Journal of Allergy and Clinical Immunology
Atopic Dermatitis Intervention to Control the Atopic MarchAtopic dermatitis and the atopic march
Section snippets
Three phases of atopic dermatitis
The infantile phase of AD reflects the manifestations of AD from birth to 2 years of age (Fig 1). The erythematous papules and vesicles typically begin on the cheeks, forehead, or scalp and are intensely pruritic. Lesions might remain localized to the face or might extend to the trunk or particularly the extensor aspects of the extremities in scattered, ill-defined, often symmetrical patches. Exacerbation of facial dermatitis on the medial cheeks and chin is often seen concomitant with teething
Infections and other clinical manifestations associated with AD
Several other clinical signs are seen with increased frequency in children with AD (Table II), although they might appear in children without AD as well. Children with AD also have an increased risk of developing cutaneous Staphylococcus aureus infection and cutaneous dissemination of the viral organisms herpes simplex and molluscum contagiosum. S aureus can be cultured from 93% of dermatitic lesions and 76% of uninvolved (normal-appearing) skin of patients with AD.10, 11 The increased
Quality of life in atopic dermatitis
Whereas physicians note changes in the clinical signs of AD to gauge severity and response to therapy, patients and their families are equally concerned about their quality of life. When the dermatitis is active, the quality of life in infants, children, and adolescents has clearly been shown to be reduced, particularly in patients with moderate and severe disease. The resultant psychologic stress, as well as other stresses such as concurrent infectious illness, can clearly provoke AD. Recent
The atopic march
The atopic march is the natural history of atopic manifestations, characterized by a typical sequence of progression of clinical signs of atopic disease, with some signs becoming more prominent while others subside. In general, the clinical signs of AD predate the development of asthma and allergic rhinitis, suggesting that AD is an “entry point” for subsequent allergic disease (Fig 4).
Several longitudinal studies provide evidence for the atopic march from AD to the development of allergic
Role of epicutaneous sensitization in the relation between AD and other allergic disorders
Several additional studies have suggested that skin sensitization precedes airway sensitization. Dohi et al48 examined 8 patients with asthma and no AD and 8 patients with AD and no asthma for dust mite sensitization. Both groups had inhalation challenges to acetylcholine, a nonspecific bronchodilator, and to dust mites. Both groups showed airway hypersensitivity to dust mites, and the response of the AD patients to acetylcholine ranged from normal to the asthmatic range. These findings
Proposed molecular mechanism for the epicutaneous sensitization that promotes the atopic march
Several studies have provided evidence that T cells are essential for inflammation and airway sensitivity.52, 53, 54 Tape stripping with application of an allergen in mice induces a local TH2 response,55 and epicutaneous sensitization through barrier-disrupted skin enhances the TH2 cytokine expression. When intact skin is exposed to a single topical application of house dust mite antigen, lymph node expression of TH1 cytokines IL-2 and IFN-γ and of the TH2 cytokine IL-4 is increased. In
Prevention studies
Current best practice calls for intensive management of asthma early in childhood. The observations of a close relationship between asthma and AD suggest that infants and young children with AD should be a target population for the prevention of asthma. Several preliminary studies have examined the treatment of children with AD prophylactically with antihistamine agents to decrease the severity and risk of developing allergic rhinitis or asthma. Yet, no studies have examined the effect of
Conclusions
Children with poorly controlled AD have a poorer quality of life, and their families carry a tremendous financial, time, and psychologic burden. Patients with AD are at increased risk for developing other atopic disorders including asthma. Earlier sensitization and a greater severity of the AD correlate with the highest risk for developing asthma, suggesting a role for percutaneous sensitization through the impaired atopic barrier. Therapies that modify the severity of AD in infants and young
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Cited by (0)
- 1
Dr Spergel is a consultant to Novartis and Fujisawa, has received research support/grants from Merck, Novartis, Genetech, Tanox. Dr Spergel is also a member of the speakers' bureau for GlaxoSmithKline, Novartis and Fujisawa.
- 2
Dr Paller is a consultant and speaker for Novartis and Fujisawa.