Review
The atopic march: what's the evidence?

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Objective

To review and compile data from published studies that provide support for the existence of the atopic march.

Data Sources

Relevant articles and references found via a PubMed search using the following keywords: atopic march, allergic march, atopic dermatitis, eczema, atopic eczema, atopy, rhinitis, wheeze, bronchiolitis, and asthma.

Study Selection

All articles were reviewed and the most relevant were selected for inclusion in this review and for the compilation and graphical presentation of disease trends.

Results

Data on the prevalence of each phenotype of the atopic march confirm the temporal pattern of progression from eczema to allergic rhinitis and asthma. However, the atopic march as it is currently defined, is lacking precision, which affects its usefulness. Early events in the atopic march, such as eczema, may be more useful with more careful refinement of the phenotype into atopic and nonatopic eczema.

Conclusion

Evidence supports that the atopic march is a useful paradigm to describe the clinically observed progression of atopy in certain children. There may be more precise phenotypes of the early stages of the atopic march that may improve its utility in predicting the development of later atopic, comorbid chronic disease.

Section snippets

INTRODUCTION

The atopic march is a term that describes the progression of atopic disorders, from eczema in young infants and toddlers to allergic rhinitis and finally to asthma in older toddlers and children.1Atopy is derived from a Greek word meaning “strange or out of place” and was first introduced by Coca and Cooke in 1923.2 Atopy is defined as a personal and/or familial tendency to produce IgE antibodies and sensitization in response to ordinary exposures.3 Atopy is associated with the development of

THE BEGINNING OF THE ATOPIC MARCH: ECZEMA

Eczema is a chronic relapsing inflammatory skin condition characterized by dry skin lesions with lichenification, pruritic excoriations, and a predilection for skin flexures.7, 8 It is the most common inflammatory skin disease in childhood, with most cases manifesting within the first year of life.9, 10 In a population-based US study, the prevalence of eczema among children ages 5 to 9 years was estimated at 17.2%.11 In the International Study of Asthma and Allergies in Childhood, the

LINKING STAGES OF THE ATOPIC MARCH: ECZEMA, RHINITIS, AND ASTHMA

The prevalence of eczema is increasing, similar to that of other atopic disorders, including allergic rhinitis and asthma, which could support shared environmental and genetic triggers.13, 18 Few longitudinal studies have examined the relationship between eczema and subsequent allergic rhinitis. In a German birth cohort, eczema present before the age of 2 years was a significant risk factor for the development of seasonal allergic rhinitis by 7 years of age (adjusted odds ratio [OR], 2.5).19 In

THE INFLUENCE OF EARLY SYMPTOMS OF ASTHMA IN TODDLERS: ECZEMA, EARLY WHEEZE, AND ASTHMA

The German Multicenter Atopy Study is a population-based, prospective birth cohort that evaluated the phenotype of eczema with and without the cofactor of early wheeze. Those with eczema and without early wheeze were not at increased risk for the development of asthma, suggesting that eczema alone may not be the first most predictive phenotype in the atopic march.25 Early eczema, defined as eczema before 2 years of age, was significantly associated with early wheeze, defined as wheezing before

EARLY RESPIRATORY VIRAL-ASSOCIATED WHEEZING ILLNESS, ATOPY, AND ASTHMA

Several birth cohorts have established a strong association between early childhood viral respiratory tract infections and the subsequent development of childhood asthma.21, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40 Thus, specific respiratory viral infections early in the life of a child, particularly a child with an atopic predisposition, could influence the development of asthma in later childhood, indicating that environmental factors, in this case respiratory viruses, influence progression

THE RELATIONSHIP BETWEEN RHINITIS AND ASTHMA

Allergic rhinitis is clinically defined as a symptomatic disorder of the nose characterized by IgE-mediated inflammation induced by allergen exposure to the mucosal membranes.41 Epidemiologic studies have consistently reported strong associations between rhinitis and asthma (Table 2, Table 3).42, 43, 44, 45, 46, 47, 48 The prevalence of asthma in patients with rhinitis varies from 10% to 40%, depending on the study, and is much higher than in the general population without rhinitis.42, 49, 50,

DISCUSSION

The atopic march is a useful paradigm to describe the clinically observed progression of atopic diseases in certain children. Whether each step in the march is necessary for progression to the next or further defining of these phenotypes would be more useful in identifying children at risk for developing lifelong chronic diseases is still a matter of debate. Better understanding of what places a subset of children with eczema or allergic rhinitis into the risk group for developing asthma is

CONCLUSIONS

Numerous investigations support the existence of a temporal trend of atopic diseases that comprise the atopic march. The identification of early-life diseases or phenotypes in the atopic march as predictors for the development of lifelong chronic diseases offers entry points for primary or secondary disease prevention. Current evidence suggests that further refining early childhood eczema phenotypes may represent a more robust measure of the first phenotype of the atopic march, with a greater

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  • Cited by (0)

    Funding Sources: This study was supported by a Thrasher Research Fund Clinical Research Grant and a National Institutes of Health Mid Career Investigator AwardK24 A1 077930 to Dr Hartert.

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