Atopic Disease Prevention — A Research Schema for Evaluating Skin Barrier Protection and Phthalate Exposure Reduction

RationaleGlobally, the prevalence of atopic diseases continues to rise. Up to 20% of the population is thought to be affected, exerting enormous health, social and financial burdens. Emerging data suggests atopic dermatitis precedes allergic sensitization and may increase the predisposition to food allergy, allergic rhinitis and asthma later in life. Pilot testing has suggested infant skin barrier protection may reduce the risk of atopic dermatitis. Parallel research has suggested exposure to phthalates may be driving the inflammatory process at the dermal level. MethodsThe altered skin barrier and hapten-atopy hypotheses are summarized. A schema for a pragmatically designed, randomized controlled trial is developed to address: 1.Does skin barrier protection using an occlusive moisturizer and measures to reduce phthalate exposure among infants reduce the incidence of atopic dermatitis and the prevalence of atopic diseases, and 2.If so, do these interventions reduce risk in an additive or synergistic manner? ResultsPopulation based recruitment of newborn infants to one of three interventions or a control arm is proposed. The first arm would involve the application of an occlusive skin moisturizer to protect skin barrier integrity; the second, measures to reduce dietary and environmental phthalate exposures and the third would add skin barrier protection to the phthalate exposure reduction protocol. The protocol phase would ideally continue for three years, while the observation phase for the detection of disease incidence and prevalence would span 18 years. Recommendations for data interpretation include regression analysis for modeling the intervention effects on other environmental and dietary exposures thought to increase the risk of atopic diseases. ConclusionsPragmatic design would optimize the generalizability of the results. Study findings would clarify public health approaches for atopic disease prevention by broadening the current understanding of the effects of phthalates on child health and by informing best practices for infant skin care.