyridoxine hydrochloride 50 mg in improving erythema, itching, or nocturnal sleep disturbance associated with AD in a cohort of 48 children. The investigators concluded that pyridoxine supplementation cannot be recommended to improve the symptoms of AD in children.¹⁹

Zinc is an essential nutrient that functions as an important cofactor in cell metabolism and growth pathways.²⁰ One study showed that intracellular erythrocyte zinc levels were significantly lower in AD patients compared to healthy controls (P<.001); however, there was no observed difference in serum zinc levels (P=.148). Furthermore, greater disease severity as determined by the SCORing Atopic Dermatitis (SCORAD) index was negatively correlated with erythrocyte zinc levels (r=−0.791; P<.001).²¹ Kim et al²² investigated hair zinc levels and the efficacy of oral zinc supplementation in children with mild to moderate AD. Mean (SD) hair zinc levels were lower in the AD group compared to the control group (113.10 [33.6] μg vs 130.90 [36.63] μg [P=.012]). Of 41 AD patients with low zinc levels, 22 were allocated to group A, which received oral zinc oxide 12 mg for 8 weeks, and 19 were allocated to group B, which did not receive any supplementation over the same period. Groups A and B also received oral antihistamines and topical moisturizers. Mean (SD) zinc levels increased significantly in group A from 96.36 (21.05) μg to 131.81 (27.45) μg (P<.001). Furthermore, relative to group B, group A showed significantly greater improvements in eczema area and severity index (P=.044), transepidermal water loss (P=.015), and visual analog scale for pruritus (P<.001) at the end of 8 weeks. The authors concluded that oral zinc supplementation might be an effective adjunctive therapy for AD patients with low hair zinc levels.²²

Researchers also have explored the efficacy of fat-soluble vitamins D and E in treating AD. Vitamin D is thought to downregulate IgE-mediated skin reactions and decrease adverse effects of UV light on the skin.^23,24 A double-blind, placebo-controlled trial randomized 45 patients with AD to 4 groups: vitamins D and E placebos (n=11), 1600 IU vitamin D₃ plus vitamin E placebo (n=12), 600 IU vitamin E (synthetic all-rac-α-tocopherol) plus vitamin D placebo (n=11), and 1600 IU vitamin D₃ plus 600 IU vitamin E (synthetic all-rac-α-tocopherol)(n=11).²⁵ After 60 days, the SCORAD index was reduced by 28.9% in the placebo group, 34.8% in the vitamin D₃ group, 35.7% in the vitamin E group, and 64.3% in the combined vitamins D and E group (P=.004). Furthermore, prior to intervention, a negative correlation was demonstrated between plasma α-tocopherol concentration and the SCORAD index (r=−.33; P=.025).²⁵ Thus, supplementing vitamins D and E may play a beneficial role in the treatment of AD.

Other emerging studies are investigating the role of the gut microbiome in various pathologies. Prebiotics may alter the gut microbiome and are thought to play a role in reducing intestinal inflammation.²⁶ One randomized, placebo-controlled, parallel study examined the effect of prebiotic oligosaccharide supplementation on the development of AD in at-risk children, defined as having a biological parent with a history of asthma, allergic rhinitis, or AD.²⁷ At 6-month follow-up, 10 infants (9.8%)(95% CI, 5.4%-17.1%) in the intervention group (n=102) and 24 infants (23.1%)(95% CI, 16.0%-32.1%) in the placebo group (n=104) had developed AD. The authors postulated that the prebiotic oligosaccharides might play a role in immune modulation by altering bowel flora and preventing the development of AD in infancy.²⁷

Notably, a 2012 Cochrane review evaluated 11 studies of dietary supplements as possible treatment options for AD. The authors concluded that the evidence was minimal to support the regular use of dietary supplements, especially due to their high cost as well as the possibility that high levels of certain vitamins (eg, vitamin D) may cause long-term complications.²⁶

Psoriasis

Psoriasis is an autoimmune skin condition that has an annual prevalence ranging from approximately 1% to 9% in adults residing in Western countries.^28,29 Some have argued that due to decreased bacterial diversity and increased bacterial growth in the small bowel, psoriatic patients are exposed to higher levels of bacterial peptidoglycans and endotoxins.³⁰ To combat the absorption of these substances in psoriasis patients, we advocate for a vegetarian diet with low fats, limited alcohol consumption, and supplements of bile acids and bioflavonoid.

The effects of very long chain fatty acids also have been examined. A 4-month, double-blind, multicenter RCT compared the effects of daily supplementation with 6 g of either omega-3 fatty acids or omega-6 fatty acids in patients with mild to moderate plaque psoriasis.³¹ Psoriasis area and severity index scores and patient subjective scores did not change significantly in either group; however, scaling was reduced in both groups (P<.01). The group receiving omega-3 fatty acids had decreased cellular infiltration (P<.01), and the group receiving omega-6 fatty acids had decreased desquamation and redness (P<.05). In the omega-6 group, there was a significant correlation between clinical improvement (decrease in clinical score) and increase in serum eicosapentaenoic acid (r=−0.34; P<.05) and total omega-3 fatty acids (r=−0.36; P<.05). Overall, the authors concluded that supplementation with omega-3 fatty acids (fish oil) was no better than omega-6 fatty acids (corn oil) for treatment of psoriasis.³¹

Some dermatologists have advocated for the use of oral vitamin D supplementation as an adjunctive treatment of psoriasis, given that it is inexpensive and also may play a role in reducing the risk for cancer and cardiovascular events.³² One study evaluated the level of 25-hydroxy vitamin D in 43 psoriasis patients compared to 43 healthy controls. Mean (SD) vitamin D levels were significantly lower in psoriasis patients (13.3 [6.9]) compared to controls (22.4 [18.4])(P=.004).³³ A cross-sectional study similarly found significantly higher rates of vitamin D deficiency (25-hydroxy vitamin D <20 ng/mL) in psoriatic patients (57.8%) compared to patients with rheumatoid arthritis (37.5%) and healthy controls (29.7%)(P<.001). Interestingly, during winter the prevalence of vitamin D deficiency increased to 80.9%, 41.3%, and 30.3% in the 3 groups, respectively; however, no significant correlation was seen between psoriasis severity, as measured by psoriasis area and severity index, and serum vitamin D levels.³⁴ Although vitamin D deficiency may be more prevalent among patients with psoriasis, data regarding the efficacy of treating psoriasis with oral vitamin D supplementation is still lacking.

Conclusion

Our understanding of the link between diet and dermatologic conditions continues to evolve. Recent data for several dietary supplements and therapies showed promising results in repairing signs of photoaging, as well as treating AV, AD, and psoriasis. As patients seek these adjunctive therapies, it is important for physicians to be well informed on the benefits and risks to appropriately counsel patients.

Globally, physicians advocate for a low-glycemic diet rich in fruits and vegetables. Furthermore, the cosmetic diet can be enhanced by the consumption of dietary supplements such as beta-carotene, collagen peptides, zinc, and fat-soluble vitamins such as vitamins D and E. However, prospective RCTs are needed to further investigate the role of these dietary elements in treating and improving dermatologic conditions.

The connection between diet and physical beauty has been an area of increasing interest in popular culture as well as in the scientific community. Numerous supplements, plant derivatives, and antioxidants have been proposed to help improve skin conditions and prevent signs of aging.¹ Clinical and basic research has played an important role in confirming or debunking these claims, leading to new insight into oral supplements that may play a role in improving signs of photoaging, as well as symptoms of common skin diseases such as acne vulgaris (AV), atopic dermatitis (AD), and psoriasis. This article reviews some of the vitamins, supplements, and antioxidants that have been studied in the improvement of these conditions.

Photoaging

Recently, there has been increased interest among researchers in the role of antioxidants in combatting photoaging. The main determinants of photoaging are chronic sunlight exposure and melanin density. Photoaging presentation includes deep rhytides, pigmentary changes, dryness, loss of skin tone, leathery appearance, and actinic purpura.^2-4

Beta-carotene is a fat-soluble derivative of vitamin A, which has retinol activity and has an inhibitory effect on free radicals. It has been used to decrease the effect of UV light on the skin as well as to treat erythropoietic porphyria.^5-7 One study evaluated the efficacy of low-dose and high-dose beta-carotene in improving facial rhytides and elasticity in a cohort of 30 women older than 50 years.⁸ Participants were given 30 or 90 mg of beta-carotene once daily for 90 days, and the final results were compared to baseline. Those who received the 30-mg dose showed improvements in facial rhytides and elasticity, increased type I procollagen messenger RNA levels, decreased UV-induced thymine dimer staining, and decreased 8-hydroxy-2′-deoxyguanosine staining. The lower dose of beta-carotene was found to prevent photoaging and was superior to the higher dose, which actually significantly decreased the minimal erythema dose (indicating a deleterious effect)(P=.025).⁸

Another study compared the role of a 25-mg carotenoid supplement vs a combination of carotenoid and vitamin E (335 mg [500 IU] RRR-α-tocopherol) supplements in preventing erythema development on the back.⁹ Using a blue light solar stimulator for illumination, erythema on the dorsal back skin was significantly reduced after week 8 (P<.01). The erythema was lower in the combination group than the carotenoid group alone, but the difference was not statistically significant. Furthermore, after 12 weeks, yellowing of the skin was observed in both groups, especially the skin of the palms and face.⁹

Collagen peptides also have been used in the prevention and repair of photoaging. Proksch et al¹⁰ conducted a double-blind, placebo-controlled trial to investigate the role of collagen peptides on skin elasticity in 69 women aged 35 to 55 years. At 4 weeks, oral supplementation of collagen hydrolysate (2.5 g once daily or 5 g once daily for 8 weeks) showed significant (P<.05) improvement of skin elasticity in both the low-dose and high-dose groups in women older than 50 years; however, collagen peptides did not lead to statistically significant improvement in skin hydration or transepidermal water loss. No known side effects were reported; thus, collagen peptides may be both efficacious and safe in improving signs of photoaging in elderly patients.¹⁰ Thus, these studies have shown potentially positive effects of beta-carotene, vitamin E, and collagen peptides in improving the signs of photoaging.

Acne Vulgaris

Acne vulgaris is a common dermatologic condition seen in the western hemisphere, with 40 to 50 million affected individuals in the United States annually.^11,12 A landmark study that examined 1200 Kitavans from Papua New Guinea and 115 Aché individuals from a hunter-gatherer community in Paraguay found no cases of AV in either group.¹² These findings have led to the speculation that AV may be associated with environmental factors, particularly the Western diet.

An investigator-blinded randomized clinical trial (RCT) explored the role of a low-glycemic diet compared to a carbohydrate-dense diet on improvement of AV lesions after 12 weeks.¹³ The results yielded a significant decrease in lesions in the low-glycemic group (mean [SEM], −23.5 [−3.9]) vs the control group (−12.0 [−3.0])(P=.03). Furthermore, the results indicated a significant decrease in weight (P<.001) and body mass index (P=.001) with an improvement in insulin sensitivity in the low-glycemic group vs the control group.¹³ Kwon et al¹⁴ conducted a similar investigator-blinded parallel study with 32 participants receiving either a low-glycemic diet or continuing their normal diet for 10 weeks. Participants in the low-glycemic group demonstrated a significant reduction in mean noninflammatory lesions (−27.6% [P=.04]) and mean inflammatory lesions (−70.9% [P<.05]). Histologic image analysis showed a significant decrease in the mean (SEM) area of sebaceous glands in the low-glycemic group (0.32 [0.03] mm²) compared to baseline (0.24 [0.03] mm²)(P=.03). At 10 weeks, immunohistochemical specimens showed reduction in IL-8 (P=.03) and sterol regulatory element-binding protein 1 (P=.03), which regulates the synthesis of lipids.¹⁴ Thus, both studies concluded that a reduction in glycemic load may improve acne overall.^13,14

Another study attempted to investigate the role of additional dietary supplements in improving acne. A double-blinded RCT explored the efficacy of omega-3 fatty acids or γ-linoleic acid compared to a control group in improving mild to moderate AV lesions through clinical and histological evaluations.¹⁵ The 10-week prospective study included 45 patients who were allocated to 3 matched groups and randomized to 3 treatment arms. They were given omega-3 fatty acids (1000 mg each of eicosapentaenoic acid and docosahexaenoic acid) or γ-linoleic acid (borage oil with 400 mg of γ-linoleic acid) or no intervention. After treatment completion, patients in both treatment groups showed significant reduction in mean inflammatory acne lesions, mean noninflammatory acne lesions, and mean acne severity (all P<.05), while the control group showed no significant reduction in acne lesions or acne severity. Furthermore, hematoxylin and eosin and IL-8 immunohistochemical staining of biopsies from the affected areas showed significant reduction of inflammation in both treatment groups (P<.05) but not in the control group. Therefore, the authors concluded that both omega-3 fatty acids and γ-linoleic acid could be used as adjuvant therapies in AV treatment.¹⁵

Atopic Dermatitis

The prevalence of atopic dermatitis (AD) in children ranges from approximately 9% to 18% across the United States.¹⁶ Pyridoxine, or vitamin B₆, is an important water-soluble vitamin and a cofactor for numerous biochemical processes including carbohydrate and amino acid metabolism pathways and glucocorticoid receptor regulation.^17,18 However, a double-blinded, placebo-controlled RCT failed to show efficacy of once-daily pyridoxine hydrochloride 50 mg in improving erythema, itching, or nocturnal sleep disturbance associated with AD in a cohort of 48 children. The investigators concluded that pyridoxine supplementation cannot be recommended to improve the symptoms of AD in children.¹⁹

Zinc is an essential nutrient that functions as an important cofactor in cell metabolism and growth pathways.²⁰ One study showed that intracellular erythrocyte zinc levels were significantly lower in AD patients compared to healthy controls (P<.001); however, there was no observed difference in serum zinc levels (P=.148). Furthermore, greater disease severity as determined by the SCORing Atopic Dermatitis (SCORAD) index was negatively correlated with erythrocyte zinc levels (r=−0.791; P<.001).²¹ Kim et al²² investigated hair zinc levels and the efficacy of oral zinc supplementation in children with mild to moderate AD. Mean (SD) hair zinc levels were lower in the AD group compared to the control group (113.10 [33.6] μg vs 130.90 [36.63] μg [P=.012]). Of 41 AD patients with low zinc levels, 22 were allocated to group A, which received oral zinc oxide 12 mg for 8 weeks, and 19 were allocated to group B, which did not receive any supplementation over the same period. Groups A and B also received oral antihistamines and topical moisturizers. Mean (SD) zinc levels increased significantly in group A from 96.36 (21.05) μg to 131.81 (27.45) μg (P<.001). Furthermore, relative to group B, group A showed significantly greater improvements in eczema area and severity index (P=.044), transepidermal water loss (P=.015), and visual analog scale for pruritus (P<.001) at the end of 8 weeks. The authors concluded that oral zinc supplementation might be an effective adjunctive therapy for AD patients with low hair zinc levels.²²

Researchers also have explored the efficacy of fat-soluble vitamins D and E in treating AD. Vitamin D is thought to downregulate IgE-mediated skin reactions and decrease adverse effects of UV light on the skin.^23,24 A double-blind, placebo-controlled trial randomized 45 patients with AD to 4 groups: vitamins D and E placebos (n=11), 1600 IU vitamin D₃ plus vitamin E placebo (n=12), 600 IU vitamin E (synthetic all-rac-α-tocopherol) plus vitamin D placebo (n=11), and 1600 IU vitamin D₃ plus 600 IU vitamin E (synthetic all-rac-α-tocopherol)(n=11).²⁵ After 60 days, the SCORAD index was reduced by 28.9% in the placebo group, 34.8% in the vitamin D₃ group, 35.7% in the vitamin E group, and 64.3% in the combined vitamins D and E group (P=.004). Furthermore, prior to intervention, a negative correlation was demonstrated between plasma α-tocopherol concentration and the SCORAD index (r=−.33; P=.025).²⁵ Thus, supplementing vitamins D and E may play a beneficial role in the treatment of AD.

Other emerging studies are investigating the role of the gut microbiome in various pathologies. Prebiotics may alter the gut microbiome and are thought to play a role in reducing intestinal inflammation.²⁶ One randomized, placebo-controlled, parallel study examined the effect of prebiotic oligosaccharide supplementation on the development of AD in at-risk children, defined as having a biological parent with a history of asthma, allergic rhinitis, or AD.²⁷ At 6-month follow-up, 10 infants (9.8%)(95% CI, 5.4%-17.1%) in the intervention group (n=102) and 24 infants (23.1%)(95% CI, 16.0%-32.1%) in the placebo group (n=104) had developed AD. The authors postulated that the prebiotic oligosaccharides might play a role in immune modulation by altering bowel flora and preventing the development of AD in infancy.²⁷

Notably, a 2012 Cochrane review evaluated 11 studies of dietary supplements as possible treatment options for AD. The authors concluded that the evidence was minimal to support the regular use of dietary supplements, especially due to their high cost as well as the possibility that high levels of certain vitamins (eg, vitamin D) may cause long-term complications.²⁶

Psoriasis

Psoriasis is an autoimmune skin condition that has an annual prevalence ranging from approximately 1% to 9% in adults residing in Western countries.^28,29 Some have argued that due to decreased bacterial diversity and increased bacterial growth in the small bowel, psoriatic patients are exposed to higher levels of bacterial peptidoglycans and endotoxins.³⁰ To combat the absorption of these substances in psoriasis patients, we advocate for a vegetarian diet with low fats, limited alcohol consumption, and supplements of bile acids and bioflavonoid.

The effects of very long chain fatty acids also have been examined. A 4-month, double-blind, multicenter RCT compared the effects of daily supplementation with 6 g of either omega-3 fatty acids or omega-6 fatty acids in patients with mild to moderate plaque psoriasis.³¹ Psoriasis area and severity index scores and patient subjective scores did not change significantly in either group; however, scaling was reduced in both groups (P<.01). The group receiving omega-3 fatty acids had decreased cellular infiltration (P<.01), and the group receiving omega-6 fatty acids had decreased desquamation and redness (P<.05). In the omega-6 group, there was a significant correlation between clinical improvement (decrease in clinical score) and increase in serum eicosapentaenoic acid (r=−0.34; P<.05) and total omega-3 fatty acids (r=−0.36; P<.05). Overall, the authors concluded that supplementation with omega-3 fatty acids (fish oil) was no better than omega-6 fatty acids (corn oil) for treatment of psoriasis.³¹

Some dermatologists have advocated for the use of oral vitamin D supplementation as an adjunctive treatment of psoriasis, given that it is inexpensive and also may play a role in reducing the risk for cancer and cardiovascular events.³² One study evaluated the level of 25-hydroxy vitamin D in 43 psoriasis patients compared to 43 healthy controls. Mean (SD) vitamin D levels were significantly lower in psoriasis patients (13.3 [6.9]) compared to controls (22.4 [18.4])(P=.004).³³ A cross-sectional study similarly found significantly higher rates of vitamin D deficiency (25-hydroxy vitamin D <20 ng/mL) in psoriatic patients (57.8%) compared to patients with rheumatoid arthritis (37.5%) and healthy controls (29.7%)(P<.001). Interestingly, during winter the prevalence of vitamin D deficiency increased to 80.9%, 41.3%, and 30.3% in the 3 groups, respectively; however, no significant correlation was seen between psoriasis severity, as measured by psoriasis area and severity index, and serum vitamin D levels.³⁴ Although vitamin D deficiency may be more prevalent among patients with psoriasis, data regarding the efficacy of treating psoriasis with oral vitamin D supplementation is still lacking.

Conclusion

Our understanding of the link between diet and dermatologic conditions continues to evolve. Recent data for several dietary supplements and therapies showed promising results in repairing signs of photoaging, as well as treating AV, AD, and psoriasis. As patients seek these adjunctive therapies, it is important for physicians to be well informed on the benefits and risks to appropriately counsel patients.

Globally, physicians advocate for a low-glycemic diet rich in fruits and vegetables. Furthermore, the cosmetic diet can be enhanced by the consumption of dietary supplements such as beta-carotene, collagen peptides, zinc, and fat-soluble vitamins such as vitamins D and E. However, prospective RCTs are needed to further investigate the role of these dietary elements in treating and improving dermatologic conditions.

The connection between diet and physical beauty has been an area of increasing interest in popular culture as well as in the scientific community. Numerous supplements, plant derivatives, and antioxidants have been proposed to help improve skin conditions and prevent signs of aging.¹ Clinical and basic research has played an important role in confirming or debunking these claims, leading to new insight into oral supplements that may play a role in improving signs of photoaging, as well as symptoms of common skin diseases such as acne vulgaris (AV), atopic dermatitis (AD), and psoriasis. This article reviews some of the vitamins, supplements, and antioxidants that have been studied in the improvement of these conditions.

Photoaging

Recently, there has been increased interest among researchers in the role of antioxidants in combatting photoaging. The main determinants of photoaging are chronic sunlight exposure and melanin density. Photoaging presentation includes deep rhytides, pigmentary changes, dryness, loss of skin tone, leathery appearance, and actinic purpura.^2-4

Beta-carotene is a fat-soluble derivative of vitamin A, which has retinol activity and has an inhibitory effect on free radicals. It has been used to decrease the effect of UV light on the skin as well as to treat erythropoietic porphyria.^5-7 One study evaluated the efficacy of low-dose and high-dose beta-carotene in improving facial rhytides and elasticity in a cohort of 30 women older than 50 years.⁸ Participants were given 30 or 90 mg of beta-carotene once daily for 90 days, and the final results were compared to baseline. Those who received the 30-mg dose showed improvements in facial rhytides and elasticity, increased type I procollagen messenger RNA levels, decreased UV-induced thymine dimer staining, and decreased 8-hydroxy-2′-deoxyguanosine staining. The lower dose of beta-carotene was found to prevent photoaging and was superior to the higher dose, which actually significantly decreased the minimal erythema dose (indicating a deleterious effect)(P=.025).⁸

Another study compared the role of a 25-mg carotenoid supplement vs a combination of carotenoid and vitamin E (335 mg [500 IU] RRR-α-tocopherol) supplements in preventing erythema development on the back.⁹ Using a blue light solar stimulator for illumination, erythema on the dorsal back skin was significantly reduced after week 8 (P<.01). The erythema was lower in the combination group than the carotenoid group alone, but the difference was not statistically significant. Furthermore, after 12 weeks, yellowing of the skin was observed in both groups, especially the skin of the palms and face.⁹

Collagen peptides also have been used in the prevention and repair of photoaging. Proksch et al¹⁰ conducted a double-blind, placebo-controlled trial to investigate the role of collagen peptides on skin elasticity in 69 women aged 35 to 55 years. At 4 weeks, oral supplementation of collagen hydrolysate (2.5 g once daily or 5 g once daily for 8 weeks) showed significant (P<.05) improvement of skin elasticity in both the low-dose and high-dose groups in women older than 50 years; however, collagen peptides did not lead to statistically significant improvement in skin hydration or transepidermal water loss. No known side effects were reported; thus, collagen peptides may be both efficacious and safe in improving signs of photoaging in elderly patients.¹⁰ Thus, these studies have shown potentially positive effects of beta-carotene, vitamin E, and collagen peptides in improving the signs of photoaging.

Acne Vulgaris

Acne vulgaris is a common dermatologic condition seen in the western hemisphere, with 40 to 50 million affected individuals in the United States annually.^11,12 A landmark study that examined 1200 Kitavans from Papua New Guinea and 115 Aché individuals from a hunter-gatherer community in Paraguay found no cases of AV in either group.¹² These findings have led to the speculation that AV may be associated with environmental factors, particularly the Western diet.

An investigator-blinded randomized clinical trial (RCT) explored the role of a low-glycemic diet compared to a carbohydrate-dense diet on improvement of AV lesions after 12 weeks.¹³ The results yielded a significant decrease in lesions in the low-glycemic group (mean [SEM], −23.5 [−3.9]) vs the control group (−12.0 [−3.0])(P=.03). Furthermore, the results indicated a significant decrease in weight (P<.001) and body mass index (P=.001) with an improvement in insulin sensitivity in the low-glycemic group vs the control group.¹³ Kwon et al¹⁴ conducted a similar investigator-blinded parallel study with 32 participants receiving either a low-glycemic diet or continuing their normal diet for 10 weeks. Participants in the low-glycemic group demonstrated a significant reduction in mean noninflammatory lesions (−27.6% [P=.04]) and mean inflammatory lesions (−70.9% [P<.05]). Histologic image analysis showed a significant decrease in the mean (SEM) area of sebaceous glands in the low-glycemic group (0.32 [0.03] mm²) compared to baseline (0.24 [0.03] mm²)(P=.03). At 10 weeks, immunohistochemical specimens showed reduction in IL-8 (P=.03) and sterol regulatory element-binding protein 1 (P=.03), which regulates the synthesis of lipids.¹⁴ Thus, both studies concluded that a reduction in glycemic load may improve acne overall.^13,14

Another study attempted to investigate the role of additional dietary supplements in improving acne. A double-blinded RCT explored the efficacy of omega-3 fatty acids or γ-linoleic acid compared to a control group in improving mild to moderate AV lesions through clinical and histological evaluations.¹⁵ The 10-week prospective study included 45 patients who were allocated to 3 matched groups and randomized to 3 treatment arms. They were given omega-3 fatty acids (1000 mg each of eicosapentaenoic acid and docosahexaenoic acid) or γ-linoleic acid (borage oil with 400 mg of γ-linoleic acid) or no intervention. After treatment completion, patients in both treatment groups showed significant reduction in mean inflammatory acne lesions, mean noninflammatory acne lesions, and mean acne severity (all P<.05), while the control group showed no significant reduction in acne lesions or acne severity. Furthermore, hematoxylin and eosin and IL-8 immunohistochemical staining of biopsies from the affected areas showed significant reduction of inflammation in both treatment groups (P<.05) but not in the control group. Therefore, the authors concluded that both omega-3 fatty acids and γ-linoleic acid could be used as adjuvant therapies in AV treatment.¹⁵

Atopic Dermatitis

The prevalence of atopic dermatitis (AD) in children ranges from approximately 9% to 18% across the United States.¹⁶ Pyridoxine, or vitamin B₆, is an important water-soluble vitamin and a cofactor for numerous biochemical processes including carbohydrate and amino acid metabolism pathways and glucocorticoid receptor regulation.^17,18 However, a double-blinded, placebo-controlled RCT failed to show efficacy of once-daily pyridoxine hydrochloride 50 mg in improving erythema, itching, or nocturnal sleep disturbance associated with AD in a cohort of 48 children. The investigators concluded that pyridoxine supplementation cannot be recommended to improve the symptoms of AD in children.¹⁹

Zinc is an essential nutrient that functions as an important cofactor in cell metabolism and growth pathways.²⁰ One study showed that intracellular erythrocyte zinc levels were significantly lower in AD patients compared to healthy controls (P<.001); however, there was no observed difference in serum zinc levels (P=.148). Furthermore, greater disease severity as determined by the SCORing Atopic Dermatitis (SCORAD) index was negatively correlated with erythrocyte zinc levels (r=−0.791; P<.001).²¹ Kim et al²² investigated hair zinc levels and the efficacy of oral zinc supplementation in children with mild to moderate AD. Mean (SD) hair zinc levels were lower in the AD group compared to the control group (113.10 [33.6] μg vs 130.90 [36.63] μg [P=.012]). Of 41 AD patients with low zinc levels, 22 were allocated to group A, which received oral zinc oxide 12 mg for 8 weeks, and 19 were allocated to group B, which did not receive any supplementation over the same period. Groups A and B also received oral antihistamines and topical moisturizers. Mean (SD) zinc levels increased significantly in group A from 96.36 (21.05) μg to 131.81 (27.45) μg (P<.001). Furthermore, relative to group B, group A showed significantly greater improvements in eczema area and severity index (P=.044), transepidermal water loss (P=.015), and visual analog scale for pruritus (P<.001) at the end of 8 weeks. The authors concluded that oral zinc supplementation might be an effective adjunctive therapy for AD patients with low hair zinc levels.²²

Researchers also have explored the efficacy of fat-soluble vitamins D and E in treating AD. Vitamin D is thought to downregulate IgE-mediated skin reactions and decrease adverse effects of UV light on the skin.^23,24 A double-blind, placebo-controlled trial randomized 45 patients with AD to 4 groups: vitamins D and E placebos (n=11), 1600 IU vitamin D₃ plus vitamin E placebo (n=12), 600 IU vitamin E (synthetic all-rac-α-tocopherol) plus vitamin D placebo (n=11), and 1600 IU vitamin D₃ plus 600 IU vitamin E (synthetic all-rac-α-tocopherol)(n=11).²⁵ After 60 days, the SCORAD index was reduced by 28.9% in the placebo group, 34.8% in the vitamin D₃ group, 35.7% in the vitamin E group, and 64.3% in the combined vitamins D and E group (P=.004). Furthermore, prior to intervention, a negative correlation was demonstrated between plasma α-tocopherol concentration and the SCORAD index (r=−.33; P=.025).²⁵ Thus, supplementing vitamins D and E may play a beneficial role in the treatment of AD.

Other emerging studies are investigating the role of the gut microbiome in various pathologies. Prebiotics may alter the gut microbiome and are thought to play a role in reducing intestinal inflammation.²⁶ One randomized, placebo-controlled, parallel study examined the effect of prebiotic oligosaccharide supplementation on the development of AD in at-risk children, defined as having a biological parent with a history of asthma, allergic rhinitis, or AD.²⁷ At 6-month follow-up, 10 infants (9.8%)(95% CI, 5.4%-17.1%) in the intervention group (n=102) and 24 infants (23.1%)(95% CI, 16.0%-32.1%) in the placebo group (n=104) had developed AD. The authors postulated that the prebiotic oligosaccharides might play a role in immune modulation by altering bowel flora and preventing the development of AD in infancy.²⁷

Notably, a 2012 Cochrane review evaluated 11 studies of dietary supplements as possible treatment options for AD. The authors concluded that the evidence was minimal to support the regular use of dietary supplements, especially due to their high cost as well as the possibility that high levels of certain vitamins (eg, vitamin D) may cause long-term complications.²⁶

Psoriasis

Psoriasis is an autoimmune skin condition that has an annual prevalence ranging from approximately 1% to 9% in adults residing in Western countries.^28,29 Some have argued that due to decreased bacterial diversity and increased bacterial growth in the small bowel, psoriatic patients are exposed to higher levels of bacterial peptidoglycans and endotoxins.³⁰ To combat the absorption of these substances in psoriasis patients, we advocate for a vegetarian diet with low fats, limited alcohol consumption, and supplements of bile acids and bioflavonoid.

The effects of very long chain fatty acids also have been examined. A 4-month, double-blind, multicenter RCT compared the effects of daily supplementation with 6 g of either omega-3 fatty acids or omega-6 fatty acids in patients with mild to moderate plaque psoriasis.³¹ Psoriasis area and severity index scores and patient subjective scores did not change significantly in either group; however, scaling was reduced in both groups (P<.01). The group receiving omega-3 fatty acids had decreased cellular infiltration (P<.01), and the group receiving omega-6 fatty acids had decreased desquamation and redness (P<.05). In the omega-6 group, there was a significant correlation between clinical improvement (decrease in clinical score) and increase in serum eicosapentaenoic acid (r=−0.34; P<.05) and total omega-3 fatty acids (r=−0.36; P<.05). Overall, the authors concluded that supplementation with omega-3 fatty acids (fish oil) was no better than omega-6 fatty acids (corn oil) for treatment of psoriasis.³¹

Some dermatologists have advocated for the use of oral vitamin D supplementation as an adjunctive treatment of psoriasis, given that it is inexpensive and also may play a role in reducing the risk for cancer and cardiovascular events.³² One study evaluated the level of 25-hydroxy vitamin D in 43 psoriasis patients compared to 43 healthy controls. Mean (SD) vitamin D levels were significantly lower in psoriasis patients (13.3 [6.9]) compared to controls (22.4 [18.4])(P=.004).³³ A cross-sectional study similarly found significantly higher rates of vitamin D deficiency (25-hydroxy vitamin D <20 ng/mL) in psoriatic patients (57.8%) compared to patients with rheumatoid arthritis (37.5%) and healthy controls (29.7%)(P<.001). Interestingly, during winter the prevalence of vitamin D deficiency increased to 80.9%, 41.3%, and 30.3% in the 3 groups, respectively; however, no significant correlation was seen between psoriasis severity, as measured by psoriasis area and severity index, and serum vitamin D levels.³⁴ Although vitamin D deficiency may be more prevalent among patients with psoriasis, data regarding the efficacy of treating psoriasis with oral vitamin D supplementation is still lacking.

Conclusion

Our understanding of the link between diet and dermatologic conditions continues to evolve. Recent data for several dietary supplements and therapies showed promising results in repairing signs of photoaging, as well as treating AV, AD, and psoriasis. As patients seek these adjunctive therapies, it is important for physicians to be well informed on the benefits and risks to appropriately counsel patients.

Globally, physicians advocate for a low-glycemic diet rich in fruits and vegetables. Furthermore, the cosmetic diet can be enhanced by the consumption of dietary supplements such as beta-carotene, collagen peptides, zinc, and fat-soluble vitamins such as vitamins D and E. However, prospective RCTs are needed to further investigate the role of these dietary elements in treating and improving dermatologic conditions.

WASHINGTON – Treating pruritus in children necessitates different approaches than those typically used to treat adult pruritus, Suephy C. Chen, MD, said at the annual meeting of the American Academy of Dermatology.

Using special scales to measure itch in children and understanding that quality of life concerns may be different for children should also be kept in mind, said Dr. Chen, professor of dermatology at Emory University, Atlanta. Furthermore, several psychiatric comorbidities that have been associated with pediatric pruritus, such as ADHD and suicidal thoughts. Another consideration is that a child’s pruritus can have significant effects on his or her parents.

Measuring itch is challenging in children, who may have difficulty responding to visual analogue scales, verbal rating scales, and numerical rating scales. Dr. Chen and her colleagues developed the ItchyQuant scale as a self-report measure of itch severity  (J Invest Dermatol. 2017 Jan;137[1]:57-61). It is a scale from 0 to 10 with cartoon illustrations depicting increasing itch severity, from no itch to the “worst itch imaginable.” Currently it is validated only in adults, but they are working towards getting it validated in children.

Another itch assessment scale for children, Itch Man, is available, but has only been studied in children who have survived burns.

The ItchyQOL scale measures the extent to which itch affects quality of life in adults. It examines the symptoms associated with itch, as well as its functional and emotional effects. But children’s concerns about quality of life are not the same as those of adults, so Dr. Chen and her colleagues used ItchyQOL as a basis for the “Tween ItchyQOL,” which is intended for children aged 8-17 years, and the “Kids ItchyQOL,” which is intended for children aged 6-7 years. The Tween ItchyQOL includes items (such as being made fun of) that are not in the ItchyQOL and eliminates items (such as working and spending money) that do not apply to children. The Kids ItchyQOL includes cartoons to help children understand the questions.

Dermatologists often use parents as proxies to measure their children’s itch, assuming that the latter’s responses might be unreliable. But when Dr. Chen and her colleagues administered the ItchyQuant to children with pruritus, parents, and their medical providers to evaluate the extent of agreement among assessors, they found that parents’ scores were higher than their children’s scores, although the difference was not significant.

Providers’ scores, however, were significantly lower than those of children and parents. All scores were in the moderate range. Dr. Chen and colleagues also found that, for each 1-point increase in the difference between children’s and parents’ responses, parents were 1.25 times less likely to have experience with chronic pruritus, outside of their children. This finding provides a gauge of how well a parent can serve as a proxy to characterize his or her child’s itch.

Adolescents are in general a troubled group, and caregivers have concerns about suicide in the adolescent population, Dr. Chen said. She referred to a large study of adolescents published in 2012, which indicated that the prevalence of suicidal ideation was 8.4% among adolescents with no itch, compared with 21.1% among adolescents with severe itch (Acta Derm Venereol. 2012 Sep;92[5]:543-6).

In the study, those with severe itch were three times more likely to have suicidal ideation than the general population, which Dr. Chen noted was comparable with that of suicidal ideation in patients with chronic pain in the study (odds ratio, 3.8).

Cross-sectional data suggest a link between itching and ADHD, but “it’s a chicken-and-egg phenomenon,” she said. “If you’re so itchy and squirmy, you’re not going to pay attention. Then again, if you’re not paying attention, maybe you’re that much more prone to scratch.” Longitudinal data indicate that improving itch correlates with improvement in ADHD symptoms.

In addition, pruritus affects the genders disproportionately. Girls report a significantly greater impact on quality of life than boys when itching is severe, with much of the difference in emotional impact, said Dr. Chen. Boys may report more functional impact than girls.

Chronic pruritus also affects parents, who may have disturbed sleep, feel stress about their own parenting, and have difficulty enforcing discipline. “They feel an incredible amount of guilt and blame for giving this to their child,” she commented. “As more and more places develop itch centers, it would be good to have a multidisciplinary approach bringing in mental health providers and social workers, because the impact of itch on parents can be quite profound.”

Dr. Chen reported disclosures with several companies, including BioPharmX, Dermecular Therapeutics, Leo Pharma, and Unilever.

egreb@mdedge.com

WASHINGTON – Treating pruritus in children necessitates different approaches than those typically used to treat adult pruritus, Suephy C. Chen, MD, said at the annual meeting of the American Academy of Dermatology.

Using special scales to measure itch in children and understanding that quality of life concerns may be different for children should also be kept in mind, said Dr. Chen, professor of dermatology at Emory University, Atlanta. Furthermore, several psychiatric comorbidities that have been associated with pediatric pruritus, such as ADHD and suicidal thoughts. Another consideration is that a child’s pruritus can have significant effects on his or her parents.

Measuring itch is challenging in children, who may have difficulty responding to visual analogue scales, verbal rating scales, and numerical rating scales. Dr. Chen and her colleagues developed the ItchyQuant scale as a self-report measure of itch severity  (J Invest Dermatol. 2017 Jan;137[1]:57-61). It is a scale from 0 to 10 with cartoon illustrations depicting increasing itch severity, from no itch to the “worst itch imaginable.” Currently it is validated only in adults, but they are working towards getting it validated in children.

Another itch assessment scale for children, Itch Man, is available, but has only been studied in children who have survived burns.

The ItchyQOL scale measures the extent to which itch affects quality of life in adults. It examines the symptoms associated with itch, as well as its functional and emotional effects. But children’s concerns about quality of life are not the same as those of adults, so Dr. Chen and her colleagues used ItchyQOL as a basis for the “Tween ItchyQOL,” which is intended for children aged 8-17 years, and the “Kids ItchyQOL,” which is intended for children aged 6-7 years. The Tween ItchyQOL includes items (such as being made fun of) that are not in the ItchyQOL and eliminates items (such as working and spending money) that do not apply to children. The Kids ItchyQOL includes cartoons to help children understand the questions.

Dermatologists often use parents as proxies to measure their children’s itch, assuming that the latter’s responses might be unreliable. But when Dr. Chen and her colleagues administered the ItchyQuant to children with pruritus, parents, and their medical providers to evaluate the extent of agreement among assessors, they found that parents’ scores were higher than their children’s scores, although the difference was not significant.

Providers’ scores, however, were significantly lower than those of children and parents. All scores were in the moderate range. Dr. Chen and colleagues also found that, for each 1-point increase in the difference between children’s and parents’ responses, parents were 1.25 times less likely to have experience with chronic pruritus, outside of their children. This finding provides a gauge of how well a parent can serve as a proxy to characterize his or her child’s itch.

Adolescents are in general a troubled group, and caregivers have concerns about suicide in the adolescent population, Dr. Chen said. She referred to a large study of adolescents published in 2012, which indicated that the prevalence of suicidal ideation was 8.4% among adolescents with no itch, compared with 21.1% among adolescents with severe itch (Acta Derm Venereol. 2012 Sep;92[5]:543-6).

In the study, those with severe itch were three times more likely to have suicidal ideation than the general population, which Dr. Chen noted was comparable with that of suicidal ideation in patients with chronic pain in the study (odds ratio, 3.8).

Cross-sectional data suggest a link between itching and ADHD, but “it’s a chicken-and-egg phenomenon,” she said. “If you’re so itchy and squirmy, you’re not going to pay attention. Then again, if you’re not paying attention, maybe you’re that much more prone to scratch.” Longitudinal data indicate that improving itch correlates with improvement in ADHD symptoms.

In addition, pruritus affects the genders disproportionately. Girls report a significantly greater impact on quality of life than boys when itching is severe, with much of the difference in emotional impact, said Dr. Chen. Boys may report more functional impact than girls.

Chronic pruritus also affects parents, who may have disturbed sleep, feel stress about their own parenting, and have difficulty enforcing discipline. “They feel an incredible amount of guilt and blame for giving this to their child,” she commented. “As more and more places develop itch centers, it would be good to have a multidisciplinary approach bringing in mental health providers and social workers, because the impact of itch on parents can be quite profound.”

Dr. Chen reported disclosures with several companies, including BioPharmX, Dermecular Therapeutics, Leo Pharma, and Unilever.

egreb@mdedge.com

WASHINGTON – Treating pruritus in children necessitates different approaches than those typically used to treat adult pruritus, Suephy C. Chen, MD, said at the annual meeting of the American Academy of Dermatology.

Using special scales to measure itch in children and understanding that quality of life concerns may be different for children should also be kept in mind, said Dr. Chen, professor of dermatology at Emory University, Atlanta. Furthermore, several psychiatric comorbidities that have been associated with pediatric pruritus, such as ADHD and suicidal thoughts. Another consideration is that a child’s pruritus can have significant effects on his or her parents.

Measuring itch is challenging in children, who may have difficulty responding to visual analogue scales, verbal rating scales, and numerical rating scales. Dr. Chen and her colleagues developed the ItchyQuant scale as a self-report measure of itch severity  (J Invest Dermatol. 2017 Jan;137[1]:57-61). It is a scale from 0 to 10 with cartoon illustrations depicting increasing itch severity, from no itch to the “worst itch imaginable.” Currently it is validated only in adults, but they are working towards getting it validated in children.

Another itch assessment scale for children, Itch Man, is available, but has only been studied in children who have survived burns.

The ItchyQOL scale measures the extent to which itch affects quality of life in adults. It examines the symptoms associated with itch, as well as its functional and emotional effects. But children’s concerns about quality of life are not the same as those of adults, so Dr. Chen and her colleagues used ItchyQOL as a basis for the “Tween ItchyQOL,” which is intended for children aged 8-17 years, and the “Kids ItchyQOL,” which is intended for children aged 6-7 years. The Tween ItchyQOL includes items (such as being made fun of) that are not in the ItchyQOL and eliminates items (such as working and spending money) that do not apply to children. The Kids ItchyQOL includes cartoons to help children understand the questions.

Dermatologists often use parents as proxies to measure their children’s itch, assuming that the latter’s responses might be unreliable. But when Dr. Chen and her colleagues administered the ItchyQuant to children with pruritus, parents, and their medical providers to evaluate the extent of agreement among assessors, they found that parents’ scores were higher than their children’s scores, although the difference was not significant.

Providers’ scores, however, were significantly lower than those of children and parents. All scores were in the moderate range. Dr. Chen and colleagues also found that, for each 1-point increase in the difference between children’s and parents’ responses, parents were 1.25 times less likely to have experience with chronic pruritus, outside of their children. This finding provides a gauge of how well a parent can serve as a proxy to characterize his or her child’s itch.

Adolescents are in general a troubled group, and caregivers have concerns about suicide in the adolescent population, Dr. Chen said. She referred to a large study of adolescents published in 2012, which indicated that the prevalence of suicidal ideation was 8.4% among adolescents with no itch, compared with 21.1% among adolescents with severe itch (Acta Derm Venereol. 2012 Sep;92[5]:543-6).

In the study, those with severe itch were three times more likely to have suicidal ideation than the general population, which Dr. Chen noted was comparable with that of suicidal ideation in patients with chronic pain in the study (odds ratio, 3.8).

Cross-sectional data suggest a link between itching and ADHD, but “it’s a chicken-and-egg phenomenon,” she said. “If you’re so itchy and squirmy, you’re not going to pay attention. Then again, if you’re not paying attention, maybe you’re that much more prone to scratch.” Longitudinal data indicate that improving itch correlates with improvement in ADHD symptoms.

In addition, pruritus affects the genders disproportionately. Girls report a significantly greater impact on quality of life than boys when itching is severe, with much of the difference in emotional impact, said Dr. Chen. Boys may report more functional impact than girls.

Chronic pruritus also affects parents, who may have disturbed sleep, feel stress about their own parenting, and have difficulty enforcing discipline. “They feel an incredible amount of guilt and blame for giving this to their child,” she commented. “As more and more places develop itch centers, it would be good to have a multidisciplinary approach bringing in mental health providers and social workers, because the impact of itch on parents can be quite profound.”

Dr. Chen reported disclosures with several companies, including BioPharmX, Dermecular Therapeutics, Leo Pharma, and Unilever.

egreb@mdedge.com

WASHINGTON – Eczema is an independent risk factor for mental health impairment among American children, according to an analysis described at the annual meeting of the American Academy of Dermatology. Eczema appears to influence several domains of mental health, and the association remains in the absence of other atopic illnesses.

Estimates of the prevalence of eczema in children have ranged as high as 20%. European and Japanese studies have suggested that children with eczema have greater mental health impairments overall, but researchers have not evaluated this association among U.S. children. Although it has been established that children with eczema consult health care providers more often than children without eczema, data on health care utilization among children with eczema and impaired mental health are limited.

Joy Wan, MD, a dermatologist at Children’s Hospital of Philadelphia, and her colleagues performed a cross-sectional analysis of data obtained from 2013 to 2017 by the National Health Interview Survey. The Centers for Disease Control and Prevention administers the survey to a representative sample of the U.S. population. Children in each household are randomly sampled, and adult caregivers provide detailed health information about them.

Dr. Wan and her colleagues included children aged between 4 and 17 years in their analysis. The exposure of interest was eczema. Caregivers reported eczema in response to the question, “During the past 12 months, has the child had eczema or any kind of skin allergy?” The study’s primary outcome was mental health impairment. Using the Strengths and Difficulties Questionnaire (SDQ), the investigators categorized mental health impairment as none, mild, or severe. The SDQ is a validated instrument that assesses symptoms of mental health in children in domains such as conduct, emotion, peer relationships, and attention, which the researchers chose as secondary outcomes of interest. Dr. Wan’s group also examined the utilization of mental health and other health and social services among children with eczema.

The researchers performed logistic regression analysis to obtain odds ratios for mental health impairment among children with eczema, adjusting the analysis for potential socioeconomic and demographic confounders. Furthermore, they stratified the primary model by other atopic and behavioral disorders to assess for potential effects modification by these concomitant illnesses.

Approximately 12% of the children in the sample had eczema. Children with eczema tended to be female, non-Hispanic, or black; they also were more likely to report good, fair, or poor health, compared with children without eczema. Asthma, allergic rhinitis, and ADHD were more common among children with eczema than those without.

About 27% of children with eczema had any mental health impairment, compared with approximately 18% of children without eczema. About 11% of children with eczema had severe impairment; this rate was almost twice as high as that in children without eczema, Dr. Wan said. The adjusted odds of mental health impairment were 52% per year among children with eczema, compared with those without.

When the researchers examined specific domains of mental health, they found that children with eczema were significantly less likely to be reported to be well behaved or to have good attention spans. They also were significantly more likely to worry often, be unhappy or depressed, and to get along better with adults than their peers.

When Dr. Wan and his colleagues stratified the primary model by other atopic illnesses, they found that, among children without any other atopic illness, eczema remained independently associated with mental health impairment (OR, 1.52). The effect remained similar among children with asthma alone, but was attenuated among children with allergic rhinitis alone or with asthma and allergic rhinitis.

In the absence of ADHD, the investigators found a statistically significant effect of eczema on mental health impairment (OR, 1.46). In the presence of ADHD, the effect remained significant, but was attenuated.

Finally, approximately 20% of children with mildly impaired mental health had seen a mental health professional in the past year. In addition, 54% of children with severe mental health symptoms had seen a mental health professional in the past year. Among children with severe impairment, about 80% had consulted a general practitioner in the past year; 45% of them reported emotional or behavioral issues as the reason for the visit. Use of special education and early intervention services were more prevalent among children with increasing degrees of mental health impairment.

The study’s strengths include its population-based design, the use of a validated psychometric instrument, and the adjustment of data for socioeconomic factors and other comorbid illnesses, Dr. Wan said. The study is cross sectional, however, which precludes conclusions about the directionality of the relationship between eczema and mental health. In addition, the SDQ may not capture all mental health symptoms that eczema affects.

It is imperative that clinicians and caregivers recognize how common mental health impairment is among children with eczema so that children can be appropriately screened and referred for care, Dr. Wan said. “Our study suggests that there may be a critical gap in mental health services utilization by children who have eczema and concomitant mental health impairment. Some of the future directions in this area may be to understand the potential barriers to mental health care in children with eczema, and certainly to identify potentially effective interventions to reduce the mental health burden in pediatric eczema.”

Dr. Wan reported receiving research fellowship funding from Pfizer.

egreb@mdedge.com

WASHINGTON – Eczema is an independent risk factor for mental health impairment among American children, according to an analysis described at the annual meeting of the American Academy of Dermatology. Eczema appears to influence several domains of mental health, and the association remains in the absence of other atopic illnesses.

Estimates of the prevalence of eczema in children have ranged as high as 20%. European and Japanese studies have suggested that children with eczema have greater mental health impairments overall, but researchers have not evaluated this association among U.S. children. Although it has been established that children with eczema consult health care providers more often than children without eczema, data on health care utilization among children with eczema and impaired mental health are limited.

Joy Wan, MD, a dermatologist at Children’s Hospital of Philadelphia, and her colleagues performed a cross-sectional analysis of data obtained from 2013 to 2017 by the National Health Interview Survey. The Centers for Disease Control and Prevention administers the survey to a representative sample of the U.S. population. Children in each household are randomly sampled, and adult caregivers provide detailed health information about them.

Dr. Wan and her colleagues included children aged between 4 and 17 years in their analysis. The exposure of interest was eczema. Caregivers reported eczema in response to the question, “During the past 12 months, has the child had eczema or any kind of skin allergy?” The study’s primary outcome was mental health impairment. Using the Strengths and Difficulties Questionnaire (SDQ), the investigators categorized mental health impairment as none, mild, or severe. The SDQ is a validated instrument that assesses symptoms of mental health in children in domains such as conduct, emotion, peer relationships, and attention, which the researchers chose as secondary outcomes of interest. Dr. Wan’s group also examined the utilization of mental health and other health and social services among children with eczema.

The researchers performed logistic regression analysis to obtain odds ratios for mental health impairment among children with eczema, adjusting the analysis for potential socioeconomic and demographic confounders. Furthermore, they stratified the primary model by other atopic and behavioral disorders to assess for potential effects modification by these concomitant illnesses.

Approximately 12% of the children in the sample had eczema. Children with eczema tended to be female, non-Hispanic, or black; they also were more likely to report good, fair, or poor health, compared with children without eczema. Asthma, allergic rhinitis, and ADHD were more common among children with eczema than those without.

About 27% of children with eczema had any mental health impairment, compared with approximately 18% of children without eczema. About 11% of children with eczema had severe impairment; this rate was almost twice as high as that in children without eczema, Dr. Wan said. The adjusted odds of mental health impairment were 52% per year among children with eczema, compared with those without.

When the researchers examined specific domains of mental health, they found that children with eczema were significantly less likely to be reported to be well behaved or to have good attention spans. They also were significantly more likely to worry often, be unhappy or depressed, and to get along better with adults than their peers.

When Dr. Wan and his colleagues stratified the primary model by other atopic illnesses, they found that, among children without any other atopic illness, eczema remained independently associated with mental health impairment (OR, 1.52). The effect remained similar among children with asthma alone, but was attenuated among children with allergic rhinitis alone or with asthma and allergic rhinitis.

In the absence of ADHD, the investigators found a statistically significant effect of eczema on mental health impairment (OR, 1.46). In the presence of ADHD, the effect remained significant, but was attenuated.

Finally, approximately 20% of children with mildly impaired mental health had seen a mental health professional in the past year. In addition, 54% of children with severe mental health symptoms had seen a mental health professional in the past year. Among children with severe impairment, about 80% had consulted a general practitioner in the past year; 45% of them reported emotional or behavioral issues as the reason for the visit. Use of special education and early intervention services were more prevalent among children with increasing degrees of mental health impairment.

The study’s strengths include its population-based design, the use of a validated psychometric instrument, and the adjustment of data for socioeconomic factors and other comorbid illnesses, Dr. Wan said. The study is cross sectional, however, which precludes conclusions about the directionality of the relationship between eczema and mental health. In addition, the SDQ may not capture all mental health symptoms that eczema affects.

It is imperative that clinicians and caregivers recognize how common mental health impairment is among children with eczema so that children can be appropriately screened and referred for care, Dr. Wan said. “Our study suggests that there may be a critical gap in mental health services utilization by children who have eczema and concomitant mental health impairment. Some of the future directions in this area may be to understand the potential barriers to mental health care in children with eczema, and certainly to identify potentially effective interventions to reduce the mental health burden in pediatric eczema.”

Dr. Wan reported receiving research fellowship funding from Pfizer.

egreb@mdedge.com

WASHINGTON – Eczema is an independent risk factor for mental health impairment among American children, according to an analysis described at the annual meeting of the American Academy of Dermatology. Eczema appears to influence several domains of mental health, and the association remains in the absence of other atopic illnesses.

Estimates of the prevalence of eczema in children have ranged as high as 20%. European and Japanese studies have suggested that children with eczema have greater mental health impairments overall, but researchers have not evaluated this association among U.S. children. Although it has been established that children with eczema consult health care providers more often than children without eczema, data on health care utilization among children with eczema and impaired mental health are limited.

Joy Wan, MD, a dermatologist at Children’s Hospital of Philadelphia, and her colleagues performed a cross-sectional analysis of data obtained from 2013 to 2017 by the National Health Interview Survey. The Centers for Disease Control and Prevention administers the survey to a representative sample of the U.S. population. Children in each household are randomly sampled, and adult caregivers provide detailed health information about them.

Dr. Wan and her colleagues included children aged between 4 and 17 years in their analysis. The exposure of interest was eczema. Caregivers reported eczema in response to the question, “During the past 12 months, has the child had eczema or any kind of skin allergy?” The study’s primary outcome was mental health impairment. Using the Strengths and Difficulties Questionnaire (SDQ), the investigators categorized mental health impairment as none, mild, or severe. The SDQ is a validated instrument that assesses symptoms of mental health in children in domains such as conduct, emotion, peer relationships, and attention, which the researchers chose as secondary outcomes of interest. Dr. Wan’s group also examined the utilization of mental health and other health and social services among children with eczema.

The researchers performed logistic regression analysis to obtain odds ratios for mental health impairment among children with eczema, adjusting the analysis for potential socioeconomic and demographic confounders. Furthermore, they stratified the primary model by other atopic and behavioral disorders to assess for potential effects modification by these concomitant illnesses.

Approximately 12% of the children in the sample had eczema. Children with eczema tended to be female, non-Hispanic, or black; they also were more likely to report good, fair, or poor health, compared with children without eczema. Asthma, allergic rhinitis, and ADHD were more common among children with eczema than those without.

About 27% of children with eczema had any mental health impairment, compared with approximately 18% of children without eczema. About 11% of children with eczema had severe impairment; this rate was almost twice as high as that in children without eczema, Dr. Wan said. The adjusted odds of mental health impairment were 52% per year among children with eczema, compared with those without.

When the researchers examined specific domains of mental health, they found that children with eczema were significantly less likely to be reported to be well behaved or to have good attention spans. They also were significantly more likely to worry often, be unhappy or depressed, and to get along better with adults than their peers.

When Dr. Wan and his colleagues stratified the primary model by other atopic illnesses, they found that, among children without any other atopic illness, eczema remained independently associated with mental health impairment (OR, 1.52). The effect remained similar among children with asthma alone, but was attenuated among children with allergic rhinitis alone or with asthma and allergic rhinitis.

In the absence of ADHD, the investigators found a statistically significant effect of eczema on mental health impairment (OR, 1.46). In the presence of ADHD, the effect remained significant, but was attenuated.

Finally, approximately 20% of children with mildly impaired mental health had seen a mental health professional in the past year. In addition, 54% of children with severe mental health symptoms had seen a mental health professional in the past year. Among children with severe impairment, about 80% had consulted a general practitioner in the past year; 45% of them reported emotional or behavioral issues as the reason for the visit. Use of special education and early intervention services were more prevalent among children with increasing degrees of mental health impairment.

The study’s strengths include its population-based design, the use of a validated psychometric instrument, and the adjustment of data for socioeconomic factors and other comorbid illnesses, Dr. Wan said. The study is cross sectional, however, which precludes conclusions about the directionality of the relationship between eczema and mental health. In addition, the SDQ may not capture all mental health symptoms that eczema affects.

It is imperative that clinicians and caregivers recognize how common mental health impairment is among children with eczema so that children can be appropriately screened and referred for care, Dr. Wan said. “Our study suggests that there may be a critical gap in mental health services utilization by children who have eczema and concomitant mental health impairment. Some of the future directions in this area may be to understand the potential barriers to mental health care in children with eczema, and certainly to identify potentially effective interventions to reduce the mental health burden in pediatric eczema.”

Dr. Wan reported receiving research fellowship funding from Pfizer.

egreb@mdedge.com

WAIKOLOA, HAWAII – Since its approval in 2017, dupilumab (Dupixent) has proven to be a solid addition to the atopic dermatitis (AD) armamentarium.

Vidyard Video

About 80% to 85% of patients treated with the biologic will achieve a 50% reduction in their Eczema Area and Severity Index score, and some will go on to a 90% reduction, according to Jonathan Silverberg, MD, PhD, of the department of dermatology, Northwestern University, Chicago.

But one side effect associated with dupilumab has been vexing to dermatologists: conjunctivitis in 15% or so of patients. Dr. Silverberg has seen it in his own practice and said it can be hard to know whether or not to refer to ophthalmology. “We’re often left with this conundrum of ... ‘Is it a side effect of the medication, or is it just because they happen to have hay fever or keratoconjunctivitis or other ophthalmic comorbidities?’ And it’s not always easy to sort out.”


In an interview at the Hawaii Dermatology Seminar, provided by Global Academy for Medical Education/Skin Disease Education Foundation, he offered his advice on managing a patient who develops conjunctivitis during dupilumab treatment, including his treatment tips for when it is safe to handle in the dermatology clinic.

Dr. Silverberg, who was an investigator in the dupilumab phase 3 trials, said that, while dupilumab is the only systemic agent approved by the Food and Drug Administration for treating AD, and more are on the way for AD, there will always still be a role for traditional immunosuppressives. He explained why in the interview and why he favors methotrexate when old school options are in order.

This news organization and SDEF/Global Academy for Medical Education are owned by the same parent company.

aotto@mdedge.com

WAIKOLOA, HAWAII – Since its approval in 2017, dupilumab (Dupixent) has proven to be a solid addition to the atopic dermatitis (AD) armamentarium.

Vidyard Video

About 80% to 85% of patients treated with the biologic will achieve a 50% reduction in their Eczema Area and Severity Index score, and some will go on to a 90% reduction, according to Jonathan Silverberg, MD, PhD, of the department of dermatology, Northwestern University, Chicago.

But one side effect associated with dupilumab has been vexing to dermatologists: conjunctivitis in 15% or so of patients. Dr. Silverberg has seen it in his own practice and said it can be hard to know whether or not to refer to ophthalmology. “We’re often left with this conundrum of ... ‘Is it a side effect of the medication, or is it just because they happen to have hay fever or keratoconjunctivitis or other ophthalmic comorbidities?’ And it’s not always easy to sort out.”


In an interview at the Hawaii Dermatology Seminar, provided by Global Academy for Medical Education/Skin Disease Education Foundation, he offered his advice on managing a patient who develops conjunctivitis during dupilumab treatment, including his treatment tips for when it is safe to handle in the dermatology clinic.

Dr. Silverberg, who was an investigator in the dupilumab phase 3 trials, said that, while dupilumab is the only systemic agent approved by the Food and Drug Administration for treating AD, and more are on the way for AD, there will always still be a role for traditional immunosuppressives. He explained why in the interview and why he favors methotrexate when old school options are in order.

This news organization and SDEF/Global Academy for Medical Education are owned by the same parent company.

aotto@mdedge.com

WAIKOLOA, HAWAII – Since its approval in 2017, dupilumab (Dupixent) has proven to be a solid addition to the atopic dermatitis (AD) armamentarium.

Vidyard Video

About 80% to 85% of patients treated with the biologic will achieve a 50% reduction in their Eczema Area and Severity Index score, and some will go on to a 90% reduction, according to Jonathan Silverberg, MD, PhD, of the department of dermatology, Northwestern University, Chicago.

But one side effect associated with dupilumab has been vexing to dermatologists: conjunctivitis in 15% or so of patients. Dr. Silverberg has seen it in his own practice and said it can be hard to know whether or not to refer to ophthalmology. “We’re often left with this conundrum of ... ‘Is it a side effect of the medication, or is it just because they happen to have hay fever or keratoconjunctivitis or other ophthalmic comorbidities?’ And it’s not always easy to sort out.”


In an interview at the Hawaii Dermatology Seminar, provided by Global Academy for Medical Education/Skin Disease Education Foundation, he offered his advice on managing a patient who develops conjunctivitis during dupilumab treatment, including his treatment tips for when it is safe to handle in the dermatology clinic.

Dr. Silverberg, who was an investigator in the dupilumab phase 3 trials, said that, while dupilumab is the only systemic agent approved by the Food and Drug Administration for treating AD, and more are on the way for AD, there will always still be a role for traditional immunosuppressives. He explained why in the interview and why he favors methotrexate when old school options are in order.

This news organization and SDEF/Global Academy for Medical Education are owned by the same parent company.

aotto@mdedge.com

GRAND CAYMAN, CAYMAN ISLANDS – Atopic dermatitis (AD) researchers are serving up a lot more than oatmeal and steroids these days.

Moisturizers that confer skin barrier protection, lipid-replenishing topicals, and some biologics are available now or will soon be available for patients with AD, Joseph Fowler Jr., MD, said at the Caribbean Dermatology Symposium provided by Global Academy for Medical Education.

With the approval of dupilumab for moderate to severe disease in 2017, a biologic finally became available for treating AD, said Dr. Fowler of the University of Louisville (Ky.). While it’s not a cure and may take as long as 6 months to really kick in, “I think almost everyone gets some benefit from it. And although it’s not approved yet for anyone under 18, I’m sure it will be.”

He provided a brief rundown of dupilumab; crisaborole, another relatively new agent for AD; and some agents that are being investigated.

• Dupilumab. For AD, dupilumab, which inhibits interleukin-4 and interleukin-13 signaling, is usually started at 600 mg, then tapered to 300 mg subcutaneously every 2 weeks. Its pivotal data showed a mean 70% decrease in Eczema Area and Severity Index (EASI) scores over 16 weeks at that dose.*

“Again, I would say most patients do get benefit from this, but they might not see it for more than 3 months, and even up to 6 months. I’m not sure why, but some develop eye symptoms – I think these are more severe cases who also have respiratory atopy. I would also be interested to see if dupilumab might work on patients with chronic hand eczema,” he said.

• Crisaborole ointment 2%. A nonsteroidal topical phosphodiesterase 4 (PDE4) inhibitor approved in 2016 for mild to moderate AD in people aged 2 and older, crisaborole (Eucrisa) blocks the release of cyclic adenosine monophosphate (cAMP), which is elevated in AD. Lower cAMP levels lead to lower levels of inflammatory cytokines. In its pivotal phase 3 study, about 35% of patients achieved clinical success – an Investigator’s Static Global Assessment (ISGA) score of 0 or 1, or at least a two-grade improvement over baseline.

“In my opinion, it’s similar or slightly better than topical corticosteroids, and safer as well, especially in our younger patients, or when the face or intertriginous areas are involved,” Dr. Fowler said. “There is often some application site stinging and burning. If you put it in the fridge and get it good and cold when it goes on, that seems to moderate the sensation. It’s a good steroid-sparing option.”

Crisaborole is now being investigated for use in infants aged 3-24 months with mild to moderate AD.

• Tofacitinib ointment. This topical form of tofacitinib, an inhibitor of Janus kinase 1 and 3, is being evaluated in a placebo-controlled trial in adults with mild to moderate AD. There are also a few reports of oral tofacitinib improving AD, including a case report (Clin Exp Dermatol. 2017 Dec;42[8]:942-4). Dr. Fowler noted a small series of six adults with moderate to severe AD uncontrolled with methotrexate or azathioprine. The patients received oral tofacitinib 5 mg twice a day for 8-29 weeks; there was a mean 67% improvement in the Scoring Atopic Dermatitis (SCORAD) index.
• Ustekinumab. The interleukin-12 and -23 antagonist indicated for moderate to severe psoriasis has also made an appearance in the AD literature, including an Austrian report of three patients with severe AD who received 45 mg of ustekinumab (Stelara) subcutaneously at 0, 4 and 12 weeks. By week 16, all of them experienced a 50% reduction in their EASI score, with a marked reduction in interleukin-22 markers (J Am Acad Dermatol. 2017 Jan;76[1]:91-7.e3).

But no matter which therapy is chosen, regular moisturizing is critically important, Dr. Fowler remarked. Expensive prescription moisturizers are available, but he questioned whether they offer any cost-worthy extra benefit over a good nonprescription moisturizer.

“Do these super-moisturizers protect the skin barrier any more than petrolatum? I can’t answer that. They promise better results, but each patient and doc have to make the decision. If your patient can afford it, maybe some will be better for their skin, but really, it’s not as important as some of the other medications. So, I tell them, if cost is an issue, don’t worry about the fancy moisturizers.”

Dr. Fowler disclosed relationships with multiple pharmaceutical companies.

Global Academy and this news organization are owned by the same parent company.

Correction, 2/15/19: An earlier version of this article mischaracterized the chemical action of dupilumab.

msullivan@mdedge.com

GRAND CAYMAN, CAYMAN ISLANDS – Atopic dermatitis (AD) researchers are serving up a lot more than oatmeal and steroids these days.

Moisturizers that confer skin barrier protection, lipid-replenishing topicals, and some biologics are available now or will soon be available for patients with AD, Joseph Fowler Jr., MD, said at the Caribbean Dermatology Symposium provided by Global Academy for Medical Education.

With the approval of dupilumab for moderate to severe disease in 2017, a biologic finally became available for treating AD, said Dr. Fowler of the University of Louisville (Ky.). While it’s not a cure and may take as long as 6 months to really kick in, “I think almost everyone gets some benefit from it. And although it’s not approved yet for anyone under 18, I’m sure it will be.”

He provided a brief rundown of dupilumab; crisaborole, another relatively new agent for AD; and some agents that are being investigated.

• Dupilumab. For AD, dupilumab, which inhibits interleukin-4 and interleukin-13 signaling, is usually started at 600 mg, then tapered to 300 mg subcutaneously every 2 weeks. Its pivotal data showed a mean 70% decrease in Eczema Area and Severity Index (EASI) scores over 16 weeks at that dose.*

“Again, I would say most patients do get benefit from this, but they might not see it for more than 3 months, and even up to 6 months. I’m not sure why, but some develop eye symptoms – I think these are more severe cases who also have respiratory atopy. I would also be interested to see if dupilumab might work on patients with chronic hand eczema,” he said.

• Crisaborole ointment 2%. A nonsteroidal topical phosphodiesterase 4 (PDE4) inhibitor approved in 2016 for mild to moderate AD in people aged 2 and older, crisaborole (Eucrisa) blocks the release of cyclic adenosine monophosphate (cAMP), which is elevated in AD. Lower cAMP levels lead to lower levels of inflammatory cytokines. In its pivotal phase 3 study, about 35% of patients achieved clinical success – an Investigator’s Static Global Assessment (ISGA) score of 0 or 1, or at least a two-grade improvement over baseline.

“In my opinion, it’s similar or slightly better than topical corticosteroids, and safer as well, especially in our younger patients, or when the face or intertriginous areas are involved,” Dr. Fowler said. “There is often some application site stinging and burning. If you put it in the fridge and get it good and cold when it goes on, that seems to moderate the sensation. It’s a good steroid-sparing option.”

Crisaborole is now being investigated for use in infants aged 3-24 months with mild to moderate AD.

• Tofacitinib ointment. This topical form of tofacitinib, an inhibitor of Janus kinase 1 and 3, is being evaluated in a placebo-controlled trial in adults with mild to moderate AD. There are also a few reports of oral tofacitinib improving AD, including a case report (Clin Exp Dermatol. 2017 Dec;42[8]:942-4). Dr. Fowler noted a small series of six adults with moderate to severe AD uncontrolled with methotrexate or azathioprine. The patients received oral tofacitinib 5 mg twice a day for 8-29 weeks; there was a mean 67% improvement in the Scoring Atopic Dermatitis (SCORAD) index.
• Ustekinumab. The interleukin-12 and -23 antagonist indicated for moderate to severe psoriasis has also made an appearance in the AD literature, including an Austrian report of three patients with severe AD who received 45 mg of ustekinumab (Stelara) subcutaneously at 0, 4 and 12 weeks. By week 16, all of them experienced a 50% reduction in their EASI score, with a marked reduction in interleukin-22 markers (J Am Acad Dermatol. 2017 Jan;76[1]:91-7.e3).

But no matter which therapy is chosen, regular moisturizing is critically important, Dr. Fowler remarked. Expensive prescription moisturizers are available, but he questioned whether they offer any cost-worthy extra benefit over a good nonprescription moisturizer.

“Do these super-moisturizers protect the skin barrier any more than petrolatum? I can’t answer that. They promise better results, but each patient and doc have to make the decision. If your patient can afford it, maybe some will be better for their skin, but really, it’s not as important as some of the other medications. So, I tell them, if cost is an issue, don’t worry about the fancy moisturizers.”

Dr. Fowler disclosed relationships with multiple pharmaceutical companies.

Global Academy and this news organization are owned by the same parent company.

Correction, 2/15/19: An earlier version of this article mischaracterized the chemical action of dupilumab.

msullivan@mdedge.com

GRAND CAYMAN, CAYMAN ISLANDS – Atopic dermatitis (AD) researchers are serving up a lot more than oatmeal and steroids these days.

Moisturizers that confer skin barrier protection, lipid-replenishing topicals, and some biologics are available now or will soon be available for patients with AD, Joseph Fowler Jr., MD, said at the Caribbean Dermatology Symposium provided by Global Academy for Medical Education.

With the approval of dupilumab for moderate to severe disease in 2017, a biologic finally became available for treating AD, said Dr. Fowler of the University of Louisville (Ky.). While it’s not a cure and may take as long as 6 months to really kick in, “I think almost everyone gets some benefit from it. And although it’s not approved yet for anyone under 18, I’m sure it will be.”

He provided a brief rundown of dupilumab; crisaborole, another relatively new agent for AD; and some agents that are being investigated.

• Dupilumab. For AD, dupilumab, which inhibits interleukin-4 and interleukin-13 signaling, is usually started at 600 mg, then tapered to 300 mg subcutaneously every 2 weeks. Its pivotal data showed a mean 70% decrease in Eczema Area and Severity Index (EASI) scores over 16 weeks at that dose.*

“Again, I would say most patients do get benefit from this, but they might not see it for more than 3 months, and even up to 6 months. I’m not sure why, but some develop eye symptoms – I think these are more severe cases who also have respiratory atopy. I would also be interested to see if dupilumab might work on patients with chronic hand eczema,” he said.

• Crisaborole ointment 2%. A nonsteroidal topical phosphodiesterase 4 (PDE4) inhibitor approved in 2016 for mild to moderate AD in people aged 2 and older, crisaborole (Eucrisa) blocks the release of cyclic adenosine monophosphate (cAMP), which is elevated in AD. Lower cAMP levels lead to lower levels of inflammatory cytokines. In its pivotal phase 3 study, about 35% of patients achieved clinical success – an Investigator’s Static Global Assessment (ISGA) score of 0 or 1, or at least a two-grade improvement over baseline.

“In my opinion, it’s similar or slightly better than topical corticosteroids, and safer as well, especially in our younger patients, or when the face or intertriginous areas are involved,” Dr. Fowler said. “There is often some application site stinging and burning. If you put it in the fridge and get it good and cold when it goes on, that seems to moderate the sensation. It’s a good steroid-sparing option.”

Crisaborole is now being investigated for use in infants aged 3-24 months with mild to moderate AD.

• Tofacitinib ointment. This topical form of tofacitinib, an inhibitor of Janus kinase 1 and 3, is being evaluated in a placebo-controlled trial in adults with mild to moderate AD. There are also a few reports of oral tofacitinib improving AD, including a case report (Clin Exp Dermatol. 2017 Dec;42[8]:942-4). Dr. Fowler noted a small series of six adults with moderate to severe AD uncontrolled with methotrexate or azathioprine. The patients received oral tofacitinib 5 mg twice a day for 8-29 weeks; there was a mean 67% improvement in the Scoring Atopic Dermatitis (SCORAD) index.
• Ustekinumab. The interleukin-12 and -23 antagonist indicated for moderate to severe psoriasis has also made an appearance in the AD literature, including an Austrian report of three patients with severe AD who received 45 mg of ustekinumab (Stelara) subcutaneously at 0, 4 and 12 weeks. By week 16, all of them experienced a 50% reduction in their EASI score, with a marked reduction in interleukin-22 markers (J Am Acad Dermatol. 2017 Jan;76[1]:91-7.e3).

But no matter which therapy is chosen, regular moisturizing is critically important, Dr. Fowler remarked. Expensive prescription moisturizers are available, but he questioned whether they offer any cost-worthy extra benefit over a good nonprescription moisturizer.

“Do these super-moisturizers protect the skin barrier any more than petrolatum? I can’t answer that. They promise better results, but each patient and doc have to make the decision. If your patient can afford it, maybe some will be better for their skin, but really, it’s not as important as some of the other medications. So, I tell them, if cost is an issue, don’t worry about the fancy moisturizers.”

Dr. Fowler disclosed relationships with multiple pharmaceutical companies.

Global Academy and this news organization are owned by the same parent company.

Correction, 2/15/19: An earlier version of this article mischaracterized the chemical action of dupilumab.

msullivan@mdedge.com

Adults with mild to moderate atopic dermatitis showed significant improvement after 8 weeks of treatment with a novel topical cream, compared with a placebo group, based on data from 194 patients.

“Transient receptor potential vanilloid subfamily, member 1 (TRPV1) is expressed not only on sensory nerves, but also on keratinocytes, dendritic cells and sebocytes in the skin,” wrote Y.W. Lee, MD, of Konkuk University, Seoul, South Korea, and colleagues. Previous research suggests that TRPV1 may play a role in the inflammation and itching associated with atopic dermatitis, but use of a TRPV antagonist as treatment has not been well studied, the researchers said.

In a phase 2b trial published in the British Journal of Dermatology, the researchers randomized 194 adults with atopic dermatitis to one of three concentrations of a topical cream containing the selective TRPV1 antagonist PAC‐14028, or a placebo vehicle. The patients had baseline scores of 2 or 3 (mild to moderate) on the Investigator’s Global Assessment (IGA) scale. Patients were instructed to apply the cream twice daily to AD-affected areas.

After 8 weeks, treatment success (defined as a score of 0 or 1 on the IGA) occurred in 57% of patients given 1% cream, 38% of those given 0.3% cream, 43% of those given 0.1% cream, and 15% of those given a placebo cream.

In addition, other measures of improvement including the Scoring of Atopic Dermatitis (SCORAD) index, EASI 75/90, sleep disturbance score, and pruritus visual analogue scale (VAS) trended toward improvement in patients who received the treatment cream.

The mean change in the SCORAD index was significantly greater in the 0.1% and 1.0% groups, compared with the placebo group. Also of note, patients in the 1.0% cream group showed significant improvements in both sleep disturbance and VAS scores, compared with the placebo patients, the researchers said.

The incidence of adverse events was similar among the groups, and no treatment-related serious adverse events were reported. A total of 18 patients discontinued the study, but 193 received at least one dose of treatment cream.

The study findings were limited by several factors, including the small size and lack of comparison to treatment with topical corticosteroids and topical calcineurin inhibitors, the researchers noted.

However, the results support the safety and efficacy of PAC‐14028, they added. And “based on these results, a phase III program is underway to assess the efficacy and safety of PAC-14028 topical cream 10% in adolescent and adult patients with mild to moderate AD,” they said.

AmorePacific funded the study. Dr. Lee disclosed relationships with AmorePacific, as well as LG Household & Health Care and Medytox.

SOURCE: Lee YW et al. Br J Dermatol. 2019 Jan 8. doi: 10.1111/bjd.17455.

Adults with mild to moderate atopic dermatitis showed significant improvement after 8 weeks of treatment with a novel topical cream, compared with a placebo group, based on data from 194 patients.

“Transient receptor potential vanilloid subfamily, member 1 (TRPV1) is expressed not only on sensory nerves, but also on keratinocytes, dendritic cells and sebocytes in the skin,” wrote Y.W. Lee, MD, of Konkuk University, Seoul, South Korea, and colleagues. Previous research suggests that TRPV1 may play a role in the inflammation and itching associated with atopic dermatitis, but use of a TRPV antagonist as treatment has not been well studied, the researchers said.

In a phase 2b trial published in the British Journal of Dermatology, the researchers randomized 194 adults with atopic dermatitis to one of three concentrations of a topical cream containing the selective TRPV1 antagonist PAC‐14028, or a placebo vehicle. The patients had baseline scores of 2 or 3 (mild to moderate) on the Investigator’s Global Assessment (IGA) scale. Patients were instructed to apply the cream twice daily to AD-affected areas.

After 8 weeks, treatment success (defined as a score of 0 or 1 on the IGA) occurred in 57% of patients given 1% cream, 38% of those given 0.3% cream, 43% of those given 0.1% cream, and 15% of those given a placebo cream.

In addition, other measures of improvement including the Scoring of Atopic Dermatitis (SCORAD) index, EASI 75/90, sleep disturbance score, and pruritus visual analogue scale (VAS) trended toward improvement in patients who received the treatment cream.

The mean change in the SCORAD index was significantly greater in the 0.1% and 1.0% groups, compared with the placebo group. Also of note, patients in the 1.0% cream group showed significant improvements in both sleep disturbance and VAS scores, compared with the placebo patients, the researchers said.

The incidence of adverse events was similar among the groups, and no treatment-related serious adverse events were reported. A total of 18 patients discontinued the study, but 193 received at least one dose of treatment cream.

The study findings were limited by several factors, including the small size and lack of comparison to treatment with topical corticosteroids and topical calcineurin inhibitors, the researchers noted.

However, the results support the safety and efficacy of PAC‐14028, they added. And “based on these results, a phase III program is underway to assess the efficacy and safety of PAC-14028 topical cream 10% in adolescent and adult patients with mild to moderate AD,” they said.

AmorePacific funded the study. Dr. Lee disclosed relationships with AmorePacific, as well as LG Household & Health Care and Medytox.

SOURCE: Lee YW et al. Br J Dermatol. 2019 Jan 8. doi: 10.1111/bjd.17455.

Adults with mild to moderate atopic dermatitis showed significant improvement after 8 weeks of treatment with a novel topical cream, compared with a placebo group, based on data from 194 patients.

“Transient receptor potential vanilloid subfamily, member 1 (TRPV1) is expressed not only on sensory nerves, but also on keratinocytes, dendritic cells and sebocytes in the skin,” wrote Y.W. Lee, MD, of Konkuk University, Seoul, South Korea, and colleagues. Previous research suggests that TRPV1 may play a role in the inflammation and itching associated with atopic dermatitis, but use of a TRPV antagonist as treatment has not been well studied, the researchers said.

In a phase 2b trial published in the British Journal of Dermatology, the researchers randomized 194 adults with atopic dermatitis to one of three concentrations of a topical cream containing the selective TRPV1 antagonist PAC‐14028, or a placebo vehicle. The patients had baseline scores of 2 or 3 (mild to moderate) on the Investigator’s Global Assessment (IGA) scale. Patients were instructed to apply the cream twice daily to AD-affected areas.

After 8 weeks, treatment success (defined as a score of 0 or 1 on the IGA) occurred in 57% of patients given 1% cream, 38% of those given 0.3% cream, 43% of those given 0.1% cream, and 15% of those given a placebo cream.

In addition, other measures of improvement including the Scoring of Atopic Dermatitis (SCORAD) index, EASI 75/90, sleep disturbance score, and pruritus visual analogue scale (VAS) trended toward improvement in patients who received the treatment cream.

The mean change in the SCORAD index was significantly greater in the 0.1% and 1.0% groups, compared with the placebo group. Also of note, patients in the 1.0% cream group showed significant improvements in both sleep disturbance and VAS scores, compared with the placebo patients, the researchers said.

The incidence of adverse events was similar among the groups, and no treatment-related serious adverse events were reported. A total of 18 patients discontinued the study, but 193 received at least one dose of treatment cream.

The study findings were limited by several factors, including the small size and lack of comparison to treatment with topical corticosteroids and topical calcineurin inhibitors, the researchers noted.

However, the results support the safety and efficacy of PAC‐14028, they added. And “based on these results, a phase III program is underway to assess the efficacy and safety of PAC-14028 topical cream 10% in adolescent and adult patients with mild to moderate AD,” they said.

AmorePacific funded the study. Dr. Lee disclosed relationships with AmorePacific, as well as LG Household & Health Care and Medytox.

SOURCE: Lee YW et al. Br J Dermatol. 2019 Jan 8. doi: 10.1111/bjd.17455.

PARIS – Adults with atopic dermatitis (AD) are at sharply increased risk for a broad array of comorbid dermatologic conditions ranging from A to V: that is, from alopecia areata to vitiligo, and points in between, according to a large German national study.

Bruce Jancin/MDedge News

These dermatologic comorbidities are in addition to already well established strong associations between AD and allergic rhinitis and bronchial asthma, as well as the emerging evidence of increased risk for depression, sleep impairment, suicidality, and other nondermatologic conditions, Nicole Zander noted at the annual congress of the European Academy of Dermatology and Venereology.

“Atopic dermatitis patients seem to be at substantial risk for a variety of comorbidities. It’s important to recognize the whole spectrum of comorbidities as a prerequisite for provision of patient-centered care,” said Ms. Zander, a research associate at the University of Hamburg Institute for Health Services Research in Dermatology and Nursing.

This is a priority in Germany, where the prevalence of AD has doubled or even tripled in the last 3 decades, she added.

She presented a snapshot of the comorbid conditions associated with AD based upon two German large national datasets: Structured skin screening examinations conducted by dermatologists in 162,269 adults working in more than 500 German companies and national medical claims data for 1,349,671 adults aged 18 years and up.

The annual point prevalence for adult AD was 1.4% in the occupational screening, while in the claims dataset it was 3.7%. The true prevalence, as well as that of the dermatologic comorbidities, probably lies somewhere in between, since both of these enormous datasets have their limitations. The claims dataset may contain coding errors, plus many of the skin disorders entombed in that database were diagnosed by nondermatologists. And the occupational dataset is vulnerable to what epidemiologists call the healthy worker effect: some people with severe AD might be absent from work or on disability, with a resultant lower point prevalence of the disorder in the workplace, she explained.

Both datasets documented a clear decline in the prevalence of AD with advancing age. In the medical claims database, for example, the prevalence was 6.6% among 18- and 19-year-olds, 5.4% for patients in their 20s, 3.9% for those in their 30s, 3.4% for those in their 40s, 3.0% for patients in their 50s, 2.7% for those in their 70s, and 2.4% for patients in their 80s.

This is the most likely explanation for the significantly reduced risks of stroke, hypertension, diabetes, hyperlipidemia, and ischemic heart disease seen in AD patients in the claims dataset. These are all conditions that become much more common with advancing age, whereas AD is skewed toward a younger population. And for purposes of this study the data weren’t age adjusted, Ms. Zander observed.

Ms. Zander reported having no financial conflicts regarding her study, conducted without commercial support.

bjancin@mdedge.com

PARIS – Adults with atopic dermatitis (AD) are at sharply increased risk for a broad array of comorbid dermatologic conditions ranging from A to V: that is, from alopecia areata to vitiligo, and points in between, according to a large German national study.

Bruce Jancin/MDedge News

These dermatologic comorbidities are in addition to already well established strong associations between AD and allergic rhinitis and bronchial asthma, as well as the emerging evidence of increased risk for depression, sleep impairment, suicidality, and other nondermatologic conditions, Nicole Zander noted at the annual congress of the European Academy of Dermatology and Venereology.

“Atopic dermatitis patients seem to be at substantial risk for a variety of comorbidities. It’s important to recognize the whole spectrum of comorbidities as a prerequisite for provision of patient-centered care,” said Ms. Zander, a research associate at the University of Hamburg Institute for Health Services Research in Dermatology and Nursing.

This is a priority in Germany, where the prevalence of AD has doubled or even tripled in the last 3 decades, she added.

She presented a snapshot of the comorbid conditions associated with AD based upon two German large national datasets: Structured skin screening examinations conducted by dermatologists in 162,269 adults working in more than 500 German companies and national medical claims data for 1,349,671 adults aged 18 years and up.

The annual point prevalence for adult AD was 1.4% in the occupational screening, while in the claims dataset it was 3.7%. The true prevalence, as well as that of the dermatologic comorbidities, probably lies somewhere in between, since both of these enormous datasets have their limitations. The claims dataset may contain coding errors, plus many of the skin disorders entombed in that database were diagnosed by nondermatologists. And the occupational dataset is vulnerable to what epidemiologists call the healthy worker effect: some people with severe AD might be absent from work or on disability, with a resultant lower point prevalence of the disorder in the workplace, she explained.

Both datasets documented a clear decline in the prevalence of AD with advancing age. In the medical claims database, for example, the prevalence was 6.6% among 18- and 19-year-olds, 5.4% for patients in their 20s, 3.9% for those in their 30s, 3.4% for those in their 40s, 3.0% for patients in their 50s, 2.7% for those in their 70s, and 2.4% for patients in their 80s.

This is the most likely explanation for the significantly reduced risks of stroke, hypertension, diabetes, hyperlipidemia, and ischemic heart disease seen in AD patients in the claims dataset. These are all conditions that become much more common with advancing age, whereas AD is skewed toward a younger population. And for purposes of this study the data weren’t age adjusted, Ms. Zander observed.

Ms. Zander reported having no financial conflicts regarding her study, conducted without commercial support.

bjancin@mdedge.com

PARIS – Adults with atopic dermatitis (AD) are at sharply increased risk for a broad array of comorbid dermatologic conditions ranging from A to V: that is, from alopecia areata to vitiligo, and points in between, according to a large German national study.

Bruce Jancin/MDedge News

These dermatologic comorbidities are in addition to already well established strong associations between AD and allergic rhinitis and bronchial asthma, as well as the emerging evidence of increased risk for depression, sleep impairment, suicidality, and other nondermatologic conditions, Nicole Zander noted at the annual congress of the European Academy of Dermatology and Venereology.

“Atopic dermatitis patients seem to be at substantial risk for a variety of comorbidities. It’s important to recognize the whole spectrum of comorbidities as a prerequisite for provision of patient-centered care,” said Ms. Zander, a research associate at the University of Hamburg Institute for Health Services Research in Dermatology and Nursing.

This is a priority in Germany, where the prevalence of AD has doubled or even tripled in the last 3 decades, she added.

She presented a snapshot of the comorbid conditions associated with AD based upon two German large national datasets: Structured skin screening examinations conducted by dermatologists in 162,269 adults working in more than 500 German companies and national medical claims data for 1,349,671 adults aged 18 years and up.

The annual point prevalence for adult AD was 1.4% in the occupational screening, while in the claims dataset it was 3.7%. The true prevalence, as well as that of the dermatologic comorbidities, probably lies somewhere in between, since both of these enormous datasets have their limitations. The claims dataset may contain coding errors, plus many of the skin disorders entombed in that database were diagnosed by nondermatologists. And the occupational dataset is vulnerable to what epidemiologists call the healthy worker effect: some people with severe AD might be absent from work or on disability, with a resultant lower point prevalence of the disorder in the workplace, she explained.

Both datasets documented a clear decline in the prevalence of AD with advancing age. In the medical claims database, for example, the prevalence was 6.6% among 18- and 19-year-olds, 5.4% for patients in their 20s, 3.9% for those in their 30s, 3.4% for those in their 40s, 3.0% for patients in their 50s, 2.7% for those in their 70s, and 2.4% for patients in their 80s.

This is the most likely explanation for the significantly reduced risks of stroke, hypertension, diabetes, hyperlipidemia, and ischemic heart disease seen in AD patients in the claims dataset. These are all conditions that become much more common with advancing age, whereas AD is skewed toward a younger population. And for purposes of this study the data weren’t age adjusted, Ms. Zander observed.

Ms. Zander reported having no financial conflicts regarding her study, conducted without commercial support.

bjancin@mdedge.com

PARIS – Women with active atopic dermatitis during pregnancy and their physicians can find reassurance in the Danish national experience over an 18-year period, which showed no increased risk of pregnancy and birth problems other than modestly increased risks of premature rupture of membranes and neonatal staphylococcal septicemia, according to Jacob P. Thyssen, MD, PhD.

Bruce Jancin/MDedge News

At a session of the European Task Force of Atopic Dermatitis held in conjunction with the annual congress of the European Academy of Dermatology and Venereology, he presented a case control study of 10,668 births to Danish women with atopic dermatitis (AD) during 1997-2014. They were matched 1:10 by age, parity, and birth year to mothers without AD.

The risk of premature rupture of membranes was 15% higher in mothers with AD. And while the increased relative risk of neonatal staphylococcal septicemia was more substantial – a 145% increase – this was in fact a rare complication, observed Dr. Thyssen, a dermatologist at the University of Copenhagen.

There was no significant difference between women with or without AD in rates of preeclampsia, prematurity, pregnancy-induced hypertension, placenta previa, placental abruption, neonatal nonstaphylococcal septicemia, or other complications. The two groups had a similar number of visits to physicians and midwives during pregnancy.

Moreover, although the body mass index was similar in women with or without AD, the risk of gestational diabetes in women with the disease was significantly reduced by 21%; their risk of having a large-for-gestational-age baby with a birth weight of 4,500 g or more was also significantly lower than in controls.

Women received less treatment for AD during their pregnancy than they did beforehand. While pregnant, their disease was managed predominantly with topical corticosteroids and UV therapy. There was very little use of superpotent topical steroids, topical calcineurin inhibitors, or immunosuppressants, although 10% of pregnant women received systemic corticosteroids for their AD.

Dr. Thyssen reported serving as a scientific adviser and paid speaker for Leo Pharma, Roche, Eli Lilly, and Sanofi-Genzyme, although this study was conducted without commercial support.

bjancin@mdedge.com

PARIS – Women with active atopic dermatitis during pregnancy and their physicians can find reassurance in the Danish national experience over an 18-year period, which showed no increased risk of pregnancy and birth problems other than modestly increased risks of premature rupture of membranes and neonatal staphylococcal septicemia, according to Jacob P. Thyssen, MD, PhD.

Bruce Jancin/MDedge News

At a session of the European Task Force of Atopic Dermatitis held in conjunction with the annual congress of the European Academy of Dermatology and Venereology, he presented a case control study of 10,668 births to Danish women with atopic dermatitis (AD) during 1997-2014. They were matched 1:10 by age, parity, and birth year to mothers without AD.

The risk of premature rupture of membranes was 15% higher in mothers with AD. And while the increased relative risk of neonatal staphylococcal septicemia was more substantial – a 145% increase – this was in fact a rare complication, observed Dr. Thyssen, a dermatologist at the University of Copenhagen.

There was no significant difference between women with or without AD in rates of preeclampsia, prematurity, pregnancy-induced hypertension, placenta previa, placental abruption, neonatal nonstaphylococcal septicemia, or other complications. The two groups had a similar number of visits to physicians and midwives during pregnancy.

Moreover, although the body mass index was similar in women with or without AD, the risk of gestational diabetes in women with the disease was significantly reduced by 21%; their risk of having a large-for-gestational-age baby with a birth weight of 4,500 g or more was also significantly lower than in controls.

Women received less treatment for AD during their pregnancy than they did beforehand. While pregnant, their disease was managed predominantly with topical corticosteroids and UV therapy. There was very little use of superpotent topical steroids, topical calcineurin inhibitors, or immunosuppressants, although 10% of pregnant women received systemic corticosteroids for their AD.

Dr. Thyssen reported serving as a scientific adviser and paid speaker for Leo Pharma, Roche, Eli Lilly, and Sanofi-Genzyme, although this study was conducted without commercial support.

bjancin@mdedge.com

PARIS – Women with active atopic dermatitis during pregnancy and their physicians can find reassurance in the Danish national experience over an 18-year period, which showed no increased risk of pregnancy and birth problems other than modestly increased risks of premature rupture of membranes and neonatal staphylococcal septicemia, according to Jacob P. Thyssen, MD, PhD.

Bruce Jancin/MDedge News

At a session of the European Task Force of Atopic Dermatitis held in conjunction with the annual congress of the European Academy of Dermatology and Venereology, he presented a case control study of 10,668 births to Danish women with atopic dermatitis (AD) during 1997-2014. They were matched 1:10 by age, parity, and birth year to mothers without AD.

The risk of premature rupture of membranes was 15% higher in mothers with AD. And while the increased relative risk of neonatal staphylococcal septicemia was more substantial – a 145% increase – this was in fact a rare complication, observed Dr. Thyssen, a dermatologist at the University of Copenhagen.

There was no significant difference between women with or without AD in rates of preeclampsia, prematurity, pregnancy-induced hypertension, placenta previa, placental abruption, neonatal nonstaphylococcal septicemia, or other complications. The two groups had a similar number of visits to physicians and midwives during pregnancy.

Moreover, although the body mass index was similar in women with or without AD, the risk of gestational diabetes in women with the disease was significantly reduced by 21%; their risk of having a large-for-gestational-age baby with a birth weight of 4,500 g or more was also significantly lower than in controls.

Women received less treatment for AD during their pregnancy than they did beforehand. While pregnant, their disease was managed predominantly with topical corticosteroids and UV therapy. There was very little use of superpotent topical steroids, topical calcineurin inhibitors, or immunosuppressants, although 10% of pregnant women received systemic corticosteroids for their AD.

Dr. Thyssen reported serving as a scientific adviser and paid speaker for Leo Pharma, Roche, Eli Lilly, and Sanofi-Genzyme, although this study was conducted without commercial support.

bjancin@mdedge.com

Two months ago I met Ed, still working at age 71. “My life’s ambition,” he said, “has been to help high school science teachers do their jobs better.”

“How’s it going?” I asked.

Ed sighed. “I’m still at it,” he said. “Let’s just say we’re not there yet.”

I too, dear colleagues, have had a life’s ambition, secret until right now: I wanted to eliminate erroneous fungal diagnosis. Or, to put it more pungently, to help nondermatologists stop treating every roundish scaly rash as ringworm.

Alas, like Ed’s, my work is not yet done.

I get reminders of this all the time, but last week the evidence got so overwhelming that I had to take a breath to settle down. And a nip. Ten cases. In 24 hours.

1. A 66-year-old woman energetically smeared econazole cream twice daily for weeks for an itchy, lichenified rash on both dorsal feet and ankles. Switched to betamethasone. Cleared in 5 days.

2. A 48-year-old woman with scaly patches on both legs. No response to terbinafine cream, then to ketoconazole cream, then to oral fluconazole. Cleared promptly on triamcinolone.

3. A 26-year-old with an erosive vulvar rash lasting month, unresponsive to Nystatin. After 5 days on a steroid, it was gone.

4. A 45-year-old man with lots of dermatoheliosis and idiopathic guttate hypomelanosis on arms and legs. No luck with topical selenium sulfide for tinea versicolor.

5. A 42-year-old nurse treated for weeks with topical antifungals. She came in with globs of fungus cream sealed in with Tegaderm (to prevent spread). Her roommates wanted to cancel her lease. Cleared of both rash and Tegaderm in 1 week. Now allowed to touch doorknobs.

6. A 27-year-old man with 8 weeks of lichenified patches all over his torso. Antifungal creams not working. Steroids do!

7. A 25-year-old recent émigré from India, where he was treated for his itchy groin rash with a succession of antifungal creams. He cannot sleep. (Imagine the plane trip from Delhi!) Has lichenified inguinal folds and scrotum. Cleared in 1 week with a topical steroid.

8. A 22-year-old woman with widespread atopic dermatitis. No response to antifungals. She had a rash at age 2 that was called “allergy to shampoo.” Clears promptly on a steroid.

9. A 22-year-old man being treated for a scaly, bilateral periocular rash with oral cephalexin. Clears promptly on a weak topical steroid.

10. A 29-year-old woman who has been suffering for months with “sensitivity” of her vulvar skin that has been diagnosed and treated as “a yeast infection,” in the absence of any rash or discharge. Her only visible finding is inverse psoriasis in the gluteal cleft. Guess what clears her up?

And so it goes, and so it has gone, week after week, year after year, decade after decade. Medicine scales Olympus: genomics, immunotherapy, stereotactic surgery. Meantime, the it’s-not-a-fungus problem seems impervious to both education and even to daily observation as obvious as it is ineffective: If a supposed fungus does not respond to antifungal treatment, then it must be a very bad fungus. If it doesn’t respond to yet another antifungal cream, then it must be terrible fungus. Reconsidering that it may not be a fungus at all seems to demand a mental paradigm shift whose achievement will have to await a more discerning generation.

In the meantime, patients not only don’t get better, but they feel defiled and dirty. They avoid human contact, intimate and otherwise, and do a lot of superfluous and expensive cleaning of house and wardrobe. If you doubt this, ask them. If you think I overstate, spend a day with me.

Early in my career I inherited the once-yearly dermatology slot at Medical Grand Rounds at the local community hospital. I spoke about cutaneous fungus, with emphasis on the fact that lots of round rashes are nummular eczema rather than fungus, as well as what it means to patients to be told they are “fungal.”

I didn’t get much direct feedback, but the chief of medicine sprang into action. He canceled the dermatology slot. Not medical enough, I guess.

Ed tells me that many high school science teachers don’t know much science. They teach it because they thought they might like to, or because there was an opening. After Ed hangs up his cleats, there will be plenty of his work left to be done.

But then, there always is.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.

Two months ago I met Ed, still working at age 71. “My life’s ambition,” he said, “has been to help high school science teachers do their jobs better.”

“How’s it going?” I asked.

Ed sighed. “I’m still at it,” he said. “Let’s just say we’re not there yet.”

I too, dear colleagues, have had a life’s ambition, secret until right now: I wanted to eliminate erroneous fungal diagnosis. Or, to put it more pungently, to help nondermatologists stop treating every roundish scaly rash as ringworm.

Alas, like Ed’s, my work is not yet done.

I get reminders of this all the time, but last week the evidence got so overwhelming that I had to take a breath to settle down. And a nip. Ten cases. In 24 hours.

1. A 66-year-old woman energetically smeared econazole cream twice daily for weeks for an itchy, lichenified rash on both dorsal feet and ankles. Switched to betamethasone. Cleared in 5 days.

2. A 48-year-old woman with scaly patches on both legs. No response to terbinafine cream, then to ketoconazole cream, then to oral fluconazole. Cleared promptly on triamcinolone.

3. A 26-year-old with an erosive vulvar rash lasting month, unresponsive to Nystatin. After 5 days on a steroid, it was gone.

4. A 45-year-old man with lots of dermatoheliosis and idiopathic guttate hypomelanosis on arms and legs. No luck with topical selenium sulfide for tinea versicolor.

5. A 42-year-old nurse treated for weeks with topical antifungals. She came in with globs of fungus cream sealed in with Tegaderm (to prevent spread). Her roommates wanted to cancel her lease. Cleared of both rash and Tegaderm in 1 week. Now allowed to touch doorknobs.

6. A 27-year-old man with 8 weeks of lichenified patches all over his torso. Antifungal creams not working. Steroids do!

7. A 25-year-old recent émigré from India, where he was treated for his itchy groin rash with a succession of antifungal creams. He cannot sleep. (Imagine the plane trip from Delhi!) Has lichenified inguinal folds and scrotum. Cleared in 1 week with a topical steroid.

8. A 22-year-old woman with widespread atopic dermatitis. No response to antifungals. She had a rash at age 2 that was called “allergy to shampoo.” Clears promptly on a steroid.

9. A 22-year-old man being treated for a scaly, bilateral periocular rash with oral cephalexin. Clears promptly on a weak topical steroid.

10. A 29-year-old woman who has been suffering for months with “sensitivity” of her vulvar skin that has been diagnosed and treated as “a yeast infection,” in the absence of any rash or discharge. Her only visible finding is inverse psoriasis in the gluteal cleft. Guess what clears her up?

And so it goes, and so it has gone, week after week, year after year, decade after decade. Medicine scales Olympus: genomics, immunotherapy, stereotactic surgery. Meantime, the it’s-not-a-fungus problem seems impervious to both education and even to daily observation as obvious as it is ineffective: If a supposed fungus does not respond to antifungal treatment, then it must be a very bad fungus. If it doesn’t respond to yet another antifungal cream, then it must be terrible fungus. Reconsidering that it may not be a fungus at all seems to demand a mental paradigm shift whose achievement will have to await a more discerning generation.

In the meantime, patients not only don’t get better, but they feel defiled and dirty. They avoid human contact, intimate and otherwise, and do a lot of superfluous and expensive cleaning of house and wardrobe. If you doubt this, ask them. If you think I overstate, spend a day with me.

Early in my career I inherited the once-yearly dermatology slot at Medical Grand Rounds at the local community hospital. I spoke about cutaneous fungus, with emphasis on the fact that lots of round rashes are nummular eczema rather than fungus, as well as what it means to patients to be told they are “fungal.”

I didn’t get much direct feedback, but the chief of medicine sprang into action. He canceled the dermatology slot. Not medical enough, I guess.

Ed tells me that many high school science teachers don’t know much science. They teach it because they thought they might like to, or because there was an opening. After Ed hangs up his cleats, there will be plenty of his work left to be done.

But then, there always is.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.

Two months ago I met Ed, still working at age 71. “My life’s ambition,” he said, “has been to help high school science teachers do their jobs better.”

“How’s it going?” I asked.

Ed sighed. “I’m still at it,” he said. “Let’s just say we’re not there yet.”

I too, dear colleagues, have had a life’s ambition, secret until right now: I wanted to eliminate erroneous fungal diagnosis. Or, to put it more pungently, to help nondermatologists stop treating every roundish scaly rash as ringworm.

Alas, like Ed’s, my work is not yet done.

I get reminders of this all the time, but last week the evidence got so overwhelming that I had to take a breath to settle down. And a nip. Ten cases. In 24 hours.

1. A 66-year-old woman energetically smeared econazole cream twice daily for weeks for an itchy, lichenified rash on both dorsal feet and ankles. Switched to betamethasone. Cleared in 5 days.

2. A 48-year-old woman with scaly patches on both legs. No response to terbinafine cream, then to ketoconazole cream, then to oral fluconazole. Cleared promptly on triamcinolone.

3. A 26-year-old with an erosive vulvar rash lasting month, unresponsive to Nystatin. After 5 days on a steroid, it was gone.

4. A 45-year-old man with lots of dermatoheliosis and idiopathic guttate hypomelanosis on arms and legs. No luck with topical selenium sulfide for tinea versicolor.

5. A 42-year-old nurse treated for weeks with topical antifungals. She came in with globs of fungus cream sealed in with Tegaderm (to prevent spread). Her roommates wanted to cancel her lease. Cleared of both rash and Tegaderm in 1 week. Now allowed to touch doorknobs.

6. A 27-year-old man with 8 weeks of lichenified patches all over his torso. Antifungal creams not working. Steroids do!

7. A 25-year-old recent émigré from India, where he was treated for his itchy groin rash with a succession of antifungal creams. He cannot sleep. (Imagine the plane trip from Delhi!) Has lichenified inguinal folds and scrotum. Cleared in 1 week with a topical steroid.

8. A 22-year-old woman with widespread atopic dermatitis. No response to antifungals. She had a rash at age 2 that was called “allergy to shampoo.” Clears promptly on a steroid.

9. A 22-year-old man being treated for a scaly, bilateral periocular rash with oral cephalexin. Clears promptly on a weak topical steroid.

10. A 29-year-old woman who has been suffering for months with “sensitivity” of her vulvar skin that has been diagnosed and treated as “a yeast infection,” in the absence of any rash or discharge. Her only visible finding is inverse psoriasis in the gluteal cleft. Guess what clears her up?

And so it goes, and so it has gone, week after week, year after year, decade after decade. Medicine scales Olympus: genomics, immunotherapy, stereotactic surgery. Meantime, the it’s-not-a-fungus problem seems impervious to both education and even to daily observation as obvious as it is ineffective: If a supposed fungus does not respond to antifungal treatment, then it must be a very bad fungus. If it doesn’t respond to yet another antifungal cream, then it must be terrible fungus. Reconsidering that it may not be a fungus at all seems to demand a mental paradigm shift whose achievement will have to await a more discerning generation.

In the meantime, patients not only don’t get better, but they feel defiled and dirty. They avoid human contact, intimate and otherwise, and do a lot of superfluous and expensive cleaning of house and wardrobe. If you doubt this, ask them. If you think I overstate, spend a day with me.

Early in my career I inherited the once-yearly dermatology slot at Medical Grand Rounds at the local community hospital. I spoke about cutaneous fungus, with emphasis on the fact that lots of round rashes are nummular eczema rather than fungus, as well as what it means to patients to be told they are “fungal.”

I didn’t get much direct feedback, but the chief of medicine sprang into action. He canceled the dermatology slot. Not medical enough, I guess.

Ed tells me that many high school science teachers don’t know much science. They teach it because they thought they might like to, or because there was an opening. After Ed hangs up his cleats, there will be plenty of his work left to be done.

But then, there always is.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.