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Overall theme

We are interested in the epidemiology of skin diseases, covering eczema (atopic dermatitis), antimicrobial resistance in acne, herpes zoster and skin cancer. Through our work, we aim to improve the health and quality of life of people affected by skin diseases, and specifically eczema.

Much of this research uses the extensive data collected in routine clinical practice in the UK and in other settings, including Denmark and the USA to help us answer the most important questions.

Current research

Acne and antimicrobial resistance

Antibiotics are very important to treat infections and can improve survival. However, there is increasing resistance to antibiotics. Antibiotic resistance is a big problem; if antibiotics stop working, then there are limited ways of treating infections. Many teenagers get acne and doctors often treat them with antibiotics for many weeks or even months. Antibiotics are used in acne for their anti-inflammatory effects (to reduce the redness and soreness of spots) not because acne is an infection. The study will find out how many people get repeated courses of antibiotics for acne, how many of those using antibiotics get difficult-to-treat infections, and how much this costs the NHS.

Blistering skin diseases

We are working in partnership with the University of Nottingham to undertake research using linked UK health care databases to look at the incidence of two serious blistering skin diseases, bullous pemphigoid (BP) and pemphigus vulgaris (PV), and to explore whether incidence relates to sociodemographic factors.

Eczema and COVID-19

We are conducting a study to investigate if people with atopic eczema and on immune modifying treatments are at higher risk of severe COVID-19.

Eczema and fractures

We are conducting a study to investigate whether people with eczema who are prescribed oral corticosteroids receive adequate fracture preventive care, and if provision of fracture preventive care depends on prescription patterns for oral corticosteroids.

Further eczema research

Long-term outcomes

Recent studies suggest that eczema may be associated with major health and social problems, including heart disease. However, the existing studies are small, lack important information or cannot assess timing (i.e. does the outcome happen after the diagnosis of eczema). We are using international health data to assess the associations between eczema and major health and and social problems.

Gene-environment interactions

This work in partnership with the eczema network addresses the evidence for gene-environment interactions in eczema.

ECO Programme grant

This programme of work, led by the and the University of Nottingham aims to improve eczema self-care.

BIOMAP

is a major programme of work funded by the Innovative Medicines Initiative and the European Commission, aiming to improve the lives of patients with eczema and psoriasis.

Mental health conditions in eczema and psoriasis

We are researching the association between eczema, psoriasis and mental health conditions. There is strong evidence that mental health conditions such as depression and anxiety are more common in people with skin disease like eczema and psoriasis, but we do not know why. Possible causes include socioeconomic deprivation, poor sleep quality, poor lifestyle choices or inflammation. We also do not know whether people with eczema or psoriasis are at increased risk of more severe mental health conditions such as schizophrenia or bipolar disorder. We will analyse data from several sources including general practices, hospital admission, specialist mental health care, and the UK biobank to help answer this question. We also aim to identify which groups with eczema or psoriasis are most at risk of mental health conditions. Using this information can help us target screening at high risk groups. We are also working on a project with King’s College London to assess whether using technology and screening tools in waiting rooms at hospital skin clinics can help identify mental health conditions.

Phenotypes of adult eczema

We are undertaking innovative work to phenotype adult eczema using information contained in electronic health records (EHRs) and longitudinal cohort studies coupled with detailed molecular data. Eczema is a disorder with very different presentations and disease courses, suggesting the existence of different eczema subtypes. We are investigating a variety of machine learning approaches to derive a new phenotypic classification to identify these subtypes, and our research will aim to define, systematically compare and assess them, and relate them to important clinical outcomes. The reasons for doing this work are to understand eczema better. This will help us better predict disease characteristics such as persistence and severity and its likely course and, in future, will help improve treatments.

Skin cancer

We are leading the epidemiology and national database component of the UK Keratinocyte consortium of the British Association of Dermatologists in partnership with Public Health England.

Vitamin D deficiency, shingles and COVID-19

We are conducting studies to explore the association between vitamin D deficiency and the risk of shingles and COVID-19 using UK Biobank and linked electronic health records.

Previous research

Bereavement and skin disease

Stress is widely believed to play an important role in the onset of specific, common and important skin diseases, including psoriasis and eczema. However, we don’t have great evidence regarding the importance of stress in the onset of these disorders. We have been exploring the relationship between acute stress following bereavement of a partner and the onset of skin diseases. In our previous work, we found no evidence of a relationship between partner bereavement and herpes zoster. 

Eczema and cancer: England and Denmark

The existing research exploring whether there is a link between having atopic eczema and cancer was conflicting, and some of the existing studies were small and weren’t able to investigate whether having eczema came before a cancer diagnosis. So, we wanted to answer the question of whether there was a link between atopic eczema and cancer using real-world data from large numbers of people across two countries. We also felt that our study was particularly important now as new biologic drugs for atopic eczema that may affect cancer risk are being brought to market, so it is vital that we first understand the existing risk of cancer in people with atopic eczema. On the whole our findings are reassuring. For most cancers, we didn’t see any increased cancer risk for people with atopic eczema.

Eczema and fractures

In our study, we reported that adults with eczema could have an increased risk of the type of broken bones that tend to be related with a condition called osteoporosis (a condition that weakens bones increasing fracture risk). Our findings were based on a study of GP and hospital records for large numbers of people with eczema (approximately 400,000).

So, if you have eczema, what do the results mean for you? We have summarised the key points below:

• The overall risk of a broken bone is very low, so even though we have shown an increase, this is still represents a low risk of fractures (as a 10% increase of a small amount of risk is still a small amount of risk)
  Our study estimated that an extra 164 people would break a bone compared to the number of bones expected in a group of 100,000 people without eczema. 

• NICE (an organisation that guides the NHS about which treatments work and what tests should be done) guidance already highlights a lot of the issues we raised in our article, and NHS patients will be managed accordingly
  NICE guides GPs and other doctors on what they should do about assessing fracture risk. The full guidelines are available . Briefly, NICE recommend that doctors should consider assessing fracture risk in women over 65 and men over 75.  In people younger than those ages, they recommend specific groups of people where doctors should consider doing assessments. These include people on long-term oral steroids. When patients with these risk factors attend GPs, they assess risk of fracture using questionnaires and checklists that have been proved to be useful for this purpose (including tools such as FRAX or QFracture). These fracture-risk assessment tools guide GPs in determining who needs a bone scan and who needs preventive treatment. 

• People who have taken higher doses of oral steroids for long periods are an important group where doctors should consider assessing fracture risk. 
  However, increasing recognition of the risk of steroid treatment means that few people now use long-term high-dose steroid tablets for treating eczema, and it would be very rare indeed in the modern treatment of eczema.

In this study, we did not look directly at the effect of the drugs used to treat eczema.

In another study, we investigated the role of oral corticosteroid use in the relationship between eczema and fractures. We found no evidence that the increased fracture risk  seen in people with eczema could be explained by oral corticosteroid use. This suggests that the increase in bone breaks that we saw was a consequence of eczema, rather than a side effect of treatments.

Please note, there are still questions to be addressed by future focused research to further investigate the reasons for the increased fracture risk identified in our studies and whether additional bone-density screening is warranted in those with eczema, beyond the NICE recommendations above and to further understand what we can do to improve bone health for people with eczema. 

Herpes zoster

We have conducted a wide range of work on herpes zoster using UK and US data to demonstrate that the zoster vaccine is effective in preventing zoster and postherpetic neuralgia within routine clinical care, showing for the first time that the Zostavax vaccine was effective against postherpetic neuralgia in routine care. Our work has provided unprecedented understanding of risk factors for zoster and its complications and on management of zoster in primary care. This programme of work has been fundamental to informing guidelines on the prevention and management of zoster.

Phenotypes of childhood eczema

Using latent class analysis, we identified four well-defined and recognisable childhood phenotypes of eczema from symptom severity and trajectories. Thirty-four percent of children in a longitudinal cohort (ALSPAC) were most likely to have either: Severe-Frequent (4%), Moderate-Frequent (7%), Moderate-Declining (11%), or Mild-Intermittent (12%) symptoms of eczema during childhood. The remaining children (66%) were unaffected or only rarely presented symptoms. Null mutations in the filaggrin gene (FLG), a high polygenic risk score (PRS) and comorbid asthma were associated with higher risk for some or all phenotypes, and more strongly with the phenotypes with greater symptom severity and frequency; FLG and PRS further differentiated some phenotypes from each other. This differential association of risk factors among and between phenotypes is novel and requires further research.

Methods and reporting

The REporting of studies Conducted using Observational Routinely-collected Data (RECORD) is an international collaborative that developed reporting guidelines for studies conducted using routinely-collected health data (such as electronic medical record data, health administrative data, primary care surveillance data, and disease registries). The RECORD guidelines have been endorsed by many major journals. There is now an extension to RECORD to improve the reporting of pharmacoepidemiology studies (i.e. studies that explore the effects of drugs on disease) undertaken using routinely collected data. 

You can visit the RECORD website at: .

Health Data Research: .