The effect of antibacterial soap with 1.5% triclocarban on Staphylococcus aureus in patients with atopic dermatitis

This double-blind study determined whether daily bathing with an antibacterial soap would reduce the number of Staphylococcus aureus on the skin and result in clinical improvement of atopic dermatitis. For 9 weeks, 50 patients with moderately severe atopic dermatitis bathed daily with either an antimicrobial soap containing 1.5% triclocarban or the placebo soap. They also used a nonmedicated moisturizer and 0.025% triamcinolone acetonide cream as needed, but the availability of the corticosteroid cream was discontinued after 6 weeks. The antimicrobial soap regimen caused significantly greater improvement in the severity and extent of skin lesions than the placebo soap regimen, which correlated with reductions both in S aureus in patients with positive cultures at baseline and in total aerobic organisms. Outcome measures included reductions in S aureus, total aerobic organisms, and dermatologic assessments. Overall, daily bathing with an antibacterial soap was well tolerated, provided clinical improvement, and reduced levels of skin microorganisms.

The prevalence of atopic dermatitis in Oregon schoolchildren

BACKGROUND

Although surveys from many parts of the world have shown that the prevalence of atopic dermatitis (AD) in schoolchildren has increased greatly in the past 40 years, there is no current prevalence information from the United States.

OBJECTIVE

Our objective was to investigate the utility of a recently developed European questionnaire to estimate the prevalence of AD in urban and rural Oregon schoolchildren.

METHODS

The self-administered Schultz-Larsen questionnaire (SLQ) of AD symptoms and history was completed by the parents of a broad socioeconomic and ethnic mix of 5- to 9-year-old schoolchildren from 6 urban and 2 rural elementary schools in Oregon. Validation assessments included comparisons of the questionnaire scores with clinical examination in a group of age-matched children and with specific history components known to correlate with AD.

RESULTS

Data showed a prevalence of 17.2% using standard scoring criteria for the SLQ and with a lower limit of 6.8% according to highly stringent criteria derived from the validation study using dermatologic examination. A single question ("Has a doctor ever said that your child has eczema?") was highly concordant with the questionnaire determination, yielding very high predictive accuracy (91.2%).

CONCLUSION

This study of childhood AD frequency indicates a high prevalence of AD in the United States, comparable to that recently observed from studies in Europe and Japan. (J Am Acad Dermatol 2000;43:649-55.).

Old, new, and emerging therapies for atopic dermatitis

Atopic dermatitis is the most common skin condition in children under the age of 11 years. The chronic, cyclical, pruritic course of AD exacts a huge financial and emotional toll on its sufferers. Confusion about appropriate skin care and the role of allergic factors further complicates management. Although diligent moisturization and judicious use of topical steroids remain the therapeutic standard, new, effective local and systemic agents are now available, and several promising nonsteroidal products may be available soon.

Update on therapy of atopic dermatitis

Atopic dermatitis (AD) is complicated and often difficult to manage. Effective therapy is commonly impeded by 3 ambivalencies: (1) prioritization of skin care versus allergy treatment; (2) uncertainty about optimal bathing and moisturizing, and (3) hesitation about the use of adequate topical corticosteroid therapies. With a confident, well-planned approach, effective therapy management may be achieved. On initial assessment, an evaluation form is a tool to keep the focus on important history and physical features critical for the diagnosis and to review trigger factors and past therapies. Patients and parents must be educated to become more aware of the trigger factors that may lead to an exacerbation of their disease. Errors in bathing and moisturizing are the major cause of persistent AD, and the confusing paradox that water is both good and bad for the skin must be resolved to achieve therapeutic success. Avoidance/approach conflicts regarding recommendations of topical steroid use has a detrimental effect on patient outcomes. With the proper use of mid-strength topical agents and with the recent development of topical macrolides for use in AD, effective management for this disease can be realized.

Patient education in the long-term management of atopic dermatitis

Among the various forms of eczema, atopic dermatitis is the most common, distinctive, and difficult to manage. Educating patients about avoiding flare factors and proper use of moisturizers along with rational use of topical corticosteroids is crucial to effective long-term management. Openly reviewing facts and fallacies about allergies can help keep the focus on necessary skin care while dealing with patients' allergy concerns. The team approach of physician and nurse helps clarify confusing issues and maximizes patients' ability to effectively treat a chronic but controllable condition.

Biochemical and immunologic mechanisms in atopic dermatitis: new targets for emerging therapies

The immunologic and pharmacophysiologic features of atopic dermatitis have stimulated research seeking to identify relevant effector cells and mediators that characterize chronic skin inflammation. The theory that unifies the various abnormalities associated with atopic dermatitis suggests that hematopoietic cells carrying abnormal genetic expressions of atopy cause clinical disease once they infiltrate the skin and mucosa. The proposed underlying mechanism may be either abnormalities in cyclic nucleotide regulation of marrow-derived cells or allergenic overstimulation that causes secondary abnormalities. The primacy of one mechanism over the other remains unresolved, but this does not obviate their value in identifying two novel therapeutic targets: phosphodiesterase inhibition and immune-intervention alternatives to corticosteroids. New type IV phosphodiesterase inhibitors are proving promising in topical formulations, as are inhibitors of calcineurin, such as FK506 and SDZ ASM 981, an ascomycin macrolactam derivative that in early clinical research appears to offer the potency of a corticosteroid without its adverse side effects. The promising clinical trial profiles of these new topical agents may result in alternative therapies providing potent anti-inflammatory activity without the adverse effects that limit corticosteroid use.

A randomized, vehicle-controlled trial of tacrolimus ointment for treatment of atopic dermatitis in children. Pediatric Tacrolimus Study Group

BACKGROUND

A topical formulation of tacrolimus, an immunosuppressant currently marketed for the prevention of rejection after solid organ transplant, is a potential therapeutic agent for atopic dermatitis.

OBJECTIVE

We sought to determine the safety and efficacy of tacrolimus ointment in pediatric patients with moderate-to-severe atopic dermatitis.

METHODS

In this double-blind, vehicle-controlled multicenter trial, children ages 7 to 16 years were treated with twice daily application of tacrolimus ointment at 1 of 3 concentrations (0.03% [n = 43], 0.1% [n = 49], or 0.3% [n = 44]) or vehicle (n = 44) for up to 22 days, with a 2-week follow-up period.

RESULTS

The Physician's Global Evaluation of clinical response showed that 69% (95% confidence interval: 53-82) of patients in the 0.03% tacrolimus ointment group, 67% (95% confidence interval: 52-81) in the 0.1% tacrolimus ointment group, and 70% (95% confidence interval: 54-83) in the 0.3% tacrolimus ointment group, compared with 38% (95% confidence interval: 24-54) in the vehicle group, had a marked to excellent (> or =75%) improvement or clearing of their atopic dermatitis (P =.005, .007, and .004, respectively for the 3 tacrolimus groups compared with the vehicle group). The mean percent improvement for a modified Eczema Area and Severity Index at end of treatment for each of the 3 tacrolimus groups (0.03%, 72%; 0.1%, 77%: and 0.3%, 81%) was significantly better than that of the vehicle group (26%; P <.001). The median percent reduction in pruritus was significantly greater for tacrolimus-treated patients (74% to 89%) than for vehicle-treated patients (51%, P = .027). No serious systemic adverse events were noted, and systemic absorption was minimal.

CONCLUSION

Tacrolimus ointment appears to be safe and effective in children with atopic dermatitis.

Long-term effectiveness and safety of recombinant human interferon gamma therapy for atopic dermatitis despite unchanged serum IgE levels

OBJECTIVE

To assess the long-term effects of recombinant human interferon gamma treatment of atopic dermatitis (AD).

DESIGN

Case series. Patients were treated for up to 24 months.

SETTING

University dermatology outpatient clinics in Ann Arbor, Mich, and Portland, Ore.

PATIENTS

Twenty-four of 32 eligible patients who participated in a previously reported, 12-week, double-blind, placebo-controlled study of recombinant human interferon gamma treatment for AD were enrolled.

INTERVENTION

Patients self-administered recombinant human interferon gamma, 50 microg/m2, by daily subcutaneous injection.

MAIN OUTCOME MEASURES

Overall response; body surface area of involvement; clinical severity scores for pruritus, erythema, edema, excoriations, dryness, scaling, and lichenification; other atopic symptoms; and laboratory parameters, including serum IgE levels, were monitored at quarterly visits. Results at 1 and 2 years were compared with baseline values.

RESULTS

All efficacy parameters improved (P<.05). For example, pruritus was reduced by 50% after both 1 (n=24, P<.001) and 2 (n=16, P=.005) years. Allergic conjunctivitis and allergic rhinitis also improved (P<.01). Eosinophil counts decreased significantly (P<.001). IgE levels increased. Clinical improvement more closely correlated with changes in eosinophil counts (r=0.3-0.5) than with changes in IgE levels (r=0.0-0.2). Only 1 patient discontinued therapy because of adverse effects (flulike symptoms).

CONCLUSIONS

The initial efficacy and adverse effects reported for recombinant human interferon gamma treatment of patients with AD were maintained after 2 years of long-term use. Recombinant human interferon gamma seems to be a well-tolerated and effective agent in the long-term therapy of patients with AD. Therapies that correct cellular immune defects, but not humoral immune defects, may be effective in the treatment of patients with AD.

Once-weekly fluconazole (450 mg) for 4, 6, or 9 months of treatment for distal subungual onychomycosis of the toenail

BACKGROUND

Fluconazole is a bis-triazole antifungal agent approved for the treatment of oropharyngeal, esophageal, and vaginal candidiasis, serious systemic candidal infections, and cryptococcal meningitis.

OBJECTIVE

The purpose of this study was to evaluate three different durations of once-weekly fluconazole for the treatment of onychomycosis of the toenail caused by dermatophytes.

METHODS

In a multicenter, randomized, double-blind, parallel, placebo-controlled trial, 384 patients with distal subungual onychomycosis of the toenail received fluconazole, 450 mg once weekly, or placebo for 4, 6, or 9 months. For inclusion, patients were required to have mycologically confirmed distal subungual onychomycosis of the toenail with a large toenail at least 25% clinically affected but having at least 2 mm of healthy nail between the nail fold and the proximal onychomycotic border. Efficacy was assessed by clinical and mycologic (microscopic and microbiologic) measures at screening, at every treatment visit starting at month 3, and at months 2, 4, and 6 after therapy. Observed or volunteered adverse events were recorded and classified at all visits.

RESULTS

At the end of treatment, very significantly superior clinical and mycologic results were achieved in all fluconazole groups compared with placebo (p=0.0001). This superiority was largely maintained over 6 months of follow-up. The clinical and mycologic responses of the 9-month treatment duration were significantly superior to the 4- and 6-month durations. Similar percentages of patients in the fluconazole and placebo groups reported adverse experiences for all three durations of the study.

CONCLUSION

Results of this study support the efficacy and safety of fluconazole in the treatment of distal subungual onychomycosis of the toenail.

Pharmacokinetics of three once-weekly dosages of fluconazole (150, 300, or 450 mg) in distal subungual onychomycosis of the fingernail

BACKGROUND

Fluconazole has proven to be safe and effective for a variety of superficial and systemic fungal infections. Preliminary analysis of extensive Phase III studies suggests that it is very effective for the treatment of onychomycosis. Its pharmacokinetic properties, including low molecular weight and high water-solubility, suggest a unique ability to penetrate the nail. This feature is likely to account in part for fluconazole's effectiveness in the treatment of onychomycosis.

OBJECTIVE

Determinations of plasma and fingernail concentrations of fluconazole were performed as part of a larger study comparing the safety and efficacy of once-weekly fluconazole (150, 300, and 450 mg) to placebo in the treatment of distal subungual onychomycosis of the fingernails caused by dermatophytes. The relationship between fluconazole concentrations and efficacy was also examined.

METHODS

Pharmacokinetic studies were performed by means of plasma and fingernail samples from 133 patients, a subset of 349 patients participating in a double-blind, placebo-controlled clinical trial of fluconazole administered in once-weekly doses of 150, 300, or 450 mg until cure of onychomycosis or for a maximum of 9 months. Blood and fingernail samples for pharmacokinetic analysis were taken at baseline, at week 2, and at monthly intervals during the treatment phase of the study. Patients considered clinically cured or improved also participated in a 6-month follow-up study. During this phase, patients were monitored and samples taken every 2 months.

RESULTS

Significant amounts of fluconazole were detected in the earliest fingernail samples taken (after 2 weeks of treatment). After two weekly doses, 30% to 33% of steady-state concentrations had been achieved in healthy nails and 22% to 29% in affected nails. Steady state was achieved in 3 to 5 months. Fluconazole concentration in nails as well as plasma followed dose-proportional pharmacokinetics. Nail:plasma ratios in affected nails were 0.4 to 0.6 at 2 weeks and 1.7 to 1.8 at 6 months. Fluconazole concentrations fell slowly after drug discontinuation and were still detectable 4 months after end of treatment. A statistically significant correlation was found between steady-state concentration and clinical and global outcomes.

CONCLUSION

Fluconazole rapidly penetrates the fingernail, where it is retained at detectable levels for at least 4 months after drug discontinuation. A significant correlation exists between fluconazole concentration in the fingernails and clinical and global outcomes.

Once-weekly fluconazole (150, 300, or 450 mg) in the treatment of distal subungual onychomycosis of the fingernail

BACKGROUND

Onychomycosis is a prevalent infection of the nail caused primarily by dermatophytes. Fluconazole is active in vitro against the most common pathogens, penetrates into the nail bed, and is clinically effective in the treatment of a wide variety of fungal infections.

OBJECTIVE

The purpose of this study was to assess the safety and efficacy of oral fluconazole 150, 300, and 450 mg administered once weekly compared with placebo in the treatment of distal subungual onychomycosis of the fingernail caused by dermatophytes.

METHODS

This was a multicenter, randomized, double-blind, placebo-controlled study enrolling 349 patients with onychomycosis of the fingernails. Clinical and mycologic efficacy as well as measures of safety were assessed monthly for a maximum of 9 months of treatment, with additional safety visits occurring at weeks 2 and 6. For inclusion, patients were required to have clinically and mycologically documented onychomycosis of the fingernail caused by dermatophytes with at least 25% involvement of the target fingernail. After end of therapy, patients with improved or cured fingernails entered a blinded 6-month follow-up without drug treatment during which efficacy was assessed every 2 months. Efficacy was assessed by clinical (visual) and mycologic (microscopic and culture) measures. Clinical measures included assessments of the percentage of target nail involvement, measurement of the distance from the nail fold to the proximal onychomycotic border, and signs and symptoms of onychomycosis.

RESULTS

Fluconazole was significantly superior to placebo in eradicating clinical and mycologic symptoms of onychomycosis, both at the end of active treatment and at 6 months after treatment (p=0.0001 for all efficacy measures). At the end of therapy, 91% to 100% of patients in the fluconazole groups were judged clinical successes, defined as reduction of the affected area of the target nail to less than 25% or cure, compared with 8% for placebo. Clinical cure rates at end of therapy were 76%, 85%, and 90% for fluconazole 150, 300, and 450 mg, respectively, compared with 3% for placebo. These clinical success and cure rates were largely maintained or improved during follow-up. Clinical relapse in cured patients during the follow-up period was very low (1.5% to 3.3%). Fluconazole demonstrated mycologic eradication rates of 89% to 100% at the end of treatment and 90% to 99% at the end of follow-up; for placebo the rates were 8% and 12%, respectively.

CONCLUSION

Fluconazole administered once weekly is safe and effective in eradicating distal subungual onychomycosis of the fingernail caused by dermatophytes.

Critical evaluation of food and mite allergy in the management of atopic dermatitis

The subject of allergic causation of atopic dermatitis (AD) has been a source of controversy for over sixty years. While there is general agreement of allergen-induced asthma and allergic rhinoconjunctivitis, AD lesions cannot be readily or consistently induced by foods and inhalants. The most consistent perturbators of atopic conditions are irritants, probably reflecting the consistent inflammatory cell hyper-reactivity due to elevated cyclic AMP-phosphodiesterase activity. The immunologic reactions are another manifestation of that general cellular dysregulation.

Type 4 phosphodiesterase inhibitors have clinical and in vitro anti-inflammatory effects in atopic dermatitis

Increased cyclic AMP-phosphodiesterase activity in peripheral blood leukocytes is associated with the immune and inflammatory hyperreactivity that characterizes atopic dermatitis. Atopic phosphodiesterase has high sensitivity to a variety of enzyme inhibitors, suggesting an increased therapeutic advantage. The objective of this study was to use in vitro assays to identify a potent phosphodiesterase inhibitor and then to investigate its effectiveness in treating atopic dermatitis. Leukocyte enzyme activity was measured by radioenzyme assay, whereas prostaglandin E2 and interleukins 10 (IL-10) and 4 (IL-4) were measured in 24-h culture supernatants of mononuclear leukocytes by immunoassays. The effect of a topical phosphodiesterase inhibitor on atopic dermatitis lesional skin was assessed by double-blind, paired comparisons of active drug and placebo ointments applied to symmetrically involved sites over a 28-d period. Using in vitro, assays, we demonstrated the ability of selective high-potency phosphodiesterase inhibitors to reduce prostaglandin E2, IL-10, and IL-4 production in atopic mononuclear leukocyte cultures. We selected the Type 4 phosphodiesterase inhibitor, CP80,633, based on its inhibitory potency, for clinical testing by topical, bilateral paired comparisons in 20 patients with atopic dermatitis and demonstrated significant reductions of all inflammatory parameters. Phosphodiesterase inhibitors modulate several pathways contributing to the exaggerated immune and inflammatory responses, which characterize atopic dermatitis. This in vivo demonstration of anti-inflammatory efficacy may provide a useful alternative to the over-reliance on corticosteroid therapy in atopic disease.

The spectrum of cutaneous patch-test reactions in patients with atopic dermatitis

We have outlined rationale and problems associated with three types of patch tests that may provide diagnostic help in patients with difficult-to-manage AD. Each of these methods is imperfect and in need of greater study using a critical approach, better techniques, more attention to irritant controls, and better definition of atopic populations. Proof of validity for aeroallergen patch testing will necessarily require large quantities of purified antigens. In spite of all these problems, patch testing can be useful and sometimes essential for the diagnosis and management of difficult AD.

Abnormal IL-4 gene expression by atopic dermatitis T lymphocytes is reflected in altered nuclear protein interactions with IL-4 transcriptional regulatory element

Among the atopic disease, atopic dermatitis is characterized by the highest levels of serum IgE and by increased peripheral blood T-cell interleukin-4 (IL-4) production. IL-4 promotes IgE synthesis by B cells and stimulates the growth of IL-4-producing T cells and may contribute to the pathogenesis of this disease. In this study, in situ hybridization established that atopic dermatitis patients have a higher frequency of IL-4-producing peripheral blood T cell when compared to normal subjects. These in vivo-derived T cells were used to examine the signaling requirements of IL-4 production and the nuclear factors that associate with a critical IL-4 transcriptional regulatory element between -88 and -60 relative to the IL-4 transcription initiation site, the activation responsive element. We demonstrate that, as in T-cell lines, proteins belonging to the NF-AT and AP-1 family of transcription factors are present in stimulated cell extracts and specifically associate with the activation responsive element. Dysregulated IL-4 production is reflected in the nuclear proteins that associated this element. Using gel shift assays, we found that 12 of 12 nuclear extracts from stimulated atopic T cells formed the activation-dependent protein-DNA complex, compared to only 2 of 12 normal T-cell extracts. Activation complex formation correlated with the relative level of IL-4 mRNA and protein produced in stimulated T cells, suggesting that abnormal IL-4 gene expression in atopic disease may be linked to alterations in nuclear protein interactions with these promoter elements.

Allergic and irritant patch test reactions and atopic disease

This study presents a profile of patients with chronic recalcitrant eczematous disease referred by dermatologists for contact allergy evaluation. Allergic contact dermatitis (ACD) and irritant responses were carefully defined, as was the presence or absence of atopy obtained by history. Of 410 patients studied, 44% had no history of atopic disease and 46% were classed as definitely atopic. Among relevant ACD patch test reactors (n = 198), 51.5% had atopy, compared with 40.9% with no atopy but this difference was not significant. Likewise, among atopics (n = 189), 54% had definite, relevant ACD patch test responses while 33.9% had negative ACD (again not significant). Significance was seen in the higher mean number of positive allergic patch tests in the atopic group (2.7 versus 2.0, p = 0.0223). Irritant patch tests were highest among patients with both ACD and atopy (p = 0.0308) and the proportion of irritant responses correlated with increasing numbers of positive ACD tests. We conclude that atopics are at least as likely to have ACD as are non-atopics. Irritancy is increased in these patients with chronic dermatitis and the frequency of irritant reactions correlates with both greater numbers of ACD responses and with presence of atopy.

Research and dermatologic excellence

Nearly everyone, even within our small specialty, has a slightly different idea, or bias, as to what constitutes research. We hear of clinical research and academic research and pharmaceutical research and descriptive research and cutting-edge research, but the distinctions often blur and are unimportant. What is important is that research of all kinds increases knowledge and adds information that improves patients' well-being. Perhaps we can agree with a general definition: Research is inquiry. In its simplest form, it may be nothing more than a literature review pertinent to an observation or interest. More often we think of systematic research (a progression starting with questions and ideas) moving forward to a hypothesis, then planning approaches and methods for experiments, all directed toward characterizing normal features and disease mechanisms to prevent and treat illness.