Strategies for using topical corticosteroids in children and adults with eczema

Canadian Consensus Guidelines for the Management of Atopic Dermatitis with Topical Therapies

INTRODUCTION

Atopic dermatitis (AD) is a highly prevalent disease in Canada with significant patient burden. Treatment guidance for topical therapy (the mainstay of AD management), with particular consideration of emerging treatments, may further improve patient care. Here, we aim to provide healthcare professionals with AD treatment recommendations from the perspective of 10 Canadian dermatologists with expertise in managing AD.

METHODS

The panel of dermatologists conducted a systematic literature review and leveraged their clinical experience to develop generally accepted principles, consensus statements, and a treatment algorithm using an iterative consensus process.

RESULTS

The panel collectively developed six generally accepted principles, 10 consensus statements, and a treatment algorithm. The guidance notes that assessment of disease severity should encompass both physician-rated measures and patient-reported outcomes. Disease education, lifestyle-based strategies (e.g., trigger avoidance), and supportive measures (e.g., moisturizers) can help reduce signs and symptoms of AD. Choice of therapy should consider disease-, patient-, and treatment-related factors. Although topical corticosteroids (TCS) are often used as first-line treatment in AD, they should be limited to intermittent short-term use. Noncorticosteroid topical therapies (e.g., topical calcineurin inhibitors; topical phosphodiesterase-4 inhibitors; and topical Janus kinase inhibitors) can be used for widespread involvement of AD according to approved use. Once treatment goals are achieved, noncorticosteroid topical maintenance therapy should continue to prevent flares and reduce the need for TCS.

CONCLUSION

Guidance reflecting the benefits and limitations of topical AD treatments in conjunction with patient understanding of treatment goals supports robust shared decision-making in the management of AD.

Changes and clinical significance of serum vitamin A, 25-(OH)D3, TG2, IL-4 and IL-13 levels in children with eczema

The study aims to examine fluctuations in the levels of serum vitamin A, 25-(OH)D3, TG2, IL-4, and IL-13 in pediatric eczema patients and explore how these changes relate to the severity of the condition. This retrospective study analyzed the clinical data of 159 children with eczema admitted to the hospital from May 2023 to October 2024 as the experimental group. The patients were divided into groups according to the severity of the disease: mild group(≤ 25 points, n = 45), moderate group(25-50 points, n = 72) and severe group(>50 points, n = 42). Collect each group of serum serum vitamin A, 25- (OH) D3, TG2, IL-4, and IL-13 levels and analyze them. The improvements in serum vitamin A, 25-(OH)D3, TG2, IL-4, and IL-13 levels in each group of children after 3 months of treatment were further analyzed. As eczema severity escalated, there was a progressive decline in Vit A and 25-(OH)D3 levels, while TG2, IL-4, and IL-13 levels correspondingly rose (P < 0.05). Pearson correlation analysis revealed a significant negative correlation between serum Vit A and 25-(OH)D3 levels and the SCORAD scores in children with eczema (P < 0.05). Conversely, TG2, IL-4, and IL-13 levels exhibited positive correlations with the SCORAD scores (P < 0.05). 25-(OH)D3 had the highest AUC for diagnosing the severity of eczema, which was significantly better than serum vitamin A, TG2, IL-4, and IL - 13 ( all P < 0.05 ). After 3 months of treatment, the serum levels of vitamin A, 25-(OH)D3, TG2, IL-4, and IL-13 in all groups were significantly improved (P < 0.05). Vit A, 25-(OH)D3, TG2, IL-4, and IL-13 correlate with the severity of eczema symptoms. The severity of the disease can be evaluated clinically according to the changes in these serum indicators, and the clinical application value is high.

Neutrophils in Atopic Dermatitis

Neutrophils have a critical role in inflammation. Recent studies have identified their distinctive presence in certain types of atopic dermatitis (AD), yet their exact function remains unclear. This review aims to compile studies elucidating the role of neutrophils in AD pathophysiology. Proteins released by neutrophils, including myeloperoxidase, elastase, and lipocalin, contribute to pruritus progression in AD. Neutrophilic oxidative stress and the formation of neutrophil extracellular traps may further worsen AD. Elevated neutrophil elastase and high-mobility group box 1 protein expression in AD patients' skin exacerbates epidermal barrier defects. Neutrophil-mast cell interactions in allergic inflammation steer the immunological response toward Th2 imbalance and activate the Th17 pathway, particularly in response to allergens or infections linked to AD. Notably, drugs alleviating pruritic symptoms in AD inhibit neutrophilic inflammation. In conclusion, these findings underscore that neutrophils may be therapeutic targets for AD symptoms, emphasizing their inclusion in AD treatment strategies.

Managing Childhood and Adolescent Atopic Dermatitis in Primary Care: A US Expert Group Consensus

Objective

This expert-led consensus aims to provide primary care providers (PCPs) with recommendations for the care of atopic dermatitis (AD) in patients aged <18 years. The first point of contact for diagnosis and management of AD is often a PCP, and appropriate, coordinated care between PCPs and AD specialists is essential to optimizing care.

Study design

A systematic literature review was conducted followed by expert-led development of 25 consensus management recommendations relevant to 4 key themes in AD management: defining control, current and emerging treatments, referral care pathways, and patient-caregiver experience. Consensus was achieved using a modified Delphi process. For each statement, consensus for inclusion was considered achieved if ≥75% of the experts voted within the 7-9 range on a 9-point scale.

Results

Consensus was reached on 24 of 25 statements. Nine statements reached the score of 7-9 by 100% of the experts. Of these, 4 were pertinent to topical therapy for the management of childhood and adolescent AD in primary care: the need for anti-inflammatory medication to achieve clear or almost clear skin; the need to tailor decisions about therapy to the individual patient or family; the importance of coordinated management between PCPs and specialists as part of effective treatment approaches; and the importance of patient and/or caregiver engagement in shared decision-making.

Conclusions

It is hoped that these recommendations will guide the management of pediatric AD in primary care settings, facilitate coordinated care between PCPs and AD specialists, and improve outcomes for patients and their families.

Systems Biology Methods via Genome-Wide RNA Sequences to Investigate Pathogenic Mechanisms for Identifying Biomarkers and Constructing a DNN-Based Drug-Target Interaction Model to Predict Potential Molecular Drugs for Treating Atopic Dermatitis

This study aimed to construct genome-wide genetic and epigenetic networks (GWGENs) of atopic dermatitis (AD) and healthy controls through systems biology methods based on genome-wide microarray data. Subsequently, the core GWGENs of AD and healthy controls were extracted from their real GWGENs by the principal network projection (PNP) method for Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway annotation. Then, we identified the abnormal signaling pathways by comparing the core signaling pathways of AD and healthy controls to investigate the pathogenesis of AD. Then, IL-1β, GATA3, Akt, and NF-κB were selected as biomarkers for their important roles in the abnormal regulation of downstream genes, leading to cellular dysfunctions in AD patients. Next, a deep neural network (DNN)-based drug-target interaction (DTI) model was pre-trained on DTI databases to predict molecular drugs that interact with these biomarkers. Finally, we screened the candidate molecular drugs based on drug toxicity, sensitivity, and regulatory ability as drug design specifications to select potential molecular drugs for these biomarkers to treat AD, including metformin, allantoin, and U-0126, which have shown potential for therapeutic treatment by regulating abnormal immune responses and restoring the pathogenic signaling pathways of AD.

Genomic and functional divergence of Staphylococcus aureus strains from atopic dermatitis patients and healthy individuals: insights from global and local scales

Atopic dermatitis (AD) is the most common chronic inflammatory skin disease worldwide and is characterized by a complex interplay with skin microbiota, with Staphylococcus aureus often abnormally more abundant in AD patients than in healthy individuals (HE). S. aureus harbors diverse strains with varied genetic compositions and functionalities, which exhibit differential connections with the severity of AD. However, the differences in S. aureus strains between AD and HE remain unclear, with most variations seen at a specific geographic level, implying spontaneous adaptations rather than systematic distinctions. This study presents genomic and functional differences between these S. aureus strains from AD and HE on both global and local levels. We observed reduced gene content diversity but increased functional variation in the global AD-associated strains. Two additional AD-dominant clusters emerged, with Cluster 1 enriched in transposases and Cluster 2 showcasing genes linked to adaptability and antibiotic resistance. Particularly, robust evidence illustrates that the lantibiotic operon of S. aureus, involved in the biosynthesis of lantibiotics, was acquired via horizontal gene transfer from environmental bacteria. Comparisons of the gene abundance profiles in functional categories also indicate limited zoonotic potential between human and animal isolates. Local analysis mirrored global gene diversity but showed distinct functional variations between AD and HE strains. Overall, this research provides foundational insights into the genomic evolution, adaptability, and antibiotic resistance of S. aureus, with significant implications for clinical microbiology.IMPORTANCEOur study uncovers significant genomic variations in Staphylococcus aureus strains associated with atopic dermatitis. We observed adaptive evolution tailored to the disease microenvironment, characterized by a smaller pan-genome than strains from healthy skin both on the global and local levels. Key functional categories driving strain diversification include "replication and repair" and "transporters," with transposases being pivotal. Interestingly, the local strains predominantly featured metal-related genes, whereas global ones emphasized antimicrobial resistances, signifying scale-dependent diversification nuances. We also pinpointed horizontal gene transfer events, indicating interactions between human-associated and environmental bacteria. These insights expand our comprehension of S. aureus's genetic adaptation in atopic dermatitis, yielding valuable implications for clinical approaches.

Efficacy and feasibility analysis of compound fluocinolone acetonide cream combined with guaiazulene in the treatment of neurodermatitis

OBJECTIVE

To evaluate the effectiveness and feasibility of combined treatment with compound fluocinolone acetonide cream and guaiazulene in patients with neurodermatitis.

METHODS

A prospective study was conducted on 92 outpatient patients diagnosed with neurodermatitis at our dermatology department from January 2022 to December 2023. Using a random number table, these patients were evenly divided into a control group and an experimental group, with 46 individuals in each group. The control group received treatment with compound fluocinolone acetonide alone, while the experimental group additionally received oral guaiazulene tablets. Clinical symptom and sign scores, Visual Analog Scale (VAS) scores, skin lesion itching scores, comprehensive efficacy, treatment onset time, adverse reactions, and quality of life were monitored, recorded, and compared.

RESULTS

In the 2-week treatment period, patients in the experimental group showed significant improvement in skin symptoms and signs, with scores significantly lower than those in the control group (P < 0.05). After treatment, VAS and skin lesion itching scores in the experimental group were significantly reduced (P < 0.05), demonstrating a more pronounced therapeutic advantage compared to the control group (P < 0.05). Although the effective rate in the experimental group was as high as 86.96%, there was no significant advantage compared to the control group, and the difference in treatment efficacy was not significant (P > 0.05). The treatment onset time in the experimental group was significantly shorter than that in the control group (P < 0.05), and the incidence of adverse reactions was lower (P < 0.05). The quality of life in the experimental group improved significantly after treatment, with DLQI scores lower than those in the control group (P < 0.05).

CONCLUSION

Combined treatment with compound fluocinolone acetonide cream and guaiazulene demonstrates excellent efficacy and feasibility in the management of neurodermatitis. Compared to standard treatment alone, it yields superior clinical outcomes.

Short-term effect of a moderate-potency topical corticosteroid on epidermal biophysical parameters in patients with mild-to-moderate atopic dermatitis: A randomised controlled study

Introduction

Skin barrier dysfunction is an important component of atopic dermatitis (AD) pathophysiology. Topical corticosteroids (TCSs) are the mainstay therapy, but steroid phobia is emerging due to potential side effects. We aimed to determine the short-term effect of clobetasone butyrate on patients with AD.

Methods

This investigator-blinded, randomised, moisturiser-controlled study evaluated patients with stable mild-to-moderate AD. Clobetasone butyrate ointment plus aqueous cream (Aq) or Aq alone was applied on randomised sites twice daily for 6 weeks. The itch score, modified Eczema Area and Severity Index (M-EASI) and epidermal biophysical parameters were assessed at baseline and 1 h, 3 h, 2 weeks and 6 weeks after application.

Results

Sixteen patients, among whom 14 (87.5%) were women and two (12.5%) were men, participated in the study. There were no significant differences in pH, transepidermal water loss (TEWL) and hydration between TCS + Aq and Aq from 1 h to 6 weeks. A non-significant trend of pH increment was observed with TCS + Aq from baseline to 6 weeks. TEWL and hydration improved at 6 weeks for both treatment arms. The difference in TEWL from baseline was significant with Aq (P=0.01). The M-EASI at 6 weeks was comparable between the two arms. TCS + Aq improved itch and erythema better than Aq (P=0.02). No cutaneous adverse effects were observed at both sites.

Conclusion

Short-term application of clobetasone butyrate with Aq is safe with no significant changes in epidermal biophysical parameters while controlling the symptoms and signs of eczema faster than Aq alone.

Topical anti-inflammatory treatments for eczema: network meta-analysis

BACKGROUND

Eczema (atopic dermatitis) is the most burdensome skin condition worldwide and cannot currently be prevented or cured. Topical anti-inflammatory treatments are used to control eczema symptoms, but there is uncertainty about the relative effectiveness and safety of different topical anti-inflammatory treatments.

OBJECTIVES

To compare and rank the efficacy and safety of topical anti-inflammatory treatments for people with eczema using a network meta-analysis.

SEARCH METHODS

We searched the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase and trial registries on 29 June 2023, and checked the reference lists of included studies.

SELECTION CRITERIA

We included within-participant or between-participant randomised controlled trials (RCTs) in people of any age with eczema of any severity, but excluded trials in clinically infected eczema, seborrhoeic eczema, contact eczema, or hand eczema. We included topical anti-inflammatory treatments used for at least one week, compared with another anti-inflammatory treatment, no treatment, or vehicle/placebo. Vehicle is a 'carrier system' for an active pharmaceutical substance, which may also be used on its own as an emollient for dry skin. We excluded trials of topical antibiotics used alone, complementary therapies, emollients used alone, phototherapy, wet wraps, and systemic treatments.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Primary outcomes were patient-reported eczema symptoms, clinician-reported eczema signs and investigator global assessment. Secondary outcomes were health-related quality of life, long-term control of eczema, withdrawal from treatment/study, and local adverse effects (application-site reactions, pigmentation changes and skin thinning/atrophy were identified as important concerns through patient and public involvement). We used CINeMA to quantify our confidence in the evidence for each outcome.

MAIN RESULTS

We included 291 studies involving 45,846 participants with the full spectrum of eczema severity, mainly conducted in high-income countries in secondary care settings. Most studies included adults, with only 31 studies limited to children aged < 12 years. Studies usually included male and female participants, multiple ethnic groups but predominantly white populations. Most studies were industry-funded (68%) or did not report their funding sources/details. Treatment duration and trial participation were a median of 21 and 28 days (ranging from 7 days to 5 years), respectively. Interventions used were topical corticosteroids (TCS) (172), topical calcineurin inhibitors (TCI) (134), phosphodiesterase-4 (PDE-4) inhibitors (55), janus kinase (JAK) inhibitors (30), aryl hydrocarbon receptor activators (10), or other topical agents (21). Comparators included vehicle (170) or other anti-inflammatory treatments. The risk of bias was high in 242 of the 272 (89.0%) trials contributing to data analyses, most commonly due to concerns about selective reporting. Network meta-analysis (NMA) was only possible for short-term outcomes. Patient-reported symptoms NMA of 40 trials (6482 participants) reporting patient-reported symptoms as a binary outcome ranked tacrolimus 0.1% (OR 6.27, 95% CI 1.19 to 32.98), potent TCS (OR 5.99, 95% CI 2.83 to 12.69), and ruxolitinib 1.5% (OR 5.64, 95% CI 1.26 to 25.25) as the most effective, all with low confidence. Mild TCS, roflumilast 0.15%, and crisaborole 2% were the least effective. Class-level sensitivity analysis found potent/very potent TCS had similar effectiveness to potent TCI and was more effective than mild TCI and PDE-4 inhibitors. NMA of 29 trials (3839 participants) reporting patient-reported symptoms as a continuous outcome ranked very potent TCS (SMD -1.99, 95% CI -3.25 to -0.73; low confidence) and tacrolimus 0.03% (SMD -1.57, 95% CI -2.42 to -0.72; moderate confidence) the highest. Direct information for tacrolimus 0.03% was based on one trial of 60 participants at high risk of bias. Roflumilast 0.15%, delgocitinib 0.25% or 0.5%, and tapinarof 1% were the least effective. Class-level sensitivity analysis found potent/very potent TCS had similar effectiveness to potent TCI and JAK inhibitors and mild/moderate TCS was less effective than mild TCI. A further 50 trials (9636 participants) reported patient-reported symptoms as a continuous outcome but could not be included in NMA. Clinician-reported signs NMA of 32 trials (4121 participants) reported clinician signs as a binary outcome and ranked potent TCS (OR 8.15, 95% CI 4.99, 13.57), tacrolimus 0.1% (OR 8.06, 95% CI 3.30, 19.67), ruxolitinib 1.5% (OR 7.72, 95% CI 4.92, 12.10), and delgocitinib 0.5% (OR 7.61, 95% CI 3.72, 15.58) as most effective, all with moderate confidence. Mild TCS, roflumilast 0.15%, crisaborole 2%, and tapinarof 1% were the least effective. Class-level sensitivity analysis found potent/very potent TCS more effective than potent TCI, mild TCI, JAK inhibitors, PDE-4 inhibitors; and mild TCS and PDE-4 inhibitors had similar effectiveness. NMA of 49 trials (5261 participants) reported clinician signs as a continuous outcome and ranked tacrolimus 0.03% (SMD -2.69, 95% CI -3.36, -2.02) and very potent TCS (SMD -1.87, 95% CI -2.69, -1.05) as most effective, both with moderate confidence; roflumilast 0.15%, difamilast 0.3% and tapinarof 1% were ranked as least effective. Direct information for tacrolimus 0.03% was based on one trial in 60 participants with a high risk of bias. For some sensitivity analyses, potent TCS, tacrolimus 0.1%, ruxolitinib 1.5%, delgocitinib 0.5% and delgocitinib 0.25% became some of the most effective treatments. Class-level analysis found potent/very potent TCS had similar effectiveness to potent TCI and JAK inhibitors, and moderate/mild TCS was more effective than mild TCI. A further 100 trials (22,814 participants) reported clinician signs as a continuous outcome but could not be included in NMA. Investigator Global Assessment NMA of 140 trials (23,383 participants) reported IGA as a binary outcome and ranked ruxolitinib 1.5% (OR 9.34, 95% CI 4.8, 18.18), delgocitinib 0.5% (OR 10.08, 95% CI 2.65, 38.37), delgocitinib 0.25% (OR 6.87, 95% CI 1.79, 26.33), very potent TCS (OR 8.34, 95% CI 4.73, 14.67), potent TCS (OR 5.00, 95% CI 3.80, 6.58), and tacrolimus 0.1% (OR 5.06, 95% CI 3.59, 7.13) as most effective, all with moderate confidence. Mild TCS, crisaborole 2%, pimecrolimus 1%, roflumilast 0.15%, difamilast 0.3% and 1%, and tacrolimus 0.03% were the least effective. In a sensitivity analysis of low risk of bias information (12 trials, 1639 participants), potent TCS, delgocitinib 0.5% and delgocitinib 0.25% were most effective, and pimecrolimus 1%, roflumilast 0.15%, difamilast 1% and difamilast 0.3% least effective. Class-level sensitivity analysis found potent/very potent TCS had similar effectiveness to potent TCI and JAK inhibitors and were more effective than PDE-4 inhibitors; mild/moderate TCS were less effective than potent TCI and had similar effectiveness to mild TCI. Longer-term outcomes over 6 to 12 months showed a possible increase in effectiveness for pimecrolimus 1% versus vehicle (4 trials, 2218 participants) in a pairwise meta-analysis, and greater treatment success with mild/moderate TCS than pimecrolimus 1% (based on 1 trial of 2045 participants). Local adverse effects NMA of 83 trials (18,992 participants, 2424 events) reporting application-site reactions ranked tacrolimus 0.1% (OR 2.2, 95% CI 1.53, 3.17; moderate confidence), crisaborole 2% (OR 2.12, 95% CI 1.18, 3.81; high confidence), tacrolimus 0.03% (OR 1.51, 95%CI 1.10, 2.09; low confidence), and pimecrolimus 1% (OR 1.44, 95% CI 1.01, 2.04; low confidence) as most likely to cause site reactions. Very potent, potent, moderate, and mild TCS were least likely to cause site reactions. NMA of eight trials (1786 participants, 3 events) reporting pigmentation changes found no evidence for increased pigmentation changes with TCS and crisaborole 2%, with low confidence for mild, moderate or potent TCS and moderate confidence for crisaborole 2%. NMA of 25 trials (3691 participants, 36 events) reporting skin thinning found no evidence for increased skin thinning with short-term (median 3 weeks, range 1-16 weeks) use of mild TCS (OR 0.72, 95% CI 0.12, 4.31), moderate TCS (OR 0.91, 95% CI 0.16, 5.33), potent TCS (OR 0.96, 95% CI 0.21, 4.43) or very potent TCS (OR 0.88, 95% CI 0.31, 2.49), all with low confidence. Longer-term outcomes over 6 to 60 months showed increased skin thinning with mild to potent TCS versus TCI (3 trials, 4069 participants, 6 events with TCS).

AUTHORS' CONCLUSIONS

Potent TCS, JAK inhibitors and tacrolimus 0.1% were consistently ranked as amongst the most effective topical anti-inflammatory treatments for eczema and PDE-4 inhibitors as amongst the least effective. Mild TCS and tapinarof 1% were ranked amongst the least effective treatments in three of five efficacy networks. TCI and crisaborole 2% were ranked most likely to cause local application-site reactions and TCS least likely. We found no evidence for increased skin thinning with short-term TCS but an increase with longer-term TCS.

Efficacy of acupoint injection in the treatment of chronic eczema and its influence on peripheral blood T cells

BACKGROUND

Chronic eczema significantly impacts daily life, social interactions, and quality of life; however, no curative treatment has been identified.

AIM

To determine the clinical efficacy of acupoint injection for chronic eczema and its influence on peripheral blood T cells.

METHODS

Eighty patients with chronic eczema treated at our hospital between June 2022 and March 2023 were randomly assigned to a control group (n = 40), which received conventional Western medicine treatment, or an observation group (n = 40), which received routine Western medicine treatment plus acupoint injection of triamcinolone acetonide. Response and adverse reaction rates, as well as differences in the levels of serum cytokines IFN-γ, IL-2, IL-4, and IL-10 before and after treatment were investigated.

RESULTS

No difference in overall response rates were found between the observation and control groups (100% vs 90%, respectively; P > 0.05); however, the observation group had a higher marked response rate than the control group (87.5% vs 52.5%; P < 0.05). Both groups had decreased Eczema Area and Severity Index scores and increased pruritus after treatment (P < 0.05), particularly in the observation group (P < 0.05). The observation group had an adverse reaction rate of 2.5% (1/40), which did not differ significantly from that of the control group (P > 0.05). The observation group exhibited higher post-treatment INF-γ and IL-2 but lower IL-4 levels than the control group (P < 0.05); however, no significant inter-group difference was observed in post-treatment IL-10 levels (P > 0.05).

CONCLUSION

Acupoint injection of triamcinolone acetonide is safe and effective in treating chronic eczema. Its therapeutic mechanism is related to the regulation of peripheral blood T cell levels, inhibition of inflammatory reactions, and mitigation of immune imbalance.

Reasons for unsuccessful recruitment of children with atopic dermatitis in primary care in the Netherlands to a cohort study with an embedded pragmatic, randomised controlled open-label trial: a survey

BACKGROUND

The Rotterdam Eczema Study was an observational cohort study with an embedded pragmatic randomised controlled open-label trial. It was conducted in children with atopic dermatitis (AD) in the Dutch primary care system. The objective of the trial was to determine whether a potent topical corticosteroid (TCS) is more effective than a low-potency TCS.

OBJECTIVE

We are aiming to communicate transparently about the poor recruitment for the trial part and to explore the reasons why recruitment was weak.

DESIGN

We used a survey to find out what patients in the cohort did when they experienced a flare-up.

METHODS

Descriptive statistics were used to present the baseline characteristics of participants in the trial and the results of the survey.

RESULTS

In total, 367 patients were included in the cohort. Of these, 32 were randomly assigned to a trial treatment; they had a median age of 4.0 years (IQR 2.0-9.8). A total of 69 of the 86 children (80.2%) who could participate in the survey responded. 39 (56.5%) suffered a flare-up during the follow-up (making them potentially eligible for inclusion in the trial). 26 out of 39 (66.7%) increased their use of an emollient and/or TCS themselves. Only 12 of the 39 (30.7%) contacted their general practitioner (GP) as instructed in the study protocol, but 8 out of these 12 did not meet the inclusion criteria for the trial.

CONCLUSION

The main reason why cohort participants did not take part in the trial was that they did not contact their GPs when they experienced an AD flare-up. Furthermore, the majority of patients who contacted their GPs did not match the inclusion criteria of the trial. We expect that the lessons learnt from this study will be useful when developing future studies of children with AD in primary care.

Cell-free fat extract regulates oxidative stress and alleviates Th2-mediated inflammation in atopic dermatitis

Atopic dermatitis (AD) is a common inflammatory skin disease that significantly affects patients' quality of life. This study aimed to evaluate the therapeutic potential of cell-free fat extract (FE) in AD. In this study, the therapeutic effect of DNCB-induced AD mouse models was investigated. Dermatitis scores and transepidermal water loss (TEWL) were recorded to evaluate the severity of dermatitis. Histological analysis and cytokines measurement were conducted to assess the therapeutic effect. Additionally, the ability of FE to protect cells from ROS-induced damage and its ROS scavenging capacity both in vitro and in vivo were investigated. Furthermore, we performed Th1/2 cell differentiation with and without FE to elucidate the underlying therapeutic mechanism. FE reduced apoptosis and cell death of HaCat cells exposed to oxidative stress. Moreover, FE exhibited concentration-dependent antioxidant activity and scavenged ROS both in vitro and vivo. Treatment with FE alleviated AD symptoms in mice, as evidenced by improved TEWL, restored epidermis thickness, reduced mast cell infiltration, decreased DNA oxidative damage and lower inflammatory cytokines like IFN-γ, IL-4, and IL-13. FE also inhibited the differentiation of Th2 cells in vitro. Our findings indicate that FE regulates oxidative stress and mitigates Th2-mediated inflammation in atopic dermatitis by inhibiting Th2 cell differentiation, suggesting that FE has the potential as a future treatment option for AD.

From the Cochrane Library: Leukotriene Receptor Antagonists for Eczema

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Topical corticosteroids inhibit allergic skin inflammation but are ineffective in impeding the formation and expansion of resident memory T cells

BACKGROUND

Tissue-resident memory T (TRM ) cells are detrimental in allergic contact dermatitis (ACD), in which they contribute to the chronicity and severity of the disease.

METHODS

We assessed the impact of a standard topical corticosteroid (TCS) treatment, triamcinolone acetonide (TA), on the formation, maintenance and reactivation of epidermal TRM cells in a preclinical model of ACD to 2,4-dinitrofluorobenzene. TA 0.01% was applied at different time points of ACD response and we monitored skin inflammation and tracked CD8+ CD69+ CD103+ TRM by flow cytometry and RNA sequencing.

RESULTS

The impact of TA on TRM formation depended on treatment regimen: (i) in a preventive mode, that is, in sensitized mice before challenge, TA transiently inhibited the infiltration of effector T cells and the accumulation of TRM upon hapten challenge. In contrast, (ii) in a curative mode, that is, at the peak of the ACD response, TA blocked skin inflammation but failed to prevent the formation of TRM . Finally, (iii) in a proactive mode, that is, on previous eczema lesions, TA had no effect on the survival of skin TRM , but transiently inhibited their reactivation program upon allergen reexposure. Indeed, specific TRM progressively regained proliferative functions upon TA discontinuation and expanded in the tissue, leading to exaggerated iterative responses. Interestingly, TRM re-expansion correlated with the decreased clearance of hapten moieties from the skin induced by repeated TA applications.

CONCLUSIONS

Our results demonstrate that TCS successfully treat ACD inflammation, but are mostly ineffective in impeding the formation and expansion of allergen-specific TRM , which certainly restricts the induction of lasting tolerance in patients with chronic dermatitis.

The efficacy and safety of oral microecological agents as add-on therapy for atopic dermatitis: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Atopic dermatitis (AD) is a common skin disease that is hard to completely cure in a short time. Guidelines recommend the use of topical corticosteroids (TCS) as first-line anti-inflammatory therapy for AD, but long-term use has significant side effects. Microecological agents (MA), including probiotics, prebiotics and synbiotics, have been widely reported as a potential adjunctive therapy of AD, but whether MA can contribute to AD treatment is currently controversial. Therefore, we conducted a systematic review and meta-analysis to investigate whether MA as an add-on therapy for AD has synergistic and attenuated effects and to further understand the role of MA in clinical interventions for AD.

METHODS

We systematically searched Medline, Embase, Web of Science, Cochrane Library and PsycINFO databases up to Apr 11, 2023, and bibliographies were also manually searched, for potentially relevant studies regarding MA as additional therapy of AD. The Cochrane Risk of Bias Tool for assessing risk of bias was used to assess the quality of randomized controlled trials (RCTs). Two reviewers screened studies, extracted data, and evaluated the risk of bias independently. The primary outcomes (SCORAD scores and the number of adverse events) and the secondary outcomes (pruritus scores, the quality of life and the frequency of TCS) were extracted from each article. The data were combined and analyzed to quantify the safety and efficacy of the treatment. R (V4.4.3) software was used for data synthesis. The certainty of the evidence was evaluated with the Grade of Recommendation, Assessment, Development and Evaluation (GRADE) system. We also performed a trial sequential analysis to assess the reliability of the evidence.

RESULTS

A total of 21 studies, including 1230 individuals, were identified, 20 of which met the eligibility criteria for the meta-analysis. Our pooled meta-analyses showed that compared with controls, oral MA as an add-on therapy was associated with significantly lower SCORAD scores (MD = -5.30, 95% CI -8.50, -1.55, p < 0.01, I2  = 81%). However, adverse events, pruritus scores, quality of life, and frequency of TCS use showed no significant difference in this meta-analysis study (p > 0.05).

CONCLUSIONS

This meta-analysis showed that MA plus TCS could be an effective and safe treatment for patients with AD to relieve relevant symptoms, which might be used as an add-on therapy in the treatment of AD. However, due to the limited number of studies, results should be interpreted with caution. Further studies with a larger sample size are needed to explore the optimal protocol of MA plus TCS.

SNG100, a novel topical treatment for moderate atopic dermatitis, in patients aged 6 years or older: A randomised, double-blind, active-controlled trial

Background

Atopic dermatitis (AD) is one of the most common inflammatory skin diseases. It is associated with significant itch and impaired quality of life. Systemic treatments are efficient but associated with side effects. Novel topical treatments with a favourable safety profile are needed. SNG100 is a novel composition of hydrocortisone 1% in a cream base comprising sulphated polysaccharide (SPS; extracted from in-house cultivated Porphyridium Cruentum unicellular algae), a well-known hydrating, moisturising and a skin barrier repairing agent.

Objectives

To assess the safety, usability and efficacy of SNG100 cream in patients aged ≥6 years with moderate AD.

Methods

In this proof of concept phase I, double-blind, randomised trial, participants received one of three treatments for 14 days: SNG100 twice daily (BID), hydrocortisone 1% BID or mometasone furoate once daily (QD). The primary endpoint was the safety and tolerability of SNG100 cream compared to hydrocortisone 1% and mometasone furoate. The secondary endpoint was the subject's usability of SNG100. Exploratory efficacy endpoints included percent change from baseline in SCOring AD (SCORAD), Eczema Area and Severity Index, Patient-Oriented Eczema Measure, Dermatology Life Quality Index, pruritus Numerical Rating Score (NRS), peak pruritus-NRS and Investigator's Global Assessment. Subjects were also followed up without any treatment for additional 14 days.

Results

Overall, 66 participants were screened, and 60 patients were randomised. SNG100 demonstrated a high safety profile, similar to marketed products hydrocortisone 1% and mometasone furoate 0.1%, with no unanticipated drug safety related events. SNG100 and mometasone furoate 0.1% cream achieved almost similar and statistically significant greater percentage reductions from baseline in SCORAD as compared to hydrocortisone 1% cream. SNG100 demonstrated significant improvement in NRS as compared to hydrocortisone 1% cream. Remarkably, SNG100 led to a lasting effect with only 29.4% of subjects returning to IGA3 during the follow-up period compared to 50% and 38.9% in the hydrocortisone 1% and in mometasone furoate treatment arms, respectively.

Conclusions

Topical SNG100 is an effective, safe, and well-tolerated innovative treatment for moderate AD. Trial registration number: NCT04615962 (Topical Cream SNG100 for Treatment in Moderate AD Subjects).

The long-term safety of topical corticosteroids in atopic dermatitis: A systematic review

Background

Topical corticosteroids (TCS) are a first-line treatment for eczema, but there are concerns about their safety when used long-term.

Objectives

To systematically review adverse effects associated with longer-term use of TCS for eczema.

Methods

Randomised controlled trials (RCTs), cohort and case-control studies reporting adverse effects of TCS (comparators: no TCS treatment, other topicals) in patients with eczema were identified. Included studies had greater than one year of follow-up, minimum cohort size of 50 participants, or minimum 50 per arm for RCTs. Evidence was GRADE-assessed. Prospero registration CRD42021286413.

Results

We found seven studies (two randomised, five observational); two RCTs (n = 2570, including 1288 receiving TCS), two cohort (all received TCS n = 148) and three case-control studies (cases n = 10 322, controls n = 12 201). Evidence from two RCTS (n = 2570, children, three and five years' duration) comparing TCS to topical calcineurin inhibitors found intermittent TCS use probably results in little to no difference in risk of growth abnormalities, non-skin infections, impaired vaccine response and lymphoma/non lymphoma malignancies. The five-year RCT reported only one episode of skin atrophy (n = 1213 TCS arm; mild/moderate potency), suggesting TCS use probably results in little to no difference in skin thinning when used intermittently to treat flares. No cases of clinical adrenal insufficiency were reported in 75 patients using mild/moderate TCS in the three-year RCT. Small associations between TCS and type-2 diabetes and lymphoma were identified in two case-control studies compared to no TCS, but the evidence is very uncertain. No long-term studies concerning topical steroid withdrawal or eye problems were identified.

Conclusion

This review provides some reassuring data on growth and skin thinning when TCS are used intermittently for up to 5 years, but many knowledge gaps remain.

Topical proactive therapy in dermatology. A scoping review

The term 'proactive therapy' refers to a long-term management of clinically intact skin in previously disease-affected areas. This method was initially implemented in atopic dermatitis to maintain the remission and decrease the risk of exacerbations. Proactive therapy aims to limit the need for reactive treatment and improve the patients' quality of life. A proactive approach is likely to be adopted for other relapsing and inflammatory skin conditions in the future. This scoping review aims to identify dermatological conditions to be treated with the proactive approach, evaluate the available evidence for its efficacy and safety, as well as highlight the research gaps.

Topical anti‐inflammatory treatments for eczema: network meta‐analysis

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To compare the efficacy and safety of topical anti‐inflammatory treatments for reducing eczema symptoms or signs or improving eczema‐related quality of life in children and adults with eczema, by undertaking a network meta‐analysis. To provide a clinically useful ranking of these treatments according to their efficacy and safety.

Agreement and Correlation Between Different Topical Corticosteroid Potency Classification Systems

Importance

Topical corticosteroids (TCSs) are available in multiple potencies that alter their effectiveness and safety. Pharmacoepidemiologic studies on TCSs are hampered by the absence of a universal potency classification system, limiting comparisons across studies, robust exposure classification, and clinical interpretation.

Objective

To classify TCSs into 3 commonly used potency classification systems and evaluate the agreement and correlation between the 3 systems.

Design, Setting, and Participants

In this classification study, a comprehensive list of TCS formulations was compiled using sources identified in the literature, the Ontario Drug Benefit Formulary, a recent Cochrane review on the use of TCSs in people with eczema, and the Anatomical Therapeutic Classification (ATC) of the World Health Organization from August 11, 2021, to January 6, 2022. Topical corticosteroid potency classifications were assigned and compared using the 7-category US classification system, a 4-category classification from a recent Cochrane review largely based on the UK formulary, and the 4-category ATC classification. To facilitate comparisons across systems, the 7-category US system was consolidated into 4 categories.

Main Outcomes and Measures

Cohen weighted κ (κw) and Spearman rank correlation coefficients (r) were computed to examine agreement and correlation between the classification systems.

Results

A total of 232 unique TCS formulations (ATC, n = 231; US classification, n = 232; Cochrane review, n = 89) were included. Overall, there was low-to-moderate agreement but strong correlation between the classification systems. The US classification had weak agreement with the ATC system (κw, 0.53; 95% CI, 0.45-0.60) and moderate agreement with the Cochrane review classification (κw, 0.60; 95% CI, 0.48-0.73); there was weak agreement between the ATC and Cochrane review classifications (κw, 0.58; 95% CI, 0.46-0.71). The US classification strongly correlated with the ATC system (r, 0.77; 95% CI, 0.71-0.82) and Cochrane review classification (r, 0.74; 95% CI, 0.62-0.82). There was also a strong correlation between the Cochrane review and ATC classifications (r, 0.71; 95% CI, 0.58-0.80).

Conclusions and Relevance

This classification study used multiple resources to classify 232 TCS formulations into 3 potency classifications. Because these systems are often incongruent, they may yield different results in pharmacoepidemiologic studies; investigators need to be transparent in their classification approach and consider alternative potency definitions in sensitivity analyses.