Special Issue:
Challenges and Opportunities in Dermatitis
V.J. Sebastian Criton, MD, HOD
Department of Dermatology, Amala Institute of Medical Sciences, Thrissur, Kerala, India
Joy Sanjana, MBBS
Junior resident, Department of Dermatology, Amala Institute of Medical Sciences, Thrissur, Kerala, India
Abstract
Millions worldwide, particularly children, suffer from the prevalent inflammatory skin condition known as Atopic Dermatitis (AD), with its prevalence on a constant rise.It’s impact extends beyond affecting merely the skin, contributing towards more complex health problems. The exact cause of this condition is multifactorial: genetic, environmental and immunologic factors all play significant roles; however, attention has recently focused on the role gut microbiota may have in relation to ‘gut-skin’ axis disturbances. Gut microbiota imbalances may be influenced by diet, antibiotic use as well as changes in environmental conditions that may contribute to Atopic Dermatits pathogenesis. New research concentrates on therapies including probiotics, prebiotics and faecal microbiota transplantation. Multi-strain probiotic formulas in particular, are promising; such products have shown to potentially help manage Atopic Dermatitis symptoms by altering the immune response and adjusting the composition of gut microbes. The available evidence also suggests that exclusion diets can be tailored to serve as a form of dietary management. Fecal microbiota transplantation represents an innovative approach that requires additional scrutiny regarding its efficacy and safety in treating Atopic Dermatitis. The complex relationship between skin barrier function, immune responses and gut microbial composition offers possibilities for developing novel therapies targeting the microbiome in Atopic Dermatitis management.
Kalomoira Kefala, MD, M.Sc
CSMD Clavel, Foundation « Œuvre de la Croix-Saint-Simon », 75019, & Medical office, 22 Rue Quatre Septembre, 75002, Paris, France
Claude Ponvert, MD, PhD
Faculty of Medicine, University Paris-Descartes, Service de Pneumo-Allergologie Pédiatrique, Necker-Enfants Malades Hospital, Paris, France
Abstract
The recent COVID-19 pandemic provoked an outstanding increase of infection-control measures, with chlorhexidine becoming an extensively used antiseptic. Allergic contact dermatitis (ACD) to chlorhexidine is considered as a rare event in children, is often difficult to identify, and its diagnosis is often misdiagnosed as other skin diseases.
Thus, we aimed to explore the sensitization to chlorhexidine-containing antiseptics (CCA) in infants and children to determine the origin of their sensitization and the role of the excipients in their dermatosis.
We performed patch tests (PT) with chlorhexidine digluconate 0.5%, benzalkonium chloride 0.1%, benzyl alcohol 10%, 5% and 1% in ten children (1-16.5-year-old, including six children with a personal history of atopy) with severe contact reactions to chlorhexidine-based antiseptics (Biseptine®) and cosmetics. We also performed PT with sodium benzoate 5% in four of the children. Results were measured according to criteria recommended by the International Contact Dermatitis Research Group (ICDRG). Patch test reactions revealed that most children were sensitized to at least two components of CCA (chlorhexidine, benzyl alcohol and/or benzalkonium chloride).
To explore the origin of the sensitization, we searched for umbilical cord care (UCC) with CCA and the use of cosmetics and drugs containing chlorhexidine and excipients of CCA. Most parents reported prior disinfection of umbilical cord with CCA, but this was not always the case.
Allergic contact dermatosis to chlorhexidine, benzyl alcohol and benzalkonium chloride should be considered in infants and children with severe eczema and concomitant allergies. The regular use of cosmetics and drugs containing chlorhexidine, benzyl alcohol, benzalkonium chloride or sodium benzoate should probably be cautioned or avoided in children with severe eczema or pre-existing allergies.
Early suspicion and allergology exploration of ACD to CCA and their excipients is of paramount importance to help prevent severe allergic reactions to topical antiseptics and numerous cosmetics.
Russell J. Hopp, D.O. FAAP, FAAAAI
Professor of Pediatrics, University of Nebraska Medical Center and Children’s Hospital and Medical Center, Omaha, NE 68198
Abstract
Food-related disease processes can have a wide presentation picture. We present here a review of their clinical patterns in infants to allow a prompt diagnosis and appropriate management. Included in the discussion in infants from birth to 12 months includes IgE-mediated food allergy, food protein–induced allergic proctocolitis , food protein enterocolitis syndrome, atopic dermatitis, eosinophilic esophagitis, and eosinophilic gastrointestinal disease. The bibliography is updated to the past two years unless the latest guideline pre-dated 2018, or the reference was of a classic nature.
Emily E Dando, MD
Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, PA
Misha Rosenbach, MD
Department of Dermatology, University of Pennsylvania, Philadelphia, PA
Joseph C English III, MD
Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, PA
Abstract
Granulomatous drug reactions have been associated with many medications, including targeted therapeutics such as biologics and small molecule inhibitors. The four main clinicopathologic reaction patterns are drug-induced sarcoidosis-like reaction, reactive granulomatous dermatitis, granuloma annulare, and accelerated rheumatoid nodulosis. These reactions often develop months after exposure to the causative medication and clinically can mimic other granulomatous diseases or metastatic cancer, which may be differentiated with biopsy, tissue culture, and radiographic imaging. Granulomatous inflammation may be limited to the skin, where early recognition helps to facilitate diagnosis. Cutaneous manifestations vary by reaction pattern, ranging from erythema nodosum-like lesions to painful rheumatoid nodules to annular indurated plaques. Systemic granulomatous inflammation is typically only observed in sarcoidosis-like reaction or accelerated rheumatoid nodulosis and most often involves the lungs or lymph nodes. Targeted therapeutics implicated in granulomatous drug reactions are TNFα inhibitors, BRAF and MEK inhibitors, immune checkpoint inhibitors and, to a lesser extent, other cytokine modulators. TNFα inhibitors, in particular, are among the most common drugs in any class associated with the four primary granulomatous drug eruptions. We review the current literature on granulomatous reactions to these agents, including proposed mechanisms and the range of clinical manifestations. Management may include drug discontinuation, topical therapy, or systemic immunosuppression depending on the severity of the granulomatous drug reaction. In the setting of malignancy, granulomatous inflammation does not appear to be of prognostic value, although more studies are needed.
Anna Korsgaard Berg
Copenhagen University Hospital – Steno Diabetes Center Copenhagen, Herlev, Denmark
Claus Zachariae
Department of Dermatology and Allergy, Herlev and Gentofte Hospital, Gentofte, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
Kirsten Nørgaard
Copenhagen University Hospital – Steno Diabetes Center Copenhagen, Herlev, Denmark ; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
Jannet Svensson
Copenhagen University Hospital – Steno Diabetes Center Copenhagen, Herlev, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.; University of Linköping, Sweden; Department of Pediatrics, Herlev and Gentofte Hospital, Herlev, Denmark
Abstract
Diabetes devices, such as insulin pumps, glucose sensors, and integrated automated insulin delivery systems, have brought about a transformative impact on the management of diabetes. This impact has been particularly significant for individuals with type 1 diabetes and increasingly for those with type 2 diabetes. These devices are designed for continuous wear, necessitating the consistent use of infusion sets, patch pumps, or glucose sensors that are inserted into the skin.
Regrettably, numerous studies have highlighted that skin-related issues stemming from diabetes devices are rather common. These problems encompass various forms of skin injury, allergic and irritative contact dermatitis, itching, wound formation, scarring, and lipodystrophies. The utilization of diabetes devices, both in the present and the foreseeable future, faces significant challenges due to these skin complications, but preventive strategies exist for especially skin injuries including use of a skin care regimen or patches. These challenges culminate not only in the discontinuation of device usage but also in decrease in quality of life and heavier disease burden.
This narrative literature review comprehensively synthesizes existing knowledge about skin problems triggered by diabetes devices, encompassing children, adolescents, and adults. The review delves into definitions, underlying causes, prevention strategies, and treatment approaches. Finally, the review provides recommendations for future research directions in skin problems and suggestions for advancement of in the part of diabetes devices in close contact with the skin to reduce device-related skin problems.
Rare Complications of Celiac Disease: Clinicopathologic Features
Abstract
Celiac disease (CD) is an immune mediated disorder characterised by intolerance to glutens in certain grains like whet, barley, and rye. The exposure to gliadin protein component in the susceptible individuals leads to an inflammatory reaction damaging small bowel mucosa with progressive disappearance of intestinal villi. The damaged intestinal mucosa leads to malabsorption. The usual symptoms of celiac disease include diarrhea, steatorrhea, weight loss, fatigue, and abdominal pain. Diagnosis is based on clinical features, duodenal biopsy, elevated levels of anti-gliadin antibodies and response to gluten free diet. Contrary to common belief, celiac disease is a protein systemic disease rather than merely a pure digestive alteration. Celiac disease is closely associated with genes that code HLA -II antigens mainly of DQ2 and DQ8 classes, production of disease specific antibodies (i.e., endomysial antibodies), multiorgan involvement, comorbidity with other autoimmune diseases (shared autoimmunity), familial aggregation, and immune system dysregulation.
The clinical presentation of celiac disease can be variable. In mild form, patients can be almost asymptomatic whereas in the most severe form, the patients are at increased risk of life-threatening complications. Celiac disease has a well-known association with other autoimmune diseases such as autoimmune liver diseases (autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis), diabetes mellitus, autoimmune thyroid diseases, skin diseases such as dermatitis herpetiformis, rheumatoid arthritis, systemic lupus erythematosus, Sjogren’s syndrome, psoriasis, sarcoidosis, immune thrombocytopenic purpura, and pancreatitis. In addition, celiac disease may be associated with rare but potentially serious complications such as, collagenous sprue, ulcerative jejunoileitis, refractory celiac disease (RCD), enteropathy associated T-cell lymphoma, small bowel adenocarcinoma (SBA), hyposplenism, and cavitating mesenteric lymph node syndrome (CMLNS). The present article describes clinicopathologic features of these rare but serious complications of celiac disease.
Tassalapa Daengsuwan
Division of Allergy and Immunology, Department of Pediatrics Queen Sirikit National Institute of Child Health, Bangkok, Thailand; College of Medicine, Rangsit University, Bangkok, Thailand
On-anong Nilwalaikul
Division of Allergy and Immunology, Department of Pediatrics Queen Sirikit National Institute of Child Health, Bangkok, Thailand
Abstract
Background: Impulse oscillometry (IOS), a new respiratory impedance measurement, is increasing in its popularity as a means to assess airway resistance in young children. Its great advantage lies in its effortless and fast performance, making the airway obstruction measurement easier for patients who are not able to perform spirometry tests. However, studies comparing spirometry with IOS in Thai children are rare.
Aims: To evaluate the correlation between IOS and spirometry parameters in Thai childhood asthma
Methods: Vyntus IOS (JEAGER®, Germany) and spirometry tests (Vyntus SPIRO) were performed in 48 children, aged 5-15 years old, who fulfilled the GINA asthma criteria. The study, approved by the hospital’s ethics committee, was conducted between March 1, 2020 and March 31, 2021 at the Queen Sirikit National Institute of Child Health, Thailand. (TCTR20220527005)
Results: Forty-eight childhood asthma patients with a median age of 10.79 (IQR = 8.41, 11.87) years underwent both IOS and spirometry measurements. Male sex was predominant (64.58%), and 77% of patients had well-controlled asthma (C-ACT score ≥20). In our study population, the atopic comorbidities were allergic rhinitis (91.67%), atopic dermatitis (10.42%) and food allergy (10.42%). Moreover, parental asthma was found in 16.67% of the participants. In comparison with spirometry, the percentage change of FEF25-75% was significantly negatively correlated with R5, R10, AX, and mean R5-R20 (r = -0.608, -0.528, -0.500, -0.511, respectively; p <0.001). Likewise, FEV1 was significantly negatively correlated with R15 and R20 (r = -0.520, -0.565, respectively; p <0.001). The linear regression prediction model demonstrated that a 30% increase in FEF25-75% was related to a 22.7% reduction in R5 (p = 0.007).
Conclusion: The percentage change of FEF25-75% was found to negatively correlate in statistically significant terms with R5 in Thai childhood asthma. Hence, IOS is an effective and feasible replacement for spirometry as a measurement modality of lung function, especially in young children.
