Kelly H. Tyler MD, FACOG; Matthew J. Zirwas MD, FAAD
Drs. Tyler and Zirwas are from the Ohio State University, Division of Dermatology, Columbus, Ohio.
Abstract
There is a recent accumulation of data suggesting that decreased exposure to ultraviolet light in childhood could be a major factor contributing to the increasing rates of atopic dermatitis in children and adolescents. It would be worthwhile to study the relationship between vigilant sun protective behaviors in children and the incidence of atopic dermatitis. (J Clin Aesthet Dermatol. 2014;7(11):38–39.)
It is a well-established fact that sun exposure and ultraviolet A/ultraviolet B phototherapy are beneficial for patients with a diagnosis of atopic dermatitis,[1] so it is no surprise that there is a growing body of evidence that ultraviolet-induced immunomodulation or a lack thereof is playing a roll in the increasing prevalence of atopic disease both in the United States and other countries.[2],[3] In addition, a recent study found an association between increased sun exposure and a reduced risk of atopic dermatitis in children and adolescents.[4]
The data in the United States and worldwide show a steady increase in the rates of atopic dermatitis in children, and one must wonder if the vigilant use of sunscreen and sun avoidance in children as recommended by the American Academy of Pediatrics[5] is one of the underlying reasons behind this trend. An article in Pediatrics looking at office visits for atopic dermatitis as a surrogate for the prevalence of atopic dermatitis in a patient population from newborns to age 18 throughout the United States from 1997 to 2004 showed a statistically significant increase in the number of visits over time even though the number of office visits for all diagnoses remained stable.[6] It appears that as sunscreen use for children has become more widespread in the United States, the number of children diagnosed with atopic dermatitis has increased as well.
Multiple studies have found that atopic eczema is more prevalent in affluent children.[7–12] The literature shows that this same population of individuals with higher socioeconomic status in the United States and other countries is also more stringent about sun protective behaviors.[13–14] As one might expect given the findings from studies on socioeconomic status, people with lower socioeconomic status living in rural areas are both less likely to engage in sun-protective behaviors and less likely to develop atopic dermatitis.[15] A multitude of studies show that growing up on a farm protects against the development of allergic disease,[16–23] which taken together with the other literature on socioeconomic status supports our hypothesis that increased time outdoors, decreased sun-protective behavior, and thus increased exposure to ultraviolet light decreases the incidence of atopic disease. One might infer that the trend toward children spending less time outdoors and more time inside watching television and playing video games is also directly affecting the increase in atopic disease.
Given the recent accumulation of data regarding the relationship between atopic disease and ultraviolet-induced immunomodulation, the authors believe the question of if ultraviolet avoidance in childhood increases the risk of atopic dermatitis deserves additional study. If there does appear to be a correlation, we should consider whether we need to create less stringent guidelines for ultraviolet avoidance.
References
1. Honigsmann H, Schwarz T. Ultraviolet therapy. In: Bolognia JL, Jorizzo JL, Schaffer JV, eds. Dermatology, 3rd edition. Philadelphia, PA: Elsevier; 2012:2219–2235.
2. Gorman S, McGlade JP, Lambert MJ, et al. UV exposure and protection against allergic airways disease. Photochem Photobiol. 2010;9:571–577.
3. Norval M. The challenges of UV-induced immunomodulation for children’s health. Prog Biophys Mol Biol. 2011;107: 323–332.
4. Kemp AS, Ponsonby AL, Pezic A, et al. The influence of sun exposure in childhood and adolescence on atopic disease at adolescence. Pediatr Allergy Immunol. 2013;24:493–500.
5. American Academy of Pediatrics Committee on Environmental Health. Ultraviolet light: a hazard to children. Pediatrics. 1999;104:328–333.
6. Horii KA, Simon SD, Liu DY, Sharma V. Atopic dermatitis in children in the United States, 1997?2004: visit trends, patient and provider characteristics, and prescribing patterns. Pediatrics. 2007;120;e527–e534.
7. Miyake Y, Tanaka K, Sasaki S, Hirota Y. Parental employment, income, education, and allergic disorders in children: a prebirth cohort study in Japan. Int J Tuberc Lung Dis. 2012;16:756–761.
8. Schlaud M, Atzpodien K, Thierfelder W. Allergic diseases. Results from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS). Bundesgesundheitsblatt, Gesundheitsforschung, Gesund-heitsschutz. 2007;50:701–710.
9. Victorino CC, Gauthier AH. The social determinants of child health: variations across health outcomes—a population-based cross-sectional analysis. BMC Pediatr. 2009;9:53.
10. Bergmann RL, Edenharter G, Bergmann KE, et al. Socioeconomic status is a risk factor for allergy in parents but not in their children. Clin Exp Allergy. 2000;30:1740–1745.
11. Weber AS, Haidinger G. The prevalence of atopic dermatitis in children is influenced by their parents’ education: results of two cross-sectional studies conducted in Upper Austria. Pediatr Allergy Immunol. 2010;21:1028–1035.
12. Hammer-Helmich L, Linneberg A, Thomsen SF, Glumer C. Association between parental socioeconomic position and prevalence of asthma, atopic eczema and hay fever in children. Scand J Public Health. 2013 Oct 2 [Epub ahead of print].
13. Hay J, Coups EJ, Ford J, DiBonaventura M. Exposure to mass media health information, skin cancer beliefs, and sun protection behaviors in a United States probability sample. J Am Acad Dermatol. 2009;61:783–792.
14. Duquia RP, Baptista Menezes AM, Reichert FF, de Almeida HL. Prevalence and associated factors with sunscreen use in Southern Brazil: a population-based study. J Am Acad Dermatol. 2007;57:73–80.
15. Zahnd WE, Goldfarb J, Scaife SL, Francis ML. Rural-urban differences in behaviors to prevent skin cancer: an analysis of the Health Information National Trends Survey. J Am Acad Dermatol. 2010;62:950–956.
16. Braun-Fahrlander C, Gassner M, Grize L, et al. Prevalence of hay fever and allergic sensitization in farmer’s children and their peers living in the same rural community. SCARPOL team. Swiss Study on Childhood Allergy and Respiratory Symptoms with Respect to Air Pollution. Clin Exp Allergy. 1999;29:28–34.
17. Riedler J, Eder W, Oberfeld G, Schreurer M. Austrian children living on a farm have less hay fever, asthma and allergic sensitization. Clin Exp Allergy. 2000;30:194–200.
18. Von Ehrenstein OS, von Mutius E, Illi S, et al. Reduced risk of hay fever and asthma among children of farmers. Clin Exp Allergy. 2000;30:187–193.
19. Kilpelainen M, Terho EO, Helenius H, Koskenvuo M. Farm environment in childhood prevents the development of allergies. Clin Exp Allergy. 2000;30:201–208.
20. Ernst P, Cormier Y. Relative scarcity of asthma and atopy among adolescents raised on a farm. Am J Respir Crit Care Med. 2000;161:1563–1566.
21. Riedler J, Braun-Fahrlander C, Eder W, et al. Exposure to farming in early life and development of asthma and allergy: a cross-sectional survey. Lancet. 2001;358:1129–1133.
22. Illi S, Depner M, Genuneit J, et al. Protection from childhood asthma and allergy in Alpine farm environments—the GABRIEL Advanced Studies. J Allergy Clin Immunol. 2012;129:1470–1477.
23. Fuchs O, Genuneit J, Latzin P, et al. Farming environments and childhood atopy, wheeze, lung function, and exhaled nitric oxide. J Allergy Clin Immunol. 2012;130:382–388.
Is Decreased Ultraviolet Exposure During Childhood the Cause of the Increased Prevalence of Atopic Dermatitis?
Kelly H. Tyler MD, FACOG; Matthew J. Zirwas MD, FAAD
Drs. Tyler and Zirwas are from the Ohio State University, Division of Dermatology, Columbus, Ohio.
Abstract
There is a recent accumulation of data suggesting that decreased exposure to ultraviolet light in childhood could be a major factor contributing to the increasing rates of atopic dermatitis in children and adolescents. It would be worthwhile to study the relationship between vigilant sun protective behaviors in children and the incidence of atopic dermatitis. (J Clin Aesthet Dermatol. 2014;7(11):38–39.)
It is a well-established fact that sun exposure and ultraviolet A/ultraviolet B phototherapy are beneficial for patients with a diagnosis of atopic dermatitis,[1] so it is no surprise that there is a growing body of evidence that ultraviolet-induced immunomodulation or a lack thereof is playing a roll in the increasing prevalence of atopic disease both in the United States and other countries.[2],[3] In addition, a recent study found an association between increased sun exposure and a reduced risk of atopic dermatitis in children and adolescents.[4]
The data in the United States and worldwide show a steady increase in the rates of atopic dermatitis in children, and one must wonder if the vigilant use of sunscreen and sun avoidance in children as recommended by the American Academy of Pediatrics[5] is one of the underlying reasons behind this trend. An article in Pediatrics looking at office visits for atopic dermatitis as a surrogate for the prevalence of atopic dermatitis in a patient population from newborns to age 18 throughout the United States from 1997 to 2004 showed a statistically significant increase in the number of visits over time even though the number of office visits for all diagnoses remained stable.[6] It appears that as sunscreen use for children has become more widespread in the United States, the number of children diagnosed with atopic dermatitis has increased as well.
Multiple studies have found that atopic eczema is more prevalent in affluent children.[7–12] The literature shows that this same population of individuals with higher socioeconomic status in the United States and other countries is also more stringent about sun protective behaviors.[13–14] As one might expect given the findings from studies on socioeconomic status, people with lower socioeconomic status living in rural areas are both less likely to engage in sun-protective behaviors and less likely to develop atopic dermatitis.[15] A multitude of studies show that growing up on a farm protects against the development of allergic disease,[16–23] which taken together with the other literature on socioeconomic status supports our hypothesis that increased time outdoors, decreased sun-protective behavior, and thus increased exposure to ultraviolet light decreases the incidence of atopic disease. One might infer that the trend toward children spending less time outdoors and more time inside watching television and playing video games is also directly affecting the increase in atopic disease.
Given the recent accumulation of data regarding the relationship between atopic disease and ultraviolet-induced immunomodulation, the authors believe the question of if ultraviolet avoidance in childhood increases the risk of atopic dermatitis deserves additional study. If there does appear to be a correlation, we should consider whether we need to create less stringent guidelines for ultraviolet avoidance.
References
1. Honigsmann H, Schwarz T. Ultraviolet therapy. In: Bolognia JL, Jorizzo JL, Schaffer JV, eds. Dermatology, 3rd edition. Philadelphia, PA: Elsevier; 2012:2219–2235.
2. Gorman S, McGlade JP, Lambert MJ, et al. UV exposure and protection against allergic airways disease. Photochem Photobiol. 2010;9:571–577.
3. Norval M. The challenges of UV-induced immunomodulation for children’s health. Prog Biophys Mol Biol. 2011;107: 323–332.
4. Kemp AS, Ponsonby AL, Pezic A, et al. The influence of sun exposure in childhood and adolescence on atopic disease at adolescence. Pediatr Allergy Immunol. 2013;24:493–500.
5. American Academy of Pediatrics Committee on Environmental Health. Ultraviolet light: a hazard to children. Pediatrics. 1999;104:328–333.
6. Horii KA, Simon SD, Liu DY, Sharma V. Atopic dermatitis in children in the United States, 1997?2004: visit trends, patient and provider characteristics, and prescribing patterns. Pediatrics. 2007;120;e527–e534.
7. Miyake Y, Tanaka K, Sasaki S, Hirota Y. Parental employment, income, education, and allergic disorders in children: a prebirth cohort study in Japan. Int J Tuberc Lung Dis. 2012;16:756–761.
8. Schlaud M, Atzpodien K, Thierfelder W. Allergic diseases. Results from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS). Bundesgesundheitsblatt, Gesundheitsforschung, Gesund-heitsschutz. 2007;50:701–710.
9. Victorino CC, Gauthier AH. The social determinants of child health: variations across health outcomes—a population-based cross-sectional analysis. BMC Pediatr. 2009;9:53.
10. Bergmann RL, Edenharter G, Bergmann KE, et al. Socioeconomic status is a risk factor for allergy in parents but not in their children. Clin Exp Allergy. 2000;30:1740–1745.
11. Weber AS, Haidinger G. The prevalence of atopic dermatitis in children is influenced by their parents’ education: results of two cross-sectional studies conducted in Upper Austria. Pediatr Allergy Immunol. 2010;21:1028–1035.
12. Hammer-Helmich L, Linneberg A, Thomsen SF, Glumer C. Association between parental socioeconomic position and prevalence of asthma, atopic eczema and hay fever in children. Scand J Public Health. 2013 Oct 2 [Epub ahead of print].
13. Hay J, Coups EJ, Ford J, DiBonaventura M. Exposure to mass media health information, skin cancer beliefs, and sun protection behaviors in a United States probability sample. J Am Acad Dermatol. 2009;61:783–792.
14. Duquia RP, Baptista Menezes AM, Reichert FF, de Almeida HL. Prevalence and associated factors with sunscreen use in Southern Brazil: a population-based study. J Am Acad Dermatol. 2007;57:73–80.
15. Zahnd WE, Goldfarb J, Scaife SL, Francis ML. Rural-urban differences in behaviors to prevent skin cancer: an analysis of the Health Information National Trends Survey. J Am Acad Dermatol. 2010;62:950–956.
16. Braun-Fahrlander C, Gassner M, Grize L, et al. Prevalence of hay fever and allergic sensitization in farmer’s children and their peers living in the same rural community. SCARPOL team. Swiss Study on Childhood Allergy and Respiratory Symptoms with Respect to Air Pollution. Clin Exp Allergy. 1999;29:28–34.
17. Riedler J, Eder W, Oberfeld G, Schreurer M. Austrian children living on a farm have less hay fever, asthma and allergic sensitization. Clin Exp Allergy. 2000;30:194–200.
18. Von Ehrenstein OS, von Mutius E, Illi S, et al. Reduced risk of hay fever and asthma among children of farmers. Clin Exp Allergy. 2000;30:187–193.
19. Kilpelainen M, Terho EO, Helenius H, Koskenvuo M. Farm environment in childhood prevents the development of allergies. Clin Exp Allergy. 2000;30:201–208.
20. Ernst P, Cormier Y. Relative scarcity of asthma and atopy among adolescents raised on a farm. Am J Respir Crit Care Med. 2000;161:1563–1566.
21. Riedler J, Braun-Fahrlander C, Eder W, et al. Exposure to farming in early life and development of asthma and allergy: a cross-sectional survey. Lancet. 2001;358:1129–1133.
22. Illi S, Depner M, Genuneit J, et al. Protection from childhood asthma and allergy in Alpine farm environments—the GABRIEL Advanced Studies. J Allergy Clin Immunol. 2012;129:1470–1477.
23. Fuchs O, Genuneit J, Latzin P, et al. Farming environments and childhood atopy, wheeze, lung function, and exhaled nitric oxide. J Allergy Clin Immunol. 2012;130:382–388.