Clinical Effectiveness of Moisturizers in Atopic Dermatitis and Related Disorders: A Systematic Review

Evaluating the Efficacy and Safety of Alpha-Hydroxy Acids in Dermatological Practice: A Comprehensive Clinical and Legal Review

The global market for alpha-hydroxy acids (AHAs) is undergoing significant expansion, propelled by increasing demand for skincare products that address aging and environmental damage. This review focuses on the dermatological applications of AHAs, particularly in cosmetic formulations like chemical peels. We have identified that AHAs, such as glycolic and lactic acids, enhance skin rejuvenation by promoting apoptosis in skin cells, boosting collagen and elastin synthesis, and improving skin texture and luminosity. Our comprehensive analysis reveals a nuanced understanding of AHAs' effectiveness across various skin types and conditions, demonstrating their broad utility in treating conditions like acne, hyperpigmentation, and photoaging. However, the optimal concentrations for therapeutic efficacy with minimal side effects are yet to be precisely defined, necessitating further research. Regulatory compliance is underscored as essential for the safe application of AHAs in cosmetics, with international guidelines recommending specific concentrations and pH levels to minimize potential skin irritation. In Conclusion, the review highlights the effectiveness of AHAs in cosmetic dermatology, emphasizing the necessity for continued research and rigorous regulatory adherence to maximize their safe and beneficial application worldwide.

A Skin Care Program to Prevent Skin Problems due to Diabetes Devices in Children and Adolescents: A Cluster-Controlled Intervention Study

OBJECTIVE

Diabetes devices that deliver insulin and measure blood glucose levels are cornerstones in modern treatment of type 1 diabetes. However, their use is frequently associated with the development of skin problems, particularly eczema and wounds. Proper skin care may prevent skin problems, yet evidence-based information from interventional studies is missing. Providing this information is the aim of this study.

RESEARCH DESIGN AND METHODS

This cluster-controlled intervention study tested the efficacy of a basic skin care program (including use of lipid cream, removal, and avoidance of disinfection). A total of 170 children and adolescents with type 1 diabetes were included and assigned either to the intervention group (n = 112) or the control group (n = 58). Participants were seen quarterly the first year after device initiation, with clinical assessment and interview in an unblinded setting.

RESULTS

Eczema or wounds were observed in 33.6% of the intervention group compared with 46.6% of control participants (absolute difference, 12.9% [95% CI -28.7%, 2.9%]; P = 0.10). The adjusted odds of wound development were decreased by 71% in the intervention compared with control group (for wounds, odds ratio 0.29 [95% CI 0.12, 0.68]; P = 0.005). In total, only eight infections were seen, without a higher frequency in the intervention group, despite advice to omit disinfection.

CONCLUSIONS

These data indicate our basic skin care program partially prevented diabetes device-induced skin reactions. However, more preventive strategies with other adhesives, patches, and/or types of lotions are needed for optimized prevention.

The Skin Barrier and Moisturization: Function, Disruption, and Mechanisms of Repair

BACKGROUND

The anatomic layers of the skin are well-defined, and a functional model of the skin barrier has recently been described. Barrier disruption plays a key role in several skin conditions, and moisturization is recommended as an initial treatment in conditions such as atopic dermatitis. This review aimed to analyze the skin barrier in the context of the function model, with a focus on the mechanisms by which moisturizers support each of the functional layers of the skin barrier to promote homeostasis and repair.

SUMMARY

The skin barrier is comprised of four interdependent layers - physical, chemical, microbiologic, and immunologic - which maintain barrier structure and function. Moisturizers target disruption affecting each of these four layers through several mechanisms and were shown to improve transepidermal water loss in several studies. Occlusives, humectants, and emollients occlude the surface of the stratum corneum (SC), draw water from the dermis into the epidermis, and assimilate into the SC, respectively, in order to strengthen the physical skin barrier. Acidic moisturizers bolster the chemical skin barrier by supporting optimal enzymatic function, increasing ceramide production, and facilitating ideal conditions for commensal microorganisms. Regular moisturization may strengthen the immunologic skin barrier by reducing permeability and subsequent allergen penetration and sensitization.

KEY MESSAGES

The physical, chemical, microbiologic, and immunologic layers of the skin barrier are each uniquely impacted in states of skin barrier disruption. Moisturizers target each of the layers of the skin barrier to maintain homeostasis and facilitate repair.

Efficacy and In-Use Tolerance of Venusia Baby Moisturizer for Skin Hydration in Babies With Dry and/or Normal Skin

Introduction Skin hydration is important for maintaining adequate skin barrier function. After delivery, the baby's skin faces the most difficult challenge as they are exposed to the exterior world's environmental changes, friction, and microorganisms. The management is further complicated by the availability of a large range of infant skin-care products with varying claims. The first-ever Indian study on babies was done to analyze the test product (Venusia baby moisturizer; Dr. Reddy's Laboratories Ltd., Hyderabad, India) in order to bring scientific clarity to consumers. This product is devoid of parabens, alcohol, and animal origin (Dr. Reddy's Laboratories Ltd., Hyderabad, India) and is designed for skin hydration and in-use tolerance in babies with dry and/or normal skin. The endpoints were hydration and clinical evaluation of the skin, evaluated using a moisture meter scale (MMSC; Delfin Technologies Ltd., Kuopio, Finland) and parent self-assessment questionnaire, respectively. Material and methods A total of 136 healthy babies aged between six months to two years were enrolled in a four-group, monocentric, non-randomized, evaluator-blinded study: Group 1 (Venusia baby cream for dry skin), Group 2 (Venusia baby lotion for Dry Skin), Group 3 (Venusia baby cream for normal skin), and Group 4 (Venusia baby lotion for normal skin). The endpoints were hydration and clinical evaluation of the skin, evaluated using an MMSC and parent self-assessment questionnaire, respectively. Results In babies with dry skin, skin hydration was improved with Venusia baby cream (37.50%) and Venusia baby lotion (66.40%). Additionally, 66.66% of participants strongly agreed that the baby's skin became softer and smoother after the application of Venusia baby cream; 76.47% of participants strongly agreed that the baby's skin became softer and smoother after the application of Venusia baby lotion. In babies with normal skin, skin hydration was improved with Venusia baby cream (12.20%) and Venusia baby lotion (7.20%); 59.37% of participants strongly agreed that the baby's skin became softer and smoother after the application of Venusia baby cream; and 84.84% of participants strongly agreed that the baby's skin became softer and smoother after the application of Venusia baby lotion. Conclusion Significant improvement was seen in skin hydration using Venusia baby cream and Venusia baby lotion in babies with dry skin and normal skin. No skin intolerances and product-related adverse or serious adverse events were clinically observed or reported during the study duration. Venusia baby lotion had the highest effect (66.4%) on skin hydration in babies with dry skin, where there was a significant shift from dry skin to normal skin range.

S2k-Leitlinie Diagnostik, Prävention und Therapie des Handekzems: S2k guideline diagnosis, prevention and therapy of hand eczema

Die S2k‐Leitlinie „Diagnostik, Prävention und Therapie des Handekzems (HE)“ gibt auf der Grundlage eines evidenz‐ und konsensbasierten Ansatzes konkrete Handlungsanweisungen und Empfehlungen für die Diagnostik, Prävention und Therapie des HE. Die Leitlinie wurde auf der Grundlage der deutschen Leitlinie „Management von Handekzemen“ aus dem Jahr 2009 und der aktuellen Leitlinie der European Society of Contact Dermatitis (ESCD) „Guidelines for diagnosis, prevention and treatment of hand eczema“ aus dem Jahr 2022 erstellt. Allgemeines Ziel der Leitlinie ist es, Dermatologen und Allergologen in der Praxis und Klinik eine akzeptierte, evidenzbasierte Entscheidungshilfe für die Auswahl sowie Durchführung einer geeigneten und suffizienten Therapie für Patienten mit Handekzemen zur Verfügung zu stellen. Die Leitlinie basiert auf zwei Cochrane‐Reviews zu therapeutischen und präventiven Interventionen beim HE. Die übrigen Kapitel wurden überwiegend basierend auf nicht systematischen Literaturrecherchen durch die Expertengruppe erarbeitet und konsentiert. Die Expertenkommission bestand aus Mitgliedern von allergologischen und berufsdermatologischen Fachgesellschaften und Arbeitsgruppen, einer Patientenvertretung und Methodikern. Im Rahmen einer Konsensuskonferenz am 15.09.2022 wurden die Vorschläge für die Empfehlungen und Kernaussagen unter Verwendung eines nominalen Gruppenprozesses konsentiert. Der strukturierte Konsensfindungsprozess wurde professionell moderiert. Die vorliegende Leitlinie hat eine Gültigkeit bis zum 22.02.2028.

S2k guideline diagnosis, prevention, and therapy of hand eczema

The consensus-based guideline "Diagnosis, prevention, and treatment of hand eczema (HE)" provides concrete instructions and recommendations for diagnosis, prevention, and therapy of HE based on an evidence- and consensus-based approach. The guideline was created based on the German guideline "Management von Handekzemen" from 2009 and the current guideline of the European Society of Contact Dermatitis (ESCD) "Guidelines for diagnosis, prevention, and treatment of hand eczema" from 2022. The general goal of the guideline is to provide dermatologists and allergologists in practice and clinics with an accepted, evidence-based decision-making tool for selecting and conducting suitable and sufficient therapy for patients with hand eczema. The guideline is based on two Cochrane reviews of therapeutic and preventive interventions for HE. The remaining chapters were mainly developed and consented based on non-systematic literature research by the expert group. The expert group consisted of members of allergological and occupational dermatological professional associations and working groups, a patient representative, and methodologists. The proposals for recommendations and key statements were consented by using a nominal group process during a consensus conference on September 15, 2022. The structured consensus-building process was professionally moderated. This guideline is valid until February 22, 2028.

Systematic review and network meta-analysis of different types of emollient for the prevention of atopic dermatitis in infants

Prophylactic application of emollients has been an effective strategy against infant atopic dermatitis (AD); however, the difference of different emollients is unknown. We performed this network meta-analysis to compare different emollients in preventing infant AD. A systematic search was performed in PubMed, EMBASE and Cochrane library to identify relevant studies from their inception through 28 February, 2022. We evaluated the quality of eligible studies using the Cochrane risk of bias assessment tool. Data analysis was performed using STATA 14.0. Eleven studies were included for data analysis. Direct meta-analysis suggested that early application of emollients effectively prevented AD development in high-risk infants (risk ratio [RR], 0.64; 95% confidence interval [CI], 0.47 to 0.88). Network meta-analysis suggested that emollient emulsion might the better option for preventing infant AD development, with a surface under the cumulative ranking curve (SUCRA) of 82.6% for all populations, 78.0% for high-risk populations and 79.2% for populations with food sensitization. Moreover, subjects receiving emollients more frequently experienced adverse events. Overall, early application of emollients is an effective strategy for preventing AD development in high-risk infants and emollient emulsion may be the optimal type. Future study with well-designed and large scale are warranted to validate our findings.

The use of urea for skin barrier correction

The review summarizes information about the main causes and pathogenesis of xerosis cutis as one of the conditions indicating a violation of the epidermal barrier. Xerosis cutis is a clinical sign of a decrease in the amount and/or quality of lipids and/or hydrophilic substances in the stratum corneum of the epidermis. The modern approach to the treatment of dermatoses accompanied by violations of the epidermal barrier includes basic moisturizers. Urea not only moisturizes the skin. It is involved in the regulation of barrier function and antimicrobial protection. It is a low-molecular regulator of protein synthesis in keratinocytes, such as filaggrin, loricrin, involucrin and transglutaminase 1, cathelicidin, beta-defensin-2, water and urea carrier proteins into the cell, as well as proteins that promote the synthesis of intercellular matrix lipids. The main dermatotropic pharmacological effects of urea (hydration of the epidermis, strengthening of the barrier function of the skin, keratolytic effect, increased penetration of drugs into the skin) have been used in dermatological practice for many years. External agents with urea are used to treat skin diseases accompanied by dryness and excessive keratinization, to correct the deformation of nail plates of various genesis, to facilitate the local penetration of medicines. The use of topical UrocrEM5, UrocrEM10, Uroderm ointments containing 5%, 10% and 30% urea, respectively, is effective and safe.

"Normal" TEWL-How Can it be Defined?: A Systematic Review

BACKGROUND

Transepidermal water loss (TEWL), the total non-eccrine sweat water evaporating from a given area of epidermis over time, is a measurement of skin barrier integrity. Skin diseases (e.g. psoriasis and atopic dermatitis) often result in transient increases in TEWL, so knowledge of "normal" TEWL values may be used to predict disease progression in dermatological settings. Variables such as age, race, and anatomic location have been suggested to affect TEWL, but current regulatory agencies have failed to control for additional variables of interest. Thus, this review summarizes variables that may cause TEWL variation.

METHODS

A comprehensive literature search was performed using Embase, PubMed, and Web of Science to find human studies that provided data on variables affecting TEWL.

RESULTS

31 studies, analyzing 22 affecting TEWL, were identified. Variables causing increased TEWL were mask-use (n=1), Dry Eye Disease (n=1), Chronic Venous Disease (n=1), Coronary Artery Disease (n=1), age (infants vs. adults) (n=4), nourishment in infants (n=1), stress within individuals (n=2), Body Mass Index (n=2), bathing versus showering (n=2), and scratching/friction (n=1). Variables with decreases in TEWL were genetic variability with SNPs on chromosome 9q34.3 (n=1) and cancer-cachexia (n=1).

CONCLUSION

We summarized 12 variables that impact TEWL and are not typically controlled for in experimental settings. Therefore, defining normal TEWL may currently be problematic. Thus, regulatory agencies should provide stricter guidelines on proper measurement of TEWL to minimize human introduced TEWL variation, and we should continue to examine factors impacting individual skin integrity.

Moisturizer therapy in prevention of atopic dermatitis and food allergy: To use or disuse?

OBJECTIVE

To critically appraise the evidence for the role of regular moisturizer application in early life to prevent atopic dermatitis (AD) and food allergy (FA).

DATA SOURCES

Primary peer-reviewed literature.

STUDY SELECTIONS

Original research articles based on systematic reviews, interventional studies, retrospective studies, case-control studies, and cohort studies related to the subject matter.

RESULTS

There is good evidence to show that epicutaneous sensitization through a defective skin barrier is important in the development of AD and FA. This supports moisturizer use in prevention because some of them have been proven to restore skin barrier with clear benefits in AD, whereas there is some limited evidence that these products may reduce allergic sensitization. However, moisturizers have varied effects depending on ingredients and formulation, some of which are paradoxical, such as increasing transepidermal water loss and enhancing penetration of substances in the skin. These effects may be responsible for some of the conflicting outcomes of prevention studies, some of which suggest that moisturizers are not useful in prevention of AD and FA, whereas others show a positive trend. Interestingly, there is some suggestion that moisturizers may increase the risk for allergy development perhaps through these paradoxical effects.

CONCLUSION

Although moisturizer use is beneficial in the management of AD, current evidence suggests that it may be ineffective in prevention of AD and FA. Further studies are needed to determine the effects of moisturization on allergic sensitization and inflammation and to investigate whether moisturizer type, frequency, duration, and age of application substantially affect the prevention and development of these allergies.

Effectiveness of Emollients in the Prevention of Atopic Dermatitis in Infants: A Meta-Analysis

BACKGROUND

Atopic dermatitis (AD) is a chronic skin disease characterized by dry skin, severe itching, inflammation and impaired quality of life. Moisturizing is an integral part of treatment for AD, but its potential for prevention of AD is unclear.

OBJECTIVE

To evaluate whether the early use of emollients in infancy can prevent later development of AD.

METHODS

We searched Medline, Embase, Web of Science, PubMed, Cochrane Library and other databases to collect randomized controlled trials on early use of emollients in infants for a meta-analysis.

RESULTS

Nine articles were included. The OR value for incidence rate was 0.7 (95% CI: 0.48-1.01). No significant publication bias was found by Egger's test. The sensitivity analysis indicated that the final conclusion was reliable.

CONCLUSIONS

We found that the difference in incidence rate of AD between the experimental and control groups was not statistically significant. However, due to different methods of using emollients, different follow-up times and different sample sizes included in this meta-analysis, a definitive conclusion could not be reached in this study. In the future, it is still necessary to carry out randomized controlled, multicenter, large-sample trials with an excellent study design and high methodological quality on early application of emollients in high-risk infants to prevent AD.

What are the highest yielding search strategy terms for systematic reviews in atopic dermatitis? A systematic review

The impact of search strategies on systematic reviews (SR) of atopic dermatitis (AD) is unknown. The purpose of this review was to evaluate search strategies used in SR of AD and their impact on the frequency of manuscripts identified. MEDLINE and EMBASE were searched for SR related to AD. Simulations were performed by running combinations of search terms in MEDLINE and EMBASE. Overall, 250 SR met inclusion criteria, of which 225 specified search strategies. SR using 5-6 terms (20.0% to 12.1%) or ≥ 7 (40.0% to 18.8%) terms decreased, whereas SR using 3-4 terms numerically increased (18.8% to 30.2%) and 1-2 terms remained similar (37.5% to 38.9%) from 1999-2009 to 2015-2019. The most commonly searched terms were "atopic dermatitis" (n = 166), followed by "eczema" (n = 156), "dermatitis atopic'" (n = 81), "atopic eczema" (n = 74), "neurodermatitis" (n = 59), "Besniers prurigo" (n = 29), "infantile eczema" (n = 27), and "childhood eczema" (n = 19). Simulations revealed that "eczema" and "atopic dermatitis" yielded the most hits. The number of search terms that maximized hits in MEDLINE and EMBASE was 5 and 4, respectively. Search strategies for AD were heterogeneous, with high proportions of search strategies providing few search hits. Future studies should use standardized and optimized search terms.

Urea in Dermatology: A Review of its Emollient, Moisturizing, Keratolytic, Skin Barrier Enhancing and Antimicrobial Properties

Urea is a hygroscopic molecule (capable of absorbing water) present in the epidermis as a component of the natural moisturizing factor (NMF) and is essential for the adequate hydration and integrity of the stratum corneum. Urea improves skin barrier function including antimicrobial defense by regulating gene expression in keratinocytes relevant for their differentiation and antimicrobial peptide production. It also plays a fundamental role in regulating keratinocyte proliferation. One of the first uses of urea in modern medicine was the topical treatment of wounds due to its proteolytic and antibacterial properties. At present, urea is widely used in dermatology to improve skin barrier function and as one of the most common moisturizers and keratolytic agents. Urea-containing formulations are available in diverse formulations and concentrations. Multiple clinical trials on the use of urea-containing formulations have shown significant clinical improvement in many of the dermatosis presenting with scaly and dry skin such as atopic dermatitis, ichthyosis, xerosis, seborrheic dermatitis and psoriasis, among others. Furthermore, urea can increase skin penetration and optimize the action of topical drugs. Urea-based products are well tolerated; their side effects are mild and are more frequent at high concentration. Here, we present a review of the use of urea in dermatology, discussing its mechanism of action, safety profile and frequent indications.

Understanding humectant behaviour through their water-holding properties

OBJECTIVE

Humectants perform essential roles in the formulation of topical moisturizing products in terms of delivery of active ingredients, consumer experience and biophysical behaviour. How they retain and release water is key to understanding their behaviour.

METHODS

Dynamic vapour sorption (DVS) was used to monitor the dehydration kinetics of three humectants widely used in topical formulations-glycerine, dexpanthenol and urea. Model aqueous solutions with concentrations of 20% w/w were tested and compared against pure deionized water.

RESULTS

The three humectants varied in their ability to retain water during the dehydration process. Dexpanthenol was able to retain water most efficiently during the latter stages of dehydration. Urea demonstrated evidence of crystallization during the final stage of water loss, which was not shown by glycerine or dexpanthenol.

CONCLUSIONS

Humectants perform vital roles in the formulation of consumer acceptable topical products including the delivery of actives to the skin. Their ability to influence water movement in the skin is also essential for the maintenance of stratum corneum flexibility. DVS assessment of aqueous solutions has demonstrated how the behaviour of three commonly used humectants differs. Knowledge of the mechanisms by which these humectants operate enables the formulator to develop topical products optimized for the roles for which they are intended.

Urea-containing topical formulations

Urea is a well-known moisturiser and keratolytic topical agent. As it is widely used in dermatology, several formulations at different concentrations have been marketed: lotions, creams, foams, ointments, gels and lacquers. Availability of different vehicles and concentration may vary in different countries, but in general products at low, medium and high urea concentration are accessible worldwide. The proper formulation should be chosen according to the disorder to treat, its severity, body areas involved and patients' preference.

An Emollient Containing Aquaphilus dolomiae Extract is Effective in the Management of Xerosis and Pruritus: An International, Real-World Study

INTRODUCTION

Xerosis and pruritus are common manifestations of numerous dermatologic and systemic diseases. We evaluated the effectiveness of an emollient containing an Aquaphilus dolomiae extract (ADE-G1) for the management of pruritus and xerosis in patients of all age with a range of dermatologic and systemic diseases.

METHODS

This open-label, real-world study involved 5910 patients from 33 European, South American, Asian, and North and South African countries, who applied the product for 7 days twice daily to the face and body after the skin had been cleansed and dried. The physician assessed xerosis severity and patients assessed pruritus severity, the duration of itch, sleep quality, and the impact of their skin disease on their quality of life, using scales derived from the SCORing Atopic Dermatitis (SCORAD) index and questionnaires, at inclusion and after 7 days of use.

RESULTS

The 7-day care regimen resulted in 56% and 60% reductions in xerosis and pruritus severity, respectively, regardless of the underlying pathology (p < 0.0001), with the largest decreases observed for patients with ichthyosis for xerosis and for patients post scabies treatment for pruritus. The mean sleep disturbance and mean total Dermatology Life Quality Index (DLQI) scores were also reduced by 58% and 60% (p < 0.0001), respectively. The emollient was effective whether the product was used alone or in combination with topical or systemic treatments and was well tolerated.

CONCLUSION

Our study shows that the 7-day regimen with the emollient was a universally effective treatment for pruritus and xerosis, regardless of the underlying pathology.

Efficacy of Nonprescription Moisturizers for Atopic Dermatitis: An Updated Review of Clinical Evidence

Twice-daily moisturization is recommended by international guidelines as the bedrock of the management of atopic dermatitis (AD). Moisturizers should be selected based on proven clinical effectiveness in improving the skin barrier and improving the symptoms of AD. We searched the PubMed database for clinical trials assessing daily moisturization for the treatment of AD published between 2006 and 2019. Studies had to assess the efficacy of commercially available moisturizers using objective measures of corneometry, transepidermal water loss, or incidence of flare as endpoints, and treatments had to be currently available to patients. Clinical studies showed that moisturization (typically twice daily) significantly improved the skin barrier in adults and children with AD. Longer-term flare studies showed that daily moisturization reduced the incidence of flares and extended the time between flares. Proactive moisturization of infants at high risk of developing AD may reduce its manifestation. Therapeutic moisturizers for AD are specifically formulated with ingredients that target symptoms of AD, such as itch, inflammation, or compromised skin barrier. The US FDA requires that any moisturizer available in the USA and claiming to treat AD must contain colloidal oatmeal. Healthcare providers can maximize compliance and outcomes by educating patients on the benefits of liberally applying a therapeutic moisturizer twice daily to support the skin barrier and help reduce the incidence of flares. Specific recommendations should be for clinically tested moisturizers evaluated using objective, validated skin assessments.

Poly-γ-Glutamate microneedles as transdermal immunomodulators for ameliorating atopic dermatitis-like skin lesions in Nc/Nga mice

Atopic dermatitis (AD), a common, relapsing, inflammatory disorder of the skin, is associated with T helper type 2 (Th2)-biased immune responses. Despite the efficacy of existing drugs for AD treatment, their safety and side effects cause concern. The present study describes the use of dissolvable poly-γ-glutamate (γ-PGA) microneedles (MNs) with immunomodulatory effects for effectively relieving AD-like symptoms in Nc/Nga mice. γ-PGA MNs can easily penetrate the epidermis and release γ-PGA into the dendritic cell-rich dermis to interact with dendritic cells for modulating immune responses. Transdermal administration of high-molecular-weight (HMW, 1100 kDa) γ-PGA MNs significantly reduced clinical dermatitis scores, epidermal thickness, and mast cell infiltration in mice by downregulating immunoglobulin (Ig)E and IgG1 levels (Th2-associated antibodies) compared with the AD control group. However, low-molecular-weight (200-400 kDa) γ-PGA MNs ameliorated AD-like skin lesions less effectively than HMW γ-PGA MNs, thus indicating that the MW of γ-PGA may affect its immunomodulatory properties. Notably, the mouse skin quickly recovered its barrier function within 4 h after MN application. No weight loss or abnormality was observed in the MN-treated mice during the 8-week treatment period. These results suggest that the γ-PGA MNs represent an innovative, safe, and reliable therapeutic strategy for AD management. STATEMENT OF SIGNIFICANCE: This study is the first to explore the feasibility of using poly-γ-glutamate (γ-PGA) microneedles (MNs) as transdermal immunomodulators for improving atopic dermatitis (AD) symptoms and to evaluate their immunomodulatory effect in mice with spontaneously developed AD. Transdermal administration of γ-PGA MNs enables the γ-PGA to localize in the skin for activation of dermal dendritic cells, thus modulating immune responses. We demonstrate that high-molecular-weight γ-PGA MNs can be retained in the skin for at least 6 days and effectively suppress AD-like skin lesions in mice by reducing infiltration of mast cells and downregulating Th2-associated antibody production (IgE and IgG1). The developed MN device has the potential to replace conventional therapy and to become an innovative treatment strategy for AD.

Diagnosis and treatment of xerosis cutis - a position paper

BACKGROUND AND RATIONALE

Xerosis cutis (also referred to as xeroderma, dry skin, asteatosis) affects more than 10 million individuals in Germany. It is among the most common dermatological diagnoses and a cardinal symptom of many dermatological, internal and neurological diseases. Even though it has been established that basic skin care plays a significant role in the management of patients with xerosis cutis, there are as yet no evidence-based algorithms for diagnosis and treatment.

OBJECTIVE

The present position paper provides physicians across all specialties with a practical, symptom-based approach to the prevention, diagnosis and treatment of xerosis cutis.

METHODS

Within a structured decision-making process, a panel of experienced dermatologists first defined questions relevant to everyday clinical practice, which were then addressed by a systematic review of the literature. Based on the evidence available as well as expert consensus, diagnostic and treatment algorithms were subsequently developed and agreed upon.

RESULTS

Xerosis cutis is generally diagnosed on clinical grounds. Possible trigger factors must be avoided, and comorbidities should be adequately and specifically treated. Suitable skin care products should be chosen with a view to improving skin hydration and restoring its barrier function. They should therefore contain both rehydrating and lipid-replenishing components. The "drier" the skin appears, the greater the lipid content should be (preferably using water-in-oil formulations). The choice of ingredients is based on a patient's individual symptoms, such as scaling (e.g., urea), fissures/rhagades (e.g., urea or dexpanthenol), erythema (e.g., licochalcone A) and pruritus (e.g., polidocanol). Other factors to be considered include the site affected and patient age. Ingredients or rather combinations thereof for which there is good clinical evidence should be preferentially used. The best evidence by far is available for urea, whose efficacy in the treatment of xerosis is further enhanced by combining it with other natural moisturizing components and ceramides. The "xerosimeter" is a tool developed in an effort to facilitate patient management and for training purposes. It not only includes practical tools for diagnosis and follow-up but also a classification of ingredients and a structured treatment algorithm.

CONCLUSION

The structured symptom- and evidence-based approach proposed herein contains a road map for diagnosis and treatment of xerosis cutis. It aims to raise awareness in terms of prevention and early treatment of this condition and may thus improve quality of life and prevent potential sequelae.

Allergic Contact Dermatitis Secondary to Moisturizers

Background: Moisturizers are cosmetic products used routinely to manage various skin conditions. Even though moisturizers are often thought to have minimal or no adverse reactions, allergic contact dermatitis (ACD) to these products can develop in some cases. Methods: We studied ingredients included in 3 of the most commonly used moisturizer brands, identified their presence in standard patch testing series, and evaluated their allergenic potential, categorizing the allergens as frequent or infrequent. The standard patch testing series used as reference were the Thin-layer Rapid Use Epicutaneous patch test (T.R.U.E. test), the North American Contact Dermatitis Group (NACDG) screening standard series, and the American Contact Dermatitis Society (ACDS) core allergen series. Results: Aveeno, Cetaphil, and Cerave products had a total of 12, 14, and 9 potential allergens, respectively, the majority of which were infrequent and not included in standard patch testing series. Conclusion: Being aware of the allergenic potential of commonly used moisturizers may help healthcare providers when evaluating patients with ACD. Further testing is recommended in a targeted manner when suspecting ACD with negative standard patch testing series or when ACD is refractory to treatment.

Woad extract containing cream improves significantly dry, irritated, and pruritic skin

Objective of this open, noninterventional, noncontrolled study was to investigate the tolerability and performance of a woad extract containing cream in subjects with dry, pruritic skin after twice daily application over 2 weeks. Assessments included sensorial characteristics, skin condition, pruritus (numeric rating scale [NRS], dynamic pruritus score [DPS]), skin dryness (itch-controlled days [ItchCD], overall dry skin [ODS]), transepidermal water loss (TEWL), skin hydration and quality of life (5PLQ, DLQI). All sensorial characteristics were well perceived (>4), with tolerability (4.77 ± 0.47) and no negative skin feelings (4.73 ± 0.74) achieving the highest scores (0-5 scale). Dry skin and symptoms improved significantly (p < .001) for all variables: NRS (from 4.8 ± 1.74 to 1.83 ± 2.18), ItchCD (from 8.23 ± 4.40 to 4.81 ± 4.07), ODS (from 1.80 ± 0.85 to 0.65 ± 0.65), hydration (23.33 ± 1.33 to 40.70 ± 1.86), and quality of life (5PLQ: from 7.12 ± 4.25 to 4.24 ± 3.67; DLQI: from 5.29 ± 4.79 to 3.00 ± 3.98). The DPS revealed a moderate antipruritic effect. The TEWL decreased slightly (p = .511). No side effects were reported. The study suggests that, the cream is effective, and well tolerated in treating dry, irritated, and pruritic skin.

Atopic dermatitis yardstick: Practical recommendations for an evolving therapeutic landscape

The implementation of treatment guidelines for atopic dermatitis is challenging, in part because of different guidance documents being used by different groups of specialists and in part because the language of guidelines often reflects the evidence base rather than the practical "how to." The Atopic Dermatitis Yardstick is part of a series developed in response to the need to proactively address the loss of disease control for atopic illnesses at all levels of severity. It presents a comprehensive update on how to conduct a sustained step-up in therapy for the patient with inadequately controlled or poorly controlled atopic dermatitis. Patient profiles, based on current guidelines and the authors' combined clinical experience, provide a practical and clinically meaningful guide to aid physicians in helping their patients achieve the goal of clear to almost clear. The intent is not to replace guidelines but to complement their recommendations incorporating the latest research and therapies.

Using therapeutic ultrasound to promote irritated skin recovery after surfactant-induced barrier disruption

BACKGROUND

Surfactant-induced skin barrier disruption can enhance blood flow and water content in the superficial skin. The effect of therapeutic ultrasound on accelerating the recovery of superficial skin after skin barrier disruption has seldom been studied.

OBJECTIVE

To understand the effects of therapeutic ultrasound on barrier recovery, we used the sodium lauryl sulfate irritation model and treatment with ultrasound intervention.

METHODS

The study allocated 30 healthy subjects into an ultrasound group (n = 15) and a control group (n = 15), each divided into three subgroups (sodium lauryl sulfate at concentrations of 1.0%, 0.5%, and 0%). Pulsed ultrasound (1 MHz, 0.3 W/cm²_SATA) was applied to ultrasound subgroups. The treatment effect was evaluated by the recovery rate of enhanced blood flow and water content.

RESULTS

The results indicated a surfactant dose-dependent effect on blood flow, but not on water content. The recovery rates of enhanced blood flow were higher in the 0.5% and 1.0% ultrasound subgroups than in the control subgroups throughout the experiment. However, recovery rates of water content were higher in the ultrasound subgroups than in the control subgroups only on Day2.

CONCLUSIONS

Pulsed ultrasound accelerated the barrier recovery by reducing the enhanced blood flow and water content after skin barrier disruption.

Topical urea in skincare: A review

Alterations in barrier function are associated with a number of skin diseases, including xerosis, atopic dermatitis, and psoriasis. Urea, a component of the natural moisturizing factor of the skin, plays an important role in the preservation of skin hydration and integrity. Several studies have investigated the effects of urea in the clinical setting. Here, we summarize the available clinical evidence regarding the effects of urea in the maintenance of healthy skin and management of skin disorders. At lower doses (≤10%), urea-containing topical formulations act as a skin moisturizer, while at higher concentrations (>10% urea), urea-based preparations exert a keratolytic action. Urea is also useful in combination therapies with anti-inflammatory and anti-fungal drugs, due to its activity as a penetration enhancer.

Cost and effectiveness of prescribing emollient therapy for atopic eczema in UK primary care in children and adults: a large retrospective analysis of the Clinical Practice Research Datalink

BACKGROUND

The Clinical Practice Research Datalink (CPRD) was used to evaluate the overall costs to the National Health Service, including healthcare utilisation, of prescribing emollients in UK primary care for dry skin and atopic eczema (DS&E).

METHODS

Primary care patients in the UK were identified using the CPRD and their records were interrogated for the 2 years following first diagnosis of DS&E. Data from patients with (n = 45,218) and without emollient prescriptions (n = 9780) were evaluated. Multivariate regression models were used to compare healthcare utilisation and cost in the two matched groups (age, sex, diagnosis). Two sub-analyses of the Emollient group were performed between matched groups receiving (1) a colloidal oatmeal emollient (Aveeno-First) versus non-colloidal oatmeal emollients (Aveeno-Never) and (2) Aveeno prescribed first-line (Aveeno-First) versus prescribed Aveeno later (Aveeno-Subsequently). Logistic regression models calculated the odds of prescription with either potent / very potent topical corticosteroids (TCS) or skin-related antimicrobials.

RESULTS

Costs per patient were £125.80 in Emollient (n = 7846) versus £128.13 in Non-Emollient (n = 7846) matched groups (p = 0.08). The Emollient group had fewer visits/patient (2.44 vs. 2.66; p < 0.0001) and lower mean per-visit costs (£104.15 vs. £113.25; p < 0.0001), compared with the Non-Emollient group. Non-Emollient patients had 18% greater odds of being prescribed TCS and 13% greater odds of being prescribed an antimicrobial than Emollient patients. In the Aveeno-First (n = 1943) versus Aveeno-Never (n = 1943) sub-analysis, costs per patient were lower in the Aveeno-First compared with the Aveeno-Never groups (£133.46 vs. £141.11; p = 0.0069). The Aveeno-Never group had ≥21% greater odds of being prescribed TCS or antimicrobial than the Aveeno-First group. In the Aveeno-First (n = 1357) versus Aveeno-Subsequently (n = 1357) sub-analysis, total costs were lower in the Aveeno-First group (£140.35 vs. £206.43; p < 0.001). Patients in the Aveeno-Subsequently group had 91% greater odds of being prescribed TCS and 75% greater odds of being prescribed an antimicrobial than the Aveeno-First group.

CONCLUSIONS

Acknowledging limitations from unknown disease severity in the CRPD, the prescription of emollients to treat DS&E was associated with fewer primary care visits, reduced healthcare utilisation and reduced cost. Prescribing emollients, especially those containing colloidal oatmeal, was associated with fewer TCS and antimicrobial prescriptions.

TRIAL REGISTRATION

The study is registered at http://isrctn.com/ISRCTN91126037 .

Basic skin care in atopic dermatitis - new and established treatment options

Basic skin care (basic therapy) is a mainstay in the treatment of atopic dermatitis, irrespective of disease severity and current disease activity. Consistent application of basic skin care plays a key role in restoring skin barrier function and reducing xerosis as well as pruritus. Moreover, it has been shown that concurrent basic therapy has steroid-sparing effects in acute disease flares. In long-term atopic dermatitis management, the use of basic skin care is associated with prolonged recurrence-free intervals. Recent studies have also demonstrated that early initiation of basic skin therapy has protective effects in infants at risk of developing atopic dermatitis. The present review addresses these topics with a focus on established treatments and new developments.

High Staphylococcus epidermidis Colonization and Impaired Permeability Barrier in Facial Seborrheic Dermatitis

BACKGROUND

Seborrheic dermatitis (SD) is a common inflammatory skin condition. The etiology is unclear, although overgrowth of Malassezia on the skin has been suggested to cause SD. This study investigated whether colonization with Staphylococcus plays a role in facial SD, which was not well addressed previously.

METHODS

The study was conducted from September 1, 2011 to February 20, 2012 in the First Hospital of China Medical University. In the first phase, the study evaluated the level of transepidermal water loss (TEWL) and the number of colony-forming units (CFU) of Staphylococcus in defined skin areas of SD patients who were human immunodeficiency virus (HIV) seropositive (HIV [+] SD [+] group, n = 13), classical SD (HIV [-] SD [+] group, n = 24) patients, HIV seropositive-non-SD (HIV [+] SD [-] group, n = 16) patients, and healthy volunteers (HIV [-] SD [-] group, n = 16). In the second phase, we enrolled another cohort of HIV (-) SD (+) patients who applied topical fusidic acid (n = 15), tacrolimus (n = 16), or moisturizer (n = 12). Changes in the Seborrheic Dermatitis Area Severity Index (SDASI), TEWL, and Staphylococcus density were evaluated 2 weeks later. Comparisons of each index were performed using analysis of variance (ANOVA) and least significant difference method.

RESULTS

The level of TEWL was greater through lesional sites in the HIV (+) SD (+) group than that in HIV (+) SD (-) and HIV (-) SD (-) groups (95% confidence interval [CI]: 18.873-47.071, P < 0.001 and 95% CI: 28.755-55.936, P < 0.001, respectively). The number of CFU of Staphylococcus was greater in the HIV (+) SD (+) group than that in HIV (+) SD (-) and HIV (-) SD (-) groups (95% CI: 37.487-142.744, P = 0.001 and 95% CI: 54.936-156.400, P < 0.001, respectively). TEWL was significantly more improved in patients treated with tacrolimus and fusidic acid than that in those treated with moisturizers (95% CI: 7.560-38.987, P = 0.004 and 95% CI: 4.659-37.619, P = 0.011, respectively). Topical tacrolimus and fusidic acid were significantly associated with decreased SDASI as compared with moisturizer (95% CI: 0.03-0.432, P = 0.025 and 95% CI: 0.033-0.44, P = 0.024, respectively).

CONCLUSIONS

High colonization with Staphylococcus epidermidis, along with impaired skin permeability barrier function, contributes to the occurrence of SD.

Emollients and moisturizers for eczema: abridged Cochrane systematic review including GRADE assessments

Eczema is a chronic inflammatory skin disorder with considerable impact on quality of life. Emollients or moisturizers are widely recommended, but are these effective and safe? We searched for randomized controlled trials (RCTs) in the Cochrane Skin Group Specialised Skin Register, CENTRAL in The Cochrane Library, MEDLINE, Embase, LILACS, the GREAT database and five trial registers to December 2015. We included 77 RCTs with 6603 participants. Seven studies (9%) were at low risk of bias, 34 (44%) had unclear risk and 36 (47%) were at high risk. The quality of the evidence was mainly low or moderate for the prespecified outcomes. The most important comparison, 'moisturizer vs. no moisturizer', showed improved Scoring Atopic Dermatitis values in the moisturizer group compared with no moisturizer [mean difference -2·42, 95% confidence interval (CI) -4·55 to -0·28], but did not meet the minimal important difference of 8·7. Fewer flares were seen (risk ratio 0·40, 95% CI 0·23-0·70) and the rate of flares was reduced (hazard ratio 3·74, 95% CI 1·86-7·50). The groups applying moisturizer used less topical corticosteroids over 6-8 weeks (mean difference -9·30 g, 95% CI 15·3 to -3·27). Glycyrrhetinic acid-, urea- and glycerol-containing creams worked better than their controls (vehicle, placebo or no moisturizer) according to both participants and physicians. More flares were reported with moisturizer alone than when combined with twice-weekly fluticasone propionate (risk ratio 2·17, 95% CI 1·55-3·11). Adding moisturizers to topical anti-inflammatory treatment was more effective than anti-inflammatory treatment alone and resulted in fewer flares.

Use of moisturizers among Danish atopic dermatitis patients-which perceived product characteristics associate with long-term adherence?

PURPOSE

To identify factors perceived as most important regarding choice and continued use of moisturizers for adult patients with AD.

METHOD AND MATERIALS

Online survey among members of the Atopic eczema society Denmark.

RESULTS

Among 75 participants, the most commonly tried (89.3%) and preferred (16%) product was Locobase^® (Leo Pharma, Denmark). A-derma^® (Pierre Fabre, France) had most continued use. The main reason for choosing preferred product was 'Best effect, in my experience' (36%). 'High lipid content' and 'GP/dermatologist suggested product' were considered as important main factors. 'Consistency', 'absorbs fast', and 'nice to wear' were secondary reasons for preferred product. A majority, 81.3% of respondents claimed to be very aware of perfumes and additives, 52% were very aware of allergy certification bodies on the product.

CONCLUSION

AD patients state that the most important factor when choosing a product is out of personal experience followed by high lipid content and recommended by GP/dermatologist. As secondary reasons 'consistency', 'absorbs fast', and 'nice to wear' were important. Respondents generally use more than one product and are aware of additives. Evidence-based guidance on the choice of emollients is needed. The role of the professionals supporting the patient in navigating this market of emollients is therefore particularly important.

Performance and Tolerability of the Moisturizers Cetaphil® and Excipial® in Atopic Dermatitis: What is the Evidence Based on Randomized Trials?

Introduction

Moisturizers play a prominent role in the management of atopic dermatitis by improving the impaired skin barrier function and enhancing skin hydration. Their efficacy was evaluated in a recently published Cochrane Review ‘Emollients and moisturizers for eczema’.

Objective

In the present review, we summarize the performance and safety of Cetaphil^® and Excipial^® moisturizing products.

Methods

This review was carried out in compliance with standard Cochrane methodological procedures, which means independent study selection, data extraction, assessment of risk of bias, and analyses by two review authors. The quality of evidence for the predefined outcomes was rated with the GRADE approach. The prespecified outcomes of the review included participant assessments, satisfaction, adverse events, investigator assessments, prevention of flares, change in use of topical active treatment, skin barrier function and quality of life.

Results

Four randomized controlled studies examining these moisturizers were included in the previously published Cochrane Review. For the performance and tolerability of these moisturizers, there was very low to moderate quality evidence for the prespecified outcomes.

Conclusion

The results from these four studies are in line with those of the Cochrane Review that moisturizers themselves have beneficial effects, and that combining moisturizers with active topical treatment produced better results when compared to active topical treatment alone.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-017-0184-3) contains supplementary material, which is available to authorized users.

Selected active naturals for atopic dermatitis: Atopic Dermatitis Part 1

The desire for naturally derived agents is a growing trend for patients, physicians, and pharmaceutical companies. Studies indicate that complementary and alternative medicine is often used by patients and parents of children with atopic dermatitis, not necessarily with beneficial results. A half-dozen natural agents (ie, topical agents: coconut oil, colloidal oatmeal, sunflower oil, mustard oil, glycerin, and oral Chinese herbal therapy) are discussed because they have become popular for their expected activity in the therapy of atopic dermatitis. A critical review of the published literature on these agents is presented with specific focus on potential such side effects as hepatotoxicity with Chinese herbals.

Emollients and moisturisers for eczema

BACKGROUND

Eczema is a chronic skin disease characterised by dry skin, intense itching, inflammatory skin lesions, and a considerable impact on quality of life. Moisturisation is an integral part of treatment, but it is unclear if moisturisers are effective.

OBJECTIVES

To assess the effects of moisturisers for eczema.

SEARCH METHODS

We searched the following databases to December 2015: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, the GREAT database. We searched five trials registers and checked references of included and excluded studies for further relevant trials.

SELECTION CRITERIA

Randomised controlled trials in people with eczema.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures.

MAIN RESULTS

We included 77 studies (6603 participants, mean age: 18.6 years, mean duration: 6.7 weeks). We assessed 36 studies as at a high risk of bias, 34 at unclear risk, and seven at low risk. Twenty-four studies assessed our primary outcome 'participant-assessed disease severity', 13 assessed 'satisfaction', and 41 assessed 'adverse events'. Secondary outcomes included investigator-assessed disease severity (addressed in 65 studies), skin barrier function (29), flare prevention (16), quality of life (10), and corticosteroid use (eight). Adverse events reporting was limited (smarting, stinging, pruritus, erythema, folliculitis).Six studies evaluated moisturiser versus no moisturiser. 'Participant-assessed disease severity' and 'satisfaction' were not assessed. Moisturiser use yielded lower SCORAD than no moisturiser (three studies, 276 participants, mean difference (MD) -2.42, 95% confidence interval (CI) -4.55 to -0.28), but the minimal important difference (MID) (8.7) was unmet. There were fewer flares with moisturisers (two studies, 87 participants, RR 0.40, 95% CI 0.23 to 0.70), time to flare was prolonged (median: 180 versus 30 days), and less topical corticosteroids were needed (two studies, 222 participants, MD -9.30 g, 95% CI -15.3 to -3.27). There was no statistically significant difference in adverse events (one study, 173 participants, risk ratio (RR) 15.34, 95% CI 0.90 to 261.64). Evidence for these outcomes was low quality.With Atopiclair (three studies), 174/232 participants experienced improvement in participant-assessed disease severity versus 27/158 allocated to vehicle (RR 4.51, 95% CI 2.19 to 9.29). Atopiclair decreased itching (four studies, 396 participants, MD -2.65, 95% CI -4.21 to -1.09) and achieved more frequent satisfaction (two studies, 248 participants, RR 2.14, 95% CI 1.58 to 2.89), fewer flares (three studies, 397 participants, RR 0.18, 95% CI 0.11 to 0.31), and lower EASI (four studies, 426 participants, MD -4.0, 95% CI -5.42 to -2.57), but MID (6.6) was unmet. The number of participants reporting adverse events was not statistically different (four studies, 430 participants, RR 1.03, 95% CI 0.79 to 1.33). Evidence for these outcomes was moderate quality.Participants reported skin improvement more frequently with urea-containing cream than placebo (one study, 129 participants, RR 1.28, 95% CI 1.06 to 1.53; low-quality evidence), with equal satisfaction between the two groups (one study, 38 participants, low-quality evidence). Urea-containing cream improved dryness (investigator-assessed) more frequently (one study, 128 participants, RR 1.40, 95% CI 1.14 to 1.71; moderate-quality evidence) with fewer flares (one study, 44 participants, RR 0.47, 95% CI 0.24 to 0.92; low-quality evidence), but more participants in this group reported adverse events (one study, 129 participants, RR 1.65, 95% CI 1.16 to 2.34; moderate-quality evidence).Three studies assessed glycerol-containing moisturiser versus vehicle or placebo. More participants in the glycerol group noticed skin improvement (one study, 134 participants, RR 1.22, 95% CI 1.01 to 1.48; moderate-quality evidence), and this group saw improved investigator-assessed SCORAD (one study, 249 participants, MD -2.20, 95% CI -3.44 to -0.96; high-quality evidence), but MID was unmet. Participant satisfaction was not addressed. The number of participants reporting adverse events was not statistically significant (two studies, 385 participants, RR 0.90, 95% CI 0.68 to 1.19; moderate-quality evidence).Four studies investigated oat-containing moisturisers versus no treatment or vehicle. No significant differences between groups were reported for participant-assessed disease severity (one study, 50 participants, RR 1.11, 95% CI 0.84 to 1.46; low-quality evidence), satisfaction (one study, 50 participants, RR 1.06, 95% CI 0.74 to 1.52; very low-quality evidence), and investigator-assessed disease severity (three studies, 272 participants, standardised mean difference (SMD) -0.23, 95% CI -0.66 to 0.21; low-quality evidence). In the oat group, there were fewer flares (one study, 43 participants, RR 0.31, 95% CI 0.12 to 0.7; low-quality evidence) and less topical corticosteroids needed (two studies, 222 participants, MD -9.30g, 95% CI 15.3 to -3.27; low-quality evidence), but more adverse events were reported (one study, 173 participants; Peto odds ratio (OR) 7.26, 95% CI 1.76 to 29.92; low-quality evidence).All moisturisers above were compared to placebo, vehicle, or no moisturiser. Participants considered moisturisers more effective in reducing eczema (five studies, 572 participants, RR 2.46, 95% CI 1.16 to 5.23; low-quality evidence) and itch (seven studies, 749 participants, SMD -1.10, 95% CI -1.83 to -0.38) than control. Participants in both treatment arms reported comparable satisfaction (three studies, 296 participants, RR 1.35, 95% CI 0.77 to 2.26; low-quality evidence). Moisturisers led to lower investigator-assessed disease severity (12 studies, 1281 participants, SMD -1.04, 95% CI -1.57 to -0.51; high-quality evidence) and fewer flares (six studies, 607 participants, RR 0.33, 95% CI 0.17 to 0.62; moderate-quality evidence), but there was no difference in adverse events (10 studies, 1275 participants, RR 1.03, 95% CI 0.82 to 1.30; moderate-quality evidence).Topical active treatment combined with moisturiser was more effective than active treatment alone in reducing investigator-assessed disease severity (three studies, 192 participants, SMD -0.87, 95% CI -1.17 to -0.57; moderate-quality evidence) and flares (one study, 105 participants, RR 0.43, 95% CI 0.20 to 0.93), and was preferred by participants (both low-quality evidence). There was no statistically significant difference in number of adverse events (one study, 125 participants, RR 0.39, 95% CI 0.13 to 1.19; very low-quality evidence). Participant-assessed disease severity was not addressed.

AUTHORS' CONCLUSIONS

Most moisturisers showed some beneficial effects, producing better results when used with active treatment, prolonging time to flare, and reducing the number of flares and amount of topical corticosteroids needed to achieve similar reductions in eczema severity. We did not find reliable evidence that one moisturiser is better than another.

Choice of Moisturiser for Eczema Treatment (COMET): feasibility study of a randomised controlled parallel group trial in children recruited from primary care

OBJECTIVES

To determine the feasibility of a randomised controlled trial of 'leave on' emollients for children with eczema.

DESIGN

Single-centre, pragmatic, 4-arm, observer-blinded, parallel, randomised feasibility trial.

SETTING

General practices in the UK.

PARTICIPANTS

Children with eczema aged 1 month to <5 years.

OUTCOME MEASURES

Primary outcome-proportion of parents who reported use of the allocated study emollient every day for the duration of follow-up (12 weeks). Other feasibility outcomes-participant recruitment and retention, data collection and completeness and blinding of observers to allocation.

INTERVENTIONS

Aveeno lotion, Diprobase cream, Doublebase gel, Hydromol ointment.

RESULTS

197 children were recruited-107 by self-referral (mainly via practice mail-outs) and 90 by inconsultation (clinician consenting and randomising) pathways. Participants recruited inconsultation were younger, had more severe Patient-Oriented Eczema Measure scores and were more likely to withdraw than self-referrals. Parents of 20 (10%) of all the randomised participants reported using the allocated emollient daily for 84 days. The use of other non-study emollients was common. Completeness of data collected by parent-held daily diaries and at monthly study visits was good. Daily diaries were liked (81%) but mainly completed on paper rather than via electronic ('app') form. Major costs drivers were general practitioner consultations and eczema-related prescriptions. Observer unblinding was infrequent, and occurred at the baseline or first follow-up visit through accidental disclosure.

CONCLUSIONS

It is feasible in a primary care setting to recruit and randomise young children with eczema to emollients, follow them up and collect relevant trial data, while keeping observers blinded to their allocation. However, reported use of emollients (study and others) has design implications for future trials.

TRIAL REGISTRATION NUMBER

ISRCTN21828118/EudraCT2013-003001-26.

Trying to understand the genetics of atopic dermatitis

Atopic dermatitis (AD) is a common and complex skin disease associated with both genetic and environmental factors. Loss-of-function mutations in the filaggrin gene, encoding a structural protein with an important role in epidermal barrier function, constitutes a well recognised susceptibility locus for AD. Further, genome-wide association studies (GWAS), including large meta-analyses, have discovered 38 additional susceptibility loci with genome-wide significance. However, the reported variations only explain a fraction of the overall heritability of AD. Here, we summarize the current knowledge of the role of filaggrin and the epidermal differentiation complex as well as the results of GWAS, with an emphasis on novel findings and observations made in the past two years. Additionally, we present first results of exome sequencing for AD and discuss novel therapeutic strategies.

A review on the role of moisturizers for atopic dermatitis

Effective management of atopic dermatitis (AD) involves the treatment of a defective skin barrier. Patients with AD are therefore advised to use moisturizers regularly. To date, there are few comparative studies involving moisturizers in patients with AD, and no classification system exists to objectively determine which types of moisturizers are best suited to specific AD phenotypes. With this in mind, a group of experts from allergy and immunology, adult and pediatric dermatology, and pediatrics centers within Southeast Asia met to review current data and practice, and to develop recommendations regarding the use of moisturizers in patients with AD within the Asia-Pacific region. Chronicity and severity of AD, along with patient age, treatment compliance, and economic background should all be taken into account when selecting an appropriate moisturizer for AD patients. Other considerations include adjuvant properties of the product, cosmetic acceptability, and availability over the counter. Well-defined clinical phenotypes of AD could optimally benefit from specific moisturizers. It is hoped that future studies may identify such differences by means of filaggrin mutation subtypes, confocal microscopic evaluation, pH, transepidermal water loss or presence of allergy specific IgE. Recommendations to improve the regular use of moisturizers among AD patients include measures that focus on treatment compliance, patient and caregiver education, appropriate treatment goals, avoidance of sensitizing agents, and collaboration with other relevant specialists.