Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 43397

AbstractMaterial and MethodsResultsDiscussionConclusionAcknowledgementReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
Knowledge is treasure of a wise man. The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help ones reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journalsNo manuscriptsNo authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2012 | Month : September | Volume : 6 | Issue : 7 | Page : 1162 - 1166 Full Version

The Clinico-Epidemiological Profile and the Risk Factors Associated with the Severity of Atopic Dermatitis (AD) in Eastern Indian Children


Published: September 1, 2012 | DOI: https://doi.org/10.7860/JCDR/2012/.2457
Mani Kant Kumar, Punit Kumar Singh, Mohammad Mahtab Ali Tahir

1. Assistant Professor, Department of Pediatrics, 2. Assistant Professor, Department of Dermatology, 3. Junior Resident ,Department of Pediatrics, Narayan Medical College and Hospital, Jamuhar, Sasaram, Dist- Rohtas, Pin-821305 Bihar, India.

Correspondence Address :
Dr. Mani Kant Kumar
Assistant Professor, Department of Pediatrics,
Narayan Medical College and Hospital, At+PO- Jamuhar,
Sasaram, Dist- Rohtas, Bihar, Pin-821305 , India.
Phone: +919162095353, +919234461396
E-mail: manikant7@yahoo.com

Abstract

Objective:
To study the clinical features and the various epidemiological risk factors and their correlation with the severity of atopic dermatitis in eastern Indian children (Bihar).
Design:
A prospective hospital based study.
Settings:
The Paediatrics OPD and the Dermatology OPD of a tertiary care teaching hospital which was located in the Rohtas district of Bihar, India. The study was carried out over a period of 2 years from January 2010 to December 2011.
Participants:
One hundred and thirty two children of the ages of zero months to 15 years, who were diagnosed with atopic dermatitis. Main Outcome: The demographic profile, the common clinical features and the various risk factors and their correlation with the severity of atopic dermatitis in eastern Indian children.
Results:
Out of a total of 1829 paediatric patients of the ages of zero months to 15 years with paediatric dermatoses, 132 (7.21 %) had atopic dermatitis. Of the 132 patients, 57 (43.2%) were boys and 75 (56.8%) were girls, with a male to female ratio of 1: 1.3. Among these, 29 were infants and 103 were children. Two (62.1%) patients belonged to rural areas, while 50 (37.9%) belonged to urban areas. A personal history, a family history (up to the third degree relatives) and both a personal and a family history of atopy were present in 43.18 %, 33.34 % and 12.1 % of the patients respectively. Forty (30.3 %) patients had been exclusively breast fed during the first six months of their lives. A majority (89.4 %) of the patients had the onset of the disease before they were five years of age. In infantile AD, the mean age ± SD at onset was 5.2 ± 3.01months. In the infantile group, 8 (27.6 %) patients had mild, 14 (48.3 %) had moderate and 7 (24.1 %) had severe atopic dermatitis. Infantile AD had a statistically significant higher SCORAD (SCORing Atopic Dermatitis)index score in all the three grade of severity of the disease. One hundred and three patients had childhood AD, out of which 40 (38.8 %) were boys and 63 (61.2 %) were girls, with a male to female ratio of 1: 1.57. In childhood AD, the mean age ± SD at the onset of the disease was 3.47 years ± 3.02. . Sixty three (61.1 %) patients belonged to the rural areas, while 40 (38.9 %) were from urban areas. In the first six months of their lives, 31 (30 %) children had been exclusive breast fed, 64 (62.23 %) had been mixed fed and 8 (7.77 %) had been exclusively bottle fed. One hundred and thirty (98 %) patients presented with itching. The exclusively breast fed children were more likely to have mild AD. The mixed fed and the bottle fed children had a higher risk for developing moderate and severe AD, with an odds ratio of 2.24 (95 % CI 0.58-8.3) and 2.741 (95% CI 0.397- 18.9) respectively. In winter season, statistically significant risk to had moderate and severe form atopic dermatitis than other seasons (rainy and summer).
Conclusion:
Although the prevalence of AD has been considered to be increasing, it still remains low in comparison to that in the developed countries. In Indian children, the disease is relatively milder than in the children of the developed countries. This study identified the winter season, bottle feeding during the first six months of life and infantile AD as the risk factors for moderate and severe AD. Exclusive breast feeding during the first six months of life seemed to protect against moderate and severe AD.

Keywords

Atopic dermatitis, Risk factors, Eastern India, Children

Introduction
Atopic Dermatitis (AD) is a chronic or a chronically relapsing, eczematous skin disease that is also called as atopic eczema and it is characterized by itching, dry, inflamed and easily irritated skin which is accompanied by a cutaneous functional dysfunction. There is no laboratory “gold standard” for the diagnosis of AD. The diagnosis of AD is based on a constellation of signs and symptoms (1). It arises as the result of a complex interplay between various genetic, immunological and environmental factors. Atopic dermatitis has a strong familial basis. Twin studies have shown that monozygotic twins had about an 86% risk to develop Original Article Paediatrics SectionAD if the twin partner had the disease, whereas there was only a 21% disease risk in dizygotic twins (2). The prevalence of AD has been increasing over the past 30 years. Changes in the environmental pollutants and the breast feeding pattern and increased awareness and urbanization are some of the reasons which have been cited for this change (3). There is lot of published research on the natural history, epidemiology, aetiopathogenesis, clinical patterns and the management of AD in the world literature, but there are only very few large Indian studies which have been on this topic. There is only one published study which had been done in Eastern Indian Children , which has analyzed the clinico-epidemiological profile of AD in Indian children. In this study, we studied the clinical and the epidemiological profile of AD and we tried to identify the various risk factors which were associated with the severity of atopic dermatitis in the eastern Indian children.

Material and Methods

This hospital based, prospective study was carried out in the Outpatients Department (OPD), of the Department of Pediatrics and the Department of Dermatology, at Narayan Medical College and Hospital, Jamuhar, Rohtas, Bihar, India, for a period of two years from January 2010 to December 2011. The institute’s ethical committee approved the study protocol. After taking an informed written consent from the parents of the every patient, all the patients were enrolled on a pre structured proforma. This proforma included the data on the present age, the age at onset of the disease, the area of residence, the personal and the family history of the atopy, the seasonal variation, the religion of the patient, the development of milestones, the socioeconomic status of the parents, the history of relapse and the status of breast feeding (exclusive breast feeding/ no breast feeding (top feeding)/mixed feeding). A thorough clinical examination was done, which included the measurement of height, weight, distribution of the lesion, severity of the skin lesion and the type of the skin lesion. In every patient, the diagnosis of AD was confirmed after a consultation with the dermatologist. The eczema was categorized after a thorough clinical examination of the lesions. The atopic dermatitis was classified as acute, sub acute and chronic, according to the stage of the disease. Erythema, oedema, vesiculation and oozing were a part of the “acute AD”, while the “sub acute AD” was defined as patches with minimal oozing, crusting and scaling. Dry, rough lichenified plaques with or without scaling denoted the “chronic AD”. The severity of the disease was assessed by the SCORAD index (4). The SCORAD index is a clinical tool which is used to assess the extent and the severity of eczema (SCORing Atopic Dermatitis). The SCORAD index consists of the interpretation of the extent of the disorder, that is, the intensity, which is composed of six items (erythema, oedema/ papules, the effect of scratching, oozing/crust formation, lichenification, and dryness), and two subjective symptoms (itch and sleeplessness). The maximum score is 103 points.
Inclusion Criteria: Children of ages of zero months to 15 years who were diagnosed with Atopic dermatitis.
Exclusion Criteria: The patients of AD with any associated congenital skin disorders immunodeficiency disorders or drug rashes.
Statistical analysis
The mean age of the patients was expressed in mean ± SD. The data were analyzed by using the Open Epi statistical software, version 2.3.1. The mean, standard deviation, odds ratio and the relative risk were calculated by using appropriate statistical methods. A P value of < 0.05 was considered as statistically significant for any given measures

Results

Out of a total of 1829 paediatric patients of ages of zero months to 15 years, who were seen in the Outpatients Department (OPD) of the Department of Paediatrics and the Department of Dermatology from January 2010 to December 2011, 132 children were found to have atopic dermatitis. In this study, the prevalence of atopic 2dermatitis was 7.21% of all the paediatrics dermatoses in this age group. Among these132 patients, 57 (43.2%) were boys and 75 (56.8%) were girls, with a male to female ratio of 1: 1.3. Eighty two (62.1%) patients belonged to rural areas, while 50 (37.9%) patients belonged to urban areas. Among the rural area patients, 30 (36.6%) were boys and 52 were girls with a male to female ratio of 1: 1.7, whereas among the urban area patients, 27 (54%) were boys and 23 (46%) were girls with male to female ratio of 1: 1.2. Of the 132 patients, 98 (74.2%) were Hindus, 30 (22.7%) were Muslims and 4 (3.1) were of other religions. Socioeconomically, 34(25.8%) were from higher socio-economic groups, 61 (46.2%) were from the middle class and 37 (28%) were from the lower socio- economic strata. The personal history, family history (up to the third degree relatives) and both the personal and the family history of atopy was present in 42.18 %, 31.34 % and 11.1 % patients respectively. One hundred and eight (81.8 %) patients had a history of relapse. One hundred and eighteen (89.4 %) patients had the onset of atopy before they were five years of age. The distribution of the patients according to the age of onset of atopy has been shown in (Table/Fig 1). Of the 132 patients, 29 were infants (up to 1 year of age) among whom 17(58.6%) were boys and 12(41.4%) were girls, with a male to female ratio of 1.4: 1. The mean age (Standard deviation- SD) at onset was 5.2 (±3.01) months. Nineteen (65.5 %) belonged to the rural areas, while 10 (34.5 %) were from urban areas. Nine (31 %) had been exclusively fed on breast milk for the initial 6 months of their lives, while 17 (58.7 %) had been fed on mixed feed (breast milk and cow / buffalo milk/ formula milk powder) and 3 (10.3 %) had been exclusively bottle fed (cow or buffalo milk or formula milk powder). In the infantile group, 8 (27.6 %) had mild, 14 (48.3 %) moderate and 7 (24.1 %) had severe atopic dermatitis. Infantile AD had a statistically significant higher SCORAD Index score in all the three grades of severity of the disease, as has been shown in (Table/Fig 2). One hundred and three patients were in the childhood group (1-15 year), among which 40 (38.8 %) were boys and 63 (61.2 %) were girls, with a male to female ratio of 1: 1.57. The mean age ± SD at onset of the disease was 3.47 years ± 3.02. Sixty three (61.1 %) patients belonged to the rural areas, while 40 (38.9 %) were from urban areas. In the first six months of life, 31 (30 %) children had been exclusively breast fed, 64 (62.23 %) had been mixed fed (breast milk and cow / buffalo milk/ formula milk powder) and 8 (7.77 %) had been bottle fed (cow or buffalo milk or formula milk powder). Childhood AD had a statistically significant lower SCORAD Index score in all the three grades of severity of the disease. One hundred and thirty (98 %) patients presented with the complaint of itching or pruritus, as has been shown in (Table/Fig 3). The exclusively breast fed children were more likely to have mild AD as compared to the mixed fed children or the bottle fed children. The mixed fed and the bottle fed children had a higher risk of developing moderate and severe AD, with an odd ratios of 2.24 (95 % CI 0.58-8.3) and 2.741 (95% CI 0.397- 18.9) respectively. On comparing the SCORAD Index score between the exclusively breast fed children and the mixed fed children, the mixed fed children were found to have a statistically significant higher score in moderate and severe AD, as has been documented in (Table/Fig 4). It was found that in the winter season, there was a statistically significant risk of developing the moderate and the severe forms of atopic dermatitis, as has been shown in (Table/Fig 5).

Discussion

Atopic dermatitis (AD) is a chronic or a chronically relapsing eczematous skin disease that is also called as atopic eczema and it is characterized by itching, dry, inflamed and easily irritated skin which is accompanied by a cutaneous functional dysfunction. Eczema literally means to boil out (Ec-out, Zema- boil) and the terms, ‘eczema’ and ‘dermatitis’ are often used synonymously. Atopic dermatitis has three phases (1). The infantile phase (upto 2 years of age) primarily involves the face, scalp, neck and the extensor surface of the extremities, with erythematous oozing papulo-vesiculous lesions (2). In the childhood phase (between 2 years- 10 years of age), the lesions are sub acute , more scattered and often localized in the flexor folds of the neck, elbows,3wrist and the knees (3). In the adolescent and the adult phases (more than 10 years of age), the lesions are primarily dry, lichanified and hyperpigmented plaques in the flexor areas. The prevalence of AD has been increasing over the past 4 decades in the developed countries and also in India [3,5]. Our study was hospital based rather than population based and so the exact incidence of AD in the community could not be estimated. But these patients comprised of 7.21% of all the paediatric dermatoses cases in the study age group. A four decades old study from Bihar reported an incidence of 0.38% among the total number of outpatient attendees (6). In contrast to the findings of our study, a north Indian hospital based study reported 28.46 % (7) and 29.9 %8 patients of AD among the total numbers of paediatric dermatology patients. The “Hygiene Hypothesis” can explain the relatively lower occurrence of AD in our study as compared to that in the north Indian children. The overall hygiene was poor and various infections in childhood were rampant in this part of the country because of the poor socio-economic status. However, the prevalence in Bihar also had increased over the past four decades (6). The reasons for this increase has not been known but they are probably the increased environmental pollution , the exposure to agricultural chemicals, the decline in breast feeding, earlier weaning, urbanization, increased awareness, better case detection techniques and the improved quality of life which can explain the increasing trend in the occurrence of AD. In the previous studies which were done, there was a contrasted view regarding the gender ratio, though most of the studies had reported a male predominance with a male to female ratio of 2.13 :1 for infants and 1.09:1 for children (among males) 7 and of 2.25:1 for infants and 1.6:1 for children (among females) (8). In contrary, our study found that girls outnumbered the boys, with a female to male ratio of 1.3: 1. However, in the infantile group, boys outnumbered the girls, with a male to female ratio of 1.4: 1. In the childhood group, the female to male ratio was 1.57:1. Our study results were comparable to those of a study which was done by Rajka G et al., who found a female predominance with a female to male ratio of 1.5:1 (9). Todd G et al., (10) and Poysh L et al., (11) found a higher prevalence of AD in the urban areas than in the rural areas. In contrast to these findings, our study found a higher prevalence in the rural areas, with a rural to urban ratio of 1.64:1. This finding can be explained by the fact that our hospital caters predominantly to the rural population. Our findings on the basis of religion were proportionate to the percentage populations of the different religions in eastern India. William HC found that the prevalence of AD increased with an improvement in the socio-economic condition (3). A similar finding was reported by Spergel et al., They found that the prevalence of AD had increased by 2 to 3 folds during the past three decades in the industrialized countries due to the improvement in the socio-economic conditions and the improved life style (12). In contrast, in our study, 46.2 % patients had hailed from the middle class, 28 % from the lower socio-economic class and only 25.8% from the upper socio-economic class, which was comparable to the findings of an Indian study which was done by Sarkar and Kanwar, in which they had found that a majority of the patients belonged to middle class families (53.8 % for up to 1 year and 57.57 % onwards), while a minority of the patients were from the lower strata of the society (15.5 5 % for up to 1 year and 23.23 % for above one year) (8). In our study, the mean age (±Standard deviation SD) at the onset of the disease was 5.2 (±3.01) months for infantile AD and it was 3.47 years ± 3.02 for childhood AD. This was comparable to the findings of other Indian studies in which the mean age at onset was 4.2 months for infantile AD and 4.5 years for childhood AD (7) and 4.5 months for infantile AD and 4 years for childhood AD (8). In the present study, 28.8 % of the children developed the disease by the age of one year and 89.4 % developed it by the age of five years. Only 10.6 % developed it after five years of age. In a study which was done by Rajka J, it was found that 60% of the patients had the onset of the disease in the first year of life and that 85 % had it by five years of age (13). In a north Indian study, it was found 55.2 % patients had developed the disease by one year of age and and only 5.6 % had developed the disease after 6 years of age (8). In our study, the late presentation can be explained by the fact that in the rural areas, the milder disease is often ignored, especially during infancy, in the lower socio-economic strata of the society. In the present study, 65.8 % children had a history of atopy, among which, 42.18 %, 31.34 % and 11.1 % of children had a personal history, a family history (up to the third degree relatives) and both a personal and a family history of atopy. Halbert et al., Found that approximately 70 % of the patients had a family history of atopy (14). The family history was found to be varied in different studies. In an Indian study, a personal or a family history of atopy was observed in 54 % and 65 % of the patients respectively (15). In the present study, infantile AD had a statistically significant higher SCORAD Index score in the mild , moderate and the severe forms of AD, with mean ± SD scores of 17.8± 4.29 vs. 12.3 ± 5.1 (P=0.0065), 38.35± 8.28 vs. 33.3± 7.5 (P=0.032) and 88.42±14.24 vs. 64.9± 11.89 (P=0.002) respectively. Sarkar R and Kanwar AJ, in a study which was done in north India, also reported that infantile AD was relatively more severe than childhood AD (8). The role of breast-feeding in AD has been controversial. Gdalvich M et al., found that exclusive breast feeding of the high risk infants for at least 4 months prevented the development of AD (16). Saarinen UM and Kajossari M, found that a prolonged breast feeding was associated with a reduced incidence of allergy or atopic dermatitis (17). In this study, 30.3 % of the patients (31% with Infantile AD and 30 % with childhood AD) were exclusively breast fed during the initial 6 months of life, 61.4 % were mixed fed and only 7.6 % were exclusively bottle fed. Although in our study, mixed or bottle feeding didn’t increase the risk of mild AD, the mixed fed and the bottle fed children had a higher risk of developing moderate and severe AD with odds ratios of 2.24 (95 % CI 0.58-8.3) and 2.741 (95% CI 0.397- 18.9) respectively. The mixed fed children also had a statistically significant higher score in moderate (p=0.022) and severe AD (p=0.038) than the exclusively breast fed children. Thus, exclusive breast feeding seemed to protect against the severe form of AD. In India, breast feeding is the custom and the AD is milder in India as compared to that in the west. In this study, the most common (98 %) clinical presentation was itching. The face was affected in 76.8 % patients with infantile AD and in 56.8% patients with childhood AD. Our findings were comparable to those of Dhar S and Kanwar AJ (7). In our study, the disease severity was assessed by SCORAD and we found that 42.4 %, 44.7% and 12.9 % of the patients had mild, moderate and severe disease, which was almost comparable to the findings of another Indian study which was done by Dhar et al., (15) . In this study, we found that in winter, the AD was more severe than in the summer season. On ANOVA analysis, with respect to the effect of the season on the severity of the disease, the severity score (SCORAD Index score) was found to significantly higher in winter than in summer (36.48±7.67 vs. 31.52±7.29, p=0.0438 and 81.96±14.62 vs. 59.78±11.77, p=0.0344, for moderate and severe AD respectively). However, the severity score was not significantly different for mild AD. There was no significant difference in the severity scores in the summer and the rainy seasons. No earlier Indian study had compared the SCORAD severity score in different grades of the disease in different seasons. Atopic dermatitis is known to be severe and to exacerbate during the winter and to improve during summer, most likely, due to the seasonal variations in the skin moisturization (9). In a study by Vocks et al., they found that itch intensity in patients with AD, inversely correlated with temperature but that there was a lesser effect of humidity, air pressure and hours of sunshine (18).

Conclusion

The epidemiological data on atopic dermatitis in India is mainly hospital based, The data on the true point prevalence in the community is still scanty. Although the prevalence of AD has been considered to be increasing, it still remains low in comparison to that in the developed countries. In Indian children, the disease is relatively milder than in the children from the developed countries. This study identified the winter season, bottle feeding during the first six months of life and infantile AD as the risk factors for moderate and severe AD. This study also identified that the severity score (SCORAD Index) was inversely correlated with the temperature. Exclusive breast feeding during the first six months of life seemed to protect against moderate and severe AD. A better knowledge on its epidemiology in different climatic regions can help in a better management of the patients and in improving the quality of their lives. Our study has some limitations: (1) as this was a hospital based study, the true point prevalence in the community couldn’t be extrapolated. (2) In the older children, the history was completely based on the recall of the parents. So, there was a possibility of a recall bias, especially in patients from the rural areas and from the lower socio-economic strata of the society

Acknowledgement

We wish to thanks our Dean, Prof. (Dr.) M.L. Verma, Narayan Medical College and Hospital, Jamuhar, Sasaram, Bihar, India for allowing us to publish this study. Contributors: MKK and PKS were involved in the management of the patient, conception, literature search, drafting of the manuscript and review of the manuscript. MKK, PKS and MMAT were involved in collection of data, analyzing the data and critical revision of the manuscript. MKK will act as the guarantor of the manuscript.

References

1.
Hanifin JM, Rajka G. The diagnostic features of atopic dermatitis.Acta Derm venerol [Stockh] 1980; 92: 42-47.
2.
Bradley M, Kockum I, Soderhall C, et al. The characterization by phenotype of the families with atopic dermatitis. Acta Derm Venerol 2000; 80: 106-10.
3.
Williams HC. Is the prevalence of atopic dermatitis increasing? Clin Exp Dermatol 1992;17: 385-91.
4.
Kunz B, Oranje AP, Labreze L, Stalder JF et al., The clinical validation and the guidelines for the SCORAD index: the consensus report of the European Task Force on atopic dermatitis. Dermatology 1997; 195 (1): 10-19.
5.
Dhar S. Atopic dermatitis: the Indian scenario. Indian J Dermatol venerol Leprol 1999;65:253-57.
6.
Sinha PK. The clinical profile of infantile eczema in Bihar. Indian J Dermatol venerol Leprol 1972; 38:179-84.
7.
Dhar S, Kanwar AJ. The epidemiology and the clinical pattern of atopic dermatitis in the north Indian pediatric population. Pediatr Dermatol 1998;15:347-51.
8.
Sarkar R, Kanwar AJ. The clinico-epidemiological profile and the factors which affected the severity of atopic dermatitis in north Indian children. Indian J Dermatol 2004; 49:117-22.
9.
Rajka G. Atopic eczema- a correlation of the environmental factors with the frequency of the disease. Int J Dermatol 1986;25:301- 04.
10.
Todd G, Saxe N, Milne J et al., The prevalence of atopic dermatitis in Xhosa children who were living in rural, periurban and urban areas. Curr Allergy Clin Immunol. 2004; 17:140.
11.
Poysh L, Korppi M, Pietikainen M et al., Asthma, allergic rhinitis and atopic eczema in Finnish school children and adolescents. Allergy 1991; 46:161-65.
12.
Spergel JM. From atopic dermatitis to asthma: The atopic march. Ann Allergy Asthma Immunol 2010; 105:99-106.
13.
Rajka G. The essential aspects of atopic dermatitis (monograph). New York: Springer Verlag, 1989.
14.
Halbert AR, Weston WL, Morelli JG. Atopic dermatitis: is it an allergic disease? J Am Acad Dermatol. 1995; 33(6):1008-18.
15.
Dhar S, Mandal B, Ghosh A. The epidemiology and the clinical pattern of atopic dermatitis in 100 children, which were seen in a city hospital. Indian J Dermatol 2002; 47: 202-04.
16.
Gdalvich M, Robin G, Mimouni D et al. Breastfeeding and the onset of atopic dermatitis in childhood: a systematic review and a metaanalysis of the prospective studies. J Am Acad Dermatol 2001;45: 520-27.
17.
Saarinen UM, Kajosaari M. Breast-feeding as a prophylaxis against atopic diseases: A prospective follow up study until the subjects were 17 years old. Lancet 1995; 346: 1065-69.
18.
Vocks E, Busch R, Frohlich et al., The influence of the weather and the climate on the subjective symptom intensity in atopic eczema. Int

DOI and Others

Date of Submission: Jun 27, 2012
ID: JCDR/2012/4771:2457

Date of Peer Review: Jul 22, 2012
Date of Acceptance: Aug 25, 2012
Date of Publication: Sep 30, 2012

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com