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Bone mineral density in children with moderate to severe atopic dermatitis

Published:September 20, 2010DOI:https://doi.org/10.1016/j.jaad.2009.12.015

      Background

      Low bone mineral density (BMD) has been reported in 30.4% of adult patients with atopic dermatitis (AD).

      Objective

      The aim of this study was to determine the prevalence of low BMD in children with moderate to severe AD and to investigate the relation between BMD and corticosteroid and cyclosporine therapy.

      Methods

      Lumbar spine BMD was measured by dual-energy X-ray absorptiometry in 60 children (age 5-16 years) with moderate to severe AD. BMD (in g/cm2) was expressed in Z-scores, the number of SD above or below the mean value of an age- and sex-matched reference population. In children, low BMD was defined as a Z-score less than –2. Information on lifestyle parameters and bone fractures were collected by use of a standardized questionnaire. The cumulative dose of corticosteroids and cyclosporine therapy was calculated for the previous 5-year period.

      Results

      Three patients (5%) had low BMD; one patient (1.7%) had osteoporosis. The observed prevalence of low BMD in this study (6.7%; 95% confidence interval 1.8%-16.2%) does not differ from the expected prevalence of low BMD in the general population (P = .06). Overall, use of topical corticosteroids in the previous 5 years was not associated with a decrease in BMD (Z-score). When children received additional systemic treatment (oral corticosteroids and/or cyclosporine) in the previous 5 years, BMD decreased, although the decrease was not statistically significant. Correction for lifestyle parameters did not change these associations.

      Limitations

      The number of patients studied was limited. The cumulative dose of corticosteroids and cyclosporine therapy was only registered for the previous 5 years, and relatively low amounts of topical corticosteroids were used. The definition of low BMD differs between adults (Z-score < –1) and children (Z-score < –2). Because there is no Dutch BMD reference population for children, normative BMD references were obtained from a different population (US children).

      Conclusions

      Low BMD did not occur more frequently in this population of children with moderate to severe AD compared with the general population. Use of topical corticosteroids in the previous 5 years was not associated with a decrease in BMD.

      Key words

      Abbreviations used:

      AD (atopic dermatitis), BMD (bone mineral density), DXA (dual-energy X-ray absorptiometry), 25-OH-vitamin D (25-hydroxyvitamin D), PTH (parathyroid hormone), SCORAD (scoring atopic dermatitis)
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      References

        • Mortz C.G.
        • Lauritsen J.M.
        • Bindslev-Jensen C.
        • Andersen K.E.
        Prevalence of atopic dermatitis, asthma, allergic rhinitis, and hand and contact dermatitis in adolescents: the Odense adolescence cohort study on atopic diseases and dermatitis.
        Br J Dermatol. 2001; 144: 523-532
        • Semeao E.J.
        • Jawad A.F.
        • Stouffer N.O.
        • Zemel B.S.
        • Piccoli D.A.
        • Stallings V.A.
        Risk factors for low bone mineral density in children and young adults with Crohn's disease.
        J Pediatr. 1999; 135: 593-600
        • Vihinen M.K.
        • Kolho K.L.
        • Ashorn M.
        • Verkasalo M.
        • Raivio T.
        Bone turnover and metabolism in pediatric patients with inflammatory bowel disease treated with systemic glucocorticoids.
        Eur J Endocrinol. 2008; 159: 693-698
        • Munro D.D.
        The effect of percutaneously absorbed steroids on hypothalamic–pituitary–adrenal function after intensive use in in-patients.
        Br J Dermatol. 1976; 94: 67-76
        • James V.H.
        • Munro D.D.
        • Feiwel M.
        Pituitary-adrenal function after occlusive topical therapy with betamethasone-17-valerate.
        Lancet. 1967; 2: 1059-1061
        • Haeck I.M.
        • Hamdy N.A.T.
        • Timmer-de M.L.
        • Lentjes E.G.
        • Verhaar M.J.
        • Knol M.J.
        • et al.
        Low bone mineral density in adult patients with moderate to severe atopic dermatitis.
        Br J Dermatol. 2009; 161: 1248-1254
        • Boot A.M.
        • Bouquet J.
        • de Ridder M.A.
        • Krenning E.P.
        • de Muinck Keizer-Schrama S.M.
        Determinants of body composition measured by dual-energy X-ray absorptiometry in Dutch children and adolescents.
        Am J Clin Nutr. 1997; 66: 232-238
        • Pedreira C.C.
        • King E.
        • Jones G.
        • Moore E.
        • Zacharin M.
        • Varigos G.
        • et al.
        Oral cyclosporin plus topical corticosteroid therapy diminishes bone mass in children with eczema.
        Pediatr Dermatol. 2007; 24: 613-620
        • Lewiecki E.M.
        • Gordon C.M.
        • Baim S.
        • Leonard M.B.
        • Bishop N.J.
        • Bianchi M.L.
        • et al.
        International Society for Clinical Densitometry 2007 adult and pediatric official positions.
        Bone. 2008; 43: 1115-1121
        • Kapoor R.
        • Menon C.
        • Hoffstad O.
        • Bilker W.
        • Leclerc P.
        • Margolis D.J.
        The prevalence of atopic triad in children with physician-confirmed atopic dermatitis.
        J Am Acad Dermatol. 2008; 58: 68-73
        • Novembre E.
        • Vierucci A.
        Milk allergy/intolerance and atopic dermatitis in infancy and childhood.
        Allergy. 2001; 56: 105-108
        • Stone K.D.
        Atopic diseases of childhood.
        Curr Opin Pediatr. 2002; 14: 634-646
        • Hanifin J.M.
        • Rajka G.
        Diagnostic features of atopic dermatitis.
        Acta Derm Venereol Suppl (Stockh). 1980; 92: 44-47
        • Binkley T.L.
        • Berry R.
        • Specker B.L.
        Methods for measurement of pediatric bone.
        Rev Endocr Metab Disord. 2008; 9: 95-106
        • Prentice A.
        • Parsons T.J.
        • Cole T.J.
        Uncritical use of bone mineral density in absorptiometry may lead to size-related artifacts in the identification of bone mineral determinants.
        Am J Clin Nutr. 1994; 60: 837-842
        • Kristmundsdottir F.
        • David T.J.
        Growth impairment in children with atopic eczema.
        J R Soc Med. 1987; 80: 9-12
        • Ellison J.A.
        • Patel L.
        • Kecojevic T.
        • Foster P.J.
        • David T.J.
        • Clayton P.E.
        Pattern of growth and adiposity from infancy to adulthood in atopic dermatitis.
        Br J Dermatol. 2006; 155: 532-538
        • van der Sluis I.
        • de Ridder M.A.
        • Boot A.M.
        • Krenning E.P.
        • de Muinck Keizer-Schrama S.M.
        Reference data for bone density and body composition measured with dual energy X-ray absorptiometry in white children and young adults.
        Arch Dis Child. 2002; 87: 341-347
        • Kalkwarf H.J.
        • Zemel B.S.
        • Gilsanz V.
        • Lappe J.M.
        • Horlick M.
        • Oberfield S.
        • et al.
        The bone mineral density in childhood study: bone mineral content and density according to age, sex, and race.
        J Clin Endocrinol Metab. 2007; 92: 2087-2099
        • Kunz B.
        • Oranje A.P.
        • Labreze L.
        • Stalder J.F.
        • Ring J.
        • Taieb A.
        Clinical validation and guidelines for the SCORAD index: consensus report of the European task force on atopic dermatitis.
        Dermatology. 1997; 195: 10-19
        • Kakinuma T.
        • Nakamura K.
        • Wakugawa M.
        • Mitsui H.
        • Tada Y.
        • Saeki H.
        • et al.
        Thymus and activation-regulated chemokine in atopic dermatitis: serum thymus and activation-regulated chemokine level is closely related with disease activity.
        J Allergy Clin Immunol. 2001; 107: 535-541
        • Hijnen D.
        • de Bruin-Weller M.
        • Oosting B.
        • Lebre C.
        • De Jong E.
        • Bruijnzeel-Koomen C.
        • et al.
        Serum thymus and activation-regulated chemokine (TARC) and cutaneous T cell-attracting chemokine (CTACK) levels in allergic diseases: TARC and CTACK are disease-specific markers for atopic dermatitis.
        J Allergy Clin Immunol. 2004; 113: 334-340
        • Holick M.F.
        Vitamin D status: measurement, interpretation, and clinical application.
        Ann Epidemiol. 2009; 19: 73-78
        • Long C.C.
        • Mills C.M.
        • Finlay A.Y.
        A practical guide to topical therapy in children.
        Br J Dermatol. 1998; 138: 293-296
        • Kelly H.W.
        • Van Natta M.L.
        • Covar R.A.
        • Tonascia J.
        • Green R.P.
        • Strunk R.C.
        Effect of long-term corticosteroid use on bone mineral density in children: a prospective longitudinal assessment in the childhood asthma management program (CAMP) study.
        Pediatrics. 2008; 122: e53-e61
        • Roux C.
        • Kolta S.
        • Desfougeres J.L.
        • Minini P.
        • Bidat E.
        Long-term safety of fluticasone propionate and nedocromil sodium on bone in children with asthma.
        Pediatrics. 2003; 111: e706-e713
        • Rao R.
        • Gregson R.K.
        • Jones A.C.
        • Miles E.A.
        • Campbell M.J.
        • Warner J.O.
        Systemic effects of inhaled corticosteroids on growth and bone turnover in childhood asthma: a comparison of fluticasone with beclomethasone.
        Eur Respir J. 1999; 13: 87-94
        • Rodino M.A.
        • Shane E.
        Osteoporosis after organ transplantation.
        Am J Med. 1998; 104: 459-469
        • Mazzantini M.
        • Di M.O.
        • Sinigaglia L.
        • Bianchi G.
        • Rossini M.
        • Mela Q.
        • et al.
        Effect of cyclosporine A on bone density in female rheumatoid arthritis patients: results from a multicenter, cross-sectional study.
        Clin Exp Rheumatol. 2007; 25: 709-715
        • Gafni R.I.
        • McCarthy E.F.
        • Hatcher T.
        • Meyers J.L.
        • Inoue N.
        • Reddy C.
        • et al.
        Recovery from osteoporosis through skeletal growth: early bone mass acquisition has little effect on adult bone density.
        FASEB J. 2002; 16: 736-738
        • Black R.E.
        • Williams S.M.
        • Jones I.E.
        • Goulding A.
        Children who avoid drinking cow milk have low dietary calcium intakes and poor bone health.
        Am J Clin Nutr. 2002; 76: 675-680
        • Infante D.
        • Tormo R.
        Risk of inadequate bone mineralization in diseases involving long-term suppression of dairy products.
        J Pediatr Gastroenterol Nutr. 2000; 30: 310-313
        • Henderson R.C.
        • Hayes P.R.
        Bone mineralization in children and adolescents with a milk allergy.
        Bone Miner. 1994; 27: 1-12
        • Taylor R.W.
        • Goulding A.
        Validation of a short food frequency questionnaire to assess calcium intake in children aged 3 to 6 years.
        Eur J Clin Nutr. 1998; 52: 464-465
        • Boot A.M.
        • de Ridder M.A.
        • Pols H.A.
        • Krenning E.P.
        • de Muinck Keizer-Schrama S.M.
        Bone mineral density in children and adolescents: relation to puberty, calcium intake, and physical activity.
        J Clin Endocrinol Metab. 1997; 82: 57-62
        • Gafni R.I.
        • Baron J.
        Childhood bone mass acquisition and peak bone mass may not be important determinants of bone mass in late adulthood.
        Pediatrics. 2007; 119: S131-S136
        • Lewiecki E.M.
        • Gordon C.M.
        • Baim S.
        • Binkley N.
        • Bilezikian J.P.
        • Kendler D.L.
        • et al.
        Special report on the 2007 adult and pediatric position development conferences of the International Society for Clinical Densitometry.
        Osteoporos Int. 2008; 19: 1369-1378