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Lazar M, Zhang AD, Vashi NA. Topical Treatments in Atopic Dermatitis: An Expansive Review. J Clin Med 2024; 13:2185. [PMID: 38673458 PMCID: PMC11050343 DOI: 10.3390/jcm13082185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Atopic dermatitis (AD) is a common inflammatory skin condition found worldwide. It impacts patient quality of life (QoL) and is thought to arise as an inflammatory response to epidermal barrier dysfunction and hypersensitivity. AD can lead to large out-of-pocket costs and increased healthcare expenses over a lifetime. An analysis of all randomized control trials conducted since 1990 on topical therapies for AD were reviewed, including 207 trials in the final analysis. It was found that an average of 226 patients were enrolled over 2.43 arms. Common topical treatments included corticosteroids, calcineurin inhibitors, JAK inhibitors, and phosphodiesterase inhibitors. The most utilized tools to identify treatment efficacy were the EASI, IGA, SCORAD, and PGA. There was a paucity of data on trials that evaluated efficacy, QoL, and cost of treatment simultaneously. This review highlights the need for comprehensive trials that evaluate multiple aspects of treatment, including financial cost and QoL impact, to ensure each patient has the best treatment modality for the management of their AD.
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Affiliation(s)
| | | | - Neelam A. Vashi
- Department of Dermatology, Boston University School of Medicine, 609 Albany St., J502, Boston, MA 02118, USA
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2
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Chu DK, Chu AWL, Rayner DG, Guyatt GH, Yepes-Nuñez JJ, Gomez-Escobar L, Pérez-Herrera LC, Díaz Martinez JP, Brignardello-Petersen R, Sadeghirad B, Wong MM, Ceccacci R, Zhao IX, Basmaji J, MacDonald M, Chu X, Islam N, Gao Y, Izcovich A, Asiniwasis RN, Boguniewicz M, De Benedetto A, Capozza K, Chen L, Ellison K, Frazier WT, Greenhawt M, Huynh J, LeBovidge J, Lio PA, Martin SA, O'Brien M, Ong PY, Silverberg JI, Spergel JM, Smith Begolka W, Wang J, Wheeler KE, Gardner DD, Schneider L. Topical treatments for atopic dermatitis (eczema): Systematic review and network meta-analysis of randomized trials. J Allergy Clin Immunol 2023; 152:1493-1519. [PMID: 37678572 DOI: 10.1016/j.jaci.2023.08.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/24/2023] [Accepted: 08/31/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Atopic dermatitis (AD) is a common skin condition with multiple topical treatment options, but uncertain comparative effects. OBJECTIVE We sought to systematically synthesize the benefits and harms of AD prescription topical treatments. METHODS For the 2023 American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters AD guidelines, we searched MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, ICTRP, and GREAT databases to September 5, 2022, for randomized trials addressing AD topical treatments. Paired reviewers independently screened records, extracted data, and assessed risk of bias. Random-effects network meta-analyses addressed AD severity, itch, sleep, AD-related quality of life, flares, and harms. The Grading of Recommendations Assessment, Development and Evaluation approach informed certainty of evidence ratings. We classified topical corticosteroids (TCS) using 7 groups-group 1 being most potent. This review is registered in the Open Science Framework (https://osf.io/q5m6s). RESULTS The 219 included trials (43,123 patients) evaluated 68 interventions. With high-certainty evidence, pimecrolimus improved 6 of 7 outcomes-among the best for 2; high-dose tacrolimus (0.1%) improved 5-among the best for 2; low-dose tacrolimus (0.03%) improved 5-among the best for 1. With moderate- to high-certainty evidence, group 5 TCS improved 6-among the best for 3; group 4 TCS and delgocitinib improved 4-among the best for 2; ruxolitinib improved 4-among the best for 1; group 1 TCS improved 3-among the best for 2. These interventions did not increase harm. Crisaborole and difamilast were intermediately effective, but with uncertain harm. Topical antibiotics alone or in combination may be among the least effective. To maintain AD control, group 5 TCS were among the most effective, followed by tacrolimus and pimecrolimus. CONCLUSIONS For individuals with AD, pimecrolimus, tacrolimus, and moderate-potency TCS are among the most effective in improving and maintaining multiple AD outcomes. Topical antibiotics may be among the least effective.
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Key Words
- Atopic dermatitis (eczema)
- disease severity
- induction of remission and maintenance of remission (reactive or proactive therapy)
- network meta-analysis (comparative effects)
- patient-important outcomes (eczema severity, intensity, itch, sleep, quality of life, flares or flare-ups or exacerbations)
- topical Janus kinase (JAK) inhibitors (ruxolitinib, delgocitinib)
- topical calcineurin inhibitors (pimecrolimus, tacrolimus)
- topical corticosteroids (steroids)
- topical phosphodiesterase-4 (PDE-4) inhibitors (crisaborole, difamilast, lotamilast, roflumilast)
- topical treatments (therapy)
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Affiliation(s)
- Derek K Chu
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada; The Research Institute of St. Joe's Hamilton, Hamilton, Canada.
| | - Alexandro W L Chu
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - Daniel G Rayner
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Gordon H Guyatt
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Juan José Yepes-Nuñez
- Universidad de Los Andes, Bogotá, Colombia; Fundacion Santa Fe de Bogotá University, Bogotá, Colombia
| | | | | | - Juan Pablo Díaz Martinez
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | | | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Anesthesia, McMaster University, Hamilton, Canada
| | - Melanie M Wong
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - Renata Ceccacci
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - Irene X Zhao
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - John Basmaji
- Department of Medicine, Western University, London, Canada
| | - Margaret MacDonald
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - Xiajing Chu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - Nazmul Islam
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada; Department of Public Health, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
| | - Ya Gao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Qatar
| | - Ariel Izcovich
- Servicio de Clínica Médica, Hospital Aleman, Buenos Aires, Argentina
| | | | - Mark Boguniewicz
- Division of Pediatric Allergy and Clinical Immunology, National Jewish Health, Denver, Colo; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Anna De Benedetto
- Department of Dermatology, University of Rochester Medical Center, Rochester, NY
| | - Korey Capozza
- Global Parents for Eczema Research, Santa Barbara, Calif
| | - Lina Chen
- Evidence in Allergy Group, McMaster University, Hamilton, Canada; Department of Pediatrics, McMaster University, Hamilton, Canada
| | | | | | - Matthew Greenhawt
- Division of Pediatric Allergy and Clinical Immunology, National Jewish Health, Denver, Colo; Section of Allergy and Immunology, Children's Hospital Colorado, Aurora, Colo
| | - Joey Huynh
- Sepulveda VA Medical Center, North Hills, Calif
| | - Jennifer LeBovidge
- Division of Immunology, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Peter A Lio
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Ill; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | | | | | - Peck Y Ong
- Division of Clinical Immunology and Allergy, Children's Hospital Los Angeles, Los Angeles, Calif; Department of Pediatrics, Keck School of Medicine of USC, Los Angeles, Calif
| | - Jonathan I Silverberg
- Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Jonathan M Spergel
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | | | - Julie Wang
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Lynda Schneider
- Division of Immunology, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
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Abstract
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.
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Galli E, Fortina AB, Ricci G, Maiello N, Neri I, Baldo E, Berti I, Bonamonte D, Capra L, Carboni E, Carello R, Caroppo F, Cavagni G, Chinellato I, Cipriani F, Comberiati P, Diociaiuti A, Di Lernia V, Duse M, Filippeschi C, Giannetti A, Giovannini M, Licari A, Marseglia GL, Pace M, Patrizi A, Pajno GB, Peroni D, Villani A, Eichenfield L. Narrative review on the management of moderate-severe atopic dermatitis in pediatric age of the Italian Society of Pediatric Allergology and Immunology (SIAIP), of the Italian Society of Pediatric Dermatology (SIDerP) and of the Italian Society of Pediatrics (SIP). Ital J Pediatr 2022; 48:95. [PMID: 35701810 PMCID: PMC9195338 DOI: 10.1186/s13052-022-01278-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/10/2022] [Indexed: 02/06/2023] Open
Abstract
Currently, there are a few detailed guidelines on the overall management of children and adolescents with moderate-severe atopic dermatitis. AD is a complex disease presenting with different clinical phenotypes, which require an individualized and multidisciplinary approach. Therefore, appropriate interaction between primary care pediatricians, pediatric allergists, and pediatric dermatologists is crucial to finding the best management strategy. In this manuscript, members of the Italian Society of Pediatric Allergology and Immunology (SIAIP), the Italian Society of Pediatric Dermatology (SIDerP), and the Italian Society of Pediatrics (SIP) with expertise in the management of moderate-severe atopic dermatitis have reviewed the latest scientific evidence in the field. This narrative review aims to define a pathway to appropriately managing children and adolescents with moderate-severe atopic dermatitis.
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Affiliation(s)
- Elena Galli
- Pediatric Allergology Unit, Department of Pediatric Medicine, S.Pietro Hospital Fatebenefratelli, Roma, Italy
| | - Anna Belloni Fortina
- Pediatric Dermatology Unit, Department of Medicine, University of Padua, Padova, Italy
| | - Giampaolo Ricci
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Nunzia Maiello
- Department of Woman, Child and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Iria Neri
- Dermatology Unit, IRCCS of Azienda Ospedaliero-Universitaria Policlinico Sant'Orsola Hospital, Bologna, Italy
| | - Ermanno Baldo
- Giovan Battista Mattei" Research Institute, Stenico, Italy
| | - Irene Berti
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Domenico Bonamonte
- Department of Biomedical Science and Human Oncology, Section of Dermatology, University of Bari, Bari, Italy
| | | | - Elena Carboni
- Unit of Paediatrics, Maggiore Hospital, ASST-Cremona, Cremona, Italy
| | - Rossella Carello
- Pediatric Allergology Unit, Department of Pediatric Medicine, S.Pietro Hospital Fatebenefratelli, Roma, Italy
| | - Francesca Caroppo
- Pediatric Dermatology Unit, Department of Medicine, University of Padua, Padova, Italy
| | - Giovanni Cavagni
- Allergology Service European Diagnostic DRP Centre Parma, Parma, Italy
| | | | | | - Pasquale Comberiati
- Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, Pisa, Italy
| | - Andrea Diociaiuti
- Dermatology Unit and Genodermatosis Unit, Genetics and Rare Diseases Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Vito Di Lernia
- Dermatology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Marzia Duse
- Pediatrics, Sapienza University, Rome, Italy
| | - Cesare Filippeschi
- Dermatology Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Arianna Giannetti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 11, 40138, Bologna, Italy.
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Amelia Licari
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy, University of Pavia, Pavia, Italy
| | - Gian Luigi Marseglia
- Clinica Pediatrica Università di Pavia - Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Manuela Pace
- Department of Pediatrics, S. Maria del Carmine Hospital, Rovereto, Italy
| | - Annalisa Patrizi
- Dermatology Unit, IRCCS of Azienda Ospedaliero-Universitaria Policlinico Sant'Orsola Hospital, Bologna, Italy.,Dermatology, Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma MaterStudiorum University of Bologna, Bologna, Italy
| | | | - Diego Peroni
- Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, Pisa, Italy
| | - Alberto Villani
- Emergency and General Pediatrics Department Bambino Gesù Children Hospital - IRCCS, Rome, Italy
| | - Lawrence Eichenfield
- Department of Dermatology, University of California, San Diego and Rady Children's Hospital, San Diego, USA
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Singh S, Behl T, Sharma N, Zahoor I, Chigurupati S, Yadav S, Rachamalla M, Sehgal A, Naved T, Arora S, Bhatia S, Al-Harrasi A, Mohan S, Aleya L, Bungau S. Targeting therapeutic approaches and highlighting the potential role of nanotechnology in atopic dermatitis. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2022; 29:32605-32630. [PMID: 35195869 DOI: 10.1007/s11356-021-18429-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/27/2021] [Indexed: 06/14/2023]
Abstract
Atopic dermatitis is a chronic as well as widespread skin disease which has significant influence on the life attributes of affected people and their families. Systemic immunosuppressive drugs can be utilised for effective care of disease, although they are often prescribed for rigorous disruption or disease that is complicated to manage. Therefore, topical applications of corticosteroids are considered the primary pharmacologic therapies for atopic dermatitis, and research recommends that these medications might be helpful in preventing disease flare-ups. However, topical medicine administration to deeper layers of skin is challenging because of the skin anatomic barrier that restricts deeper drug permeation, and also due to barrier function abnormalities in atopic dermatitis skin, which might result in systemic drug absorption, provoking systemic consequences. Hence, effective management of atopic dermatitis needs new, effective, safe and targeted treatments. Therefore, nanotechnology-based topical therapeutics have attracted much interest nowadays because of their tendency to increase drug diffusion and bioavailability along with enormous drug targeting potential to affected cells, and, thereby, reducing the adverse effects of medications. In this review, we mention different symptoms of atopic dermatitis, and provide an overview of the different triggering factors causing atopic dermatitis, with emphasis on its epidemiology, pathophysiology, clinical features and diagnostic, and preventive measures. This review discusses existing therapeutics for treating atopic dermatitis, and the newer approaches as well as the current classical pharmacotherapy of atopic dermatitis against new nanoparticle skin delivery systems. This review has also briefly summarised the recent patents and clinical status of therapeutic modalities for atopic dermatitis.
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Affiliation(s)
- Sukhbir Singh
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Tapan Behl
- Chitkara College of Pharmacy, Chitkara University, Punjab, India.
| | - Neelam Sharma
- Chitkara College of Pharmacy, Chitkara University, Punjab, India.
| | - Ishrat Zahoor
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Sridevi Chigurupati
- Department of Medicine Chemistry and Pharmacognosy, Qassim University, Buraidah, Kingdom of Saudi Arabia
| | - Shivam Yadav
- Yashraj Institute of Pharmacy, Noida, Uttar Pradesh, India
| | - Mahesh Rachamalla
- Department of Biology, University of Saskatchewan, 112 Science Place, Saskatoon, Canada
| | - Aayush Sehgal
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Tanveer Naved
- Amity Institute of Pharmacy, Amity University, Noida, Uttar Pradesh, India
| | - Sandeep Arora
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Saurabh Bhatia
- Natural & Medical Sciences Research Center, University of Nizwa, Nizwa, Oman
- School of Health Science, University of Petroleum and Energy Studies, Dehradun, Uttarakhand, India
| | - Ahmed Al-Harrasi
- Natural & Medical Sciences Research Center, University of Nizwa, Nizwa, Oman
| | - Syam Mohan
- Substance Abuse and Toxicology Research Center, Jazan University, Jazan, Saudi Arabia
| | - Lotfi Aleya
- School of Health Science, University of Petroleum and Energy Studies, Dehradun, Uttarakhand, India
| | - Simona Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea, Romania
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Lax SJ, Harvey J, Axon E, Howells L, Santer M, Ridd MJ, Lawton S, Langan S, Roberts A, Ahmed A, Muller I, Ming LC, Panda S, Chernyshov P, Carter B, Williams HC, Thomas KS, Chalmers JR. Strategies for using topical corticosteroids in children and adults with eczema. Cochrane Database Syst Rev 2022; 3:CD013356. [PMID: 35275399 PMCID: PMC8916090 DOI: 10.1002/14651858.cd013356.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Eczema is a common skin condition. Although topical corticosteroids have been a first-line treatment for eczema for decades, there are uncertainties over their optimal use. OBJECTIVES To establish the effectiveness and safety of different ways of using topical corticosteroids for treating eczema. SEARCH METHODS We searched databases to January 2021 (Cochrane Skin Specialised Register; CENTRAL; MEDLINE; Embase; GREAT) and five clinical trials registers. We checked bibliographies from included trials to identify further trials. SELECTION CRITERIA Randomised controlled trials in adults and children with eczema that compared at least two strategies of topical corticosteroid use. We excluded placebo comparisons, other than for trials that evaluated proactive versus reactive treatment. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods, with GRADE certainty of evidence for key findings. Primary outcomes were changes in clinician-reported signs and relevant local adverse events. Secondary outcomes were patient-reported symptoms and relevant systemic adverse events. For local adverse events, we prioritised abnormal skin thinning as a key area of concern for healthcare professionals and patients. MAIN RESULTS We included 104 trials (8443 participants). Most trials were conducted in high-income countries (81/104), most likely in outpatient or other hospital settings. We judged only one trial to be low risk of bias across all domains. Fifty-five trials had high risk of bias in at least one domain, mostly due to lack of blinding or missing outcome data. Stronger-potency versus weaker-potency topical corticosteroids Sixty-three trials compared different potencies of topical corticosteroids: 12 moderate versus mild, 22 potent versus mild, 25 potent versus moderate, and 6 very potent versus potent. Trials were usually in children with moderate or severe eczema, where specified, lasting one to five weeks. The most reported outcome was Investigator Global Assessment (IGA) of clinician-reported signs of eczema. We pooled four trials that compared moderate- versus mild-potency topical corticosteroids (420 participants). Moderate-potency topical corticosteroids probably result in more participants achieving treatment success, defined as cleared or marked improvement on IGA (52% versus 34%; odds ratio (OR) 2.07, 95% confidence interval (CI) 1.41 to 3.04; moderate-certainty evidence). We pooled nine trials that compared potent versus mild-potency topical corticosteroids (392 participants). Potent topical corticosteroids probably result in a large increase in number achieving treatment success (70% versus 39%; OR 3.71, 95% CI 2.04 to 6.72; moderate-certainty evidence). We pooled 15 trials that compared potent versus moderate-potency topical corticosteroids (1053 participants). There was insufficient evidence of a benefit of potent topical corticosteroids compared to moderate topical corticosteroids (OR 1.33, 95% CI 0.93 to 1.89; moderate-certainty evidence). We pooled three trials that compared very potent versus potent topical corticosteroids (216 participants). The evidence is uncertain with a wide confidence interval (OR 0.53, 95% CI 0.13 to 2.09; low-certainty evidence). Twice daily or more versus once daily application We pooled 15 of 25 trials in this comparison (1821 participants, all reported IGA). The trials usually assessed adults and children with moderate or severe eczema, where specified, using potent topical corticosteroids, lasting two to six weeks. Applying potent topical corticosteroids only once a day probably does not decrease the number achieving treatment success compared to twice daily application (OR 0.97, 95% CI 0.68 to 1.38; 15 trials, 1821 participants; moderate-certainty evidence). Local adverse events Within the trials that tested 'treating eczema flare-up' strategies, we identified only 26 cases of abnormal skin thinning from 2266 participants (1% across 22 trials). Most cases were from the use of higher-potency topical corticosteroids (16 with very potent, 6 with potent, 2 with moderate and 2 with mild). We assessed this evidence as low certainty, except for very potent versus potent topical corticosteroids, which was very low-certainty evidence. Longer versus shorter-term duration of application for induction of remission No trials were identified. Twice weekly application (weekend, or 'proactive therapy') to prevent relapse (flare-ups) versus no topical corticosteroids/reactive application Nine trials assessed this comparison, generally lasting 16 to 20 weeks. We pooled seven trials that compared weekend (proactive) topical corticosteroids therapy versus no topical corticosteroids (1179 participants, children and adults with a range of eczema severities, though mainly moderate or severe). Weekend (proactive) therapy probably results in a large decrease in likelihood of a relapse from 58% to 25% (risk ratio (RR) 0.43, 95% CI 0.32 to 0.57; 7 trials, 1149 participants; moderate-certainty evidence). Local adverse events We did not identify any cases of abnormal skin thinning in seven trials that assessed skin thinning (1050 participants) at the end of treatment. We assessed this evidence as low certainty. Other comparisons Other comparisons included newer versus older preparations of topical corticosteroids (15 trials), cream versus ointment (7 trials), topical corticosteroids with wet wrap versus no wet wrap (6 trials), number of days per week applied (4 trials), different concentrations of the same topical corticosteroids (2 trials), time of day applied (2 trials), topical corticosteroids alternating with topical calcineurin inhibitors versus topical corticosteroids alone (1 trial), application to wet versus dry skin (1 trial) and application before versus after emollient (1 trial). No trials compared branded versus generic topical corticosteroids and time between application of emollient and topical corticosteroids. AUTHORS' CONCLUSIONS Potent and moderate topical corticosteroids are probably more effective than mild topical corticosteroids, primarily in moderate or severe eczema; however, there is uncertain evidence to support any advantage of very potent over potent topical corticosteroids. Effectiveness is similar between once daily and twice daily (or more) frequent use of potent topical corticosteroids to treat eczema flare-ups, and topical corticosteroids weekend (proactive) therapy is probably better than no topical corticosteroids/reactive use to prevent eczema relapse (flare-ups). Adverse events were not well reported and came largely from low- or very low-certainty, short-term trials. In trials that reported abnormal skin thinning, frequency was low overall and increased with increasing potency. We found no trials on the optimum duration of treatment of a flare, branded versus generic topical corticosteroids, and time to leave between application of topical corticosteroids and emollient. There is a need for longer-term trials, in people with mild eczema.
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Affiliation(s)
- Stephanie J Lax
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Jane Harvey
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Emma Axon
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Laura Howells
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Miriam Santer
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | | | - Sandra Lawton
- Department of Dermatology, Rotherham NHS Foundation Trust, Rotherham, UK
| | - Sinéad Langan
- London School of Hygiene and Tropical Medicine, London, UK
| | - Amanda Roberts
- Nottingham Support Group for Carers of Children with Eczema, Nottingham, UK
| | - Amina Ahmed
- c/o Cochrane Skin Group, University of Nottingham, Nottingham, UK
| | - Ingrid Muller
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Long Chiau Ming
- PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam, Gadong, Brunei Darussalam
| | - Saumya Panda
- Department of Dermatology, KPC Medical College and Hospital, Kolkata, India
| | - Pavel Chernyshov
- Department of Dermatology and Venereology, National Medical University, Kiev, Ukraine
| | - Ben Carter
- Biostatistics and Health Informatics, King's College London; Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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New Strategies for Improving Budesonide Skin Retention. Pharmaceutics 2021; 14:pharmaceutics14010030. [PMID: 35056927 PMCID: PMC8781796 DOI: 10.3390/pharmaceutics14010030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 12/16/2021] [Accepted: 12/21/2021] [Indexed: 11/30/2022] Open
Abstract
The aim of this work was to evaluate the ex vivo effect of the combination of two strategies, complexation with cyclodextrin, and poloxamer hydrogels, for improving water solubility in the dermal absorption of budesonide. Two hydrogels containing 20% poloxamer 407, alone or in combination with poloxamer 403, were prepared. Each formulation was loaded with 0.05% budesonide, using either pure budesonide or its inclusion complex with hydroxypropyl-β-cyclodextrin, and applied in finite dose conditions on porcine skin. The obtained results showed that for all formulations, budesonide accumulated preferentially in the epidermis compared to the dermis. The quantity of budesonide recovered in the receptor compartment was, in all cases, lower than the LOQ of the analytical method, suggesting the absence of possible systemic absorption. The use of a binary poloxamer mixture reduced skin retention, in line with the lower release from the vehicle. When the hydrogels were formulated with the inclusion complex, an increase in budesonide skin retention was observed with both hydrogels. Poloxamer hydrogel proved to be a suitable vehicle for cutaneous administration of budesonide.
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Kritsanaviparkporn C, Sangaphunchai P, Treesirichod A. Efficacy of moisturizers in paediatric atopic dermatitis: A systematic review and meta-analysis of randomised controlled trials. Indian J Dermatol Venereol Leprol 2021; 88:22-31. [PMID: 34623061 DOI: 10.25259/ijdvl_1384_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 07/01/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Topical moisturizer is recommended for atopic dermatitis. AIMS The aim of the study was to investigate the knowledge gap regarding the efficacy of moisturizer in young patients. METHODS A systematic review and meta-analysis were conducted on randomised controlled trials comparing participant's ≤15 years with atopic dermatitis, receiving either topical moisturizer or no moisturizer treatment. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. RESULTS Six trials were included (intervention n= 436; control n= 312). Moisturizer use extended time to flare by 13.52 days (95% confidence interval 0.05-26.99, I2 88%). Greater reduction in risk of relapse was observed during the first month of latency (pooled risk ratio 0.47, 95% confidence interval 0.31-0.72, I2 28%) compared to the second and third months (pooled risk ratio 0.65, 95% confidence interval 0.47-0.91, I2 35% and pooled risk ratio 0.63, 95% confidence interval 0.47-0.83, I2 33%, respectively).Treated patients were 2.68 times more likely to experience a three-six months remission (95% confidence interval1.18-6.09, I2 56%). Moisturizer minimally improved disease severity and quality of life. LIMITATIONS There is a dire need to conduct randomised controlled trialswith more robust and standardised designs. CONCLUSION Moisturizer benefits young patients with atopic dermatitis. However, more research is needed to better estimate its efficacy.
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Affiliation(s)
- Chawan Kritsanaviparkporn
- Department of Paediatrics, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhonnayok, Thailand
| | - Phoomphut Sangaphunchai
- Department of Paediatrics, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhonnayok, Thailand
| | - Arucha Treesirichod
- Department of Paediatrics, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhonnayok, Thailand
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Gür Çetinkaya P, Şahiner ÜM. Childhood atopic dermatitis: current developments, treatment approaches, and future expectations. Turk J Med Sci 2019; 49:963-984. [PMID: 31408293 PMCID: PMC7018348 DOI: 10.3906/sag-1810-105] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Atopic dermatitis (AD) is the most common chronic inflammatory skin disorder of childhood. Underlying factors that contribute to AD are impaired epithelial barrier, alterations in the lipid composition of the skin, immunological imbalance including increased Th2/Th1 ratio, proinflammatory cytokines, decreased T regulatory cells, genetic mutations, and epigenetic alterations. Atopic dermatitis is a multifactorial disease with a particularly complicated pathophysiology. Discoveries to date may be considered the tip of the iceberg, and the increasing number of studies in this field indicate that there are many points to be elucidated in AD pathophysiology. In this review, we aimed to illustrate the current understanding of the underlying pathogenic mechanisms in AD, to evaluate available treatment options with a focus on recently discovered therapeutic agents, and to determine the personal, familial, and economic burdens of the disease, which are frequently neglected issues in AD. Currently available therapies only provide transient solutions and cannot fully cure the disease. However, advances in the understanding of the pathogenic mechanisms of the disease have led to the production of new treatment options, while ongoing drug trials also have had promising results.
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Affiliation(s)
- Pınar Gür Çetinkaya
- Division of Pediatric Allergy and Asthma Unit, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ümit Murat Şahiner
- Division of Pediatric Allergy and Asthma Unit, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Chalmers JR, Axon E, Harvey J, Santer M, Ridd MJ, Lawton S, Langan S, Roberts A, Ahmed A, Muller I, Long CM, Panda S, Chernyshov P, Carter B, Williams HC, Thomas KS. Different strategies for using topical corticosteroids in people with eczema. Hippokratia 2019. [DOI: 10.1002/14651858.cd013356] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Joanne R Chalmers
- University of Nottingham; Centre of Evidence Based Dermatology; Room A103, King’s Meadow Campus, Lenton Lane Nottingham UK NG7 2NR
| | - Emma Axon
- University of Nottingham; Centre of Evidence Based Dermatology; Room A103, King’s Meadow Campus, Lenton Lane Nottingham UK NG7 2NR
| | - Jane Harvey
- University of Nottingham; Centre of Evidence Based Dermatology; Room A103, King’s Meadow Campus, Lenton Lane Nottingham UK NG7 2NR
| | - Miriam Santer
- University of Southampton; Department of Primary Care and Population Sciences; Aldermoor Health Centre, Aldermoor Close Southampton UK SO16 5ST
| | - Matthew J Ridd
- University of Bristol; 25-27 Belgrave Road Bristol UK BS8 2AA
| | - Sandra Lawton
- Rotherham NHS Foundation Trust; Department of Dermatology; Moorgate Road Rotherham UK S60 2UD
| | - Sinéad Langan
- London School of Hygiene and Tropical Medicine; Keppel Street London UK WC1E 7HT
| | - Amanda Roberts
- Nottingham Support Group for Carers of Children with Eczema; Nottingham UK NG5 4FG
| | - Amina Ahmed
- University of Nottingham; c/o Cochrane Skin Group; King's Meadow Campus Nottingham UK NG7 2NR
| | - Ingrid Muller
- University of Southampton; Department of Primary Care and Population Sciences; Aldermoor Health Centre, Aldermoor Close Southampton UK SO16 5ST
| | - Chiau Ming Long
- School of Medicine, University of Tasmania; Department of Pharmacy; Hobart Australia
| | - Saumya Panda
- KPC Medical College and Hospital; Department of Dermatology; 18D/11, Anupama Housing Complex Phase I Kolkata India 700052
| | - Pavel Chernyshov
- National Medical University; Department of Dermatology and Venereology; Bulvar Shevchenko, 13 Kiev Ukraine 01601
| | - Ben Carter
- King's College London; Institute of Psychiatry, Psychology & Neuroscience; Biostatistics and Health Informatics; Denmark Hill London UK
| | - Hywel C Williams
- University of Nottingham; Centre of Evidence Based Dermatology; Room A103, King’s Meadow Campus, Lenton Lane Nottingham UK NG7 2NR
| | - Kim S Thomas
- University of Nottingham; Centre of Evidence Based Dermatology; Room A103, King’s Meadow Campus, Lenton Lane Nottingham UK NG7 2NR
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11
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van Halewijn KF, Bohnen AM, van den Berg PJ, Pasmans SGMA, Bindels PJE, Elshout G. Different potencies of topical corticosteroids for a better treatment strategy in children with atopic dermatitis (the Rotterdam Eczema study): protocol for an observational cohort study with an embedded randomised open-label controlled trial. BMJ Open 2019; 9:e027239. [PMID: 31221882 PMCID: PMC6588953 DOI: 10.1136/bmjopen-2018-027239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Topical corticosteroids (TCS) of different potencies are the main treatment to control atopic dermatitis (AD). The Dutch guideline on AD for general practitioners (GPs) recommends a stepwise approach in which treatment steps are tailored to the severity of the disease, starting with the lowest possible potency of TCS. However, it remains unclear whether the recommended stepwise approach is most efficient. This randomised open-label controlled trial aims to determine whether a potent TCS is more effective than a low-potency TCS in the initial treatment of children with a moderate flare-up of AD in primary care. In the observational cohort, the overall aim is to determine the frequency, burden and determinants of flare-ups of AD during follow-up. METHODS AND ANALYSIS The study is an observational cohort study with an embedded pragmatic randomised controlled, open-label trial. Eligible are patients diagnosed with AD (aged 12 weeks to 18 years) who visited the GP for AD or received repeated prescriptions for AD in the previous 12 months; follow-up of the cohort is 1 year. Children are enrolled in the trial if they have a flare-up of AD during follow-up in the cohort. Eligible children are randomised to the intervention group (with a potent TCS once daily) or to the GP guideline group (with a low potency TCS once daily). Primary outcome is the difference in average subjective disease severity over 24 weeks follow-up in the trial, measured with the patient-oriented eczema measure. As secondary outcome, the Eczema Area and Severity Index is measured. ETHICS AND DISSEMINATION This study tests the hypothesis that immediate treatment with a potent TCS during a flare-up of AD leads to faster and more efficacious results as compared with starting with a TCS with low potency with less overall use of TCS. The study protocol is approved by the Medical Ethics Committee (MEC) of the Erasmus Medical Center Rotterdam, the Netherlands (MEC-2017-328). The results of the study will be published in international peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER NTR: 6679; Pre-results.
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Affiliation(s)
| | - Arthur M Bohnen
- Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Patrick J E Bindels
- Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Gijs Elshout
- Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands
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12
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LePoidevin LM, Lee DE, Shi VY. A comparison of international management guidelines for atopic dermatitis. Pediatr Dermatol 2019; 36:36-65. [PMID: 30303557 DOI: 10.1111/pde.13678] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND/OBJECTIVES Atopic dermatitis (AD) is a chronic condition that is predominantly found in pediatric patients and commonly presents therapeutic challenges. The management of AD encompasses a variety of factors, and the pillars of optimal management revolve around skin barrier repair and antiinflammatory, antimicrobial, and antipruritic treatment. AD management guidelines exist in various geographic regions globally. The purpose of this review was to compare international guidelines to highlight the similarities and variances among populations and skin types. Comparisons were made for recommendations regarding moisturization, bathing, wet wrap therapy, topical corticosteroids, topical calcineurin inhibitors, antihistamines, antipruritics, antibiotics, systemic immunosuppressants, and biologics. METHODS A literature search of the PubMed, EMBASE, and MEDLINE databases was performed for published guidelines in each geographic region. Inclusion criteria included publications available in English that were established by a dermatological association or group including dermatologists, pertained to the treatment of AD in humans, were the most recent guidelines available that were published between 2007 and 2018, and included comprehensive treatment recommendations. RESULTS Publications from Europe, North America, Asia, the Asia-Pacific region, Australia, and Africa were reviewed, encompassing 14 guidelines. Notable diversity exists across these guidelines regarding recommendations for moisturization and bathing, as well as topical and systemic therapies for AD. CONCLUSIONS Due to the heterogeneity of the disease and regional treatment accessibility, complete standardization of AD management guidelines may be difficult. Nevertheless, more consensus on management guidelines is needed, and recommendations should be updated as new treatment modalities become available.
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Affiliation(s)
| | - Dylan E Lee
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Vivian Y Shi
- Department of Medicine, Dermatology Division, University of Arizona, Tucson, Arizona
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13
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Rubio-Gomis E, Martinez-Mir I, Morales-Olivas FJ, Martorell-Aragones A, Palop-Larrea V, Bernalte-Sesé A, Cerda-Mir JC, Polo-Martín P, Febrer I, Aranda-Grau L, Llosa-Cortes I, Tejedor-Sanz MJ, Julia-Benito JC, Alvarez-de-Laviada-Mulero T, Planelles-Cantarino MV, Apolinar-Valiente E, Loriente-Tur M, Abella-Bazataqui AM, Alvarez-Gonzalez I, Morales-Carpi C, Burches-Greus ME, Ferrer-Bautista AB, Felix-Toledo R, Marmaneu-Laguia D, Garcia-Martinez VE, Beltran-Marques MA, Rodriguez-Gracia B. Fluticasone in mild to moderate atopic dermatitis relapse: A randomized controlled trial. Allergol Immunopathol (Madr) 2018; 46:378-384. [PMID: 29373242 DOI: 10.1016/j.aller.2017.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 11/21/2017] [Accepted: 12/02/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The long-term efficacy of corticosteroids to prevent atopic dermatitis (AD) relapses has partially been addressed in children. This study compared an intermittent dosing regimen of fluticasone propionate (FP) cream 0.05% with its vehicle base in reducing the risk of relapse in children with stabilized AD. METHODS A randomized controlled, multicentric, double-blind trial was conducted. Children (2-10 years) with mild/moderate AD (exclusion criteria: >30% affected body surface area and/or head) were enrolled into an Open-label Stabilization Phase (OSP) of up to 2 weeks on twice daily FP. Those who achieved treatment success entered the Double-blind Maintenance Phase (DMP). They were randomly allocated to receive FP or vehicle twice-weekly on consecutive days for 16 weeks. The primary study endpoint was relapse rate; time to relapse and severity of disease were also studied. Kaplan-Meier estimates were calculated. RESULTS Fifty-four patients (29 girls) entered the OSP (23 mild AD) and 49 (26 girls) continued into the DMP. Mean age was 5.5 (SD: 2.8) and 5.1 (SD: 2.3) yrs for FP and vehicle groups, respectively. Four patients withdrew from the DMP (two in every group). Patients treated with FP twice weekly had a 2.7 fold lower risk of experiencing a relapse than patients treated with vehicle (relative risk 2.72, SD: 1.28; p=0.034). FP was also superior to vehicle for delaying time to relapse. Both treatment therapies were well tolerated. CONCLUSION This long-term study shows that twice weekly FP provides an effective maintenance treatment to control the risk of relapse in children with AD.
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Affiliation(s)
- E Rubio-Gomis
- Unidad de Farmacología Clínica, Consorcio Hospital General Universitario de Valencia CHGUV, Valencia, Spain; Departamento Farmacología, Universitat de Valéncia, Valencia, Spain.
| | - I Martinez-Mir
- Dirección Gerencia-Fundación HGU, CHGUV, Valencia, Spain
| | | | | | - V Palop-Larrea
- Subdirección Médica Asistencial, Departamento de Salud La Ribera, Alzira, Valencia, Spain
| | | | - J C Cerda-Mir
- Unidad de Alergía Pediátrica, CHGUV, Valencia, Spain
| | - P Polo-Martín
- Centro de Salud (CS) Barrio de la Luz, Xirivella, Valencia, Spain
| | - I Febrer
- Servicio Dermatología, CHGUV, Valencia, Spain
| | - L Aranda-Grau
- Centro de Atención Primaria de Pobla de Vallbona, Valencia, Spain
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Shukla S, Feldman SR, Strowd LC. A safety review of the medications used to treat atopic dermatitis. Expert Opin Drug Saf 2017; 17:179-183. [PMID: 29195486 DOI: 10.1080/14740338.2018.1411478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Atopic dermatitis (AD) is a common disease in children and adults which causes severe physical discomfort and psychosocial distress. Recently novel therapies for AD have been FDA approved for use which creates the need to review the safety surrounding current FDA approved AD medications. AREAS COVERED Published clinical studies involving topical and oral FDA approved medications for AD are included in this review. Authors used PubMed research database to search for clinical trials involving AD patients. EXPERT OPINION AD is a common disease which currently has limited FDA approved medications. Given the chronicity of this disease, medications are needed which control disease while minimizing side effects to allow for long term use. Newer approved medications show promise but safety data is limited given their relatively new utilization for AD.
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Affiliation(s)
- Shweta Shukla
- a University of Maryland School of Medicine , Baltimore , MD , USA
| | - Steven R Feldman
- b Department of Dermatology , Wake Forest School of Medicine , Winston-Salem , NC , USA
| | - Lindsay C Strowd
- b Department of Dermatology , Wake Forest School of Medicine , Winston-Salem , NC , USA
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15
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Howells LM, Chalmers JR, Cowdell F, Ratib S, Santer M, Thomas KS. 'When it goes back to my normal I suppose': a qualitative study using online focus groups to explore perceptions of 'control' among people with eczema and parents of children with eczema in the UK. BMJ Open 2017; 7:e017731. [PMID: 29146642 PMCID: PMC5695402 DOI: 10.1136/bmjopen-2017-017731] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To inform the development of a core outcome set for eczema by engaging with people with eczema and parents of children with eczema to understand their experiences and understanding of the concept 'eczema control'. DESIGN 37 participants took part in a total of six semi-structured online focus groups held in a typed chatroom with 5-7 participants per group. Three groups involved adults with eczema and three groups involved parents of children with eczema. Framework analysis was used for data analysis. SETTING A community-based sample was recruited from across the UK via social media and email. PARTICIPANTS 19 adults aged 17-61 years (15/19 female, 16/19 white) and 18 parents of children with eczema aged 9 months-17 years (9/18 female, 18/19 white). RESULTS Four main themes were identified:(1) 'Commonalities and differences in the experiences of control': a reduction in symptoms such as itch and sleep loss characterised eczema control, but what level was acceptable differed across participants;(2) 'Eczema control goes beyond the skin': psychological factors, social factors, the constant scratching and the impact on everyday activities are a variety of ways an individual can be impacted;(3) 'Stepping up and down of treatment': participants' stepped-up treatment in response to loss of control, but several factors complicated this behaviour. Control needed to be maintained after stepped-up treatment ended to be acceptable; and (4) 'How to measure control': self-report was generally preferred to allow frequent measurements and to capture unobservable features. Although most thought their eczema needed to be measured frequently, many also felt that this was not always realistic or desirable. CONCLUSIONS 'Eczema control' is a complex experience for people with eczema and parents of children with the condition. These experiences could have important implications on how long-term control should be measured in eczema clinical trials and clinical practice.
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Affiliation(s)
- Laura M Howells
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Fiona Cowdell
- Faculty of Health Education and Life Sciences, Birmingham City University, Birmingham, UK
| | - Sonia Ratib
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Miriam Santer
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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Udkoff J, Waldman A, Ahluwalia J, Borok J, Eichenfield LF. Current and emerging topical therapies for atopic dermatitis. Clin Dermatol 2017; 35:375-382. [DOI: 10.1016/j.clindermatol.2017.03.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
The purpose of this article is to review the current available material pertaining to atopic dermatitis, contact dermatitis, urticaria, and angioedema. This article focuses on each disease process's clinical presentation, diagnosis, and management. Although atopic dermatitis and contact dermatitis are similar, their development is different and can affect a patient's quality of life. Urticaria and angioedema are also similar, but the differentiation of the two processes is crucial in that they have significant morbidity and mortality, each with a different prognosis.
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Affiliation(s)
- Van Nguyen
- Department of Family Medicine, Loma Linda University, 25455 Barton Road, Suite 209B, Loma Linda, CA 92354, USA.
| | - Lauren Simon
- Department of Family Medicine, Loma Linda University, 25455 Barton Road, Suite 209B, Loma Linda, CA 92354, USA
| | - Ecler Jaqua
- Department of Family Medicine, Loma Linda University, 25455 Barton Road, Suite 209B, Loma Linda, CA 92354, USA
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Drug nanocarrier, the future of atopic diseases: Advanced drug delivery systems and smart management of disease. Colloids Surf B Biointerfaces 2016; 147:475-491. [DOI: 10.1016/j.colsurfb.2016.08.027] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 08/15/2016] [Accepted: 08/18/2016] [Indexed: 12/14/2022]
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Siegfried EC, Jaworski JC, Kaiser JD, Hebert AA. Systematic review of published trials: long-term safety of topical corticosteroids and topical calcineurin inhibitors in pediatric patients with atopic dermatitis. BMC Pediatr 2016; 16:75. [PMID: 27267134 PMCID: PMC4895880 DOI: 10.1186/s12887-016-0607-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 05/13/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Many clinicians have concerns about the safety of atopic dermatitis (AD) treatments, particularly in children requiring long-term daily maintenance therapy. Topical corticosteroids (TCS) have been widely used for >5 decades. Long-term TCS monotherapy has been associated with adverse cutaneous effects including atrophy, rebound flares, and increased percutaneous absorption with potential for adverse systemic effects. Topical calcineurin inhibitors (TCIs), tacrolimus and pimecrolimus, available for 1-2 decades, are not associated with atrophy or increased percutaneous absorption after prolonged use and have much lower potential for systemic effects. However, since 2006 TCIs have carried a controversial Boxed Warning based on a theoretical risk of malignancy (eg, skin and lymphoma) that has limited TCI use for standard-of-care maintenance therapy. METHODS A comparative systematic search of PubMed was done for long-term (≥12 week) clinical trials of TCS or TCI treatment in patients <12 years with AD. Citations were reviewed for inclusion based on MeSH terms, abstracts, and relevant article text. Studies were excluded if they did not encompass subjects <12 years, or were <12 weeks' duration, retrospective, meta-analyses, or limited to anecdotal case reports. RESULTS Of 27 trials meeting criteria, 21 included 5825 pediatric patients treated with TCIs, and 6 included 1999 patients treated with TCS. TCS studies were limited to low- to mid-potency products, and all but one study lacked a vehicle control. Eight TCI studies were vehicle-controlled, and safety data were well reported, with ≤5 % of patients reporting discontinuation due to adverse effects (DAEs). Cutaneous and systemic adverse events (AEs) were similar in TCI and vehicle groups, with no reports of lymphoma. Safety data in TCS trials were less well reported. DAE incidence was addressed in just 2 trials, and systemic and cutaneous AEs were mostly unreported. CONCLUSIONS Data supporting long-term use of TCIs are robust, documenting safety and efficacy, while data supporting long-term TCS use are limited to low- to mid-potency products. Our review identifies a lack of information on the safety of commonly prescribed, long-term monotherapy with mid- to high-potency TCS in pediatric AD, and supports standard-of-care maintenance therapy with TCIs and intermittent use of low- to mid-potency TCS for flares.
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Affiliation(s)
- Elaine C Siegfried
- Saint Louis University, Cardinal Glennon Children's Hospital, 1465 South Grand Avenue, St Louis, MO, 63104, USA.
| | - Jennifer C Jaworski
- Prescott Medical Communications Group, 205 North Michigan Avenue, Suite 3400, Chicago, IL, 60601, USA
| | - Jennifer D Kaiser
- Prescott Medical Communications Group, 205 North Michigan Avenue, Suite 3400, Chicago, IL, 60601, USA
| | - Adelaide A Hebert
- University of Texas-Houston Medical School, 6655 Travis, Suite 980, Houston, TX, 77030, USA
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Guthrie S, Bienkowska-Gibbs T, Manville C, Pollitt A, Kirtley A, Wooding S. The impact of the National Institute for Health Research Health Technology Assessment programme, 2003-13: a multimethod evaluation. Health Technol Assess 2016; 19:1-291. [PMID: 26307643 DOI: 10.3310/hta19670] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme supports research tailored to the needs of NHS decision-makers, patients and clinicians. This study reviewed the impact of the programme, from 2003 to 2013, on health, clinical practice, health policy, the economy and academia. It also considered how HTA could maintain and increase its impact. METHODS Interviews (n = 20): senior stakeholders from academia, policy-making organisations and the HTA programme. Bibliometric analysis: citation analysis of publications arising from HTA programme-funded research. Researchfish survey: electronic survey of all HTA grant holders. Payback case studies (n = 12): in-depth case studies of HTA programme-funded research. RESULTS We make the following observations about the impact, and routes to impact, of the HTA programme: it has had an impact on patients, primarily through changes in guidelines, but also directly (e.g. changing clinical practice); it has had an impact on UK health policy, through providing high-quality scientific evidence - its close relationships with the National Institute for Health and Care Excellence (NICE) and the National Screening Committee (NSC) contributed to the observed impact on health policy, although in some instances other organisations may better facilitate impact; HTA research is used outside the UK by other HTA organisations and systematic reviewers - the programme has an impact on HTA practice internationally as a leader in HTA research methods and the funding of HTA research; the work of the programme is of high academic quality - the Health Technology Assessment journal ensures that the vast majority of HTA programme-funded research is published in full, while the HTA programme still encourages publication in other peer-reviewed journals; academics agree that the programme has played an important role in building and retaining HTA research capacity in the UK; the HTA programme has played a role in increasing the focus on effectiveness and cost-effectiveness in medicine - it has also contributed to increasingly positive attitudes towards HTA research both within the research community and the NHS; and the HTA focuses resources on research that is of value to patients and the UK NHS, which would not otherwise be funded (e.g. where there is no commercial incentive to undertake research). The programme should consider the following to maintain and increase its impact: providing targeted support for dissemination, focusing resources when important results are unlikely to be implemented by other stakeholders, particularly when findings challenge vested interests; maintaining close relationships with NICE and the NSC, but also considering other potential users of HTA research; maintaining flexibility and good relationships with researchers, giving particular consideration to the Technology Assessment Report (TAR) programme and the potential for learning between TAR centres; maintaining the academic quality of the work and the focus on NHS need; considering funding research on the short-term costs of the implementation of new health technologies; improving the monitoring and evaluation of whether or not patient and public involvement influences research; improve the transparency of the priority-setting process; and continuing to monitor the impact and value of the programme to inform its future scientific and administrative development.
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Nankervis H, Thomas KS, Delamere FM, Barbarot S, Rogers NK, Williams HC. Scoping systematic review of treatments for eczema. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04070] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BackgroundEczema is a very common chronic inflammatory skin condition.ObjectivesTo update the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) systematic review of treatments for atopic eczema, published in 2000, and to inform health-care professionals, commissioners and patients about key treatment developments and research gaps.Data sourcesElectronic databases including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Skin Group Specialised Register, Latin American and Caribbean Health Sciences Literature (LILACS), Allied and Complementary Medicine Database (AMED) and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched from the end of 2000 to 31 August 2013. Retrieved articles were used to identify further randomised controlled trials (RCTs).Review methodsStudies were filtered according to inclusion criteria and agreed by consensus in cases of uncertainty. Abstracts were excluded and non-English-language papers were screened by international colleagues and data were extracted. Only RCTs of treatments for eczema were included, as other forms of evidence are associated with higher risks of bias. Inclusion criteria for studies included availability of data relevant to the therapeutic management of eczema; mention of randomisation; comparison of two or more treatments; and prospective data collection. Participants of all ages were included. Eczema diagnosis was determined by a clinician or according to published diagnostic criteria. The risk of bias was assessed using the Cochrane Collaboration risk-of-bias tool. We used a standardised approach to summarising the data and the assessment of risk of bias and we made a clear distinction between what the studies found and our own interpretation of study findings.ResultsOf 7198 references screened, 287 new trials were identified spanning 92 treatments. Trial reporting was generally poor (randomisation method: 2% high, 36% low, 62% unclear risk of bias; allocation concealment: 3% high, 15% low, 82% unclear risk of bias; blinding of the intervention: 15% high, 28% low, 57% unclear risk of bias). Only 22 (8%) trials were considered to be at low risk of bias for all three criteria. There was reasonable evidence of benefit for the topical medications tacrolimus, pimecrolimus and various corticosteroids (with tacrolimus superior to pimecrolimus and corticosteroids) for both treatment and flare prevention; oral ciclosporin; oral azathioprine; narrow band ultraviolet B (UVB) light; Atopiclair™ and education. There was reasonable evidence to suggest no clinically useful benefit for twice-daily compared with once-daily topical corticosteroids; corticosteroids containing antibiotics for non-infected eczema; probiotics; evening primrose and borage oil; ion-exchange water softeners; protease inhibitor SRD441 (Serentis Ltd); furfuryl palmitate in emollient; cipamfylline cream; andMycobacterium vaccaevaccine. Additional research evidence is needed for emollients, bath additives, antibacterials, specialist clothing and complementary and alternative therapies. There was no RCT evidence for topical corticosteroid dilution, impregnated bandages, soap avoidance, bathing frequency or allergy testing.LimitationsThe large scope of the review coupled with the heterogeneity of outcomes precluded formal meta-analyses. Our conclusions are still limited by a profusion of small, poorly reported studies.ConclusionsAlthough the evidence base of RCTs has increased considerably since the last NIHR HTA systematic review, the field is still severely hampered by poor design and reporting problems including failure to register trials and declare primary outcomes, small sample size, short follow-up duration and poor reporting of risk of bias. Key areas for further research identified by the review include the optimum use of emollients, bathing frequency, wash products, allergy testing and antiseptic treatments. Perhaps the greatest benefit identified is the use of twice weekly anti-inflammatory treatment to maintain disease remission. More studies need to be conducted in a primary care setting where most people with eczema are seen in the UK. Future studies need to use the same core set of outcomes that capture patient symptoms, clinical signs, quality of life and the chronic nature of the disease.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Helen Nankervis
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Finola M Delamere
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Sébastien Barbarot
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Natasha K Rogers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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23
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Galli E, Neri I, Ricci G, Baldo E, Barone M, Belloni Fortina A, Bernardini R, Berti I, Caffarelli C, Calamelli E, Capra L, Carello R, Cipriani F, Comberiati P, Diociaiuti A, El Hachem M, Fontana E, Gruber M, Haddock E, Maiello N, Meglio P, Patrizi A, Peroni D, Scarponi D, Wielander I, Eichenfield LF. Consensus Conference on Clinical Management of pediatric Atopic Dermatitis. Ital J Pediatr 2016; 42:26. [PMID: 26936273 PMCID: PMC4776387 DOI: 10.1186/s13052-016-0229-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 02/14/2016] [Indexed: 01/01/2023] Open
Abstract
The Italian Consensus Conference on clinical management of atopic dermatitis in children reflects the best and most recent scientific evidence, with the aim to provide specialists with a useful tool for managing this common, but complex clinical condition. Thanks to the contribution of experts in the field and members of the Italian Society of Pediatric Allergology and Immunology (SIAIP) and the Italian Society of Pediatric Dermatology (SIDerP), this Consensus statement integrates the basic principles of the most recent guidelines for the management of atopic dermatitis to facilitate a practical approach to the disease. The therapeutical approach should be adapted to the clinical severity and requires a tailored strategy to ensure good compliance by children and their parents. In this Consensus, levels and models of intervention are also enriched by the Italian experience to facilitate a practical approach to the disease.
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Affiliation(s)
- Elena Galli
- Pediatric Allergy Unit, Research Center, San Pietro Hospital - Fatebenefratelli, Rome, Italy.
| | - Iria Neri
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy.
| | - Giampaolo Ricci
- Pediatric Unit - Department of Medical and Surgical Sciences, S. Orsola Malpighi Hospital, University of Bologna, Pad. 16, Via Massarenti, 11 - 40138, Bologna, Italy.
| | - Ermanno Baldo
- Pediatric Department, "S. Maria del Carmine" Hospital of Rovereto, APSS (Provincial Agency for Health Services), Trento, Italy.
| | | | - Anna Belloni Fortina
- Pediatric Dermatology Unit, Department of Medicine, University of Padua, Padua, Italy.
| | | | - Irene Berti
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy.
| | - Carlo Caffarelli
- Pediatric Unit, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy.
| | - Elisabetta Calamelli
- Pediatric Unit - Department of Medical and Surgical Sciences, S. Orsola Malpighi Hospital, University of Bologna, Pad. 16, Via Massarenti, 11 - 40138, Bologna, Italy.
| | - Lucetta Capra
- Department of Medical Sciences, Section of Paediatrics, University of Ferrara, Ferrara, Italy.
| | - Rossella Carello
- Pediatric Allergy Unit, Research Center, San Pietro Hospital - Fatebenefratelli, Rome, Italy.
| | - Francesca Cipriani
- Pediatric Unit - Department of Medical and Surgical Sciences, S. Orsola Malpighi Hospital, University of Bologna, Pad. 16, Via Massarenti, 11 - 40138, Bologna, Italy.
| | | | - Andrea Diociaiuti
- Dermatology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Maya El Hachem
- Dermatology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Elena Fontana
- Pediatric Dermatology Unit, Department of Medicine, University of Padua, Padua, Italy.
| | - Michaela Gruber
- Department of Pediatrics, Central Hospital of Bolzano, Bolzano, Italy.
| | - Ellen Haddock
- Departments of Pediatrics and Dermatology, School of Medicine, University of California, San Diego, CA, USA.
| | - Nunzia Maiello
- Department of Woman, Child and General and Specialized Surgery, Second University of Naples, Naples, Italy.
| | - Paolo Meglio
- Primary Care Pediatrician, Health National Service, Rome, Italy.
| | - Annalisa Patrizi
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy.
| | - Diego Peroni
- Department of Medical Sciences, Section of Paediatrics, University of Ferrara, Ferrara, Italy.
| | - Dorella Scarponi
- Pediatric Unit - Department of Medical and Surgical Sciences, S. Orsola Malpighi Hospital, University of Bologna, Pad. 16, Via Massarenti, 11 - 40138, Bologna, Italy.
| | - Ingrid Wielander
- Department of Pediatrics, Central Hospital of Bolzano, Bolzano, Italy.
| | - Lawrence F Eichenfield
- Departments of Pediatrics and Dermatology, School of Medicine, University of California, San Diego, CA, USA.
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24
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Thomas W, Werner A, Frank A, Matthias A, Tilo B, Thomas D, Regina FH, Uwe G, Annice H, Julia K, Alexander K, Alexander N, Katja N, Hagen O, Bernhard P, Martin R, Martin S, Peter SG, Jochen S, Thomas S, Doris S, Margitta W. Leitlinie Neurodermitis [atopisches Ekzem; atopische Dermatitis]. J Dtsch Dermatol Ges 2015; 14:e1-75. [DOI: 10.1111/ddg.12884] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
| | - Aberer Werner
- Österreichische Gesellschaft für Dermatologie und Venerologie
| | - Ahrens Frank
- Gesellschaft für Pädiatrische Allergologie und Umweltmedizin e.V
| | - Augustin Matthias
- Arbeitsgemeinschaft Gesundheitsökonomie und Evidenzbasierte Medizin der Deutschen Dermatologischen Gesellschaft
| | | | - Diepgen Thomas
- Arbeitsgemeinschaft Berufs- und Umweltdermatologie der Deutschen Dermatologischen Gesellschaft
| | - Fölster-Holst Regina
- Arbeitsgemeinschaft Pädiatrische Dermatologie der Deutschen Dermatologischen Gesellschaft
| | | | | | | | - Kapp Alexander
- Deutsche Gesellschaft für Allergologie und Klinische Immunologie
| | - Nast Alexander
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V. (Moderation)
| | - Nemat Katja
- Berufsverband der Kinder- und Jugendärzte e.V
| | - Ott Hagen
- Deutsche Gesellschaft für Kinder- und Jugendmedizin e.V
| | - Przybilla Bernhard
- Arbeitsgemeinschaft Allergologie der Deutschen Dermatologischen Gesellschaft
| | | | | | | | | | | | - Staab Doris
- Arbeitsgemeinschaft Neurodermitisschulung e.V
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25
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Abstract
The approach to children and adults with atopic dermatitis is similar. In both age groups, failure to respond to conventional therapy should prompt evaluation for complicating factors such as secondary infection and secondary ACD. Immunologic, metabolic, genetic, and nutritional disorders should be considered in the differential diagnosis of refractory pediatric atopic dermatitis. Cutaneous T cell lymphoma (CTCL), cutaneous drug reactions, other spongiotic dermatoses, psoriasis, dermatomycosis, and infestations should be considered in the differential of refractory atopic dermatitis in adults. Systemic therapies prescribed to both children and adults with severe atopic dermatitis include oral corticosteroids, cyclosporine, methotrexate, azathioprine, and mycophenolate mofetil.
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Affiliation(s)
- Smita Awasthi
- Department of Pediatric and Adolescent Dermatology, Rady Children's Hospital, 8010 Frost Street, Suite 602, San Diego, CA 92123.
| | - Marti Jill Rothe
- Department of Dermatology, University of Connecticut Health Center, 21 South Rd, Farmington, CT 06032
| | - Lawrence F Eichenfield
- Department of Pediatric and Adolescent Dermatology, Rady Children's Hospital, 8010 Frost Street, Suite 602, San Diego, CA 92123
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26
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Hon KL, Tsang YCK, Pong NH, Luk DCK, Lee VW, Woo WM, Lam CYJ, Yeung YTE, Chau YSS, Chui KKK, Li KHG, Leung TF. Correlations among steroid fear, acceptability, usage frequency, quality of life and disease severity in childhood eczema. J DERMATOL TREAT 2015; 26:418-25. [PMID: 25895012 DOI: 10.3109/09546634.2015.1025030] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED Topical corticosteroids (CSs) are the mainstay of treatment for eczema but CS phobia and fears are prevalent and influence therapeutic efficacy. AIM To quantify if CS acceptability and fear affect patients' quality-of-life (QoL). METHODS Patients with eczema managed in the pediatric dermatology outpatient clinic of a university hospital were surveyed. Nottingham Eczema Severity Score (NESS) for severity, Children's Dermatology Life Quality Index (CDLQI) for QoL, CS fear, acceptability and reported frequency of CS use were measured with quantified questions. RESULTS CS fears were prevalent among parents and caregivers of patients with eczema. Fifty-eight percent of parents reported general acceptability of CS as being very good or good, and many applied CS to their child regularly every week. However, >40% of parents reported CS fear "always" or "often", 41% reported that they "always" or "often" apply CS only when eczema got worse, 57% would discuss CS fear with their doctors, 30% would request CS-sparing medications and 14% "always" or "often" use traditional Chinese herbal medicine. Fears were predominantly interpersonal and less often iatrogenic in nature. Skin problems were the most concerned side effects of CS. CS acceptability, frequency of CS usage, CS fear and usage of alternative medications were independent domains in eczema management: CS fears correlated with CDLQI; CS usage frequency correlated with NESS and negatively with parental education; and CS acceptability correlated with parental education. Ordinal logistic regressions showed worse QoL was associated with more CS fear (odds ratio: 1.092 [95% CI: 1.023-1.165], p = 0.008). CONCLUSIONS The extent of CS fears is independent of CS acceptability, but correlates with patients' QoL. Desensitization of parental CS fears should be integral part of eczema education and therapeutics in order to improve therapeutic efficacy and patients' QoL.
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Affiliation(s)
- Kam Lun Hon
- a Department of Paediatrics , The Chinese University of Hong Kong , Hong Kong , Hong Kong SAR , China
| | - Yin Ching K Tsang
- a Department of Paediatrics , The Chinese University of Hong Kong , Hong Kong , Hong Kong SAR , China
| | - Nga Hin Pong
- a Department of Paediatrics , The Chinese University of Hong Kong , Hong Kong , Hong Kong SAR , China
| | - David C K Luk
- b Department of Paediatrics & Adolescent Medicine , United Christian Hospital , Kwun Tong , Hong Kong SAR , China
| | - Vivian W Lee
- c School of Pharmacy, The Chinese University of Hong Kong , Hong Kong , Hong Kong SAR , China , and
| | - Wing Man Woo
- d Faculty of Medicine , The Chinese University of Hong Kong , Hong Kong , Hong Kong SAR , China
| | - Chak Yiu Justin Lam
- d Faculty of Medicine , The Chinese University of Hong Kong , Hong Kong , Hong Kong SAR , China
| | - Yun Ting Eunice Yeung
- d Faculty of Medicine , The Chinese University of Hong Kong , Hong Kong , Hong Kong SAR , China
| | - Yiu Shing Sunny Chau
- d Faculty of Medicine , The Chinese University of Hong Kong , Hong Kong , Hong Kong SAR , China
| | - Ka Kam Kenneth Chui
- d Faculty of Medicine , The Chinese University of Hong Kong , Hong Kong , Hong Kong SAR , China
| | - Ka Hin Gabriel Li
- d Faculty of Medicine , The Chinese University of Hong Kong , Hong Kong , Hong Kong SAR , China
| | - Ting Fan Leung
- a Department of Paediatrics , The Chinese University of Hong Kong , Hong Kong , Hong Kong SAR , China
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27
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Mooney E, Rademaker M, Dailey R, Daniel BS, Drummond C, Fischer G, Foster R, Grills C, Halbert A, Hill S, King E, Leins E, Morgan V, Phillips RJ, Relic J, Rodrigues M, Scardamaglia L, Smith S, Su J, Wargon O, Orchard D. Adverse effects of topical corticosteroids in paediatric eczema: Australasian consensus statement. Australas J Dermatol 2015; 56:241-51. [DOI: 10.1111/ajd.12313] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 01/08/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Emma Mooney
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
| | - Marius Rademaker
- Department of Dermatology; Waikato Hospital; Hamilton New Zealand
| | | | - Ben S Daniel
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
| | - Catherine Drummond
- Department of Dermatology; Canberra Hospital; Canberra Australian Capital Territory
- Australian National University; Canberra Australian Capital Territory
| | - Gayle Fischer
- Department of Dermatology; Royal North Shore Hospital; Sydney New South Wales
- Sydney Medical School; University of Sydney; Sydney New South Wales
| | - Rachael Foster
- Department Paediatric Dermatology; Princess Margaret Hospital for Children; Perth Western Australia Australia
| | - Claire Grills
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
| | - Anne Halbert
- Department Paediatric Dermatology; Princess Margaret Hospital for Children; Perth Western Australia Australia
| | - Sarah Hill
- Department of Dermatology; Waikato Hospital; Hamilton New Zealand
| | - Emma King
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
| | - Elizabeth Leins
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
| | - Vanessa Morgan
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
- Department of Dermatology; Royal Melbourne Hospital; Melbourne Victoria
| | - Roderic J Phillips
- Department of Paediatrics; Monash University; Melbourne Victoria
- Department of Vascular Biology; Royal Children's Hospital; Melbourne Victoria
- Murdoch Children's Research Institute; Melbourne Victoria
| | - John Relic
- Department of Dermatology; Royal Newcastle Centre; Newcastle New South Wales
| | - Michelle Rodrigues
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
- Department of Dermatology; St Vincent's Hospital; Melbourne Victoria
| | - Laura Scardamaglia
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
- University of Melbourne; Melbourne Victoria
- Department of Dermatology; Royal Melbourne Hospital; Melbourne Victoria
- Department of Dermatology; Western Hospital; Melbourne Victoria
| | - Saxon Smith
- Department of Dermatology; Royal North Shore Hospital; Sydney New South Wales
- Sydney Medical School; University of Sydney; Sydney New South Wales
| | - John Su
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
- University of Melbourne; Melbourne Victoria
- Department of Dermatology, Eastern Health; Murdoch Children's Research Institute; Melbourne Victoria
- Monash University; Melbourne Victoria
- Murdoch Children's Research Institute; Melbourne Victoria
| | - Orli Wargon
- Department Paediatric Dermatology; Sydney Children's Hospital; Sydney New South Wales
| | - David Orchard
- Department of Paediatric Dermatology; Royal Children's Hospital; Melbourne Victoria
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28
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Tang TS, Bieber T, Williams HC. Are the concepts of induction of remission and treatment of subclinical inflammation in atopic dermatitis clinically useful? J Allergy Clin Immunol 2014; 133:1615-25.e1. [DOI: 10.1016/j.jaci.2013.12.1079] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 12/19/2013] [Accepted: 12/20/2013] [Indexed: 11/25/2022]
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29
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Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol 2014; 71:116-32. [PMID: 24813302 DOI: 10.1016/j.jaad.2014.03.023] [Citation(s) in RCA: 753] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Revised: 03/13/2014] [Accepted: 03/13/2014] [Indexed: 12/22/2022]
Abstract
Atopic dermatitis is a common and chronic, pruritic inflammatory skin condition that can affect all age groups. This evidence-based guideline addresses important clinical questions that arise in its management. In this second of 4 sections, treatment of atopic dermatitis with nonpharmacologic interventions and pharmacologic topical therapies are reviewed. Where possible, suggestions on dosing and monitoring are given based on available evidence.
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30
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Langan S, Schmitt J, Williams H, Smith S, Thomas K. How are eczema ‘flares’ defined? A systematic review and recommendation for future studies. Br J Dermatol 2014; 170:548-56. [DOI: 10.1111/bjd.12747] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2013] [Indexed: 01/06/2023]
Affiliation(s)
- S.M. Langan
- Department of Epidemiology and Population Health; London School of Hygiene and Tropical Medicine; Keppel Street London WC1E 7HT U.K
| | - J. Schmitt
- Centre for Evidence-based Healthcare; Medizinische Fakultät Carl Gustav Carus, der Technischen Universität Dresden; Dresden Germany
| | - H.C. Williams
- Centre of Evidence-based Dermatology; University of Nottingham; Nottingham U.K
| | - S. Smith
- Centre of Evidence-based Dermatology; University of Nottingham; Nottingham U.K
| | - K.S. Thomas
- Centre of Evidence-based Dermatology; University of Nottingham; Nottingham U.K
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31
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Inoue Y, Maeda R, Furuya K, Isamu M, Masayuki K, Kanamoto I. Relationship between the usability and physicochemical properties of triamcinolone acetonide ointments. RESULTS IN PHARMA SCIENCES 2013; 3:15-9. [PMID: 25756000 PMCID: PMC3940594 DOI: 10.1016/j.rinphs.2013.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 10/29/2013] [Accepted: 10/30/2013] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to examine the physicochemical properties of TA ointments and conduct a human sensory test to assess the properties of those ointments. Physicochemical assessment was done via near-infrared (NIR) absorption spectroscopy, measurement of water content, microscopy, and measurement of viscoelasticity. The human sensory test examined 5 aspects (texture, cohesiveness, spreadability, smell, and feel). Three TA ointments were used: TA-A, a brand-name preparation, and TA-B and TA-C, two generics. The sensory test revealed significant differences between TA-A and TA-B and TA-C in terms of cohesiveness and spreadability. Significant differences between TA-A and TA-C and between TA-B and TA-C in terms of feel were noted. Microscopic examination revealed that TA-C had good dispersibility while TA-A and TA-B produced crystallization. NIR spectroscopy revealed differences in absorption spectra attributed to oil and water content in TAA, TA-B, and TA-C. Measurement of water content indicated water content of 0.06 ± 0.02% for TA-A, 0.08 ± 0.08% for TA-B, and 36.7 ± 1.19% for TA-C. Assessment of viscoelasticity indicated that stress decreased for all 3 ointments at 35 °C compared to that at 25 °C. TA-A and TA-B were found to have a higher percent decrease in stress than was TA-C. These findings indicate that differences in the types and content of additives caused differences in the physicochemical properties of individual ointments. In addition, differences in physicochemical properties presumably resulted in the close correlation between cohesiveness and spreadability in the sensory test.
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Affiliation(s)
- Yutaka Inoue
- Laboratory of Drug Safety Management, Faculty of Pharmaceutical Sciences, Josai University, 1-1 Keyakidai, Sakado-shi, Saitama 3500295, Japan
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Curto L, Carnero L, López-Aventin D, Traveria G, Roura G, Giménez-Arnau A. Fast itch relief in an experimental model for methylprednisolone aceponate topical corticosteroid activity, based on allergic contact eczema to nickel sulphate. J Eur Acad Dermatol Venereol 2013; 28:1356-62. [DOI: 10.1111/jdv.12292] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 09/18/2013] [Indexed: 01/06/2023]
Affiliation(s)
- L. Curto
- Department of Dermatology; Hospital del Mar; Universitat Autònoma; Barcelona Spain
| | - Ll. Carnero
- Department of Dermatology; Hospital del Mar; Universitat Autònoma; Barcelona Spain
| | - D. López-Aventin
- Department of Dermatology; Hospital del Mar; Universitat Autònoma; Barcelona Spain
| | | | - G. Roura
- Adknoma; Health Research; Barcelona Spain
| | - A.M. Giménez-Arnau
- Department of Dermatology; Hospital del Mar; Universitat Autònoma; Barcelona Spain
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33
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Dodington S, Basra M, Finlay A, Salek M. The Dermatitis Family Impact questionnaire: a review of its measurement properties and clinical application. Br J Dermatol 2013; 169:31-46. [DOI: 10.1111/bjd.12232] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Lebwohl MG, Del Rosso JQ, Abramovits W, Berman B, Cohen DE, Guttman E, Mancini AJ, Schachner LA. Pathways to managing atopic dermatitis: consensus from the experts. THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY 2013; 6:S2-S18. [PMID: 24171071 PMCID: PMC3809588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Mark G Lebwohl
- Professor & Chairman, Department of Dermatology The Icahn School of Medicine at Mount Sinai, New York, NY
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35
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Aronson PL, Shah SS, Mohamad Z, Yan AC. Topical corticosteroids and hospital length of stay in children with eczema herpeticum. Pediatr Dermatol 2013; 30:215-21. [PMID: 23039248 DOI: 10.1111/j.1525-1470.2012.01859.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
There is concern that the use of topical corticosteroids in patients with eczema herpeticum may facilitate dissemination of herpes simplex virus and worsen disease. Our primary aim therefore was to determine whether topical corticosteroid use in children hospitalized with eczema herpeticum is associated with longer hospital length of stay (LOS). We performed a multicenter retrospective cohort study of 1,331 children ages 2 months to 17 years admitted with a diagnosis of eczema herpeticum between January 1, 2001, and March 31, 2010, to 42 tertiary care children's hospitals in the Pediatric Health Information System database. Multivariable linear regression models determined the association between receipt of topical corticosteroid therapy on the first day of hospitalization and the main outcome measure: LOS. Receipt of topical corticosteroid therapy on day 1 of hospitalization was not associated with a longer LOS on unadjusted or multivariable analysis (p = 0.75). Receipt of topical calcineurin inhibitors during the hospitalization was also not associated with a longer LOS (p = 0.12). Receipt of systemic corticosteroids was associated with an 18% adjusted longer LOS (95% confidence interval 2%-36%; p = 0.03). Further study is needed to identify which children with eczema herpeticum may benefit from topical corticosteroids, but their use during active infection is not associated with poorer outcomes, although the use of systemic corticosteroids was associated with a longer LOS and should be avoided in patients with eczema herpeticum pending future prospective study.
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Affiliation(s)
- Paul L Aronson
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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Wootton CI, Koller K, Lawton S, O'Leary C, Thomas KS. Are accelerometers a useful tool for measuring disease activity in children with eczema? Validity, responsiveness to change, and acceptability of use in a clinical trial setting. Br J Dermatol 2012; 167:1131-7. [PMID: 22970691 DOI: 10.1111/j.1365-2133.2012.11184.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Actigraphy, which uses accelerometers to record movement, has been proposed as an objective method of itch assessment in eczema. Previous studies have found strong correlations with actigraphy and video surveillance, disease severity and biological markers in patients with eczema. OBJECTIVES To assess the validity of accelerometer data, its responsiveness to change and the practicality and acceptability of accelerometers when used as an outcome measure in a clinical trial. METHODS This study used data collected from 336 participants of the Softened Water Eczema Trial (SWET). Accelerometer data were compared with three standardized scales: Six Area, Six Sign Atopic Dermatitis (SASSAD) severity score, Patient Oriented Eczema Measure (POEM) and Dermatitis Family Impact (DFI). Spearman's rank testing was used for correlations. RESULTS Only 70% of trial participants had complete data, compared with 96% for the primary outcome (eczema severity - SASSAD). The convergent validity of accelerometer data with other measures of eczema severity was poor: correlation with SASSAD 0·15 (P = 0·02) and POEM 0·10 (P = 0·13). Assessing for divergent validity against quality of life measures, the correlation with the DFI was low (r = 0·29, P < 0·0001). Comparing the change scores from baseline to week 12 for SASSAD, POEM and DFI with the change in accelerometer scores we found low, negative correlations (r = -0·02, P = 0·77; r = -0·12, P = 0·06; and r = -0·01, P = 0·87, respectively). In general, the units were well tolerated but suggestions were made that could improve their usability in children. CONCLUSIONS Actigraphy did not correlate well with disease severity or quality of life when used as an objective outcome measure in a multicentre clinical trial, and was not responsive to change over time. Further work is needed to establish why this might be, and to establish improved methods of distinguishing between eczema-related and eczema-nonrelated movements.
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Abstract
Compliance raises very specific questions in dermatology related to the frequent use of local treatments: creams or ointments, including topical corticosteroids. The adherence in dermatology is a complex issue. It is difficult to quantify objectively because of the patient subjectivity, the constant adaptation to changes in the course of the disease, and due to the lack of adapted device. Moreover poor compliance may be related to topical corticosteroid phobia, defined as a fear vis-à-vis the topical corticosteroids, rational or not. The topical corticosteroid phobia is very common in the management of chronic inflammatory skin diseases especially in atopic dermatitis.
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Fukuyama T, Tajima Y, Hayashi K, Ueda H, Kosaka T. Prior or coinstantaneous oral exposure to environmental immunosuppressive agents aggravates mite allergen-induced atopic dermatitis-like immunoreaction in NC/Nga mice. Toxicology 2011; 289:132-40. [PMID: 21864637 DOI: 10.1016/j.tox.2011.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 08/04/2011] [Accepted: 08/06/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND Immunosuppressive environmental chemicals may increase the potency of allergens and thereby play a role in the development of allergic diseases such as allergic rhinitis, asthma and atopic dermatitis (AD). OBJECTIVES This study's primary objective was to examine the mechanisms behind the development of allergic diseases and immunosuppression induced by some environmental chemicals. We focused on the aggravation of AD by the organophosphorus pesticide O,O-diethyl-O-4-nitro-phenylthiophosphate (parathion) and the organochlorine pesticide 1,1,1-trichloro-2,2-bis(4-methoxyphenyl)ethane (methoxychlor), in NC/Nga mice sensitized with extract of Dermatophagoides farinae (Df). METHODS NC/Nga mice were exposed orally to parathion or methoxychlor prior or coinstantaneous with sensitization with Df. The mice were subsequently challenged with Df. One day after the last challenge with Df, we analyzed dermatitis severity and expression of genes in the ear auricle, immunoglobulin (Ig) E and IgG(2a) levels in serum, and in auricular lymph nodes, T- or B-cell numbers and cytokine production. RESULTS Prior exposure to parathion or methoxychlor induced marked increases in the following: dermatitis severity and gene expression in the ear auricle, IgE and IgG(2a) levels in serum, expression of surface antigens on helper T-cell and IgE-positive B-cell, production of Th1 and Th2 cytokines, and production of IgE in auricular lymph-node cells. In contrast, coinstantaneous exposure to parathion or methoxychlor yielded, at most, small but significant decreases in all parameters. CONCLUSIONS Our results indicate that atopic dermatitis can be aggravated by prior exposure to immunosuppressive environmental chemicals.
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Affiliation(s)
- T Fukuyama
- Institute of Environmental Toxicology, Ibaraki 303-0043, Japan.
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Lee SI, Kim J, Han Y, Ahn K. A proposal: Atopic Dermatitis Organizer (ADO) guideline for children. Asia Pac Allergy 2011; 1:53-63. [PMID: 22053298 PMCID: PMC3206255 DOI: 10.5415/apallergy.2011.1.2.53] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 07/10/2011] [Indexed: 01/28/2023] Open
Abstract
Atopic dermatitis (AD) is the most common chronic inflammatory skin disorder in children, with a worldwide cumulative prevalence in children of 8-20%. The number of AD patients is beyond the level that can be dealt with at clinics and it is time to make an effort to reduce the number of AD patients in the community. Thus, caregivers and all persons involved with AD management, including health care providers, educators, technologists and medical policy makers, should understand the development and the management of AD. Although a number of guidelines such as Practical Allergy (PRACTALL) report have been developed and used, community understanding of these is low. This is probably because there are still remarkable differences in management practices between specialists and between countries and most of the reported guidelines have been prepared for physicians. From the viewpoint of providing a basis for a multidisciplinary team approach, easily comprehensible guidelines for organizing treatment of AD, i.e. an Atopic Dermatitis Organizer (ADO), are required. guidelines should be simple and well organized. We suggest an easy approach with a new classification of AD symptoms into early and/or progressive lesions in acute and/or chronic symptoms. The contents of this ADO guideline basically consist of 3 steps approaches: conservative management, topical anti-inflammatory therapy, and systemic anti-inflammatory therapy.
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Affiliation(s)
- Sang-Il Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea
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Schmitt J, Apfelbacher CJ, Flohr C. Eczema. BMJ CLINICAL EVIDENCE 2011; 2011:1716. [PMID: 21609512 PMCID: PMC3217753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Eczema, as defined by the World Allergy Organization (WAO) revised nomenclature in 2003, affects 15% to 20% of school children and 2% to 5% of adults worldwide. About 50% of people with eczema demonstrate atopy, with specific immunoglobulin E responses to allergens. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of topical medical treatments, and dietary interventions in adults and children with established eczema? What are the effects of breastfeeding, reducing allergens, or dietary interventions for primary prevention of eczema in predisposed infants? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 54 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: breastfeeding, controlling house dust mites, corticosteroids, dietary exclusion of eggs or cow's milk, elementary diets, emollients, essential fatty oils, few-foods diet, multivitamins, pimecrolimus, probiotics, pyridoxine, reducing maternal dietary allergens, tacrolimus, vitamin E, and zinc supplements.
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Affiliation(s)
- Jochen Schmitt
- Department of Dermatology, Medical Faculty, Technische Universitat Dresden, Dresden, Germany
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Schmitt J, von Kobyletzki L, Svensson A, Apfelbacher C. Efficacy and tolerability of proactive treatment with topical corticosteroids and calcineurin inhibitors for atopic eczema: systematic review and meta-analysis of randomized controlled trials. Br J Dermatol 2010; 164:415-28. [PMID: 20819086 DOI: 10.1111/j.1365-2133.2010.10030.x] [Citation(s) in RCA: 184] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Long-term low-level topical anti-inflammatory therapy has been suggested as a new paradigm in the treatment of atopic eczema (AE). OBJECTIVES To determine the efficacy and tolerability of topical corticosteroids and calcineurin inhibitors for flare prevention in AE. METHODS Systematic review of randomized controlled trials reporting efficacy of topical corticosteroids and/or topical calcineurin inhibitors for flare prevention in AE. Identification of relevant articles by systematic electronic searches (Cochrane Library, Medline) supplemented by hand search. Primary efficacy endpoint: proportion of participants experiencing at least one flare during proactive anti-inflammatory treatment. Relative risks (RRs) and corresponding 95% confidence intervals (CIs) were calculated and pooled by pharmaceutical agent using random-effects meta-analysis. Sensitivity analysis included meta-regression to explore the influence of study-specific covariates. RESULTS Nine articles reporting on eight vehicle-controlled trials were included. Three, four and one trial(s) evaluated proactive therapy with topical tacrolimus, fluticasone propionate and methylprednisolone aceponate, respectively. Each agent under study was more efficacious to prevent flares than vehicle. Meta-analysis suggested that topical fluticasone propionate (RR 0·46, 95% CI 0·38-0·55) may be more efficacious to prevent disease flares than topical tacrolimus (RR 0·78, 95% CI 0·60-1·00). Meta-regression indicated robustness of these findings. Proactive anti-inflammatory therapy was generally well tolerated. The trials identified, however, do not allow firm conclusions about long-term safety. CONCLUSIONS Vehicle-controlled trials indicate efficacy of proactive treatment with tacrolimus, fluticasone propionate and methylprednisolone aceponate to prevent AE flares. Indirect evidence from vehicle-controlled trials suggests that twice weekly application of the potent topical corticosteroid fluticasone propionate may be more efficacious to prevent AE flares than tacrolimus ointment. Head to head trials should be conducted to confirm these results. Future studies are also needed to evaluate the long-term safety of proactive treatment of AE.
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Affiliation(s)
- J Schmitt
- Department of Dermatology, University Hospital Carl Gustav Carus, Technical University Dresden, D-01307 Dresden, Germany.
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Walling HW, Swick BL. Update on the management of chronic eczema: new approaches and emerging treatment options. Clin Cosmet Investig Dermatol 2010; 3:99-117. [PMID: 21437065 PMCID: PMC3047944 DOI: 10.2147/ccid.s6496] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Indexed: 01/24/2023]
Abstract
Atopic dermatitis (AD) is a common disease with worldwide prevalence, affecting up to 20% of children and 3% of adults. Recent evidence regarding pathogenesis has implicated epidermal barrier defects deriving from filagrin mutations with resulting secondary inflammation. In this report, the authors comprehensively review the literature on atopic dermatitis therapy, including topical and systemic options. Most cases of AD will benefit from emollients to enhance the barrier function of skin. Topical corticosteroids are first-line therapy for most cases of AD. Topical calcineurin inhibitors (tacrolimus ointment, pimecrolimus cream) are considered second line therapy. Several novel barrier-enhancing prescription creams are also available. Moderate to severe cases inadequately controlled with topical therapy may require phototherapy or systemic therapy. The most commonly employed phototherapy modalites are narrow-band UVB, broadband UVB, and UVA1. Traditional systemic therapies include short-term corticosteroids, cyclosporine (considered to be the gold standard), methotrexate, azathioprine, mycophenolate mofetil, and most recently leflunamide. Biologic therapies include recombinant monoclonal antibodies acting on the immunoglobulin E / interleukin-5 pathway (omalizumab, mepolizumab), acting as tumor necrosis factor-α inhibitors (infliximab, etanercept, adalimumab), and acting as T-cell (alefacept) and B-cell (rituxumab) inhibitors, as well as interferon γ and intravenous immunoglobulin. Efficacy, safety, and tolerability are reviewed for each medication.
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Bieber T. Atopic dermatitis. Ann Dermatol 2010; 22:125-37. [PMID: 20548901 DOI: 10.5021/ad.2010.22.2.125] [Citation(s) in RCA: 428] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Revised: 04/28/2010] [Accepted: 04/30/2010] [Indexed: 12/14/2022] Open
Abstract
Atopic dermatitis (AD) is a chronic and relapsing disease affecting an increasing number of patients. Usually starting in early childhood, AD can be the initial step of the so-called atopic march, i.e. followed by allergic rhinitis and allergic asthma. AD is a paradigmatic genetically complex disease involving gene-gene and gene-environment interactions. Genetic linkage analysis as well as association studies have identified several candidate genes linked to either the epidermal barrier function or to the immune system. Stress, bacterial or viral infections, the exposure to aero- or food-allergens as well as hygienic factors are discussed to aggravate symptoms of AD. Athough generalized Th2-deviated immune response is closely linked to the condition of AD, the skin disease itself is a biphasic inflammation with an initial Th2 phase and while chronic lesions harbour Th0/Th1 cells. Regulatory T cells have been shown to be altered in AD as well as the innate immune system in the skin. The main treatment-goals include the elimination of inflammation and infection, preserving and restoring the barrier function and controlling exacerbating factors. The overall future strategy in AD will be aimed to control skin inflammation by a more proactive management in order to potentially prevent the emergence of sensitization as well as to design customized management based on genetic and pathophysiologic information.
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Affiliation(s)
- Thomas Bieber
- Department of Dermatology and Allergy, Friedrich-Wilhelms-University, Bonn, Germany
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Farhi D, Taïeb A, Tilles G, Wallach D. The historical basis of a misconception leading to undertreating atopic dermatitis (eczema):facts and controversies. Clin Dermatol 2010; 28:45-51. [DOI: 10.1016/j.clindermatol.2009.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Lynde C, Barber K, Claveau J, Gratton D, Ho V, Krafchik B, Langley R, Marcoux D, Murray E, Shear N. Canadian practical guide for the treatment and management of atopic dermatitis. J Cutan Med Surg 2009; 8 Suppl 5:1-9. [PMID: 19830906 DOI: 10.1007/s10227-005-8080-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Atopic dermatitis is a common condition, with a lifetime prevalence of approximately 10% to 20% among the Canadian population. A clear, practical, Canadian guideline for the management of these patients has been lacking. OBJECTIVE To provide primary-care physicians, pediatricians and dermatologists with the first practical and comprehensive set of Canadian recommendations for the management of atopic dermatitis. METHODS A group of Canadian dermatologists convened to review the current issues of diagnosis, treatment and international guidelines and adapt them to the Canadian context. The reviewers used the latest clinical trial data on atopic dermatitis, complemented by clinical experience, to develop the consensus recommendations found in this review. RESULTS In the present report, following a brief review of the epidemiology of and clinical diagnosis criteria for atopic dermatitis, the recommendations for treatment and management are detailed. These recommendations, which are intended to provide clinicians with a useful and valuable tool to help manage their patients with atopic dermatitis, are divided into the following sections: epidemiology, diagnosis, general measures/skin care, acute management of atopic dermatitis, long-term management/disease control, adjunct therapies, and considerations for switching between antiinflammatory therapies/handling treatment failure. General measures discussed include hydration with bathing and the use of moisturizers. Management strategies discussed include topical corticosteroids, topical calcineurin inhibitors, antihistamines and anti-infectives. A management algorithm is also presented.
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Kirkup ME, Birchall NM, Weinberg EG, Helm K, Kennedy CTC. Acute and maintenance treatment of atopic dermatitis in children – two comparative studies with fluticasone propionate (0.05%) cream. J DERMATOL TREAT 2009; 14:141-8. [PMID: 14522623 DOI: 10.1080/09546630310013388] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Two multicentre, randomised, parallel group, double-blind, comparative studies in children (2-14 yr) evaluated fluticasone propionate (FP) 0.05% cream for both acute and maintenance treatment of moderate to severe atopic dermatitis (AD). METHODS One study compared FP with hydrocortisone (HC) 1% cream (FP 70, HC 67) and the other with hydrocortisone butyrate (HCB) 0.1% cream (FP 67, HCB 62). Treatments were applied twice daily, for 2-4 weeks until the AD was stabilised, and thereafter intermittently ('as required') for up to 12 weeks. RESULTS The primary outcome measure, Total AD Score, recorded at the end of the acute and maintenance phases, was significantly lower (indicating improvements in disease severity) following treatment with FP compared with either HC or HCB (acute phase difference vs. HC, -2.39, 95%CI -3.47, -1.31; p<0.001 and vs. HCB, -1.25, 95%CI -2.46, -0.05; p=0.042) and (maintenance phase difference vs. HC, -1.88, 95%CI -3.20, -0.56; p=0.006 and vs. HCB, -1.39, 95%CI -2.72, -0.05; p=0.042). In both studies treatments were equally well tolerated with no visible signs of skin atrophy. CONCLUSION In both the acute and longer term management of AD in children, FP demonstrated a high level of efficacy and maintenance of disease control with a tolerability similar to HC 1%, a lower potency corticosteroid.
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Affiliation(s)
- M E Kirkup
- Bristol Royal Infirmary and Bristol Royal Hospital for Sick Children, Bristol, UK.
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Yokoi K, Kawaai T, Konomi A, Uchida Y. Dermal absorption of inorganic germanium in rats. Regul Toxicol Pharmacol 2008; 52:169-73. [DOI: 10.1016/j.yrtph.2008.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2008] [Revised: 07/07/2008] [Accepted: 07/11/2008] [Indexed: 11/26/2022]
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Thomas KS, Sach TH. A multicentre randomized controlled trial of ion-exchange water softeners for the treatment of eczema in children: protocol for the Softened Water Eczema Trial (SWET) (ISRCTN: 71423189). Br J Dermatol 2008; 159:561-6. [PMID: 18616772 DOI: 10.1111/j.1365-2133.2008.08704.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is epidemiological evidence linking increased water hardness with increased eczema prevalence. A number of plausible mechanisms can be forwarded to suggest why hard water could exacerbate eczema. The most likely explanation is increased soap usage in hard water areas, the deposits of which can cause skin irritation in individuals with eczema. OBJECTIVES To assess the cost and cost-effectiveness of ion-exchange water softeners for the treatment of eczema in children. PATIENTS/METHODS Three hundred and ten children aged 6 months to 16 years, with moderate to severe eczema. The children must live in hard water areas (>or= 200 mg L(-1) of calcium carbonate) and have a home that is suitable for the installation of a water softener. This is a single-blind, parallel-group, randomized controlled trial of 12 weeks duration followed by a 4-week cross-over period. RESULTS/ANALYSIS PLAN: PRIMARY OUTCOME difference in the mean change in disease severity (Six Area, Six Sign Atopic Dermatitis score) at 12 weeks compared with baseline. SECONDARY OUTCOMES (i) proportion of time spent moving during the night; (ii) self-reported global changes in eczema severity; (iii) amount of topical treatment used; (iv) Patient Oriented Eczema Measure; (v) number of totally controlled and well controlled weeks; (vi) impact on health-related quality of life for the child (EQ-5D) and the family (Dermatitis Family Impact questionnaire); and (vii) cost-effectiveness. It is planned that recruitment will be completed by the end of 2008 and results will be available towards the end of 2009.
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Affiliation(s)
- K S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, King's Meadow Campus, UK.
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Fleischer AB. Diagnosis and management of common dermatoses in children: atopic, seborrheic, and contact dermatitis. Clin Pediatr (Phila) 2008; 47:332-46. [PMID: 18057146 DOI: 10.1177/0009922807309421] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Atopic, seborrheic, and contact dermatitis can significantly reduce the quality of life of patients and their families. Although differing in specific aspects of their epidemiology, etiology, and pathobiology, all 3 dermatoses are common in the pediatric population, and they share a common treatment approach. Although effective and widely used to manage exacerbations of pediatric dermatitis, the use of topical corticosteroid remains a concern for some physicians and parents because of its potential for systemic absorption and adverse events associated with prolonged use. Newer additions to the dermatitis treatment algorithm, such as the topical calcineurin inhibitors, may provide an effective steroid-sparing treatment option. Adjuvant treatments, such as antihistamines, antifungals, and antibiotics, also can provide benefit in appropriate circumstances. As there is no cure for dermatitis, a comprehensive, multipronged management strategy of preventive measures, such as trigger avoidance and periodic pharmacologic treatment, will provide patients and caregivers with the best opportunity to successfully control the disease.
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Affiliation(s)
- Alan B Fleischer
- Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
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Peserico A, Städtler G, Sebastian M, Fernandez RS, Vick K, Bieber T. Reduction of relapses of atopic dermatitis with methylprednisolone aceponate cream twice weekly in addition to maintenance treatment with emollient: a multicentre, randomized, double-blind, controlled study. Br J Dermatol 2008; 158:801-7. [DOI: 10.1111/j.1365-2133.2008.08436.x] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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