Topical psoralen photochemotherapy for atopic dermatitis: evaluation of two therapeutic regimens for inpatients and outpatients

Forty-seven adolescent and adult patients suffering from long-standing atopic dermatitis (AD) too severe to respond to conventional therapies were treated with topical psoralen photochemotherapy (PUVA) and relatively low doses of ultraviolet (UV) irradiation. For practicality and convenience, two different therapeutic regimens were implemented; short-term hospitalization with almost daily irradiation (inpatient group, n = 23) and weekly irradiation combined with topical corticosteroids which had failed to manage symptoms before initiating the treatment (outpatient group, n = 25). Excellent therapeutic effects were achieved in 72% of the inpatients after 5-38 (mean 18.2) times of irradiation (mean cumulative dose; 44.7 J/cm2). In addition, 56% of outpatients responded excellently to the treatment after 6-22 (mean 13.0) times (mean cumulative dose; 25.8 J/cm2). In fact, 16 of the inpatients and 10 of the outpatients achieved almost complete remission. The duration of remission in these patients was 1-25 months (mean 6.3 months) in the inpatients and 1-6 months (mean 3.0 months) in the outpatients. Peripheral blood eosinophils significantly decreased after the treatments. A follow-up study showed a delayed decrease in serum IgE levels. In contrast, the specific IgE to house dust antigens and the water holding capacity of stratum corneum did not vary after treatment.     

Half-side comparison study on the efficacy of 8-methoxypsoralen bath-PUVA versus narrow-band ultraviolet B phototherapy in patients with severe chronic atopic dermatitis

In patients with severe chronic atopic dermatitis (AD), both photochemotherapy [psoralen ultraviolet A (PUVA)] and narrow-band (TL-01) UV B phototherapy have been reported to be very effective. As no data exist on the relative therapeutic efficacy of these two regimens, we performed a randomized investigator-blinded half-side comparison study on 12 patients with severe chronic AD. Half-side irradiation with threshold erythemogenic doses of 8-methoxypsoralen bath-PUVA and narrow-band UVB was performed three times weekly over a period of 6 weeks. The severity of the disease was assessed separately for the paired halves of the patients' bodies by a modified SCORAD score at baseline and after 2, 4 and 6 weeks of treatment. Ten of the 12 patients completed the trial. All but one showed marked improvement or complete remission with both treatments. The mean baseline SCORAD score decreased by 65.7% by the bath-PUVA treatment and by 64.1% by the narrow-band UVB treatment (P = 0.48). No serious adverse reactions to either of the two regimens were observed. Our data confirm the high efficacy of bath-PUVA and narrow-band UVB phototherapy in the treatment of patients with chronic severe AD. Both regimens appear to be equally effective when administered in equi-erythemogenic doses.     

Bicentre experience in the treatment of severe generalised atopic dermatitis with extracorporeal photochemotherapy

Pilot studies have shown an improvement of atopic dermatitis in approximately 65% of patients during extracorporeal photopheresis (ExP) therapy. The purpose of the present clinical trial was to investigate the response to ExP by controlling clinical and laboratory parameters during short term ExP therapy in patients with severe generalised atopic dermatitis. Thirty-five patients with severe, therapy-resistant atopic dermatitis were treated with ExP in an open clinical trial at two week intervals over a period of 6 to 10 cycles. Disease activity was measured before each cycle by SCORAD index together with a standardized protocol for blood samples. ExP led to a significant decrease (p < 0.05) in SCORAD from 74.4 +/- 15.5 before to 36.8 +/- 16.8 after ExP therapy (mean 10 cycles). Approximately 70% (24/33 patients = responder) of patients had a favourable response to ExP requiring at least 6 cycles. The decrease in SCORAD was accompanied by a significant decrease of eosinophil cationic protein (27%), sE-selectin (37%) and sIL-2R (53%) levels in serum (p < 0.05). No significant correlation between a decrease in these levels and values of blood eosinophils or lymphocytes was found (p > 0.05). In comparison to responders, most non-responders were characterised by very high levels of total IgE before and during therapy (p < 0.05). The present clinical trial confirms that short term ExP is an effective treatment for certain patients with severe atopic dermatitis based on anti-inflammatory mechanisms. Total IgE could be a predictor of outcome in ExP treatment.     

Mycophenolate mofetil for severe childhood atopic dermatitis: experience in 14 patients

BACKGROUND: Reports of successful treatment of atopic dermatitis (AD) with mycophenolate mofetil (MMF) have thus far been limited to adults. Considering that the condition typically develops during childhood and is most active during this period, MMF would represent a valuable addition to the therapeutic armamentarium for paediatric AD. OBJECTIVES: To evaluate the safety and efficacy of MMF in the treatment of severe childhood AD. METHODS: A retrospective analysis was performed of all children treated with MMF as systemic monotherapy for severe, recalcitrant AD between August 2003 and August 2006 at New York University Medical Center. Fourteen patients meeting these criteria were identified. RESULTS: Four patients (29%) achieved complete clearance, four (29%) had > 90% improvement (almost complete), five (35%) had 60-90% improvement and one (7%) failed to respond. Initial responses occurred within 8 weeks (mean 4 weeks), and maximal effects were attained after 8-12 weeks (mean 9 weeks) at MMF doses of 40-50 mg kg(-1) daily in younger children and 30-40 mg kg(-1) daily in adolescents. The medication was well tolerated in all patients, with no infectious complications or development of leucopenia, anaemia, thrombocytopenia or elevated aminotransferases. CONCLUSIONS: This retrospective case series demonstrates that MMF can be a safe and effective treatment for severe, refractory AD in children. MMF represents a promising therapeutic alternative to traditional systemic immunosuppressive agents with less favourable side-effect profiles, and prospective controlled studies are warranted, further to assess its benefits in paediatric AD.     

Prevalence of atopic dermatitis in Japanese adults

BACKGROUND: Adult atopic dermatitis (AD) in Japan has become a significant social problem, with as many as one-third of adult patients with severe AD absenting themselves from work or classes due to aggravation of the disease. Reports of such patients have become increasingly common in recent years. Despite the pressing need for epidemiological studies to clarify the prevalence and distribution of AD and to determine its aetiology, no previous research has been carried out on the prevalence of AD within the adult population in Japan. OBJECTIVES: To clarify the prevalence of adult AD in Japan, using the U.K. Working Party's diagnostic criteria. METHODS: The subjects of this study were mostly government officials or their family members visiting the Medical Center of Health Science, Toranomon Hospital in Tokyo for annual health check-ups in the period from September 1997 to August 1998. Questionnaires completed by 10 762 persons (8076 men and 2686 women) aged 30 years or above were analysed. The questionnaire consisted of 14 questions on allergic disease. The U.K. Working Party's diagnostic criteria were used after translation into Japanese. Three types of prevalence were used as indicators of prevalence: point, 1-year and lifetime prevalence. RESULTS: The point prevalence, 1-year prevalence and lifetime prevalence of AD in Japanese adults were 2.9%, 3.0% and 3.3%, respectively. No significant statistical differences were observed between the sexes or among age groups within each sex. The survey indicated that 88.6% of those who had ever had AD were currently affected by active AD, while 93.4% of those who had had at least one episode of AD in the past had experienced an episode over the previous year. CONCLUSIONS: This study gives the first indication of the prevalence of adult AD among the Japanese, based on the U.K. criteria. Both the internal and external validity of this study are believed to be high; it would be safe to conclude that the 1-year prevalence of AD in Japanese adult populations living in urban areas is 3.0%.     

特应性皮炎患者血中结合珠蛋白含量的检测及临床意义

目的：检测特应性皮炎（AD）患者血中结合珠蛋白（Hp）含量，并分析与病情严重程度之间的相关性。方法：采用醋酸纤维素薄膜电泳后比色的方法检测124例特应性皮炎患者（其中轻度40例、中度44例、重度40例）和134例正常对照者血中Hp水平。结果：与正常对照组相比，患者组血中Hp含量明显增高（P〈0．001），其中病情中度和重度患者组均显著增高（P〈0．05），轻度组增高无统计学意义。Hp含量与AD病情严重程度呈正相关（P〈0．001）。结论：Hp可能通过一种负反馈机制来抑制皮损局部的过度炎症反应，而参与了AD患者体内的免疫调节和抗炎作用。     

Rarity of hypertension in adult patients with atopic dermatitis

BACKGROUND: Patients with atopic dermatitis show a tendency for vasoconstriction of the small vessels in the skin. As peripheral vasoconstriction contributes to the cause of hypertension, it is natural to suppose that blood pressures might be on the high side in adult patients with atopic dermatitis. In the literature, however, there was little information on the subject. OBJECTIVES: To study the incidence of hypertension in adult patients with atopic dermatitis. PATIENTS/METHODS: Blood pressure was measured in 521 adult patients with active atopic dermatitis (235 males; 286 females) aged 30-59 years, and 87 adults with "healed" atopic dermatitis (26 males; 61 females) aged 34-52 years. The blood pressures were classified as definite hypertension, borderline hypertension or normal blood pressure. RESULTS: In those patients aged 30-39 years with active atopic dermatitis, the incidence of definite hypertension in the male patients and the female patients was 1.1% and 1.6%, respectively. The incidence remained almost at a plateau for the 30-39-year-old age group through to the 50-59-year-old age group, in both the male and female patients. There was no difference in the incidence of definite hypertension between patients with severe dermatitis and patients with mild dermatitis. Adult patients with "healed" atopic dermatitis also showed a low incidence of definite hypertension. CONCLUSIONS: These findings indicate that hypertension is rare in adult patients with atopic dermatitis. It is most probable that the rarity of hypertension is a primary feature of the disease.     

迟发型特应性皮炎的研究进展

特应性皮炎（AD）是一种炎症性皮肤病,与皮肤屏障功能受损密切相关。遗传因素、生活方式、环境因素的暴露都可导致该病的发生。尽管AD常见于婴幼儿,仍有成年后首次出现AD症状,被称为迟发型AD（AOAD）。与儿童期始发的AD相比,AOAD在分型、免疫学机制及与其他疾病的关联方面都存在着显著的差异。皮损分布与婴幼儿期初发的AD相似,但以亚急性和慢性皮炎为主要表现,呈现干燥的、肥厚的皮炎损害,少见渗出。Th1/Th2失衡及抗原提呈细胞的功能亢进是AD发生的免疫学基础。FLG基因突变会影响AD的发生,IL-13升高使FLG存在获得性的表达缺陷仅发生于成年人,提示了AOAD不同于婴幼儿期初发并迁延至成年期的AD。感染、皮肤及肠道菌群改变、吸烟等均可成为诱发AOAD的重要因素,因此在诊断AOAD时询问相关疾病史和吸烟史有助于AOAD的诊断。     

Impact of disease severity on work productivity and activity impairment in Japanese patients with atopic dermatitis

Atopic dermatitis (AD) is a common inflammatory skin disease that is characterized by chronic and persisting pruritic and eczematous lesions. There has been no study of work productivity and activity in AD patients in relation to disease severity. The purpose of this study was to examine the impact of disease severity on work productivity and activity impairment (WPAI) in adult AD patients using the Japanese version of the questionnaire. Data were collected from 112 AD patients who visited the Jikei University Hospital. Outcomes as measured by the questionnaire included employment status, total work productivity impairment (TWPI) and total activity impairment (TAI). We investigated the correlation between TWPI or TAI scores and severity scoring of AD (SCORAD) for disease severity and dermatology life quality index (DLQI) for quality of life impairment. Both TWPI and TAI scores were significantly correlated with the SCORAD and DLQI scores (P < 0.001), indicating disease severity is significantly associated with WPAI in Japanese adult AD patients. Further studies are necessary to evaluate the effects of treatments on WPAI for severe AD patients.     

Efficacy of treatment with oral alitretinoin in patient suffering from lichen simplex chronicus and severe atopic dermatitis of hands

Lichen simplex chronicus (LSC) is a skin disorder characterized by chronic itching and scratching, which can lead to thick, leathery, brownish skin, sometimes with papules and can be associated with atopic eczema. We report the case of a 52‐year‐old man with a 45‐year atopic condition and presenting LSC in his dorsum. After a 3‐month treatment with alitretinoin at the daily dosage of 30 mg, we have observed a moderate improvement of the hand eczema together with a substantial clinical improvement of LSC and an almost complete resolution of pruritus. We want to report this peculiar case to suggest the use of oral alitretinoin for LSC.     

Effectiveness of dupilumab in pediatric patients with a nummular phenotype of atopic dermatitis

The nummular phenotype of atopic dermatitis is clinically characterized by pruritic, coin-shaped plaques that are frequently recalcitrant to treatment. In this study, a retrospective chart review was conducted to evaluate the effectiveness and safety of dupilumab in children with nummular lesions of dermatitis. Twelve out of 14 patients demonstrated significant clinical improvement at a median time of 2.5 months (interquartile range, 1–4) after dupilumab initiation. A single case of paradoxical psoriasiform eruption was the only side effect reported in our cohort.     

213例儿童特应性皮炎临床及病理特点分析

本研究对213例AD儿童患者临床及组织病理学特点进行分析,患儿平均发病年龄为0.88±1.73岁,约85.9%的患者表现为慢性皮炎;约78.9%的患者有个人或家族遗传过敏史。组织病理学示角化过度、微水疱形成、棘层肥厚、海绵水肿、浅层血管周围炎症及嗜酸性粒细胞浸润。     

Features and prognoses of infantile patients with atopic dermatitis hospitalized for severe complications

Although atopic dermatitis (AD) itself is regarded as a non-life threatening disease, childhood AD may be rarely accompanied by some serious complications. Six infantile AD patients who were hospitalized because of severe systemic complications, in addition to severe dermatitis on almost the entire body surface, are described. They were complicated by hypoproteinemia, hypovolemia, thrombocytosis, reduced serum immunoglobulin G, elevated serum liver enzymes and growth retardation. They had not been treated with topical corticosteroid before hospitalization. They were treated with topical corticosteroid and their eruption remarkably improved within 20 days (median) of hospitalization. Most of the abnormal clinical data including platelet numbers, serum levels of total protein, and liver enzymes had become normal at the day of discharge. After 30 +/- 4 months of follow up, their skin condition was fair with daily application of moisturizer and occasional use of topical corticosteroid, without any systemic problems. Although severe infantile AD may be accompanied by potentially life-threatening systemic complications, their prognoses concerning AD are favorable if they are treated adequately from the beginning of their infancy.     

Treatment of atopic dermatitis with the xenon chloride excimer laser

BACKGROUND: Narrow-band ultraviolet B phototherapy is an effictive and safe treatment for atopic dermatitis. We have previously found that the 308 nm xenon chloride excimer laser was more effective than the narrow-band ultraviolet B light for the treatment of psoriasis, suggesting that ultraviolet B laser might offer advantages over narrow-band ultraviolet B. OBJECTIVE: The purpose of this study was to evaluate the therapeutic efficacy of the 308 nm excimer laser in atopic dermatitis. PATIENTS AND METHODS: Fifteen patients with atopic dermatitis (less than 20% body area involvement) were treated with a xenon chloride excimer laser (XTRAC laser, Photomedex Inc.) twice weekly. The severity of the atopic dermatitis was assessed via (i) a clinical score characterizing the intensity of erythema, infiltration, lichenification and excoriation; (ii) the quality of life, determined by means of a questionnaire; and (iii) a visual linear analogue scale, with which the patients scored the severity of their pruritus. RESULTS: After 1 month of laser therapy, the clinical scores were significantly lower than the initial values. Similar decreases were observed for the quality of life and pruritus scores. No serious or unpleasant side-effects were observed. CONCLUSION: These results suggest that the xenon chloride excimer laser is an effective and well-tolerated treatment for localized atopic dermatitis.     

Dietary habits in adult Japanese patients with atopic dermatitis

Dietary habits can modulate the pathogenesis of atopic dermatitis. We evaluated these habits in adult Japanese patients with atopic dermatitis using a validated, brief‐type self‐administered diet history questionnaire and compared the results to those of age‐ and sex‐matched healthy controls. Patients with atopic dermatitis showed higher intakes of carbohydrate and potatoes and lower intakes of alcohol, niacin, meat and oils/fats compared with those of the healthy controls. The results of logistic regression analysis showed that the intake of alcohol was negatively associated with atopic dermatitis (odds ratio, 0.905; 95% confidence interval, 0.832–0.983; P = 0.0181). The intakes of vitamin B₆ and fruit were positively correlated with the severity scoring of atopic dermatitis. Multiple regression analysis revealed that vitamin B₆ intake was a predictor of the severity scoring of atopic dermatitis (β = 26.98508709, t = 2.3995292, P = 0.01933781). The intakes of vegetable fat, n‐6 polyunsaturated fatty acid, and confections were lower in the severe atopic dermatitis group (severity scoring of atopic dermatitis, ≥33) than those in the mild group. Atopic dermatitis is negatively associated with alcohol intake, and intake of vitamin B₆ is a predictor of severity scoring of atopic dermatitis. The intake of n‐6 polyunsaturated fatty acid is lower in the severe atopic dermatitis group than that in the mild group. Further study is warranted on the relationships of these results with abnormal immune responses, impaired skin barrier or pruritus in atopic dermatitis.