Food allergy, dermatologic diseases, and anaphylaxis
Diagnosis and treatment of atopic dermatitis in children and adults: European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus Report

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There are remarkable differences in the diagnostic and therapeutic management of atopic dermatitis practiced by dermatologists and pediatricians in different countries. Therefore, the European Academy of Allergy and Clinical Immunology and the American Academy of Allergy, Asthma and Immunology nominated expert teams who were given the task of finding a consensus to serve as a guideline for clinical practice in Europe as well as in North America. The consensus report is part of the PRACTALL initiative, which is endorsed by both academies.

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Genetic and other risk factors for AD

Parental atopy, in particular AD, is significantly associated with the manifestation and severity of early AD in children. The circumstance by which the genetics of AD might play a role in the level of natural history and development has been reflected in 2 forms of genetic studies:

  • genome-wide screens that identify broad regions of the genome linked with AD and

  • candidate gene studies that examine a presumed contribution of genetic variants of disease-process genes in case-control association

Immunopathology

The pathophysiology of AD is the product of a complex interaction between various susceptibility genes, host environments, infectious agents, defects in skin barrier function, and immunologic responses.24 Activation of T lymphocytes, dendritic cells (DCs), macrophages, keratinocytes, mast cells, and eosinophils are characteristic of AD skin inflammatory responses.

Symptoms and signs and diagnostic criteria

The use of well-defined diagnostic criteria is important in the diagnosis of AD, especially for those patients who lack the typical phenotype of the disease, and the diagnostic criteria developed by Hanifin and Rajka are widely accepted (Fig 3).100 Other criteria have been developed101 that correlate well with those of Hanifin and Rajka, although use of only visible eczema as a criterion might lead to overdiagnosis of the disease. Skin biopsies are not essential for the diagnosis but might be

Systemic and topical treatment

The management of AD presents a clinical challenge.

Antimicrobial treatment

Systemic antibiotic treatment is indicated for widespread bacterial secondary infection, (primarily S aureus). First- or second-generation cephalosporins or semisynthetic penicillins for 7 to 10 days are usually effective. Erythromycin-resistant organisms are fairly common, making macrolides less useful alternatives.159 In cases of penicillin or cephalosporin allergy, clindamycin or oral fusidic acid are possible alternatives. Unfortunately, recolonization after a course of antistaphylococcal

Education

The goal of the patients' education should be living with atopic dermatitis by means of an empowered patient or, in the case of infants and young children, a caregiver who can work as a partner with the doctor in self-managing their own or their children's disease.

Education to enhance disease knowledge, psychologic improvement in disease perception, and scratch control behavior modification, together with regular daily treatment, will lead to better skin care. This improvement in disease

Potential approaches for primary and secondary prevention of AD

Based on the idea of diet as modulatory, a number of controlled interventions have tested this hypothesis of primary prevention through the nutritional route. Hydrolyzed cow's milk formula consists of predigested peptides of whey and casein. The formulas have equivalent nutritional values but a reduced capacity to induce IgE-mediated reactions.194, 195, 196, 197 A large controlled study in high-risk infants using different partially and extensively hydrolyzed formulas for the first 6 months of

References (200)

  • N. Novak et al.

    IgE receptors

    Curr Opin Immunol

    (2001)
  • M. Toda et al.

    Polarized in vivo expression of IL-11 and Il-17 between acute and chronic skin lesions

    J Allergy Clin Immunol

    (2003)
  • R.A. Taha et al.

    Evidence for increased expression of eotaxin and monocyte chemotactic protein-4 in atopic dermatitis

    J Allergy Clin Immunol

    (2000)
  • D. Hijnen et al.

    Serum thymus and activation-regulated chemokine (TARC) and cutaneous T cell–attracting chemokine (CTACK) levels in allergic diseases: TARC and CTACK are disease-specific markers for atopic dermatitis

    J Allergy Clin Immunol

    (2004)
  • T. Echigo et al.

    Expression of fractalkine and its receptor, CX3CR1, in atopic dermatitis: possible contribution to skin inflammation

    J Allergy Clin Immunol

    (2004)
  • N. Novak et al.

    Allergic and nonallergic forms of atopic diseases

    J Allergy Clin Immunol

    (2003)
  • N. Novak et al.

    Allergic hyperreactivity to microbial components: a trigger factor of “intrinsic” atopic dermatitis?

    J Allergy Clin Immunol

    (2003)
  • K. Kerschenlohr et al.

    Clinical and immunologic reactivity to aeroallergens in “intrinsic” atopic dermatitis patients

    J Allergy Clin Immunol

    (2003)
  • P.G. Sator et al.

    Comparison of epidermal hydration and skin surface lipids in healthy individuals and in patients with atopic dermatitis

    J Am Acad Dermatol

    (2003)
  • J. Arikawa et al.

    Decreased levels of sphingosine, a natural antimicrobial agent, may be associated with vulnerability of the stratum corneum from patients with atopic dermatitis to colonization by Staphylococcus aureus

    J Invest Dermatol

    (2002)
  • Y. Vasilopoulos et al.

    Genetic association between an AACC insertion in the 3′UTR of the stratum corneum chymotryptic enzyme gene and atopic dermatitis

    J Invest Dermatol

    (2004)
  • W. Hoetzenecker et al.

    Pimecrolimus leads to an apoptosis-induced depletion of T cells, but not Langerhans cells in patients with atopic dermatitis

    J Allergy Clin Immunol

    (2005)
  • L.S. Chan et al.

    Expression of interleukin-4 in the epidermis of transgenic mice results in a pruritic inflammatory skin disease: an experimental animal model to study atopic dermatitis

    J Invest Dermatol

    (2001)
  • C.A. Akdis et al.

    Apoptosis in tissue inflammation and allergic disease

    Curr Opin Immunol

    (2004)
  • D.T. Umetsu et al.

    Regulatory T cells control the development of allergic disease and asthma

    J Allergy Clin Immunol

    (2003)
  • R. Carneiro et al.

    T cell epitope-specific defects in the immune response to cat allergen in patients with atopic dermatitis

    J Invest Dermatol

    (2004)
  • W. Lin et al.

    Allergic dysregulation and hyperimmunoglobulinemia E in Foxp3 mutant mice

    J Allergy Clin Immunol

    (2005)
  • L.S. Ou et al.

    T regulatory cells in atopic dermatitis and subversion of their activity by superantigens

    J Allergy Clin Immunol

    (2004)
  • N. Novak et al.

    FcepsilonRI engagement of Langerhans cell-like dendritic cells and inflammatory dendritic epidermal cell-like dendritic cells induces chemotactic signals and different T-cell phenotypes in vitro

    J Allergy Clin Immunol

    (2004)
  • A. Wollenberg et al.

    Plasmacytoid dendritic cells: a new cutaneous dendritic cell subset with distinct role in inflammatory skin diseases

    J Invest Dermatol

    (2002)
  • N. Novak et al.

    Characterization of FcepsilonRI-bearing CD123 blood dendritic cell antigen-2 plasmacytoid dendritic cells in atopic dermatitis

    J Allergy Clin Immunol

    (2004)
  • M.L. Giustizieri et al.

    Keratinocytes from patients with atopic dermatitis and psoriasis show a distinct chemokine production profile in response to T cell-derived cytokines

    J Allergy Clin Immunol

    (2001)
  • S. Pastore et al.

    Interferon-gamma promotes exaggerated cytokine production in keratinocytes cultured from patients with atopic dermatitis

    J Allergy Clin Immunol

    (1998)
  • A. Trautmann et al.

    The differential fate of cadherins during T cell-induced keratinocyte apoptosis leads to spongiosis in eczematous dermatitis

    J Invest Dermatol

    (2001)
  • A. Trautmann et al.

    Targeting keratinocyte apoptosis in the treatment of atopic dermatitis and allergic contact dermatitis

    J Allergy Clin Immunol

    (2001)
  • G. Schmid-Ott et al.

    Levels of circulating CD8+ T-lymphocytes, natural killer cells and eosinophils increase upon acute psychosocial stress in patients with atopic dermatitis

    J Allergy Clin Immunol

    (2001)
  • B. Wedi et al.

    Delayed eosinophil programmed cell death in vitro: a common feature of inhalant allergy and extrinsic and intrinsic atopic dermatitis

    J Allergy Clin Immunol

    (1997)
  • U. Raap et al.

    Brain-derived neurotrophic factor is increased in atopic eczema and modulates eosinophil functions compared with that seen in nonatopic subjects

    J Allergy Clin Immunol

    (2005)
  • D.Y. Leung et al.

    Atopic dermatitis

    Lancet

    (2003)
  • H.L. Leo et al.

    Effect of pimecrolimus cream 1% on skin condition and sleep disturbance in children with atopic dermatitis

    J Allergy Clin Immunol

    (2004)
  • L.F. Eichenfield et al.

    Safety and efficacy of pimecrolimus (ASM 981) cream 1% in the treatment of mild and moderate atopic dermatitis in children and adolescents

    J Am Acad Dermatol

    (2002)
  • A. Takaoka et al.

    Expression of IL-31 gene transcripts in NC/Nga mice with atopic dermatitis

    Eur J Pharmacol

    (2005)
  • J. Bilsborough et al.

    IL-31 is associated with cutaneous lymphocyte antigen-positive skin homing T cells in patients with atopic dermatitis

    J Allergy Clin Immunol

    (2006)
  • E. Sonkoly et al.

    IL-31: a new link between T cells and pruritus in atopic skin inflammation

    J Allergy Clin Immunol

    (2006)
  • H.A. Sampson

    Update on food allergy

    J Allergy Clin Immunol

    (2004)
  • P.J. Hauk et al.

    Tacrolimus (FK506): new treatment approach in superantigen-associated diseases like atopic dermatitis?

    J Allergy Clin Immunol

    (2001)
  • M.D. Howell et al.

    Cathelicidin deficiency predisposes to eczema herpeticum

    J Allergy Clin Immunol

    (2006)
  • M. Plaut et al.

    Risks of smallpox vaccination: 200 years after Jenner

    J Allergy Clin Immunol

    (2003)
  • D.M. Scalabrin et al.

    Use of specific IgE in assessing the relevance of fungal and dust mite allergens to atopic dermatitis: a comparison with asthmatic and nonasthmatic control subjects

    J Allergy Clin Immunol

    (1999)
  • N. Mothes et al.

    The cradle of IgE hyperreactivity in atopic eczema lies in infancy

    J Allergy Clin Immunol

    (2005)
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    This article is being copublished by The Journal of Allergy and Clinical Immunology and Allergy.

    Disclosure of potential conflict of interest: T. Bieber has consultant arrangements with Novartis and Schering. C. Bindslev-Jensen serves on the advisory board for Schering-Plough. A. Kapp has received grants/research support from Novartis, Astellas, UCB, ALK, and DPO and served on the speakers' bureau for Novartis, Astellas, UCB, and ALK. K. Turjanmaa a grant and research support from Ansell. U. Wahn has received grants and lecture honoraria from Novartis, MSD, GSK, UCB-Pharma, ALK, and Stallergenes. T. Zuberbier has served on the speakers' bureau for Novartis, Schering-Plough, UCB, Schering, MSD, Stallergenes, and Leti. M. Boguniewicz has received grants/research support from Novartis, Astellas, and Sinclair and has received lecture honoraria from Novartis and Astellas. D. Y. M. Leung has received grants/research support from Novartis and has served on the speakers' bureau for Novartis and Astellas. L. Rosenwasser has consultant arrangements with Novartis and Genentech. J. Spergel has received grants/research support from Novartis and the NIH and served on the speakers' bureau for GSK and Astellas. The rest of the authors have declared that they have no conflict of interest.

    The EAACI/AAAAI/PRACTALL Consensus Group was chaired by Professor Ulrich Wahn.

    The PRACTALL program is a common initiative of both academies, focusing on practical issues of allergology. It is supported by an unrestricted educational grant from Novartis.

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