Recall Bias in Childhood Atopic Diseases Among Adults in The Odense Adolescence Cohort Study

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1 Syddnsk Universitet Recll Bis in Childhood Atopic Diseses Among Adults in The Odense Adolescence Cohort Study Mørtz, Chrlotte G; Andersen, Klus Ejner; Bindslev-Jensen, Crsten Published in: Act Dermto-Venereologic DOI: / Publiction dte: 2015 Document version Publisher's PDF, lso known s Version of record Cittion for pulished version (APA): Mortz, C. G., Andersen, K. E., & Bindslev-Jensen, C. (2015). Recll Bis in Childhood Atopic Diseses Among Adults in The Odense Adolescence Cohort Study. Act Dermto-Venereologic, 95(8), DOI: / Generl rights Copyright nd morl rights for the publictions mde ccessible in the public portl re retined by the uthors nd/or other copyright owners nd it is condition of ccessing publictions tht users recognise nd bide by the legl requirements ssocited with these rights. Users my downlod nd print one copy of ny publiction from the public portl for the purpose of privte study or reserch. You my not further distribute the mteril or use it for ny profit-mking ctivity or commercil gin You my freely distribute the URL identifying the publiction in the public portl? Tke down policy If you believe tht this document breches copyright plese contct us providing detils, nd we will remove ccess to the work immeditely nd investigte your clim. Downlod dte: 18. jul

2 Act Derm Venereol 2015; 95: CLINICAL REPORT Recll Bis in Childhood Atopic Diseses Among Adults in The Odense Adolescence Cohort Study Chrlotte G. MORTZ, Klus E. ANDERSEN nd Crsten BINDSLEV-JENSEN Deprtment of Dermtology nd Allergy Centre, Odense Reserch Centre for Anphylxis (ORCA), Odense University Hospitl, University of Southern Denmrk, Odense, Denmrk Atopic dermtitis (AD) is common disese in childhood nd n importnt risk fctor for the lter development of other topic diseses. Mny publictions on childhood AD use questionnires bsed on informtion obtined in dulthood, which introduce the possibility of recll bis. In prospective cohort study, recll bis ws evluted in 1,501 unselected schoolchildren (men ge 14 yers) evluted for the first time in 1995 with stndrdized questionnire combined with clinicl exmintion nd repeted in The lifetime prevlence of AD ws 34.1% including dt obtined both during school ge nd 15 yers lter, compred with 23.6% including dt only from dulthood. The most importnt fctors for remembering hving hd AD in childhood were: (i) long durtion of dermtitis in childhood; (ii) dult hnd eczem; nd (iii) concomitnt topic disese. Recll bis for childhood AD ffected the results of logistic regression on dult hnd eczem nd is significnt problem in retrospective epidemiologicl questionnire studies evluting previous AD s risk fctor for development of other diseses. Key words: recll bis; topic dermtitis; sthm; llergic rhinitis; questionnire; prospective studies. Accepted Apr 27, 2015; Epub hed of print Apr 28, 2015 Act Derm Venereol 2015; 95: Chrlotte G. Mortz, Deprtment of Dermtology nd Allergy Centre, Odense University Hospitl, Sdr. Boulevrd 29, DK-5000 Odense C, Denmrk. E-mil: Chrlotte. moertz@rsyd.dk Atopic dermtitis (AD) is common, with lifetime prevlence in the generl popultion of pproximtely 20 25% (1, 2). AD usully strts before the ge of 2 yers, nd mny children outgrow the disese before strting school (3, 4). AD is considered one of the most importnt risk fctors for developing dult hnd eczem (5, 6). Since most studies of hnd eczem in dults re cross-sectionl or hve follow-up period during dult life, these studies ssess risk fctors in childhood bsed on questionnires performed in dulthood. Self-report questionnires sking dults bout risk fctors in childhood hve the drwbcks of recll bis nd the possibility of misclssifying the dignosis of AD. Even short pssge of time cn introduce mjor recll bis, s people forget tht they hve hd eczem (7). When sking dults bout diseses occurring before school ge the nswers would therefore be even less ccurte. The present study evluted schoolchildren in the 8 th grde (men ge 14 yers) in 1995 using stndrdized questionnire nswered by the children nd their prents, combined with clinicl exmintion for eczem. The sme procedure ws repeted 15 yers lter in the sme popultion (men ge 29 yers, prents not involved) to evlute the course of topic diseses nd recll bis. MATERIAL AND METHODS Popultion nd study design Phse One of The Odense Adolescence Cohort Study (TOACS) ws conducted in s cross-sectionl study mong 1,501 8 th grde schoolchildren in the Municiplity of Odense, encompssing questionnires, interviews nd clinicl exmintions, blood smples for immunoglobulin E (IgE) mesurement nd ptch tests. Phse Two ws conducted in s cse-control study in selected groups of schoolchildren (1). Phse Three is 15-yer follow-up study in the sme popultion (28 30 yers of ge). From the originl cohort, 1,271 subjects hd provided consent to be contcted gin nd hd provided their personl identifiction number for trcing. An invittion to the follow-up study ws sent in 2010 together with code to ccess n online questionnire with 147 questions. If subjects did not nswer fter hving been sent 2 reminders, the questionnire ws sent twice more s pper version. Furthermore, prticipnts were offered clinicl exmintion, mesurement of specific IgE, skin-prick tests, pulmonry function test nd ptch tests. The exmintion nd testing ws performed in Odense, Copenhgen nd Arhus by the sme investigtor (CGM) who performed the Phse One nd Two studies, ssisted by 2 experienced dermtologicl nurses nd lbortory technicin. Detils of the follow-up study re published elsewhere (5, 8, 9). Phse Three questionnire The respondents completed the questionnire with questions on AD, sthm, llergic rhino-conjunctivitis, hnd eczem, urticri/ngioedem nd Type I nd IV llergy. The questionnire included the sme questions s in Phse One, supplemented with new questions tht included occuptionl spects. In Phse One the schoolchildren nd their prents were sked to complete the questionnire together, while the young dults completed the questionnire by themselves in Phse Three. The lifetime prevlence of AD ws defined by published questionnire criteri bsed on severl questions (Schultz Lr The Authors. doi: / Journl Compiltion 2015 Act Dermto-Venereologic. ISSN

3 Recll bis in topic diseses 969 sen criteri) (2) with sensitivity of 88% nd specificity of 89%. Furthermore, single question on the lifetime prevlence of AD ws included bsed on the Tuohilmpi questionnire: Hve you ever hd childhood eczem (AD), n itchy rsh (eczem) which hs ffected skin creses or folds (folds of elbows, behind the knees)? (10, 11). The lifetime prevlences of sthm nd llergic rhinitis were evluted using the Tuohilmpi questionnire/nosq-2002 questionnire, by nswering the 2 questions: Hve you ever hd sthm? nd Hve you ever hd hy fever or other symptoms of nsl llergy (bouts of sneezing, ichy or running nose ) from e.g. pollen or nimls? (10, 11). A question on llergic eye symptoms ws lso included. All questions on topic diseses were followed by the question, Ws the dignosis confirmed by doctor? The lifetime prevlence of hnd eczem ws lso determined by using the Tuohilmpi questionnire/nosq-2002 questionnire (10, 11). The criteri for history of hnd eczem were eczem (rsh) on the fingers, finger webs, plms or bck of hnds, which hd ppered once nd continued for t lest 2 weeks, or hd ppered severl times, or hd been persistent. Clinicl exmintion The 1-yer period prevlence nd point prevlence of AD were evluted cliniclly ccording to the Hnifin & Rjk criteri (12) both in 1995 nd 2010 by dermtologist (CGM). Ethics The study ws pproved by the Regionl Ethicl Committee for Southern Denmrk (S-VF ). Dt hndling nd sttistics A totl of 743 of the respondents nswered the electronic questionnire, while 156 nswered the pper version. The responses from the pper version were subsequently entered into the dtbse by the first uthor (CGM). All dt from the clinicl exmintion were entered twice. When differences were found, comprison with rw input forms ws mde nd corrections mde ccordingly. Sttisticl nlysis ws performed with STATA/SE 11.0 (Stt Corportion, TX, USA). The results re given s prevlence proportions nd 95% confidence intervl (CI). Comprisons were mde using χ 2 -bsed tble nlysis. Sttisticl significnce ws defined s p < RESULTS A totl of 1,206 subjects of the 1,271 (95%) from the originl cohort were retrieved in Denmrk through the ntionl centrl person register; 4 hd died, 1 person ws missing, nd 60 hd emigrted. After 4 reminders the response rte for nswering the questionnire ws 74.6% (899/1,206), nd 469/1,206 (38.9%) of the invited subjects (52.2% of those who responded by questionnire) prticipted in the clinicl exmintion. The 899 subjects nswering the questionnire in 2010 were representtive prt of the 1995 popultion, except tht more women thn men prticipted in the follow-up questionnire nd more with AD in childhood prticipted, s shown in Tble I (5). Tble II shows the lifetime prevlence of AD (Schultz Lrsen criteri [2]) in the cohort of persons prticipting Tble I. Comprison of bseline chrcteristics (1995) between prticipnts nd non-prticipnts in the questionnire in the follow-up study (2010) (reproduced from ref. 5) Bseline chrcteristics 1995 Sex Femle Prticipnts 2010 Non-prticipnts 2010 p-vlue Prevlence, Prevlence, 56.3 (506) 43.7 (393) 38.4 (207) 61.6 (332) < 0.05 Mle Present or pst: Atopic dermtitis 23.9 (215/899) 16.9 (91/539) < Hnd eczem 9.8 (88/899) 8.4 (45/539) 0.36 Allergic rhinitis 19.7 (177/899) 16.9 (91/539) 0.19 Asthm 12.0 (108/899) 11.3 (61/539) 0.69 Present: Contct llergy 15.4 (120/778) 14.7 (54/368) 0.74 Positive specific 28.1 (171/609) 33.1 (86/260) 0.14 IgE b In Phse One 1,146 of the 1,438 prticipted in ptch testing. b In Phse One 869 of the 1,438 prticipted in blood smple for IgE mesurement. in both Phse One nd Phse Three. The lifetime prevlence of AD ws 24.0% in Phse One; 15 yers lter similr lifetime prevlence ws found (23.6%; 95% CI ). However, on pooling those reporting AD in 1995 nd/or 2010, the lifetime prevlence ws 34.1% (95% CI ). In 1995, 215/897 fulfilled the criteri for AD. In 2010, however, only 121 of the originl 215 subjects could identify themselves s hving hd childhood AD bsed on the sme questions (Fig. 1), while 94 did not recll childhood AD (94/215; 43.7%, 95% CI ). Among the 94 subjects not found in 2010, 56 hd reported AD in 1995, with onset before the ge of 5 yers (34 before 2 yers of ge, nd 22 between 2 nd 5 yers of ge). In 30 of the 56 subjects, the dermtitis hd clered in less thn 5 yers. In 2010, 91 new cses were found (Fig. 1). It ws not possible to estimte lifetime prevlence of AD bsed on clinicl exmintion becuse the prticipnts were only exmined twice during the study period (1995 nd 2010). According to the Hnifin & Tble II. Lifetime prevlence of topic dermtitis (AD) (Schultz Lrsen criteri (2)) in the 897 prticipting in both Phse One nd Three questionnires Totl popultion n = 897 [95% CI] Women n = 505 Men n = 392 Phse One nd/or Three 34.1 (306) [ ] 38.0 (192) 29.1 (114) Phse Three 23.6 (212) [ ] 26.5 (134) 19.9 (78) Phse One (lifetime 0 14 yers) 24.0 (215) 27.5 (139) 19.4 (76) In totl 899 subjects nswered the questionnire; however, only 897 nswered the questions on topic dermtitis.

4 970 C. G. Mørtz et l. Atopic dermtitis 1995 Atopic dermtitis 2010 Rjk criteri (12), the 1-yer period prevlence of AD in 1995 ws 6.7% (90/1,340) nd the point prevlence 3.6% (48/1340). In 2010 the 1-yer period prevlence ws 10.0% (47/469) nd the point prevlence 6.2% (29/469). In 2010, 36/47 subjects with AD during the lst yer lso hd hnd eczem (dults fulfilling the Hnifin & Rjk criteri for AD nd hving eczem on Tble III. Lifetime prevlence of topic dermtitis (AD), llergic rhinitis (AR) nd sthm bsed on single questions (Tuohilmpi questionnire (10, 11)) in the 897 prticipting in both Phse One nd Three questionnires Phse One nd/or Three Phse Three Totl popultion n = 897 [95% CI] Women n = 505 Men n = (253) [ ] 31.5 (159) 24.0 (94) 18.8 (169) [ ] 22.0 (111) 14.8 (58) Phse One (lifetime 0 14 yers) 21.6 (194) 23.8 (120) 18.9 (74) Ever AR Phse One nd/or Three Ever AR Phse Three 40.8 (366) [ ] 41.4 (209) 40.1 (157) 36.2 (325) [ ] 35.8 (181) 36.7 (144) Ever AR Phse One (lifetime 0 14 yers) 19.7 (177) 20.2 (102) 19.1 (75) Ever sthm Phse One nd/or Three Ever sthm Phse Three Fig. 1. Reltionship betweeen topic dermtitis in 1995 nd Number of persons reporting topic dermtitis ever in 1995 nd when sked the sme questionnire gin fter 15 yers in In totle 215 reported topic dermtitis by questionnire in Of these, 121 nswered the sme in 2010 while 94 did not recll topic dermtitis in childhood when sked gin 15 yers lter. In 2010, 91 new cses were found (181) [ ] 22.2 (112) 17.6 (69) 17.3 (155) [ ] 18.8 (95) 15.3 (60) Ever sthm Phse One (lifetime 0 14 yers) 12.0 (108) 10.9 (55) 13.5 (53) In totl 899 subjects nswered the questionnire; however, only 897 nswered the questions on topic dermtitis, sthm nd llergic rhinitis. their hnds). On the other hnd, in 2010, 81/127 subjects with hnd eczem during the lst yer hd or hd hd AD. The ssocition between AD nd hnd eczem, including different types of hnd eczem, hs been described previously (5). Almost ll ptients dignosed s hving AD (Hnifin & Rjk) by the dermtologist during the clinicl exmintion were lso identified by the questionnire criteri (Schultz Lrsen criteri) both in 1995 (85/90) nd in 2010 (44/47). Using single question on AD (Tuohilmpi questionnire) both in 1995 nd 2010 similr result ws obtined (Tble III) s using the published questionnire criteri from Schultz Lrsen (Tble II). In 1995, 21.6% of subjects nswered tht they hve/hve hd AD; in 2010 this proportion hd reduced to 18.8%. However, by pooling the dt from 1995 nd 2010, lifetime prevlence incresed to 28.2% (95% CI ) insted of 18.8% (95% CI ). In 1995, 194/897 nswered yes to AD, nd in 2010 only 110 of the 194 gve the sme nswer. Fifty of the 84 subjects giving negtive nswer in 2010 hd their debut of AD before the ge of 5 yers (34 before the ge of 2 yers, 16 between the ge of 2 nd 5 yers), nd 32/50 hd durtion of AD of less thn 5 yers. Compred with AD, the lifetime prevlence of sthm nd llergic rhinitis ws nerly identicl, s evluted by the questionnire in 2010 compred with results evluted by pooled dt from 1995 nd 2010 (Tble III). The sme questions on hnd eczem were lso used both in 1995 nd The lifetime prevlence clculted by pooling the dt from 1995 nd 2010 ws 23.0% (95% CI ) compred with 18.2% (95% CI ) using dt reported only in 2010 (dt not shown). Hnd eczem ws found in 42.8% of subjects with AD. When exmining different fctors (Tble IV) in those subjects fulfilling the criteri for AD in both 1995 nd 2010 (Schultz Lrsen criteri) compred with those not reclling AD in childhood, the most importnt fctors for remembering AD were: (i) long durtion of dermtitis in childhood; (ii) dult hnd eczem; nd (iii) concomitnt topic diseses. Middle to high eductionl level compred with no or short eduction did not ffect recll. Of the 306 fulfilling the Schultz Lrsen criteri for AD ever (1995 nd/or 2010) 153 reported dermtitis during the lst yer in 2010 (50%), while 50% hd outgrown the dermtitis. In the 153 with present AD, 45 reported durtion of AD of more thn 20 yers, 39 of yers, 30 of 5 10 yers, nd 38 of less thn 5 yers (1 did not know). Looking t those with present AD nd durtion less thn 10 yers, it ppers tht 68/306 of subjects should hve developed AD fter the ge of 18 yers. However, including dt from 1995, 29/68 lredy fulfilled the criteri for AD in dolescence. This men tht no more

5 Recll bis in topic diseses 971 Tble IV. Different fctors in reltion to the group of dults remembering hving hd topic dermtitis (AD) in childhood compred with those not reclling AD in childhood (Schultz Lrsen criteri (2)) Remembering AD in childhood Do not recll AD in childhood Durtion of AD > 10 yers t 14 yers of ge 54.5 (66/121) 21.3 (20/94) < Hnd eczem during the lst yer s dult 40.0 (48/120) 5.4 (5/93) < Visit to physicin due to hnd eczem s dult 23.3 (28/120) 1.2 (1/93) < Allergic rhinitis 64.5 (78/121) 42.6 (40/94) < Asthm 38.8 (47/121) 21.3 (20/94) < 0.03 Middle high eductionl level 52.9 (64/121) 52.1 (49/94) NS Two did not nswer the questions on hnd eczem in NS: not significnt. p-vlue thn 39/306 (12.7%) with AD could hve developed AD fter the ge of 18 yers. DISCUSSION Recll bis is mjor problem in retrospective epidemiologicl studies in dults, especilly when including informtion bout diseses in childhood. We found tht significnt proportion of dults forgot tht they hd hd childhood AD when they responded to questionnire t the ge of 29 yers compred with the nswer given by themselves nd their prents 15 yers erlier. Those who remembered AD with 15-yer intervl more often hd long durtion of AD in childhood, hnd eczem in dulthood nd other topic diseses. A study from Wisconsin showed tht even short pssge of time cn introduce mjor recll bis (7): in dults with AD, only 59% self-reported the disese correctly, nd even prentl recll of skin disese in children ws only 70%. Furthermore, Swedish study reported tht 29% of subjects dignosed with AD in the school helth medicl records could not recll tht they hd hd the disese when sked yers lter (13). Those remembering hving AD in childhood hd higher prevlence of dermtitis fter the ge of 15 yers nd higher prevlence of hnd eczem, in greement with our results. Culturl nd eductionl fctors my lso ffect the response to questionnires on AD (14). However, eductionl level did not ffect recll bis in this study. The severity of AD in childhood ws not evluted in the questionnire nd therefore not included in the nlysis. It is possible tht those with severe AD in childhood tend to remember hving hd AD in childhood compred with those with only mild dermtitis. Furthermore, in childhood the questionnire ws nswered by the prent nd the schoolchildren, while the questionnire 15 yers lter ws nswered only by the young dults. This cn ffect recll, s prents remember diseses from erly childhood tht the 29-yer-old dults did not recll. Compred with the results obtined for AD, ptients tend to hve less recll bis regrding sthm nd llergic rhinitis, perhps due to the lter debut of these diseses (in older childhood nd dolescence). Furthermore, the occurrence of repeted ttcks of sthm or rhinitis my increse memory nd limit recll bis. In the TOACS cohort, 50% of the dults with AD hd outgrown their eczem in 2010, nd those with persistent AD s dults often hd long durtion of AD. Less thn 13% of those with dult AD hd been first dignosed fter 18 yers of ge. A questionnire-bsed study lwys crries the risk of misclssifiction of diseses compred with the clinicl dignosis, which must be considered the true dignosis. Much effort hs been mde to mke vlidted questionnires for the dignosis AD (2, 15, 16). However, it cn be difficult to mke questionnire fesible for ll ge groups, e.g. infnts, children, dolescents nd dults. At the time of this study in , the only vlidted questionnire in Dnish ws chosen for evlution of AD (2). The sme questionnire ws used 15 yers lter, knowing tht the questionnire hd not been vlidted in dults. Nerly ll ptients with clinicl dignosis of AD present t the ge of 14 yers nd 29 yers were found by the questionnire. As we did not perform periodic clinicl exmintion of the cohort, the lifetime prevlence of AD cnnot be estimted by clinicl exmintion, nd we re unble to determine if the questionnire overestimted the prevlence of AD. In 1995 nd 2010 single question on AD ws used in nother prt of the questionnire, together with questions on sthm nd llergic rhinitis, which gve nerly identicl estimtion of AD s the questionnirebsed criteri bsed on summtion of 18 questions (Schultz Lrsen criteri). In recent study from Sweden it ws shown tht the nswer to single question on AD tends to overestimte the prevlence of AD (17). In the Swedish study, 71% of cses with AD identified in the school helth medicl system nswered yes to hving hd AD (29% nswered no ), while 10% of controls nswered yes to hving hd AD. The specificity ws 71% nd the sensitivity 90%. The sensitivity ws higher nd the specificity ws lower in subgroup with current hnd eczem. Ptients without AD sometimes report childhood AD becuse they hve hd some eczem or other skin diseses tht re misclssified s AD (e.g.

6 972 C. G. Mørtz et l. llergic contct dermtitis, irritnt contct dermtitis, seborrhoeic dermtitis or skin diseses such s psorisis or fungl infection). We found tht lrge proportion of young dults did not recll AD in childhood, either using vlidted questionnire with 18 questions on AD or single question on AD. They did, however, recll sthm nd llergic rhinitis. Studies on hnd eczem in dults, often include questions on childhood AD when evluting risk fctors for dult hnd eczem, nd the mgnitude of recll bis will influence the nlysis for risk fctors in such studies. In prospective follow-up studies risk fctors from childhood cn be evluted in reltion to the development of dult disese. However, if the study is retrospective, recll bis regrding fctors from childhood cn be presented nd cn ffect risk ssessment. Erlier we reported risk fctors for dult hnd eczem (5). We showed tht childhood AD (AD dignosed in 1995) is risk fctor for dult hnd eczem in logistic regression model with n odds rtio (OR) of 1.9 (5) (prospective follow-up study). However, if we used dt on childhood AD obtined in 2010 (retrospective design) in the sme logistic regression model n OR of 4.1 ws obtined (dt not shown). This would hve overestimted the role of AD in dult hnd eczem, giving n OR of 4.1 insted of 1.9, due to recll bis in the retrospective design, nd must be tken into ccount in future studies on dults tht include history of childhood AD. Furthermore, there is need for improved nd vlidted dignostic criteri for AD tht re useful for both children nd dults. ACKNOWLEDGEMENTS This work ws supported by Age Bng s Foundtion, nd Odense University Hospitl Reserch Council. The uthors declre no conflicts of interest. REFERENCES 1. Mortz CG, Luritsen JM, Bindslev-Jensen C, Andersen KE. Prevlence of topic dermtitis, sthm, llergic rhinitis, nd hnd nd contct dermtitis in dolescents. The Odense Adolescence Cohort Study on Atopic Diseses nd Dermtitis. Br J Dermtol 2001; 144: Schultz Lrsen F, Diepgen T, Svensson Å. The occurrence of topic dermtitis in north Europe: n interntionl questionnire study. J Am Acd Dermtol 1996; 34: Rystedt I. Long term follow-up in topic dermtitis. Act Derm Venereol 1985; Suppl 114: Willims HC. Clinicl prctice. Atopic dermtitis. N Engl J Med 2005; 352: Mortz CG, Bindslev-Jensen C, Andersen KE. Hnd eczem in the TOACS cohort: Prevlence, incidence nd risk fctors from dolescence to dulthood. Br J Dermtol 2014; 171: Meding B, Swnbeck G. Predictive fctors for hnd eczem. Contct Dermtitis 1990; 23: Nlewy AL, Belongi EA, Greenlee RT, Kieke BA, Jr, Chen RT, Shy DK. Eczemtous skin disese nd recll of pst dignoses: implictions for smllpox vccintion. Ann Intern Med 2003; 139: Mortz CG, Bindslev-Jensen C, Andersen KE. Prevlence, incidence rtes nd persistence of contct llergy nd llergic contct dermtitis in The Odense Adolescence Cohort Study: 15-yer follow-up. Br J Dermtol 2013; 168: Mortz CG, Bindslev-Jensen C, Andersen KE. Nickel llergy from dolescence to dulthood in the TOACS cohort. Contct Dermtitis 2013; 68: Susitivl P, Knerv L, Hnnuksel M, Jolnki R, Estlnder T. Tuohilmpi questionnire for epidemiologicl studies of contct dermtitis nd topy. People nd Work 1996; 10: Susitivl P, Flyvholm MA, Meding B, Knerv L, Lindberg M, Svensson A, et l. Nordic Occuptionl Skin Questionnire (NOSQ-2002): new tool for surveying occuptionl skin diseses nd exposure. Contct Dermtitis 2003; 49: Hnifin JM, Rjk G. Dignostic fetures of topic dermtitis. Act Derm Venereol 1980; Suppl 92: Moberg C, Meding B, Stenberg B, Svensson A, Lindberg M. Remembering childhood topic dermtitis s n dult: fctors tht influence recollection. Br J Dermtol 2006; 155: Krmer U, Schfer T, Behrendt H, Ring J. The influence of culturl nd eductionl fctors on the vlidity of symptom nd dignosis questions for topic eczem. Br J Dermtol 1998; 139: Willims HC, Burney PG, Hy RJ, Archer CB, Shipley MJ, Hunter JJ, et l. The U.K. Working Prty s Dignostic Criteri for Atopic Dermtitis. I. Derivtion of minimum set of discrimintors for topic dermtitis. Br J Dermtol 1994; 131: Willims HC, Burney PG, Pembroke AC, Hy RJ. Vlidtion of the U.K. dignostic criteri for topic dermtitis in popultion setting. U.K. Dignostic Criteri for Atopic Dermtitis Working Prty. Br J Dermtol 1996; 135: Stenberg B, Lindberg M, Meding B, Svensson A. Is the question Hve you hd childhood eczem? useful for ssessing childhood topic eczem in dult popultion surveys? Contct Dermtitis 2006; 54: