Prognosis and prognostic factors in adult patients with atopic dermatitis: a long-term follow-up questionnaire study.

BACKGROUND: Atopic dermatitis (AD) is a chronic relapsing skin disease. Several investigations concerning the long-term prognosis of AD among children and teenagers have been performed but there are only few data among adults. OBJECTIVES: To investigate the prognosis and prognostic factors in adult patients with AD by a long-term follow-up (25-38 years). The prognostic factors were defined as those factors of importance for the persistence of AD. PATIENTS AND METHODS: A follow-up questionnaire was sent in November/December 1998 to 922 AD patients examined in our outpatient clinic between 1960 and 1973 among 1366 registered patients with AD. The patients were aged 20 years or older when they visited the clinic and 45 years or older when they answered the follow-up questionnaire. RESULTS: The response rate was 90.4%. The age range at the time of follow-up was 45-86 years (mean 55 years). Of the 833 patients who responded, 59% reported AD at some time during the last 12 months, which we defined as persistent AD. The mean value of clearance rate per person-years was 18%. One of the most important factors associated with persistence of AD was a head and neck dermatitis with or without other AD locations at the time of examination according to the old patient records. CONCLUSIONS: This study showed that the majority of adults with AD still had AD when they became older. This applies particularly if negative prognostic factors existed.

Atopy patch test reactions to Malassezia allergens differentiate subgroups of atopic dermatitis patients.

BACKGROUND: The yeast Malassezia is considered to be one of the factors that can contribute to atopic dermatitis (AD). OBJECTIVES: To investigate the reactivity to Malassezia allergens, measured as specific serum IgE, positive skin prick test and positive atopy patch test (APT), in adult patients with AD. METHODS: In total, 132 adult patients with AD, 14 with seborrhoeic dermatitis (SD) and 33 healthy controls were investigated for their reactions to M. sympodialis extract and three recombinant Malassezia allergens (rMal s 1, rMal s 5 and rMal s 6). RESULTS: Sixty-seven per cent of the AD patients, but only one of the SD patients and none of the healthy controls, showed a positive reaction to at least one of the Malassezia allergens (extract and/or recombinant allergens) in at least one of the tests. The levels of M. sympodialis-specific IgE in serum correlated with the total serum IgE levels. Elevated serum levels of M. sympodialis-specific IgE were found in 55% and positive APT reactions in 41% of the AD patients with head and neck dermatitis. A relatively high proportion of patients without head and neck dermatitis and patients with low total serum IgE levels had a positive APT for M. sympodialis, despite lower proportions of individuals with M. sympodialis-specific IgE among these groups of patients. CONCLUSIONS: These results support that Malassezia can play a role in eliciting and maintaining eczema in patients with AD. The addition of an APT to the test battery used in this study reveals a previously overlooked impact of Malassezia hypersensitivity in certain subgroups of AD patients.

PUVA in early mycosis fungoides may give long-term remission and delay extracutaneous spread.

We report a follow-up for 3-18 years of 24 patients with the non-infiltrated patch and infiltrated plaque stage of mycosis fungoides, treated with psoralen photochemotherapy (PUVA) and on resistant infiltration or development of tumours also with fractionated radiation therapy. All patients with patch and limited plaques showed complete remission after initial PUVA therapy. Half of the patients with patch stage mycosis fungoides and also half of the patients with plaque stage mycosis fungoides were in complete remission when the study ended. Most of them had remission periods for years after early PUVA treatment. Patients with more advanced mycosis fungoides needed repeated periods of PUVA therapy. Two patients with extensive infiltrated plaques did not reach complete remission at all during the study but progressed and finally died of their T-cell lymphoma. Another 4 patients with extensive plaque stage mycosis fungoides died after initial complete remission for a maximum of 3 years. In this investigation the clinical evaluation was made by one dermatologist and the histopathological evaluation by one pathologist. This is of importance since in the early stages of mycosis fungoides the diagnosis is challenging and may require a combination of clinical, histopathological and molecular evaluations. The identification of early disease is crucial for the rapid implementation of adequate treatment. The study shows that early PUVA therapy may delay extracutaneous spread and possibly also in some cases be curative.

Indications of a considerable decrease in the death rate in mycosis fungoides by PUVA treatment.

PUVA therapy has its roots in ancient India and Egypt and began to come into general use in the highly developed countries in the middle of the 1970's (1). The first reports of PUVA treatment of mycosis fungoides were published in 1976 (2); these were followed by several other studies in the two following years (3-7). Some of the early work on PUVA therapy was carried out in Sweden (8,9), and the modality was in general use in most major clinics by 1977. The dramatic effect on mycosis fungoides of PUVA therapy is well known, but whether the death rate is influenced is not known. For ethical reasons no controlled clinical studies have been performed. Sweden is a highly organized country with reliable death statistics at least for diseases as conspicuous as mycosis fungoides. The purpose of the present study was to provide data on the death rate in mycosis fungoides in Sweden from 1961 to 1990, which we think is relevant to the question whether PUVA treatment decreases the death rate in mycosis fungoides.