Clinical Signs, Staphylococcus and Atopic Eczema-Related Seromarkers

A Higher Dose of Staphylococcus aureus Enterotoxin B Led to More Th1 and Lower Th2/Th1 Ratio in Th Cells

Exposure to Staphylococcus aureus enterotoxin B (SEB) is one of the causes of food poisoning and is associated with several immune diseases due to its superantigen capability. This study aimed to characterize the differentiations of naïve Th cells stimulated with different doses of SEB. The expression of T-bet, GATA-3, and Foxp3 or secretion of IFN-γ, IL-4, IL-5, IL-13, and IL-10 were evaluated in wild-type (WT) or DO11.10 CD4 T cells co-cultured with bone marrow dendritic cells (BMDCs). We found that the balance of Th1/Th2 could be dominated by the doses of SEB stimulation. A higher SEB dose could induce more Th1 and a lower Th2/Th1 ratio in Th cells co-cultured with BMDCs. This different tendency of Th cell differentiation induced by the SEB complements the existing knowledge about SEB acting as a superantigen to activate Th cells. Additionally, it is also helpful in managing the colonization of S. aureus and food contamination of SEB.

Skin microbiome and its association with host cofactors in determining atopic dermatitis severity

BACKGROUND

Atopic dermatitis (AD) is a heterogeneous, chronic inflammatory skin disease linked to skin microbiome dysbiosis with reduced bacterial diversity and elevated relative abundance of Staphylococcus aureus (S. aureus).

OBJECTIVES

We aimed to characterize the yet incompletely understood association between the skin microbiome and patients' demographic and clinical cofactors in relation to AD severity.

METHODS

The skin microbiome in 48 adult moderate-to-severe AD patients was investigated using next-generation deep sequencing (16S rRNA gene, V1-V3 region) followed by denoising (DADA2) to obtain amplicon sequence variant (ASV) composition.

RESULTS

In lesional skin, AD severity was associated with S. aureus relative abundance (r_S  = 0.53, p < 0.001) and slightly better with the microbiome diversity measure Evenness (r_S  = -0.58, p < 0.001), but not with Richness. Multiple regression confirmed the association of AD severity with microbiome diversity, including Shannon (in lesional skin, p < 0.001), Evenness (in non-lesional skin, p = 0.015) or S. aureus relative abundance (p < 0.012), and with patient's IgE levels (p < 0.001), race (p < 0.032), age (p < 0.034) and sex (p = 0.012). The lesional model explained 62% of the variation in AD severity, and the non-lesional model 50% of the variation.

CONCLUSIONS

Our results specify the frequently reported "reduced diversity" of the AD-related skin microbiome to reduced Evenness, which was in turn mainly driven by S. aureus relative abundance, rather than to a reduced microbiome Richness. Finding associations between AD severity, the skin microbiome and patient's cofactors is a key aspect in developing new personalized AD treatments, particularly those targeting the AD microbiome.

Serum Mediators in Patients with Both Type 2 Diabetes Mellitus and Pruritus

Chronic pruritus is an unpleasant sensory perception that negatively affects quality of life and is common among patients with type 2 diabetes mellitus. Current antipruritic therapies are insufficiently effective. Thus, the mediation of diabetic pruritus by histamine-independent pathways is likely. The aim of this study was to identify possible mediators responsible for diabetic pruritus. A total of 87 patients with type 2 diabetes mellitus were analysed, of whom 59 had pruritus and 28 did not. The 2 groups were assessed for baseline demographics, serum biochemistry parameters, cytokines, and chemokines. This study also investigated the associations of these factors with the severity of itching. Neither haemoglobin A1c nor serum creatinine levels were correlated with severity of itching. Significantly higher levels of interleukin-4 (p = 0.004), interleukin-13 (p = 0.006), granulocyte-macrophage colony-stimulating factor (p < 0.001) and C-X-C motif chemokine ligand 10 (p = 0.028) were observed in the patients with pruritus than in those without pruritus. Moreover, the levels of these mediators were positively correlated with the severity of itching. Thus, novel antipruritic drugs can be developed to target these molecules. This is the first study to compare inflammatory mediators comprehensively in patients with diabetes mellitus with pruritus vs those without pruritus.

Differences between Staphylococcus aureus nasal carriage and IgE-sensitization to Staphylococcus aureus enterotoxin on risk factors and effects in adult population

Background

Staphylococcus aureus (SA) nasal carriage (SA carriage) and IgE-sensitization to SA enterotoxin (SE IgE-sensitization) are known to be associated with chronic airway disease.

Objective

This study aimed to evaluate the differences in risk factors, type 2 inflammation and respiratory symptoms between SA carriage and SE IgE-sensitization.

Methods

We conducted a cross-sectional study of a community-based adult population to evaluate the environmental exposure and health impact of the Pohang Industrial Complex, Korea. Participants were examined based on self-reported questionnaires, nasal swab, and blood sampling.

Results

There were 307 participants, and the overall prevalence of SA carriage and SE IgE-sensitization was 26.1% (80/307) and 25.7% (79/307), respectively. An urban environment was significantly correlated with SA carriage, whereas age and obesity were significantly correlated with SE IgE-sensitization. SA carriage was not associated with an increase in total IgE and blood eosinophil count, whereas SE IgE-sensitization was associated with an increased total IgE and blood eosinophil count. SA carriage was significantly correlated with cough persisting for more than three weeks (OR, 3.044; 95% CI, 1.137–8.153) and sputum (OR, 2.429; 95% CI, 1.008–5.854). SE IgE-sensitization was a significant correlation with only sputum (OR, 2.452; 95% CI, 1.066–5.640). SA carriage and SE IgE-sensitization showed a synergistic effect on the prevalence of cough and sputum.

Conclusion

SA carriage was associated with the urban environment, and SE IgE-sensitization was associated with the elderly and obesity. SA carriage and SE IgE-sensitization had different correlation with type 2 inflammation and airway symptoms.

Atopic Dermatitis: Conventional and Integrative Medicine

Although Western medicine and ideas about atopic dermatitis (AD) have become popular in many Asian countries, local beliefs about the disease and its treatment often prevail. The multi- racial background of these countries as well as the influence of the diverse religions (such as Taoism and Ramadan) in these regions often lead to diverse belief systems about the causes of AD (such as the Chi concept, also known as the balance of yin and yang) and the types of treatment (e.g. herbal remedies, topical versus concoctions, and decoctions). In addition, many of the cultural practices are preserved among the Southeast Asian minorities residing in the United Kingdom and North America. Eastern treatments typically take a holistic approach to AD and emphasize the psychosomatic component of the disorder. This overview provides a summary of the difference between conventional, complementary, alternative, and integrative medicine in terms of epidemiology, aetiology, therapy, and prognosis in children with AD. There are a number of similarities in genetic and environmental factors in epidemiology and aetiology; however, differences exist in terms of the concept of management. Complementary and alternative medicine, traditional Chinese medicine, and integrative medicine usage are not only prevalent among the Asian population but are also becoming more popular and accepted in Western societies.

Staphylococcus aureus Infections in the Paediatric Intensive Care Unit: Illustrated Cases

Staphylococcus aureus is known to be one of the most common gram-positive microorganisms and an important pathogen associated with sepsis and toxic shock. We present four anonymized consecutive cases in a paediatric intensive care unit (PICU) to illustrate the different clinical manifestations of staphylococcal infections, including local infection versus systemic infection, toxic shock versus septic shock, and osteomyelitis. Eczema, short gut syndrome, and scald injury may be associated. Haematologic and coagulopathic abnormalities may be present. Prompt diagnosis and use of appropriate antimicrobial treatments is essential to reducing mortality and morbidity associated with staphylococcal infections.

Experimental Drugs with the Potential to Treat Atopic Eczema

Introduction

Eczema or atopic dermatitis (AD) is a chronically relapsing dermatosis characterized by pruritus and a significant impact on the quality of life.

Methods

The authors undertook a structured search of peer-reviewed research articles from PubMed and Google Scholar. Recent and up-to-date studies relevant to the topic were included.

Results

This report overviews current treatment and experimental drug for AD. Topical agents including topical phosphodiesterase E4 (PDE4) inhibitors such as crisaborole are efficacious in the treatment of AD with few side effects. Monoclonal antibodies such as dupilumab given subcutaneously are efficacious for more severe disease. Systemic treatment can ameliorate symptoms in severe and recalcitrant AD. New systemic treatment includes several traditional herbal formulations that have undergone clinical trials using modern research methodology to determine their efficacy and safety. AD is associated with many complicating psychosocial issues. Often suboptimal efficacy is due to unrealistic expectations and poor compliance making treatment difficult in spite of effective treatment and efforts in drug discovery. Randomized trials have shown that novel topical and subcutaneous medications are safe and efficacious. Regarding herbs, a methodology for the investigation of herbal medications is often flawed and scientific evidence is lacking. Experimental drugs include various biologics, PDE4 and JAK inhibitors in topical, oral, subcutaneous or intravenous forms are in various phases of trials.

Conclusion

Many novel medications demonstrate efficacy for AD. Experimental drugs include various biologics, PDE4 and JAK inhibitors are in various phases of trials.

C-reactive protein predicts complications in community-associated S. aureus bacteraemia: a cohort study

Background

Staphylococcus aureus (S. aureus) bacteraemia is increasingly acquired from community settings and is associated with a mortality rate of up to 40% following complications. Identifying risk factors for complicated S. aureus bacteraemia would aid clinicians in targeting patients that benefit from expedited investigations and escalated care.

Methods

In this prospective observational cohort study, we aimed to identify risk factors associated with a complicated infection in community-onset S. aureus bacteraemia. Potential risk factors were collected from electronic medical records and included: - patient demographics, symptomology, portal of entry, and laboratory results.

Results

We identified several potential risk factors using univariate analysis. In a multiple logistic regression model, age, haemodialysis, and entry point from a diabetic foot ulcer were all significantly protective against complications. Conversely, an unknown entry point of infection, an entry point from an indwelling medical device, and a C-reactive protein concentration of over 161 mg/L on the day of admission were all significantly associated with complications.

Conclusions

We conclude that several factors are associated with complications including already conducted laboratory investigations and portal of entry of infection. These factors could aid the triage of at-risk patients for complications of S. aureus bacteraemia.

Practical Recommendations for the Topical Treatment of Atopic Dermatitis in South and East Asia

Introduction

There is some evidence to suggest that the prevalence of atopic dermatitis (AD) in Asia is rising. We have therefore developed an algorithm for the topical treatment of AD throughout South and East Asia for use by primary care physicians, pediatricians and dermatologists.

Methods

Nine AD experts from South and East Asia and one from Europe developed the algorithm based upon treatment guidelines, relevant literature and local treatment practices. The algorithm outlines current best practice for the use of emollients, topical corticosteroids (TCS) and topical calcineurin inhibitors (TCI), with the intention of simplifying the treatment regimen of mild-to-moderate AD in South and East Asia.

Results

Patients with AD should bathe and cleanse affected skin to remove crusts and scales daily. Emollients should also be applied daily as a maintenance treatment. When selecting appropriate topical anti-inflammatory treatment for AD flares, several factors should be taken into consideration, including the patient’s age, attitude to treatment options and site of AD lesions. Given the concerns regarding the risk of skin atrophy with use of TCS, a TCI should be used to treat AD lesions in sensitive skin areas: pimecrolimus is recommended for mild-to-moderate AD in these locations, while tacrolimus should be considered for moderate and severe cases. Either pimecrolimus or tacrolimus is recommended for flares in other, non-sensitive body locations. A proactive or intermittent maintenance treatment strategy involving regular emollient use and twice-weekly application of a TCI to previously affected areas is encouraged to reduce the risk of flares.

Conclusions

The algorithm proposed here is intended to simplify the topical treatment of mild-to-moderate AD in daily practice in South and East Asian countries.

Are skin equipment for assessing childhood eczema any good?

AIM

Symptomatology and severity of atopic dermatitis (AD) can be objectively measured with equipment. This study aimed to compare skin measurements and investigate their correlations with various clinical severity scores.

METHODS

Skin hydration (SH), transepidermal water loss (TEWL), pH, erythema, pigmentation, and ITA (individual typology angle) were measured (using Delfin, Courage + Khazaka, and Mettler Toledo equipment), and correlated with Patient-Oriented Eczema Measure (POEM, a short-term subjective-symptom score), Scoring Atopic Dermatitis (SCORAD, a short-term subjective-symptom and objective-sign score), Nottingham Eczema Severity Score (NESS, a long-term subjective-symptom score), Children Dermatology Life Quality Index (CDLQI, a short-term subjective-symptom score) with Spearman's rho coefficient.

RESULTS

80 sets of clinical scores from eczema patients (mean age: 10.8 ± 4.9 years; 44.6% male) were evaluated. The POEM, objective SCORAD, CDLQI correlated well with each other. Skin pH ranged from 4.3 to 7.0 (mean 5.7 ± 0.61). Skin pH was correlated with Objective SCORAD components, including area (rho = 0.269, p = .036), erythema (rho = 0.302, p = .018), and lichenification (rho = 0.365, p = .026) and with the usage frequency of topical antibiotics. Skin pH was also correlated with other skin measurements, including SH (Delfin equipment: rho = -0.38, p < .001). SH and TEWL as measured by Delfin equipment correlated better with a number of symptoms and signs than Courage + Khazaka equipment. Other clinical measurements including erythema, melanin, and skin color did not demonstrate strong correlations with clinical symptom scores.

CONCLUSION

Skin pH (using Mettler Toledo), SH, and TEWL (using Delfin equipment) correlated well with various clinical symptomatology scores. Less acidic pH appears to be associated with worse clinical scores of symptomatology, and increase usage of topical antibiotics, These findings not only support the supplementary usage of equipment in aiding objective documentation of clinical symptomatology in eczema therapeutic research but also the advocacy of maintaining more acidic skin and avoiding alkaline soap and emollient products.

A Phytocomplex Consisting of Tropaeolum majus L. and Salvia officinalis L. Extracts Alleviates the Inflammatory Response of Dermal Fibroblasts to Bacterial Lipopolysaccharides

Background

The antimicrobial activity and effects of a phytocomplex consisting of Tropaeolum flos (T) and Salviae folium (S) extracts on the cytokine levels and transcription factors on dermal fibroblast BJ exposed to bacterial lipopolysaccharides were examined.

Methods

In order to select the most optimal combination ratio of the two extracts for using in vitro, the physicochemical characterization of vegetal extract mixtures was performed and the antioxidant and antibacterial activities were evaluated on five different formulations of T : S, namely, 1 : 1, 1 : 2, 2 : 1, 3 : 1, and 1 : 3. The best combination of bioactive compounds with regard to antioxidant and antibacterial activities (T : S 1 : 2) was selected for in vitro evaluation of the anti-inflammatory effect. Human dermal fibroblast BJ cells were treated with two doses of the extract mixture and then exposed to bacterial lipopolysaccharides (LPS). The levels of the cytokines involved in inflammatory response, namely, interleukin- (IL-) 6, tumor necrosis factor- (TNF-) α, IL-31, and IL-33, were quantified by ELISA, and the expression of transcription factors, namely, signal transducer and activator of transcription (STAT) 3, nuclear factor kappa B (NFκB), and phosphorylated NFκB (pNFκB), were evaluated by western blot analysis.

Results

The results have shown that the mixture of T : S 1 : 2 exhibited significant antibacterial effects on Staphylococcus aureus ATCC 25923. LPS exposure increased the cytokine levels in BJ cells and enhanced the NFκB expression. The pretreatment of BF cells exposed to LPS with the two doses of the extract mixture markedly inhibited the increase of IL-33 and TNF-α levels and amplified the NFκB expression and its activation, especially with the high dose. The low doses of the extract reduced NFκB expression but increased its activation.

Conclusions

These experimental findings suggest that the mixture of T : S 1 : 2 can exert some protection against bacterial infections and inflammation induced by LPS in BJ cells being a good therapeutic option in related conditions associated with inflammation.

Effect of pine-tar bath on disease severity in moderate-to-severe childhood eczema: an investigator-blinded, crossover, randomized clinical trial

Background: Atopic dermatitis (AD) is a chronic inflammatory disease associated with pruritus and sleep loss. Pine-tar has long been used for various chronic skin conditions in which its polycyclic aromatic hydrocarbon (PAH) component is anti-inflammatory and its resin acids antiseptic. The null hypothesis of this trial is that there is no difference in clinical efficacy between a pine-tar product and its vehicle for AD.Methods: A 3-month, investigator-blinded, crossover, randomized control trial (RCT) was conducted in which each patient was assigned to bathing with pine-tar bath oil for one month and vehicle bath oil for another, with a washout period of 1-month in-between. Acceptability and efficacy of the bath products were measured. Disease severity scores (scoring atopic dermatitis (SCORAD) and patient-oriented eczema measure (POEM), quality of life questionnaires, noninvasive skin biophysiological measurements, blood IgE levels, and Staphylococcus aureus (SA) colonization status were assessed before and following bathing.Results: Significant improvements were found in total SCORAD (p = .030), POEM (p = .004), SA colonization status (p = .002), and log-transformed IgE level (p = .009) among patients who bathed with pine-tar in the overall RCT study using intention-to-treat analysis. For per protocol analysis, significant improvements were found in total SCORAD (p = .024), objective SCORAD (p = .011), extent (p = .014), intensity (p = .032), pruritus (p = .047), POEM (p = .044), SA colonization status (p = .035), and log-transformed IgE level (p = .028). Acceptability to both bath-oils was good, and no product-related serious adverse events were recorded.Conclusions: Bathing with pine-tar is an efficacious and recommendable adjuvant practice for AD patients. Disease improvement is associated with reduction of SA and IgE.

An overview of drug discovery efforts for eczema: why is this itch so difficult to scratch?

Introduction: Atopic dermatitis (AD) is a type of allergic/inflammatory dermatitis characterized by itch and an impairment in quality of life.Areas covered: Herein, the authors review drug discovery efforts for AD, highlighting the clinical efficacy of novel drugs, with a particular focus on the relief of pruritus. Topical agents include emollients, topical antihistamines, corticosteroids, calcineurin inhibitors and herbs. Recently, topical phosphodiesterase E4 (PDE4) inhibitors like crisaborole have become available and are efficacious for mild to moderate AD with few side effects. For more severe AD, monoclonal antibodies like dupilumab are considered as efficacious subcutaneous treatment options. In severe and recalcitrant AD, systemic treatment can ameliorate AD symptoms.Expert opinion: Many topical and systemic medications have demonstrated therapeutic benefits for AD. Indeed, randomized trials have shown that topical PDE4 inhibitors and subcutaneous dupilumab are safe and efficacious. Objective tools to evaluate itch and gauge treatment efficacy is important, but current methodology relies primarily on clinical scores. AD is a systemic atopic disease with a lot of complicated psychosocial issues. Suboptimal efficacy is often due to poor compliance and unrealistic expectation of curative treatment, rendering treatment difficult despite the existence of effective medications.

Staphylococcus aureus: an underestimated factor in the pathogenesis of atopic dermatitis?

Atopic dermatitis is a common, recurrent pruritic dermatosis with a complex pathogenesis. It has been associated with disordered patterns of immunological response and impaired epithelial barrier integrity. These features predispose the patients to robust colonization of skin lesions by Staphylococcus aureus. Virulence factors of S. aureus (e.g. superantigens, α- and δ-toxin, protein A) have been shown to exacerbate and perpetuate the course of atopic dermatitis. Novel therapeutic options with potential for restoring natural microbiome composition are being elaborated and may enter clinical practice in the future.

Dismissing the fallacies of childhood eczema management: case scenarios and an overview of best practices

BACKGROUND

Eczema or atopic dermatitis (AD) is a common relapsing childhood dermatologic illness. Treatment of AD is primarily topical with emollients and corticosteroid/calcineurin inhibitor, which is efficacious for the majority of patients. However, AD is often complicated and difficult to manage in many Asian cities. Effective therapy is impeded by fallacies in the following aspects: (1) mistrust and unrealistic expectations about Western medicine, (2) skin care and allergy treatment, (3) ambiguity about optimal bathing and moisturizing, (4) hesitation and phobias about the usage of adequate topical corticosteroid and immunomodulatory therapies, (5) food and aeroallergen avoidance and dietary supplementation, and (6) complementary and alternative therapies.

METHODS AND RESULTS

Eleven anonymized case scenarios are described to illustrate issues associated with these fallacies. A literature review is performed and possible solutions to handle or dismiss these fallacies are discussed.

CONCLUSIONS

The first step in patient care is to accurately assess the patient and the family to evaluate possible concerns, anxiety, and phobias that could impede therapeutic efficacy. Education about the disease should be individualized. Conflicting recommendations on the usage of topical steroid have a detrimental effect on management outcomes, which must be avoided.

Investigational drugs for atopic dermatitis

INTRODUCTION

Many novel medications and herbal medicines have claimed efficacy on atopic dermatitis (AD).

AREAS COVERED

This review covers evidence on efficacy of topical and oral forms of novel and investigational drugs. Topical agents include emollients, phosphodiesterase E4 (PDE4) inhibitors, and topical herbs. There is little evidence that ceramides or natural moisturizing factors provide relief in AD. PDE4 inhibitors have shown promise as an effective topical treatment for mild-to-moderate AD with minimal adverse events, and dupilumab as an effective subcutaneous agent for the treatment of moderate-to-severe AD in adult patients with little adverse effects. However, only preliminary data are available for dupilumab in children with AD. The long-term effects of dupilumab are also not known. Potential new systemic treatments include a number of herbal concoctions.

EXPERT OPINION

Randomized, double-blind placebo-controlled trials (RCTs) have demonstrated topical PDE4 inhibitors are effective and safe in the treatment of both children and adults with AD but further evaluations are needed. RCTs have also shown that subcutaneous dupilumab is an effective and safe agent for the treatment of AD in adults. Long-term effects of these topical and systemic investigational drugs are currently unavailable. Regarding herbal medications, scientific methods are often flawed and objective evidence is lacking.

In vitro antimicrobial effects of a novel Pentaherbs concoction for atopic dermatitis

BACKGROUND

In a series of bench and clinical trials, our group has determined the immunologic effects and clinical efficacy of a concoction of five herbal ingredients (PentaHerbs Formula, PHF) in treating children with atopic eczema (AE). This study investigates the antimicrobial effects that may be induced with PHF treatment.

METHODS

We investigated the effects of PHF on the minimal inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of Staphylococcus aureus and various bacteria that are commonly present on the skin of patients with AE.

RESULTS

Staphylococcus aureus ATCC 25923, Methicllin resistant Staphylococcus aureus (MRSA) ATCC BAA-43, Enterococcus faecalis ATCC 29212, Pseudomonas aeruginosa ATCC 27853, Escherichia coli ATCC 25922, Enterobacter cloacae ATCC 13047, Proteus vulgaris ATCC 6380, and Acinetobacter baumannii ATCC 19606 were tested. PHF was more effective against Staphylococcus aureus ATCC 25923 and Methicllin resistant Staphylococcus aureus (MRSA) ATCC BAA-43. MIC and MBC were 1 and 25 mg/mL, respectively.

CONCLUSION

PHF was more effective against Staphylococcus aureus ATCC 25923 and Methicllin resistant Staphylococcus aureus (MRSA) ATCC BAA-43t. PHF may be developed into a Staphylococcus aureus targeting topical application.