Epidemiology and Economic Burden of Atopic Dermatitis: Real-World Retrospective Data from a Large Nationwide Israeli Healthcare Provider Database.

INTRODUCTION: Real-world data on the epidemiology and economic burden of atopic dermatitis (AD) are limited. Here we describe the epidemiology and economic burden of AD using electronic healthcare data from Israel. METHODS: A retrospective study was performed using the Maccabi Healthcare Services database. AD incidence in 2008-2017 and point prevalence (ADprev) on 31 December 2017 were described using diagnosis codes for overall patients, and sex and age subgroups. For ADprev, severity was defined using recently dispensed treatments for AD. Annual healthcare resource utilization in AD prevalent patients was compared with non-AD matched controls using generalized linear modelling. Direct annual costs were estimated also. RESULTS: AD incidence was 7.0/1000 person-years; overall prevalence was 4.4% (female patients 4.5%, male patients 4.3%; age 0 to less than 6 months, 0.9%; 6 months to less than 12 years, 11.0%; 12 to less than 18 years, 5.8%; 18 years or older, 2.2%). Among ADprev (n = 94,483), mild, moderate, and severe AD comprised 57.7%, 36.2%, and 6.1% (adults 43.8%, 46.3%, 9.9%), respectively. Dermatologist and allergist visits and hospitalization rates (at least one) were 40.7%, 6.6%, and 3.8% in 2017. Compared with controls, overall and moderate-to-severe AD were associated with 36% and 52% increases in annual per-person costs (incremental costs $126 and $190). CONCLUSIONS: AD epidemiology in Israel is comparable with other real-world database studies. AD imposes an economic burden that increases with disease severity.

Occurrence and costs of atopic dermatitis in IsraelAtopic dermatitis is a disease that causes the skin to be inflamed and itchy. Atopic dermatitis is most common in children but can also occur in adolescents and adults. Using data from a large healthcare provider in Israel, this study aimed to describe how common atopic dermatitis is within the population. Costs related to the use of healthcare services (such as visits to dermatologists and creams to treat atopic dermatitis) in the year 2017 were compared between persons with versus without atopic dermatitis. For the years 2008 to 2017, approximately 7 out of 1000 people were newly diagnosed with atopic dermatitis each year (incidence). Among people alive on 31 December 2017, 4.4% had atopic dermatitis (prevalence), with 42.3% suggestive of moderate to severe disease. Patients with atopic dermatitis, particularly those with more severe disease, used healthcare services more frequently. Compared with people without atopic dermatitis, medical costs among patients with atopic dermatitis were 36% higher (corresponding to added costs of $126 per person per year). This study helps to better understand how many people have atopic dermatitis, and what healthcare resources are needed to manage this disease.

Cutaneous Comorbidities Associated With Atopic Dermatitis in Israel: A Retrospective Real-World Data Analysis.

BACKGROUND: Patients with atopic dermatitis (AD) are susceptible to infectious and inflammatory cutaneous comorbidities. OBJECTIVE: The aim of the study was to describe the prevalence of cutaneous comorbidities associated with AD, including their relationship with AD severity. METHODS: A retrospective cross-sectional analysis was performed using the Israeli Maccabi Healthcare Services database. Prevalent AD cases on December 31, 2017, were diagnosed with AD at any time since 1998 and had 1 or more recent (2013-2017) AD diagnoses. Dispensed AD treatments within 5 or fewer years served as a surrogate for AD severity. Cutaneous comorbidities in AD cases were compared with non-AD controls matched 1:1 on age, sex, and residential area. Among adults, comorbidities were compared across AD severity using multinomial logistic regression. RESULTS: The eligible population included 94,483 patients with mild (57.7%), moderate (36.2%), or severe (6.1%) AD, and 94,483 matched non-AD controls. Skin infections, inflammatory skin conditions, cutaneous manifestations of AD, and sweat gland disorders were more prevalent ( P < 0.001) in patients with AD than in controls. Most cutaneous comorbidities that were more prevalent in adult patients with AD were also significantly ( P < 0.001) associated with AD severity. CONCLUSIONS: This study suggests that AD is associated with many infectious and inflammatory cutaneous comorbidities and highlights the relationship between AD severity and comorbidity prevalence.

Current controversies in oral lichen planus: report of an international consensus meeting. Part 2. Clinical management and malignant transformation.

Despite recent advances in understanding the immunopathogenesis of oral lichen planus (LP), the initial triggers of lesion formation and the essential pathogenic pathways are unknown. It is therefore not surprising that the clinical management of oral LP poses considerable difficulties to the dermatologist and the oral physician. A consensus meeting was held in France in March 2003 to discuss the most controversial aspects of oral LP. Part 1 of the meeting report focused on (1) the relationship between oral LP and viral infection, with special emphasis on hepatitis C virus (HCV), and (2) oral LP pathogenesis, in particular the immune mechanisms resulting in lymphocyte infiltration and keratinocyte apoptosis. Part 2 focuses on patient management and therapeutic approaches and includes discussion on malignant transformation of oral LP.

Current controversies in oral lichen planus: report of an international consensus meeting. Part 1. Viral infections and etiopathogenesis.

Despite recent advances in understanding the immunopathogenesis of oral lichen planus (LP), the initial triggers of lesion formation and the essential pathogenic pathways are unknown. It is therefore not surprising that the clinical management of oral LP poses considerable difficulties to the dermatologist and the oral physician. A consensus meeting was held in France in March 2003 to discuss the most controversial aspects of oral LP. Part 1 of the meeting report focuses on (1) the relationship between oral LP and viral infection with special emphasis on hepatitis C virus (HCV), and (2) oral LP pathogenesis, in particular the immune mechanisms resulting in lymphocyte infiltration and keratinocyte apoptosis. Part 2 focuses on patient management and therapeutic approaches and includes discussion on malignant transformation of oral LP.

Kinetics of gene expression in murine cutaneous graft-versus-host disease.

The kinetics of gene expression associated with the development of cutaneous graft-versus-host disease (GVHD) were examined in a mouse model of MHC-matched allogeneic hematopoietic stem cell transplantation. Ear skin was obtained from recipient mice with or without GVHD between 7 and 40 days after transplantation for histopathological analysis and gene expression profiling. Gene expression patterns were consistent with early infiltration and activation of CD8(+) T and mast cells, followed by CD4(+) T, natural killer, and myeloid cells. The sequential infiltration and activation of effector cells correlated with the histopathological development of cutaneous GVHD and was accompanied by up-regulated expression of many chemokines and their receptors (CXCL-1, -2, -9, and -10; CCL-2, -5, -6, -7, -8, -9, -11, and -19; CCR-1 and CCR-5), adhesion molecules (ICAM-1, CD18, Ly69, PSGL-1, VCAM-1), molecules involved in antigen processing and presentation (TAP1 and TAP2, MHC class I and II, CD80), regulators of apoptosis (granzyme B, caspase 7, Bak1, Bax, and BclII), interferon-inducible genes (STAT1, IRF-1, IIGP, GTPI, IGTP, Ifi202A), stimulators of fibroblast proliferation and matrix synthesis (interleukin-1beta, transforming growth factor-beta1), and markers of keratinocyte proliferation (keratins 5 and 6), and differentiation (small proline-rich proteins 2E and 1B). Many acute-phase proteins were up-regulated early in murine cutaneous GVHD including serum amyloid A2 (SAA2), SAA3, serpins a3g and a3n, secretory leukocyte protease inhibitor, and metallothioneins 1 and 2. The kinetics of gene expression were consistent with the evolution of cutaneous pathology as well as with current models of disease progression during cutaneous GVHD.

Th1 cytokines in oral lichen planus.

BACKGROUND: Cell-mediated immune responses in oral lichen planus (OLP) may be regulated by cytokines and their receptors. METHODS: In situ cytokine expression and in vitro cytokine secretion in OLP were determined by immunohistochemistry and ELISA. RESULTS: The majority of subepithelial and intraepithelial mononuclear cells in OLP were CD8+. In some cases, intraepithelial CD8+ cells were adjacent to degenerating keratinocytes. CD4+ cells were observed mainly in the deep lamina propria with occasional CD4+ cells close to basal keratinocytes. Mononuclear cells expressed IFN-gamma in the superficial lamina propria and TNF-alpha adjacent to basal keratinocytes. Basal keratinocytes expressed TNF-alpha as a continuous band. TNF R1 was expressed by mononuclear cells and basal and suprabasal keratinocytes. There was variable expression of TGF-beta1 in the subepithelial infiltrate while all intraepithelial mononuclear cells were TGF-beta1-. Keratinocytes in OLP stained weakly for TGF-beta1. Unstimulated OLP lesional T cells secreted IFN-gamma in vitro. TNF-alpha stimulation down-regulated IFN-gamma secretion and up-regulated TNF-alpha secretion. IL-4, IL-10 and TGF-beta1 secretion were not detected. CONCLUSIONS: These data suggest the development of a T helper 1 immune response that may promote CD8+ cytotoxic T-cell activity in OLP.

Patient selection for endosseous dental implants: oral and systemic considerations.

This paper reviews the literature and discusses patient selection for endosseous dental implants and the effect of systemic and local pathology on the success rate of dental implants. Endosseous dental implants may be preferable to conventional dentures in patients with compromised supporting bone or mucosa, xerostomia, allergy to denture materials, severe gag reflex, susceptibility to candidiasis, diseases affecting orofacial motor function or in patients who demand optimal bite force, esthetics, and phonetics. Conventional dentures or fixed partial prostheses may be preferable to endosseous dental implants in growing and epileptic patients and patients at risk of oral carcinoma, anaphylaxis, severe hemorrhage, steroid crisis, endocarditis, osteoradionecrosis, myocardial infarction, or peri-implantitis. A systematic approach to dental implant patient selection is outlined and centralized reporting of dental implant outcomes is recommended.

Intra-epithelial CD8+ T cells and basement membrane disruption in oral lichen planus.

BACKGROUND: We investigated basement membrane (BM) disruption and the distribution of mast cells (MCs) and T cell subsets, in oral lichen planus (OLP) and normal buccal mucosa (NBM) using immunohistochemistry. In OLP, there were increased numbers of tryptase+ MCs in areas of BM disruption (P < 0.05). METHOD: We identified clusters of intraepithelial CD8+ T cells in OLP, specifically in regions of BM disruption. The number of intraepithelial CD8+ T cells in regions of BM disruption was significantly greater than in regions of BM continuity (P < 0.05). RESULTS: There were comparable numbers of lamina propria CD8+ T cells in regions of BM disruption and BM continuity. The number of CD4+ T cells in the epithelium and lamina propria of OLP lesions did not vary between regions of BM disruption and BM continuity. CONCLUSION: These data suggest a role for MCs in epithelial BM disruption in OLP. CD8+ T cells may migrate through BM breaks to enter the OLP epithelium.