French national protocol for the management of congenital ichthyosis

Congenital ichthyoses (CI) comprise a heterogeneous group of monogenic genetic skin diseases characterized by diffuse scaling, often associated with skin inflammation. Diagnosis of the individual form of ichthyosis is complex and is guided by clinical expertise. CI usually has a major impact on quality of life (QOL) and thus requires lifelong treatment. To date, there are no curative therapies, although various symptomatic treatment options exist. The present protocol for the management of CI has been drawn up in accordance with the recommendations published in 2012 by the French National Authority for Health, based on a literature review, with the help and validation of members of the French network for rare skin diseases (FIMARAD). It provides a summary of evidence and expert-based recommendations and is intended to help clinicians with the management of these rare and often complex diseases.

Inherited ichthyosis as a paradigm of rare skin disorders: Genomic medicine, pathogenesis, and management

Great advances have been made in the field of heritable skin disorders using next-generation sequencing (NGS) technologies (ie, whole-genome sequencing, whole-exome sequencing, whole-transcriptome sequencing, and disease-targeted multigene panels). When NGS first became available, the cost and lack of access to these technologies were limiting factors; however, with decreasing sequencing costs and the expanding knowledge base of genetic skin diseases, fundamental awareness of NGS has become prudent. The heritable ichthyoses comprise a genotypically and phenotypically heterogeneous group of monogenic keratinization disorders characterized by persistent scaling, with at least 55 distinct genes currently implicated in causing nonsyndromic and syndromic forms of the disease. By providing a simplified overview of available NGS techniques and applying them in the context of ichthyosis, one of the most common genodermatoses, we hope to encourage dermatologists to offer, when appropriate, genetic testing earlier in patients with unsolved presentations. With the aid of NGS, dermatologists can provide diagnostic certainty in cases of suspected genodermatoses and offer potentially life-changing genome-guided and targeted therapies as they become available.

Otological problems in ichthyosis: A literature review

BACKGROUND

Ichthyoses are a rare group of keratinization disorders characterized by scaling of the skin due to an impaired barrier function. Few studies have addressed ear involvement in patients with ichthyosis, although it is a probably underestimated aspect of the disease.

OBJECTIVE

This study aims to provide an overview of the otological manifestations in ichthyosis and propose specific treatment options.

METHODS

Articles were collected using PubMed, EMBASE, and Web of Science. A total of 53 articles were included in this literature review.

RESULTS

The most common ear problem in patients with ichthyosis is scale accumulation in the ear canals, which can lead to conductive hearing loss and increases the risk of ear infections. Furthermore, some types of ichthyosis are associated with outer ear malformations. Lastly, sensorineural hearing loss is common in syndromic forms of ichthyosis.

CONCLUSIONS

Otological problems are present in all types of ichthyoses and their treatment is challenging. The involvement of ear, nose, and throat specialists in the routine care of ichthyosis patients is essential for early identification and treatment of these manifestations. More research is needed to provide more insight into the otological problems in ichthyosis and to ameliorate treatment options.

Ichthyosis: presentation and management

PURPOSE OF REVIEW

This review focuses on the presentation and management of ichthyoses and highlights recent advances in treatment that hold promise for better targeted therapy.

RECENT FINDINGS

The ichthyoses are a group of rare genetic diseases with a wide phenotypic spectrum, characterized most often by generalized hyperkeratosis and scaling with variable erythema. The highly visible scaling and frequent itch contribute to decreased quality of life. Management for ichthyosis focuses on symptomatic relief and scale reduction with emollients, keratolytics, and retinoids. Recent advances in immune profiling and genotype-phenotype mapping have increased understanding of ichthyosis and shifted focus to pathogenesis-based targeted therapies with emerging biologics, small molecular inhibitors, and gene therapy.

SUMMARY

This article discusses clinical assessment and genotyping to make the diagnosis of specific forms of ichthyosis, provides guidance for management, and reviews new treatment options with systemic agents.

Novel mixed-method, inclusive protocol involving global key stakeholders, including carers as experts, to co-develop relevant Caregiver-Reported Outcome Domains (CRODs) in skin disease

INTRODUCTION

Ichthyoses comprise a heterogenous group of rare genetic skin disorders that involves the entire skin surface, often with additional syndromic features, and pose many clinical challenges. Without curative intervention, the mainstay of life-long symptom management is supportive in nature and can remain the responsibility of the caregiver. Although impact on the wider family is considered an important outcome of policies and services, there is a lack of caregiver consensus on what outcome domains to measure to fully assess the impact of ichthyosis on the patient and the caregiver. This project aims to identify a set of core outcome domains towards a core outcome set for ichthyosis that can measure all relevant concepts of ichthyosis in clinical practice, service delivery and research.

METHODS AND ANALYSIS

Following the COMET (Core Outcome Measures in Effectiveness Trials) initiative, this project will employ a mixed-method study design which was developed using public and patient involvement and an international multidisciplinary expert group (clinical experts, patients and their representatives, policymakers, researchers and service providers). Experts by experience, or caregivers, will be recruited through online ichthyosis support groups. Phase one will focus on item generation and involve: (1) a systematic literature review, (2) a multimethods international qualitative study with ichthyosis caregivers and (3) co-development of items for an e-survey. Phase two, item refinement, will employ a novel four-pronged consensus approach: (1) an e-Delphi survey, (2) statistical analysis of e-Delphi survey results, (3) online qualitative feedback and (4) an online consensus discussion. All methodological considerations will be clearly linked with each Core Outcome Set-STAndards for Developing recommendation.

ETHICS AND DISSEMINATION

Research Ethics Committee approval obtained from the School of Psychology, Ulster University (UK)(Ref:REC/20/0004). Results will be presented in published international peer-reviewed journals, at scientific meetings and support groups.

REGISTRATION

COMET database (January 2019).

Treatments for Non-Syndromic Inherited Ichthyosis, Including Emergent Pathogenesis-Related Therapy

The term 'inherited ichthyosis' refers to a heterogeneous group of mendelian disorders of cornification that involve the integument with varying degrees of scaling. The management of ichthyosis poses a challenge for most physicians. Treatment options proposed in the literature include moisturizers, topical keratolytics, topical and systemic vitamin D analogues, and topical and systemic retinoids; however, some of these modalities are less reliable than others. Despite the therapeutic impasse imposed by the options above, the emergence of pathogenesis-based treatments along with novel gene therapies appear promising and hold the potential to halt or even revert disorders that arise from single genetic mutations, although research is still quite lacking in this domain. Hence, this review aims to highlight the various treatment modalities available for the management of the cutaneous manifestations of non-syndromic inherited ichthyosis, with an added emphasis on pathogenesis-targeted therapies.

Management of Ichthyosis: A Brief Review

The ichthyoses, also termed the disorders of keratinization, are a heterogenous group of skin diseases in which a distinctive horny layer arises secondary to excessive transepidermal water loss. Although occasionally acquired, the majority of ichthyoses are inherited and can be pinpointed to characteristic genetic mutations. Management depends on disease severity and includes topical agents and lifestyle modifications with or without oral retinoids. Genetic counseling is also an important consideration. This review aims to highlight advances in our understanding of disease pathogenesis as well as the holistic approach necessary to adequately manage ichthyosis patients.

Grover's Disease in a Kidney Transplant Recipient

Dear Editor, It is not unusual for patients with renal insufficiency to develop skin pathologies. There are reports in the literature of increased incidence of calciphylaxis, pruritus, perforating dermatoses, and porphyria cutanea tarda in this patient population (1). Although it is quite rare, Grover's disease (GD) has been reported in several patients with renal insufficiency, but only once in a renal transplant recipient (2). The disease follows three patterns: persistently pruritic, transient eruptive, or a chronic asymptomatic course (3). Common risk factors concomitant with disease prevalence are immunosuppression, HIV, hemodialysis, viral and bacterial infections, malignancies, and other skin pathologies like contact and atopic dermatitis (4). A 60-year-old woman had a family history of polycystic kidney disease and was subsequently diagnosed in 1997. The patient had concomitant hepatic involvement and a stable aneurysm of the anterior cerebral artery. Consequently, the patient preemptively received a kidney transplant in 2015. The immunosuppressive therapy consisted of tacrolimus, mycophenolate mofetil, and prednisone with basiliximab induction. In 2017, a biopsy of the right thigh demonstrated squamous cell carcinoma in situ measuring 1×1cm in size. The lesion was treated with surgical excision. The patient also exhibited an erythematous brown macule with undefined borders on the left side of the nose with a size of 12 mm; it was later determined to be actinic keratosis. The lesion was treated successfully with cryotherapy. During this period, a fever prompted a PCR for BK virus DNA which showed a substantial amount of copies, measuring 28,850 copies/mL in urine and 98 copies/mL in blood. The mycophenolate dose was reduced, and tacrolimus trough concentration was maintained at between 3 and 5 µg/L. In 2018 the patient presented with multiple pruritic erythematous papules located on the trunk. Upon histological biopsy, there was dominant suprabasal acantholysis with numerous cells separating from the epithelium. Furthermore, there was a moderate amount of mononuclear infiltrate in the upper portion of the dermis and sparse suprabasal clefts (Figure 1). Clinical presentation and histologic examination were consistent with Grover's disease. The patient was treated topically with betamethasone cream twice daily for four weeks. The skin changes persisted for only a few weeks. The pathophysiological mechanism causing GD is still unknown. It is usually only a transient skin condition that lasts no more than a few weeks, but there have been more chronic cases lasting for years, particularly in patients on hemodialysis (5). The lesions commonly affect the chest area but may spread to diffusely envelope the body as erythematous papules, pustules, lichenoid lesions, or vesicles (2). Grover characterized 4 different subtypes based on the pathohistological findings as Darier-like (the most common), pemphigus vulgaris-like, Hailey-Hailey-like, or spongiotic subtype (3). The histological patterns are not exclusive to one patient and may even be found concomitantly in a single lesion. The condition is definitively diagnosed through histology, showing distinctive acantholysis along the epidermis with dyskeratosis that is described as "corps ronds" and "grains" (3). Grover's disease is more prevalent in middle-aged Caucasian men than any other group, with a 1.6-2.1 gender ratio (6). It was originally thought that the disease was caused by dysfunctional eccrine sweat glands, as the ailment was more common in patients that had increased perspiration either due to environmental heat, fever, or extensive bedrest. This idea was reinforced by histological evidence of atrophied sweat glands in uremic patients with renal insufficiency (7). Moreover, a case series and case report described remissions of GD in their patients on hemodialysis that received a renal transplant (5,8). However, subsequent studies have not supported an association with sweat dysfunction and disease development, while others have only managed to attribute sweat gland dysfunction as the primary trigger in 20-30% of cases (9). Conversely, cold dry air and xerosis cutis is thought to trigger the disease because it is four times more likely to be diagnosed in the winter months (10). Ultraviolet radiation has been identified as an exacerbating factor for GD, which could have been the trigger for onset of disease in our patient as demonstrated by her squamous cell carcinoma and actinic keratosis (11). Despite immunosuppression being a risk factor for GD, as shown by its association in patients with HIV, bone marrow transplantation, hemodialysis, and hematological malignancies, GD has been reported only once in the literature after a renal transplant (2,4). As our case, that patient developed GD a few years after transplant without an obvious trigger and the lesions appeared as red papules that were disseminated over the anterior thorax. Their patient's cutaneous lesion resolved spontaneously after 2 weeks and never returned in the 2.5-year follow-up period. Their patient has had two renal allografts over a 20 year timespan, while ours had had her graft for only two years. The immunosuppressive regimen was slightly different: cyclosporine, azathioprine, and methylprednisolone versus our combination of tacrolimus, mycophenolate mofetil, and prednisone. Grover's disease can be treated conservatively by avoiding risk factors such as UV light and sweating as well as and applying moisturizing emollients which may cause the lesion to resolve spontaneously. Medical therapy consists of topic corticosteroids, topical vitamin D analogues, oral retinoids, and oral corticosteroids, PUVA, and methotrexate for resistant cases (6,12). When a patient exhibits pruritic papules of the skin, GD should be considered in differential diagnosis, especially in kidney transplant patients and those on hemodialysis. While the condition is rare, increased recognition in this patient population will allow for studies to further characterize this poorly understood disease.

Cd30-Positive Cutaneous Anaplastic Large Cell Lymphoma with Ichthyosis Acquisita

Anaplastic large cell lymphoma (ALCL) is a high-grade non-Hodgkin's lymphoma recognized by the expression of the CD30 marker and by its morphology. We report an unusual case of ALCL in a 42-year-old woman. For ten years the patient only had pruritic erythematous skin lesions, then a plaque with nodules and ulcers on the right thigh and leg developed, followed by ichthyosis acquisita. The development of ALCL in women and the association of ichthyosis acquisita with this type of lymphoma are uncommon.

Inherited Nonsyndromic Ichthyoses: An Update on Pathophysiology, Diagnosis and Treatment

Hereditary ichthyoses are due to mutations on one or both alleles of more than 30 different genes, mainly expressed in the upper epidermis. Syndromic as well as nonsyndromic forms of ichthyosis exist. Irrespective of etiology, virtually all types of ichthyosis exhibit a defective epidermal barrier that constitutes the driving force for hyperkeratosis, skin scaling, and inflammation. In nonsyndromic forms, these features are most evident in severe autosomal recessive congenital ichthyosis (ARCI) and epidermolytic ichthyosis, but to some extent also occur in the common type of non-congenital ichthyosis. A correct diagnosis of ichthyosis-essential not only for genetic counseling but also for adequate patient information about prognosis and therapeutic options-is becoming increasingly feasible thanks to recent progress in genetic knowledge and DNA sequencing methods. This paper reviews the most important aspects of nonsyndromic ichthyoses, focusing on new knowledge about the pathophysiology of the disorders, which will hopefully lead to novel ideas about therapy.

Monolateral Grover's Disease with Blaschkoid Distribution

Dear Editor, Grover's disease, also known as transient acantholytic dermatosis, is an idiopathic and acquired pruritic eruption of small vesicles and erythematous papules, classically on the central chest. The pathogenesis is not clearly defined, although heat sweating and occlusion have been interpreted as predisposing factors. We describe a case of monolateral acantholytic eruption with blaschkoid distribution in a patient treated with an orthopedic bandage for a shoulder injury. A 53-years-old man was referred to the dermatologic department because of an acute eruption of pruritic, discrete, pinkish grey papulovesicles, developed on the right side of the trunk 14 days after the positioning of an orthopedic bandage for a shoulder injury. This skin eruption followed a multilinear distribution along Blaschko lines (Figure 1, a, b). The medical history was unremarkable. The patient's family history was negative for similar dermatosis. Histopathological analysis showed acantholytic dyskeratosis with suprabasal cleft. A basket weave epidermic pattern with hyperkeratosis was observed, with a perivascular lymphocytic infiltration in the upper dermis (Figure 1, c, d). Given the clinical and histopathological features, a diagnosis of monolateral Grover's disease was established. The patient was treated with topical mometasone furoate 0.1% cream for 3 weeks with clinical improvement. Monolateral blaschkoid distribution in Grover's disease is extremely rare, with only 1 case reported in the literature (1). Two cases of zosteriform distribution have been described (2,3). The exact pathogenesis and the differential diagnosis with linear Darier's disease were the main topics of discussion, while the pathogenesis is still in debate. In our case, it appears that a shoulder bandage can cause an occlusive environment that can elicit the disease (4). Similar conditions were present in a previously described cases of bedridden patients (1). Some authors have postulated that such conditions may act as precipitating factors on a genetically predisposed epidermis (1). In monolateral and localized cases, postzygotic somatic mutations along Blasckho's lines or in dermatomes could be present. It is also important to distinguish this monolateral and blasckhoid Grover's disease from other acantholytic dermatoses. In this case, the differential diagnosis with an eruptive linear Darier's disease is very difficult (5). Histopathological analysis is not useful. Both monolateral and ordinary variants of Darier's disease can be elicited by environmental factors such as heat, sweating, or occlusion. The diagnosis of monolateral blaschkoid Grover's disease was preferred due to the patient's anamnesis (late-onset and no familiar history of similar dermatosis) and the clinical features (sparing of the head, extremities, and flexures). Since only additional genetic analysis could definitively resolve this question, it was performed. No mutation in genes coding the Ca2+ pump using genomic DNA from the patient's white blood cells or from a skin biopsy was found. A clinical anamnestic and genetic correlation is always crucial in these rare and unique acantholytic dermatoses.

Pruritic eruption on the chest

The fact that this patient's rash was limited to his chest provided an important diagnostic clue.

Can early skin care normalise dry skin and possibly prevent atopic eczema? A pilot study in young infants

BACKGROUND

Atopic eczema (AE) affects approximately 20% of children in Northern countries. Onset during early infancy is common and is characterised by altered skin barrier, increased water loss and defective lipid layer. Restoration of skin barrier by emollients and/or oil baths is an important part of AE treatment, but its role in preventing xerosis and AE is unknown. The present pilot study aimed to assess if xerosis, and possibly AE, could be reduced at six months of age by early introduction of frequent oil baths/facial fat cream in infants with dry skin.

METHODS

A controlled intervention pilot study included 56 six-week-old infants with xerosis, but not AE. Skin quality score ranging from 0 (normal skin) to 4 (probable AE), was assessed at inclusion, three and six months of age, with skin quality at six months as main outcome. One well baby clinic was recruited for intervention, frequent skin care (oil bath (0.5 dl) and facial fat cream, five well baby clinics recruited for observation only.

RESULTS

The intervention group (n=24) had more often normal skin (75%) at six months than the observation group (37.5%) (p<0.001), and less often probable AE (4.0 vs. 19.0%, respectively, ns). Oil baths were performed regularly, 2-4 up to 5-7 times/week in the intervention group, vs. fewer oil baths with sparse volume of oil in the observation group. No adverse reactions were reported.

CONCLUSION

Regular oil baths in infants seem to reduce xerosis and may possibly reduce atopic eczema.

Surprising prenatal toxicity of epidermal lipoxygenase-3

Metabolites of the epidermal lipoxygenase-3 (eLOX-3) are involved in various metabolic pathways. Most unexpectedly, intra-amniotic delivery of eLOX-3 to mice at gestational day 14.5, both via an adenoviral vector and as recombinant protein, resulted in fetal growth restriction and intrauterine death. Periodic acid-Schiff staining and RT-PCR analysis of placentae from fetuses exposed to eLOX-3 indicated a lack of glycogen trophoblasts in the junctional zone. Placenta-specific gene expression was altered. Thus, the observed prenatal toxicity of eLOX-3 could be due to a strong effect on placental development.

Topical enzyme-replacement therapy restores transglutaminase 1 activity and corrects architecture of transglutaminase-1-deficient skin grafts

Transglutaminase-1 (TG1)-deficient autosomal-recessive congenital ichthyosis (ARCI) is a rare and severe genetic skin disease caused by mutations in TGM1. It is characterized by collodion babies at birth, dramatically increased transepidermal water loss (TEWL), and lifelong pronounced scaling. The disease has a tremendous burden, including the problem of stigmatization. Currently, no therapy targeting the molecular cause is available, and the therapeutic situation is deplorable. In this study, we developed the basis for a causative therapy aiming at the delivery of the enzyme to the inner site of the keratinocytes' plasma membrane. We prepared sterically stabilized liposomes with encapsulated recombinant human TG1 (rhTG1) and equipped with a highly cationic lipopeptide vector to mediate cellular uptake. The liposomes overcame the problems of insufficient cutaneous delivery and membrane penetration and provided excellent availability and activity of rhTG1 in primary keratinocytes. To demonstrate the general feasibility of this therapeutic approach in a humanized context, we used a skin-humanized mouse model. Treatment with rhTG1 liposomes resulted in considerable improvement of the ichthyosis phenotype and in normalization of the regenerated ARCI skin: in situ monitoring showed a restoration of TG1 activity, and cholesterol clefts vanished ultrastructurally. Measurement of TEWL revealed a restoration of epidermal barrier function. We regard this aspect as a major advance over available nonspecific approaches making use of, for example, retinoid creams. We conclude that this topical approach is a promising strategy for restoring epidermal integrity and barrier function and provides a causal cure for individuals with TG1 deficiency.

Unraveling the mystery of the disorder of keratinization: the path of syndromic ichthyoses

In the last few years the progresses in molecular analysis allow better definitions of ichthyoses and lead to the necessity of a new classification and a review of nomenclature of inherited ichthyoses. So, in 2007 the First Consensus Conference on Ichthyoses was performed. We present here a short review of the new classification of syndromic ichthyoses together with clinical and molecular features.

Emollient therapy for dry and inflammatory skin conditions

Most nurses will encounter patients with dry skin conditions such as atopic eczema and psoriasis in their everyday practice. Emollients can be beneficial for most dry skin conditions, although they are widely underused. Increased knowledge and awareness of the benefits and optimal use of emollient therapy can improve patient care and outcomes.

Ichthyosis: clinical manifestations and practical treatment options

Ichthyoses constitute a large group of cornification disorders that affect the entire integument. The skin is characterized by visible scaling and in many cases by inflammation, for example, in bullous/keratinopathic ichthyosis or Netherton syndrome. From the viewpoint of classification it is useful to distinguish non-syndromic from syndromic types of ichthyosis. Ichthyosis vulgaris and recessive X-linked ichthyosis are common disorders - often of delayed onset, in contrast to congenital ichthyoses, which belong to the group of rare diseases and present at birth with either the features of collodion membrane or congenital ichthyosiform erythroderma. The diagnostic steps are based on clinical data, analyses such as the steroid sulfatase activity test, skin biopsies, and genetic results. However, the dramatic increase in knowledge about the pathophysiology of these conditions has not led to a curative therapy so far. The therapeutic management is multidisciplinary and involves ichthyosis patient organizations in many countries. The mainstay of treatment remains with moisturizing creams containing, for example, urea, lactic acid and other humectants and keratolytics, regular bathing, and mechanical scale removal. Patients with lamellar ichthyosis or ichthyosiform erythroderma in particular profit from oral therapy with retinoids or retinoic acid metabolism-blocking agents.

Granulomatous slack skin presenting as acquired ichthyosis and muscle masses

We describe a case of granulomatous slack skin in a 31-year-old woman with an unusual presentation of acquired ichthyosis and muscular masses involving four limbs over 3 years. Vesicles and ulcerative skin nodules first appeared only 3 months prior to diagnosis. The diagnosis was confirmed after sequential biopsies of muscle, skin lesions, and lymph nodes, together with molecular genetic studies. The patient responded poorly to various therapies, including thalidomide, and died of doxorubicin-related cardiomyopathy.

Sjögren-larsson syndrome: a study of clinical symptoms and dermatological treatment in 34 Swedish patients

Sjögren-Larsson syndrome (SLS) is a recessively inherited disease with congenital ichthyosis, spastic diplegia or tetraplegia and mental retardation, caused by a deficiency of fatty aldehyde dehydrogenase. The aim of this study was to examine all 34 Swedish patients with SLS, emphasizing skin symptoms, dermatological treatment, and neurological symptoms (evaluated in some cases for more than 25 years by one and the same investigator). Structured interviews were conducted with the patients and their close relatives. All patients had generalized ichthyosis. The degree of scaling varied markedly inter-individually from moderate to severe, but there was no obvious change with age. Most patients had pruritus, suffered from hypohidrosis, and had palmo-plantar keratoderma. Nineteen patients (56%) were on oral acitretin and all patients were using some type of topical therapy. Motor disability with spasticity and muscular paresis was most pronounced in the legs and fairly slight in the arms. Twenty patients (59%) were dependent on a wheelchair for mobility. Poor blood circulation in the lower legs and oedematous feet were frequently found in adults. All patients had learning disability, which varied from slight to pronounced and was expressed in their speech disorders. Thirteen patients (38%) were being treated medically for epilepsy and all had photophobia. In conclusion, SLS is a chronic, severely disabling neurocutaneous disease in which optimal dermatological therapy is essential to relieve at least the patient's ichthyosis problem.

[Xerosis: a dysfunction of the epidermal barrier]

Xerosis or dry skin is a common skin disorder among the general population. It is characterized clinically by rough, scaly, and often itchy skin. This disorder is present in the course of some dermatoses such as atopic dermatitis, although it can also occur in healthy individuals if a combination of certain etiologic factors is present. It is characterized pathophysiologically by a disrupted stratum corneum, dehydration, and impaired keratinocyte differentiation. Treatment of xerosis should seek to restore physiologic lipids in the epidermis and provide substances that facilitate epidermal differentiation.

A novel congenital ichthyosiform syndrome with associated panhypopituitarism, corneal opacities and mental retardation

A 15-year-old male presented with ichthyosis since infancy with panhypopituitarism, short stature and knock-knees, delayed puberty, high scrotal retractile testes, mental retardation and corneal opacities. He developed recurrent tinea capitis and tinea corporis. The clinical symptomatology indicates that this case cannot be considered as a subtype of inherited ichthyosis group, but suggests a new syndrome as a separate nosologic entity. Two previously reported cases with possibly the same syndrome also had ichthyosis associated with variable endocrinopathy. Thorough endocrinological evaluation and appropriate intervention in patients of ichthyosis with short stature may reduce the morbidity associated with retarded skeletal growth and gonadal maturation.

A systematic review of topical skin care in aged care facilities

AIM

This systematic review aimed to evaluate the best available evidence regarding the effectiveness of topical skin care interventions for residents of aged care facilities.

INTRODUCTION

Natural changes to skin, as well as increased predisposition to pressure sores and incontinence, means residents of aged care facilities readily require topical skin care. A range of interventions exist that aim to maintain or improve the integrity of skin of older adults.

METHODS

Pubmed, Embase, Current Contents, CINAHL and The Cochrane Library databases were searched, as well as Health Technology Assessment websites up to April 2003. Systematic reviews and randomized or non-randomized controlled trials were evaluated for quality and data were independently extracted by two reviewers.

RESULTS

The effectiveness of topical skin interventions was variable and dependent on the skin condition being treated. Studies examined the effectiveness of washing products on incontinence irritated skin. Disposable bodyworns may prevent deterioration of skin condition better than non-disposable underpads or bodyworns. Clinisan, a no-rinse cleanser may reduce the incidence of incontinence associated pressure ulcers when compared with soap and water.

CONCLUSION

In general the quality of evidence for interventions to improve or maintain the skin condition in the older person was poor and more research in this area is needed.

RELEVANCE TO CLINICAL PRACTICE

Skin care is a major issue for nurses working with older people. On the basis of this review no clear recommendations can be made. This lack of strong evidence for nurses to base effective practice decisions is problematic. However, the 'best' evidence suggests that disposable bodyworns are a good investment in the fight against skin deterioration. No rinse cleansers are to be preferred over soap and the use of the bag bath appears to be a useful practice to reduce the risk of dry skin (a risk factor for breaches in skin integrity).

Atopic xerosis: employment of noninvasive biophysical instrumentation for the functional analyses of the mildly abnormal stratum corneum and for the efficacy assessment of skin care products

The subtle dryness of the skin surrounding the lesions of atopic dermatitis (AD) is called atopic dry skin or atopic xerosis (AX). AX is more susceptible to the development of AD skin lesions under various environmental stimuli than the clinically normal skin of the people who have or have had or will have AD, which might be called normal atopic skin (NAS) that shows no functional differences as compared to the skin of normal individuals. Routine histopathologic studies of AX that involve the invasive procedures of biopsy are not so helpful in clarifying the underlying pathogenesis. Modern, noninvasive biophysical instrumentation provides rich and quantitative information about various functional aspects of skin. The stratum corneum (SC) of AX reveals not only decreased hydration but also mildly impaired barrier function demonstrable as an increase in transepidermal water loss, elevated pH values, and an increased turnover rate of the SC consisting of thick layers of smaller-sized corneocytes. These data suggest that AX is related to mildly increased epidermal proliferation as a result of the presence of subclinical cutaneous inflammation. Although AX skin does not display any impairment in the recovery of barrier function after physical skin irritation by tape-stripping, it produces a much more severe, long-lasting inflammatory response together with a delay in barrier repair after chemical irritation such as that induced by sodium lauryl sulphate. The SC of AX is biochemically characterized by reduction in the amounts of ceramides, especially ceramide I, sebum lipids, and water-soluble amino acids. None of these changes in SC functions are seen in NAS, which includes not only the normal-looking skin of AD patients long after regression of all active lesions but also of latent atopic skin such as neonates who later develop AD. This suggests that all of the observed functional as well as biochemical abnormalities of AX are a reflection of subclinical inflammation. The presence of the underlying inflammation in AX also differentiates it from senile xerosis. The mildly impaired SC functions of AX can be improved by daily repeated applications of effective moisturizers, i.e., corneotherapy, which is effective in preventing the exacerbating progression of AX to AD resulting from inadvertent scratching of the skin that facilitates the penetration of environmental allergens into the skin. The biophysical confirmation of such efficacy of moisturizers, including cosmetic bases on the mildly impaired barrier function and decreased water-holding capacity of the SC of AX, definitely substantiates the importance of skin care for the cosmetic skin problems that affect every individual in the cold and dry season ranging from late autumn to early spring.

Genodermatoses care in the Mediterranean region: a new initiative

This article looks at a regional initiative to improve the quality of medical and social care for patients with severe skin diseases. The programme called "Genodermatoses and the Mediterranean--Together for a better care" aims to use shared international experience to alleviate the painful aspects of this condition and the methods used to facilitate this.

The clinical benefit of moisturizers

Moisturizing creams marketed to consumers often contain trendy ingredients and are accompanied by exciting names and attractive claims. Moisturizers are also an important part of the dermatologist's armamentarium to treat dry skin conditions and maintain healthy skin. The products can be regarded as cosmetics, but may also be regulated as medicinal products if they are marketed against dry skin diseases, such as atopic dermatitis and ichthyosis. When moisturizers are used on the so-called dry skin, many distinct disorders that manifest themselves with the generally recognized symptoms of dryness are treated. Dryness is not a single entity, but is characterized by differences in chemistry and morphology in the epidermis depending on the internal and external stressors of the skin. Patients and the society expect dermatologists and pharmacists to be able to recommend treatment for various dry skin conditions upon evidence-based medicine.

LEARNING OBJECTIVE

Upon completing this paper, the reader should be aware of different types of moisturizers and their major constituents. Furthermore, s/he will know more about the relief of dryness symptoms and the functional changes of the skin induced by moisturizers.

[The so-called dry skin of the diabetic patient]

Rough skin or xerosis, known by the laity as dry skin, results from a defect in the stratum corneum desquamation which normally remains imperceptible. This condition is negatively influenced by winter climatic conditions. Atopic dermatitis and trophic changes related to post-menopause, ageing, diabetes mellitus, as well as other endrocrine and metabolic disturbances are also involved in this process. Xerosis can be improved at various degrees by emollients, humectants, hydrating agents and squamolytic agents.

[Ichthyoses and related keratinization disorders. Management, clinical features and genetics]

This review concerns ichthyoses and related keratinization disorders. These are rare genetic skin diseases which are associated with marked scaling, often considerable cutaneous inflammation and a severe disease burden both physically as well as psychosomatically. The review briefly discusses how to establish a clinical diagnosis, how to provide genetic counseling for the patient and their family and how to best manage such diseases. Particular emphasis is given to the new possibilities in diagnosis and treatment opened by the recently established network for ichthyoses and related keratinization disorders (NIRK). This network is funded by the German Ministry for Education and Research and aims to integrate research efforts into disease mechanisms and to spread and transfer knowledge about these diseases to achieve better clinical care for the patients.

Skin lesions in the neonate

Neonatal skin provides physical protection and assists in fluid balance,immunosurveillance, and thermoregulation; thus, playing a vital role in the newborn's transition from an aqueous to an air-dominant environment. Worried parents often seek medical attention from their child's physician regarding skin lesions. Thus,a working knowledge of both normal and abnormal cutaneous lesions of the neonate is required to properly address these issues. In this article, the authors briefly discuss transient benign lesions,pustular and vesicular infections, "birthmarks" (vascular and pigmentary lesions), common congenital abnormalities, select blistering disorders, and various other skin conditions.

Role of topical emollients and moisturizers in the treatment of dry skin barrier disorders

Emollients and moisturizing creams are used to break the dry skin cycle and to maintain the smoothness of the skin. The term 'moisturizer' is often used synonymously with emollient, but moisturizers often contain humectants in order to hydrate the stratum corneum. Dryness is frequently linked to an impaired barrier function observed, for example, in atopic skin, psoriasis, ichthyosis, and contact dermatitis. Dryness and skin barrier disorders are not a single entity, but are characterized by differences in chemistry and morphology in the epidermis. Large differences also exist between moisturizing creams. Moisturizers have multiple functions apart from moistening the skin. Similar to other actives, the efficacy is likely to depend on the dosage, where compliance is a great challenge faced in the management of skin diseases. Strong odor from ingredients and greasy compositions may be disagreeable to the patients. Furthermore, low pH and sensory reactions, from lactic acid and urea for example, may reduce patient acceptance. Once applied to the skin, the ingredients can stay on the surface, be absorbed into the skin, be metabolized, or disappear from the surface by evaporation, sloughing off, or by contact with other materials. In addition to substances considered as actives, e.g. fats and humectants, moisturizers contain substances conventionally considered as excipients (e.g. emulsifiers, antioxidants, preservatives). Recent findings indicate that actives and excipients may have more pronounced effects in the skin than previously considered. Some formulations may deteriorate the skin condition, whereas others improve the clinical appearance and skin barrier function. For example, emulsifiers may weaken the barrier. On the other hand, petrolatum has an immediate barrier-repairing effect in delipidized stratum corneum. Moreover, one ceramide-dominant lipid mixture improved atopic dermatitis and decreased transepidermal water loss (TEWL) in an open-label study in children. In double-blind studies moisturizers with urea have been shown to reduce TEWL in atopic and ichthyotic patients. Urea also makes normal and atopic skin less susceptible against irritation to sodium laurilsulfate. Treatments improving the barrier function may reduce the likelihood of further aggravation of the disease. In order to have optimum effect it is conceivable that moisturizers should be tailored with respect to the epidermal abnormality. New biochemical approaches and non-invasive instruments will increase our understanding of skin barrier disorders and facilitate optimum treatments. The chemistry and function of dry skin and moisturizers is a challenging subject for the practicing dermatologist, as well as for the chemist developing these agents in the pharmaceutical/cosmetic industry.

Health-related quality of life among patients with ichthyosis

Ichthyosis encompasses a heterogeneous group of hereditary skin disorders, which can be present at birth or develop in childhood. The aim of the present study was to investigate the Health related quality of life (HRQoL) of patients with ichthyosis. Two questionnaires (Dermatology Life Quality Index [DLQI], and the generic Short Form [SF] - 36) and a subjective measure of disease activity employing a visual analogue scale (VAS) were mailed to 144 patients. 122 patients aged 17-78 years responded. The median for DLQI was 5.0, which was significantly higher (worse) for Lamellar ichthyosis than for X-linked recessive ichthyosis. The SF-36 showed significantly lower (worse) scores for the study group in four of the eight dimensions compared to age- and gender-adjusted Swedish norm scores. No differences in SF-36 were found between men and women or between the different groups of ichthyosis. The results demonstrate that ichthyosis has an adverse effect on HRQoL.

Management of the ichthyoses

The ichthyoses are a heterogeneous group of inherited scaling skin disorders that can also affect other organs. Management should be directed at both the skin and other sites. Skin therapy is not specific at this time, although new products may offer more directed therapy in the future. Moisturizers and keratolytics are the mainstay of topical therapy. Calcipotriene, retinoids, and for select types, anti-inflammatories such as topical steroids and calcineurin inhibitors have also been used. Systemic therapy is limited to the retinoids. Superinfection of the skin should be anticipated and treated. Pruritus can be disabling. Failure to sweat normally may result in heat intolerance. Eye care should seek to prevent corneal changes resulting from ectropion and more specific changes associated with specific disorders. Haring can be impaired by the accumulation of material in the external auditory canal. Severely affected children may require caloric supplementation to avoid growth retardation. Affected individuals and their family should be counseled about the long term outlook and the genetic nature of their disorder, and informed of FIRST, the Foundation for Ichthyosis and Related Skin Types, the lay foundation that offers support and information.

Papulosquamous diseases in the elderly

This article refers to papulosquamous diseases that are seen in the elderly. Many of these diseases are complex to diagnose due to the fact that they are difficult to identify, because they may resemble a similar disorder, which can be misleading. The problem that is frequently seen with these diseases is that they are commonly misdiagnosed. In this article the authors include information that will help with identifying these diseases. The authors also provide important laboratory exams that can be performed and can help guide diagnosis, as well as differential diagnosis and treatment options.

Ichthyosis: etiology, diagnosis, and management

The ichthyoses are a heterogeneous group of disorders with both inherited and acquired forms. Clinical presentation, pattern of inheritance, and laboratory evaluation may establish a precise diagnosis, which can assist in prognosis and genetic counseling. Congenital autosomal recessive ichthyosis (CARI) usually presents at birth, often as a collodion baby. CARI can progress into any one of a spectrum of disorders. Lamellar ichthyosis is characterized by dark, plate (armor)-like scale. This disease is often caused by mutations in the gene encoding the enzyme transglutaminase 1. Congenital ichthyosiform erythroderma is another phenotype within CARI, marked by generalized redness and fine white scale. Epidermolytic hyperkeratosis is an autosomal dominant disorder characterized by hyperkeratosis and blistering, and at least six clinical phenotypes have been described. It may be due to mutations in the gene encoding the intermediate filament proteins keratin 1 and 10. Ichthyosis vulgaris is the most common ichthyosis, and is inherited in an autosomal dominant pattern. Involvement is generally mild and may vary greatly with climate and humidity. X-linked ichthyosis, due to a defect in the enzyme steroid sulfatase, affects males with generalized scaling that usually begins soon after birth. There may be associated corneal opacities that do not affect vision. Sjögren-Larsson syndrome is an autosomal recessive ichthyosis associated with progressive spastic paralysis and mental retardation. This condition is caused by mutations in the gene for fatty aldehyde dehydrogenase. Refsum's disease, due to accumulation of phytanic acid, results in ichthyosis and progressive neurologic dysfunction. The erythrokeratodermas are characterized by hyperkeratosis and localized erythema. Erythrokeratodermia variabilis is autosomal dominant and characterized by generalized or localized hyperkeratosis and migratory red patches. Mutations in the genes encoding the gap junction proteins, connexins, underlie this disorder. Netherton's syndrome is an autosomal recessive disorder characterized by ichthyosis, a hair shaft abnormality and atopy. The ichthyosis may present at birth with erythroderma or in some cases a collodion presentation. However, a frequent characteristic skin manifestation is ichthyosis linearis circumflexa. Netherton's syndrome has been found to be due to an abnormality in a serum protease inhibitor. Acquired ichthyosis can have a variety of underlying causes including neoplastic, infectious, drugs, endocrine, metabolic, autoimmune, malabsorptive states, and hereditary. Topical, and in more severe cases, systemic, therapy are useful in managing this array of disorders of cornification.

Collodion baby: a follow-up study of 17 cases

Seventeen cases of collodion baby are reported. Clinical aspects, complications, treatment, final outcome and family history were studied. We did not observe any clinical features in the collodion baby that could serve as a clue in predicting the final diagnosis. Infections were observed in nine, hypothermia in five and hypernatraemic dehydration in four cases. Skin infection mainly occurred in babies treated with emollients (petrolatum, lanolin and cetomacrogolis cream were used). We therefore recommend treating the collodion baby in a humidified incubator, if necessary with intravenous rehydration, but not to use emollients. The final outcome of these study patients was erythrodermic autosomal recessive lamellar ichthyosis in seven cases (41%), non-erythrodermic autosomal recessive lamellar ichthyosis in three cases (18%), Sjögren-Larsson in one case (6%), epidermolytic hyperkeratosis in one case (6%), acute neonatal variant of Gaucher disease in one case (6%) and normal skin in four cases (24%).

[Xerosis]

The clinical characteristic of xerosis is rough or coarse skin. Physiopathologically, the structure of the stratum corneum is modified and abnormalities in keratinization, proliferation, surface lipid, water metabolism and also pH and sebum exist. There are two forms of xerosis: dry skin forms and ichtyosis or ichtyosis-like forms. Xerosis has many etiologies including external aggression, senescence, drugs, infection, atopy, deficiencies, malignant diseases, endocrine affections, eating disorders and renal failure in dialyzed patients. It provokes cutaneous discomfort and unaesthetic appearance that justify appropriate treatment. Treatment is essentially local, symptomatic and must be accompanied by general measures. Many products include moisturizers and emollients (keratolytics: salicylic acid, urea and alpha-hydroxy acid).

Genetic skin disorders

Neonatologists do not require a detailed knowledge of all genetic skin disorders but need to recognize one if they see it. The unique accessibility of the skin makes it possible to observe the physical signs and deduce the child's immediate needs from first principles. The morphological classification given here will help the nondermatologist establish a clinical diagnosis. Tremendous advances over the last 10 years in understanding the molecular basis of skin disease make it possible, in many cases, to confirm the diagnosis and to counsel the family accurately.