Breastfeeding duration is a risk factor for atopic eczema

BACKGROUND: The results of numerous studies on the influence of breastfeeding in the prevention of atopic disorders are often contradictory. One of the most important problems is confounding by other lifestyle factors. OBJECTIVE: The aim of the present study was to analyse the effect of any breastfeeding duration on the prevalence of atopic eczema in the first seven years of life taking into account other risk factors. METHODS: In an observational birth cohort study 1314 infants born in 1990 were followed-up for seven years. At 3, 6, 12, 18, 24 months and every year thereafter, parents were interviewed and filled in questionnaires, children were examined and blood was taken for in vitro allergy tests. Generalized Estimation Equations (GEE)-models were used to model risk factors for the prevalence of atopic eczema and for confounder adjustment RESULTS: Breastfeeding was carried out for longer if at least one parent had eczema, the mother was older, did not smoke in pregnancy, and the family had a high social status. The prevalence of atopic eczema in the first seven years increased with each year of age (OR 1.05; 95% CI 1.01-1.09 for each year), with each additional month of breastfeeding (1.03; 1.00-1.06 for each additional month), with a history of parental atopic eczema (2.06; 1.38-3.08), and if other atopic signs and symptoms appeared, especially specific sensitization (1.53; 1.25-1.88), and asthma (1.41; 1.07-1.85). Although breastfeeding should be recommended for all infants, it does not prevent eczema in children with a genetic risk. CONCLUSION: Parental eczema is the major risk factor for eczema. But in this study, each month of breastfeeding also increased the risk.     

Breast-feeding and atopic eczema dermatitis syndrome: protective or harmful?

Numerous studies have addressed the potential of breast-feeding to protect for the development of allergic diseases, and in particular of atopic eczema dermatitis syndrome (AEDS). Although the majority of studies, as well as several meta-analyses, are strongly in favour of breast-feeding, there are some conflicting results and open issues. Furthermore, breast-feeding might be detrimental in a subgroup of young infants with severe early manifestations of AEDS and immunoglobulin E sensitizations to common foods. The aim of this review is not to analyse systematically the current literature, but to suggest a scientifically and clinically based analysis of the benefits of breast-feeding in atopic infants.     

Atopic eczema: role of microorganisms on the skin surface

The pathophysiology of atopic eczema (AE) is still poorly understood. One possible concept favors IgE-mediated reactivity towards allergens that enter the skin from the outside or through the blood. Microorganisms of the cutaneous flora also might represent a stimulus for allergic skin reactions. Abnormal bacterial skin colonization is a characteristic feature of AE. Staphylococcus aureus (S. aureus ) is the most common pathogen. Binding to host cells involves special receptors, such as fibronectin or laminin. Specific IgE antibodies to S. aureus can be detected in the blood. Whereas the clinical relevance of anti-staphylococcal antibodies is still controversial, specific IgE antibodies to Pityrosporum species as well as positive type I prick test reactions to these yeasts seem to correlate with the intensity of eczematous lesions in the head and neck regions of patients with AE. Both antimicrobial and antifungal treatment has been shown helpful in some cases of AE.     

Molluscum contagiosum and associations with atopic eczema in children: a retrospective longitudinal study in primary care

Background

Molluscum contagiosum (MC) is a common skin condition in children. Consultation rates and current management in primary care, and how these have changed over time, are poorly described. An association between the presence of atopic eczema (AE) and MC has been shown, but the subsequent risk of developing MC in children with a diagnosis of AE is not known.

Aim

To describe the consultation rate and management of MC in general practice in the UK over time, and test the hypothesis that a history of AE increases the risk of developing MC in childhood.

Design and setting

Two studies are reported: a retrospective longitudinal study of MC cases and an age–sex matched case-cohort study of AE cases, both datasets being held in the UK Clinical Practice Research Datalink from 2004 to 2013.

Method

Data of all recorded MC and AE primary care consultations for children aged 0 to 14 years were collected and two main analyses were conducted using these data: a retrospective longitudinal analysis and an age–sex matched case-cohort analysis.

Results

The rate of MC consultations in primary care for children aged 0 to 14 years is 9.5 per 1000 (95% CI = 9.4 to 9.6). The greatest rate of consultations for both sexes is in children aged 1–4 years and 5–9 years (13.1 to 13.0 (males) and 13.0 to 13.9 (females) per 1000 respectively). Consultation rates for MC have declined by 50% from 2004 to 2013. Children were found to be more likely to have an MC consultation if they had previously consulted a GP with AE (OR 1.13; 95% CI = 1.11 to 1.16; P<0.005).

Conclusion

Consultations for MC in primary care are common, especially in 1–9-year-olds, but they declined significantly during the decade under study. A primary care diagnosis of AE is associated with an increased risk of a subsequent primary care diagnosis of MC.     

Dietary exclusions for improving established atopic eczema in adults and children: systematic review

Atopic eczema is the most common inflammatory skin disease of childhood in developed countries. We performed a systematic review of randomized controlled trials to assess the effects of dietary exclusions for the treatment of established atopic eczema. Nine trials (421 participants) were included, most of which were poorly reported. Six were studies of egg and milk exclusion ( n  = 288), one was a study of few foods ( n  = 85) and two were studies of an elemental diet ( n  = 48). There appears to be no benefit of an egg- and milk-free diet in unselected participants with atopic eczema. There is also no evidence of benefit in the use of an elemental or few-foods diet in unselected cases of atopic eczema. There may be some benefit in using an egg-free diet in infants with suspected egg allergy who have positive specific IgE to eggs – one study found 51% of the children had a significant improvement in body surface area with the exclusion diet as compared with normal diet (95% CI 1.07–2.11) and change in surface area and severity score was significantly improved in the exclusion diet as compared with the normal diet at the end of 6 weeks (MD 5.50, 95% CI 0.19–10.81) and end of treatment (MD 6.10, 95% CI 0.06–12.14). Despite their frequent use, we find little good quality evidence to support the use of exclusion diets in atopic eczema.     

Atopic dermatitis in 5-6-year-old Swedish children: cumulative incidence, point prevalence, and severity scoring

Background: This study aimed to evaluate the cumulative incidence, point prevalence, and severity of atopic dermatitis (AD) in a pediatric population. We also aimed to identify differential diagnoses relevant to AD in this population. Methods: Children scheduled for a health visit at 5.5 years of age were selected consecutively during the period October 1997–March 1998 from two cities in southern Sweden (Göteborg and Kristianstad). Schultz Larsen's questionnaire was used to evaluate the cumulative incidence of AD. Clinical examination was performed by dermatologists (A.B. and Å.S.) for those children with active eczema. The UK working party's criteria were used for the clinical diagnosis of AD. The SCORAD index was used to evaluate the severity of eczema. This index includes evaluation of extent, intensity, and subjective symptoms to a maximum score of 103 points. Results: In Göteborg 1219 and in Kristianstad 742 questionnaires were answered regarding 1961 children, 1004 boys and 957 girls. The response rate was 89%. According to the answers to Schultz Larsen's questionnaire, the cumulative incidence of AD in the whole material was 20.7% (406/1961) (CI 95% 18.9–22.5). In Göteborg, 104 of the examined children fulfilled the UK working party's criteria, equivalent to a point prevalence of 8.5% (CI 95% 7.0–10.1). In Kristianstad, the corresponding point prevalence was 11.5% (CI 95% 9.2–13.8). The severity of AD was evaluated in all children with visible eczema. SCORAD evaluation was performed in 155 of the 157 children with visible eczema. The majority of children had mild or moderate eczema; mean value 20.5 (CI 95% 18.7–22.3), median 19.6. Of the 96 children who did not fulfil the criteria of AD, other skin disorders were diagnosed in 51 at the clinical examination. Dry skin was by far the most common differential diagnosis. Conclusions: We have used validated protocols to evaluate the cumulative incidence, point prevalence, and severity of AD in a population‐based study in southern Sweden The present study, involving a rural and urban pediatric population, shows that AD is common, usually classified as mild or moderate, and seems to increase over time.     

Increased levels of urinary leukotriene E4 in children with severe atopic eczema/dermatitis syndrome

BACKGROUND: Leukotrienes are thought to play a role in the pathogenesis of atopic eczema/dermatitis syndrome (AEDS). Urinary leukotriene E4 (U-LTE4) is a marker of whole-body cysteinyl-leukotriene production. AIMS OF THE STUDY: To evaluate the role of leukotrienes in children with AEDS by measuring levels of U-LTE4, and to evaluate whether levels of U-LTE4 may reflect disease activity and allergic sensitization in AEDS. METHODS: U-LTE4 was measured by enzyme-linked immunosorbent assay in 87 children with mild (n=32), moderate (n=34) and severe (n=21) AEDS, as well as in 72 nonatopic healthy controls. Fifty-eight of the children with AEDS were sensitized to common allergens, and 29 were not. RESULTS: Levels of U-LTE4 were higher in children with severe AEDS (140; 66-166 microg/mmol creatinine, median; quartiles) than in controls (52; 30-90, P <0.05), whereas levels of U-LTE4 in moderate and mild disease were similar to controls. U-LTE4 levels were similar in children with or without sensitization to common allergens, but severe AEDS children with sensitization had higher levels of U-LTE4 than those without sensitization. CONCLUSION: The results suggest a role for leukotrienes in the pathogenesis of severe AEDS, and may support a role for leukotriene-antagonists in the treatment of this disorder. Levels of U-LTE4 may reflect the disease severity and sensitization to allergens in AEDS.     

Atopic eczema is associated with delayed maturation of the antibody response to pneumococcal vaccine

The aim of this study was to investigate a previously undocumented observation, that children with atopic eczema under 9 years of age tended to have a poor antibody response to Pneumococcal vaccination. Thirty-five children (mean age 8.8 years, range 3-16 years) with moderate to severe atopic eczema but no history of systemic infection were studied retrospectively. Pneumococcal antibody responses after immunization with Pneumovax II were compared with a hospital control group consisting of 36 children (mean age 6.0 years, range 3-16 years) with recurrent upper respiratory tract infections. Only 17% of children with atopic eczema aged 3-8 years responded to Pneumovax. This response was significantly poorer than that of the controls (57%) (odds ratio 0.20, 95% confidence interval (CI) 0.05-0.84, P = 0.03). There were no significant differences in the levels of total IgG2, the component of IgG associated with protective antibody responses to Pneumococcus between the two groups. Delay in maturation of the total IgG and IgG2 antibody response to Pneumococcus is a feature in this group of children with moderately severe atopic eczema.     

Atopic eczema and other manifestations of atopy: results of a study in East and West Germany

Within an environmental health study, dermatologic examination of 1273 pre-school-age children (5–7 years old) was carried out in selected areas of East (n= 287) and West (n= 987) Germany in spring 1991. On the basis of comparable genetic background, the influence of a different exposure to air pollutants on the manifestation of atopic diseases was investigated. Halle an der Saale (East Germany) and Duisburg (North/South) as well as Essen (West Germany) were chosen as polluted study areas, whereas the countryside town of Borken (West Germany) served as a control region. Outdoor pollution with particles and SO₂ was significantly higher in Halle an der Saale. Of the total study group. 12.9% suffered from atopic eczema at the time of examination. The prevalence was highest in East Germany (17.5%; adjusted odds ratio [OR] 1.39, confidence intervals [CI] 0.77–2.52, compared to Borken). The reported frequencies of hay fever and asthma in the total study population were 2% and 1.3%, respectively, without significant differences between study sites. Some 34.7% of the children showed at least one positive skin prick test reaction; significantly (P< 0.001) higher sensitization rates were obtained in western regions (Essen, Duisburg-South) than in the control region (Borken) and East Germany. Multivariate analysis of the prevalence of atopic eczema showed associations with parental predisposition (OR 1.52, CI 1.03–2.25), sex (for boys, OR 0.63, CI 0.43–0.92), location (Duisburg-South vs Borken OR 0.52, CI 0.30–0.96). month of investigation (May vs April, and March vs February OR 0.55, CI 0.37–0.81), contact with rabbits (for girls, OR 2.90, CI 1.36–6.19), animal fur in bedrooms (2.17, 1.01–4.67), indoor use of gas without hood (1.68, 1.11–2.56), and distance of homes from a busy road (<50 m 1.71, 1.07–2.73). Nonsignificant associations were observed for history of helminthic infections (OR 1.61, CI 0.98–2.64) and high parental education level (OR 1.83, CI 0.83–4.02). In East and West Germany, atopic eczema seems to follow a course different from that of respiratory allergic diseases and specific sensitization, a fact which underlines the need for a differentiated analysis.     

Effect of climatic change in children with atopic eczema

BACKGROUND: Climate and sunlight (ultraviolet radiation) influence activity of atopic eczema. OBJECTIVE: To evaluate the effect of moving from a subarctic/temperate climate to a sunny subtropical climate on children's atopic eczema. METHODS: Children, 4-13 years, with severe atopic eczema were randomized to stay 4 weeks in Gran Canary (index patients = 30) and home in Norway (controls = 26), with a follow up of 3 months. SCORing of Atopic Dermatitis (SCORAD) was primary variable, and secondary were Children's Dermatology Life Quality Index (CDLQI), Staphylococcus aureus skin colonization and pharmacological skin treatment. RESULTS: SCORing of Atopic Dermatitis decreased from 37.2 (29.4-44.9) to 12.2 (9.0-15.4) [mean (95% confidence intervals)] after 4 weeks and 21.2 (17.2-25.1) 3 months thereafter in index patients (P < 0.0005), much less in controls.Children's Dermatology Life Quality Index in the index group improved from 8.7 to 2.2 and 4.5 after 4 weeks and 3 months (P < 0.0005), not in controls. Bacterial skin colonization with S. aureus decreased in the index group from 23/30 (77%) to 12/30 (40%; P = 0.001) and 12/30 (40%; P = 0.005) after 1 month and 3 months, and the use of local steroids decreased in index patients but not in controls. CONCLUSIONS: The change from a subartic/temperate to a subtropical climate for 4 weeks improved significantly skin symptoms (SCORAD) and quality of life, even for 3 months after return.     

Association between mast cell chymase genotype and atopic eczema: comparison between patients with atopic eczema alone and those with atopic eczema and atopic respiratory disease

BACKGROUND: It has remained unclear whether genetic background of patients with atopic eczema (AE) alone is identical to that of patients with both AE and atopic respiratory disease. OBJECTIVE: We aimed to assess whether there is a genetic difference between these two groups of AE patients. METHOD: We determined the genotype with regard to an allelic polymorphism in the gene for mast cell chymase (MCC; a serine protease secreted from mast cells) in 169 AE patients. RESULTS: MCC genotype was significantly associated with pure AE patients who did not have a predisposition to atopic respiratory disease and whose serum IgE concentration was < 500 IU/mL. The distribution of MCC genotypes also differed significantly between the latter patients and those AE patients with bronchial asthma and a serum IgE concentration of > 2000 IU/mL. CONCLUSION: These results suggest that pure AE is associated with genetic variants of MCC, and that the genetic basis of pure AE differs from that of AE associated with atopic asthma.     

A Comprehensive Review of the Treatment of Atopic Eczema

Atopic eczema (AE) is a chronic, inflammatory skin disorder which usually develops in early childhood. In spite of intensive investigations, the causes of AE remain unclear, but are likely to be multifactorial in nature. Environmental factors or genetic-environmental interactions seem to play a key role in disease progression. Among various measures of AE managment, cutaneous hydration, which improves barrier function and relieve itchiness, may be helpful to reduce the need for topical steroid use and therefore should be used as a basic treatment. Avoiding aggravating factors is also a basic treatment of AE. Standard medical treatment with a pharmacologic approach may be necessary if basic treatment fails to control symptoms satisfactorily. Recently, more attention is given to a proactive therapeutic by regular intermittent application of low potency steroids or topical calcineurin inhibitors to prevent new flares. Furthermore, various targeted biologics are being introduced for AE control and are proposed as promising therapies. This paper provides a summary of the recent literature on the manangement of AE and a treatment guideline.