Can Atopic Dermatitis Be Prevented? | Actas Dermo-Sifiliográficas

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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "278" "paginaFinal" => "284" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "E. Gómez-de la Fuente" "autores" => array:1 [ 0 => array:3 [ "nombre" => "E." "apellidos" => "Gómez-de la Fuente" "email" => array:1 [ 0 => "egomezf@fhalcorcon.es" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Fundación Alcorcón, Madrid, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Se puede prevenir la dermatitis atópica?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 654 "Ancho" => 1004 "Tamanyo" => 125003 ] ] "descripcion" => array:1 [ "en" => "Etiology and pathogenesis of atopic dermatitis." ] ] ] "textoCompleto" => "INTRODUCTIONAtopic dermatitis (AD) is a chronic inflammatory disease whose prevalence has increased considerably in recent years, with the consequent marked effect on patient quality of life and very high costs. Furthermore, it is usually the first manifestation of the so-called atopic march, and a high percentage of patients with AD eventually develop food allergy, asthma, and/or allergic rhinitis. Approximately, one-third of patients with AD will develop asthma and two-thirds allergic rhinitis; however, there is no conclusive evidence on the percentage who will develop food allergy.<a class="elsevierStyleCrossRefs" href="#bib0320">1,2</a> Therefore, AD has become a real health problem in our setting. Since AD is a chronic disease with no cure, it would be extremely interesting to have effective preventive measures. Based on a critical review of available scientific evidence and levels of evidence for specific interventions (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>),<a class="elsevierStyleCrossRef" href="#bib0330">3</a> the present article aims to determine whether there are effective ways of preventing AD.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Prevention can be at several levels. Here, interventions will be reviewed at primary and secondary level. By primary prevention, we mean the set of actions aimed at preventing onset of the disease; by secondary prevention, we mean early diagnosis and treatment to reduce morbidity and/or mortality. In the former, we try to reduce the incidence of DA, and in the latter, we try to reduce severity and complications.Preventive measures should be based on appropriate knowledge of the etiology and pathogenesis of a disease, which is a limitation in AD given that both are unknown. A series of genetic factors, in particular loss-of-function mutations in the filaggrin gene, interact with environmental factors to produce the various clinical manifestations of AD (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0335">4,5</a> These genetic factors themselves are insufficient to account for the increased prevalence of AD, as shown by the fact that immigrants from developing countries acquire the prevalence of their host country or the rural/urban difference within a single country.<a class="elsevierStyleCrossRef" href="#bib0345">6</a> Therefore, a series of environmental factors favor the development of an atopic phenotype, whereas others protect against this phenotype. These factors act mainly at very early stages of development (last months of pregnancy and first year of life), as shown by the observation that in more than 60% of cases, AD manifests during the first year of life. Preventive measures should focus on this stage.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Primary PreventionExposure to Microbes: Hygiene HypothesisThe hygiene hypothesis posits that reduced exposure to specific microorganisms during key periods of development leads to immunologic modification favoring acquisition or maintenance of an atopic phenotype.<a class="elsevierStyleCrossRef" href="#bib0350">7</a> It is important to highlight the role of intestinal flora—at least 60% of lymphocytes are in the digestive tract—which is essential for the development of sensitization and immune tolerance.Probiotics and PrebioticsIn utero, the intestine is sterile, although it quickly becomes colonized after delivery. Intestinal flora is less diverse in children with AD, with reduced presence of Bifidobacterium species and increased presence of Staphylococcus aureus.<a class="elsevierStyleCrossRef" href="#bib0355">8</a> We might ask whether addition of a probiotic or prebiotic could modify intestinal flora by modulating reactivation of the immune system to prevent AD. The relevant literature is abundant, with contradictory findings and considerable heterogeneity between studies in terms of factors such as diagnostic criteria, methodology, strains, and dose. Therefore, it is very difficult to compare studies and the conclusions from meta-analyses. The fact that many authors and the World Allergy Organization feel that more studies are necessary means that it is too early to make appropriate recommendations.<a class="elsevierStyleCrossRefs" href="#bib0360">9–11</a> Nevertheless, research should continue in this direction. Special mention should be made of a recent paper,<a class="elsevierStyleCrossRef" href="#bib0375">12</a> in which 26 randomized studies were reviewed (level of evidence, 1a). The authors concluded that probiotics are useful for prevention of AD, but only if they are administered sequentially during the last months of pregnancy and the first months of life. They would prove useless if administered only after birth.EndotoxinsSeveral epidemiological studies have established an association between specific situations and protection against AD. As mentioned above, these situations are characterized by exposure—especially during pregnancy and the first year of life—to specific microorganisms that can reduce the risk of AD by modifying the immune system. The reduced risk could be due to endotoxins, a group of lipopolysaccharides present in the walls of gram-negative bacteria.Farm Animals and Unpasteurized MilkChildren who live on farms are thought to have a lower risk of AD, although there is no evidence that merely living on a farm exercises a protective effect.<a class="elsevierStyleCrossRef" href="#bib0340">5</a> The reasons underlying this possibility could be the effect of unpasteurized milk (rich in lactobacilli) and contact with farm animals, especially if exposure is both before and after birth. This protective effect has even been observed in persons from an urban environment who drink unpasteurized milk (level of evidence, 3b).<a class="elsevierStyleCrossRef" href="#bib0380">13</a>PetsThe presence of pets during the first year of life could protect against AD. Several studies show a uniform protective effect with dogs (level of evidence, 2a)<a class="elsevierStyleCrossRef" href="#bib0385">14</a>; however, this effect is less clear with cats, and findings are contradictory.<a class="elsevierStyleCrossRef" href="#bib0390">15</a> The risk is greater in children with mutations in the filaggrin gene, suggesting that alterations in the barrier function could facilitate sensitization to cat dander and development of AD.<a class="elsevierStyleCrossRefs" href="#bib0395">16,17</a>Helminth InfectionSome articles showed an inverse association between AD and helminth infection, thus explaining, at least in part, differences between developed and developing countries and rural and urban areas (level of evidence, 3b).<a class="elsevierStyleCrossRefs" href="#bib0405">18,19</a> Greater evidence for this association is found in various interventional studies, which show an increased risk in pregnant women taking antihelminth therapy in endemic areas (level of evidence, 1b).<a class="elsevierStyleCrossRef" href="#bib0415">20</a> The immunologic basis for this protective effect is not clear, although it could result from an anti-inflammatory effect caused by increased production of interleukin (IL) 10.<a class="elsevierStyleCrossRef" href="#bib0420">21</a>Infections and VaccinesThe several studies that examine infections (viral and bacterial) occurring before birth or during infancy report contradictory results. Some found a slight increase in the risk of AD<a class="elsevierStyleCrossRef" href="#bib0425">22</a> and others a protective effect.<a class="elsevierStyleCrossRef" href="#bib0430">23</a> Schmitt et al.<a class="elsevierStyleCrossRef" href="#bib0435">24</a> observed no association and linked the possible increased risk to more frequent use of antibiotics.The same is true with vaccines. Whereas some studies suggest a slight increase in risk, more modern studies found no association with AD.AntibioticsAlthough it can be difficult to discriminate between the use of antibiotics and the infection they are prescribed for, several studies have associated antibiotic therapy with an increased risk of AD. Tsakok et al.<a class="elsevierStyleCrossRef" href="#bib0440">25</a> recently performed a systematic review of 20 studies and found a positive association between antibiotic therapy and the subsequent risk of developing AD, especially if the antibiotics are broad-spectrum. This association was maintained both in the 7 cross-sectional studies and in the 13 longitudinal studies analyzed. The risk was present when therapy was administered both before and after birth. In addition, the risk was cumulative, that is, the more cycles of antibiotics taken, the greater the risk of developing AD. Once again, this increased risk is thought to be due to an alteration in the microflora, which would in turn lead to an alteration in the immune system. Thus, until more robust evidence becomes available, it seems reasonable to recommend that antibiotics, especially broad-spectrum antibiotics, be prescribed with caution (level of evidence, 2a and 3a).Dietary ModificationsThe recommendations and actions reported in the literature are as follows:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsit0015">-Modification of maternal diet, with a reduction in the so-called allergenic foods, ω-3 supplements, fatty acids, and vitamin D</li><li class="elsevierStyleListItem" id="lsti0005">-Replacement of infant formulas with hydrolyzed formulas, soy milk, mineral supplements, and vitamin supplements (eg, vitamin D)</li><li class="elsevierStyleListItem" id="lsti0010">-Promotion of breastfeeding</li></ul>Again, study results are controversial and contradictory, in part owing to very heterogeneous designs. Research in this field is ongoing. It is no surprise that at visits, patients—or parents—ask us which foods should be avoided or if taking a supplement would help to improve the patient's symptoms. In accordance with the information provided above, and until further trials have been performed, no routine recommendations can be made, as demonstrated by meta-analyses (with their inherent bias).<a class="elsevierStyleCrossRefs" href="#bib0360">9,26</a>BreastfeedingBreastfeeding has traditionally been considered a major barrier against AD and allergy. In fact, the World Health Organization recommends breastfeeding as the only source of food during the first 6 months. Nevertheless, recent studies and various meta-analyses have shown that this approach could be erroneous, as far as reduction in the frequency of AD and allergy is concerned. Data from the phase II International Study of Asthma and Allergies in Childhood (ISAAC), which includes more than 51 000 children, found no evidence that breastfeeding alone is capable of preventing AD.<a class="elsevierStyleCrossRef" href="#bib0450">27</a> Similarly, a meta-analysis of 27 prospective studies found no protection against AD.<a class="elsevierStyleCrossRef" href="#bib0455">28</a> Breastfeeding is considered the most complete source of food because of its nutritional properties and effects on the immune system. These studies do not change this notion but merely point out that breastfeeding is not useful for preventing atopy and that this should be taken into account when informing patients (level of evidence, 2a). Once again, the reason could be the greater frequency of intestinal infection and colonization with artificial milk; however, immunologic mechanisms could also be involved. A deeply rooted idea in our setting is that late introduction of solid foods can prevent allergy. However, several studies show that early introduction of solid foods, unlike strict allergen avoidance, could be more likely to induce immune tolerance than sensitization.<a class="elsevierStyleCrossRefs" href="#bib0460">29,30</a> The several clinical trials that are under way to verify the effect of breastfeeding only compared with breastfeeding and early introduction of solid foods could shed some light on this issue.<a class="elsevierStyleCrossRef" href="#bib0470">31</a>House Dust MitesA significant percentage of patients with AD are sensitized to house dust mites, and some experience outbreaks after exposure.<a class="elsevierStyleCrossRef" href="#bib0475">32</a> Nevertheless, one systematic review found no evidence of improvement when house dust levels were reduced.<a class="elsevierStyleCrossRef" href="#bib0480">33</a> Some studies even found a paradoxical increase in the risk of AD in families who avoided the allergen, much in the same way as when endotoxins are avoided.<a class="elsevierStyleCrossRefs" href="#bib0485">34,35</a> Therefore, in practical terms, strict avoidance of house dust mites should not be recommended as a strategy for prevention or treatment, since it is difficult, impractical, and, possibly, erroneous.Secondary PreventionSecondary prevention measures are aimed at reducing the number and intensity of outbreaks and preventing or diminishing the atopic march. These strategies could have an effect on each other. Furthermore, secondary prevention measures are occasionally involved in primary prevention strategies, since genetic and environmental risk factors are present before and after the disease develops.Modification of the Atopic MarchThe atopic march is the natural history of atopic manifestations, of which AD is usually the first, followed by food allergy, asthma, and allergic rhinitis. This development is a real phenomenon, although there is some debate as to whether it represents a causal relationship or concurrent manifestations of an atopic phenotype that shares environmental and genetic risk factors.<a class="elsevierStyleCrossRefs" href="#bib0495">36,37</a> Since the discovery of the filaggrin gene and its loss-of-function mutation as a risk factor for AD, the loss of the barrier function of the epidermis has become increasingly relevant. The filaggrin mutation is associated with asthma in patients with AD, although not in those with mutations who do not have AD<a class="elsevierStyleCrossRefs" href="#bib0505">38,39</a>; hence the potential importance of the barrier function of the stratum corneum in sensitization to allergens. The association between severity of AD and more marked alteration of the barrier function and a higher percentage of subsequent sensitizations points to a causal mechanism.<a class="elsevierStyleCrossRefs" href="#bib0500">37,40–42</a> It has been postulated that an epidermis with a faulty barrier function enables passage of microorganisms and allergens, leading to epicutaneous sensitization that triggers the atopic march.<a class="elsevierStyleCrossRefs" href="#bib0495">36,39,43</a>If we assume that the atopic march is causal and that it is due, at least in part, to a defective skin barrier, then it could be avoided or at least diminished if we could restore the skin barrier. How to achieve this is a key issue.Restoration of the Defective Skin BarrierThe 2 basic assets in this area are emollients and control of inflammation. In AD, inflammation produces a series of cytokines that can exercise a negative effect on the expression of filaggrin and the synthesis of specific lipids present in the stratum corneum, thus leading to greater transepidermal elimination of water and more marked loss of barrier function.<a class="elsevierStyleCrossRefs" href="#bib0535">44–46</a> Therefore, when restoring the epidermal barrier, it is important to control outbreaks.Reduction of the Intensity/Severity of OutbreaksAD involves subclinical inflammation, with histologic and immunologic abnormalities in the unaffected skin of patients with the disease.<a class="elsevierStyleCrossRef" href="#bib0550">47</a> Several studies report a reduction in the number and intensity of outbreaks when subclinical inflammation is treated with topical tacrolimus administered over 2-3 days per week in both adults and children (level of evidence, 1b).<a class="elsevierStyleCrossRefs" href="#bib0555">48,49</a> This so-called proactive treatment is not restricted to calcineurin inhibitors; it can also be administered via topical corticosteroids twice weekly (level of evidence, 1b).<a class="elsevierStyleCrossRefs" href="#bib0565">50,51</a> The most appropriate regimen in terms of clinical and cost-effectiveness criteria remains to be determined; however, this is not the object of the present review. Very few studies analyze modification of respiratory symptoms using these treatments. Two studies report on the same group of patients (moderate-severe AD) treated with tacrolimus cream for 1 year for minimal symptoms and up to 1 week after the outbreak was resolved.<a class="elsevierStyleCrossRefs" href="#bib0575">52,53</a> The patients were evaluated at 4 and 10 years. The authors found that the severity of the skin manifestations had decreased and that the respiratory symptoms had improved. Nevertheless, the study is subject to bias, since it is open-label with no control group, thus preventing us from drawing clear conclusions (level of evidence, 4). In addition, the study population comprised adult patients with AD and established respiratory symptoms. Ideally, children should be analyzed to evaluate the effect of these early treatments on subsequent manifestations of atopic disease. A similarly designed trial was performed with topical pimecrolimus; however, unfortunately, the study ended early owing to loss of patients, and no conclusions could be drawn.<a class="elsevierStyleCrossRef" href="#bib0585">54</a> This trial coincided with the alert from the United States Food and Drug Administration on the risk of neoplasm associated with calcineurin inhibitors. The alert may account for the loss of patients and the early termination of the study.EmollientsMoisturizing with emollients has traditionally been the cornerstone of management of AD.<a class="elsevierStyleCrossRef" href="#bib0590">55</a> In addition to reducing the loss of water through the skin, emollients relieve itching and increase the efficacy of and reduce the need for topical corticosteroids.<a class="elsevierStyleCrossRefs" href="#bib0595">56,57</a> They are increasingly used as a result of the discovery of the role of filaggrin and other proteins in the stratum corneum and advances in our knowledge of the lipid composition of this layer. Just as inflammation leads to a more intense alteration of barrier function, correct hydration can reduce the inflammation observed in the dry skin of patients with AD.<a class="elsevierStyleCrossRefs" href="#bib0515">40,58,59</a>Emollients can be classed as nonphysiologic (eg, petrolatum and lanolin), that is, they are not present naturally in the skin, or physiologic. Physiologic emollients are composed of lipids present in the stratum corneum and have proven to be defective in patients with AD. They include ceramides, cholesterol, and free fatty acids. Emollients can penetrate the stratum corneum, are taken up by keratinocytes, processed in lamellar bodies, and resecreted to the stratum corneum more naturally. However, our knowledge is theory-based, since the few studies available were performed with low numbers of patients and short follow-up periods. Furthermore, almost no results are available from randomized controlled trials on the various types of emollients, although several studies are ongoing.Emollients used in primary preventionCurrent efforts to develop emollients are focused on restoration of barrier function and improvement in the symptoms of AD. Very few studies examine primary prevention. Simpson et al.<a class="elsevierStyleCrossRef" href="#bib0615">60</a> studied 22 neonates from families at a high risk of developing AD who used an emollient (oil-in-water) from birth. Clear conclusions cannot be drawn, since the study did not have a control group. However, a comparison with historic controls led the authors to suggest a decrease in incidence (level of evidence, 4). More recently, Inoue et al.<a class="elsevierStyleCrossRef" href="#bib0620">61</a> compared 147 neonates with a control group but found no differences with respect to incidence. They did find differences, however, for severity, which was lower in children treated twice daily with emollients. The authors performed a single measurement at 4 months of age, which is insufficient in a disease such as AD (level of evidence, 3b). In any case, this approach is being investigated in ongoing clinical trials, although more time and more studies are necessary before firm conclusions can be drawn.Conclusions and ReflectionsIt is impossible to prevent a disease as complex and multifactorial as AD by eliminating a single risk factor. AD requires an integral approach involving various health professionals and public authorities and enabling different prevention strategies to be promoted. Unfortunately, such strategies have not yet been established and cannot be routinely recommended, since there is insufficient evidence (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). However, this does not necessarily mean that these strategies do not work, only that we must perform additional studies, many of which are already under way. The clearest example is the use of probiotics and prebiotics in primary prevention, which has yielded promising results in some clinical trials. Other measures are simply impractical and cannot be applied at the population level. Although helminth infection and the endotoxins of specific bacteria reduce the risk of AD, infecting children or pregnant women with this purpose in mind is unthinkable. Instead, attempts are being made to isolate components of the helminth wall and various bacterial lipopolysaccharides so that they can be administered exogenously. Results are available from murine and human studies, although these remain scarce. Nevertheless, this aspect warrants further analysis.<a class="elsevierStyleCrossRefs" href="#bib0625">62,63</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Halting the atopic march is of considerable interest, since a clear temporal relationship and biological plausibility have been observed. Nevertheless, interventional studies confirming causality and the real possibility of halting the disease have yet to be performed. If this progression could be prevented by controlling inflammation (clinical and subclinical) and restoring barrier function, disease course could actually be modified.Also controversial is the selection of candidates for preventive measures. The high prevalence of AD and its implication in the development of other atopic diseases would justify taking measures in the general population. Nevertheless, as mentioned above, these measures have not been well defined, and many clinical trials have focused on at-risk patients (first-degree relatives of atopic individuals). Furthermore, dermatologists have easy access to these individuals. It is in this specific group that we can establish appropriate measures or, based at least on our knowledge of etiology and pathogenesis and advances in epidemiology, we could inform patients appropriately and avoid unsuitable and erroneous measures and disinformation.Lastly, genetic studies and new biomarkers will probably enable different subtypes or phenotypes of AD to be established, thus enabling more personalized therapeutic and preventive measures to be developed.Conflicts of InterestThe author declares that he has no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres494658" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec515866" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres494657" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec515867" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "INTRODUCTION" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Primary Prevention" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Exposure to Microbes: Hygiene Hypothesis" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Probiotics and Prebiotics" ] 2 => array:3 [ "identificador" => "sec0025" "titulo" => "Endotoxins" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Farm Animals and Unpasteurized Milk" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Pets" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Helminth Infection" ] 3 => array:2 [ "identificador" => "sec0045" "titulo" => "Infections and Vaccines" ] ] ] 3 => array:2 [ "identificador" => "sec0050" "titulo" => "Antibiotics" ] 4 => array:3 [ "identificador" => "sec0055" "titulo" => "Dietary Modifications" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Breastfeeding" ] ] ] 5 => array:2 [ "identificador" => "sec0065" "titulo" => "House Dust Mites" ] ] ] 6 => array:3 [ "identificador" => "sec0070" "titulo" => "Secondary Prevention" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0075" "titulo" => "Modification of the Atopic March" ] 1 => array:3 [ "identificador" => "sec0080" "titulo" => "Restoration of the Defective Skin Barrier" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0085" "titulo" => "Reduction of the Intensity/Severity of Outbreaks" ] 1 => array:3 [ "identificador" => "sec0090" "titulo" => "Emollients" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0095" "titulo" => "Emollients used in primary prevention" ] ] ] ] ] ] ] 7 => array:2 [ "identificador" => "sec0100" "titulo" => "Conclusions and Reflections" ] 8 => array:2 [ "identificador" => "sec0105" "titulo" => "Conflicts of Interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-06-30" "fechaAceptado" => "2014-12-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec515866" "palabras" => array:3 [ 0 => "Atopic dermatitis" 1 => "Prevention" 2 => "Atopic march" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec515867" "palabras" => array:3 [ 0 => "Dermatitis atópica" 1 => "Prevención" 2 => "Marcha atópica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Atopic dermatitis has become a health problem in our setting due to its rising prevalence, impact on quality of life, associated costs, and role in the progression to other atopic diseases. Furthermore, atopic dermatitis has no definitive cure and therefore preventive measures are important. In this article, we review the latest advances in both primary prevention (reduction of the incidence of atopic dermatitis) and secondary prevention (reduction of associated morbidity and reduction of the atopic march). We analyze the different preventive strategies available, including modification of the immune system through microbial exposure, induction of immune tolerance through antigen exposure, and restoration of skin barrier function to halt the atopic march. Dermatologists need to be familiar with these strategies in order to apply them where necessary and to accurately inform patients and their relatives to prevent misguided or inappropriate actions." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La dermatitis atópica (DA) se ha convertido en un problema de salud en nuestro medio debido al aumento de su prevalencia, la alteración de la calidad de vida, los gastos que ocasiona y su implicación en la progresión a otras enfermedades atópicas. Además no tiene una cura definitiva, por lo que sería interesante la aplicación de medidas preventivas. En este artículo se revisan los últimos avances implicados en su prevención, tanto primaria (disminución de incidencia), como secundaria (disminución de morbilidad, evitar la progresión de la marcha atópica). Se abordan las diversas estrategias implicadas, entre las que se encuentran la modificación del sistema inmune mediante exposición microbiana, la inducción de tolerancia inmunológica por exposición antigénica y la restauración de la función barrera para frenar la marcha atópica. Estas medidas deberían ser conocidas por los dermatólogos para aplicarlas cuando sea posible, y poder informar adecuadamente a los pacientes y familiares, evitando actuaciones inadecuadas y/o erróneas." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Gómez-de la Fuente E. ¿Se puede prevenir la dermatitis atópica?. Actas Dermosifiliogr. 2015;106:278–284." ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 654 "Ancho" => 1004 "Tamanyo" => 125003 ] ] "descripcion" => array:1 [ "en" => "Etiology and pathogenesis of atopic dermatitis." ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Source: Sackett and Wennberg.<a class="elsevierStyleCrossRef" href="#bib0330">3</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Level of Evidence \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">1a \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Meta-analysis of well-designed randomized controlled clinical trials \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">1b \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Individual randomized controlled trial \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">2a \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Systematic review of cohort studies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">2b \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Individual cohort study. Individual low-quality randomized controlled trial \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">3a \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Systematic review of case-control studies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">3b \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Individual case-control study \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Case series, poor quality cohort case-control studies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Expert opinions or documents \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab785728.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Levels of Evidence." ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Primary Prevention \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Exposure to Microbes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Probiotics and prebiotics \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Endotoxins \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Pets \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Unpasteurized milk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Reduced use of broad-spectrum antibiotics \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Immune tolerance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Environmental allergens \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Foods \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Secondary Prevention \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Effective control of outbreaks \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Restoration of the skin barrier \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Treatment of subclinical inflammation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Emollients \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab785727.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Strategies for the Prevention of Atopic Dermatitis." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:63 [ 0 => array:3 [ "identificador" => "bib0320" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk of developing asthma in young children with atopic eczema: A systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.E. 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Controversies in Dermatology

Can Atopic Dermatitis Be Prevented?

¿Se puede prevenir la dermatitis atópica?

E. Gómez-de la Fuente

Servicio de Dermatología, Hospital Universitario Fundación Alcorcón, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">INTRODUCTION</span><p id="par0005" class="elsevierStylePara elsevierViewall">Atopic dermatitis &#40;AD&#41; is a chronic inflammatory disease whose prevalence has increased considerably in recent years&#44; with the consequent marked effect on patient quality of life and very high costs&#46; Furthermore&#44; it is usually the first manifestation of the so-called atopic march&#44; and a high percentage of patients with AD eventually develop food allergy&#44; asthma&#44; and&#47;or allergic rhinitis&#46; Approximately&#44; one-third of patients with AD will develop asthma and two-thirds allergic rhinitis&#59; however&#44; there is no conclusive evidence on the percentage who will develop food allergy&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">1&#44;2</span></a> Therefore&#44; AD has become a real health problem in our setting&#46; Since AD is a chronic disease with no cure&#44; it would be extremely interesting to have effective preventive measures&#46; Based on a critical review of available scientific evidence and levels of evidence for specific interventions &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">3</span></a> the present article aims to determine whether there are effective ways of preventing AD&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Prevention can be at several levels&#46; Here&#44; interventions will be reviewed at primary and secondary level&#46; By primary prevention&#44; we mean the set of actions aimed at preventing onset of the disease&#59; by secondary prevention&#44; we mean early diagnosis and treatment to reduce morbidity and&#47;or mortality&#46; In the former&#44; we try to reduce the incidence of DA&#44; and in the latter&#44; we try to reduce severity and complications&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Preventive measures should be based on appropriate knowledge of the etiology and pathogenesis of a disease&#44; which is a limitation in AD given that both are unknown&#46; A series of genetic factors&#44; in particular loss-of-function mutations in the filaggrin gene&#44; interact with environmental factors to produce the various clinical manifestations of AD &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">4&#44;5</span></a> These genetic factors themselves are insufficient to account for the increased prevalence of AD&#44; as shown by the fact that immigrants from developing countries acquire the prevalence of their host country or the rural&#47;urban difference within a single country&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">6</span></a> Therefore&#44; a series of environmental factors favor the development of an atopic phenotype&#44; whereas others protect against this phenotype&#46; These factors act mainly at very early stages of development &#40;last months of pregnancy and first year of life&#41;&#44; as shown by the observation that in more than 60&#37; of cases&#44; AD manifests during the first year of life&#46; Preventive measures should focus on this stage&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Primary Prevention</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Exposure to Microbes&#58; Hygiene Hypothesis</span><p id="par0020" class="elsevierStylePara elsevierViewall">The hygiene hypothesis posits that reduced exposure to specific microorganisms during key periods of development leads to immunologic modification favoring acquisition or maintenance of an atopic phenotype&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">7</span></a> It is important to highlight the role of intestinal flora&#8212;at least 60&#37; of lymphocytes are in the digestive tract&#8212;which is essential for the development of sensitization and immune tolerance&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Probiotics and Prebiotics</span><p id="par0025" class="elsevierStylePara elsevierViewall">In utero&#44; the intestine is sterile&#44; although it quickly becomes colonized after delivery&#46; Intestinal flora is less diverse in children with AD&#44; with reduced presence of <span class="elsevierStyleItalic">Bifidobacterium</span> species and increased presence of <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">8</span></a> We might ask whether addition of a probiotic or prebiotic could modify intestinal flora by modulating reactivation of the immune system to prevent AD&#46; The relevant literature is abundant&#44; with contradictory findings and considerable heterogeneity between studies in terms of factors such as diagnostic criteria&#44; methodology&#44; strains&#44; and dose&#46; Therefore&#44; it is very difficult to compare studies and the conclusions from meta-analyses&#46; The fact that many authors and the World Allergy Organization feel that more studies are necessary means that it is too early to make appropriate recommendations&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">9&#8211;11</span></a> Nevertheless&#44; research should continue in this direction&#46; Special mention should be made of a recent paper&#44;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">12</span></a> in which 26 randomized studies were reviewed &#40;level of evidence&#44; 1a&#41;&#46; The authors concluded that probiotics are useful for prevention of AD&#44; but only if they are administered sequentially during the last months of pregnancy and the first months of life&#46; They would prove useless if administered only after birth&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Endotoxins</span><p id="par0030" class="elsevierStylePara elsevierViewall">Several epidemiological studies have established an association between specific situations and protection against AD&#46; As mentioned above&#44; these situations are characterized by exposure&#8212;especially during pregnancy and the first year of life&#8212;to specific microorganisms that can reduce the risk of AD by modifying the immune system&#46; The reduced risk could be due to endotoxins&#44; a group of lipopolysaccharides present in the walls of gram-negative bacteria&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Farm Animals and Unpasteurized Milk</span><p id="par0035" class="elsevierStylePara elsevierViewall">Children who live on farms are thought to have a lower risk of AD&#44; although there is no evidence that merely living on a farm exercises a protective effect&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">5</span></a> The reasons underlying this possibility could be the effect of unpasteurized milk &#40;rich in lactobacilli&#41; and contact with farm animals&#44; especially if exposure is both before and after birth&#46; This protective effect has even been observed in persons from an urban environment who drink unpasteurized milk &#40;level of evidence&#44; 3b&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Pets</span><p id="par0040" class="elsevierStylePara elsevierViewall">The presence of pets during the first year of life could protect against AD&#46; Several studies show a uniform protective effect with dogs &#40;level of evidence&#44; 2a&#41;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">14</span></a>&#59; however&#44; this effect is less clear with cats&#44; and findings are contradictory&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">15</span></a> The risk is greater in children with mutations in the filaggrin gene&#44; suggesting that alterations in the barrier function could facilitate sensitization to cat dander and development of AD&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">16&#44;17</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Helminth Infection</span><p id="par0045" class="elsevierStylePara elsevierViewall">Some articles showed an inverse association between AD and helminth infection&#44; thus explaining&#44; at least in part&#44; differences between developed and developing countries and rural and urban areas &#40;level of evidence&#44; 3b&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">18&#44;19</span></a> Greater evidence for this association is found in various interventional studies&#44; which show an increased risk in pregnant women taking antihelminth therapy in endemic areas &#40;level of evidence&#44; 1b&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">20</span></a> The immunologic basis for this protective effect is not clear&#44; although it could result from an anti-inflammatory effect caused by increased production of interleukin &#40;IL&#41; 10&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Infections and Vaccines</span><p id="par0050" class="elsevierStylePara elsevierViewall">The several studies that examine infections &#40;viral and bacterial&#41; occurring before birth or during infancy report contradictory results&#46; Some found a slight increase in the risk of AD<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">22</span></a> and others a protective effect&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">23</span></a> Schmitt et al&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">24</span></a> observed no association and linked the possible increased risk to more frequent use of antibiotics&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The same is true with vaccines&#46; Whereas some studies suggest a slight increase in risk&#44; more modern studies found no association with AD&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Antibiotics</span><p id="par0060" class="elsevierStylePara elsevierViewall">Although it can be difficult to discriminate between the use of antibiotics and the infection they are prescribed for&#44; several studies have associated antibiotic therapy with an increased risk of AD&#46; Tsakok et al&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">25</span></a> recently performed a systematic review of 20 studies and found a positive association between antibiotic therapy and the subsequent risk of developing AD&#44; especially if the antibiotics are broad-spectrum&#46; This association was maintained both in the 7 cross-sectional studies and in the 13 longitudinal studies analyzed&#46; The risk was present when therapy was administered both before and after birth&#46; In addition&#44; the risk was cumulative&#44; that is&#44; the more cycles of antibiotics taken&#44; the greater the risk of developing AD&#46; Once again&#44; this increased risk is thought to be due to an alteration in the microflora&#44; which would in turn lead to an alteration in the immune system&#46; Thus&#44; until more robust evidence becomes available&#44; it seems reasonable to recommend that antibiotics&#44; especially broad-spectrum antibiotics&#44; be prescribed with caution &#40;level of evidence&#44; 2a and 3a&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dietary Modifications</span><p id="par0065" class="elsevierStylePara elsevierViewall">The recommendations and actions reported in the literature are as follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsit0015"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">Modification of maternal diet&#44; with a reduction in the so-called allergenic foods&#44; &#969;-3 supplements&#44; fatty acids&#44; and vitamin D</p></li><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">Replacement of infant formulas with hydrolyzed formulas&#44; soy milk&#44; mineral supplements&#44; and vitamin supplements &#40;eg&#44; vitamin D&#41;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall">Promotion of breastfeeding</p></li></ul></p><p id="par0080" class="elsevierStylePara elsevierViewall">Again&#44; study results are controversial and contradictory&#44; in part owing to very heterogeneous designs&#46; Research in this field is ongoing&#46; It is no surprise that at visits&#44; patients&#8212;or parents&#8212;ask us which foods should be avoided or if taking a supplement would help to improve the patient&#39;s symptoms&#46; In accordance with the information provided above&#44; and until further trials have been performed&#44; no routine recommendations can be made&#44; as demonstrated by meta-analyses &#40;with their inherent bias&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">9&#44;26</span></a></p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Breastfeeding</span><p id="par0085" class="elsevierStylePara elsevierViewall">Breastfeeding has traditionally been considered a major barrier against AD and allergy&#46; In fact&#44; the World Health Organization recommends breastfeeding as the only source of food during the first 6 months&#46; Nevertheless&#44; recent studies and various meta-analyses have shown that this approach could be erroneous&#44; as far as reduction in the frequency of AD and allergy is concerned&#46; Data from the phase II International Study of Asthma and Allergies in Childhood &#40;ISAAC&#41;&#44; which includes more than 51&#160;000 children&#44; found no evidence that breastfeeding alone is capable of preventing AD&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">27</span></a> Similarly&#44; a meta-analysis of 27 prospective studies found no protection against AD&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">28</span></a> Breastfeeding is considered the most complete source of food because of its nutritional properties and effects on the immune system&#46; These studies do not change this notion but merely point out that breastfeeding is not useful for preventing atopy and that this should be taken into account when informing patients &#40;level of evidence&#44; 2a&#41;&#46; Once again&#44; the reason could be the greater frequency of intestinal infection and colonization with artificial milk&#59; however&#44; immunologic mechanisms could also be involved&#46; A deeply rooted idea in our setting is that late introduction of solid foods can prevent allergy&#46; However&#44; several studies show that early introduction of solid foods&#44; unlike strict allergen avoidance&#44; could be more likely to induce immune tolerance than sensitization&#46;<a class="elsevierStyleCrossRefs" href="#bib0460"><span class="elsevierStyleSup">29&#44;30</span></a> The several clinical trials that are under way to verify the effect of breastfeeding only compared with breastfeeding and early introduction of solid foods could shed some light on this issue&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">31</span></a></p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">House Dust Mites</span><p id="par0090" class="elsevierStylePara elsevierViewall">A significant percentage of patients with AD are sensitized to house dust mites&#44; and some experience outbreaks after exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">32</span></a> Nevertheless&#44; one systematic review found no evidence of improvement when house dust levels were reduced&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">33</span></a> Some studies even found a paradoxical increase in the risk of AD in families who avoided the allergen&#44; much in the same way as when endotoxins are avoided&#46;<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">34&#44;35</span></a> Therefore&#44; in practical terms&#44; strict avoidance of house dust mites should not be recommended as a strategy for prevention or treatment&#44; since it is difficult&#44; impractical&#44; and&#44; possibly&#44; erroneous&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Secondary Prevention</span><p id="par0095" class="elsevierStylePara elsevierViewall">Secondary prevention measures are aimed at reducing the number and intensity of outbreaks and preventing or diminishing the atopic march&#46; These strategies could have an effect on each other&#46; Furthermore&#44; secondary prevention measures are occasionally involved in primary prevention strategies&#44; since genetic and environmental risk factors are present before and after the disease develops&#46;</p><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Modification of the Atopic March</span><p id="par0100" class="elsevierStylePara elsevierViewall">The atopic march is the natural history of atopic manifestations&#44; of which AD is usually the first&#44; followed by food allergy&#44; asthma&#44; and allergic rhinitis&#46; This development is a real phenomenon&#44; although there is some debate as to whether it represents a causal relationship or concurrent manifestations of an atopic phenotype that shares environmental and genetic risk factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">36&#44;37</span></a> Since the discovery of the filaggrin gene and its loss-of-function mutation as a risk factor for AD&#44; the loss of the barrier function of the epidermis has become increasingly relevant&#46; The filaggrin mutation is associated with asthma in patients with AD&#44; although not in those with mutations who do not have AD<a class="elsevierStyleCrossRefs" href="#bib0505"><span class="elsevierStyleSup">38&#44;39</span></a>&#59; hence the potential importance of the barrier function of the stratum corneum in sensitization to allergens&#46; The association between severity of AD and more marked alteration of the barrier function and a higher percentage of subsequent sensitizations points to a causal mechanism&#46;<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">37&#44;40&#8211;42</span></a> It has been postulated that an epidermis with a faulty barrier function enables passage of microorganisms and allergens&#44; leading to epicutaneous sensitization that triggers the atopic march&#46;<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">36&#44;39&#44;43</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">If we assume that the atopic march is causal and that it is due&#44; at least in part&#44; to a defective skin barrier&#44; then it could be avoided or at least diminished if we could restore the skin barrier&#46; How to achieve this is a key issue&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Restoration of the Defective Skin Barrier</span><p id="par0110" class="elsevierStylePara elsevierViewall">The 2 basic assets in this area are emollients and control of inflammation&#46; In AD&#44; inflammation produces a series of cytokines that can exercise a negative effect on the expression of filaggrin and the synthesis of specific lipids present in the stratum corneum&#44; thus leading to greater transepidermal elimination of water and more marked loss of barrier function&#46;<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">44&#8211;46</span></a> Therefore&#44; when restoring the epidermal barrier&#44; it is important to control outbreaks&#46;</p><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Reduction of the Intensity&#47;Severity of Outbreaks</span><p id="par0115" class="elsevierStylePara elsevierViewall">AD involves subclinical inflammation&#44; with histologic and immunologic abnormalities in the unaffected skin of patients with the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">47</span></a> Several studies report a reduction in the number and intensity of outbreaks when subclinical inflammation is treated with topical tacrolimus administered over 2-3 days per week in both adults and children &#40;level of evidence&#44; 1b&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">48&#44;49</span></a> This so-called proactive treatment is not restricted to calcineurin inhibitors&#59; it can also be administered via topical corticosteroids twice weekly &#40;level of evidence&#44; 1b&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0565"><span class="elsevierStyleSup">50&#44;51</span></a> The most appropriate regimen in terms of clinical and cost-effectiveness criteria remains to be determined&#59; however&#44; this is not the object of the present review&#46; Very few studies analyze modification of respiratory symptoms using these treatments&#46; Two studies report on the same group of patients &#40;moderate-severe AD&#41; treated with tacrolimus cream for 1 year for minimal symptoms and up to 1 week after the outbreak was resolved&#46;<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">52&#44;53</span></a> The patients were evaluated at 4 and 10 years&#46; The authors found that the severity of the skin manifestations had decreased and that the respiratory symptoms had improved&#46; Nevertheless&#44; the study is subject to bias&#44; since it is open-label with no control group&#44; thus preventing us from drawing clear conclusions &#40;level of evidence&#44; 4&#41;&#46; In addition&#44; the study population comprised adult patients with AD and established respiratory symptoms&#46; Ideally&#44; children should be analyzed to evaluate the effect of these early treatments on subsequent manifestations of atopic disease&#46; A similarly designed trial was performed with topical pimecrolimus&#59; however&#44; unfortunately&#44; the study ended early owing to loss of patients&#44; and no conclusions could be drawn&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">54</span></a> This trial coincided with the alert from the United States Food and Drug Administration on the risk of neoplasm associated with calcineurin inhibitors&#46; The alert may account for the loss of patients and the early termination of the study&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Emollients</span><p id="par0120" class="elsevierStylePara elsevierViewall">Moisturizing with emollients has traditionally been the cornerstone of management of AD&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">55</span></a> In addition to reducing the loss of water through the skin&#44; emollients relieve itching and increase the efficacy of and reduce the need for topical corticosteroids&#46;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">56&#44;57</span></a> They are increasingly used as a result of the discovery of the role of filaggrin and other proteins in the stratum corneum and advances in our knowledge of the lipid composition of this layer&#46; Just as inflammation leads to a more intense alteration of barrier function&#44; correct hydration can reduce the inflammation observed in the dry skin of patients with AD&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">40&#44;58&#44;59</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Emollients can be classed as nonphysiologic &#40;eg&#44; petrolatum and lanolin&#41;&#44; that is&#44; they are not present naturally in the skin&#44; or physiologic&#46; Physiologic emollients are composed of lipids present in the stratum corneum and have proven to be defective in patients with AD&#46; They include ceramides&#44; cholesterol&#44; and free fatty acids&#46; Emollients can penetrate the stratum corneum&#44; are taken up by keratinocytes&#44; processed in lamellar bodies&#44; and resecreted to the stratum corneum more naturally&#46; However&#44; our knowledge is theory-based&#44; since the few studies available were performed with low numbers of patients and short follow-up periods&#46; Furthermore&#44; almost no results are available from randomized controlled trials on the various types of emollients&#44; although several studies are ongoing&#46;</p><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Emollients used in primary prevention</span><p id="par0130" class="elsevierStylePara elsevierViewall">Current efforts to develop emollients are focused on restoration of barrier function and improvement in the symptoms of AD&#46; Very few studies examine primary prevention&#46; Simpson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">60</span></a> studied 22 neonates from families at a high risk of developing AD who used an emollient &#40;oil-in-water&#41; from birth&#46; Clear conclusions cannot be drawn&#44; since the study did not have a control group&#46; However&#44; a comparison with historic controls led the authors to suggest a decrease in incidence &#40;level of evidence&#44; 4&#41;&#46; More recently&#44; Inoue et al&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">61</span></a> compared 147 neonates with a control group but found no differences with respect to incidence&#46; They did find differences&#44; however&#44; for severity&#44; which was lower in children treated twice daily with emollients&#46; The authors performed a single measurement at 4 months of age&#44; which is insufficient in a disease such as AD &#40;level of evidence&#44; 3b&#41;&#46; In any case&#44; this approach is being investigated in ongoing clinical trials&#44; although more time and more studies are necessary before firm conclusions can be drawn&#46;</p></span></span></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusions and Reflections</span><p id="par0135" class="elsevierStylePara elsevierViewall">It is impossible to prevent a disease as complex and multifactorial as AD by eliminating a single risk factor&#46; AD requires an integral approach involving various health professionals and public authorities and enabling different prevention strategies to be promoted&#46; Unfortunately&#44; such strategies have not yet been established and cannot be routinely recommended&#44; since there is insufficient evidence &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; However&#44; this does not necessarily mean that these strategies do not work&#44; only that we must perform additional studies&#44; many of which are already under way&#46; The clearest example is the use of probiotics and prebiotics in primary prevention&#44; which has yielded promising results in some clinical trials&#46; Other measures are simply impractical and cannot be applied at the population level&#46; Although helminth infection and the endotoxins of specific bacteria reduce the risk of AD&#44; infecting children or pregnant women with this purpose in mind is unthinkable&#46; Instead&#44; attempts are being made to isolate components of the helminth wall and various bacterial lipopolysaccharides so that they can be administered exogenously&#46; Results are available from murine and human studies&#44; although these remain scarce&#46; Nevertheless&#44; this aspect warrants further analysis&#46;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">62&#44;63</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">Halting the atopic march is of considerable interest&#44; since a clear temporal relationship and biological plausibility have been observed&#46; Nevertheless&#44; interventional studies confirming causality and the real possibility of halting the disease have yet to be performed&#46; If this progression could be prevented by controlling inflammation &#40;clinical and subclinical&#41; and restoring barrier function&#44; disease course could actually be modified&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Also controversial is the selection of candidates for preventive measures&#46; The high prevalence of AD and its implication in the development of other atopic diseases would justify taking measures in the general population&#46; Nevertheless&#44; as mentioned above&#44; these measures have not been well defined&#44; and many clinical trials have focused on at-risk patients &#40;first-degree relatives of atopic individuals&#41;&#46; Furthermore&#44; dermatologists have easy access to these individuals&#46; It is in this specific group that we can establish appropriate measures or&#44; based at least on our knowledge of etiology and pathogenesis and advances in epidemiology&#44; we could inform patients appropriately and avoid unsuitable and erroneous measures and disinformation&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Lastly&#44; genetic studies and new biomarkers will probably enable different subtypes or phenotypes of AD to be established&#44; thus enabling more personalized therapeutic and preventive measures to be developed&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of Interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">The author declares that he has no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "Probiotics and Prebiotics"
            ]
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              "identificador" => "sec0025"
              "titulo" => "Endotoxins"
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                0 => array:2 [
                  "identificador" => "sec0030"
                  "titulo" => "Farm Animals and Unpasteurized Milk"
                ]
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                  "titulo" => "Pets"
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                  "identificador" => "sec0040"
                  "titulo" => "Helminth Infection"
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                  "identificador" => "sec0045"
                  "titulo" => "Infections and Vaccines"
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              "identificador" => "sec0050"
              "titulo" => "Antibiotics"
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            4 => array:3 [
              "identificador" => "sec0055"
              "titulo" => "Dietary Modifications"
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                0 => array:2 [
                  "identificador" => "sec0060"
                  "titulo" => "Breastfeeding"
                ]
              ]
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              "identificador" => "sec0065"
              "titulo" => "House Dust Mites"
            ]
          ]
        ]
        6 => array:3 [
          "identificador" => "sec0070"
          "titulo" => "Secondary Prevention"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0075"
              "titulo" => "Modification of the Atopic March"
            ]
            1 => array:3 [
              "identificador" => "sec0080"
              "titulo" => "Restoration of the Defective Skin Barrier"
              "secciones" => array:2 [
                0 => array:2 [
                  "identificador" => "sec0085"
                  "titulo" => "Reduction of the Intensity&#47;Severity of Outbreaks"
                ]
                1 => array:3 [
                  "identificador" => "sec0090"
                  "titulo" => "Emollients"
                  "secciones" => array:1 [
                    0 => array:2 [
                      "identificador" => "sec0095"
                      "titulo" => "Emollients used in primary prevention"
                    ]
                  ]
                ]
              ]
            ]
          ]
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        7 => array:2 [
          "identificador" => "sec0100"
          "titulo" => "Conclusions and Reflections"
        ]
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          "identificador" => "sec0105"
          "titulo" => "Conflicts of Interest"
        ]
        9 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2014-06-30"
    "fechaAceptado" => "2014-12-14"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec515866"
          "palabras" => array:3 [
            0 => "Atopic dermatitis"
            1 => "Prevention"
            2 => "Atopic march"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec515867"
          "palabras" => array:3 [
            0 => "Dermatitis at&#243;pica"
            1 => "Prevenci&#243;n"
            2 => "Marcha at&#243;pica"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Atopic dermatitis has become a health problem in our setting due to its rising prevalence&#44; impact on quality of life&#44; associated costs&#44; and role in the progression to other atopic diseases&#46; Furthermore&#44; atopic dermatitis has no definitive cure and therefore preventive measures are important&#46; In this article&#44; we review the latest advances in both primary prevention &#40;reduction of the incidence of atopic dermatitis&#41; and secondary prevention &#40;reduction of associated morbidity and reduction of the atopic march&#41;&#46; We analyze the different preventive strategies available&#44; including modification of the immune system through microbial exposure&#44; induction of immune tolerance through antigen exposure&#44; and restoration of skin barrier function to halt the atopic march&#46; Dermatologists need to be familiar with these strategies in order to apply them where necessary and to accurately inform patients and their relatives to prevent misguided or inappropriate actions&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La dermatitis at&#243;pica &#40;DA&#41; se ha convertido en un problema de salud en nuestro medio debido al aumento de su prevalencia&#44; la alteraci&#243;n de la calidad de vida&#44; los gastos que ocasiona y su implicaci&#243;n en la progresi&#243;n a otras enfermedades at&#243;picas&#46; Adem&#225;s no tiene una cura definitiva&#44; por lo que ser&#237;a interesante la aplicaci&#243;n de medidas preventivas&#46; En este art&#237;culo se revisan los &#250;ltimos avances implicados en su prevenci&#243;n&#44; tanto primaria &#40;disminuci&#243;n de incidencia&#41;&#44; como secundaria &#40;disminuci&#243;n de morbilidad&#44; evitar la progresi&#243;n de la marcha at&#243;pica&#41;&#46; Se abordan las diversas estrategias implicadas&#44; entre las que se encuentran la modificaci&#243;n del sistema inmune mediante exposici&#243;n microbiana&#44; la inducci&#243;n de tolerancia inmunol&#243;gica por exposici&#243;n antig&#233;nica y la restauraci&#243;n de la funci&#243;n barrera para frenar la marcha at&#243;pica&#46; Estas medidas deber&#237;an ser conocidas por los dermat&#243;logos para aplicarlas cuando sea posible&#44; y poder informar adecuadamente a los pacientes y familiares&#44; evitando actuaciones inadecuadas y&#47;o err&#243;neas&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; G&#243;mez-de la Fuente E&#46; &#191;Se puede prevenir la dermatitis at&#243;pica&#63;&#46; Actas Dermosifiliogr&#46; 2015&#59;106&#58;278&#8211;284&#46;</p>"
      ]
    ]
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Etiology and pathogenesis of atopic dermatitis&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Sackett and Wennberg&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">3</span></a></p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Meta-analysis of well-designed randomized controlled clinical trials&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Systematic review of case-control studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">3b&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Individual case-control study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Case series&#44; poor quality cohort case-control studies&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Expert opinions or documents&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Primary Prevention</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Reduced use of broad-spectrum antibiotics&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Secondary Prevention</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Effective control of outbreaks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Restoration of the skin barrier&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Strategies for the Prevention of Atopic Dermatitis&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:63 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Risk of developing asthma in young children with atopic eczema&#58; A systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46;E&#46; Van der Hulst"
                            1 => "H&#46; Klip"
                            2 => "P&#46;L&#46; Brand"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.jaci.2007.05.042"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Allergy Clin Immunol"
                        "fecha" => "2007"
                        "volumen" => "120"
                        "paginaInicial" => "565"
                        "paginaFinal" => "569"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17655920"
                            "web" => "Medline"
                          ]
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            1 => array:3 [
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              "etiqueta" => "2"
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                    0 => array:2 [
                      "titulo" => "Epidemiology of atopic dermatitis and atopic march in children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46;M&#46; Spergel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.iac.2010.06.003"
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                        "tituloSerie" => "Immunol Allergy Clin North Am"
                        "fecha" => "2010"
                        "volumen" => "30"
                        "paginaInicial" => "269"
                        "paginaFinal" => "280"
                        "link" => array:1 [
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                          ]
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              "etiqueta" => "3"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Choosing the best research design for each question"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "D&#46;L&#46; Sackett"
                            1 => "J&#46;E&#46; Wennberg"
                          ]
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                      ]
                    ]
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                    0 => array:1 [
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                        "tituloSerie" => "BMJ"
                        "fecha" => "1997"
                        "volumen" => "315"
                        "paginaInicial" => "1636"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9448521"
                            "web" => "Medline"
                          ]
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              "identificador" => "bib0335"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Immunology of atopic eczema&#58; Overcoming the Th1&#47;Th2 paradigm"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "K&#46; Eyerich"
                            1 => "N&#46; Novak"
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                      ]
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                  ]
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                    0 => array:2 [
                      "doi" => "10.1111/all.12184"
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                        "fecha" => "2013"
                        "volumen" => "68"
                        "paginaInicial" => "974"
                        "paginaFinal" => "982"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23889510"
                            "web" => "Medline"
                          ]
                        ]
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                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0340"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Genetics of atopic dermatitis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "C&#46; Bussmann"
                            1 => "S&#46; Weidinger"
                            2 => "N&#46; Novak"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1610-0387.2011.07656.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Dtsch Dermatol Ges"
                        "fecha" => "2011"
                        "volumen" => "9"
                        "paginaInicial" => "670"
                        "paginaFinal" => "676"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21518425"
                            "web" => "Medline"
                          ]
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                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0345"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "New insights into the epidemiology of childhood atopic dermatitis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "C&#46; Flohr"
                            1 => "J&#46; Mann"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/all.12270"
                      "Revista" => array:6 [
                        "tituloSerie" => "Allergy"
                        "fecha" => "2014"
                        "volumen" => "69"
                        "paginaInicial" => "3"
                        "paginaFinal" => "16"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24417229"
                            "web" => "Medline"
                          ]
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                      ]
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              ]
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            6 => array:3 [
              "identificador" => "bib0350"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Atopic dermatitis and the hygiene hypothesis revisited"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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Article information

ISSN: 15782190
Original language: English

DOI:10.1016/j.adengl.2015.03.020

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	9	5	14
2024 October	80	42	122
2024 September	80	34	114
2024 August	132	54	186
2024 July	97	28	125
2024 June	86	38	124
2024 May	83	34	117
2024 April	86	28	114
2024 March	91	36	127
2024 February	84	28	112
2024 January	97	40	137
2023 December	99	26	125
2023 November	90	30	120
2023 October	76	26	102
2023 September	79	37	116
2023 August	69	14	83
2023 July	84	52	136
2023 June	79	27	106
2023 May	81	37	118
2023 April	58	19	77
2023 March	93	22	115
2023 February	71	27	98
2023 January	44	18	62
2022 December	59	45	104
2022 November	40	39	79
2022 October	31	25	56
2022 September	37	62	99
2022 August	30	40	70
2022 July	25	38	63
2022 June	19	34	53
2022 May	51	39	90
2022 April	62	59	121
2022 March	53	43	96
2022 February	61	41	102
2022 January	70	61	131
2021 December	52	40	92
2021 November	43	54	97
2021 October	67	47	114
2021 September	51	41	92
2021 August	57	43	100
2021 July	46	35	81
2021 June	50	40	90
2021 May	40	34	74
2021 April	133	36	169
2021 March	85	27	112
2021 February	72	31	103
2021 January	48	23	71
2020 December	40	20	60
2020 November	37	31	68
2020 October	28	13	41
2020 September	51	16	67
2020 August	33	29	62
2020 July	35	27	62
2020 June	36	30	66
2020 May	34	15	49
2020 April	50	21	71
2020 March	35	18	53
2020 February	4	0	4
2020 January	6	2	8
2019 December	8	1	9
2019 November	4	2	6
2019 September	4	2	6
2019 August	4	4	8
2019 July	4	9	13
2019 June	4	32	36
2019 May	6	30	36
2019 April	2	8	10
2019 March	4	7	11
2019 February	2	4	6
2019 January	2	0	2
2018 December	2	0	2
2018 November	1	0	1
2018 October	3	0	3
2018 September	4	0	4
2018 March	9	1	10
2018 February	23	7	30
2018 January	50	7	57
2017 December	32	9	41
2017 November	30	7	37
2017 October	27	11	38
2017 September	19	6	25
2017 August	23	7	30
2017 July	11	12	23
2017 June	38	17	55
2017 May	21	11	32
2017 April	39	18	57
2017 March	18	54	72
2017 February	28	15	43
2017 January	19	11	30
2016 December	29	21	50
2016 November	43	13	56
2016 October	36	13	49
2016 September	0	3	3
2016 August	0	4	4
2016 July	10	1	11
2016 June	6	1	7
2016 May	4	3	7
2016 April	9	2	11
2016 March	20	3	23
2016 February	8	2	10
2016 January	2	1	3
2015 December	5	4	9
2015 November	4	4	8
2015 October	0	9	9
2015 September	0	8	8
2015 August	0	7	7
2015 July	11	8	19
2015 June	1	4	5
2015 May	9	9	18

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