Density of the microflora in hand eczema before and after topical treatment with a potent corticosteroid

Management of chronic hand and foot eczema. An Australia/New Zealand Clinical narrative

Chronic hand/foot eczemas are common, but treatment is often challenging, with widespread dissatisfaction over current available options. Detailed history is important, particularly with regard to potential exposure to irritants and allergens. Patch testing should be regarded as a standard investigation. Individual treatment outcomes and targets, including systemic therapy, should be discussed early with patients, restoring function being the primary goal, with clearing the skin a secondary outcome. Each new treatment, where appropriate, should be considered additive or overlapping to any previous therapy. Management extends beyond mere pharmacological or physical treatment, and requires an encompassing approach including removal or avoidance of causative factors, behavioural changes and social support. To date, there is little evidence to guide sequences or combinations of therapies. Moderately symptomatic patients (e.g. DLQI ≥ 10) should be started on a potent/super-potent topical corticosteroid applied once or twice per day for 4 weeks, with tapering to twice weekly application. If response is inadequate, consider phototherapy, and then a 12-week trial of a retinoid (alitretinoin or acitretin). Second line systemic treatments include methotrexate, ciclosporin and azathioprine. For patients presenting with severe symptomatic disease (DLQI ≥ 15), consider predniso(lo)ne 0.5-1.0 mg/kg/day (or ciclosporin 3 - 5 mg/kg/day) for 4-6 weeks with tapering, and then treating as for moderate disease as above. In non-responders, botulinum toxin and/or iontophoresis, if associated with hyperhidrosis, may sometimes help. Some patients only respond to long-term systemic corticosteroids. The data on sequencing of newer agents, such as dupilumab or JAK inhibitors, are immature.

The role of bacterial skin infections in atopic dermatitis: expert statement and review from the International Eczema Council Skin Infection Group

Patients with atopic dermatitis (AD) have an increased risk of bacterial skin infections, which cause significant morbidity and, if untreated, may become systemic. Staphylococcus aureus colonizes the skin of most patients with AD and is the most common organism to cause infections. Overt bacterial infection is easily recognized by the appearance of weeping lesions, honey‐coloured crusts and pustules. However, the wide variability in clinical presentation of bacterial infection in AD and the inherent features of AD – cutaneous erythema and warmth, oozing associated with oedema, and regional lymphadenopathy – overlap with those of infection, making clinical diagnosis challenging. Furthermore, some features may be masked because of anatomical site‐ and skin‐type‐specific features, and the high frequency of S. aureus colonization in AD makes positive skin swab culture of suspected infection unreliable as a diagnostic tool. The host mechanisms and microbial virulence factors that underlie S. aureus colonization and infection in AD are incompletely understood. The aim of this article is to present the latest evidence from animal and human studies, including recent microbiome research, to define the clinical features of bacterial infections in AD, and to summarize our current understanding of the host and bacterial factors that influence microbial colonization and virulence.

Hand dermatitis: a review of clinical features, prevention and treatment

Hand dermatitis is a socially significant health problem. This review provides a discussion on the clinical features and patterns as well as the differential diagnosis of hand dermatitis, because these are essential for proper diagnosis in clinical practice. The morphology, however, is poorly related to the etiology in chronic cases. In all cases of chronic hand dermatitis, a full diagnostic examination should be undertaken and the etiology should be clarified and addressed in the treatment concept, instead of just moving directly from a morphological diagnosis to therapy. Preventive measures should be included in the treatment concept according to etiology. A stepwise approach for escalating therapy is advised, including basic topical therapy, topical corticosteroids, calcineurin inhibitors, as well as phototherapy and systemic therapy with corticosteroids, alitretinoin, cyclosporine, methotrexate, azathioprine, and others.

Nosocomial outbreak of staphyloccocal scalded skin syndrome in neonates in England, December 2012 to March 2013

Staphylococcal scalded skin syndrome (SSSS) is a blistering skin condition caused by exfoliative toxin-producing strains of Staphylococcus aureus. Outbreaks of SSSS in maternity settings are rarely reported. We describe an outbreak of SSSS that occurred among neonates born at a maternity unit in England during December 2012 to March 2013. Detailed epidemiological and microbiological investigations were undertaken. Eight neonates were found to be infected with the outbreak strain of S. aureus, of spa type t346, representing a single pulsotype. All eight isolates contained genes encoding exfoliative toxin A (eta) and six of them contained genes encoding toxin B (etb). Nasal swabs taken during targeted staff screening yielded a staphylococcal carriage rate of 21% (17/80), but none contained the outbreak strain. Mass screening involving multi-site swabbing and pooled, enrichment culture identified a healthcare worker (HCW) with the outbreak strain. This HCW was known to have a chronic skin condition and their initial nasal screen was negative. The outbreak ended when they were excluded from work. This outbreak highlights the need for implementing robust swabbing and culture methodswhen conventional techniques are unsuccessful in identifying staff carrier(s). This study adds to the growing body of evidence on the role of HCWs in nosocomial transmission of S. aureus.

Staphylococcus aureus and hand eczema severity

BACKGROUND

The role of bacterial infections in hand eczema (HE) remains to be assessed.

OBJECTIVES

To determine the prevalence of Staphylococcus aureus in patients with HE compared with controls, and to relate presence of S. aureus, subtypes and toxin production to severity of HE.

METHODS

Bacterial swabs were taken at three different visits from the hand and nose in 50 patients with HE and 50 controls. Staphylococcus aureus was subtyped by spa typing and assigned to clonal complexes (CCs), and isolates were tested for exotoxin-producing S. aureus strains. The Hand Eczema Severity Index was used for severity assessment.

RESULTS

Staphylococcus aureus was found on the hands in 24 patients with HE and four controls (P < 0.001), and presence of S. aureus was found to be related to increased severity of the eczema (P < 0.001). Patients carried identical S. aureus types on the hands and in the nose in all cases, and between visits in 90% of cases. Ten different CC types were identified, no association with severity was found, and toxin-producing strains were not found more frequently in patients with HE than in controls.

CONCLUSIONS

Staphylococcus aureus was present on hands in almost half of all patients with HE, and was significantly related to severity of the disease. This association indicates that S. aureus could be an important cofactor for persistence of HE.

Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 5. Sources of contamination and pathogen excretion from infected persons

In this article, the fifth in a series reviewing the role of food workers in foodborne outbreaks, background information on the routes of infection for food workers is considered. Contamination most frequently occurs via the fecal-oral route, when pathogens are present in the feces of ill, convalescent, or otherwise colonized persons. It is difficult for managers of food operations to identify food workers who may be excreting pathogens, even when these workers report their illnesses, because workers can shed pathogens during the prodrome phase of illness or can be long-term excretors or asymptomatic carriers. Some convalescing individuals excreted Salmonella for 102 days. Exclusion policies based on stool testing have been evaluated but currently are not considered effective for reducing the risk of enteric disease. A worker may exhibit obvious signs of illness, such as vomiting, but even if the ill worker immediately leaves the work environment, residual vomitus can contaminate food, contact surfaces, and fellow workers unless the clean-up process is meticulous. Skin infections and nasopharyngeal or oropharyngeal staphylococcal or streptococcal secretions also have been linked frequently to worker-associated outbreaks. Dermatitis, rashes, and painful hand lesions may cause workers to reduce or avoid hand washing. Regardless of the origin of the contamination, pathogens are most likely to be transmitted through the hands touching a variety of surfaces, highlighting the need for effective hand hygiene and the use of barriers throughout the work shift.

Role of bacterial pathogens in atopic dermatitis

The skin of atopic dermatitis (AD) patients exhibits a striking susceptibility to colonization and infection with Staphylococcus aureus. This review summarizes our understanding about the role of S. aureus in AD. Indeed, S. aureus colonization is both a cause and a consequence of allergic skin inflammation. The mechanisms that allergic skin inflammation of AD promotes the increase of S. aureus colonization include skin barrier dysfunction, increased synthesis of the extracellular matrix adhesins for S. aureus, and defective innate immune responses due to decreased production of endogenous antimicrobial peptides. On the other hand, the exotoxins secreted by S. aureus are superantigens. Staphylococcal superantigens (SsAgs) may penetrate the skin barrier and contribute to the persistence and exacerbation of allergic skin inflammation in AD through the stimulation of massive T cells, the role of allergens, direct stimulation of antigen-presenting cells and keratinocytes, the expansion of skin-homing cutaneous lymphocyte-associated antigen-positive T cells, and the augmentation of allergen-induced skin inflammation. SsAgs also induce corticosteroid resistance. In therapeutic interventions, anti-inflammatory therapy alone is very effective in reducing S. aureus colonization on the skin, but antibiotic treatment alone is unable to improve the allergic skin inflammation of AD. Therefore, we recommend the combination therapy of anti-inflammatory drugs and antibiotics in the AD patients with secondary bacterial infection, exacerbated AD, or poorly controlled AD. However, when AD is well controlled by anti-inflammatory drugs alone, we do not recommend the antibiotic therapy.

Staphylococcus colonization in atopic dermatitis treated with fluticasone or tacrolimus with or without antibiotics

BACKGROUND

The skin of patients with atopic dermatitis (AD) exhibits a striking susceptibility to colonization and infection by Staphylococcus aureus. Treatment with topical anti-inflammatory drugs alone can reduce S. aureus colonization.

OBJECTIVES

To compare the clinical severity of AD and the S. aureus colonization rate between AD patients treated with topical glucocorticoids and those treated with tacrolimus and to evaluate the effects of complementary topical antistaphylococcal antibiotic therapy and the development of fusidic acid-resistant S. aureus.

METHODS

Sixty AD patients were enrolled in a prospective, parallel, randomized study of an 8-week treatment with topical 0.05% fluticasone propionate or 0.03% tacrolimus, with or without complementary fusidic acid. Disease severity scoring of AD based on SCORing of Atopic Dermatitis (SCORAD), colonization rate and density of S. aureus on the skin, and antibiotic susceptibility of S. aureus isolates were evaluated.

RESULTS

The reduction in SCORAD scores correlated with the reduction of S. aureus numbers. Treatment with topical tacrolimus resulted in a comparable reduction in SCORAD scores to fluticasone but a slower eradication of S. aureus. Complementary fusidic acid had no additional benefit compared with fluticasone or tacrolimus alone. Two patients developed fusidic acid-resistant S. aureus after 8 weeks of fusidic acid treatment.

CONCLUSION

Tacrolimus is an appropriate alternative treatment for chronic AD. Topical anti-inflammatory therapy alone to improve the allergic skin inflammation of AD can reduce S. aureus colonization of the skin. Topical antibiotics should be reserved for short-term use in obvious secondary bacterial infection.

Nosocomial outbreak of staphylococcal scalded skin syndrome in neonates: epidemiological investigation and control

Over a three-month period, 13 neonates developed staphylococcal scalded skin syndrome (SSSS) in a maternity unit, between four and 18 days after their birth. An epidemiological and descriptive study followed by a case-control study was performed. A case was defined as a neonate with blistering or peeling skin, and exfoliative toxin A Staphylococcus aureus positive cultures. Controls were selected at random from the asymptomatic, non-colonized neonates born on the same day as the cases. All staff members and all neonates born during the outbreak period were screened for carriage by nasal swabs and umbilical swabs, respectively. S. aureus isolates were polymerase chain reaction (PCR) screened for etA gene and genotyped by pulsed-field gel electrophoresis (PFGE). Two clusters of eight and five cases were identified. Receiving more than one early umbilical care procedure by the same ancillary nurse was the only risk factor identified in the case-control study (odds ratio=15, 95% confidence intervals 2-328). The ancillary nurse suffered from chronic dermatitis on her hands that favoured S. aureus carriage. Exfoliative-toxin-A-producing strains, as evidenced by PCR and indistinguishable by PFGE, were isolated from all but one of the SSSS cases, from four asymptomatic neonates, from two staff members and from the ancillary nurse's hands. Removal of the ancillary nurse from duty, infection control measures (isolation precautions, chlorhexidine handwashing and barrier protections), and treatment of the carriers (nasal mupirocin and chlorhexidine showers) led to control of the epidemic. In conclusion, this study emphasizes the need for tight surveillance of chronic dermatitis in healthcare workers.

The role of topical calcineurin inhibitors in atopic dermatitis:

For more than five decades, topical corticosteroids and emollients have been the mainstay of therapy for atopic dermatitis. However, the potential for side-effects limits the clinical utility of corticosteroids in providing long-term disease control. With a unique mode of action that differs from that of corticosteroids, the steroid-free topical calcineurin inhibitors (TCIs), tacrolimus ointment and pimecrolimus cream, provide skin-selective treatment that targets key factors involved in the pathogenesis of this chronic disease. An extensive series of clinical trials involving more than 16,000 patients with predominantly moderate to severe atopic dermatitis in tacrolimus studies and over 2000 patients with primarily mild to moderate disease in pimecrolimus studies has shown that both TCIs provide effective and well-tolerated treatment for atopic dermatitis. Randomized controlled trials have demonstrated that tacrolimus is superior to conventional hydrocortisone-based regimens and does not cause skin atrophy or other steroidal side-effects. Both tacrolimus and pimecrolimus prevent disease flares and provide progressive and sustained disease improvement with long-term therapy. These and other clinical benefits of TCIs are discussed, together with the safety profiles of tacrolimus and pimecrolimus and their use in clinical practice. In addition, this review summarizes findings from the many trials carried out with these agents and outlines how TCIs can provide long-term treatment and control of a chronic skin disease that may persist for years.

Secondary infections in patients with atopic dermatitis

Clinicians have long since been aware that bacteria and other microorganisms play a role in the etiology of atopic dermatitis. Indeed, the immunological profile of atopy favors colonization by Staphylococcus aureus, and the bacteria are present in most patients with atopic dermatitis, even in the absence of skin lesions. Clinical signs of impetiginization, such as weeping and crusting, periauricular fissuration, or small superficial pustules are a sensitive indicator that the numbers of S. aureus may have increased and a clinical indication of secondary infected dermatitis. However, recent research that has focussed on the role of S. aureus in atopic dermatitis, offers a reversed perspective, by presenting evidence that the underlying pathology of atopic dermatitis, i.e. an alteration of the skin barrier and inflammation of the upper dermis, depends itself on the presence of an infectious process. In other words, secondary infection with S. aureus emerges as a cause of atopic dermatitis. Secondary infections due to fungi have, comparatively, received less attention, but there is evidence for a role for Malassezia spp. as a factor in dermatitis with a head and neck distribution pattern. Viral infections, such as herpes simplex virus, and mixed infections of intertriginous spaces, may complicate an underlying atopic dermatitis, but are not perceived as etiologic factors. Recent research has greatly contributed to our understanding of the pathophysiological potential of S.aureus superantigens in atopic dermatitis, suggesting that antibiotic therapy might be an important element in the therapeutic management of atopic dermatitis. At present, however, the clinical evidence is scarce with regards to demonstrating a clear advantage of combined anti-inflammatory and antibiotic treatment, compared with anti-inflammatory treatment alone. If there is a consensus that the presence of clinically infected lesions in atopic dermatitis warrants a course of specific antibiotic topical therapy, the clinical benefit of antibiotic agents in apparently uninfected atopic dermatitis, as present in the majority of patients, remains an open question.Moreover, the impact of adjuvant skin care on the cutaneous microflora needs to be quantified in order to properly assess the role of specific antibiotic therapy in clinically uninfected atopic dermatitis. In the meantime, secondary infections in atopic dermatitis remain a secondary problem in clinical atopic dermatitis management, and specific anti-infective therapy remains a method of fine-tuning for optimizing individual atopic dermatitis treatment.

Clinical, microbial, and biochemical aspects of the exfoliative toxins causing staphylococcal scalded-skin syndrome

The exfoliative (epidermolytic) toxins of Staphylococcus aureus are the causative agents of the staphylococcal scalded-skin syndrome (SSSS), a blistering skin disorder that predominantly affects children. Clinical features of SSSS vary along a spectrum, ranging from a few localized blisters to generalized exfoliation covering almost the entire body. The toxins act specifically at the zona granulosa of the epidermis to produce the characteristic exfoliation, although the mechanism by which this is achieved is still poorly understood. Despite the availability of antibiotics, SSSS carries a significant mortality rate, particularly among neonates with secondary complications of epidermal loss and among adults with underlying diseases. The aim of this article is to provide a comprehensive review of the literature spanning more than a century and to cover all aspects of the disease. The epidemiology, clinical features, potential complications, risk factors, susceptibility, diagnosis, differential diagnoses, investigations currently available, treatment options, and preventive measures are all discussed in detail. Recent crystallographic data on the toxins has provided us with a clearer and more defined approach to studying the disease. Understanding their mode of action has important implications in future treatment and prevention of SSSS and other diseases, and knowledge of their specific site of action may provide a useful tool for physiologists, dermatologists, and pharmacologists.

Topical ointment therapy benefits premature infants

OBJECTIVE

Premature infants have an ineffective epidermal barrier. The aim of this study was to investigate the cutaneous and systemic effects of preservative-free topical ointment therapy in premature infants.

STUDY DESIGN

We conducted a prospective, randomized study of 60 infants less than 33 weeks' estimated gestational age. The treated infants received therapy for 2 weeks with twice-daily preservative-free topical ointment therapy while the control group received no topical treatment or as-needed therapy with a water-in-oil emollient. Data collection included transepidermal water loss (TEWL) measurement, skin condition evaluations, fungal and quantitative bacterial skin cultures, analysis of fluid requirements, patterns of weight low or gain, and the incidence of blood and cerebrospinal fluid cultures positive for microorganisms.

RESULTS

We found that topical ointment therapy significantly decreased TEWL during the first 6 hours after the initial application. TEWL was decreased by 67% (p = 0.0001) when measured 30 minutes after application and 34% (p = 0.001) when measured 4 to 6 hours after application. We also observed significantly superior skin condition scores in the treated group on study days 7 and 14 (p = 0.001) and 0.0004, respectively). Quantitative bacterial cultures revealed significantly less colonization of the axilla on day 2, 3, or 4 and on day 14 (p = 0.008 and 0.04, respectively). The incidence of positive findings in blood and/or cerebrospinal fluid cultures was 3.3% in the treated group of infants versus 26.7% in the control group (p = 0.02). There was no statistical difference in the fluid requirements or patterns of weight gain or loss during the 2 weeks of the study.

CONCLUSIONS

Preservative-free topical ointment therapy decreased TEWL for 6 hours after application, decreased the severity of dermatitis, and decreased bacterial colonization of axillary skin. Infants treated with ointment had fewer blood and cerebrospinal fluid cultures positive for microorganisms. These data support the use of topical ointment therapy in very premature infants during the first weeks after birth.

Local steroid therapy and bacterial skin flora in atopic dermatitis

A double-blind, randomized trial was conducted to determine the influence of topical steroid therapy on atopic skin flora. The bacteriological and clinical effects of desonide (Locapred), compared with those of its excipient, were studied in 40 children. Clinical scoring and bacteriological sampling were performed before the start of the trial and after 7 days of once-daily topical treatment. Before treatment, no differences in clinical score or Staphylococcus aureus colonization were noted between the two groups. After treatment, the clinical score improved (P < 0.001) in the desonide group, and S. aureus density decreased dramatically (P < 0.001). In the excipient group, no significant differences in clinical score or S. aureus density were noted. A comparison of the two groups demonstrated statistically significant differences with regard to clinical score (P < 0.001) and S. aureus density (P < 0.05). These results show the efficacy of topical corticosteroid treatment alone on S. aureus colonization in atopic skin, and confirm the critical role of inflammation in bacterial colonization.

Topical corticosteroids and Staphylococcus aureus in atopic dermatitis

BACKGROUND

Atopic dermatitis is commonly colonized with Staphylococcus aureus in high densities.

OBJECTIVE

Our purpose was to study the effect of topical corticosteroids on the colonization of S. aureus in atopic dermatitis.

METHODS

Sixty-six patients were treated with moderately potent, or very potent corticosteroids. Quantification of S. aureus and evaluation of the severity of the eczema was performed before, after 1 week, and after 2 weeks of treatment.

RESULTS

Fifty-three patients carried S. aureus in the most pronounced lesion before treatment. The colonization was significantly correlated with the severity of the eczema. The density of S. aureus was reduced by topical corticosteroids. The reduction increased with the potency of the corticosteroid and was most pronounced during the first week. S. aureus was eliminated after a successful 2-week treatment with a very potent corticosteroid. Propylene glycol 25% added to a moderately potent corticosteroid did not significantly increase the reduction of S. aureus.

CONCLUSION

Topical corticosteroids of sufficient potency reduce the density of S. aureus in atopic dermatitis.

Do topical corticosteroids modulate skin irritation in human beings? Assessment by transepidermal water loss and visual scoring

The efficacy of topically applied corticosteroid formulations of different potencies on irritant skin reactions was assessed in human beings. Chronic irritant contact dermatitis was produced by repeated application of a low-molarity sodium lauryl sulfate solution. Neither corticoid nor vehicle inhibited visible response to the irritant. Barrier function, as measured by transepidermal water loss, was impaired. The corticoid formulations and the vehicles did not significantly influence barrier function. These data raise the question of the value of certain topical corticoids and vehicles in chronic irritant contact dermatitis when the irritant is not removed.

Microbiology of the skin: resident flora, ecology, infection

Humans exist in an environment replete with microorganisms, but only a few become resident on the skin surface. The skin possesses protective mechanisms to limit colonization, and the survival of organisms on the surface lies in part in the ability of the organisms to resist these mechanisms. Microbial colonization on the skin adds to the skin's defense against potentially pathogenic organisms. Although microbes normally live in synergy with their hosts, occasionally colonization can result in clinical infection. Common infections consist of superficial infections of the stratum corneum or appendageal structures that can respond dramatically to therapy but commonly relapse. In rare circumstances, these infections can be quite severe, particularly in immunocompromised patients or in hospitalized patients with indwelling foreign devices. These infections are often resistant to conventional antibiotics and can result in infection with other opportunistic pathogens.