Do urea and sodium chloride together increase the efficacy of moisturisers for atopic dermatitis Skin? A comparative, double-blind and randomised study

Urea has long been used to treat dry skin. In the present report, we compared two creams, identical with the exception that one contained both urea and sodium chloride and the other urea alone, in 22 patients with atopic dermatitis. Following a 2-week wash-out period, their clinically non-eczematous, rough or normal-appearing skin on the forearms was treated twice daily in a double-blind and randomised manner. We examined the treated areas by measuring transepidermal water loss, capacitance and electrical impedance. Our findings suggest that a moisturiser containing both urea and sodium chloride seems somewhat more effective than the same moisturiser without sodium chloride, at least concerning the ability to reverse impedance indices of atopic skin towards normal, an effect ascribed mainly to changes in hydration of the stratum corneum. However, the clinical significance of our impedance measurements is somewhat premature to decide.     

FS09.5Patch testing with allopurinol and oxypurinol in drug eruptions

The rapidly increasing frequency of contact allergy to methyldibromo glutaronitrile (MDBGN) is of concern. This study investigates the allergic response elicited in pre‐sensitised individuals from exposure to a leave‐on product preserved with 50 or 100 ppm MDBGN.
Material and methods:  Eighteen volunteers with contact allergy to MDBGN and 10 healthy controls were exposed to repeated open allication tests (ROAT) with two moisturisers with a high and a low lipid content, respectively, both containing MDBGN in a concentration of 50 ppm. The ROATs were performed on the left and the right side of the neck for 14 days, or until a positive reaction was seen. If a positive reaction did not develop within the first 14 days the application with analogous moisturisers containing 100 ppm MDBGN continued for further 14 days.
Results:  Eleven (61.1%) developed dermatitis on the test area, and 10 (55.5%) developed a positive reaction to 50 ppm moisturiser. Reactions to the low‐ moisturiser were the most frequent. the controls all had negative ROATs.
Conclusion:  A concentration of 50 ppm MDBGN in a leave‐on product was found to elicit an allergic reaction in more than half of sensitised individuals when applied on the neck.     

The effect of two moisturisers on skin barrier damage in allergic contact dermatitis

Nickel (Ni)-induced allergic contact dermatitis (ACD) was performed in human volunteers to study the role of moisturisers in preventing ACD-related skin barrier damage. 15 Ni-sensitive females (mean age: 29.5 years; range: 23-38) were included. On days 1, 21, 24 and 26, TEWL, stratum corneum (SC)-capacitance and clinical score were evaluated on four test sites on the right and left forearms. Both a highly and a poorly hydrating moisturising formulation were applied on two sites from days 1 to 21, after which Ni-ACD was induced on the 2 pre-treated sites and one non-treated area. On day 24, TEWL values were significantly increased on the site pre-treated with poorly hydrating product compared to the rich formulation pre-treated site. SC-hydration was significantly improved on the latter site on days 21, 23 and 26. Long-term use of inadequate moisturiser increases skin barrier damage due to Ni-ACD.     

Evaluation of an experimental patch test model for the detection of irritant skin reactions to moisturisers

Background/aims: Moisturisers are used daily by a large number of people to prevent dryness of the skin. Irritant skin reactions to moisturisers are, however, known to occur. In order to prevent such irritant reactions reliable test methods for irritancy testing of moisturisers are needed. This study was undertaken to evaluate a non‐invasive patch test model for the detection of irritant skin reactions to moisturisers. Methods: Twenty healthy volunteers were patch tested with three different moisturisers: empty chamber, sodium lauryl sulphate and a moisturizer known to be non‐irritating. Skin reactions were evaluated by visual scoring, measurement of transepidermal water loss (TEWL) by an Evaporimeter, blood flow by laser Doppler flowmetry and electrical capacitance by a Corneometer. Results: A statistically significant increase in blood flow was found 48 h after application of one of the moisturisers tested, indicating an irritant effect of the product. A statistically significant decrease in skin hydration was found for the same moisturiser after 48 h. No statistically significant differences between the moisturisers were found by visual scoring. None of the products tested had any negative effect on the skin barrier function. Conclusion: The non‐invasive patch test model was found useful for detecting irritant skin reactions to moisturisers.     

Instrumental and dermatologist evaluation of the effect of glycerine and urea on dry skin in atopic dermatitis

Background/aims: Moisturising creams are useful treatment adjuncts in inflammatory dermatoses and have beneficial effects in the treatment of dry, scaly skin. The effects on dryness and skin permeability of a new moisturising cream with 20% glycerine was compared with its placebo and with a medicinally authorised cream with 4% urea (combined with 4% sodium chloride) in the treatment of dry skin.
Methods: Patients ( n =109) with atopic dermatitis were treated for 30 days with a moisturiser in a randomised, parallel and double-blind fashion. Transepidermal water loss (TEWL) and skin capacitance were assessed instrumentally, and changes in the dryness of the skin were assessed by the dermatologist.
Results: No difference in TEWL was found between glycerine treatment and its placebo, whereas a lower value was found in the urea-treated area compared to the glycerine-treated area. No difference in skin capacitance was found. The clinical assessment of dryness showed urea to be superior to glycerine in treating the condition.
Conclusions: Moisturising creams are different, not only with respect to composition but also with respect to their influence on skin as a barrier to water in patients with atopic dermatitis.     

Moisturisers for psoriatic skin--do gross morphological differences matter?

Studies suggest that moisturisers have a beneficial effect on psoriasis, and their use in preventive or adjuvant dermatological therapy is therefore of considerable clinical interest, although no classification of these products exists to guide their use. We have previously suggested a classification based on the ability of moisturisers to induce mechanical changes in normal skin. In psoriasis patients obvious objective differences exist between plaques and clinically uninvolved skin. This study was undertaken to investigate if these differences influence the mechanical response to moisturisers. Skin mechanics distension and hysteresis, Dermaflex as well as capacitance Corneometer 812 CM and moisturiser absorption were measured on psoriasis plaques and adjacent clinically uninvolved skin of 17 psoriasis patients. Three commonly available moisturisers, a barrier cream and a gel were tested. Baseline distensibility and capacitance were significantly lower for plaques (p < 0.0001), and all moisturisers increased distensibility in both lesions and adjacent skin. Hysteresis was generally affected to a greater degree by Locobase. The gel caused greater increases in hysteresis outside plaques. Capacitance was significantly increased in plaques, except for areas treated with Locobase, while only Decubal appeared to cause significant increases in uninvolved skin. Locobase showed better absorption in plaques than in control areas. No objective differences were found in the effects of moisturisers between psoriatic plaques and adjacent clinically uninvolved skin, suggesting that the significant clinical differences between lesional and paralesional skin do not influence the efficacy of moisturisers.     

Facial anti-wrinkle cream: influence of product presentation on effectiveness: a randomized and controlled study

BACKGROUND/AIMS: The great interest in eternal youth has developed a large market for skin care products claiming anti-wrinkle effects. A high-priced luxurious anti-wrinkle cream dispensed in its original packaging and in a neutral jar, were compared with the effects from a regular moisturizing face cream in a luxurious jar. METHODS: Eighty Swedish women aged 35-64 years were randomly divided into three groups; group A treated their facial skin for 6 weeks with the expensive cream in its luxury jar, B used a regular moisturiser filled in the luxury jar, and C used the expensive cream filled in a neutral jar. Evaluation was made by the subjects, clinical evaluation by a trained observer, and measurement of skin surface relief by optical profilometry. RESULTS: Participants using jars A and B consumed more product than participants using jar C, and the luxury jar thus resulted in better compliance. There were no significant differences between the three groups relating to the effects on wrinkles and smoothness, nor in subject assessment of their skin feeling younger or more beautiful. Facial appearance was the same. Profilometry showed reduced surface microrelief with all products. CONCLUSIONS: The present study conducted as a formal trial could not verify a claim of anti-wrinkle effect of a known prestigious product. Surprisingly, there was no systematic effect on subjective and objective cosmetic parameters of the luxury packaging, except a better compliance. Product appreciation by consumers may, however, be different in spontaneous use not biased by study conditions.     

The plastic sing effect of moisturizers on human skin in vivo: a measure of moisturizing potency?

Background/aims: Moisturisers have many different effects on the skin, but increased plasticity is an important effect of moisturising. We have studied the short-term effects of six commonly used brands of moisturisers on the plasticity of normal and atopic skin. Methods: Measurements of skin mechanics and capacitance were made in 25 healthy volunteers and 15 patients with atopic dermatitis, before and after moisturiser application. Results: Baseline mechanical values did not differ in the two groups. Capacitance was significantly lower in atopics (P<0.001). All moisturisers increased distensibility and hysteresis of normal as well as atopic skin. Vaseline® and Locobase® caused significantly greater distensibility increases than other moisturisers tested in normal skin, and Vaseline® caused a significantly greater increase in the hysteresis of normal skin. Hysteresis was unaffected by Kerodex®and Clinique® in normal skin. No differences were seen between the effects of different moisturisers in atopic skin. Capacitance measurements fell significantly in normal skin, possibly because of residual cream on the skin surface, while an increase or a significantly smaller reduction were seen in atopic skin. This may reflect better absorption of the moisturisers in atopic skin. Conclusions: The results suggest that high lipid moisturisers cause significantly greater changes in plasticity of normal skin than low-lipid moisturisers, and that atopic skin is influenced to a higher degree by moisturisers than normal skin.     

Long‐term management of moderate‐to‐severe atopic dermatitis with dupilumab and concomitant topical corticosteroids (LIBERTY AD CHRONOS): a critical appraisal

Atopic dermatitis (AD) is a common, chronic inflammatory skin disorder. The mainstay of treatment is daily moisturiser and anti‐inflammatory cream, usually topical corticosteroid (TCS). Immune‐suppressive medicines, used in severe cases, can cause adverse effects (unwanted side effects). Last year a trial of a new immune‐suppressive treatment for AD called dupilumab was published in The Lancet. Here, dermatologists from Nottingham in the UK critically review that study. The industry‐sponsored research examined the long‐term efficacy and safety of dupilumab, a “biologic” medicine that selectively suppresses immune cells involved in AD. The randomised, double‐blinded, placebo‐controlled trial was carried out across 161 clinics internationally. Dupilumab 300mg was injected in adults with moderate to severe AD, weekly (319 patients) or fortnightly (106 patients), for 52 weeks All patients, including 315 given placebo, continued to use TCS as required. The researchers found that dupilumab + TCS was well tolerated (meaning patients were able to stay on the treatment) and improved AD more than TCS alone but was associated with more adverse effects (particularly conjunctivitis). No difference in efficacy was reported between weekly and fortnightly injections. This was generally a well‐conducted study, but the reviewers had some reservations. More participants were recruited than could be justified statistically: this suggests “seeding”, that is widespread testing to promote familiarity and confidence in the drug. The reviewers’ re‐analysis showed that fortnightly dosing was more effective than weekly, at half the cost. Most participants had moderate AD, but biologics are usually reserved for patients with severe disease. The comparison could have been with another systemic immune‐suppressant rather than placebo. These factors may bias conclusions in favour of the drug.     

In vivo quantitative analysis of the effect of hydration (immersion and Vaseline treatment) in skin layers using high‐resolution MRI and magnetisation transfer contrast*

Background/aims: Many claims are made as to the efficacy of topical preparations in moisturising the skin, yet most of these claims cannot be substantiated by scientific study for the skin layers beneath the stratum corneum, and yield no information on the remainder of the epidermis and dermis. This argues for an in vivo quantitative method for measuring the effect of water loading extended to various layers of the skin. Methods: Detailed high‐resolution in vivo MRI studies of hydration and dehydration of finger pad skin layers were conducted on one normal subject using two moisturisation methods (topical white soft paraffin (Vaseline) and water immersion). The dehydration study was carried out immediately following removal from prolonged skin moisturisation. Inter‐individual variability for skin hydration (group study) was studied in seven healthy volunteers at 0 and 7 h hydration with Vaseline. Location dependence in skin hydration was investigated on the same subject by looking into the hydration of forearm and finger pad skin. System stability and measurement reproducibility was verified through a detailed phantom study. Results: Images of normal and hydrated human skin were obtained in vivo at voxel dimensions of 50 μm×150 μm×1000 μm. The effect of hydration and dehydration as a function of exposure to moisturiser (i.e. water and Vaseline) on the image signal intensity, observed T1, and interaction of free and bound water in specific tissues were identified and correlated with existing physiological knowledge. Swelling of stratum corneum due to hydration was expressed as an in vivo model of tissue hydration. Conclusion: Results of the dehydration study showed that the changes due to the previous hydration of the skin are reversible for all skin layers. For both moisturisation methods (i.e. Vaseline and skin bathing), the effects of hydration and dehydration on the skin were similar. The trends of the MRI parameters for finger pad and arm skin were similar. The group study showed low inter‐subject variability of hydration on stratum corneum and epidermis.     

Extramammary Paget's disease: evaluation of the histopathological patterns of Paget cell proliferation in the epidermis

Extramammary Paget's disease (EMPD) is a rare malignant skin neoplasm. The prototypical pattern of tumor cell proliferation in the epidermis includes single cells and/or nest arrangements, mainly in the lower epidermis. Although other patterns have been recognized, they have not previously been investigated in detail. We aimed to examine the patterns of tumor cell proliferation in the epidermis. Surgical specimens were obtained from 38 patients with primary EMPD. We defined six patterns, in addition to the prototypical one: (i) glandular; (ii) acantholysis-like; (iii) upper nest; (iv) tall nest; (v) budding; and (vi) sheet-like. There were 26 males and 12 females (mean age, 75.0 years). Lesions were located on the scrotum (26 cases) and vulva (12). There were 22 in situ EMPD and 16 invasive EMPD. The frequencies of the different proliferation patterns were: glandular, 36.8%; acantholysis-like, 73.7%; upper nest, 68.4%; tall nest, 28.9%; budding, 47.4%; and sheet-like, 23.7%. Upper nest pattern and the presence of more than three patterns were significantly more frequent in invasive EMPD than in situ EMPD (P < 0.05). We identified the histopathological patterns of Paget cell proliferation in the epidermis in EMPD, and suggest that the characteristic patterns and the diversity of patterns could be associated with progression and dermal invasion in EMPD.     

Typical dermoscopic patterns of benign melanocytic nevi

Dermoscopy often is an effective diagnostic tool for differentiating benign and malignant pigmented skin lesions. The observed dermoscopic structures and patterns of lesions provide valuable sources of information that are not accessible by routine clinical examination. Recognition and interpretation of these dermoscopic structures and patterns require training and experience. Mentioned here are some fundamental guidelines for differentiating malignant and benign lesions. Some of the classic patterns associated with a list of benign melanocytic nevi also have been illustrated. Additional research is needed to identify other patterns of these benign lesions. More importantly, analysis of the prevalence of various patterns associated with the various benign lesions will be helpful to clinicians having the responsibility of making in vivo diagnoses of benign compared with malignant melanocytic neoplasms.     

Pattern analysis of drug-induced skin diseases

Drug eruptions are common adverse reactions to drug therapy and are a frequent reason for consultation in clinical practice. Even though any medication can potentially cause an adverse cutaneous reaction, some drugs are implicated more commonly than others. Histologically, drugs can elicit a variety of inflammatory disease patterns in the skin and panniculus, no pattern being specific for a particular drug. The most common pattern elicited by systemically administered medications is the perivascular pattern. Psoriasiform or granulomatous patterns are rarely caused by medications. The usual histologic patterns of drug eruptions are discussed in this review using the basic patterns of inflammatory diseases. Clinicopathologic correlation is established for relevant patterns. However, the changes of drug-induced skin disease must be made considering clinical presentation, histopathological analysis, and course of the disease.     

Erythronychia

Erythronychia is a term that covers a range of pathological patterns of red discoloration of the subungual tissues. The intensity of the red contrasts with the pale pink of the nail bed or the cream color of the lunula. It is typically due to one or more actors that include inflammation, vessel proliferation, and engorgement and focal thinning of the nail plate. This article describes the patterns both within an individual digit and when it extends to multiple digits. These patterns cover diverse inflammatory, infiltrative, and neoplastic diseases, and the correlation between these diagnoses and patterns is discussed alongside means of surgical diagnosis and cure.     

Antinuclear antibodies: a simplified classification of the nuclear immunofluorescent patterns.

The key to a simplified classification of the nuclear immunofluorescent patterns is to separate out only two patterns, the speckled and nucleolar, from the nonhomogeneous particulate group (showing stained particles). There are only six categories divided into two major groups: nonparticulate and particulate. The nonparticulate group consists of the (1) peripheral, (2) homogeneous, and (3) leukocyte specific patterns. The particulate group is divided into (1) nucleolar, (2) speckled, and (3) "other particulates." The major diagnostic and prognostic values of of the test are retained by the simple expedient of separating out only two morphologically distinct and diagnostically important patterns from the particulate group, the nucleolar and speckled patterns, seen mainly in scleroderma but not in lupus erythematosus.     

Delineation of the various shapes and patterns of nevi

It has been proposed that all nevi reflect mosaicism, and this concept has been corroborated at the molecular level in a number of nevi. If the concept of mosaicism holds true, one would expect that the various types of nevi should be characterized by intrinsic shapes or patterns. A photographic review of 1,188 recognizable images of a list of nevi of the skin was undertaken in order to delineate a classification of the various shapes and patterns of nevi. We disclosed three distinct shapes and two so far undescribed archetypical patterns, in addition to the well-known Blaschko-linear, flag-like and extensive garment-like patterns, to which all lesions could be allocated. The newly delineated shapes are called round or oval shape; patches with indented borders; and teardrop or triangular shape. The newly proposed archetypical configurations are the agminated pattern and the diffuse patchy pattern. Other mosaic patterns, such as the phylloid pattern or the lateralization pattern, were not observed in any of the images reviewed. We conclude that the various types of nevi can be assigned to specific shapes or patterns. Admittedly, however, a given nevus may manifest itself in several different shapes, whereas its archetypical pattern tends to be the same. This 'archetypical' pattern can be taken as the perfect or ideal model of a given type of nevus, whereas the newly described shapes are subordinated to the archetypical patterns and are best considered to be 'nonarchetypical'. Our work gives more consistency to the idea that nevi reflect mosaicism, because they display repetitive shapes and patterns.     

Linear patterns of the skin and their dermatoses

Knowledge about the linear patterns of the skin is a key competence of dermatologists. Four major groups of linear patterns can be distinguished: Langer lines, dermatomes, Blaschko lines and exogenous patterns. Langer lines run in the direction of the underlying collagen fibers (least skin tension) and play an important diagnostic role for some exanthematous skin diseases. In the thoracodorsal region, the distribution of the Langer lines gives rise to what is referred to as a ’Christmas tree pattern’. A dermatome is an area of skin that is supplied by a single spinal nerve. Disorders with a neuronal origin follow this pattern of distribution. The lines of Blaschko delineate the lines of migration of epidermal cells during embryogenesis. Exogenous linear patterns are caused by external factors. The present CME article will highlight important skin disorders that primarily present in the form of one of the aforementioned patterns. In addition, we will also address skin conditions that may secondarily follow with these patterns (or distinctly not do so) as the result of various mechanisms such as the Koebner phenomenon, reverse Koebner phenomenon, and Wolf’s isotopic response.     

Introduction to dermoscopy

When approaching a pigmented lesion with dermoscopy, the entire architecture of the lesion should be considered. The presence of certain pigment patterns, structural patterns, or border characteristic alone are insufficient to make the most accurate diagnosis. Because pigmented lesions are dynamic and have many variations in their patterns, there can exist no exact defining classifications among each type of pigmented lesion.     

Videodermoscopic pattern analysis of acral melanocytic nevi

Three major and three minor types of acral melanocytic lesions have been described: parallel furrow, lattice-like, fibrillar, reticular, homogeneous and globular. To examine the dermoscopic patterns of acral melanocytic lesions and to investigate the association of these patterns with clinical features. This study included 419 acral melanocytic lesions of 295 patients. Dermoscopic images were stored in a standardized digital system and assessed. The incidence rates of the patterns were as follows: parallel furrow (62.5%), reticular (12.2%), globular (7.6%), fibrillar (5.0%), lattice-like (4.3%), homogeneous (3.8%), non-typical (3.8%), globulostreak-like (0.5%) and parallel ridge (0.2%). There was a significant association between pattern and diameter; nevi showing globular pattern were significantly smaller than those showing lattice-like pattern. There was a significant correlation between pattern and localization. The fibrillar pattern was observed more commonly on the feet, and the lattice-like pattern was seen almost entirely on the hands. Homogeneous and globular patterns were proportionately more common on the feet than on the hands. A significant association was found between patterns and colors. Compared with the lattice-like pattern, parallel furrow, fibrillar and homogeneous patterns were lighter in color; the globular pattern was darker than the homogeneous pattern. There was no significant correlations between pattern and clinical presentation. In conclusion, unlike all other studies, in the present study, the two most common patterns following the parallel furrow pattern were reticular and globular, which are minor patterns. Besides the differences in pattern distribution and inherent variability in individual assessment, the age of the study group and location of nevi influence the pattern, possibly in association with race.     

Molecular typing of Neisseria gonorrhoeae by restriction fragment length polymorphisms.

OBJECTIVE--To characterise Neisseria gonorrhoeae isolates by restriction fragment length polymorphisms (RFLPs) in ribosomal RNA genes. DESIGN--Generation of RFLP patterns by HincII restriction of rRNA genes followed by hybridisation with a non-radioactive labelled broad spectrum 16 + 23S rRNA gene probe. This typing method was developed and compared with MAb based serotyping. SPECIMENS--Forty three randomly collected isolates from Bangkok (27 isolates) and Singapore (16 isolates) were studied. RESULTS--The RFLP patterns generated were reproducible and highly discriminatory between strains. Analysis of RFLPs produced by HincII restriction of rRNA genes established 9 patterns amongst the 43 isolates examined. Strains present within a common serovar could be further subdivided by RFLP typing. Identical RFLP patterns were found in some strains that belonged to various serovars. CONCLUSION--RFLP typing based on heterogeneities of rRNA gene restriction patterns could be advantageously used to complement monoclonal antibody based serotyping for further subdivision of serovars. Higher sensitivity of this combined approach would enable better differentiation of strains in epidemiological studies.