The relationship between environmental exposures and the development of AD continues to be an area of intense interest, and this study adds a piece to that puzzle. The major focus thus far has been on environmental triggers of AD, such as pollutants and bacteria, but this study is exciting because it is looking at potential ways to reduce the risk. The finding that higher levels of residential greenness in early life were associated with a reduced risk of AD in Japanese children is exciting and consistent with other studies linking environmental biodiversity to immune development.
However, these results should be interpreted with some caution. The observed effect size, while statistically significant, was modest, and the outcome relied on parental report of a physician diagnosis rather than standardized clinical assessment. In addition, measures such as the NDVI capture the presence of vegetation but do not reflect important factors, such as the type of vegetation, allergen burden, time spent outdoors or the nature of a child’s interaction with green spaces. These nuances likely play a role in determining whether environmental exposures are protective, neutral or even harmful.
From a clinical perspective, the findings are not necessarily surprising, but they are reassuring. Many clinicians already encourage families to support healthy outdoor activity and exposure to natural environments as part of a balanced lifestyle. This study strengthens the conceptual foundation for that advice, even if it does not yet justify specific clinical recommendations about residential location or environmental modification.
The next steps in this line of research should focus on better characterizing the quality and diversity of environmental exposures, as well as identifying which children are most likely to benefit. In particular, integrating measures of microbial diversity, behavior and genetic susceptibility may help clarify the mechanisms underlying these associations. We still have a lot to learn here.
Overall, this study highlights the importance of considering the environment as an important contributor to skin health and reminds us that prevention of AD may extend beyond the clinic and into the spaces where children live and grow.
Peter A. Lio, MD, FAAD
Disclosures: Lio reports being on the speakers bureau for AbbVie, Arcutis, Eli Lilly, Galderma, Incyte, La Roche-Posay/L’Oreal, Pfizer, Pierre-Fabre Dermatologie, Regeneron/Sanofi Genzyme and Verrica; being on consulting/advisory boards for Alphyn Biologics, AbbVie, Almirall, Amyris, Apogee, Arcutis, Astria Therapeutics, Castle Biosciences, Codex Labs, Concerto Biosciences, Dermavant, Eli Lilly, Galderma, Kenvue, LEO Pharma, Lipidor, L’Oreal, Merck, Micreos, MyOr Diagnostics, Nektar Therapeutics, Nia Health, Pelthos Therapeutics, Novartis, Phyla, Regeneron/Sanofi Genzyme, Sibel Health, Skinfix, Song Lab Skincare, Soteri Skin, Stratum Biosciences, Sun Pharma, Theraplex, Thimble Health, Topaz Biosciences, Unilever, Verdant Scientific, Verrica and Yobee Care; having stock options with Akeyna Inc., Alphyn Labs, Codex Labs, Concerto Biosciences, Song Lab Skincare, Soteri Skin, Stratum Biosciences, Thimble, Topaz Biosciences, Yobee Care and Verdant Scientific; receiving royalties for a Theraplex product; and being a scientific advisory committee member emeritus of the National Eczema Association.
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