Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity

Consensus Guidelines for the Treatment of Atopic Dermatitis in Korea (Part I): General Management and Topical Treatment

Background

Since the treatment guidelines for atopic dermatitis (AD) were released by the Korean Atopic Dermatitis Association (KADA) work group in 2006, there have been several advances in AD management.

Objective

We aimed to establish updated evidence- and experience-based treatment guidelines for Korean AD.

Methods

We collected a database of references from relevant systematic AD reviews and guidelines regarding general AD management such as bathing and skin care, avoidance of exacerbating factors, education and psychosocial support, and the use of moisturizers and topical anti-inflammatory and antipruritic drugs. Evidence for each statement was graded and the strength of the recommendation for each statement classified. Thirty-nine KADA council members participated in three rounds of voting to establish an expert consensus of recommendations.

Results

Basic AD treatment includes proper bathing and skin care, avoidance of exacerbating factors, proper education and psychosocial support, and use of moisturizers. The regular use of moisturizer has a steroid-sparing effect and reduces relapse episodes. The short- and long-term use of topical corticosteroids and calcineurin inhibitors improves AD symptoms and should be encouraged to use in an active and proactive treatment. Wet-wrap therapy can be used for rapid recovery of acute exacerbation. Topical antipruritic drugs cannot be recommended for the treatment of AD.

Conclusion

This report provides up-to-date evidence- and experience-based treatment guidelines for AD regarding general management and topical treatment. In addition, the average agreement scores obtained by a panel of experts based on the Korean healthcare system and patient adherence are presented.

NOD2 and TLR2 ligands trigger the activation of basophils and eosinophils by interacting with dermal fibroblasts in atopic dermatitis-like skin inflammation

The skin of patients with atopic dermatitis (AD) has a unique predisposition for colonization by Staphylococcus aureus (S. aureus), which contributes to the inflammation and grim prognosis of AD. Although the mechanism underlying the S. aureus-induced exacerbation of AD remains unclear, recent studies have found a pivotal role for pattern recognition receptors in regulating the inflammatory responses in S. aureus infection. In the present study, we used a typical mouse model of AD-like skin inflammation and found that S. aureus-associated nucleotide-binding oligomerization domain-containing protein 2 (NOD2) and toll-like receptor 2 (TLR2) ligands exacerbated AD-like symptoms, which were further deteriorated by the in vivo expansion of basophils and eosinophils. Subsequent histological analyses revealed that dermal fibroblasts were pervasive in the AD-like skin lesions. Co-culture of human dermal fibroblasts with basophils and eosinophils resulted in a vigorous cytokine/chemokine response to the NOD2/TLR2 ligands and the enhanced expression of intercellular adhesion molecule-1 on the dermal fibroblasts. Basophils and eosinophils were primarily responsible for the AD-related cytokine/chemokine expression in the co-cultures. Direct intercellular contact was necessary for the crosstalk between basophils and dermal fibroblasts, while soluble mediators were sufficient to mediate the eosinophil-fibroblast interactions. Moreover, the intracellular p38 mitogen-activated protein kinase, extracellular signal-regulated kinase, and nuclear factor-kappa B signaling pathways were essential for NOD2/TLR2 ligand-mediated activation of basophils, eosinophils, and dermal fibroblasts in AD-related inflammation. This study provides the evidence of NOD2/TLR2-mediated exacerbation of AD through activation of innate immune cells and therefore sheds light on a novel mechanistic pathway by which S. aureus contributes to the pathophysiology of AD.

Barrier function and microbiotic dysbiosis in atopic dermatitis

Atopic dermatitis (AD) or atopic eczema is the common inflammatory skin disorder, the prevalence of which has considerably increased during the last 30 years. It affects 15%-30% of children and 2%-10% of adults. AD characteristically alternates between periods of exacerbation or flares and periods of remission, which may be therapeutically induced or spontaneous. Current knowledge about AD includes abnormalities of the skin barrier (physical and chemical), the immune barrier, and more recently, the microbial barrier or microbiota. There is growing evidence for a tight relationship between them. To obtain satisfactory control of this condition, the clinical strategy to manage AD involves prescribing both anti-inflammatory medications and dermocosmetic products. The role of the physician is therefore to advise the patient with regard to hygiene measures aimed to help to improve these three barriers or to prevent any further deterioration.

Evaluation of Treatments for Pruritus in Epidermolysis Bullosa

Pruritus is a common complication in patients with epidermolysis bullosa (EB). There is limited published data about the treatments that individuals with EB use for pruritus. The objective of the current study was to determine quantitatively which treatments individuals with EB have used for pruritus and to evaluate the perceived effectiveness of these treatments in pruritus relief. A questionnaire was developed to evaluate the treatments and therapies used for pruritus in patients of all ages and for all types of EB. Questions about bathing products, moisturizers, topical products, oral medications, dressings, and alternative therapies were included. A 5-point Likert scale (-2 = relieves itch a lot, -1 = relieves itch a little, 0 = no change, 1 = increases itch a little, 2 = increases itch a lot) was used to evaluate perceived effectiveness. Patients from seven North American EB centers were invited to participate. Greasy ointments (53.4%), lotions (45.2%), creams (40.4%), and oral hydroxyzine (39.0%) were the most frequently used treatments for pruritus. Treatments that were used frequently and perceived to be the most effective included creams (mean = -1.1), topical prescription corticosteroids (mean = -1.0), oils (mean = -0.9), oral hydroxyzine (mean = -0.9), topical diphenhydramine (mean = -0.9), and vaporizing rub (menthol, camphor, eucalyptus) (mean = -0.9). Systemic opioids (mean = 0.3), adherent bandages (mean = 0.3), and bleach baths (mean = 0.2) slightly increased pruritus. Randomized controlled trials of therapies will be necessary to develop evidence-based recommendations for control of pruritus in individuals with EB.

Translating Atopic Dermatitis Management Guidelines Into Practice for Primary Care Providers

Atopic dermatitis affects a substantial number of children, many of whom seek initial treatment from their pediatrician or other primary care provider. Approximately two-thirds of these patients have mild disease and can be adequately managed at the primary care level. However, recent treatment guidelines are written primarily for use by specialists and lack certain elements that would make them more useful to primary care providers. This article evaluates these recent treatment guidelines in terms of evaluation criteria, treatment recommendations, usability, accessibility, and applicability to nonspecialists and integrates them with clinical evidence to present a streamlined severity-based treatment model for the management of a majority of atopic dermatitis cases. Because each patient's situation is unique, individualization of treatment plans is critical as is efficient communication and implementation of the plan with patients and caregivers. Specifically, practical suggestions for individualizing, optimizing, implementing, and communicating treatment plans such as choosing a moisturizer formulation, avoiding common triggers, educating patients/caregivers, providing written treatment plans, and scheduling physician follow-up are provided along with a discussion of available resources for patients/caregivers and providers.

Atopic dermatitis: current treatment guidelines. Statement of the experts of the Dermatological Section, Polish Society of Allergology, and the Allergology Section, Polish Society of Dermatology

Atopic dermatitis (AD) is a condition frequently encountered in medical practices across the country. More than 60% of children with AD are at risk to develop allergic rhinitis or asthma (the atopic march). Patients with AD have a unique predisposition to colonization or infection by Staphylococcus aureus. Treatments for AD need to rapidly control symptoms of the disease, improve quality of life and prevent exacerbations. Given the chronic and relapsing nature of the disease, therapies need to encourage good compliance and be well tolerated.

Alternative, Complementary, and Forgotten Remedies for Atopic Dermatitis

Atopic dermatitis, perhaps more than other dermatologic diseases, has garnered much attention in the realm of alternative medicine. This may be because its etiopathogenesis is incompletely understood, it is increasingly common, and it waxes and wanes often without clear precipitants, opening up many opportunities for misinterpretation. Herein we explore the evidence for a number of different alternative and complementary therapies, from textiles to vitamin supplements. By definition, none have enough data to be deemed "effective" in a conventional sense, but it is hopeful that some show promising evidence that may one day lead to mainstream acceptance with further research.

Alternative, Complementary, and Forgotten Remedies for Atopic Dermatitis

Atopic dermatitis, perhaps more than other dermatologic diseases, has garnered much attention in the realm of alternative medicine. This may be because its etiopathogenesis is incompletely understood, it is increasingly common, and it waxes and wanes often without clear precipitants, opening up many opportunities for misinterpretation. Herein we explore the evidence for a number of different alternative and complementary therapies, from textiles to vitamin supplements. By definition, none have enough data to be deemed “effective” in a conventional sense, but it is hopeful that some show promising evidence that may one day lead to mainstream acceptance with further research.

Correlation Between Serum 25-Hydroxyvitamin D and Virulence Genes of Staphylococcus aureus Isolates Colonizing Children with Atopic Dermatitis

The skin of children with atopic dermatitis (AD) is colonized with Staphylococcus aureus more frequently than that of their peers. We investigated the prevalence of skin and nares colonization by S. aureus in children with AD, the virulence genes of the isolates, and their association with allergy, AD severity, and serum vitamin D (25(OH)D). This was an observational, cross-sectional study in a sample of children diagnosed with AD in two settings in Spain. The samples were collected in 2012. Swabs from affected skin and nares were taken for microbiologic culture. The prevalence of S. aureus and presence of 17 staphylococcal virulence genes were studied using polymerase chain reaction. A total of 114 patients with a mean age of 5.7 ± 4.1 (range 3 mos to 14 yrs) were included in the study. Swabs were taken from the skin of 113 individuals with AD and from the nares of 85; 28.3% had S. aureus on the skin, which was significantly associated with positive allergen-specific immunoglobulin E antibodies and higher Scoring Atopic Dermatitis (SCORAD) scores in the multivariate analysis. The presence of virulence factors tsst-1, eta, cna, aur, and sec in cutaneous S. aureus isolates was associated with lower serum levels of 25(OH)D. S. aureus on nasal swabs correlated with its presence on the skin and was associated with lower 25(OH)D levels. In conclusion, S. aureus colonization is associated with allergy and severity in AD, whereas certain virulence genes are associated with lower serum 25(OH)D levels.

Chinese herbal medicine network and core treatments for allergic skin diseases: Implications from a nationwide database

ETHNO-PHARMACOLOGICAL RELEVANCE

Chinese herbal medicine (CHM) is commonly used to treat skin diseases, but CHM prescription patterns are difficult to understand due to their complexity and inter-connections. This study aimed to demonstrate CHM core treatments and network for treatment of allergic skin diseases by analyzing a nationwide prescription database.

MATERIALS AND METHODS

All CHM prescriptions made for atopic dermatitis (with age limitation ≤ 12 years) and urticaria for the entire year of 2011 were included. Association rule mining (ARM) combined with social network analysis (SNA) were used to analyze CHM prescriptions and explore the CHM prescription pattern and network.

RESULTS

A total of 27,350 and 97,188 prescriptions for atopic dermatitis and urticaria, respectively, were analyzed. Xiao-Feng-San (XFS) was the most commonly used CHM (32% of prescriptions for atopic dermatitis and 47.4% for urticaria) and was the core treatment for both diseases. Moreover, 42 and 82 important CHM-CHM combinations were identified to establish the CHM network, and XFS with Dictamnus dasycarpus Turcz was the most prevalent (6.4% for atopic dermatitis and 9.1% for urticaria). Traditional Chinese Medicine heat syndrome was most prevalent cause. Extensive anti-inflammation, anti-allergy, anti-oxidation, and anti-bacterial effects were also found among the CHMs.

CONCLUSIONS

Network analysis on CHM prescriptions provides graphic and comprehensive illustrations regarding CHM treatment for atopic dermatitis and urticaria. The CHM network analysis of prescriptions is essential to realize the CHM treatments and to select suitable candidates for clinical use or further studies.

Advances in the diagnosis and therapeutic management of atopic dermatitis

Atopic dermatitis is a very prevalent disease that affects children as well as adults. The disease has a severe impact on quality of life for the patients and their families. The skin in atopic dermatitis patients is a site of both a severe inflammatory reaction dominated by lymphocytes and decreased skin barrier function. The treatment of the disease is mainly aimed at reducing the inflammation in the skin and/or restoring the skin barrier function. However, most of the treatments used today singularly aim at reducing the inflammation in the skin. Depending on the severity of the disease, the anti-inflammatory treatment may be topical or systemic, but basic treatment, no matter the severity, should always be emollients. In addition, new studies have shown good effects of psychosocial interventions, such as eczema schools, for patients and their families. This review covers the latest trends in the treatment of atopic dermatitis.

Treatment of Childhood Atopic Dermatitis and Economic Burden of Illness in Asia Pacific Countries

Atopic dermatitis (AD) is a common chronic inflammatory skin condition in children. In Asia, the prevalence of AD is increasing, which is largely attributed to environmental and socioeconomic factors including family income, parental education, lifestyle and metropolitan living. Current clinical guidelines recommend a stepped approach in the management of eczema in children, with treatment steps tailored to the severity of the eczema. To address the skin barrier dysfunction, skin hydration and the application of emollients is essential. There is evidence supporting the use of bleach baths as an antimicrobial therapy against Staphylococcus aureus. In patients in whom topical treatment fails, wet wrap therapy may be considered as a treatment option before considering systemic therapies. In the second part of this article, the economic burden of AD is addressed. AD not only negatively impacts the child's quality of life but also that of the whole family and is associated with a burden on health-care costs and society. AD in an infant will lead to frequent additional visits to the pediatrician, to additional and partially expensive treatment costs and, in rare cases, to hospitalization. It is thus of utmost importance to define efficient strategies to not only treat AD but also to decrease the risk of developing the disease.

Dysbiosis and Staphylococcus aureus Colonization Drives Inflammation in Atopic Dermatitis

Staphylococcus aureus skin colonization is universal in atopic dermatitis and common in cancer patients treated with epidermal growth factor receptor inhibitors. However, the causal relationship of dysbiosis and eczema has yet to be clarified. Herein, we demonstrate that Adam17(fl/fl)Sox9-(Cre) mice, generated to model ADAM17-deficiency in human, developed eczematous dermatitis with naturally occurring dysbiosis, similar to that observed in atopic dermatitis. Corynebacterium mastitidis, S. aureus, and Corynebacterium bovis sequentially emerged during the onset of eczematous dermatitis, and antibiotics specific for these bacterial species almost completely reversed dysbiosis and eliminated skin inflammation. Whereas S. aureus prominently drove eczema formation, C. bovis induced robust T helper 2 cell responses. Langerhans cells were required for eliciting immune responses against S. aureus inoculation. These results characterize differential contributions of dysbiotic flora during eczema formation, and highlight the microbiota-host immunity axis as a possible target for future therapeutics in eczematous dermatitis.

In Vitro Evaluation of Antimicrobial Photodynamic Therapy Associated with Hydroalcoholic Extracts of Schinopsis brasiliensis Engl.: New Therapeutic Perspectives

OBJECTIVE

The aim of this study was to evaluate the photodynamic potential of extracts of Schinopsis brasiliensis Engl. on bacteria involved in several human infections.

BACKGROUND DATA

Photodynamic therapy (PDT) involves the interaction of light with an appropriate and photosensitizer wavelength, and the prospect of existing photosensitive compounds in herbal extracts enhanced by the application of laser diode has been promising.

METHODS

The antibacterial activity against Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa and Enterococcus faecalis was obtained by the disk diffusion method on agar. The laser diode InGaAIP was used with 660 nm wavelength, 100 mW, and 4 J/cm(2), and the application was performed in a timely manner for 34 sec on each disk tested. The groups tested were: Laser and bark extract (B+L+); bark extract only (B+L-); Laser and leaf extract (F+L+); leaf extract only (F+L-); Laser and malachite green (M+L+); malachite green only (M+L-); and laser only (L+).

RESULTS

There were significant differences between the B+L- and B+L+ groups (p=0.029) and between the L+F- and L+F+ groups (p=0.029) at various concentrations of the nebulized extracts of bark and leaf. Among the tested pathogens, S. aureus showed the highest zone of inhibition, 24.55±0.36 mm in group B+L+, 500 mg.mL(-1).

CONCLUSIONS

PDT with malachite green was effective, and groups B+L+ and F+L+ showed excellent activity on the bacteria tested, suggesting the presence of photosensitizers in extracts of S. brasiliensis Engl.

[Diversity of cutaneous bacteria decreases inflammation]

Human microbiota includes all microorganisms, saprophytes and pathogens that colonize our bodies. Recent advances in metagenomic analysis techniques have expanded our knowledge of the microbiota and fundamentally changed our view of its relationships with the immune system. The commensal flora appears to be essential to the development of the immune system, and the diversity of the microbiota is correlated with good health status of individuals. These findings open up new conceptual and therapeutic approaches in chronic inflammatory diseases.

Identifying chinese herbal medicine network for eczema: implications from a nationwide prescription database

Eczema is a highly prevalent dermatological disease that can severely affect the patient's quality of life. Chinese herbal medicine (CHM) is commonly used in combination for eczema due to the complicated pathogenesis. This study aimed to identify a CHM network for the treatment of eczema by using a nationwide database. During 2011, 381,282 CHM prescriptions made for eczema (ICD-9-CM 692.x) were obtained from the National Health Insurance Research Database (NHIRD) in Taiwan and analyzed by using association rule mining and social network analysis. Among 661 available CHMs, 44 important combinations were identified. Among the CHM networks, seven clusters with the predominant traditional Chinese medicine (TCM) pattern were recognized. The largest CHM cluster was used to treat the wind-dampness-heat pattern, and Xiao-Feng-San (24.1% of all prescriptions) was the core of this cluster with anti-inflammation, antioxidation, and antiallergic effects. Lonicera japonica (11.0% of all prescriptions) with Forsythia suspense (17.0% of all prescriptions) was the most commonly used CHM combination and was also the core treatment for treating the heat pattern, in which an antimicrobial effect is found. CHM network analysis is helpful for TCM doctors or researchers to choose candidates for clinical practice or further studies.

Ratiometric detection of hypochlorite applying the restriction to 2-way ESIPT: simple design for “naked-eye” tap water analysis

Chemosensor is sensitive enough to prove that boiling tap water for ten minutes is a good practice before drinking it.

Atopic dermatitis: skin-directed management

Atopic dermatitis is a common inflammatory skin condition characterized by relapsing eczematous lesions in a typical distribution. It can be frustrating for pediatric patients, parents, and health care providers alike. The pediatrician will treat the majority of children with atopic dermatitis as many patients will not have access to a pediatric medical subspecialist, such as a pediatric dermatologist or pediatric allergist. This report provides up-to-date information regarding the disease and its impact, pathogenesis, treatment options, and potential complications. The goal of this report is to assist pediatricians with accurate and useful information that will improve the care of patients with atopic dermatitis.

Atopic dermatitis in children: clinical features, pathophysiology, and treatment

Atopic dermatitis (AD) is a chronic, relapsing, highly pruritic skin condition resulting from disruption of the epithelial barrier and associated immune dysregulation in the skin of genetically predisposed hosts. AD generally develops in early childhood, has a characteristic age-dependent distribution and is commonly associated with elevated IgE, peripheral eosinophilia, and other allergic diseases. Medications such as antihistamines have demonstrated poor efficacy in controlling AD-associated itch. Education of patients regarding the primary underlying defects and provision of a comprehensive skin care plan is essential for disease maintenance and management of flares.

The role of antiseptic agents in atopic dermatitis

The skin of individuals with atopic dermatitis has a susceptibility to be colonized with Staphylococcus aureus. This has been associated with increased frequency and severity of exacerbations of atopic dermatitis. Therefore, there is a growing interest in the use of antiseptic agents to target primary bacterial colonization and infection. Antiseptic agents have been found to be better tolerated and less likely to induce bacterial resistance as compared to antibiotics. There is also a wide variety of antiseptic agents available. The efficacy of antiseptic agents has yet to be established as the studies reviewed previously have been small and of suboptimal quality. This review discusses the rationale behind targeting S. aureus with antiseptic agents and presents findings from a review of studies assessing the efficacy of antiseptics in atopic dermatitis in the last five years. Four studies were found, including a bleach bath study which has already been reviewed elsewhere. The remaining 3 studies assessed the efficacy of sodium hypochlorite containing cleansing body wash, sodium hypochlorite baths and 1% triclosan in leave on emollient. These studies suggested some benefit for the inclusion of antiseptic use with the mainstay management of atopic dermatitis, including a potential steroid sparring effect. However, there are many limitations to these studies which therefore warrant further investigation on the impact of antiseptic use in atopic dermatitis.

Toxic interaction between Th2 cytokines and Staphylococcus aureus in atopic dermatitis

Patients with atopic dermatitis (AD) are commonly colonized/infected with Staphylococcus aureus, and this bacterium is known to worsen the dermatitis. In this issue, Brauweiler et al. demonstrate a newly discovered mechanism by which Th2 cytokines involved in AD augments the toxicity of the lytic staphylococcal protein alpha toxin. This review presents mechanisms by which Th2 cytokines may interact with S. aureus to the detriment of the dermatitis.

Eosinophilic esophagitis: a clinicopathological review

Eosinophilic esophagitis (EoE) is considered to be a chronic antigen-driven disease whereby food and/or aeroallergens induce a chronic inflammatory infiltrate in the esophagus, resulting in pathological hyperplasia of the epithelia and muscular layers, and fibrosis of the lamina propria (referred to collectively as remodelling) and the symptoms of dysphagia and food impaction. EoE shares features with other atopic conditions of asthma and atopic dermatitis, such as a TH2 cytokine milieu and a mixed inflammatory infiltrate of eosinophils, mast cells and lymphocytes. Relatively distinct features include the strong male predominance amongst adult patients, and the expression of the eosinophil chemokine eotaxin 3. Current first line treatments such as strict dietary modification and corticosteroids fail many patients. Looking forward, clarification of distinct genotype/phenotype associations, determining the reversibility of remodelling following treatment, and the development of new pharmacotherapies that target fibrotic pathways (as opposed to eosinophilic inflammation per se) or specifically improve barrier integrity appear relevant.

The skin microbiome: potential for novel diagnostic and therapeutic approaches to cutaneous disease

A vast diversity of microorganisms, including bacteria, fungi, viruses, and arthropods, colonize the human skin. Culture-independent genomic approaches for identifying and characterizing microbial communities have provided glimpses into the topographical, temporal, and interpersonal complexity that defines the skin microbiome. Identification of changes associated with cutaneous disease, including acne, atopic dermatitis, rosacea, and psoriasis, are being established. In this review, our current knowledge of the skin microbiome in health and disease is discussed, with particular attention to potential opportunities to leverage the skin microbiome as a diagnostic, prognostic, and/or therapeutic tool.

An important role of α-hemolysin in extracellular vesicles on the development of atopic dermatitis induced by Staphylococcus aureus

Skin barrier disruption and dermal inflammation are key phenotypes of atopic dermatitis (AD). Staphylococcus aureus secretes extracellular vesicles (EVs), which are involved in AD pathogenesis. Here, we evaluated the role of EVs-associated α-hemolysin derived from S. aureus in AD pathogenesis. α-hemolysin production from S. aureus was detected using western blot analyses. The cytotoxic activity of α-hemolysin on HaCaT keratinocytes was evaluated by measuring cell viability after treating cells with soluble and EVs-associated α-hemolysin. To determine the type of cell death, HaCaT keratinocytes were stained with annexin V and 7-AAD. The in vivo effects of α-hemolysin were evaluated by application of soluble and EV-associated α-hemolysin on the mouse skin. The present study showed that increased α-hemolysin was produced by S. aureus colonized on AD patients compared to healthy subjects. α-hemolysin production was also related to AD severity. In addition, EV-associated α-hemolysin was more cytotoxic to HaCaT keratinocytes than soluble α-hemolysin, and α-hemolysin-negative EVs did not induce keratinocyte death. EV-associated α-hemolysin induced necrosis, but soluble α-hemolysin induced apoptosis of keratinocytes. In vivo, skin barrier disruption and epidermal hyperplasia were induced by soluble and EV-associated α-hemolysin. However, AD-like dermal inflammation was only caused by EV-associated α-hemolysin. Moreover, neither skin barrier disruption nor AD-like skin inflammation was induced by α-hemolysin-negative EVs. Taken together, α-Hemolysin secreted from S. aureus, particularly the EV-associated form, induces both skin barrier disruption and AD-like skin inflammation, suggesting that EV-associated α-hemolysin is a novel diagnostic and therapeutic target for the control of AD.

Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies

Atopic dermatitis is a common and chronic, pruritic inflammatory skin condition that can affect all age groups. This evidence-based guideline addresses important clinical questions that arise in its management. In this second of 4 sections, treatment of atopic dermatitis with nonpharmacologic interventions and pharmacologic topical therapies are reviewed. Where possible, suggestions on dosing and monitoring are given based on available evidence.

Optimizing outcomes for paediatric atopic dermatitis

Atopic dermatitis (AD) is considered the most prevalent chronic inflammatory condition in very young children, with a prevalence approaching 20% in some industrialized countries. Recent advances in the understanding of the aetiology and pathogenesis of AD - particularly in relation to genetically determined skin barrier dysfunction and the role of microbial infections in AD flares - have helped to galvanize thinking on approaches to treatment in young patients. Topical anti-inflammatory medicines (corticosteroids and calcineurin inhibitors) in addition to emollients are the mainstay of therapy in children, but parents need help to understand how and when to apply them and reassurance to allay their fears about the long-term effects of these treatments. At the same time, more work is required in order to identify which clinical signs, symptoms, long-term control of flares, and quality of life measures are the best outcome domains for AD clinical trials in order to continue to improve control of AD in children.

Effect of emollients containing vegetable-derived lactobacillus in the treatment of atopic dermatitis symptoms: split-body clinical trial

Background

Atopic dermatitis (AD) patients suffer from xerosis. Proper skin care, including the use of emollients, may help improve xerosis and minimize disease exacerbation. Lactobacillus sakei probio 65, isolated from the Korean vegetable-based product kimchi, can decrease interleukin 4 and immunoglobulin E levels and inhibit Staphylococcus aureus. Moreover, it has reportedly shown positive dermatological effects in both animal and clinical studies.

Objective

To compare the effects of an emollient that contains Lactobacillus (treated) with a normal emollient (control) on AD.

Methods

This double-blind, randomized, split-body clinical trial involved 28 patients with AD. The patients applied the Lactobacillus-containing emollient on one side of their body and the control emollient on the other side twice daily for 4 weeks. Trans-epidermal water loss (TEWL) and skin capacitance were evaluated and investigator global assessment and the visual analogue scale (VAS) were administered on weeks 0, 1, 2, and 4.

Results

The treated sides had significantly lower TEWL and VAS values and significantly higher skin capacitance values over time than the control sides.

Conclusion

Topical application of Lactobacillus-containing emollients may improve the skin permeability of patients with AD.

Microbiome and skin diseases

PURPOSE OF REVIEW

This article reviews recent findings on the skin microbiome. It provides an update on the current understanding of the role of microbiota in healthy skin and in inflammatory and allergic skin diseases.

RECENT FINDINGS

Advances in computing and high-throughput sequencing technology have enabled in-depth analysis of microbiota composition and functionality of human skin. Most data generated to date are related to the skin microbiome of healthy volunteers, but recent studies have also addressed the dynamics of the microbiome in diseased and injured skin. Currently, reports are emerging that evaluate the strategies to manipulate the skin microbiome, intending to modulate diseases and/or their symptoms.

SUMMARY

The microbiome of normal human skin was found to have a high diversity and high interpersonal variation. Microbiota compositions of diseased lesional skin (in atopic dermatitis and psoriasis) showed distinct differences compared with healthy skin. The function of microbial colonization in establishing immune system homeostasis has been reported, whereas host-microbe interactions and genetically determined variation of stratum corneum properties might be linked to skin dysbiosis. Both are relevant for cutaneous disorders with aberrant immune responses and/or disturbed skin barrier function. Modulation of skin microbiota composition to restore host-microbiota homeostasis could be future strategies to treat or prevent disease.

Atopic dermatitis in children

A 7-year-old girl presented with atopic dermatitis (AD) that did not respond to standard therapy. She was avoiding dairy, egg, and wheat in her diet because of a history of skin flares. Her weight gain was poor, and laboratory test results showed low iron and zinc levels. Over the previous 6 months, she had been prescribed numerous courses of antibiotics, but, despite this, she continued to have secondary skin infections as well as deep circumscribed erosions on her shins. She was awake much of the night because of scratching and displayed repetitive and habitual behavior. She also had troublesome allergic rhinoconjunctivitis with positive allergy testing results to house dust mite. Methicillin-resistant Staphylococcus aureus was isolated from her skin, which was successfully treated with appropriate antibiotics and flares controlled with topical antiseptics and better personal and caregiver hygiene. Although milk, egg, and wheat specific IgE were raised, these foods were successfully reintroduced back into her diet with improvement of her nutritional status and no flare of her AD. In view of her habitual behavior and family history of obsessive compulsive disorder, she underwent cognitive behavioral therapy, and her general well-being, sleep, and ulcers over her shins improved. Despite high house dust mite-specific IgE, house dust mite sublingual immunotherapy led to no additional improvement in her AD although it did improve her rhinitis. Although there may be no "quick fixes" in patients with AD, the clinician should be aware of antimicrobial, allergen, and educational and/or behavioral interventions, which may greatly improve eczema severity and the patient's well-being.

Colonization by S. aureus increases the EASI and the number of appointments by patients with atopic dermatitis: cohort with 93 patients

BACKGROUND

Atopic dermatitis leads to epidermal barrier dysfunction and bacteria colonization. The relationship of the last factor with the severity of the disease and the frequency of exacerbation is not fully known.

OBJECTIVES

Verify the severity of the atopic dermatitis and the number of appointments generated by dermatosis, comparing patients colonized with patients not colonized by S. aureus. Verify the frequency of colonization by methicillin resistant Staphylococcus aureus acquired in the community.

METHODS

Cohort study with a 12 months follow-up, in a sample of patients from Porto Alegre, RS public network. Cultures in active injuries and nasal cavities were carried out as well as methicillin sensitivity tests to S. aureus. The severity of atopic dermatitis was defined by Eczema Area and Severity Index (EASI).

RESULTS

We included 93 patients, 43% female and 56% male, 26 colonized by S. aureus in the nasal orifices, 56 in the skin damage. The mean of initial Eczema Area and Severity Index was 5.5 and final 3.9. The initial Eczema Area and Severity Index of patients colonized by S. aureus in the skin and nasal cavity was larger than the number of patients without colonization(p< 0.05). During the period of one year, in average, there were six appointments/patient. There was linear correlation between the number of appointments during one year and the inicial Eczema Area and Severity Index (r = 0,78). There were no patients with methicillin resistant Staphylococcus aureus acquired in the community.

CONCLUSION

There is a relevant influence of staphylococcal colonization on the severity of atopic dermatitis and the number of appointments required by its exacerbation. Methicillin resistance among those affected by S. aureus does not seem to be an emergent problem, in this Brazilian sample.

Atopic dermatitis

Atopic dermatitis (AD) is a common chronic inflammatory skin condition characterized by intense pruritus and a waxing and waning course. AD often presents in infancy and childhood and can persist throughout adulthood. The exact cause of AD is unknown, but it likely reflects an interplay between genetic and environmental factors. AD affects up to 20% of children in the United States, and prevalence may be increasing. Treatment can be effective in alleviating symptoms but serves only to manage the disease, not cure it. Appropriate therapy can also prevent significant complications, such as infection, sleep disturbance, behavioral problems, and growth impairment.

Diagnosis and management of diaper dermatitis

This article presents an overview of diaper dermatitis for the pediatric community. The pathogenesis, differential diagnosis, and management of this common condition in infancy are reviewed. This information will assist in making the appropriate diagnosis and managing this irritant contact dermatitis of the diaper area. With conservative management, most cases of irritant diaper dermatitis are self-limited. When the condition persists, one must consider other diagnoses.

Emergence of multiresistant methicillin-resistant Staphylococcus aureus in two patients with atopic dermatitis requiring linezolid treatment

We report two patients with atopic dermatitis who developed methicillin-resistant Staphylococcus aureus (MRSA) skin infections resistant to clindamycin and trimethoprim-sulfamethoxazole requiring repeated linezolid treatment. For one patient and family members who received an aggressive regimen of staphylococcal decolonization, including intranasal mupirocin, dilute bleach baths, and bleach cleansing of household items and surfaces, subsequent culture results demonstrated methicillin-susceptible S. aureus colonization and infection. These findings underscore the challenges presented by multiresistant MRSA infections in children with atopic dermatitis.

Non-pharmacologic therapies for atopic dermatitis

Atopic dermatitis (AD) continues to present significant therapeutic challenges, especially in severe cases. Navigating the line between risk and benefit can be difficult for more powerful medications such as immunosuppressants, but non-pharmacologic treatments are often overlooked and underutilized. Creative application of these more physical therapies can serve to minimize the pharmacologic treatments and their side effects, and possibly even create synergy between modalities, to maximize benefit to the patient.

The pH of antiseptic cleansers

BACKGROUND

Daily bathing with antiseptic cleansers are proposed by some physicians as an adjunctive management of atopic dermatitis (AD). As atopic skin is sensitive, selection of cleansing products becomes a topic of concern.

OBJECTIVE

Our purpose is to evaluate the pH of various antiseptic body cleansers to give an overview for recommendation to patients with AD.

METHODS

Commonly bar and liquid cleansers consisted of antiseptic agents were measured for pH using pH meter and pH-indicator strips. For comparison, mild cleansers and general body cleansers were also measured.

RESULTS

All cleansing bars had pH 9.8-11.3 except syndet bar that had neutral pH. For liquid cleansers, three cleansing agents had pH close to pH of normal skin, one of antiseptic cleansers, one of mild cleansers and another one of general cleansers. The rest of antiseptic cleansers had pH 8.9-9.6 while mild cleansers had pH 6.9-7.5. Syndet liquid had pH 7 and general liquid cleansers had pH 9.6.

CONCLUSION

The pH of cleanser depends on composition of that cleanser. Adding antiseptic agents are not the only factor determining variation of pH. Moreover, benefit of antiseptic properties should be considered especially in cases of infected skin lesions in the selection of proper cleansers for patients with AD.

Non-toxic plant metabolites regulate Staphylococcus viability and biofilm formation: a natural therapeutic strategy useful in the treatment and prevention of skin infections

In the present study, the efficacy of generally recognised as safe (GRAS) antimicrobial plant metabolites in regulating the growth of Staphylococcus aureus and S. epidermidis was investigated. Thymol, carvacrol and eugenol showed the strongest antibacterial action against these microorganisms, at a subinhibitory concentration (SIC) of ≤ 50 μg ml(-1). Genistein, hydroquinone and resveratrol showed antimicrobial effects but with a wide concentration range (SIC = 50-1,000 μg ml(-1)), while catechin, gallic acid, protocatechuic acid, p-hydroxybenzoic acid and cranberry extract were the most biologically compatible molecules (SIC ≥ 1000 μg ml(-1)). Genistein, protocatechuic acid, cranberry extract, p-hydroxybenzoic acid and resveratrol also showed anti-biofilm activity against S. aureus, but not against S. epidermidis in which, surprisingly, these metabolites stimulated biofilm formation (between 35% and 1,200%). Binary combinations of cranberry extract and resveratrol with genistein, protocatechuic or p-hydroxibenzoic acid enhanced the stimulatory effect on S. epidermidis biofilm formation and maintained or even increased S. aureus anti-biofilm activity.

Systemic therapy for atopic dermatitis

Systemic therapy for atopic dermatitis (AD) is indicated in patients with severe disease refractory to adequate topical treatment. Currently available drugs aim to decrease inflammation by suppressing and/or modulating immune responses and thus may indirectly improve skin barrier function, resulting in a decrease in clinical signs and symptoms in particular pruritus. Before considering systemic treatment, patient adherence to topical treatment including skin care has to be ensured. The selection of the drug depends on the disease severity, localization, complications, concomitant diseases, and age of the patient, but also on their availability and costs as well as the doctor's experience. Bearing in mind the potential risk of resistance, systemic therapy with antibiotics should be exclusively considered in clinically manifest infections such as in children. Here, we review recently published clinical trials and case reports on systemic therapy of pediatric and adult patients with AD to draw conclusions for clinical practice. Although AD is a common disease, controlled clinical studies investigating the efficacy of systemic drugs are scarce, except for cyclosporine, which has been approved for the therapy of severe AD.