Early intervention in the management of atopic dermatitis.

This issue of the Asia Pacific Allergy (AP Allergy) features important reviews and articles on atopic dermatitis (AD). AD is the most common chronic inflammatory skin disease in children [1]. Although AD is a genetically transmitted disease, its full clinical expression is dependent on environmental exposures [2, 3]. Critical genes that predispose to AD include filaggrin mutations as well as genes that control allergic responses such as TSLP and IL-13, and innate immune responses that react to danger signals on initial contact between the patient and its environment [4].

Since AD often starts in infancy, the diagnosis and treatment of AD should focus on control of this common skin disease early in life. Most guidelines for the treatment of AD are written for physicians and subspecialists in allergy and dermatology. In the current issue of the AP Allergy, Lee et al. [5] have written a proposal on "Atopic Dermatitis Organizer (ADO) guidelines for children" targeting the general community involved in the management of AD including patients, parents, medical policy makers, educators as well as health care providers. It includes a comprehensive review of the epidemiologic characteristics of AD, its natural course, and an approach to the diagnosis and management of AD including the control of environmental triggers such as foods, inhalant allergens and infection as well as the appropriate use of anti-inflammatory therapy which has also been emphasized in other global guidelines and reviews [6, 7].

In this same issue of AP Allergy, Furue and colleagues have updated us with the current status of AD in Japan [8]. Interestingly, the prevalence of childhood AD varies according to geographic location in Japan, e.g. the prevalence of childhood AD is 12-13% in mainland Japan but only about 6% in children from Ishigaki Island, Okinawa. Assuming relative genetic homogeneity within Japan, this suggests that the environment plays an important role in clinical expression of AD. However, overcoming patient and family's behavior about AD are difficult hurdles in bringing best care to these individuals, e.g. "topical steroid phobia" is common in patients thereby leading to undertreatment of patients and persistent skin inflammation in AD.

Readers of this journal will also find several other interesting articles on AD. On January 28th-29th, 2011, an international group of AD investigators gathered in Jinan-gun, Korea to participate in the First West Pacific Allergy Forum on a "Better Environment for Atopic Dermatitis". During the Jinan Conference, there was a strong emphasis on the environment in contributing to the clinical phenotype of AD. In a hypothesis & experience article, Lee and coauthors [9] summarize their presentation at the Jinan Conference where they reported data supporting the role of indoor air quality in contributing to severity of AD. They found that severity of AD was reduced when patients were hospitalized in a low pollution hospital room suggesting that pollution, which has been on the rise in Korea, contributes to severity of AD.

In this issue, Munasir et al. [10] reports on the role of allergic risk and other factors that affect the occurrence of AD in the first 6 months of life in Indonesia. Fifty-seven percent of AD presented in the first month of age and immunologic changes could be detected in many of the patients. These findings suggest the importance of early intervention in AD. In a separate article from Thailand, Kulthanan and coauthors [11] describes the clinical features of extrinsic and intrinsic types of adult-onset AD. Extrinsic AD affected 87.5% of adult-onset AD. However both groups had similar severity of skin disease. Interestingly, elevated serum IgE levels was detected in only 37% of extrinsic AD. Positive skin prick test to food and inhalant allergens were more sensitive in detecting extrinsic AD supporting the importance of studying the role of specific allergens in these patients.

In summary, the inclusion of a theme on AD in this early edition of the AP Allergy is an important step in the evolution of this young journal as AD is often the first step in the atopic march. It also recognizes AD as part of a multi-organ disease. Early intervention in the treatment of allergic diseases are important initiatives to promote a decline in the prevalence of AD and allergy in the Asian-Pacific region. I look forward to seeing more papers on the important topic of AD published in future issues of AP Allergy.