Karin B. Fieten

High-altitude treatment in atopic and nonatopic patients with severe asthma

The beneficial effects of high-altitude treatment in asthma have been attributed to allergen avoidance. Recent evidence shows that this treatment also improves airway inflammation in nonallergic patients. We hypothesised that high-altitude treatment is clinically equally effective in patients with severe refractory asthma, with or without allergic sensitisation. In a prospective observational cohort study, 137 adults with severe refractory asthma (92 with allergic sensitisation), referred for high-altitude (1,600 m) treatment in Davos, Switzerland, were consecutively included. We measured asthma control (Asthma Control Questionnaire (ACQ)), asthma-related quality of life (Asthma-Related Quality of Life Questionnaire (AQLQ)), sino-nasal symptoms (Sino-Nasal Outcome Test (SNOT-20)), medication requirement, postbronchodilator (post-BD) forced expiratory volume in 1 s (FEV1), 6-min walking distance (6MWD), total immunoglobulin (Ig)E, blood eosinophils and exhaled nitric oxide fraction (FeNO) at admission and after 12 weeks. Sensitised and nonsensitised patients showed similar improvements in ACQ (-1.4 and -1.5, respectively; p=0.79), AQLQ (1.6 and 1.5, respectively; p=0.94), SNOT-20 (-0.7 and -0.5, respectively; p=0.18), post-BD FEV1 (6.1% and 5.8% pred, respectively; p=0.87), 6MWD (+125 m and +147 m, respectively; p=0.43) and oral steroids (40% versus 44%, respectively; p=0.51). Sensitised patients showed a larger decrease in total IgE, blood eosinophils and FeNO. High-altitude treatment improves clinical and functional parameters, and decreases oral corticosteroid requirement in patients with severe refractory asthma, irrespective of allergic sensitisation.

Alpine climate treatment of atopic dermatitis: a systematic review

Climate therapy has been used for decades in the treatment of atopic dermatitis (AD), but evidence of its effectiveness has not yet been assessed systematically. A systematic literature search in Medline, Embase, and the Cochrane library was performed to identify all original studies concerning alpine climate treatment. The risk of bias of individual studies was assessed following the Cochrane Handbook, and level of evidence was rated using GRADE guidelines. Fifteen observational studies were included concerning 40 148 patients. Four studies concerning 2670 patients presented follow‐up data over a period of 1 year. Disease activity decreased in the majority of patients during treatment (96% of n = 39 006) and 12‐month follow‐up (64% of n = 2670). Topical corticosteroid use could often be reduced or stopped during treatment (82% of n = 1178) and during 12‐month follow‐up (72% of n = 3008). Quality assessment showed serious study limitations, therefore resulting in a very low level of evidence for the described outcomes. Randomized controlled trials designed with a follow‐up period including well‐defined patient populations, detailed description and measurement of applied interventions during climate therapy and using validated outcomes including cost‐effectiveness parameters, are required to improve the evidence for alpine climate therapy as an effective treatment for patients with AD.

Effectiveness of alpine climate treatment for children with difficult to treat atopic dermatitis : results of a pragmatic randomized controlled trial (DAVOS trial)

Alpine climate treatment has historically been used in Europe to treat atopic dermatitis (AD), but no randomized trials have been conducted to provide evidence for its effectiveness.

Fecal Microbiome and Food Allergy in Pediatric Atopic Dermatitis: A Cross-Sectional Pilot Study

Background: Exposure to microbes may be important in the development of atopic disease. Atopic diseases have been associated with specific characteristics of the intestinal microbiome. The link between intestinal microbiota and food allergy has rarely been studied, and the gold standard for diagnosing food allergy (double-blind placebo-controlled food challenge [DBPCFC]) has seldom been used. We aimed to distinguish fecal microbial signatures for food allergy in children with atopic dermatitis (AD). Methods: Pediatric patients with AD, with and without food allergy, were included in this cross-sectional observational pilot study. AD was diagnosed according to the UK Working Party criteria. Food allergy was defined as a positive DBPCFC or a convincing clinical history, in combination with sensitization to the relevant food allergen. Fecal samples were analyzed using 16S rRNA microbial analysis. Microbial signature species, discriminating between the presence and absence food allergy, were selected by elastic net regression. Results: Eighty-two children with AD (39 girls) with a median age of 2.5 years, and 20 of whom were diagnosed with food allergy, provided fecal samples. Food allergy to peanut and cows milk was the most common. Six bacterial species from the fecal microbiome were identified, that, when combined, distinguished between children with and without food allergy: Bifidobacterium breve, Bifidobacterium pseudocatenulatum, Bifidobacterium adolescentis, Escherichia coli, Faecalibacterium prausnitzii, and Akkermansia muciniphila (AUC 0.83, sensitivity 0.77, specificity 0.80). Conclusions: In this pilot study, we identified a microbial signature in children with AD that discriminates between the absence and presence of food allergy. Future studies are needed to confirm our findings.

Predictors of treatment success in children with difficult to treat atopic dermatitis using a personalized integrative multidisciplinary (PIM) treatment programme

A 6‐week personalized integrative multidisciplinary treatment programme (PIM) was developed for children with difficult to treat AD who appeared unresponsive to treatment according to current guidelines.

Parental treatment management skills in paediatric atopic dermatitis

ciclosporin 150 mg/day was started, which was mildly effective. Psoriasis restricted to the nail is rare. In the present case, nail dystrophy was observed in all 20 nails, whereas no psoriasis lesion was observed in any area other than the nail. Histological examination revealed a number of mast cells below the nail epidermis, as well as intraepithelial mast cells, which were positive for toluidine blue. It is known that tryptaseand chymase-positive mast cells are increased in number in the upper dermis of psoriatic lesions at an early phase. Furthermore, upon activation, degranulated mast cells release various growth factors and mediators. However, there are only a few reports on epidermal mast cells in psoriasis. Using the Gomori–Giemsa stain, Green et al. examined epidermal mast cells in biopsy specimens from patients with neurodermatitis and prurigo, pseudoepitheliomatous hyperplasia (tuberculosis verrucosa cutis, blastomycosis, bromoderma), pemphigus, and urticaria pigmentosa. They suggested that the inflammatory conditions that show numerous dermal mast cells within an area of the chronic dermal inflammation and epidermal proliferation may allow the migration of mast cells into the epidermis. By contrast, there are no reports of intraepidermal mast cells in nail psoriasis to date. The possible mechanisms of mast cell invasion into the epidermis are related to mast cell-derived proteases. Tryptase can affect the basement membrane, because it degrades fibronectin and activates matrix metalloproteinase (MMP)-3, MMP-9, pro-urokinase, and gelatinase. Tryptase can modify the extracellular matrix and basement membrane, which subsequently allows mast cells to migrate into the epidermis. Mast cells may contribute to the pathogenesis of nail psoriasis by T-cell activation and angiogenesis, via mast cell-derived cytokines such as interferon-c and interleukin-17, because various inflammatory cytokines are expressed in psoriatic nails.

Treatment for moderate to severe atopic dermatitis in alpine and moderate maritime climates differentially affects helper T cells and memory B cells in children

Treatment of atopic dermatitis (AD) is focused on topical anti‐inflammatory therapy, epidermal barrier repair and trigger avoidance. Multidisciplinary treatment in both moderate maritime and alpine climates can successfully reduce disease activity in children with AD. However, it remains unclear whether abnormalities in B cell and T cell memory normalize and whether this differs between treatment strategies.

Legends of Allergy: Carla Bruijnzeel-Koomen

Professor Carla Bruijnzeel-Koomen was born on 1 November 1954 in Kerkrade as the youngest of 8 children. She studied medicine in Utrecht and decided to specialize in dermatology. In 1989 she successfully defended her PhD thesis cum laude on atopic dermatitis, the atopy patch test and IgE+ Langerhans cells, and then became head of the Immunodermatology department at the Swiss Institute of Allergy and Asthma Research in Davos, Switzerland. This article is protected by copyright. All rights reserved.