Probiotics for Atopic Dermatitis Prevention in Infants: Emerging Promise Amid Inconsistent Evidence and Guideline Divergence - A Perspective for Hospital Pharmacists.

Atopic dermatitis (AD) imposes a global health burden for children and is a risk factor for developing food allergy and asthma. Few studies have evaluated emollient intervention for primary AD prevention in infants not selected for risk. To determine whether emollient intervention in infants not selected for risk reduces AD incidence by age 24 months. A randomized, decentralized pragmatic clinical trial was conducted that involving 1247 infant-parent dyads recruited from 25 community-based pediatric and family medicine clinics that are members of 4 statewide practice-based research networks. Participants were recruited from July 2018 to February 2021, with follow-up completed through February 2023. Dyads were randomized to 1 of 2 groups: a daily full-body emollient application daily moisturizer group starting by age 9 weeks or a control group that refrained from emollient use. The primary outcome was physician-diagnosed AD recorded in the patient's medical record by age 24 months. Participants completed quarterly electronic surveys to report adverse events and alert the team if an AD diagnosis had been made. Trained research coordinators abstracted participants' medical records. Of 1247 infants, 553 (44.3%) were female, and the mean (SD) age at randomization was 23.9 (16.3) days. At 24 months, the cumulative incidence of AD was 36.1% (SE, 2.1) in the daily moisturizer group and 43.0% (SE 2.1) in the control group, with a relative risk (RR) of 0.84 (95% CI, 0.73-0.97; P = .02), and the magnitude of effect was larger in the population not at high risk of AD (RR, 0.75; 95% CI, 0.60-0.90; P = .01). The protective effect was significantly modified by the presence of a dog in the home (RR, 0.68; 95% CI, 0.50-0.90; P = .01). There were no between-group differences in cutaneous adverse events. This randomized clinical trial found that daily emollient application beginning before age 9 weeks in a representative US population not selected for risk reduced the cumulative incidence of AD at age 24 months. Implementing this approach to pediatric skin care may be a feasible way to reduce the burden of AD in US communities. ClinicalTrials.gov Identifier: NCT03409367.

450 Systematic Review of the Recommendations on the Prevention of Allergic Manifestations in Children

Prebióticos en las fórmulas para lactantes. ¿Podemos modificar la respuesta inmune?

Allergic diseases have been linked to genetic and/or environmental factors, such as antibiotic use, westernized high fat and low fiber diet, which lead to early intestinal dysbiosis, and account for the rise in allergy prevalence, especially in western countries. Allergic diseases have shown reduced microbial diversity, including fewer lactobacilli and bifidobacteria, within the neonatal microbiota, before the onset of atopic diseases. Raised interest in microbiota manipulating strategies to restore the microbial balance for atopic disease prevention, through prebiotics, probiotics, or synbiotics supplementation, has been reported. We reviewed and discussed the role of prebiotics and/or probiotics supplementation for allergy prevention in infants. We searched PubMed and the Cochrane Database using keywords relating to “allergy” OR “allergic disorders,” “prevention” AND “prebiotics” OR “probiotics” OR “synbiotics.” We limited our evaluation to papers of English language including children aged 0–2 years old. Different products or strains used, different period of intervention, duration of supplementation, has hampered the draw of definitive conclusions on the clinical impact of probiotics and/or prebiotics for prevention of allergic diseases in infants, except for atopic dermatitis in infants at high-risk. This preventive effect on eczema in high-risk infants is supported by clear evidence for probiotics but only moderate evidence for prebiotic supplementation. However, the optimal prebiotic or strain of probiotic, dose, duration, and timing of intervention remains uncertain. Particularly, a combined pre- and post-natal intervention appeared of stronger benefit, although the definition of the optimal intervention starting time during gestation, the timing, and duration in the post-natal period, as well as the best target population, are still an unmet need.

Therapeutic modalities for cow's milk allergy

Lactobacillus casei GG for atopic eczema prevention in infants?

Atopic dermatitis: Therapeutic concepts evolving from new pathophysiologic insights

BackgroundMaternal probiotic supplementation has a promising effect on atopic dermatitis (AD) prevention in infancy. In the randomised controlled study, Probiotics in the Prevention of Allergy among Children in Trondheim (ProPACT), maternal probiotics reduced the cumulative incidence of AD in their offspring by 40% at 2 years of age. However, our understanding on how probiotics prevented AD is still limited, and the role of inflammatory proteins in infants following maternal probiotic supplementation is unclear. We hypothesised that maternal probiotics lowered pro-inflammatory proteins and increased anti-inflammatory proteins in their 2-year-old children as a mechanism of AD prevention. We aimed to explore this hypothesis and the association between these proteins and the presence of AD, severity of AD, and the degree of preventive effect of probiotics.MethodsPlasma samples were collected from 2-year-old children (n = 202) during the ProPACT study, a randomised placebo-controlled trial of maternal probiotic supplementation. These samples were analysed for 92 inflammatory proteins using a multiplex proximity extension assay. Associations between inflammatory proteins and the presence and severity of AD, and the degree of preventive effect, was estimated individually using regression analysis and then collectively using unsupervised cluster analysis.ResultsSeveral proteins were observed to differ between the groups. The probiotic group had lower CCL11 and IL-17C, while children with AD had higher IL-17C, MCP-4, uPA, and CD6. Cytokine CCL20 and IL-18 had moderate correlation (r = 0.35 and r = 0.46) with the severity of AD. The cluster analysis revealed that children in the cluster of samples with the highest value of immune checkpoint receptors and inflammatory suppressor enzymes showed the greatest AD preventive effect from probiotics.ConclusionsThe proteins associated with both maternal probiotic supplementation and the presence and severity of AD warrant attention because of their potential biological relevance. Cluster analysis may provide a new insight when considering which subgroups benefit from probiotic supplementation. Larger studies are needed to confirm the results.Trial registration number: The study was retrospectively registered at ClinicalTrials.gov (NCT00159523) on 12nd September 2005.

Diagnosis and treatment of atopic dermatitis in children and adults: European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus Report

Background Atopic dermatitis (AD) is a chronic inflammatory skin condition characterized by barrier dysfunction and immune dysregulation, often leading to increased allergen penetration, sensitization, and secondary infections. Colloidal oat emollients are widely used in adult AD management, but their role in pediatric AD treatment, prevention, and allergy modulation remains under investigation. Methods A comprehensive literature review evaluated clinical and preclinical studies on colloidal oat-containing emollients in pediatric AD treatment and prevention. Studies assessing skin barrier function, immune modulation, AD prevention, food allergy risk, and healthcare utilization were included. Results Colloidal oat emollients improved skin hydration, reduced transepidermal water loss (TEWL), and supported barrier repair, leading to fewer AD flares and reduced reliance on steroid treatments. Studies suggest that early, consistent use of advanced emollient formulations may lower AD incidence in high-risk infants and reduce food sensitization rates. Real-world data indicate that patients using colloidal oat emollients have fewer clinic visits and lower overall healthcare costs. Concerns about oat sensitization remain unsubstantiated in most studies. Conclusion Colloidal oat emollients are effective, well-tolerated, and cost-efficient for pediatric AD management. Their barrier-restorative and anti-inflammatory properties may reduce AD and allergy risk. Future research should focus on head-to-head emollient comparisons to optimize treatment strategies.

Atopic dermatitis (AD) is a highly prevalent condition. Recent evidence suggests a link between the altered gut microbiome and the development of AD. Probiotics and/or prebiotics have been used in the treatment and prevention of AD with the intention of correcting the aberrant gut microbiome. As of now, data from meta-analyses show some promise in the use of probiotics for the prevention of AD with the effect being seen only when administered both prenatally and postnatally. Prebiotics and synbiotics have less compelling evidence to support their effectiveness in AD prevention or treatment, mainly due to the discrepancies of results. Explanations for the variations in the results may come from environmental factors, probiotic/prebiotic factors, and host factors that affect efficacy of the probiotic/prebiotic. More studies are needed to understand the mechanisms of action of probiotics/prebiotics and also to identify their true benefits in the prevention and treatment of AD.

Atopic dermatitis is the most common chronic skin disease affecting the pediatric population. Probiotics have been proposed to be effective in preventing the development of pediatric atopic dermatitis. Although studies show promise for the use of probiotics, the evidence is still inconclusive due to significant heterogeneity and imprecision. To determine the comparative effectiveness of the different types of probiotic strains in preventing the development of atopic dermatitis among pediatric patients. A systematic search of Cochrane Library, MEDLINE, TRIP Database, and Centre for Research and Dissemination was conducted. Manual search of the reference lists and search for unpublished articles were also done. All randomized controlled trials available from inception until April 12, 2020, on the use of probiotics in the prevention of atopic dermatitis among children were included. The comparator groups considered are other probiotic strains and placebo. The primary outcome of interest was the development of atopic dermatitis. Two authors independently searched for articles, screened the articles for inclusion, appraised the articles using the Cochrane risk of bias tool version 2, and extracted the data. In case of disagreement, the two authors discussed the source of disagreement until consensus was reached. If consensus was not reached, an independent third party reviewer was consulted. Frequentist network meta-analysis was conducted using STATA 14 software. The ranking probabilities and surface under the cumulative ranking curve (SUCRA) values were obtained to determine ranking of the different probiotic strains based on efficacy and safety data. We included 21 original studies represented by 35 records and a total of 5406 children with atopic dermatitis as diagnosed by clinicians or fulfillment of validated diagnostic criteria. All studies were randomized placebo-controlled trials. The top 3 probiotic preparations in terms of efficacy in reducing the risk of atopic dermatitis are Mix8 (Lactobacillus paracasei ST11, Bifidobacterium longum BL999), LP (Lactobacillus paracasei ssp paracasei F19) and Mix3 (Lactobacillus rhamnosus GG, Bifidobacterium animalis ssp lactis Bb-12). Mix8 compared with placebo probably reduces the risk of atopic dermatitis based on low-quality evidence (RR = 0.46, 95% CI 0.25-0.85). Mix3 compared with placebo also probably reduces the risk of atopic dermatitis based on low-quality evidence (RR = 0.50, 95% CI 0.27-0.94). It is uncertain whether LP compared with placebo reduces the risk of atopic dermatitis due to very-low-quality certainty of evidence (RR = 0.49, 95% CI 0.20-1.19). In terms of adverse events, LGG may slightly lead to less adverse events compared with placebo based on low-quality evidence (RR = 0.70, 95% CI 0.32-1.52). Mix4 may slightly lead to more adverse events compared with placebo based on low-quality evidence (RR = 1.06, 95% CI 0.02-51.88). Based on subgroup analysis of studies involving infants, Mix3 compared with placebo probably reduces the risk of atopic dermatitis based on low-quality evidence (RR = 0.46, 95% CI 0.22-0.97). In the subgroup analysis of studies where probiotics were administered to pregnant women and to infants, LRH compared with placebo probably reduces the risk of atopic dermatitis based on moderate-quality evidence (RR = 0.54, 95% CI 0.26-1.11). Certain probiotic preparations demonstrate efficacy in reducing the risk of developing atopic dermatitis when administered to pregnant women, infants, or both.

Targeting the skin in atopic dermatitis

Introduction: Atopic dermatitis (AD) is a prevalent pediatric sensitive skin condition, yet data on parental awareness and preventive practices in India remain limited. This study aimed to assess parents' knowledge, attitudes, and practices (KAP) regarding AD in children under five years of age.Methods: A cross-sectional, nationwide online survey was conducted among 1,003 Indian parents, selected from a pool of 3,012 respondents to ensure regional representation. Administered by Censuswide, the survey adhered to the British Polling Council, the Market Research Society (MRS), and the European Society for Opinion and Marketing Research (ESOMAR) ethical guidelines. The 20-item questionnaire primarily employed a Likert scale to assess parental knowledge, management strategies, and attitudes toward AD. Descriptive statistical analyses (frequencies, means, and percentages) were applied, with data stratification by demographics to enhance result interpretation.Results: A survey conducted among 1,003 Indian parents of children under five years of age reported an AD prevalence of 17.85% (179 cases). Among the respondents, 687 (68.49%) were aware of strategies to delay AD onset in high-risk children, and 895 (89%) expressed interest in learning about preventive measures. Of the 179 children diagnosed with AD, 144 parents (80.45%) reported attempting preventive treatments prior to the diagnosis. The primary barrier to initiating preventive measures was a lack of awareness. Approximately 575 (57.3%) parents indicated a willingness to use moisturizers proactively before symptom onset in high-risk children. However, only 130 parents (12.96%) specifically identified moisturizers as their preferred preventive strategy for children at risk of developing AD. Parents prioritized safety, efficacy, and dermatologist recommendations when selecting topical treatments.Conclusion: The findings highlight substantial parental interest in AD prevention, although gaps in awareness remain a critical barrier. These insights emphasize the need for targeted educational initiatives and early intervention strategies to enhance AD management and prevention in India. Further research utilizing inferential statistical analyses could provide deeper insight into the factors influencing parental decision-making and intervention effectiveness.

Atopic dermatitis (AD) is a chronic, inflammatory skin disorder characterized by disruption of epidermal barrier function and aberrant immune response to antigens. Current therapies focus on symptom management by restoring epidermal barrier function with emollients and reducing inflammation. Given the prevalence of "steroid phobia" and reported dissatisfaction with first-line therapies, oral vitamins and supplements have been proposed as promising complementary and alternative therapies. The purpose of this systematic review is to evaluate the evidence for various oral vitamins and supplements for the treatment of AD. A literature search was performed in February 2018 in MEDLINE, EMBASE, and Cochrane databases. Included studies were clinical trials and meta-analyses on the oral supplementation of vitamins and supplements for the treatment or prevention of AD. The search identified over 300 articles, of which 37 were included for review. Supplementation with vitamins E and D have the most robust evidence for AD symptom management. Probiotics may play a role in the prevention of infantile AD. Fatty acids such as docosahexaenoic acid, sea buckthorn oil, and hempseed oil also have preliminary evidence for use as supplements to decrease AD severity, but randomized controlled trials are needed. Vitamins and supplements may have a role in the management of AD, however, many of the studies reviewed are limited by small sample size. More studies are needed to better inform medical providers and patients about the role of these treatments in the management of AD.