research article prevalence and clinical features of

Research ArticlePrevalence and Clinical Features of Atopic Dermatitis in China

Xin Wang12 Lin-Feng Li1 Da-yu Zhao2 and Yi-wei Shen2

1Department of Dermatology Beijing Friendship Hospital Capital Medical University Beijing 100050 China2Department of Dermatology Beijing Shijitan Hospital Capital Medical University Beijing 100038 China

Correspondence should be addressed to Lin-Feng Li zoonlisinacom

Received 10 July 2016 Revised 25 September 2016 Accepted 13 October 2016

Academic Editor Rachid Tazi-Ahnini

Copyright copy 2016 Xin Wang et al This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Background The epidemiology of atopic dermatitis (AD) in Chinese outpatients is yet to be clarified Objectives To investigatepopulation-based prevalence and clinical features of AD in Chinese outpatientsMethods A multicenter cross-sectional study wasconducted in outpatients with eczema or dermatitis from 39 tertiary hospitals in 15 provinces Results This study included 682patients diagnosed with AD with the mean age of 288 plusmn 201 years and the median course of 53 plusmn 69 years AD patients hadmore severe itching (304 versus 138 119901 lt 0001) and clinically suspected bacterial infection (217 versus 161 119901 lt 0001)than those of other types of dermatitis Older patients were more susceptible to have a history of flexion dermatitis (119901 lt 0001)bacterial infection (119901 = 0005) and severe itching (119901 lt 0001) Outpatients with clinically suspected bacterial infection had 353-fold increased risk of AD than those without it (119901 lt 0001) The morbidity rate of AD in the (20ndash25∘N) region is 286 times higherthan that in the (40ndash45∘N) region [OR (95 CI) 0352 (0241ndash0514) 119901 lt 0001] Conclusions AD is characterized by uniqueclinicaldemographic features Bacterial infection and latitude region may have an impact on the incidence of AD in China

1 Introduction

Atopic dermatitis (AD) is a type of dermatitis (inflammationof the skin) resulting in itchy red swollen and crackedskin As a common dermal condition the incidence of ADis increasing annually worldwide including China A recentsystematic review of 69 cross-sectional and cohort studieshas confirmed that AD is a worldwide phenomenon witha lifetime prevalence of gt20 in many countries [1] Theprevalence of childhood AD is ranging from 15 to 30 andfrom2 to 10of adult AD in industrialized countries [2] Aswe all know many studies have shown that the prevalence ofthis disease among children has increased substantially overrecent years [3] In China the prevalence of AD in studentsaged 6ndash20 years was only 07 in 2000 [4] however it hadreached up to 83 (95 CI 76ndash91) in children aged 3 to6 years in Shanghai in 2012 [5] Intriguingly few studies havepaid attention to AD patients of all ages despite the fact thatthe occurrence of AD among adults has been shown to sig-nificantly affect socioeconomic conditions in both Asian andWestern countries [6] A recent survey has investigated clin-ical features of adultadolescent (12 years and over) AD [7]

but the epidemiology of AD at all ages in China is yet to beelucidated Therefore the purpose of the current study is todetermine the actual prevalence and clinical features of ADat all ages in outpatients with dermatitis and eczema acrosslarge tertiary hospitals in China

2 Methods

21 Study Population This study has been approved byInstitutional Review Board (IRB) committee at each hospitalinvolved in this study Oral informed consent was acquiredfrom each participant before enrollment All procedureswere conducted according to the guidelines approved by theethics committee at each hospital Demographic and clinicalinformation was acquired from patients who were treated inthe respective hospitals from July 1 to September 30 2014Patients were diagnosed with AD in 39 tertiary hospitals of 15provinces and municipalities in mainland China includingGuangdong Chongqing Hunan Jiangxi Henan ZhejiangShanghai Hubei Jiangsu Anhui Shanxi Beijing TianjinShandong and Liaoning Province that generally representedmost regions of China

Hindawi Publishing CorporationBioMed Research InternationalVolume 2016 Article ID 2568301 6 pageshttpdxdoiorg10115520162568301

2 BioMed Research International

22 Diagnostic Criteria of AD All dermatologists involved inthis study have abundant experience in clinical diagnosis andtreatment for AD and have been trained in a standardizedmanner before the start of the project First each subjectwas inspected by a dermatologist independently Then aquestionnaire survey was conducted by dermatologists after10ndash15 minutesrsquo dermatological physical examination Alldiagnostic criteria mentioned in Williams diagnostic criteria[8] were integrated and recorded in detail the parents orguardians had filled the consent forms for children patientsAccording to the questionnaire and physiciansrsquo evaluation acomprehensive diagnosis of AD was made based on the goldstandard ldquoWilliams diagnostic criteriardquo after investigationMoreover all patients with other types of dermatitis andeczema seen in the same period by the same investigatorsserved as controls Other types of dermatitis and eczemasuch as irritant contact dermatitis (ICD) widespread eczemahand eczema allergic contact dermatitis (ACD) neuroder-matitis seborrheic dermatitis nummular eczema asteatoticeczema photo-contact dermatitis autosensitization eczemadyshidrotic eczema and stasis dermatitis were classifiedbased on International Classification of Diseases (ICD-10)[9] and diagnosed accordingly based on medical historyand clinical features No laboratorial test was performed fordermatologists to make the diagnosis

23 Data Collection All enrolled patients had completeda specific survey containing questionnaires regarding theirgeneral demographic characteristics disease duration sever-ity of itching lesionrsquos distribution type of skin lesion andmedical history Itch was evaluated and divided into 4 levels(i) no itching (ii) mild itching that interrupted neither dailyactivities nor sleep of the participant (iii) moderate itchingthat interrupted daily activities but not affected sleep and(iv) severe itching that affected both daily activities andsleep of the participant History of allergic disease dry skininfantile eczema and flexion dermatitis was also recordedAllergic diseases included asthma allergic rhinitis allergicconjunctivitis and AD Secondary bacterial infection wasclinically suspected if superficial pustules prudent exudationor yellow colored crust was detected

24 Statistical Analysis Statistical analyses were processedby SPSS software (version 170) Differences in age anddisease course between AD groups were analyzed by t-testsDifferences in age and disease course between AD amongdifferent age groups were analyzed by One-Way ANOVADifferences in gender all kinds of medical history andclinically suspected bacterial infection between AD groupswere analyzed by Chi-square tests Itching grade betweenAD groups was analyzed by Chi-square test Age genderand other significant factors were adjusted in Binary Logisticregression models for odds ratio (OR) and 95 confidenceinterval (CI) estimation All analyses were two-sided with asignificant level of 119901 lt 005

Table 1 Comparison of AD with other types of dermatitis

Variables AD(119873 = 682)

Other types ofdermatitis (119873 = 8076)

Median agelowast (years meanplusmn SD) 288 plusmn 201 367 plusmn 184

Median courselowast (yearsmean plusmn SD) 53 plusmn 69 28 plusmn 48

Gender (men) (119899 ) 368 (540) 4067 (504)History of allergic diseaselowastlowast(119899 ) 535 (784) 750 (93)

History of asthmalowastlowast (119899 ) 134 (196) 165 (20)History of allergicrhinitislowastlowast (119899 ) 184 (270) 289 (36)

History of allergicconjunctivitislowastlowast (119899 ) 167 (245) 223 (28)

History of ADlowastlowast (119899 ) 87 (128) 100 (12)History of dry skinlowastlowast (119899 ) 502 (736) 1388 (172)History of flexiondermatitislowastlowast (119899 ) 437 (641) 441 (55)

History of infantileeczemalowastlowast (119899 ) 285 (418) 534 (66)

Itchinglowastlowast

No (119899 ) 0 (00) 259 (32)Mild (119899 ) 119 (174) 2510 (311)Moderate (119899 ) 356 (522) 4189 (519)Severe (119899 ) 207 (304) 1118 (138)

Clinically suspectedbacterial infectionlowastlowast (119899 ) 148 (217) 1302 (161)lowast119901 lt 0001 119905-testlowastlowast119901 lt 0001 Chi-square test

3 Results

31 Demographic Characteristics of AD Data were collectedon a total of 8758 outpatients with dermatitis and eczemaOverall the prevalence of AD in outpatients was 78 (95CI 73ndash84) The comparison of demographic and clinicalcharacteristics between AD and other types of dermatitis issummarized in Table 1 The mean age of AD patients waslower than those of other types of dermatitis (288 plusmn 201versus 367 plusmn 184 years 119901 lt 0001) but median course wasmuch longer (53plusmn69 versus 28plusmn48 years119901 lt 0001)Thereis no difference in gender make-up (119901 = 0071)

32 Clinical Characteristics of AD 784 AD patients hadhistory of allergic disease which was significantly higherthan that of other types of dermatitis (93 119901 lt 0001)Furthermore history of dry skin flexion dermatitis andinfantile eczemaweremore frequent than those of other typesof dermatitis (736 versus 172 641 versus 55 and418 versus 66 119901 lt 0001) In terms of the severity ofitching theADpatientsmay bemore severe than that of othertypes of dermatitis patients (304 versus 138 119901 lt 0001)The clinically suspected bacterial infection in AD patientswas statistically significant higher than that of other types ofdermatitis patients (217 versus 161 119901 lt 0001)

BioMed Research International 3

441

374336

309 306 301267

236 227

169 152 150 144 136 133 13085 75 69

3425

103 86123

229186

258212

121 137

211

143114

74 9948 41 40

97

2738

ADOther types of dermatitis

05

101520253035404550

()

Vulv

ar

Criss

um

Axi

llalowast

Eyelowast

Earlowast

Ches

tlowastBa

cklowast

Scal

p

Han

dW

aist

lowast

Abdo

men

lowast

Thig

hlowastSh

anklowast

Face

lowast

Knee

lowast

Back

ofn

ecklowast

Butto

ckslowast

Food

Foss

acub

italis

lowast

Nec

kfro

ntlowast

Upp

erlim

blowast

Figure 1 Lesions distribution of AD and other types of dermatitis lowastThis body location was more involved in AD than other types ofdermatitis 119901 lt 005 Chi-square test This body location was more involved in other types of dermatitis than AD 119901 lt 005 Chi-square test

611573

545

457

383

280 277

186 164 157 150 129 111 98

610

294

484

323268

172221

146 124 137 12390 87 96


010203040506070

()

Nod

ule

Pustu

larlowast

Yello

w-c

rust

lowast

Plaq

uelowast

Blist

er

Eros

ionlowast

Lich

enifi

catio

nlowast

Exud

atelowast

Scal

elowast

Scra

tchlowast

Papu

lelowast

Xero

sislowast

Eryt

hem

a

Papu

love

sicle

lowast

Figure 2 Skin lesion types of AD and other types of dermatitis lowastThis skin lesion typewasmore common inAD than other types of dermatitis119901 lt 005 Chi-square test

The top five frequent sites involved in AD were fossacubitalis (441) knee (374) neck front (336) upperlimb (309) and face (306)Thehand (211 versus 169119901 lt 005) and foot (97 versus 69 119901 lt 005) were morefrequent sites involved in other types of dermatitis than ADand little variation on scalp crissum and vulvar betweenthem (143 versus 152 27 versus 34 and 38 versus25 resp 119901 gt 005) however other body locations weremuch less involved in other types of dermatitis (Figure 1)

Themost common skin lesion types of ADwere erythema(611) xerosis (573) papule (545) scratch (457) andscale (383) All skin lesion types weremore common inADthan other types of dermatitis especially in xerosis scratchand scale (573 versus 294 457 versus 323 and 383versus 268 resp 119901 lt 005) but not in erythema blisterand nodule (611 versus 610 157 versus 137 and 98versus 96 119901 gt 005) (Figure 2)

33 The Stratifying Analysis Based on Age Groups Threestages of AD are proposed including infantile AD (age lt 2

years) childhood AD (age 2ndash12) and adolescentadult AD(age gt 12 years) There were no significant statistical differ-ences between three groups with respect to their sex (119901 =058) history of allergic rhinitis (119901 = 087) dry skin (119901 =078) and AD (119901 = 018) And there were high at both endsbut low in the middle like a ldquoUrdquo shaped curve in the field ofhistory of allergic disease (119901 = 0005) asthma (119901 lt 0001)and allergic conjunctivitis (119901 = 0024) As AD patients getolder they have higher proportion of history of flexion der-matitis (119901 lt 0001) clinically suspected bacterial infection(119901 = 0005) and severe itching (119901 lt 0001) but lower pro-portion of history of infantile eczema (119901 lt 0001) (Table 2)

34 The Multivariable Logistic Regression Analysis of AD andRelated Factors In multivariable logistic regression analy-sis of AD and related factors the independent indicatorsincluded age disease duration latitude and bacterial infec-tion

It has indicated that the probability of developing ADincreases 22 and 36 respectively as age and disease


Table 2 Comparison of AD with different ages

Variables lt2 years(119873 = 63)

2ndash12 years(119873 = 135)

gt12 years(119873 = 484)

Median agelowast (yearsmean plusmn SD) 13 plusmn 07 73 plusmn 31 384 plusmn 157

Median courselowast(years mean plusmn SD) 07 plusmn 07 45 plusmn 35 61 plusmn 78

Gender (men) (119899 ) 38 (603) 72 (533) 258 (533)History of allergicdiseaselowastlowast (119899 ) 47 (746) 93 (689) 395 (816)

History of asthmalowastlowast(119899 ) 4 (63) 5 (37) 88 (82)

History of allergicrhinitis (119899 ) 12 (190) 29 (215) 106 (219)

History of allergicconjunctivitislowastlowast (119899 ) 11 (175) 15 (111) 104 (215)

History of AD (119899 ) 8 (127) 11 (81) 31 (64)History of dry skin (119899) 44 (698) 100 (741) 358 (74)

History of flexiondermatitislowastlowast (119899 ) 25 (397) 88 (652) 324 (669)

History of infantileeczemalowastlowast (119899 ) 60 (952) 117 (867) 108 (223)

Itchinglowastlowast

Mild (119899 ) 10 (159) 15 (111) 94 (194)Moderate (119899 ) 44 (698) 85 (63) 227 (469)Severe (119899 ) 9 (143) 35 (259) 163 (337)

Clinically suspectedbacterial infectionlowastlowast(119899 )

8 (127) 17 (126) 115 (238)

lowast119901 lt 0001 One-Way ANOVA testlowastlowast119901 lt 005 Chi-square test

duration increased by one yearTheoutpatientswith clinicallysuspected bacterial infection may have 3532-times increasedrisk of AD than those without it Thirty-nine hospitals weredivided into 5 groups based on their latitude the meansummer temperature increased as latitude decreased Themorbidity rate of AD in the lowest latitude region 20ndash25∘Nis 286 times higher than that in the highest latitude region40ndash45∘N (Table 3)

4 Discussion and Conclusion

AD is a global public health concern considering its greatinfluence on peoplersquos life and social economyThere have beennumerous epidemiological studies of AD using question-naires but very few have been performed by dermatologistsrsquophysical examinations owing to being time consuming andlabor cost [10] In order to guarantee uniformity of diagnosisa panel of experienced dermatologists was involved in phys-ical examination and detailed medical records The presentstudy has provided the first outpatient-based prevalence ofAD at all ages in dermatology clinics inmainlandChina withseveral interesting findings

Our research shows that the incidence of AD in outpa-tients (78) has been raised in recent years much higher

Table 3 Binary Logistic regression of AD and related factors

OR 95 CI pAge 1022 1009ndash1035 0001Disease duration 1036 1018ndash1053 lt0001Gender

Male 10 (ref)Female 0894 0758ndash1055 0183

Latitude20ndash25∘N 10 (ref)25ndash30∘N 0733 0511ndash1051 009130ndash35∘N 0821 0637ndash1059 012935ndash40∘N 0858 0655ndash1122 026340ndash45∘N 0352 0241ndash0514 lt0001

Clinically suspectedbacterial infection

No 10 (ref)Yes 3532 2779ndash4489 lt0001

Thirty-nine hospitals were divided into 5 groups based on their latitude (i)20∘011015840ndash25∘N Guangdong Province (ii) 25∘011015840ndash30∘N Chongqing Hunanand Jiangxi Provinces (iii) 30∘011015840ndash35∘N Henan Zhejiang Shanghai HubeiJiangsu Anhui and Shanxi Provinces (iv) 35∘011015840ndash40∘ Beijing Tianjin andShandong Province and (v) 40∘011015840ndash45∘N Liaoning Province

than that from our previous study (23 14599) [11] Thehigher prevalence and longer duration of AD compared withother types of dermatitis have indicated that more attentionshould be paid to this disease Although the occurrenceof AD may be associated with genetic factors [12 13] arecent markedly increased incidence rate is more likely tobe attributed to environmental factors [14ndash16] and changinglifestyles such as airwatersoil pollution an increase inaeroallergens frequent bathing and regular use of soap Inaddition the awareness of AD by dermatologists and patientsmay also contribute to this phenomenon In China thesymmetrical eczematous dermatitis tends to be diagnosedas eczema in the past decades indicating an overdiagnosedeczema and underdiagnosed AD [7] Until recent years webegan to pay attention toAD and have improved the accuracyof diagnosis

We have observed significant differences in terms ofmedical history between AD and other types of dermatitisIt has been widely accepted that AD is a systemic diseasenot only dermal manifestations AD in infancy is thoughtto contribute to the development of subsequent allergiesknown as atopic march [17] more than half of children withmoderate to severe ADwould develop allergic rhinitis andorasthma [18] Up to 784 of AD patients had a history ofallergic diseases indicating that dermatologists should focuson medical history when a patient has symmetrical eczema-tous dermatitis As AD patients were getting older a rdquoUrdquoshaped curve was observed between age groups regarding ahistory of allergic diseases asthma and allergic conjunctivitis(Table 2)This phenomenonmay confer the characteristics ofallergic diseases A study in Algeria has observed significantdifferences in the prevalence of asthma between different age


groups the highest in children aged lt16 and in the oldestgroup (gt54 years) [19] Further investigation is required toexplore mechanisms and significance of this phenomenon

The proportion of AD patients with a history of flexiondermatitis or severe itching was positively associated withage (Table 2) Undoubtedly scratching is one reason for thisobservation This means a coexistent relationship between ahistory of flexion dermatitis and severe itching which createsa vicious feedback loop of flexion dermatitis-severe itching-scratching

Our study has indicated that AD is prone to clinicallysuspected bacterial infection especially in older patientsA major cause for stratum corneum barrier disruptionin AD is attributed to loss-of-function mutations in FLGgene that encodes filaggrin a structural protein in ker-atinocytescorneocytes which allows outside-in penetrationof foreign antigens and subsequent sensitization [20]TheADpatients with barrier-disrupted skin are more susceptible tobacterial infection which in turn increases the severity ofAD In China bacterial culture was not usually performed inclinics This survey may have greater significance in clinicalpractice because how doctors define secondary bacterialinfection would affect the choice of antibiotics

Compared to other types of dermatitis AD has moreextensive body location involvement especially in fossacubitalis knee and neck front (441 versus 103 374versus 86 and 336 versus 123 resp Figure 1) Thereason for this difference is unclear probably related tothickness of cut-in and frequency of friction for these partsof the body have thinner stratum corneum (SC) and arevulnerable to friction with the limbs activity Converselythe body locations with thick SC like hand and foot arenot susceptible to suffer from AD which is characterizedby epidermal barrier dysfunction AD has more diverse skinlesion types than other types of dermatitis especially inxerosis scratch and scale (Figure 2)This has emphasized theimportance of using emollients in AD patients which is welltolerated and mainly in an attempt to restoring or replacingthe intrinsic andor externally induced abnormalities ofthe skin [21] Those disparities of AD and other types ofdermatitis are to some extent helpful to diagnosis in clinicalpractice

Multiple factorial analysis has suggested a strong trendtowards a decrease in the incidence of AD with an increasein latitude (Table 3) demonstrating dual roles of geographyand economy A large-scale prospective longitudinal cohortstudy has evaluated the effect of long-term weather patternson the severity of eczema symptoms in children and revealedthat geographic areas with increased temperature sun expo-sure (total UVA and UVB) and humidity were associatedwith poorly controlled disease [22] It is possible that warmand humid weather leads to enhanced sweating which hasan irritant effect on the skin [23 24] The economic andliving condition in southern China is becoming better thanthat in northern China including more fastidious hygienebetter living conditions such as air conditioners and higherstandards of medical care It is logistic to infer that economicconditionmay contribute to the higher rate ofAD in southernChina

Several limitations should be considered when interpret-ing our results (i) all of the 39 participating centers weretertiary referral hospitals located in 15 provincial capital orcentral cities and most patients visiting these hospitals werein a better financial condition andmedical insurance than theaverage people in China (ii) the sample size in the presentstudy was relatively small considering the total 13 billionChinese population and (iii) although we had demonstratedthat clinically suspected secondary bacterial infection wasquite reliable [25] bacterial culture is guaranteed to confirmthe current findings All these factors may lead to inevitableselection bias

In conclusion this research highlights atopic dermatitiswith unique clinical characteristics which has become a com-mon dermatologic disease in China Importantly secondarybacterial infection and latitude region may have a profoundimpact on the incidence of AD

Competing Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper

Acknowledgments

This research is supported by Dermatology CommitteeChinese Association of Integrative Medicine

References

[1] I A G Deckers S McLean S Linssen M Mommers C P vanSchayck andA Sheikh ldquoInvestigating international time trendsin the incidence and prevalence of atopic eczema 1990ndash2010 asystematic review of epidemiological studiesrdquo PLoS ONE vol 7no 7 Article ID e39803 2012

[2] T Bieber ldquoAtopic dermatitisrdquo The New England Journal ofMedicine vol 358 no 14 pp 1483ndash1494 2008

[3] M I Asher S Montefort B Bjorksten et al ldquoWorldwidetime trends in the prevalence of symptoms of asthma allergicrhinoconjunctivitis and eczema in childhood ISAAC phasesone and three repeat multicountry cross-sectional surveysrdquoTheLancet vol 368 no 9537 pp 733ndash743 2006

[4] H Gu Y Yan and C Chen ldquoEpidemiology of atopic dermatitisin 6ndash20 year-old population in Chinardquo Chinese Journal ofDermatology vol 6 no 1 pp 379ndash382 2000

[5] F Xu S Yan F Li et al ldquoPrevalence of childhood atopicdermatitis an urban and rural community-based study inShanghai Chinardquo PLoS ONE vol 7 no 5 Article ID e361742012

[6] KNishioka ldquoAtopic eczemaof adult type in JapanrdquoAustralasianJournal of Dermatology vol 37 no 1 pp S7ndashS9 1996

[7] P Liu Y Zhao Z L Mu Q J Lu L Zhang and X YaoldquoClinical features of adultadolescent atopic dermatitis andchinese criteria for atopic dermatitisrdquo Chinese Medical Journalvol 129 no 7 pp 757ndash762 2016

[8] H C Williams ldquoDiagnostic criteria for atopic dermatitisrdquo TheLancet vol 348 no 9038 pp 1391ndash1392 1996

[9] ldquoInternational statistical classification of diseases and relatedhealth problems-10th revisionrdquo World Health Organization2010


[10] H Saeki H Iizuka Y Mori et al ldquoPrevalence of atopic der-matitis in Japanese elementary schoolchildrenrdquo British Journalof Dermatology vol 152 no 1 pp 110ndash114 2005

[11] L-F Li G Liu and J Wang ldquoPrognosis of unclassified eczemaA Follow-Up StudyrdquoArchives of Dermatology vol 144 no 2 pp160ndash164 2008

[12] H Y Kim E Y Jang J H Sim et al ldquoEffects of family history onthe occurrence of atopic dermatitis in infantsrdquo Pediatric Allergyand Respiratory Disease vol 19 no 2 pp 106ndash114 2009

[13] H Bisgaard L B Halkjaeligr R Hinge et al ldquoRisk analysis ofearly childhood eczemardquo The Journal of Allergy and ClinicalImmunology vol 123 no 6 pp 1355ndash1360e5 2009

[14] I J Wang Y L Guo H J Weng et al ldquoEnvironmental riskfactors for early infantile atopic dermatitisrdquo Pediatric Allergyand Immunology vol 18 no 5 pp 441ndash447 2007

[15] Y Miyake Y Ohya K Tanaka et al ldquoHome environment andsuspected atopic eczema in Japanese infants the Osaka Mater-nal and Child Health Studyrdquo Pediatric Allergy and Immunologyvol 18 no 5 pp 425ndash432 2007

[16] B Sebok I Schneider and F Harangi ldquoPrimary care paedia-tricians in baranya countyrdquo Journal of the European Academy ofDermatology and Venereology vol 20 no 4 pp 418ndash422 2006

[17] H-M Lee I-H Park J-M Shin et al ldquoXXIV world allergycongress 2015 Seoul Korea 14ndash17 October (2015)rdquo WorldAllergy Organization Journal vol 9 no 1 p 1 2016

[18] H H Kong J Oh C Deming et al ldquoTemporal shifts in theskin microbiome associated with disease flares and treatmentin children with atopic dermatitisrdquo Genome Research vol 22no 5 pp 850ndash859 2012

[19] S Nafti S Taright M El Ftouh et al ldquoPrevalence of asthma inNorth Africa the Asthma Insights and Reality in the Maghreb(AIRMAG) studyrdquo Respiratory Medicine vol 103 no 2 pp S2ndashS11 2009

[20] A D Irvine W H I McLean and D Y M Leung ldquoFilaggrinmutations associated with skin and allergic diseasesrdquo The NewEngland Journal of Medicine vol 365 no 14 pp 1315ndash1327 2011

[21] M Boguniewicz and D Y M Leung ldquoRecent insights intoatopic dermatitis and implications for management of infec-tious complicationsrdquo Journal of Allergy and Clinical Immunol-ogy vol 125 no 1ndash3 pp 4ndash13 2010

[22] M R Sargen O Hoffstad and D J Margolis ldquoWarm humidand high sun exposure climates are associated with poorlycontrolled Eczema PEER (Pediatric Eczema Elective Registry)Cohort 2004ndash2012rdquo Journal of Investigative Dermatology vol134 no 1 pp 51ndash57 2014

[23] S M Langan J F Bourke P Silcocks and H C Williams ldquoAnexploratory prospective observational study of environmentalfactors exacerbating atopic eczema in childrenrdquo British Journalof Dermatology vol 154 no 5 pp 979ndash980 2006

[24] S M Langan P Silcocks and H C Williams ldquoWhat causesflares of eczema in childrenrdquo British Journal of Dermatologyvol 161 no 3 pp 640ndash646 2009

[25] L F Li and X Y Yuan ldquoDetection and analysis of bacteriaflora in the skin of the patients with non-atopic eczematousdermatitisrdquo Journal of Clinical Dermatology vol 32 no 2 pp74ndash75 2003

Submit your manuscripts athttpwwwhindawicom

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Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014


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Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


22 Diagnostic Criteria of AD All dermatologists involved inthis study have abundant experience in clinical diagnosis andtreatment for AD and have been trained in a standardizedmanner before the start of the project First each subjectwas inspected by a dermatologist independently Then aquestionnaire survey was conducted by dermatologists after10ndash15 minutesrsquo dermatological physical examination Alldiagnostic criteria mentioned in Williams diagnostic criteria[8] were integrated and recorded in detail the parents orguardians had filled the consent forms for children patientsAccording to the questionnaire and physiciansrsquo evaluation acomprehensive diagnosis of AD was made based on the goldstandard ldquoWilliams diagnostic criteriardquo after investigationMoreover all patients with other types of dermatitis andeczema seen in the same period by the same investigatorsserved as controls Other types of dermatitis and eczemasuch as irritant contact dermatitis (ICD) widespread eczemahand eczema allergic contact dermatitis (ACD) neuroder-matitis seborrheic dermatitis nummular eczema asteatoticeczema photo-contact dermatitis autosensitization eczemadyshidrotic eczema and stasis dermatitis were classifiedbased on International Classification of Diseases (ICD-10)[9] and diagnosed accordingly based on medical historyand clinical features No laboratorial test was performed fordermatologists to make the diagnosis

23 Data Collection All enrolled patients had completeda specific survey containing questionnaires regarding theirgeneral demographic characteristics disease duration sever-ity of itching lesionrsquos distribution type of skin lesion andmedical history Itch was evaluated and divided into 4 levels(i) no itching (ii) mild itching that interrupted neither dailyactivities nor sleep of the participant (iii) moderate itchingthat interrupted daily activities but not affected sleep and(iv) severe itching that affected both daily activities andsleep of the participant History of allergic disease dry skininfantile eczema and flexion dermatitis was also recordedAllergic diseases included asthma allergic rhinitis allergicconjunctivitis and AD Secondary bacterial infection wasclinically suspected if superficial pustules prudent exudationor yellow colored crust was detected

24 Statistical Analysis Statistical analyses were processedby SPSS software (version 170) Differences in age anddisease course between AD groups were analyzed by t-testsDifferences in age and disease course between AD amongdifferent age groups were analyzed by One-Way ANOVADifferences in gender all kinds of medical history andclinically suspected bacterial infection between AD groupswere analyzed by Chi-square tests Itching grade betweenAD groups was analyzed by Chi-square test Age genderand other significant factors were adjusted in Binary Logisticregression models for odds ratio (OR) and 95 confidenceinterval (CI) estimation All analyses were two-sided with asignificant level of 119901 lt 005

Table 1 Comparison of AD with other types of dermatitis

Variables AD(119873 = 682)

Other types ofdermatitis (119873 = 8076)

Median agelowast (years meanplusmn SD) 288 plusmn 201 367 plusmn 184

Median courselowast (yearsmean plusmn SD) 53 plusmn 69 28 plusmn 48

Gender (men) (119899 ) 368 (540) 4067 (504)History of allergic diseaselowastlowast(119899 ) 535 (784) 750 (93)

History of asthmalowastlowast (119899 ) 134 (196) 165 (20)History of allergicrhinitislowastlowast (119899 ) 184 (270) 289 (36)

History of allergicconjunctivitislowastlowast (119899 ) 167 (245) 223 (28)

History of ADlowastlowast (119899 ) 87 (128) 100 (12)History of dry skinlowastlowast (119899 ) 502 (736) 1388 (172)History of flexiondermatitislowastlowast (119899 ) 437 (641) 441 (55)

History of infantileeczemalowastlowast (119899 ) 285 (418) 534 (66)

Itchinglowastlowast

No (119899 ) 0 (00) 259 (32)Mild (119899 ) 119 (174) 2510 (311)Moderate (119899 ) 356 (522) 4189 (519)Severe (119899 ) 207 (304) 1118 (138)

Clinically suspectedbacterial infectionlowastlowast (119899 ) 148 (217) 1302 (161)lowast119901 lt 0001 119905-testlowastlowast119901 lt 0001 Chi-square test

3 Results

31 Demographic Characteristics of AD Data were collectedon a total of 8758 outpatients with dermatitis and eczemaOverall the prevalence of AD in outpatients was 78 (95CI 73ndash84) The comparison of demographic and clinicalcharacteristics between AD and other types of dermatitis issummarized in Table 1 The mean age of AD patients waslower than those of other types of dermatitis (288 plusmn 201versus 367 plusmn 184 years 119901 lt 0001) but median course wasmuch longer (53plusmn69 versus 28plusmn48 years119901 lt 0001)Thereis no difference in gender make-up (119901 = 0071)

32 Clinical Characteristics of AD 784 AD patients hadhistory of allergic disease which was significantly higherthan that of other types of dermatitis (93 119901 lt 0001)Furthermore history of dry skin flexion dermatitis andinfantile eczemaweremore frequent than those of other typesof dermatitis (736 versus 172 641 versus 55 and418 versus 66 119901 lt 0001) In terms of the severity ofitching theADpatientsmay bemore severe than that of othertypes of dermatitis patients (304 versus 138 119901 lt 0001)The clinically suspected bacterial infection in AD patientswas statistically significant higher than that of other types ofdermatitis patients (217 versus 161 119901 lt 0001)


441

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2ndash12 years(119873 = 135)

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8 (127) 17 (126) 115 (238)























Competing Interests


Acknowledgments


References
































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















441

374336

309 306 301267

236 227

169 152 150 144 136 133 13085 75 69

3425

103 86123

229186

258212

121 137

211

143114

74 9948 41 40

97

2738


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men

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186 164 157 150 129 111 98

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146 124 137 12390 87 96


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Nod

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love

sicle

lowast











2ndash12 years(119873 = 135)

gt12 years(119873 = 484)










Itchinglowastlowast



8 (127) 17 (126) 115 (238)























Competing Interests


Acknowledgments


References
































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



















2ndash12 years(119873 = 135)

gt12 years(119873 = 484)










Itchinglowastlowast



8 (127) 17 (126) 115 (238)























Competing Interests


Acknowledgments


References
































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
























Competing Interests


Acknowledgments


References
































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of






































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















research article prevalence and clinical features of

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