Contact allergy and allergic contact dermatitis in adolescents: prevalence measures and associations. The Odense Adolescence Cohort Study on Atopic Diseases and Dermatitis (TOACS)

The aims of this cross-sectional study were to establish the prevalence measures of contact allergy and allergic contact dermatitis in 8th grade schoolchildren (aged 12-16 years) in Odense, Denmark, and to examine the associations with atopic dermatitis, inhalant allergy and hand eczema. Contact allergy to a standard series allergen was found in 15.2% of schoolchildren. The point prevalence of allergic contact dermatitis was 0.7% and the lifetime prevalence 7.2%, predominantly in girls. The most common contact allergens were nickel (8.6%) and fragrance mix (1.8%). Nickel allergy was clinically relevant in 69% and fragrance allergy in 29% of cases. A significant association was found between contact allergy and hand eczema while no association was found between contact allergy and atopic dermatitis or inhalant allergy. In the future this cohort of schoolchildren will be followed with regard to the course and development of atopic diseases, hand eczema and contact dermatitis. Key words: school-     

Nickel sensitization in adolescents and association with ear piercing,use of dental braces and hand eczema. The Odense Adolescence Cohort Study on Atopic Diseases and Dermatitis (TOACS)

The prevalence of nickel allergy (sensitization) and the associations with ear piercing, use of dental braces and hand eczema were assessed in a cohort of 1,501 8th grade schoolchildren (aged 12-16 years) in Odense, Denmark. Nickel allergy was found in 8.6% and was clinically relevant in 69% of cases. Nickel allergy was found most frequently in girls and the association with ear piercing was confirmed. Application of dental braces (oral nickel exposure) prior to ear piercing (cutaneous nickel exposure) was associated with a significantly reduced prevalence of nickel allergy. In adolescents a significant association was found between hand eczema and nickel allergy. A follow-up study of this population is planned in order to assess the course and development of contact dermatitis, hand eczema and atopic diseases in adulthood and after choice of occupation.     

Prevalence of atopic dermatitis, asthma, allergic rhinitis, and hand and contact dermatitis in adolescents. The Odense Adolescence Cohort Study on Atopic Diseases and Dermatitis

BACKGROUND: Atopic diseases are common in children and adolescents. However, epidemiological knowledge is sparse for hand eczema and allergic contact dermatitis in this age group. Furthermore, no population-based studies have evaluated the prevalence of atopic diseases and hand and contact dermatitis in the same group of adolescents. OBJECTIVES: To assess prevalence measures of atopic dermatitis (AD), asthma, allergic rhinitis and hand and contact dermatitis in adolescents in Odense municipality, Denmark. METHODS: The study was carried out as a cross-sectional study among 1501 eighth grade school children (age 12-16 years) and included questionnaire, interview, clinical examination and patch testing. RESULTS: The lifetime prevalence of AD was 21.3% (girls 25.7% vs. boys 17.0%, P < 0.001) using predefined questionnaire criteria. The 1-year period prevalence of AD was 6.7% and the point prevalence 3.6% (Hanifin and Rajka criteria). In the interview the lifetime prevalence of inhalant allergy was estimated as 17.7% (6.9% allergic asthma, 15.7% allergic rhinitis). The lifetime prevalence of hand eczema based on the questionnaire was 9.2%, the 1-year period prevalence was 7.3% and the point prevalence 3.2%, with a significant predominance in girls. A significant association was found both between AD and inhalant allergy, and between AD and hand eczema using lifetime prevalence measures. The point prevalence of contact allergy was 15.2% (girls 19.4% vs. boys 10.3%, P < 0.001), and present or past allergic contact dermatitis was found in 7.2% (girls 11.3% vs. boys 2.5%). Contact allergy was most common to nickel (8.6%) and fragrance mix (1.8%). CONCLUSIONS: High prevalence figures were found for atopic diseases, hand eczema and allergic contact dermatitis, and the diseases were closely associated. A considerable number of adolescents still suffers from AD, and a considerable sex difference was noted for hand eczema and allergic contact dermatitis. Nickel allergy and perfume allergy were the major contact allergies. In the future this cohort of eighth grade school children will be followed up with regard to the course and development of atopic diseases, hand eczema and contact dermatitis.     

Thymus and activation regulated chemokines in children with atopic dermatitis: Kyushu University Ishigaki Atopic Dermatitis Study (KIDS)

The purpose of this population-based study was to investigate the clinical significance of serum thymus and activation-regulated chemokine (TARC) in children with atopic dermatitis (AD). Between 2003 and 2004, 1359 Japanese children aged 5 years and under were prospectively followed. Serum levels of TARC by using an ELISA in each child were monitored throughout the study period. The first tested year, the mean serum level of TARC in children with sustained AD (mean; 691.7 pg/mL) was significantly higher than that of regressed AD children (569.9 pg/mL), newly developed AD children (380.1 pg/ mL), and healthy children (506.3 pg/mL). The changes of TARC levels in sustained AD children found no significance between 2003 (691.7 pg/mL) and 2004 (682.0 pg/mL). The mean levels of TARC of both regressed AD and healthy children significantly decreased from 2003 to 2004 (644.2 pg/mL to 448.7 pg/mL and 506.3 pg/mL to 442.1 pg/mL, respectively). The mean TARC level of newly developed AD children significantly increased from 2003 to 2004 (380.1 pg/mL to 491.8 pg/mL). We demonstrated strong associations between TARC levels and the natural course of childhood AD. Monitoring serum TARC levels of AD children may be useful for the biological evaluation of AD.     

Association factors for atopic dermatitis in nursery school children in Ishigaki islands - Kyushu University Ishigaki Atopic Dermatitis Study (KIDS)

Atopic dermatitis (AD) is a multifactorial disease that usually decreases the quality of life of affected patients. The purpose of this study was to evaluate the associated factors for atopic dermatitis, asthma, rhinitis, and food allergy by physical examination of the skin and a questionnaire in nursery school children in Ishigaki Island, Okinawa, Japan. Enrolled in this study were 460 children from 0 to 6 years of age. Physical examination of skin symptoms and blood tests were performed. Information on past history and family history of atopic dermatitis, asthma, rhinitis, and food allergy were collected by questionnaire. The prevalence of atopic dermatitis was 12.2% (56/460). The cumulative prevalence of asthma, rhinitis, and food allergy was 19.9% (91/458), 3.3% (15/457), and 5.5% (25/456), respectively. In multivariate analysis, maternal history of rhinitis, atopic dermatitis siblings, past history of asthma and food allergy, and elevation of total IgE were significantly related to atopic dermatitis. A high total IgE level was a strong risk factor specific for atopic dermatitis in this population.     

Incidence of atopic dermatitis in nursery school children - a follow-up study from 2001 to 2004, Kyushu University Ishigaki Atopic Dermatitis Study (KIDS)

Atopic dermatitis (AD) is a multifactorial disease that usually decreases the quality of life of affected patients. We monitored the incidence of AD and serum total IgE levels annually among nursery school children in Ishigaki Island, Okinawa, Japan, from 2001 to 2004. A total of 1731 children were enrolled. The prevalence of AD ranged from 3.7 to 11% in each year, with no significant difference between boys and girls. 869 children were examined at least twice. 71.6% (53/74) of AD patients regressed spontaneously, whereas 5.5% (44/795) of non-AD individuals developed AD during the 3-year follow-up. Increases in total IgE levels were greater and more rapid in children with long-term AD than in those who had spontaneously regressed, had newly-developed AD or did not have AD. The regression rate of AD was > 70% while new-onset AD occurred at a rate of 3.67%/person year in nursery school children of Ishigaki Island.     

The U.K. Working Party's Diagnostic Criteria for Atopic Dermatitis II. Observer variation of clinical diagnosis and signs of atopic dermatitis

The level of agreement between 14 physicians as to what constitutes a case of atopic dermatitis was tested on 15 selected patients with a range of diagnoses. Between-observer agreement was good, with a mean pair agreement index (P₀) of 0.94, and a chance corrected index (κ) of 0.78. Between- observer agreement in the recording of 18 separate physical signs of atopic dermatitis was then tested by asking the 14 physicians to note the presence or absence of each sign in a different group of patients to those seen in the first part of the exercise. Substantial between-observer agreement (κ>0.61) was only present for truncal dermatitis. Most signs showed only fair to moderate agreement (κ0.21–0.60), and some signs, such as keratosis pilaris, xerosis, orbital pigmentation, fine hair, and extensor dermatitis, showed poor agreement (κ0.01–0.20). The findings were similar when the responses of two independent observers from the national study outlined in Paper I were compared for each sign. Within-observer variation for the recording of physical signs was substantially better than between-observer variation. Physicians interested in atopic dermatitis agree reasonably well on what constitutes a typical case of atopic dermatitis. Between-observer variation with regard to some physical signs of atopic dermatitis is of a magnitude which argues against their continued use in clinical and epidemiological studies.     

Prevalence,incidence rates and persistence of contact allergy and allergic contact dermatitis in The Odense Adolescence Cohort Study: a 15‐year follow‐up

Background A cohort of 1501 unselected 8th grade schoolchildren was established 15 years ago with the aim to follow the course of contact allergy and allergic contact dermatitis (ACD) from school age into adult life. To date no studies have evaluated incidence rates and persistence of contact allergy and ACD in an unselected population from adolescence to adulthood. Objectives To estimate the incidence rates and persistence of contact allergy and ACD from adolescence to adulthood, and the point prevalence in adulthood. Methods In total, 1206 young adults from the cohort were contacted and asked to complete a questionnaire and participate in a clinical examination including patch testing with TRUE Test^®. The questionnaire was answered by 899 (74.6%), however, only 442 (36·7%) of those invited participated in patch testing. Results Over the 15‐year period the incidence rates of contact allergy and ACD were 13·4% and 7·8%, respectively. The point prevalence of contact allergy was 20·1%, and present or past ACD was found in 12·9% of those followed. Nickel was the most common contact allergen (11·8%), followed by cobalt (2·3%), colophony (2·0%), thiomersal (1·4%) and p‐phenylenediamine (1·1%). Most nickel reactions were persistent, and a significant number of new nickel sensitizations were found. Fragrance mix I reactions from adolescence could not be reproduced. Conclusions From adolescence to adulthood the incidence rates of contact allergy and ACD were high. Nickel was still the most common contact allergen, and new sensitizations occurred despite the European Union nickel regulation. Fragrance mix I was a poor marker for history of eczematous skin reaction to perfumed products.     

A new instrument for assessing quality of life in atopic dermatitis: international development of the Quality of Life Index for Atopic Dermatitis (QoLIAD)

BACKGROUND: Atopic dermatitis (AD) is a chronic or chronically relapsing inflammatory skin condition that can have a considerable impact on those affected. There are a number of instruments available to measure outcome in dermatological conditions but none have been developed specifically for AD. In addition, most measure symptoms and/or daily functioning, which are potential influences on quality of life (QoL) rather than assessments of the construct itself. OBJECTIVES: The aim of the current study was to develop a new instrument specifically designed to measure QoL in adults with AD-the Quality of Life Index for Atopic Dermatitis (QoLIAD). METHODS: The instrument was developed based on the needs-based model of QoL and was produced in several different countries simultaneously. Its content was derived from 65 in-depth interviews with relevant patients in the U.K., Italy and the Netherlands. The initial version of the measure was produced in U.K. English and translations were produced for the Netherlands, Italy, Germany, France and the U.S.A. using a dual translation panel methodology. A Spanish version was developed using the same adaptation process after the instrument was finalized. Field-test interviews were conducted with approximately 20 patients in each country to assess face and content validity. The instrument [in addition to the Dermatology Life Quality Index (DLQI) and the Psychological General Well-Being Schedule (PGWB)] was then administered to up to 300 AD patients in each country at two time points to finalize the instrument and test its psychometric properties. RESULTS: The initial version of the QoLIAD had 56 items that reflected the areas of need fulfillment identified in the qualitative interviews as having been affected by AD: mental and emotional stimulation, physical and emotional stability, security, sharing and belonging, self-esteem, personal development and fulfillment. Comments from patients in field-test interviews resulted in the removal of 14 items, to leave a 42-item instrument that was considered relevant and acceptable. The number of patients participating in the survey were 286 in the U.K., 46 in the Netherlands, 213 in France, 187 in Germany, 178 in the U.S.A. and 83 in Spain. Application of the Rasch model to these data identified the final 25-item QoLIAD. Unidimensionality was confirmed, with deviation of the total scale from the Rasch model evident at a single time point in one country only (the U.K.). All language versions, with the exception of the Dutch measure, had test-retest reliability coefficients in excess of 0.85. The test-retest in the Netherlands was 0.80. However, this country had the smallest sample size and the corresponding reliability for the DLQI was only 0.40. The QoLIAD had adequate internal consistency and the initial indications of construct validity were good. The levels of association with the DLQI indicated that the two instruments measure related but distinct constructs. CONCLUSIONS: The QoLIAD is a practical, reliable, valid and culturally applicable instrument for measuring the impact of AD and its treatment on QoL in clinical trials or in routine clinical practice.     

The prevalence of common skin conditions in Australian school students: 2. Atopic dermatitis

The prevalence of atopic dermatitis (AD) was recorded following examination by dermatologists and dermatology registrars of a random sample of 2491 school students throughout the State of Victoria, Australia. The overall prevalence, based on clinical examination, was 16.3% (95% confidence interval, CI 14.1-18.5), being higher in girls (17.7%; 95% CI 15.0-20.4) than boys (14.8%; 95% CI 11.8-17.8). Using the U.K. Working Party Diagnostic Criteria for AD reduced the prevalence to 10.8% (95% CI 9.3-12.3) with the prevalence in girls 12.3% (95% CI 10.1-14.4) and in boys 9.2% (95% CI 7.1-11.4). The prevalence was highest in 4-6 year olds (18.7% on clinical examination, 11.5% using the U.K. Working Party Criteria), decreasing with increasing age to 11.6% on clinical examination (8. 6% on U.K. Working Party Criteria) among 16-18 year olds. Most of those with AD were classified as having mild disease (54.1%), with 32.1% classified as having minimal and 13.8% as having moderate to severe disease. Over 80% of those who reported on the questionnaire that they had dermatitis that was then confirmed on examination had been using one or more products to treat it. Nearly 90% of these products were classified as efficacious, with medical practitioners being the major source of advice for their use (77%). Pharmacists (8%), family/friends (6%) and others (9%), including beauticians and naturopaths, made up the remainder of the persons from whom those affected had sought advice about their treatment. These data, the first community-based prevalence data on AD published from Australia, confirm that the condition is common among those of school age. There is a need for AD to be included among those conditions that are discussed in health education lessons in schools.     

The prevalence of Malassezia yeasts in patients with atopic dermatitis, seborrhoeic dermatitis and healthy controls

Cultures for Malassezia yeasts were taken from both normal-looking skin and lesional skin in 124 patients with atopic dermatitis, 16 patients with seborrhoeic dermatitis and from normal skin of 31 healthy controls. Positive Malassezia growth was found in fewer patients with atopic dermatitis (56%) than in patients with seborrhoeic dermatitis (88%) or in healthy controls (84%, p<0.01). In the patients with atopic dermatitis, fewer positive cultures were found in lesional (28%) than in non-lesional skin (44%, p<0.05), while positive cultures were found in 75% of both lesional and non-lesional skin of patients with seborrhoeic dermatitis (not significant). M. sympodialis dominated in patients with atopic dermatitis (46%) and in healthy controls (69%). In patients with seborrhoeic dermatitis both M. sympodialis and M. obtusa were cultured in 43%. A Malassezia species extract mixture would increase the possibility of detecting IgE sensitization to Malassezia in patients with atopic dermatitis.     

Development of the Childhood Atopic Dermatitis Impact Scale: initial validation of a quality-of-life measure for young children with atopic dermatitis and their families

To measure the effects of atopic dermatitis (AD) on the quality of life of affected young children and their families, we developed a prototype 62-item instrument, the Childhood Atopic Dermatitis Impact Scale (CADIS). The prototype CADIS was developed from a comprehensive conceptual framework based on data from parents and clinicians. The instrument had eight subscales (four each for child and parent): physical health, emotional health, physical functioning, and social functioning. The goal of this work was to test the validity of and to refine the prototype of CADIS. Two hundred seventy parents of children under the age of 6 y with AD responded to the instrument. Content validity was demonstrated by expert and parent reviews of the drafted and refined instrument, and by analyzing parents' responses to open-ended questions about their children's skin disease. Construct validity was assessed in exploratory factor analyses which supported a refinement in the conceptual framework to consist of two dimensions with five domains: child dimensions (symptoms and activity limitation/behavior), and parent dimensions (family/social function, sleep, and emotions). Seventeen items were eliminated, yielding a 45-item refined version of CADIS (score 0-180) with evidence of content and construct validity and suggested use in clinical research.     

The objective severity assessment of atopic dermatitis (OSAAD) score: validity, reliability and sensitivity in adult patients with atopic dermatitis

BACKGROUND: The Objective Severity Assessment of Atopic Dermatitis (OSAAD) score is a recently developed scale for evaluation of severity of atopic dermatitis, constructed from the assessment of epidermal barrier function, and properties using noninvasive bioengineering methods and computer-assisted estimates of disease extent. The method has been validated for use in infants and children with atopic dermatitis and compared with a referent scoring system. OBJECTIVES: The aim of the present study was to test the validity, reliability and sensitivity of the OSAAD score as an objective tool for the assessment of the severity of atopic dermatitis in adult patients. METHODS: Thirty-two adult patients with atopic dermatitis were included in the study. To assess the validity of the OSAAD score we tested it against the Severity Scoring of Atopic Dermatitis (SCORAD) index of the European Task Force on Atopic Dermatitis as a referent clinical severity scale, and the serum levels of interleukin (IL)-16 as a laboratory variable for monitoring the activity of atopic dermatitis. Responsiveness to change was assessed in a longitudinal study comparing OSAAD, SCORAD and serum levels of IL-16 before and after treatment. To test the reliability of the OSAAD score we studied the interobserver variability of the score recorded by three independent board-certified dermatologists in 16 patients and compared it with SCORAD. RESULTS: We report a significant correlation between the OSAAD and the SCORAD index as an acknowledged referent severity scale. The OSAAD score correlated significantly with the serum levels of IL-16 in the acute stage of atopic dermatitis. In a longitudinal study, the OSAAD score decreased significantly, parallel with improvement of the skin findings and a significant decrease in the SCORAD score and IL-16 serum levels. We report improved interobserver variability for the OSAAD score compared with SCORAD. CONCLUSIONS: This is the first study validating the OSAAD score as a sensitive and reliable tool for the assessment of the severity of atopic dermatitis in adult patients.     

Contact sensitivity and atopic dermatitis: association with prognosis, a follow-up study in 801 atopic patients

The influence of contact sensitivities on the course of atopic dermatitis (AD) is not known. The objective of the study is to find the course of AD in atopic patients with and without contact sensitivities. A total of 801 atopic patients were studied and patch tested in 1983/84. A questionnaire focusing on the occurrence of dermatitis was sent to these patients 16 years later. During the follow up the number of symptom-free patients increased from 36.7% to 40.7%. In patients with positive patch-test reactions, 30.1% were symptom free in 1983/84 and 38.3% at the follow up (P= 0.001). Among those with positive patch-test reactions to fragrance mix and/or balsam of Peru, the number of symptom-free patients had increased the most: from 26.9% to 42.6% (P= 0.0095), and a similar tendency was seen among those with nickel allergy. The occurrence of dermatitis did not change among patients without contact sensitivities. Thus, the study concluded that contact allergy does not impair the prognosis of dermatitis in atopic patients.     

The management of moderate to severe atopic dermatitis in adults with topical fluticasone propionate. The Netherlands Adult Atopic DermatitisStudy Group.

This study was designed to investigate a long-term therapeutic strategy for the management of recurring atopic dermatitis (AD) in adults using fluticasone propionate (FP) ointment (CutivateTM) whereby FP could help to prevent a relapse of AD once symptoms were under control. Adult patients with chronic, moderate to severe AD entered this multicentre study. All patients were initially treated with FP 0.005% (g/g) ointment in two different regimens. Patients whose AD had been completely healed by these treatments then entered a long-term treatment phase applying FP or placebo ointment once daily, two times per week for 16 weeks to 'known' healed lesions. By the end of the initial treatment period, mean SCORAD values had significantly (P < 0.0005) improved from baseline. Patients who entered the maintenance phase and were treated with intermittent FP for up to 16 weeks, demonstrated its superior efficacy (P = 0.018) over placebo, maintaining the improvements achieved after the initial treatment phase, reducing risk of relapse and delaying time to relapse (P = 0.013). No significant changes were detected in either treatment group in serum cortisol levels or in skin thickness measurements. Intermittent FP applied two times per week maintained a significant level of control, and delayed relapse of AD by comparison with placebo.