Efficacy of crisis intervention treatment with topical corticosteroid prednicarbat with and without partial wet-wrap dressing in atopic dermatitis

BACKGROUND: The wet-wrap treatment has been reported to be beneficial in acute episodes of atopic dermatitis (AD) skin lesions. OBJECTIVE: The efficacy of topical corticosteroid prednicarbat with and without additional wet-wrap dressing was investigated in a prospective, randomized and controlled study. METHODS: In the left-right comparison study, 24 adults and children with an acute episode of AD were included. One arm or leg was randomly treated with the topical corticosteroid prednicarbat plus wet-wrap dressing; only prednicarbat was applied on the leg or arm of the other side. RESULTS: After 48-72 h of treatment, in both groups an improvement of the local SCORAD was observed. In comparison to the side of the body treated with corticosteroid alone, the decrease of the local SCORAD in the corticosteroid plus wet-wrap dressing group was significantly better. The severity of AD improved in the wet-wrap group at an average of 4.4 points, in the corticosteroid group 3.0 (p<0.011). CONCLUSIONS: Wet-wrap therapy with a topical corticosteroid is an effective treatment option in patients with exacerbated AD. The treatment is helpful in improving skin conditions, shortening the time of corticosteroid application.     

Treatment of refractory atopic dermatitis using 'wet-wrap' dressings and diluted corticosteroids: results of standardized treatment in both children and adults

BACKGROUND: 'Wet-wrap' dressings with diluted corticosteroids form an alternative treatment in patients with refractory atopic dermatitis (AD). OBJECTIVE: To evaluate a standardized treatment, using wet-wrap dressings with diluted corticosteroids, in patients with refractory AD. METHODS: Results of treatment, complications and possible side effects were retrospectively evaluated in 14 children and 12 adults. RESULTS: Skin lesions improved dramatically during 1 week of inpatient treatment. A significant decrease in early-morning serum cortisol levels was measured. Levels below the normal range were only observed after 1 week in 2 adults and on day 4 in 3 children. Suppression of the hypothalamus-pituitary-adrenal-cortex axis in 1 adult and a new exacerbation of AD in 2 children and 3 adults complicated long-term treatment at home. Additional complications included folliculitis, a Pseudomonas aeruginosa infection, a secondary bacterial infection and refractory skin lesions between bandages. CONCLUSION: Wet-wrap dressings and diluted corticosteroids form an effective treatment in patients with refractory AD.     

Efficacy and safety of 'wet-wrap' dressings as an intervention treatment in children with severe and/or refractory atopic dermatitis: a critical review of the literature

BACKGROUND: During the last two decades wet-wrap treatment (WWT) has been advocated as a relatively safe and effective treatment modality in children with severe and/or refractory atopic dermatitis (AD). Unfortunately, there are still many unsolved issues concerning the use of wet-wrap dressings in patients with AD. OBJECTIVES: To make an inventory of the different methodologies and to evaluate the currently available evidence for the use of WWT as an intervention treatment in children with severe and/or refractory AD. METHODS: We performed a search of the literature via the online PubMed database. Reference lists from relevant articles were scanned for additional publications. Publications describing a treatment modality for children with severe and/or refractory AD, which included the application of wet dressings, were collected and evaluated using the guidelines of the NHS Centre for Reviews and Dissemination, University of York. RESULTS: Twenty-four publications were included for evaluation. Eleven of the publications detailed original clinical studies (study design level 2-4), while 13 revealed expert opinions (study design level 5). Evidence levels did not exceed level 4. CONCLUSIONS: Large prospective studies evaluating the efficacy and safety profile of WWT are lacking. We were able to formulate the following conclusions with a grade C of recommendation. (i) WWT using cream or ointment and a double layer of cotton bandages, with a moist first layer and a dry second layer, is an efficacious short-term intervention treatment in children with severe and/or refractory AD. (ii) The use of wet-wrap dressings with diluted topical corticosteroids is a more efficacious short-term intervention treatment in children with severe and/or refractory AD than wet-wrap dressings with emollients only. (iii) The use of wet-wrap dressings with diluted topical corticosteroids for up to 14 days is a safe intervention treatment in children with severe and/or refractory AD, with temporary systemic bioactivity of the corticosteroids as the only reported serious side-effect. (iv) Lowering the absolute amount of applied topical corticosteroid to once daily application and further dilution of the product can reduce the risk of systemic bioactivity.     

Efficacy and safety of wet-wrap dressings in children with severe atopic dermatitis: influence of corticosteroid dilution

BACKGROUND: The wet-wrap treatment involves emollients or corticosteroid dilutions under occlusive wet dressings, and has been reported to be highly effective in severe refractory atopic dermatitis (AD). OBJECTIVES: To investigate the influence of different corticosteroid dilutions on the efficacy and hypothalamic-pituitary-adrenal (HPA) axis suppression in children with severe refractory AD having wet-wrap dressings. METHODS: Eighteen children were treated with a 50% dilution of fluticasone propionate (FP) 0.05% cream for 2 weeks. In another five children a side-to-side comparison was conducted with 10%, 25% and 50% dilutions of FP cream under wet wrap. A third group of eight children was treated with 0% (= emollient), 5%, 10% or 25% dilutions of FP cream applied on the whole body under wet wrap. RESULTS: After 1 week, a major improvement averaging 74% was observed, without apparent differences between 5%, 10% or 25% dilutions of FP cream under wet wrap, with less improvement in the second week of treatment. The first and second group of children showed HPA axis suppression in only three of 23 children using measurements of 09.00 h serum cortisol after 2 weeks. The third group of children showed HPA axis suppression, as indicated by 06.00 h serum cortisol levels, which was related to the absolute amount of FP applied. CONCLUSIONS: This suggests that weaker corticosteroid dilutions had comparable high efficacy, but lower risk of HPA axis suppression.     

The effect of wet-wrap dressing on epidermal barrier in patients with atopic dermatitis

BACKGROUND: Wet-wrap dressing has been shown to be effective for atopic dermatitis; however, the therapeutic mechanism of wet-wrap dressing is only the hypothesis based on the recovery of decreased epidermal barrier function. OBJECTIVES: To examine the therapeutic efficacy as well as the mechanism of wet-wrap dressing in atopic dermatitis patients. METHODS: To examine the difference of non-lesional and lesional atopic skin and to evaluate the change between epidermal barrier function before and after the treatment, SCORAD, epidermal water content, transepidermal water loss, the lipid amount of skin surface, immunohistochemical staining of filaggrin and loricrin, transmission electron microscopic examination, and calcium ion capture cytochemistry method were done in 10 severe form atopic dermatitis patients. RESULTS: In atopic dermatitis patients, SCORAD was clearly decreased, epidermal water content was increased, and transepidermal water loss was decreased after wet-wrap dressing. After wet-wrap dressing, increased release of lamellar body and the recovery of the damaged lamellar structure of intercellular lipid were observed; nevertheless, neither the change in keratinocyte differentiation nor the change of calcium ion gradient was detected. A week after the termination of wet-wrap dressing, increased water content and decreased transepidermal water loss were still maintained. CONCLUSION: We confirmed the abnormality of the epidermal barrier in atopic dermatitis, and the effects of wet-wrap were associated with the recovery of epidermal barrier. In atopic lesions, wet-wrap dressing induced clinical improvement by the release of lamellar body and the restoration of intercellular lipid lamellar structure.     

Short-term growth and bone turnover in children undergoing occlusive steroid ('Wet-Wrap') dressings for treatment of atopic eczema

To assess the effects of steroid wet-wrap therapy on short-term growth and bone turnover, eight prepubertal (M:F,5:3) children with a median age of 5.1years (range 3.3-8.8) were studied over a 2-week period prior to therapy and at 2-week intervals during therapy. Short-term growth was assessed by measuring lower leg length velocity (LLLV) by knemometry and bone and collagen turnover was assessed by urinary deoxypyridinoline crosslink excretion corrected for creatinine excretion (DPD). Median duration of study during occlusive dressings was 12 weeks (range 2-18). Topical beclomethasone dipropionate diluted 1:10 or 1:4 in white soft paraffin was applied under tubular (Tubifast) bandages in 7/8 children. Median LLLV before and during therapy were 0.43 mm/week (10(th),90(th) centile; 0.0,0.7) and 0.42 mm/week (10(th),90(th) centile; -0.35,1.01), respectively (not significant). Median DPD before and during therapy were 25.9 nmol/l/creatinine (10(th),90(th) centile; 20.8, 33.0) and 26.3 nmol/l/creatinine (10(th),90(th) centile; 21.7, 34.1) respectively (not significant). Non-invasive assessment of the effects of steroid wet-wrap therapy can be performed in children with eczema. These preliminary results show no substantial growth promoting or adverse effects of therapy.     

Behandlung des akut exazerbierten atopischen Ekzems mit fett-feuchten Verbänden und topischem Chlorhexidin

Six patients (3 children and 3 adults) with acute exacerbated atopic eczema were treated with basic emollients in combination with chlorhexidine-soaked dressings over a period of three days using the "wet-pyjama" technique. Improvement of eczema was documented with the severity score "Scoring of Atopic Dermatitis" (SCORAD); most pronounced changes were found for the subjective parameters itch and sleep loss. Paralleling skin improvement a reduction of Staphylococcus aureus colonisation was noted. Improvement of skin changes lasted beyond the active treatment period. Wet-wrap dressings are an effective treatment modality for atopic eczema without use of corticosteroids and can be used easily on an outpatient basis when manufactured dressings are used.     

Management of leg ulcers with hydrocolloid occlusive dressing

Twenty-two patients with 31 leg ulcers of various causes received local wound management consisting of the application of an adhesive hydrocolloid (HC) occlusive dressing (DuoDerm). Group 1 comprised 15 patients (11 outpatients) with 19 ulcers. Approximately two thirds (12/19) of the ulcers healed when treated solely with the HC dressing; mean treatment time was 57 days. Group 2 comprised seven hospitalized patients with at least two leg ulcers of similar size and distribution. The 20 ulcers in the seven patients were treated with either mild topical antimicrobial wet dressings (Sweitzer's 1:32 solution) or HC dressings, with each patient serving as his own "control." All 20 ulcers healed; the average time to healing was 44 days with HC dressing and 42 days with wet dressing management. Most of the patients reported convenience in management and substantial relief of pain with the use of HC dressings.     

Evaluating the efficacy and safety of calcipotriene/betamethasone ointment occluded with a hydrogel patch: a 6-week bilaterally controlled, investigator-blinded trial

Occlusive therapy with or without topical agents is effective in the treatment of psoriasis. This study assessed the efficacy and safety of an occlusive hydrogel dressing. Participants were treated with calcipotriene 0.005%-betamethasone dipropionate 0.064% ointment with and without a hydrogel patch. Thirty participants completed the 6-week, bilaterally controlled, investigator-blinded, single-center study. Substantial reductions in total modified psoriasis area and severity index (PASI) scores of occluded lesions versus nonoccluded lesions were seen as early as the first week of treatment and sustained through 4 weeks of the study. No adverse effects related to the study, including skin irritation, were observed or reported. Hydrogel dressings provide an effective and safe occlusive option to enhance topical therapy for psoriasis.     

Evaluation of a silicone occlusive dressing after laser skin resurfacing

BACKGROUND: Closed dressings are thought to promote postoperative wound healing after laser skin resurfacing; however, quantitative data are lacking. OBJECTIVE: To compare postoperative healing after combination carbon dioxide and erbium:YAG full-face laser skin resurfacing in patients who were treated with a silicone occlusive dressing (Silon-TSR; Bio Med Sciences, Inc, Bethlehem, Pa) vs open-wound care consisting of soaks and ointment application. DESIGN: Thirty-five patients with closed dressings compared retrospectively with 35 control subjects with open-wound care. In a prospective evaluation, 27 patients with closed dressings were then compared with 27 historical controls matched by age, sex, skin type, and treatment technique. Erythema, crusting, swelling, pain, pruritus, purpura, long-term complications, and dressing comfort were evaluated. SETTING: Referral-based academic practice. RESULTS: Prospectively, closed-dressing and open-wound care groups differed significantly in maximum erythema severity (1.8 vs 2.0 on a scale of 0-3; P =.03), noticeable erythema duration (15.4 vs 31.1 days; P =.04), and time until complete erythema resolution (41.8 vs 96.1 days; P =.02). Swelling resolution was more rapid in the dressing group (12.1 vs 29.5 days; P =.02). Crusting was limited to uncovered areas in the dressing group, and crusting duration was shorter (5.0 vs 9.1 days; P<.001). Pain was more likely to be reported prospectively, but severity was mild, in the closed-dressing group. Other short- and long-term complications did not differ significantly. Subjective patient attitudes toward the dressing were positive. CONCLUSIONS: Occlusive silicone dressing application decreases immediate postoperative morbidity with significantly reduced severity and duration of erythema and decreased duration of swelling and crusting. Long-term results and complication rates remain unchanged.     

Comparison of the open technique with a new wound dressing, H2460, in the healing of an acute wound after laser skin resurfacing.

BACKGROUND: Applying various dressings or leaving the treated area open are two techniques in use after laser skin resurfacing (LSR). OBJECTIVE: This study was conducted to compare healing of an acute wound using a new hydrocolloid dressing, H2460, with the open technique. METHODS: Immediately after LSR, one side was covered with the new hydrocolloid dressing H2460 and the other side was left open. Participants were instructed to clean the open side four times a day and replace the H2460 dressing if it was dislodged. RESULTS: In the volunteers' and investigator's evaluations, the new dressing H2460 generally outperformed the 'open' technique. At the 1-month follow-up, eight of 10 volunteers reported that the H2460 side resulted in better healing; two of 10 volunteers felt there was no difference between the two sides for final outcome and none believed that the open side had better healing. Overall, the H2460 side healed better in the majority of participants as graded by the blinded observer (60%) and participant themselves (80%). CONCLUSION: The new hydrocolloid dressing H2460 is a better and suitable alternative to the open technique to manage an acute wound after LSR.     

New pressure ulcers dressings to alleviate human soft tissues: A finite element study

Pressure Ulcers (PU) are real burdens for patients in healthcare systems, affecting their quality of life. External devices such as prophylactic dressings may be used to prevent the onset of PU. A new type of dressing was designed to alleviate soft tissue under pressure, with the objective to prevent PU and to improve the healing conditions of category-1 and category-2 wounds. The mechanical interactions of this dressing with a generic model of human skin/hypodermal soft tissue was simulated using the Finite Element (FE) method. Different cases with intact skin tissues and injured tissues with a category-2 PU, with and without dressings in place, were modeled. The tissues were deformed under compressive load; internal strains were computed. The results showed a clear benefit from the use of the dressing to reduce the peak internal strains both in the intact and injured tissues models by 17–25%, respectively. The intact soft tissues model was evaluated via sacral pressure measurements performed on one healthy volunteer. Results showed a good agreement between pressure measurements and estimations both with and without the dressing in place; particularly under the bony prominence and in surrounding tissues. As a conclusion, the importance of dressings to maintain a proper biochemical environment for the healing of PU is incontestable. Yet, new concepts of dressings may be developed to prevent the onset of PU, but also to provide local stress and strain reliefs and create mechanical conditions as less damaging as possible for the tissues.     

A fibre-free alginate dressing in the treatment of split thickness skin graft donor sites

Background Alginate dressings are gaining acceptance in wound management although comparative published data with conventional treatment is inconclusive.
Aims The aim of this randomised controlled study was to compare a fibre-free alginate dressing (Comfeel SeaSorb) with conventional treatment of standardised split-thickness skin graft donor sites in 17 patients regarding initial absorption of blood and healing.
Results The alginate dressing absorbed 40% ( P < 0.05) more blood, measured as total iron content of used dressings, during the first 10 post-wounding minutes than fine mesh gauze, resulting in less subsequent bleeding. Light microscopic examination of punch biopsies obtained from 10 wounds on post-operative day 6 demonstrated that nine wounds treated with the alginate dressing compared with seven wounds treated conventionally with paraffin-impregnated gauze (Jelonet®) were completely epithelialised, a statistically non-significant difference ( P = 0.46).
Conclusions In conclusion, the fibre-free alginate dressing showed increased initial blood absorption resulting in quicker haemostasis but showed no greater beneficial effect on epithelialisation of split-thickness skin graft donor sites compared with conventional topical treatment     

Effect of retinoids on wound healing in diabetic rats

Summary In order to clarify the effect of retinoids on wound healing, diabetic rats were treated with oral acitretin or isotretinoin at 1 mg/kg for 5 days prior to the setting of deep punch biopsies, 6 mm in diameter, and for 14 days thereafter. Wound care was done with either a dry or a wet dressing. Wound surface area and transepidermal water loss were measured twice weekly at the time of the change of dressings. Statistically significant increases of both test parameters were noted after 1 week in retinoid-treated animals, but only with dry dressings. No excessive granulation tissue was observed at any time. The data suggest that under certain unfavorable circumstances, problems in wound healing may arise under retinoid treatment.     

Local environment of chronic wounds under synthetic dressings

Local wound environment under oxygen-permeable and oxygen-nonpermeable dressings in patients with chronic ulcers was investigated. The oxygen tensions under both these dressings were very low or zero. Wound fluid was more acidic under the nonpermeable hydrocolloid dressing than under the oxygen-permeable polyurethane dressing. Bacterial growth studied in vitro was retarded at the more acidic pH similar to that found under the hydrocolloid dressing. Viable and functioning neutrophils were found under both the polyurethane and hydrocolloid dressings, with a greater percentage of viable cells under the polyurethane film. Our data suggest that these synthetic dressings create hypoxic conditions in which wound healing occurs whether or not the dressing is permeable to oxygen. Furthermore the local wound environment can be modified by use of synthetic dressings.     

FIBRIN CUFF LYSIS IN CHRONIC VENOUS ULCERS TREATED WITH A HYDROCOLLOID DRESSING

Background. Pericapillary fibrin cuffs (PFC) are a recognized part of the pathology of venous stasis ulcers. A hydrocolloid dressing capable of lysing wound surface fibrin was tested in venous ulcers for its capacity to lyse pericapillary fibrin below the wound surface. Methods. Tissue biopsies from the rims of 19 venous ulcers were evaluated for thickness of shallow and deep dermal PFCS before and after treatment with DuoDERM covered by Unna's boot and a compression bandage (DD+UB; n=9) versus the same treatment without the hydrocolloid dressing (UB; n=10). Frozen sections of all biopsies were stained with an immunofluorescent antibody to fibrin for rating of PFC thickness. Separate sections were stained with hematoxylin and eosin to assess capillary frequency, histopathology, and inflammation. All ratings and pathology assessments were performed blinded to treatment conditions. Results. Both deep and shallow PFCS were reduced in 89% of ulcers treated with DD+UB versus 40% of ulcers treated with UB (α < 0.04). No other significant differences in inflammation, histopathology, or capillary frequency were observed. Conclusions. Treatment with DD+UB reduced PFCS in twice the number of ulcers than UB alone in 1 week. This is the first scientific documentation that a topical wound dressing could reduce the pathophysiology associated with venous ulcers, beyond the known beneficial effect of graduated compression. Not all hydrocolloid dressings are fibrinolytic, so this effect may not generalize to other dressings.     

Comparison of the open technique with a new wound dressing,H2460, in the healing of an acute wound after laser skin resurfacing

Background: Applying various dressings or leaving the treated area open are two techniques in use after laser skin resurfacing (LSR). Objective: This study was conducted to compare healing of an acute wound using a new hydrocolloid dressing, H2460, with the open technique. Methods: Immediately after LSR, one side was covered with the new hydrocolloid dressing H2460 and the other side was left open. Participants were instructed to clean the open side four times a day and replace the H2460 dressing if it was dislodged. Results: In the volunteers' and investigator's evaluations, the new dressing H2460 generally outperformed the ‘open’ technique. At the 1‐month follow‐up, eight of 10 volunteers reported that the H2460 side resulted in better healing; two of 10 volunteers felt there was no difference between the two sides for final outcome and none believed that the open side had better healing. Overall, the H2460 side healed better in the majority of participants as graded by the blinded observer (60%) and participant themselves (80%). Conclusion: The new hydrocolloid dressing H2460 is a better and suitable alternative to the open technique to manage an acute wound after LSR.     

湿包裹治疗13例儿童重度特应性皮炎临床效果观察

目的 观察湿包裹疗法(WWT)治疗儿童重度特应性皮炎(AD)的效果和安全性.方法 2016年9月至2017年3月在北京儿童医院皮肤科收集重度AD患儿(符合Williams诊断标准,SCORAD＞50分)13例,每日接受WWT,共治疗3～5d,评估治疗前后患儿SCORAD评分及VAS评分改善情况.选取其中3例患儿双侧肢体对称皮损进行WWT与传统治疗的对比观察,比较治疗3d后双侧局部皮损严重度评分.结果 13例患儿治疗前SCORAD评分及VAS评分分别为60.2±9.7和7.3±1.8,WWT治疗3～5d后,分别降至24.7±5.8和2.4±1.0,治疗前后差异均有统计学意义(t值分别为15.128、9.385,均P＜ 0.001);12例患儿SCORAD改善率达50％以上.3例患儿双侧皮损治疗3d后,WWT侧皮损严重度评分低于对照侧(t=7.0,P＜ 0.05).WWT不良反应轻微,3例患儿主诉治疗过程中潮湿引起不适感.结论 WWT治疗儿童重度AD起效快,不良反应少,效果优于传统单纯外用药物.     

Inhibitory effects of Rumex japonicus Houtt. on the development of atopic dermatitis-like skin lesions in NC/Nga mice

BACKGROUND: Rumex japonicus Houtt. (RJH) is one of the herbs used in Eastern countries for the treatment of atopic dermatitis (AD). It has been shown to have an antioxidative effect in human skin disease. OBJECTIVES: To examine whether RJH extract (RJH-E) suppresses the development of AD-like skin lesions in NC/Nga mice, which are induced by the repeated application of picryl chloride (PC). METHODS: The efficacy of RJH-E in NC/Nga mice was assessed by measuring symptom severity, scratching behaviour, Staphylococcus aureus numbers on an ear, and serum levels of IgE, interleukin (IL)-4 and interferon (IFN)-gamma. RESULTS: Oral administration of RJH-E to NC/Nga mice treated with PC inhibited the development of AD-like skin lesions as exemplified by a significant decrease in total skin symptom severity scores, and a decrease in hypertrophy, hyperkeratosis and infiltration of inflammatory cells in the skin. The scratching behaviour and numbers of S. aureus, which are known to be exacerbated in AD, were also significantly reduced by RJH-E. No significant change was observed in the serum levels of IFN-gamma, whereas IgE and IL-4 levels were significantly reduced by RJH-E. CONCLUSIONS: These results suggest that RJH-E inhibits the development of AD-like skin lesions in NC/Nga mice by suppressing the T-helper 2 cell response. Our results indicate that RJH treatment could provide an effective alternative therapy for the management of AD.     

Comparison of two wound dressings after laser skin resurfacing.

BACKGROUND: It has been reported that the final outcome of laser resurfacing still depends to a large degree on the efficiency of the post laser resurfacing wound care in promoting wound healing and preventing early and late complications. OBJECTIVE: The objective of this study was to evaluate and compare a new hydrocolloid dressing, H2460, with Flexzan(TM) for healing of an acute wound after laser skin resurfacing (LSR). METHODS: Ten volunteers received LSR of the peri-orbital area with an erbium:YAG laser. Identical parameters were used on both sides: 2 J, 5 mm spot, 8 Hz, 300 micros pulse, two passes on the upper eyelids, four passes on the lower eyelids and six passes on the crow's feet area. Soon after the LSR, one side was covered with Flexzan dressing and the other side was covered with a new hydrocolloid dressing -- H2460. The side of the dressing was randomized by alternating both dressings. All volunteers were evaluated and digitally photographed every day for a week and at 1 month after LSR. The degree of erythema, swelling, bleeding, oozing, crusting, pigmentary changes, scarring, discomfort, itching, burning, ease of application of dressings, initial adhesion, overall adhesion, leakage of fluid, maceration of surrounding skin, ease of removal and adhesive residue upon removal were documented. RESULTS: In all volunteer and investigator's evaluations, the new dressing, H2460, achieved far better results than Flexzan in each category. After a 1-week follow-up all volunteers and the investigator evaluated the H2460 side as: healed better, simple to use, and caused less discomfort in 10 out of 10 volunteers. The blinded observer's assessment showed that the Flexzan side healed better in one volunteer. CONCLUSION: The new dressing, H2460, is a better and suitable alternative to Flexzan as a post LSR dressing.