Bone mineral density in children with moderate to severe atopic dermatitis

doi:10.1016/j.jaad.2009.12.015

Journal of the American Academy of Dermatology

Volume 63, Issue 5, November 2010, Pages 824-831

https://doi.org/10.1016/j.jaad.2009.12.015 Get rights and content

Background

Low bone mineral density (BMD) has been reported in 30.4% of adult patients with atopic dermatitis (AD).

Objective

The aim of this study was to determine the prevalence of low BMD in children with moderate to severe AD and to investigate the relation between BMD and corticosteroid and cyclosporine therapy.

Methods

Lumbar spine BMD was measured by dual-energy X-ray absorptiometry in 60 children (age 5-16 years) with moderate to severe AD. BMD (in g/cm²) was expressed in Z-scores, the number of SD above or below the mean value of an age- and sex-matched reference population. In children, low BMD was defined as a Z-score less than –2. Information on lifestyle parameters and bone fractures were collected by use of a standardized questionnaire. The cumulative dose of corticosteroids and cyclosporine therapy was calculated for the previous 5-year period.

Results

Three patients (5%) had low BMD; one patient (1.7%) had osteoporosis. The observed prevalence of low BMD in this study (6.7%; 95% confidence interval 1.8%-16.2%) does not differ from the expected prevalence of low BMD in the general population (P = .06). Overall, use of topical corticosteroids in the previous 5 years was not associated with a decrease in BMD (Z-score). When children received additional systemic treatment (oral corticosteroids and/or cyclosporine) in the previous 5 years, BMD decreased, although the decrease was not statistically significant. Correction for lifestyle parameters did not change these associations.

Limitations

The number of patients studied was limited. The cumulative dose of corticosteroids and cyclosporine therapy was only registered for the previous 5 years, and relatively low amounts of topical corticosteroids were used. The definition of low BMD differs between adults (Z-score < –1) and children (Z-score < –2). Because there is no Dutch BMD reference population for children, normative BMD references were obtained from a different population (US children).

Conclusions

Low BMD did not occur more frequently in this population of children with moderate to severe AD compared with the general population. Use of topical corticosteroids in the previous 5 years was not associated with a decrease in BMD.

Section snippets

Patients

In this cross-sectional study 60 children with moderate to severe AD were included between January 2008 and February 2009. All patients were aged between 5 and 16 years. The diagnosis of AD was made according to the criteria of Hanifin and Rajka.¹³ All children were currently treated at the outpatient department of pediatric dermatology/allergology of our institution. Children were included if one of the following criteria was present: objective scoring AD (SCORAD) index greater than 20; more

Baseline characteristics of study population

Baseline characteristics are presented in Table II. Sixty children, 24 boys and 36 girls, age 5 to 16 years, with moderate to severe AD were included. At the moment of inclusion patients had active skin disease, indicated by a mean objective SCORAD of 31 ± 14 (±SD) and a median serum thymus and activation-regulated cytokine of 945 (interquartile range: 457-1895) pmol/L. Patients had received treatment for 1.5 to 16.2 (median 7.7) years. All patients used topical corticosteroids to control their

Discussion

Children with moderate to severe AD may be at risk for having low BMD. We assessed several risk factors such as corticosteroid and cyclosporine use and lifestyle parameters for their potential to influence BMD in 60 children with moderate to severe AD. In this study we found that 4 of 60 (6.7%) children with AD had a low BMD (Z-score < –2) in the lumbar spine. The difference between the expected (2.5%) and observed (6.7%) percentage of children with a low BMD is not statistically significant.

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Risk and management of osteoporosis due to inhaled, epidural, intra-articular or topical glucocorticoids
2023, Joint Bone Spine
Glucocorticoids (GCs) are widely used by several specialties for the treatment of a variety of diseases and conditions. The unfavorable effect of oral GCs on bone health is well-documented. The ensuing from their use glucocorticoid-induced osteoporosis (GIOP) is the most common cause of medication-induced osteoporosis and fractures. It is uncertain, however, if, and in what extent, GCs administered by other routes affect the skeleton. In the present review, we quote current evidence on the effect of inhaled GCs, epidural and intra-articular steroid injections, and topical GCs on bone outcomes. Although evidence is limited and weak, it seems that a small proportion of the administered GCs may be absorbed, enter the systemic circulation, and adversely affect the skeleton. Potent GCs, higher doses, and longer treatment duration seem to infer the greater risk for bone loss and fractures. There are scarce data, and only for inhaled GCs, regarding the efficacy of antiosteoporotic medications in patients receiving GCs through routes other than oral. Further studies are needed to clarify the relationship between GC administration through these routes and bone outcomes and to help establishing guidelines for the optimal management of such patients.
Corticosteroid exposure and cumulative effects in patients with eczema: Results from a patient survey
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Citation Excerpt :
The median (interquartile range) cumulative TCS load in the studies of adults was 1890 (885–3973) g during a 5-year study period in one study, 1630 (815–3175) g during a 5-year study period in another study, and a mean (SD) of 86.8 (80.5) g during a 2-year study period in a third study.18-20 In one study of children with eczema, the mean (SD) cumulative load of TCS was 2044 (1838) g in the previous 5 years.21 Survey participants indicated that since starting treatment with corticosteroids for their eczema their condition had worsened, and many indicated that they had developed new symptoms or conditions.
Individuals with eczema may have substantial lifetime corticosteroid exposure, increasing the risk of corticosteroid-related side effects.
To conduct a patient survey evaluating corticosteroid exposure and its cumulative effects in individuals with eczema.
The multinational online survey was conducted between November 5, 2020, and January 11, 2021. Participants were aged 18 years or older and a patient (n = 1889) or a caregiver of a child (n = 271) diagnosed with having eczema by a medical professional.
All participants reported using corticosteroids. Average duration of topical corticosteroid (TCS) use was 15.3 years in adults and 3.6 years in children; 75% used TCS 1 to 2 times a day and 50% applied TCS 15 to 30 days/mo. Frequency and duration could not be determined by varying prescription TCS potencies. Oral corticosteroid use was reported by 36% of the participants (23% for eczema), with a lifetime average of 8.4 courses in adults and 8.1 courses in children. Corticosteroids for non-eczema atopic conditions were reported by 49% of the participants. In participants using TCS, 83% of adults and 64% of children experienced worsening symptoms over time. Development of new symptoms and conditions increased with a greater number of corticosteroid treatments and longer duration of TCS use but may have been owing to eczema progression. Symptoms consistent with topical steroid withdrawal syndrome after TCS discontinuation were reported by many participants.
Reported substantial corticosteroid exposure throughout their lifetime eczema experience placed participants at risk of negative outcomes. Corticosteroids are a critical component of eczema treatment for many patients. However, careful corticosteroid prescribing practices and monitoring are needed to avoid side effects. When possible, corticosteroid-sparing strategies should be explored.
Association between topical corticosteroid use and fracture risk among pediatric patients with atopic dermatitis
2022, Journal of the American Academy of Dermatology
Vitamin D: Skin, sunshine, and beyond
2021, Clinics in Dermatology
Citation Excerpt :
Some studies have postulated that low serum vitamin D level, particularly in winter, may correlate with the worsening and severity of the disease. The role of vitamin D in the pathogenesis of AD, however, has not been fully elucidated.70-73 A recent study in Spain compared 134 children with AD to 105 controls without AD and found that serum vitamin D levels were significantly lower in moderate and severe AD than in mild AD, although this association was only significant for patients with light Fitzpatrick skin types.74
Vitamin D is a steroid hormone of importance to the field of dermatology. Skin is unique in that it is the site of vitamin D synthesis upon sun exposure and a target organ for its activity. We explore the physiology and metabolic mechanism of action of vitamin D, as well as its effects on the skin. We also discuss the current evidence of the efficacy and safety of oral and topical vitamin D analogues on skin conditions such as psoriasis, atopic dermatitis, vitiligo, sunburn, actinic keratosis, and fibrosing skin disorders. Based on currently available scientific evidence, the National Academy of Medicine's recommended dietary allowance for vitamin D ranges from 400 IU to 800 IU daily based on age categories.
Vertebral, pelvic, and hip fracture risk in adults with severe atopic dermatitis
2020, Journal of Allergy and Clinical Immunology
Associations of self-reported allergic diseases and musculoskeletal problems in children: A US population–based study
2017, Annals of Allergy, Asthma and Immunology
Citation Excerpt :
Although these trends are less clear in children, a study of 3,049 children and adolescents (aged 8–19 years) reported decreased BMD in children with atopic dermatitis.12 However, this finding has not been reported consistently, and prior studies have not accounted for BMI.12,19 Children with asthma were more likely to have current or previous bone, joint, or muscle problems.
Previous studies have found increased rates of musculoskeletal problems in adults with allergic disease, but whether this association holds true for children is unknown.
To investigate the association of bone, joint, and muscle problems in children with a history of allergic disease.
Data were obtained from the 2007 Child and Adolescent Health Measurement Initiative. Univariable and multivariable logistic regression models accounting for the sampling design were used to evaluate associations of bone, joint, and muscle problems with allergic diseases, such as asthma, hay fever, food allergies, and eczema. Associations were summarized with odds ratios (ORs) and 95% confidence intervals (CIs).
The survey included 91,642 individuals aged 0 to 17 years. Multivariable modeling found statistically significant associations between the number of allergic diseases and bone, joint, and muscle problems (1 allergic disease: adjusted OR, 1.28; 95% CI, 1.04–1.56; P = .02; 2 allergic diseases: adjusted OR, 2.55; 95% CI, 1.92–3.39; P < .001; 3 allergic diseases: adjusted OR, 2.70; 95% CI, 1.88–3.86; P < .001; and 4 allergic diseases: adjusted OR, 4.35; 95% CI, 2.46–7.69; P < .001). Severe eczema (but not mild eczema) was associated with bone, joint, and muscle problems (adjusted OR, 2.81; 95% CI, 1.64–4.81; P < .001) and with bone problems (adjusted OR, 6.08; 95% CI, 1.94–19.12; P = .002).
Self-reported allergic diseases in children were associated with bone, joint, and muscle problems, and associations strengthened with allergic disease severity and number of allergic diseases. Severe eczema may be associated with bone problems in children. Bone, joint, and muscle problems must be considered in children with severe allergic disease, and prospective studies are necessary to define this association.

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: Conflicts of interest: None declared.

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Original articleBone mineral density in children with moderate to severe atopic dermatitis

Background

Objective

Methods

Results

Limitations

Conclusions

Section snippets

Patients

Baseline characteristics of study population

Discussion

J Pediatr

Lancet

Am J Clin Nutr

Bone

J Am Acad Dermatol

Am J Clin Nutr

J Allergy Clin Immunol

J Allergy Clin Immunol

Ann Epidemiol

Am J Med

Am J Clin Nutr

Bone Miner

Prevalence of atopic dermatitis, asthma, allergic rhinitis, and hand and contact dermatitis in adolescents: the Odense adolescence cohort study on atopic diseases and dermatitis

Br J Dermatol

Bone turnover and metabolism in pediatric patients with inflammatory bowel disease treated with systemic glucocorticoids

Eur J Endocrinol

The effect of percutaneously absorbed steroids on hypothalamic–pituitary–adrenal function after intensive use in in-patients

Br J Dermatol

Low bone mineral density in adult patients with moderate to severe atopic dermatitis

Br J Dermatol

Oral cyclosporin plus topical corticosteroid therapy diminishes bone mass in children with eczema

Pediatr Dermatol

Milk allergy/intolerance and atopic dermatitis in infancy and childhood

Allergy

Original article
Bone mineral density in children with moderate to severe atopic dermatitis