Atopic eczema and domestic water hardness

McNally, Nick; Williams, HC; Phillips, David; Smallman–Raynor, Matthew; Lewis, Sarah; Venn, Andrea; Britton, John

doi:10.1016/s0140-6736(98)01402-0

Cited by 164 publications

(120 citation statements)

References 14 publications

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“…An observational study in the UK found that water hardness was associated with both lifetime and 1-year prevalence of AD in children aged 4-11, but not 11-16 years [111]. Similarly, a Japanese ecological study demonstrated higher prevalences of AD in urban areas with the highest water hardness [112].…”

Section: Water Hardnessmentioning

confidence: 97%

“…Topical exposure to hard water has been hypothesized to aggravate AD by several mechanisms: (1) calcium and magnesium in high concentrations are skin irritants; (2) greater quantities of soap are needed to achieve lather when cleansing with hard water [110][111][112]160] The health effects of hard water have been examined in cardiovascular disease, growth retardation, and reproductive failure [161]. However, their effects in AD remain controversial.…”

Section: Water Hardnessmentioning

confidence: 99%

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Environmental risk factors and their role in the management of atopic dermatitis

Kantor

Silverberg

2016

Expert Review of Clinical Immunology

278

225

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Introduction-The etiology of atopic dermatitis (AD) is multifactorial with interaction between genetics, immune and environmental factors.Areas covered-We review the role of prenatal exposures, irritants and pruritogens, pathogens, climate factors, including temperature, humidity, ultraviolet radiation, outdoor and indoor air pollutants, tobacco smoke exposure, water hardness, urban vs. rural living, diet, breastfeeding, probiotics and prebiotics on AD.Expert commentary-The increased global prevalence of AD cannot be attributed to genetics alone, suggesting that evolving environmental exposures may trigger and/or flare disease in predisposed individuals. There is a complex interplay between different environmental factors, including individual use of personal care products and exposure to climate, pollution, food and other exogenous factors. Understanding these complex risk factors is crucial to developing targeted interventions to prevent the disease in millions. Moreover, patients require counseling on optimal regimens for minimization of exposure to irritants and pruritogens and other harmful exposures.

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Section: Water Hardnessmentioning

confidence: 97%

Section: Water Hardnessmentioning

confidence: 99%

Environmental risk factors and their role in the management of atopic dermatitis

Kantor

Silverberg

2016

Expert Review of Clinical Immunology

278

225

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“…Anecdotal evidence that eczema in soft water areas is less severe 362,363 and that people who emigrate find their eczema suddenly getting much better or worse have led to suspicions that the hardness of the water could have an impact on the severity of eczema.…”

Section: Overall Implications For Research and Practicementioning

confidence: 99%

Scoping systematic review of treatments for eczema

Nankervis

Kim

Delamere

et al. 2016

Programme Grants Appl Res

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BackgroundEczema is a very common chronic inflammatory skin condition.ObjectivesTo update the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) systematic review of treatments for atopic eczema, published in 2000, and to inform health-care professionals, commissioners and patients about key treatment developments and research gaps.Data sourcesElectronic databases including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Skin Group Specialised Register, Latin American and Caribbean Health Sciences Literature (LILACS), Allied and Complementary Medicine Database (AMED) and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched from the end of 2000 to 31 August 2013. Retrieved articles were used to identify further randomised controlled trials (RCTs).Review methodsStudies were filtered according to inclusion criteria and agreed by consensus in cases of uncertainty. Abstracts were excluded and non-English-language papers were screened by international colleagues and data were extracted. Only RCTs of treatments for eczema were included, as other forms of evidence are associated with higher risks of bias. Inclusion criteria for studies included availability of data relevant to the therapeutic management of eczema; mention of randomisation; comparison of two or more treatments; and prospective data collection. Participants of all ages were included. Eczema diagnosis was determined by a clinician or according to published diagnostic criteria. The risk of bias was assessed using the Cochrane Collaboration risk-of-bias tool. We used a standardised approach to summarising the data and the assessment of risk of bias and we made a clear distinction between what the studies found and our own interpretation of study findings.ResultsOf 7198 references screened, 287 new trials were identified spanning 92 treatments. Trial reporting was generally poor (randomisation method: 2% high, 36% low, 62% unclear risk of bias; allocation concealment: 3% high, 15% low, 82% unclear risk of bias; blinding of the intervention: 15% high, 28% low, 57% unclear risk of bias). Only 22 (8%) trials were considered to be at low risk of bias for all three criteria. There was reasonable evidence of benefit for the topical medications tacrolimus, pimecrolimus and various corticosteroids (with tacrolimus superior to pimecrolimus and corticosteroids) for both treatment and flare prevention; oral ciclosporin; oral azathioprine; narrow band ultraviolet B (UVB) light; Atopiclair™ and education. There was reasonable evidence to suggest no clinically useful benefit for twice-daily compared with once-daily topical corticosteroids; corticosteroids containing antibiotics for non-infected eczema; probiotics; evening primrose and borage oil; ion-exchange water softeners; protease inhibitor SRD441 (Serentis Ltd); furfuryl palmitate in emollient; cipamfylline cream; andMycobacterium vaccaevaccine. Additional research evidence is needed for emollients, bath additives, antibacterials, specialist clothing and complementary and alternative therapies. There was no RCT evidence for topical corticosteroid dilution, impregnated bandages, soap avoidance, bathing frequency or allergy testing.LimitationsThe large scope of the review coupled with the heterogeneity of outcomes precluded formal meta-analyses. Our conclusions are still limited by a profusion of small, poorly reported studies.ConclusionsAlthough the evidence base of RCTs has increased considerably since the last NIHR HTA systematic review, the field is still severely hampered by poor design and reporting problems including failure to register trials and declare primary outcomes, small sample size, short follow-up duration and poor reporting of risk of bias. Key areas for further research identified by the review include the optimum use of emollients, bathing frequency, wash products, allergy testing and antiseptic treatments. Perhaps the greatest benefit identified is the use of twice weekly anti-inflammatory treatment to maintain disease remission. More studies need to be conducted in a primary care setting where most people with eczema are seen in the UK. Future studies need to use the same core set of outcomes that capture patient symptoms, clinical signs, quality of life and the chronic nature of the disease.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

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“…We also have to address, with epidemiological studies, the issue of what harms the epidermal barrier in the ''westernized'' at-risk population. In particular, we should probably look more closely at the aggravating changes in probably more agressive skin care and the quality of water used for skin hygiene (34). Eventually, gene or gene-product delivery in situ, to compensate for underlying defects, could be a tentative solution in the long term, to avoid repeated local treatment which is difficult in older children and adults.…”

Section: Practical Deductionsmentioning

confidence: 99%

Hypothesis: from epidermal barrier dysfunction to atopic disorders

Taı̈eb

1999

Contact Dermatitis

136

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The rô le of a genetically-impaired epidermal barrier as the primary cause of the rapid increase in prevalence of atopic dermatitis and respiratory atopy is proposed, based on available clinical and experimental data. The subsequently increased exposure to irritants and allergens postnatally in predisposed individuals would lead in a subset of these to a specific TH 2 cell activation favouring the development of IgE responses to atopens. Other routes of sensitization are probably important, but skin offers a good target to implement prevention strategies, so far completely ignored in the prophylactic recommendations given to high-risk families. Candidate genes for skin-barrier impairment are possibly those associated with ichthyosis vulgaris and X-linked hypohidrotic ectodermal dysplasia.

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Atopic eczema and domestic water hardness

Cited by 164 publications

References 14 publications

Environmental risk factors and their role in the management of atopic dermatitis

Environmental risk factors and their role in the management of atopic dermatitis

Scoping systematic review of treatments for eczema

Hypothesis: from epidermal barrier dysfunction to atopic disorders

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