ReviewThe atopic march: what's the evidence?
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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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.