Acute Exacerbation Of Atopic Dermatitis Research Articles

Biological and psychosocial factors associated with the persistence of pruritus symptoms: protocol for a prospective, exploratory observational study in Germany (individual project of the Interdisciplinary SOMACROSS Research Unit [RU 5211])

IntroductionChronic pruritus (CP) is a symptom of dermatologic, neurologic, systemic and psychosomatic diseases. CP has a prevalence of ~20% in the general population and is therefore a significant burden on...

12983 The effectiveness of high-dose ultraviolet A-1 phototherapy on acute exacerbated atopic dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disease, characterized by pruritus, a chronic course of exacerbations and remissions. High-dose ultraviolet A-1 (UVA-1) phototherapy has been shown to be effective in the treatment of acute exacerbated AD, however, there was no previous case study in Asia. We present a retrospective review of our experiences with high-dose UVA-1 phototherapy. This study was conducted on 16 patients with acute exacerbation of AD. High-dose (100 J/cm2) regimens of UVA-1 therapy were employed. The therapeutic effectiveness was assessed according to the clinical examination and SCORAD index before and after the 5th and 10th sessions of treatment. In addition, side effects and recurrence during follow-up were retrospectively evaluated. The patients were between 7 and 50 years of age with average age of 25.8 years. The SCORAD index of 16 patients were between 41 and 89.5 with average score of 64.9. Among the 16 patients, two patients discontinued the treatement because of side effects such as erythema and pruritus. Of 14 patients who completed the 10 sessions of high-dose UVA-1 phototherapy, nine patients (64.3%) showed complete remission and five patients (35.7%) showed partial remission. The average SCORAD index was reduced from 64.2 (before treatment) to 23.3 (after 10th session of treatment). This is the first case study of high-dose UVA-1 phototherapy on Asian acute exacerbated AD patients, suggesting that high dose UVA-1 phototherapy can be a well tolerated and effective treatment for acute exacerbated AD. Afterwards, large-scale prospective studies are needed.

The effectiveness of high-dose ultraviolet A-1 phototherapy for acute exacerbation of atopic dermatitis in Asians.

Atopic dermatitis (AD) is an inflammatory skin disease characterized by a chronic course of exacerbations and remissions. High-dose ultraviolet A-1 (UVA-1) phototherapy has been effective in the treatment of acute exacerbations of AD. However, there have been no case studies in Asian patients to date. We investigated the effectiveness of high-dose UVA-1 phototherapy for treating acute exacerbation of AD in Asian patients. This study included 16 patients with acute exacerbation of AD. High-dose (100J/cm2 ) regimens of UVA-1 therapy were employed. Therapeutic effectiveness was assessed based on the findings of clinical examinations and scoring of AD (SCORAD) index before treatment and after the 5th and 10th sessions of treatment. Additionally, side effects and recurrence during follow-up were retrospectively evaluated. The patients were between 7 and 50years of age, with a mean age of 25.8years. The SCORAD index was between 41 and 89.5, with a mean score of 64.9. Among the 16 patients, two patients discontinued treatment due to the aggravation of erythema and pruritus. Of the 14 patients who completed the 10 sessions of high-dose UVA-1 phototherapy, nine patients (64.3%) showed complete remission and five patients (35.7%) showed partial remission. The mean SCORAD index reduced from 64.9 (before treatment) to 23.3 (after the 10th session of treatment). This is the first case study of high-dose UVA-1 phototherapy for acute exacerbation of AD in Asian patients, suggesting that high-dose UVA-1 phototherapy can be a well-tolerated and effective treatment for acute exacerbated AD. Future large-scale prospective studies are needed.

Antibiotic Choice and Methicillin-Resistant Staphylococcus aureus Rate in Children Hospitalized for Atopic Dermatitis

To examine the prescribing patterns of systemic antibiotics for children hospitalized for atopic dermatitis (AD) exacerbation compared with infectious complications.A total of 174 patients with AD who were admitted to Children’s Hospital Los Angeles from 2013 to 2018 were included (70 with AD exacerbation and 104 with infectious complications).Subjects were identified via retrospective chart review by International Classification of Diseases, Ninth Revision and International Classification of Diseases, 10th Revision codes for AD. Secondary codes for contact dermatitis and other eczema, dermatitis unspecified, and unspecified contact dermatitis, unspecified cause were only included in patients with a physician diagnosis of AD. Infectious complications of AD included patients experiencing focal infections (cellulitis or abscess), invasive infections (bacteremia, osteomyelitis, septic arthritis, or endocarditis), or eczema herpeticum, whereas acute exacerbation of AD was confirmed in the history of present illness, physical examination, or diagnosis on physician discharge summary.Systemic antibiotics were administered in 80% (56 out of 70) of patients with AD exacerbation and 94% (98 out of 104) of those with infectious complications. The most frequently prescribed antibiotics on admission offered empirical coverage against methicillin-resistant Staphylococcus aureus (MRSA), specifically clindamycin and vancomycin, at a total rate of 88% for both AD exacerbation and infectious complications. Rates of use were similar between both groups (75% and 74% for clindamycin and 13% and 14% for vancomycin, in AD versus infectious groups, respectively). Anti-MRSA agents were prescribed at discharge at similar rates between both groups; clindamycin was most commonly prescribed (54% of AD patients and 59% of patients with infectious complications). Sulfamethoxazole-trimethoprim was also prescribed a similar rates for both groups (4% AD, 5% infectious). MRSA was significantly less common in children with AD exacerbation (22%) versus infectious complications (39%) on wound culture results. Significant differences in patients with infections complications included longer length of stay (P < .0001) and higher C-reactive protein levels and erythrocyte sedimentation rates (P = .007 and P = .003, respectively). Patients with AD exacerbation had higher total serum immunoglobulin E levels, but the difference was not significant (P = .07).Although AD is a risk factor for S aureus infections, distinguishing clinical characteristics between AD exacerbation and infectious complications is challenging, and no standard definition for secondary infection or superinfection of AD exists. Antibiotic use for AD exacerbation varies, but empirical use of anti-MRSA agents may not be appropriate. C-reactive protein or erythrocyte sedimentation rate may have a role in distinguishing patients with infectious complications from those with exacerbation.Overall, this study informs the practice of empirical systemic antibiotic use in pediatric patients admitted for AD exacerbation and infectious complications. Further studies are needed, but empirical antibiotic therapy used for infectious complications may not be appropriate for AD exacerbation, particularly while promoting antimicrobial stewardship.

Infective endocarditis in a patient with atopic dermatitis

We present the case of a 39-year-old plumber who was diagnosed with infective endocarditis due to Staphylococcus aureus. The route of entry was attributed to the patient scratching pruritic lesions of his poorly controlled atopic dermatitis (eczema). We recommend that medical practitioners of patients with poorly controlled atopic dermatitis should pay particular attention to, and take measures to mitigate against, this risk.<Learning objective: Infective endocarditis can arise in the context of acute exacerbations of atopic dermatitis (eczema). Clinicians need to be aware of this risk and ought actively to manage such acute flares in order to reduce the risk of infective endocarditis arising from pruritic lesions in this population group.>

Alcohol Intake in Pregnancy Increases the Child's Risk of Atopic Dermatitis. The COPSAC Prospective Birth Cohort Study of a High Risk Population

BackgroundAtopic dermatitis has increased four-fold over the recent decades in developed countries, indicating that changes in environmental factors associated with lifestyle may play an important role in this epidemic. It has been proposed that alcohol consumption may be one contributing risk factor in this development.ObjectiveTo analyze the impact of alcohol intake during pregnancy on the development of atopic dermatitis during the first 7 years of life.MethodThe COPSAC cohort is a prospective, longitudinal, birth cohort study of 411 children born to mothers with a history of asthma, followed up for 7 years with scheduled visits every 6 months as well as visits for acute exacerbations of atopic dermatitis. Risk of atopic dermatitis from any alcohol consumption during pregnancy was analyzed as time-to-diagnosis and adjusted for known risk factors.Results177 of 411 children developed atopic dermatitis before age 7 years. We found a significant effect of alcohol intake during pregnancy on atopic dermatitis development (HR 1.44, 95% CI 1.05–1.99 p = 0.024). This conclusion was unaffected after adjustment for smoking, mother's education and mother's atopic dermatitis.LimitationsThe selection of a high-risk cohort, with all mothers suffering from asthma, and all children having a gestational age above 35 weeks with no congenital abnormality, systemic illness, or history of mechanical ventilation or lower airway infection.ConclusionAlcohol intake by pregnant women with a history of asthma, is significantly associated with an increased risk for the child for developing atopic dermatitis during the first 7 years of life.

Successful treatment of microstomia with UVA1 phototherapy in systemic sclerosis

To the Editor, The introduction of phototherapy has substantially changed the therapeutic response of localized scleroderma (LS). Systemic agents have been proposed for the treatment of LS, some with potential side effects and varying degrees of success. There is sufficient evidence in the literature to demonstrate that low dose (20 J/cm) and medium dose (50 J/cm) UVA1 phototherapy is beneficial in LS. The development of a metal halide lamp emitting high levels of UVA1 radiation (340–400 nm) was first described in 1981 (1), but the therapeutic potential for UVA1 phototherapy did not emerge until 1992 with the first successful report of treating patients for acute exacerbations of atopic dermatitis. It has now been shown to soften thickened plaques, increase skin elasticity and reduce lesional skin thickness in scleroderma (2–4). Recently (4), low-dose UVA1, mediumdose UVA1 and narrowband UVB phototherapy were compared demonstrating comparable efficacy of narrowband UVB and low-dose UVA1 but medium-dose UVA1 being more effective. In systemic sclerosis (SSc), studies of UVA1 are limited. Improvement has been documented in acrosclerosis in those patients with SSc (5). There is no documentation of treatment of other features of SSc by phototherapy in the literature. We describe a case of successful treatment of microstomia with UVA1 phototherapy in a patient with SSc. Case report

T Cell-Regulated Neutrophilic Inflammation in Autoinflammatory Diseases

Previous studies of acute generalized exanthematous pustulosis, a peculiar drug hypersensitivity reaction, suggested that CXCL8-producing T cells regulate sterile, polymorphonuclear neutrophil-rich skin inflammations. In this study, we test the hypothesis of whether CXCL8-producing T cells are present in autoinflammatory diseases like pustular psoriasis and Behçet's disease. Immunohistochemistry of normal skin revealed few CD4+ and CD8+ T cells, few CXCL8+ cells, and no neutrophilic infiltration, whereas in acute exacerbations of atopic dermatitis, numerous CD4+ T cells but few CD8+ T cells, neutrophils, or CXCL8+ cells were detected. In contrast, a pronounced infiltration of neutrophils and of predominantly CD4+ T cells was observed in skin biopsies from pustular psoriasis, Behçet's disease, and acute generalized exanthematous pustulosis, with infiltrating T cells strongly positive for CXCL8 and the chemokine receptor CCR6. Skin-derived T cell clones from pustular skin reactions were positive for CCR6 but negative for CCR8 and secreted high amounts of CXCL8 and GM-CSF, often together with IFN-gamma and TNF-alpha after in vitro stimulation. Moreover, some skin-derived T cell clones from Behçet's disease and from pustular psoriasis predominantly produced CXCL8 and GM-CSF, but failed to secrete IL-5 and IFN-gamma. These cells might represent a particular subset as they differ from both Th1 as well as Th2 T cells and are associated with a unique, neutrophil-rich sterile inflammation. Our findings suggest that CXCL8/GM-CSF-producing T cells may orchestrate neutrophil-rich pathologies of chronic autoinflammatory diseases like pustular psoriasis and Behçet's disease.

High levels of urinary pentosidine, an advanced glycation end product, in children with acute exacerbation of atopic dermatitis: relationship with oxidative stress

Pentosidine is an advanced glycation end product formed by sequential glycation and oxidation. The formation of pentosidine is increased in diseases associated with oxidative stress, such as inflammatory conditions. The aim of the present study was to determine the urinary concentration of pentosidine in atopic dermatitis (AD) and its relationship to the inflammatory status of AD. Urine samples of 32 children with AD and 30 age-matched healthy control subjects were assayed for pentosidine, pyrraline (another advanced glycation end product formed by nonoxidative glycation), and 8-hydroxy-2’-deoxyguanosine (8-OHdG) (an established marker of oxidative stress). Of these 3 markers, urinary concentrations of pentosidine were significantly higher in patients with acute exacerbation of AD than in healthy controls and patients with stable AD. Urinary concentrations of 8-OHdG were significantly higher in AD patients with and without acute exacerbation than in healthy controls. Urinary pentosidine levels correlated significantly with those of 8-OHdG when all data of healthy controls and AD patients were plotted. In patients with acute exacerbation of AD, both urinary pentosidine and 8-OHdG significantly decreased after 7 to 9 days of treatment. Our findings in patients with acute exacerbation of AD suggest that pentosidine levels are partly determined by the prevailing oxidative stress in these patients.

Oxidative stress and altered antioxidant defenses in children with acute exacerbation of atopic dermatitis

The underlying mechanisms of skin inflammation in atopic dermatitis (AD) are not completely understood. The purpose of the present study was to examine the involvement of oxidative stress and antioxidant defenses in children with acute exacerbation of AD. We studied 13 children who were hospitalized for acute exacerbation of AD with purulent skin infection by Staphylococcal aureus (age, 1.5 to 10.0 years), and 28 age-matched healthy subjects (controls). Urine samples obtained from the patients on admission, on 2nd and 7th–9th hospital days, as well as from the controls were analyzed for 8-hydroxy-2′-deoxyguanosine (8-OHdG) (a marker of oxidative DNA damage), acrolein-lysine adducts (a marker of lipid peroxidation), bilirubin oxidative metabolites (BOM) (a marker of antioxidant activity of bilirubin under oxidative stress) and nitrite/nitrate (NOx−) (a marker of endogenous nitric oxide production). Of these, urinary concentrations of 8-OHdG, acrolein-lysine adducts and BOM, but not NOx−, were significantly higher in AD children on admission than those in control subjects. Response to treatment was associated with significant falls in the concentrations of 8-OHdG and acrolein-lysine adducts. Urinary concentrations of acrolein-lysine adducts, but not 8-OHdG, were still significantly higher in AD patients on the 7th–9th hospital day relative to the control. Urinary BOM remained almost constant and significantly high in AD children during hospitalization. Our findings indicate that oxidative stress and altered antioxidant defenses are involved in the pathophysiology of acute exacerbation of AD, and that suppression of oxidative stress might be a potentially useful strategy for the treatment of AD.

Urinary leukotriene E4 levels in patients with atopic dermatitis

Leukotriene synthesis may be increased in a variety of inflammatory diseases. Urinary leukotriene E4 is a stable metabolite of leukotrienes C4 and D4 which has previously been found to be increased in exacerbations of severe asthma and after antigen inhalation. Levels of urinary LTE4 in seven patients during and after a severe flare of atopic dermatitis were measured by high-performance liquid chromatography (HPLC) and radioimmunoassay (RIA). Mean urinary LTE4 levels (+/- SEM) were not increased during (16.7 +/- 3.7 pg/mumol) or after (16.9 +/- 4.8 mumol) the acute exacerbation of atopic dermatitis when compared with the normal range (mean = 23.8 [95% confidence interval 19.9-28.2] pg/mumol creatinine). These findings do not provide evidence of cysteine leukotriene involvement in the pathogenesis of atopic dermatitis.

High-dose UVA1 therapy in the treatment of patients with atopic dermatitis

Besides glucocorticosteroids, there is currently no known effective therapy for patients with acute atopic dermatitis. The therapeutic effectiveness of high-dose UVA1 irradiation in the management of patients with acute exacerbation of atopic dermatitis was examined. Patients in the high-dose UVA1 group (n = 15) were irradiated with 130 joules/cm2 UVA1; the control group (n = 10) was treated with UVA-UVB therapy in a minimal erythema dose-dependent manner (total number of treatments 15). High-dose UVA1 irradiation was found to induce a significant clinical improvement of atopic dermatitis (p less than 0.001). In comparison with UVA-UVB therapy, significant differences in favor of high-dose UVA1 were observed (p less than 0.01). High-dose UVA1, but not UVA-UVB treatment, significantly reduced the elevated serum level of eosinophil cationic protein in patients with atopic dermatitis (p less than 0.003). These studies indicate that high-dose UVA1 irradiation may represent a novel phototherapeutic modality for the treatment of patients with an acute exacerbation of atopic dermatitis.

High-dose-UVA1 phototherapy: a novel and highly effective approach for the treatment of acute exacerbation of atopic dermatitis.

High-Dose-UVA1 irradiation has recently been found to be a new, prompt-acting and highly effective phototherapeutic approach to the treatment of patients with acute exacerbation of atopic dermatitis. This therapeutic efficacy was demonstrated by a marked improvement of clinical symptoms as well as of laboratory parameters, which were found to reflect disease activity in atopic dermatitis. Investigation of the photoimmunological mechanisms responsible for the therapeutic effectiveness of this modality indicates that eosinophils and epidermal Langerhans cells may be targets for High-Dose-UVA1.