Safety review of phenoxyethanol when used as a preservative in cosmetics

Phenoxyethanol, or 2-phenoxyethanol, has a large spectrum of antimicrobial activity and has been widely used as a preservative in cosmetic products for decades. It is effective against various Gram-negative and Gram-positive bacteria, as well as against yeasts, and has only a weak inhibitory effect on resident skin flora. According to the European Scientific Committee on Consumer Safety, phenoxyethanol is safe for all consumers - including children of all ages - when used as a preservative in cosmetic products at a maximum concentration of 1%. Adverse systemic effects have been observed in toxicological studies on animals but only when the levels of exposure were many magnitudes higher (around 200-fold higher) than those to which consumers are exposed when using phenoxyethanol-containing cosmetic products. Despite its widespread use in cosmetic products, phenoxyethanol is a rare sensitizer. It can be considered as one of the most well-tolerated preservatives used in cosmetic products.

European task force on atopic dermatitis position paper: treatment of parental atopic dermatitis during preconception, pregnancy and lactation period

Atopic dermatitis (AD) is a common inflammatory skin disease that affects both children and adults, including a large number of adults of reproductive age. Several guidelines for the treatment of AD exist, yet specific recommendations for the treatment of pregnant or lactating women and for adults planning to have a child are often lacking. This position paper from the European Task force on Atopic Dermatitis (ETFAD) is based on up-to-date scientific literature on treating pregnant and lactating women as wells as adults with AD planning to have a child. It is based on the expert opinions of members of the ETFAD and on existing safety data on the proposed treatments, many of which are derived from patients with other inflammatory diseases or from transplantation medicine. For treating future parents, as well as pregnant and lactating women with AD, the use of topical treatments including moisturizers, topical corticosteroids, tacrolimus, antiseptics such as chlorhexidine, octenidine, potassium permanganate and sodium hypochlorite (bleach) is deemed to be safe. Ultraviolet (UV) therapy may also be used. Systemic treatment should be prescribed only after careful consideration. According to the opinion of the ETFAD, treatment should be restricted to systemic corticosteroids and cyclosporine A, and, in selected cases, azathioprine.

Beta-blockers for hemangiomas

Infantile hemangiomas (IHs) are the most common tumors in infancy. Their typical natural history is characterized by an early rapid growth in the first months of life and by a slow spontaneous involution in the first years of life. Even though spontaneous regression of IHs could suggest therapeutic abstention, systemic treatment is the therapy of choice in many patients in which these situations occur: 1) rapid growth of IHs; 2) location of IHs in aesthetically critic areas; 3) recurrent hemorrhages, ulcerations or infections of IHs; 3) IHs interfering with important physiological functions (breathing, feeding, vision, hearing, etc.); 4) large or multicentric IHs that can cause heart failure. Since 2008, systemic administration of propranolol, an old non‑selective β‑blocker, was found, serendipitously, to improve the treatment of IHs replacing older and more dangerous therapies like oral steroids, vincristine, interferon‑alpha or vascular lasers. At present, oral propranolol has dramatically changed the approach of IHs because its efficacy is almost 100% and its action is rapid, without important side effects. The formal approval by FDA and EMA has been obtained in Spring 2014.

Multiple cutaneous and hepatic infantile hemangiomas having a successful response to propranolol as monotherapy at neonatal period

Infantile hepatic hemangioma (IHH) is a common liver tumors of infancy with a higher incidence in females. Various treatments for infantile hepatic hemangioma such as systemic corticosteroids, interferon-alpha, vincristine and cyclophosphamide have been suggested, though no consensus exists about the first-choice treatment. Recent evidences suggest that propranolol, a nonselective β-blocker, may be effective and safe as first-line therapy for infantile hepatic hemangioma. We report a case of female born at term with a weight of 2.450 g started to develop multiple cutaneous IHs at 10 days of age and presenting concomitant multiple cutaneous and hepatic infantile hemangiomas confirmed on magnetic resonance imaging. Propranolol, used as monotherapy, was started at 14 days of age at a dose of 2 mg/kg/day orally and maintained for 6 months. Patient was monitored in the hospital during first days of treatment with propranolol, and discharged after no side-effects were detected. Hepatic and cutaneous lesions had complete resolution in three months, although the fibro-fatty residuum of largest cutaneous nodule was still palpable at month 6. A further control after 6 months showed no recurrences. Our report case suggests that propranolol can be a safe and effective first-line therapy for neonates with concomitant multiple cutaneous and hepatic infantile hemangiomas.

Guidelines for treatment of atopic eczema (atopic dermatitis) part I

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.

Guidelines for treatment of atopic eczema (atopic dermatitis) Part II

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.

Atopic dermatitis (AD) management in an Italian pediatric clinic

AIM

Atopic dermatitis (AD) is a common, chronic relapsing inflammatory skin disease characterized by dry skin and variable pruritus sometimes associated with allergic disease in other organs as asthma and rhinoconjunctivitis. AD affects deeply the Quality of Life, thus can be extremely disabling and may cause psychological problems for both affected children and their families.

METHODS

In order to investigate the estimated prevalence of the disease and the beliefs of the Italian pediatricians, a group of 437 Italian family pediatricians covering a population of almost 380000 children participated in a study based on a questionnaire of 38 items.

RESULTS

According to answers of the participants, the incidence of AD has been estimated around 10% of the population and food allergy is believed to be the trigger of the acute phase of the disease in infants. As a second opinion, dermatologists are consulted more frequently than allergologists.

CONCLUSION

The use of emollients is advised in general whilst topical corticosteroids treatment is prescribed only in selected cases; more than 50% of pediatricians do not prescribe topical calcineurin inhibitors.

Patient-Oriented SCORAD (PO-SCORAD): a new self-assessment scale in atopic dermatitis validated in Europe

BACKGROUND

Patient-oriented medicine is an emerging concept, encouraged by the World Health Organization, to greater involvement of the patient in the management of chronic diseases. The Patient-Oriented SCORing Atopic Dermatitis (PO-SCORAD) index is a self-assessment score allowing the patient to comprehensively evaluate the actual course of atopic dermatitis (AD), using subjective and objective criteria derived mainly from the SCORAD, a validated AD severity clinical assessment tool.

OBJECTIVES

To validate the PO-SCORAD index in a large European population of patients exhibiting all forms of AD severity by assessing its correlation with the SCORAD index.

PATIENTS/METHODS

Four hundred and seventy-one patients (185 adults, 286 children) consulting for AD in hospitals from 9 European countries were recruited. The investigators and the patients used the SCORAD and PO-SCORAD scales, respectively, to assess AD severity at inclusion (D0) and 28 ± 7 days later (D28).

RESULTS

Patient-Oriented SCORing Atopic Dermatitis and SCORAD scores were significantly correlated at D0 [r = 0.67 (95% CI: 0.62; 0.72), P < 0.0001]. Consistency was confirmed at D28, with a stronger linear correlation between both scales [r = 0.79 (95% CI: 0.75; 0.83), P < 0.0001]. Absolute changes from baseline in SCORAD and PO-SCORAD scores were also significantly correlated [r= 0.71 (95% CI: 0.64; 0.76), P < 0.0001]. Although no specific intervention was investigated, AD improved over the study, with a decrease of PO-SCORAD and SCORAD scores from D0 to D28 by -19.19% and -24.39%, respectively. The consistency of the correlations was similar in the adult and children groups.

CONCLUSIONS

This study validated the use of PO-SCORAD to self-assess AD severity and demonstrated its good correlation with SCORAD.

Italian position paper on urticaria. Italian Board on Urticaria

The Italian Board on Urticaria has prepared a document focusing on the definition and classification of urticaria, taking into account the recent progress in identifying the causes, eliciting factors, and pathomechanisms of this disease. As urticaria has a profound impact on the quality of life, effective treatment is important. Therefore, specific treatment options for the management of urticaria are evaluated on the basis of the recent literature. Non-sedating H(1) antihistamines are recommended as the first-line treatment as they have proven effective in several randomized double-blind controlled studies. Dosages higher than those recommended may be necessary in some cases. However, additional or alternative therapies may be required for different urticaria subtypes and in view of individual variations in the course of the disease and response to treatment. Immunosuppressive drugs such as corticosteroids are not recommended for long-term treatment due to unavoidable, severe adverse effects.

The value of SCORAD and beyond. Towards a standardized evaluation of severity?

The clinical scoring systems of atopic dermatitis were analysed and compared. Some biological parameters that can correlate with the clinical score were also reviewed. After the definition of the disease based on validated clinical criteria, the second necessity was the availability of reliable severity scores to allow clinicians to verify the course of the disease and the efficacy of treatments. After many proposals, the SCORAD (SCORing Atopic Dermatitis), that required more than three years of work, was the first one that was validated. SCORAD is freely available from an internet site and can be easily calculated using dedicated software. EASI (Eczema Area and Severity Index) score has also been validated but it has been modified twice. Simpler systems include SASSAD (Six Area, Six Sign Atopic Dermatitis) and TIS score (Three-Item Severity score). In parallel, biological parameters were investigated. Eosinophil cationic protein, circulating basophils, major basic protein, soluble E-selectin, antistaphylococcal enterotoxin B, immunoglobulin E titres and macrophage-derived chemokine, can correlate significantly with the clinical score. The clinicians will not benefit directly from laboratory techniques and will employ clinical scores.

The epidemiology of atopic dermatitis in Italian schoolchildren

BACKGROUND

Atopic dermatitis (AD) is common in children in industrialized countries. Only one large population study on its prevalence has been conducted in Italy, based on self-report questionnaire. The present study was designed to estimate the prevalence of AD in schoolchildren in Italy by dermatologists' assessment and by UK Working Party criteria, and to investigate associated symptoms and factors.

METHODS

Cross-sectional survey on a random sample of 9-year-old schoolchildren from seven Italian cities. Children were examined by experienced dermatologists. Parents and teachers answered standardized questionnaires.

RESULTS

Of the 1369 children examined, 88 had a diagnosis of AD, with an estimated point prevalence of 5.8% (95% CI 4.5-7.1) in the reference population. The reported lifetime prevalence was 15.2 (95% CI 12.2-18.2) for AD, 11.9% (95% CI 9.0-14.8) for asthma, and 17.6% (95% CI 14.6-20.7) for rhino-conjunctivitis. The strongest associated factor was the presence of AD in at least one parent. No association of AD with maternal smoking during pregnancy, birth weight, maternal age at the time of the child birth and breast-feeding was observed. The environmental characteristics of the house and the school did not correlate with the prevalence of AD. Episodes of lower respiratory tract infections were associated with asthma, and to a lower extent also with AD and rhinitis.

CONCLUSIONS

The prevalence of doctor-diagnosed AD in Italian schoolchildren is comparable to those reported for other developed countries. Family history of atopy was the single most important associated factor, while the complex interplay of environmental factors remains to be elucidated.

Clear cell papulosis (pagetoid papulosis) in a non-Asian patient

Clear cell papulosis is a recently described disorder which is characterized by multiple flat, slightly elevated, hypopigmented papules, distributed mainly on the lower part of the trunk of healthy children. Histologically, the disease shows 'clear cells' with a pagetoid appearance spread among keratinocytes in basal and suprabasal layers of the epidermis. These cells stain for AE1, CEA and EMA, making a relationship to eccrine or apocrine elements likely. All cases reported until now describe Asian children. The first European child with clear cell papulosis is presented.

Aplasia cutis congenita in surviving co-twins: four unrelated cases

Four unrelated patients born from twin pregnancies and showing extracranial aplasia cutis congenita are reported. All the patients lost their co-twins during the first half of the pregnancy. Two of the patients had the characteristic truncal and symmetrical type of aplasia cutis associated with fetus papyraceus and placental abnormalities. The presence of multiple hepatic hematomas in one of them gives further credit to a "vascular disruption" as the possible pathogenetic mechanism of the disorder. The two other patients were born with symmetrical aplasia cutis at the extensory aspects of both knees, which presumably represents a milder expression of the former defect. Thus the so-called aplasia cutis with fetus papyraceus shows heterogeneity in localization, extension, presence of extracutaneous abnormalities, and possible association with fetus papyraceus at birth. To include all the patients affected by this peculiar type of aplasia cutis congenita, the designation of aplasia cutis with extracranial symmetrical involvement is proposed.

Skin cleansing in children

The problems of skin cleansing in infants have been re-evaluated in recent years on the basis of current understanding of cosmetology and skin physiology. The anatomical and functional peculiarities of infant's skin have been elucidated and, although it is known that the barrier function is established at birth in normal babies, it remains the case that children's skin is more delicate and therefore more prone to irritant and allergic contact dermatitis. These factors determine the choice of cleansing agents during infancy. The products available on the market differ markedly. Indeed detergents, bath oils, bath powders, due to their distinctive properties, have different indications and different benefits. The method of cleansing the skin, i.e. bathing or showering, is also important. The frequency of cleansing should take into account the age and the degree of exposure to pollutants. For special purposes, e.g. impetiginized dermatoses, antiseptics such as potassium permanganate or chlorhexidine can be added to the water in appropriate concentrations. The ideal paediatric detergent should be very mild to avoid irritant dermatitis, and very simple to avoid allergic dermatitis.

Heterochromia of the scalp hair: a result of pigmentary mosaicism?

Five patients who presented stable bands of hair of a different color with respect to the surrounding hair are reported. In 4 patients this was an isolated finding. One patient also had diffuse linear skin hypopigmentation and other abnormalities. We hypothesize that these 5 cases represent a distinct type of hair heterochromia, possibly because of somatic mosaicism for genes affecting pigmentation.

Uncommon clinical presentations of juvenile xanthogranuloma

Two unusual clinical presentations of juvenile xanthogranuloma (JXG), the most common non-Langerhans cell histiocytosis, are described: a flat 'plaque-like' and a 'paired' form. This report confirms the great variability of JXG. Besides representing a dermatological curiosity, the recognition of these atypical forms of presentation should facilitate the clinical diagnosis of the disorder.

Tungiasis in a 3-year-old child

Tungiasis is an infestation of the skin caused by the flea Tunga penetrans. It is not rare in western Europe because of tourism to tropical and subtropical countries. However, tungiasis has been very rarely reported in children. We describe a case of tungiasis in a 3-year-old child. The infestation was localized to the second toe of the left foot and was characterized by an atypical clinical presentation.

Congenital cutaneous multifocal kaposiform hemangioendothelioma

Kaposiform hemangioendothelioma is a rare vascular neoplasm in children often associated with Kasabach-Merritt syndrome. The tumor usually presents in retroperitoneal location and is rarely present at birth. Cutaneous lesions manifest after birth and must be clinically differentiated from infantile hemangiomas and diffuse neonatal hemangiomatosis. Histologically, it bears similarities with Kaposi sarcoma. We present a case of congenital cutaneous multifocal kaposiform hemangioendothelioma (KHE).

Skin dimpling as a consequence of amniocentesis

No reports of cutaneous lesions after amniocentesis have been published after the advent of real-time ultrasonography. Two infants with multiple skin dimpling caused by needle puncture during fetal life are described. They had pitted scars on the thighs and abdomen that were not associated with internal injury. Both mothers had undergone a diagnostic amniocentesis at the beginning of the second trimester of pregnancy. Real-time ultrasound monitoring of amniocentesis has not completely eliminated the risk of needle puncture scarring of the fetus.

Severe self-healing nail dystrophy in a patient on peritoneal dialysis

The unusual case of a patient on peritoneal dialysis who progressively developed onychodystrophy of the hands 2 months after Acinetobacter peritonitis had been reported. The nail disease consisted of acute pseudoclubbing, elkonyxis, severe Beau's lines and onychomadesis and showed spontaneous recovery within 4 months. Although reminiscent of severe Beau's lines and reflex sympathetic dystrophy, this observation shows a peculiar nail disorder of unknown cause.

Steatocystoma multiplex and leuconychia in a child with Alagille syndrome

Alagille syndrome is a rare autosomal dominant developmental disorder, characterized by congenital paucity of interlobular bile ducts, peculiar facies, posterior embryotoxon, bone abnormalities, and peripheral pulmonary artery stenosis. Cutaneous involvement in this disorder is quite rare and the association of Alagille syndrome with multiple comedones and cysts has been described only once. Here, we report the clinical and histological findings of a 7-year-old patient affected by Alagille syndrome who presented multiple cystic lesions and comedones reminiscent of steatocystoma multiplex and a congenital total true leuconychia. Although unexplained, the association of this syndrome with a developmental disorder of the pilosebaceous unit may not be fortuitous.