Japanese cedar pollen as an exacerbation factor in atopic dermatitis: results of atopy patch testing and histological examination

Atopy patch testing with Japanese cedar pollen extract has been used to investigate patients with atopic dermatitis whose condition is exacerbated by contact with Japanese cedar pollen. Comparative atopy patch testing, scratch tests, and assays for total IgE and specific IgE were performed in 74 patients with atopic dermatitis, 5 patients with Japanese cedar pollinosis and 15 control subjects. A skin biopsy was performed on any sites that were positive to Japanese cedar pollen patch test. The results after 48 h of atopy patch testing were compared with the patient's history, skin scratch test and specific IgE. Twenty-two of the 74 patients (30%) had a history of exacerbation every spring after contact with Japanese cedar. Of these patients 68% showed a positive reaction to Japanese cedar pollen extract, as did 21% of patients with atopic dermatitis without a history of exacerbation by Japanese cedar pollen, 20% of patients with Japanese cedar pollinosis without eruption and 7% of control subjects. A histological examination revealed eczematous changes and infiltration of lymphocytes and eosinophils in atopy patch testing positive sites. In conclusion, atopy patch testing with Japanese cedar pollen extract is a useful method for investigating trigger factors for eczematous skin lesions in a subgroup of patients with atopic dermatitis.     

Absorption of hydrocortisone from the skin reservoir in atopic dermatitis

Percutaneous absorption of hydrocortisone was measured in four children and three adults with atopic dermatitis after the application of 1% hydrocortisone cream and again 12 h after the application of a moisturizer containing 80% water and 5% propylene glycol to the same areas. A significant increase in the level of the plasma cortisol was observed after both applications and these levels were still elevated at 24 h. Topically applied hydrocortisone, stored in eczematous skin, could be released from this reservoir by a moisturizer containing propylene glycol.     

The analgesic effect of EMLA cream on facial skin. Quantitative evaluation using argon laser stimulation.

The hypoalgesic effect of EMLA cream (Eutectic Mixture of Local Anesthetics) applied for 5, 15, and 30 min on facial skin was evaluated. Hypoalgesia was assessed by changes in pain thresholds to brief argon laser stimuli 0, 2, 5, 10, 15, 20, 25, 30, 45, and 60 min after removal of EMLA cream. The local cutaneous vascular changes induced by EMLA cream was evaluated by Erythema Index determined by reflectance spectroscopy and by laser Doppler blood flowmetry. A large inter-individual variability in analgesic efficacy was observed. The volunteers could be divided into two groups, one group of 6 persons where EMLA induced analgesia or considerable hypoalgesia, and one group of 4 persons where EMLA had no or only slight hypoalgesic effect. This great variability should be considered when EMLA cream is used for facial application in the clinic. Differences in local blood flow probably contribute to the variability. Application of EMLA cream for 5 and 15 min did not change erythema of the skin, while 30 min of application caused minor blanching.     

Eczematous Skin Reaction from Patch Testing with Aeroallergens in Atopic Children With and Without Atopic Dermatitis

Abstract: To determine whether aeroaltergens could induce eczematous lesions, 30 patients with atopic dermatitis were studied in comparison with 30 patients with respiratory atopy without atopic dermatitis. All patients were between 2 end 14 years of age. Patch testing with five aeroallergens—housedust, mite, cockroach, mold mix, and grass mixwas done on skin that was stripped by 10 applications of adhesive tape. Intradermal tests with the same antigens were done on the forearm. In 27 (90%) children with staple dermatitis, patch testing with aeroallergens Induced eczematous lesions at one or more sites. Mite, cockroach, house dust, mold mix, and grass mix caused reactions In 21 (70%), 21 (70%), 19 (63%), 15 (50%), and 13 (43%) patients, respectively. Three patients had a dermatitis flare at the antecubital and popliteal fossae during testing. Only three (10%) atopic children without atopic dermatitis had eczematous lesions, which was significantly different from children with atopic dermatitis ( P < 10⁻⁵). Intradermai skin tests in both groups were not significantly different This study supports previous reports that aeroallergens play an Important role in causing eczamatous skin lesions.     

A study of the role of house dust mite in atopic dermatitis

Subjects with positive skin-prick tests to house dust mite (HDM) solution, including those with and without atopic dermatitis, participated in a double-blind, controlled study of the role of HDM exposure in the pathogenesis of atopic dermatitis. HDM solution and diluent control were applied daily to mildly eczematous or clinically uninvolved skin of the antecubital or popliteal fossae, without prior abrasion, for 5 days. Responses were assessed by a clinical grading system and by measurement of area of dermatitis; pruritus was recorded on visual analogue scales. The clinical grading system showed that marked or moderate delayed local reactions developed in one third of patients with atopic dermatitis in response to HDM application to both mildly eczematous and clinically uninvolved skin. Relative to control sites, significant increases in area of dermatitis and degree of pruritus were also recorded in response to HDM application to mildly eczematous sites. Application of HDM solution to normal, unabraded skin of prick test positive subjects without a history of dermatitis, produced pruritus and immediate urticarial responses which were not seen at control sites, findings which demonstrate that HDM antigen may be rapidly absorbed in normal skin. Application of vehicle or antigen solution to which subjects were negative on prick testing, produced no significant local reactions. This study provides objective evidence for a role for cutaneous HDM exposure in the pathogenesis of atopic dermatitis.     

Regional variations in analgesic efficacy of EMLA cream. Quantitatively evaluated by argon laser stimulation

The effect of EMLA cream (a eutectic mixture of local analgesics) applied for 30, 60, 90 and 120 min on the forehead, cheek, back, cubital fossa, and dorsum of the hand was studied. Analgesic onset, efficacy and duration were evaluated by sensory and pain thresholds to laser stimulation measured before, and 5, 60, 120, and 180 min after the cream was removed from the skin. Cutaneous blood flow was measured and found to be 4-5 times as high on the face as on the other locations. On the forehead the analgesic efficacy decreased with increased application time. For all other locations, efficacy increased with increasing application time. On the back, onset was rapid and sufficient analgesia could be obtained, but analgesias began to wane immediately after removal of the cream. In the cubital fossa and on the hand, onset was tardy, and efficacy continued to increase for 60 min after cream removal, followed by a slow decline. Blood flow, epidermal and dermal thickness are important factors affecting onset, efficacy and duration of EMLA analgesia.     

EMLA Cream Provides Rapid Pain Relief for the Curettage of Molluscum Contagiosum in Children with Atopic Dermatitis without Causing Serious Application-Site Reactions

Abstract: Twenty-nine children with atopic dermatitis, 4 to 9 years of age, were included in an open study of the analgesic efficacy and the application-site reactions produced by EMLA cream 5% at a maximum dose of 10 g applied for 30 minutes under occlusion prior to the curettage of molluscum contagiosum. Molluscum areas with and without eczema were treated. The overall magnitude of pain was assessed first by the child and then by the physician on a four-step verbal rating scale immediately after completion of the curettage. Prior to the surgical treatment, the application site was examined for local skin reactions. Eighty-three percent of the children rated the pain from the surgical procedure as none or mild, while the physicians rated the pain as none or mild in 86% of the children. The application-site reactions were pallor, redness, and edema. These reactions were transient and required no clinical attention. Their incidence or severity did not differ significantly between areas with and without eczema. In conclusion, EMLA cream 5% applied for 30 minutes under an occlusive dressing provides effective local analgesia without serious application-site reactions for the curettage of mollusca contagiosa in children with atopic dermatitis.     

The morphologic characteristics of dry skin in atopic dermatitis

Uninvolved skin sites in 436 consecutive patients, 6 to 25 years old, with atopic dermatitis were observed during the winter months (from November to February). Ichthyosis vulgaris occurred in 133 patients. Of the 303 remaining patients, only 11 (4%) had generalized dry skin; 191 (63%) exhibited focal areas of dry skin; and 95 (33%) showed only normal-appearing skin. Microscopically, in 41 patients, dry skin associated with atopic dermatitis showed mild eczematous changes. Dry skin coexistent with ichthyosis in patients with atopic dermatitis revealed ichthyotic changes frequently superimposed on eczematous changes. We suggest that in patients with atopic dermatitis the presence of dry skin may reflect mild eczematous changes, a manifestation of concomitant ichthyosis, or a complex of both of these changes.     

Staphylococcus aureus in Atopic Dermatitis and in Nonatopic Dermatitis

Skin colonization with Staphylococcus aureus (S. aureus) was examined in 30 patients with atopic dermatitis (AD), in 25 patients with nonatopic eczema (NAE) and in 30 individuals as healthy controls (HC). Bacteria growth was examined in aerobic cultures and the population densities per dish were estimated; S. aureus colonization was found in the eczematous skin of 24 of 30 (80%) AD patients and in 13 of 25 (52%) NAE patients (NS, p greater than 0.1). In nonaffected skin S. aureus colonization was found in 19 of 30 (63%) of all AD patients compared with 6 of 25 (24%) in NAE patients and 1 of 30 (3%) in HC, respectively (p less than 0.05). In nonaffected skin, coagulase negative strains of staphylococcus were found in 25 of 30 (84%) controls and in 18 of 25 (72%) NAE patients compared with 12 of 30 (40%) patients with AD. It seems that colonization with S. aureus is not a characteristic feature for atopic dermatitis but is a frequent event in damaged skin; significantly elevated values were also observed in nonatopic eczema. The degree of colonization may depend on the severity and duration of the eczematous lesions.     

An efficient new formulation of fusidic acid and betamethasone 17-valerate (fucicort lipid cream) for treatment of clinically infected atopic dermatitis

To relieve the dryness of atopic dermatitis skin, a lipid formulation of fusidic acid and betamethasone 17-valerate (Fucicort Lipid cream) was developed as an additional treatment option to the established Fucicort cream. The two formulations were compared in patients with clinically infected atopic dermatitis. A total of 629 patients were randomized to twice daily double-blind treatment for 2 weeks with either Fucicort Lipid cream, Fucicort cream, or the new lipid cream vehicle. Clinical assessment was based on a Total Severity Score of the eczematous lesions. Bacteriological samples were taken at inclusion and at subsequent visit(s) if clinically infected lesions persisted. At the end of treatment, the mean reduction in Total Severity score was 82.9% in the lipid cream group, 82.7% in the cream group, and 33.0% in the vehicle group. The percentage of patients with a successful bacteriological response was 89.7%, 89.6% and 25.0%, respectively. Thus, the clinical and anti-bacterial effect of the lipid cream was found to be similar to that of the established cream formulation, and significantly better than that of the vehicle. The new lipid formulation, therefore, offers an efficient, safe and well-tolerated alternative for the short-term treatment of clinically infected atopic dermatitis.     

Purpura after application of EMLA cream in two children

The eutectic mixture of local anesthetic cream, a 1 : 1 mixture of prilocaine and lidocaine, 2.5% each, is frequently used in pediatric and dermatologic practice to obtain local anesthesia. Side effects include transient skin blanching, erythema, urticaria, allergic contact dermatitis, irritant contact dermatitis, hyperpigmentation, and purpura. We report two children with a purpuric reaction after application of this mixture cream. Purpura after application of this anesthetic cream is a rare nonallergic reaction and only 17 occurrences have been reported, to our knowledge, in the literature. Patch tests could not be performed in our two patients because of lack of parental consent but we suggest that the purpuric reactions were most probably of toxic origin. The pathogenesis of purpura after application of eutectic mixture of local anesthetics cream, which resolves within 2 weeks without dermatologic sequelae and without any specific therapy, is complex. The lesions are probably caused by the direct effect of the cream components on the vessels but many other factors, such as atopic dermatitis, prematurity, subjective predisposition to purpura, trauma, and thrombocytopenia may play important pathogenetic roles.     

Skin susceptibility of atopic individuals

The relevance of the irritant skin reaction of individuals with an atopic history (atopic dermatitis, rhinoconjunctivitis or atopic asthma) to sodium lauryl sulfate (SLS), a widely used irritant, is still controversial. The aim of this study was to evaluate transepidermal water loss (TEWL) as an indicator of stratum corneum integrity, before and after SLS patch testing, in various groups of atopic individuals with and without atopic dermatitis. 95 volunteers were divided into 4 groups: (1) individuals with active atopic dermatitis; (2) individuals with a history of atopic dermatitis but without active skin lesions; (3) individuals with rhinoconjunctivitis or atopic asthma without any symptoms at the time of testing; (4) healthy individuals serving as controls. The volunteers were patch-tested at the unaffected volar side of the forearm with aqueous SLS 0.5% for 48 h. TEWL was measured before application and after removal of the patch. Individuals with active atopic dermatitis showed a significantly higher TEWL value after SLS and a tendency to a higher basal TEWL as compared to the 3 other groups. There were no significant differences in TEWL between individuals who were classified as atopic but without active dermatitis, individuals with rhinoconjunctivitis or atopic asthma and healthy controls, either at the basal or at the post-SLS measurement. Enhanced skin susceptibility is only present in individuals with active dermatitis. The skin susceptibility of atopic individuals might therefore be increased as soon as the skin becomes eczematous, suggesting a reduced epidermal integrity probably caused by the endogenous atopy and/or respiratory allergens. When interpreting the atopy score in relation to skin susceptibility, the actual condition of the skin should hence be taken into consideration.     

Periorbital dermatitis: Causes,differential diagnoses and therapy

Periorbital dermatitis is common and frequently difficult to treat. Patients with periorbital dermatitis often suffer severely because their disease is in such a visible location. Because of the variety of clinical appearance, the differential diagnostic considerations are often difficult. We examined the causes of periorbital dermatitis and compared the data of 88 patients from the Department of Dermatology, University Hospital Erlangen to those of the German IVDK (Information Network of the Departments of Dermatology). Between 1999 and 2004, predominant causes of periorbital dermatitis were allergic contact dermatitis (Erlangen 44 %, IVDK 32 %), atopic eczema (Erlangen 25 %, IVDK 14 %), airborne contact dermatitis (Erlangen 10 %, IVDK 2 %) and irritant contact dermatitis (Erlangen 9 %, IVDK 8 %). Less frequent causes for secondary eczematous periocular skin lesions were periorbital rosacea, allergic conjunctivitis or psoriasis vulgaris. Female gender, atopic skin diathesis and age of 40 years and older were identified as risk factors for periocular dermatitis. Common elicitors of periorbital allergic contact dermatitis were leave‐on cosmetic products (face cream, eye shadow) and eye drops with the usual allergens being fragrances, preservatives and drugs. Exact identification of relevant contact allergens and allergen elimination are essential for successful treatment. Calcineurin inhibitors are the first‐line therapy for facial atopic eczema. They may be also effective in periocular eczematous lesions of other origins although they are not approved for such use.     

Pharmacokinetics of topical hydrocortisone at plasma level after applications once or twice daily in patients with widespread dermatitis

Percutaneous absorption of hydrocortisone was measured by determining plasma cortisol during dexamethasone suppression in 26 patients with widespread atopic dermatitis. The first and second days of treatment with applications of 1% hydrocortisone cream twice daily were studied separately in two groups of six patients. Plasma cortisol levels rose after the first two applications, reaching a maximum in 24 h. The levels then began to fall, indicating possible restoration of the skin barrier. In two other groups of seven patients, the second application was made with a cream base alone. Two types of cream base were studied, one with 60% water and the other with 30% water. With the base containing 10% water, a brief increment was seen after 2 h. On the basis of this pharmacokinetic study, treatment of acute dermatitis could be intensified by applying hydrocortisone cream twice a day on the first day, but from the second day onward one application a day seems to be sufficient.     

Spotlight on topical pimecrolimus in atopic dermatitis

Pimecrolimus (SDZ ASM 981), an ascomycin derivative, is a nonsteroid, has anti-inflammatory activity, and has demonstrated efficacy in reducing symptoms of atopic dermatitis in adult and pediatric patients when applied topically. Compared with vehicle, topical pimecrolimus 1.0% cream was significantly more effective at reducing symptoms of atopic dermatitis, as measured by the Eczema Area and Severity Index (EASI), in infants aged 3 to 23 months, children aged 2 to 17 years, and adults. The median reductions from baseline in the total EASI score in adults after treatment with pimecrolimus 1.0% or corresponding vehicle twice daily for 3 weeks were 47 and 0%, respectively. In infants and children, treatment with pimecrolimus 1.0% twice daily for 6 weeks resulted in significant decreases in mean EASI scores compared with vehicle. The severity of pruritus was significantly reduced in patients of all age groups after topical treatment with pimecrolimus 1.0% cream. Compared with vehicle, the incidence of eczematous flares was also reduced by intermittent long-term use of topical pimecrolimus 1.0% in adults, children and infants. Sixty-one percent of children treated with pimecrolimus for 1 year completed the first 6 months of treatment without experiencing a flare, compared with 35% of patients who received vehicle. Furthermore, the use of topical corticosteroids for the treatment of uncontrolled flares in adults, children and infants was lower in the pimecrolimus groups than in the vehicle groups. Topical pimecrolimus 1.0% cream is well tolerated in atopic dermatitis patients of all age groups. There were no clinically relevant systemic adverse events reported from any of the studies in patients with atopic dermatitis. The most frequently reported adverse events pertained to application site reactions, such as burning and a feeling of warmth. In conclusion, topical pimecrolimus 1.0% cream has shown efficacy in the treatment of mild to moderate atopic dermatitis in infants, children and adults. Although tolerability data concerning infants and children have not yet been published in full, the drug appears to be well tolerated in all age groups, and there have been no reports of clinically relevant systemic adverse events. Furthermore, pimecrolimus has shown no potential for skin atrophy, a problem commonly associated with treatment with topical corticosteroids. Topical pimecrolimus 1.0% provides a promising and well tolerated treatment option in the management of infants, children and adults with mild to moderate atopic dermatitis.     

Effect of EMLA cream on skin thickness and subcutaneous venous diameter. A randomized, placebo-controlled study in children

EMLA cream, which is used to provide analgesia prior to venepuncture, induces a skin-blanching reaction. This reaction may be caused by both skin hydration and vasoconstriction. Twenty healthy children with veins suitable for venepuncture on the dorsa of the hands or at the antecubital fossae had applied either EMLA cream or placebo cream under occlusion for 60-70 min in a randomized, double-blind, cross-over study. An ultrasound examination of the skin was conducted. The mean percentage change in vein diameter after removal of EMLA cream was not significant whereas, 15 min after EMLA cream removal, the decrease in the initial vein diameter (13.5%) was significant (p<0.01). The mean percent increase in skin thickness after the removal of EMLA cream was also significant (19.3%; p=0.01). The changes in vein diameter and skin thickness due to the application of EMLA cream do not seem to be of clinical importance to vein cannulation.     

Effect of the lactic acid bacterium Streptococcus thermophilus on stratum corneum ceramide levels and signs and symptoms of atopic dermatitis patients

A reduced amount of total ceramides could be responsible for functional abnormalities of the skin of atopic dermatitis (AD) patients. The ability of an experimental cream containing sonicated Streptococcus thermophilus to increase skin ceramide levels in healthy subjects has been previously reported. The aim of the present work was to investigate the effects of the topical administration of a S. thermophilus-containing cream on ceramide levels of stratum corneum from AD patients. A 2-week application of the cream, containing a sonicated preparation of the lactic acid bacterium S. thermophilus, in the forearm skin of 11 patients led to a significant and relevant increase of skin ceramide amounts, which could have resulted from the sphingomyelin hydrolysis through the bacterial sphingomyelinase. Moreover, in all patients the topical application of our experimental cream also resulted in the improvement of the signs and symptoms characteristic of AD skin (i.e. erythema, scaling, pruritus).     

Quantitative Assessment of Combination Bathing and Moisturizing Regimens on Skin Hydration in Atopic Dermatitis

Abstract:  Standard recommendations for skin care for patients with atopic dermatitis stress the importance of skin hydration and the application of moisturizers. However, objective data to guide recommendations regarding the optimal practice methods of bathing and emollient application are scarce. This study quantified cutaneous hydration status after various combination bathing and moisturizing regimens. Four bathing/moisturizer regimens were evaluated in 10 subjects, five pediatric subjects with atopic dermatitis and five subjects with healthy skin. The regimens consisted of bathing alone without emollient application, bathing and immediate emollient application, bathing and delayed application, and emollient application alone. Each regimen was evaluated in all subjects, utilizing a crossover design. Skin hydration was assessed with standard capacitance measurements. In atopic dermatitis subjects, emollient alone yielded a significantly (p < 0.05) greater mean hydration over 90 minutes (206.2% baseline hydration) than bathing with immediate emollient (141.6%), bathing and delayed emollient (141%), and bathing alone (91.4%). The combination bathing and emollient application regimens demonstrated hydration values at 90 minutes not significantly greater than baseline. Atopic dermatitis subjects had a decreased mean hydration benefit compared with normal skin subjects. Bathing without moisturizer may compromise skin hydration. Bathing followed by moisturizer application provides modest hydration benefits, though less than that of simply applying moisturizer alone.     

Skin colonization of Staphylococcus aureus in atopic dermatitis patients seen at the National Skin Centre, Singapore

Objective This prospective study sought to determine the bacterial colonization rates on eczematous and non-eczematous skin and nasal mucosa of patients with atopic dermatitis Patients Patients, of any age, presenting with atopic dermatitis at the subsidized clinic of the National Skin Centre, Singapore, between 23 August 1996 and 14 September 1996, were included in the study. Results Thirty-three patients with atopic dermatitis were seen at the outpatient clinic during the study period. Staphylococcus aureus was isolated in 69.7% of the eczematous lesions and in 42.4% of non-eczematous skin of patients with atopic dermatitis. S. aureus was isolated in 53% of patients with mild dermatitis, and in 100% with moderate and severe dermatitis. The nasal carriage rate of S. aureus was higher in atopic dermatitis patients (51.5%) than in non-atopies (35%) (not significant). S. aureus was isolated in 42% of noneczematous skin in atopies compared with only 5% in the control group (p= 0.003). In patients with atopic dermatitis, all S. aureus isolated was sensitive to cloxacillin, cephalexin, clindamycin, and co-trimoxazole; 92% was sensitive to erythromycin, but only 13% was sensitive to penicillin and ampicillin. In the control group, all S. aureus isolated was sensitive to cloxacillin, cephalexin, erythromycin, clindamycin, and co-trimoxazole, but only 13% was sensitive to penicillin and ampicillin, and 87% to tetracycline. Conclusions This study confirmed that the skin of patients with atopic dermatitis was more frequently colonized with S. aureus than that of non-atopics. The more severe the dermatitis, the higher the rate of colonization. S. aureus is also more often present in non-eczematous skin of atopics than of non-atopics. There is also a higher percentage of S. aureus nasal carriage in patient's with atopic dermatitis than in non-atopics. Hence antibiotics may have a role in the treatment of atopic dermatitis. Because 87% of S. aureus is resistant to penicillin and ampicillin, antibiotics such as cloxacillin and cephalexin should be used to eradicate S. aureus in the skin of atopic dermatitis individuals.     

Assessment of the efficacy of topical anesthetics using the tactile spatial resolution method

The aim of this study was to compare the purported advantages of 4% tetracaine gel (Ametop gel) and 4% liposomal lidocaine gel (LMX4 gel) with EMLA cream (eutectic mixture of 2.5% lidocaine and 2.5% prilocaine) using an objective and repeatable method. Ametop gel and LMX4 gel were administered under occlusion for 30 min and compared to EMLA cream applied for 30 and 60 min on the intact upper lip skin of 15 volunteers each. The efficacy of the anesthetics was assessed by the spatial resolution method. Measurements were conducted just after removal of the products from the skin, then 20, 40 and 60 min later. Each of the formulations, except for EMLA cream applied for 30 min, decreased tactile spatial discrimination thresholds significantly just after removal from the skin when compared to the output levels (p<0.05). Ametop gel kept significantly good skin anesthesia also 20, 40 and 60 min later (p<0.05). The efficacy of LMX4 gel and EMLA(60) cream decreased to the initial levels after 40-min application. Ametop gel anesthetized the skin in a highly homogeneous manner providing similar effect in most subjects, which was not the case in the EMLA and LMX4 groups. In conclusion, LMX4 gel and Ametop gel appeared to be faster acting than EMLA cream. Our results showed the 30-min application of LMX4 and Ametop gel under occlusion to be equivalent to 60-min administration of EMLA cream. Ametop gel, in contrast to the rest, provides very good anesthesia for up to 60 min. The application of EMLA cream under occlusion over only 30 min cannot guarantee appropriate effects.