Foundations and self‐tanning products: Do they provide any protection from the sun?

As soon as the weather turns sunny, everyone wants a tan. People with skin phototypes III and IV, called melanocompetent, have no problem meeting this fashion requirement. But things are quite different for people with phototypes I and II and so these individuals look for alternative solutions. In essence, light skin burns easily when exposed to the sun. Therefore, light-skinned people are offered a cosmetic solution through self-tanning products or foundations. It seemed interesting to us to evaluate the sun protection power of this type of product. To do this, we used an in vitro method to determine the typical indicators related to sunscreen products, such as sun protection factor (SPF), ultraviolet (UV)-A protection factor (PF-UVA), UV-B/UV-A ratio as well as the critical wavelength because these artificial tanning products could be considered sunscreen products by users. It is important to know whether a self-tanning product and/or a foundation provide sun protection and whether they meet the standards set for other sunscreen products. Protection which is imbalanced for either UV-B or UV-A radiation is potentially harmful for users believing themselves adequately protected. To do this, we assembled the requisite conditions for forming melanoidins in the cosmetic itself. We tested seven amino acids found in the corneal cells of the epidermis. Regardless of the amino acid used, the corresponding SPF was essentially zero (approximately SPF 2). Foundations, on the other hand, proved to be much more interesting because they possess a non-negligible SPF as well as good photostability making these products safe in terms of their mode of application (applied once daily).     

Do perioperative antibiotics reduce the risk of surgical‐site infections following excision of ulcerated skin cancers? A Critically Appraised Topic

Skin cancer is the commonest type of cancer in the United Kingdom and the numbers are increasing worldwide. Most skin cancers are treated with surgery to remove the cancer from the skin. The risk of having a wound infection after skin surgery is less than 5%. Current evidence suggests that this risk is increased if there is a break on the surface of the skin cancer – called ulceration. At present, there is no guidance in the U.K. for using antibiotics after skin surgery to potentially reduce the risk of infection. This report aimed to review all the research evidence available to help doctors decide if prescribing antibiotics to patients having skin cancers removed by surgery, reduces the chances of wound infection after their skin surgery. A total of 1018 scientific articles were identified in the English Language. The team identified 13 trials as high quality (called randomised controlled trials) where different types of antibiotics were used to see if they reduced infection rates after skin surgery. These included antibiotics applied on the wound surface, antibiotics ingested by mouth, antibiotics given by injection into the muscle or directly into the bloodstream. The research team concluded that based on this review there is not enough evidence to show that taking any form of antibiotic reduces the chances of wound infections following skin cancer surgery. The authors recommend that in the future, researchers should perform a well‐designed clinical trial to answer this question, as this may help prevent some people receiving antibiotics after skin surgery when it may not be needed.     

Nucleic acid‐based non‐invasive prenatal diagnosis of genetic skin diseases: are we ready?

The discovery of circulating fetal nucleic acids is a great step on the way of developing non‐invasive prenatal diagnosis (NIPD) for genetic disorders. Here, we briefly discuss the current applications of circulating fetal nucleic acids in genetic testing for different kinds of hereditary diseases with an emphasis on using circulating cell‐free fetal DNA in diagnosis of monogenic disorders. As the genetic skin disorders impair the quality of life at different levels, we next discuss some ethical issues in NIPD for genetic skin diseases of various severities and in particular, the responsibility of doctors and parents, respectively, in the prenatal genetic testing.     

Are placebo‐controlled trials of creams for athlete’s foot still justified?

Background Placebo‐controlled trials are useful in identifying effective treatments where none has existed, but their continued use once efficacy is established arguably contravenes ethical standards for medical research. Objectives To consider whether sufficient evidence exists to recommend the abandonment of vehicle‐controlled studies in trials of topical treatments for athlete’s foot. Methods We searched nine electronic databases and bibliographies of review articles as part of an ongoing Cochrane systematic review from 1966 to 2007. Randomized controlled trials (RCTs) using a vehicle control design involving participants with a mycological diagnosis of a dermatophyte infection of the skin of the foot were included. Results Allylamines, azoles, ciclopiroxolamine, tolnaftate, butenafine and undecanoates were all more effective than vehicle controls. Evidence of the superiority of azole creams over vehicle controls was fairly consistent from 1975 onwards. Data from patients treated with allylamines have shown their superior effects relative to vehicle controls since 1991 for even short‐term outcomes. Conclusions The superiority of allylamines and azoles over vehicle in vehicle‐controlled trials has been well established, and data demonstrating this fact have been available since the completion of early RCTs. These preparations are effective and safe, and investigators of RCTs evaluating topical treatments for athlete’s foot need to choose potential comparators as control interventions in the light of this knowledge and to consider the ethics of withholding effective treatment from patients who seek treatment for this common foot infection.     

Targeting the gut‐skin axis—Probiotics as new tools for skin disorder management?

The existence of a gut‐skin axis is supported by increasing evidence, but its translational potential is not widely recognized. Studies linked inflammatory skin diseases to an imbalanced gut microbiome; hence, the modulation of the gut microbiota to improve skin condition seems to be a feasible approach. Today, there is a growing interest in natural products as alternatives to synthetic drugs. In this respect, oral probiotics could be a simple, safe and cheap modality in the therapeutic management of skin inflammation. Unfortunately, very few studies have looked into how probiotic supplementation influences inflammatory skin disorders. The result, though promising, are difficult to implement in clinical practice due to the heterogeneity of the applied supplemental regimen in the different studies. In this Viewpoint, we aim to encourage the conduction of more research in that direction to explore unambiguously the therapeutic potential of oral probiotics in dermatology. We focus on the most common inflammatory skin diseases (atopic dermatitis, psoriasis, rosacea, acne vulgaris) with an associated gut dysbiosis, but we also discuss some less common, but very serious skin pathologies (eg erythema nodosum, pyoderma gangrenosum, hidradenitis suppurativa) that are possibly linked to a disturbed gut flora composition. We dissect the possible mechanisms along the gut‐skin axis and highlight novel points where probiotics could interfere in this communication in the diseased state.     

TNF‐α: a treatment target or cause of sarcoidosis?

Sarcoidosis is a systemic granulomatous disease that affects numerous organs, commonly manifesting at the lungs and skin. While corticosteroids remain the first line of treatment, tumour necrosis factor alpha (TNF‐α) inhibitors have been investigated as one potential steroid sparing treatment for sarcoidosis. TNF‐α is one of many components involved in the formation of granulomas in sarcoidosis. While there have been larger scale studies of biologic TNF‐α inhibition in systemic sarcoidosis, studies in cutaneous disease are limited. Paradoxically, in some patients treated with biologic TNF‐α inhibitors for other diseases, treatment can induce the development of sarcoidosis. In the light of this complexity, we discuss the role of TNF‐α in granuloma formation, the therapeutic role of TNF‐α inhibition and immunologic abnormalities following treatment with these TNF‐α inhibitors including drug‐specific alterations involving interferon‐γ, lymphotoxin‐α, TNF receptor 2 (TNFR2) and T‐regulatory cells.     

Is the human skin a pheromone‐producing organ?

It is controversial whether or not humans convey specific compounds within their body odours which can potentially affect the physiology and behaviour of others. Such compounds are called pheromones and have been discovered in many other species, including mammals. It has been suggested that humans might have a special organ within their nose that can transmit such chemosensory information. However, the evidence for this organ is highly questionable. In any case, the main olfactory system is a highly diverse system, capable of transmitting pheromonal information. So far, no single substance has been found that acts as a chemical messenger for erotic attraction. On the other hand, studies investigating the pheromonal properties of natural complex body odour have proven that it does deliver information about the sender and that it has an effect on the physiology and likely behaviour of other humans. Its significance for human mating preferences probably lies not in driving them to choose the right mate but rather in warning them not to choose the wrong one.     

Targeting leukocyte trafficking to inflamed skin – still an attractive therapeutic approach?

Research into leukocyte trafficking and its therapeutic exploitation appears to be a multistep process, just like the trafficking cascade itself. The initial euphoria evoked by an early understanding of the trafficking steps was followed by considerable disappointment following the clinical failure of the first selectin antagonist Cylexin (CY-1503), a sialyl Lewis(X) mimetic. The research area recovered and identified additional attractive pharmacological targets such as chemokine receptors and integrins. However, after lack of efficacy in anti-chemokine trials and the fatalities associated with anti VLA-4 therapy (Tysabri), the question arose again whether targeting leukocyte trafficking is really promising or whether such a complex, multistep process with many redundant and/or functionally overlapping molecules is simply too challenging to deal with. In this article, we delineate some pros and cons of this approach followed by a brief update on where we stand in the field and where we might move in the future.     

Do patients with skin allergies have higher levels of anxiety than patients with allergic respiratory diseases? Results of a large‐scale cross‐sectional study in a French population

BACKGROUND: Psychological comorbidity is a known aspect of allergic disease. However, there is recent evidence that a large proportion of allergic patients remains undiagnosed and untreated for psychological disease. In addition, the complexities of the anxiety-allergy relationship, i.e. differences for current and past disease, or differences among allergic disease types, are not well understood. OBJECTIVES: To measure the level of anxiety in a large allergic population in France using a standardized measure, the State/Trait Anxiety Inventory (STAI). METHODS: Allergy patients in France (n = 3939) who visited their allergy specialists participated in the study. The patients completed a questionnaire which was then linked to the questionnaire completed by their physician. Only patients with both subject and physician questionnaire were kept in the analyses. Mean STAI scores for the State (S) and Trait (T) scales were obtained for each allergic disease. ANCOVA models testing group differences on the mean scores, using the categories "current disease", "past disease" and "allergic disease ever", were assessed along with relevant confounders. RESULTS: Allergic rhinitis (AR), asthma and atopic dermatitis (AD) were the most prevalent conditions of the 12 allergic diseases assessed in the study. Women had higher mean STAI S/T scores than men and age was also found to be associated with higher S scores; therefore, both age and gender were included as covariates where relevant. A single ANCOVA model for each STAI scale showed a statistical difference among the various allergic diseases. Using the category "current disease" each allergic disease was assessed separately regarding the presence or absence of that disease. Higher, statistically significant mean STAI scores were found for AD and allergic urticaria on the S scale and for AD on the T scale. Similarly, for the category "allergic disease ever", AD and allergic urticaria reached statistical significance on the S scale, while on the T scale only AD was statistically significant. When patients were assessed for anxiety based on their past disease, asthma, AR and sinusitis were significant on the S scale while asthma and nasal polyps were statistically significant on the T scale. When asthma and AD were tested simultaneously, only the latter was significant. CONCLUSIONS: High mean scores for State and Trait anxiety were mostly associated with AD.     

Can the brain inhibit inflammation generated in the skin? The lesson of α‐melanocyte‐stimulating hormone

The neuro-immuno-cutaneous-endocrine network is not a simple construct featuring organ systems intimately involved in the bridge between body and mind. Mind-body influences are bi-directional and the skin should be considered an active neuroimmunoendocrine interface, where effector molecules of neuropeptides act as common words used in a dynamic dialogue between brain, immune system and skin. Gamma-melanocyte stimulating hormone (gamma-MSH), one of the principal neuroimmunomodulating peptides, seems to exercise some control on the cutaneous inflammatory process, through a central action mediated by descending anti-inflammatory neural pathways and via local direct influence on inflammatory cells infiltrating the dermis, such as monocytes, macrophages and neutrophils. Gamma-MSH down-regulates the production of proinflammatory cytokines, while the production of the anti-inflammatory cytokine IL-10 is stimulated by gamma-MSH. Finally, gamma-MSH seems to regulate the expression of surface molecules in immunocompetent cells. Thus, further studies may lead to the use of gamma-MSH as an important anti-inflammatory agent in clinical dermatology.     

Do tetracyclines and erythromycin exert anti‐acne effects by inhibition of P450‐mediated degradation of retinoic acid?

For decades, retinoic acid (RA) is known as the most potent therapeutic option in the therapy of acne and altered homeostasis of endogenous retinoids has been discussed in the context of acne pathogenesis. Besides retinoids, antibiotics such as tetracyclines or erythromycin are well established in acne pharmacotherapy. Accumulating evidence points towards common molecular pathways being targeted by both RA and anti‐acne antibiotics; however, a precise ‘common denominator’ connecting these chemically diverse anti‐acne agents has not yet been identified. Interestingly, tetracyclines are associated with the occurrence of pseudotumor cerebri, a rare neurological side effect otherwise associated with retinoid intoxication or RA exposure. This association at the clinical level suggests an interaction between tetracyclines and endogenous RA signalling. As erythromycin does not cross the blood brain barrier, CNS side effects are not to be expected, yet not precluding a possible local interaction of erythromycin with endogenous RA metabolism in the skin. We hypothesize tetracyclines and erythromycin to locally inhibit endogenous RA metabolism in the skin and thus mimic therapeutic action of RA. This readily testable hypothesis suggests inhibition of endogenous RA metabolism and amplification of endogenous RA signalling as a mechanism underlying the biochemical actions of antibiotics in acne therapy. Elucidation of such interactions may ultimately enhance our understanding of acne therapy and pathogenesis and may yield a sound, scientific basis for hypothesis‐driven development of novel therapeutic compounds.     

Does ad hoc quality‐of‐life discussion in inflammatory skin disease consultations reflect standardized patient‐reported outcomes?

BACKGROUND: There is little information concerning how much health-related quality-of-life (HRQoL) information is elicited in dermatology outpatient consultations. OBJECTIVES: To observe and record ad hoc HRQoL discussion in inflammatory skin disease consultations, to systematically measure the patient's HRQoL and to measure patient satisfaction with dermatology care. METHODS: Clinic consultations of patients with inflammatory skin conditions attending a secondary care clinic were observed by a single researcher (CP). Data were collected on the 10 subject areas of the Dermatology Life Quality Index (DLQI) and on sleep, burden, frustration and depression. Patients were sent the DLQI and Medical Interview Satisfaction Scale (MISS)-21 questionnaires after the consultation. RESULTS: In total, 100 consultations were observed (psoriasis n = 50, eczema n = 17, acne n = 13 and others n = 20). In 26% (n = 26), there was no mention of HRQoL issues. In 59% (n = 44), HRQoL discussions were initiated by the clinician. In only 26% (n = 19) of consultations were > or = 3 items on the observer's checklist raised. In all, 57 evaluable DLQI and MISS-21 questionnaires were returned. The mean +/- SD DLQI score was 7.2 +/- 7.0 (n = 18) for patients with whom there was no HRQoL discussion and 10.8 +/- 6.7 (n = 39, P = 0.038) for those with whom HRQoL was discussed. The mean +/- SD MISS-21 score was 108.8 +/- 16.5 (n = 18) for the patients with whom there was no HRQoL discussion and 111.3 +/- 13.6 (n = 39, P = 0.42) for those with whom HRQoL was discussed. The mean +/- SD patient expectation score was 5.5 +/- 1.0 (median 5, range 3-7). There was a positive correlation between the patient expectation and MISS-21 scores (r(s) = 0.815, P < 0.0001). CONCLUSIONS: Despite little extent or depth to HRQoL discussion, HRQoL issues were raised in the majority of inflammatory skin disease consultations. The consultations usually met the patients' expectations and most patients were satisfied.