Key clinical point: Treatment with dupilumab vs cyclosporine or mycophenolate is not associated with an increased risk for arthralgia in patients with atopic dermatitis (AD).

Major finding: The pooled 180-day incidence rate of arthralgia for dupilumab vs cyclosporine or mycophenolate was 100.7 vs 65.4/1000 person-years (adjusted hazard ratio 1.27; 95% CI 0.93-1.72).

Study details: Findings are from a cohort study that included patients age < 50 years with AD who initiated treatment with either dupilumab (n = 4011) or cyclosporine/mycophenolate (n = 2220).

Disclosures: This study was supported by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, USA. Some authors declared serving as consultants or investigators for or receiving research grants from various sources.

Source: Schneeweiss MC et al. Joint pain in patients with atopic dermatitis receiving treatment with dupilumab: A US nation-wide cohort study. J Am Acad Dermatol. 2023 (Aug 18). doi: 10.1016/j.jaad.2023.08.025

Key clinical point: Treatment with dupilumab vs cyclosporine or mycophenolate is not associated with an increased risk for arthralgia in patients with atopic dermatitis (AD).

Major finding: The pooled 180-day incidence rate of arthralgia for dupilumab vs cyclosporine or mycophenolate was 100.7 vs 65.4/1000 person-years (adjusted hazard ratio 1.27; 95% CI 0.93-1.72).

Study details: Findings are from a cohort study that included patients age < 50 years with AD who initiated treatment with either dupilumab (n = 4011) or cyclosporine/mycophenolate (n = 2220).

Disclosures: This study was supported by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, USA. Some authors declared serving as consultants or investigators for or receiving research grants from various sources.

Source: Schneeweiss MC et al. Joint pain in patients with atopic dermatitis receiving treatment with dupilumab: A US nation-wide cohort study. J Am Acad Dermatol. 2023 (Aug 18). doi: 10.1016/j.jaad.2023.08.025

Key clinical point: Treatment with dupilumab vs cyclosporine or mycophenolate is not associated with an increased risk for arthralgia in patients with atopic dermatitis (AD).

Major finding: The pooled 180-day incidence rate of arthralgia for dupilumab vs cyclosporine or mycophenolate was 100.7 vs 65.4/1000 person-years (adjusted hazard ratio 1.27; 95% CI 0.93-1.72).

Study details: Findings are from a cohort study that included patients age < 50 years with AD who initiated treatment with either dupilumab (n = 4011) or cyclosporine/mycophenolate (n = 2220).

Disclosures: This study was supported by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, USA. Some authors declared serving as consultants or investigators for or receiving research grants from various sources.

Source: Schneeweiss MC et al. Joint pain in patients with atopic dermatitis receiving treatment with dupilumab: A US nation-wide cohort study. J Am Acad Dermatol. 2023 (Aug 18). doi: 10.1016/j.jaad.2023.08.025

Key clinical point: Patients with non-alcoholic fatty liver disease (NAFLD), especially younger patients, have a significantly decreased risk of developing atopic dermatitis (AD).

Major finding: The risk for AD was significantly lower among patients with NAFLD (adjusted hazard ratio [aHR] 0.93; P = .024), particularly those age ≤ 40 years (aHR 0.80; P < .001), compared with control individuals without NAFLD.

Study details: This retrospective cohort study included 307,743 patients with NAFLD and 1,230,972 matched control individuals without NAFLD.

Disclosures: This study was funded by the Chung Shan Medical University Hospital and China Medical University, Taiwan. The authors declared no conflicts of interest.

Source: Gau SY et al. The association between non-alcoholic fatty liver disease and atopic dermatitis: A population-based cohort study. Front Immunol. 2023;14:1171804 (Aug 18). doi: 10.3389/fimmu.2023.1171804

Key clinical point: Patients with non-alcoholic fatty liver disease (NAFLD), especially younger patients, have a significantly decreased risk of developing atopic dermatitis (AD).

Major finding: The risk for AD was significantly lower among patients with NAFLD (adjusted hazard ratio [aHR] 0.93; P = .024), particularly those age ≤ 40 years (aHR 0.80; P < .001), compared with control individuals without NAFLD.

Study details: This retrospective cohort study included 307,743 patients with NAFLD and 1,230,972 matched control individuals without NAFLD.

Disclosures: This study was funded by the Chung Shan Medical University Hospital and China Medical University, Taiwan. The authors declared no conflicts of interest.

Source: Gau SY et al. The association between non-alcoholic fatty liver disease and atopic dermatitis: A population-based cohort study. Front Immunol. 2023;14:1171804 (Aug 18). doi: 10.3389/fimmu.2023.1171804

Key clinical point: Patients with non-alcoholic fatty liver disease (NAFLD), especially younger patients, have a significantly decreased risk of developing atopic dermatitis (AD).

Major finding: The risk for AD was significantly lower among patients with NAFLD (adjusted hazard ratio [aHR] 0.93; P = .024), particularly those age ≤ 40 years (aHR 0.80; P < .001), compared with control individuals without NAFLD.

Study details: This retrospective cohort study included 307,743 patients with NAFLD and 1,230,972 matched control individuals without NAFLD.

Disclosures: This study was funded by the Chung Shan Medical University Hospital and China Medical University, Taiwan. The authors declared no conflicts of interest.

Source: Gau SY et al. The association between non-alcoholic fatty liver disease and atopic dermatitis: A population-based cohort study. Front Immunol. 2023;14:1171804 (Aug 18). doi: 10.3389/fimmu.2023.1171804

Key clinical point: Among patients with atopic dermatitis (AD), those with vs without a history of Staphylococcus aureus skin infections have significantly higher odds of having a history of eczema herpeticum (EH).

Major finding: Patients with AD and with vs without a history of S aureus skin infections had a 6.60-fold increased risk of having a history of EH (adjusted odds ratio 6.60; P = .002).

Study details: This multicenter, clinical registry study included 112 patients with AD and with (n = 56) or without (n = 56) a history of EH, matched by age and AD severity.

Disclosures: This study was supported partly by a National Eczema Association Engagement Research Grant. Several authors declared serving as consultants or investigator for or receiving grants, personal fees, or clinical trial support from various organizations.

Source: Moran MC et al. History of S. aureus skin infection significantly associates with history of eczema herpeticum in patients with atopic dermatitis. Dermatol Ther (Heidelb). 2023 (Aug 24). doi: 10.1007/s13555-023-00996-y

Key clinical point: Among patients with atopic dermatitis (AD), those with vs without a history of Staphylococcus aureus skin infections have significantly higher odds of having a history of eczema herpeticum (EH).

Major finding: Patients with AD and with vs without a history of S aureus skin infections had a 6.60-fold increased risk of having a history of EH (adjusted odds ratio 6.60; P = .002).

Study details: This multicenter, clinical registry study included 112 patients with AD and with (n = 56) or without (n = 56) a history of EH, matched by age and AD severity.

Disclosures: This study was supported partly by a National Eczema Association Engagement Research Grant. Several authors declared serving as consultants or investigator for or receiving grants, personal fees, or clinical trial support from various organizations.

Source: Moran MC et al. History of S. aureus skin infection significantly associates with history of eczema herpeticum in patients with atopic dermatitis. Dermatol Ther (Heidelb). 2023 (Aug 24). doi: 10.1007/s13555-023-00996-y

Key clinical point: Among patients with atopic dermatitis (AD), those with vs without a history of Staphylococcus aureus skin infections have significantly higher odds of having a history of eczema herpeticum (EH).

Major finding: Patients with AD and with vs without a history of S aureus skin infections had a 6.60-fold increased risk of having a history of EH (adjusted odds ratio 6.60; P = .002).

Study details: This multicenter, clinical registry study included 112 patients with AD and with (n = 56) or without (n = 56) a history of EH, matched by age and AD severity.

Disclosures: This study was supported partly by a National Eczema Association Engagement Research Grant. Several authors declared serving as consultants or investigator for or receiving grants, personal fees, or clinical trial support from various organizations.

Source: Moran MC et al. History of S. aureus skin infection significantly associates with history of eczema herpeticum in patients with atopic dermatitis. Dermatol Ther (Heidelb). 2023 (Aug 24). doi: 10.1007/s13555-023-00996-y

Key clinical point: Dupilumab rapidly improves the severity of atopic dermatitis (AD) symptoms and shows a favorable safety profile in children with moderate-to-severe AD.

Major finding: Dupilumab significantly reduced the mean Eczema Area and Severity Index (EASI) score at weeks 16, 24, and 52 (all P < .0001) and from weeks 16 to 24 (P < .01) and weeks 16 to 52 (P < .001). By week 52, 86.8% of patients had achieved a ≥ 75% improvement in the EASI score. No serious adverse events were observed, and none of the children discontinued treatment.

Study details: Findings are from a retrospective, observational, real-life study including 96 children (age 6-11 years) with moderate-to-severe AD inadequately controlled with conventional topical therapies who received dupilumab (300 mg on days 1 and 15 and 300 mg every 4 weeks).

Disclosures: This study did not receive any funding. Several authors reported receiving honoraria, travel support, or personal fees from or serving as consultants, investigators, speakers, or advisory board members for or having other ties with various sources.

Source: Patruno C et al. A 52-week multicenter retrospective real-world study on effectiveness and safety of dupilumab in children with atopic dermatitis aged from 6 to 11 years. J Dermatolog Treat. 2023;34:2246602 (Aug 14). doi: 10.1080/09546634.2023.2246602

Key clinical point: Dupilumab rapidly improves the severity of atopic dermatitis (AD) symptoms and shows a favorable safety profile in children with moderate-to-severe AD.

Major finding: Dupilumab significantly reduced the mean Eczema Area and Severity Index (EASI) score at weeks 16, 24, and 52 (all P < .0001) and from weeks 16 to 24 (P < .01) and weeks 16 to 52 (P < .001). By week 52, 86.8% of patients had achieved a ≥ 75% improvement in the EASI score. No serious adverse events were observed, and none of the children discontinued treatment.

Study details: Findings are from a retrospective, observational, real-life study including 96 children (age 6-11 years) with moderate-to-severe AD inadequately controlled with conventional topical therapies who received dupilumab (300 mg on days 1 and 15 and 300 mg every 4 weeks).

Disclosures: This study did not receive any funding. Several authors reported receiving honoraria, travel support, or personal fees from or serving as consultants, investigators, speakers, or advisory board members for or having other ties with various sources.

Source: Patruno C et al. A 52-week multicenter retrospective real-world study on effectiveness and safety of dupilumab in children with atopic dermatitis aged from 6 to 11 years. J Dermatolog Treat. 2023;34:2246602 (Aug 14). doi: 10.1080/09546634.2023.2246602

Key clinical point: Dupilumab rapidly improves the severity of atopic dermatitis (AD) symptoms and shows a favorable safety profile in children with moderate-to-severe AD.

Major finding: Dupilumab significantly reduced the mean Eczema Area and Severity Index (EASI) score at weeks 16, 24, and 52 (all P < .0001) and from weeks 16 to 24 (P < .01) and weeks 16 to 52 (P < .001). By week 52, 86.8% of patients had achieved a ≥ 75% improvement in the EASI score. No serious adverse events were observed, and none of the children discontinued treatment.

Study details: Findings are from a retrospective, observational, real-life study including 96 children (age 6-11 years) with moderate-to-severe AD inadequately controlled with conventional topical therapies who received dupilumab (300 mg on days 1 and 15 and 300 mg every 4 weeks).

Disclosures: This study did not receive any funding. Several authors reported receiving honoraria, travel support, or personal fees from or serving as consultants, investigators, speakers, or advisory board members for or having other ties with various sources.

Source: Patruno C et al. A 52-week multicenter retrospective real-world study on effectiveness and safety of dupilumab in children with atopic dermatitis aged from 6 to 11 years. J Dermatolog Treat. 2023;34:2246602 (Aug 14). doi: 10.1080/09546634.2023.2246602

Key clinical point: Severe atopic dermatitis (AD) is associated with higher risks for venous thromboembolism and cardiovascular diseases in both children and adults.

Major finding: Children with severe AD vs those without AD had a significantly increased risk (adjusted hazard ratio; 95% CI) for cerebrovascular accidents (2.43; 1.13-5.22), diabetes (1.46; 1.06-2.01), and deep vein thrombosis (DVT; 2.13; 1.17-3.87). Among adults, the severe AD vs non-AD group had a significantly higher risk for cerebrovascular accidents (1.21; 1.13-1.30), diabetes (1.15; 1.09-1.22), dyslipidemia (1.11; 1.06-1.17), myocardial infarction (1.27; 1.15-1.39), DVT (1.64; 1.49-1.82), and pulmonary embolism (1.39; 1.21-1.60).

Study details: This population-based cohort study included 409,431 children (age < 18 years) and 625,083 adults with AD who were matched with 1,809,029 children and 2,678,888 adults without AD, respectively.

Disclosures: This study was supported by a contract from Pfizer, Inc. Some authors declared serving as consultants for or receiving research grants, honoraria, or consulting fees from various sources, including Pfizer. AR Lemeshow declared being an employee of Pfizer, Inc.

Source: Wan J, Chiesa Fuxench  ZC, et al. Incidence of cardiovascular disease and venous thromboembolism in patients with atopic dermatitis. J Allergy Clin Immunol Pract. 2023 (Aug 10). doi: 10.1016/j.jaip.2023.08.007

Key clinical point: Severe atopic dermatitis (AD) is associated with higher risks for venous thromboembolism and cardiovascular diseases in both children and adults.

Major finding: Children with severe AD vs those without AD had a significantly increased risk (adjusted hazard ratio; 95% CI) for cerebrovascular accidents (2.43; 1.13-5.22), diabetes (1.46; 1.06-2.01), and deep vein thrombosis (DVT; 2.13; 1.17-3.87). Among adults, the severe AD vs non-AD group had a significantly higher risk for cerebrovascular accidents (1.21; 1.13-1.30), diabetes (1.15; 1.09-1.22), dyslipidemia (1.11; 1.06-1.17), myocardial infarction (1.27; 1.15-1.39), DVT (1.64; 1.49-1.82), and pulmonary embolism (1.39; 1.21-1.60).

Study details: This population-based cohort study included 409,431 children (age < 18 years) and 625,083 adults with AD who were matched with 1,809,029 children and 2,678,888 adults without AD, respectively.

Disclosures: This study was supported by a contract from Pfizer, Inc. Some authors declared serving as consultants for or receiving research grants, honoraria, or consulting fees from various sources, including Pfizer. AR Lemeshow declared being an employee of Pfizer, Inc.

Source: Wan J, Chiesa Fuxench  ZC, et al. Incidence of cardiovascular disease and venous thromboembolism in patients with atopic dermatitis. J Allergy Clin Immunol Pract. 2023 (Aug 10). doi: 10.1016/j.jaip.2023.08.007

Key clinical point: Severe atopic dermatitis (AD) is associated with higher risks for venous thromboembolism and cardiovascular diseases in both children and adults.

Major finding: Children with severe AD vs those without AD had a significantly increased risk (adjusted hazard ratio; 95% CI) for cerebrovascular accidents (2.43; 1.13-5.22), diabetes (1.46; 1.06-2.01), and deep vein thrombosis (DVT; 2.13; 1.17-3.87). Among adults, the severe AD vs non-AD group had a significantly higher risk for cerebrovascular accidents (1.21; 1.13-1.30), diabetes (1.15; 1.09-1.22), dyslipidemia (1.11; 1.06-1.17), myocardial infarction (1.27; 1.15-1.39), DVT (1.64; 1.49-1.82), and pulmonary embolism (1.39; 1.21-1.60).

Study details: This population-based cohort study included 409,431 children (age < 18 years) and 625,083 adults with AD who were matched with 1,809,029 children and 2,678,888 adults without AD, respectively.

Disclosures: This study was supported by a contract from Pfizer, Inc. Some authors declared serving as consultants for or receiving research grants, honoraria, or consulting fees from various sources, including Pfizer. AR Lemeshow declared being an employee of Pfizer, Inc.

Source: Wan J, Chiesa Fuxench  ZC, et al. Incidence of cardiovascular disease and venous thromboembolism in patients with atopic dermatitis. J Allergy Clin Immunol Pract. 2023 (Aug 10). doi: 10.1016/j.jaip.2023.08.007

Key clinical point: Adults with newly diagnosed atopic dermatitis (AD) have a 44% increased risk of subsequently developing type 2 diabetes (T2D).

Major finding: The risk for new-onset T2D was significantly higher in adults with newly diagnosed AD vs control individuals without AD (adjusted hazard ratio 1.44; P < .001), with the risk being significantly greater in both men and women with AD (both P < .001).

Study details: Findings are from a retrospective cohort study including 36,692 adult patients with AD and 36,692 matched control individuals who had never been diagnosed with AD.

Disclosures: This study was supported by the National Research Foundation of Korea funded by the Ministry of Education, Science, and Technology and others. The authors declared no conflicts of interest.

Source: Won Lee S et al. Risk of type 2 diabetes mellitus in adult patients with atopic dermatitis. Diabetes Res Clin Pract. 2023;110883 (Aug 16). doi: 10.1016/j.diabres.2023.110883

Key clinical point: Adults with newly diagnosed atopic dermatitis (AD) have a 44% increased risk of subsequently developing type 2 diabetes (T2D).

Major finding: The risk for new-onset T2D was significantly higher in adults with newly diagnosed AD vs control individuals without AD (adjusted hazard ratio 1.44; P < .001), with the risk being significantly greater in both men and women with AD (both P < .001).

Study details: Findings are from a retrospective cohort study including 36,692 adult patients with AD and 36,692 matched control individuals who had never been diagnosed with AD.

Disclosures: This study was supported by the National Research Foundation of Korea funded by the Ministry of Education, Science, and Technology and others. The authors declared no conflicts of interest.

Source: Won Lee S et al. Risk of type 2 diabetes mellitus in adult patients with atopic dermatitis. Diabetes Res Clin Pract. 2023;110883 (Aug 16). doi: 10.1016/j.diabres.2023.110883

Key clinical point: Adults with newly diagnosed atopic dermatitis (AD) have a 44% increased risk of subsequently developing type 2 diabetes (T2D).

Major finding: The risk for new-onset T2D was significantly higher in adults with newly diagnosed AD vs control individuals without AD (adjusted hazard ratio 1.44; P < .001), with the risk being significantly greater in both men and women with AD (both P < .001).

Study details: Findings are from a retrospective cohort study including 36,692 adult patients with AD and 36,692 matched control individuals who had never been diagnosed with AD.

Disclosures: This study was supported by the National Research Foundation of Korea funded by the Ministry of Education, Science, and Technology and others. The authors declared no conflicts of interest.

Source: Won Lee S et al. Risk of type 2 diabetes mellitus in adult patients with atopic dermatitis. Diabetes Res Clin Pract. 2023;110883 (Aug 16). doi: 10.1016/j.diabres.2023.110883

The years go by, and nothing much changes: The first 2 weeks of the new school year have brought with them a rise in emergency department (ED) admissions for asthma in patients under age 15 years. A more relaxed approach to maintenance therapy for the condition over the summer holidays, exposure to allergens at school, and the surge in viral respiratory infections that accompanies the return to group settings explain this trend, which can be foreseen.

As soon as September begins, asthma cases increase rapidly in children. According to Public Health France, which has just relaunched its epidemiological monitoring, these cases reach their peak around 2 weeks after the start of the new term.

In its first weekly review on Aug. 22, 2023, the authority reported a slight uptick in cases in its Indian Ocean overseas departments, and the calm before the storm in mainland France.

Last year, between weeks 35 and 36, the increases were 82% for SOS Médecins (the French home doctor visit service), 169% for EDs, and 33% for hospital admissions.

These data are similar to the figures obtained over the past 3 years. The authors of this monitoring, using the SurSaUD system, France’s program for monitoring emergency cases and deaths, attribute these increases to the surge in viral respiratory infections seen after the return to group settings after the school summer holidays.

Indeed, viral-induced exacerbations are mostly caused by rhinoviruses, which circulate throughout the year, but more so during the autumn and winter months. These are probably the main culprits behind the epidemics seen once schools have reopened. Yet relaxation of maintenance asthma treatment (inhaled corticosteroids alone or in combination with long-acting bronchodilators) during the summer holidays also plays a significant role in this yearly recurrence.
 

Compliance ends with school

Flore Amat, MD, PhD, pediatric respiratory and allergy specialist and coordinating doctor at the Zephyr asthma clinic (Robert-Debré Hospital, Paris Public Hospitals) acknowledged, “The summer holidays are often a time when compliance with maintenance therapy is relaxed.” Aware of this fact, doctors prefer to strike a deal with their young patients. “For some of our young and teenage asthma patients, we support their relaxed approach to medication during the summer holidays,” she admitted. “In July and August, there are fewer viruses circulating, and the weather is often dry, which limits the risk of an asthma attack, meaning we can ease off the maintenance therapy, or even stop taking it altogether. We tell parents and children to start taking them again 2 weeks before school starts; 2 weeks being the minimum time needed for inhaled corticosteroids to start taking effect again.” Unsurprisingly, some forget to do so or simply don’t.

Two other things contribute to the rise in asthma attacks in children in early September. The first relates to exposure to allergens, especially dust mites. “Ninety percent of asthmatic children are allergic,” said Frédéric le Guillou, MD, respiratory medicine specialist and chair of the French Society for Respiratory Health, an organization aimed at patients and health care professionals. “Don’t forget that asthma is the leading chronic condition in childhood, with a prevalence estimated at between 8% and 10% of children and adolescents. So, we’re talking about considerable numbers of children being affected.”

Although dust mites are a year-round problem, their peak period of reproduction mainly occurs during the wetter months (March to April and September to November). This means that there is a risk of relapse in asthmatic children who are allergic to dust mites when school starts again after the summer holidays. “In such children, any signs of unmanageable allergic rhinitis should be examined,” said Dr. Amat, “these signs being permanent nasal congestion, runny nose, et cetera.”

Finally, we can also add “the stress and anxiety generated by the school setting and settling back into a routine” to the list of likely explanations for this peak in asthma attacks, Dr. Amat concluded.
 

Check-up time

Children and teenagers with asthma should have a check-up with their respiratory medicine specialists at the start of the new term to confirm that their condition is under control and to determine whether any changes need to be made to their maintenance therapy. “Looking back at previous Septembers and winters is informative in adapting a patient’s treatment plan,” said Dr. Amat. “If maintenance therapy has been stopped during the summer, take the opportunity to represcribe it or modify it if, for example, the dose of inhaled corticosteroids has not been enough to prevent attacks in years gone by. Adequate control of symptoms over the summer months suggests that treatment should be bolstered with preventive therapy to cope with the autumn and winter months. Finally, the factors aggravating poor management of asthma should be dealt with, such as intranasal antihistamines and corticosteroids in allergic rhinitis, specific immunotherapy in patients with controlled asthma but with significant allergy symptoms.”

The start-of-term visit to the doctor’s office is also the perfect opportunity to carry out respiratory function testing (RFT), if this has not been done for over a year in patients whose asthma is well managed. “RFT is indicated in the 3 months following any changes to maintenance therapy, every 3 to 6 months in patients with poorly controlled asthma, and after stopping maintenance therapy or when considering stopping treatment permanently or for an extended period of time,” noted Dr. Amat.

The distinction between difficult asthma (suboptimal treatment plan, poor compliance, persisting allergen exposure, etc.) and severe asthma may be made during this back-to-school asthma review. In specialist clinics, children with severe asthma (not controlled by combined treatment with maximum-dose corticosteroids and maximum-dose bronchodilators) may, like adults, benefit from some biotherapies.
 

Commentary from Madiha Ellaffi, MD, respiratory medicine specialist

When children experience relatively calm summers without seasonal summer allergies to certain pollens or molds (such as Alternaria, some grasses, etc.) that require maintenance therapy to be continued, we know full well that compliance is often left up to the child. What would be better would be striking a “deal” with these young people: Maintenance treatment can be stopped over the summer, providing that their usual dose is quite low or their asthma is considered mild to moderate, but it must be restarted before going back to school in September. An action plan should be discussed in the event of an asthma attack, and treatment bolstered to overcome this hurdle, should it occur, such as double inhaled corticosteroid doses, etc. Indeed, this period is conducive to asthma exacerbations due to stress, the return of students to confined classrooms, pollutants released by the deep cleaning of school buildings that occurs at the start of term (particularly the release of volatile organic compounds that irritate the airways), and the lack of ventilation in classrooms, which is conducive to the spread of viruses that can cause worsening asthma symptoms. I’d also like to remind parents of the importance of detecting early symptoms (such as wheezing, cough, bronchitis, itchy throat and nose, etc.) in warding off asthma attacks or severe symptoms. I insist on basic measures, such as nasal irrigation, treating allergic rhinitis, which can exacerbate asthma, and ensuring good habits at home to prevent dust mites and mold, such as vacuuming, airing houses, etc. It is sensible to assess the risk of asthma attacks at the start of term according to the child’s allergy profile and their previous history, like starting treatment for allergic rhinitis if not already being taken.

This article was translated from Medscape’s French edition. A version of this article appeared on Medscape.com.

The years go by, and nothing much changes: The first 2 weeks of the new school year have brought with them a rise in emergency department (ED) admissions for asthma in patients under age 15 years. A more relaxed approach to maintenance therapy for the condition over the summer holidays, exposure to allergens at school, and the surge in viral respiratory infections that accompanies the return to group settings explain this trend, which can be foreseen.

As soon as September begins, asthma cases increase rapidly in children. According to Public Health France, which has just relaunched its epidemiological monitoring, these cases reach their peak around 2 weeks after the start of the new term.

In its first weekly review on Aug. 22, 2023, the authority reported a slight uptick in cases in its Indian Ocean overseas departments, and the calm before the storm in mainland France.

Last year, between weeks 35 and 36, the increases were 82% for SOS Médecins (the French home doctor visit service), 169% for EDs, and 33% for hospital admissions.

These data are similar to the figures obtained over the past 3 years. The authors of this monitoring, using the SurSaUD system, France’s program for monitoring emergency cases and deaths, attribute these increases to the surge in viral respiratory infections seen after the return to group settings after the school summer holidays.

Indeed, viral-induced exacerbations are mostly caused by rhinoviruses, which circulate throughout the year, but more so during the autumn and winter months. These are probably the main culprits behind the epidemics seen once schools have reopened. Yet relaxation of maintenance asthma treatment (inhaled corticosteroids alone or in combination with long-acting bronchodilators) during the summer holidays also plays a significant role in this yearly recurrence.
 

Compliance ends with school

Flore Amat, MD, PhD, pediatric respiratory and allergy specialist and coordinating doctor at the Zephyr asthma clinic (Robert-Debré Hospital, Paris Public Hospitals) acknowledged, “The summer holidays are often a time when compliance with maintenance therapy is relaxed.” Aware of this fact, doctors prefer to strike a deal with their young patients. “For some of our young and teenage asthma patients, we support their relaxed approach to medication during the summer holidays,” she admitted. “In July and August, there are fewer viruses circulating, and the weather is often dry, which limits the risk of an asthma attack, meaning we can ease off the maintenance therapy, or even stop taking it altogether. We tell parents and children to start taking them again 2 weeks before school starts; 2 weeks being the minimum time needed for inhaled corticosteroids to start taking effect again.” Unsurprisingly, some forget to do so or simply don’t.

Two other things contribute to the rise in asthma attacks in children in early September. The first relates to exposure to allergens, especially dust mites. “Ninety percent of asthmatic children are allergic,” said Frédéric le Guillou, MD, respiratory medicine specialist and chair of the French Society for Respiratory Health, an organization aimed at patients and health care professionals. “Don’t forget that asthma is the leading chronic condition in childhood, with a prevalence estimated at between 8% and 10% of children and adolescents. So, we’re talking about considerable numbers of children being affected.”

Although dust mites are a year-round problem, their peak period of reproduction mainly occurs during the wetter months (March to April and September to November). This means that there is a risk of relapse in asthmatic children who are allergic to dust mites when school starts again after the summer holidays. “In such children, any signs of unmanageable allergic rhinitis should be examined,” said Dr. Amat, “these signs being permanent nasal congestion, runny nose, et cetera.”

Finally, we can also add “the stress and anxiety generated by the school setting and settling back into a routine” to the list of likely explanations for this peak in asthma attacks, Dr. Amat concluded.
 

Check-up time

Children and teenagers with asthma should have a check-up with their respiratory medicine specialists at the start of the new term to confirm that their condition is under control and to determine whether any changes need to be made to their maintenance therapy. “Looking back at previous Septembers and winters is informative in adapting a patient’s treatment plan,” said Dr. Amat. “If maintenance therapy has been stopped during the summer, take the opportunity to represcribe it or modify it if, for example, the dose of inhaled corticosteroids has not been enough to prevent attacks in years gone by. Adequate control of symptoms over the summer months suggests that treatment should be bolstered with preventive therapy to cope with the autumn and winter months. Finally, the factors aggravating poor management of asthma should be dealt with, such as intranasal antihistamines and corticosteroids in allergic rhinitis, specific immunotherapy in patients with controlled asthma but with significant allergy symptoms.”

The start-of-term visit to the doctor’s office is also the perfect opportunity to carry out respiratory function testing (RFT), if this has not been done for over a year in patients whose asthma is well managed. “RFT is indicated in the 3 months following any changes to maintenance therapy, every 3 to 6 months in patients with poorly controlled asthma, and after stopping maintenance therapy or when considering stopping treatment permanently or for an extended period of time,” noted Dr. Amat.

The distinction between difficult asthma (suboptimal treatment plan, poor compliance, persisting allergen exposure, etc.) and severe asthma may be made during this back-to-school asthma review. In specialist clinics, children with severe asthma (not controlled by combined treatment with maximum-dose corticosteroids and maximum-dose bronchodilators) may, like adults, benefit from some biotherapies.
 

Commentary from Madiha Ellaffi, MD, respiratory medicine specialist

When children experience relatively calm summers without seasonal summer allergies to certain pollens or molds (such as Alternaria, some grasses, etc.) that require maintenance therapy to be continued, we know full well that compliance is often left up to the child. What would be better would be striking a “deal” with these young people: Maintenance treatment can be stopped over the summer, providing that their usual dose is quite low or their asthma is considered mild to moderate, but it must be restarted before going back to school in September. An action plan should be discussed in the event of an asthma attack, and treatment bolstered to overcome this hurdle, should it occur, such as double inhaled corticosteroid doses, etc. Indeed, this period is conducive to asthma exacerbations due to stress, the return of students to confined classrooms, pollutants released by the deep cleaning of school buildings that occurs at the start of term (particularly the release of volatile organic compounds that irritate the airways), and the lack of ventilation in classrooms, which is conducive to the spread of viruses that can cause worsening asthma symptoms. I’d also like to remind parents of the importance of detecting early symptoms (such as wheezing, cough, bronchitis, itchy throat and nose, etc.) in warding off asthma attacks or severe symptoms. I insist on basic measures, such as nasal irrigation, treating allergic rhinitis, which can exacerbate asthma, and ensuring good habits at home to prevent dust mites and mold, such as vacuuming, airing houses, etc. It is sensible to assess the risk of asthma attacks at the start of term according to the child’s allergy profile and their previous history, like starting treatment for allergic rhinitis if not already being taken.

This article was translated from Medscape’s French edition. A version of this article appeared on Medscape.com.

The years go by, and nothing much changes: The first 2 weeks of the new school year have brought with them a rise in emergency department (ED) admissions for asthma in patients under age 15 years. A more relaxed approach to maintenance therapy for the condition over the summer holidays, exposure to allergens at school, and the surge in viral respiratory infections that accompanies the return to group settings explain this trend, which can be foreseen.

As soon as September begins, asthma cases increase rapidly in children. According to Public Health France, which has just relaunched its epidemiological monitoring, these cases reach their peak around 2 weeks after the start of the new term.

In its first weekly review on Aug. 22, 2023, the authority reported a slight uptick in cases in its Indian Ocean overseas departments, and the calm before the storm in mainland France.

Last year, between weeks 35 and 36, the increases were 82% for SOS Médecins (the French home doctor visit service), 169% for EDs, and 33% for hospital admissions.

These data are similar to the figures obtained over the past 3 years. The authors of this monitoring, using the SurSaUD system, France’s program for monitoring emergency cases and deaths, attribute these increases to the surge in viral respiratory infections seen after the return to group settings after the school summer holidays.

Indeed, viral-induced exacerbations are mostly caused by rhinoviruses, which circulate throughout the year, but more so during the autumn and winter months. These are probably the main culprits behind the epidemics seen once schools have reopened. Yet relaxation of maintenance asthma treatment (inhaled corticosteroids alone or in combination with long-acting bronchodilators) during the summer holidays also plays a significant role in this yearly recurrence.
 

Compliance ends with school

Flore Amat, MD, PhD, pediatric respiratory and allergy specialist and coordinating doctor at the Zephyr asthma clinic (Robert-Debré Hospital, Paris Public Hospitals) acknowledged, “The summer holidays are often a time when compliance with maintenance therapy is relaxed.” Aware of this fact, doctors prefer to strike a deal with their young patients. “For some of our young and teenage asthma patients, we support their relaxed approach to medication during the summer holidays,” she admitted. “In July and August, there are fewer viruses circulating, and the weather is often dry, which limits the risk of an asthma attack, meaning we can ease off the maintenance therapy, or even stop taking it altogether. We tell parents and children to start taking them again 2 weeks before school starts; 2 weeks being the minimum time needed for inhaled corticosteroids to start taking effect again.” Unsurprisingly, some forget to do so or simply don’t.

Two other things contribute to the rise in asthma attacks in children in early September. The first relates to exposure to allergens, especially dust mites. “Ninety percent of asthmatic children are allergic,” said Frédéric le Guillou, MD, respiratory medicine specialist and chair of the French Society for Respiratory Health, an organization aimed at patients and health care professionals. “Don’t forget that asthma is the leading chronic condition in childhood, with a prevalence estimated at between 8% and 10% of children and adolescents. So, we’re talking about considerable numbers of children being affected.”

Although dust mites are a year-round problem, their peak period of reproduction mainly occurs during the wetter months (March to April and September to November). This means that there is a risk of relapse in asthmatic children who are allergic to dust mites when school starts again after the summer holidays. “In such children, any signs of unmanageable allergic rhinitis should be examined,” said Dr. Amat, “these signs being permanent nasal congestion, runny nose, et cetera.”

Finally, we can also add “the stress and anxiety generated by the school setting and settling back into a routine” to the list of likely explanations for this peak in asthma attacks, Dr. Amat concluded.
 

Check-up time

Children and teenagers with asthma should have a check-up with their respiratory medicine specialists at the start of the new term to confirm that their condition is under control and to determine whether any changes need to be made to their maintenance therapy. “Looking back at previous Septembers and winters is informative in adapting a patient’s treatment plan,” said Dr. Amat. “If maintenance therapy has been stopped during the summer, take the opportunity to represcribe it or modify it if, for example, the dose of inhaled corticosteroids has not been enough to prevent attacks in years gone by. Adequate control of symptoms over the summer months suggests that treatment should be bolstered with preventive therapy to cope with the autumn and winter months. Finally, the factors aggravating poor management of asthma should be dealt with, such as intranasal antihistamines and corticosteroids in allergic rhinitis, specific immunotherapy in patients with controlled asthma but with significant allergy symptoms.”

The start-of-term visit to the doctor’s office is also the perfect opportunity to carry out respiratory function testing (RFT), if this has not been done for over a year in patients whose asthma is well managed. “RFT is indicated in the 3 months following any changes to maintenance therapy, every 3 to 6 months in patients with poorly controlled asthma, and after stopping maintenance therapy or when considering stopping treatment permanently or for an extended period of time,” noted Dr. Amat.

The distinction between difficult asthma (suboptimal treatment plan, poor compliance, persisting allergen exposure, etc.) and severe asthma may be made during this back-to-school asthma review. In specialist clinics, children with severe asthma (not controlled by combined treatment with maximum-dose corticosteroids and maximum-dose bronchodilators) may, like adults, benefit from some biotherapies.
 

Commentary from Madiha Ellaffi, MD, respiratory medicine specialist

When children experience relatively calm summers without seasonal summer allergies to certain pollens or molds (such as Alternaria, some grasses, etc.) that require maintenance therapy to be continued, we know full well that compliance is often left up to the child. What would be better would be striking a “deal” with these young people: Maintenance treatment can be stopped over the summer, providing that their usual dose is quite low or their asthma is considered mild to moderate, but it must be restarted before going back to school in September. An action plan should be discussed in the event of an asthma attack, and treatment bolstered to overcome this hurdle, should it occur, such as double inhaled corticosteroid doses, etc. Indeed, this period is conducive to asthma exacerbations due to stress, the return of students to confined classrooms, pollutants released by the deep cleaning of school buildings that occurs at the start of term (particularly the release of volatile organic compounds that irritate the airways), and the lack of ventilation in classrooms, which is conducive to the spread of viruses that can cause worsening asthma symptoms. I’d also like to remind parents of the importance of detecting early symptoms (such as wheezing, cough, bronchitis, itchy throat and nose, etc.) in warding off asthma attacks or severe symptoms. I insist on basic measures, such as nasal irrigation, treating allergic rhinitis, which can exacerbate asthma, and ensuring good habits at home to prevent dust mites and mold, such as vacuuming, airing houses, etc. It is sensible to assess the risk of asthma attacks at the start of term according to the child’s allergy profile and their previous history, like starting treatment for allergic rhinitis if not already being taken.

This article was translated from Medscape’s French edition. A version of this article appeared on Medscape.com.

Key clinical point: Tralokinumab is well tolerated and effective in older adults with moderate-to-severe atopic dermatitis (AD).

Major finding: Compared with the placebo group, a significantly higher proportion of patients in ECZTRA 1 and 2 achieved ≥ 75% improvement in the Eczema Area and Severity Index score (33.9% vs 4.76%; P < .001) and an Investigator’s Global Assessment 0 or 1 score (16.95% vs 0%; P < .001) in the tralokinumab group at week 16. The adverse event (AE) rate was comparable between the groups; however, fewer patients discontinued treatment due to AE in the tralokinumab vs placebo group (5.3% vs 6.9%).

Study details: Findings are from a post hoc analysis of ECZTRA 1, 2, and 3 trials and included 104 older patients (≥65 years) with AD who received tralokinumab (n = 75) or placebo (n = 29).

Disclosures: This study was supported by LEO Pharma. Two authors declared being employees of LEO Pharma. Some authors declared receiving grants, personal fees, or consulting fees from LEO Pharma and other sources.

Source: Merola JF et al. Safety and efficacy of tralokinumab in older adults with moderate-to-severe atopic dermatitis: A secondary analysis. JAMA Dermatol. 2023 (Aug 23). doi: 10.1001/jamadermatol.2023.2626

Key clinical point: Tralokinumab is well tolerated and effective in older adults with moderate-to-severe atopic dermatitis (AD).

Major finding: Compared with the placebo group, a significantly higher proportion of patients in ECZTRA 1 and 2 achieved ≥ 75% improvement in the Eczema Area and Severity Index score (33.9% vs 4.76%; P < .001) and an Investigator’s Global Assessment 0 or 1 score (16.95% vs 0%; P < .001) in the tralokinumab group at week 16. The adverse event (AE) rate was comparable between the groups; however, fewer patients discontinued treatment due to AE in the tralokinumab vs placebo group (5.3% vs 6.9%).

Study details: Findings are from a post hoc analysis of ECZTRA 1, 2, and 3 trials and included 104 older patients (≥65 years) with AD who received tralokinumab (n = 75) or placebo (n = 29).

Disclosures: This study was supported by LEO Pharma. Two authors declared being employees of LEO Pharma. Some authors declared receiving grants, personal fees, or consulting fees from LEO Pharma and other sources.

Source: Merola JF et al. Safety and efficacy of tralokinumab in older adults with moderate-to-severe atopic dermatitis: A secondary analysis. JAMA Dermatol. 2023 (Aug 23). doi: 10.1001/jamadermatol.2023.2626

Key clinical point: Tralokinumab is well tolerated and effective in older adults with moderate-to-severe atopic dermatitis (AD).

Major finding: Compared with the placebo group, a significantly higher proportion of patients in ECZTRA 1 and 2 achieved ≥ 75% improvement in the Eczema Area and Severity Index score (33.9% vs 4.76%; P < .001) and an Investigator’s Global Assessment 0 or 1 score (16.95% vs 0%; P < .001) in the tralokinumab group at week 16. The adverse event (AE) rate was comparable between the groups; however, fewer patients discontinued treatment due to AE in the tralokinumab vs placebo group (5.3% vs 6.9%).

Study details: Findings are from a post hoc analysis of ECZTRA 1, 2, and 3 trials and included 104 older patients (≥65 years) with AD who received tralokinumab (n = 75) or placebo (n = 29).

Disclosures: This study was supported by LEO Pharma. Two authors declared being employees of LEO Pharma. Some authors declared receiving grants, personal fees, or consulting fees from LEO Pharma and other sources.

Source: Merola JF et al. Safety and efficacy of tralokinumab in older adults with moderate-to-severe atopic dermatitis: A secondary analysis. JAMA Dermatol. 2023 (Aug 23). doi: 10.1001/jamadermatol.2023.2626

Key clinical point: Children and adults with atopic dermatitis (AD) have a significantly increased risk of developing inflammatory bowel disease (IBD), including Crohn’s disease (CD).

Major finding: Children with vs without AD had a significantly higher risk for IBD (adjusted HR [aHR] 1.44; 95% CI 1.31-1.58) and CD (aHR 1.74; 95% CI 1.54-1.97), but the risk for ulcerative colitis (UC; aHR 1.65; 95% CI 1.02-2.67) was higher only in children with severe AD. Adults with vs without AD had a significantly increased risk for IBD (aHR 1.34; 95% CI 1.27-1.40), CD (aHR 1.36; 95% CI 1.26-1.47), and UC (aHR 1.32; 95% CI 1.24-1.41).

Study details: This population-based cohort study matched children (n = 409,431; age < 18 years) and adults (n = 625,083) with AD with control children (n = 1,809,029) and adults (n = 2,678,888) without AD, respectively.

Disclosures: This study was supported by a contract from Pfizer Inc. Five authors declared receiving grants, personal fees, and fellowship funding from various sources, including Pfizer Inc.

Source: Chiesa Fuxench ZC et al. Risk of inflammatory bowel disease in patients with atopic dermatitis. JAMA Dermatol. 2023 (Aug 30). doi: 10.1001/jamadermatol.2023.2875

Key clinical point: Children and adults with atopic dermatitis (AD) have a significantly increased risk of developing inflammatory bowel disease (IBD), including Crohn’s disease (CD).

Major finding: Children with vs without AD had a significantly higher risk for IBD (adjusted HR [aHR] 1.44; 95% CI 1.31-1.58) and CD (aHR 1.74; 95% CI 1.54-1.97), but the risk for ulcerative colitis (UC; aHR 1.65; 95% CI 1.02-2.67) was higher only in children with severe AD. Adults with vs without AD had a significantly increased risk for IBD (aHR 1.34; 95% CI 1.27-1.40), CD (aHR 1.36; 95% CI 1.26-1.47), and UC (aHR 1.32; 95% CI 1.24-1.41).

Study details: This population-based cohort study matched children (n = 409,431; age < 18 years) and adults (n = 625,083) with AD with control children (n = 1,809,029) and adults (n = 2,678,888) without AD, respectively.

Disclosures: This study was supported by a contract from Pfizer Inc. Five authors declared receiving grants, personal fees, and fellowship funding from various sources, including Pfizer Inc.

Source: Chiesa Fuxench ZC et al. Risk of inflammatory bowel disease in patients with atopic dermatitis. JAMA Dermatol. 2023 (Aug 30). doi: 10.1001/jamadermatol.2023.2875

Key clinical point: Children and adults with atopic dermatitis (AD) have a significantly increased risk of developing inflammatory bowel disease (IBD), including Crohn’s disease (CD).

Major finding: Children with vs without AD had a significantly higher risk for IBD (adjusted HR [aHR] 1.44; 95% CI 1.31-1.58) and CD (aHR 1.74; 95% CI 1.54-1.97), but the risk for ulcerative colitis (UC; aHR 1.65; 95% CI 1.02-2.67) was higher only in children with severe AD. Adults with vs without AD had a significantly increased risk for IBD (aHR 1.34; 95% CI 1.27-1.40), CD (aHR 1.36; 95% CI 1.26-1.47), and UC (aHR 1.32; 95% CI 1.24-1.41).

Study details: This population-based cohort study matched children (n = 409,431; age < 18 years) and adults (n = 625,083) with AD with control children (n = 1,809,029) and adults (n = 2,678,888) without AD, respectively.

Disclosures: This study was supported by a contract from Pfizer Inc. Five authors declared receiving grants, personal fees, and fellowship funding from various sources, including Pfizer Inc.

Source: Chiesa Fuxench ZC et al. Risk of inflammatory bowel disease in patients with atopic dermatitis. JAMA Dermatol. 2023 (Aug 30). doi: 10.1001/jamadermatol.2023.2875

Key clinical point: Dupilumab significantly improved the overall sleep continuity and quality, itch, and other signs and symptoms of atopic dermatitis (AD) in patients with moderate-to-severe AD.

Major finding: At week 12, dupilumab vs placebo led to a significant improvement in the sleep Numeric Rating Scale (NRS), peak pruritus NRS, SCORing Atopic Dermatitis (SCORAD), SCORAD sleep visual analog scale, Eczema Area and Severity Index, Epworth Sleepiness Scale, and sleep-related impairment T-scores (all P < .001) and a lower overall treatment-emergent adverse event rate (56.7% vs 67.2%).

Study details: Findings are from the prospective phase 4 DUPISTAD study including patients with moderate-to-severe AD who were randomly assigned to receive 300 mg dupilumab every 2 weeks (n = 127) or placebo (n = 61).

Disclosures: This study was sponsored by Sanofi and Regeneron Pharmaceuticals Inc. Three authors declared being employees of and holding stocks or stock options in Sanofi or Regeneron. Other authors declared receiving grant support, travel grants, or speaker fees from or serving as principal investigators, advisory board members, or consultants for various sources.

Source: Merola JF et al. Dupilumab significantly improves sleep in adults with atopic dermatitis: Results from the 12-week placebo-controlled period of the 24-week phase 4 randomized double-blinded placebo-controlled DUPISTAD study. Br J Dermatol. 2023 (Aug 10). doi: 10.1093/bjd/ljad284

Key clinical point: Dupilumab significantly improved the overall sleep continuity and quality, itch, and other signs and symptoms of atopic dermatitis (AD) in patients with moderate-to-severe AD.

Major finding: At week 12, dupilumab vs placebo led to a significant improvement in the sleep Numeric Rating Scale (NRS), peak pruritus NRS, SCORing Atopic Dermatitis (SCORAD), SCORAD sleep visual analog scale, Eczema Area and Severity Index, Epworth Sleepiness Scale, and sleep-related impairment T-scores (all P < .001) and a lower overall treatment-emergent adverse event rate (56.7% vs 67.2%).

Study details: Findings are from the prospective phase 4 DUPISTAD study including patients with moderate-to-severe AD who were randomly assigned to receive 300 mg dupilumab every 2 weeks (n = 127) or placebo (n = 61).

Disclosures: This study was sponsored by Sanofi and Regeneron Pharmaceuticals Inc. Three authors declared being employees of and holding stocks or stock options in Sanofi or Regeneron. Other authors declared receiving grant support, travel grants, or speaker fees from or serving as principal investigators, advisory board members, or consultants for various sources.

Source: Merola JF et al. Dupilumab significantly improves sleep in adults with atopic dermatitis: Results from the 12-week placebo-controlled period of the 24-week phase 4 randomized double-blinded placebo-controlled DUPISTAD study. Br J Dermatol. 2023 (Aug 10). doi: 10.1093/bjd/ljad284

Key clinical point: Dupilumab significantly improved the overall sleep continuity and quality, itch, and other signs and symptoms of atopic dermatitis (AD) in patients with moderate-to-severe AD.

Major finding: At week 12, dupilumab vs placebo led to a significant improvement in the sleep Numeric Rating Scale (NRS), peak pruritus NRS, SCORing Atopic Dermatitis (SCORAD), SCORAD sleep visual analog scale, Eczema Area and Severity Index, Epworth Sleepiness Scale, and sleep-related impairment T-scores (all P < .001) and a lower overall treatment-emergent adverse event rate (56.7% vs 67.2%).

Study details: Findings are from the prospective phase 4 DUPISTAD study including patients with moderate-to-severe AD who were randomly assigned to receive 300 mg dupilumab every 2 weeks (n = 127) or placebo (n = 61).

Disclosures: This study was sponsored by Sanofi and Regeneron Pharmaceuticals Inc. Three authors declared being employees of and holding stocks or stock options in Sanofi or Regeneron. Other authors declared receiving grant support, travel grants, or speaker fees from or serving as principal investigators, advisory board members, or consultants for various sources.

Source: Merola JF et al. Dupilumab significantly improves sleep in adults with atopic dermatitis: Results from the 12-week placebo-controlled period of the 24-week phase 4 randomized double-blinded placebo-controlled DUPISTAD study. Br J Dermatol. 2023 (Aug 10). doi: 10.1093/bjd/ljad284