Steps towards implementation of protocolized dose reduction of adalimumab, etanercept and ustekinumab for psoriasis in daily practice

BACKGROUND

Dose reduction (DR) of adalimumab, etanercept and ustekinumab has proven to be (cost-)effective in psoriasis patients with low disease activity. Further implementation is needed to establish application of DR for eligible patients.

OBJECTIVES

To evaluate the implementation of protocolized biologic DR in daily practice.

METHODS

A pilot implementation study was performed in 3 hospitals during 6 months. By combining education and protocol development, involved healthcare providers (HCPs) were directed toward the adoption of protocolized DR. DR of adalimumab, etanercept, and ustekinumab was achieved by stepwise injection interval prolongation. Implementation outcomes (fidelity, feasibility) were assessed. Factors for optimizing implementation were explored in interviews with HCPs. Uptake was measured in patients by chart review.

RESULTS

The implementation strategy was executed as planned. Implementation fidelity was less than 100% as not all provided tools were used across study sites. HCPs indicated the feasibility of implementing protocolized DR, although time investment was needed. Identified additional factors for successful implementation included support for patients, uptake of DR into guidelines, and supportive electronic health record systems. During the 6 months intervention period, 52 patients were eligible for DR of whom 26 (50%) started DR. The proposed DR protocol was followed in 22/26 patients (85%) on DR.

CONCLUSION

Additional staff for support, extra time during consultations, education on DR for HCPs and patients, and effective tools such as a feasible protocol can lead to more patients on biologic DR.

Predictive factors for Day 7 positive patch test readings at a secondary referral centre

Background

Based on studies at tertiary centres it is known that patch test reading on Day (D) 7 may show additional positive reactions. Female gender, higher age and allergen groups of topicals and corticosteroids were identified as predictive factors.

Objectives

The first aim was to study the value of reading patch tests on D2, D3 and D7 at a secondary referral centre. The second aim was to investigate the predictive potential of the factors sex, age, atopic dermatitis, body location, allergen group and clinical relevance for a positive reaction only on D7.

Methods

Retrospective data from patients tested between 2013 and 2016 were evaluated. The factors sex, age, atopic dermatitis, body location, allergen group and clinical relevance were tested by regression analysis.

Results

Two hundred and sixty-three out of a total of 396 patients had a positive reaction only on D2, D3 and D7 in 14 (2.5%), 152 (27.5%) and 61 (11.0%) occasions, observed in 10 (2.5%), 108 (27.3%) and 51 (12.9%) patients, respectively. These reactions were deemed relevant in 0 (0%), 12 (2.2%) and 9 (1.6%) occasions, observed 0 (0%), 11 (2.8%) and 9 (2.3%) patients, respectively. Higher age and allergen groups of metals, fragrances and resins were predictive for late positive reactions.

Conclusions

D7 patch test reading should also be routinely adopted at secondary referral centres. D7 positive reactions were associated with higher age and sensitization to metals, fragrances and resins.

Paraneoplastic hypertrichosis lanuginosa acquisita: uncommon or overlooked?

Acquired hypertrichosis lanugo-type or hypertrichosis lanuginosa acquisita (HLA) is often associated with metabolic and endocrine disorders and use of certain drugs. The occurrence of HLA with malignancy was first noted in 1865, and it has since been described in 56 patients as a paraneoplastic syndrome both in women and in men. Sometimes HLA occurs concurrent with acanthosis nigricans, papillary hypertrophy of the tongue, and glossitis. The predominance of female cases is striking. Malignancy-associated HLA seems to occur especially in the age group 40-70 years. In women with HLA the most frequent malignancy is colorectal cancer, followed in order by lung cancer and breast cancer; in men lung cancer is the malignancy most frequently associated with HLA, followed by colorectal cancer. In 3 years we saw 10 patients with HLA, in whom the malignancy was usually metastasized. Only one patient had local disease; after removal of the primary tumour it took 2 years before the lanugo hair recurred. The aetiology of the syndrome is not clear: no specific hormonal or biochemical abnormalities have been identified as yet. The difference between hirsutism and lanugo-type hypertrichosis is discussed. It is stressed that the appearance of lanugo-type hypertrichosis in body areas previously perceived by patients as 'hairless' is highly indicative of internal malignancy.

Prediction of irritancy in the human skin irritancy model and occupational setting

It is of great importance to find ways to lower the incidence of chronic irritant contact dermatitis. In this process, it is crucial to have insight in the factors that can predict irritancy. This review offers a survey of recent findings in the field of skin irritancy testing, discussed in the context of renowned, older work. Extrinsic and intrinsic factors that may determine the outcome of irritancy testing in the human skin model are considered. In recent decades, there has been increasing interest in factors influencing the development of occupational dermatitis by means of prospective cohort studies. This promising new area of investigation is discussed separately.

Irritancy ranking of anionic detergents using one-time occlusive, repeated occlusive and repeated open tests

Discrepancies between the one-time patch test and the wash test regarding the ranking of irritancy of detergents have been found in the literature. The aim of the present study was to investigate the concordance of irritancy rank order of 4 anionic detergents tested by 3 different exposure methods, namely one-time occlusive, repeated short-time occlusive and repeated short-time open tests. These detergents were sodium cocoyl isethionate (ISE), sodium lauryl sulfate (SLS), soap and disodium lauryl 3-ethoxysulfosuccinate (SUC). The reactions were evaluated by visual scoring and by transepidermal water loss (TEWL) measurement. When scored visually, the rank order in the one-time test was: SOAP > or = SLS > or = ISE > SUC. The other test methods yielded a different order: SLS > ISE > or = SOAP > SUC. A similar rank order was obtained with TEWL measurement for all exposure methods. Generally, the concordance among the different exposure methods was high when evaluated by TEWL. The concordance was lower when evaluation was performed by visual scoring. The present study demonstrates that the choice of exposure model and evaluation method may be important variables influencing the outcome of irritancy testing. It is proposed that the repeated open test is the best way to simulate most in-use situations where the uncovered skin is exposed to detergents. The repeated occlusive test or the one-time patch test may be better to simulate situations in which the skin is occluded after irritation by detergents.

House-dust mite hypersensitivity, eczema, and other nonpulmonary manifestations of allergy

The pathogenetic role of house-dust mites (HDM) in atopic dermatitis (AD) remains controversial, mainly because there is no common agreement on a provocation test that mimics ordinary exposure to HDM. This is related to the lack of knowledge of the mechanism of how HDM allergens enter the body. Theoretically, there are two possible routes: directly through the epidermis, or by inhalation. In "atopy patch testing", a concentrated HDM suspension is tested on the skin under occlusion. This method is frequently used as a model of the epidermal route. The clinical relevance of this method as a provocation test for AD is discussed. As opposed to atopy patch testing, we describe another method, namely, "allergen inhalation testing", as a model of the respiratory route. Twenty patients with AD underwent bronchial provocations with HDM extract in a double-blind, randomized, placebo-controlled study. In nine out of 20 AD patients, bronchial challenge with HDM evoked skin symptoms. All patients with HDM-induced dermatitis had a history of asthma, and as a group they had a higher mean total log-transformed IgE level than the "negative skin responders". Thus, the respiratory route may be relevant in the provocation of AD in a subset of AD patients and may represent an appropriate model of provocation in these patients. Furthermore, the role of HDM in urticaria and allergic rhinitis is discussed.

Irritancy of antiseptics tested by repeated open exposures on the human skin, evaluated by non-invasive methods

The aim of the study was to test the irritancy of 6 antiseptics in an open exposure model. The following agents were tested in their normal use concentrations using open exposures, 2x daily for 4 days in 20 subjects: chlorhexidine 4% (CH), chlorhexidine 0.5% in ethanol 70% (CE), ethanol 70% (ET), iodine 1% in ethanol 70% (IE), povidone-iodine 10% (PI) and sodium hypochlorite 0.25% (SH). Responses were evaluated by visual scoring, subjective irritancy scoring, stratum corneum hydration (Corneometer), transepidermal water loss and laser Doppler flowmetry. Exposure to SH had to be discontinued after 4 applications because of severe subjective irritation. The same held true for IE (7 applications), whereas the other agents were exposed 8x. All evaluation methods showed SH to be significantly more irritating than IE, which was in turn more irritating than CH, CE, ET and PI. Thus, it can be concluded that CH, CE, ET and PI were non-irritating in this open exposure model.

Severity scoring of atopic dermatitis: a comparison of three scoring systems

In studies on atopic dermatitis (AD), different scoring systems are used to evaluate the severity of the disease. The objective of this study was to investigate agreement between observers in the assessment of the overall severity of AD, and interobserver variation in the assessment of severity of AD for each scoring item separately, using the Simple Scoring System (SSS), the Scoring Atopic Dermatitis (SCORAD) index, and the Basic Clinical Scoring System (BCSS), and, furthermore, to investigate agreement between these three scoring systems in the assessment of the overall severity of AD. Eighty-two patients (42 male) with AD, mean age 13.4 years (range 0.2-67.0), were included. Agreement between observers in assessing the overall AD severity scores, and interobserver variation in assessing AD severity of each scoring item separately were determined in 34 of these 82 patients by two physicians scoring the severity of AD by the three scoring systems. To determine agreement between the scoring systems, one physician scored the severity of AD in all patients with the three scoring systems. Agreement between observers and agreement between the three scoring systems was calculated by Cohen's kappa (kappa) and by the measure of agreement according to Bland & Altman. kappa > 0.4 represents fair agreement; kappa > 0.75 excellent agreement. In addition, interobserver variation for each scoring item separately was calculated by the Wilcoxon signed rank test. The mean differences (d) and the limits of agreement (d +/- 2 SD of the differences) between observers by the SSS and the SCORAD were -0.82 +/- 5.58 and -0.28 +/- 7.49, respectively, kappa between observers for the BCSS was 0.90 (95% CI 0.79-1.03). By the SSS, significant interobserver variation was found in assessing the severity of excoriations (P = 0.02) and scales (P = 0.02). By the SCORAD, significant interobserver variation was found in assessing the severity of edema/population (P = 0.04), erythema (P = 0.04), and excoriations (P = 0.01). No significant interobserver variation was found in assessing the extent of AD. The mean difference and the limits of agreement between the SSS and the SCORAD were -4.17 +/- 9.52. kappa between the SSS and the BCSS was 0.21 (95% CI 0.09-0.33), and kappa between the SCORAD and the BCSS was 0.38 (95% CI 0.26-0.51). We found good agreement between observers assessing the overall severity of AD in the lower and higher scoring rates by the SSS and the SCORAD, and excellent agreement by the BCSS. Significant interobserver variation was found on the isolated intensity items scales, excoriations, edema/population, and erythema. We found poor agreement between the three scoring systems in assessing the overall severity of AD, indicating that the SSS, the SCORAD, and the BCSS cannot be used interchangeably to assess the overall severity of AD.

Guidelines on sodium lauryl sulfate (SLS) exposure tests. A report from the Standardization Group of the European Society of Contact Dermatitis

This report reviews the clinical and histopathological reactions caused by sodium lauryl sulfate (SLS), and the non-invasive methods that can characterize these reactions. Furthermore, SLS exposure techniques and factors that may influence the outcome of these exposures are discussed. Finally, guidelines are introduced for each exposure technique in order to have a uniform approach to SLS testing in man. Since different study aims warrant different testing conditions, we have proposed 2 categories, namely susceptibility testing and provocative testing, tailored to the aim with which the study is performed.

Induction of atopic dermatitis by inhalation of house dust mite

BACKGROUND

The pathogenetic role of house dust mite in atopic dermatitis remains controversial. Recent studies have shown that intensive epicutaneous contact of house dust mite allergen with premanipulated skin may induce dermatitis. It is, however, uncertain whether such conditions are met during natural contact with house dust mite. In the past, allergen inhalation has been suggested to induce exacerbation of atopic dermatitis. The aim of this study was to investigate whether dermatitis could be induced in patients with atopic dermatitis by inhalation of house dust mite.

METHODS

Twenty patients with atopic dermatitis underwent bronchial provocations with house dust mite. Challenge tests were performed with four concentrations of a standardized house dust mite extract in a double-blind, randomized, placebo-controlled fashion. Spirometry was performed, and FEV1 was measured before and after each challenge dose. Changes in severity or localization of itching or erythema were recorded.

RESULTS

In nine of 20 patients with atopic dermatitis bronchial challenge with house dust mite induced unequivocal skin symptoms after 1.5 to 17 hours. Pruritic erythematous lesions on noninvolved sites together with exacerbations of existing lesions were seen in three patients. Three patients had an exacerbation only, and three other patients had new lesions only. In eight of nine patients with house dust mite inhalation-induced dermatitis, skin symptoms were preceded by an early bronchial reaction. All patients with house dust mite-induced dermatitis had a history of asthma, and as a group they had a higher mean blood total IgE level compared with the "negative skin responders." One patient had pruritic erythema on the placebo challenge day, without a preceding bronchoconstrictive reaction. The number of patients who had a skin response on the house dust mite challenge day was significantly higher than the number of patients who had a skin response on the placebo day (p = 0.011 [Prescott's test]).

CONCLUSIONS

The respiratory route may be relevant in the induction and exacerbation of dermatitis in a subset of patients with atopic dermatitis who have early bronchial reactions after house dust mite inhalation, a history of asthma, and an elevated blood total IgE level. Furthermore, these findings suggest a possible causal relationship between bronchial reactions and skin reactions.

Irritant susceptibility and weal and flare reactions to bioactive agents in atopic dermatitis. II. Influence of season

Many atopic dermatitis (AD) patients have exacerbations of their skin disease in winter. These exacerbations may be caused by non-immunological 'non-specific' factors, such as low sun exposure and low temperature. To date, the influence of season on non-specific skin reactivity in AD has not been studied. The aim of the present investigation was to assess the influence of season on two skin parameters which may be used as quantitative measures of non-specific skin reactivity in AD: (i) susceptibility to repeated epicutaneous irritant (sodium lauryl sulphate, SLS) exposure, and (ii) weal and flare responses to intracutaneous injection of bioactive agents (codeine, FMLP, histamine, methacholine, substance P, trypsin). Four of 16 AD patients had dermatitis which was more severe in November than in July. Susceptibility to SLS was increased in November, both in AD patients and in control subjects. AD patients were more susceptible to SLS than control subjects in both July and November. Pre-exposure barrier function and skin hydration were reduced in November. The increased irritant susceptibility in November may be attributed to reduced barrier function, reduced skin hydration, and/or absence of the beneficial effects of ultraviolet light on cellular targets beneath the stratum corneum. Flare responses to codeine, methacholine, substance P and trypsin were also increased in November compared with July, especially in AD patients. However, smaller flares were observed in AD patients than in control subjects, in both July and November. Flare values were negatively correlated with dermatitis severity, probably because of down-regulation. Weal responses did not show a clear seasonal variation. Hence, susceptibility to epicutaneous irritants and reactivity to intracutaneously injected bioactive agents are parameters which may be used to monitor season-dependent changes in non-specific skin reactivity.

Irritant susceptibility and weal and flare reactions to bioactive agents in atopic dermatitis. I. Influence of disease severity

The two main pathogenetic characteristics of atopic dermatitis (AD) are: (i) antigen-dependent 'specific' reactivity, and (ii) altered non-immunological 'non-specific' reactivity. Our understanding of the role of non-specific reactivity is hampered by the fact that methods available for its quantification are limited. The aim of the present study was to assess the usefulness of two parameters as quantitative measures of non-specific skin reactivity in AD: (i) susceptibility to repeated epicutaneous exposure to an irritant (sodium lauryl sulphate, SLS), assessed by visual scoring and transepidermal water loss (TEWL) measurement, and (ii) reactivity to intracutaneously injected bioactive agents (codeine, FMLP, histamine, methacholine, substance P, trypsin), assessed by measurement of weal and flare size. These two parameters were tested in a group of AD patients, subdivided according to the severity of their dermatitis, and a control group. The visual score and TEWL after SLS exposure tended to be higher in the AD group than in the control group. Furthermore, visual score and post-exposure TEWL were positively correlated with the dermatitis severity score. Weal size following injection of codeine, histamine and substance P, and flare size following injection of all agents, except methacholine, were significantly lower in the AD group than in the control group. Negative correlations were found between weal and flare sizes and the dermatitis severity score. These findings can be explained by down-regulation of structures involved in weal and flare reactions. In conclusion, we propose that epicutaneous irritant susceptibility and reactivity to intracutaneous bioactive agents may be useful indicators of non-specific skin reactivity in AD.

Variability in transepidermal water loss of the skin: evaluation of a method to assess susceptibility to contact dermatitis in epidemiological studies

Transepidermal water loss (TEWL) has been suggested to be a measure which can be used to identify subjects at risk for the development of contact dermatitis. Transepidermal water loss is high when the barrier function of the skin is impaired. It is assumed that subjects with a high TEWL have skin which is more permeable to substances causing contact dermatitis. The inter-individual and intra-individual variability of simultaneous TEWL measurements and TEWL measurements over a period of three weeks were estimated in healthy individuals. The intra-individual coefficient of variation (CV) of simultaneous measurements was 13.5%. The intra-individual coefficient of variation of the measurements on consecutive days was somewhat higher (15.1%). The intra-individual coefficients of variation were low compared to the inter-individual coefficients of variation. The results indicate that transepidermal water loss is a stable personal characteristic, which can be studied as a risk factor in epidemiologic studies on contact dermatitis.

Susceptibility to irritants: role of barrier function, skin dryness and history of atopic dermatitis

The susceptibility of the skin to various irritants was investigated with the aim of determining the role of the barrier function of the stratum corneum, skin dryness and whether a history of atopic dermatitis (AD) was a factor. The transepidermal water loss (TEWL) was measured using an evaporimeter and skin hydration using a Corneometer and by visual scoring. The group with a history of AD (n = 20) had a lower pre-exposure barrier function and a higher TEWL value following irritant exposure than the group with a history of allergic contact dermatitis (n = 18) and a control group (n = 18). Clinically dry skin was more susceptible than normal skin, though no difference was noted in the pre-exposure barrier function. The increased susceptibility to irritants in those with a past history of AD was probably due to impaired barrier function and/or the presence of a dry skin.

Guidelines for transepidermal water loss (TEWL) measurement. A report from the Standardization Group of the European Society of Contact Dermatitis

This report reviews individual-related variables, environment-related variables and instrument-related variables, with a focus on the Evaporimeter EP1 (ServoMed). Start-up and use is described, and guidelines for good laboratory practice given.

Water vapour loss threshold and induction of cholinergic urticaria

A patient is described with cholinergic urticaria (CU) in whom the symptoms could be provoked by gustatory stimuli. The aim of this study was to investigate whether there is a threshold of sweating (monitored by skin water vapour loss (SVL) measurements) at which CU can be provoked. Provocations with lemon and sal-ammoniac liquorice induced transient sweating differing both in degree and duration. Only 'doubly salted' liquorice, which caused the most intense sweat response, resulted in urticarial lesions. This findings suggest a threshold dependency for the induction of CU. SVL measurement may be a useful method for the evaluation of sweating tests in CU patients.

Evaluation of detergent-induced irritant skin reactions by visual scoring and transepidermal water loss measurement

Transepidermal water loss measurements proved to be more accurate and sensitive than visual scoring in discriminating the irritating action of detergents on the skin. Further, the baseline transepidermal water loss might be a reliable indicator of an individual's susceptibility to weak irritants.

The intra- and inter-individual variability and reliability of transepidermal water loss measurements

An analysis of variance was conducted to estimate the intra- and inter-individual variations in TEWL on the forearms, by sites (8 measurement sites) and by days (10 different days), in 30 non-exposed healthy individuals. The estimated intra- and inter-individual variations, by sites, were 15.5% and 84.5%, respectively, the sum of the 2 components always being 100%. With the exclusion of the 2 most distal sites near the wrist, which had significantly higher baseline TEWL values and fluctuations in TEWL, an improvement in the intra-individual variation was obtained. Thus, of the 6 sites, the estimated intra- and inter-individual variations were 8.4% and 91.6%, respectively. This finding supports the exclusion of these most distal sites for future investigations. The estimated intra- and inter-individual variations, by days, were 20.6% and 79.4%, respectively. The low site-to-site (8.4%) and day-to-day (20.6%) intra-individual variations, as compared to the large inter-individual variations of the same (91.6% and 79.4%), indicate that baseline TEWL is a stable personal characteristic. Thus, individual susceptible to irritant contact dermatitis (ICD), due to occupational exposure, may be reliably characterized by utilizing their baseline TEWL values, for "prediction" of risk in epidemiological field studies.

Transepidermal water loss with and without sweat gland inactivation

The influence of eccrine sweating on transepidermal water loss (TEWL) was investigated. TEWL was simultaneously measured on both forearms, with and without topical inactivation of the eccrine sweat glands by 0.3 ml of 0.5% aqueous scopolamine hydrobromide (HBr), applied under 1 h occlusive patches. The degree of sweat inhibition, after exercise, was measured at 2, 3 and 4 h after patch removal. In 42 out of 44 subjects, complete sweat inhibition (on exercise) was achieved only at 4 h after removal. After a 15-min rest in a room at 20 degrees C, the pre-exercise TEWL values (at 4 h) on the treated and untreated sites were not different (P greater than 0.05), in 38 out of 44 subjects. By this rest period, sweating due to slight physical, thermal or even emotional stimuli may be prevented in most subjects. In the other 6 subjects, the pre-exercise TEWL values (at 4 h) on the untreated site were 1-1.8 g/m2h higher than (P less than 0.001) on the treated site, due to emotional sweating. Thus, accurate baseline TEWL measurements may only be made after anticholinergic suppression of the sweat glands. In this way, accurate TEWL measurements may be made even outside favourable laboratory conditions, at industrial sites etc., where circumstances are far from ideal. The effect of this agent applied to a skin site previously irritated artificially by a 24-h occlusive sodium lauryl sulphate (SLS, 0.3 ml, 0.5% aq.) patch, was also investigated in 17 subjects. In all subjects, 4 h after removal, sweating (on exercise) was completely inhibited on the scopolamine-treated site, pre-irritated with SLS.(ABSTRACT TRUNCATED AT 250 WORDS)

Prediction of susceptibility to an irritant response by transepidermal water loss

The roles of the natural permeability of the stratum corneum to water, and the changes in that permeability effected by a single patch test, were investigated as parameters to predict the susceptibility of the skin to repeated exposures of an irritant. One site on the forearm skin of 27 non-atopic healthy subjects was exposed to a 0.5% concentration of sodium lauryl sulphate by a single occlusive 24-h patch. Another site was exposed to a twice daily 4-day repeated occlusive patch with the same irritant solution. The effects were evaluated by transepidermal water loss measurements made prior to the applications (baseline) on day 1 (BASE), following the single 24-h patch on day 2 (SINGL), and following the 4-day repeated applications on day 5 (REPET). Individuals with higher BASE had higher SINGL (R = 0.80, P less than 0.001) and higher REPET (R = 0.76, P less than 0.001). There was also a significant linear correlation between SINGL and REPET (R = 0.63, P less than 0.001). Multiple linear regression analysis of results, however, indicated that a high baseline TEWL is better indication of an individual's increased susceptibility (high REPET) to weak irritants than a high TEWL value following a single 24-h patch test. Baseline TEWL may therefore be used as a reasonably accurate preliminary "predictive" screening test for susceptibility to irritants.

Baseline transepidermal water loss (TEWL) as a prediction of susceptibility to sodium lauryl sulphate

The rôle of different factors in the susceptibility of the skin to weak irritants was studied by means of multiple linear regression models. The skin of 37 healthy subjects was exposed to a solution of sodium lauryl sulphate of low molarity 2 x daily for 4 days. The condition of the skin was evaluated by transepidermal water loss (TEWL) measurements on the 1st day (before exposure, TEWL1) and on the 5th day of exposure (TEWL5), and by a visual scoring system. The TEWL5 value was strongly related to the TEWL1 value (R = 0.71). The influence of such factors as history of mucosal atopy, history of sensitivity to soap, dry skin, skin type, sex and age on the TEWL5 value was negligible. The baseline TEWL level (TEWL1) might be a reliable indication of an individual's susceptibility to weak irritants.

Comparability and reproducibility of the results of water loss measurements: a study of 4 evaporimeters

A study was made of the comparability and reproducibility of the results of measurements of water loss, both in vitro and in vivo, using 4 ServoMed Evaporimeters (3 single-probe and 1 double-probe instrument). The optimum time for recording transepidermal water loss (TEWL) after the initial application of the probe to the skin (in vivo), and the best technique for optimizing the accuracy of measuring TEWL were determined. An evaporation device with a constant level of water loss was constructed for in vitro studies. The volar aspect of the right forearm skin of one subject was used in vivo. Both in vitro and in vivo measurements showed that there were some differences between the results of 4 of the 5 probes. The other probe was distinctly out of range. For all probes, the reproducibility of results of successive measurements was high. Stabilization of TEWL values was reached for all probes from 30-45 s after their initial application to the skin. It is recommended that TEWL be recorded for a further 30-s period, after the initial stabilization (45 s), and that this be taken as the true value. The manufacturer's recommended calibration procedure is based only on adjustments for the standard specified humidities and zero water loss. The importance of incorporating an additional calibration procedure which includes adjustments for an actual standard constant water loss is thus strongly stressed.

[Immunomapping in localized bullous pemphigoid]

A 70-year-old Caucasian patient is described, who presented with a bullous dermatosis on an amputation stump. The bullous lesions had developed after practice with a Kondylen-Bettung-Münster (KBM) prosthesis. The lesions disappeared completely after prednisone therapy and replacement of the prosthesis with a Thomas splint. The patient has remained free of symptoms ever since, even though prednisone was completely withdrawn after 9 months. According to skin immunofluorescence criteria, the patient suffered from pemphigoid, rather than epidermolysis bullosa acquisita as strongly suggested by the anamnesis. In particular, the presence of linear IgG at the level of the lamina lucida of the epidermal basement membrane zone and the localization of laminin antigen at the blister floor are highly suggestive of pemphigoid.

The influence of repeated exposure to surfactants on the human skin as determined by transepidermal water loss and visual scoring

The purpose of this study was to develop a new model for the induction of chronic irritant contact dermatitis, which would reflect well the conditions of daily practice. Various weak irritant agents were tested for irritating potency on the skin and the sensitivity of transepidermal water loss (TEWL) measurements in the detection of early skin changes was also studied. 10 widely used surfactants and 1 solubilizer were applied to the skin of the forearms of healthy volunteers in aqueous solutions of 12.5 millimoles/l for 45 min twice daily for 3 weeks. The effect on the skin was evaluated daily by means of TEWL measurements and by a visual scoring system. Each solution caused an increase in TEWL value over time due to the cumulative irritating action on the epidermal barrier. This increase in TEWL was different for the various solutions, resulting in different mean TEWL values on the last day of the experiment. Thus, it was possible to rank the agents according to irritating potency. This ranking order was the same in almost every individual and remained constant during the 3 weeks. In comparison with the visual scoring system, the TEWL measurements were more sensitive in the detection of early changes in the skin.

Effect of mineral oil and linoleic-acid-containing emulsions on the skin vapour loss of sodium-lauryl-sulphate-induced irritant skin reactions

This study evaluates the influence of mineral oil and linoleic-acid-containing emulsions on the skin vapour loss (SVL) of detergent-induced irritant skin reactions. During a period of 2 weeks, 2 x 45 min applications of a sodium lauryl sulphate solution of low molarity were performed on the forearm of 9 volunteers. In the same period, a standard amount of each emulsion was applied on the induced irritant skin reactions, 3 times each day. The effect of the emulsions on the barrier function of the skin was evaluated by means of SVL measurements. The emulsion based on mineral greases significantly reduced SVL values during both weeks, possibly because of an occlusive effect. The emulsion with 15% of linoleic acid significantly reduced SVL values during the 1st week but not during the 2nd week. The emulsion with 38% of linoleic acid did not reduce SVL values at all.