Summary
Background
Staphylococcus aureus is increasingly implicated as a possible causal factor in the pathogenesis of atopic dermatitis (AD). However, the reported prevalence rates of skin and nasal ...colonization in the literature vary widely.
Objectives
This study evaluates the prevalence and odds of skin and nasal colonization with S. aureus in patients with AD.
Methods
A systematic literature search was conducted. Odds ratios (ORs) for colonization in patients vs. controls and the prevalence of colonization in patients were pooled using the random‐effects model.
Results
Overall, 95 observational studies were included, of which 30 had a control group. The Newcastle–Ottawa Scale was used to assess study quality, with the majority of studies being of fair to poor quality. Patients with AD were more likely to be colonized with S. aureus than healthy controls OR 19·74, 95% confidence interval (CI) 10·88–35·81. Differences were smaller in nonlesional skin (OR 7·77, 95% CI 3·82–15·82) and in the nose (OR 4·50, 95% CI 3·00–6·75). The pooled prevalence of S. aureus colonization among patients was 70% for lesional skin, 39% for nonlesional skin and 62% for the nose. In lesional skin, meta‐regression showed that the prevalence of colonization increased with disease severity. Study heterogeneity should be taken into consideration when interpreting the results.
Conclusions
These results demonstrate the importance of colonization with S. aureus in AD. Further evaluation of the mechanisms by which S. aureus influences inflammation is required in addition to the development of targeted strategies to decrease skin and nasal S. aureus load.
What's already known about this topic?
Staphylococcus aureus colonizes the skin of patients with atopic dermatitis.
What does this study add?
For the first time, data on S. aureus colonization in atopic dermatitis are systematically summarized showing an increased risk of colonization of lesional skin, nonlesional skin and the nose in patients vs. healthy controls.
Staphylococcus aureus
might amplify symptoms in chronic inflammatory skin diseases. This study evaluates skin and mucosal colonization with
S. aureus
in patients with psoriasis, acne and rosacea. A ...systematic literature search was conducted. Both odds ratios (OR) for colonization in patients versus controls and the prevalence of colonization in patients are reported. Fifteen articles about psoriasis and 13 about acne (12 having a control group) were included. No study in rosacea met our inclusion criteria. For psoriasis, one study out of three controlled studies showed increased skin colonization (OR 18.86; 95 % confidence interval CI 2.20–161.99). Three out of the five studies that reported on nasal colonization showed significant ORs varying from 1.73 (95 % CI 1.16–2.58) to 14.64 (95 % CI 2.82–75.95). For acne one of the three studies that evaluated skin colonization reported a significant OR of 4.16 (95 % CI 1.74–9.94). A relation between nasal colonization and acne was not found. Limitations in study design and low sample sizes should be taken into consideration when interpreting the results. Colonisation with
S. aureus
seems to be increased in patients with psoriasis. This bacterial species, known for its potential to induce long-lasting inflammation, might be involved in psoriasis pathogenesis. Information on acne is limited. Prospective controlled studies should further investigate the role of
S. aureus
in chronic inflammatory skin diseases.
Summary
Background
Eczema phenotypes and emotional and behavioural problems are highly prevalent in childhood, but their mutual relationship is not fully clear.
Objectives
To examine the associations ...of eczema phenotypes with school‐age emotional and behavioural problems, and the bidirectional associations of eczema and emotional and behavioural problems from birth until 10 years.
Methods
This study among 5265 individuals was embedded in a prospective population‐based cohort study. Never, early transient, mid‐transient, late transient and persistent eczema phenotypes were identified based on parent‐reported, physician‐diagnosed eczema from age 6 months until 10 years. Emotional (internalizing) and behavioural (externalizing) problems were measured repeatedly using the Child Behavior Checklist from age 1·5 to 10 years. Cross‐lagged models were applied for bidirectional analyses.
Results
All eczema phenotypes were associated with more internalizing problems and attention problems at age 10 years, compared with never having eczema: range of Z‐score differences 0·14 95% confidence interval (CI) 0·01–0·27 to 0·39 (95% CI 0·18–0·60). Children with early transient eczema had more aggressive behaviour symptoms at age 10 years (Z = 0·16, 95% CI 0·05–0·27). Bidirectional analysis showed that eczema at 0–2 years was associated with more internalizing and externalizing problems at ages 3–6 and 10 years, while, inversely, only internalizing problems at 0–2 years were associated with an increased risk of eczema at age 10 years.
Conclusions
Eczema phenotypes are very modestly associated with more somatic symptoms and attention problems at school age. Early transient eczema is associated with more aggressive behaviour symptoms. Directional effects seem to occur from early‐life eczema to later‐life internalizing and externalizing problems, rather than the reverse.
What's already known about this topic?
Previous cohort studies using non‐data‐driven methods to define eczema phenotypes observed that children with early‐onset and persistent eczema had a higher risk of emotional and behavioural problems in preadolescence.
Alternatively, previous cohort studies showed that children with emotional and behavioural problems had more severe eczema and eczema exacerbations in childhood.
The direction of effects between eczema and emotional and behavioural problems is not fully clear.
What does this study add?
Taking the variability of eczema onset and persistence within and between children over time into account, all identified eczema phenotypes were very modestly associated with more somatic symptoms and attention problems at school age.
Directional effects seem to occur from eczema leading to emotional and behavioural problems, rather than the reverse.
Future research should focus on the effect of early optimal eczema management on mental health disorders in children later in life.
Plain language summary available online
Summary
Background
Alterations of the skin microbiome have been associated with atopic dermatitis (AD) and its severity. The nasal microbiome in relation to AD severity is less well studied.
...Objectives
We aimed to characterize the nasal and skin microbiomes in children with AD in relation to disease severity. In addition, we explored the differences and correlations between the nasal and skin communities.
Methods
We characterized the microbial composition of 90 nasal and 108 lesional skin samples cross‐sectionally from patients with AD, using 16S‐rRNA sequencing. In addition, a quantitative polymerase chain reaction was performed for Staphylococcus aureus and Staphylococcus epidermidis on the skin samples, and AD severity was estimated using the self‐administered Eczema Area and Severity Index.
Results
We found an association between the microbial composition and AD severity in both the nose and skin samples (R2 = 2·6%; P = 0·017 and R2 = 7·0%; P = 0·004), strongly driven by staphylococci. However, other species also contributed, such as Moraxella in the nose. Skin lesions were positive for S. aureus in 50% of the children, and the presence and the load of S. aureus were not associated with AD severity. Although the nose and skin harbour distinct microbial communities (n = 48 paired samples; P < 0·001), we found that correlations exist between species in the nose and (other) species on the skin.
Conclusions
Our results indicate that both the nasal and the skin microbiomes are associated with AD severity in children and that, next to staphylococci, other species contribute to this association.
What's already known about this topic?
Changes in the skin microbiome have been associated with atopic dermatitis (AD) and its severity.
Although the anterior nares could be an important reservoir for self‐contamination and bacterial spread from the nose to the skin or vice versa, research on the relation between the skin and nasal microbiome in AD is limited.
What does this study add?
Both the nasal and the skin microbiome are associated with the severity of AD in children.
Next to staphylococci, other species contribute to the association between the microbiome and AD severity.
Linked Comment: Clausen and Agner. Br J Dermatol 2019; 181:661–662.
Respond to this article
Summary
Background
Staphylococcus aureus plays a role in the pathogenesis of atopic dermatitis (AD), possibly via the expression of various virulence antigens. An altered antibody response towards ...these antigens might contribute to inflammation.
Objectives
To provide an overview of the varying prevalences and odds of antibody responses against S. aureus antigens in patients with AD.
Methods
Data were systematically obtained from Embase, MEDLINE, Web of Science, Scopus, Cochrane, PubMed and Google Scholar up to 12 February 2016. We selected all original observational and experimental studies assessing antistaphylococcal antibodies in serum of patients with AD. Prevalences and odds ratios (ORs) of IgE, IgG, IgM and IgA against S. aureus in patients with AD vs. healthy controls were pooled using the random‐effects model. We calculated I2 statistics to assess heterogeneity and rated study quality using the Newcastle–Ottawa Scale.
Results
Twenty‐six articles (2369 patients) were included, of which 10 were controlled studies. Study quality was fair to poor. Patients with AD had higher prevalences of IgE against staphylococcal enterotoxin (SE)A (OR 8·37, 95% confidence interval 2·93–23·92) and SEB (OR 9·34, 95% confidence interval 3·54–24·93) compared with controls. Prevalences of antistaphylococcal IgE were 33% for SEA, 35% for SEB and 16% for toxic shock syndrome toxin‐1. However, study heterogeneity and imprecision should be taken into consideration when interpreting the results. Data on IgG, IgM and IgA, as well as other antigens, are limited.
Conclusions
Patients with AD more often show an IgE antibody response directed against S. aureus superantigens than healthy controls, supporting a role for S. aureus in AD pathogenesis.
What's already known about this topic?
Staphylococcus aureus is implicated as a causal factor in the pathogenesis of atopic dermatitis (AD).
An altered immune response towards various S. aureus antigens might contribute to inflammation.
The current literature reports varying prevalences of antibodies against S. aureus antigens in AD.
What does this study add?
The prevalence of IgE against staphylococcal superantigens (SEA and SEB) is increased in patients with AD compared with healthy controls.
Literature on IgG‐, IgM‐ and IgA‐mediated humoral immune responses is very limited.
Linked Comment: Seddon and Hughes. Br J Dermatol 2018; 178:1234.
Plain language summary available online
Summary
Background
Childhood eczema is variable in onset and persistence.
Objectives
To identify eczema phenotypes during childhood, and their associations with early‐life environmental and genetic ...factors.
Methods
In this study of 5297 children from a multiethnic population‐based prospective cohort study, phenotypes based on parent‐reported physician‐diagnosed eczema from age 6 months to 10 years were identified using latent class growth analysis. Information on environmental factors was obtained using postal questionnaires. Four filaggrin mutations were genotyped and a risk score was calculated based on 30 genetic variants. Weighted adjusted multinomial models were used for association analyses.
Results
We identified the following five eczema phenotypes: never (76%), early transient (8%), mid‐transient (6%) and late transient (8%) and persistent eczema (2%). Early transient and persistent eczema were most common in first‐born children, those with a parental history of eczema, allergy or asthma and those with persistent wheezing range of odds ratio (OR): 1.37, 95% confidence interval (CI) 1.07–1.74 and OR 3.38, 95%CI 1.95–5.85. Early transient eczema was most common in male children only (OR 1·49, 95% CI 1·18–1·89). Children with late transient or persistent eczema were more often of Asian ethnicity (OR 2·04, 95% CI 1·14–3·65 and OR 3·08, 95% CI 1·34–7·10, respectively). Children with early, late transient and persistent eczema more often had a filaggrin mutation or additional risk alleles (range OR: 1.07, 95%CI 1.02–1.12 and OR 2.21, 95%CI 1.39–3.50). Eczema phenotypes were not associated with maternal education, breastfeeding, day care attendance and pet exposure.
Conclusions
Five eczema phenotypes were identified in a multiethnic paediatric population with limited differences in risk profiles, except for sex and ethnicity.
What's already known about this topic?
Two previous studies in longitudinal birth cohorts identified four and six different eczema phenotypes, predominantly in children of European ethnicity.
What does this study add?
Five eczema phenotypes were identified in a multiethnic paediatric population using latent class growth analysis.
Children with early transient and persistent eczema were most often first‐born children and had persistent wheezing, filaggrin mutation or additional risk alleles.
Previously known eczema risk factors had limited differentiating capabilities for eczema phenotypes, except for the association of early transient eczema with male children, and late transient and persistent eczema with Asian ethnicity.
Plain language summary available online
Respond to this article
Background
Congenital melanocytic naevi (CMN) can have a great impact on patients’ lives owing to perceived stigmatization, and the risk of melanoma development and neurological complications. ...Development of a core outcome set (COS) for care and research in CMN will allow standard reporting of outcomes. This will enable comparison of outcomes, allowing professionals to offer advice about the best management options. In previous research, stakeholders (patients, parents and professionals) reached consensus on the core domains of the COS. To select the appropriate measurement instruments, the domains should be specified by outcomes.
Objectives
To reach consensus on the specific core outcomes describing the core domains pertaining to clinical care and research in CMN.
Methods
A list of provisional outcomes (obtained earlier) was critically reviewed by the Outcomes for COngenital MElanocytic Naevi (OCOMEN) research team and by relevant stakeholders through an online questionnaire, to refine this list and provide clear definitions for every outcome. When needed, discussion with individual participants was undertaken over the telephone or by email. During an online consensus meeting, stakeholders discussed the inclusion of potential outcomes. After the meeting, participants voted in two rounds for the inclusion of outcomes.
Results
Forty‐four stakeholders from 19 countries participated. Nine core outcomes were included in the COS relative to clinical care and 10 core outcomes for research.
Conclusions
These core outcomes will enable standard reporting in future care and research of CMN. This study facilitates the next step of COS development: selecting the appropriate measurement instruments for every outcome.
What is already known about this topic?
Congenital melanocytic naevi (CMN) can be associated with psychosocial burden and increased risk of melanoma and/or neurological complications.
Outcomes measured for research and care in CMN are heterogeneous, impeding comparison.
A core outcome set (COS) may enhance standardized use and reporting, and reduce selective reporting bias.
In previous research, relevant stakeholders reached consensus on what domains should be included in the core domain set (CDS).
What does this study add?
To select the appropriate measurement instruments for the domains included in the CDS, the domains should be further specified by outcomes.
We reached consensus on what outcomes should describe the domains of the CDS of CMN care and research.
Through a consensus procedure, including online discussions, online consensus meeting and voting, relevant stakeholders reached consensus on a limited number of core outcomes describing the core domains.
What are the clinical implications of this work?
Development of a COS will allow standard reporting of outcomes in future care and research of CMN.
This will enable pooling and comparison of outcomes, allowing guideline development of optimal management policy.
Linked Comment: M.V. Heppt et al. Br J Dermatol 2021; 185:881–882.
Plain language summary available online
Summary
Background
Medium, large and giant congenital melanocytic naevi (CMN) can impose a psychosocial burden on patients and families, and are associated with increased risk of developing melanoma ...or neurological symptoms. Lack of consensus on what outcomes to measure makes it difficult to advise patients and families about treatment and to set up best practice for CMN.
Objectives
Fostering consensus among patient representatives and professionals, we aim to develop a core outcome set, defined as the minimum set of outcomes to measure and report in care and all clinical trials of a specific health condition. We focused on the ‘what to measure’ aspect, the so‐called core domain set (CDS), following the COMET and CS‐COUSIN guidelines.
Methods
We conducted a systematic review to identify outcomes reported in the literature. Focus groups with patient representatives identified patient‐reported outcomes. All these outcomes were classified into domains. Through e‐Delphi surveys, 144 stakeholders from 27 countries iteratively rated the importance of domains and outcomes. An online consensus meeting attended by seven patient representatives and seven professionals finalized the CDS.
Results
We reached consensus on six domains, four of which were applied to both care and research: ‘quality of life’, ‘neoplasms’, ‘nervous system’ and ‘anatomy of skin’. ‘Adverse events’ was specific to care and ‘pathology’ to research.
Conclusions
We have developed a CDS for medium‐to‐giant CMN. Its application in reporting care and research of CMN will facilitate treatment comparisons. The next step will be to reach consensus on the specific outcomes for each of the domains and what instruments should be used to measure these domains and outcomes.
What is already known about this topic?
Medium, large and giant congenital melanocytic naevi (CMN) are associated with psychosocial burden for patients and their families because of their unusual appearance and increased risk of melanoma and/or neurocutaneous melanocytosis.
Outcome reporting of treatment options for CMN is heterogeneous. Current lack of consensus in outcome reporting hinders the development of evidence‐based treatment guidelines for CMN.
Development of a core outcome set (COS) may enhance standardized reporting.
What does this study add?
We focus on the core domain set, the ‘what to measure’, for the COS.
By following the guidelines of COMET and CS‐COUSIN, we reached consensus on six domains.
Four of the domains were applied to both care and research: ‘quality of life’, ‘neoplasms’, ‘nervous system’ and ‘anatomy of skin’. ‘Adverse events’ was specific to care and ‘pathology’ to research.
What are the clinical implications of this work?
Uptake of the core domain set in future clinical care of, and research about, medium‐to‐giant CMN should facilitate comparisons across different treatment choices for both patients and professionals.
Linked Comment: M.V. Heppt et al. Br J Dermatol 2021; 185:247–248.
Plain language summary available online
Summary
Background The Dermatology Department of the University Medical Centre Utrecht, the Netherlands, developed an e‐health portal for patients with atopic dermatitis (AD), consisting of ...e‐consultation, a patient‐tailored website, monitoring and self‐management training.
Objectives To determine the cost‐effectiveness of individualized e‐health compared with usual face‐to‐face care for children and adults with AD.
Methods A randomized controlled cost‐effectiveness study from a societal perspective in adults and parents of children with moderate AD. Outcomes were quality of life, severity of AD, itching and direct and indirect costs. Data were collected at baseline and at 3 and 12 months after randomization. Linear mixed models were used to analyse clinical outcomes. After multiple imputation of missing data, costs and differences in costs were calculated over a period of 1 year.
Results In total, 199 patients were included. There were no significant differences in disease‐specific quality of life, severity of AD and intensity of itching between both groups at the three time points. The difference in direct costs between the intervention and control groups was €24 95% confidence interval (CI) −360 to 383, whereas this difference was −€618 (95% CI −2502 to 1143) for indirect costs. Overall, individual e‐health was expected to save €594 (95% CI −2545 to 1227) per patient in the first year of treatment, mainly through a reduction in work absenteeism. Uncertainty analyses revealed that the probability of e‐health reducing costs was estimated to be ≥ 73%.
Conclusions E‐health during follow‐up of patients with AD is, after initial diagnosis and treatment during face‐to‐face contact, just as effective as usual face‐to‐face care with regard to quality of life and severity of disease. However, when costs are considered, e‐health is likely to result in substantial cost savings. Therefore, e‐health is a valuable service for patients with AD.
Summary
Background
Maternal psychiatric symptoms during pregnancy might affect the developing immune system and subsequent risk of childhood atopic diseases.
Objective
Our aim was to examine the ...associations of maternal psychiatric symptoms during pregnancy with allergic sensitization, allergy and eczema in children until age 10 years.
Methods
This study among 5205 children was performed in a population‐based prospective cohort from foetal life onwards. We assessed maternal and paternal psychiatric symptoms (overall, depressive, anxiety) during pregnancy and at 36 months after delivery, and maternal psychiatric symptoms at 2 and 6 months after delivery using the Brief Symptom Inventory. Inhalant and food allergic sensitization were measured by skin prick tests, and physician‐diagnosed inhalant and food allergy or eczema by questionnaires from birth until age 10 years. We used multivariate logistic regression, multinomial logistic regression or generalized estimating equation models where appropriate.
Results
We observed no association of maternal psychiatric symptoms during pregnancy with allergic sensitization. Maternal overall psychiatric, depressive and anxiety symptoms during pregnancy were associated with an increased risk of inhalant allergy only (adjusted odds ratio (95% confidence interval) 1.96 (1.44, 2.65), 1.58 (1.25, 1.98) and 1.61 (1.27, 2.03), respectively, per 1‐unit increase). Maternal overall psychiatric and anxiety symptoms during pregnancy were associated with an increased risk of eczema (1.21 (1.05, 1.39) and 1.15 (1.02, 1.29), respectively, per 1‐unit increase). Effect estimates did not materially change when maternal psychiatric symptoms after delivery, or paternal psychiatric symptoms during pregnancy and after delivery were taken into account.
Conclusions and Clinical Relevance
Maternal psychiatric symptoms during pregnancy were associated with increased risks of childhood inhalant allergy and eczema, independent of maternal psychiatric symptoms after delivery and of paternal psychiatric symptoms.
PDF
