Atopic Dermatitis Stander, Sonja
The New England journal of medicine,
03/2021, Letnik:
384, Številka:
12
Journal Article
Recenzirano
Atopic dermatitis is a chronic disorder that usually starts in childhood but often persists in adulthood. The appearance and extent of lesions vary with age and race or ethnic group. Topical and ...systemic treatments targeting the underlying immune condition have been introduced.
Nickel is the most frequent cause of contact allergy worldwide and has been studied extensively. This clinical review provides an updated overview of the epidemiology, exposure sources, methods for ...exposure quantification, skin deposition and penetration, immunology, diagnosis, thresholds for sensitization and elicitation, clinical pictures, prevention, and treatment. The implementation of a nickel regulation in Europe led to a decrease in the prevalence of nickel allergy, and changes in the clinical picture and disease severity. Nevertheless, the prevalences of nickel allergy in the European general population are approximately 8% to 19% in adults and 8% to 10% in children and adolescents, with a strong female predominance. Well‐known consumer items such as jewellery and metal in clothing are still the main causes of nickel allergy and dermatitis, although a wide range of items for both private and occupational use may cause dermatitis. Allergic nickel dermatitis may be localized to the nickel exposure site, be more widespread, or present as hand eczema. Today, efficient methods for exposure quantification exist, and new insights regarding associated risk factors and immunological mechanisms underlying the disease have been obtained. Nevertheless, questions remain in relation to the pathogenesis, the persistent high prevalence, and the treatment of severe cases.
- Contact skin lesions may be the consequences of contact with various irritants or allergens, or due to other factors (e.g., UV radiation, microbials), intrinsic factors (e.g., in autoimmune ...responses), or even their combination. There are many substances related to irritant contact dermatitis (CD), causing irritant or toxic effects, e.g., chemical and physical agents, plants, phototoxic agents, airborne irritants, etc. Impaired barrier function (e.g., aberrancies in epidermal pH buffering capabilities) also participates by promoting bacterial biofilms and creating an environment favoring sensitization. Development of allergic CD skin lesions includes complex immune pathways and inflammatory mediators, influenced by both genetic (predominantly filaggrin mutations) and environmental triggers. In the pathogenesis of allergic CD, antimicrobial peptides play a prominent role; they are produced by various skin cells (e.g., keratinocytes, sebocytes) and move to inflamed lesions during an inflammation process. Also, in allergic CD skin lesions, the skin shows different types of immune responses to individual allergens, although clinical manifestations do not depend on the causative allergen type, e.g., nickel stimulates immune activation primarily of the Th1/Th17 and Th22 components. Also important are alarmins, proteases, immunoproteomes, lipids, natural moisturizing factors, tight junctions, smoking, etc. We expect that future perspectives may reveal new pathogenetic factors and scientific data important for the workup and treatment of patients with CD.
Contact dermatitis (CD) is a common inflammatory skin disease caused by exposure to contact allergens and irritants. It is also the most common reason of occupational dermatitis and contributes ...greatly to hand dermatitis and facial dermatitis. Besides the two major forms of contact dermatitis: allergic contact dermatitis and irritant contact dermatitis, other subtypes of CD have been recognized including immediate skin reactions, photoinduced contact dermatitis, systemic contact dermatitis, and non-eczematous contact dermatitis. CD is a great imitator which can mimic many kinds of skin diseases, such as atopic dermatitis, lichen planus, and angioedema. For the diagnosis of CD, a complete medical history, including occupational history, is very important. It can give a clue of CD and provide a list of suspected substances. Besides the well-known diagnostic test, patch testing, there are many other diagnostic tests can be used to help diagnosis of CD and identify the causative allergens, including photopatch test, skin tests for detecting of immediate contact reactions, serum allergen-specific IgE test, and qualitative and quantitative testing of allergen in the suspected materials patients exposed to and challenge test. Before the treatment, the suspected irritants or allergens should be avoided completely. This includes both the removal of the patient from the environment that contains those substances and the promotion of the metabolism and expulsion of the allergens that have been absorbed by the body. In addition, it is also important to restore the skin barrier and reduce skin inflammation through multiple treatments, such as emollients, topical corticosteroids, and antihistamines, as well as systemic corticosteroids and immunosuppressants. Early and appropriate treatments are important to prevent further deterioration and persistence of the skin condition.
Background
The international classification of diseases, 10th revision (ICD‐10) includes several unvalidated diagnostic codes for hand eczema (HE). Knowledge is sparse on HE patient characteristics.
...Objectives
To validate selected HE ICD‐10 codes in the Danish National Patient Registry (DNPR) and describe disease characteristics, lifestyle factors and medication use in adult HE patients.
Methods
Nineteen HE ICD‐10 codes were selected and validated based on patient charts. Five cohorts were constructed based on the diagnostic code, DL30.8H (HE unspecified), in the DNPR: (i) patients with DL30.8H code (n = 8386), (ii) patients with DL30.8H code, but without atopic dermatitis (AD) (n = 7406), (iii) sex‐ and age‐matched general population (n = 8386) without HE. Two additional cohorts nested in the DNPR included participants from the Danish Skin Cohort, (iv) patients with DL30.8H code but without AD (n = 1340) and (v) general population cohort (n = 9876).
Results
ICD‐10 codes revealed positive predictive values ≥90% except irritant contact dermatitis (unspecified) (79.7%) and hyperkeratotic hand and foot eczema (84.1%). HE patients were most often women, middle‐aged or older, of Danish ethnicity, had an atopic medical history and were smokers. Topical corticosteroid prescriptions were almost doubled in HE cohorts compared to general populations.
Conclusion
We validated several HE ICD‐10 codes and identified important HE patient characteristics.
ICD‐10 diagnostic codes for hand eczema (HE) coded by physicians in Denmark have high positive predictive values. Danish HE patients with the DL30.8H diagnostic code are mostly women, smoke more and are less physically active than the general population. Potent topical corticosteroids are relatively common in HE patients.
Background
Occupational contact dermatitis (OCD) is a prevalent, often chronic disease that poses a risk for job loss and decreased quality of life. In Germany, a multi‐step prevention programme ...emphasising early detection and highly specialised multidisciplinary treatment has been implemented with great success.
Objectives
To examine the effectiveness of a Danish‐adapted version of the German prevention effort on OCD severity, quality of life and occupational consequences at 3‐month follow‐up.
Methods
Randomised, controlled trial. Participants were recruited after the first referral from General Practitioner to Dermatologist with suspected OCD. The intervention group (IG) received a Danish‐adapted, multidisciplinary intervention, while the control group (CG) navigated the Danish healthcare system without interference from the study. OCD severity, occupational consequences and quality of life were assessed at 3‐month follow‐up using self‐reported questionnaires.
Results
A statistically significant decrease in the severity of eczema was found at 3‐month follow‐up in the IG compared to the CG. The IG were statistically significantly more likely to have seen a dermatologist at 3‐month follow‐up. Higher treatment level in the IG was indicated by the results but was not statistically significant. No significant difference was found in quality of life or occupational consequences.
Conclusions
These initial findings suggest that early and specialised treatment of OCD improves OCD prognosis.
Randomised controlled trial examining the effect of an intervention consisting of fast dermatological treatment, extensive exposure assessment, extended allergen testing and education on skin protective behaviour in patients with suspected occupational hand eczema (OHE).
At 3‐month follow‐up by questionnaire intervention group participants had:
Significantly less OHE
Significantly lower severity of OHE
Were significantly more likely to have seen a dermatologist.
ZusammenfassungDas Verständnis der Mechanismen, die der atopischen Dermatitis (AD) zugrunde liegen, war ein entscheidender Katalysator für die Entwicklung neuartiger Medikamente zur Behandlung dieser ...Krankheit. Weltweit entwickeln derzeit mehr als siebzig Pharmaunternehmen mindestens ein neues Medikament für die Behandlung der AD. Diese Übersichtsarbeit soll den aktuellen Stand der wichtigsten neuartigen Therapieansätze auf der Grundlage des heutigen Verständnisses der Pathophysiologie der AD beschreiben.
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