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Augustin M, Wilsmann-Theis D, Körber A, Kerscher M, Itschert G, Dippel M, Staubach P. Diagnosis and treatment of xerosis cutis - a position paper. J Dtsch Dermatol Ges 2020; 17 Suppl 7:3-33. [PMID: 31738016 DOI: 10.1111/ddg.13906] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND RATIONALE Xerosis cutis (also referred to as xeroderma, dry skin, asteatosis) affects more than 10 million individuals in Germany. It is among the most common dermatological diagnoses and a cardinal symptom of many dermatological, internal and neurological diseases. Even though it has been established that basic skin care plays a significant role in the management of patients with xerosis cutis, there are as yet no evidence-based algorithms for diagnosis and treatment. OBJECTIVE The present position paper provides physicians across all specialties with a practical, symptom-based approach to the prevention, diagnosis and treatment of xerosis cutis. METHODS Within a structured decision-making process, a panel of experienced dermatologists first defined questions relevant to everyday clinical practice, which were then addressed by a systematic review of the literature. Based on the evidence available as well as expert consensus, diagnostic and treatment algorithms were subsequently developed and agreed upon. RESULTS Xerosis cutis is generally diagnosed on clinical grounds. Possible trigger factors must be avoided, and comorbidities should be adequately and specifically treated. Suitable skin care products should be chosen with a view to improving skin hydration and restoring its barrier function. They should therefore contain both rehydrating and lipid-replenishing components. The "drier" the skin appears, the greater the lipid content should be (preferably using water-in-oil formulations). The choice of ingredients is based on a patient's individual symptoms, such as scaling (e.g., urea), fissures/rhagades (e.g., urea or dexpanthenol), erythema (e.g., licochalcone A) and pruritus (e.g., polidocanol). Other factors to be considered include the site affected and patient age. Ingredients or rather combinations thereof for which there is good clinical evidence should be preferentially used. The best evidence by far is available for urea, whose efficacy in the treatment of xerosis is further enhanced by combining it with other natural moisturizing components and ceramides. The "xerosimeter" is a tool developed in an effort to facilitate patient management and for training purposes. It not only includes practical tools for diagnosis and follow-up but also a classification of ingredients and a structured treatment algorithm. CONCLUSION The structured symptom- and evidence-based approach proposed herein contains a road map for diagnosis and treatment of xerosis cutis. It aims to raise awareness in terms of prevention and early treatment of this condition and may thus improve quality of life and prevent potential sequelae.
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Affiliation(s)
- Matthias Augustin
- Hamburg-Eppendorf University Medical Center, Institute for Healthcare Research in Dermatology and Nursing (IVDP), Martinistr. 52, 20246, Hamburg, Germany
| | - Dagmar Wilsmann-Theis
- Department of Dermatology and Allergology, University Medical Center, Friedrich Wilhelm University, Sigmund Freud Str. 25, 53105, Bonn, Germany
| | - Andreas Körber
- Office-based Dermatologist, Rüttenscheider Str. 143, 45130, Essen, Germany
| | - Martina Kerscher
- University of Hamburg, Division of Cosmetic Sciences, Papendamm 21, 20146, Hamburg, Germany
| | - Götz Itschert
- Office-based Dermatologist, Am Rathaus 2a, 25421, Pinneberg, Germany
| | - Michaela Dippel
- MD medscript & consult, Am Kuhtriftberg 21, 67098, Bad Dürkheim, Germany
| | - Petra Staubach
- Department of Dermatology, University Medical Center, Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
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Wollenberg A, Barbarot S, Bieber T, Christen-Zaech S, Deleuran M, Fink-Wagner A, Gieler U, Girolomoni G, Lau S, Muraro A, Czarnecka-Operacz M, Schäfer T, Schmid-Grendelmeier P, Simon D, Szalai Z, Szepietowski JC, Taïeb A, Torrelo A, Werfel T, Ring J. Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part II. J Eur Acad Dermatol Venereol 2018; 32:850-878. [PMID: 29878606 DOI: 10.1111/jdv.14888] [Citation(s) in RCA: 413] [Impact Index Per Article: 68.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 01/29/2018] [Indexed: 12/17/2022]
Abstract
This guideline was developed as a joint interdisciplinary European project, including physicians from all relevant disciplines as well as patients. It is a consensus-based guideline, taking available evidence from other guidelines, systematic reviews and published studies into account. This second part of the guideline covers antimicrobial therapy, systemic treatment, allergen-specific immunotherapy, complementary medicine, psychosomatic counselling and educational interventions, whereas the first part covers methods, patient perspective, general measures and avoidance strategies, basic emollient treatment and bathing, dietary intervention, topical anti-inflammatory therapy, phototherapy and antipruritic therapy. Management of AE must consider the individual clinical variability of the disease. Systemic immunosuppressive treatment with cyclosporine, methotrexate, azathioprine and mycophenolic acid is established option for severe refractory cases, and widely available. Biologicals targeting the T helper 2 pathway such as dupilumab may be a safe and effective, disease-modifying alternative when available. Oral drugs such as JAK inhibitors and histamine 4 receptor antagonists are in development. Microbial colonization and superinfection may cause disease exacerbation and can require additional antimicrobial treatment. Allergen-specific immunotherapy with aeroallergens may be considered in selected cases. Psychosomatic counselling is recommended especially in stress-induced exacerbations. Therapeutic patient education ('Eczema school') is recommended for children and adult patients. General measures, basic emollient treatment, bathing, dietary intervention, topical anti-inflammatory therapy, phototherapy and antipruritic therapy have been addressed in the first part of the guideline.
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Affiliation(s)
- A Wollenberg
- Department Dermatology and Allergy, Ludwig-Maximilian University, Munich, Germany.,Klinik Thalkirchner Straße, Munich, Germany
| | - S Barbarot
- Department of Dermatology, Centre Hospitalier Universitaire CHU Nantes, Nantes, France
| | - T Bieber
- Department of Dermatology and Allergy, Christine Kühne-Center for Allergy Research and Education, University Bonn, Bonn, Germany
| | - S Christen-Zaech
- Pediatric Dermatology Unit, Departments of Dermatology and Pediatrics, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - M Deleuran
- Department Dermatology, Aarhus University Hospital, Aarhus, Denmark
| | - A Fink-Wagner
- European Federation of Allergy and Airways Diseases Patients' Associations (EFA), Global Allergy and Asthma Patient Platform (GAAPP), Konstanz, Germany
| | - U Gieler
- Department of Dermatology, University of Gießen and Marburg GmbH, Gießen, Germany.,Department of Psychosomatics and Psychotherapy, University of Gießen and Marburg GmbH, Gießen, Germany
| | - G Girolomoni
- Department of Medicine, Section of Dermatology, University of Verona, Verona, Italy
| | - S Lau
- Pediatric Pneumology and Immunology, Universitätsmedizin Berlin, Berlin, Germany
| | - A Muraro
- Centro di Specializzazione Regionale per lo Studio e la Cura delle Allergie e delle Intolleranze Alimentari presso l'Azienda Ospedaliera, Università di Padova, Padova, Italy
| | | | - T Schäfer
- Dermatological Practice, Immenstadt, Germany
| | - P Schmid-Grendelmeier
- Allergy Unit, Department of Dermatology, University of Zurich, Zurich, Switzerland.,Christine Kühne-Center for Allergy Research and Education (CK-CARE), Davos, Switzerland
| | - D Simon
- Department Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Z Szalai
- Department of Dermatology, Heim Pál Children's Hospital, Budapest, Hungary
| | - J C Szepietowski
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland
| | - A Taïeb
- Department of Dermatology & Pediatric Dermatology, Hôpital St André, Bordeaux, France
| | - A Torrelo
- Department of Dermatology, Hospital Niño Jesus, Madrid, Spain
| | - T Werfel
- Department Dermatology and Allergy, Hannover Medical School, Hannover, Germany
| | - J Ring
- Christine Kühne-Center for Allergy Research and Education (CK-CARE), Davos, Switzerland.,Department Dermatology and Allergy Biederstein, Technische Universität München, Munich, Germany
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Augustin M, Wilsmann-Theis D, Körber A, Kerscher M, Itschert G, Dippel M, Staubach P. Positionspapier: Diagnostik und Therapie der Xerosis cutis. J Dtsch Dermatol Ges 2018; 16 Suppl 4:3-35. [DOI: 10.1111/ddg.13580] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Matthias Augustin
- Universitätsklinikum Hamburg-Eppendorf; Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP); Martinistr. 52 20246 Hamburg
| | - Dagmar Wilsmann-Theis
- Klinik und Poliklinik für Dermatologie und Allergologie der Rheinischen-Friedrich-Wilhelms Universität Bonn; Sigmund-Freud-Str. 25 53105 Bonn
| | | | - Martina Kerscher
- Universität Hamburg; Fachbereich Kosmetikwissenschaft; Papendamm 21 20146 Hamburg
| | | | - Michaela Dippel
- MD medscript & consult; Am Kuhtriftberg 21 67098 Bad Dürkheim
| | - Petra Staubach
- Hautklinik und Poliklinik der Universitätsmedizin; Johannes Gutenberg-Universität; Langenbeckstr. 1 55131 Mainz
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Abstract
Itch, or pruritus, is a hallmark feature of atopic dermatitis (AD). The impact of AD-related pruritus can range from mildly distressing or distracting to completely disabling. Traditionally, management of itch in AD patients has focused on restoring the altered skin barrier with topical emollients and/or reducing inflammation. A growing emphasis has been placed on directly targeting the neural transmission pathways that mediate itch signaling. Off-label use of neuromodulatory agents has helped reduce this aggravating symptom in atopic patients. This article reviews the current literature on the use of neuromodulatory agents and nonpharmacologic alternative therapies used to treat AD-related pruritus.
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Affiliation(s)
- Sarina B Elmariah
- Department of Dermatology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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Hess C, Krämer M, Madea B. Topical application of THC containing products is not able to cause positive cannabinoid finding in blood or urine. Forensic Sci Int 2017; 272:68-71. [PMID: 28122323 DOI: 10.1016/j.forsciint.2017.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 12/30/2016] [Accepted: 01/08/2017] [Indexed: 11/28/2022]
Abstract
A male driver was checked during a traffic stop. A blood sample was collected 35min later and contained 7.3ng/mL THC, 3.5ng/mL 11-hydroxy-THC and 44.6ng/mL 11-nor-9-carboxy-THC. The subject claimed to have used two commercially produced products topically that contained 1.7ng and 102ng THC per mg, respectively. In an experiment, three volunteers (25, 26 and 34 years) applied both types of salves over a period of 3days every 2-4h. The application was extensive (50-100cm2). Each volunteer applied the products to different parts of the body (neck, arm/leg and trunk, respectively). After the first application blood and urine samples of the participants were taken every 2-4h until 15h after the last application (overall n=10 urine and n=10 blood samples, respectively, for each participant). All of these blood and urine samples were tested negative for THC, 11-hydroxy-THC and 11-nor-9-carboxy-THC by a GC-MS method (LoD (THC)=0.40ng/mL; LoD (11-hydroxy-THC)=0.28ng/mL; LoD (THC-COOH)=1.6ng/mL;. LoD (THC-COOH in urine)=1.2ng/mL). According to our studies and further literature research on in vitro testing of transdermal uptake of THC, the exclusive application of (these two) topically applied products did not produce cannabinoid findings in blood or urine.
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Affiliation(s)
- C Hess
- University of Bonn, Institute of Forensic Medicine, Department of Forensic Toxicology, Germany.
| | - M Krämer
- University of Bonn, Institute of Forensic Medicine, Department of Forensic Toxicology, Germany
| | - B Madea
- University of Bonn, Institute of Forensic Medicine, Department of Forensic Toxicology, Germany
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Vieira BL, Lim NR, Lohman ME, Lio PA. Complementary and Alternative Medicine for Atopic Dermatitis: An Evidence-Based Review. Am J Clin Dermatol 2016; 17:557-581. [PMID: 27388911 DOI: 10.1007/s40257-016-0209-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Complementary and alternative interventions are becoming increasingly utilized as adjuncts to conventional treatment of atopic dermatitis (AD). While the number of studies continues to grow, the vastness of the subject coupled with the relatively poor quality and small size of the studies limit their usefulness to clinicians. PURPOSE Our aim was to comprehensively review randomized controlled trials (RCTs) of complementary and alternative therapies for AD. METHODS Searches were performed on PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, and the Global Resource for EczemA Trial (GREAT) databases, focusing on RCTs of alternative or complementary AD therapies, with a sample size of ≥10, through March 2015 and limited to the English language. A total of 70 manuscripts met the inclusion criteria and were included in the final analysis. RESULTS There is at least some level I evidence to support the use of acupuncture and acupressure, stress-reducing techniques such as hypnosis, massage, and biofeedback, balneotherapy, herbal preparations (with many important caveats), certain botanical oils, oral evening primrose oil, vitamin D supplementation, and topical vitamin B12. Many other therapies either have sufficient data to suggest that they are ineffective, or simply do not have enough evidence to formulate a verdict. CONCLUSIONS Careful review of the literature reveals several promising therapies in this domain; such findings may help direct further research that is necessary to bolster clinical recommendations for alternative or complementary treatments of AD.
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Affiliation(s)
- Brittany L Vieira
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Neil R Lim
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mary E Lohman
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Peter A Lio
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Medical Dermatology Associates of Chicago, 363 W. Erie Street Suite 350, Chicago, IL, 60654, USA.
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Thandar Y, Gray A, Botha J, Mosam A. Topical herbal medicines for atopic eczema: a systematic review of randomized controlled trials. Br J Dermatol 2016; 176:330-343. [DOI: 10.1111/bjd.14840] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Y. Thandar
- Department of Basic Medical Sciences Faculty of Heath Sciences Durban University of Technology Durban South Africa
| | - A. Gray
- Division of Pharmacology Discipline of Pharmaceutical Sciences University of KwaZulu‐Natal Durban South Africa
| | - J. Botha
- Division of Pharmacology Discipline of Pharmaceutical Sciences University of KwaZulu‐Natal Durban South Africa
| | - A. Mosam
- Department of Dermatology Nelson R. Mandela School of Medicine University of KwaZulu‐Natal Durban South Africa
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Ring J, Alomar A, Bieber T, Deleuran M, Fink-Wagner A, Gelmetti C, Gieler U, Lipozencic J, Luger T, Oranje AP, Schäfer T, Schwennesen T, Seidenari S, Simon D, Ständer S, Stingl G, Szalai S, Szepietowski JC, Taïeb A, Werfel T, Wollenberg A, Darsow U. Guidelines for treatment of atopic eczema (atopic dermatitis) Part II. J Eur Acad Dermatol Venereol 2012; 26:1176-93. [PMID: 22813359 DOI: 10.1111/j.1468-3083.2012.04636.x] [Citation(s) in RCA: 254] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The existing evidence for treatment of atopic eczema (atopic dermatitis, AE) is evaluated using the national standard Appraisal of Guidelines Research and Evaluation. The consensus process consisted of a nominal group process and a DELPHI procedure. Management of AE must consider the individual symptomatic variability of the disease. Basic therapy is focused on hydrating topical treatment, and avoidance of specific and unspecific provocation factors. Anti-inflammatory treatment based on topical glucocorticosteroids and topical calcineurin inhibitors (TCI) is used for exacerbation management and more recently for proactive therapy in selected cases. Topical corticosteroids remain the mainstay of therapy, but the TCI tacrolimus and pimecrolimus are preferred in certain locations. Systemic immune-suppressive treatment is an option for severe refractory cases. Microbial colonization and superinfection may induce disease exacerbation and can justify additional antimicrobial treatment. Adjuvant therapy includes UV irradiation preferably with UVA1 wavelength or UVB 311 nm. Dietary recommendations should be specific and given only in diagnosed individual food allergy. Allergen-specific immunotherapy to aeroallergens may be useful in selected cases. Stress-induced exacerbations may make psychosomatic counselling recommendable. 'Eczema school' educational programs have been proven to be helpful. Pruritus is targeted with the majority of the recommended therapies, but some patients need additional antipruritic therapies.
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Affiliation(s)
- J Ring
- Department of Dermatology and Allergy Biederstein, Christine Kühne-Center for Allergy Research and Education, Technische Universität München, Munich, Germany.
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HUH SY, SHIN JW, NA JI, HUH CH, YOUN SW, PARK KC. Efficacy and safety of liposome-encapsulated 4-n-butylresorcinol 0.1% cream for the treatment of melasma: A randomized controlled split-face trial. J Dermatol 2010; 37:311-5. [DOI: 10.1111/j.1346-8138.2010.00787.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kanehara S, Ohtani T, Uede K, Furukawa F. Clinical effects of undershirts coated with borage oil on children with atopic dermatitis: a double-blind, placebo-controlled clinical trial. J Dermatol 2008; 34:811-5. [PMID: 18078406 DOI: 10.1111/j.1346-8138.2007.00391.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
It has been reported that gamma-linolenic acid contained in borage oil is effective against atopic dermatitis. The clinical effects of undershirts coated with borage oil rich in gamma-linolenic acid on atopic dermatitis were evaluated. Thirty-two children, aged 1-10 years, were involved in the clinical control study. Sixteen had worn undershirts coated with borage oil everyday for 2 weeks, and 16 had worn non-coated undershirts as a placebo. Their symptoms were assessed on a 4-point scale. Those children who had worn undershirts coated with borage oil for 2 weeks showed improvements in their erythema and itch, which were statistically significant. Transepidermal water loss from the back was decreased. In the placebo group, there were no statistically significant differences. The undershirts coated with borage oil were found to be statistically effective, and had no side-effects on children with mild atopic dermatitis.
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Affiliation(s)
- Shoko Kanehara
- Department of Dermatology, Wakayama Medical University, Wakayama City, Wakayama, Japan.
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Abstract
Research from the 1930s to the 1950s established that a deficit of n-6 essential fatty acids (EFAs) leads to an inflammatory skin condition in both animals and humans. In a common inherited skin condition, atopic dermatitis (eczema), there was evidence of low blood EFA concentrations and of a therapeutic response to exceptionally high doses of linoleic acid. More recently, it has been established that there is no deficit of linoleic acid in atopic eczema. Concentrations of linoleic acid instead tend to be elevated in blood, milk, and adipose tissue of patients with atopic eczema, whereas concentrations of linoleic acid metabolites are substantially reduced. This suggests reduced conversion of linoleic acid to gamma-linolenic acid (GLA). In most but not all studies, administration of GLA has been found to improve the clinically assessed skin condition, the objectively assessed skin roughness, and the elevated blood catecholamine concentrations of patients with atopic eczema. Atopic eczema may be a minor inherited abnormality of EFA metabolism.
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Affiliation(s)
- D F Horrobin
- Laxdale Research, Stirling, Scotland, United Kingdom.
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Tollesson A, Frithz A, Berg A, Karlman G. Essential fatty acids in infantile seborrheic dermatitis. J Am Acad Dermatol 1993; 28:957-61. [PMID: 8496460 DOI: 10.1016/0190-9622(93)70137-i] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In infantile seborrheic dermatitis (ISD) several different pathogenetic mechanisms have been proposed. OBJECTIVE The purpose of the study was to investigate the importance of essential fatty acids (EFAs) and their metabolites in the origin of ISD. METHODS The serum EFA patterns of 30 children with ISD, 1 to 6 months of age, were studied for 2 to 5 months. Blood samples were obtained at the time of diagnosis and after spontaneous recovery. Control samples were taken from age-matched healthy children. RESULTS In children with active dermatitis levels of EFA 18:1w9 were increased and levels of 18:2w6 were decreased, whereas 20:4w6 levels remained normal. The rare fatty acid 20:2w6 was found in significant amounts in 20 patients, but at only barely detectable levels in the controls. All deviant values but the levels of 20:2w6 were normal at the time of recovery. Breast milk samples were obtained at the time of diagnosis from the patients' mothers and from a control group consisting of healthy nursing mothers. The EFA patterns were identical. The differences in EFA pattern between children with ISD and those free of skin disease were significant. The normalization of the deviation in ISD paralleled the recovery at any age it occurred. CONCLUSION The laboratory findings suggest a transient impaired function of the enzyme delta-6-desaturase. The altered EFA pattern in ISD may be important in the pathogenesis of the disease.
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Affiliation(s)
- A Tollesson
- Department of Dermatology, Karolinska Institutet, Stockholm, Sweden
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