Abstract
Introduction
Atopic dermatitis (AD) is a chronic, pruritic inflammatory skin disorder that typically begins in early childhood and affects up to 20% of children. Infants with a family history of allergic diseases or with elevated total IgE levels are at increased risk of developing AD. Emerging evidence shows that a subgroup of AD patients produce IgE autoantibodies against skin self-peptides, which are suggested to play a role in disease pathophysiology and predict the development of allergic diseases later in life. Notably, such autoantibodies have been detected in up to 15% of infants with AD under 1 year of age, indicating that IgE autoantibodies can arise early in life. The ‘Development of IgE Autoantibodies in Newborns with (high risk to develop) Atopic dermatitis’ (DIANA) study is a prospective birth cohort designed to address these knowledge gaps by following a target of 500 newborns during their first 24 months of life.
Methods and dissemination
It aims to investigate the presence of IgE autoantibodies at birth (cord blood) and during early life (6, 12 and 24 months) using an immunoassay and their association with the development of AD in children from high-risk (n=400) and low-risk (n=100) families. Genetic and environmental influences are evaluated through questionnaires. Additional assessments will include skin and gut microbiome profiling using 16S rRNA sequencing (swabs), non-invasive evaluation of skin barrier function using electrical impedance spectrometry and analysis of the natural moisturising factor. We aim to decipher the underlying cause of IgE autoantibody development and allow preventive measures to counteract this.
Ethics and dissemination
This prospective, non-interventional observational study has been approved by the Ethics Committee of Universitair Ziekenhuis Brussel/VUB (07/06/2023; EC-2023-074) and will follow Good Clinical Practice, applicable regulations and the Declaration of Helsinki. Written informed consent will be obtained from parents or legal guardians. Participation is voluntary, and consent can be withdrawn at any time. All procedures comply with GDPR to ensure data confidentiality. Participant data will be pseudonymised, with the coding key accessible only to designated study members and securely stored on a restricted-access VUB server. Findings will be disseminated through peer-reviewed publications and conference presentations. Pseudonymised data will be made available upon reasonable request in accordance with institutional policies and data protection regulations
Trial registration number
Keywords: DERMATOLOGY, PAEDIATRICS, IMMUNOLOGY, Eczema
STRENGTHS AND LIMITATIONS OF THIS STUDY.
Large, well-characterised and demographically diverse cohort with extensive early-life data, including cord blood.
Interdisciplinary design with close follow-up until the age of 2 years, enabling detailed monitoring of atopic dermatitis and other conditions.
Comprehensive dataset covering infants and parents, including questionnaires, skin measurements and microbiome sampling.
Recruitment limited to one hospital, with potential selection biases related to family allergy history, siblings and ability to attend follow-up visits.
Some missing questionnaire data expected but partially addressed by encouraging completion during follow-up visits.
Introduction
The prevalence of allergic and inflammatory diseases, such as atopic dermatitis (AD), is increasing worldwide. AD is a chronic and relapsing inflammatory skin disorder characterised by intense pruritus, inflammatory plaques, and dry, scaly skin.1 It typically begins in early childhood, mostly within the first 2 years of life, and affects up to 20% of children overall. More specifically, its prevalence among infants aged 6 to 12 months is approximately 11%, although rates may vary depending on genetic, lifestyle and environmental factors. Beyond physical symptoms, the psychological burden associated with AD does not only affect children themselves (sleep deprivation, lack of concentration, anxiety) but also their parents/caregivers causing an important impact on their quality of life.2
The primary causes typically involve an interplay between immune dysregulation and impairment of the epidermal barrier. Recent non-invasive approaches for assessing skin barrier function include electrical impedance spectrometry (EIS), which measures the response of a skin region to an externally applied current. EIS provides insights into barrier integrity and has been shown to distinguish between healthy and diseased skin. In addition, natural moisturising factor (NMF), which is important in maintaining the skin barrier function, was shown to be a useful biomarker for the filaggrin (FLG) mutation status in a multi-ethnic paediatric AD cohort.3 NMF components are derived from further degradation of FLG into amino acids together with a mixture of salts and amino acid derivatives in the stratum corneum. Patients with FLG mutations are at higher risk to develop severe AD and sensitisation to food or aeroallergens.4 One or more FLG mutations have been identified in approximately 30% of patients with AD.3 Regarding immune alterations in AD, patients typically exhibit an overproduction of type 2 cytokines such as interleukin (IL)-4 and IL-13. In addition, infants with persistently elevated serum total immunoglobulin E (IgE) levels are at increased risk of developing AD by 12 months of age.5 Allergen-specific IgE responses are primarily directed against exogenous antigens (eg, pollen). Notably, AD often represents the first clinical manifestation in a sequence of allergic conditions including allergic asthma (AA), allergic rhinitis (AR) and food allergies (FA), known as the atopic march.6 Evidence from prior studies further indicates a potential correlation between allergy development and iron deficiency, highlighting the need for continued investigation.7
Interestingly, a subgroup of patients with AD has been found to produce IgE autoantibodies against self-peptides present in the skin. These autoantibodies are particularly prevalent in individuals with comorbid allergic diseases and are absent in most healthy controls, suggesting a link between IgE autoreactivity and allergic disease burden.8 One study reported a prevalence of 15% of IgE autoantibodies in infants with AD younger than 1 year, suggesting that IgE autoantibodies can emerge very early in life.9 However, the small sample size and lack of precise age stratification among infants are limiting factors. The development of IgE autoantibodies may involve molecular mimicry of exogenous and self-antigens. This occurs in proteins that share more than 50% structural homologies between epitopes of foreign antigens and self-antigens. An example is the Malassezia sympodialis allergen Mala s 11, which shares 50% sequence homology with human manganese superoxide dismutase (hMnSOD), leading to IgE cross-reactivity in AD patients.10
The presence of IgE autoantibodies suggests a systemic process of autoimmunity that can contribute to AD pathophysiology. However, despite growing evidence, the exact time of onset, the prevalence, the underlying mechanisms of IgE autoreactivity and its potential role in the development of AD and progression along the atopic march remain poorly understood. To address this knowledge gap, the ongoing longitudinal birth cohort study (DIANA, EC-2023-074) focuses on identifying the presence of IgE autoantibodies at birth (cord blood) and during early life (6, 12 and 24 months) and their association with the development of AD (high-risk vs low-risk children). The study also explores hereditary and environmental factors (breastfeeding, infections, affected siblings), skin/gut microbiome diversity as well as skin barrier assessments. By characterising the earliest stages of IgE autoreactivity and their potential role in the pathogenesis of AD, this research may decipher the underlying cause of IgE autoantibody development in AD and other allergic diseases and allow preventive measures to counteract this.
Methods and analysis
Study objectives
The primary objective is to determine the prevalence at birth or early development of IgE autoantibodies against skin self-peptides in newborns by measuring their presence in cord blood.
The secondary objectives are to investigate whether the presence of IgE autoantibodies is associated with the development/severity of AD during the first 2 years of life. Furthermore, the contribution of heredity (family history of atopy, maternal spillover) and environmental exposures (mode of delivery, month of birth (pollen season), diet, urban/rural environment, comorbidities, medications, smoking and lifestyle factors) to the development of IgE autoantibodies will be assessed. In addition, the link between IgE autoantibodies and the presence of distinct inflammatory profiles and systemic iron levels will be studied, alongside the evolution and adaptations of B cell subsets in response to diverse early-life exposures.
The tertiary objectives are to investigate whether skin barrier function/composition (measured by EIS and NMF) correlates with the development of AD and/or IgE autoantibodies. In addition, potential shifts in skin and gut microbiome composition will be correlated with the presence of IgE autoantibodies.
Study population
The study population will comprise approximately 500 male and female newborns with (n=400) and without (n=100) a physician-diagnosed family history of atopic diseases (AD, AA, AR, FA) who are planned to be born at the maternity ward of the Universitair Ziekenhuis (UZ) Brussel. Only the patients that satisfy the inclusion criteria and none of the exclusion criteria shown in table 1 are eligible to participate in the study.
Table 1. Eligibility criteria.
| Category | Criteria |
|---|---|
| Inclusion criteria |
|
| Exclusion criteria |
|
NICU, neonatal intensive care unit; UZ, Universitair Ziekenhuis.
Study design
This study is a prospective, non-interventional, observational, non-randomised birth cohort study conducted exclusively at UZ Brussel university hospital. Recruitment of the first participant started on 5/10/2023, and the final enrolment is expected to be completed by 31/12/2027.
Study visits
Recruitment is facilitated through posters and flyers in the gynaecology waiting areas at UZ Brussel, peripheral hospitals, and private practices referring to UZ Brussel. In addition, during each consultation, gynaecologists receive an electronic prompt with two questions: (1) whether the patient consents to being contacted by phone regarding the study and (2) whether there is a personal or family history of atopy. Based on these responses, the study team will approach eligible parents and, if interested, schedule the baseline visit (visit 1). A total of five visits are scheduled in a timespan of 2 years. The first visit will ideally take place prenatally at approximately 36 weeks of gestation, coinciding with routine peripheral blood collection. After delivery, cord blood is obtained and the second visit will occur within one or 2 days postpartum. Follow-up visits will then be conducted at 6 months (visit 3), 12 months (visit 4) and 24 months (visit 5) of age. An overview of the study timeline is provided in figure 1.
Figure 1. Overview of study visits including assessments performed during each visit. AD, atopic dermatitis; EIS, electrical impedance spectrometry; NMF, natural moisturising factor. *NMF measurements are performed at 12 months if it cannot be done at 6 months.
Methods
Study procedures are conducted at UZ Brussel and primarily involve blood sampling, initially from cord blood, followed by peripheral blood collection from the child during follow-up visits, and once from each parent. Additional data collection includes clinical examinations of the child performed by trained dermatologists who were blinded to the family history of atopic diseases and laboratory results. Questionnaires and non-invasive skin assessments, including EIS (Nevisense, SciBase, Sweden) and NMF (NMFScan, RiverD, The Netherlands) are performed as previously described.3 11 Skin and stool samples (COPAN) are also collected for microbiome analysis. Presence of AD will be diagnosed using the Hanifin and Rajka criteria.12 Further details regarding each assessment are provided in online supplemental tables 1–3.
Data analysis and statistics
Data collection is performed by study nurses, doctoral students, laboratory staff members and medical doctors involved in the study. Study data, questionnaires and study-related assessments are collected and managed using REDCap (Research electronic data capture) tools hosted at UZ Brussel.
For the primary outcome, sample size estimation was based on an expected prevalence of IgE autoantibody positivity of 2% among healthy controls and 15% among children with AD under 1 year of age.8 9 An a priori power analysis using G*Power 3.1 (Fisher’s exact test, two-tailed) with α=0.05, power=0.80 and an allocation ratio of 4 (AD:Control) indicated that 50 healthy controls and 200 children with AD were required. As approximately half of the high-risk children are expected to develop AD by 1 year of age, 400 high-risk infants and 100 low-risk children will be enrolled, resulting in a total cohort of 500 participants.
However, as the secondary and tertiary objectives have not been previously documented, sample size estimation for these outcomes was not feasible. An interim analysis will be conducted after recruitment of 50% of participants to evaluate and, if necessary, adjust the sample size to ensure adequate statistical power.
Expected outcomes/endpoints
Primary endpoints
Prevalence and age of onset of IgE autoantibodies (at birth or first developmental stages) directed against keratinocyte-derived proteins in newborns (with high risk of atopic dermatitis) up to 24 months old.
Secondary endpoints
Correlation between the presence of IgE autoantibodies and the development of atopic dermatitis.
Relation of IgE autoantibodies with total and allergen-specific IgE (food and/or airborne allergens).
Investigation of the hereditary factor (ethnicity, atopic family history vs maternal spillover in utero) in the case of IgE autoantibodies being present.
Role of environmental factors on the development of IgE autoantibodies in infants: skin and gut microbiome composition/diversity, infections, medications, smoking, living conditions, diet, pollution, comorbidities and lifestyle changes.
AD severity over time (eg, EASI and SCORAD) and its association with IgE autoantibodies.
Analysis and characterisation of early-life B cell populations from newborn children using single-cell RNA sequencing.
Tertiary endpoints
Determination of serum inflammatory mediators and their association with IgE autoantibodies.
Assessment of skin barrier function using EIS and the association with IgE autoantibodies and the incidence of AD.
Assessment of skin barrier function using NMF and the association with IgE autoantibodies and the incidence of AD.
Iron deficiency and the association with IgE autoantibodies and AD.
Correlation of the skin-gut axis with atopic dermatitis and/or IgE autoantibodies.
Ethics and dissemination
This prospective, non-interventional, observational study will be conducted in accordance with the protocol approved by the Ethics Committee of the Universitair Ziekenhuis (UZ) Brussel/Vrije Universiteit Brussel (VUB) (07/06/2023; EC-2023-074). The study will adhere to Good Clinical Practice (GCP) guidelines, all applicable regulatory requirements, and the principles of the Declaration of Helsinki.
Written informed consent will be obtained from the parents or legal guardians prior to any study-related procedures. They will be informed that participation is voluntary and that consent may be withdrawn at any time without consequences. All procedures will comply with the General Data Protection Regulation (GDPR; European law, 25 May 2018) to ensure the confidentiality and protection of personal data.
Participant anonymity will be safeguarded through pseudonymisation using a coding key accessible only to designated study team members. All study data will be stored securely on a local VUB server with restricted access.
Patient and public involvement
Members of the public contributed to the refinement of the questionnaires by reviewing the content and confirming that all items were clear and understandable. This process was conducted in all languages used in the study (French, Dutch and English), according to each participant’s mother tongue, prior to finalising the informed consent forms (ICFs).
Supplementary material
Footnotes
Funding: The study is conducted with the financial support of the Research Foundation–Flanders (FWO) grants (G056322N, 1801325N). It is also supported by an unrestricted Sanofi Regeneron Pathways Global Innovation Grant (2020) and a local start-up research fund Wetenschappelijk Fonds Willy Gepts of the UZ Brussels. The UZ Brussel covers the blood samples and their registration in the biobank. Copan supports the study by supplying 2000 eNAT swabs free of charge. SciBase provided two Nevisense device trainings and 1100 electrodes for the measurements of the electrical impedance. RiverD supports the study of the prototype of the NMFScan, training and evaluation of the use of the device.
Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2025-114509).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Consent obtained from parent(s)/guardian(s)
Ethics approval: The present study will be conducted in accordance with the protocol approved by the Ethics Committee of the Universitair Ziekenhuis (UZ) Brussel/Vrije Universiteit Brussel (VUB) (07/06/2023; EC-2023-074). Participants gave informed consent to participate in the study before taking part.
Patient and public involvement: Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Data availability statement
Data sharing is not applicable as no datasets were generated and/or analysed for this study. Data are available upon reasonable request.
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