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 (Lead / Corresponding author)

Research output: Contribution to journalArticle

19 Citations (Scopus)

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 languageEnglish
Pages (from-to)509-516
Number of pages8
JournalJournal of Allergy and Clinical Immunology
Volume138
Issue number2
Early online date28 Apr 2016
DOIs
Publication statusPublished - Aug 2016

Fingerprint

Chlorine
Hardness
Atopic Dermatitis
Cross-Sectional Studies
Water
Population
Odds Ratio
Skin
Mutation
Calcium Carbonate
Water Quality
Forearm
Parturition
Equipment and Supplies

Keywords

  • Atopic dermatitis
  • Eczema
  • Filaggrin
  • Transepidermal water loss
  • Water hardness

Cite this

Perkin, Michael R. ; Craven, Joanna ; Logan, Kirsty ; Strachan, David ; Marrs, Tom ; Radulovic, Suzana ; Campbell, Linda E. ; MacCallum, Stephanie F. ; McLean, W. H Irwin ; Lack, Gideon ; Flohr, Carsten. / Association between domestic water hardness, chlorine, and atopic dermatitis risk in early life : A population-based cross-sectional study. In: Journal of Allergy and Clinical Immunology. 2016 ; Vol. 138, No. 2. pp. 509-516.
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title = "Association between domestic water hardness, chlorine, and atopic dermatitis risk in early life: A population-based cross-sectional study",
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.",
keywords = "Atopic dermatitis, Eczema, Filaggrin, 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",
note = "The main components of the Enquiring About Tolerance (EAT) Study are jointly funded by the UK Food Standards Agency (FSA; grant code T07051) and the Medical Research Council (MRC). The skin-related aspects of the study are supported by the UK National Institute for Health Research (NIHR). C.F. holds a NIHR Clinician Scientist Award (NIHRCS/01/2008/009). Disclosure of potential conflict of interest: M. R. Perkin, J. Craven, K. Logan, T. Marrs, S. Radulovic, and G. Lack declare receiving a grant from the Food Standards Agency and a grant from the Medical Research Council. T. Marrs also declares receiving a grant from the British Skin Foundation and a grant from the National Institute for Health Research (NIHR). G. Lack also declares receiving grants from the NIHR and the National Peanut Board and is a board member and stock holder of DBV Technologies. W. H. I. McLean declares receiving a grant from Wellcome Trust.",
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Perkin, MR, Craven, J, Logan, K, Strachan, D, Marrs, T, Radulovic, S, Campbell, LE, MacCallum, SF, McLean, WHI, Lack, G & Flohr, C 2016, '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

Association between domestic water hardness, chlorine, and atopic dermatitis risk in early life : A population-based cross-sectional study. / Perkin, Michael R.; Craven, Joanna; Logan, Kirsty; Strachan, David; Marrs, Tom; Radulovic, Suzana; Campbell, Linda E.; MacCallum, Stephanie F.; McLean, W. H Irwin; Lack, Gideon; Flohr, Carsten (Lead / Corresponding author).

In: Journal of Allergy and Clinical Immunology, Vol. 138, No. 2, 08.2016, p. 509-516.

Research output: Contribution to journalArticle

TY - JOUR

T1 - 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

N1 - The main components of the Enquiring About Tolerance (EAT) Study are jointly funded by the UK Food Standards Agency (FSA; grant code T07051) and the Medical Research Council (MRC). The skin-related aspects of the study are supported by the UK National Institute for Health Research (NIHR). C.F. holds a NIHR Clinician Scientist Award (NIHRCS/01/2008/009). Disclosure of potential conflict of interest: M. R. Perkin, J. Craven, K. Logan, T. Marrs, S. Radulovic, and G. Lack declare receiving a grant from the Food Standards Agency and a grant from the Medical Research Council. T. Marrs also declares receiving a grant from the British Skin Foundation and a grant from the National Institute for Health Research (NIHR). G. Lack also declares receiving grants from the NIHR and the National Peanut Board and is a board member and stock holder of DBV Technologies. W. H. I. McLean declares receiving a grant from Wellcome Trust.

PY - 2016/8

Y1 - 2016/8

N2 - 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.

AB - 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.

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KW - Eczema

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KW - Water hardness

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