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.     

他克莫司软膏治疗儿童特应性皮炎疗效和依从性评价

目的评价0.03%他克莫司软膏治疗儿童轻、中度特应性皮炎(AD)的疗效和安全性及依从性。方法采用随机双盲平行对照方法将入选的60例AD患儿分为对照组和试验组,每组各30例。试验组患儿外用0.03%他克莫司软膏,对照组患儿外用凡士林乳膏、夫西地酸软膏,两组均连续治疗3周,采用AD评分评价疗效。结果试验组患儿瘙痒、症状积分下降明显大于对照组(P<0.05);症状控制时间和临床治愈用药时间明显短于对照组(P<0.05)。试验组和对照组治疗的有效率分别为93.3%和69.5%,两组疗效比较差异有统计学意义(P<0.05);试验组和对照组依从率分别为100%和76.7%,两组比较差异具有统计学意义(P<0.05)。结论 0.03%他克莫司软膏治疗儿童轻、中度AD安全而有效,患儿依从性良好。     

依巴斯汀三倍剂量治疗轻中度特应性皮炎的疗效和安全性

目的：评价依巴斯汀三倍剂量治疗特应性皮炎的有效性和安全性。方法：选取轻度至中度的特应性皮炎患者为研究对象,随机分为观察组和对照组。观察组口服依巴斯汀片30 mg/d联合医用凡士林外用,对照组口服依巴斯汀片10 mg/d联合医用凡士林外用,观察两组患者在28天治疗后的瘙痒评分、SCORAD总分、临床总有效率以及发生的不良反应。结果：共收集患者128例,其中观察组和对照组各64例,观察组的瘙痒评分、SCORAD总分分别为3.02±1.19和21.83±3.05均显著低于对照组的6.77±1.33和29.28±4.91（P<0.05）;观察组临床总有效率为93.33%高于对照组的68.75%,差异有统计学意义（P<0.05）;观察组不良反应发生率为6.3%,对照组为9.4%,两组不良反应比较无统计学差异（P＞0.05）。结论：与常规剂量的依巴斯汀比较,30 mg/d的依巴斯汀治疗特应性皮炎疗效优于10 mg/d,不良反应无明显差异。     

Sweating response to moderate thermal stress in atopic dermatitis

The local sweating response to thermal stress (mean ambient temperature 33 degrees C) was assessed under resting conditions on the non-eczematous back skin of 26 young men with atopic dermatitis (AD) and in 22 non-atopic controls with other dermatoses. The baseline (transepidermal) water loss was separately determined at room temperature (mean 23.6 degrees C) to calculate the pure sweat loss. A gravimetric collecting method was used for the measurements at 40, 60 and 80 min. In the heated room the sweat loss in AD patients was significantly lower at all time intervals. The cumulative sweat loss was 50-60% lower in AD patients than in the controls (P less than 0.02). Subjects with dry AD skin had a lower sweat loss than subjects with normal-looking skin. Compared with controls the sweat loss in AD patients was lowest at 40 min, suggesting a retarded sweating response. Half of the patients with AD and half of the controls had active participation in sports, and showed a greater sweat loss compared to the non-sporting subjects in the same group.     

A prospective,randomized clinical trial comparing topical aloe vera with 0.1% triamcinolone acetonide in mild to moderate plaque psoriasis

Background Topical aloe vera (AV) has been used to treat various skin conditions, including psoriasis, with good results. Objectives This study aims to compare the efficacy of AV and 0.1% triamcinolone acetonide (TA) in mild to moderate plaque psoriasis. Methods A randomized, comparative, double‐blind, 8‐week study was designed. Eighty patients randomly received AV or 0.1% TA cream and their clinical response were evaluated using the Psoriasis Area Severity Index (PASI) and the Dermatology Life Quality Index (DLQI). Results After 8 weeks of treatment, the mean PASI score decreased from 11.6 to 3.9 (–7.7) in the AV group and from 10.9 to 4.3 (–6.6) in the TA group. Between‐group difference was 1.1 (95% confidence interval –2.13, –0.16, P = 0.0237). The mean DLQI score decreased from 8.6 to 2.5 (–6.1) in the AV group and from 8.1 to 2.3 (–5.8) in the TA group. Between‐group difference was 0.3 (95% confidence interval –1.18, –0.64, P = 0.5497). There was no follow‐up period after the 8‐week treatment. Conclusions AV cream may be more effective than 0.1% TA cream in reducing the clinical symptoms of psoriasis; however, both treatments have similar efficacy in improving the quality of life of patients with mild to moderate psoriasis.     

Mycophenolate mofetil therapy for moderate to severe atopic dermatitis

BACKGROUND: Atopic dermatitis (AD) is a chronic inflammatory disease of the skin that can be refractory to topical and systemic corticosteroids, phototherapy, topical immunomodulators and systemic immunosuppressive drugs. Recent studies have shown promise for the use of mycophenolate mofetil (MMF) to treat recalcitrant AD. AIM: To assess the effectiveness and adverse effects of MMF used for moderate to severe AD in a university outpatient dermatology clinic. METHODS: A retrospective chart review of 20 patient charts was conducted for patient age, gender, duration of disease, prior therapies, concomitant therapy, clinical response and adverse side-effects. RESULTS: Of the 20 patients, 17 improved within 4 weeks of starting MMF therapy. Ten patients had disease remission and were subsequently able to discontinue MMF. Seven attained satisfactory control of their AD using MMF as maintenance therapy. Overall, MMF was well tolerated, with mild headaches, gastrointestinal complaints and fatigue as the commonest side-effects. During therapy, herpes zoster developed in four patients, Staphylococcus aureus cutaneous infections in two, and herpes simplex in one. One patient discontinued MMF because of insufficient control of pruritus. CONCLUSION: MMF can be rapidly effective and well tolerated in patients with moderate to severe AD resistant to conventional therapies. The limitations of this retrospective study include no control group and a lack of a standardized scoring index to assess improvement, and the concomitant use of adjuvant therapies makes the contribution of MMF alone difficult to assess. Larger controlled studies are needed.     

Azone® enhances clinical effectiveness of an optimized formulation of triamcinolone acetonide in atopic dermatitis

BACKGROUND: Atopic dermatitis is a chronic, relapsing condition affecting up to 14% of the population in Western countries. Topical corticosteroids are the mainstay of treatment. Triamcinolone acetonide, a corticoid of intermediate potency, has proven useful in the treatment of atopic dermatitis. AIM: To evaluate the effectiveness of a triamcinolone acetonide-laurocapram combination in the treatment of atopic dermatitis. METHODS: One hundred and fifty patients were enrolled in a three-arm, parallel group, controlled clinical trial evaluating the effectiveness of a triamcinolone acetonide (0.05%) and laurocapram combination, applied twice daily for 2 weeks, in the treatment of atopic dermatitis. Fifty patients received triamcinolone acetonide-laurocapram (TNX), 50 triamcinolone acetonide (TN), and 50 a vehicle control formulation (AN). Response to treatment was evaluated by change in disease severity at 6 h, at 3, 8, and 15 days after the start of treatment, and by the global change in disease status. RESULTS: TNX effected a significantly higher degree of improvement in the signs and symptoms of atopic dermatitis (erythema, induration, and pruritus) and a greater overall improvement in disease status compared with treatment with TN or AN. Treatment-associated side-effects were local reactions, occurring in three, two, and six patients in the TNX, TN, and AN groups, respectively. CONCLUSIONS: The results suggest that the incorporation of laurocapram in the formulation enhances the effectiveness of triamcinolone acetonide, without compromising its safety profile.     

Impact of filaggrin mutations on Raman spectra and biophysical properties of the stratum corneum in mild to moderate atopic dermatitis

Background Atopic dermatitis (AD) is associated with null mutations in the filaggrin (FLG) gene. Objective To assess the impact of FLG null mutations on biophysical properties and the molecular composition of the stratum corneum (SC) in healthy individuals and AD patients. Methods A total of 196 French adults, including 97 with a history of mild to moderate AD, were genotyped for the three major European FLG mutations. Components of the natural moisturizing factor (NMF), lipids and water content in the SC were determined using Raman spectroscopy. In addition, trans‐epidermal water loss, capacitance and pH of the SC were measured. Results Stratum corneum concentrations of total NMF, water, ornithine and urocanic acid (UCA) were significantly lower in AD patients than in healthy controls. Null mutations of FLG were detected in 4% of controls and 10% of AD patients. FLG mutations were associated with increased SC levels of lactate, reduced concentrations of most other NMF components and higher disease severity in AD patients. In AD patients without FLG mutations, the content of NMF constituents decreased with increasing disease severity. The concomittant presence of low concentrations of histidine, alanine and either glycine or pyrrolidone‐5‐carboxylic acid (PCA) in the SC was associated with FLG mutations with 92% specificity. Conclusions Our findings suggest a low prevalence of FLG mutations in mild AD and support an important role for filaggrin in determining the physicochemical parameters of the SC. The combined measurement of several filaggrin breakdown products in the SC may be useful to specifically predict the presence of FLG mutations.     

Non-invasive evaluation of inflammation in atopic dermatitis*

In atopic dermatitis the inflammatory reaction is quantified either clinically or histologically. While clinical evaluation has the major disadvantage of inter- and intraoperator variance, histological investigation requires invasive procedures. Therefore, standard techniques which provide both an objective and non-invasive form of examination are desirable. We investigated 20 patients with atopic dermatitis by means of high resolution 20-MHz b-*scan ultrasound. Investigations were performed on inflammatory skin lesions at regular intervals using a standardized combination of external treatment with α-methyl-prednisolon-aceponat ointment and UV-A/UV-B phototherapy until the lesions had healed. Skin colour (erythema) was assessed with the Minolta Chromameter CR 200 colorimeter according to the L*a*b* colour system. Sonograms of affected skin show a zone of low echogenicity below the so-called entry-echo. We refer to this as the echolucent area. Healing of a lesion is seen as a decrease in thickness and an increase in density of the skin in the sonographic image; the echolucent area disappears totally when the lesion has clinically healed. In five patients we excised small areas of skin to compare the sonographic and histological pictures of exactly the same site. This showed that the thickness of the subepidermal echolucent area corresponds to the inflammatory reaction representing both edema and cellular infiltration. Comparing the findings in sonography with the change in skin colour measurements we found that the a*-value of the L*a*b* colour system representing redness correlated well with the sonographic density of the echolucent area. In conclusion, 20-MHz-b-scan sonography and colorimetry are suitable methods for non-invasive, objective evaluation of the inflammatory process in atopic dermatitis.     

Delayed type hypersensitivity to intralesional triamcinolone acetonide

Corticosteroids are the most widely used class of drugs in dermatology. In the past, allergic contact dermatitis to topical corticosteriods was rarely reported. In this article, we present a case of delayed type hypersensitivity to triamcinolone acetonide.     

The management of moderate to severe atopic dermatitis in adults with topical fluticasone propionate

This study was designed to investigate a long-term therapeutic strategy for the management of recurring atopic dermatitis (AD) in adults using fluticasone propionate (FP) ointment (Cutivate^TM) whereby FP could help to prevent a relapse of AD once symptoms were under control. Adult patients with chronic, moderate to severe AD entered this multicentre study. All patients were initially treated with FP 0.005% (g/g) ointment in two different regimens. Patients whose AD had been completely healed by these treatments then entered a long-term treatment phase applying FP or placebo ointment once daily, two times per week for 16 weeks to 'known' healed lesions. By the end of the initial treatment period, mean SCORAD values had significantly ( P  < 0.0005) improved from baseline. Patients who entered the maintenance phase and were treated with intermittent FP for up to 16 weeks, demonstrated its superior efficacy ( P  = 0.018) over placebo, maintaining the improvements achieved after the initial treatment phase, reducing risk of relapse and delaying time to relapse ( P  = 0.013). No significant changes were detected in either treatment group in serum cortisol levels or in skin thickness measurements. Intermittent FP applied two times per week maintained a significant level of control, and delayed relapse of AD by comparison with placebo.     

Skin prick testing to food allergens in breast-fed young infants with moderate to severe atopic dermatitis

SUMMARY The role of food allergy in atopic dermatitis is controversial. This study presents results of skin prick tests to 31 different food allergens in a selected population of predominantly breast-fed young infants who had moderate to severe generalized atopic dermatitis. Of the 59 infants (22 female, mean age 26.5 weeks) tested, 54 infants (91.5%) had positive responses to one or more foods, 53 infants (90%) were positive to one or more of the five common food allergens (egg white, cow's milk, peanuts, wheat or soy) and 80% were positive to egg white, which was by far the most common positive test. A total of 37 infants had strongly positive responses to one or more foods, with 33 of these 37 having strongly positive responses to egg white. The significance of these responses is discussed. It is concluded that positive skin prick tests to foods, particularly to egg white, are very common in this selected population of breast-fed infants with moderate to severe atopic dermatitis.     

Distinct molecular signatures of mild extrinsic and intrinsic atopic dermatitis

Atopic dermatitis (AD) is a common inflammatory skin disease with underlying defects in epidermal function and immune responses. In this study, we used microarray analysis to investigate differences in gene expression in lesional skin from patients with mild extrinsic or intrinsic AD compared to skin from healthy controls and from lesional psoriasis skin. The primary aim was to identify differentially expressed genes involved in skin barrier formation and inflammation, and to compare our results with those reported for patients with moderate and severe AD. In contrast to severe AD, expression of the majority of genes associated with skin barrier formation was unchanged or upregulated in patients with mild AD compared to normal healthy skin. Among these, no significant differences in the expression of filaggrin (FLG) and loricrin at both mRNA and protein level were found in lesional skin from patients with mild AD, despite the presence of heterozygous FLG mutations in the majority of patients with mild extrinsic AD. Several inflammation‐associated genes such as S100A9, MMP12, CXCL10 and CCL18 were highly expressed in lesional skin from patients with mild psoriasis and were also increased in patients with mild extrinsic and intrinsic AD similar to previous reports for severe AD. Interestingly, expression of genes involved in inflammatory responses in intrinsic AD resembled that of psoriasis more than that of extrinsic AD. Overall, differences in expression of inflammation‐associated genes found among patients with mild intrinsic and extrinsic AD correlated with previous findings for patients with severe intrinsic and extrinsic AD.     

Perforin and granzyme B may contribute to skin inflammation in atopic dermatitis and psoriasis

BACKGROUND: Infiltration of the skin by pathogenic T cells is regarded as a key factor in the development of inflammatory skin diseases such as atopic dermatitis (AD) and psoriasis. OBJECTIVES: To investigate whether T cells containing cytotoxic proteins may contribute to the generation of skin inflammation in these skin diseases. METHODS: Skin biopsy specimens were obtained from non-lesional and lesional skin of patients with chronic AD (n = 8) and psoriasis (n = 6), and from non-atopic controls with normal skin (n = 6). Expression of perforin and granzyme B was investigated by immunohistochemistry. RESULTS: A significant enhancement of perforin and granzyme B expression was observed in lesional AD skin as compared with normal skin, non-lesional AD skin and psoriasis. Expression of these cytotoxic proteins was also increased in psoriasis as compared with normal skin and non-lesional psoriatic skin. Immunoreactivity for perforin and granzyme B was mainly found in the cytoplasm of lymphocytic cells located in the perivascular infiltrate. In AD increased numbers of positive cells were also observed focally at sites of spongiosis in the epidermis. Double immunostaining revealed that both CD4+ and CD8+ T cells are capable of expressing perforin and granzyme B. CONCLUSIONS: Our data suggest that cytotoxic CD4+ and CD8+ T cells containing perforin and granzyme B may play an integral part in eliciting cutaneous inflammation in AD.     

Selected eosinophil proteins as markers of inflammation in atopic dermatitis patients

Atopic dermatitis (AD) is an inflammatory skin disease characterized by chronic and recurrent course, beginning primarily in early childhood. The etiopathogenesis of AD has not yet been fully understood, although various types of inflammatory cells including eosinophils may be involved in its pathomechanism. The basic aim of the study was to evaluate the usefulness of selected eosinophil proteins in serum and urine of AD patients, as markers of disease severity. The study also aimed to analyze correlations between the level of examined proteins and parameters such as skin prick test (SPT) results, serum concentration of total IgE, and coexistence of symptoms of other atopic diseases. The study included 30 AD patients and two control groups: 30 patients suffering from chronic urticaria and 30 healthy individuals. The mean level of eosinophil proteins measured in serum and urine of AD patients was higher than that in controls, although a significant difference was only recorded for serum and urine level of eosinophil protein X (EPX). Patients with very severe/severe AD presented higher levels of eosinophil proteins than patients presenting with mild/moderate AD, although no significant difference was found between these two groups. AD patients with positive SPT results and detectable specific IgE in serum, and with coexisting symptoms of other atopic diseases presented with higher mean levels of serum and urine eosinophil proteins than AD cases with negative SPT results and without any symptoms of other atopic diseases. In children suffering from AD, serum eosinophil cationic protein level, EPX level and urine EPX level were higher than those in healthy children, however, without statistical significance. Study results suggested a significant role of eosinophils in the etiopathogenesis of AD. Serum and urine levels of selected eosinophil proteins may serve as an important part of diagnostic approach to AD patients, especially in differentiation of allergic and non-allergic forms of AD. The results are also promising for the usefulness of selected eosinophil proteins in the diagnosis of AD in children, however, thorough analysis on a larger group of patients is needed.     

A randomized half-body,double blind,controlled trial on the effects of a pH-modified moisturizer vs. standard moisturizer in mild to moderate atopic dermatitis

BackgroundHigher skin pH in atopic dermatitis contributes to impaired epidermal barrier. A moisturizer compatible with physiological pH could improve atopic dermatitis.ObjectiveTo determine the effect of a physiologically compatible pH moisturizer in atopic dermatitis.MethodsA randomized half body, double blind, controlled trial involving patients with stable atopic dermatitis was performed. pH-modified moisturizer and standard moisturizer were applied to half body for 6 weeks.ResultsA total of 6 (16.7%) males and 30 (83.3%) females participated. Skin pH reductions from week 0, week 2 and 6 were significant at the forearms (5.315 [0.98] to 4.85 [0.54] to 5.04 [0.78], p = 0.02) and abdomen (5.25 [1.01], 4.82 [0.64], 5.01 [0.59], p = 0.00) but not at the shins (5.01 [0.80], 4.76 [0.49], 4.85 [0.79], p = 0.09) with pH-modified moisturizer. Transepidermal water loss (TEWL) at the forearms decreased (4.60 [2.55] to 3.70 [3.10] to 3.00 [3.55], p = 0.00), abdomen (3.90 [2.90] to 2.40 [3.45] to 2.70 [2.25], p = 0.046). SCORAD improved from 14.1 ± 12.75 to 10.5 ± 13.25 to 7 ± 12.25, p = 0.00. In standard moisturizer group, pH reductions were significant at the forearms (5.29 [0.94] to 4.84 [0.55] to 5.02 [0.70], p = 0.00) and abdomen (5.25 [1.09], 4.91 [0.63], 5.12 [0.66], p = 0.00). TEWL at the forearm were (4.80 [2.95], 4.10 [2.15], 4.60 [3.40], p = 0.67), shins (3.80 [1.40], 3.50 [2.35], 4.00 [2.50], p = 0.91) and abdomen (3.70 [2.45], 4.10 [3.60], 3.40 [2.95], p = 0.80). SCORAD improved from 14.2 ± 9.1 to 10.9 ± 10.65 to 10.5 ± 11, p = 0.00. Reduction in pH was observed with both moisturizers while TEWL significantly improved with pH-modified moisturizer. pH-modified moisturizer resulted in greater pH, TEWL and SCORAD improvements however the differences were not significant from standard moisturizer.Study limitationSkin hydration was not evaluated.ConclusionMoisturization is beneficial for atopic dermatitis; use of physiologically compatible pH moisturizer is promising.