The Association between Domestic Water Hardness, Chlorine and Atopic Dermatitis Risk in Early Life: A Population-Based Cross-Sectional Study

Michael R. Perkin; Joanna Craven; Kirsty Logan; David Strachan; Tom Marrs; Suzana Radulovic; Linda E. Campbell; Stephanie F. MacCallum; W.H. Irwin McLean; Gideon Lack; Carsten Flohr

doi:10.1016/j.jaci.2016.03.031

The Association between Domestic Water Hardness, Chlorine and Atopic Dermatitis Risk in Early Life: A Population-Based Cross-Sectional Study

Michael R. Perkin, Joanna Craven, Kirsty Logan, David Strachan, Tom Marrs, Suzana Radulovic, Linda E. Campbell, Stephanie F. MacCallum, W.H. Irwin McLean, Gideon Lack, Carsten Flohr

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Abstract

Background

Domestic water hardness and chlorine have been suggested as important risk factors for atopic dermatitis (AD).
Objective

We sought to examine the link between domestic water calcium carbonate (CaCO3) and chlorine concentrations, skin barrier dysfunction (increased transepidermal water loss), and AD in infancy.
Methods

We recruited 1303 three-month-old infants from the general population and gathered data on domestic water CaCO3 (in milligrams per liter) and chlorine (Cl2; in milligrams per liter) concentrations from local water suppliers. At enrollment, infants were examined for AD and screened for filaggrin (FLG) skin barrier gene mutation status. Transepidermal water loss was measured on unaffected forearm skin.
Results

CaCO3 and chlorine levels were strongly correlated. A hybrid variable of greater than and less than median levels of CaCO3 and total chlorine was constructed: a baseline group of low CaCO3/low total chlorine (CaL/ClL), high CaCO3/low total chlorine (CaH/ClL), low CaCO3/high total chlorine (CaL/ClH) and high CaCO3/high total chlorine (CaH/ClH). Visible AD was more common in all 3 groups versus the baseline group: adjusted odds ratio (AOR) of 1.87 (95% CI, 1.25-2.80; P = .002) for the CaH/ClL group, AOR of 1.46 (95% CI, 0.97-2.21; P = .07) for the CaL/ClH, and AOR of 1.61 (95% CI, 1.09-2.38; P = .02) for the CaH/ClH group. The effect estimates were greater in children carrying FLG mutations, but formal interaction testing between water quality groups and filaggrin status was not statistically significant.
Conclusions

High domestic water CaCO3 levels are associated with an increased risk of AD in infancy. The influence of increased total chlorine levels remains uncertain. An intervention trial is required to see whether installation of a domestic device to decrease CaCO3 levels around the time of birth can reduce this risk.

Original language	English
Pages (from-to)	509-516
Journal	Journal of Allergy and Clinical Immunology
Volume	138
Issue number	2
Early online date	28 Apr 2016
DOIs	https://doi.org/10.1016/j.jaci.2016.03.031
Publication status	Published - Aug 2016

Keywords

Filaggrin
eczema
atopic dermatitis
transepidermal water loss
water hardness

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10.1016/j.jaci.2016.03.031

The Association between Domestic _PERKIN_Acc16March2016_Publishedonline28April2016_GREEN AAM (CC BY-NC-ND)Accepted author manuscript, 1.4 MBLicence: CC BY-NC-ND

Cite this

Perkin, M. R., Craven, J., Logan, K., Strachan, D., Marrs, T., Radulovic, S., Campbell, L. E., MacCallum, S. F., McLean, W. H. I., Lack, G., & Flohr, C. (2016). The Association between Domestic Water Hardness, Chlorine and Atopic Dermatitis Risk in Early Life: A Population-Based Cross-Sectional Study. Journal of Allergy and Clinical Immunology, 138(2), 509-516. https://doi.org/10.1016/j.jaci.2016.03.031

@article{5810f63cf5814e68b9f4aebfa0b66223,

title = "The Association between Domestic Water Hardness, Chlorine and Atopic Dermatitis Risk in Early Life: A Population-Based Cross-Sectional Study",

abstract = "BackgroundDomestic water hardness and chlorine have been suggested as important risk factors for atopic dermatitis (AD).ObjectiveWe sought to examine the link between domestic water calcium carbonate (CaCO3) and chlorine concentrations, skin barrier dysfunction (increased transepidermal water loss), and AD in infancy.MethodsWe recruited 1303 three-month-old infants from the general population and gathered data on domestic water CaCO3 (in milligrams per liter) and chlorine (Cl2; in milligrams per liter) concentrations from local water suppliers. At enrollment, infants were examined for AD and screened for filaggrin (FLG) skin barrier gene mutation status. Transepidermal water loss was measured on unaffected forearm skin.ResultsCaCO3 and chlorine levels were strongly correlated. A hybrid variable of greater than and less than median levels of CaCO3 and total chlorine was constructed: a baseline group of low CaCO3/low total chlorine (CaL/ClL), high CaCO3/low total chlorine (CaH/ClL), low CaCO3/high total chlorine (CaL/ClH) and high CaCO3/high total chlorine (CaH/ClH). Visible AD was more common in all 3 groups versus the baseline group: adjusted odds ratio (AOR) of 1.87 (95% CI, 1.25-2.80; P = .002) for the CaH/ClL group, AOR of 1.46 (95% CI, 0.97-2.21; P = .07) for the CaL/ClH, and AOR of 1.61 (95% CI, 1.09-2.38; P = .02) for the CaH/ClH group. The effect estimates were greater in children carrying FLG mutations, but formal interaction testing between water quality groups and filaggrin status was not statistically significant.ConclusionsHigh domestic water CaCO3 levels are associated with an increased risk of AD in infancy. The influence of increased total chlorine levels remains uncertain. An intervention trial is required to see whether installation of a domestic device to decrease CaCO3 levels around the time of birth can reduce this risk.",

keywords = "Filaggrin, eczema, atopic dermatitis, transepidermal water loss, water hardness",

author = "Perkin, {Michael R.} and Joanna Craven and Kirsty Logan and David Strachan and Tom Marrs and Suzana Radulovic and Campbell, {Linda E.} and MacCallum, {Stephanie F.} and McLean, {W.H. Irwin} and Gideon Lack and Carsten Flohr",

year = "2016",

month = aug,

doi = "10.1016/j.jaci.2016.03.031",

language = "English",

volume = "138",

pages = "509--516",

journal = "Journal of Allergy and Clinical Immunology",

issn = "0091-6749",

publisher = "MOSBY, INC",

number = "2",

}

Perkin, MR, Craven, J, Logan, K, Strachan, D, Marrs, T , Radulovic, S , Campbell, LE, MacCallum, SF, McLean, WHI, Lack, G & Flohr, C 2016, 'The Association between Domestic Water Hardness, Chlorine and Atopic Dermatitis Risk in Early Life: A Population-Based Cross-Sectional Study', Journal of Allergy and Clinical Immunology, vol. 138, no. 2, pp. 509-516. https://doi.org/10.1016/j.jaci.2016.03.031

TY - JOUR

T1 - The Association between Domestic Water Hardness, Chlorine and Atopic Dermatitis Risk in Early Life

T2 - A Population-Based Cross-Sectional Study

AU - Perkin, Michael R.

AU - Craven, Joanna

AU - Logan, Kirsty

AU - Strachan, David

AU - Marrs, Tom

AU - Radulovic, Suzana

AU - Campbell, Linda E.

AU - MacCallum, Stephanie F.

AU - McLean, W.H. Irwin

AU - Lack, Gideon

AU - Flohr, Carsten

PY - 2016/8

Y1 - 2016/8

N2 - BackgroundDomestic water hardness and chlorine have been suggested as important risk factors for atopic dermatitis (AD).ObjectiveWe sought to examine the link between domestic water calcium carbonate (CaCO3) and chlorine concentrations, skin barrier dysfunction (increased transepidermal water loss), and AD in infancy.MethodsWe recruited 1303 three-month-old infants from the general population and gathered data on domestic water CaCO3 (in milligrams per liter) and chlorine (Cl2; in milligrams per liter) concentrations from local water suppliers. At enrollment, infants were examined for AD and screened for filaggrin (FLG) skin barrier gene mutation status. Transepidermal water loss was measured on unaffected forearm skin.ResultsCaCO3 and chlorine levels were strongly correlated. A hybrid variable of greater than and less than median levels of CaCO3 and total chlorine was constructed: a baseline group of low CaCO3/low total chlorine (CaL/ClL), high CaCO3/low total chlorine (CaH/ClL), low CaCO3/high total chlorine (CaL/ClH) and high CaCO3/high total chlorine (CaH/ClH). Visible AD was more common in all 3 groups versus the baseline group: adjusted odds ratio (AOR) of 1.87 (95% CI, 1.25-2.80; P = .002) for the CaH/ClL group, AOR of 1.46 (95% CI, 0.97-2.21; P = .07) for the CaL/ClH, and AOR of 1.61 (95% CI, 1.09-2.38; P = .02) for the CaH/ClH group. The effect estimates were greater in children carrying FLG mutations, but formal interaction testing between water quality groups and filaggrin status was not statistically significant.ConclusionsHigh domestic water CaCO3 levels are associated with an increased risk of AD in infancy. The influence of increased total chlorine levels remains uncertain. An intervention trial is required to see whether installation of a domestic device to decrease CaCO3 levels around the time of birth can reduce this risk.

AB - BackgroundDomestic water hardness and chlorine have been suggested as important risk factors for atopic dermatitis (AD).ObjectiveWe sought to examine the link between domestic water calcium carbonate (CaCO3) and chlorine concentrations, skin barrier dysfunction (increased transepidermal water loss), and AD in infancy.MethodsWe recruited 1303 three-month-old infants from the general population and gathered data on domestic water CaCO3 (in milligrams per liter) and chlorine (Cl2; in milligrams per liter) concentrations from local water suppliers. At enrollment, infants were examined for AD and screened for filaggrin (FLG) skin barrier gene mutation status. Transepidermal water loss was measured on unaffected forearm skin.ResultsCaCO3 and chlorine levels were strongly correlated. A hybrid variable of greater than and less than median levels of CaCO3 and total chlorine was constructed: a baseline group of low CaCO3/low total chlorine (CaL/ClL), high CaCO3/low total chlorine (CaH/ClL), low CaCO3/high total chlorine (CaL/ClH) and high CaCO3/high total chlorine (CaH/ClH). Visible AD was more common in all 3 groups versus the baseline group: adjusted odds ratio (AOR) of 1.87 (95% CI, 1.25-2.80; P = .002) for the CaH/ClL group, AOR of 1.46 (95% CI, 0.97-2.21; P = .07) for the CaL/ClH, and AOR of 1.61 (95% CI, 1.09-2.38; P = .02) for the CaH/ClH group. The effect estimates were greater in children carrying FLG mutations, but formal interaction testing between water quality groups and filaggrin status was not statistically significant.ConclusionsHigh domestic water CaCO3 levels are associated with an increased risk of AD in infancy. The influence of increased total chlorine levels remains uncertain. An intervention trial is required to see whether installation of a domestic device to decrease CaCO3 levels around the time of birth can reduce this risk.

KW - Filaggrin

KW - eczema

KW - atopic dermatitis

KW - transepidermal water loss

KW - water hardness

U2 - 10.1016/j.jaci.2016.03.031

DO - 10.1016/j.jaci.2016.03.031

M3 - Article

SN - 0091-6749

VL - 138

SP - 509

EP - 516

JO - Journal of Allergy and Clinical Immunology

JF - Journal of Allergy and Clinical Immunology

IS - 2

ER -

The Association between Domestic Water Hardness, Chlorine and Atopic Dermatitis Risk in Early Life: A Population-Based Cross-Sectional Study

Abstract

Keywords

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