Federica Bellini

The effect of component-resolved diagnosis on specific immunotherapy prescription in children with hay fever

BACKGROUND Sensitization to profilins and other cross-reacting molecules might hinder proper specific immunotherapy (SIT) prescription in polysensitized patients with pollen-related allergic rhinitis (AR). In these patients, component-resolved diagnosis (CRD) might modify SIT prescription by improving the identification of the disease-eliciting pollen sources. OBJECTIVES We sought to measure the effect of CRD on SIT prescription in children with pollen-related AR. METHODS Children (n = 651) with moderate-to-severe pollen-related AR were recruited between May 2009 and June 2011 in 16 Italian outpatient clinics. Skin prick test (SPT) reactivity to grass, cypress, olive, mugwort, pellitory, and/or Betulaceae pollen was considered clinically relevant if symptoms occurred during the corresponding peak pollen season. IgE sensitization to Phl p 1, Phl p 5, Bet v 1, Cup a 1, Art v 1, Ole e 1, Par j 2, and Phl p 12 (profilin) was measured by using ImmunoCAP. SIT prescription was modeled on SPT responses first and then remodeled considering also CRD according to GA(2)LEN-European Academy of Allergology and Clinical Immunology guidelines and the opinions of 14 pediatric allergists. RESULTS No IgE to the respective major allergens was detected in significant proportions of patients with supposed clinically relevant sensitization to mugwort (45/65 [69%]), Betulaceae (146/252 [60%]), pellitory (78/257 [30%]), olive (111/390 [28%]), cypress (28/184 [15%]), and grass (56/568 [10%]). IgE to profilins, polcalcins, or both could justify 173 (37%) of 464 of these SPT reactions. After CRD, the SPT-based decision on SIT prescription or composition was changed in 277 (42%) of 651 or 315 (48%) of 651 children according to the European or American approach, respectively, and in 305 (47%) of 651 children according to the opinion of the 14 local pediatric allergists. CONCLUSIONS In children with pollen-related AR, applying CRD leads to changes in a large proportion of SIT prescriptions as opposed to relying on clinical history and SPT alone. The hypothesis that CRD-guided prescription improves SIT efficacy deserves to be tested.

Atopic dermatitis : quality of life of young italian children and their families and correlation with severity score

The aim of this study was to determine the ways in which atopic dermatitis (AD) affects the lives of young Italian children and their families, in terms of quality of life, and correlate it with AD severity and the perception of severity as estimated by the family. The parents of 45 children aged 3–84 months affected by AD were asked to complete two validated questionnaires after clinical examination. The first questionnaire was about the childs quality of life (Infants’ Dermatitis Quality of Life Index); the second regarded the familys quality of life (Dermatitis Family Impact questionnaire). In a further question parents were asked to estimate the severity of the disease of the child. Childrens quality of life appeared slightly‐moderately altered (mean score 10.2) compared with the value of a control group (3.3), and itching, sleep problems and the influence of the disease on the childs mood were the cause of greatest discomfort for the child. Family quality of life appeared moderately altered (mean score 11) compared with the value of the control group (7.4). The greatest problem was the disturbed sleep of the family members. Other important problems were the economic cost for the management of the disease and the tiredness and irritability caused by the disease in parents. Analysis of the responses confirms the incorrect estimation of the severity of the disease perceived by the family. In our opinion, the two questionnaires may be useful in clinical practice to understand better the difficulties suffered by a family with a child affected by AD. They also provide data that may help to improve the clinical approach for the child and the family, and to assess the degree of under‐/overestimation of the disease by the family.

Pollen-induced allergic rhinitis in 1360 Italian children: comorbidities and determinants of severity.

Pollen‐induced allergic rhinoconjunctivitis (AR) is highly prevalent and rapidly evolving during childhood. General practitioners may not be fully aware of the nature and severity of symptoms experienced by patients and might underestimate the prevalence of moderate or severe disease. Thus, the relevance of early diagnosis and intervention may be overlooked.

Use of Textiles in Atopic Dermatitis

Atopic dermatitis (AD) is a chronic relapsing inflammatory skin disease which usually starts during the first years of life. In the management of AD, the correct approach requires a combination of multiple treatments to identify and eliminate trigger factors, and to improve the alteration of the skin barrier. In this article we try to explain the importance of skin care in the management of AD in relation to the use of textiles: they may be useful to improve disrupted skin but they are also a possible cause of triggering or worsening the lesions. Garments are in direct contact with the skin all day long, and for this reason it is important to carefully choose suitable fabrics in atopic subjects who have disrupted skin. Owing to their hygienic properties fabrics produced from natural fibres are preferential. Wool fibres are frequently used in human clothes but are irritant in direct contact with the skin. Wool fibre has frequently been shown to be irritant to the skin of atopic patients, and for this reason wool intolerance was included as a minor criterion in the diagnostic criteria of AD by Hanifin and Rajka in 1980. Cotton is the most commonly used textile for patients with AD; it has wide acceptability as clothing material because of its natural abundance and inherent properties like good folding endurance, better conduction of heat, easy dyeability and excellent moisture absorption. Silk fabrics help to maintain the body temperature by reducing the excessive sweating and moisture loss that can worsen xerosis. However, the type of silk fabric generally used for clothes is not particularly useful in the care and dressing of children with AD since it reduces transpiration and may cause discomfort when in direct contact with the skin. A new type of silk fabric made of transpiring and slightly elastic woven silk is now commercially available (Microair Dermasilk) and may be used for the skin care of children with AD. The presence of increased bacterial colonization has been demonstrated in patients with AD. Such colonization has been included in the group of trigger factors for eczema in AD. Silver products have recently been demonstrated to offer two advantages in the control of bacterial infections. Textiles may be used not only for clothes, but also to prevent dust mite sensitization in atopic patients. A marked clinical improvement of AD was observed in a group of adults and children with positive skin tests (not necessarily towards mites), after an intensive eradication programme for mite allergens. Skin treatment with acaricide and house dust mite control measures can decrease AD symptoms. Different textiles have various potential worsening links with allergies: e.g. clothing has been proposed as an additional source of exposure to mite and cat allergens. On the other hand, special textiles can be used to prevent dust mite sensitization.

Atopic dermatitis and the atopic march: what is new?

Objective. In this paper the authors review the management of atopic dermatitis (AD) and the association between AD and allergic respiratory diseases. Data Sources. PubMed databases, researching articles in the last 15 years. Results. Studies about atopic march are cross-sectional population studies at different ages. They show that the most important predisposing factor for atopy is a decrease of the filaggrins expression. Conclusions. The most modern theories seem to show that the most important factor which starts the atopic march is represented by an impaired epidermal barrier. It causes an increase in skin permeability to allergens that could induce sensitization even in the airways. The major predisposing factor is a primary inherited epithelial barrier defect resulting from filaggrin gene mutation, but other factors may play a role in this complex mechanism. Further studies are needed to focus on AD treatment and preventive strategies.

Vitamin D, allergies and asthma: focus on pediatric patients

In recent years, the interest of the scientific world towards vitamin D gradually increased, and several studies have been conducted to dissect its possible role in modulating the development/course of allergic diseases. Also, Vitamin D supplementation has been assessed as a beneficial approach for treating allergies in some, but not all studies. We reviewed herein the available and relevant literature concerning the possible links between Vitamin D, its supplementation and allergic diseases. A literature search was made independently by the Authors, identifying articles for a narrative review. As per literature, Vitamin D plays a key role in calcium and phosphate metabolism, and it is essential for bone health in infants, children and adolescents. However, there is presently insufficient evidence to support vitamin D supplementation for prevention or treatment of allergic diseases in infants, children and adolescents, concerning allergic rhinitis, asthma, food allergy and atopic dermatitis.

Cytokines Levels in Children Affected by Atopic and Nonatopic Eczema

Patients with atopic eczema present higher serum levels of total IgE and different pattern of cytokines, com- pared to nonatopic eczematous patients. This study aimed to evaluate serum levels of IL-2, IL-4, IL-5, IL-10, IFN� , TNF� in eczematous children in relation to atopic and nonatopic form. We enrolled 45 eczematous children and 12 controls. To- tal IgE and specific IgE against principal food and inhalant allergens were evaluated by UniCap1000 and levels of cytoki- nes by Cytometric Bead Array System. The geometric means of levels of IL-4 were higher in eczematous patients than controls (P=0.036). Serum levels of IL-10 and IFNwere higher in nonatopic eczematous children than in atopic eczema- tous patients and controls (P= 0.004, P= 0.003). Our data confirm that cytokines may play an important role in the patho- genesis of eczema: nonatopic eczema seems to be characterized by increased levels of IL-10 and IFNcompared to atopic form.

End point prick test: could this new test be used to predict the outcome of oral food challenge in children with cow's milk allergy?

BackgroundCows milk allergy (CMA) is the most frequent food allergy in childhood; the trend of CMA is often characterized by a progressive improvement to achieve tolerance in the first 4 to 5 years of life.It has been observed that specific IgE (sIgE) towards cows milk proteins decrease when the age increases.Although food allergy can be easily diagnosed, it is difficult to predict the outcome of the oral food challenge (OFC), that remains the gold standard in the diagnosis of food allergy, by allergometric tests.MethodsWe considered 44 children with CMA diagnosed through OFC who returned to our Allergy and Immunology Pediatric Department between January to December 2010 to evaluate the persistence of allergy or the achievement of tolerance.On the basis of the history, we performed both allergometric skin tests and OFC in children that were still following a milk-free diet, whereas only allergometric skin tests those that had already undergone spontaneous introduction of milk protein at home without presenting symptoms.ObjectiveThe aim of this study was to investigate the relationship between the persistence of CMA or the acquisition of tolerance and the results of the end point prick test (EPT).Results and DiscussionThe OFC with cows milk was performed on 30 children, 4 children were excluded because of a history of severe reactions to cows milk, and 10 because they had spontaneously already taken milk food derivates at home without problems. 16/30 (53%) children showed clinical reactions and the challenge was stopped, 14/30 (47%) did not have any reaction.Comparing the mean wheal diameter of every EPTs dilution between the group of allergic children and the tolerant ones, we obtained a significant difference (p < 0.05) for the first 4 dilutions.We have also calculated sensitivity (SE), specificity (SP), the positive predictive value (PPV) and the negative predictive value (NPV) for each EPT dilution.ConclusionsEPT is a safe and cheap test, easy to be executed and that could provide good prediction of the outcome of OFC; so it might be used to avoid OFC-induced anaphylaxis in children affected by CMA. It can also help avoiding dietetic restrictions in tolerant children who show sensitization towards cows milk proteins.

Mycosis fungoides following pityriasis lichenoides: An exceptional event or a potential evolution

To the Editor: We carefully read the article of Boccara et al. [1] recently published in Pediatric Blood & Cancer and think that the issue needs some comments. The authors report that 4/5 patients affected by mycosis fungoides (MF) had a pre-existing pityriasis lichenoides cronica (PLC). Based on this, they conclude that the association between MF and PLC is not fortuitous and PLC can represent a predisposing factor for MF or other cutaneous lympho-proliferative disorders. Accordingly, patients with PLC should be carefully followed because of the risk of lymphomatous transformation. Although we agree that follow-up is required in this setting, we do not believe that the evolution of PLC into MF is a frequent event. We looked for PLC cases observed at our clinic during the last 18 years. Thirty-eight examples were retrieved and all had pathology reviewed. The median age at diagnosis was 6 years and the mean follow-up 10 years, from the diagnosis. Only one patient (2.6%) developed MF (stage IA), while the remaining ones had a self-limiting disease. Our findings are in keeping with previous observations in the literature. In particular, Magro et al. [2] reported that only 2 patients developed MF among 46 followed for PLC. Ersoy-Evans et al. [3] reported that no transformation in their series including 124 PLC cases. This leads to conclude that PLC transformation into MF is rare observed in 3/208 reported cases. A possible bias of the report of Boccara et al. is the reason that the diagnosis of PLC was clinically made in four of five cases, with only one having undergone a biopsy. Thus, a question is whether or not the remaining four cases were MF. Alessandro Pileri, MD* Iria Neri, MD Beatrice Raone, MD Selena Ciabatti, MD Division of Dermatology Department of Internal Medicine Geriatrics and Nephrology University of Bologna, Bologna, Italy

Seroprevalence of antibodies against vaccine preventable diseases in internationally adopted children

We investigated whether differences in the immunization status of adoptees might be related to their region of origin. 151 internationally-adopted children (35.1% from Latin America; 32.4% from Eastern Europe and ex-Soviet Union countries; 21.2% from South-east Asia and 11.3% from Africa; mean age 4.5 years) were assessed with 45 days of arrival in Italy. 26.5% of patients had invalid, or no, documentation of previous immunizations. Valid records were available for 88.7% and 87.8% of children from Latin America and Eastern Europe respectively, but in only 43.8% and 41.2% of children from South-east Asia and Africa. 76/131 (58.0%) of children tested had protective anti-HBs antibody titres. Protective titres of anti-tetanus, -diphtheria and -pertussis antibodies were found in 59.7%, 80.4% and 41.5% of children, respectively. Antibodies against measles, mumps and rubella were found in 77.1%, 53.4% and 76.7% respectively among children older than 12 months. Considerable differences in immunization status exist between adoptees coming from different regions. Evaluation of their immune status is necessary so that they can be properly immunized as a result of differences in immunization schedule and concerns about vaccination records and effectiveness of vaccines received.