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Chu V, Ong PY. Constant vigilance! Managing threats to the skin barrier. Ann Allergy Asthma Immunol 2024; 132:678-685. [PMID: 38360106 DOI: 10.1016/j.anai.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/02/2024] [Accepted: 02/02/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE Skin barrier defects are one of the primary causes of atopic dermatitis (AD). The basis of skin barrier defects in AD is due to a deficiency in various barrier proteins including filaggrin, involucrin, claudins, and lipids such as ceramide, fatty acids, and cholesterol. This review updates a more detailed lipid dysregulation in the skin barrier of AD based on recent lipidomic analysis. The clinical implications, treatments, prevention, and predictive capability of skin barrier defects are also reviewed. DATA SOURCES Published literature obtained through PubMed searches. STUDY SELECTIONS Studies relevant to the mechanisms, clinical implications, treatments, prevention, and predictors of AD development. RESULTS Skin barrier defects contribute to transepidermal water loss, infections, IgE sensitizations, and cutaneous inflammation in AD. Preventive treatments include daily hydration and application of moisturizers. Because skin barrier defects precede the development of AD, they provide an opportunity for prediction and intervention. CONCLUSION Skin barrier defects play an important role in the comorbidities of AD including infectious complications, disease flare, and allergic diathesis. Current research focuses on prevention and prediction of AD development.
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Affiliation(s)
- Vanessa Chu
- Department of Pediatrics, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Peck Y Ong
- Division of Clinical Immunology and Allergy, Children's Hospital Los Angeles, Los Angeles, California; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California.
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2
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Ousaaid D, Bakour M, Laaroussi H, El Ghouizi A, Lyoussi B, El Arabi I. Fruit vinegar as a promising source of natural anti-inflammatory agents: an up-to-date review. Daru 2024; 32:307-317. [PMID: 38040916 PMCID: PMC11087403 DOI: 10.1007/s40199-023-00493-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 11/14/2023] [Indexed: 12/03/2023] Open
Abstract
OBJECTIVES Fruit vinegar is one of the most famous fruit byproducts worldwide with several unique properties. There are two types of fruit vinegar, artisanal and industrial, for consumers to choose from. This review aims to assess for the first time the phytochemistry of fruit vinegar and its anti-inflammatory effects. METHOD The present work was conducted based on a literature search that selected the relevant papers from indexed databases such as Scopus, Science Direct, MDPI, PubMed, Hindawi, and Web of Science. We used numerous terms to assure a good search in different databases, including fruit vinegar, phytochemistry, bioavailability and bioaccessibility, and anti-inflammatory effect. All articles were selected based on their relevance, quality, and problematic treatment. RESULTS Literature data have shown that vinegar has a long medicinal history and has been widely used by different civilizations, due to its richness in bioactive molecules, vinegar plays an important role in the prevention and treatment of various inflammatory diseases, including atopic dermatitis, mastitis, asthma, arthritis, acute pancreatitis, and colitis. Fruit vinegar consumption benefit is highly dependent on its chemical composition, especially organic acids and antioxidants, which can act as nutraceuticals. CONCLUSION Fruit vinegar has a rich chemical composition, including organic acids that can be transformed in the digestive system into compounds that play an important role in health-promoting features such as anti-inflammatory effects throughout the control of intestinal microbiota and pro-inflammatory cytokine production.
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Affiliation(s)
- Driss Ousaaid
- Laboratory of Natural Substances, Pharmacology, Environment, Modeling, Health and Quality of Life (SNAMOPEQ), Faculty of Sciences Dhar El Mahraz, Sidi Mohamed Ben Abdellah University, Fez, 30000, Morocco.
| | - Meryem Bakour
- Laboratory of Natural Substances, Pharmacology, Environment, Modeling, Health and Quality of Life (SNAMOPEQ), Faculty of Sciences Dhar El Mahraz, Sidi Mohamed Ben Abdellah University, Fez, 30000, Morocco
| | - Hassan Laaroussi
- Laboratory of Natural Substances, Pharmacology, Environment, Modeling, Health and Quality of Life (SNAMOPEQ), Faculty of Sciences Dhar El Mahraz, Sidi Mohamed Ben Abdellah University, Fez, 30000, Morocco
| | - Asmae El Ghouizi
- Laboratory of Natural Substances, Pharmacology, Environment, Modeling, Health and Quality of Life (SNAMOPEQ), Faculty of Sciences Dhar El Mahraz, Sidi Mohamed Ben Abdellah University, Fez, 30000, Morocco
| | - Badiaa Lyoussi
- Laboratory of Natural Substances, Pharmacology, Environment, Modeling, Health and Quality of Life (SNAMOPEQ), Faculty of Sciences Dhar El Mahraz, Sidi Mohamed Ben Abdellah University, Fez, 30000, Morocco
| | - Ilham El Arabi
- Laboratory of Natural Substances, Pharmacology, Environment, Modeling, Health and Quality of Life (SNAMOPEQ), Faculty of Sciences Dhar El Mahraz, Sidi Mohamed Ben Abdellah University, Fez, 30000, Morocco
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3
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Chu DK, Schneider L, Asiniwasis RN, Boguniewicz M, De Benedetto A, Ellison K, Frazier WT, Greenhawt M, Huynh J, Kim E, LeBovidge J, Lind ML, Lio P, Martin SA, O'Brien M, Ong PY, Silverberg JI, Spergel JM, Wang J, Wheeler KE, Guyatt GH, Capozza K, Begolka WS, Chu AWL, Zhao IX, Chen L, Oykhman P, Bakaa L, Golden D, Shaker M, Bernstein JA, Greenhawt M, Horner CC, Lieberman J, Stukus D, Rank MA, Wang J, Ellis A, Abrams E, Ledford D, Chu DK. Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations. Ann Allergy Asthma Immunol 2024; 132:274-312. [PMID: 38108679 DOI: 10.1016/j.anai.2023.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Guidance addressing atopic dermatitis (AD) management, last issued in 2012 by the American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force, requires updating as a result of new treatments and improved guideline and evidence synthesis methodology. OBJECTIVE To produce evidence-based guidelines that support patients, clinicians, and other decision-makers in the optimal treatment of AD. METHODS A multidisciplinary guideline panel consisting of patients and caregivers, AD experts (dermatology and allergy/immunology), primary care practitioners (family medicine, pediatrics, internal medicine), and allied health professionals (psychology, pharmacy, nursing) convened, prioritized equity, diversity, and inclusiveness, and implemented management strategies to minimize influence of conflicts of interest. The Evidence in Allergy Group supported guideline development by performing systematic evidence reviews, facilitating guideline processes, and holding focus groups with patient and family partners. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach informed rating the certainty of evidence and strength of recommendations. Evidence-to-decision frameworks, subjected to public comment, translated evidence to recommendations using trustworthy guideline principles. RESULTS The panel agreed on 25 recommendations to gain and maintain control of AD for patients with mild, moderate, and severe AD. The eAppendix provides practical information and implementation considerations in 1-2 page patient-friendly handouts. CONCLUSION These evidence-based recommendations address optimal use of (1) topical treatments (barrier moisturization devices, corticosteroids, calcineurin inhibitors, PDE4 inhibitors [crisaborole], topical JAK inhibitors, occlusive [wet wrap] therapy, adjunctive antimicrobials, application frequency, maintenance therapy), (2) dilute bleach baths, (3) dietary avoidance/elimination, (4) allergen immunotherapy, and (5) systemic treatments (biologics/monoclonal antibodies, small molecule immunosuppressants [cyclosporine, methotrexate, azathioprine, mycophenolate, JAK inhibitors], and systemic corticosteroids) and UV phototherapy (light therapy).
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Affiliation(s)
- Derek K Chu
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University and The Research Institute of St. Joe's Hamilton, Hamilton, Canada.
| | - Lynda Schneider
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts.
| | | | - Mark Boguniewicz
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Division of Pediatric Allergy and Clinical Immunology, National Jewish Health, Denver, Colorado
| | - Anna De Benedetto
- Department of Dermatology, University of Rochester Medical Center, Rochester, New York
| | | | - Winfred T Frazier
- Department of Family Medicine, UPMC St. Margaret, Pittsburgh, Pennsylvania
| | - Matthew Greenhawt
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Section of Allergy and Immunology, Children's Hospital Colorado, Aurora, Colorado
| | - Joey Huynh
- Sepulveda VA Medical Center, North Hills, California
| | | | - Jennifer LeBovidge
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Mary Laura Lind
- School for Engineering of Matter, Transport and Energy, Arizona State University, Tempe, Arizona
| | - Peter Lio
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephen A Martin
- University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Monica O'Brien
- Tufts University School of Medicine, Boston, Massachusetts
| | - Peck Y Ong
- Division of Clinical Immunology and Allergy, Children's Hospital Los Angeles, Los Angeles, California; Department of Pediatrics, USC Keck School of Medicine, Los Angeles, California
| | - Jonathan I Silverberg
- Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Jonathan M Spergel
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Julie Wang
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Kathryn E Wheeler
- Department of Pediatrics, University of Florida, Gainesville, Florida
| | - Gordon H Guyatt
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University and The Research Institute of St. Joe's Hamilton, Hamilton, Canada
| | - Korey Capozza
- Global Parents for Eczema Research, Santa Barbara, California
| | | | - Alexandro W L Chu
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University and The Research Institute of St. Joe's Hamilton, Hamilton, Canada
| | - Irene X Zhao
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University and The Research Institute of St. Joe's Hamilton, Hamilton, Canada
| | - Lina Chen
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University and The Research Institute of St. Joe's Hamilton, Hamilton, Canada
| | - Paul Oykhman
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University and The Research Institute of St. Joe's Hamilton, Hamilton, Canada
| | - Layla Bakaa
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University and The Research Institute of St. Joe's Hamilton, Hamilton, Canada
| | - David Golden
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marcus Shaker
- Dartmouth Geisel School of Medicine and Dartmouth Hitchcock Medical Center, Section of Allergy, Lebanon, New Hampshire
| | | | - Matthew Greenhawt
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Section of Allergy and Immunology, Children's Hospital Colorado, Aurora, Colorado
| | - Caroline C Horner
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Jay Lieberman
- University of Tennessee Health Science Center and LeBonheur Children's Hospital, Memphis, Tennessee
| | - David Stukus
- Nationwide Children's Hospital and Ohio State University College of Medicine, Columbus, Ohio
| | - Matthew A Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, Arizona
| | - Julie Wang
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Anne Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Elissa Abrams
- Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dennis Ledford
- Morsani College of Medicine, University of South Florida and James A. Haley Veterans' Affairs Hospital, Tampa, Florida
| | - Derek K Chu
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University and The Research Institute of St. Joe's Hamilton, Hamilton, Canada
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Lapeere H, Speeckaert R, Baeck M, Dezfoulian B, Lambert J, Roquet-Gravy PP, Stockman A, White J, Castelijns F, Gutermuth J. Belgian atopic dermatitis guidelines. Acta Clin Belg 2024; 79:62-74. [PMID: 37997950 DOI: 10.1080/17843286.2023.2285576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 10/13/2023] [Indexed: 11/25/2023]
Abstract
Atopic dermatitis (AD) is one of the most common, bothersome and difficult to treat skin disorders. Recent introduction of new systemic treatments has revolutionized the management of AD. The goal of this guideline is to provide evidence-based recommendations for the management of patients suffering from atopic dermatitis that easily can be implemented in clinical practice. These recommendations were developed by 11 Belgian AD experts. Comments of all experts on the proposed statements were gathered, followed by an online voting session. The most relevant strategies for the management and treatment of AD in the context of the Belgian health care landscape are discussed. General measures, patient education and adequate topical treatment remain the cornerstones of AD management. For moderate to severe AD, the introduction of biologics and JAK inhibitors show unprecedented efficacy, although currently access is limited to a subgroup of patients meeting the reimbursement criteria.
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Affiliation(s)
- Hilde Lapeere
- Department of Dermatology, Ghent University Hospital, Ghent, Belgium
| | | | - Marie Baeck
- Department of Dermatology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Bita Dezfoulian
- Department of Dermatology, Liège University Hospital, Liège, Belgium
| | - Julien Lambert
- Department of Dermatology, University Hospital Antwerp (UZA), Edegem, Belgium
| | | | - Annelies Stockman
- Department of Dermatology, AZ Delta campus Rembert Torhout, Torhout, Belgium
| | - Jonathan White
- Department of Dermatology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Jan Gutermuth
- Vrije Universiteit Brussel (VUB), Department of Dermatology, Universitair Ziekenhuis Brussel, Brussels, Belgium
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5
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Pagliaro M, Pecoraro L, Stefani C, Pieropan S, Piacentini G, Pietrobelli A. Bathing in Atopic Dermatitis in Pediatric Age: Why, How and When. Pediatr Rep 2024; 16:57-68. [PMID: 38251315 PMCID: PMC10801494 DOI: 10.3390/pediatric16010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/06/2023] [Accepted: 01/03/2024] [Indexed: 01/23/2024] Open
Abstract
Atopic dermatitis is a chronic inflammatory skin disease. The treatment plays an important role in influencing the patients' quality of life. The basic management consists of appropriate skin cleansing, including bathing and eventually using bathing additives. Recommendations regarding frequency and duration of bathing, water temperature and usefulness of bathing additives are widely different, often leading to confusion among patients. This review aims to give insights into the best bathing practices and the use of bathing additives in atopic dermatitis in children. Several bathing additives, including bleach baths, commercial baby cleansers, bath baby oils and bath salt, appear to be promising adjunctive therapies for atopic dermatitis due to their anti-inflammatory, anti-bacterial, anti-pruritus and skin barrier repair properties through different mechanisms of action. However, their efficacy and safety are not fully understood in some cases. The usefulness of other bath additives, such as acidic and more natural substances (green tea extracts, pine tar, sodium bicarbonate), is still under investigation. Further studies are needed to determine their optimal use to achieve clinical benefit safely.
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Affiliation(s)
- Margherita Pagliaro
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, 37126 Verona, Italy (C.S.); (A.P.)
| | - Luca Pecoraro
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, 37126 Verona, Italy (C.S.); (A.P.)
| | - Camilla Stefani
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, 37126 Verona, Italy (C.S.); (A.P.)
| | - Sara Pieropan
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, 37126 Verona, Italy (C.S.); (A.P.)
| | - Giorgio Piacentini
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, 37126 Verona, Italy (C.S.); (A.P.)
| | - Angelo Pietrobelli
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, 37126 Verona, Italy (C.S.); (A.P.)
- Pennington Biomedical Research Center, Baton Rouge, LA 70808, USA
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6
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Banovic F, Reno L, Lawhon SD, Wu J, Hoffmann AR. Tolerability and the effect on skin Staphylococcus pseudintermedius density of repeated diluted sodium hypochlorite (bleach) baths at 0.005% in healthy dogs. Vet Dermatol 2023; 34:489-494. [PMID: 37357372 DOI: 10.1111/vde.13186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/24/2023] [Accepted: 03/29/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Dilute sodium hypochlorite (bleach) baths at 0.005% concentration twice weekly have been shown to markedly reduce the severity of atopic dermatitis in children, yet no tolerability and efficacy data are available for this treatment in dogs. OBJECTIVES To determine the local tolerability and the longitudinal effect on the density of Staphylococcus pseudintermedius of repeated diluted bleach baths on healthy dog skin. ANIMALS Four healthy hound cross-bred dogs. METHODS Bleach baths (0.005%; twice weekly for 15 min) were applied to four healthy hound cross-bred dogs over four weeks (eight baths). Local tolerability was assessed for axillae, abdomen and legs by an investigator before, immediately after and 24 h after each bath. The longitudinal effect on density of S. pseudintermedius from axillae and groin was analysed through quantitative PCR before treatment [at Day (D)-7 and -3], during treatment on D4, D11 and D25, and on D30. RESULTS There was no erythema or scaling after the baths in any dog. Copy numbers of S. pseudintermedius in axillae, groin and both (axillae and groin together) were not significantly different at any time point during the study. CONCLUSIONS AND CLINICAL RELEVANCE Repeated 0.005% hypochlorite bleach baths over four weeks were safe and well-tolerated in healthy dogs without significant changes in the density of S. pseudintermedius.
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Affiliation(s)
- Frane Banovic
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Lisa Reno
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Sara D Lawhon
- Departments of Veterinary Pathobiology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Jing Wu
- Departments of Veterinary Pathobiology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Aline Rodrigues Hoffmann
- Departments of Veterinary Pathobiology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
- Department of Comparative, Diagnostic and Population Medicine, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
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7
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Stolarczyk A, Perez-Nazario N, Knowlden SA, Chinchilli E, Grier A, Paller A, Gill SR, De Benedetto A, Yoshida T, Beck LA. Bleach baths enhance skin barrier, reduce itch but do not normalize skin dysbiosis in atopic dermatitis. Arch Dermatol Res 2023; 315:2883-2892. [PMID: 37755506 PMCID: PMC10615920 DOI: 10.1007/s00403-023-02723-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/02/2023] [Accepted: 09/06/2023] [Indexed: 09/28/2023]
Abstract
Studies have demonstrated that bleach baths improve atopic dermatitis (AD) severity; however, the effects on itch, skin barrier, and cutaneous microbial composition are less clear. We examined whether bleach baths reduce itch, normalize skin barrier function, reduce S. aureus absolute abundance, and increase microbial diversity in adults with AD who were colonized with S. aureus on their non-lesional skin. This was an open label, non-randomized, controlled trial performed at a single academic center. Fifteen AD and five non-atopic healthy controls (NA) were instructed to take two bleach baths (0.005% NaClO; 5-10 min duration) per week for a total of 12 weeks as add-on therapy. Adults 18 to 65 years (inclusive) with mild to severe AD were recruited with EASI score > 6.0, S. aureus culture positivity, access to a bathtub, and ability and willingness to maintain current topical or systemic treatments. They were evaluated at baseline (before bleach baths), 6 weeks, and 12 weeks after the intervention of twice-weekly bleach baths. Efficacy measurements included EASI as well as 5-D Pruritus and ItchyQoL™. Transepidermal water loss (TEWL) and stratum corneum (SC) integrity assay were performed to assess the skin barrier. Skin dysbiosis was measured by S. aureus cultivation, S. aureus abundance (qPCR of thermonuclease gene), and V1-V3 16S rRNA gene sequencing on non-lesional and lesional AD skin. After 12 weeks of bleach baths, 8/15 (53.3%) AD subjects achieved an EASI50 and a significant reduction in itch as measured by 5-D pruritus and Itchy QoL. Eighty-seven percent reported improvements in sleep quality. At study entry, AD subjects had higher non-lesional TEWL values than NA subjects, and only AD subjects experienced a reduction with bleach baths (p = 0.006). Similarly, SC integrity improved as early as 6 weeks after bleach baths in AD subjects. Notably, bleach baths had no significant effect on S. aureus culture-positivity, qPCR absolute abundance, or microbial diversity. The addition of twice-weekly bleach baths improves investigator-assessed AD severity, patient-reported pruritus and sleep as well as physiological measures of skin barrier function in adult AD subjects while having no effect on qualitative and quantitative measures of cutaneous S. aureus. Trial Registration: ClinicalTrials.gov Identifier: NCT01996150, Date of registration: November 27th, 2013.
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Affiliation(s)
- Ania Stolarczyk
- Department of Dermatology, University of Rochester Medical Center, 601 Elmwood Ave, Box 697, Rochester, NY, 14642, USA
| | - Nelissa Perez-Nazario
- Department of Dermatology, University of Rochester Medical Center, 601 Elmwood Ave, Box 697, Rochester, NY, 14642, USA
| | - Sara A Knowlden
- Department of Dermatology, University of Rochester Medical Center, 601 Elmwood Ave, Box 697, Rochester, NY, 14642, USA
| | - Ellen Chinchilli
- Department of Dermatology, University of Rochester Medical Center, 601 Elmwood Ave, Box 697, Rochester, NY, 14642, USA
| | - Alex Grier
- University of Rochester Genomics Research Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Amy Paller
- Department of Dermatology, Northwestern University, Chicago, IL, USA
| | - Steven R Gill
- University of Rochester Genomics Research Center, University of Rochester Medical Center, Rochester, NY, USA
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, NY, USA
| | - Anna De Benedetto
- Department of Dermatology, University of Rochester Medical Center, 601 Elmwood Ave, Box 697, Rochester, NY, 14642, USA
| | - Takeshi Yoshida
- Department of Dermatology, University of Rochester Medical Center, 601 Elmwood Ave, Box 697, Rochester, NY, 14642, USA
| | - Lisa A Beck
- Department of Dermatology, University of Rochester Medical Center, 601 Elmwood Ave, Box 697, Rochester, NY, 14642, USA.
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8
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Kakkar V, Saini K, Singh KK. Challenges of current treatment and exploring the future prospects of nanoformulations for treatment of atopic dermatitis. Pharmacol Rep 2023; 75:1066-1095. [PMID: 37668937 PMCID: PMC10539427 DOI: 10.1007/s43440-023-00510-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 09/06/2023]
Abstract
Atopic dermatitis (AD) is a predominant and deteriorating chronic inflammation of the skin, categorized by a burning sensation and eczematous lesions in diverse portions of the body. The treatment of AD is exclusively focused to limit the itching, reduce inflammation, and repair the breached barrier of the skin. Several therapeutic agents for the treatment and management of AD have been reported and are in use in clinics. However, the topical treatment of AD has been an unswerving challenge for the medical fraternity owing to the impaired skin barrier function in this chronic skin condition. To surmount the problems of conventional drug delivery systems, numerous nanotechnology-based formulations are emerging as alternative new modalities for AD. Latter enhances the bioavailability and delivery to the target disease site, improves drug permeation and therapeutic efficacy with reduced systemic and off-target side effects, and thus improves patient health and promotes compliance. This review aims to describe the various pathophysiological events involved in the occurrence of AD, current challenges in treatment, evidence of molecular markers of AD and its management, combinatorial treatment options, and the intervention of nanotechnology-based formulations for AD therapeutics.
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Affiliation(s)
- Vandita Kakkar
- Department of Pharmaceutics, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, 160014, India.
| | - Komal Saini
- Department of Pharmaceutics, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, 160014, India
- School of Pharmacy and Biomedical Sciences, Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston, PR1 2HE, Lancashire, UK
| | - Kamalinder K Singh
- School of Pharmacy and Biomedical Sciences, Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston, PR1 2HE, Lancashire, UK.
- UCLan Research Centre for Smart Materials, University of Central Lancashire, Preston, PR1 2HE, Lancashire, UK.
- UCLan Research Centre for Translational Biosciences and Behaviour, University of Central Lancashire, Preston, PR1 2HE, Lancashire, UK.
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9
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Bromfield JI, Hugenholtz P, Frazer IH, Khosrotehrani K, Chandra J. Targeting Staphylococcus aureus dominated skin dysbiosis in actinic keratosis to prevent the onset of cutaneous squamous cell carcinoma: Outlook for future therapies? Front Oncol 2023; 13:1091379. [PMID: 36816953 PMCID: PMC9933124 DOI: 10.3389/fonc.2023.1091379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/17/2023] [Indexed: 02/05/2023] Open
Abstract
Cutaneous squamous cell carcinoma (cSCC) and its premalignant precursor, actinic keratosis (AK), present a global health burden that is continuously increasing despite extensive efforts to promote sun safety. Chronic UV exposure is a recognized risk factor for the development of AK and cSCC. However, increasing evidence suggests that AK and cSCC is also associated with skin microbiome dysbiosis and, in particular, an overabundance of the bacterium Staphylococcus aureus (S. aureus). Studies have shown that S. aureus-derived toxins can contribute to DNA damage and lead to chronic upregulation of proinflammatory cytokines that may affect carcinogenesis. Eradication of S. aureus from AK lesions and restoration of a healthy microbiome may therefore represent a therapeutic opportunity to alter disease progression. Whilst antibiotics can reduce the S. aureus load, antibiotic resistant S. aureus pose an increasing global public health threat. The use of specific topically delivered probiotics has been used experimentally in other skin conditions to restore eubiosis, and could therefore also present a non-invasive treatment approach to decrease S. aureus colonization and restore a healthy skin microbiome on AK lesions. This article reviews mechanisms by which S. aureus may contribute to cutaneous carcinogenesis, and discusses hypotheses and theories that explore the therapeutic potential of specific bacterial species which compete with S. aureus in an attempt to restore microbial eubiosis in skin.
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Affiliation(s)
| | - Philip Hugenholtz
- Australian Centre for Ecogenomics, The University of Queensland, St. Lucia, QLD, Australia,School of Chemistry and Molecular Biosciences, The University of Queensland, St. Lucia, QLD, Australia
| | - Ian Hector Frazer
- Frazer Institute, Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia
| | - Kiarash Khosrotehrani
- Frazer Institute, Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia,Department of Dermatology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Janin Chandra
- Frazer Institute, Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia,*Correspondence: Janin Chandra,
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10
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Ong PY, Boguniewicz J, Chu DK. Skin Antiseptics for Atopic Dermatitis: Dissecting Facts From Fiction. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1385-1390. [PMID: 36702247 DOI: 10.1016/j.jaip.2023.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/05/2023] [Accepted: 01/10/2023] [Indexed: 01/24/2023]
Abstract
Staphylococcus aureus is a known trigger and cause of infectious complications in atopic dermatitis (AD). Various antiseptics have been used in an attempt to decrease the burden of S. aureus in AD. In this Commentary, we present the evidence for and against some of the commonly used antiseptics in clinical and research settings. These agents remain attractive as an adjunct therapy for AD owing to their relative low cost and potential benefits of reducing S. aureus. Although a number of studies have evaluated the use of dilute bleach, its mechanisms remain controversial. A higher concentration of bleach than the commonly used 0.005% is likely needed for its anti-S. aureus effect. Silver-coated textiles have demonstrated anti-S. aureus effects in various studies; however, their efficacy and side effects in AD remain to be confirmed. Other antiseptics including chlorhexidine, triclosan, and triclocarban are also discussed. Variables that may affect the outcomes of these studies include length of use, concurrent application of moisturizers, and anti-inflammatory medications.
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Affiliation(s)
- Peck Y Ong
- Division of Clinical Immunology and Allergy, Children's Hospital Los Angeles, Los Angeles, Calif; Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, Calif.
| | - Juri Boguniewicz
- Section of Infectious Diseases, Children's Hospital Colorado, Aurora, Colo; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Derek K Chu
- Department of Medicine, Evidence in Allergy Group, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada
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11
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Tamai M, Yamazaki Y, Ito T, Nakagawa S, Nakamura Y. Pathogenic role of the staphylococcal accessory gene regulator quorum sensing system in atopic dermatitis. Front Cell Infect Microbiol 2023; 13:1178650. [PMID: 37124047 PMCID: PMC10140505 DOI: 10.3389/fcimb.2023.1178650] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/03/2023] [Indexed: 05/02/2023] Open
Abstract
The skin is home to various bacteria, archaea, fungi, and viruses, collectively referred to as the skin microbiota. Patients with certain skin diseases reportedly have unique skin "dysbiosis," a condition involving imbalanced microbiota, suggesting that dysbiosis in the skin may be either causal or a consequence of specific skin diseases. Atopic dermatitis (AD) is the most common allergic skin disease that affects 15-20% of children and 2-10% of adults worldwide. Both intrinsic genetic factors, such as susceptibility to type 2 inflammation or skin barrier dysfunction, and extrinsic environmental factors, such as air pollen and skin microbiota, contribute to AD. Staphylococcus aureus, which does not often colonize the skin of healthy individuals, is commonly identified in the lesional skin of patients with AD and is correlated with the disease flare. However, the role of S. aureus in the pathogenesis of AD has not been elucidated. Here, we discuss the pathological behavior of S. aureus, focusing on accessory gene regulator (Agr) quorum sensing, which is a fundamental bacterial cell-to-cell interaction mechanism that affects the behavior of S. aureus and other members of the microbial community. Importantly, beyond bacteria-bacteria interactions, the Agr quorum sensing system also regulates various virulence factors, which induce type 2 and IL-17-dependent skin inflammation in the host. Furthermore, the colonization of Agr-positive S. aureus in early life accelerates the development of pediatric AD. Finally, we aim to highlight the current efforts to establish novel therapeutic methods to ameliorate or prevent AD through Agr-targeted intervention.
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Affiliation(s)
- Masakazu Tamai
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuriko Yamazaki
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, Japan
- Cutaneous Allergy and Host Defense, Immunology Frontier Research Center, Osaka University, Osaka, Japan
- *Correspondence: Yuumi Nakamura, ; Yuriko Yamazaki,
| | - Tomoka Ito
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Seitaro Nakagawa
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, Japan
- Department of Pathology and Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Yuumi Nakamura
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, Japan
- Cutaneous Allergy and Host Defense, Immunology Frontier Research Center, Osaka University, Osaka, Japan
- *Correspondence: Yuumi Nakamura, ; Yuriko Yamazaki,
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12
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Fatani MI, Al Sheikh AA, Alajlan MA, Alharithy RS, Binamer Y, Albarakati RG, Alenzi KA, Khardaly AM, Alomari BA, Almudaiheem HY, Al-Jedai A, Eshmawi MT. National Saudi Consensus Statement on the Management of Atopic Dermatitis (2021). Dermatol Ther (Heidelb) 2022; 12:1551-1575. [PMID: 35788543 PMCID: PMC9252549 DOI: 10.1007/s13555-022-00762-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/15/2022] [Indexed: 11/26/2022] Open
Abstract
Atopic dermatitis (AD) is a chronic inflammatory skin disease with an increasing prevalence regionally and globally. It is characterized by intense itching and recurrent eczematous lesions. With the increase in the availability of treatment options for healthcare practitioner and patients, new challenges arise for treatment selection and approach. The current consensus statement has been developed to provide up-to-date evidence and evidence-based recommendations to guide dermatologists and healthcare professionals managing patients with AD in Saudi Arabia. By an initiative from the Ministry of Health (MOH), a multidisciplinary work group of 11 experts was convened to review and discuss aspects of AD management. Four consensus meetings were held on January 14, February 4, February 25, and March 18 of 2021. All consensus content was voted on by the work group, including diagnostic criteria, AD severity assessment, comorbidities, and therapeutic options for AD. Special consideration for the pediatric population, as well as women during pregnancy and lactation, was also discussed. The present consensus document will be updated as needed to incorporate new data or therapeutic agents.
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Affiliation(s)
| | - Afaf A Al Sheikh
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdulaziz Medical City (National Guard Health Affairs), Riyadh, Saudi Arabia
| | | | - Ruaa S Alharithy
- Princess Nourah Bint Abdul Rahman University, Riyadh, Saudi Arabia
- Security Forces Hospital, Riyadh, Saudi Arabia
| | - Yousef Binamer
- King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | | | - Khalidah A Alenzi
- Regional Drug Information and Pharmacovigilance Center, Ministry of Health, Tabuk, Saudi Arabia
| | - Amr M Khardaly
- Deputyship of Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia
| | | | | | - Ahmed Al-Jedai
- Deputyship of Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia
| | - Maysa T Eshmawi
- King Abdullah Medical Complex, Prince Nayef Street, Northern Abhor, Jeddah, 23816, Saudi Arabia.
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13
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Paller AS, Beck LA. Bleach baths for atopic dermatitis: Evidence of efficacy but more data are needed. Ann Allergy Asthma Immunol 2022; 128:617-618. [PMID: 35618389 DOI: 10.1016/j.anai.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 03/08/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Amy S Paller
- Departments of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Lisa A Beck
- Departments of Dermatology, Medicine, and Pathology, University of Rochester School of Medicine, Rochester, New York
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14
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Bakaa L, Pernica JM, Couban RJ, Tackett KJ, Burkhart CN, Leins L, Smart J, Garcia-Romero MT, Elizalde-Jiménez IG, Herd M, Asiniwasis RN, Boguniewicz M, De Benedetto A, Chen L, Ellison K, Frazier W, Greenhawt M, Huynh J, LeBovidge J, Lind ML, Lio P, O'Brien M, Ong PY, Silverberg JI, Spergel JM, Wang J, Begolka WS, Schneider L, Chu DK. Bleach baths for atopic dermatitis: A systematic review and meta-analysis including unpublished data, Bayesian interpretation, and GRADE. Ann Allergy Asthma Immunol 2022; 128:660-668.e9. [PMID: 35367346 DOI: 10.1016/j.anai.2022.03.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/22/2022] [Accepted: 03/24/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Bleach bathing is frequently recommended to treat atopic dermatitis (AD), but its efficacy and safety are uncertain. OBJECTIVE To systematically synthesize randomized controlled trials (RCTs) addressing bleach baths for AD. METHODS We searched MEDLINE, EMBASE, CENTRAL, and GREAT from inception to December 29, 2021, for RCTs assigning patients with AD to bleach vs no bleach baths. Paired reviewers independently and in duplicate screened records, extracted data, and assessed risk of bias (Cochrane version 2) and GRADE quality of evidence. We obtained unpublished data, harmonized individual patient data and did Frequentist and Bayesian random-effects meta-analyses. RESULTS There were 10 RCTs that enrolled 307 participants (median of mean age 7.2 years, Eczema Area Severity Index baseline mean of means 27.57 [median SD, 10.74]) for a median of 6 weeks (range, 4-10). We confirmed that other trials registered globally were terminated. Bleach baths probably improve AD severity (22% vs 32% improved Eczema Area Severity Index by 50% [ratio of means 0.78, 95% credible interval 0.59-0.99]; moderate certainty) and may slightly reduce skin Staphylococcal aureus colonization (risk ratio, 0.89 [95% confidence interval, 0.73-1.09]; low certainty). Adverse events, mostly dry skin and irritation, along with itch, patient-reported disease severity, sleep quality, quality of life, and risk of AD flares were not clearly different between groups and of low to very low certainty. CONCLUSION In patients with moderate-to-severe AD, bleach baths probably improve clinician-reported severity by a relative 22%. One in 10 will likely improve severity by 50%. Changes in other patient-important outcomes are uncertain. These findings support optimal eczema care and the need for additional large clinical trials. TRIAL REGISTRATION PROSPERO Identifier: CRD42021238486.
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Affiliation(s)
- Layla Bakaa
- Evidence in Allergy Group, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey M Pernica
- Department of Pediatrics, Division of Infectious Diseases, McMaster University, Hamilton, Ontario, Canada
| | - Rachel J Couban
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Kelly Jo Tackett
- Department of Dermatology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Craig N Burkhart
- Department of Dermatology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Liz Leins
- Royal Children's Hospital, Allergy & Immunology, Victoria, Australia
| | - Joanne Smart
- Royal Children's Hospital, Allergy & Immunology, Victoria, Australia
| | | | - Itzel Guadalupe Elizalde-Jiménez
- Department of Dermatology, National Institute of Pediatrics, Mexico City, Mexico; Ministry of Health, General Directorate of Quality and Education of Health, Mexico City, Mexico
| | - Michael Herd
- Paediatric Department, Waitakere Hospital, Waitemata District Health Board, Auckland, New Zealand; Current location: Paediatric Department, Whakatane Hospital Bay of Plenty District Health Board, Whakatane, New Zealand
| | | | | | | | - Lina Chen
- University of Ottawa, Ottawa, Ontario, Canada
| | | | - Winfred Frazier
- Department of Family Medicine, UPMC St. Margaret, Pittsburgh, Pennsylvania
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Joey Huynh
- Orthopedic Neurological Rehabilitation, Northridge, California
| | - Jennifer LeBovidge
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Mary Laura Lind
- School for Engineering of Matter, Transport and Energy, Arizona State University, Tempe, Arizona
| | - Peter Lio
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Monica O'Brien
- Tufts University School of Medicine, Boston, Massachusetts. Medical Student, Class of 2025
| | - Peck Y Ong
- Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, California
| | - Jonathan I Silverberg
- Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Jonathan M Spergel
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York City, New York
| | | | - Lynda Schneider
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Derek K Chu
- Evidence in Allergy Group, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada.
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15
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Butala S, Paller AS. Optimizing topical management of atopic dermatitis. Ann Allergy Asthma Immunol 2022; 128:488-504. [PMID: 35288275 DOI: 10.1016/j.anai.2022.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 03/03/2022] [Accepted: 03/03/2022] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Provide a review of atopic dermatitis management, focusing on optimizing topical therapy, creating a stepwise approach for treatment plans, and providing guidance on when to start systemic therapy. DATA SOURCES PubMed search of articles in the English language regarding atopic dermatitis in all ages. STUDY SELECTION Articles on the subject matter were selected and reviewed. RESULTS Topical corticosteroids are the first-line treatment for managing atopic dermatitis. Topical nonsteroidal agents, calcineurin inhibitors, crisaborole, and recently, ruxolitinib, which cause no cutaneous atrophy, are options for reducing the use of topical corticosteroids, including on sensitive sites. Emerging topical agents are in clinical trials. Proactive management, with continued application 2 to 3 times weekly of a midpotency topical corticosteroid or tacrolimus, may maintain control for clear (or almost clear) localized sites of dermatitis that rapidly recur when topical anti-inflammatory medication is stopped. If topical therapy alone cannot control disease and quality of life is impacted, reevaluation to confirm the diagnosis, manage comorbid conditions, address compliance and patient-specific concerns, and optimize topical therapy must be undertaken before deciding to advance to systemic medication. Dupilumab, an interleukin-4 receptor inhibitor, has become first-line systemic therapy given its efficacy and safety, allowing long-term treatment without laboratory monitoring. Other biologics and Janus kinase inhibitors are emerging as alternatives that could eliminate the need for immunosuppressants with their higher risks. CONCLUSION Several options are now available for topical treatment. A stepwise approach is needed to consider alternative therapies and diagnoses before advancing to systemic treatment, but the safety of newer immunomodulators will lower the threshold for more aggressive intervention.
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Affiliation(s)
- Sneha Butala
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Amy S Paller
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
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16
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Miyano T, Irvine AD, Tanaka RJ. Model-based meta-analysis to optimise S. aureus-targeted therapies for atopic dermatitis. JID INNOVATIONS 2022; 2:100110. [PMID: 35757782 PMCID: PMC9214323 DOI: 10.1016/j.xjidi.2022.100110] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/18/2022] [Accepted: 01/25/2022] [Indexed: 11/29/2022] Open
Abstract
Several clinical trials of Staphylococcus aureus (S. aureus)‒targeted therapies for atopic dermatitis (AD) have shown conflicting results about whether they improve AD severity scores. This study performs a model-based meta-analysis to investigate the possible causes of these conflicting results and suggests how to improve the efficacies of S. aureus‒targeted therapies. We developed a mathematical model that describes systems-level AD pathogenesis involving dynamic interactions between S. aureus and coagulase-negative Staphylococcus (CoNS). Our model simulation reproduced the clinically observed detrimental effects of the application of S. hominis A9 and flucloxacillin on AD severity and showed that these effects disappeared if the bactericidal activity against CoNS was removed. A hypothetical (modeled) eradication of S. aureus by 3.0 log10 colony-forming unit per cm2 without killing CoNS achieved Eczema Area and Severity Index 75 comparable with that of dupilumab. This efficacy was potentiated if dupilumab was administered in conjunction with S. aureus eradication (Eczema Area and Severity Index 75 at week 16) (S. aureus eradication: 66.7%, dupilumab 61.6% and combination 87.8%). The improved efficacy was also seen for virtual dupilumab poor responders. Our model simulation suggests that killing CoNS worsens AD severity and that S. aureus‒specific eradication without killing CoNS could be effective for patients with AD, including dupilumab poor responders. This study will contribute to designing promising S. aureus‒targeted therapy.
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Affiliation(s)
- Takuya Miyano
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Alan D. Irvine
- Pediatric Dermatology, Children’s Health Ireland at Crumlin, Dublin, Ireland
- Clinical Medicine, College of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Reiko J. Tanaka
- Department of Bioengineering, Imperial College London, London, United Kingdom
- Correspondence: Reiko J. Tanaka, Department of Bioengineering, Imperial College London, South Kensington Campus, London SW7 2AZ, United Kingdom.
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17
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Nanamori H, Sawada Y. Epigenetic Modification of PD-1/PD-L1-Mediated Cancer Immunotherapy against Melanoma. Int J Mol Sci 2022; 23:ijms23031119. [PMID: 35163049 PMCID: PMC8835029 DOI: 10.3390/ijms23031119] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/10/2022] [Accepted: 01/19/2022] [Indexed: 02/06/2023] Open
Abstract
Malignant melanoma is one of the representative skin cancers with unfavorable clinical behavior. Immunotherapy is currently used for the treatment, and it dramatically improves clinical outcomes in patients with advanced malignant melanoma. On the other hand, not all these patients can obtain therapeutic efficacy. To overcome this limitation of current immunotherapy, epigenetic modification is a highlighted issue for clinicians. Epigenetic modification is involved in various physiological and pathological conditions in the skin. Recent studies identified that skin cancer, especially malignant melanoma, has advantages in tumor development, indicating that epigenetic manipulation for regulation of gene expression in the tumor can be expected to result in additional therapeutic efficacy during immunotherapy. In this review, we focus on the detailed molecular mechanism of epigenetic modification in immunotherapy, especially anti-PD-1/PD-L1 antibody treatment for malignant melanoma.
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Abstract
The skin microbiome is a key component of pathogenesis in atopic dermatitis (AD). The skin of AD patients is characterized by microbial dysbiosis, with a reduction of microbial diversity and overrepresentation of pathogenic Staphylococcus aureus (S. aureus). Recent exciting studies have elucidated an importance of establishing an appropriate immune response to microbes in early life and uncovered the new mechanisms of microbial community dynamics in modulating our skin microbiome. Several microbes are associated with AD pathogenesis, with proposed pathogenic effects from S. aureus and Malassezia. The complex relationships between microbes within the skin microbiome consortia includes various species, such as Staphylococcal, Roseomonas and Cutibacterium strains, that can inhibit S. aureus and are potential probiotics for AD skin. Numerous microbes are now also reported to modulate host response via communication with keratinocytes, specialized immune cells and adipocytes to improve skin health and barrier function. This increased understanding of skin microbiota bioactives has led to new biotherapeutic approaches that target the skin surface microenvironment for AD treatment.
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19
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De A, Sharma N, Dhar S, Godse K, Krupa Shankar DS, Zawar V, Girdhar M, Shah B. Use of bleach baths for atopic dermatitis: An Indian perspective. Indian J Dermatol 2022; 67:273-278. [PMID: 36386066 PMCID: PMC9644761 DOI: 10.4103/ijd.ijd_536_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Atopic dermatitis (AD) is a chronic, relapsing inflammatory skin disorder affecting 15–20% of children and 1–10% of adults. Staphylococcus aureus (S. aureus) infection is the most frequent complication of AD and is involved in the worsening of the disease. Systemic and topical antibiotics are used in the treatment for AD but there are concerns over increasing resistance. Bleach (sodium hypochlorite, NaOCl) baths are an inexpensive, widely accessible, alternative antibiotic treatment that may not worsen antibiotic resistance. Bleach baths are used as adjunctive treatment in AD patients to treat superinfections, although their mechanism of action is not well understood. Balancing safety concerns with efficacious treatment should be important especially for AD where the majority of patients are in pediatrics age groups. Studies available in PubMed databases were included in this review. Most suggested bleach bath improves clinical symptoms of AD and restores surface microbiome by eradicating bacteria, most notably S. aureus. Some studies have noted that this antimicrobial effect has reduced the need for topical corticosteroids. In addition, bleach seems to have strong anti-inflammatory and antipruritic effects. Overall, bleach baths seem to be safe on human skin, without disrupting the epidermal barrier function. The review concluded, although there are some advantages of use of bleach baths, more studies to investigate long-term efficacy and safety of bleach baths are required before fixing its role in the treatment of AD especially in the context of the Indian scenario.
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20
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Epigenetics of Cutaneous Sarcoma. Int J Mol Sci 2021; 23:ijms23010422. [PMID: 35008848 PMCID: PMC8745302 DOI: 10.3390/ijms23010422] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/25/2021] [Accepted: 12/28/2021] [Indexed: 12/13/2022] Open
Abstract
Epigenetic changes influence various physiological and pathological conditions in the human body. Recent advances in epigenetic studies of the skin have led to an appreciation of the importance of epigenetic modifications in skin diseases. Cutaneous sarcomas are intractable skin cancers, and there are no curative therapeutic options for the advanced forms of cutaneous sarcomas. In this review, we discuss the detailed molecular effects of epigenetic modifications on skin sarcomas, such as dermatofibrosarcoma protuberans, angiosarcoma, Kaposi's sarcoma, leiomyosarcoma, and liposarcoma. We also discuss the application of epigenetic-targeted therapy for skin sarcomas.
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21
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Narla S, Silverberg JI. Dermatology for the internist: optimal diagnosis and management of atopic dermatitis. Ann Med 2021; 53:2165-2177. [PMID: 34787024 PMCID: PMC8604464 DOI: 10.1080/07853890.2021.2004322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/02/2021] [Indexed: 11/29/2022] Open
Abstract
Internists are front-line health care providers that commonly provide the first encounter to patients for dermatological conditions, especially atopic dermatitis (AD). Internists need to be comfortable with managing mild-moderate AD in their practices. Criteria and guidelines established in dermatology literature are available to help the general practitioner diagnose and treat AD. AD is a systemic disease associated with multiple cutaneous and extra-cutaneous comorbidities that warrant screening by internists, especially mental health conditions. Environmental factors may play a role in the development or worsening of AD; however, there is currently no strong evidence to guide specific population- or clinic-based interventions for their avoidance. While food allergies are common in AD patients, the role of food allergens as an exacerbating factor for AD is controversial. Before starting any dietary modifications, careful evaluation should be performed by an allergist. If the patient is not well-controlled despite adequate topical therapies or is experiencing severe/worsening disease, early referral to dermatology is warranted to rule out confounding diagnoses and/or escalation to systemic therapies. Finally, it is important to recognise the racial disparities present in AD and address these when formulating treatment plans.Key messages:Confounding dermatoses, either instead of or in addition to AD, should be considered in treatment-refractory AD, and the appropriate workup may be initiated while awaiting dermatology referral.AD patients have multiple cutaneous and extra-cutaneous comorbidities that warrant screening by internists, especially mental health conditions.
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Affiliation(s)
- Shanthi Narla
- Department of Dermatology, St. Luke’s University Health Network, Easton, PA, USA
| | - Jonathan I. Silverberg
- Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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22
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Hülpüsch C, Weins AB, Traidl‐Hoffmann C, Reiger M. A new era of atopic eczema research: Advances and highlights. Allergy 2021; 76:3408-3421. [PMID: 34407212 DOI: 10.1111/all.15058] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 05/03/2021] [Accepted: 08/12/2021] [Indexed: 01/09/2023]
Abstract
Atopic eczema (AE) is an inflammatory skin disease with involvement of genetic, immunological and environmental factors. One hallmark of AE is a skin barrier disruption on multiple, highly interconnected levels: filaggrin mutations, increased skin pH and a microbiome dysbiosis towards Staphylococcus aureus overgrowth are observed in addition to an abnormal type 2 immune response. Extrinsic factors seem to play a major role in the development of AE. As AE is a first step in the atopic march, its prevention and appropriate treatment are essential. Although standard therapy remains topical treatment, powerful systemic treatment options emerged in the last years. However, thorough endotyping of the individual patients is still required for ideal precision medicine approaches in future. Therefore, novel microbial and immunological biomarkers were described recently for the prediction of disease development and treatment response. This review summarizes the current state of the art in AE research.
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Affiliation(s)
- Claudia Hülpüsch
- Department of Environmental Medicine Faculty of Medicine University of Augsburg Augsburg Germany
- Institute of Environmental Medicine Helmholtz Zentrum München Augsburg Germany
- CK CARE – Christine Kühne Center for Allergy research and Education Davos Switzerland
| | - Andreas B. Weins
- Department of Dermatology Faculty of Medicine University of Augsburg Augsburg Germany
| | - Claudia Traidl‐Hoffmann
- Department of Environmental Medicine Faculty of Medicine University of Augsburg Augsburg Germany
- Institute of Environmental Medicine Helmholtz Zentrum München Augsburg Germany
- CK CARE – Christine Kühne Center for Allergy research and Education Davos Switzerland
- ZIEL Technical University of Munich Freising Germany
| | - Matthias Reiger
- Department of Environmental Medicine Faculty of Medicine University of Augsburg Augsburg Germany
- Institute of Environmental Medicine Helmholtz Zentrum München Augsburg Germany
- CK CARE – Christine Kühne Center for Allergy research and Education Davos Switzerland
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O'Neill AM, Worthing KA, Kulkarni N, Li F, Nakatsuji T, McGrosso D, Mills RH, Kalla G, Cheng JY, Norris JM, Pogliano K, Pogliano J, Gonzalez DJ, Gallo RL. Antimicrobials from a feline commensal bacterium inhibit skin infection by drug-resistant S. pseudintermedius. eLife 2021; 10:66793. [PMID: 34664551 PMCID: PMC8592530 DOI: 10.7554/elife.66793] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 10/02/2021] [Indexed: 12/13/2022] Open
Abstract
Methicillin-resistant Staphylococcus pseudintermedius (MRSP) is an important emerging zoonotic pathogen that causes severe skin infections. To combat infections from drug-resistant bacteria, the transplantation of commensal antimicrobial bacteria as a therapeutic has shown clinical promise. We screened a collection of diverse staphylococcus species from domestic dogs and cats for antimicrobial activity against MRSP. A unique strain (S. felis C4) was isolated from feline skin that inhibited MRSP and multiple gram-positive pathogens. Whole genome sequencing and mass spectrometry revealed several secreted antimicrobials including a thiopeptide bacteriocin micrococcin P1 and phenol-soluble modulin beta (PSMβ) peptides that exhibited antimicrobial and anti-inflammatory activity. Fluorescence and electron microscopy revealed that S. felis antimicrobials inhibited translation and disrupted bacterial but not eukaryotic cell membranes. Competition experiments in mice showed that S. felis significantly reduced MRSP skin colonization and an antimicrobial extract from S. felis significantly reduced necrotic skin injury from MRSP infection. These findings indicate a feline commensal bacterium that could be utilized in bacteriotherapy against difficult-to-treat animal and human skin infections.
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Affiliation(s)
- Alan M O'Neill
- Department of Dermatology, University of California, San Diego, San Diego, United States
| | - Kate A Worthing
- College of Veterinary Medicine, University of Arizona, Oro Valley, United States
| | - Nikhil Kulkarni
- Department of Dermatology, University of California, San Diego, San Diego, United States
| | - Fengwu Li
- Department of Dermatology, University of California, San Diego, San Diego, United States
| | - Teruaki Nakatsuji
- Department of Dermatology, University of California, San Diego, San Diego, United States
| | - Dominic McGrosso
- Department of Pharmacology, University of California, San Diego, San Diego, United States.,Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, San Diego, United States
| | - Robert H Mills
- Department of Pharmacology, University of California, San Diego, San Diego, United States.,Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, San Diego, United States
| | - Gayathri Kalla
- Division of Biological Sciences, University of California, San Diego, San Diego, United States
| | - Joyce Y Cheng
- Department of Dermatology, University of California, San Diego, San Diego, United States
| | - Jacqueline M Norris
- Sydney School of Veterinary Science, University of Sydney, Sydney, Australia
| | - Kit Pogliano
- Division of Biological Sciences, University of California, San Diego, San Diego, United States
| | - Joe Pogliano
- Division of Biological Sciences, University of California, San Diego, San Diego, United States
| | - David J Gonzalez
- Department of Pharmacology, University of California, San Diego, San Diego, United States.,Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, San Diego, United States
| | - Richard L Gallo
- Department of Dermatology, University of California, San Diego, San Diego, United States
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Khadka VD, Key FM, Romo-González C, Martínez-Gayosso A, Campos-Cabrera BL, Gerónimo-Gallegos A, Lynn TC, Durán-McKinster C, Coria-Jiménez R, Lieberman TD, García-Romero MT. The Skin Microbiome of Patients With Atopic Dermatitis Normalizes Gradually During Treatment. Front Cell Infect Microbiol 2021; 11:720674. [PMID: 34631601 PMCID: PMC8498027 DOI: 10.3389/fcimb.2021.720674] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background Atopic dermatitis (AD) is characterized by an altered skin microbiome dominantly colonized by S. aureus. Standard treatment includes emollients, anti-inflammatory medications and antiseptics. Objectives To characterize changes in the skin microbiome during treatment for AD. Methods The skin microbiomes of children with moderate-to-severe AD and healthy children were investigated in a longitudinal prospective study. Patients with AD were randomized to receive either standard treatment with emollients and topical corticosteroids or standard treatment with the addition of dilute bleach baths (DBB) and sampled at four visits over a three-month period. At each visit, severity of AD was measured, swabs were taken from four body sites and the composition of the microbiome at those sites was assessed using 16S rRNA amplification. Results We included 14 healthy controls and 28 patients. We found high relative abundances of S. aureus in patients, which correlated with AD severity and reduced apparent alpha diversity. As disease severity improved with treatment, the abundance of S. aureus decreased, gradually becoming more similar to the microbiomes of healthy controls. After treatment, patients who received DBB had a significantly lower abundance of S. aureus than those who received only standard treatment. Conclusions There are clear differences in the skin microbiome of healthy controls and AD patients that diminish with treatment. After three months, the addition of DBB to standard treatment had significantly decreased the S. aureus burden, supporting its use as a therapeutic option. Further study in double-blinded trials is needed.
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Affiliation(s)
- Veda D. Khadka
- Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA, United States
- Department of Civil and Environmental Engineering, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Felix M. Key
- Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA, United States
- Department of Civil and Environmental Engineering, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Carolina Romo-González
- Experimental Bacteriology Laboratory, National Institute of Pediatrics, Mexico City, Mexico
| | | | | | | | - Tucker C. Lynn
- Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA, United States
- Department of Civil and Environmental Engineering, Massachusetts Institute of Technology, Cambridge, MA, United States
| | | | - Rafael Coria-Jiménez
- Experimental Bacteriology Laboratory, National Institute of Pediatrics, Mexico City, Mexico
| | - Tami D. Lieberman
- Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA, United States
- Department of Civil and Environmental Engineering, Massachusetts Institute of Technology, Cambridge, MA, United States
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25
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[The skin microbiome-useful for diagnosis and therapy?]. Hautarzt 2021; 72:579-585. [PMID: 34115159 DOI: 10.1007/s00105-021-04830-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Our skin is a very important and complex organ of the body. The microorganisms of the skin, the so-called microbiome, represent an important part of the healthy skin barrier and are influenced by various external and internal factors. AIM The question to what extent the skin microbiome represents a diagnostic or even therapeutic target in the context of skin diseases is discussed. MATERIALS AND METHODS A literature search was performed. RESULTS Several diseases are associated with negative alterations of the skin microbiome. In atopic dermatitis, a correlation between severity and increased availability of Staphylococcus aureus is known, with a loss of bacterial diversity on the skin. In the future, S. aureus will not only be used as a diagnostic marker in atopic dermatitis, but also represents a promising target as a predictive marker for therapeutic success. The role of the skin microbiome in psoriasis has not yet been researched in depth. However, there is evidence that dysbiosis of the skin microbiome contributes to the course of psoriasis and that there is a disturbance in immune tolerance in patients. In the case of acne, the involvement of Cutibacterium acnes in the clinical picture is well known; however, recent findings show that it is not sufficient to identify the species, but certain characteristics of C. acnes strains are associated. CONCLUSION Microbial biomarkers are currently only established in atopic dermatitis. For other diseases, this might be the case in the future; however combinations of microorganisms, single species and also strains with specific characteristics must be considered.
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Bilimoria S, Tegtmeyer K, Lio P. Advances in the Translational Science of Dermatitis. Immunol Allergy Clin North Am 2021; 41:361-373. [PMID: 34225894 DOI: 10.1016/j.iac.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The cycle of converting mechanistic insight into therapeutic interventions is called translational science. It has been relatively sluggish in atopic dermatitis (AD), but finally pathomechanisms have been identified and therapeutic targets selected and refined. From inflammatory mediators, skin barrier enhancement, itch relief, and alteration of the microbiota, several therapies have been proposed and are actively being studied for AD, suggesting an end to the drought of innovation.
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Affiliation(s)
- Sara Bilimoria
- Northwestern University Feinberg School of Medicine, 363 West Erie Street, Suite 350, Chicago, IL 60616, USA
| | - Kyle Tegtmeyer
- Northwestern University Feinberg School of Medicine, 363 West Erie Street, Suite 350, Chicago, IL 60616, USA
| | - Peter Lio
- Northwestern University Feinberg School of Medicine, 363 West Erie Street, Suite 350, Chicago, IL 60616, USA.
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Apple cider vinegar soaks do not alter the skin bacterial microbiome in atopic dermatitis. PLoS One 2021; 16:e0252272. [PMID: 34077434 PMCID: PMC8172074 DOI: 10.1371/journal.pone.0252272] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 05/13/2021] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Atopic dermatitis is a common skin disease characterized by altered cutaneous immunity in which patients often exhibit lower skin microbiota diversity compared to healthy skin and are prone to colonization by Staphylococcus aureus. Apple cider vinegar has been shown to have antibacterial effects; however, its effects on the skin microbiome have not previously been well-described. OBJECTIVES We aimed to examine the effects of topical dilute apple cider vinegar soaks on Staphylococcus aureus abundance, skin bacterial microbiome composition, and skin bacterial microbiome diversity in atopic dermatitis participants compared to healthy skin. METHODS Eleven subjects with atopic dermatitis and 11 healthy controls were enrolled in this randomized, non-blinded, single-institution, split-arm pilot study. Subjects soaked one forearm in dilute apple cider vinegar (0.5% acetic acid) and the other forearm in tap water for 10 minutes daily. Skin bacteria samples were collected from subjects' volar forearms before and after 14 days of treatment. 16S sequencing was used to analyze Staphylococcus aureus abundance and skin bacterial microbiome composition, and alpha diversity of microbiota were determined using Shannon diversity index. RESULTS There was no difference in skin bacterial microbiome in atopic dermatitis subjects after 2 weeks of daily water or apple cider vinegar treatments (p = 0.056 and p = 0.22, respectively), or in mean abundance of S. aureus on apple cider vinegar-treated forearms (p = 0.60). At 2 weeks, the skin bacterial microbiomes of healthy control subjects were not significantly different from the skin bacterial microbiome of atopic dermatitis subjects (p = 0.14, 0.21, 0.12, and 0.05). CONCLUSIONS Our results suggest that daily soaks in 0.5% apple cider vinegar are not an effective method of altering the skin bacterial microbiome in atopic dermatitis. Further studies are needed to explore the effects of different concentrations of apple cider vinegar on skin microflora and disease severity. TRIAL NUMBER UVA IRB-HSR #19906.
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Nakatsuji T, Hata TR, Tong Y, Cheng JY, Shafiq F, Butcher AM, Salem SS, Brinton SL, Rudman Spergel AK, Johnson K, Jepson B, Calatroni A, David G, Ramirez-Gama M, Taylor P, Leung DYM, Gallo RL. Development of a human skin commensal microbe for bacteriotherapy of atopic dermatitis and use in a phase 1 randomized clinical trial. Nat Med 2021; 27:700-709. [PMID: 33619370 PMCID: PMC8052297 DOI: 10.1038/s41591-021-01256-2] [Citation(s) in RCA: 140] [Impact Index Per Article: 46.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 01/15/2021] [Indexed: 01/31/2023]
Abstract
Staphylococcus aureus colonizes patients with atopic dermatitis (AD) and exacerbates disease by promoting inflammation. The present study investigated the safety and mechanisms of action of Staphylococcus hominis A9 (ShA9), a bacterium isolated from healthy human skin, as a topical therapy for AD. ShA9 killed S. aureus on the skin of mice and inhibited expression of a toxin from S. aureus (psmα) that promotes inflammation. A first-in-human, phase 1, double-blinded, randomized 1-week trial of topical ShA9 or vehicle on the forearm skin of 54 adults with S. aureus-positive AD (NCT03151148) met its primary endpoint of safety, and participants receiving ShA9 had fewer adverse events associated with AD. Eczema severity was not significantly different when evaluated in all participants treated with ShA9 but a significant decrease in S. aureus and increased ShA9 DNA were seen and met secondary endpoints. Some S. aureus strains on participants were not directly killed by ShA9, but expression of mRNA for psmα was inhibited in all strains. Improvement in local eczema severity was suggested by post-hoc analysis of participants with S. aureus directly killed by ShA9. These observations demonstrate the safety and potential benefits of bacteriotherapy for AD.
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Affiliation(s)
- Teruaki Nakatsuji
- Department of Dermatology, University of California, San Diego, La Jolla, CA, USA
| | - Tissa R Hata
- Department of Dermatology, University of California, San Diego, La Jolla, CA, USA
| | - Yun Tong
- Department of Dermatology, University of California, San Diego, La Jolla, CA, USA
| | - Joyce Y Cheng
- Department of Dermatology, University of California, San Diego, La Jolla, CA, USA
| | - Faiza Shafiq
- Department of Dermatology, University of California, San Diego, La Jolla, CA, USA
| | - Anna M Butcher
- Department of Dermatology, University of California, San Diego, La Jolla, CA, USA
| | - Secilia S Salem
- Department of Dermatology, University of California, San Diego, La Jolla, CA, USA
| | - Samantha L Brinton
- Department of Dermatology, University of California, San Diego, La Jolla, CA, USA
| | - Amanda K Rudman Spergel
- Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Keli Johnson
- Rho Federal Systems Division, Inc., Durham, NC, USA
| | - Brett Jepson
- Rho Federal Systems Division, Inc., Durham, NC, USA
| | | | - Gloria David
- Rho Federal Systems Division, Inc., Durham, NC, USA
| | - Marco Ramirez-Gama
- Division of Allergy and Immunology, Department of Pediatrics, National Jewish Health, Denver, CO, USA
| | - Patricia Taylor
- Division of Allergy and Immunology, Department of Pediatrics, National Jewish Health, Denver, CO, USA
| | - Donald Y M Leung
- Division of Allergy and Immunology, Department of Pediatrics, National Jewish Health, Denver, CO, USA
| | - Richard L Gallo
- Department of Dermatology, University of California, San Diego, La Jolla, CA, USA.
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Wang V, Boguniewicz J, Boguniewicz M, Ong PY. The infectious complications of atopic dermatitis. Ann Allergy Asthma Immunol 2021; 126:3-12. [PMID: 32771354 PMCID: PMC7411503 DOI: 10.1016/j.anai.2020.08.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/31/2020] [Accepted: 08/04/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Atopic dermatitis (AD) is a chronic inflammatory skin disease that is complicated by an increased risk for skin and systemic infections. Preventive therapy for AD is based on skin barrier improvement and anti-inflammatory treatments, whereas overt skin and systemic infections require antibiotics or antiviral treatments. This review updates the pathophysiology, diagnosis, management, controversy of antibiotic use, and potential treatments of infectious complications of AD. DATA SOURCES Published literature obtained through PubMed database searches and clinical pictures. STUDY SELECTIONS Studies relevant to the mechanisms, diagnosis, management, and potential therapy of infectious complications of AD. RESULTS Skin barrier defects, type 2 inflammation, Staphylococcusaureus colonization, and cutaneous dysbiosis are the major predisposing factors for the increased infections in AD. Although overt infections require antibiotics, the use of antibiotics in AD exacerbation remains controversial. CONCLUSION Infectious complications are a comorbidity of AD. Although not common, systemic bacterial infections and eczema herpeticum can be life-threatening. Preventive therapy of infections in AD emphasizes skin barrier improvement and anti-inflammatory therapy. The use of antibiotics in AD exacerbation requires further studies.
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Affiliation(s)
- Vivian Wang
- Veterans Affairs Greater Los Angeles Healthcare System, United States Department of Veteran Affairs, Los Angeles, California
| | - Juri Boguniewicz
- Section of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Mark Boguniewicz
- Division of Allergy-Immunology, Department of Pediatrics, National Jewish Health, Denver, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Peck Y Ong
- Division of Clinical Immunology and Allergy, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California.
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Davari DR, Nieman EL, McShane DB, Morrell DS. Current Perspectives on the Management of Infantile Atopic Dermatitis. J Asthma Allergy 2020; 13:563-573. [PMID: 33177843 PMCID: PMC7652565 DOI: 10.2147/jaa.s246175] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 10/13/2020] [Indexed: 01/01/2023] Open
Abstract
Atopic dermatitis (AD) is a common disease of childhood, and infantile AD may manifest from birth to 2 years. Guidelines for the management of infantile AD are lacking, and our aim is to provide a comprehensive review of best practices and possible interventions. We will focus on topical therapy, since the use of systemic immunomodulating agents in infantile AD is rarely advised. Topical agents include emollients, topical corticosteroids (TCS), topical calcineurin inhibitors (TCIs), and phosphodiesterase 4 (PDE-4) inhibitors. We will also provide a brief overview of promising emerging therapies currently under investigation in the pediatric population.
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Affiliation(s)
- Danielle R Davari
- Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Elizabeth L Nieman
- Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Diana B McShane
- Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Dean S Morrell
- Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Hülpüsch C, Tremmel K, Hammel G, Bhattacharyya M, Tomassi A, Nussbaumer T, Neumann AU, Reiger M, Traidl‐Hoffmann C. Skin pH-dependent Staphylococcus aureus abundance as predictor for increasing atopic dermatitis severity. Allergy 2020; 75:2888-2898. [PMID: 32562575 DOI: 10.1111/all.14461] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/12/2020] [Accepted: 06/01/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Atopic eczema (atopic dermatitis, AD) is characterized by disrupted skin barrier associated with elevated skin pH and skin microbiome dysbiosis, due to high Staphylococcus aureus loads, especially during flares. Since S aureus shows optimal growth at neutral pH, we investigated the longitudinal interplay between these factors and AD severity in a pilot study. METHOD Emollient (with either basic pH 8.5 or pH 5.5) was applied double-blinded twice daily to 6 AD patients and 6 healthy (HE) controls for 8 weeks. Weekly, skin swabs for microbiome analysis (deep sequencing) were taken, AD severity was assessed, and skin physiology (pH, hydration, transepidermal water loss) was measured. RESULTS Physiological, microbiome, and clinical results were not robustly related to the pH of applied emollient. In contrast to longitudinally stable microbiome in HE, S aureus frequency significantly increased in AD over 8 weeks. High S aureus abundance was associated with skin pH 5.7-6.2. High baseline S aureus frequency predicted both increase in S aureus and in AD severity (EASI and local SCORAD) after 8 weeks. CONCLUSION Skin pH is tightly regulated by intrinsic factors and limits the abundance of S aureus. High baseline S aureus abundance in turn predicts an increase in AD severity over the study period. This underlines the importance and potential of sustained intervention regarding the skin pH and urges for larger studies linking skin pH and skin S aureus abundance to understand driving factors of disease progression.
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Affiliation(s)
- Claudia Hülpüsch
- Chair and Institute of Environmental Medicine UNIKA‐T Technical University of Munich and Helmholtz Zentrum München Augsburg Germany
| | - Karolina Tremmel
- Chair and Institute of Environmental Medicine UNIKA‐T Technical University of Munich and Helmholtz Zentrum München Augsburg Germany
| | - Gertrud Hammel
- Chair and Institute of Environmental Medicine UNIKA‐T Technical University of Munich and Helmholtz Zentrum München Augsburg Germany
| | - Madhumita Bhattacharyya
- Chair and Institute of Environmental Medicine UNIKA‐T Technical University of Munich and Helmholtz Zentrum München Augsburg Germany
| | - Amedeo Tomassi
- Chair and Institute of Environmental Medicine UNIKA‐T Technical University of Munich and Helmholtz Zentrum München Augsburg Germany
| | - Thomas Nussbaumer
- Chair and Institute of Environmental Medicine UNIKA‐T Technical University of Munich and Helmholtz Zentrum München Augsburg Germany
| | - Avidan U. Neumann
- Chair and Institute of Environmental Medicine UNIKA‐T Technical University of Munich and Helmholtz Zentrum München Augsburg Germany
| | - Matthias Reiger
- Chair and Institute of Environmental Medicine UNIKA‐T Technical University of Munich and Helmholtz Zentrum München Augsburg Germany
- CK CARE – Christine Kühne Center for Allergy research and Education Davos Switzerland
| | - Claudia Traidl‐Hoffmann
- Chair and Institute of Environmental Medicine UNIKA‐T Technical University of Munich and Helmholtz Zentrum München Augsburg Germany
- ZIEL Technical University of Munich Freising Germany
- CK CARE – Christine Kühne Center for Allergy research and Education Davos Switzerland
- Outpatient Clinic for Environmental Medicine Universitätsklinikum Augsburg Augsburg Germany
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Abstract
Atopic dermatitis (AD) is a common frequent chronic inflammatory skin disease which begins frequently in infancy. The clinical expression of AD is a recurrent eczema on a dry skin. AD is a multifactorial disease characterized by two linked abnormalities: a skin barrier defect and a cellular inflammation, with type-2 main components. However, the pathophysiology of AD is not as simple as this description looks like. In this review, we will present a synthesis of current knowledge on natural history of AD and the involved factors, in order to clarify AD care. The evolution of AD is associated with many atopic comorbidities, following the "atopic march" scheme: IgE-mediated food allergy, allergic asthma and rhinitis occurring classically after AD. In fact, this is rarely the case, but the atopic march seems to be associated with AD severity. AD has also many neuropsychological complications which are essential to be detected. Other factors could influence the natural history of AD: genetic mutations on different genes (proteins of skin barrier, innate and adaptive immunity pathways), skin dysbiosis with colonization by Staphylococcus aureus, sensitization against environmental proteins. AD treatment is based on the restauration of the skin barrier using emollients and on anti-inflammatory drugs (notably topical corticosteroids) during the inflammatory flares. It is not recommended to treat the skin colonization by S. aureus, excepted in case of skin infection. The probiotics have no efficiency as curative treatment of AD, but could have an interest for the primary prevention, especially in at-risk populations. © 2019 Elsevier Masson SAS. All rights reserved.
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Affiliation(s)
- C Braun
- Centre international de recherche en infectiologie (CIRI) (International Center for Infectiology Research), INSERM U1111, CNRS UMR 5308, 21 avenue Tony-Garnier, 69007 Lyon, France; Hospices civils de Lyon, service de pneumologie et allergologie pédiatriques, hôpital Femme-Mère-Enfant, Bron, France.
| | - A Nosbaum
- Centre international de recherche en infectiologie (CIRI) (International Center for Infectiology Research), INSERM U1111, CNRS UMR 5308, 21 avenue Tony-Garnier, 69007 Lyon, France; Hospices civils de Lyon, service d'allergologie et immunologie clinique, centre hospitalier Lyon-Sud, Pierre-Bénite, France
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Majewski S, Bhattacharya T, Asztalos M, Bohaty B, Durham KC, West DP, Hebert AA, Paller AS. Sodium hypochlorite body wash in the management of Staphylococcus aureus-colonized moderate-to-severe atopic dermatitis in infants, children, and adolescents. Pediatr Dermatol 2019; 36:442-447. [PMID: 30983053 PMCID: PMC6767696 DOI: 10.1111/pde.13842] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES A cleansing body wash containing diluted sodium hypochlorite (0.006% NaOCl) was evaluated for management of moderate-to-severe Staphylococcus aureus-colonized, atopic dermatitis in children. METHODS A 6-week, prospective, open-label study was conducted with 50 evaluable participants (ages 6 months to 17 years) who had moderate-to-severe atopic dermatitis with S aureus skin colonization documented by culture. Participants were instructed to continue using their current medications while using the study product, 0.006% NaOCl body wash, once daily to affected areas for 6 weeks. Primary outcome measures were Investigator's Global Assessment, Eczema Area and Severity Index, and Body Surface Area scores. Secondary outcome measures were the Visual Analog Scale for pruritus, Family Dermatology Life Quality Index, and Patient Satisfaction Questionnaire for Problem Areas. A subject daily diary and a six-item subject questionnaire that provided information on preferences for bleach bath vs body wash were secondary outcome measures. RESULTS Daily use of the 0.006% NaOCl body wash led to improvement for all outcome measures comparing baseline to 2-week and to 6-week evaluations. Of the 50 skin S aureus-positive subjects, 32/50 (64%) were still positive at 2 weeks. A 36.5% decrease in subject's daily record of topical corticosteroid application at end of study compared to baseline was found. Participant surveys indicated preferences for the body wash over bleach baths. CONCLUSIONS Sodium hypochlorite (NaOCl) body wash improved all outcome measures for moderate-to-severe S aureus-colonized AD in infants, children, and adolescents. The limited reduction in S aureus further suggests that sodium hypochlorite has ameliorative effects other than antimicrobial actions.
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Affiliation(s)
- Sara Majewski
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tanya Bhattacharya
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Manuela Asztalos
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Benjamin Bohaty
- Department of Dermatology, The UTHealth McGovern Medical School-Houston, Houston, Texas
| | - Katherine C Durham
- Department of Dermatology, The UTHealth McGovern Medical School-Houston, Houston, Texas
| | - Dennis P West
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Adelaide A Hebert
- Department of Dermatology, The UTHealth McGovern Medical School-Houston, Houston, Texas
| | - Amy S Paller
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Pathophysiology, Diagnosis, and Management of Infections in Atopic Dermatitis. CURRENT DERMATOLOGY REPORTS 2019. [DOI: 10.1007/s13671-019-0256-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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