Council of Dermatology & Venereology

Vitamin D Level among Pediatric Patients with

Atopic Dermatitis in Khartoum State
(2022-2023)

By
Dr. Ruaa Abd Al-Gaffar Ibrahim Elhassan
Registrar of Dermatology and Venerology

A thesis submitted in partial fulfillment for the requirements of MD Degree in

Dermatology & Venereology

Supervisor

Dr. Ibahim Said Ahmed

Consultant of Dermatology and Venerology

SMSB 2024
 DEDICATION

To my parents …
Who encouraged me at all stages of my
life …
To my brothers and sisters …
For their unlimited support …
.

I
 ACKNOWLEDGEMENT

I would like to express my sincere gratitude and thankfulness to my supervisor, for

the guidance, meticulous supervision, revising and discussing all aspects of this
study. His valuable advices and comments are highly appreciated.

My great thanks also extend to all who contributed in a way or another for the
success of this study.

II
 ABBREVIATIONS

AD Atopic Dermatitis

DFQI Dermatology Family Quality of Life Index

DLQI Dermatology Life Quality Index

EASI Eczema Area and Severity Index

IU International Units

PGA Physicians Global Assessment Scores

POEM Patient-Oriented Eczema Measure

PO-SCORAD Patient-Oriented SCORAD

RCT Randomized Controlled Trial

SA-EASI Self-Administered Eczema Area and Severity Index

SCORAD SCORing Atopic Dermatitis

SPSS Statistical Package for Social Sciences

Vit D Vitamin D

III
 ABSTRACT
Background Vitamin D supplementation has garnered attention as a potential adjunctive therapy for atopic
dermatitis (AD) in pediatric patients. Studies suggest a correlation between low serum vitamin D levels and
AD severity, prompting exploration of supplementation's therapeutic role. However, the efficacy and optimal
dosage of vitamin D supplementation in managing pediatric AD remain areas of ongoing research.

Objective To study the relation of vitamin D level with atopic dermatitis severity.

Methods This cross-sectional study, conducted in Khartoum state from 2022 to 2023, aimed to assess
pediatric patients with atopic dermatitis (AD) and low serum vitamin D levels. Data from 30 participants
were collected through structured questionnaires, blood samples, and SCORAD scale assessments. Statistical
analysis using SPSS 28.0 included descriptive statistics, bivariate analysis, and correlation coefficients.
Ethical clearance and participant consent were obtained, ensuring confidentiality.

Results This study covered 30 pediatric patients diagnosed with atopic dermatitis. The distribution of
participants by age revealed that the majority were within the age range of less than 1 year to 5 years, with
40.0% of participants falling under the category of less than 1 year, 33.3% aged between 1 and 5 years, and
the remaining 26.7% falling in the 5 to 10 years age group. The mean age of the participants was
approximately 3.6 years. Moreover, there was a higher representation of female patients, accounting for
70.0% of the total participants, compared to male patients, who constituted 30.0%. Regarding clinical
characteristics, the duration since diagnosis varied among the participants. A considerable proportion of
patients had been diagnosed within the past year (23.3%), while a majority had been living with the condition
for 1 to 5 years (60.0%). Additionally, family history played a role in some cases, with 30.0% of participants
having a positive family history of atopic dermatitis. Analysis of vitamin D levels among the pediatric patients
with atopic dermatitis indicated that a significant portion of participants (70.0%) had vitamin D levels ≤ 20
mg / dL, suggesting a prevalence of vitamin D insufficiency or deficiency within the cohort. The mean
vitamin D level was approximately 14.80 mg / dL, with levels ranging from 5 to 25 mg / dL. Severity
assessment using the SCORAD scale revealed varying degrees of disease severity among the participants,
with scores ranging from 6 to 48 and a mean score of approximately 15.84. Furthermore, the nature of the
disease was predominantly progressive (66.7%), while a minority of cases were categorized as static (33.3%).
A notable finding was the significant negative correlation observed between vitamin D level and disease
severity, as assessed using the Eczema Area and Severity Index (EASI). The Pearson correlation coefficient
was -0.375, with a corresponding p-value of 0.041, indicating a potential association between higher vitamin
D levels and lower disease severity in pediatric patients with atopic dermatitis.

Conclusion In conclusion, this study underscores the importance of exploring the relationship between
vitamin D levels and atopic dermatitis (AD) severity among pediatric patients. The findings reveal a
prevalence of vitamin D insufficiency or deficiency in the studied cohort, with a significant negative
correlation observed between vitamin D levels and disease severity, as assessed by the Eczema Area and
Severity Index (EASI). The majority of participants fell within the age range of less than 1 year to 5 years,
with a higher representation of female patients. Additionally, varying durations since diagnosis and family
history of AD were noted among the participants. These results highlight the potential role of vitamin D
supplementation as an adjunctive therapy for pediatric AD, emphasizing the need for further research to
elucidate optimal dosage and efficacy in managing the condition.

IV
 ‫ملخص األطروحة‬
‫الخلفية لقد حظيت مكمالت فيتامين د باالهتمام كعالج مساعد محتمل اللتهاب الجلد التأتبي (‪ )AD‬لدى المرضى‬
‫األطفال‪ .‬تشير الدراسات إلى وجود عالقة بين انخفاض مستويات فيتامين د في الدم وشدة مرض التهاب الجلد التأتبي‪،‬‬
‫مما يدفع إلى استكشاف الدور العالجي للمكمالت الغذائية‪ .‬ومع ذلك‪ ،‬فإن فعالية مكمالت فيتامين د والجرعة المثلى‬
‫ا‬
‫مجاال للبحث المستمر‪.‬‬ ‫منها في عالج المرض عند األطفال ال تزال‬
‫الهدف ‪ :‬دراسة عالقة مستوى فيتامين د مع شدة التهاب الجلد التأتبي‪.‬‬
‫المنهجية ‪ :‬تهدف هذه الدراسة المقطعية‪ ،‬التي أجريت في والية الخرطوم في الفترة من ‪ 2022‬إلى ‪ ،2023‬إلى تقييم‬
‫مرضى األطفال المصابين بالتهاب الجلد التأتبي (‪ ) AD‬وانخفاض مستويات فيتامين د في الدم‪ .‬تم جمع البيانات من‬
‫‪ 30‬مشار اكا من خالل استبيانات منظمة وعينات الدم وتقييمات مقياس ‪ .SCORAD‬شمل التحليل اإلحصائي باستخدام‬
‫‪ SPSS 28.0‬اإلحصائيات الوصفية‪ ،‬والتحليل ثنائي المتغير‪ ،‬ومعامالت االرتباط‪ .‬وتم الحصول على االذن األخالقي‬
‫وموافقة ذوي المشاركين‪ ،‬مما يضمن السرية‪.‬‬
‫النتائج‪ :‬غطت هذه الدراسة ‪ 30‬مريضا ا من األطفال الذين تم تشخيص إصابتهم بالتهاب الجلد التأتبي‪ .‬وكشف توزيع‬
‫المشاركين حسب العمر أن األغلبية كانوا ضمن الفئة العمرية أقل من سنة واحدة إلى ‪ 5‬سنوات‪ ،‬حيث يندرج ‪%40.0‬‬
‫من المشاركين ضمن الفئة أقل من سنة واحدة‪ ،‬و‪ %33.3‬تتراوح أعمارهم بين ‪ 1‬و‪ 5‬سنوات‪ ،‬و و‪ %26.7‬المتبقية‬
‫تقع في الفئة العمرية من ‪ 5‬إلى ‪ 10‬سنوات‪ .‬وكان متوسط عمر المشاركين حوالي ‪ 3.6‬سنة‪ .‬عالوة على ذلك‪ ،‬كان‬
‫هناك تمثيل أعلى للمرضى اإلناث‪ ،‬حيث شكلن ‪ % 70.0‬من إجمالي المشاركين‪ ،‬مقارنة بالمرضى الذكور الذين شكلوا‬
‫‪ .%30.0‬فيما يتعلق بالخصائص السريرية‪ ،‬تباينت المدة منذ التشخيص بين المشاركين‪ .‬تم تشخيص نسبة كبيرة من‬
‫المرضى خالل العام الماضي (‪ ،)% 23.3‬في حين أن األغلبية كانوا يعيشون مع هذه الحالة لمدة تتراوح بين سنة إلى‬
‫دورا في بعض الحاالت‪ ،‬حيث كان لدى ‪ %30‬من‬ ‫‪ 5‬سنوات (‪ .)%60.0‬باإلضافة إلى ذلك‪ ،‬لعب تاريخ العائلة ا‬
‫المشاركين تاريخ عائلي إيجابي لإلصابة بالتهاب الجلد التأتبي‪ .‬أشار تحليل مستويات فيتامين د بين مرضى األطفال‬
‫كبيرا من المشاركين (‪ )٪70.0‬لديهم مستويات فيتامين د ≥ ‪ 20‬ملغم ‪/‬‬ ‫ا‬ ‫المصابين بالتهاب الجلد التأتبي إلى أن جز اءا‬
‫ديسيلتر‪ ،‬مما يشير إلى انتشار قصور فيتامين د أو نقصه داخل المجموعة‪ .‬كان متوسط مستوى فيتامين د حوالي‬
‫‪ 14.80‬ملجم‪/‬ديسيلتر‪ ،‬مع مستويات تتراوح من ‪ 5‬إلى ‪ 25‬ملجم‪/‬ديسيلتر‪ .‬كشف تقييم الخطورة باستخدام مقياس‬
‫سكوراد عن درجات متفاوتة من شدة المرض بين المشاركين‪ ،‬حيث تراوحت الدرجات من ‪ 6‬إلى ‪ 48‬ومتوسط درجة‬
‫حوالي ‪ . 15.84‬عالوة على ذلك‪ ،‬كانت طبيعة المرض تقدمية في الغالب (‪ ،)%66.7‬في حين تم تصنيف أقلية من‬
‫الحاالت على أنها ثابتة (‪ .)% 33.3‬وكان من النتائج الملحوظة هو االرتباط السلبي الكبير الذي لوحظ بين مستوى‬
‫فيتامين د وشدة المرض‪ ،‬كما تم تقييمه باستخدام منطقة األكزيما ومؤشر الخطورة (‪ .)EASI‬كان معامل ارتباط‬
‫بيرسون ‪ ،0.375-‬مع قيمة ‪ p‬مقابلة قدرها ‪ ، 0.041‬مما يشير إلى وجود عالقة محتملة بين ارتفاع مستويات فيتامين‬
‫د وانخفاض شدة المرض لدى مرضى األطفال المصابين بالتهاب الجلد التأتبي‪.‬‬
‫الخالصة‪ :‬تؤكد هذه الدراسة على أهمية استكشاف العالقة بين مستويات فيتامين د وشدة التهاب الجلد التأتبي (‪)AD‬‬
‫بين مرضى األطفال‪ .‬تكشف النتائج عن انتشار قصور فيتامين د أو نقصه في المجموعة المدروسة‪ ،‬مع وجود عالقة‬
‫سلبية كبيرة ملحوظة بين مستويات فيتامين د وشدة المرض‪ ،‬وفقاا لتقييم منطقة األكزيما ومؤشر الخطورة (‪.)EASI‬‬
‫تراوحت أعمار غالبية المشاركين بين أقل من سنة واحدة إلى ‪ 5‬سنوات‪ ،‬مع وجود تمثيل أعلى للمرضى اإلناث‪.‬‬
‫باإلضافة إلى ذلك‪ ،‬لوحظت فترات متفاوتة منذ التشخيص والتاريخ العائلي لمرض التهاب الجلد التأتبي بين المشاركين‪.‬‬
‫تسلط هذه النتائج الضوء على الدور المحتمل لمكمالت فيتامين د كعالج مساعد للمرض عند األطفال‪ ،‬مما يؤكد الحاجة‬
‫إلى مزيد من البحث لتوضيح الجرعة والفعالية المثلى في معالجة الحالة‪.‬‬

‫‪V‬‬
 TABLE OF CONTENTS
DEDICATION II

ACKNOWLEDGEMENT III

ABBREVIATION IV

ABSTRACT ENGLISH V

ABSTRACT ARABIC VI

TABLE OF CONTENTS IX

LIST OF TABLES X

LIST OF FIGURES XI

CHAPTER ONE 1

Introduction. Rationale, literature review and objectives 2

CHAPTER TWO 16

Materials and methods 17

CHAPTER THREE 20

Results 21

CHAPTER FOUR 34

Discussion, Limitation, Conclusion and Recommendations 35

REFERENCES 43

APPENDIXES 48

APPENDIX 1: questionnaire 48

VI
 LIST OF TABLES
Table 1 Distribution of Participants by Age

Table 2 Quantitative Summary for Age of Participants

Table 3 Distribution of Participants by Gender

Table 4 Distribution of Participants by Duration Since Diagnosis

Table 5 Quantitative Summary for Disease Duration Among Participants

Table 6 Distribution of Participants by Family History of Atopic Dermatitis

Table 7 Distribution of Participants by Vitamin D Level

Table 8 Quantitative Summary for Vitamin D Level Among Participants

Table 9 Distribution of Participants by Nature of the Disease

Table 10 Quantitative Summary for the SCORAD Scale Among Participants

Table 11 Correlation Between Vitamin D Level and Disease Severity (EASI) Among
Participants

VII
 LIST OF FIGURES
Figure 1 Distribution of Participants by Age

Figure 2 Distribution of Participants by Gender

Figure 3 Distribution of Participants by Duration Since Diagnosis

Figure 4 Distribution of Participants by Family History of Atopic Dermatitis

Figure 5 Distribution of Participants by Vitamin D Level

Figure 6 Distribution of Participants by Nature of the Disease

Scatter Plot Showing Correlation Between Vitamin D Level and Disease Severity
Figure 7
(EASI) Among Participants

VIII
Chapter One

Introduction, Rationale, Literature

Review and Objectives

1
 1.1 INTRODUCTION

Atopic dermatitis (AD) is a chronic relapsing inflammatory skin disease with intermittent
flares and debilitating effects on the patient's quality of life. It is the most common skin
disorder in children, affecting approximately 15% to 20% worldwide. [1]

Atopic dermatitis is clinically distinguished by pruritus, eczematous plaques, and a defective

epidermal barrier. [2] The pathology of AD is not entirely understood. It involves a complex
interplay of dysfunctions of immune response, genetic and environmental factors. [3]
Currently, the conventional AD treatments include immune modulatory agents, such as
topical and/or oral steroids and topical calcineurin inhibitors. [4] The control of patients with
AD may be difficult to be achieved in some patients; this suggests the presence of some
other associated factors. The findings obtained in both clinical and observational studies
revealed that the deficiency of vitamin D (Vit D) may be a factor to be considered in the
pathophysiology of AD. [5]

Vitamin D3 correlate well with synthesis of proteins that are necessary for skin barrier
function, these mechanisms suggest a role of 1,25- dihydroxyvitamin D in modulating AD
severity. [6-8] There is growing interest in the possible role of vit D deficiency in the
development of AD. A recent meta-analysis of interventional studies documented that Vit D
supplementation was linked to clinically relevant reduction in AD disease severity both in
adult and pediatric patients. [6]

SCORAD is a clinical tool used to assess the extent and severity of eczema (SCORing Atopic
Dermatitis). Dermatologists may use this tool before and after treatment to determine
whether the treatment has been effective. [9]

Vitamin D, primarily known for its role in calcium homeostasis and bone health, also exerts
immunomodulatory effects. It regulates the function of various immune cells, including T
cells, B cells, and antigen-presenting cells, thereby influencing both innate and adaptive
immune responses. Moreover, vitamin D plays a crucial role in maintaining the integrity of
the skin barrier, which is compromised in atopic dermatitis [4].

2
Several studies have investigated the relationship between vitamin D status and the severity
of atopic dermatitis, albeit with mixed results. While some observational studies have
reported an association between low vitamin D levels and increased disease severity, others
have found no significant correlation. However, randomized controlled trials (RCTs)
evaluating the effects of vitamin D supplementation on AD outcomes have shown promising
results [5].
The mechanisms underlying the beneficial effects of vitamin D supplementation in atopic
dermatitis are not fully understood. However, several hypotheses have been proposed.
Vitamin D may modulate the immune response by inhibiting the production of pro-
inflammatory cytokines and promoting the synthesis of anti-inflammatory mediators [6].
Additionally, vitamin D plays a crucial role in maintaining the integrity of the skin barrier
by regulating the expression of genes involved in epidermal differentiation and lipid
production.
While vitamin D supplementation appears to hold promise as an adjunctive therapy for
pediatric patients with atopic dermatitis, several considerations should be taken into account.
Firstly, it is essential to assess the patient's vitamin D status through blood tests before
initiating supplementation, as excessive vitamin D intake can lead to toxicity. Secondly, the
optimal dosage and duration of supplementation remain unclear and may vary depending on
individual factors such as age, weight, and baseline vitamin D levels. Therefore, a tailored
approach is warranted, with close monitoring of vitamin D levels and clinical response [7 –
9].
Therefore, vitamin D supplementation has emerged as a potential adjunctive therapy for
pediatric patients with atopic dermatitis. While further research is needed to elucidate the
optimal dosage, duration, and mechanisms of action, existing evidence suggests that vitamin
D may exert beneficial effects on disease severity and flare-ups [9]. Clinicians should
consider assessing vitamin D status and implementing supplementation as part of the
comprehensive management of atopic dermatitis in children, with careful monitoring to
ensure safety and efficacy.

Throughout this context, this study was an attempt to assess the vitamin d supplementation
among pediatric patients with atopic dermatitis in Khartoum State (2022-2023)

3
 1.2 PROBLEM STATEMENT

Atopic dermatitis carries a high risk on the child life and decease the quality of life for the
child and the family. Many researches have investigated difference between 25-
dihydroxyvitamin D 25(OH) D levels in AD pediatric patients and matched healthy control.
A meta-analysis of these studies found a mean deference of -16 nmol/L in pediatric AD
patients compared to healthy control. [6]

There is growing interest in the possible role of vit D deficiency in the development of AD.
The aggravation of AD in winter, especially in higher-latitude countries, where serum
25(OH)D levels tend to be predominantly low in this season, has been documented. [7]

In addition, genetic polymorphisms of the Vit D receptor have been identified as contributor
to the development of AD. [8] So, the question is: what is the role of Vitamin D in
management of patients with Atopic dermatitis?

4
 1.4 JUSTIFICATION

There is no published study to investigate potential benefits of Vit D supplementation in

children and adolescents with severe AD. Therefore, the primary aim of this trial was to
determine the impact of Vit D supplementation in conjunction with standard treatment in
severe AD. This study is necessary to help the children and improve their treatment plans.

Research on the use of vitamin D supplementation among pediatric patients with AD in

Khartoum State has the potential to impact healthcare practices and public health policies.
If supplementation is found to be effective in improving AD outcomes, it could inform
guidelines for healthcare providers and encourage the integration of vitamin D assessment
and supplementation into routine care protocols. Moreover, raising awareness about the
importance of vitamin D and its potential role in managing AD can empower patients and
caregivers to make informed decisions about their health.

Conducting research on vitamin D supplementation among pediatric patients with AD in

Khartoum State fills a gap in the existing literature, particularly regarding geographical and
cultural contexts. By generating local data, researchers can contribute valuable insights to
the global understanding of AD management and vitamin D supplementation strategies. This
can facilitate future comparative studies and meta-analyses, ultimately enhancing our
knowledge of the efficacy and safety of supplementation across diverse populations. Overall,
investigating the use of vitamin D supplementation among pediatric patients with AD in
Khartoum State is justified and holds the potential to improve healthcare outcomes for
children in the region and beyond.

5
 1.4 LITERATURE REVIEW

Atopic dermatitis (AD), a chronic inflammatory skin disorder, is a significant health concern
among pediatric populations globally. Khartoum State, located in Sudan, is no exception,
with a notable prevalence of AD cases among children.
In recent years, there has been growing interest in exploring alternative treatment options for
AD, particularly focusing on the potential role of vitamin D supplementation. Vitamin D,
known for its immunomodulatory properties, has emerged as a promising adjunctive therapy
for AD management, offering a novel approach to alleviate symptoms and improve the
overall quality of life for affected individuals. However, the efficacy and safety of vitamin
D supplementation in pediatric patients with AD in Khartoum State remain relatively
understudied.
This literature review aims to provide a comprehensive overview of existing research
conducted between 2022 and 2023 on the topic of vitamin D supplementation among
pediatric patients with AD in Khartoum State.

Through reviewing and analyzing the available evidence, this review seeks to elucidate the
current understanding of the potential benefits, challenges, and implications of vitamin D
supplementation as a therapeutic intervention for AD in this specific population.

Additionally, this review will explore gaps in the literature and propose avenues for future
research to address unanswered questions and enhance our knowledge of the role of vitamin
D in AD management among pediatric patients in Khartoum State.

A study was conducted by Morteza A, et al to evaluate the effect of vitamin D

supplementation on patients with AD. 60 AD patients were included in a randomized,
double-blind, placebo-controlled trial study. They were randomly divided into two groups
and treated for 60 days: group vitamin D (n=30), and placebo group (n=30). The two groups
were as follows: Group D, 1600 IU cholecalciferol (vitamin D) and second group placebo.
The severity of AD was evaluated based on SCORAD (Scoring Atopic Dermatitis) and TIS
(Three Item Severity score) value by the same trained physician before and after the trial.
They found that according to SCORAD and TIS value index in the vitamin D group showed

6
significant improvement in patients with mild, moderate and severe AD (P<0.05) and in
patients who the intake placebo, this improvement didn't show (P>0.05). [10]

Noha O, et al conducted a study to evaluate the impact of vitamin D supplementation on

response to standard treatment in pediatrics with severe atopic dermatitis. The patients were
randomized to receive either vitamin D 3 1600 IU/day or placebo, plus baseline therapy of
topical 1% hydrocortisone cream twice daily for 12 weeks. The primary endpoints were the
change in mean Eczema Area and Severity Index (EASI) score at the end of the study and
the mean percent change in EASI score from baseline to week 12. Eighty-six subjects
completed the study. The treated group achieved a significant higher level of 25 hydroxy
vitamin D (P<.001) compared to control group at week 12. The mean EASI score was
significantly lower in the treatment group compared to placebo group (P=.035). The percent
change in EASI score from baseline differed significantly between the supplementation
(56.44 ± 29.33) and placebo (42.09 19.22) groups after intervention (P=.039). [11]

Christine C, et al conducted a study to analyzing correlations between PO-SCORAD and

physician and patient assessment scores of atopic dermatitis (AD) severity and quality of
life. They performed an observational study conducted in 12 European countries in 4,222
atopic patients aged ≥1 month and prescribed Exomega emollient cream. AD severity was
measured by the SCORAD index, PO-SCORAD, Patient- Oriented Eczema Measure
(POEM) and Self-Administered Eczema Area and Severity Index (SA-EASI) scales. They
reported that PO-SCORAD was the only self-assessment score to be highly correlated with
the SCORAD index and POEM (r ≥ 0.70). It was also the best correlated with the DLQI (r
= 0.67) and DFQI (r = 0.56). After a 5-week treatment, SCORAD index and PO-SCORAD
severity scores had decreased significantly by 60 and 56% (p <0.0001), and quality of life
had improved. [12]

Daniela B, et al conducted a study to evaluate whether QoL correlates with AD severity,

evaluated through the physician and the patient perspective, in a sample of Italian children.
40 children with AD were evaluated. Disease severity was assessed by the physician and the
patients (or their parents) using the SCORAD and the patient-oriented SCORAD (PO-
SCORAD) tools, respectively. Patients or their parents completed specific QoL

7
questionnaires (IDQOL/CDLQI). SCORAD e PO-SCORAD were moderately but
significantly correlated (p Spearman-0.55, P<0.01). QoL scores ranged from 1 to 23, with a
median score of 4.0 (higher scores represent more impaired QoL). After adjustment for age
and sex, children with SCORAD>40 had significantly higher QoL scores (more impaired
QoL) than those with SCORAD≤40 (median QoL of 5 and 4, respectively, P-0.048). Even
higher differences emerged when AD severity was self- assessed (median QoL of 6 and 3.5
for children with PO-SCORAD>40 and PO-SCORAD≤40, respectively, P-0.01). AD
children with concomitant food allergy had a significantly more impaired QoL than those
with AD only (P=0.040). No significant difference in QoL was observed according to sex or
age. [13]

Ulrich A, et al conducted a study to compare serum levels of 25(OH) vitamin D (calcidiol)

in outpatients suffering from different skin diseases using the same laboratory method in one
study. In routine serum samples of 1,532 patients from the previous 12 months we identified
retrospectively 180 (mean age 49.4 years, 80 females, 100 male) and 205 (mean age 36.3
years, 116 females, 89 male) patients with psoriasis (PSO) and atopic dermatitis (AD),
respectively. Clinical disease activity and quality of life was evaluated using Physicians
Global Assessment Scores (PGA), Dermatology Life Quality Index (DLQI), and a Visual
Analog Scale for pruritus in AD, respectively. The median 25(OH)D serum level of all
patients (22.97 ng/mL, range 2.61-96.0, n = 1,461) was significantly lower in comparison to
healthy controls (41.6 ng/mL, range 16.9-77.57, p < 0.0001, n = 71). In PSO and AD we
measured 21.05 ng/mL (44% < 20 ng/mL) and 22.7 ng/mL (39% < 20 ng/mL), respectively
(p = 0.152). Among all subgroups, patients with severe acute or chronic infectious skin
diseases had the lowest median 25(OH)D serum levels (17.11 ng/mL, n= 94, 66% <20
ng/mL, p<0,001 vs. AD, p=0,007 vs. PSO). [14]

In a systematic review and meta-analysis conducted by Afif Nurul Hidayati et al., the
efficacy of vitamin D supplementation on the severity of atopic dermatitis (AD) in children
aged 0-18 years old was investigated. The study, published in F1000Research, aimed to
assess the impact of vitamin D supplementation on AD severity, considering its controversial
status as a therapeutic intervention for the condition. Through a systematic search of multiple
databases from January 2010 to October 2020, eight articles were identified and four were

8
included for analysis. The meta-analysis revealed a mean difference of -0.93 (95%CI -1.76,
to -0.11, p<0.001) in patient outcome between vitamin D supplementation and placebo
groups, indicating a reduction in AD severity with supplementation. However, there was no
statistically significant difference in cure rate (risk ratio 1.46 (95%CI 0.72, to 2.97,
p=0.008)) between the two groups. The study concluded that while vitamin D
supplementation may lead to improvements in the severity of pediatric AD, the optimal dose
and duration of administration remain inconclusive [15].

In a systematic review published in Pediatric Dermatology by Christina M. Huang et al., the

effects of vitamin D (VD) levels and supplementation on atopic dermatitis (AD) in children
were investigated. AD, a chronic inflammatory skin condition affecting a significant
percentage of children worldwide, has been the subject of studies suggesting a potential
correlation between serum VD levels and disease severity, as well as a therapeutic role for
VD supplementation. Through a comprehensive search of Ovid MEDLINE, EMBASE, and
Cochrane Library databases, the review included 21 publications focusing on children aged
0-18 years old with AD. Among these, 15 studies evaluated VD levels, 5 assessed VD
supplementation, and 1 examined both factors in relation to AD severity. The analysis
revealed a significant inverse correlation between VD levels and AD severity in 62.5%
(10/16) of studies, indicating a potential association between lower VD levels and increased
disease severity. Furthermore, 67% (4/6) of studies reported a significant improvement in
AD severity with VD supplementation. However, the review noted limitations such as the
heterogeneity of included studies in terms of location, season, and VD supplementation
regimen, as well as potential language and publication bias. Despite these limitations, the
majority of literature reviewed supported a link between serum VD levels and AD severity
in children, with limited evidence supporting the efficacy of VD supplementation in
improving AD. The review concluded by highlighting the need for future large-scale studies
to further validate these findings and guide clinical practice [16].

In a study conducted by Irene Lara-Corrales et al., published in the Journal of Cutaneous

Medicine and Surgery, the relationship between vitamin D (VD) levels, supplementation,
and atopic dermatitis (AD) severity in pediatric patients was investigated. AD, characterized
by a pruritic eczematous rash, is a chronic inflammatory skin condition with inconsistent

9
evidence regarding the role of serum VD in modifying disease severity. The study comprised
two phases: a cross-sectional phase evaluating the correlation between VD levels and AD
severity, and a double-blinded RCT assessing the effects of VD supplementation on disease
modification. In phase 1, 77 pediatric patients with AD were included, and it was found that
increased disease severity significantly correlated with lower VD levels (P = .015).
Subsequently, 45 patients with abnormal VD levels were eligible for phase 2 and randomized
to receive either VD supplementation (2000 IU/d) or placebo for three months. Despite the
correlation between VD levels and AD severity, the RCT results indicated that VD
supplementation did not significantly improve disease severity compared to placebo (P =
.7). The study concluded that while VD levels were correlated with AD severity,
supplementation did not lead to significant improvements, highlighting the complexity of
the relationship between VD and AD in pediatric patients. [17]

In an observational study published in Allergologia et Immunopathologia by Renata Robl

Imoto et al., the influence of vitamin D (VD) supplementation on the severity of atopic
dermatitis (AD) in pediatric patients was assessed through a pre-post interventional design.
The study aimed to evaluate the impact of VD supplementation on AD severity, utilizing the
SCORing Atopic Dermatitis (SCORAD) index for classification. A total of 152 patients
under 14 years old were included, with AD severity categorized as mild, moderate, or severe
based on SCORAD scores. Serum VD levels were classified as sufficient (≥30 ng/mL),
insufficient (29 to 21 ng/mL), and deficient (≤20 ng/mL). Patients with inadequate VD levels
received oral supplementation for three months and were reassessed post-treatment. Results
indicated that patients with sufficient VD levels exhibited lower SCORAD values (p = 0.04),
suggesting a potential association between VD sufficiency and reduced AD severity.
Following VD supplementation, VD levels significantly increased from baseline (23.7
ng/mL) to post-treatment (35.9 ng/mL, p < 0.001), accompanied by a decrease in SCORAD
index (19.4 before vs 12.3 after supplementation, p < 0.001), indicating an improvement in
AD severity. Furthermore, the study observed that female gender was associated with a
poorer treatment response (p = 0.02). The findings suggest that VD supplementation may
serve as an adjuvant therapy in reducing the severity of AD in pediatric patients [18].

10
In a comparative study published in the Journal of the American Academy of Dermatology
by Zbigniew Samochocki et al., the effects of vitamin D on atopic dermatitis (AD) were
investigated. Given the immunomodulatory properties of vitamin D and the involvement of
immunologic mechanisms in AD pathogenesis, the study aimed to assess the correlation
between vitamin D concentrations and various factors associated with AD, as well as to
determine the impact of vitamin D supplementation on the clinical manifestations of the
disease. The study included 95 patients with AD and 58 control subjects, evaluating clinical
and laboratory parameters alongside the severity of AD using the SCORing Atopic
Dermatitis (SCORAD) index. Results indicated that the mean serum concentration of 25-
hydroxyvitamin D3 (25(OH)D3) in patients with AD did not significantly differ from control
subjects. However, patients with AD and lower 25(OH)D3 levels exhibited a higher
frequency of bacterial skin infections. No statistically significant associations were found
between vitamin D levels and other laboratory or clinical parameters. Following vitamin D
supplementation, both mean objective SCORAD and SCORAD index significantly
decreased (P < .05), suggesting an improvement in clinical signs of AD. The study concluded
that vitamin D supplementation may help alleviate the clinical manifestations of AD and can
be considered a safe and well-tolerated form of therapy, highlighting its potential as an
adjunctive treatment option for AD management. [19]

In a meta-analysis published in Nutrients by Sonal R Hattangdi-Haridas et al., the

relationship between vitamin D deficiency and atopic dermatitis (AD) severity, as well as
the effects of vitamin D supplementation on disease severity, were systematically reviewed
and analyzed in both adults and children. The study aimed to provide an up-to-date
understanding of 25-hydroxyvitamin D (25(OH)D) levels in the AD population and the
changes in AD severity following vitamin D supplementation. Through electronic searches
of MEDLINE, EMBASE, and COCHRANE databases up to February 2018, sixteen relevant
articles were identified and included in the analysis. Meta-analyses revealed that AD patients
had significantly lower 25(OH)D levels compared to healthy controls, with a mean
difference of -14 nmol/L for all studies and -16 nmol/L for pediatric studies alone.
Additionally, a meta-analysis of three vitamin D supplementation trials demonstrated a
significant reduction in SCORAD (SCORing Atopic Dermatitis) scores by -11 points (95%
CI -13 to -9, p < 0.00001). This reduction exceeded the Minimal Clinical Important
11
Difference for AD severity, indicating a clinically meaningful improvement. Trials lasting
three months and utilizing a mean weighted dose of 1500-1600 IU/daily showed greater
improvements in AD severity. The meta-analysis concluded that the AD population,
particularly pediatric patients, may be at high risk for lower serum 25(OH)D levels, and
supplementation with around 1600 IU/daily can result in a significant reduction in AD
severity. [20]

In a cross-sectional study published in Annals of Dermatology and Venereology by S.

Ronceray et al., the association between atopic dermatitis (AD) severity and vitamin D
concentration was examined. The study aimed to investigate the correlation between serum
25-hydroxyvitamin D (25(OH)D) concentration and the severity of AD, assessed using the
SCORing Atopic Dermatitis (SCORAD) and PO-SCORAD indexes. The study, conducted
from June 2011 to March 2013, included 60 patients diagnosed with AD, comprising 30 with
severe AD and 30 with mild-to-moderate AD. Results revealed that patients with severe AD
had lower 25(OH)D concentrations compared to those with mild-to-moderate AD (15.9 ±
8.3 ng/mL vs. 21.5 ± 8.2 ng/mL; P=0.01). Furthermore, a negative correlation was observed
between 25(OH)D concentration and both SCORAD (r=-0.47; P<0.001) and PO-SCORAD
(r=-0.4; P=0.004) values. This correlation remained significant even after adjustment for
age, phototype, and season. However, the study highlighted the absence of a causal link
between vitamin D deficiency and AD severity, emphasizing the need for further large-scale,
comparative interventional studies to confirm the association between these variables.
Notably, confounding factors such as sun exposure and socioeconomic status were not
accounted for in this study, suggesting the importance of addressing these variables in future
research to elucidate the relationship between vitamin D and AD severity comprehensively
[21].

In a cross-sectional study published in Pediatric Dermatology by Renata Robl et al., the

relationship between serum vitamin D levels and the severity of atopic dermatitis (AD) in a
Brazilian population was investigated. Conducted from April to November 2013, the study
included patients under 14 years of age diagnosed with AD according to the Hanifin and
Rajka Diagnostic Criteria. Disease severity was assessed using the SCORing Atopic
Dermatitis (SCORAD) index and classified as mild, moderate, or severe. Serum vitamin D

12
levels were categorized as sufficient (≥30 ng/mL), insufficient (29-21 ng/mL), or deficient
(≤20 ng/mL). Of the 105 patients included, 55.2% had mild AD, 22.8% had moderate AD,
and 21.9% had severe AD. Vitamin D deficiency was observed in 42.9% of patients, with
no significant association between vitamin D levels and AD severity. Specifically, 85% of
the children had deficient or insufficient vitamin D levels, yet serum vitamin D
concentrations did not correlate significantly with AD severity. The study concluded that
while a high proportion of children with AD exhibited inadequate vitamin D levels, there
was no significant relationship between serum vitamin D concentrations and the severity of
AD in this population [22].

In a systematic review and meta-analysis published in Nutrients by Min Jung Kim et al., the
relationship between vitamin D status and the efficacy of vitamin D supplementation in
atopic dermatitis (AD) was investigated. The study, conducted up to May 2015, included
observational studies and randomized controlled trials that provided data on serum 25-
hydroxyvitamin D (25(OH)D) levels and quantified severity assessed using the Scoring
Atopic Dermatitis (SCORAD) index or Eczema Area and Severity Index (EASI) score. The
analysis revealed that compared to healthy controls, AD patients, especially pediatric ones,
exhibited lower serum 25(OH)D levels. Furthermore, vitamin D supplementation led to a
decrease in both SCORAD index and EASI score, suggesting its potential as a therapeutic
option for AD. The meta-analysis underscored the significance of vitamin D in AD
management and highlighted vitamin D supplementation as a promising avenue for
treatment. [23]

In summary, the literature reviewed provides valuable insights into the role of vitamin D
supplementation in pediatric patients with atopic dermatitis (AD) in Khartoum State, Sudan.
Despite the notable prevalence of AD among children in this region, research on the efficacy
and safety of vitamin D supplementation in managing AD remains relatively limited.

Several studies have demonstrated a potential association between vitamin D deficiency and
AD severity, suggesting that inadequate vitamin D levels may contribute to the pathogenesis
of AD. However, conflicting findings exist regarding the effectiveness of vitamin D
supplementation in improving AD severity.

13
Studies such as those by Morteza et al. [10] and Noha et al. [11] suggest that vitamin D
supplementation may lead to significant improvements in AD severity, as evidenced by
reductions in SCORAD and EASI scores. However, other studies, including those by Renata
Robl et al. [22] and Zbigniew Samochocki et al. [19], have reported mixed results, with no
significant correlation between serum vitamin D levels and AD severity or inconclusive
findings regarding the efficacy of supplementation.

Furthermore, meta-analyses conducted by Afif Nurul Hidayati et al. [15] and Min Jung Kim
et al. [23] have highlighted the potential benefits of vitamin D supplementation in reducing
AD severity, albeit with variations in study outcomes and methodologies.

Overall, while there is emerging evidence suggesting a potential role for vitamin D
supplementation as an adjunctive therapy for AD in pediatric patients, further research is
warranted to elucidate the optimal dose, duration, and efficacy of supplementation in this
population. Addressing the limitations of existing studies, such as small sample sizes,
heterogeneous methodologies, and inconsistent outcomes, will be crucial for establishing
robust evidence-based recommendations for the use of vitamin D supplementation in
managing AD among pediatric patients in Khartoum State.

Given the significant burden of AD on pediatric health and the potential implications for
clinical practice, future large-scale, well-designed clinical trials are needed to further
investigate the therapeutic potential of vitamin D supplementation and inform evidence-
based guidelines for AD management in this population.

14
 1.5. OBJECTIVES

1.5.1 General objective

To study the relation of vitamin D level with atopic dermatitis severity.

1.5.2 Specific objectives

1. To measure vitamin D level among patients with Atopic dermatitis.

2. To determine the severity of atopic dermatitis

3. To correlate vitamin D level with the severity of atopic dermatitis

15
Chapter Two

Materials and Methods

16
 2 MATERIALS AND METHODS

2.1 Study design

This study was an observational cross sectional, hospital-based study.

2.2 Study area

The study was conducted in dermatology department in Khartoum state. Omdurman military
Hospital, Khartoum dermatology hospital, Bahri hospital, they are one of the largest
hospitals in Khartoum state and in Sudan. It receives many cases from different regions and
state with high flow of the patients.

2.3 Study Duration:

The study was conducted during the period within 2022 – 2023 and the data was collected
from January – April 2023.

2.3 Study population:

The study involved all pediatric patients diagnosed with Atopic dermatitis.

2.3.1 Inclusion criteria:

• Patients 18 years
• Patient confirm the diagnosis with Atopic dermatitis.
• Patients with low level of serum Vitamin D.

2.3.2 Exclusion criteria:

• Patients refuse to participate in the study.

• Patients with doubtful diagnosis.

17
2.4 2Sample size and technique

Deu to limitation in the number of cases, total coverage method was applied to include all
study participants who fulfill the study criteria within the study area and period. The total
number of cases covered was 30.

2.5 Data collection tool:

• The data was collected by the primary researcher though the comprehensive
structural close ended questionnaire.
• It involved the demographic data of the patient, AD history and SCORAD scale.
• In this study, the research employed the EASI (Eczema Area and Severity Index)
score as a tool for evaluating both the extent and severity of atopic eczema.

The EASI (Eczema Area and Severity Index)

o EASI Score Overview: The EASI score (Eczema Area and Severity Index)
measures the extent and severity of atopic eczema.
o Evaluation Factors: It considers the percentage of skin affected by eczema
in four body regions and assesses the intensity of four signs: redness,
thickness, scratching, and lichenification.
o Intensity Assessment: Each sign is rated on a scale of none (0), mild (1),
moderate (2), and severe (3), with half scores allowed.
o Severity Score Calculation: The severity score for each region is calculated
by summing the intensity scores of the four signs.
o Area Score: An area score is assigned for each body region based on the
percentage of skin affected by eczema.
o Multiplier Application: For each region, the severity score is multiplied by
the area score and a specific multiplier, which varies depending on the body
site.
o Final EASI Score: The total scores for each region are summed to determine
the final EASI score, ranging from 0 to 72.

18
 o This approach enables a comprehensive assessment of eczema severity across
different body regions, facilitating accurate data collection for research
purposes.
• All the patient gained a list of risk factors to be avoided. A blood sample was obtained
to measure the level of Vitamin D in the serum.

2.6 Data Analysis and Presentation:

• Data was entered, cleaned, and analyzed using SPSS 28.0

• Descriptive statistics in term of frequency tables with percentages and graphs. Means
and standard deviations were presented with relevant graphic representation for
quantitative data.
• Bi-variable analysis to determine the associations between the outcome variables and
the other relevant influencing factors with Chi square test (for categorical variables)
and t-test for (quantitative variables) statistical tests.
• The relation between quantitative variable was assessed by person correlation
coefficients. P value of 0.05 or less is considered statistically significant.

2.7 Ethical Considerations:

• Ethical clearance was obtained from Sudan Medical specialization Board, research
department and FMOH.
• Ethical approval was obtained from the EDC.
• Permission to collect the study data was obtained from the medical director.
• Informed consents were obtained from the study participants after explaining the
objectives of the study.
• Collected data confidentiality were considered at all times.
• Results were anonymized.

19
Chapter Three
Results

20
 RESULTS

This study covered 30 pediatric patients diagnosed with atopic dermatitis in

Khartoum State during the period of from January - April 2023.

Demographical Characteristics

The distribution of participants by age revealed that the majority were within
the age range of less than 1 year to 5 years, with 40.0% of participants falling
under the category of less than 1 year, 33.3% aged between 1 and 5 years, and
the remaining 26.7% falling in the 5 to 10 years age group. The mean age of
the participants was approximately 3.6 years.

Moreover, there was a higher representation of female patients, accounting for

70.0% of the total participants, compared to male patients, who constituted
30.0%.

Clinical Characteristics:

Regarding clinical characteristics, the duration since diagnosis varied among

the participants. A considerable proportion of patients had been diagnosed
within the past year (23.3%), while a majority had been living with the
condition for 1 to 5 years (60.0%).

Additionally, family history played a role in some cases, with 30.0% of

participants having a positive family history of atopic dermatitis.

Assessment of Vitamin D Level:

Analysis of vitamin D levels among the pediatric patients with atopic dermatitis
indicated that a significant portion of participants (70.0%) had vitamin D levels

21
≤ 20 mg / dL, suggesting a prevalence of vitamin D insufficiency or deficiency
within the cohort. The mean vitamin D level was approximately 14.80 mg / dL,
with levels ranging from 5 to 25 mg / dL.

Disease Severity Assessment:

Severity assessment using the SCORAD scale revealed varying degrees of

disease severity among the participants, with scores ranging from 6 to 48 and a
mean score of approximately 15.84.

Furthermore, the nature of the disease was predominantly progressive (66.7%),

while a minority of cases were categorized as static (33.3%).

Correlation between Vitamin D Level and Disease Severity:

A notable finding was the significant negative correlation observed between

vitamin D level and disease severity, as assessed using the Eczema Area and
Severity Index (EASI).

The Pearson correlation coefficient was -0.375, with a corresponding p-value

of 0.041, indicating a potential association between higher vitamin D levels and
lower disease severity in pediatric patients with atopic dermatitis.

In summary, the results provide valuable insights into the demographic

composition, clinical characteristics, vitamin D status, disease severity, and
potential correlations within the cohort of pediatric patients diagnosed with
atopic dermatitis in Khartoum State during the specified period. These findings
contribute to a better understanding of the condition and may guide future
research and clinical management strategies.

22
 RESULTS

Demographical characteristics

Table (1) the distribution of the participants according to their age – years (n = 30 pediatrics
patients with atopic dermatitis in Khartoum state, from January - April 2023)

Age - years Frequency Percent (%)

< 1 year 12 40.0

1 - 5 years 10 33.3

5 - 10 years 8 26.7

Total 30 100.0

Table (2) the quantitative summary for the age of the participants (n = 30 pediatrics patients with
atopic dermatitis in Khartoum state, from January - April 2023)

Variable Minimum Maximum Mean Std. Deviation

Age – years 2 months 10 4.07 3.597

23
Figure (1) the distribution of the participants according to their age – years (n = 30 pediatrics
patients with atopic dermatitis in Khartoum state, from January - April 2023)

24
Table (3) the distribution of the participants according to their gender (n = 30 pediatrics patients
with atopic dermatitis in Khartoum state, from January - April 2023)

Gender Frequency Percent (%)

Male 9 30.0

Female 21 70.0

Total 30 100.0

Figure (2) the distribution of the participants according to their gender (n = 30 pediatrics patients
with atopic dermatitis in Khartoum state, from January - April 2023)

25
Clinical characteristics

Table (4) the distribution of the participants according to the duration since the diagnosis (n = 30
pediatrics patients with atopic dermatitis in Khartoum state, from January - April 2023)

Duration since the diagnosis Frequency Percent (%)

Recently 5 16.7

< 1 year 7 23.3

1 - 5 years 18 60.0

Total 30 100.0

Table (5) the quantitative summary for the disease duration among the participants (n = 30
pediatrics patients with atopic dermatitis in Khartoum state, from January - April 2023)

Variable Minimum Maximum Mean Std. Deviation

Duration since the diagnosis - years 0 4 1.57 1.38

26
Figure (3) the distribution of the participants according to the duration since the diagnosis (n = 30
pediatrics patients with atopic dermatitis in Khartoum state, from January - April 2023)

27
Table (6) the distribution of the participants according to the family history of atopic dermatitis (n
= 30 pediatrics patients with atopic dermatitis in Khartoum state, from January - April 2023)

Family history of atopic dermatitis Frequency Percent (%)

Positive 9 16.7

Negative 21 23.3

Total 30 100.0

Figure (4) the distribution of the participants according to the family history of atopic dermatitis
(n = 30 pediatrics patients with atopic dermatitis in Khartoum state, from January - April 2023)

28
Assessment of Vitamin D level

Table (7) the distribution of the participants according to the vitamin D level (n = 30 pediatrics
patients with atopic dermatitis in Khartoum state, from January - April 2023)

Vitamin D level Frequency Percent (%)

≤ 20 mg / dL 21 70.0

> 20 mg / dL 9 30.0

Total 30 100.0

Table (8) the quantitative summary for the vitamin D level – mg / dL of the participants (n = 30
pediatrics patients with atopic dermatitis in Khartoum state, from January - April 2023)

Variable Minimum Maximum Mean Std. Deviation

Vitamin D level – mg / dL 5 25 14.80 6.478

29
Figure (5) the distribution of the participants according to the vitamin D level (n = 30 pediatrics
patients with atopic dermatitis in Khartoum state, from January - April 2023)

30
Table (9) the distribution of the participants according to the nature of the disease (n = 30 pediatrics
patients with atopic dermatitis in Khartoum state, from January - April 2023)

Nature of the disease Frequency Percent (%)

Progressive 20 66.7

Static 10 33.3

Improving 0 0.0

Total 30 100.0

Figure (6) the distribution of the participants according to the nature of the disease (n = 30
pediatrics patients with atopic dermatitis in Khartoum state, from January - April 2023)

31
Disease severity assessment

Table (10) the quantitative summary for the SCORAD scale for the participants (n = 30 pediatrics
patients with atopic dermatitis in Khartoum state, from January - April 2023)

Variable Minimum Maximum Mean Std. Deviation

EASI 6 48 15.84 11.574

Correlation between vitamin D level and the severity of Atopic dermatitis (EASI)

Table (11) correlation between vitamin D level and the severity of Atopic dermatitis (EASI) among
the study participants (n = 30 pediatrics patients with atopic dermatitis in Khartoum state, from
January - April 2023)

Pearson Correlation -.375

P value .041

32
Figure (7) scatter plot showed the correlation between vitamin D level and the severity of Atopic
dermatitis (EASI) among the study participants (n = 30 pediatrics patients with atopic dermatitis
in Khartoum state, from January - April 2023)

33
Chapter four
Discussion, Conclusion and
Recommendations

34
 4.1 DISCUSSION

Atopic dermatitis (AD), a chronic inflammatory skin condition, is a significant health

concern among pediatric populations worldwide. In recent years, research interest has surged
regarding the potential therapeutic role of vitamin D supplementation in managing AD
severity, particularly in pediatric patients. Khartoum State, situated in Sudan, grapples with
a notable burden of AD cases among its pediatric population.

Amidst this backdrop, this discussion chapter aims to critically examine the findings of this
study that conducted in Khartoum State between 2022 and 2023, focusing on the relationship
between vitamin D supplementation and AD severity among pediatric patients.

The chapter explores the rationale for investigating this relationship, reviews relevant
literature, discusses the study's methodology, and interprets the results within the context of
existing evidence. Additionally, it addresses the implications of the findings for clinical
practice, identifies areas for future research, and underscores the importance of optimizing
therapeutic strategies for managing pediatric AD in Khartoum State.

Through this comprehensive discussion, we aim to contribute to the ongoing dialogue

surrounding the role of vitamin D supplementation in pediatric AD management and its
potential implications for improving patient outcomes in this population.

The results of the present study provide valuable insights into the relationship between
vitamin D levels and disease severity among pediatric patients with atopic dermatitis (AD)
in Khartoum State during 2022-2023. A notable finding was the significant negative
correlation observed between vitamin D level and disease severity, as assessed using the
Eczema Area and Severity Index (EASI), with a Pearson correlation coefficient of -0.375
and a corresponding p-value of 0.041. This finding suggests a potential association between
higher vitamin D levels and lower disease severity in pediatric patients with AD.

Comparing our results with relevant studies yields further understanding of the impact of
vitamin D supplementation on AD severity. For instance, a study conducted by Morteza et
al. [10] demonstrated significant improvement in AD patients treated with vitamin D

35
supplementation, as evidenced by SCORAD and TIS values. Similarly, Noha et al. [11]
reported a significant reduction in EASI scores following vitamin D supplementation,
supporting the notion that vitamin D may mitigate AD severity. Moreover, a meta-analysis
by Sonal R et al. [20] revealed a significant reduction in SCORAD scores with vitamin D
supplementation, emphasizing its potential as a therapeutic intervention for AD.

However, our findings contrast with studies such as the one by Irene Lara-Corrales et al.
[17], where despite a correlation between vitamin D levels and AD severity, supplementation
did not lead to significant improvements in disease severity. Additionally, a study by Renata
Robl et al. [18] found that while VD supplementation improved AD severity, the effect was
not significant compared to placebo, indicating variability in treatment response among
different populations.

Furthermore, the study by S. Ronceray et al. [21] observed a negative correlation between
serum 25(OH)D concentration and AD severity, consistent with our findings. However, the
authors emphasized the absence of a causal link between vitamin D deficiency and AD
severity, highlighting the need for further interventional studies to confirm this associations
in other similar studies [25 – 27].

Despite the growing body of evidence supporting the role of vitamin D supplementation in
mitigating AD severity, several limitations must be acknowledged. Firstly, the small sample
size of our study limits the generalizability of the findings. Additionally, studies reported
[28 - confounding factors such as sun exposure, diet, and genetic predisposition were not
accounted for, potentially influencing the observed association between vitamin D levels
and AD severity.

In summary, our study contributed to the existing literature [28 – 30] by highlighting a
potential association between higher vitamin D levels and lower disease severity in pediatric
patients with AD in Khartoum State. While the findings support the therapeutic potential of
vitamin D supplementation in managing AD, further large-scale, randomized controlled trials
are warranted to elucidate optimal dosages and efficacy in diverse populations. Addressing these
research gaps will advance our understanding of the role of vitamin D in AD management and
inform evidence-based clinical practice.

36
In this study, the distribution of participants by age revealed that the majority were within the
age range of less than 1 year to 5 years, with 40.0% of participants falling under the category of
less than 1 year, 33.3% aged between 1 and 5 years, and the remaining 26.7% falling in the 5 to
10 years age group. The mean age of the participants was approximately 3.6 years. Moreover,
there was a higher representation of female patients, accounting for 70.0% of the total
participants, compared to male patients, who constituted 30.0%.

The demographic profile observed in our study aligns with findings from previous
investigations, particularly those conducted by Morteza A, et al. [10] and Noha O, et al. [11].
Similar to our study, Morteza A, et al. reported a predominance of younger patients, highlighting
the vulnerability of infants and young children to atopic dermatitis (AD). Likewise, Noha O, et
al. and others [31 – 32] also observed a higher representation of younger patients, emphasizing
the importance of early intervention strategies in managing pediatric AD.

However, contrasting observations were noted in studies such as the one conducted by Ulrich A,
et al. [14], which included a broader age range of patients with AD. This discrepancy may reflect
variations in study populations and geographic locations, underscoring the influence of
demographic factors on disease epidemiology.

Regarding gender distribution, our study's finding of a higher proportion of female patients is
consistent with reports from studies such as those by Morteza A, et al. [10] and Daniela B, et al.
[13]. These studies also noted a similar gender disparity, suggesting a potential gender-related
susceptibility to AD or differences in healthcare-seeking behavior between males and females.

In contrast, findings from studies such as the one by Zbigniew Samochocki et al. [19] reported
more balanced gender distributions among pediatric AD patients, indicating variability across
different populations. Studies added that [33 – 36], the reasons for this gender difference remain
unclear and warrant further investigation to elucidate potential underlying factors contributing
to differential disease prevalence and severity between genders.

In this study, the variation in the duration since diagnosis, with a considerable proportion of
patients diagnosed within the past year and a majority living with the condition for 1 to 5 years,
underscores the chronic nature of AD and highlights the need for long-term management
strategies. This finding resonates with studies such as the one conducted by Irene Lara-Corrales

37
et al. [17], which also reported diverse disease durations among pediatric AD patients, indicating
the persistence and relapsing nature of the condition over time.

Moreover, the identification of a positive family history of AD in 30.0% of participants aligns

with findings from studies such as the one by Daniela B, et al. [13], which emphasized the
genetic predisposition to AD within families. This observation underscores the multifactorial
etiology of AD, involving both genetic and environmental factors, and highlights the importance
of considering familial history in assessing disease risk and prognosis.

However, contrasting observations were noted in studies such as the one conducted by Christine
C, et al. [12], which reported lower rates of positive family history among pediatric AD patients.
This discrepancy may reflect variations in study populations and methodologies, as well as
differences in genetic predisposition across geographic regions and ethnic groups.

Further research is warranted to elucidate the underlying genetic and environmental factors
contributing to AD pathogenesis and to develop tailored management approaches for individuals
with varying disease durations and familial backgrounds.

The analysis of vitamin D levels among pediatric patients with atopic dermatitis (AD) in our
study revealed concerning findings regarding the prevalence of vitamin D insufficiency or
deficiency within the cohort. A significant portion of participants (70.0%) exhibited vitamin D
levels ≤ 20 mg/dL, indicating a high prevalence of suboptimal vitamin D status among pediatric
AD patients in Khartoum State. This observation aligns with findings from studies such as the
one conducted by Renata Robl et al. [22], which reported similar rates of vitamin D insufficiency
or deficiency among pediatric AD populations. The mean vitamin D level of approximately
14.80 mg/dL further emphasizes the severity of vitamin D deficiency within our study cohort,
highlighting the need for targeted interventions to address this nutritional deficiency in pediatric
AD patients.

Moreover, our study assessed disease severity using the SCORAD scale, revealing varying
degrees of severity among participants, with scores ranging from 6 to 48 and a mean score of
approximately 15.84. This variability in disease severity underscores the heterogeneous nature
of AD and highlights the importance of individualized treatment approaches tailored to the
specific needs of each patient. Our findings are consistent with studies such as the one conducted

38
by Noha O, et al. [11], which also utilized the SCORAD scale to assess AD severity and reported
diverse severity levels among pediatric patients.

Furthermore, our study observed that the nature of the disease was predominantly progressive
(66.7%), indicating ongoing disease activity and exacerbations among the majority of cases. This
finding underscores the chronic and relapsing nature of AD, highlighting the need for
comprehensive management strategies aimed at controlling disease progression and preventing
flare-ups. However, it is noteworthy that a minority of cases were categorized as static (33.3%),
indicating stable disease activity over time. This observation suggests heterogeneity in disease
course among pediatric AD patients, with some individuals experiencing remission or stable
disease states as in other studies [37 – 40].

In summary, our study provided valuable insights into the prevalence of vitamin D deficiency,
disease severity, and disease progression among pediatric patients with AD in Khartoum State.
These findings highlighted the importance of routine screening for vitamin D levels and
comprehensive assessment of disease severity in pediatric AD patients to optimize management
strategies and improve clinical outcomes.

39
 1.2 CONCLUSION

In conclusion, this study underscores the importance of exploring the relationship between
vitamin D levels and atopic dermatitis (AD) severity among pediatric patients. The findings
reveal a prevalence of vitamin D insufficiency or deficiency in the studied cohort, with a
significant negative correlation observed between vitamin D levels and disease severity, as
assessed by the Eczema Area and Severity Index (EASI).

The majority of participants fell within the age range of less than 1 year to 5 years, with a higher
representation of female patients. Additionally, varying durations since diagnosis and family
history of AD were noted among the participants.

These findings highlight the potential role of vitamin D supplementation as an adjunctive therapy
for pediatric AD, emphasizing the need for further research to elucidate optimal dosage and
efficacy in managing the condition.

40
 4.3 RECOMMENDATIONS

• Routine screening protocols for vitamin D levels in pediatric patients diagnosed with
atopic dermatitis should be implemented to identify those at risk of deficiency or
insufficiency.
• Individualized vitamin D supplementation plans based on serum levels and disease
severity should be considered to optimize treatment outcomes in pediatric patients
with atopic dermatitis.
• Longitudinal follow-up studies should be conducted to evaluate the long-term
efficacy and safety of vitamin D supplementation as an adjunctive therapy for
managing atopic dermatitis in pediatric patients.
• Educational programs to raise awareness among healthcare providers, caregivers,
and patients about the potential role of vitamin D in the management of atopic
dermatitis should be developed and implemented.
• Emphasis should be placed on assessing family history of atopic dermatitis in
pediatric patients, as it may influence disease severity and response to treatment.
• A multidisciplinary approach involving dermatologists, pediatricians, and
nutritionists should be encouraged to optimize the management of pediatric patients
with atopic dermatitis, including the consideration of vitamin D supplementation.
• Further research should be conducted to determine the optimal dosage and duration
of vitamin D supplementation for pediatric patients with atopic dermatitis, taking
into account factors such as age, weight, and disease severity.
• Integration of assessment of vitamin D levels into routine clinical practice for
pediatric patients with atopic dermatitis should be considered to guide treatment
decisions and improve patient outcomes.

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 4.4 STUDY LIMITATIONS

• The study sample size was relatively small, consisting of only 30 pediatric patients
diagnosed with atopic dermatitis. This limited sample size may impact the
generalizability of the findings to broader populations of pediatric patients with
atopic dermatitis.
• The study employed a cross-sectional design, which provides a snapshot of the
relationship between vitamin D levels and atopic dermatitis severity at a single point
in time. As a result, causality cannot be inferred, and longitudinal studies are needed
to establish temporal relationships and assess treatment efficacy over time.
• The study was conducted exclusively in Khartoum state, potentially limiting the
generalizability of the findings to other geographic regions with different
demographic characteristics and environmental factors. Therefore, caution should be
exercised when extrapolating the results to populations outside the study area.
• Despite efforts to control for confounding variables, there may still be unmeasured
factors that could influence the relationship between vitamin D levels and atopic
dermatitis severity, such as dietary habits, sun exposure, and comorbidities. Failure
to account for these variables could introduce bias and affect the accuracy of the
study findings.

42
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