Editorial

A significant portion of this issue is dedicated to atopic dermatitis—not only due to its prevalence in the general population, particularly among children, but also because of the wide range of drugs currently available and of the various options still under discussion. These include the latest biologics, which offer a highly effective treatment option, albeit one associated with very high healthcare costs. The ability to intervene effectively at an earlier stage — using preventive approaches from the very beginning of life — would therefore offer a two-fold benefit: on one hand, a biological and prognostic advantage by preventing the progression of allergic disease (the “atopic march”); on the other, significant savings, not only in terms of lost work or school days but also in substantial reductions in actual healthcare expenditure.

It is in this context that the paper “Skin barrier and skin microbiota in the primary prevention of atopic dermatitis: current evidence and future perspectives” by Cascone et al., prepared on behalf of the Commission for the Primary and Secondary Prevention of Allergic Diseases, is presented (p. 29). It offers a narrative review of findings to date. It is interesting to note that the well-established pathogenesis involving a barrier defect links closely to skin dysbiosis, with each factor exacerbating the inflammatory damage caused by the other. The authors analyze the results accumulated so far regarding the efficacy of prevention strategies and attempts to modify the skin microbiota (steering it toward a “beneficial” profile) or skin hydration (using topical moisturizers). Despite resting on convincing theoretical foundations and an impeccable rationale, all approaches attempted to date —whether used individually or in combination— have yielded disappointing results, likely due to the complexity of atopic dermatitis. The authors conclude that we remain far from achieving convincing results or definitive conclusions.

The atopic dermatitis committee, coordinated by Elena Galli, also presents the second part of its study on the holobiome (p. 39) ¹. An overview of therapeutic strategies targeting cutaneous dysbiosis in patients with atopic dermatitis. As the title suggests, this section focuses less on potential preventive strategies and critically examines possible applications for treating both acute and chronic forms of the disease. Indeed, modulating the skin microbiome could represent a promising complementary strategy to the complex pharmacological approach. This paper is truly valuable: it provides a detailed, highly educational analysis of all possible approaches, ranging from skin cleansing and phototherapy to the use of emollients, topical and systemic antibiotics, and anti-inflammatories, all the way to biologics, and concludes with an interesting look at the latest hypotheses regarding the potential key pathogenetic role of Staphylococcus aureus.

Michele Miraglia del Giudice et al. present the paper: “The role of vitamin D in pediatric respiratory diseases” (p. 3). The authors examine in detail the various functions of vitamin D, particularly from immunological and biological perspectives. Clinically, the beneficial effects of vitamin D supplementation are most evident in severely deficient children presenting primarily with respiratory symptoms, such as recurrent wheezing or respiratory infections. The fact that vitamin D shows less clinical impact in children with normal levels is a given and does not justify withholding supplementation. Indeed, the conclusion is that “vitamin D should be considered a significant nutritional and immunological factor for overall pediatric respiratory health, rather than merely a standalone treatment for asthma or recurrent respiratory infections. Supplementation promotes general well-being, supporting everything from growth and neuromuscular function to optimal respiratory health.”

Of great interest — albeit a niche topic — is the study by Mattia Moratti and Francesca Conti: “Guidelines for vaccination in preschool-aged children undergoing thymectomy: an in-depth immunological and clinical analysis” (p. 11). Indeed, children requiring thoracotomy during the neonatal period or early infancy due to severe heart disease (usually congenital) or other thoracic conditions undergo thymectomy out of sheer anatomical necessity — specifically, to facilitate median sternotomy.

While this procedure was once considered trivial — given that the thymus naturally atrophies with growth — we now understand (with increasing clarity) that it profoundly affects immune system development, causing significant iatrogenic secondary immunodeficiency and premature immunosenescence. The authors detail the immunological consequences of thymectomy, identifying the affected subpopulations, the extent to which central tolerance mechanisms are altered, and the compensatory mechanisms activated by the immune system.

These considerations have led to a reduction in the use of total thymectomy over time; whenever possible, surgeons now aim to preserve some neonatal thymic tissue and its basal blood supply, thereby maintaining at least partial regenerative capacity in the remaining parenchyma. The authors examine the full spectrum of scenarios — from total to partial thymectomy — and outline, for each patient profile, the criteria for selecting suitable vaccines versus those strictly contraindicated due to the risk of severe sequelae or even fatal outcomes, such as with the yellow fever vaccine.

Last is the paper by the Commission on New Digital Technologies, coordinated by Salvatore Tripodi (p. 18). It offers a comprehensive and well-documented overview of artificial intelligence: “ChatGPT and similar tools in pediatric allergology and immunology: allies or ‘false friends’?” The medical application of artificial intelligence (AI) is now widespread across many fields, including allergology. The key issue is understanding the extent to which AI-generated responses are accurate and truly applicable to the practice of allergology. The work by Tripodi and his colleagues details the full range of possibilities currently available in the fields of allergology and immunology, as well as the tools at hand; the critical responsibility of the reader and AI user is repeatedly emphasized — bearing in mind that AI is, and must remain, a tool for stimulating critical thought rather than an indisputable authority.