Atopic dermatitis in Indian children: The influence of lower socioeconomic status (2023)

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Article preview Clinics in Dermatology Abstract Introduction Section snippets Etiology Diagnosis and clinical features Atopic dermatitis and the eye Atopic dermatitis and growth Severity grading Differential diagnosis Impact Management Treatment measures Conclusions References (41) Complement Ther Med Biomed Pharmacother Clin Dermatol Atopic dermatitis: A cross-sectional (descriptive) study of 100 cases Indian J Dermatol Epidemiology and clinical pattern of atopic dermatitis in a north Indian pediatric population Pediatr Dermatol Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three J Allergy Clin Immunol Pattern of pediatric dermatoses in a referral center in South India Indian Pediatr A clinico-etiologic study of dermatoses in pediatric age group in tertiary health care center in south gujarat region Indian J Dermatol. Clinical pattern of infantile atopic eczema in Bihar Indian J Dermatol Venereol Leprol Clinico-epidemiologic profile and factors affecting severity of atopic dermatitis in north Indian children Indian J Dermatol Diagnostic features of atopic dermatitis Acta Derm Venereol Suppl (Stockh) Epidemiology and clinical pattern of atopic dermatitis in 100 children seen in a city hospital Indian J Dermatol Venereol Leprol Comparison between the severity of atopic dermatitis in Indian children born and brought up in UK and USA and that of Indian children born and brought up in India Indian J Dermatol Venereol Leprol Methicillin-resistant staphylococcus aureus colonization and disease severity in atopic dermatitis: A cross-sectional study from south India Indian J Dermatol Venereol Leprol Do helminth parasites protect against atopy and allergic disease? Clin Exp Allergy Skin prick test in patients with chronic allergic skin disorders Indian J Dermatol A study of allergen-specific IgE antibodies in Indian patients of atopic dermatitis Indian J Dermatol Venereol Leprol Immunologic response to parthenium hysterophorus in Indian patients with parthenium sensitive atopic dermatitis Immunol Investig Minor clinical features of atopic dermatitis. Evaluation of their diagnostic significance Dermatologica Frequency and significance of minor clinical features in various age-related subgroups of atopic dermatitis in children Pediatr Dermatol Cited by (3) An analysis of selected factors influencing the efficacy of psoriasis therapy Clinical aspects of atopic dermatitis of children in Brazzaville, Congo Recommended articles (6) FAQs Videos
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Clinics in Dermatology

Volume 36, Issue 5,

September–October 2018

, Pages 585-594

Author links open overlay panelRashmiSarkarMDPersonEnvelopeIshaNarangMD

(Video) Foods triggering eczema flare up | Help your child avoid the itch! - Dr. Udhay Sidhu

Abstract

Atopic dermatitis (AD) is a chronic inflammatory condition afflicting children and adults. In developing countries like India, the scenario is slightly different from its western counterparts, where the disease has been commonly described. Despite running a milder course, AD still has a significant negative impact on the quality of life. Environmental factors have a great influence on pathogenesis. While the diagnosis has remained clinical, variations in minor clinical features have been observed worldwide. Many indigenous and herbal agents are used for its treatment in India, in addition to conventional therapies. Treatment modalities in India emphasize less costly therapies and family education. This contribution reviews the epidemiologic issues and therapeutic differences in the Indian population with AD, highlighting important nuances in the care of the Indian patient.

Introduction

Atopic dermatitis (AD) is a chronic inflammatory condition that has interested pediatricians and dermatologist worldwide due to its rising prevalence and increasing morbidity.

Hospital based studies have indicated a variable incidence of AD in India ranging from 0.24%1 (0-18 years) to 0.42%2 (0-14 years) which is notably lower than that of the Western world. In the International Study of Asthma and Allergies in Childhood (ISAAC) Phase 3 prevalence of current eczema symptoms among the age group 6 to 7 years was lowest from India, that is 0.9% in Jodhpur compared with the highest 22.5% in Quito, Ecuador. Also, in age groups 13 to 14 years, lower prevalence rates (<5%) were found. Overall prevalence of AD in India was as low as 4.4% as opposed to a global total of 14.2%.3 India has varied climatic conditions owing to its vast extent and topography, but largely it is tropical; hence, there is a wide variation in its prevalence. AD is commonly seen and described in the northern part of India and less frequently in the South (0.01%).4Most of the northern and western parts have hot and dry weather, with wheat being the staple diet, while the southern areas are cooler and wet, with rice and seafood being commonly consumed. The relative variation can be attributed to this complex, poorly understood interplay between climate, dietary habits, and allergens.[4], [5]

The initial epidemiologic studies (Table 1) on AD in India showed a lower incidence of AD with a later age of onset, possibly explained by the protective effect of breastfeeding, longer weaning, and introduction of solid foods later in the diet that exposes the child to food allergies at a relatively older age. Seasonal flares have been attributed to allergens from flowers, pollens, and farming activities.6 Recently, there has been an increased incidence of AD credited to urbanization, greater atmospheric pollution, agricultural chemicals, decline in breastfeeding and earlier weaning, and food additives. Also, there is an increased awareness of the disease in both the general public and among doctors. The smaller family unit enhances greater awareness of children which leads to increased detection of AD cases.[2], [7] The better detection rate can also be attributed to the use of the Hanifin and Rajka Criteria,8 along with a growth of dermatology in the past few decades as a specialty in India.

Section snippets

Etiology

Among the various pathogenic factors, environmental factors have particular relevance in the pathogenesis of AD in India compared to hereditary and genetic factors. Most of the Indian studies demonstrate a low incidence of personal and family history of atopy.[2], [7], [9] Although the role of heredity is strongly established, no studies have been undertaken in India to evaluate these factors in light of the recent development of genes implicated in barrier function (ie, filaggrin) and those

Diagnosis and clinical features

A detailed history and a characteristic clinical picture will aid in establishing the diagnosis of AD. Both Western and Indian studies have shown variation in specificity and sensitivity in the minor clinical features proposed by Hanifin and Rajka.[16], [17] A statistical advantage for the Hanifin and Rajka Criteria over the UK Working Party’s Diagnostic Criteria has been found in Indian patients from the North.18

Indian studies demonstrate variability in significance of minor clinical features

Atopic dermatitis and the eye

The eye is less often involved in Indian atopic patients. In a study of 100 patients, only 43% of the patients had ocular involvement which was more common in men. Most of the Indian studies show involvement limited to only the eyelid with conjunctivitis; and none of the Indian studies showed keratoconus, Hertoghe sign, or anterior subcapsular cataract, which may be related to less severe disease. Many of these studies have included younger cohorts who do not necessarily develop complications

Atopic dermatitis and growth

Growth patterns were found to be lower in Indian patients with AD, especially severe AD. Mean values for height and head circumferences were found to be significantly lower in girls probably due to more severe disease in boys. The height was most compromised, with an existing tendency for catch up growth.23 In India, preferential care and treatment is given to boys in contrast to girls, and this could contribute to the difference in growth in addition to the severity of the disease. Also,

Severity grading

Because there is no gold standard measure of severity, the perception of severity will always vary between physicians and patients. In a study using Rajka and Langeland grading, 41.3%, 50%, and 3.7% had mild, moderate, and severe forms of AD, respectively, with mean severity scores of 3.5, 5.7, and 8.3. Patients with moderate AD had a positive personal history of atopy and a prolonged course. Overall, this study showed milder disease in Indian children from northern India.24 Milder disease in

Differential diagnosis

AD should always be differentiated from two entities: Scabies and seborrheic dermatitis, neither of which is mutually exclusive. In Indian patients, improper hygiene, low socioeconomic status, and overcrowding may lead to a higher prevalence of scabies (Figure 6). Further complications include poor nutrition, a high prevalence of infectious diseases, and immunodeficiency states like HIV/AIDS.

Impact

Children with AD in an Indian study had an increased number of psychologic disorders, despite the disease being milder than its western counterparts. More mothers of children with AD were submissive and overprotective which could contribute to a more dependent self-image and maintenance of the dermatitis in the children of these mothers. Overall, the mothers appeared well-adjusted socially possibly due to a stronger family system and social support, and a less severe form of disease. This

Management

An indispensable aspect in the management of AD is to spend adequate time with the parents explaining the nature of the disease and treatment expectations. The physician should explain and educate the parents about the application of topical preparations, the avoidance of exacerbating factors, and how to care for sensitive skin, including bathing and applying emollients.

In India, like other developing countries, there is a lack of awareness regarding AD among parents. The relapsing-remitting

Treatment measures

Topical corticosteroids are a first-line treatment. While an ointment may be the most effective preparation, in hot and humid weather, cream formulations are more useful in avoiding folliculitis. The efficacy, safety, and tolerability of tacrolimus ointment have been evaluated in Indian patients having moderate to severe AD. A statistically significant decrease in the modified Eczema Area Sensitivity Index (EASI) was found along with complete resolution to very good improvement in most of the

Conclusions

AD is on the rise in India with the mild to moderate type of AD being the most common. Environmental factors have been more commonly implicated and studied in the etiopathogenesis of AD. Due to resource-poor settings, there has been more stress on indigenous emollient practices and the use of topical steroids. Parental counseling regarding the disease, adequate immunization, and nutrition play an important contributory role in the overall management of AD.

References (41)

  • N.S. Al-WailiTopical application of natural honey, beeswax and olive oil mixture for atopic dermatitis or psoriasis: Partially controlled, single-blinded study

    Complement Ther Med

    (2003)

  • Z. Hussain et al.Phytotherapeutic potential of natural herbal medicines for the treatment of mild-to-severe atopic dermatitis: A review of human clinical studies

    Biomed Pharmacother

    (2017)

  • N.B. SilverbergSelected active naturals for atopic dermatitis: Atopic dermatitis part 1

    Clin Dermatol

    (2017)

  • V. Sehgal et al.

    Atopic dermatitis: A cross-sectional (descriptive) study of 100 cases

    (Video) Emerging treatments in atopic dermatitis (eczema) – webinar held 7 June 2022

    Indian J Dermatol

    (2015)

  • S. Dhar et al.

    Epidemiology and clinical pattern of atopic dermatitis in a north Indian pediatric population

    Pediatr Dermatol

    (1998)

  • J.A. Odhiambo et al.

    Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three

    J Allergy Clin Immunol

    (2009)

  • K. Karthikeyan et al.

    Pattern of pediatric dermatoses in a referral center in South India

    Indian Pediatr

    (2004)

  • S.A. Jawade et al.

    A clinico-etiologic study of dermatoses in pediatric age group in tertiary health care center in south gujarat region

    Indian J Dermatol.

    (2015)

  • P. Sinha

    Clinical pattern of infantile atopic eczema in Bihar

    Indian J Dermatol Venereol Leprol

    (1972)

  • R. Sarkar et al.

    Clinico-epidemiologic profile and factors affecting severity of atopic dermatitis in north Indian children

    Indian J Dermatol

    (2004)

  • J. Hanifin et al.

    Diagnostic features of atopic dermatitis

    Acta Derm Venereol Suppl (Stockh)

    (1980)

  • S. Dhar et al.

    Epidemiology and clinical pattern of atopic dermatitis in 100 children seen in a city hospital

    Indian J Dermatol Venereol Leprol

    (2002)

  • S. Dhar et al.

    Comparison between the severity of atopic dermatitis in Indian children born and brought up in UK and USA and that of Indian children born and brought up in India

    Indian J Dermatol Venereol Leprol

    (2003)

  • S. Jagadeesan et al.

    Methicillin-resistant staphylococcus aureus colonization and disease severity in atopic dermatitis: A cross-sectional study from south India

    Indian J Dermatol Venereol Leprol

    (2014)

  • C. Flohr et al.

    Do helminth parasites protect against atopy and allergic disease?

    Clin Exp Allergy

    (2009)

  • P. Bains et al.

    Skin prick test in patients with chronic allergic skin disorders

    Indian J Dermatol

    (2015)

  • V.K. Somani

    A study of allergen-specific IgE antibodies in Indian patients of atopic dermatitis

    Indian J Dermatol Venereol Leprol

    (2008)

  • S. Kumar et al.

    Immunologic response to parthenium hysterophorus in Indian patients with parthenium sensitive atopic dermatitis

    Immunol Investig

    (2012)

  • B. Mevorah et al.

    Minor clinical features of atopic dermatitis. Evaluation of their diagnostic significance

    Dermatologica

    (1988)

  • Kanwar A.J. Nagaraja et al.

    Frequency and significance of minor clinical features in various age-related subgroups of atopic dermatitis in children

    Pediatr Dermatol

    (1996)

    (Video) Using Biologics to Manage Moderate to Severe Atopic Dermatitis

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    • Research article

      Synergistic effect of platelet-rich plasma injections and scalp lifting in androgenetic alopecia

      Clinics in Dermatology, Volume 36, Issue 5, 2018, pp. 673-679

      Androgenetic alopecia (AGA) is a common hair loss disorder, especially in men and the elderly. In this study, we analyzed the therapeutic effects of platelet-rich plasma (PRP) injections and embedded sutures in patients with AGA. In each participant, we administered different treatments in one area of hair loss that was divided into four sections. Each section received one of the following treatments: No treatment, PRP injection, suture embedding, and combined PRP injection/suture-embedded areas. The thickness of the scalp, and scalp perfusion were measured using an ultrasound imaging system and Moor FLPI full-field laser perfusion imaging system, respectively. The diameters of the hair were measured using optical microscopy. Our results show that PRP injection treatments increased the diameter of the hair (P = 0.034), and the combined PRP injection/suture-embedded treatments had a significant effect on the thickness of the scalp (P = 0.002), the blood flow (P = 0.014) through the scalp, and the diameter of the hair (P= 0.013). This study has demonstrated that there is a synergistic effect between PRP injections and suture embedding for increasing the thickness and blood flow of the scalp, and diameter of the hair. Combined PRP injection/suture-embedded PRP injections might have therapeutic benefit for patients with AGA.

    • Father Damien de Veuster, or Saint Damien of Molokai (1840-1889), was one of the pioneers of the holistic approach to care provision for leprosy patients and contributed to the overcoming of the patients’ social stigmatization. He devoted his life to the lepers living in America’s only leper colony, on the Hawaiian island of Molokai, where people with leprosy were required to live under government-sanctioned medical quarantine. Father Damien gained practical skills in caring for the sick, eagerly learning wound cleansing, bandaging techniques, and drug administration from a nurse. Mahatma Gandhi said that Father Damien's work had inspired his own social campaigns in India.

    • Research article

      Atopic Dermatitis in Children

      The Journal of Allergy and Clinical Immunology: In Practice, Volume 2, Issue 4, 2014, pp. 388-395

      A 7-year-old girl presented with atopic dermatitis (AD) that did not respond to standard therapy. She was avoiding dairy, egg, and wheat in her diet because of a history of skin flares. Her weight gain was poor, and laboratory test results showed low iron and zinc levels. Over the previous 6 months, she had been prescribed numerous courses of antibiotics, but, despite this, she continued to have secondary skin infections as well as deep circumscribed erosions on her shins. She was awake much of the night because of scratching and displayed repetitive and habitual behavior. She also had troublesome allergic rhinoconjunctivitis with positive allergy testing results to house dust mite. Methicillin-resistant Staphylococcus aureus was isolated from her skin, which was successfully treated with appropriate antibiotics and flares controlled with topical antiseptics and better personal and caregiver hygiene. Although milk, egg, and wheat specific IgE were raised, these foods were successfully reintroduced back into her diet with improvement of her nutritional status and no flare of her AD. In view of her habitual behavior and family history of obsessive compulsive disorder, she underwent cognitive behavioral therapy, and her general well-being, sleep, and ulcers over her shins improved. Despite high house dust mite–specific IgE, house dust mite sublingual immunotherapy led to no additional improvement in her AD although it did improve her rhinitis. Although there may be no “quick fixes” in patients with AD, the clinician should be aware of antimicrobial, allergen, and educational and/or behavioral interventions, which may greatly improve eczema severity and the patient's well-being.

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      An assessment of the use of antihistamines in the management of atopic dermatitis

      Journal of the American Academy of Dermatology, Volume 79, Issue 1, 2018, pp. 92-96

      Antihistamines are often used to treat pruritus associated with atopic dermatitis (AD) despite lack of evidence for their efficacy. The American Academy of Dermatology does not recommend the general use of antihistamines in the management of AD, although the value of short-term sedating antihistamine use for insomnia secondary to itch is recognized.

      To assess the use of sedating and nonsedating antihistamines for AD in 2003-2012.

      The National Ambulatory Medical Care Survey provided data on physician visits in 2003-2012. Sedating and nonsedating antihistamine use was identified at visits for AD.

      There were 990,000 annual visits for AD. Antihistamines were prescribed for AD in a significant proportion of visits across physician specialties (16%-44%). Dermatologists and pediatricians primarily used sedating antihistamines (58%-70%), whereas the majority of family/general practitioners, internists, and other specialists prescribed nonsedating antihistamines for AD (55%-100%)

      We were limited by the accuracy of AD diagnosis and medication recording.

      Antihistamines are widely used for the treatment of AD. There is no high-level evidence to suggest that nonsedating antihistamines reduce itch in patients with AD or that sedating antihistamines provide benefit in controlling AD symptoms (except perhaps sleep and AD comorbidities, such as allergic rhinitis).

    • Research article

      Atopic dermatitis: Kids are not just little people

      Clinics in Dermatology, Volume 33, Issue 6, 2015, pp. 594-604

      The approach to children and adults with atopic dermatitis is similar. In both age groups, failure to respond to conventional therapy should prompt evaluation for complicating factors such as secondary infection and secondary ACD. Immunologic, metabolic, genetic, and nutritional disorders should be considered in the differential diagnosis of refractory pediatric atopic dermatitis. Cutaneous T cell lymphoma (CTCL), cutaneous drug reactions, other spongiotic dermatoses, psoriasis, dermatomycosis, and infestations should be considered in the differential of refractory atopic dermatitis in adults. Systemic therapies prescribed to both children and adults with severe atopic dermatitis include oral corticosteroids, cyclosporine, methotrexate, azathioprine, and mycophenolate mofetil.

    • Research article

      Illness perceptions and quality of life in families with child with atopic dermatitis

      Allergologia et Immunopathologia, Volume 48, Issue 6, 2020, pp. 603-611

      To assess the Quality of Life (QoL) of children with Atopic Dermatitis (AD) and their families and the impact of the mothers’ illness perceptions on the family QoL.

      Seventy-five children with AD (54 infants and 21 children) and their mothers participated in the study. The following questionnaires were administrated: 1. Brief Illness Perception Questionnaire (Brief IPQ); 2. Infant's Dermatitis Quality of Life Index (IDQOL); 3. Children's Dermatology Life Quality Index (CDLQI); 4. Dermatitis Family Impact Questionnaire (DFIQ) and 5. The Severity Scoring of Atopic Dermatitis (SCORAD).

      Atopic dermatitis had a moderate impact on the QoL of the infants (6.67±5.30), children (7.86±7.19) and their families (9.42±7.03). The DFIQ was associated with certain dimensions of the Brief IPQ, specifically, with Illness Identity (greater symptom burden) (r=0.615, p=0.000), beliefs about the Consequences of the illness (r=0.542, p=0.000), the Concerns (r=0.421, p=0.000) and the Emotional Representations (r=0.510, p=0.000). Correlation was demonstrated between IDQOL and DFIQ (r=0.662, p=0.000) and between CDLQI and DFIQ (r=0.832, p=0.000), and a weaker correlation between SCORAD and DFIQ (r=0.255, p=0.035). The chronicity of the AD showed negative association with DFIQ (p<0.001).

      The QoL of families with a child with AD is associated with the mother's illness perceptions about AD, the children's QoL and with both the severity and the chronicity of the disease. Therefore, clinicians should pay attention not only to the clinical characteristics of the children, but also to the parents’ beliefs and emotions, to improve the family QoL.

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    FAQs

    Are certain ethnicities more prone to eczema? ›

    The CDC reports that eczema affects around 11% of children overall. According to this study, of the 3 million children with eczema, 66% are white; 18% are black; and 16% are Hispanic.

    What cultural group is most affected by eczema? ›

    Eczema is a chronic, inflammatory skin condition that has a higher prevalence in some racial and ethnic groups than in others. In the United States, it is particularly common among Black children. “Eczema is more common and is often more severe in Black Americans compared with white Americans,” Dr. E.

    How common is atopic dermatitis in India? ›

    Prevalence of Atopic Dermatitis

    A study conducted among school-going children reported male to female ratio of 1:1.73 including 42.2% boys and 57.8% girls.

    What environmental factors cause atopic dermatitis? ›

    environmental factors or allergens – such as cold and dry weather, dampness, and more specific things such as house dust mites, pet fur, pollen and moulds. food allergies – such as allergies to cows' milk, eggs, peanuts, soya or wheat. certain materials worn next to the skin – such as wool and synthetic fabrics.

    What nationality has the most eczema? ›

    Eczema affects people of all races and ethnicities but appears to be more common in African Americans.

    Which country has the most eczema? ›

    AD prevalence rates varied widely from country to country around the world, as well as by age groups (see graphic). The highest rate in adults was observed in China. South Korea had the highest rates in both children and adolescents.

    Who gets eczema the most? ›

    Eczema affects around the same number of girls and boys. But experts have found that the condition is more common in women than it is in men. In one study, researchers found that 9.1% of men had eczema while 11.1% of women had the skin condition.

    Are Asians more likely to get eczema? ›

    Atopic dermatitis has a significant and increasing prevalence in both pediatric and adult Asian populations worldwide.

    What percentage of Black people have eczema? ›

    Although African American adults are slightly less likely to have eczema compared to people of other races, 20% of Black children have eczema, which is almost double the rate found in white, Asian, Native American, and Hispanic children.

    Can eczema be genetic? ›

    Eczema is probably caused by a combination of things that may include: Genetics. A major risk factor is having relatives who have or had eczema, asthma, or seasonal allergies. A large percentage of children with severe eczema will later develop asthma or other allergies.

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