Atopic Dermatitis Intervention to Control the Atopic March
Atopic dermatitis and the atopic march

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Abstract

Atopic dermatitis (AD), one of the most common skin disorders seen in infants and children, usually has its onset during the first 6 months of life. The prevalence of AD is similar in the United States, Europe, and Japan and is increasing, similar to that of other atopic disorders, particularly asthma. AD has been classified into 3 sequential phases: infantile, childhood, and adult, each with characteristic physical findings. AD has a tremendously negative effect on the quality of life of patients as well as family, most commonly disturbing sleep. The condition also creates a great financial burden for both the family and society. The cutaneous manifestations of atopy often represent the beginning of the atopic march. On the basis of several longitudinal studies, approximately half of AD patients will develop asthma, particularly with severe AD, and two thirds will develop allergic rhinitis. Epicutaneous sensitization has been thought to be responsible, with subsequent migration of sensitized T cells into the nose and airways, causing upper and lower airway disease. Animal models and human observation concur with this theory. Preliminary prevention studies with oral antihistamines provide evidence that early intervention might slow 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.

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