This study will examine how microbes (e.g., bacteria, yeast, viruses) that live on human skin interact with each other and with their human host to contribute to health and disease. It will analyze what substances the human cells and microbes produce, how the microbes contribute to human health, and how the balance of these organisms might change in patients with atopic dermatitis, a skin condition also known as eczema.

Healthy volunteers and people with eczema between 3 and 40 years of age may be eligible for this study.

Participants undergo the following tests and procedures:

• Medical history, including medication and family history
• Skin examination
• Blood tests
• Skin samples to analyze microbes. Samples are obtained by the following methods: swabbing the skin with a cotton swab; scraping the skin gently with a blade to remove only the most exterior layers of skin; and only in adults, biopsy (surgical removal) of a small skin sample less than ?-inch (5 mm) in diameter.
• Nose swabs to analyze microbes.
• Patients with eczema may have photographs of their skin taken to help monitor the skin rashes.

Participants may be contacted periodically for follow-up studies. Patients with atopic dermatitis may have additional skin samples collected to examine changes in the skin bacteria over time and in all of the stages of eczema. In addition, patients who have a flare of their eczema are asked to undergo a skin sample collection as soon as possible.

We hypothesize that skin microflora (bacteria, fungi, viruses, phage, archae) plays a significant role in common dermatological conditions, such as atopic dermatitis (a common form of eczema). There are two classical explanations for the role microbes play in skin disease: (1) a specific microbe colonizes the skin to disrupt the balance of commensal microflora, or (2) microbes release toxic substances or invade cells to induce an inflammatory response directly. Since culture-dependent skin sampling methods are incomplete and often biased assessments of microbial diversity, we propose to use genomic methods to sample skin microflora and shed light on the above conjectures. A cultivation-independent genomic approach directly sequences the microbial DNA, enabling us to imply microbial community membership, structure and diversity. Our initial study of skin bacteria will analyze the bacterial 16s rRNA gene, which contains highly conserved regions, allowing for amplification with specific primers, that flank highly variable regions. These sequences suggest the identity of the species being sampled and enable us to infer phylogenetic relationships.

Atopic dermatitis (AD, eczema ) is a prevalent chronic disorder that affects ~15% of the population with an age of onset in the first year of life. AD is characterized by barrier-impaired, dry, itchy skin with immune cell infiltration. $1 billion is spent annually in the USA on treatment and associated costs of AD (Bickers, AAD 2006). A recent study has identified the first human genetic alteration that is strongly associated with AD as null mutations in the filaggrin (FLG) gene, which encodes an epidermal structural protein (Sandilands, Nat Gen 2006). These FLG mutations are associated with AD in a semi-dominant fashion and are present in ~47% of European Caucasians with AD. We have recently developed a filaggrin-deficient animal model that shows a selective shift in the microbial community structure, integrating the gene-environment interaction of the host and the microflora.

Chronic eczema is also typical of two rare primary immunodeficiencies: Wiskott Aldrich syndrome (WAS), which is also characterized by impaired cellular and humoral immunity, thrombocytopenia, and increased frequency of infections, and Hyper-IgE syndrome (HIES) which is also characterized, recurrent infections, and increased serum IgE. WAS and HIES are caused by mutations in the WASp and STAT3 genes, respectively.

These studies will investigate changes in microbial diversity associated with AD, WAS, and HIES in pediatric and adult populations to structure future experiments on how to medically manage AD. We will also explore if the progression of eczema is correlated with a selective shift in the skin microbiome specific to the underlying genetic etiology.

• Atopic Dermatitis
• Eczema
• Ichthyosis Vulgaris

• Bibel DJ, Aly R, Bayles C, Strauss WG, Shinefield HR, Maibach HI. Competitive adherence as a mechanism of bacterial interference. Can J Microbiol. 1983 Jun;29(6):700-3.
• Amann RI, Ludwig W, Schleifer KH. Phylogenetic identification and in situ detection of individual microbial cells without cultivation. Microbiol Rev. 1995 Mar;59(1):143-69. Review.
• Gao Z, Tseng CH, Pei Z, Blaser MJ. Molecular analysis of human forearm superficial skin bacterial biota. Proc Natl Acad Sci U S A. 2007 Feb 20;104(8):2927-32. Epub 2007 Feb 9.

• INCLUSION CRITERIA FOR AD/HIES/WAS PATIENTS (unless specified otherwise):

  1. Males or females 3 - 40 years of age. Minimum age of 3 enriches for patients that have active AD and are statistically less likely to resolve during this longitudinal study. Maximum age of 40 is to reduce chance of recruiting patients with age-related changes in skin.
  2. AD patients: Diagnosis of atopic dermatitis on the basis of the criteria defined by UK Working Party's Diagnostic Criteria for Atopic Dermatitis.
  3. HIES or WAS patients: Must have mutation-proven diagnosis, with or without eczematous dermatitis.
  4. AD patients: SCORAD (SCORing Atopic Dermatitis) score of greater than or equal to 25 indicating AD severity of moderate to severe.
  5. AD patients: At least one antecubital (or popliteal) fossae must be affected at the time of enrollment to serve as a target site.
  6. Must have a primary care professional who will continue care/evaluation in tandem with the protocol to whom information can be communicated.

EXCLUSION CRITERIA FOR AD/HIES/WAS PATIENTS:

1. Subjects with unstable or uncontrolled medical conditions that could require hospitalization during the course of the study or who have been hospitalized in the last month.
2. Subjects receiving or planning to receive an IND agent, ultraviolet light therapy, monoclonal antibodies, or systemic immunosuppressants less than 7 days or 5 half-lives (whichever is the longer time period) of initiating this protocol.
3. AD patients: Subjects who are unable to remain off systemic (oral) antibiotics or systemic (oral) steroids for at least 7 days prior to skin sample collection. Subjects who are unable to temporarily discontinue use of topical steroids or calcineurin inhibitors for greater than or equal to 7 days to small areas of skin intended for sampling. (Topical therapies for AD may be continued to non-adjacent, non-target sites.)
4. AD patients: Subjects with underlying immunodeficiency, either as primary disease or secondary to treatment.
5. WAS/HIES patients: unable to remain off topical steroids and emollients (skin sampling sites only) for at least 24 hours prior to skin sampling. HIES/WAS patients will not be taken off their systemic (oral) antibiotics or systemic (oral) steroids. (Topical therapies may be continued to non-adjacent, non-target sites.)

6 Subjects who are currently or have previously received treatment with chemotherapy or radiation for treatment of malignancies.

7. Subject with a chronic disease requiring treatment; e.g. diabetes, bone marrow transplant, hepatitis.

INCLUSION CRITERIA FOR HEALTHY VOLUNTEERS:

1. Males or females 3 - 40 years of age.
2. Interval visits and age of controls must match enrolled AD patients.

EXCLUSION CRITERIA FOR HEALTHY VOLUNTEERS AND AGE MATCHED CONTROLS:

1. Subjects with unstable or uncontrolled medical conditions that could require hospitalization during the course of the study or who have been hospitalized in the last month.
2. Subjects receiving or planning to receive an IND agent, ultraviolet light therapy, monoclonal antibodies, or systemic immunosuppressants less than 7 days or 5 half-lives (whichever is the longer time period) of initiating this protocol.
3. Subjects who are unable to remain off systemic (oral) antibiotics or systemic (oral) steroids for at least 7 days.
4. Subjects with underlying immunodeficiency, either as primary disease or secondary to treatment.
5. Subjects who are currently or have previously received treatment with chemotherapy or radiation.
6. Subject with a chronic disease requiring treatment; e.g. diabetes, bone marrow transplant, hepatitis.
7. Subject with a history of chronic sinusitis, asthma or allergic airway hyperresponsiveness.
8. Subject with severe food allergies and/or contact allergies. Mild responses will be documented in the medical record.
9. Subject with other documented chronic dermatologic disease, such as AD or psoriasis, that may interfere with evaluation of cutaneous microbiome. Common transient conditions, such as acne, are permissible.
10. Subjects who work or reside in healthcare facilities or in non-hopsital settings that provide healthcare such as assisted living facilities, homeless shelters, jails and prisons as well as subjects with frequent exposure to laboratory animals, in order to minimize potential ascertainment bias. Certain pathogens such as Staphylococcus aureus and multi-drug resistant organisms are disproportionately associated with delivery of healthcare.