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Atopic dermatitis is a common chronic inflammatory skin disorder, with a complex pathogenesis. It is characterized by eczematous skin lesions, pruritus, and recurrent skin infections and has a negative impact on patients’ and caregivers’ quality of life. The American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma and Immunology Joint Task Force Atopic Dermatitis Guideline Panel recently released updated AD guidelines. This guideline focuses on addressing clinical questions using trustworthy guideline development standards, including mitigating the potential influence of financial and nonfinancial conflicts of interest, and Grading of Recommendations Assessment, Development, and Evaluation methodology. A multidisciplinary panel used systematic reviews and meta-analyses to inform specific recommendations addressing optimal use of topical treatments, dilute bleach bath, dietary avoidance/elimination, allergen immunotherapy, and systemic treatments. The comprehensive recommendations, emphasizing the third principle of evidence-based medicine—that evidence alone is never enough, and that patient values and preferences must be carefully considered when determining optimal treatments for patients and populations—provide a framework to support clinicians in selecting an optimal treatment plan for each patient. This review provides an overview of the guideline and discusses how those recommendations relate to current practice.

Dupilumab is a monoclonal antibody that targets the interleukin (IL)-4 receptor alpha subunit, thus blocking the effects of IL-4 and IL-13, and has shown efficacy in treating various conditions including asthma, atopic dermatitis, eosinophilic esophagitis, and others. Because of its immune modulatory effects, clinical trials that studied dupilumab did not allow patients to receive live vaccines during the clinical trials because of an abundance of caution, and thus package inserts recommend that patients who are being treated with dupilumab should avoid live vaccines. Because dupilumab is now approved for use in patients from 6 months of age for the treatment of atopic dermatitis, this reported contraindication is now posing a clinical dilemma for patients and clinicians.

Atopic dermatitis (AD) is a chronic inflammatory skin condition with a highly variable clinical phenotype.

Atopic dermatitis (AD) skin lesions are associated with oozing, bleeding, and erythema. This suggests that AD is associated with vascular changes. Dupilumab is an antibody to the alpha subunit of IL-4 receptor that demonstrates strong efficacy in the treatment of AD. IL-4 is known to reduce the permeability barrier function of vascular endothelium.

IMPORTANCE: Patient values and preferences can inform atopic dermatitis (AD) care. Systematic summaries of evidence addressing patient values and preferences have not previously been available. OBJECTIVE: To inform American Academy of Allergy, Asthma & Immunology (AAAAI)/American College of Allergy, Asthma and Immunology (ACAAI) Joint Task Force on Practice Parameters AD guideline development, patient and caregiver values and preferences in the management of AD were systematically synthesized. EVIDENCE REVIEW: Paired reviewers independently screened MEDLINE, Embase, PsycINFO, and CINAHL databases from inception until March 20, 2022, for studies of patients with AD or their caregivers, eliciting values and preferences about treatment, rated risk of bias, and extracted data. Thematic and inductive content analysis to qualitatively synthesize the findings was used. Patients, caregivers, and clinical experts provided triangulation. The GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation–Confidence in the Evidence from Reviews of Qualitative Research) informed rating of the quality of evidence. FINDINGS: A total of 7780 studies were identified, of which 62 proved eligible (n = 19 442; median age across studies [range], 15 years [3-44]; 59% female participants). High certainty evidence showed that patients and caregivers preferred to start with nonmedical treatments and to step up therapy with increasing AD severity. Moderate certainty evidence showed that adverse effects from treatment were a substantial concern. Low certainty evidence showed that patients and caregivers preferred odorless treatments that are not visible and have a minimal effect on daily life. Patients valued treatments capable of relieving itching and burning skin and preferred to apply topical corticosteroids sparingly. Patients valued a strong patient-clinician relationship. Some studies presented varied perspectives and 18 were at high risk for industry sponsorship bias. CONCLUSIONS AND RELEVANCE: In the first systematic review to address patient values and preferences in management of AD to our knowledge, 6 key themes that may inform optimal clinical care, practice guidelines, and future research have been identified.

Atopic dermatitis is a prevalent condition in children and can be effectively managed with medications such as topical calcineurin inhibitors (pimecrolimus or tacrolimus). A key unresolved safety concern is whether use of topical calcineurin inhibitors is associated with cancer. We systematically reviewed the risk of cancer in patients with atopic dermatitis exposed to topical calcineurin inhibitors.

Objectives This continuing nursing educational (CNE) activity is designed for nurses and other health care providers who care for and educate patients and their families regarding atopic dermatitis. For those wishing to obtain CNE credit, an evaluation follows. After studying the information presented in this article, the nurse will be able to: 1. Heighten his/her awareness of the prevalence of atopic dermatitis, its impact on quality of life, and association with asthma and allergies. 2. Examine a multi-faceted approach to management of patients with atopic dermatitis including non-pharmacologic and pharmacologic interventions. 3. Summarize common interventions including hydration, moisturizers, and pharmaceutical agents. 4. Discuss appropriate safety issues related to topical and systemic therapies., Successful strategies for managing atopic dermatitis require an accurate diagnosis, identification and elimination of exacerbating factors including irritants and allergens, adequate hydration of the skin, control of pruritus and infections, [...]

A study was carried out of six children with chronic relapsing colitis (inflammation of the large bowel) due to Clostridium difficile, an infectious organism. The children had undergone antibiotic treatment before the study began. Chronic relapsing colitis may result, in some cases, from patients' abnormally low levels of antibodies against toxin A, one of two toxins produced by Clostridium difficile. To learn more about this possibility, blood tests were carried out on the six patients, 24 healthy children, and 18 healthy adults. Results showed that patients' levels of IgG antibodies (a type of antibody) against toxin A were lower than the levels in control children or adults. Five children were treated with intravenously administered gamma globulin (IVGG, an infusion containing antibodies); during this time, no antibiotics were given. This led to a reduction in the frequency of bowel movements and to the elimination of symptoms of colitis in four patients even after IVGG therapy stopped. It is likely that colitis caused by toxins released by Clostridium difficile developed in these patients as a complication of antibiotic treatment of upper respiratory tract infections. IVGG therapy appears effective for treating chronic relapsing colitis due to Clostridium difficile, particularly in patients who have low levels of IgG antibodies against toxin A. (Consumer Summary produced by Reliance Medical Information, Inc.)

PURPOSE: ReCombinant gamma interferon (rIFN(gamma)) inhibits IgE synthesis in 4tro bY human Peripheral blood mononuclear cells (PBMC). These data suggest a role for rIFN-(gamma) in the treatment of patients with severe atopic dermatitis (AD) and elevated IgE levels. The purpose of this study was to determine the effect of rIFN-(gamma) treatment on IgE production in patients with AD. PATIENTS AND METHODS: Twenty-two patients with chronic severe AD were treated with rIFN-(gamma). In part I of the study, 14 patients were treated with daily subcutaneous injections at three successive dose levels (0.01 mg/M(sup 2)0.05 mg/M(sup 2, and 0.1 Mg/M (sup 2) for 5 days with 2 days off between each dose level. In part II, eight patients received rIFN-(gamma) at 0.05 Mg/M(sup 2), daily for 6 weeks. One patient from part I and eight patients from part Il of the study received three times per week maintenance therapy for up to 14 months. Prior to and at selected times during and after treatment, the clinical and immunologic status of the patients was assessed. RESULTS. In part 1, spontaneous de novo IgE synthesis by PBMC was inhibited in 10 patients receiving rIFN--(gamma) at 0.01 mg/M(sup 2) (p = 0.038) and in nine at 0.1 Mg/M(sup 2) (p = 0.066). There was no reduction of serum IgE levels at any of the three dose levels. Total clinical severity showed improvement at each dose level p, Atopic dermatitis (AD) is a skin inflammation, accompanied by severe itchiness. Hospitalization may be required to control chronic AD, and treatment is directed toward control of symptoms. The cause of AD is not known, but it has been suggested that elevated levels of immunoglobulin E (IgE) may contribute to the condition. It has been reported that interferon gamma may suppress the synthesis of IgE. Laboratory experiments have suggested that this suppression is carried out by human peripheral blood mononuclear cells (PBMC). This study was designed to determine the effect of gamma interferon on IgE production in AD patients. Twenty-two patients with AD were treated with gamma interferon; 14 patients were treated with daily injections of various doses of IgE. There were no reductions in IgE levels at any dose level. However, clinical improvement increased with dose, and the condition worsened when therapy was discontinued. In part two of the study, eight patients were given gamma interferon daily for six weeks. These patients showed no decrease in IgE synthesis by PBMC, or in serum IgE levels. There was significant reduction in clinical disease severity, and this improvement continued during maintenance therapy. It is concluded that treatment with IgE may be effective in treating AD, and further research is warranted. (Consumer Summary produced by Reliance Medical Information, Inc.)

Atopic dermatitis (AD) is a chronic inflammatory skin disease that is complicated by an increased risk for skin and systemic infections. Preventive therapy for AD is based on skin barrier improvement and anti-inflammatory treatments, whereas overt skin and systemic infections require antibiotics or antiviral treatments. This review updates the pathophysiology, diagnosis, management, controversy of antibiotic use, and potential treatments of infectious complications of AD.

Atopic dermatitis (AD) is a common chronic inflammatory skin disease that has become a global health problem. The pathophysiology of AD includes both skin barrier and immune abnormalities, with type 2 immune deviation central to several clinical phenotypes and underlying endotypes. Recognition of the persistent nature and systemic aspects of AD provides a rationale for treatment with a biologic. Dupilumab has been approved for patients 6 years of age and older with moderate to severe AD. Monoclonal antibodies are in phase 3 trials and may become part of a precision medicine approach to AD.

IMPORTANCE: Adolescents with atopic dermatitis (AD) have high disease burden negatively affecting quality of life, with limited treatment options. The efficacy and safety of dupilumab, a monoclonal antibody, approved for treatment in adolescent patients with inadequately controlled AD, remain unknown in this patient population. OBJECTIVE: To assess the efficacy and safety of dupilumab monotherapy in adolescents with moderate to severe inadequately controlled AD. DESIGN, SETTING, AND PARTICIPANTS: A randomized, double-blind, parallel-group, phase 3 clinical trial was conducted at 45 US and Canadian centers between March 21, 2017, and June 5, 2018. A total of 251 adolescents with moderate to severe AD inadequately controlled by topical medications or for whom topical therapy was inadvisable were included. INTERVENTIONS: Patients were randomized (1:1:1; interactive-response system; stratified by severity and body weight) to 16-week treatment with dupilumab, 200 mg (n = 43; baseline weight <60 kg), or dupilumab, 300 mg (n = 39; baseline weight ≥60 kg), every 2 weeks; dupilumab, 300 mg, every 4 weeks (n = 84); or placebo (n = 85). MAIN OUTCOMES AND MEASURES: Proportion of patients with 75% or more improvement from baseline in Eczema Area and Severity Index (EASI-75) (scores range from 0 to 72, with higher scores indicating greater severity) and Investigator’s Global Assessment (IGA) 0 or 1 on a 5-point scale (scores range from 0 to 4, with higher scores indicating greater severity) at week 16. RESULTS: A total of 251 patients were randomized (mean [SD] age, 14.5 [1.7] years; 148 [59.0%] male). Of 250 patients with data available on concurrent allergic conditions, most had comorbid type 2 diseases (asthma, 134 [53.6%]; food allergies, 60.8%; allergic rhinitis, 65.6%). A total of 240 patients (95.6%) completed the study. Dupilumab achieved both coprimary end points at week 16. The proportion of patients with EASI-75 improvement from baseline increased (every 2 weeks, 41.5%; every 4 weeks, 38.1%; placebo, 8.2%) with differences vs placebo of 33.2% (95% CI, 21.1%-45.4%) for every 2 weeks and 29.9% (95% CI, 17.9%-41.8%) for every 4 weeks (P < .001). Efficacy of the every-2-week regimen was generally superior to the every-4-week regimen. Patients in the dupilumab arms had higher percentage values of conjunctivitis (every 2 weeks, 9.8%; every 4 weeks, 10.8%; placebo, 4.7%) and injection-site reactions (every 2 weeks, 8.5%; every 4 weeks, 6.0%; placebo, 3.5%), and lower nonherpetic skin infections (every 2 weeks, 9.8%; every 4 weeks, 9.6%; placebo, 18.8%). CONCLUSIONS AND RELEVANCE: In this study, dupilumab significantly improved AD signs, symptoms, and quality of life in adolescents with moderate to severe AD, with an acceptable safety profile. Placebo-corrected efficacy and safety of dupilumab were similar in adolescents and adults. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03054428

Atopic dermatitis (AD) is a common chronic pruritic inflammatory skin disease that affects all ages and is recognized as a global health problem. Pathophysiology is complex with skin barrier abnormalities, immune dysregulation, and microbial dysbiosis all implicated. Markers of immune and inflammatory activation in the circulation provide a rationale for systemic therapy. Type 2 immune polarization is central, though other cytokine pathways including Th22 and Th17/IL-23 have been described, suggesting additional therapeutic targets in a subset of patients. Dupilumab and tralokinumab are monoclonal antibodies currently approved for moderate-to-severe AD with lebrikizumab and nemolizumab in late stages of development.

Population-based estimates on the prevalence of atopic dermatitis in adults vary widely. The objectives of this study were to determine the prevalence of atopic dermatitis in the population of the United States, the distribution of disease severity, and its impact on health-related quality of life. Among 1,278 participating adults, the prevalence (95% confidence interval) of atopic dermatitis was 7.3% (5.9–8.8). Overall, 60.1% (56.1–64.1) of participants were classified as having mild, 28.9% (25.3–32.7) as having moderate, and 11% as having severe (8.6–13.7) disease. Patients with atopic dermatitis and those with more severe disease had higher scores in the dermatology life quality index (mean [standard deviation] for AD patients = 4.71 [6.44] vs. control individuals = 0.97 [2.12]) (P< 0.001) and the hospital anxiety (mean [standard deviation] for AD patients = 7.03 [4.80] vs. control individuals = 4.73 [4.8]) and depression (mean, [standard deviation] for AD patients = 5.83 [4.54] vs. control individuals = 3.62 [3.61]) scales, indicating a worse impact on quality of life and an increased likelihood of anxiety or depression. Based on our prevalence estimates, 16.5 million adults would have a diagnosis of atopic dermatitis, with 6.6 million meeting criteria for moderate to severe disease. Our study confirms the high prevalence and disease burden of atopic dermatitis in this population.

Patients with severe atopic dermatitis (AD) are reported to represent between 10% and 18% of all patients with AD. However, in this subgroup of patients, quality of life is significantly affected and patients may have a number of atopic and nonatopic comorbidities. Treatment of this severe population has often been reactive with inappropriate use of systemic corticosteroids and unapproved immunosuppressants. Recent insights point to the systemic nature of AD, which has important therapeutic implications. Management of severe AD requires a comprehensive approach that incorporates proper diagnosis, assessment of disease severity, and impact on patient's and caregiver's quality of life, along with education regarding the chronic relapsing nature of the disease as well as treatment options. Biologics such as dupilumab offer a novel, targeted therapeutic approach for this systemic disease.

Patients with atopic dermatitis (AD) are commonly colonized with Staphylococcus aureus(AD S. aureus+), but what differentiates this group from noncolonized AD patients (AD S. aureus–) has not been well studied. To evaluate whether these two groups have unique phenotypic or endotypic features, we performed a multicenter, cross-sectional study enrolling AD S. aureus+(n = 51) and AD S. aureus–(n = 45) participants defined by the presence or absence of S. aureusby routine culture techniques and nonatopic, noncolonized control individuals (NA S. aureus–) (n = 46). Filaggrin (FLG) genotypes were determined, and disease severity (Eczema Area and Severity Index, Rajka-Langeland Severity Score, Investigator’s Global Assessment score, Numerical Rating Scale, and Dermatology Life Quality Index) was captured. Skin physiology was assessed (transepidermal water loss [TEWL], stratum corneum integrity, hydration, and pH), and serum biomarkers were also measured. We found that AD S. aureus+patients had more severe disease based on all scoring systems except itch (Numerical Rating Scale), and they had higher levels of type 2 biomarkers (eosinophil count, tIgE, CCL17, and periostin). Additionally, AD S. aureus+patients had significantly greater allergen sensitization (Phadiatop and tIgE), barrier dysfunction (TEWL and stratum corneum integrity), and serum lactate dehydrogenase (LDH) than both the AD S. aureus–and NA S. aureus–groups. FLGmutations did not associate with S. aureus+colonization. In conclusion, adult patients with AD who are colonized on their skin with S. aureushave more severe disease, greater type 2 immune deviation, allergen sensitization, barrier disruption, and LDH level elevation than noncolonized patients with AD.

The patient burden and quality of life (QOL) impact of atopic dermatitis (AD) in the United States population is not well established.

Atopic dermatitis (AD), a common chronic pruritic inflammatory skin disease, impacts the quality of life of patients and caregivers and has become a global health problem. It is increasingly recognized as a disease not only of children but also of adults who may have a persistent or relapsing course from childhood or who develop new-onset adult disease. Besides well-established atopic comorbidities, associations with a number of nonatopic comorbidities have been reported. AD is characterized by both immune dysregulation and epidermal barrier dysfunction. The findings that nonlesional skin in AD has both terminal keratinocyte differentiation defects and immune abnormalities as well as multiple markers of immune and inflammatory activation in the circulation point to the systemic nature of the disease and have important translational implications. Although AD is predominantly associated with type 2 immune responses, activation of other cytokine pathways including TH1, TH22, and TH17/IL-23 has been reported, suggesting potential therapeutic targets and provide a rationale for treatment with novel biologics. Dupilumab, a fully human mAb targeting the IL-4 Rα subunit, blocks signaling of both IL-4 and IL-13 and is the first biologic to be approved for the treatment of moderate-to-severe AD in adult patients. Other biologics in current trials for AD are targeting the IL-31 receptor, IL-13, and the common p40 subunit of IL-12/IL-23.

Atopic dermatitis (AD) is a common, chronic, relapsing, inflammatory skin disease that affects children and adults. Until recently, the only Food and Drug Administration–approved systemic treatment option for patients with moderate-to-severe AD was systemic steroids, which are not recommended by current guidelines and are commonly associated with disease rebound. Instead, clinicians choose from several off-label immunosuppressants, which can have serious adverse effects. A significant number of these patients go untreated. Research on the immunopathogenesis of AD has paved the way for new, targeted, systemic therapies for moderate-to-severe AD. In early 2017, the Food and Drug Administration approved dupilumab for adults with moderate-to-severe AD whose disease is not adequately controlled with topical therapies. Although the national guidelines can be very helpful to clinicians, the process for updating them does not allow for timely incorporation of novel therapies. A steering committee of AD experts, including dermatologists, allergists, and a patient advocacy group representative, developed recommendations on the basis of a literature review and expert opinion to help clinicians understand how new therapies fit into the current treatment paradigm and to provide practical recommendations for assessing AD severity, treatment response, and treatment failure.

Atopic dermatitis (AD) is a chronic, remitting-relapsing inflammatory dermatitis often managed by a multidisciplinary group of providers including allergists, dermatologists, and primary care practitioners. As the pathogenesis of AD is complex and multifactorial, there are numerous approaches to therapeutic management. Current AD management guidelines cover a broad range of interventions, from treating acute flares to environmental modifications. Allergists and dermatologists have both common and distinct approaches to AD management highlighted in their respective guidelines, providing multiple approaches to disease management. We compare and contrast the recent AAAAI/ACAAI JTF 2012 AD Practice Parameter and AAD 2014 guidelines, highlighting differing approaches to disease management.

National and international guidelines address stepwise atopic dermatitis (AD) management. Wet wrap therapy (WWT) is important as an acute therapeutic intervention for treatment of moderate to severe AD. Using clothing instead of bandages makes this intervention simpler, less time intensive, and less expensive. Education of patients and caregivers is critical to success; methodology must be standardized. Future studies must carefully describe all procedure components. Incorporation of validated outcomes tools would help with interpretation. WWT should be considered as a potential treatment option ahead of systemic immunosuppressive therapies for patients failing conventional therapy.

Guidance addressing atopic dermatitis (AD) management, last issued in 2012 by the American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force, requires updating as a result of new treatments and improved guideline and evidence synthesis methodology.

Emerging treatments for moderate-to-severe atopic dermatitis (AD) may provide greater and faster improvement in AD signs and symptoms than current therapies.

Allergic contact dermatitis (ACD) may complicate the clinical course of atopic dermatitis (AD), and patch testing remains the criterion standard for diagnosing ACD. To date, there have been no guidelines or consensus recommendations on when and how to patch test individuals with AD. Failure to patch test when appropriate may result in overlooking an important and potentially curable complicating comorbidity. In this article, we present consensus recommendations regarding when to perform patch testing in the AD patient, best practices, and common pitfalls. Patch testing should be considered in AD patients with dermatitis that fails to improve with topical therapy; with atypical/changing distribution of dermatitis, or pattern suggestive of ACD; with therapy-resistant hand eczema in the working population; with adult- or adolescent-onset AD; and/or before initiating systemic immunosuppressants for the treatment of dermatitis. A suggested patch testing algorithm for AD patients is provided.

Les traitements systémiques sont généralement associés aux dermocorticoïdes (DC) afin d’obtenir un contrôle de la dermatite atopique (DA) modérée à sévère. Nous avons évalué l’effet d’épargne en dermocorticoïdes d’upadacitinib, un inhibiteur de Janus kinase (JAK) oral présentant une inhibition plus importante de JAK 1 que de JAK 2, JAK 3 ou de la tyrosine kinase 2, sur la base des données issues de l’essai AD Up.

The influence of diet on atopic dermatitis (AD) is complex, and the use of dietary elimination as a treatment has conflicting views.

Bleach bathing is frequently recommended to treat atopic dermatitis (AD), but its efficacy and safety are uncertain.

Atopic dermatitis (AD) is the most common chronic, relapsing inflammatory skin disease of children and is a global public health problem. National and international AD guidelines address AD care in a stepwise fashion. Wet wrap therapy (WWT) is a therapeutic intervention for moderate-to-severe AD.

Atopic dermatitis is a complex, chronic inflammatory skin disease. Affected individuals, particularly those with moderate to severe disease, often suffer from significant morbidity, such as sleep loss, skin infections, and school or work disruption. Treatment for these patients can be especially challenging. Restoring skin barrier function, eliminating allergic and nonallergic triggers, and properly using anti-inflammatory and antimicrobial medications are all important components of a comprehensive treatment plan. Wet wraps and systemic immunosuppressants are alternative treatments for patients with severe, refractory atopic dermatitis.

Background: In atopic dermatitis (AD) there is evidence of tissue fibrosis involving a number of structural changes, including papillary dermal fibrosis and epidermal hyperplasia. These changes are suggested to be the result of chronic inflammation of the skin. Several remodeling-associated cytokines, including transforming growth factor (TGF) β1, IL-11, and IL-17, have been shown to be increased in allergic diseases, including asthma. Objective: We investigated TGF-β1, IL-11, and IL-17 expression in skin biopsy specimens recovered from acute and chronic skin lesions from patients with AD, as well as from uninvolved skin of patients with AD and skin from healthy volunteers. We also examined the correlation between the expression of these cytokines and the extent of total, type I, and type III collagen deposition. Methods: We evaluated the expression of TGF-β1, IL-11, and IL-17 by means of immunohistochemistry. Collagen deposition was assessed by means of immunohistochemistry and van Gieson staining. Results: TGF-β1 expression was markedly enhanced in both acute and particularly chronic lesions (P< .001). Although IL-11 expression was significantly increased only in chronic lesions (P< .0001), IL-17 was preferentially associated with acute lesions (P< .005). Although collagen type III deposition was not significantly different among the groups, type I collagen deposition was significantly increased in chronic AD lesions (P< .0005). There was a significant correlation between IL-11 and type I collagen deposition, as well as the number of eosinophils in skin specimens from patients with AD (r2= 0.527, and r2= 0.622, respectively; P< .0001). Conclusion: These results suggest that TGF-β1, IL-11, and IL-17 are involved in the remodeling of skin lesions in patients with AD. However, IL-11 and IL-17 are preferentially expressed at different stages of the disease. Type I collagen appeared to be the major subtype involved in this repair process.

Background:Few cost-effectiveness analyses have been conducted on topical therapies for atopic dermatitis. Objective:We sought to compare cost-effectiveness of high-potency topical corticosteroids (HPTCs) and tacrolimus ointment for the treatment of moderate to severe atopic dermatitis for patients who are not responsive to or not well controlled with mid-potency topical corticosteroids. Methods:A Markov model represented the cyclic nature of atopic dermatitis. Clinical outcomes were derived from published literature. “Efficacy” was defined as disease-controlled days on which patients experienced a greater than 75% improvement in their disease. Resource use and changes in management were on the basis of opinions of a physician panel; secondary treatment was an oral antibiotic with topical corticosteroids. Sensitivity analyses were conducted for all variables. Results:The model was sensitive to duration of continuous treatment with HPTCs. HPTCs, when limited to 2-week treatment cycles, were associated with the highest total costs ($1682 per year) and the least efficacy (185 disease-controlled days). HPTCs in 4-week treatment intervals and tacrolimus ointment were similar in total costs and efficacy ($1317 vs $1323 for 194 vs 190 disease-controlled days, respectively). Although primary drug costs were higher for patients treated with tacrolimus ointment, patients treated with regimens of HPTCs incurred higher secondary drug costs. Conclusion:In the base case analyses, tacrolimus ointment was more cost-effective than HPTCs administered in 2-week treatment cycles, and similar in cost-effectiveness to 4-week cycles of HPTCs. (J Am Acad Dermatol 2003;48:553-63.)

During the past year there have been significant advances in our understanding of the mechanisms underlying allergic skin diseases. This article reviews some of these advances in atopic dermatitis and urticaria. The introduction of a new class of topical anti-inflammatory medications, topical calcineurin inhibitors, has significantly increased our treatment options and led to a rethinking of potential management approaches in atopic dermatitis. (J Allergy Clin Immunol 2003;111:S805-12.)

Background:Atopic dermatitis/eczema (AD/E) is a common disease. Few studies have attempted to quantify the cost to third-party payers. Objective:Our purpose was to identify the annual cost of medical services and prescription drugs for the treatment of AD/E to private insurance and Medicaid payers in the United States. Methods:We used a retrospective study design employing claims data from 1997 and 1998 from a private insurer and a state Medicaid program to analyze costs incurred. Beneficiaries were considered to have AD/E if they had at least one claim in 1997 with a primary or secondary listing of 1 of 3 diagnosis codes: 691.8, other atopic dermatitis and related conditions; 692.9, contact dermatitis and other eczema when no cause is specified; or 373.3, noninfectious dermatoses of eyelid. Patients who did not meet the diagnosis criteria served as a control group in each payer for comparisons of expenditures with the AD/E group. Results:Disease prevalence was 2.4% (private insurer) to 2.6% (Medicaid) of all eligible beneficiaries, and 3.5% to 4.1% of patients submitted at least one health care claim during the study period. Medicaid-insured patients used outpatient hospital visits and hospitalizations at a greater rate than did privately insured patients; neither used emergency departments extensively. The third-party payer cost of illness for AD/E ranged from $0.9 billion to $3.8 billion when projected across the total number of persons younger than 65 years insured by private insurers and Medicaid in the United States. More than one fourth of all health care costs for patients with AD/E may be attributed to AD/E and co-morbid conditions. Conclusions:Annual costs of AD/E are similar to those of other diseases such as emphysema, psoriasis, and epilepsy. Patients incur significant costs associated with AD/E and co-morbid conditions. (J Am Acad Dermatol 2002;46:361-70.)

Background:Staphylococcus aureuscolonizes the skin lesions of more than 90% of patients with atopic dermatitis (AD). The mechanism for increased S aureuscolonization in AD is unknown. However, the initial event in colonization requires adherence of S aureusto the skin. Objective:The purpose of this study was to examine the roles of various bacterial adhesins on S aureusbinding to AD skin. Methods:In an attempt to delineate the mechanism behind this adherence process, an in vitro bacterial binding assay was developed to quantitate the adherence of various S aureusstrains to AD, psoriatic, and normal skin sections. S aureusstrains used in this study were obtained either from cultures of AD skin lesions or from genetically manipulated strains of S aureusthat lacked specific microbial surface components recognizing adhesive matrix molecules (MSCRAMMs)—namely, fibronectin-binding protein (Fnbp), fibrinogen-binding protein (Clf), collagen-binding protein (Cna), and their parent strains. In addition, S aureusstrains from patients with AD were pretreated with fibronectin or fibrinogen to block MSCRAMM receptors and interfere with binding. Results:Under all experimental conditions, binding of S aureuswas localized primarily to the stratum corneum. Immunocytochemical staining of AD skin sections showed a redistribution of fibronectin to the cornified layer, an observation not seen in normal skin. S aureusbinding to uninvolved AD skin was significantly greater than the binding to uninvolved psoriatic skin (P< .0001) and normal skin (P< .0005). The Fnbp-negative S aureusshowed a significant reduction in binding to the AD skin (P< .0001) but not to the psoriatic and normal skin. In the AD skin, a significant reduction in the binding of S aureuswas also observed in the Clf-negative strain (P< .0001) but not in the Cna-negative S aureus. Preincubation of S aureuswith either fibronectin or fibrinogen also inhibited bacterial binding to AD skin (P< .0001). Conclusion:These data suggest that fibronectin and fibrinogen—but not collagen—play a major role in the enhanced binding of S aureusto the skin of patients with AD. (J Allergy Clin Immunol 2001;108:269-74.)

Background:Atopic dermatitis (AD) is a chronic inflammatory skin disease associated with tissue eosinophilia and the activation of T lymphocytes. The novel eosinophil chemoattractants, eotaxin and monocyte chemotactic protein (MCP)-4, are up-regulated at sites of allergic inflammation, yet their contribution to the pathophysiologic mechanisms of AD remains to be determined. Objective:We sought to investigate the expression of eotaxin and MCP-4 in acute and chronic lesions from patients with AD and to determine their relationship to the numbers of resident inflammatory cells. Methods:With use of in situ hybridization, the expression of eotaxin and MCP-4 messenger RNA (mRNA) in skin biopsy specimens from patients with acute and chronic AD skin lesions was compared with that of uninvolved skin from these patients and skin from healthy volunteers. Results:There was a constitutive expression of eotaxin and MCP-4 mRNA in skin biopsy specimens from healthy subjects. Positive signal for chemokine mRNA was observed both within the epidermis and inflammatory cells (macrophages, eosinophils, and T cells) of the subepidermis in AD skin lesions. Within the subepithelium acute and chronic skin lesions exhibited a significant increase in the numbers of eotaxin and MCP-4 mRNA-positive cells compared with uninvolved skin (P< .01), whereas the numbers of eotaxin and MCP-4 mRNA-positive cells were significantly higher in chronic AD compared with acute AD skin lesions (P< .005, P< .001, respectively). Correlations were observed between the expression of eotaxin and MCP-4 mRNA and the presence of eosinophils and macrophages, respectively, in AD lesions (r2= 0.84, r2= 0.94). Conclusion:There is an increased expression of eotaxin and MCP-4 in acute and chronic lesions, suggesting that these chemotactic factors play a major role in the pathophysiologic mechanisms of AD. (J Allergy Clin Immunol 2000;105:1002-7.)

Previous studies have shown that both nucleosides and oligonucleotides linked to isologous gammaglobulin suppress anti-nucleic acid antibody production both in vivoand in vitro. The aim of this study was to determine whether one can make a DNA-human gammaglobulin (HGG) conjugate which can inhibit anti-double stranded DNA (dsDNA) antibodies obtained from a heterogeneous population of systemic lupus eruthematosus (SLE) sera. To do so, we constructed conjugates of sonicated dsDNA fragments of 100-400 base pairs covalently linked to HGG with varying degrees of substitution of DNA:HGG. An ELISA inhibition assay was used to determine which conjugate best inhibits the binding of anti-dsDNA antibodies. Conjugate 2, prepared with monomeric HGG (150 kD) with a high degree of substitution (3.72 DNA:HGG) inhibited the binding of anti-dsDNA antibodies from 27 of 31 SLE sera. In addition, this conjugate inhibited the spontaneous formation of anti-dsDNA in vitro by cultured lymphoid cells from selected SLE patients. Together, this data suggests that a 'generic' tolerogen may provide an antigen specific therapy for SLE.

Atopic dermatitis is the most common chronic skin disease of young children and is frequently associated with asthma and allergies. Th2-type cytokine secreting T cells expressing the cutaneous lymphocyte-associated antigen play a central role in the induction of local IgE responses and recruitment of eosinophils in this disease. Chronic inflammation in atopic dermatitis likely involves a number of interdependent factors, including repeated or persistent exposure to allergens, which can lead to Th2-cell expansion. In addition, exotoxins secreted by Staphylococcus aureusacting as both superantigens and allergens can contribute to persistent inflammation or exacerbations of atopic dermatitis. Treatment of atopic dermatitis with topical agents such as tacrolimus ointment and phospho-diesterase-4 inhibitors offers new approaches directed at correction of the immune dysfunction associated with this disease.

Background:Atopic dermatitis (AD) is a chronic inflammatory skin disease with immunopathologic features that vary depending on the duration of the lesion. Acute lesions are associated with a T-cell infiltrate and a high expression of IL-4 mRNA compared with chronic lesions, uninvolved AD skin, or skin from normal control subjects. Chronic lesions are rich in eosinophils and monocyte/macrophages and contain a greater number of IL-5, granulocyte-macrophage colony-stimulating factor (GM-CSF), and IL-12 (p40) mRNA-positive cells. Objectives:In this study, we investigated the mRNA expression of the IL-4 receptor (IL-4Rα), IL-5Rα, GM-CSFRα, and IL-12Rβ2in biopsy specimens from acute and chronic AD lesions, uninvolved AD skin, normal skin, and psoriatic skin lesions. Methods:Cytokine receptor mRNA was examined in paraformaldehyde-fixed biopsy specimens with in situ hybridization with specific antisense riboprobes. Results:Acute and chronic skin lesions exhibited a significant increase in numbers of IL-5Rα and GM-CSFRα mRNA-positive cells compared with uninvolved AD skin and normal skin (P< .001). Chronic skin lesions had a significantly greater number of IL-5Rα and GM-CSFRα mRNA-positive cells when compared with acute AD skin (P< .001). In contrast, IL-4Rα mRNA expression was increased in acute but not chronic AD lesions compared with uninvolved and normal skin (P< .001). No significant differences were observed in numbers of IL-12Rβ2mRNA-positive cells when comparing acute AD, chronic AD, uninvolved AD, and normal skin. In psoriatic skin, the numbers of GM-CSFRα and IL-12Rβ2mRNA-positive cells were significantly increased compared with acute AD lesions, uninvolved skin, and normal control skin (P< .01). Conclusions:These results demonstrate that acute AD is associated with a high expression of IL-4Rα, whereas IL-5Rα and GM-CSFRα mRNA are predominantly increased in chronic AD and to lesser extent in acute lesions. These findings support the biphasic role of IL-4, IL-5, and GM-CSF in the pathophysiology of AD. (J Allergy Clin Immunol 1998;102:245-50)

Dupilumab has demonstrated efficacy with acceptable safety in clinical trials in patients with moderate to severe atopic dermatitis (AD).

Focuses on hypersensitivity pneumonitis (HP) which is caused by inhalation of a number of organic dusts that affect the distal airways. Pathophysiology of HP; Other syndromes to be considered when evaluating patients with HP.

Presents a medical case of a male factory worker diagnosed with a pruritic rash, or what he called his `seven-year itch.' Treatment approaches; Results of allergy tests; Potential difficulties of dealing with a chronic pruritic rash; Possible causes of the skin disease; Prognosis of patients with extracutaneous disease.

Describes how the authors diagnosed a patient with mastocytosis. Causes of flushing and hypotension; Opinions about idiopathic anaphylaxis; Treatment of mastocytosis.