Clinical Practice
Atopic Dermatitis
N Engl J Med 2005; 352:2314-2324June 2, 2005
- Article
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations.
A 10-year-old girl with atopic dermatitis reports itching that has recently become relentless, resulting in sleep loss. Her mother has been reluctant to treat the girl with topical corticosteroids, because she was told that they damage the skin, but she is exhausted and wants relief for her child. How should the problem be managed?
The Clinical Problem
Atopic dermatitis (or atopic eczema) is an itchy, inflammatory skin condition with a predilection for the skin flexures.1 It is characterized by poorly defined erythema with edema, vesicles, and weeping in the acute stage and skin thickening (lichenification) in the chronic stage (Figure 1AFigure 1
Atopic Dermatitis. and Figure 1B). Although termed atopic, up to 60 percent of children with the clinical phenotype do not have demonstrable IgE-mediated sensitivity to allergens,2 an observation that led the World Allergy Organization to propose a revised nomenclature.3 Approximately 70 percent of cases of atopic dermatitis start in children under five years of age,4 although 10 percent of cases seen in hospital settings start in adults.5 Asthma develops in approximately 30 percent of children with atopic dermatitis, and allergic rhinitis in 35 percent.6 Diagnostic Criteria
Atopic dermatitis is difficult to define because of its variable morphology and distribution and its intermittent nature. Several diagnostic criteria have been developed.7 Consensus criteria for the main clinical features of atopic dermatitis8 have led to a short list of reliable and valid discriminators that are used worldwide9 (Table 1Table 1
Criteria for the Diagnosis of Atopic Dermatitis.).Assessing disease severity is problematic when there is no objective marker.10 The many severity scales used in clinical trials are generally not suitable for rapid assessment in the clinic.11 The presence or absence of sleep disturbance, the number and location of involved sites, and the clinical course are the indicators of severity that probably provide the best basis for making decisions about treatment.12
Prevalence, Cost, and Prognosis
According to the International Study of Asthma and Allergies in Childhood, the prevalence of symptoms of atopic dermatitis in children six or seven years of age during a one-year period varied from less than 2 percent in Iran and China to approximately 20 percent in Australia, England, and Scandinavia.13 A high prevalence has also been found in the United States.14 In the United Kingdom, one population survey of 1760 affected children from one to five years of age found that 84 percent of cases were mild, 14 percent were moderate, and 2 percent were severe.15
Studies suggest that atopic dermatitis imposes a high economic burden,16 with out-of-pocket expenses and overall costs that are similar to those for the treatment of asthma.17 Causes of family stress related to caring for children with moderate or severe atopic dermatitis (e.g., sleep deprivation, loss of employment, time-consuming treatment, and financial costs) may rival those related to caring for children with diabetes mellitus type 1.18
Approximately 60 percent of patients with childhood atopic dermatitis are free of symptoms in early adolescence,19 although up to 50 percent may have recurrences in adulthood.20 Early-onset disease, severe early disease, concomitant asthma and hay fever, and a family history of atopic dermatitis may predict a more persistent course.4 One recent cohort study of 1314 German children showed that the prognosis was related to disease severity and atopic sensitization, as evidenced by elevated serum levels of IgE antibodies to food and inhalant allergens at two years of age.21
Causes
Atopic dermatitis is probably a complex disease relying on the interplay of several factors.22 Several genes have been identified that may explain some cases.23 Genetics alone, however, cannot explain the results of studies of migrant populations that show, for example, that Jamaican children living in London are twice as likely to have atopic dermatitis as Jamaican children living in Jamaica; the increased risk of atopic dermatitis in smaller families and among higher social classes; and the rising prevalence of atopic dermatitis in some countries. These observations suggest a key role for the environment in mediating disease expression.24 Whereas allergens such as house-dust mites and foods may be important in some cases, nonallergic factors such as rough clothing, Staphylococcus aureus infections, exposure to microbes during infancy, excessive heat, and exposure to irritants that disrupt the function of the skin barrier may also be important. Mechanisms for and implications of the possible prevention of atopic dermatitis are reviewed elsewhere.25,26
Strategies and Evidence
Diagnosis
Skin biopsy is of little value in the diagnosis of atopic dermatitis; instead, diagnosis is based on clinical features7-9 (Table 1). The differential diagnosis depends on age and the country of residence (Figure 2Figure 2
Discoid (Nummular) Eczema in an Infant. and Table 2Table 2
Differential Diagnosis of Atopic Dermatitis.). Because of their high negative predictive value (above 95 percent), negative skin-prick or radioallergosorbent tests for foods and environmental allergens may be useful for assessing the contribution of allergies to disease expression in children with severe disease.27 Positive tests are less useful, with positive predictive values of about 40 percent.27 Concomitant food allergy may be manifested as urticaria and gastrointestinal symptoms and may not necessarily exacerbate atopic dermatitis. Double-blind, placebo-controlled food challenges are the standard for diagnosing associated food allergy, but they are time consuming and not available in many hospitals.
The clinical utility of patch testing with airborne allergens is still unclear.28 Patch tests are useful for excluding a diagnosis of suspected superimposed allergic contact dermatitis.29
Treatment
Topical Corticosteroids
One systematic review identified 83 randomized controlled trials of the use of topical corticosteroids in atopic dermatitis.30 Vehicle-controlled studies lasting less than one month indicate that approximately 80 percent of people report good, excellent, or clear responses with topical corticosteroids, whereas 38 percent of persons in control groups reported such responses.
Potency of topical corticosteroids is classified by the potential for vasoconstriction — a surrogate for clinical efficacy and skin thinning (Table 3Table 3
Therapeutic Interventions for Atopic Dermatitis.). In general, only preparations that have very weak or moderate strength are used on the face and genital area, whereas those that have moderate or potent strength are used on other areas of the body.31 Lower-potency corticosteroids may be sufficient on all areas of the body in younger children. Preparations are typically used in bursts of three to seven days in order to achieve control. There is little difference in outcome between short-term use of potent preparations or longer use of weaker preparations in children with mild-to-moderate disease.32 Lichenified atopic dermatitis requires more potent preparations for longer periods.Long-term studies of moderate-to-potent preparations in children are scarce. One study of 231 children with stabilized atopic dermatitis randomly assigned to receive twice-weekly 0.05 percent fluticasone propionate (plus emollients) or vehicle alone plus emollients for 16 weeks showed that patients in the control group were more likely, by a factor of 8, to have a relapse (95 percent confidence interval, 4.3 to 15.2).33 A four-month trial of persons 12 to 64 years of age with moderate-to-severe disease showed that the application of fluticasone to previously active and new sites of atopic dermatitis for two consecutive days each week reduced flares significantly, as compared with a group receiving an emollient only.34
Reduced efficacy of topical corticosteroids may be related to disease severity rather than to glucocorticoid resistance.35 There is little evidence that the application of topical corticosteroids twice a day is more effective than once-daily applications,36 and more frequent use may cause more local side effects.
A main concern with the use of topical corticosteroids is irreversible skin thinning. Although thinning is possible, the concern on the part of patients (and parents) is often well out of proportion to the true risk.37 Although inappropriate use of potent preparations can cause skin thinning, four 16-week randomized trials did not show any clinically significant skin thinning,32-34,38 and a 1-year study showed no significant effect on collagen synthesis.39 A one-year study of unrestricted continual use of a potent corticosteroid on the limbs and trunk, a weak preparation on the face, or both showed that striae developed in 3 of 330 adults with moderate-to-severe atopic dermatitis.40 Similar studies in children are lacking. Other possible side effects of corticosteroids include facial telangiectasia and glaucoma from periocular use (rarely reported in adults).
Secondary adrenal suppression and the suppression of growth resulting from systemic absorption of topical corticosteroids are also concerns, although clinically relevant adrenal suppression is very rare.41 One study involving children with atopic dermatitis did not find any relationship between height velocity and the use of mild-potency as compared with moderate-potency topical corticosteroids.42 Another study showed biochemical evidence of suppression of the hypothalamic–pituitary–adrenal axis only in children with atopic dermatitis who used potent or very potent topical corticosteroids and in those who had received glucocorticoids from other routes, and not in those who had used topical corticosteroids of mild or moderate strength for a median of 6.9 years.35
Emollients
There is no evidence that emollients improve atopic dermatitis directly. However, emollients are widely used because they improve the appearance and symptoms of the dry skin (xerosis) associated with this condition.30,31,43 One study has shown that emollients may reduce the need for topical corticosteroids by approximately 50 percent,44 and another study found that emollients enhanced the response to treatment with topical corticosteroids.45 There is little basis for suggesting the use of one emollient over another, and the preference of the patient is probably the most important factor.31
Topical Calcineurin Inhibitors
Topical tacrolimus and pimecrolimus have both been shown to be effective in vehicle-controlled studies. For 1 percent pimecrolimus, the rate ratio for the proportion of patients clear or almost clear of atopic dermatitis at three weeks in five vehicle-controlled trials involving 783 patients was 2.72 (95 percent confidence interval, 1.84 to 4.03).46 For 0.03 percent and 0.1 percent tacrolimus, the rate ratios for the proportion of patients who were clear or who had excellent improvement at 12 weeks were 4.50 (95 percent confidence interval, 2.91 to 6.96) and 5.62 (95 percent confidence interval, 3.67 to 8.61), respectively, in three vehicle-controlled trials involving 656 patients.46 Short-term studies suggest that 0.1 percent topical tacrolimus may be similar in strength to potent topical corticosteroids,46 whereas topical pimecrolimus is considerably weaker.40,47
Few long-term studies compare intermittent use of topical calcineurin inhibitors with intermittent use of topical corticosteroids. A 12-month vehicle-controlled study of children with atopic dermatitis showed that early use of pimecrolimus reduced the frequency of flares from 51 percent to 28 percent,48 although early use of mild topical corticosteroids might have shown similar effects.
Topical calcineurin inhibitors do not cause skin thinning. Both tacrolimus and pimecrolimus are associated with mild burning sensations when applied to the skin (Table 3). Five-year studies show a good safety profile for these agents.49 In the United Kingdom, the National Institute of Clinical Excellence approves the use of topical tacrolimus for children older than two years of age with moderate-to-severe atopic dermatitis not controlled by topical corticosteroids, and of topical pimecrolimus as a second-line option for resistant dermatitis of the head and neck.50 In the United States, both of these topical calcineurin inhibitors are approved as second-line agents, and the site of application is not restricted for pimecrolimus.
In March 2005, the Food and Drug Administration issued an alert to health care professionals concerning a potential link between topical pimecrolimus and tacrolimus and cancer (mainly lymphoma and skin cancer) on the basis of studies in animals, case reports, and knowledge of how these drugs work.51,52 The alert emphasizes the importance of using these preparations only as labeled and when first-line treatment has failed or cannot be tolerated.
Other Topical Agents
A study of a refined-coal cream used on one side of the body in adults with mild-to-moderate atopic dermatitis as compared with 1 percent hydrocortisone used on the other side suggested similar efficacy after four weeks.53 There is insufficient evidence to conclude whether topical cromoglycate preparations are effective.30,54 Other topical treatments — such as St. John's wort cream, vitamin B12, and licorice gel — whose use is supported by single small, randomized trials require further evaluation before they can be recommended for the treatment of atopic dermatitis.
Oral Antihistamines
Evidence is lacking to support the use of antihistamines for the treatment of atopic dermatitis,55 although they are sometimes recommended for their sedative effects.56 Reports on nonsedative antihistamines are conflicting.30,56,57 The largest study failed to demonstrate any overall benefit from prolonged use of cetirizine in children with atopic dermatitis.58
Topical Doxepin
Topical doxepin produces some relief from itching within 48 hours. However, a clinically useful beneficial effect on disease severity has yet to be shown, and drowsiness may be a problem.30
Antibiotic Agents
Secondary infection with S. aureus is common (Figure 3Figure 3
Acute, Secondary Infection in an Infant with Atopic Dermatitis.) and usually is treated with short courses of antibiotics such as floxacillin, cephalexin, or amoxicillin–clavulanate. One randomized trial found no benefit to prescribing floxacillin continually for four weeks as compared with placebo, and methicillin-resistant strains were more common in those who were prescribed antibiotics.59 Although combinations of topical corticosteroids and antibiotics are used for atopic dermatitis, no good evidence suggests that they offer additional benefits as compared with topical corticosteroids alone.30 Ultraviolet Light
Randomized clinical trials have shown that ultraviolet light (ultraviolet B, narrow-band ultraviolet B, and high-intensity ultraviolet A) is beneficial for atopic dermatitis in the short term.30 Burning and itching may occur, and carcinogenicity is a long-term concern. Phototherapy is usually used as a second- or third-line treatment.31
Immunosuppressive Agents
A brief course of oral corticosteroids (less than three weeks) may be used to control a flare of severe disease, although data from randomized clinical trials are lacking. Ongoing use of systemic immunosuppressive agents (oral corticosteroids, cyclosporine, azathioprine, mycophenolate, and interferon gamma) is limited by adverse effects and is usually reserved for people with severe disease who do not respond to other measures.30,43
Nonpharmacologic Approaches
Avoiding foods suspected to cause flares may be helpful in young children with severe disease, but usually is not helpful in adults.30,60 Little evidence supports dietary exclusion of milk and eggs in unselected cases.61 Some evidence supports egg-free diets in infants with atopic dermatitis who produce IgE antibodies to egg protein.60 No good evidence supports highly restrictive diets, which can sometimes cause malnutrition.62 Studies have failed to show clinically useful benefits from supplements such as evening primrose oil, borage oil,63 zinc, pyridoxine, or vitamin E,30 or from viable lactobacilli (probiotics).30,64
Small randomized trials support psychological approaches such as behavior therapy (to reduce the habit of scratching) and relaxation therapy.30 Parental-education programs and demonstration of topical treatments by caregivers may be helpful.65,66 Reduction of house-dust-mite allergen can reduce severity scores for atopic dermatitis, but the clinical relevance and sustainability of such reductions is unknown.30 Impermeable mattress covers are very effective in reducing levels of mite antigens, but they have no clear clinical benefit.67
No good evidence supports the use of bandages containing zinc paste. The use of “wet wraps” (an outer dry bandage overlying an inner damp bandage used over either emollients or topical corticosteroids) has become a popular second- or third-line measure for children with resistant atopic dermatitis but is not supported by randomized trials, and enhanced systemic absorption remains a concern.41 No good data support alternative or complementary therapies such as homeopathy and bioresonance.30
Areas of Uncertainty
Randomized trials are lacking to assess the benefits of many simple interventions, such as emollients and other nonpharmacologic approaches.30 The lack of common outcome measures hinders meaningful comparisons across trials.11 Trials with active comparators are needed to inform choices among agents.47 Data on the optimal use of topical corticosteroids are needed, along with long-term data on adverse events. Data concerning the long-term safety of topical tacrolimus and pimecrolimus are also needed. The benefits of routine allergy testing require clarification. Moreover, it is unclear whether early aggressive therapy in children with atopic dermatitis alters the natural history of the disease.
Guidelines
The American Academy of Dermatology recently published evidence-based guidelines for atopic dermatitis that contain recommendations that are consistent with the evidence summarized in this article.43 In addition, many useful Web sites are available (Table 4Table 4
Web Sites with Information about Eczema.).Conclusions and Recommendations
Patients and families, such as the girl and her mother who are described in the vignette, often have concerns about topical corticosteroids that can be alleviated by appropriate education.68 Patients and families should be taught about the course of atopic dermatitis; that is, that a single cause and cure are unlikely, although good control is nearly always possible. Discussions should be supplemented by written information and a demonstration of the use of topical treatment.
For the girl in the vignette, I would recommend inducing a remission with once-daily application of a potent topical corticosteroid to the limbs and trunk for 10 days before scheduling a second visit to evaluate progress. Although data to support the use of emollients are limited, I would attempt to maintain remission by liberal use of emollients only, with recourse to five-day courses of potent or moderate-strength topical corticosteroids for flares.33 If such a regimen failed to maintain adequate quality of life, I would introduce “weekend therapy” — that is, the application of a potent corticosteroid to new and previously active sites of atopic dermatitis each Saturday and Sunday evening to reduce flares.34 Alternatively, intermittent use of topical tacrolimus or pimecrolimus may be used to reduce flares.50 If facial dermatitis requires continual use of mild topical corticosteroids, I would recommend the use of topical tacrolimus, 0.03 percent, twice daily for three weeks and then once daily until the atopic dermatitis clears up.50
Source Information
From the Center of Evidence-Based Dermatology, Queen's Medical Center, University of Nottingham, Nottingham, United Kingdom.
Address reprint requests to Professor Williams at the Center of Evidence-Based Dermatology, Queen's Medical Center, University of Nottingham, Nottingham NG7 2UH, United Kingdom, or at hywel.williams@nottingham.ac.uk.
- References
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- Citing Articles (90)
Citing Articles
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José Enrique Eizayaga, Juan Ignacio Eizayaga. (2012) Prospective observational study of 42 patients with atopic dermatitis treated with homeopathic medicines. Homeopathy 101:1, 21-27
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Anna Freyja Finnbogadóttir, Björn Árdal, Herbert Eiríksson, Birgir Hrafnkelsson, Helgi Valdimarsson, Björn Rúnar Lúðvíksson, Ásgeir Haraldsson. (2012) A long-term follow-up of allergic diseases in Iceland. Pediatric Allergy and Immunologyno-no
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Hyuck Hoon Kwon, Kyu Han Kim. (2012) Intravenous Immunoglobulin Treatment in a Child with Resistant Atopic Dermatitis. Annals of Dermatology 24:1, 66
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Rajendra Karki, Myung-A Jung, Keuk-Jun Kim, Dong-Wook Kim. (2012) Inhibitory Effect of Nelumbo nucifera (Gaertn.) on the Development of Atopic Dermatitis-Like Skin Lesions in NC/Nga Mice. Evidence-Based Complementary and Alternative Medicine 2012, 1-7
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Fu-Tong Liu, Heidi Goodarzi, Huan-Yuan Chen. (2011) IgE, Mast Cells, and Eosinophils in Atopic Dermatitis. Clinical Reviews in Allergy & Immunology 41:3, 298-310
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Hywel Williams. (2011) Perspective: Acting on the evidence. Nature 479:7374, S16-S16
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Sara J Brown, Karin Kroboth, Aileen Sandilands, Linda E Campbell, Elizabeth Pohler, Sanja Kezic, Heather J Cordell, W H Irwin McLean, Alan D Irvine. (2011) Intragenic Copy Number Variation within Filaggrin Contributes to the Risk of Atopic Dermatitis with a Dose-Dependent Effect. Journal of Investigative Dermatology
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M. Romanos, A. Buske-Kirschbaum, R. Fölster-Holst, M. Gerlach, S. Weidinger, J. Schmitt. (2011) Itches and scratches - is there a link between eczema, ADHD, sleep disruption and food hypersensitivity?. Allergy 66:11, 1407-1409
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Irvine, Alan D., McLean, W.H. Irwin, Leung, Donald Y.M., . (2011) Filaggrin Mutations Associated with Skin and Allergic Diseases. New England Journal of Medicine 365:14, 1315-1327
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Andrew Sohn, Amylynne Frankel, Rita V. Patel, Gary Goldenberg. (2011) Eczema. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine 78:5, 730-739
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J.-F. Stalder, S. Barbarot, A. Wollenberg, E. A. Holm, L. De Raeve, S. Seidenari, A. Oranje, M. Deleuran, F. Cambazard, A. Svensson, D. Simon, E. Benfeldt, T. Reunala, J. Mazereeuv, F. Boralevi, B. Kunz, L. Misery, C. G. Mortz, U. Darsow, C. Gelmetti, T. Diepgen, J. Ring, M. Moehrenschlager, U. Gieler, A. Taïeb, . (2011) Patient-Oriented SCORAD (PO-SCORAD): a new self-assessment scale in atopic dermatitis validated in Europe. Allergy 66:8, 1114-1121
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T. Hinz, D. Zaccaro, M. Byron, K. Brendes, T. Krieg, N. Novak, T. Bieber. (2011) Atopic dermo-respiratory syndrome is a correlate of eczema herpeticum. Allergy 66:7, 925-933
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I. Marenholz, A. Bauerfeind, J. Esparza-Gordillo, T. Kerscher, R. Granell, R. Nickel, S. Lau, J. Henderson, Y.-A. Lee. (2011) The eczema risk variant on chromosome 11q13 (rs7927894) in the population-based ALSPAC cohort: a novel susceptibility factor for asthma and hay fever. Human Molecular Genetics 20:12, 2443-2449
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M Udompataikul, W Srisatwaja. (2011) Comparative trial of moisturizer containing licochalcone A vs. hydrocortisone lotion in the treatment of childhood atopic dermatitis: a pilot study. Journal of the European Academy of Dermatology and Venereology 25:6, 660-665
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A.A. Hogewoning, J.N. Bouwes Bavinck, A.S. Amoah, D.A. Boakye, M. Yazdanbakhsh, P.G. Kremsner, A.A. Adegnika, S.K.A.D. De Smedt, R. Willemze, A.P.M. Lavrijsen. (2011) Point and period prevalences of eczema in rural and urban schoolchildren in Ghana, Gabon and Rwanda. Journal of the European Academy of Dermatology and Venereologyno-no
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J. Schmitt. (2011) Versorgungsforschung am Beispiel Neurodermitis. Der Hautarzt 62:3, 178-188
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Jochen Schmitt, Sinéad Langan, Tanja Stamm, Hywel C Williams. (2011) Core Outcome Domains for Controlled Trials and Clinical Recordkeeping in Eczema: International Multiperspective Delphi Consensus Process. Journal of Investigative Dermatology 131:3, 623-630
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J. Schmitt, L. von Kobyletzki, Å. Svensson, C. Apfelbacher. (2011) Efficacy and tolerability of proactive treatment with topical corticosteroids and calcineurin inhibitors for atopic eczema: systematic review and meta-analysis of randomized controlled trials. British Journal of Dermatology 164:2, 415-428
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H.C. Williams. (2011) Preventing eczema flares with topical corticosteroids or tacrolimus: which is best?. British Journal of Dermatology 164:2, 231-233
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C. J. Apfelbacher, T. L. Diepgen, J. Schmitt. (2011) Determinants of eczema: population-based cross-sectional study in Germany. Allergy 66:2, 206-213
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Nam-Kwen Kim, Dong-Hyo Lee, Hyung-Sik Seo, Seung-Ho Sun, Yong-Leol Oh, Ji-Eun Kim, In-Hwan Yoon, Eun-Sung Seo, Gye-Seon Shim, Christopher Zaslawski. (2011) Hwangryunhaedoktang in adult patients with Atopic Dermatitis: a randomised, double-blind, placebo-controlled, two-centre trial - study protocol. BMC Complementary and Alternative Medicine 11:1, 68
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U-C. Hipler, C. Wiegand. 2011. Biofunctional textiles based on cellulose and their approaches for therapy and prevention of atopic eczema. , 280-294.
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G. Ciprandi, M. De Amici, L. Berardi, M. Vignini, S. Caimmi, A. Marseglia, G. Marseglia, D. Fuchs. (2011) Serum neopterin levels in spontaneous urticaria and atopic dermatitis. Clinical and Experimental Dermatology 36:1, 85-87
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AA Hogewoning, IA Larbi, HA Addo, AS Amoah, D Boakye, F Hartgers, M Yazdanbakhsh, R Van Ree, JN Bouwes Bavinck, APM Lavrijsen. (2010) Allergic characteristics of urban schoolchildren with atopic eczema in Ghana. Journal of the European Academy of Dermatology and Venereology 24:12, 1406-1412
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J. Schmitt, H. Williams, . (2010) Harmonising Outcome Measures for Eczema (HOME).Report from the First International Consensus Meeting (HOME 1), 24 July 2010, Munich, Germany. British Journal of Dermatology 163:6, 1166-1168
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J. Schmitt, A. Buske-Kirschbaum, V. Roessner. (2010) Is atopic disease a risk factor for attention-deficit/hyperactivity disorder? A systematic review. Allergy 65:12, 1506-1524
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K Ibler, TN Dam, R Gniadecki, K Kragballe, GBE Jemec, T Agner. (2010) Efalizumab for severe refractory atopic eczema: retrospective study on 11 cases. Journal of the European Academy of Dermatology and Venereology 24:7, 837-839
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Hyeung-Sik Lee, Byung-Chang Lee, Sae-Kwang Ku. (2010) Effect of DHU001, a Polyherbal Formula, on Dinitrofluorobenzene-induced Contact Dermatitis (Type I allergy). Toxicological Research 26:2, 123-130
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P. F.-Y. Cheung, C.-K. Wong, A. W.-Y. Ho, S. Hu, D.-P. Chen, C. W.-K. Lam. (2010) Activation of human eosinophils and epidermal keratinocytes by Th2 cytokine IL-31: implication for the immunopathogenesis of atopic dermatitis. International Immunology 22:6, 453-467
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P. S. Friedmann, M. R. Ardern-Jones, C. A. Holden. 2010. Atopic Dermatitis. , 1-34.
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J. Schmitt, K. Schäkel, R. Fölster-Holst, A. Bauer, R. Oertel, M. Augustin, W. Aberer, T. Luger, M. Meurer. (2010) Prednisolone vs. ciclosporin for severe adult eczema. An investigator-initiated double-blind placebo-controlled multicentre trial. British Journal of Dermatology 162:3, 661-668
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Jochen Schmitt, Christian Apfelbacher, Chih-Mei Chen, Marcel Romanos, Stefanie Sausenthaler, Sibylle Koletzko, Carl-Peter Bauer, Ute Hoffmann, Ursula Krämer, Dietrich Berdel, Andrea von Berg, H.-Erich Wichmann, Joachim Heinrich. (2010) Infant-onset eczema in relation to mental health problems at age 10 years: Results from a prospective birth cohort study (German Infant Nutrition Intervention plus). Journal of Allergy and Clinical Immunology 125:2, 404-410
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Claude Favrot, Jean Steffan, Wolfgang Seewald, Federicca Picco. (2010) A prospective study on the clinical features of chronic canine atopic dermatitis and its diagnosis. Veterinary Dermatology 21:1, 23-31
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Thomas Bieber. (2010) Atopic Dermatitis. Annals of Dermatology 22:2, 125
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David Farhi, Alain Taïeb, Gérard Tilles, Daniel Wallach. (2010) The historical basis of a misconception leading to undertreating atopic dermatitis (eczema):facts and controversies. Clinics in Dermatology 28:1, 45-51
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L Misery, S Boussetta, P Shooneman, C Taieb. (2009) Dermatological future of european patients with atopic dermatitis. Journal of the European Academy of Dermatology and Venereology 23:12, 1383-1388
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Jennifer Ker, Tina V. Hartert. (2009) The atopic march: what's the evidence?. Annals of Allergy, Asthma & Immunology 103:4, 282-289
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Giampaolo Ricci, Arianna Dondi, Annalisa Patrizi. (2009) Useful Tools for the Management of Atopic Dermatitis. American Journal of Clinical Dermatology 10:5, 287-300
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K. Kondo-Endo, Y. Ohashi, H. Nakagawa, T. Katsunuma, Y. Ohya, K. Kamibeppu, I. Masuko. (2009) Development and validation of a questionnaire measuring quality of life in primary caregivers of children with atopic dermatitis (QPCAD). British Journal of Dermatology 161:3, 617-625
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C. Mailhol, V. Lauwers-Cances, F. Rancé, C. Paul, F. Giordano-Labadie. (2009) Prevalence and risk factors for allergic contact dermatitis to topical treatment in atopic dermatitis: a study in 641 children. Allergy 64:5, 801-806
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Mieczysława Czerwionka-Szaflarska, Anna Zawadzka-Gralec. (2009) „Marsz alergiczny” – u dzieci i młodzieży. Pediatria Polska 84:3, 270-273
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Jochen Schmitt, Marcel Romanos. (2009) Lack of studies investigating the association of childhood eczema, sleeping problems, and attention-deficit/hyperactivity disorder. Pediatric Allergy and Immunology 20:3, 299-300
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Christian J Apfelbacher, Isabella Ebert, Reginald Scheidt, Thomas L Diepgen, Elke Weisshaar, Christian J Apfelbacher. 2009. H1 antihistamines for eczema. .
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Jochen Schmitt, Natalie M. Schmitt, Wilhelm Kirch, Michael Meurer. (2009) Outpatient care and medical treatment of children and adults with atopic eczema. Journal der Deutschen Dermatologischen Gesellschaft 7:4, 345-351
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J. Schmitt, N.M. Schmitt, W. Kirch, M. Meurer. (2009) Bedeutung des atopischen Ekzems in der ambulanten medizinischen Versorgung. Der Hautarzt 60:4, 320-327
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Ayelet Shani-Adir, Dganit Rozenman, Aharon Kessel, Batya Engel-Yeger. (2009) The Relationship Between Sensory Hypersensitivity and Sleep Quality of Children with Atopic Dermatitis. Pediatric Dermatology 26:2, 143-149
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JOSÉ ANTONIO PLAZA, VICTOR G. PRIETO. 2009. Inflammatory Skin Conditions. , 1843-1889.
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Giampaolo Ricci, Arianna Dondi, Annalisa Patrizi, Massimo Masi. (2009) Systemic Therapy of Atopic Dermatitis in Children. Drugs 69:3, 297-306
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A.P. Oranje, R. Verbeek, P. Verzaal, I. Haspels, E. Prens, L. Nagelkerken. (2009) Wet-wrap treatment using dilutions of tacrolimus ointment and fluticasone propionate cream in human APOC1 (+/+) mice with atopic dermatitis. British Journal of Dermatology 160:1, 54-61
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R Xu. (2008) Herba Saxifragae cream in treatment of chronic eczema: a randomized controlled trial. Journal of Chinese Integrative Medicine 6:12, 1246-1249
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A. Conde-Taboada, F.J. González-Barcala, J. Toribio. (2008) Dermatitis atópica infantil: revisión y actualización. Actas Dermo-Sifiliográficas 99:9, 690-700
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Robert John Boyle, Fiona J Bath-Hextall, Jo Leonardi-Bee, Dedee F Murrell, Mimi LK Tang, Robert John Boyle. 2008. Probiotics for treating eczema. .
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J. Schmitt, A. Bauer, M. Meurer. (2008) Atopisches Ekzem im Erwachsenenalter. Der Hautarzt 59:10, 841-852
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Alexa Boer Kimball, Michael H. Gold, Beth Zib, Mark W. Davis. (2008) Clobetasol propionate emulsion formulation foam 0.05%: Review of phase II open-label and phase III randomized controlled trials in steroid-responsive dermatoses in adults and adolescents. Journal of the American Academy of Dermatology 59:3, 448-454.e1
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Adelaide A. Hebert. (2008) Desonide foam 0.05%: Safety in children as young as 3 months. Journal of the American Academy of Dermatology 59:2, 334-340
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Jochen Schmitt, Friederike Csötönyi, Andrea Bauer, Michael Meurer. (2008) Determinants of treatment goals and satisfaction of patients with atopic eczema. JDDG 6:6, 458-465
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A KRAKOWSKI, M DOHIL. (2008) Topical Therapy in Pediatric Atopic Dermatitis. Seminars in Cutaneous Medicine and Surgery 27:2, 161-167
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Marcus Maurer, Margitta Worm, Torsten Zuberbier. 2008. Antihistamines in atopic dermatitis. , 197-206.
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Hywel Williams, Alistair Stewart, Erika von Mutius, William Cookson, H. Ross Anderson. (2008) Is eczema really on the increase worldwide?. Journal of Allergy and Clinical Immunology 121:4, 947-954.e15
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Gregoria I Betsi, Evangelia Papadavid, Matthew E Falagas. (2008) Probiotics for the Treatment or Prevention of Atopic Dermatitis. American Journal of Clinical Dermatology 9:2, 93-103
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Jochen Schmitt, Sinead Langan, Hywel C. Williams. (2007) What are the best outcome measurements for atopic eczema? A systematic review. Journal of Allergy and Clinical Immunology 120:6, 1389-1398
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Florian Schulz, Ingo Marenholz, Regina Fölster-Holst, Christiane Chen, Alexander Sternjak, Ria Baumgrass, Jorge Esparza-Gordillo, Christoph Grüber, Renate Nickel, Stefan Schreiber, Monika Stoll, Michael Kurek, Franz Rüschendorf, Norbert Hubner, Ulrich Wahn, Young-Ae Lee. (2007) A common haplotype of the IL-31 gene influencing gene expression is associated with nonatopic eczema. Journal of Allergy and Clinical Immunology 120:5, 1097-1102
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Darren M Ashcroft, Li-Chia Chen, Ruth Garside, Ken Stein, Hywel C Williams, Darren M Ashcroft. 2007. Topical pimecrolimus for eczema. .
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Paul L. P. Brand, Berber J. Vlieg-Boerstra, Anthony E. J. Dubois. (2007) Dietary prevention of allergic disease in children: Are current recommendations really based on good evidence?. Pediatric Allergy and Immunology 18:6, 475-479
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Howard Donsky, Don Clarke. (2007) Reli??va, a Mahonia Aquifolium Extract for the Treatment of Adult Patients With Atopic Dermatitis. American Journal of Therapeutics 14:5, 442-446
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Steven J Ersser, Sue Latter, Andrew Sibley, Philip A Satherley, Sarah Welbourne, Steven J Ersser. 2007. Psychological and educational interventions for atopic eczema in children. .
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J Schmitt, N Schmitt, M Meurer. (2007) Cyclosporin in the treatment of patients with atopic eczema ? a systematic review and meta-analysis. Journal of the European Academy of Dermatology and Venereology 0:0, 070206173308005-???
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J. Callen, S. Chamlin, L.F. Eichenfield, C. Ellis, M. Girardi, M. Goldfarb, J. Hanifin, P. Lee, D. Margolis, A.S. Paller, D. Piacquadio, W. Peterson, K. Kaulback, M. Fennerty, B.U. Wintroub. (2007) A systematic review of the safety of topical therapies for atopic dermatitis. British Journal of Dermatology 156:2, 203-221
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Brian P Vickery. (2007) Skin barrier function in atopic dermatitis. Current Opinion in Pediatrics 19:1, 89-93
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Ramon Grimalt, Valérie Mengeaud, Frédéric Cambazard. (2007) The Steroid-Sparing Effect of an Emollient Therapy in Infants with Atopic Dermatitis: A Randomized Controlled Study. Dermatology 214:1, 61-67
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Jochen Schmitt, Elisabeth Heese, Gottfried Wozel, Michael Meurer. (2007) Effectiveness of Inpatient Treatment on Quality of Life and Clinical Disease Severity in Atopic Dermatitis and Psoriasis Vulgaris – A Prospective Study. Dermatology 214:1, 68-76
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Susan Haller Psaila. 2007. Atopic Dermatitis. , 60.
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Gertie J Oostingh, Ralf J Ludwig, Sven Enders, Sabine Grüner, Gesche Harms, W Henning Boehncke, Bernhard Nieswandt, Rudolf Tauber, Michael P Schön. (2007) Diminished Lymphocyte Adhesion and Alleviation of Allergic Responses by Small-Molecule- or Antibody-Mediated Inhibition of L-Selectin Functions. Journal of Investigative Dermatology 127:1, 90-97
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Melinda K. Gordon, Madeleine Kraus, Koen van Besien. (2007) Interdigitating dendritic cell tumors in two patients exposed to topical calcineurin inhibitors. Leukemia & Lymphoma 48:4, 816-818
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Matthias Möhrenschlager, Johannes Ring. (2006) Atopic Eczema. Current Allergy and Asthma Reports 6:6, 445-447
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AP Oranje, ACA Devillers, B Kunz, SL Jones, L DeRaeve, D Van Gysel, FB de Waard-van der Spek, R Grimalt, A Torrelo, J Stevens, J Harper. (2006) Treatment of patients with atopic dermatitis using wet-wrap dressings with diluted steroids and/or emollients. An expert panel's opinion and review of the literature. Journal of the European Academy of Dermatology and Venereology 20:10, 1277-1286
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C. Abels, E. Proksch. (2006) Therapie des atopischen Ekzems. Der Hautarzt 57:8, 711-725
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S. LEWIS-JONES. (2006) Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. International Journal of Clinical Practice 60:8, 984-992
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RJ Boyle, F Bath-Hextall, S Donath, D Murrell, MLK Tang, J Taylor, G Varigos, Robert John Boyle. 2006. Probiotics for atopic eczema. .
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Luz Fonacier, Ernest N. Charlesworth, Jonathan M. Spergel, Donald Y.M. Leung. (2006) The black box warning for topical calcineurin inhibitors: looking outside the box. Annals of Allergy, Asthma & Immunology 97:1, 117-120
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Edward R. Conner, Lisa A. Beck. (2006) Emerging therapeutic options for atopic dermatitis: Beyond TIMs. Current Allergy and Asthma Reports 6:4, 275-281
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A. Farkas, L. Kemeny. (2006) Applications of the 308-nm excimer laser in dermatology. Laser Physics 16:5, 876-883
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M Mohrenschlager, U Darsow, C Schnopp, J Ring. (2006) Atopic eczema: what's new?. Journal of the European Academy of Dermatology and Venereology 20:5, 503-513
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Y.-D. Park, Y.-J. Lyou, K.-J. Lee, D.-Y. Lee, J.-M. Yang. (2006) Towards profiling the gene expression of fibroblasts from atopic dermatitis patients: human 8K complementary DNA microarray. Clinical <html_ent glyph="@amp;" ascii="&"/> Experimental Allergy 36:5, 649-657
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Alicia D Miller, Lawrence F Eichenfield. (2006) Evolving management of atopic dermatitis. Expert Review of Dermatology 1:1, 31-41
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Chun Wook Park. (2006) The Pharmacologic Treatment of Atopic Dermatitis. Journal of the Korean Medical Association 49:11, 1046
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MATTHIAS MOHRENSCHLAGER, STEPHAN WEIDINGER, JOHANNES HUSS-MARP, URSULA KRAMER, HEIDRUN BEHRENDT, JOHANNNES RING. (2005) DO GENDER-SPECIFIC DIFFERENCES IN EYELASH LENGTH IN 5- TO 6-YEAR-OLD PRESCHOOLCHILDREN WITH AND WITHOUT ATOPIC ECZEMA EXIST? RESULTS FROM THE MIRIAM STUDY CONDUCTED IN AUGSBURG, GERMANY. Pediatric Dermatology 22:6, 576-577
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(2005) Atopic Dermatitis. New England Journal of Medicine 353:10, 1069-1070
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Michael O'Donoghue, Michael D. Tharp. (2005) Antihistamines and their role as antipruritics. Dermatologic Therapy 18:4, 333-340
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Emma Guttman-Yassky. (2004) Exogenous Factors in Atopic Dermatitis. Exogenous Dermatology 3:5, 228-236
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