A Janus tale of the two faces of corticosteroid therapy: A potential for adverse effects versus a steroid-sparing benefit of certain therapies

T to the publication of diverse issues that comprise and challenge the field of allergy and immunology, the allergist/immunologists, and the patients we serve, this issue of the Proceedings features a Janus spectrum of articles that bridge diverse conditions, which range from chronic urticarial, food allergy, asthma, allergic rhinoconjunctivitis to immunodeficiency and drug allergy, all of which present with a dichotomy of disease expression that challenges the expertise of the allergist/immunologist. Nowhere is this polarity of disease expression better illustrated than by the burden of illness related to chronic urticaria, which spans the life spectrum from infancy to the elderly. Filling a void for more information regarding chronic urticaria in the pediatric population, Azkur et al. evaluated the clinical features, possible causes, associated findings, and laboratory results of different subtypes of chronic urticaria in 222 children. When treatment options, e.g., antihistamines, for patients with chronic urticaria are ineffectual, oral corticosteroids are commonly used. However, the risks associated with oral corticosteroid therapy among patients with chronic urticarial have not been fully elucidated. To this end Ledford et al. analyzed a commercial claims data base of 12,000 patients with chronic urticaria to assess the relationship between oral corticosteroid use and the associated risk of developing adverse effects to oral corticosteroids and the associated health care costs. In this issue of the Proceedings, they reported that patients with chronic urticaria who were treated with oral corticosteroid have an increased risk of oral corticosteroid–related adverse effects and higher total health care costs. Another cutaneous condition that requires the expertise of the allergy/immunology specialist is hereditary angioedema. One of the frequently used treatment options is C1 inhibitor, which is currently available only for the intravenous route of administration. A subcutaneous formulation of C1 inhibitor may provide a preferred mode of administration for some patients; and, in this issue of the Proceedings, Riedl et al. report their results of a randomized, double-blind, dose-ranging, crossover study of subcutaneous, plasma-derived C1 inhibitor with the dispersing agent recombinant human hyaluronidase in 47 patients with the diagnosis of hereditary angioedema. A disorder often considered in the differential diagnosis of urticaria and angioedema is food allergy. The diagnosis of this condition may ultimately require confirmatory oral food challenge, a test considered to be the criterion standard for diagnosing food allergy. In this issue of the Proceedings, Wang provides a lucid review of the utility of component diagnostic testing in guiding oral food challenges to milk and egg. Advancements in diagnostic testing for food allergy have been propelled by its rising prevalence, which is frequently attributed to the hygiene hypothesis. To explore this hypothesis further, a study of 1359 children was conducted by Gupta et al. who report the associations between childhood food allergy and asthma with hygiene factors, such as the number of siblings, antibiotic usage, infection history, pet exposure, childcare exposure, and maternal-child factors. How hygiene factors affect the prevalence and pathogenesis of asthma is yet another area of ongoing investigation. The pathogenesis of allergic asthma is primarily characterized by a Th2 cell abnormality in the IgE pathway, which indicates a possible role for follicular T-helper (Tfh) cells in the generation of excessive IgE accumulation. Gong et al. investigated circulating Tfh-cells subset distribution in patients with asthma to assess the relationship between Tfh-cells subset distribution and serum IgE level. They report an altered circulating Tfh-cells subset distribution, and their findings indicated that this cell subset may play an important role in the pathogenesis of asthma. The pathogenesis of asthma not only involves altered immune function but also an altered environmental response, which is reflected by seasonal trends in asthma exacerbations. To this end, Wisniewski et al. compared seasonal trends in asthma exacerbations among school-age children who lived in different geographic locations within the United States. They report that seasonal peaks for asthma exacerbations varied among children who lived in geographic locations with different climates and that were not restricted to the beginning of the school year. The anticipated outcome of the study was that the use of local, geographic information to recognize seasonal changes in the frequency of asthma exacerbations, together with individual patient risk factors (e.g., allergic sensitizations), would enhance efforts to optimize the treatment of children with asthma during periods when they are