Atopic dermatitis: A disease “More common in families that sneeze and wheeze”

Marion Sulzberger (1895–1983) who, together with Fred Wise (1881–1950), is often credited with introducing the term atopic dermatitis to dermatology, wrote this prescient limerick in 1933:

Atopic dermatitis, while not perfection,

At least points in the right direction,

It says that here's a skin disease,

More common in families that sneeze and wheeze.

Revisiting atopic dermatitis, a disease addressed in previous issues of the Proceedings, [1–6] this issue features a review article by Reed and Blaiss⁷ which highlights the burden of illness attributable to this disease. The authors reviewed the impact of atopic dermatitis not only on quality of life of the afflicted patient, including effects on sleep, daily activities such as school and work, and psychological stressors but also the stressful effects of the disease on parents and caregivers. The authors also examined the burgeoning direct and indirect costs attributable to the disorder and conclude that the consequences of atopic dermatitis are more significant than previously recognized.

Contributing to these concerns are the comorbidities known to be associated with atopic dermatitis, including asthma, allergic rhinitis, and food allergy; however, surprisingly little is known regarding the association of atopic dermatitis with other clinical entities, such as chronic urticaria. In an attempt to fill this void, Kitsioulis et al.⁸ provide a retrospective analysis of pediatric patients with atopic dermatitis presenting to an outpatient allergy unit. Their results suggested that atopic dermatitis may constitute an important risk factor for the subsequent development of chronic spontaneous urticaria. Continuing with the theme of atopic dermatitis, Kwon and Beck⁹ provide a state-of-the-art therapeutic update for the management of severe atopic dermatitis. The authors focus on new and emerging biologics for treatment of this disease, including dupilumab as well as other drugs, both topical and systemic, which are currently in development.

Transitioning this issue's focus to the topic of asthma is a group of articles including Alzaabi et al.,¹⁰ who provide a report on the burden of asthma in the Gulf region and Russia. Their study, based on the “Asthma Insights and Management (AIM)” survey makes clear the unmet need for improvements in patient education and asthma care in these geographic regions. This is followed by two studies by Piekarska et al.^11,12 concerning the effects of indoor air quality on the incidence of respiratory diseases, specifically asthma and rhinitis. Their results reveal the hazards resulting from active and passive tobacco smoke exposure, utilization of certain types of heating and cooking appliances, as well as building age. Addressing asthma treatment, Plaza et al.¹³ studied the association of patient satisfaction with inhaler therapy, adherence, and health outcomes in asthma. The authors report that inhaler satisfaction, irrespective of received medication, was related to adherence and asthma control. Because of the importance of this article and its clinically useful implications, it was chosen for this issue's “For the Patient” section. This segment, found in the final pages of the print version of this issue and also available online, consists of a one-page article synopsis written in a readily comprehensible fashion to help patients better understand the content of the full article. Rounding out the asthma articles in this issue, Corrao¹⁴ provids a succinct summary of clinically useful pearls and pitfalls associated with the diagnosis of cough variant asthma.

Moving to the topic of food allergy, Randhawa et al.¹⁵ provide novel insights regarding the probability of negative tree nut skin-prick test results and successful tree nut challenges among peanut-allergic children. The authors report that the majority of patients with peanut allergy will have negative skin test results and food challenges to certain tree nuts, especially macadamia, pine nut, and coconut. In a second food allergy article, Sardecka et al.¹⁶ report on early risk factors for cow's milk allergy in children in their first year of life. They conclude that a positive family history of allergy and a higher degree of maternal education increased the risk of cow's milk allergy in children in the first year of life, while having pets at home and longer periods of breast-feeding decreased the risk.

Eosinophilic esophagitis can be comorbid condition frequently associated with food allergy. Lin et al.¹⁷ performed a telephone survey to examine issues concerned with the management of patients referred for eosinophilic esophagitis. The authors were able to identify several challenges, including potential misdiagnosis or overtreatment, lack of standardization in testing, and dietary recommendations as well as patient adherence issues.

Transitioning to the topic of drug allergy are two papers. In the first article, Reilly et al.¹⁸ perform a systematic review and a meta-analysis which addresses the question of how preoperative penicillin skin testing affects the subsequent perioperative use of non-beta-lactam antibiotics. The authors conclude that preoperative antibiotic allergy testing protocols seemed to be safe and effective tools in reducing the use of non–β-lactam antibiotics during surgery. The second drug allergy report concerns issues associated with adverse reactions with iodinated radiocontrast media. Although there is good evidence that warming of contrast media changes the bolus kinetics and injection pressure of iodinated contrast media, there has been little evidence that it affects the rate of clinical adverse events in a meaningful way. In this issue, Zhang et al.¹⁹ present evidence that extrinsic warming to 37°C before intravenous administration was associated with a reduction in the rate of allergic-like reactions to three different low-osmolality iodinated contrast media agents.

The next topic addressed in this Proceedings deals with the use of epinephrine for the management of severe allergic reactions that manifest as anaphylaxis, whether induced by drugs, foods, or other agents. In this issue, Edwards et al.²⁰ present the results of a human factors engineering study which validated the user interface for a novel 0.1-mg epinephrine autoinjector. This is a welcome therapeutic option as it addresses an unmet need in anaphylaxis management for infants who weigh under 33lbs (15kg).

This issue's Patient-Oriented Problem Solving “POPS” case presentation explores the differential diagnosis of a 58-year-old woman with a generalized rash and pruritus. The “POPS” case presentation is a recurring feature of the Proceedings, which, as per tradition, is written by an allergy/immunology fellow-in-training from one of the U.S. allergy/immunology training programs. The purpose of the POPS series is to provide an innovative and practical learning experience for the allergist/immunologist in-training by using a didactic format of clinical presentation and deductive reasoning. In this issue's POPS, Lutzkanin et al.²¹ from the Penn State Milton S. Hershey Medical Center led the reader through this learning process, illustrating the complexity of the differential diagnostic process for this clinical dermatologic presentation and the importance of a detailed history, physical examination, and appropriate laboratory assessment in arriving at a correct diagnosis.

In summary, the collection of articles found within the pages of this issue provides further insight into the intersecting crossroads of genetics and the environment which manifest as the allergic, cutaneous, and respiratory disorders afflicting patients whom the allergist/immunologist serves. In particular, they exemplify how the complexities of asthma, atopic dermatitis, food allergy, drug allergy, and anaphylaxis continue to challenge the allergist/immunologist. In keeping with the overall mission of the Proceedings, which is to distribute timely information regarding advancements in the knowledge and practice of allergy, asthma, and immunology to clinicians entrusted with the care of patients, it is our hope that the articles found within this issue will help foster enhanced patient management and outcomes. On behalf of the Editorial Board, we hope that you are able to make practical use of the diversity of literature offered in this issue of the Proceedings.