Have oral contraceptives reduced the prevalence of acne? a population-based study of acne vulgaris,tobacco smoking and oral contraceptives

BACKGROUND: The prevalence of acne among adolescents appears to vary geographically. This study was therefore undertaken to describe the prevalence rate of acne among Danish adolescents and to study the possible influence of oral contraceptives (OC) and tobacco smoking on disease prevalence and severity. Both have been suggested to influence acne and are therefore potential confounders in studies of acne prevalence. METHODS: A random sample of 186 15- to 22-year-old subjects participating in a population-based study of allergic diseases in Copenhagen County were also examined for acne. Questionnaire data on demographic variables, acne problems, smoking status and use of OC were recorded, and acne was graded according to the Leeds scale. RESULTS: The prevalence of clinical acne (Leeds score >1) was 40.7% for men and 23.8% for women (odds ratio, OR, acne vs. no acne: 0.46, 95% confidence interval, CI: 0.24-0.85). Acne was perceived as a personal problem by 37.6% of all subjects, and this was associated with clinical acne (OR: 5.5, 95% CI: 2.7-10.9). The use of OC was associated with a significantly lower prevalence of acne (OR: 0.32, 95% CI: 0.11-0.86), while the use of tobacco smoking was not significantly associated with acne (OR: 0.54, 95% CI: 0.17-1.78). CONCLUSION: In congruence with recent reports from other countries, the prevalence rate of acne among adolescents was found to be lower than previously described in older reports. In this population, the use of OC was associated with a lower prevalence of acne.     

Acne prevalence, knowledge about acne and psychological morbidity in mid-adolescence: a community-based study

BACKGROUND: Acne vulgaris is a distressing condition that affects the majority of adolescents, but its impact on mental health in this age group is poorly understood. OBJECTIVES: To determine the prevalence of acne, knowledge about acne and rates of help-seeking behaviour in English teenagers. It was hypothesized that presence of acne would be associated with higher rates of emotional and behavioural difficulties. METHODS: Three hundred and seventeen pupils (80% response rate) aged 14-16 years participated from a comprehensive school in Nottingham. An age-appropriate, validated measure of emotional well-being, the Strengths and Difficulties Questionnaire (SDQ), and an Acne Management Questionnaire were used to assess participants' psychological health, level of acne knowledge and help-seeking behaviour. Acne severity was by graded by visual facial examination using an adaptation of the Leeds Acne Grading Technique. RESULTS: There was a prevalence of acne in 50% of the study sample, with 11% of participants having moderate to severe acne (> 20 inflammatory lesions). Participants with definite acne (12+ lesions) (P < 0.01) and girls (P < 0.05) had higher levels of emotional and behavioural difficulties. Participants with acne were nearly twice as likely as those without acne to score in the abnormal/borderline range of the SDQ (32% vs. 20%; odds ratio 1.86, 95% confidence interval 1.03-3.34). Knowledge about the causes of acne was low (mean 45%), and was unrelated to acne status. Fewer than a third of participants with definite acne had sought help from a doctor. CONCLUSIONS: Acne is a common disorder in English adolescents and appears to have a considerable impact on emotional health in this age group. Low levels of acne knowledge and poor acne management are concerns that could be amenable to a school-based education programme.     

Acne prevalence and beyond: acne disability and its predictive factors among Chinese late adolescents in Hong Kong

Background.  Data are lacking on the prevalence of acne, its effects on quality of life (QOL) and the treatment usage among Chinese patients in late adolescence.
Aim.  To derive data about the prevalence and predictive factors of acne, the disability caused by acne and choice of treatment used by Chinese late adolescents in Hong Kong.
Methods.  This was a cross-sectional study of a random sample of 389 entrants in a university in Hong Kong, using the Global Acne Grading System (GAGS) to measure the clinical severity of acne and the Cardiff Acne Disability Index (CADI) to measure QOL.
Results.  The response rate was 99.3%. The prevalence of acne was of 81.5% (95% CI 77.6–85.4%) and coexisted with a high frequency of acne disability at a rate of 81.8% (95% CI 78.1–85.6%). Assessment of the clinical severity of acne did not correlate strongly with the effect on QOL (γ_s = 0.445, P  < 0.001). Over the previous 6 months, 30.3% of subjects had used topical treatments, 3.9% had taken systemic conventional western drugs and 3.2% of the subjects had used traditional Chinese medicine. Multivariate logistic regression was used to explore the predictive factors for acne disability. Female gender ( P  = 0.002), higher GAGS score ( P  < 0.001), higher perceived stress ( P  = 0.01) and willingness to pay Hong Kong$15 000 (£970) for a hypothetical permanent cure ( P  = 0.03) were positive predictors.
Conclusions.  Acne is prevalent in Hong Kong and has considerable psychological effects. The association between clinical severity and impaired QOL is not strong.     

Analysis of trends and status of physician‐based evaluation methods in acne vulgaris from 2000 to 2019

Various evaluation methods for acne severity have been used without standardization, and the diversity of acne outcome measures is an obstacle to the integrated analysis of various acne studies. In this study, we sought to investigate physician‐based evaluation methods used in clinical studies of acne vulgaris and to determine differences according to time, region and study design. PubMed was searched for articles on acne published from January 2000 to June 2019 in five dermatology journals: Journal of the American Academy of Dermatology, JAMA Dermatology, British Journal of Dermatology, Journal of the European Academy of Dermatology and Venereology and Acta Dermato‐Venereologica. A total of 186 articles with acne evaluation methods were selected. Among the selected studies, region, study design, type of intervention and the number of subjects were identified and analyzed. Articles from 2010 to 2019 used Investigator Global Assessment (IGA; odds ratio [OR], 5.808; 95% CI, 1.894–17.811) more often and the Leeds technique (OR, 0.282; 95% CI, 0.098–0.812) less often compared with articles from 2000 to 2009. Controlled experimental studies preferred lesion counting (OR, 238.637; 95% CI, 46.795–1216.954), IGA (OR, 9.177; 95% CI, 3.053–27.586) and Leeds Revised Acne Grading System (LRAGS; OR, 10.844; 95% CI, 3.050–38.559) compared with observational studies. North American studies applied lesion counting (OR, 4.573; 95% CI, 1.173–17.836) and IGA (OR, 11.330; 95% CI, 3.487–36.818) more often and LRAGS (OR, 0.171; 95% CI, 0.039–0.758) less often compared with European studies. This study demonstrated the diversity and heterogeneity of acne outcome measures even in highly influential dermatology journals. This is due to the limitations of current methods and suggests the importance of developing a core outcome measure.     

Self‐Reported Acne Severity,Treatment, and Belief Patterns across Multiple Racial and Ethnic Groups in Adolescent Students

Abstract: Acne vulgaris is a common condition among adolescents regardless of age, gender, and race. We compare the frequency, severity, help‐seeking behavior, treatment, and beliefs about acne among students based on race, ethnicity, gender, and age. Anonymous surveys were administered to 1,214 students aged 10–19 years of varied gender, race, and ethnicity in public middle and high schools in New Jersey. Results showed the frequency and severity of acne were high (76% and 65%, respectively) and more prevalent in white compared to non‐white respondents (RR = 1.13, 95% CI = 1.04–1.24 and RR = 1.22, 95% CI = 1.09–1.37, respectively), and also in older compared to younger ages (RR = 1.24, 95% CI = 1.17–1.32 and RR = 1.43, 95% CI = 1.32–1.55, respectively). The majority of respondents (83%) reported never having seen a physician for their acne; however, those reporting acne of some severity were more likely to have seen a physician compared with those who did not report acne (21% vs. 8%, p < 0.001). Blacks who reported mild or moderate severity of acne were more likely to have seen a health professional compared to white respondents with same the acne severity (RR = 3.63, 95% CI = 2.06–6.37 and RR = 3.06, 95% CI = 2.02–4.65, respectively). Conversely, Hispanic respondents with mild or moderate acne were less likely to have seen a health professional compared to whites with the same acne severity (RR = 0.56, 95% CI = 0.35–0.89 and RR = 0.47, 95% CI = 0.26–0.86, respectively). Beliefs about external factors affecting acne also varied by race and ethnicity. In conclusion, the severity, frequency, and beliefs about acne all play a role in help‐seeking behaviors, which vary to a significant extent by race and ethnicity.     

Cigarette smoking and acne in adolescents: results from a cross-sectional study

BACKGROUND: Previous studies on the association between smoking and acne have reported conflicting results. OBJECTIVE: To investigate the association between smoking and acne among school-going adolescents. METHODS: A cross-sectional study was conducted. Smoking was defined as smoking > 3 cigarettes daily for 6 months or more. We defined acne as having > 20 retentional and/or inflammatory facial acne lesions. Multivariate (proportional) logistic regression models were used to adjust for confounding variables. RESULTS: Of the 594 participants, 36.2% had acne. Acne sufferers were less likely to smoke (18.1 vs. 23.7%, P = 0.10). In girls, smoking was significantly associated with lower prevalence of acne (adjusted OR = 0.41, 95% CI = 0.13, 0.82). Smoking, daily cigarette consumption and duration of smoking appeared to be protective in the development of inflammatory acne in girls. No significant associations between acne and smoking variables were detected among boys. Limitations: although this study suggests a significant negative association between smoking and inflammatory acne in girls, it does not prove causality. This association did show a trend for linear relationship. Because of the unexpected differences between boys and girls, sample size may have affected our results. CONCLUSION: The anti-inflammatory effects of smoking may inhibit the development of papulopustular acne in girls more than in boys. However, smoking should not be considered a therapeutic option for acne. Additional studies that consider possible differences across age, gender and type of acne are needed to clarify the association between smoking and acne.     

Epidemiology of acne in the general population: the risk of smoking

BACKGROUND: Acne is a common skin disorder, but epidemiological data from the general population obtained by examination are scarce. Clinical experience suggests an association between smoking and acne, although confirmatory evidence from appropriate studies is lacking. OBJECTIVES: To determine the prevalence and demographic factors of acne in a general population sample and to investigate the association of smoking and acne on a qualitative and quantitative level. METHODS: In a cross-sectional study, 896 citizens (aged 1--87 years, median 42) of the City of Hamburg were dermatologically examined. The prevalence and severity of acne were recorded and further information on demographic variables, medical history, and alcohol and cigarette consumption were obtained by a standardized interview. RESULTS: According to the clinical examination, acne was present in 26.8% overall, and was more prevalent in men (29.9%) than women (23.7%) (odds ratio, OR 1.37, 95% confidence interval, CI 1.01--1.87). Prevalence followed a significant linear trend over age with peak prevalence between 14 and 29 years (P < 0.001). The reported age at onset was significantly lower in women than men (P = 0.015). According to multiple logistic regression analyses acne prevalence was significantly higher in active smokers (40.8%, OR 2.04, 95% CI 1.40--2.99) as compared with non-smokers (25.2%). A significant linear relationship between acne prevalence and number of cigarettes smoked daily was obtained (trend test: P < 0.0001). In addition, a significant dose-dependent relationship between acne severity and daily cigarette consumption was shown by linear regression analysis (P = 0.001). CONCLUSIONS: Smoking is a clinically important contributory factor to acne prevalence and severity.     

Therapeutic considerations and clinical characteristics of a sample of adolescent patients with acne vulgaris in Tirana,Albania: A cross‐sectional study

Acne vulgaris is a common adolescent disorder but the data related to acne vulgaris is insufficient in Albania. The aim of this study was to assess the epidemiologic features of acne vulgaris and to identify lifestyle and constitutional factors in formulating a proper management protocol. A cross‐sectional study conducted on a representative sample of 2036 adolescents from 10 high schools located in Tirana. A self‐administered questionnaire was administered to collect the data. The binary logistic regression was applied to assess the factors linked to the presence of acne vulgaris in adolescents. The mean age in the study population was 16.2 ± 0.9 years. The self‐reported prevalence of acne was 50.3% (52.1% in females and 47.9% in males). Lifetime prevalence was 68.5%. The factors significantly associated with an increased likelihood over time were: frequent consumption of sweets, frequent endurance of stress, poor quality of sleep, positive family history of acne, oily and combination skin, menstrual disorders. Acne vulgaris is common among adolescents in our country. The identification of various modifiable factors related to acne generates opportunities to tailor and focus prevention efforts and better management and treatment planning in relevant high‐risk groups.     

Acne vulgaris: prevalence and clinical forms in adolescents from S?o Paulo,Brazil

BACKGROUND

Acne is a common disease in adolescents, but there are no epidemiological data for acne in Brazil.

OBJECTIVES

To estimate the prevalence and degree of acne in adolescents from Sao Paulo and study socio-demographic factors, family history and lifestyle, associated with the disease.

METHODS

Cross-sectional study with 452 adolescents aged between 10 and 17 (mean=13.3 years), students from elementary and high school, examined by 3 independent evaluators.

RESULTS

62.4% were female, 85.8% white and 6.4% were aged 14. The prevalence was 96.0% and increased with age - all students over 14 had acne. The most prevalent form of acne was comedonal (61.1%), followed by mild (30.6%) and moderate (7.6%) papular-pustular, which affected mostly the face (97.5%). About half of the adolescents reported family history for acne in mother or father, and 20.6% reported previous treatment for acne. There was a higher chance of presenting non-comedonal acne with increased age (p<0.001).

DISCUSSION

The prevalence of acne in adolescents varies widely due to the clinical features and diagnostic methods used. Adolescents whose brothers/sisters had acne (OR=1.7-p=0.027) and those over 13 (OR=8.3-p<0.001), were more likely to have non-comedonal acne.

CONCLUSION

This study showed high prevalence of acne in adolescents from Sao Paulo, predominantly the comedonal form on the face, with a higher chance of presenting non-comedonal acne with increased age.     

Keratosis pilaris and prevalence of acne vulgaris: a cross-sectional study

BACKGROUND

Acne vulgaris has an important genetic predisposition, as well as keratosis pilaris. Clinical observations suggest that patients with keratosis pilaris have less frequent or less severe acne breakouts; however, we found no studies on this regard

OBJECTIVE

To determine if the presence of keratosis pilaris is associated with lower prevalence and severity of acne.

METHODS

A cross-sectional study was conducted with dermatology outpatients aged between 14 and 35 years. We evaluated history and clinical grade of acne, demographic variables, history of atopy, smoking, and use of hormonal contraceptives. Two groups were defined by the presence or absence of moderate to severe keratosis pilaris on the arms and were compared by bivariate analysis and by conditional multiple logistic regression.

RESULTS

We included 158 patients (66% women), with a median age of 23±11 years. Twenty-six percent of them had keratosis pilaris, which was associated with a history of atopy (odds ratio [OR]=2.80 [1.36 to 5.75]; p<0.01). Acne was present in 66% of subjects, and was related to family history of acne (OR=5.75 [2.47 to 13.37]; p<0.01). In bivariate and multivariate analysis, the group with keratosis pilaris had a less frequent history of acne (OR=0.32 [0.14 to 0.70]; p<0.01).

CONCLUSION

The presence of moderate to severe keratosis pilaris on the arms was associated with lower prevalence of acne vulgaris and lower severity of facial lesions in adolescents and young adults.     

Prevalence of facial acne in adults.

BACKGROUND: Acne is usually considered a disorder of adolescence, and a number of studies have examined the prevalence of this condition in the adolescent population. There are, however, relatively few data on the prevalence of acne in the adult population. OBJECTIVE: A community-based study was carried out to investigate the current prevalence of facial acne in adults. METHODS: Seven hundred forty-nine persons older than 25 years were examined for facial acne by means of the Leeds acne-grading technique. RESULTS: A degree of facial acne was recorded in 231 women and 130 men, giving an overall prevalence of 54% (95% confidence interval [CI], 49-58) in women and 40% (95% CI, 35-45) in men (P <.001). The acne observed in volunteers consisted principally of physiological acne, but clinical facial acne (grade > 0.75) was recorded in 3% (95% CI, 1.2-4.8) of men and in 12% (95% CI, 9-15) of women (P <.001). The prevalence of acne did not substantially decrease until after the age of 44 years (P <.001). CONCLUSION: This study shows a prevalence of clinical facial acne in women of 12%, which is likely to persist into middle age.     

Acne: prevalence, perceptions and effects on psychological health among adolescents in Aydin, Turkey

Background Acne vulgaris is a common disease among adolescents and known to have adverse effects on psychological status. Methods A cross‐sectional study was conducted on 600 participants by means of a questionnaire designed for this study in high school students. In addition, an objective evaluation of acne in participants was undertaken. The questionnaire consisted of questions about acne, General Health Questionnaire (GHQ) and Rosenberg Self‐Esteem Scale (RSES). Results Five hundred and sixty‐three questionnaires out of 600 were answered and 550 adolescents who gave permission for examination were evaluated. The study population consisted of 303 girls and 260 boys between the ages 13 and 19, and the mean age was 15.24 ± 1.05 years. Acne prevalence was 63.6% with 29.2% non‐inflammatory and 34.4% inflammatory acne. It was more prevalent and severe in boys than in girls. Not the objective but the subjective severity of acne and opinion that one could benefit from acne treatment was found to be related to anxiety, depression and self‐esteem. Factors implicated among causes of acne were food, bad skin hygiene and hormones in decreasing frequency. Forty‐eight per cent of adolescents expect a maximum duration of 4 weeks for treatment. Conclusion Despite the high prevalence of acne, there is still much deficiency of knowledge and wrong beliefs about acne. This indicates that there is an urgent need for education about etiopathogenesis, potential complications and importance of effective treatment for acne. Effective treatment may make significant contributions for the mental health of adolescent and as well as adult populations.     

Scalp seborrheic dermatitis: prevalence and associated factors in male adolescents

Background The prevalence of seborrheic dermatitis (SD) in the general population is variable in the literature. Factors associated with SD are not well understood. Objective To verify the prevalence of scalp SD in a selected survey of male adolescents on mandatory military service and to find possible associated factors (skin color, socioeconomic level, triceps skin fold, acne, and tobacco consumption). Methods This cross‐sectional study included 18‐year‐old male adolescents on compulsory military service in a southern Brazilian city. Scalp SD was considered as erythema and scaling in any part of the scalp. Skin color, socioeconomic level, triceps skin fold, acne, and tabagism comprised the independent variables studied in our population. Results A total of 2201 adolescents entered the study. The global prevalence of scalp SD was 11%. White skin [adjusted prevalence ratio (PR) 1.42; 95% CI 1.06–1.92; P = 0.02] and triceps skin fold >19.5 mm (adjusted PR 1.56; 95% CI 1.12–2.18; P = 0.009) were significantly associated with scalp SD. The other variables were not associated with the outcome. Conclusions Prevalence of scalp SD in our survey of male adolescents was 11%. The occurrence of scalp SD was associated with white skin and a higher body fat content.     

Adolescents’ self perceived acne-related beliefs: from myth to science

BackgroundAcne vulgaris is recognized as the third most prevalent skin disease worldwide, with highest prevalence among adolescents. Beliefs and perceptions of adolescents about acne are incoherent in the literature.ObjectivesTo assess the most frequently reported acne-related beliefs in adolescents in order to focus on misconceptions and develop proper recommendations.MethodsA cross-sectional community-based study on representative sample of 2516 schoolchildren was conducted in six randomly selected secondary schools in Belgrade, Serbia. Only schoolchildren with present or past acne history participated. Factors believed to aggravate or ameliorate acne were recorded and analyzed, and the comparisons between girls and boys were evaluated using Pearson's chi-squared test.ResultsA total of 1452 schoolchildren with acne participated, aged 14–18 years, among them 801 (55.2%) girls and 651 (44.8%) boys. Boys significantly more frequently believed that sweating, exercise, and dairy foods aggravate acne, whereas girls significantly more frequently blamed emotional stress, sweets, fatty foods, sun, and lack of sleep. The top four amelioration factors were as follows: comedone extraction, healthy diet, sun exposure, and increased water consumption. Acne regression was more frequently perceived to be linked with cigarettes in boys, but with sun exposure and weight loss in girls.Study limitationsThe narrow age span of adolescents (14–18 years) and exclusion of acne-free adolescents are limitations due to study design.ConclusionThis survey is part of the first epidemiological study on a representative sample in the Western Balkan region. The significance of the most frequent acne-related beliefs is discussed and myths about acne are highlighted.     

Acne vulgaris: The metabolic syndrome of the pilosebaceous follicle

Acne vulgaris is an epidemic inflammatory disease of the human sebaceous follicle and represents the most common skin disease affecting about 85% of adolescents in Westernized populations. Acne vulgaris is primarily a disease of wealthy countries and exhibits higher prevalence rates in developed compared with developing countries. No acne has been found in non-Westernized populations still living under Paleolithic dietary conditions constraining hyperglycemic carbohydrates, milk, and dairy products. The high prevalence rates of adolescent acne cannot be explained by the predominance of genetic factors but by the influence of a Western diet that overstimulates the key conductor of metabolism, the nutrient- and growth factor–sensitive kinase mTORC1. Increased mTORC1 activity has been detected in lesional skin and sebaceous glands of acne patients compared with acne-free controls. Increased mTORC1 signaling is a characteristic feature of insulin resistance, obesity, type 2 diabetes mellitus, cancer, and neurodegenerative diseases. Acne vulgaris is a family member of mTORC1-driven diseases of civilization and represents the MetS of the sebaceous follicle.     

Anxiety, depression, and nature of acne vulgaris in adolescents

BACKGROUND: The reported prevalence of acne in adolescence is variable; improved treatment may have modified its prevalence and severity; acne has been related to psychiatric morbidity for many years. METHODS: Two thousand six hundred and fifty-seven high school students were examined, and adolescents with acne were interviewed about the subject of acne vulgaris. The severity of acne was graded using the Global Acne Grading System (GAGS). The Hospital Anxiety and Depression (HAD) scale was evaluated for one of every two subjects with acne (n = 308) and for the same number of sex-matched control subjects (n = 308) to determine the prevalence of depression and anxiety. RESULTS: Six hundred and fifteen of the subjects (23. 1%) were determined to have acne. Acne prevalence in girls and boys was 16.1% and 29.2%, respectively (P < 0.001). Two hundred and twenty-five (15.8%) of 1424 boys and only 109 (8.8%) of 1233 girls had moderate or severe/very severe acne (P < 0.001), but the GAGS scores in the groups of boys and girls with acne were not significantly different. The acne and control groups showed no significant differences in the HAD anxiety and depression subscale scores. The HAD anxiety subscale scores of girls were significantly higher than those of boys in the acne group. The severity of acne was not correlated with the HAD anxiety or depression subscale scores. CONCLUSIONS: Acne results in higher anxiety in adolescent girls. Although acne and moderate/severe acne are more common in adolescent boys, the severity of acne was found to be similar in boys and girls with acne. Adolescent girls are more vulnerable than boys to the negative psychological effects of acne.     

Combination of short CAG and GGN repeats in the androgen receptor gene is associated with acne risk in North East China

Background Acne vulgaris is one of the most common skin disorders, and androgen is known to play a key role in the development of acne. However, the exact genetic mechanism by which androgen receptor (AR) gene affects acne development is still unclear. Objective Our study aimed to investigate whether CAG and GGN polymorphism of the AR gene are associated with acne risk. Patients and methods Two hundred thirty‐eight patients and 207 controls were included in the study. The repeat lengths of the AR gene were determined by GeneScan analysis. Results Men with CAG < 23 and women with CAG < 24 had significant risk compared to those men with CAG ≥ 23 [odds ratio (OR), 2.07; 95% confidence interval (95% CI), 1.21–3.54] and women with CAG ≥ 24 (OR, 2.05; 95% CI, 1.18–3.56). In males, GGN repeats, considered independently of the CAG repeat, have no significant effect on the acne risk; however, when combined with CAG repeats, the acne patients exhibited significantly higher frequency of the haplotypes CAG < 23/GGN ≤ 23 (OR, 3.33; 95% CI, 1.10–10.07; P < 0.05) compared with the controls. Conclusion Our results of this study strongly indicated that a shorter CAG repeat length and specific haplotypes of AR attributed to the risk of acne development and thus could serve as a susceptibility marker.     

Dietary restriction and supplementation in children with atopic eczema

Issues on empirical dietary restriction or supplementation are important but inadequately studied in children with atopic eczema (AE). The dietary habits of children with AE followed at a paediatric dermatology clinic (n = 179) were compared with those without eczema (n = 78). The mothers of 53% of the patients with or without eczema did not breastfeed their children. Common food items avoided by parents whose children have moderate-to-severe AE included fish or seafood [64% vs. 32% of controls, odds ratio (OR) 3.84, 95% CI 2.12-6.95], beef (42% vs. 17%; OR = 3.57, 95% CI 1.79-7.11), eggs (34% vs. 14%; OR = 3.05, 95% CI 1.46-6.34) and cows' milk (18% vs. 4%; OR = 5.56, 95% CI 1.61-19.12); whereas their avoidance was less frequent in children with noneczematous diseases. The avoidance of these foods were often based on belief, but 66% of all AE patients who had avoided any of the above foods reported previous experience of eczema exacerbation by these items. Patients with moderate-to-severe AE were more likely to have consumed 'bird's nest' soup and traditional Chinese medicines. It is important to evaluate whether the AE patients are genuinely 'allergic' to some of these food items. Management is suboptimal if children with food allergy and severe disease continue to consume the culprit food. Conversely, avoidance of common foods in children without food allergy could result in food faddism or malnutrition.