Topical corticosteroid phobia in patients with atopic eczema

Topical corticosteroids are widely prescribed by dermatologists caring for patients with atopic eczema. Patients' fears about using topical corticosteroids may have important implications for compliance with treatment. We carried out a questionnaire-based study of 200 dermatology outpatients with atopic eczema (age range 4 months-67.8 years) to assess the prevalence and source of topical corticosteroid phobia. We also questioned patients on their knowledge of the potencies of different topical corticosteroids. Overall, 72.5% of people worried about using topical corticosteroids on their own or their child's skin. Twenty-four per cent of people admitted to having been non-compliant with topical corticosteroid treatment because of these worries. The most frequent cause for concern was the perceived risk of skin thinning (34.5%). In addition, 9.5% of patients worried about systemic absorption leading to effects on growth and development. The most commonly used topical corticosteroid was hydrocortisone, yet 31% of patients who used this preparation classified it as either strong, very strong or did not know the potency. Only 62.5% of the 48 patients who had used both Dermovate (Glaxo) and hydrocortisone in the past were able to correctly grade Dermovate as being more potent than hydrocortisone. The most common source of patient information regarding topical corticosteroid safety was the general practitioner. Although skin thinning and systemic effects can develop very occasionally in people using topical corticosteroids, the concern expressed by people using them seems out of proportion in relation to the evidence of harm. This study highlights the need for provision of better information and education to patients and possibly general practitioners regarding the safety, potency and appropriate use of topical corticosteroids.     

保湿剂并用糖皮质激素治疗异位性皮炎的疗效观察

目的：研究保湿剂对外用糖皮质激素治疗异位性皮炎疗效的影响。方法：通过随机对照临床研究，采用湿疹面积及严重度指数评分法，对外用糖皮质激素和保湿剂治疗45例轻中度异位性皮炎患者的临床疗效进行评估。结果：与单独外用糖皮质激素或保湿剂相比，联合外用糖皮质激素加保湿剂治疗轻、中度异位性皮炎，较单用糖皮质激素疗效显著，单独外用保湿剂可明显减轻轻中度异位性皮炎患者的临床症状。结论：外用保湿剂能增强局部糖皮质激素的疗效，单独外用保湿剂治疗异位性皮炎可获得与糖皮质激素相近的疗效。     

Factors contributing to poor treatment outcomes in childhood atopic dermatitis

Atopic dermatitis (AD) is a chronic relapsing inflammatory disease of the skin and is the most common paediatric dermatological condition. While no cure is available, it can be treated effectively if adherence to a therapeutic plan is maintained. Poor adherence to treatment is common in AD and can lead to treatment failure, which has significant impacts on the patient, family and society. A comprehensive literature search was conducted to identify factors that contribute to poor treatment adherence in childhood AD and to identify possible strategies to remedy these. Identified factors leading to poor treatment adherence include: complexity of treatment regimen, lack of knowledge, impaired quality of life, dissatisfaction with treatment strategies, infrequent follow up, corticosteroid phobia and the use of complementary and alternative medicine. Effective strategies to increase treatment adherence include: caregiver education and utilisation of education adjuncts, optimisation of the patient/caregiver–clinician relationship, early and frequent follow up and improvement of patient and caregiver quality of life.     

A comparative study of childhood psoriasis and atopic dermatitis and greater understanding of the overlapping condition, psoriasis-dermatitis

Background and Objectives: Psoriasis (Pso) in children may be confused clinically with atopic dermatitis (AD) and, indeed, the two conditions may co‐exist. The aim of this study was to determine historical and clinical features that are different in paediatric Pso and AD and to describe children who have features of both: psoriasis‐dermatitis overlap (PD). Methods: Children with features of psoriasis or eczema, or both, who were referred to paediatric outpatients and/or private rooms were evaluated. Data were collected from 170 consecutive children aged less than 12 years between July 2011 and November 2011. Participants were classified by described criteria as having Pso (n = 64), AD (n = 62) or PD (n = 44). Results: Only 9.4% of children with Pso were correctly diagnosed by the referring doctor. Children with Pso relative to AD were more likely to have had a history of scaly scalp and nappy rash in infancy, a family history of psoriasis, current scalp and periauricular rashes, defined, patchy plaque morphology and papulosquamous rashes not typical of adult psoriasis on extensor elbows and knees. Children with PD had features of both but presented most often as typical paediatric psoriasis combined with flexural eczema. Children with Pso and PD responded well to specific treatment strategies for psoriasis, including potent topical corticosteroids (TCS), calcipotriol and phototherapy. Both Pso and PD tended to require more potent TCS than AD to achieve disease suppression. Conclusion: We found that Pso and PD in children both differ clinically from AD and have identified historical and clinical features that characterise childhood Pso.     

Consensus guidelines for the management of atopic dermatitis: An Asia–Pacific perspective

Atopic dermatitis (AD) is a relatively common disease in patients in the Asia–Pacific region. It presents a particular clinical challenge and requires careful clinical management. The chronic nature of AD characterized by flares, exacerbations and periods of quiescence requires a multipronged approach aimed at reducing itch, inflammation and the appearance of secondary lesions. In addition, varying levels of maintenance therapy may be required to avoid exacerbations. Survey data from the region indicate that there is significant variation across the Asia–Pacific with regard to current treatment practices. The management of AD may also be influenced by differing health‐care systems, variable climate, access to medical care and cultural diversity. The current consensus guidelines have been developed to provide up‐to‐date and concise evidence‐ and experience‐based recommendations directed towards general practitioners and general dermatologists in the Asia–Pacific region on the management of pediatric and adult AD.     

The differential diagnosis of atopic dermatitis in childhood

Atopic is the most common of the dermatitides seen in infancy and childhood, but there are numerous other diseases that can mimic the skin findings. These include seborrheic dermatitis, immunodeficiency, and psoriasis in infancy; scabies, tinea corporis infection, perioral, nummular, contact, and molluscum dermatitis in childhood. It is sometimes extremely difficult to differentiate between ichthyosis and AD, and it is also important to differentiate AD from erythrodermic conditions including acrodermatitis enteropathica, biotin deficiency, and Netherton syndrome. A rare condition in children that may mimic AD is mycosis fungoides.     

Tacrolimus decreases the expression of eotaxin, CCR3, RANTES and interleukin-5 in atopic dermatitis

Background There is a lack of studies on the effect of tacrolimus on eosinophils and related molecules including eotaxin, CCR3, RANTES and interleukin (IL)‐5. Objectives To investigate the effects of tacrolimus on in vivo eosinophil counts and on the related molecules eotaxin, CCR3, RANTES and IL‐5 in patients with atopic dermatitis (AD). Methods Lesional skin specimens and sera were obtained from 15 patients with AD and from 15 normal controls. For 8 weeks, the patients with AD applied 0·03% tacrolimus ointment to all affected areas twice daily. Blood sampling and skin biopsies were then repeated. We evaluated serum eotaxin and IL‐5 levels, and tissue eotaxin, CCR3, RANTES and IL‐5 levels. Additionally, tissue levels of eotaxin and CCR3 mRNA were measured. Results After treatment with topical tacrolimus twice daily for 8 weeks, significant decreases were found in serum IL‐5 levels, immunoreactive cell counts of eotaxin, IL‐5, CCR3 and RANTES in AD skin, and tissue eosinophil counts. However, the change in the serum eosinophil count was not statistically significant, and mRNA levels of eotaxin and CCR3 were not decreased significantly after treatment. Conclusions Topical tacrolimus reduces the number of eosinophils in tissue and suppresses the expression of eotaxin, CCR3, RANTES and IL‐5 related to proliferation, recruitment, activation and survival of eosinophils.     

Dosage and adverse effects of topical tacrolimus and steroids in daily management of atopic dermatitis

Since 1999, combination therapy with tacrolimus and topical steroids has been widely used for the treatment of adolescent/adult-type atopic dermatitis. In order to determine the clinical doses of topical tacrolimus and steroids for daily treatment of atopic dermatitis and to elucidate their beneficial and adverse effects, we analyzed the clinical data from 215 patients with atopic dermatitis who were more than 16 years old. Less than 70 g of tacrolimus and less than 15 g of steroids were applied to 90% of the patients on the face and neck, and less than 75.8 g of tacrolimus and less than 322 g of steroids were applied to 90% of the patients on the trunk and extremities during the six-month treatment period. Topical tacrolimus is much more frequently used on face and neck lesions (99.1%); in only 39.5% of cases was it used on the trunk and extremities. The majority of patients improved after six months of the combination topical therapy; however, atopic dermatitis was not controlled in 6% of the patients. The combination therapy did not seem to increase the risk of cutaneous infections; however, the incidence of herpes simplex infection on the face and neck was 2.8% at pre-treatment and slightly increased to 4.7% during the therapy. The incidence of all steroid-induced adverse effects was reduced both in frequency and intensity with a decrease in the dose of topical steroids through simultaneous tacrolimus application. Combination therapy with topical tacrolimus and steroids is useful for treating atopic dermatitis, but a small percentage of the patients still cannot be satisfactorily treated. For such patients, adjustments of the dose and rank of topical steroids and tacrolimus and other therapeutic adjuncts are necessary.     

A randomized, double-blind study to assess the efficacy of addition of tetracycline to triamcinolone acetonide in the treatment of moderate to severe atopic dermatitis

Objective To assess the efficacy of tetracycline in triamcinolone acetonide ointment compared with triamcinolone acetonide ointment in patients with moderate to severe atopic dermatitis. Design Randomised, double‐blind parallel group study of 8 weeks’ duration. Setting Outpatient clinic in a university hospital. Participants Forty‐four adult patients with moderate to severe atopic dermatitis (objective SCORAD > 25). Interventions Initial phase (2 weeks): 3% tetracycline 0.1% triamcinolone acetonide vs. 0.1% triamcinolone acetonide twice daily all over the body. Maintenance phase (6 weeks) 0.1% triamcinolone acetonide once daily for 2 weeks, followed by every other day for 2 weeks. In the last 2 weeks, two applications a week were done. An emollient was used additionally once daily. Main outcome measures Primary outcomes were the disease severity scores assessed by objective SCORAD and SASSAD at week 2. Secondary outcomes were the objective SCORAD and SASSAD at weeks 4 and 8, and Staphylococcus aureus colonization at weeks 0 and 2. Results No significant differences in disease severity outcomes were found between the two groups. Both groups showed clinically relevant improvements in disease severity compared with baseline at weeks 2 and 4. At week 8, there was some worsening in disease severity in both groups, but the disease severity was still significantly lower than at the beginning of the study. Improvement of bacterial colonization was seen in 14 (63.6%) out of the 22 patients in the 3% tetracycline 0.1% triamcinolone acetonide group and in 5 (22.7%) out of the 22 patients in the 0.1% triamcinolone acetonide group. Conclusion The addition of tetracycline was effective on skin colonization by S. aureus but did in our patients with atopic dermatitis not result in a significantly different improvement compared with the group treated without tetracycline.     

Familiar and environmental factors influencing atopic dermatitis in the childhood

BACKGROUND: The increase in the incidence of atopic dermatitis (AD) in developed countries has been related to familiar and environmental factors. This survey was undertaken to investigate the family background, birthweight and the home environment of children suffering from AD in order to point out the possible factors that provoke the development of the disease. METHODS: The study uses data collected by means of self-administered questionnaires and discusses 461 cases of children (age 0-12) with active skin signs of AD. The control group comprised of 343 children (age 0-12) with no skin signs or positive lifetime history of AD. Associations between familiar and various home environmental factors and the risk of AD were calculated by means of odds ratios. RESULTS: There were statistically significant positive associations between atopic eczema symptoms and higher birthweight, small households, wall-to-wall carpets, as well as indoor-kept pets. Day-nursery attendance, heating system and indoor smoking, however, did not significantly alter the risk of the disease. CONCLUSIONS: Because of the limitations of a retrospective questionnaire study, further research is needed to confirm these associations and clarify whether they are causative.     

Clinical dose and adverse effects of topical steroids in daily management of atopic dermatitis

BACKGROUND: Topical steroids are used as the first-line therapy for atopic dermatitis. OBJECTIVES: To determine the clinical doses of topical steroids for the daily treatment of atopic dermatitis in clinics and to elucidate their adverse effects. PATIENTS AND METHODS: A multicentre retrospective analysis of a series of 1271 patients (210 infants, 546 children, and 515 adolescents and adults) with atopic dermatitis. RESULTS: Less than 89.5 g, 135 g and 304 g of topical steroid were applied in 90% of the patients in the infant, childhood, and adolescent and adult AD groups, respectively, on the entire body during the 6-month treatment period. The majority of patients were controlled well; however, 7% of infant, 10% of childhood and 19% of adolescent and adult patients remained in a very severe or severe state or experienced exacerbation even though they applied larger amounts of topical steroids. With regard to adverse effects, the incidence of telangiectasia on cheeks tended to increase in patients who had a longer duration of disease and who applied more than 20 g to the face during the 6-month treatment period. The steroid-induced atrophy of the antecubital and popliteal fossae was more frequently observed in males than in females. CONCLUSIONS: Topical steroids are useful for treating atopic dermatitis, but a substantial percentage of patients cannot be satisfactorily treated with topical steroids. For such patients, adjustments of dose and rank of topical steroids and other therapeutic adjuncts are necessary.     

Role of the epidermal barrier in atopic dermatitis

The skin's permeability barrier protects against extensive water loss and prevents the entry into the skin of harmful substances like irritants, allergens and microorganisms. The permeability barrier is mainly located in the stratum corneum and consists of corneocytes and a lipid‐enriched intercellular domain. The barrier is formed during epidermal differentiation. In atopic dermatitis the skin barrier is disturbed already in non‐lesional skin. The disturbed skin barrier allows the entry of environmental allergens from house dust mites, animal dander and grass pollen into the skin. In predisposed individuals these allergens may trigger via immunologic pathways the inflammation of atopy. The causes for the disturbed epidermal skin barrier are changes in skin lipids and in epidermal differentiation, in particular filaggrin mutations. Filaggrin mutations lead to a disturbed skin barrier and dry skin which are hallmarks in atopic dermatitis. Therapeutic agents influence the skin barrier differently; topical therapy with potent corticosteroids does not lead to the repair of the barrier in atopic dermatitis, whereas therapy with the calcineurin inhibitors and lipid‐containing emulsions support barrier repair.     

Electrical conductance: a controversial parameter in the evaluation of emollients in atopic dermatitis

Background/aims: Essential fatty acids are important in maintaining skin function and their deficiency is associated with scali-ness and increased transepidermal water loss (TEWL). This can be one of the pathogenic processes implicated in atopic dermatitis (AD). Several studies have assessed the value of essential fatty acid-enriched diets in AD but the benefits of topical γ-lino-lenic acid (GLA) therapy have been less well evaluated. The aims of this study were: a) to compare the effects of GLA-con-taining emollients and classical emollients, regarding clinical benefits, cutaneous hydration (by a conductance method) and TEWL; b) to assess the clinical relevance of these two biomet-rical methods (conductance and TEWL). Methods: Twenty-three AD children were randomised into four groups, to compare three emollients containing GLA in different concentrations and one classical emollient. They were evaluated in eight visits for 12 weeks, using a clinical score and measurements of TEWL with the Tewameter? and of cutaneous hydration with the Nova?. Results: Kruskal-Wallis statistical analysis showed significant differences in cutaneous hydration (P<0.05) between each of the three treatment groups and the control group. TEWL and clinical scores did not show statistically significant differences. During the study no children from the GLA groups developed eczematous lesions versus two children from the non-GLA group. Conclusions: Discrepancies between conductance and TEWL measurements may represent false positive results of the former method due to electrical phenomena related to polarity of the GLA molecule or of other elements in the formulations. However, some differences in clinical evolution between the GLA and non-GLA groups require further studies to assess the possible additional benefits of topical emollients containing GLA.