Safety and efficacy of topical calcineurin inhibitors in the treatment of childhood atopic dermatitis

Recent Advances in Phytochemical-Based Topical Applications for the Management of Eczema: A Review

Eczema (atopic dermatitis, AD) is a skin disease characterized by skin barrier dysfunction due to various factors, including genetics, immune system abnormalities, and environmental triggers. Application of emollients and topical drugs such as corticosteroids and calcineurin inhibitors form the mainstay of treatments for this challenging condition. This review aims to summarize the recent advances made in phytochemical-based topical applications to treat AD and the different carriers that are being used. In this review, the clinical efficacy of several plant extracts and bioactive phytochemical compounds in treating AD are discussed. The anti-atopic effects of the herbs are evident through improvements in the Scoring Atopic Dermatitis (SCORAD) index, reduced epidermal thickness, decreased transepidermal water loss, and alleviated itching and dryness in individuals affected by AD as well as in AD mouse models. Histopathological studies and serum analyses conducted in AD mouse models demonstrated a reduction in key inflammatory factors, including thymic stromal lymphopoietin (TSLP), serum immunoglobulin E (IgE), and interleukins (IL). Additionally, there was an observed upregulation of the filaggrin (FLG) gene, which regulates the proteins constituting the stratum corneum, the outermost layer of the epidermis. Carriers play a crucial role in topical drug applications, influencing dose delivery, retention, and bioavailability. This discussion delves into the efficacy of various nanocarriers, including liposomes, ethosomes, nanoemulsions, micelles, nanocrystals, solid-lipid nanoparticles, and polymeric nanoparticles. Consequently, the potential long-term side effects such as atrophy, eruptions, lymphoma, pain, and allergic reactions that are associated with current topical treatments, including emollients, topical corticosteroids, topical calcineurin inhibitors, and crisaborole, can potentially be mitigated through the use of phytochemical-based natural topical treatments.

Topical Prescription Management

With recent advances in topical therapies for atopic dermatitis (AD), steroid-sparing options like calcineurin inhibitors, Janus kinase (JAK) inhibitors, and phosphodiesterase-4 (PDE-4) inhibitors are becoming mainstays in therapy, underscoring the importance of careful selection and usage of topical corticosteroids (TCSs) to minimize side effects. Alongside the necessity of emollient use, these steroid-sparing alternatives offer rapid itch relief and efficacy in improving disease severity. While TCSs still hold a prominent role in AD management, promising novel topical treatments like tapinarof and live biotherapeutics to modulate the skin microbiome are also discussed. Overall, the recent addition of novel topical therapies offers diverse options for AD management and underscores the importance of topical treatments in the management of AD.

A comparative randomized clinical trial evaluating the efficacy and safety of tacrolimus versus hydrocortisone as a topical treatment of atopic dermatitis in children

Background: Atopic dermatitis (AD) aetiology is not exactly identified, but it is characterized by pruritic skin reactions with elevation in the levels of inflammatory markers. Despite the fact that Corticosteroids are the mainstay therapy in the management of AD, they have many local and systemic adverse effects. Objective: The aim of this study is to evaluate the efficacy and safety of topical tacrolimus ointment in comparison to topical hydrocortisone cream in the management of the AD of children diagnosed with AD. Patients and Methods: This study was conducted on 200 children with AD. They were simply randomized into two groups, the tacrolimus group treated with 0.03% topical tacrolimus ointment and the hydrocortisone group treated with 1% hydrocortisone cream twice daily during the 3 weeks study period. Results: At the end of the study, both the tacrolimus and hydrocortisone groups showed a significant decline in the mean serum level of IL-10, IL-17, and IL-23 (p < 0.05) when compared to their baseline levels. However, the tacrolimus group showed a more significant decrease (p < 0.05) in the mean serum level of IL-10, IL-17, and IL-23 as compared to the hydrocortisone group [Mean differences = 1.600, 95% CI: 0.9858-2.214; 1.300, 95% CI: 1.086-1.514 and 4.200, 95% CI: 3.321-5.079]. Moreover, the median mEASI decreased similarly from 32 to 21 in the tacrolimus group and from 30 to 22 in the hydrocortisone group (p > 0.05) [Median difference = -2.000, 95% CI: -2.651 to -1.349; Median difference = 1.000, 95% CI: 0.3489-1.651]. Mild to moderate transient stinging and erythema were the main adverse effects that showed higher incidence in the tacrolimus group than in the hydrocortisone group (p < 0.05). In most cases, they resolved within 3-4 days. Besides, tacrolimus ointment did not cause skin atrophy as compared to the hydrocortisone group (p < 0.05). Conclusion: Tacrolimus ointment is more beneficial than hydrocortisone cream in managing AD in children in terms of lowering the inflammatory markers, however, there is no difference on the dermatitis severity scale. Moreover, tacrolimus is safer with a better side effect profile compared to hydrocortisone. Trial Registration: The trial is registered at ClinicalTrials.gov (CT.gov identifier: NCT05324618).

Shedding light on key pharmacological knowledge and strategies for pediatric atopic dermatitis

INTRODUCTION

Atopic dermatitis (AD) is an inflammatory disease affecting over 20% of the pediatric population, with 85% of cases presenting before the age of five. Recently, therapeutic options in pediatric patients have evolved rapidly, following extensive development in adult treatments.

AREAS COVERED

This review will encompass relevant molecular drivers, along with an overlook on treatment modalities in pediatric AD, as well as a summary of pipeline treatments in clinical trials for pediatric patients from PubMed, Google Scholar, and Clinicaltrials.gov up to July 2022. Topical corticosteroids are the mainstay for AD flares in adults and children. Topical approved agents in pediatric AD are calcineurin inhibitors, crisaborolecrisaborole, and ruxolitinib. Dupilumab is the only FDA approved biologic for patients with AD from six months of age. A Janus kinase inhibitor, upadacitinib, is a systemic treatment approved for pediatric AD patients (age >12 years). Systemic immunosuppressants used in pediatric AD include methotrexate, azathioprine, cyclosporinecyclosporine, and mycophenolate mofetil.

EXPERT OPINION

Data regarding disease prevention are conflicting, however, an abundance of research has transpired regarding amelioration of symptoms and induction of disease clearance by targeting numerous pathological mechanisms. Understanding the pediatric AD phenotype will further advance the field and the development of improved therapeutics.

The efficacy and safety of lebrikizumab monotherapy for the management of moderate-to-severe atopic dermatitis: A systematic review and meta-analysis

Background

Atopic dermatitis (AD) is a chronically relapsing disease. Few biologics are approved for moderate-to-severe AD, and novel interventions are emerging. We aimed to evaluate the safety and efficacy of lebrikizumab, an IL-13 immunomodulator, as monotherapy vs. placebo in treating moderate-to-severe AD.

Methods

Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, and ClinicalTrials.gov registry (CT.gov) databases were systematically searched. We evaluated lebrikizumab vs. placebo and measured efficacy using Eczema Area and Severity Index (EASI), Body Surface Area (BSA), and Investigator's Global Assessment (IGA) change from baseline to week 16. Safety was evaluated by the incidence of serious adverse events (SAEs), non-serious adverse events (NSAEs), and mortality. The risk of bias was investigated using the Revised Cochrane risk of bias tool.

Results

Three RCTs (n = 1,149) included 543 (47.25%) men vs. 606 (52.75%) women. Meta-analysis showed statistically significant improvement in EASI, IGA, and BSA. EASI75 at week 16 for all regimens was (RR = 2.62, 95% CI [2.06, 3.34], p < 0.00001) with the first regimen (500 mg loading dose then 200 mg every 2 weeks) showing the most significant improvement (RR = 3.02, 95% CI [2.39, 3.82], p < 0.00001). The pooled analysis of safety outcomes concluded that lebrikizumab did not correlate significantly with the incidence of SAEs, NSAEs, and mortality.

Conclusion

Overall, lebrikizumab showed a significant improvement in all efficacy outcomes. Additionally, it did not contribute to any significant incidence of SAEs, NSAEs, or mortality. The risk of bias in included RCTs was minor except in the randomization domain. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessment of the outcomes ranged from low to high, but predominantly high certainty of evidence.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022362438.

Advances in Current Drugs and Formulations for the Management of Atopic Dermatitis

Atopic dermatitis (AD) is a chronic, relapsing inflammatory skin disease with a complex pathophysiology. Treatment of AD remains challenging owing to the presence of a wide spectrum of clinical phenotypes and limited response to existing therapies. However, recent genetic, immunological, and pathophysiological insights into the disease mechanism resulted in the invention of novel therapeutic drug candidates. This review provides a comprehensive overview of current therapies and assesses various novel drug delivery strategies currently under clinical investigation. Further, this review majorly emphasizes on various topical treatments including emollient therapies, barrier repair agents, topical corticosteroids (TCS), phosphodiesterase 4 (PDE4) inhibitors, calcineurin inhibitors, and Janus kinase (JAK)-signal transducer and activator of transcription (STAT) pathway inhibitors. It also discusses biological and systemic therapies, upcoming treatments based on ongoing clinical trials. Additionally, this review scrutinized the use of pharmaceutical inactive ingredients in the approved topical dosage forms for AD treatment.

Taiwan guidelines for the diagnosis and management of pediatric atopic dermatitis: Consensus statement of the Taiwan Academy of Pediatric Allergy, Asthma and Immunology

Atopic dermatitis (also known as atopic eczema) is a chronic relapsing inflammatory skin disease commonly seen in children, with increasing prevalence over the past few decades in many countries including Taiwan. The management of pediatric atopic dermatitis can be challenging, particularly as treatment options are expanding with the emergence of novel systemic and topical anti-inflammatory medications in recent years. The Taiwan Academy of Pediatric Allergy, Asthma and Immunology (TAPAAI) has developed the Taiwan guidelines for the diagnosis and management of pediatric atopic dermatitis, which provides a concise overview of its epidemiology, clinical characteristics and diagnosis, mechanisms, treatments, and education. The contents of this guideline integrate the principles of recent national and international guidelines for the diagnosis and management of atopic dermatitis, latest research findings, and expert opinions of experienced pediatric allergy specialists in Taiwan. For practical purposes, this guideline presents simplified and easy-to-use diagnostic criteria and severity grading for pediatric atopic dermatitis. A stepwise treatment algorithm is also proposed to expedite rational, cost-effective, and evidence-based management strategy. This guideline, developed based on current best evidence and real-world experience of pediatric allergy experts in Taiwan, is intended to facilitate practical, up-to-date management of pediatric atopic dermatitis among physicians.

Appraisal of Proactive Topical Therapy in Atopic Dermatitis: Pros and Cons

Atopic dermatitis is a common inflammatory skin disease that can affect both children and adults. It is a chronic disease with recurrent, highly pruritic eczematous lesions. Topical treatment with anti-inflammatory agents is the mainstay of treatment for atopic dermatitis, either in a reactive or proactive approach according to severity of the disease and always in combination with daily application of an emollient cream. Several studies have shown that proactive therapy with either topical corticosteroids or topical calcineurin inhibitors is significantly superior at reducing the number of flares and increasing the interval between flares compared with reactive therapy in patients with moderate and severe disease. The risk of side effects is considered low, and there seem to be no extra economic costs related to this treatment approach. Proactive therapy is an advisable treatment option for patients with moderate and severe atopic dermatitis to gain prolonged disease control; however, long-term safety data and data on when to stop do not yet exist.

Topical calcineurin inhibitors as a double-edged sword in rosacea: A systematic review

BACKGROUND

Rosacea is a chronic inflammatory disease mainly with skin or ocular manifestations. Topical calcineurin inhibitors, pimecrolimus and tacrolimus, can be used to treat rosacea. However, they can also induce rosacea-like eruptions.

AIMS

This study systematically reviewed the double-edged sword effects of pimecrolimus and tacrolimus on rosacea.

METHODS

Four databases were retrieved to search for articles on the effects of pimecrolimus and tacrolimus on rosacea, including Cochrane Library, Embase, PubMed, and Web of Science. Only English articles were included in the systematic review. Relevant data were collected, and the levels of evidence were evaluated.

RESULTS

28 articles published between 2001 and 2016 were included. 11 articles were about pimecrolimus as the treatment of rosacea, 4 articles were about the pimecrolimus-induced rosacea, 9 articles were about tacrolimus as the treatment of rosacea, and 4 articles were about tacrolimus-induced rosacea. Participants for each study ranged from 1 to 200. Several types of outcome measurements were used for these publications.

CONCLUSIONS

Both pimecrolimus and tacrolimus might have double-edged sword effects on rosacea. Pimecrolimus and tacrolimus could be effective for rosacea. However, both of them could also induce rosacea. Larger, randomized, controlled studies on pimecrolimus and tacrolimus as the treatment of rosacea and studies on the mechanisms of pimecrolimus and tacrolimus in treating or inducing rosacea are needed. This systematic review emphasized the double-edged sword role of topical calcineurin inhibitors in rosacea, which may pave the way for future research.

Efficacy and safety of 0.0584% hydrocortisone aceponate topical spray and systemic oclacitinib combination therapy in dogs with atopic dermatitis: a randomized, double-blinded, placebo-controlled trial

BACKGROUND

Oclacitinib is an effective systemic therapy for dogs with atopic dermatitis (AD). Few studies have evaluated concurrent topical treatment with oclacitinib in dogs.

OBJECTIVES

To evaluate the efficacy and safety of combination therapy of oclacitinib and 0.0584% hydrocortisone aceponate (HCA) spray in dogs with AD.

ANIMALS

Eighteen dogs with AD.

METHODS AND MATERIALS

This study was a randomized, double-blinded, placebo-controlled trial. All dogs were treated with oclacitinib (0.4-0.6 mg/kg twice daily for 14 days, then once daily for 14 days) and randomized to receive either HCA spray or placebo spray, applied once daily for seven days then every other day through to Day (D)28. Clinical assessments included the Canine Atopic Dermatitis Extent and Severity Index, 4^th iteration (CADESI-4) and the pruritus Visual Analog Scale (PVAS) every seven days, and blood and urine tests every 14 days.

RESULTS

The mean CADESI-4 and PVAS scores were significantly reduced on D7 and D14 compared to D0 in both groups (P < 0.05). From D14 to D21, CADESI-4 and PVAS scores were significantly increased in the placebo group (P < 0.005), and not in the HCA-treated group. The mean reduction from baseline of the HCA-treated group was significantly higher than that of the placebo group for the PVAS and CADESI-4 on D21 (59.9% versus 27.6%, P = 0.0216) and D28 (56.0% versus 30.5%, P = 0.0109), respectively. One dog in the HCA-treated group was withdrawn as a consequence of developing diarrhoea.

CONCLUSION

Topical application of 0.0584% HCA spray may be useful for preventing exacerbation of pruritus and clinical lesions when tapering oclacitinib therapy in dogs with AD.

Pharmacological management of atopic dermatitis in the elderly

INTRODUCTION

The prevalence of atopic dermatitis (AD) in geriatric populations of industrialized countries is currently estimated at 3-4% and continues to increase. AD is associated with significant morbidity, increased susceptibility to infection, and symptoms of pruritus and pain. Treatments may negatively affect elderly patients; thus, plans should be optimized for this population.

AREAS COVERED

This review summarizes treatment options for AD in the elderly. A systematic review of the literature was conducted using the key terms atopic dermatitis, elderly, geriatric, systemic therapy, therapy, and topical therapy in PubMed. Searches yielded articles on skincare management and topical and systemic pharmacotherapies.

EXPERT OPINION

Proper use of moisturizer is crucial in all patients with AD. Topical corticosteroids are commonly prescribed; however, they carry an increased risk of adverse events such as skin atrophy. Systemic corticosteroids should be avoided in elderly patients due to questionable efficacy and increased adverse events. Topical calcineurin inhibitors and crisaborole are similarly efficacious with an excellent safety profile. Cyclosporine, azathioprine, methotrexate, and mycophenolate mofetil are systemic agents available for the treatment of refractory AD; however, insufficient data exist to indicate the superiority of any one agent. Dupilumab is a safe and efficacious injectable therapy in elderly patients.

Application of Topical Phosphodiesterase 4 Inhibitors in Mild to Moderate Atopic Dermatitis: A Systematic Review and Meta-analysis

Importance

Topical medication is the central treatment for patients with atopic dermatitis (AD), but the options are limited. Phosphodiesterase 4 (PDE4) inhibitors are a new candidate for AD therapy.

Objective

To evaluate the efficacy and safety of topical PDE4 inhibitors in mild to moderate AD.

Data Sources

Clinical trials were identified from MEDLINE, Embase, Cochrane Controlled Register of Trials, Chinese medical databases (Wanfang, Chinese National Knowledge Infrastructure, Chinese Biomedical Literature Database, and China Science and Technology Journal Database), ClinicalTrials.gov, and other trial registries from inception to August 15, 2018. No restrictions on languages were placed.

Study Selection

Only double-blind randomized clinical trials with topical PDE4 inhibitors vs topical vehicle treatment for patients with mild to moderate AD were included.

Data Extraction and Synthesis

Two reviewers independently extracted study features, intervention details, and outcomes. A meta-analysis was performed using the random-effects model. The Cochrane Collaboration's risk of bias assessment tool was used to assess the risk of bias. Funnel plots and Egger tests were used to assess the publication bias.

Main Outcomes and Measures

Changes from baseline in target lesion score were expressed in terms of standardized mean differences (SMDs) with 95% CIs. Outcomes of investigators' assessment and safety were expressed in terms of relative risk with 95% CIs.

Results

Seven studies were identified, which included 1869 patients with mild to moderate AD. Overall, compared with the topical vehicle control, topical application of PDE4 inhibitors was associated with a significant decrease in target lesion score (SMD -0.40; 95% CI, -0.61 to -0.18; P < .001) and a higher response rate in investigators' assessment of clear or almost clear skin (relative risk, 1.50; 95% CI, 1.33-1.70; P < .001). There was no difference in treatment-related adverse events or in adverse events that required discontinuation of therapy. Subgroup analyses indicated that after 14 and 28 days of therapy with PDE4 inhibitors, target lesion score was significantly decreased. However, these beneficial effects were displayed only for the PDE4 inhibitors crisaborole and AN2898 (crisaborole at day 14: SMD, -0.59; 95% CI, -1.15 to -0.02; P = .04; AN2898 at day 14: SMD, -0.76; 95% CI, -1.38 to -0.13; P = .02; crisaborole at day 28: SMD, -0.86; 95% CI, -1.44 to -0.28; P = .004; AN2898 at day 28: SMD, -0.68; 95% CI, -1.30 to -0.05; P = .03). Heterogeneity was not significant across studies.

Conclusions and Relevance

This meta-analysis suggests that topical PDE4 inhibitors are a safe and effective treatment for mild to moderate AD. Current evidence supports the use of crisaborole or AN2898 as the choice of maintenance or sequential therapy for mild to moderate AD.

Childhood atopic dermatitis: current developments, treatment approaches, and future expectations

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.

Therapeutic effectiveness of calcineurin inhibitors in canine vesicular cutaneous lupus erythematosus

BACKGROUND

Oral and topical calcineurin inhibitors (CIs) have been reported to lead to complete lesion remission in several dogs with vesicular cutaneous lupus erythematosus (VCLE).

OBJECTIVES

To report retrospectively on the effectiveness and adverse effects of systemic (ciclosporin) and/or topical (tacrolimus/pimecrolimus) CIs in 11 dogs with VCLE.

METHODS

Inclusion criteria were: (i) presence of characteristic annular, polycyclic or serpiginous ulcerations distributed over the groin, axillae and/or ventral abdomen; (ii) a histopathological diagnosis of VCLE (i.e. a lymphocyte-rich interface dermatitis with vesiculation); (iii) treatment that included CIs for at least eight weeks; and (iv) follow-up until death/euthanasia or for a minimum of 12 months post-diagnosis.

RESULTS

Initial therapy included the avoidance of excessive sun exposure, oral glucocorticoids [six of 11 dogs (55%); progressively tapered over a month] and once daily ciclosporin [11 dogs (100%); median 5.8 mg/kg]. A complete remission (CR) of signs occurred between days 35 and 70 after starting CIs in eight dogs (73%); increasing ciclosporin dosage and adding topical tacrolimus induced a CR in two additional dogs (18%). Relapses were common when doses were tapered or discontinued. With the exception of three dogs that were euthanized, clinical signs were maintained in CR with oral ciclosporin (eight of eight dogs treated, 100%) or topical tacrolimus/pimecrolimus (four of eight dogs; 50%) with a median follow-up of 2.9 years.

CONCLUSIONS AND CLINICAL IMPORTANCE

These observations support CIs as the preferable therapeutic alternatives to long-term immunosuppression with oral glucocorticoids in dogs with VCLE.

Assessing the itching intensity using visual analogue scales in atopic dermatitis patients against the background of a therapy with calcineurin inhibitors

Goal. To assess the effect of topical treatment of atopic dermatitis patients with the 0.1% tacrolimus ointment on the itching intensity and skin expression level of growth factor proteins affecting the intensity of cutaneous innervation. Materials and methods. Fifteen patients suffering from atopic dermatitis underwent treatment with the 0.1% tacrolimus ointment. The SCORAD index was calculated to assess the severity of clinical manifestations. The itching intensity was assessed using a visual analogue scale. The skin expression of nerve growth factors, amphiregulin, semaphorin 3A and PGP9.5 protein (a nerve fiber marker) was assessed by the indirect immunofluorescence method. Results. An increased expression of the nerve growth factor and reduced semaphorin 3A expression levels were noted in the patients’ epidermis; there was an increase in the quantity, mean length and fluorescence intensity of PGP9.5+ nerve fibers. As a result of the treatment, the disease severity and itching intensity were reduced, the nerve growth factor expression level was reduced while semaphorin 3A expression level increased in the epidermis, and the mean length and fluorescence intensity of PGP9.5+ nerve fibers was also reduced. A positive correlation among the itching intensity and nerve growth factor expression level, quantity and mean length of PGP9.5+ nerve fibers in the epidermis was revealed, and negative correlation between the itching intensity and semaphorin 3A expression level in the epidermis was established. Conclusion. Topical treatment with the 0.1% Tacrolimus ointment reduces the itching intensity in atopic dermatitis patients, which is related to the therapy-mediated reduction in the epidermis innervation level, decreased expression of epidermal nerve growth factor and increased semaphorin 3A expression level.

Atopic Dermatitis: A Common Pediatric Condition and Its Evolution in Adulthood

Atopic dermatitis (AD) is a chronic and pruritic inflammatory skin disorder that has a relapsing course and can affect any age group. Patients with AD have higher rates of other allergic disorders, mental health disorders, and skin infections. An important feature of AD for practitioners to recognize is that the clinical presentation varies by age from infancy into adulthood. The goals of treatment and management of AD focuses on restoring and maintaining the skin barrier function, minimizing inflammation, breaking the itch-scratch cycle, and treating possible external triggers and secondary infections that may propagate AD.

Topical tacrolimus for atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) (or atopic eczema) is a chronic inflammatory skin condition that affects children and adults and has an important impact on quality of life. Topical corticosteroids (TCS) are the first-line therapy for this condition; however, they can be associated with significant adverse effects when used chronically. Tacrolimus ointment (in its 2 manufactured strengths of 0.1% and 0.03%) might be an alternative treatment. Tacrolimus, together with pimecrolimus, are drugs called topical calcineurin inhibitors (TCIs).

OBJECTIVES

To assess the efficacy and safety of topical tacrolimus for moderate and severe atopic dermatitis compared with other active treatments.

SEARCH METHODS

We searched the following databases up to 3 June 2015: the Cochrane Skin Group Specialised Register, CENTRAL in the Cochrane Library (Issue 5, 2015), MEDLINE (from 1946), EMBASE (from 1974), LILACS (from 1982), and the Global Resource of Eczema Trials (GREAT database). We searched six trials registers and checked the bibliographies of included studies for further references to relevant trials. We contacted specialists in the field for unpublished data.A separate search for adverse effects of topical tacrolimus was undertaken in MEDLINE and EMBASE on 30 July 2013. We also scrutinised the U.S. Food and Drug Administration (FDA) websites for adverse effects information.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of participants with moderate to severe atopic dermatitis (both children and adults) using topical tacrolimus at any dose, course duration, and follow-up time compared with other active treatments.

DATA COLLECTION AND ANALYSIS

Two authors independently screened and examined the full text of selected studies for compliance with eligibility criteria, risk of bias, and data extraction. Our three prespecified primary outcomes were physician's assessment, participant's self-assessment of improvement, and adverse effects. Our secondary outcomes included assessment of improvement of the disease by validated or objective measures, such as SCORAD (SCORing Atopic Dermatitis), the EASI (Eczema Area and Severity Index), and BSA (Body Surface Area) scores.

MAIN RESULTS

We included 20 studies, with 5885 participants. The variability of drug doses, outcomes, and follow-up periods made it difficult to carry out meta-analyses.A single trial showed that tacrolimus 0.1% was better than low-potency TCS by the physician's assessment (risk ratio (RR) 3.09, 95% confidence interval (CI) 2.14 to 4.45, 1 study, n = 371, moderate-quality evidence). It was also marginally better than low-potency TCS on face and neck areas and moderate-potency TCS on the trunk and extremities by the physician's assessment (RR 1.32, 95% CI 1.17 to 1.49, 1 study, n = 972, moderate level of evidence) and for some of the secondary outcomes. Compared with pimecrolimus 1%, people treated with tacrolimus were almost twice as likely to improve by the physician's assessment (RR 1.80, 95% CI 1.34 to 2.42, 2 studies, n = 506, moderate quality of evidence). Compared with the lower concentration of 0.03%, the tacrolimus 0.1% formulation reduced the risk of not having an improvement by 18% as evaluated by the physician's assessment (RR 0.82, 95% CI 0.72 to 0.92, 6 studies, n = 1640, high-quality evidence). Tacrolimus 0.1% compared with moderate-to-potent TCS showed no difference by the physician's assessment, and 2 secondary outcomes (1 study, 377 participants) and a marginal benefit favouring tacrolimus 0.1% was found by the participant's assessment (RR 1.21, 95% CI 1.13 to 1.29, 1 study, n = 974, low quality of evidence) and SCORAD.Based on data from 2 trials, tacrolimus 0.03% was superior to mild TCS for the physician's assessment (RR 2.58, 95% CI 1.96 to 3.38, 2 studies, n = 790, moderate-quality evidence) and the participant's self-assessment (RR 1.64, 95% CI 1.41 to 1.90, 1 study, n = 416, moderate quality of evidence). One trial showed moderate benefit of tacrolimus 0.03% compared with pimecrolimus 1% on the physician's assessment (RR 1.42, 95% CI 1.02 to 1.98, 1 study, n = 139, low-quality evidence), but the effects were equivocal when evaluating BSA. In the comparison of tacrolimus 0.03% with moderate-to-potent corticosteroids, no difference was found in most of the outcomes measured (including physician's and participant's assessment and also for the secondary outcomes), but in two studies, a marginal benefit favouring the corticosteroid group was found for the EASI and BSA scores.Burning was more frequent in those using calcineurin inhibitors than those using corticosteroid tacrolimus 0.03% (RR 2.48, 95% CI 1.96 to 3.14, 5 studies, 1883 participants, high-quality evidence), but no difference was found for skin infections. Symptoms observed were mild and transient. The comparison between the two calcineurin inhibitors (pimecrolimus and tacrolimus) showed the same overall incidence of adverse events, but with a small difference in the frequency of local effects.Serious adverse events were rare; occurred in both the tacrolimus and corticosteroid groups; and in most cases, were considered to be unrelated to the treatment. No cases of lymphoma were noted in the included studies nor in the non-comparative studies. Cases were only noted in spontaneous reports, cohorts, and case-control studies. Systemic absorption was rarely detectable, only in low levels, and this decreased with time. Exception is made for diseases with severe barrier defects, such as Netherton's syndrome, lamellar ichthyosis, and a few others, with case reports of a higher absorption. We evaluated clinical trials; case reports; and in vivo, in vitro, and animal studies; and didn't find any evidence that topical tacrolimus could cause skin atrophy.

AUTHORS' CONCLUSIONS

Tacrolimus 0.1% was better than low-potency corticosteroids, pimecrolimus 1%, and tacrolimus 0.03%. Results were equivocal when comparing both dose formulations to moderate-to-potent corticosteroids. Tacrolimus 0.03% was superior to mild corticosteroids and pimecrolimus. Both tacrolimus formulations seemed to be safe, and no evidence was found to support the possible increased risk of malignancies or skin atrophy with their use. The reliability and strength of the evidence was limited by the lack of data; thus, findings of this review should be interpreted with caution. We did not evaluate costs.

Solanum tuberosum L. cv Jayoung Epidermis Extract Inhibits Mite Antigen-Induced Atopic Dermatitis in NC/Nga Mice by Regulating the Th1/Th2 Balance and Expression of Filaggrin

Solanum tuberosum L. cv Jayoung (JY) is a potato with dark purple flesh and contains substantial amounts of polyphenols. In this study, we evaluated the therapeutic effects of S. tuberosum L. cv JY in a mouse model of Dermatophagoides farinae body (Dfb)-induced atopic dermatitis (AD). The ethanol extract of the peel of JY (EPJ) ameliorated Dfb-induced dermatitis severity, serum levels of immunoglobulin E (IgE) and thymus and activation-regulated chemokine. Histological analysis of the skin also revealed that EPJ treatment significantly decreased mast cell infiltration. The suppression of dermatitis by EPJ treatment was accompanied by a decrease in the skin levels of type 2 helper T-cell cytokines such as interleukin (IL)-4, IL-5, and IL-13. The induction of thymic stromal lymphopoietin, which leads to a systemic Th2 response, was also decreased in the skin by EPJ. Nuclear translocation of nuclear factor-κB p65 was decreased by EPJ in Dfb-induced NC/Nga mice. The protein expression of filaggrin in the AD-like skin lesions was restored by EPJ treatment. These results suggested that EPJ may be a potential therapeutic tool for the treatment of AD.

Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies

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.

20-O-β-D-glucopyranosyl-20(S)-protopanaxadiol-fortified ginseng extract attenuates the development of atopic dermatitis-like symptoms in NC/Nga mice

ETHNOPHARMACOLOGICAL RELEVANCE

Ginseng and ginsenosides are frequently used in the treatment of chronic inflammatory diseases. Recently, 20-O-β-d-glucopyranosyl-20(S)-protopanaxadiol (GPD), the main metabolite of ginsenosides, was reported to have both anti-allergic and anti-pruritic effects. The immunomodulatory effects of GPD-fortified ginseng extract (GFGE) on atopic dermatitis (AD)-like symptoms in mice were investigated. This study was designed to investigate the preventive effect of GFGE on AD-like symptoms.

MATERIALS AND METHODS

The effects of orally administered GFGE on Dermatophagoides farinae body extract (DFE)-induced AD-like symptoms in NC/Nga mice were assessed by analyzing dermatitis score, ear thickness, scratching time, skin histological changes, and serum level of macrophage-derived chemokine (MDC). In addition, splenocytes were isolated from the mice and stimulated with anti-CD3 and anti-CD28 monoclonal antibodies to produce cytokines.

RESULTS

Oral administration of GFGE significantly attenuated DFE-induced increases in dermatitis score, ear thickness, scratching time, and severity of skin lesions in NC/Nga mice. GFGE treatment also reduced level of MDC in serum, infiltration of eosinophils and mast cells in skin, and production of cytokines in splenocytes.

CONCLUSIONS

These results suggest that GFGE might ameliorate DFE-induced AD-like symptoms and be an alternative therapeutic agent for the prevention of AD.

Ectoine-containing cream in the treatment of mild to moderate atopic dermatitis: a randomised, comparator-controlled, intra-individual double-blind, multi-center trial

INTRODUCTION

The natural cyclic tetrahydropyrimidine, ectoine, is a low-molecular, water-binding, organic osmolyte. Previously, topical application of ectoine to healthy human skin was shown to improve skin hydration as well as skin barrier function.

OBJECTIVES

We therefore speculated that topical application of ectoine would be beneficial for patients with atopic dermatitis (AD), in which a genetically defined defect in skin barrier function is of major pathogenetic relevance. We assessed the efficacy of an ectoine-containing cream (EHK02-01) in the management of 65 patients with mild to moderate AD in a randomized, intra-individual, double-blind, multi-center trial, in which the efficacy of ectoine was compared to a nonsteroidal anti-inflammatory cream previously found to primarily act on skin barrier function and therefore with a comparable mode of action.

METHODS

Sixty-five patients with mild to moderate AD aged 18-65 years were enrolled. The patients applied EHK02-01 and the control cream on two symmetrical lesions twice daily for 28 days. At the beginning, after 7 and after 28 days, treated skin areas were assessed by modified, objective local SCORAD (Scoring Atopic Dermatitis) and IGA (Investigator's Global Assessment) as well as the patients' judgment of efficacy and their assessment of pruritus.

RESULTS

EHK02-01 was found to be very well tolerated. Even more important, efficacy of EHK02-01 treatment was equivalent to that achieved with the reference product.

CONCLUSION

These results indicate that topical treatment with EHK02-01 may represent a novel option for the treatment of patients with AD.

CSACI position statement: safety of topical calcineurin inhibitors in the management of atopic dermatitis in children and adults

Atopic dermatitis (AD) is a condition frequently encountered in medical practices across the country. Arming ourselves with appropriate and safe treatment modalities to provide relief for this chronic and relapsing inflammatory condition is of utmost importance to our patients and their families. Utilizing topical calcineurin inhibitors (TCIs) for the treatment of AD not responsive to high-potency corticosteroids, or low-potency corticosteroids and localized to the face, eyelids, and skin folds of patients >2 years, is reasonable to include in common practice. Despite the FDA’s Black Box warning, to date no evidence has been published linking the TCIs to an increased incidence of malignancy in either children or adults that establishes causation. The Canadian Society of Allergy and Clinical Immunology (CSACI) therefore recognizes that the benefits of TCIs should be carefully weighed with the theoretical risks in advising patients, and acknowledges that long-term studies remain in progress. The safety and efficacy of topical tacrolimus and pimecrolimus should therefore be considered when treating children and adults with AD in Canadian allergy and immunology practices.

Comparative effectiveness of topical calcineurin inhibitors in adult patients with atopic dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disease characterized by extreme pruritis and lichenified papules and plaques that may begin in or persist into adulthood. Topical corticosteroids are first-line prescription therapy for AD; they are efficacious and have a well established safety profile. The topical calcineurin inhibitors tacrolimus and pimecrolimus were approved by the US FDA in 2000 and 2001, respectively, as second-line topical therapy for AD. This review evaluates the available studies on the comparative effectiveness, safety, cost, and impact on quality of life of topical corticosteroids and topical calcineurin inhibitors for the treatment of adult AD. Tacrolimus was found to be as effective as class III-V topical corticosteroids for AD of the trunk and extremities, and more effective than low-potency class VI or VII corticosteroids for AD of the face or neck. Pimecrolimus was less effective than both tacrolimus and low-potency topical corticosteroids for moderate to severe AD. The short-term safety studies found that, compared with topical corticosteroid-treated adults, patients treated with topical calcineurin inhibitors had an increased frequency of application-site reactions, an equivalent infection risk, and a decreased risk of skin atrophy. The long-term safety of topical calcineurin inhibitors remains under investigation. Currently published studies that evaluated the comparative cost and quality-of-life effects compared tacrolimus with less potent topical corticosteroids despite the availability of equivalent potency corticosteroids. Further cost and quality-of-life studies are needed that compare topical calcineurin inhibitors with stronger classes of topical corticosteroids over longer time periods. The available clinical trials data do not suggest an efficacy advantage for topical calcineurin inhibitors over topical corticosteroids in adults with AD of the trunk and extremities, and there is not yet adequate evidence to support topical calcineurin inhibitors as first-line therapy for adult AD.

Staphylococcal enterotoxin B causes proliferation of sensory C-fibers and subsequent enhancement of neurogenic inflammation in rat skin

BACKGROUND

Staphylococcal enterotoxin B (SEB) may be associated with the exacerbation of atopic dermatitis. We investigated whether SEB causes proliferation of sensory C-fibers and subsequent enhancement of plasma leakage induced by sensorineural stimulation in rat skin.

METHODS

SEB was applied intracutaneously to the abdomen of preweaning and adult rats. Evans blue dye leakage into the skin induced by topical 10% formalin was measured as an index of neurogenic skin vascular permeability. Local expression of substance P, tachykinin NK1 receptors, and nerve growth factor was assessed immunohistochemically. In addition, we assessed the effects of topical tacrolimus on these skin responses induced by SEB.

RESULTS

Increased neurogenic skin plasma leakage was seen 7 days after SEB treatment in 2 different age groups. Innervation of substance P-immunoreactive nerves and expression of tachykinin NK1 receptors and nerve growth factor were also promoted by SEB, peaking at 7 days, 7 days, and 56 h after SEB treatment, respectively. Tacrolimus markedly inhibited these skin changes.

CONCLUSIONS

SEB increased the innervation of sensory C-fibers and tachykinin NK1 receptors in rat skin, probably because of upregulated production of neurotrophins, including nerve growth factor, leading to enhancement of neurogenic skin inflammation. T cell activation induced by SEB may initiate these changes.

The safety and efficacy of tacrolimus ointment in pediatric patients with atopic dermatitis

Atopic dermatitis (AD) is the most common skin disease in children, and its prevalence is increasing. It is a chronic disorder, characterized by intermittent flares and phases of remission. Treatment regimens often require multiple therapies. These can vary between patients, and in an individual patient, depending on the state of disease. The traditional treatment for AD flares is topical corticosteroids, which are fast acting and effective for relief of symptoms, but may cause adverse effects, including those resulting from systemic absorption, particularly in children. Topical calcineurin inhibitors (TCIs) are alternative treatments for AD. Tacrolimus ointment, a TCI, is approved for patients aged 2 years and older. Multiple studies have shown that tacrolimus is effective for short-term relief of symptoms in pediatric patients with AD. Long-term trials have demonstrated that the effectiveness of tacrolimus is maintained for up to 4 years in children. Additional studies have revealed that long-term intermittent use of tacrolimus as part of maintenance therapy can prevent AD flares. Tacrolimus has a low potential for systemic accumulation, and analysis of long-term studies indicates that it has a good safety profile. Treatment with tacrolimus, alone or in combination with topical corticosteroids for acute flares, may be a useful option for long-term management of AD in pediatric patients.

Atopic dermatitis

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.

Suppression of T cell activation by hirsutenone, isolated from the bark of Alnus japonica, and its therapeutic advantages for atopic dermatitis

The increasing prevalence and severity of atopic dermatitis during recent decades has prompted the development of safe and more highly effective drugs. Although topical corticosteroids have been used for more than 50 years as first line therapy for atopic dermatitis, their potential side effects limits their clinical uses. In light of this, steroid-free topical calcineurin inhibitors were developed and have been used in patients with moderate to severe atopic dermatitis. In the present study, we examined if hirsutenone suppressed the profiles of atopic dermatitis development in vitro via mimicry of calcineurin inhibitor actions in mouse splenocytes and RBL-2H3 mast cells. Our results showed that hirsutenone effectively inhibited T cell activation by blocking dephosphorylation of nuclear factor of activated T cells (NFAT). This inhibition was confirmed by inactivation of mitogen-activated protein kinases (MAPKs), which subsequently inhibited production of cytokine mRNAs (interleukin-2, -4, -5, -13 and interferon-gamma) after T cell receptor stimulation. We also showed that the early T cell activation marker, CD25, was suppressed in the presence of hirsutenone after T cell receptor stimulation with anti-CD3. Moreover, degranulation of mast cells was remarkably suppressed, comparable to that by cyclosporine A. This indicates that hirsutenone may specifically inhibit calcium-activated processes in both T cells and mast cells. Therefore, our results suggest that hirsutenone may be a new topical drug candidate, which probably acts by mimicking calcineurin inhibitor mechanisms.

Isolation of alpha-toxin-producing Staphylococcus aureus from the skin of highly sensitized adult patients with severe atopic dermatitis

BACKGROUND

Staphylococcus aureus (S. aureus) is a well-known trigger factor of atopic dermatitis (AD). Besides staphylococcal superantigens, alpha-toxin may influence cutaneous inflammation via induction of T-cell proliferation and cytokine secretion.

OBJECTIVES

To investigate the association between sensitization to inhalant allergens and skin colonization with alpha-toxin-producing S. aureus in AD.

PATIENTS AND METHODS

We investigated 127 patients with AD, aged 14-65 years, who were on standard anti-inflammatory and antiseptic treatment before investigation. We evaluated skin colonization, medical history, severity of AD and sensitization to inhalant allergens.

RESULTS

Forty-eight of 127 patients were colonized with S. aureus, suffered from more severe AD, had asthma more often and showed higher sensitization levels to inhalant allergens. Thirty of 48 patients with S. aureus skin-colonizing strains produced alpha-toxin and had higher total IgE and specific IgE to birch pollen and timothy grass pollen.

CONCLUSIONS

Under topical treatment with antiseptic and anti-inflammatory agents the colonization of lesional skin with S. aureus was clearly lower than commonly found in untreated patients with AD. Colonization with S. aureus was associated with a higher severity of AD, higher degree of sensitization, and a higher frequency of asthma. The proportion of patients whose skin was colonized with alpha-toxin-producing S. aureus was higher than expected from a former study. Cutaneous colonization with alpha-toxin-producing S. aureus was associated with a higher sensitization level to birch pollen allergen in AD. This may point to a higher susceptibility of patients with higher T-helper 2 polarization towards alpha-toxin-producing S. aureus.

Fluocinolone acetonide 0.01% in peanut oil: safety and efficacy data in the treatment of childhood atopic dermatitis in infants as young as 3 months of age

Fluocinolone acetonide 0.01% in a blend of refined peanut and mineral oils has been established as effective and safe treatment for atopic dermatitis in patients 2 years and older, including those with peanut sensitivity, for several years. We sought to study the safety of fluocinolone acetonide 0.01% oil and its potential for adrenal axis suppression in infants as young as 3 months of age. A controlled, open-label study was performed in children aged 3 months to 2 years with moderate to severe atopic dermatitis at two academic pediatric dermatology centers. Patients received topical fluocinolone acetonide 0.01% oil twice daily to affected areas involving a minimum of 20% body surface ratio for 4 weeks. Cortisol stimulation testing was performed at baseline and at the end of the treatment phase. Patients were monitored for medication use and adverse events. Efficacy was assessed using the Investigator Global Severity and Response scales. Thirty-two patients with moderate to severe atopic dermatitis were recruited into the study and 30 were evaluated with the Physician's Global Improvement Assessment tool. The mean body surface ratio treated for all age groups was 48%. Eighty-three percent of patients had marked or better improvement scores by week 2 and 96% by week 4, with 40% completely cleared. No adrenal suppression occurred in the 24 patients that met inclusion criteria for hypothalamus-pituitary axis (HPA) axis analysis. No relevant adverse events occurred. Results of this study support the safety and efficacy of fluocinolone acetonide 0.01% in refined peanut oil vehicle, for infants as young as 3 months of age with atopic dermatitis. No evidence of adrenal suppression or adverse local effects was demonstrated after 4 weeks of twice daily treatment.

Topical calcineurin inhibitors in atopic dermatitis: a systematic review and meta-analysis

OBJECTIVES

To build a critical appraisal of the available literature to evaluate the effectiveness of topical calcineurin inhibitors in treatment of atopic dermatitis (AD), in comparison to topical corticosteroids (TCs) and/or placebo.

REVIEW METHODS

DESIGN

systematic review and meta-analysis.

DATA SOURCES

electronic search of MEDLINE Pubmed along the last 10 years (1997-2006).

STUDY SELECTION

randomized control trials of TCIs reporting efficacy outcomes, in comparison to TCs or vehicle (placebo) or both.

DATA SYNTHESIS

of 210 articles, 19 studies were included, 10 for tacrolimus and 9 for pimecrolimus, involving 7378 patients of whom 2771 applied tacrolimus, 1783 applied pimecrolimus, and 2824 were controls. Both drugs were significantly more effective than a vehicle. However, two long-term trials comparing demonstrated the value of pimecrolimus in reduction of flares and steroid-sparing effect after 6 months. Compared to TCs, both 0.1% and 0.03% tacrolimus ointments were as effective as moderate potency TCs, and more effective than a combined steroid regimen. Tacrolimus was more effective than mild TCs.

CONCLUSIONS

TCIs in AD are more effective than placebo. Although less effective than TCs, pimecrolimus has its value in long-term maintenance and as a steroid-sparing agent in AD, whenever used early enough, at first appearance of erythema and/or itching. In treatment of moderate to severe AD, topical tacrolimus is as effective as moderately potent TCs, and more effective than mild preparations. Chronic AD lesions of the face and flexures are the most justified indication for topical calcineurin inhibitors.

Tacrolimus ointment in the management of atopic dermatitis

Atopic dermatitis (AD) is a chronic, relapsing, highly pruritic inflammatory skin disease. AD long-term treatment is usually required to control and prevent flares, and patients need a treatment that is safe and efficacious when applied continuously or intermittently over a prolonged period of time. The treatment options should be chosen according to age, clinical features and severity of the disease in every single patient. For the treatment of a chronic disease like AD, sustained tolerability and efficacy of the applied medications are essential. A topical immunomodulator, tacrolimus ointment, provides an alternative to topical corticosteroids without the associated adverse events. Tacrolimus is a macrolide lactone with unique immunomodulatory properties and strong anti-inflammatory activities and can be used without increasing the risk of infection or other non-application site adverse events, and without loss of effectiveness, in patients with AD.

Topical therapy in pediatric atopic dermatitis

With a prevalence of 10% to 20% in the first decade of life, atopic dermatitis (AD) is one of the most common skin disorders in young children. It is a chronic illness with limited therapeutic options. Topical anti-inflammatory agents remain at the core of medical management; however, their efficacy must be balanced with safety concerns, especially as they relate to the pediatric population. This article discusses the principles of topical AD therapy with a detailed review of the differences between topical corticosteroids and topical calcineurin inhibitors. It also includes specialized topical treatment strategies for AD, such as wet wraps and diluted bleach baths, and highlights the most common challenges to patient compliance in atopic dermatitis.

Management of atopic dermatitis in the pediatric population

Atopic dermatitis, one of the most common skin disorders in young children, has a prevalence of 10% to 20% in the first decade of life. It is a chronic illness that requires a multifaceted treatment strategy in the setting of limited therapeutic options. Balancing safety concerns with efficacious treatment is of particular importance in the pediatric population. Parents of patients with atopic dermatitis turn to their primary caregivers for guidance regarding this physically demanding and psychologically stressful condition. In addition to serving as a review of atopic dermatitis, this article delves into the state-of-the-art therapeutic options and includes a detailed review of the differences between topical corticosteroids and topical calcineurin inhibitors. We also discuss new treatment strategies that are being used by atopic dermatitis specialists, such as comprehensive "education-as-intervention" models, wet wraps, bleach baths, and systemic immunomodulatory therapies.

Topically applied diterpenoids from Egletes viscosa (Asteraceae) attenuate the dermal inflammation in mouse ear induced by tetradecanoylphorbol 13-acetate- and oxazolone

The diterpene compounds, centipedic acid (CA) and 12-acetoxyhawtriwaic acid lactone (AHAL, tanabalin) isolated from the flower buds of Egletes viscosa LESS. (Asteraceae) were evaluated on acute and chronic models of mouse ear dermatitis. A single topical application of CA (0.125; 0.25 and 0.5 mg/ear) or AHAL (0.125, 0.25, 0.5 mg/ear) immediately before 12-O-tetradecanoylphorbol-13-acetate (TPA, 2.5 mug/ear) caused a dose-related significant inhibition of ear inflammatory edema and influx of polymorphonuclear cells, as evidenced by a decrease in ear thickness and reduced myeloperoxidase (MPO) activity and tumor necrosis factor-alpha (TNF-alpha) in ear tissue homogenates. The maximal obtained inhibition for both ear edema and neutrophil influx were almost similar to that of topically applied dexamethasone (0.05 mg/ear). The extent of inhibitions for the respective treatments of CA (0.5 mg/ear), AHAL (0.5 mg/ear), or dexamethasone (0.05 mg/ear) were in the order of 63%, 61% and 81% for the ear edema, and 90%, 95% and 95% for the neutrophil influx. Also, at similar doses, both diterpenes and dexamethasone effectively inhibited the delayed-type hypersensitivity reaction induced by repeated topical application of 1% oxazolone (OXA, 20 microl/ear), as evidenced by significant decreases in ear thickness and interferon-gamma (INF-gamma) levels in ear tissue. Histopathological analysis revealed a marked decrease in epidermal hyperplasia and neutrophil infiltration in animals pretreated with CA or AHAL, in a manner similar to dexamethasone. These data provide evidence for the anti-dermatitis effect of Egletes viscosa diterpenes, by mechanisms that involve a reduced neutrophil influx and decreased production of inflammatory cytokines, TNF-alpha and IFN-gamma.

Scratching the surface--Managing the itch associated with burns: a review of current knowledge

The problems of itch in burns patients are well recognised, however none of the current standard therapies are very effective. The standard therapies include: antihistamines which are only effective in about 20% of patients and emollients which have limited effects. We review the current literature on the molecular mechanisms of itch and neuronal itch pathways, which supports the predictable lack of effect of anti-histamines. The published studies on therapeutic options to treat itch in burns are discussed and in addition we review the work on the treatment of itch in other pathological states. Finally a treatment algorithm is proposed stratifying possible therapeutic options to assist in the management of burns patients distressed by intractable itch.

Topical calcineurin inhibitors in pediatric atopic dermatitis: a critical analysis of current issues

Atopic dermatitis (AD) is a common disease in children. Despite good skin care and trigger avoidance, many children with AD require pharmacologic treatment to manage their disease. In recent years, topical calcineurin inhibitors (TCIs) have been used as an alternative to topical corticosteroids to treat some children with AD. However, revisions to the US labeling for TCIs (i.e. a boxed warning and a medication guide) have generated concern among pediatricians regarding TCI safety and raised questions about the appropriate use of TCIs in the pediatric population. Data from several well designed studies support the efficacy of TCIs in the treatment of AD. Safety concerns arise from a small number of reported malignancies, animal toxicology studies, and the potential adverse effects (including immunosuppression and risk of lymphoma) observed in patients who received systemically administered calcineurin inhibitors for suppression of solid-organ transplant rejection. Several factors indicate that these effects do not occur with topical administration: (i) systemic levels following topical administration are at least 10-fold lower than with oral administration; (ii) the small number of lymphomas reported to date in persons exposed to TCI use are not consistent with the types seen in transplant patients or other immunosuppressed patients; and (iii) no adverse effects on the immune system (as assessed by measures including vaccination response and skin delayed-type hypersensitivity reaction) have been observed in clinical trials of TCIs in children with AD. Overall, TCIs have an established safety and efficacy profile as long-term maintenance therapy in children with AD.

The role of emollients in the management of diseases with chronic dry skin

Dry skin is a common skin condition as well as a key aspect of a number of diseases such as atopic dermatitis and psoriasis but also of other diseases and systemic conditions. Dry skin has an impact on the patient in terms of discomfort, pruritus and impaired quality of life. Within the overall treatment regimen for these diseases, the use of emollients to manage dry skin plays a considerable role in managing skin conditions. In atopic dermatitis and psoriasis, emollients help to improve skin condition and to reduce pruritus alongside more potent pharmacological agents. It is important to choose an emollient that not only soothes and rehydrates the skin but also offers numerous other dermatological supporting roles, especially induction of proper epidermal differentiation. This review will explain the role of emollients within the management of diseases with dry skin as a major symptom and the components of an ideal emollient.

Immunology and treatment of atopic dermatitis

Atopic dermatitis (AD) is a chronic inflammatory disease hypothesized to be the product of complex interactions among the host's environment, susceptibility genes, skin barrier dysfunction, and immune system dysregulation. The objective of this article is to describe the pathobiology and treatment of AD, with particular focus on the role of immune system dysregulation and therapies designed to target this. Literature review indicates that there are immunologic differences between the lesional and non-lesional skin of atopic individuals, and that the non-lesional skin of atopic individuals presents an immunologic profile distinct from that of the skin of healthy individuals. Thus, immune system dysregulation is postulated to be a key contributing factor to the complex etiology of AD. Immunomodulatory agents such as topical corticosteroids (TCSs) and topical calcineurin inhibitors (TCIs), which address the underlying immunopathology of AD, are the foundation for the pharmacologic treatment of flares. TCSs and TCIs both target the inflammatory response responsible for an AD flare but via two distinct mechanisms of action. Whereas TCSs have a more widespread impact on the immune system, the action of TCIs is targeted to the calcineurin pathway and inhibition of T-cell activation. Together, TCSs and TCIs represent the backbone of a long-term treatment strategy for AD.

Short-term growth in children with eczema during treatment with topical mometasone furoate and tacrolimus

BACKGROUND

Treatment with topical glucocorticoids in children with atopic eczema may be associated with systemic adverse effects, such as suppression of growth.

AIM

To asses if treatment with topical mometasone furoate 0.1% or topical tacrolimus 0.1% affects short-term growth in children with atopic eczema. Primary outcome measures were lower leg growth rates measured by knemometry.

METHODS

Twenty 5- to 12-year-old prepubertal children with atopic eczema were included in a randomised, investigator-blind crossover study with five periods: two treatment periods, a run in, a wash out and a run out. All periods were of 2-week duration. The subjects applied mometasone furoate ointment 0.1% once daily during one treatment period and tacrolimus ointment 0.1% twice daily during the other treatment period.

RESULTS

As compared to run in mean lower leg growth rate during mometasone furoate and tacrolimus treatment was reduced by 0.09 and 0.06 mm/week, respectively, (F = 1.12, p = 0.35). Consistently, no statistically significant effects on urine levels of eosinophil protein X and crossed-linked N-telopeptides were detected.

CONCLUSION

Treatment with mometasone furoate or tacrolimus does not affect short-term growth in children with mild to moderate atopic eczema.