pissn: 2288-0402 eissn: 2288-0410 4(5):346-353, September 2016 http://dx.doi.org/10.4168/aard.2016.4.5.346 ORIGINAL ARTICLE 경기도지역초등학생의아토피피부염유병률과연관인자 김은지, 1 이수현, 1 서성철, 2 정지태, 1,2 유영 1,2,3 1 고려대학교의과대학소아과학교실, 2 고려대학교안암병원환경보건센터, 3 고려대학교알레르기면역연구소 Prevalence of atopic dermatitis and its associated factors for elementary school children in Gyeonggi-do province Eunji Kim, 1 Soohyun Ri, 1 Sung Chul Seo, 2 Ji Tae Choung, 1,2 Young Yoo 1,2,3 1 Department of Pediatrics, Korea University College of Medicine, Seoul; 2 Environmental Health Center, Korea University Anam Hospital, Ansan; 3 Allergy Immunology Center, Korea University, Seoul, Korea Purpose: This study aimed to investigate the prevalence of atopic dermatitis (AD) and associated factors for AD in a total of 2,077 children from 5 elementary schools in Gyeonggi-do province. Methods: AD was defined when parents answered Yes to a question in the on International Study of Asthma and Allergies in Childhood questionnaire Has your child ever has itchy rashes with xax and wane pattern for at least 6 months? in October 2012. SCORing Atopic Dermatitis index, skin prick testing and blood testing, were evaluated. Results: The prevalence of AD was 25.9% among 2,077 elementary school children in Gyeonggi-do province. Proportions of obesity (8.0% vs. 4.5%, P= 0.004) and breast-feeding over 6 months (46.6% vs. 41.3%, P= 0.035) were significantly higher in children with AD than those without. No significant differences were found in terms of sex, age, body mass index, history of breast-feeding ever and mode of delivery beween AD and non-ad children. obesity (adjusted odds ration [aor], 1.80; 95% confidence interval [CI], 1.13 2.75; P= 0.006) and breast-feeding over 6 months (aor, 1.35; 95% CI, 1.03 1.77; P= 0.029) were found as significant associated factors for AD. When stratified by sex, obesity in boys (aor, 2.67; 95% CI, 1.53 4.66; P= 0.001) and breast-feeding history in girls (aor, 1.47; 95% CI, 1.03 2.11; P= 0.034) were independently considered significant associated factors for AD. We found more boys (66.7%, P= 0.028) than girls among the severe AD cases. Male sex was considered an associated factor of having severe AD (aor, 2.23; 95% CI, 1.01 4.73; P= 0.048). Conclusion: The prevalence of AD was 25.9% in elementary school children in Gyeonggi-do. province obesity and breast-feeding over 6 months were found as associated factors of having AD. Male sex was considered an associated factor for severe AD. ( 2016:4:346-353) Keywords: Atopic dermatitis, Child 서론아토피피부염은주로영유아기에발병하는소아에서가장흔한만성염증성피부질환이며, 향후천식이나알레르기비염등으로이행되는경우가많기때문에적극적인관리와치료가필요하다. 1 국내학동기소아의아토피피부염유병률은 1995년과 2000년의전국적인유병률조사에서각각 15.3% 과 17.0% 였으며, 2 2006년 21.0%, 3 2010년 27.0% 로 4 증가추세를보이고있다. 아토피피부염은 유전적, 환경적, 면역학적요인이복합적으로연관되어발병하며, 5 주거환경, 미숙아, 모유수유력, 1세이전의항생제사용력, 간접흡연, 애완동물, 경제수준, 부모의교육수준등이아토피피부염발병의환경적연관인자로보고되었다. 6-9 따라서아토피피부염의발병률감소및효율적인예방과치료를위하여환경적연관인자를분석하고관리하는것은중요하다. 경기도의인구는 2015년 8월의행정자치부 주민등록인구통계 기준으로우리나라의 24.2% 이며, 통계청의 2015년청소년통계 및 Correspondence to: Young Yoo http://orcid.org/0000-0003-3354-6969 Department of Pediatrics, Korea University Anam Hospital, 73 Inchon-ro, Seongbuk-gu, Seoul 02841, Korea Tel: +82-2-920-5090, Fax: +82-2-922-7476, E-mail: yoolina@korea.ac.kr Received: December 24, 2015 Revised: March 4, 2016 Accepted: March 6, 2016 2016 The Korean Academy of Pediatric Allergy and Respiratory Disease The Korean Academy of Asthma, Allergy and Clinical Immunology This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/). 346 http://www.aard.or.kr
김은지외 경기도초등학생의아토피피부염유병률 경기도교육청자료를기준으로관내초등학생의비율이우리나라전체의 26.9% 를차지하고있다. 과거수원이나일산등경기도내한개도시관내초등학교학생들을대상으로한아토피피부염역학연구들 10,11 이있으나, 국내 1/4 이상의초등학생인구가거주하고있는경기도의아토피피부염관련자료는아직도부족한실정이다. 이에저자들은경기도내 4개도시, 5개학교의총 2,077명초등학생들의아토피피부염유병률과중증도의현황을파악하고발병의연관인자를분석하여아토피피부염의예방및관리와치료를위한기초자료로활용하고자하였다. 대상및방법 1. 대상본연구를위해서경기도교육청은연구참여에동의한 5개초등학교의총 2,077명을 International Study of Asthma and Allergies in Childhood (ISAAC) 설문조사시행대상으로선정하였다. 본연구는보건복지부지정공용기관생명윤리위원회승인을받았다 (PIRB 12-039-02). 2. 방법 1) 아토피피부염의정의및중증도평가한국형 ISAAC 설문지를사용하여 2012년 10월에서 11월사이에대상초등학생의보호자가설문에답하도록하였다. 아토피피부염의증상에대한질문은 댁의자녀가태어나서지금까지가려운발진 ( 태열또는아토피피부염이라고도함 ) 이생겼다없어졌다하면서최소 6개월이상지속된적이있었습니까?, 댁의자녀가지난 12개월동안위와같은가려운피부발진이나타난적이있었습니까?, 댁의자녀가태어나서지금까지 습진, 태열, 또는아토피피부염 으로진단받은적이있습니까?, 댁의자녀가지난 12개월동안 습진, 태열, 또는아토피피부염 으로치료받은적이있습니까? 등의만성적증상여부, 현재의증상여부, 진단및치료여부에대한 4 가지질문외에세부문항 4가지질문을더하여총 8문항으로구성되었다. 아울러연구목적에따라분만력, 모유수유력, 출생체중등에대한문항을추가하였다. 위설문에서태어나서최소 6개월이상아토피피부염증상이지속된적이있었다고응답한경우아토피피부염으로정의하여, 총대상자를아토피피부염군 (538명 ) 과비아토피피부염군 (1,539 명 ) 으로나누었다. 아토피피부염의중증도는 SCORing Atopic Dermatitis (SCORAD) index로평가하여 40점미만인경우경증-중등증, 40점이상인경우중증으로정의하였다. 12,13 2) Body mass index 측정대상자중 1,854명의신장과체중을이동식신장측정계, 전자체 중계를이용하여측정후 body mass index (BMI) 를계산하였으며, 성별및연령을동시에고려하여 2007년질병관리본부의 소아청소년표준성장도표 를기준으로과체중은 85th percentile BMI<95th percentile 인경우, 비만은 BMI 95th percentile 인경우로정의하였다. 14 3) 혈액검사아토피피부염환아중혈액검사가가능했던 178명의전완부의정맥혈을채혈하여, 유세포분석 (flowcytometry) 으로백혈구수와백혈구감별계산 ( 백분율 ) 을하여혈액호산구분율을측정하였다. 호산구양이온단백농도는면역학적검사방법으로대상자의혈청을항호산구양이온단백결합브롬화시안활성스폰지메트릭스 (anti-eosinophilic cationic protein [ECP]-binding cyanogen bromide-activated cellulose spongelike matrix) 가들어있는 ImmunoCAP (Phadia AB, Uppsala, Sweden) 에넣고, 검체내호산구양이온단백과항원-항체면역반응을일으키면이를항호산구양이온단백효소결합체 (anti-ecp enzyme conjugate) 와의반응을이용해농도를정량화하였다. 혈청총면역글로불린 E (IgE) 농도는 Coat-A-Count Total IgE IRMA (Diagnostic Products Co., Los Angeles, CA, USA) 로측정하였다. 4) 피부단자시험혈액검사를시행한 178명의전완전부에 18종의우리나라주요흡입및식품항원 (Dermatophagoides pteronyssinus, Dermatophagoides farinae, birch, oak, alder, grass pollen mix, mugwort, Japanese hop, ragweed, cockroach, cat, dog, Alternaria alternata, Aspergillus fumigatus, egg white, milk, peanut, wheat) 과양성대조액 ( 히스타민 ), 음성대조액 ( 생리식염수 ) 를한방울씩떨어뜨린후 26게이지바늘을상피깊이까지찔러검사액이도달하도록하였다. 이후검사액을서로섞이지않게닦아내고, 15분이지난뒤팽진과발적을관찰하였다. 팽진의최장축과, 최장축의수직이등분선의길이를측정하여평균팽진길이를기록하였다. 각항원에대해팽진의평균길이가 3 mm 이상이면서동시에양성대조보다큰경우를양성으로판정하였다. 5) 통계분석두군에서연속변수의평균비교는 t-test를이용하였고, 결과값은평균 ± 표준편차로표시하였다. 혈액호산구분율, 혈청호산구양이온단백농도, 혈청총 IgE 농도는정규분포를따르지않아자연로그의평균 ± 표준편차로표시하였다. 두군간의빈도의비교는 chi-square test를시행하였고 SCORAD index 와혈액검사수치와의상관관계는 Pearson correlation을이용하였다. 아토피피부염발병의연관인자분석을위하여로지스틱회귀분석을통해각변 http://dx.doi.org/10.4168/aard.2016.4.5.346 347
Kim E, et al. Atopic dermatitis in elementary school children within Gyeonggi-do 수의교차비를구하였고신뢰구간은 95% 로하였다. 단변량로지스틱회귀분석에서 P 값이 0.05 미만인변수들을모아성별, 연령, 비만, 출생체중, 모유수유력, 분만방식을보정하여다변량로지스틱회귀분석을시행하였다. 통계분석은 IBM SPSS Statistics ver. 22.0 (IBM Co., Armonk, NY, USA) 을이용하였고 P 값이 0.05 미만인경우통계적으로유의한것으로해석하였다. 결과 1. 아토피피부염환아의특성총 2,077명의대상자의평균연령 ( 평균 ± 표준편차 ) 은 9.8±1.7 세였으며, 남아가 50.0% (1,039/2,077), 여아가 50.0% (1,038/2,077) 였다. BMI ( 평균 ± 표준편차 ) 는 18.0±3.0 kg/m 2 였으며, 비만은 5.4% (100/1,854), 과체중은 11.1% (206/1,854) 였다. 출생체중 ( 평균 ± 표준편차 ) 은 3,234.5±447.1 g, 제왕절개로출생한경우는 41.3% (855/2,072) 였다. 모유수유를한경우는 73.6% (1,524/2,072), 6개월이상모유수유를한경우는 42.7% (880/2,061) 였다 (Table 1). 아토피피부염군은 25.9% (538/2,077) 였고, 비만의빈도는 8.0% (38/476) 로, 비아토피피부염군의 4.5% (62/1,378) 보다유의하게높았다 (P = 0.004). 출생체중의평균 ± 표준편차는비아토피피부염군 (3,222.1±451.7 g) 에비해아토피피부염환자군 (3,270.0±432.3 g) 에서유의하게높았다 (P = 0.034). 6개월이상모유수유를한비율은아토피피부염환아군에서 46.6% (249/534) 로, 비아토피피부염군의 41.3% (631/1,527) 에비해유의하게높았다 (P = 0.035). 남아의비율, 연령, 평균 BMI, 과체중의빈도, 모유수유비율, 제왕절개비율은두군간에통계학적으로유의한차이가없었다 (Table 1). 2. 중증아토피피부염환아의특성 SCORAD index 평가를시행한 216명중에서경증-중등증아토피피부염군은 180명 (83.3%), 중증아토피피부염군은 36명 (16.7%) 이였다. 중증아토피피부염군에서남아의비율은 66.7% (24/36) 로 경증 - 중등증아토피피부염군의 46.7% (84/180) 보다유의하게높았 다 (P = 0.028). 두아토피피부염환아군에서평균연령, 평균 BMI, 비만의빈도, 과체중의빈도, 평균출생체중, 제왕절개의비율, 모유수유의비율, 6 개월이상모유수유를한비율은유의한차이가없었다. 중증아 토피피부염환아군에서혈액호산구분율의로그값 ( 평균 ± 표준 편차 ) 은 1.5%±0.8% 로경증 - 중등증아토피피부염환아군보다유 의하게높았다 (1.1%±0.9%, P<0.001). 두군간혈청호산구양이 온단백농도, 혈청총 IgE 농도및혈청헤모글로빈농도의평균값 은통계학적으로의미있는차이가없었다 (Table 2). 3. 아토피피부염발병의연관인자 성별, 연령, 비만, 출생체중, 모유수유력, 분만방식을보정한다 Table 2. Comparison of clinical characteristics and blood eosinophil markers between mild-to-moderate and severe atopic dermatitis subjects Parameter Mild-to-moderate AD (n= 180) Severe AD (n= 36) P-value Age (yr) 9.5± 1.7 9.5± 1.6 0.928 Boys 84/180 (46.7) 24/36 (66.7) 0.028 BMI (kg/m 2 ) 17.9± 2.8 18.3± 3.9 0.510 Obesity 8/157 (5.1) 3/32 (9.4) 0.401 Overweight 23/157 (14.6) 4/32 (12.5) 1.000 Birth weight (kg) 3.3± 0.4 3.4± 0.5 0.119 Cesarean section 78/179 (43.6) 15/35 (42.9) 0.938 Breast milk feeding 128/179 (71.5) 26/35 (74.3) 0.738 Breast milk feeding over 6 months 92/178 (51.7) 18/35 (51.4) 0.867 Hb (g/dl) 13.6± 0.7 13.7± 0.9 0.401 Log eosinophil 1.1± 0.9 1.5± 0.8 < 0.001 Log IgE (IU/mL) 4.3± 2.5 5.0± 2.7 0.130 Log ECP (ng/ml) 2.9± 1.7 3.4± 1.6 0.086 Values are presented as mean± standard deviation or number (%). BMI, body mass index; ECP, eosinophil cationic protein. Obesity: BMI 95th percentile; overweight: 85th percentile BMI< 95th percentile. Table 1. The clinical characteristics of study subjects Characteristic AD (n= 538) Non-AD (n= 1,539) Total (n= 2,077) P-value Age (yr) 9.8± 1.8 9.8± 1.7 9.8± 1.7 0.766 Boys 285/538 (53.0) 754/1,539 (49.0) 1,039/2,077 (50.0) 0.112 Body mass index (kg/m 2 ) 18.2± 3.1 18.0± 2.9 18.0± 3.0 0.219 Obesity 38/476 (8.0) 62/1,378 (4.5) 100/1,854 (5.4) 0.004 Overweight 53/476 (11.1) 153/1,378 (11.1) 206/1,854 (11.1) 0.999 Birth weight (g) 3,270.0± 432.3 3,222.1± 451.7 3,234.5± 447.1 0.034 Cesarean section 217/537 (40.4) 638/1,535 (41.6) 855/2,072 (41.3) 0.640 Breast milk feeding 408/537 (76.0) 1,116/1,535 (72.7) 1,524/2,072 (73.6) 0.139 Breast milk feeding over 6 months 249/534 (46.6) 631/1,527 (41.3) 880/2,061 (42.7) 0.035 Values are presented as mean± standard deviation or number (%). Obesity: BMI 95th percentile; overweight: 85th percentile BMI< 95th percentile. 348 http://dx.doi.org/10.4168/aard.2016.4.5.346
김은지외 경기도초등학생의아토피피부염유병률 변량로지스틱분석에서비만 (adjusted odds ration [aor], 1.80; 95% confidence interval [CI], 1.13 2.75; P = 0.006), 모유수유를 6 개월이상한경우 (aor, 1.35; 95% CI, 1.03 1.77; P = 0.029) 가아토피피부염의발병의연관인자로나타났다 (Table 3). 남녀로나누어분석시남아에서는비만 (aor, 2.67; 95% CI, 1.53 4.66; P = 0.001), 여아에서는모유수유를한경우 (aor, 1.47; 95% CI, 1.03 2.11; P = 0.034) 가통계적으로유의한아토피피부염의발병의연관인자로나타났다 (Table 4). 4. 증증아토피피부염의발병의연관인자성별, 연령, 비만여부, 출생체중, 모유수유력, 분만방식을보정한다변량로지스틱분석에서남아 (aor, 2.23; 95% CI, 1.01 4.73; P = 0.048) 가중증아토피피부염의발병의연관인자로나타났다 (Table 3). 5. 아토피피부염중증도와임상적특성과의상관관계 SCORAD index는혈액호산구분율과유의한양의상관관계를보였으나 (r = 0.147, P = 0.031), 연령, 출생체중, BMI, 모유수유기간, 혈청총 IgE 농도, 혈청호산구양이온단백농도및혈청헤모글 로빈농도와는의미있는상관관계를보이지않았다 ( 자료제시하지않음.) 6. 피부단자시험결과아토피피부염환아군중피부단자시험을시행한 178명에서양성률은 70.0% (125/178) 였고흡입항원양성률은 69.7% (124/178), 식품항원양성률은 9.0% (16/178) 였다. 각각의알레르겐에대한감작의빈도는 D. pteronyssinus 56.4%, D. farinae 52.1%, birch 16.5%, oak 14.9%, alder 10.6%, grass pollen mix 9.6%, mugwort 13.8%, Japanese hop 13.8%, ragweed 13.8%, cockroach 20.7%, cat 21.3%, dog 17.6%, A. alternata 10.6%, A. fumigatus 12.2%, egg white 5.9%, milk 4.3%, peanut 1.6% 및 wheat 5.3% 로나타났다 (Fig. 1A). 항원을총 6개군으로나누어감작의빈도를관찰한결과집먼지진드기항원군양성 57.8%, 꽃가루항원군양성 32.4%, 동물비듬항원군양성 26.2%, 바퀴벌레항원양성 20.7%, 곰팡이항원양성 18.7%, 그리고식품항원양성 9.0% 였다. 경증-중등증아토피피부염군및중증아토피피부염군간각 18 가지국내주요항원에대한감작률은대부분의항원에대하여중 Table 3. Multivariate models for atopic dermatitis and severe atopic dermatitis Variable aor* for AD (95% CI) P-value aor* for severe-ad (95% CI) P-value Age 1.02 (0.96 1.09) 0.532 1.03 (0.81 1.30) 0.806 Boys 1.15 (0.93 1.43) 0.193 2.23 (1.01 4.73) 0.048 Obesity 1.80 (1.13 2.75) 0.006 1.62 (0.37 7.18) 0.523 Overweight 1.07 (0.76 1.49) 0.706 0.73 (0.23 2.35) 0.596 Birth weight 1.02 (1.00 1.05) 0.055 1.05 (0.96 1.16) 0.263 Cesarean section 0.96 (0.77 1.18) 0.656 0.97 (0.44 2.17) 0.947 Breast milk feeding 1.26 (0.99 1.61) 0.063 1.05 (0.47 2.84) 0.760 Breast milk feeding over 6 months 1.35 (1.03 1.77) 0.029 0.77 (0.29 2.01) 0.590 aor, adjusted odds ratio; AD, atopic dermatitis; CI, confidence interval; BMI, body mass index. Obesity: BMI 95th percentile; overweight: 85th percentile BMI< 95th percentile. *Adjusted for age, sex, obesity, birth weight, breast milk feeding history and delivery mode. Table 4. Multivariate models for atopic dermatitis in boys and girls Variable Boys (n= 1,039) Girls (n = 1,038) aor* for AD (95% CI) P-value aor* for AD (95% CI) P-value Age 1.03 (0.94 1.12) 0.528 1.01 (0.93 1.11) 0.793 Obesity 2.67 (1.53 4.66) 0.001 1.06 (0.52 2.14) 0.877 Overweight 1.26 (0.81 1.97) 0.303 0.87 (0.52 1.47) 0.606 Birth weight 1.03 (1.00 1.06) 0.094 0.01 (0.98 1.05) 0.572 Cesarean section 1.09 (0.81 1.47) 0.582 0.83 (0.61 1.14) 0.248 Breast milk feeding 1.16 (0.82 1.62) 0.408 1.47 (1.03 2.11) 0.034 Breast milk feeding over 6 months 1.36 (0.95 1.96) 0.095 1.39 (0.94 2.04) 0.099 aor, adjusted odds ratio; AD, atopic dermatitis; CI, confidence interval; BMI, body mass index. Obesity: BMI 95th percentile; overweight: 85th percentile BMI< 95th percentile. *Adjusted for age, sex, obesity, birth weight, breast milk feeding history and delivery mode. http://dx.doi.org/10.4168/aard.2016.4.5.346 349
Kim E, et al. Atopic dermatitis in elementary school children within Gyeonggi-do 60 50 56.4 52.1 Sensitization rate (%) 40 30 20 10 0 16.5 14.9 10.6 Der. p. Der. f. Birch Oak Alder 20.7 21.3 13.8 13.8 13.8 9.6 Grass Mugwort Japanese Ragweed Cockroach Cat pollen mix hop 17.6 Dog 10.6 12.2 5.9 Alternaria Aspergillus Egg white 4.3 5.3 1.6 Milk Peanut Wheat A 60 Sensitization rate (%) 50 40 30 20 Mild-to-moderate AD group Severe AD group 10 0 Der. p. Der. f. Birch Oak Alder Grass Mugwort Japanese Ragweed Cockroach pollen mix hop Cat Dog Alternaria Aspergillus Egg white Milk Peanut Wheat B Fig. 1. (A) The most common sensitized allergen group was house dust mites, followed by pollen, animal dander, fungus, and food allergens and (B) the sensitization rates to the common allergens in the severe atopic dermatitis (AD) group were not significantly different from those in the mild-to-moderate AD group. Der. p., Dermatophagoides pteronyssinus; Der. f., Dermatophagoides farinae. 증아토피피부염군이경증-중등증아토피피부염군보다높았으나통계적으로의미있는차이는없었다 (Fig. 1B). 고찰본연구에서 2,077명의경기도 5개초등학교학생을대상으로설문지를통해조사한 2012년아토피피부염의유병률은 25.9% (538/2,077) 로, 초등학생 37,365을대상으로한 2006년전국적인조사의 3 21.0%, 2005년경기도일산의 2,745명을대상으로한조사의 11 24.5% 와유사하였다. 전체대상자에서 6개월이상모유수유력과비만이아토피피부염발병과연관성이있는것으로확인되었고, 남녀별로구분시특히남아에서는비만이, 여아에서는모유수유가아토피피부염발병과연관성이있는것으로분석되었다. 2001년의외국메타분석 15 은 3개월이상의모유수유시가족력이있는고위험군의아토피피부염발병률이낮아짐을보고하였으며, 다른외국의대규모무작위대조군연구 16 에서도고위험군에서모유수유가아토피피부염의방어인자임을제시하였다. 또한가족력의유무여부와상관없이 3개월이상의모유수유가아토피피부 염의방어인자임을제시하는다른여러외국연구들도있다. 17 그러나근래의연구들에서는모유수유의아토피피부염방어인자여부가명확하지않다는결과들도보고되고있다. 2009년의외국메타분석 18 에서는가족력을보정하여도모유수유의아토피피부염발병의방어인자여부는뚜렷치않다고하였다. 오히려모유수유를하는경우아토피피부염의발병률이높아질수있다고분석된연구도있는데, 21개국의 8세에서 12세사이 51,119명을대상으로한 ISAAC phase II 연구에서는모유수유력이있는경우아토피피부염의진단유병률이상승하는것으로보고되었다. 19 본연구의전체대상자에서 6개월이상모유수유를한경우, 또한여아에서모유수유력이아토피피부염유병률과상관관계가있는것으로나타났다. 본연구에서는알레르기질환력의가족력조사와아토피피부염의발생시기에대한조사가이루어지지않아알레르기질환의가족력이있는고위험영아및 6개월이전에아토피피부염이발병한영아에게예방적으로장기적인모유수유를하여오히려모유수유가아토피피부염의발병의연관인자로분석될수있는역인과관계오류의가능성을배제할수있다. 또한본연구에서완전모유수유에대한정확한정의를기준으로조사가이루어 350 http://dx.doi.org/10.4168/aard.2016.4.5.346
김은지외 경기도초등학생의아토피피부염유병률 지지않은점, 수유기간에대한회상오류가능성도고려해야할것이다. 실제로모유수유자체가아토피피부염의발병과연관이있는지에대해서는신중한해석이필요할것으로생각한다. 20 또한본연구에서비만이아토피피부염발병의연관인자로나타났다. 국내의 1995년과 2000년의전국적인조사에서중학생연령군은 BMI가증가할수록아토피피부염유병률이높았으나초등학생연령군에서는상관관계를보이지않았으며, 2010년조사에서도초등학생과중학생연령군모두에서 BMI와아토피피부염유병률사이에양의상관관계는없다는연구가있었다. 6 그러나외국의이전연구들에서비만은소아청소년의아토피피부염유병률을높이는것으로분석되어본연구와유사한결과를보였다. 1,21-24 비만과아토피피부염발병의인과관계및기전에대한연구및규명은더필요하다. 최근 2015년의외국메타분석연구에서는 1 비만이아토피피부염발병의연관인자로작용하는기전으로피부장벽의구조변화로인한상피를통한수분소실의증가, 25 지방세포들의알레르기관련싸이토카인을포함한생물활성분자분비 26 로인한저강도의만성적인피부및전신염증반응, 21,27 피부병변으로인해실내생활을선호하여비만이조장되는역인과관계 28 등을제시하고있다. 항산화효과를나타내는식품의섭취량이부족한식이패턴으로인한산화스트레스의증가 29 및 adipokine 분비의변화또한중요한기전들로생각되고있다. Adipokine 중에서첫째로, leptin 분비는비만일경우증가되어 tumor necrosis factor-α, interferon-γ, interleukin (IL)-6, IL-12 및 IL-2 등의염증전구싸이토카인들의분비를활성화시켜면역체계를변화시킨다고알려져있으나 1,30 아토피피부염에서 leptin 분비가증가하는지에대한연구들은일관되지않은결과들을제시하고있다. 31-33 둘째로, adiponectin은항염증작용을하며비만에서분비가감소되는데, 34 아토피피부염이있을경우에도감소되는것으로알려져있다. 31 이번연구에서특히남아에서비만이아토피피부염발병의연관인자로나타났다. 성별에따른비만의아토피피부염발생에있어서원인여부의차이에대하여, 외국의 ISAAC phase III 연구에서는비만이있는남아에서 6 7세, 13 14세연령대에서아토피피부염의발병률이상대적으로높았으나비만이있는여아에서는아니었다는이번연구와비슷한결과를제시하였다. 29 국내의이전연구에서는중고등학교의남학생에서만 BMI와아토피피부염증상유병률의약한양의상관관계를보고하였다. 35 반대로다른외국연구에서는 7 15세의연령군에서비만이있는여아에서만아토피피부염의발병률이상대적으로높게분석되었으나, 대상자중사춘기여아가포함되어성호르몬에의한면역기전의변화가보정되지못한제한점이있었다. 23 성별과연령군에따른비만과아토피피부염유병률의관계의차이에대한결과는일관되지않으며비만관련호르몬인 leptin이나 adiponectin 등과의관련성도아직확실하지않다. 다만, 비만의발병연령이어리거나유병기간이길수록아토피피부염 의발병률및중증아토피피부염으로의진행률이높다는외국의연구결과를참고하여, 24 학동기이전부터의비만여부와비만이환기간등을조사하여보정인자로서분석에포함시킨후속적인성별층화연구가필요하겠다. 이번연구에서는중증아토피피부염의유병률은 16.7% 였으며, 외국의 SCORAD index를사용하여 252명을대상으로시행한후향적코호트연구결과와비슷하게나타났다. 36 이번연구에서는남아가중증아토피피부염발병의연관인자로분석되었는데, 일반적으로생후 1년이내에아토피피부염이시작된경우, 농촌보다는도시에거주하는경우, 천식이나알레르기비염등다른알레르기질환이동반된경우에아토피피부염의중증도가증가하며, 그외에성별, 출생체중, 가족수등은아토피피부염의중증도와관계가없는것으로알려져있다. 37 이번연구에서는실제적으로아토피피부염의중증도를조사한대상자가 216명인표본수의제한및조사항목의제한점으로인하여이전연구결과들과유사한중증아토피피부염의연관인자로분석된항목은없었다. 본연구의아토피피부염환아군중 178명의피부단자시험양성률은 70.0% (125/178) 였으며, 흡입항원감작률은 69.7% (125/178), 식품항원감작률은 9.0% (16/178) 였다. 집먼지진드기항원군에대한감작률이 57.8% 였으며 D. pteronyssinus 56.4%, D. farinae 52.1% 로가장많이감작된흡입항원으로나타났다. 2011 2012년의초등학생연령군 122명을대상으로한국내연구 38 에서는피부단자시험에서 1개이상의실내항원 (D. pteronyssinus, D. farinae, cockroach, cat, dog) 에감작된경우에알레르기비염과천식발병의위험률은높아지나아토피피부염발병의위험률은높아지지않는것으로분석되었으며, 그이유로는아토피피부염의발병에있어서피부장벽손상등의유전적인원인과환경적인요인이복합적으로작용하는것과흡입항원의아토피피부염발병에있어서의인과관계가강하지않을수있는가능성을들었다. 또한다른국내연구 39 에서는아토피피부염의중증도가높을수록집먼지진드기항원에감작위험이높은것으로보고하였으며, 본연구에서도중증아토피피부염군의집먼지진드기항원에대한감작률이경증-중등증아토피피부염군보다높았으나통계적인의미는없었다. 본연구는제한점을가지고있는바, 부모와환아본인의알레르기질환력, 완전모유수유여부, 1세이전의항생제사용력, 형제수, 사회경제적수준, 애완동물동거여부, 새집거주여부, 간접흡연등의아토피피부염발생과관련된유전학적및환경적인위험요인에대하여심층적으로조사하지못하였다. 그러나경기도내한개도시에국한되지않고공단밀집지역인안산과도시와농촌이공존하는남양주, 용인, 동두천등총 4개도시, 5개초등학교의 2,077명의많은수를대상으로농촌및도시의다양한환경이혼재하는경기도내의아토피피부염유병률및중증도조사를시행하였다는장점이있다. http://dx.doi.org/10.4168/aard.2016.4.5.346 351
Kim E, et al. Atopic dermatitis in elementary school children within Gyeonggi-do 유아기의비만이성인시기의비만및아토피피부염의연관이있 는것으로외국의연구에서보고되는바, 40 본연구의비만과관련 된연구결과는성인기까지의장기적관점으로 3 세이전유아기부 터조기비만을발견하고적절한체중유지를하기위한가족단위 및사회적교육의참고자료로쓰일수있겠다. 아토피피부염환아 를진료할때비만예방교육을통한비만의개선과아토피피부염 의임상적인호전여부에대한후속적인자료수집및추가연구가 아토피피부염의예방및치료를위하여필요할것으로생각한다. 25 결론적으로본연구의경기도내 5 개초등학교 2,077 명의초등 학생에서아토피피부염의유병률은 25.9% 였고, 모유수유를 6 개월 이상한경우, 비만인경우가아토피피부염발병의연관인자로분 석되었다. 성별로나누어분석시남아에서비만, 여아에서모유수 유가아토피피부염발병의연관인자로분석되었다. 중증아토피피 부염의유병률은 16.7% 였고, 남아인경우가중증아토피피부염발 병의연관인자로분석되었다. 이번연구는국내초등학생인구의 26.9% 가거주하는경기도내초등학교학생의아토피피부염유병 률과발병에있어서의연관인자를분석하였으며경기도내아토피 피부염현황파악및비만의예방과개선을통한아토피피부염관 리를위한좋은기초자료가될것으로예상한다. REFERENCES 1. Zhang A, Silverberg JI. Association of atopic dermatitis with being overweight and obese: a systematic review and metaanalysis. J Am Acad Dermatol 2015;72:606-16.e4. 2. Hong SJ, Ahn KM, Lee SY, Kim KE. The prevalences of asthma and allergic diseases in Korean children. Korean J Pediatr 2008;51:343-50. 3. 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