Association of autoimmune blistering disease, and specifically, pemphigus vulgaris, with cardiovascular disease and its risk factors: a systematic review and meta-analysis.

Previous studies have found conflicting results about the association of autoimmune blistering disease (AIBD) with cardiovascular disease (CVD) risk. The objective of the study was to systematically review the relationship of AIBD, including pemphigus vulgaris (PV), and its treatment with CVD and CVD risk factors. MEDLINE, EMBASE, Cochrane, LILACS, SCOPUS, and Web of Science were searched. We included all studies of CVD and CVD risk factors in AIBD patients. Two reviewers performed title and/or abstract review and data extraction. Pooled random-effects meta-analysis was performed. Forty papers met inclusion criteria. AIBD was associated with higher odds of diabetes (DM) (odds ratio [95% confidence interval]: 1.809 [1.258-2.601]), hypertension (HTN) (1.393 [1.088-1.784]), dyslipidemia (2.177 [1.163-4.073]) and heart failure (1.919 [1.603-2.298]), but was not associated with obesity, stroke, angina, heart attack, or arrhythmia. The pooled random-effects prevalence for treatment-related adverse events (AEs) in AIBD was 13.7% for DM, 10.7% for HTN, and 17.1% for CVD. Sensitivity analysis of high-quality studies revealed similar results. AIBD patients have increased CVD risk factors and heart failure. Systemic corticosteroid treatment results in CVD-related AEs in AIBD. Increased CVD screening and prevention strategies are warranted in AIBD.

Validity and reliability of Patient-Reported Outcomes Measurement Information System Global Health scale in adults with atopic dermatitis.

BACKGROUND: Patient-Reported Outcomes Measurement Information System Global Health (PGH) was validated to assess health-related quality of life in several diseases. Little is known about its measurement properties in adult atopic dermatitis. OBJECTIVE: Examine the measurement properties of PGH in adult atopic dermatitis. METHODS: A prospective dermatology practice-based study of 994 atopic dermatitis patients (18-97 years). RESULTS: PGH physical and mental health 4-item and abridged 2-item T scores, as well as mapped EuroQol-5D score, showed strong to very strong correlation with one another and moderate to strong Spearman correlations with Patient-Oriented Scoring Atopic Dermatitis, Patient-Health Questionnaire-9, Patient-Reported Outcomes Measurement Information System sleep disturbance and related impairment, Eczema Area and Severity Index, objective Scoring Atopic Dermatitis; and weak to moderate correlations with Patient Oriented Eczema Measure, numeric rating scale worst itch and average itch, and Scoring Atopic Dermatitis. The Dermatology Life Quality Index (DLQI) had stronger correlations with Patient Oriented Eczema Measure, Patient-Oriented Scoring Atopic Dermatitis, numeric rating scale worst itch and average itch, Eczema Area and Severity Index, and Scoring Atopic Dermatitis, but weaker correlations with Patient-Health Questionnaire-9 and Patient-Reported Outcomes Measurement Information System sleep disturbance and related impairment (convergent/divergent validity). PGH and DLQI scores had similarly poor ability to differentiate between levels of self-reported global atopic dermatitis severity (known-groups validity). No floor or ceiling effects were observed. No PGH or DLQI items had differential item functioning by demographics. PGH and DLQI scores showed fair to good responsiveness. Finally, PGH and DLQI showed similarly good test-retest reliability. LIMITATIONS: Single-center study. CONCLUSION: PGH scores had sufficient validity and reliability to assess health-related quality of life in atopic dermatitis.

Measurement Properties of Patient Health Questionnaire 9 and Patient Health Questionnaire 2 in Adult Patients With Atopic Dermatitis.

BACKGROUND: Few outcome measures were validated for assessing depressive symptoms in AD. Patient Health Questionnaire-9 (PHQ9) and the abridged PHQ2 are established patient-reported outcome measures of depressive symptoms. OBJECTIVE: We sought to examine the measurement properties of PHQ9 and PHQ2 in adult AD. A prospective dermatology-practice based study of 458 AD patients (age 18-97 years) was conducted. RESULTS: PHQ9 strongly correlated with Dermatology Life Quality Index, Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep-Disturbance and Sleep-Related Impairment, and PROMIS Itch Questionnaire Mood and Sleep (PIQ-MS), and moderately correlated with Patient-Oriented Eczema Measure, Numeric Rating Scale (NRS) average-itch, NRS-sleep, Eczema Area and Severity Index, Scoring AD and Rajka-Langeland scores. PHQ2 had significantly weaker correlations than PHQ9 with PROMIS SD, SRI and PIQ-MS, but similar correlations with other outcomes. PHQ9 and PHQ2 had good discriminant validity. Changes from baseline in PHQ9 and PHQ2 were poorly or weakly correlated with changes of the other outcome measures. There was no differential item functioning of PHQ items. PHQ9 showed good reliability (intraclass correlation coefficient range: 0.80-0.87). PHQ2 had slightly lower reliability (0.76-0.82). CONCLUSIONS: PHQ9 and PHQ2 had similar measurement properties, but PHQ2 was more feasible to assess depressive symptoms in AD.

Measurement Properties of 4 Patient-Reported Outcome Measures to Assess Sleep Disturbance in Adults With Atopic Dermatitis.

BACKGROUND: The ideal patient-reported outcome measure to assess sleep disturbance in atopic dermatitis (AD) has not been determined. OBJECTIVE: We sought to determine the measurement properties of the Patient-Reported Outcomes Measurement Information System (PROMIS) Itch Questionnaire Mood and Sleep (PIQ-MS), Sleep Disturbance (SD), Sleep-Related Impairment (SRI), and Epworth Sleepiness Scale (ESS) in adults with AD. METHODS: A prospective dermatology practice-based study was performed using questionnaires and evaluation by a dermatologist (n=611). RESULTS: PIQ-MS, PROMIS SD, SRI, and ESS had good convergent validity with intensity and frequency of sleep disturbance, Patient-Oriented Eczema Measure, Eczema Area and Severity Index, total and objective-Scoring AD, Numerical Rating Scale of worst-itch and average-itch, and Dermatology Life Quality Index. PIQ-MS had significantly better correlations with other severity measures than the other sleep measures (Fisher z-scores, P≤0.007). PIQ-MS, and to lesser extent PROMIS SD, PROMIS SRI and ESS had good discriminant validity. All four sleep assessments showed fair responsiveness to change of severity of sleep-disturbance, AD and itch. PIQ-MS had the best reliability. PIQ-MS, PROMIS SD, SRI and ESS showed good internal consistency and were feasible for use in clinical practice. CONCLUSIONS: PIQ-MS, followed by PROMIS SD, had the best construct validity and reliability in adult AD.

Circumscribed palmoplantar hypokeratosis: a case report and review of the literature.

We describe an 84-year-old man presenting with a solitary, well-circumscribed, chronic erosion of the sole. Histopathologic examination confirmed diagnosis of circumscribed palmoplantar hypokeratosis. Circumscribed palmoplantar hypokeratosis is a rare and benign condition of unknown etiology presenting as an erosion on the palms or soles. Although lesions are typically asymptomatic, the entity is important for dermatologists and providers in other specialties to recognize, especially considering a differential diagnosis that includes neoplasia.

Association of itch triggers with atopic dermatitis severity and course in adults.

BACKGROUND: Atopic dermatitis (AD) is associated with heterogeneous triggers of itch, which may affect AD course and severity. OBJECTIVE: To characterize the triggers of itch in adult AD. METHODS: This was a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n = 587). Thirteen itch triggers were assessed using the patient-reported outcomes measurement information system Itch-Triggers. RESULTS: Overall, 381 (64.9%) patients reported greater than or equal to 1 itch trigger in the past week and 212 (36.1%) reported greater than or equal to 3 itch triggers. The most commonly reported triggers were stress (35.4%), sweat (30.5%), weather change (24.7%), dry air (24.4%), and heat (24.0%). In multivariable Poisson regression models, the number of itch triggers was associated with more severe patient-reported global AD severity, Numeric Rating Scale worst itch, Patient-Oriented Eczema Measure, Scoring Atopic Dermatitis sleep, Numeric Rating Scale skin pain, Eczema Area and Severity Index, and objective Scoring Atopic Dermatitis. The seasonality of AD was associated with distinct itch triggers. In multivariable logistic regression models, the number of itch triggers was associated with less than or equal to 3 months of AD remission during the year, greater than or equal to 2 AD flares, and AD being worse during some seasons. Four patterns of itch triggers were identified using latent class analysis, each associated with different clinical characteristics. CONCLUSION: Itch triggers are common and affect the course of AD. Itch triggers are an important end point to assess in patients with AD.

Association of atopic dermatitis severity with cognitive function in adults.

BACKGROUND: Atopic dermatitis (AD) is associated with itch, pain, and sleep disturbance, all of which may contribute toward cognitive dysfunction. OBJECTIVE: To determine the relationship of AD severity and cognitive function in adults. METHODS: We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n = 386). Cognitive function was assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Cognitive Function 8-item Short-Form. RESULTS: At baseline, 118 patients (58.1%) reported ≥1 symptoms of cognitive dysfunction in the past 4 weeks, with 29 (14.3%) having mild, 11 (5.4%) moderate, and 4 (2.0%) severe PROMIS Cognitive Function T-scores. In propensity score-weighted regression models, PROMIS Cognitive Function T-scores were inversely associated with patient-reported global AD severity, Patient Oriented Eczema Measure (POEM), Numeric Rating Scale worst itch and skin pain, SCORing Atopic Dermatitis (SCORAD)-sleep, POEM-sleep, Eczema Area and Severity Index, and SCORAD, with stepwise decreases of cognitive function with worsening AD severity. At all AD severity levels, cognitive dysfunction was associated with increased Dermatology Life Quality Index and ItchyQoL scores. Changes from baseline in PROMIS Cognitive Function T-scores were weakly to moderately inversely correlated with changes from baseline in multiple AD outcomes. LIMITATIONS: Single-center study without non-AD controls. CONCLUSION: Cognitive dysfunction is associated with AD severity. Cognitive function may be an important end point for monitoring treatment response in AD.

Comparison of Patient-Oriented Eczema Measure and Patient-Oriented Scoring Atopic Dermatitis vs Eczema Area and Severity Index and other measures of atopic dermatitis: A validation study.

BACKGROUND: Little is known about the measurement properties of Patient-Oriented Scoring Atopic Dermatitis (PO-SCORAD) in adults with atopic dermatitis (AD). Even less is known about how PO-SCORAD performs compared with the Patient-Oriented Eczema Measure (POEM). OBJECTIVE: To examine the measurement properties of PO-SCORAD and compare them with those of POEM. METHODS: A prospective dermatology practice-based study of 291 patients with AD (age range, 18-72 years). RESULTS: PO-SCORAD and POEM were moderately correlated with each other (Spearman ρ = 0.56) and had weak-moderate correlations with the Numeric Rating Scale (NRS) worst itch and average itch, Dermatology Life Quality Index (DLQI), ItchyQOL, Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance (SD) and Sleep-Related Impairment (SRI), Patient Health Questionnaire-9 (PHQ-9), and Eczema Area and Severity Index (EASI) (P < .001). POEM had significantly stronger correlations with DLQI, ItchyQOL, and EASI than did PO-SCORAD. PO-SCORAD and POEM had fair discriminant validity. Changes from baseline in PO-SCORAD and POEM were moderately correlated with each other; were weakly to strongly correlated with NRS worst itch and average itch, DLQI, ItchyQOL, PROMIS SD, PROMIS SRI, PHQ-9, and EASI; and had good test-retest reliability. There was no differential item functioning of items or floor or ceiling effects for PO-SCORAD or POEM. The thresholds for meaningful change for PO-SCORAD and POEM were -15.5 and -5.0, respectively. Median completion times for PO-SCORAD and POEM were 3 minutes and 1 minute, respectively. CONCLUSION: PO-SCORAD and POEM had good construct and cross-cultural validity, reliability, and responsiveness in adults with AD and were feasible for use in clinical trials and practice. However, POEM had better measurement properties than PO-SCORAD.

Validation of four single-item patient-reported assessments of sleep in adult atopic dermatitis patients.

BACKGROUND: The optimal approaches for monitoring sleep disturbances in adults with atopic dermatitis (AD) is not established. Multiple patient-reported outcome measures for AD and itch have sleep-related items. These items have not been validated previously. OBJECTIVE: Assess the measurement properties of sleep-related items from the Patient-Oriented Eczema Measure (POEM), SCORing AD (SCORAD), 5-dimensions of itch (5D), and ItchyQOL in adults with AD. METHODS: We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n = 115). RESULTS: There was modest overlap and weak-moderate concordance of responses to the different assessments. Regarding concurrent validity, POEM-sleep, SCORAD-sleep, 5D-sleep, and ItchyQOL-sleep showed moderate correlations with each other. Regarding convergent validity, all items showed moderate correlation with total POEM, but weak correlations with Eczema Area and Severity Index (EASI), objective and total SCORAD, moderate to strong correlations with mean ItchyQOL and Dermatology Life Quality Index (DLQI), but poor or no significant correlation with Numeric Rating Scale (NRS) for worst or average itch. Regarding discriminant validity, all items showed significant and stepwise increases with increasing self-reported and physician-reported AD severity (Kruskal-Wallis, P < .01 for all). Floor effects were observed for POEM-sleep (n = 53, 46.1%), SCORAD-sleep (n = 28, 24.4%), 5D-sleep (n = 41, 35.7%), and ItchyQOL-sleep (n = 33, 28.7%); no ceiling effects were observed. Change in sleep-related item scores showed moderate strong correlations with change in POEM, 5Ditch, mean ItchyQOL, DLQI, objective and total SCORAD, and EASI, but inconsistent correlations with change of itch severity. CONCLUSION: Sleep-related items from POEM, SCORAD, 5D and ItchyQOL showed good validity and responsiveness to monitor sleep disturbances in adult AD patients.

Measurement properties of the Patient-Reported Outcomes Measurement Information System Itch Questionnaire item banks in adults with atopic dermatitis.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) Itch Questionnaire (PIQ) was recently developed. OBJECTIVE: To validate PIQ short forms in adults with AD. METHODS: Self-administered questionnaires and skin examinations were performed in 239 adults with atopic dermatitis (AD) in a dermatology practice setting. RESULTS: PIQ items had good content validity. PIQ item bank T-scores strongly correlated with each other, moderately correlated with numeric and verbal rating scales for worst or average itch and with itch frequency, moderately to strongly correlated with patient-oriented eczema measure, and weakly to moderately correlated with the Eczema Area and Severity Index and Objective-Scoring AD (Spearman correlations, P < .0001). There were significant and stepwise increases of T-scores for all item banks with increasing patient-reported global severity (Wilcoxon rank sum test, P < .0001). However, there was limited ability to discriminate between the lowest or highest 2 levels of AD or itch severity. Item banks showed good internal consistency (Cronbach α, 0.91-0.95). No differential item functioning was identified by age, sex, race/ethnicity, or educational level. There were floor effects for total scores, particularly in almost clear/mild AD or itch. LIMITATIONS: Single-center study. CONCLUSIONS: PIQ item bank short forms showed good content and construct validity and are feasible for potential use in clinical trials and practice.

Development, Validation, and Interpretation of the PROMIS Itch Questionnaire: A Patient-Reported Outcome Measure for the Quality of Life Impact of Itch.

Current patient-reported outcome measures for itch are limited and may not capture its full impact on health-related quality of life. We sought to develop, calibrate, and validate banks of questions assessing the health-related quality of life impact of itch as part of the Patient-Reported Outcomes Measurement Information System. A systematic process of literature review, content-expert review, qualitative research, testing in a sample of 600 adults, classical test theory methods, and item response theory analyses were applied. Exploratory and confirmatory factor analyses were followed by item response theory model and item fit analyses. Four itch-related item banks were developed: (i) general concerns, (ii) mood and sleep, (iii) clothing and physical activity, and (iv) scratching behavior. Item response theory and expert content review narrowed the item banks to 25, 18, 15, and 5 items, respectively. Validity of the item banks was supported by good convergent and discriminant validity with itch intensity, internal consistency, and no significant floor or ceiling effects. In conclusion, the Patient-Reported Outcomes Measurement Information System Itch Questionnaire banks have excellent measurement properties and efficiently and comprehensively assess the burden of itch.

A Comprehensive Conceptual Model of the Experience of Chronic Itch in Adults.

BACKGROUND: Itch is common and often debilitating. Itch is best assessed by self-report, often using patient-reported outcome measures (PROMs). Current PROMs for itch are limited and may not capture its full impact on quality of life (QOL). OBJECTIVE: We sought to develop a comprehensive conceptual model of itch to improve the understanding of itch for clinicians and to serve as a framework for development of efficient and valid PROMs of itch. METHODS: Using mixed methods, including systematic review (n = 491 articles), semi-structured interviews (n = 33 adults with chronic itch with multiple etiologies), and grounded theory using a constant comparative approach, we developed a conceptual model of itch. RESULTS: We found the Wilson and Cleary model to be a reasonable framework for organizing our findings. It includes five primary components: biological and physiological variables, symptom status, functional status, general health perceptions, and QOL. We propose a causal relationship beginning with the biological and physiological driving factors, with direct and indirect impacts of itch and its sequelae, including pain and sleep disturbance. These can impair function, lead to task avoidance, stigma, social life and relationship problems, emotional disturbances, and treatment burden. Together, these sequelae alter one's perceptions of health, QOL, and treatment response. CONCLUSIONS: Our conceptual model demonstrates the profound patient-burden of itch and identifies unmet needs in the evaluation and management of itch.

Phenotypical Differences of Childhood- and Adult-Onset Atopic Dermatitis.

BACKGROUND: Little is known about adult-onset atopic dermatitis (AD). OBJECTIVE: To determine the associations and clinical characteristics of adult-onset AD. METHODS: A prospective study of 356 adults with AD (age ≥18 years) was performed using standardized questionnaires and examination. AD severity was assessed using the Patient-Oriented Eczema Measure, Eczema Area and Severity Index, Scoring Atopic Dermatitis, body surface area, and numeric rating scale for itch and sleeplessness. Latent class analysis was used to determine dominant clinical phenotypes. Multivariate logistic regression was used to determine the relationship between adult-onset AD and distinct phenotypes. RESULTS: One hundred forty-nine adults (41.9%) reported onset of AD during adulthood, with 87 (24.4%) after the age of 50 years. Adult- versus childhood-onset AD was associated with birthplace outside the United States (χ2, P = .0008), but not sex, race/ethnicity, current smoking status, or alcohol consumption (P ≥ .11); and decreased personal history of asthma, hay fever, and food allergy and family history of asthma and food allergy (P ≤ .0001 for all). There was no significant difference in the Eczema Area and Severity Index, Scoring Atopic Dermatitis, body surface area, numeric rating scale for itch and sleeplessness, or Patient-Oriented Eczema Measure between adult- and childhood-onset AD (Mann-Whitney U test, P ≥ .10). Latent class analysis identified 3 classes: (1) high probability of flexural dermatitis and xerosis with intermediate to high probabilities of head, neck, and hand dermatitis; (2) high probability of flexural dermatitis and xerosis, but low probabilities of head, neck, and hand dermatitis; and (3) lower probability of flexural dermatitis, but the highest probabilities of virtually all other signs and symptoms. Adult-onset AD was significantly associated with class 1 (multivariate logistic regression; adjusted odds ratio, 5.54; 95% CI, 1.59-19.28) and class 3 (adjusted odds ratio, 14.03; 95% CI, 2.33-85.50). CONCLUSIONS: Self-reported adult-onset AD is common and has distinct phenotypes with lesional predilection for the hands and/or head/neck.

Burden of skin pain in atopic dermatitis.

BACKGROUND: Atopic dermatitis (AD) is associated with itch, skin inflammation and barrier disruption, and scratching, all of which may be associated with skin pain. OBJECTIVE: To characterize the patient burden of skin pain in AD. METHODS: We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist. RESULTS: Overall, 305 patients (age range, 13-97 years) were included in the study, with 564 encounters. The cohort included 195 females (63.9%) and 193 whites (63.7%). The mean (SD) age at enrollment was 42.3 (18.1) years, and the mean (SD) age of patient-reported AD onset was 29.6 (31.9) years. At baseline, 144 patients (42.7%) reported skin pain in the past week, with 42 (13.8%) reporting severe or very severe pain. Twenty-four (16.8%) thought the skin pain was part of their itch, 16 (11.2%) from scratching, and 77 (72.0%) from both. Patients with skin pain were more likely to describe their itch using terms that resembled neuropathic pain. Prevalence of skin pain was increased in patients with vs without excoriations (72.6% vs 57.6%; χ2 test P = .02) but not other morphologic characteristics. Skin pain severity was most strongly correlated with the Patient-Oriented Eczema Measure (Spearman ρ = 0.54), followed by ItchyQOL (ρ = 0.52), 5-dimensions of itch scale (ρ = 0.47), Dermatology Life Quality Index (ρ = 0.45), numeric rating scale for itch (ρ = 0.43) and sleep (ρ = 0.36), Patient Health Questionnaire 9 (ρ = 0.36), patient-reported global AD severity (ρ = 0.34), Eczema Area and Severity Index (ρ = 0.23), and objective Scoring AD index (ρ = 0.20) (P < .001 for all). Patients with both severe itch and pain vs those with only one or neither symptom being severe had significant increases in all these measures. CONCLUSION: Skin pain is a common and burdensome symptom in AD. Skin pain severity should be assessed with itch severity in AD patients and may be an important end point for monitoring treatment response.

CD8+ mycosis fungoides: A low-grade lymphoproliferative disorder.

BACKGROUND: The prognosis of the CD8+ subtype of mycosis fungoides (MF) is controversial. Although most authors believe that determining the presence of this cell surface antigen has no prognostic value, others have observed a more indolent course for CD8+ MF compared with CD4+ MF. OBJECTIVES: To review the cases of CD8+ MF in the pediatric and adult populations seen at our institution. METHODS: This is a retrospective review of clinical and pathologic data. Age, stage at presentation, and outcomes of patients at our institution were compared with those of 2 large MF cohorts that predominantly were CD4+ from the relevant literature. RESULTS: Sixty-seven patients of a median age of 46 years were included. A higher frequency of early-stage disease was observed for CD8+ MF patients at diagnosis when compared with other cohorts, including 31 (47%) patients with stage IA, 33 (50%) with stage IB, and 2 (3%) with stage IIB (P = .001, P = .001, and P = .002, respectively). With a median follow-up (5.5 years, range 0.2-21 years) similar to other cohorts, a higher rate of complete remission was achieved (65.5%, P = .001), and a lower rate of progression was observed (P = .004). LIMITATIONS: This is a retrospective review. CONCLUSION: Our experience with CD8+ MF confirms a more indolent course of disease with this MF variant. Our results warrant a conservative treatment approach limited to skin-directed therapies and observation in most patients.

The Role of Interleukins 4 and/or 13 in the Pathophysiology and Treatment of Atopic Dermatitis.

Moderate to severe atopic dermatitis (AD) can be debilitating and often requires use of systemic immunosuppressant therapy to achieve adequate disease control. There are currently no US Food and Drug Administration-approved systemic agents for the long-term treatment of AD. Recent insight has identified the T helper 2 cytokines, interleukins 4 and 13, as playing a major role in the pathogenesis of AD. There are multiple novel biologic agents in development that target interleukins 4 and/or 13 for the treatment of moderate to severe AD. The age of targeted biologics for AD has arrived.

Environmental risk factors and their role in the management of atopic dermatitis.

INTRODUCTION: The etiology of atopic dermatitis (AD) is multifactorial with interaction between genetics, immune and environmental factors. Areas covered: We review the role of prenatal exposures, irritants and pruritogens, pathogens, climate factors, including temperature, humidity, ultraviolet radiation, outdoor and indoor air pollutants, tobacco smoke exposure, water hardness, urban vs. rural living, diet, breastfeeding, probiotics and prebiotics on AD. Expert commentary: The increased global prevalence of AD cannot be attributed to genetics alone, suggesting that evolving environmental exposures may trigger and/or flare disease in predisposed individuals. There is a complex interplay between different environmental factors, including individual use of personal care products and exposure to climate, pollution, food and other exogenous factors. Understanding these complex risk factors is crucial to developing targeted interventions to prevent the disease in millions. Moreover, patients require counseling on optimal regimens for minimization of exposure to irritants and pruritogens and other harmful exposures.

Association of atopic dermatitis with smoking: A systematic review and meta-analysis.

BACKGROUND: Tobacco exposure might be a modifiable risk factor for atopic dermatitis (AD). OBJECTIVE: We examine the association between AD and exposure to tobacco smoke. METHODS: We performed a systematic review and meta-analysis of observational studies (n = 86) in MEDLINE, EMBASE, Scopus, and Cochrane Library (1823-2015). Quality of evidence was assessed using the Newcastle-Ottawa Scale (NOS). A meta-analysis was performed using random-effects models to estimate pooled odds ratios (OR). Subset analyses were performed for different ages (children, adult), regions, study designs (cross-sectional, longitudinal), study sizes (<5000, ≥5000), study quality (NOS score <6, ≥6), and amount of smoking (mild, extensive). RESULTS: A diagnosis of AD was associated with higher odds of active smoking (OR 1.87, 95% confidence interval 1.32-2.63) and exposure to passive smoke (OR 1.18, 95% confidence interval 1.01-1.38), but not maternal smoking during pregnancy (OR 1.06, 95% confidence interval 0.80-1.40). The association between active smoking and AD remained significant in children and adults, all continents studied, and study sizes, but all were cross-sectional designs and had NOS score 6 or greater. Passive smoke was associated with AD in children and adults, cross-sectional studies, South/Central American and African studies, study size less than 5000, and NOS score less than 6. LIMITATIONS: AD severity and distribution were not assessed. CONCLUSIONS: Active and passive exposure to smoke are associated with increased AD prevalence.