Longitudinal analysis of the effect of water hardness on atopic eczema: evidence for gene-environment interaction

Z. K. Jabbar-Lopez, J. Craven, K. Logan, D. Greenblatt, T. Marrs, S. Radulovic, W. H. I. McLean, G. Lack, D. P. Strachan, M. R. Perkin, J. L. Peacock, C. Flohr (Lead / Corresponding author)

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    Background: Several studies have identified an association between water hardness and atopic eczema (AE); however, there is a paucity of longitudinal data in early life. Objectives: To examine whether water hardness is associated with an increased risk of AE and skin barrier dysfunction in infants and to assess effect modification by filaggrin (FLG) loss-of-function variants.

    Methods: We performed a longitudinal analysis of data from infants in the Enquiring About Tolerance (EAT) study, who were enrolled at 3 months and followed up until 36 months of age.

    Results: Of 1303 infants enrolled in the EAT study, 91·3% (n = 1189) attended the final clinic visit and 94·0% (n = 1225) of participants’ families completed the 36-month questionnaire. In total, 761 (58·4%) developed AE by 36 months. There was no overall association between exposure to harder (> 257 mg L −1 CaCO 3) vs. softer (≤ 257 mg L −1 CaCO 3) water: adjusted hazard ratio (HR) 1·07, 95% confidence interval (CI) 0·92–1·24. However, there was an increased incidence of AE in infants with FLG mutations exposed to hard water (adjusted HR 2·72, 95% CI 2·03–3·66), and statistically significant interactions between hard water plus FLG and both risk of AE (HR 1·80, 95% CI 1·17–2·78) and transepidermal water loss (0·0081 g m −2 h −1 per mg L −1 CaCO 3, 95% CI 0·00028–0·016).

    Conclusions: There is evidence of an interaction between water hardness and FLG mutations in the development of infantile AE.

    Original languageEnglish
    Number of pages9
    JournalBritish Journal of Dermatology
    Issue number2
    Early online date10 Oct 2019
    Publication statusPublished - Aug 2020


    • Atopic dermatitis
    • atopic eczema
    • eczema
    • water hardness
    • filaggrin

    ASJC Scopus subject areas

    • Dermatology


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