Cutaneous Fistula Due to Pulmonary Actinomycosis in a Mapuche Girl

Actinomycosis is a chronic granulomatous disease caused by Gram‐positive anaerobic bacteria of the genus Actinomyces. Pulmonary actinomycosis is a rare infection in children, and its extension into the chest wall is infrequently reported. We report a case of pulmonary actinomycosis in a 14‐year‐old girl of Mapuche descent who presented with chronic respiratory symptoms and multiple discharging skin sinuses on her right lower chest wall. The diagnosis was made by skin biopsy, which showed sulfur granules with actinomyces colonies. She was successfully treated with intravenous ceftriaxone and penicillin G for 6 weeks, followed by oral amoxicillin for 6 months.     

Total nail ablation for onychodystrophy with optimized gauze–phenol application

Background Nail disorders are frequent among the geriatric population and unfortunately, repeat avulsion procedures often result in complications. Objective To utilize a phenol‐based total matricectomy technique for permanent nail ablation and evaluate its effectiveness. Methods We performed total nail ablation on 34 toenails of the hallux (30 patients) with a gauze–phenol application technique and evaluated the degree of pain reported by the patient 12 months postoperatively compared with the preoperative stage. Furthermore, we evaluated the patients’ satisfaction with the final cosmetic appearance as well as their satisfaction with the overall procedure. Results All patients reported ‘too much’ or ‘severe’ pain prior to surgery and 94.11% reported ‘no pain’ 12 months post‐surgery. A vast majority of the patients (82.35%) felt pleased with the cosmetic results and all patients reported that they were ‘very satisfied’ or ‘strongly satisfied’ with the procedure when interviewed at their 12 month follow‐up examination. Limitations There were a limited number of participants in this study across an extensive timeframe. Conclusion Phenol‐based total nail ablation with specific gauze application is safe, inexpensive and has a high rate of patient satisfaction.     

Assessing adherence to dermatology treatments: a review of self‐report and electronic measures

Background: Nonadherence to prescribed medications is a common problem in dermatology, and assessing adherence can be difficult. Electronic monitors are not always practical, but self‐report measures may be less reliable. Purpose: To review the literature for self‐report instruments and electronic monitors used to measure medication adherence in patients with chronic disease. Methods: A PubMed literature search was conducted using the terms ‘scale,’‘measure,’‘self‐report,’‘electronic,’ and ‘medication adherence.’ Relevant articles were reviewed and selected if they addressed self‐report or electronic measures of adherence in chronic disease. Results: Eleven self‐report instruments for the measurement of adherence were identified. Four were validated using electronic monitors. All produced an estimate of adherence that correlated with actual behavior, although this correlation was not strong for any of the measures. None of the scales was tested in patients who had dermatologic disease and/or used topical medications. Several electronic monitoring systems were identified, including pill counts, pharmacy refill logs, and the Medication Event Monitoring System (MEMS^®). Validity was higher among electronic monitoring systems compared with self‐report measures. Conclusion: While several self‐report measures of adherence have been validated in chronic disease populations, their relevance in dermatology patients has not been studied. A dermatology‐specific instrument for the measurement of adherence would contribute to improved outcomes; until such a tool exists, researchers and clinicians should consider nonadherence as a possible factor in skin disease that is not responsive to treatment. Electronic monitoring provides the most reliable means of measuring adherence, and may provide additional clues to identify barriers to adherence.     

Long‐term efalizumab therapy for patients with moderate‐to‐severe,chronic plaque psoriasis: results from an Australian expanded access program

Background Psoriasis is a chronic skin disease that can impact heavily on a patient’s well‐being. Efalizumab, a unique, targeted, biological therapy, has demonstrated efficacy in treating moderate‐to‐severe, chronic plaque psoriasis with ≤36 months of continuous therapy. The objective of this Extended Access Program (EAP) was to evaluate further the benefit of efalizumab as long‐term therapy in a real‐world clinical setting. Methods After an initial conditioning dose of efalizumab (0.7 mg/kg subcutaneously), a weekly dose of efalizumab (1.0 mg/kg) was administered for ≤21 months. Patients with reduced Psoriasis Area and Severity Index (PASI) scores (≥50%, or a score ≤8) at month 3 entered the long‐term maintenance treatment period. Results In total, 101 patients (>18 years) with severe plaque psoriasis enrolled on the EAP, of these 93 (92.1%) met all the inclusion criteria. After 3 months of treatment, 84/101 (83.2%) patients had evaluable data and entered the maintenance period. After 3 months, 57/84 (67.9%) patients had achieved PASI‐50. Using an intent‐to‐treat analysis, after 21 months of treatment, PASI‐75 and PASI‐50 were achieved by 43/101 (42.6%) and 69/101 (68.3%) of patients, respectively. Efalizumab was generally well tolerated during the 21 months of continuous therapy. Conclusion Efalizumab, 1.0 mg/kg/week, is effective and well tolerated in a ‘real world’ clinical setting, providing enduring reduction of psoriasis symptoms for up to 21 months.     

Cutaneous granular bacteriosis,a rarely diagnosed infection of the head and the neck

A young man presented with a large multilobulated and mutilating tumour of the scalp, which had been relapsing for years. Histological examination of a biopsy from the lesion revealed chronic inflammation with granulation tissue and presence of granules with eosinophilic periphery, which was positive for Gram, Grocott and periodic‐acid–Schiff stains. A large excision was performed. Cultures grew Staphylococcus aureus. The patient was treated with penicillin G, but 4 weeks after the start of treatment, new small nodules appeared over the same area. All these new nodules disappeared within 2 weeks the addition of clindamycin and cotrimoxazole. This triple antibiotic treatment was carried on for 18 months, and the patient remained disease‐free after a follow‐up of 4 years. Although the lesions were clinically and histologically suggestive of actinomycosis, culture revealed that they were caused by a completely different organism. We suggest grouping such lesions under a single term “granular bacteriosis” and combining surgery with broad‐spectrum antibiotics covering Actinomyces species and botryomycosis‐causing organisms (mainly Staphylococcus).     

Pilot study of intense pulsed light for the treatment of systemic sclerosis-related telangiectases

Background Telangiectases represent microvascular changes inherent in the systemic sclerosis (SSc) disease process. Intense pulsed light (IPL) is an effective treatment for non‐SSc‐related cutaneous telangiectases. Objectives This pilot study aimed to examine the efficacy, safety and tolerability of IPL treatment in an open study of patients with SSc. Methods Patients underwent three treatments of IPL at monthly intervals and attended follow‐up examinations at 1, 6 and 12 months after final treatment. Photographs, laser Doppler imaging (LDI) and thermography were used to measure changes at each visit. Results Seventeen patients completed the study. Photographs were graded (compared with baseline) as: at 1‐month follow‐up, four ‘no change’, four ‘improved’ and eight ‘much improved’; at 6‐month follow‐up, four ‘no change’, eight ‘improved’; and four ‘much improved’; and at 12‐month follow‐up (eight images were available), three ‘no change’, two ‘improved’ and three ‘much improved’. Perfusion as measured by LDI (perfusion units) was significantly reduced, compared with baseline [median 2·66, interquartile range (1·78–3·93)], at 1 month [1·70 (1·07–2·55), P = 0·006] and 6 months [2·05 (1·42–2·36), P = 0·008] post‐treatment, but not at 12 months [1·61 (1·14–3·22), P = 0·088]. No differences were found in skin temperature between baseline and follow‐up visits. Conclusions In this pilot study (the first of IPL treatment for SSc‐related telangiectases) most patients improved after IPL treatment. However, the degree of improvement was not maintained in all patients at 6–12 months, suggesting that further treatments may be necessary. Longer term studies of this novel treatment approach are now required.     

Non‐sequential fractional ultrapulsed CO2 resurfacing of photoaged facial skin: Preliminary clinical report

This study evaluates results, adverse side effects and downtime of the protocol ‘ActiveFX’ for photodamaged facial skin. A non‐sequential fractional ultrapulsed CO₂ laser with specific settings is used in addition to a new computer pattern generator (CPG). From September 2006 to March 2007, 55 patients underwent this new ‘soft’ single‐session, single‐pass and full‐face ablative fractional treatment. The patients were evaluated at baseline and 1 and 3 months after the treatment using a five‐point scale. Seven aspects of photodamaged skin were recorded: global score, fine lines, mottled pigmentation, sallow complexion, tactile roughness, coarse wrinkles and telangiectasias. The results were compared with a non‐parametric statistical test, the Wilcoxon's exact test. Eight patients received a double‐pass treatment on the crow's feet regions and the improvement of the coarse wrinkles was analyzed with a quartile grading scale. Significant differences (p<0.05) between baseline and 1 and 3 months post‐treatment were observed for all features except telangiectasias. Coarse wrinkles presented a good improvement only in the regions submitted to a double‐pass. Minimal and isolated adverse side effects were noted and the downtime was very low. Non‐sequential fractional ultrapulsed CO₂ light treatment (‘ActiveFX’) can be considered an excellent alternative for photodamaged facial skin.     

Recurrent furunculosis: a review of the literature

Background Community‐associated methicillin‐resistant Staphylococcus aureus (CA‐MRSA) is increasing in incidence and manifests as skin and soft tissue infections including furuncles. The majority of studies have focused on the epidemiology of single furuncles and not recurrent disease. There is a lack of data concerning the incidence of furunculosis outside the U.S.A. Objectives This report reviews the literature of recurrent furunculosis and the impact of CA‐MRSA on the disease. Methods Article citations were searched within PubMed. Search terms used were ‘furunculosis’, ‘recurrent furunculosis’, ‘skin abscess’ and ‘recurrent boils’. Articles were discarded if they did not refer to furunculosis secondary to S. aureus. Results A total of 1515 articles were initially retrieved with the term ‘furunculosis’, 77 with the term ‘recurrent furunculosis’, 2778 with the term ‘skin abscess’, and 1526 with the term ‘recurrent boils’. After excluding articles not referring to S. aureus furunculosis, 86 articles were included for this review. Conclusions Furunculosis is increasing within the U.S.A. secondary to the CA‐MRSA epidemic and the resistant organism’s close association with the Panton–Valentine leucocidin (PVL) virulence factor. PVL is associated with follicular infections in general, having its strongest association with furunculosis and its recurrence. The majority of furuncles in the U.S.A. are caused by CA‐MRSA, while elsewhere in the world they are caused by methicillin‐sensitive S. aureus. Nasal carriage of S. aureus is the primary risk factor for recurrent furunculosis and occurs in 60% of individuals.     

Botryomycosis caused by fusobacteria]

In the Anglo-American literature botrymycosis is described as a chronic cutaneous granulomatous reaction to bacterial infection, containing granules resembling the sulphur granules seen in actinomycosis. The diagnostic and therapeutic aspects are discussed with reference to a recently observed patient. Fusobacterium nucleatum was isolated as the bacterial cause of the pathologic disorder.     

Repigmentation of leucotrichia in vitiligo with noncultured cellular grafting

Background Vitiligo in hair‐bearing areas is often associated with leucotrichia. Repigmentation of leucotrichia has been reported mainly with tissue and follicular hair grafts. Objectives To evaluate the repigmentation response of leucotrichia after noncultured cellular grafting. Methods We retrospectively reviewed patients with stable generalized and segmental vitiligo who underwent noncultured cellular grafting from March 2008 to November 2010 in areas with leucotrichia. The percentage repigmentation of white hairs was based on clinical assessment and standardized digital photography, and was graded ‘poor’, ‘fair’, ‘good’ or ‘excellent’, corresponding to a scale of 0–100% repigmentation with respective intervals of 25%. Results Eighty‐four patients with vitiligo underwent cellular grafting; of these, 13 had grafting in areas with leucotrichia. Twelve patients (92%) had poor repigmentation of leucotrichia 3 months after transplant. One patient defaulted follow‐up after this period. At 6 months, fair repigmentation was achieved in eight out of the 12 remaining patients (67%). After 9–12 months, however, 91% (10 out of 11) of the patients achieved good or excellent repigmentation. One patient did not reach the 9‐month follow‐up period at the time of data analysis. Leucotrichia of eyebrows yielded excellent repigmentation in eight out of nine patients, whereas hairs on the limbs and scalp showed good repigmentation in two out of two patients at 9–12 months. Conclusions Good to excellent repigmentation of leucotrichia can be achieved with noncultured cellular grafting, obviating the need for hair transplantation.     

Ablative erbium:YAG laser treatment of idiopathic chronic inflammatory non-cicatricial balanoposthitis (Zoon's disease) – A series of 20 patients with long-term outcome

Abstract

Background: Chronic inflammatory non-cicatricial balanitis/balanoposthitis (Zoon 1952) is not uncommon among aged uncircumcised males. The course is chronic and will lead to severe epidermal atrophy. This disease is poorly responsive to topical treatment. The golden standard for treatment is circumcision. Objective: This study was performed to evaluate the efficacy and safety of ablative erbium:YAG laser treatment. Methods: An uncontrolled trial was performed with 20 Caucasian male patients (mean age 64.8 years) who presented with chronic inflammatory non-cicatricial balanitis or balanoposthitis. The patients received multiple topical treatments. The disease duration ranged from 1 to more than 7 years. Diagnosis was confirmed by histology. Topical anaesthesia was performed before erbium:YAG laser ablation (focus 1.6–5 mm; frequency 8 Hz; impulse energy mostly 800 mJ; fluence between 11.3 and 20 J cm^?2). The pulses were partly overlapping. The pain sensation was recorded by visual analogue scale (VAS). Complete clearance was defined as complete absence of erythematous, smooth-faced, ‘wet’-looking patches or erosions. Patients were requested to attend a regular follow-up once a year. The outcome was further assessed by patient's global assessment (PGA). Results: In all patients a complete re-epithelialization could be achieved within 2–3 weeks. During follow-up between 3 months and 30 months (mean 12.1 ± 7.2 months), a complete and stable clearing was achieved in 20 patients (100%). There were no severe adverse effects. With topical anaesthetic cream the VAS was very low (mean 1.5 ± 4.1 mm for 18 patients and 22 treatments). All but three patients were ‘completely satisfied’ with the procedure and the outcome; three were ‘satisfied’. Conclusions: Ablative erbium:YAG laser therapy is a safe, effective and minimally invasive treatment option in chronic inflammatory non-cicatricial balanitis/balanoposthitis.     

Successful retreatment with alitretinoin in patients with relapsed chronic hand eczema

Summary Background Patients with severe chronic hand eczema (CHE) often respond to therapy with oral alitretinoin (9‐cis retinoic acid). However, the efficacy of alitretinoin after disease relapse has not been demonstrated. Objectives To assess the efficacy and safety of a second course of oral alitretinoin in patients with severe CHE who relapsed after achieving ‘clear’ or ‘almost clear’ hands following a previous course of alitretinoin. Methods The double‐blind study included 117 patients with CHE who had responded to therapy in an earlier clinical trial and subsequently relapsed. Patients were randomized to receive their previous treatment or placebo. Treatment was alitretinoin 30 mg or 10 mg or placebo given once daily for 12–24 weeks. Response was defined as an overall Physician’s Global Assessment rating of ‘clear’ or ‘almost clear’ hands at the end of therapy. Results Response rates were 80% in patients retreated with 30 mg alitretinoin compared with 8% for placebo (P < 0·001). In patients retreated with 10 mg alitretinoin response rates were 48%, compared with 10% in the placebo group. Alitretinoin was well tolerated. Adverse reactions comprised typical retinoid class effects, and no late‐arising side‐effects were observed during this second course of treatment. Conclusions The majority of patients with CHE who previously achieved ‘clear’ or ‘almost clear’ hands following treatment with alitretinoin 30 mg per day also responded to a second course of treatment. Retreatment was well tolerated. Intermittent treatment with alitretinoin is suitable for the long‐term management of CHE.     

An aberrant parasympathetic response: a new perspective linking chronic stress and itch

Perceived stress has long been known to alter the dynamic equilibrium established between the nervous, endocrine and immune system and is widely recognised to trigger or enhance pruritus. However, the exact mechanism of how the major stress response systems, such as the hypothalamus‐pituitary adrenal (HPA) axis and the autonomic nervous system induce or aggravate chronic itch, has not been elucidated. The limbic regions of the brain such as the prefrontal cortex and hippocampus are deeply involved in the regulation of the stress response and intersect with circuits that are responsible for memory and reward. According to the ‘Polyvagal Theory’, certain limbic structures that serve as a ‘higher brain equivalent of the parasympathetic nervous system’ play a foremost role in maintaining body homoeostasis by functioning as an active vagal brake. In addition, the limbic system has been postulated to regulate two distinct, yet related aspects of itch: (i) the sensory‐discriminative aspect; and (ii) the affective‐cognitive aspect. Chronic stress‐induced itch is hypothesised to be caused by stress‐related changes in limbic structure with subsequent rewiring of both the peripheral and central pruriceptive circuits. Herein, we review data suggesting that a dysfunctional parasympathetic nervous system associated with chronic stress may play a critical role in the regulatory control of key candidate molecules, receptors and brain structures involved in chronic itch.     

Extending psychosocial assessment of patients with psoriasis in the UK,using a self‐rated,web‐based survey

Background. Quality of life self‐rating using a web‐based survey has not previously been evaluated for psoriasis in the UK. Aim. To use an open‐access web‐based survey to assess the effect of psoriasis on patients’ daily life. Methods. The survey was conducted using a dedicated website endorsed by a UK psoriasis patient charity. Results. In total, 1760 patients (1102 women, 658 men; median age range 40–44 years) assessed their psoriasis using the website. Psoriasis was ‘very’ or ‘extremely’ active in 52%, and 71% had been diagnosed > 10 years previously. Psoriasis had negatively affected the working life of 59% of patients, and the educational performance of 31%. Conclusions. The use of an open‐access web‐based survey may address potential bias in previous studies, but may itself introduce a bias towards younger patients. This is the first report of a web‐based survey of UK patients with psoriasis, providing further recent evidence of how psoriasis affects patients’ lives.     

Costs and cost-effectiveness of the nursing programme 'Coping with itch' for patients with chronic pruritic skin disease

Background  Itch, a major symptom of many skin diseases, has a great impact on quality of life. The nursing programme ‘Coping with itch’ aims at reducing itch and at helping patients to cope with itch. Objectives  To explore costs and cost‐effectiveness of the programme. Methods  A randomized controlled study was carried out with 56 patients. Data were gathered on medical consumption, days off work and the frequency of itching and scratching. Differences between both groups, the cost‐effectiveness ratio and the percentage of patients falling into the four quadrants of the cost‐effectiveness analysis plane were determined. Results  The intervention group experienced a gain of 6 days with little itching [95% confidence interval (CI) –16–28] at 3 months and a gain of 35 days (95% CI –33–96) at 9 months. They paid more visits to the dermatology nurse than the control group. The point estimate of the incremental cost‐effectiveness ratio was €129·91 and €16·60 per day with little itching at 3 months and at 9 months, respectively. At 3 months, 70% of the patients experienced favourable results and 14% of them had lower costs. At 9 months, 87% had favourable results and 31% of them had lower costs. Conclusions  Most of the expenses associated with the ‘Coping with itch’ programme were incurred during the first 3 months, but the benefits in terms of days with little itch appeared to persist and increase beyond 3 months, thus leading to a more favourable incremental cost‐effectiveness ratio.     

Eosinophilic follicular reaction induced by Demodex folliculorum mite: a different disease from eosinophilic folliculitis

Eosinophilic folliculitis (EF) is an idiopathic dermatitis included in the spectrum of eosinophilic pustular follicular reactions. Demodex folliculorum has been implicated as contributing to the pathogenesis of human immunodeficiency virus‐associated EF, but it has not been described outside this context. We present an immunocompetent 65‐year‐old white man with a 5‐year history of recurrent pruritic erythematous and oedematous lesions on his face, neck and scalp. Histopathologically, an eosinophilic microabcess with Demodex folliculorum mite within a pilosebaceous follicle was seen, and considered the causal agent. There were also accumulations of eosinophil granules on collagen bundles, and flame figure formations in the dermis. We believe that ‘eosinophilic follicular reaction’ is an appropriate term to describe this case of EF induced by D. folliculorum and thus distinguish it from the idiopathic form of EF. Moreover, this case suggests that D. folliculorum can sometimes induce an eosinophilic immune reaction.     

The efficacy of '0.05% Clobetasol + 2.5% zinc sulphate' cream vs. '0.05% Clobetasol alone' cream in the treatment of the chronic hand eczema: a double-blind study

Background Many therapeutic modalities have been suggested for treatment of the chronic hand eczema. Despite good immediate efficacy of some of these treatments, there is high recurrence of the dermatitis following cessation of the treatment. Aim Regarding the beneficial effects of the zinc sulfate on the skin, we designed a double blind study to evaluate the efficacy of the ‘0.05% Clobetasol + 2.5% zinc sulphate’ cream versus ‘0.05% Clobetasol alone’ cream in the treatment of the chronic hand eczema. Subjects and Methods This study was a double‐blind, right to left, prospective, clinical trial. In total, 47 patients with chronic hand eczema admitted to dermatology center of Isfahan University of Medical Sciences were selected and their right hand or left hand were selected at random to be treated with either the ‘0.05% Clobetasol + 2.5% zinc sulphate’ cream or ‘0.05% Clobetasol alone’ cream twice daily for 2 weeks. All of the patients were treated for 2 weeks and were followed up at weeks 2, 4, 6 and 8 after starting the treatment. For determining the severity of chronic hand eczema, we assessed and scored 4 different characteristics of the lesions including redness; scaling; lichenification and pruritus. The data were analyzed using SPSS program (release 13) and statistical tests including Mann‐Whitney test. Results Overall, 47 patients (94 samples) were evaluated. All of these patients had similar and symmetrical lesions on their right and left hands. Out of them, 35 patients were females and 12 patients were male. In all of the evaluated characterisitics, the ‘0.05% Clobetasol + 2.5% zinc sulphate’ cream was more effective than ‘0.05% Clobetasol alone’ cream (P < 0.05). The recurrence rate of eczema was significantly lower in the group treated with this combination treatment (P < 0.05). Conclusion With regard to the encouraging results of the combination treatment with Clobetasol + zinc sulphate, we suggest that in a more extensive clinical trial, the efficacy of this treatment against chronic hand dermatitis be evaluated. In addition, evaluation of this combination therapy against other inflammatory dermatosis seems to be logical.     

Solitary cutaneous histiocytosis with granular cell changes: a morphological variant of reticulohistiocytoma?

We first report a case of granular cell histiocytosis occurring as a solitary polypoid lesion of the nipple in a 15‐year‐old girl. Histologically, the lesion was composed of a dermal population of medium‐ to large‐sized, short spindle‐ to round‐ to epithelioid‐shaped cells with eosinophilic cytoplasm containing numerous and small diastase‐resistant periodic acid‐Schiff (PAS) positive granules. No associated inflammatory cells were observed. Immunohistochemical studies, revealing immunoreactivity exclusively to vimentin and CD68, were consistent with their histiocytic profile. Based on clinical, morphological and immunohistochemical features, the diagnosis of ‘solitary cutaneous histiocytosis with granular cell changes’ was proposed. The absence of an inflammatory cell component, such as lymphocytes and leucocytes, along with no history of a previous trauma or medical treatment, suggest that the present lesion could fit into the morphological spectrum of the so‐called solitary epithelioid histiocytoma, also known as reticulohistiocytoma. Alternatively, the possibility of a histiocytic reaction to unknown stimuli cannot be completely ruled out. Nevertheless, awareness of solitary cutaneous histiocytosis with granular cell changes is useful to avoid confusion with other dermal tumors, especially ‘granular cell tumor’ and ‘dermal non‐neural granular cell tumor’. Caltabiano R, Magro G, Vecchio GM, Lanzafame S. Solitary cutaneous histiocytosis with granular cell changes: a morphological variant of reticulohistiocytoma?     

Lack of evidence for a protective effect of prolonged breastfeeding on childhood eczema: lessons from the International Study of Asthma and Allergies in Childhood (ISAAC) Phase Two

Summary Background Exclusive breastfeeding for at least 4 months is recommended by many governments and allergy organizations to prevent allergic disease. Objectives To investigate whether exclusive breastfeeding protects against childhood eczema. Methods Study subjects comprised 51 119 randomly selected 8‐ to 12‐year‐old schoolchildren in 21 countries. Information on eczema and breastfeeding was gathered by parental questionnaire. Children were also examined for flexural eczema and underwent skin prick testing. Odds ratios (ORs) were calculated for each study centre and then pooled across populations. Results There was a small increase in the risk of reported ‘eczema ever’ in association with ‘breastfeeding ever’ and breastfeeding < 6 months [pooled adjusted OR 1·11, 95% confidence interval (CI) 1·00–1·22 and OR 1·10, 95% CI 1·02–1·20, respectively]. There was no significant association between reported ‘eczema ever’ and breastfeeding > 6 months (pooled adjusted OR 1·09, 95% CI 0·94–1·26). Risk estimates were very similar for exclusive breastfeeding < 2 months, 2–4 months and > 4 months and for eczema symptoms in the past 12 months and eczema on skin examination. As for more severe eczema, breastfeeding per se conveyed a risk reduction on sleep disturbed eczema (pooled adjusted OR 0·71, 95% CI 0·53–0·96), but this effect was lost where children had been exclusively breastfed for > 4 months (pooled adjusted OR 1·02, 95% CI 0·67–1·54). Allergic sensitization and a history of maternal allergic disease did not modify any of these findings. Conclusions Although there was a protective effect of ever having been breastfed on more severe disease, we found no evidence that exclusive breastfeeding for 4 months or longer protects against eczema. Our results are consistent with findings from a recent systematic review of prospective studies. The U.K. breastfeeding guidelines with regard to eczema should be reviewed. Intervention studies are now required to explore how and when solids should be introduced alongside breastfeeding to aid protection against eczema and other allergic diseases.     

Extended treatment with oral alitretinoin for patients with chronic hand eczema not fully responding to initial treatment

Background. In a previous large trial (Benefit of Alitretinoin in Chronic Hand Eczema; BACH), 47.7% of patients with severe chronic hand eczema (CHE) who received alitretinoin 30 mg achieved ‘clear’ or ‘almost clear’ hands during the initial 24‐week treatment course. Objectives. The current open‐label trial was designed to study extended treatment with a further 12‐ to 24‐week course of oral alitretinoin 30 mg in patients who did not fully respond to initial treatment in the BACH study. Methods. At the end of the BACH study, patients whose eczema was rated ‘mild’, ‘moderate’ or ‘severe’ according to the Physician’s Global Assessment (PGA) were eligible for a 24‐week, open‐label, multicentre study. Patients (n = 243) received 30 mg of alitretinoin once daily, irrespective of previous treatment in BACH; either alitretinoin 30 mg, alitretinoin 10 mg or placebo. Results. By the end of the follow‐on study, the PGA response rate to the subsequent course of alitretinoin 30 mg was 50% and 39% in patients treated previously in BACH with 10 or 30 mg per day, respectively, and 51% in patients who previously received placebo in BACH. Alitretinoin was well tolerated, and no significant late‐arising toxicities were seen. Conclusions. For a considerable number of patients with CHE who did not fully respond after an initial 24‐week treatment period, a switch from either placebo to the active compound at 30 mg or from the lower to the higher dose, or treatment prolongation at the higher dose could be beneficial. Alitretinoin remains well tolerated for overall treatment durations of up to 48 weeks.