The use of corticosteroids and corticosteroid phobia in atopic dermatitis

Cyclosporin A-loaded dissolving microneedles for dermatitis therapy: Development, characterisation and efficacy in a delayed-type hypersensitivity in vivo model

Several drugs can be used for treating inflammatory skin pathologies like dermatitis and psoriasis. However, for the management of chronic and long-term cases, topical administration is preferred over oral delivery since it prevents certain issues due to systemic side effects from occurring. Cyclosporin A (CsA) has been used for this purpose; however, its high molecular weight (1202 Da) restricts the diffusion through the skin structure. Here, we developed a nano-in-micro device combining lipid vesicles (LVs) and dissolving microneedle array patches (DMAPs) for targeted skin delivery. CsA-LVs allowed the effective incorporation of CsA in the hydrophilic DMAP matrix despite the hydrophobicity of the drug. Polymeric matrix composed of poly (vinyl alcohol) (5% w/v), poly (vinyl pyrrolidine) (15% w/v) and CsA-LV dispersion (10% v/v) led to the formation of CsA-LVs@DMAPs with adequate mechanical properties to penetrate the stratum corneum barrier. The safety and biocompatibility were ensured in an in vitro viability test using HaCaT keratinocytes and L929 fibroblast cell lines. Ex vivo permeability studies in a Franz-diffusion cell setup showed effective drug retention in the skin structure. Finally, CsA-LVs@DMAPs were challenged in an in vivo murine model of delayed-type hypersensitivity to corroborate their potential to ameliorate skin inflammatory conditions. Different findings like photon emission reduction in bioluminescence study, normalisation of histological damage and decrease of inflammatory cytokines point out the effectivity of CsA-LVs@DMAPs to treat these conditions. Overall, our study demonstrates that CsA-LVs@DMAPs can downregulate the skin inflammatory environment which paves the way for their clinical translation and their use as an alternative to corticosteroid-based therapies.

Efficacy and safety of self-made WenyangJianpi-qushi Decoction combined with mometasone furoate cream in the treatment of atopic dermatitis of spleen deficiency and dampness accumulation type

Introduction: This work was to explore the efficacy and safety of self-made WenyangJianpi-qushi Decoction plus mometasone furoate cream in atopic dermatitis (AD) of spleen deficiency and dampness accumulation type. Material and method: 120 patients with this kind of atopic dermatitis were grouped: The Observation group (disease health education + basic treatment + mometasone furoate cream + self-made Decoction) and The Control group (disease health education + basic treatment + mometasone furoate cream), 60 cases in each group. The SCORAD score, serum IgE level, peripheral blood eosinophils, adverse events, recurrence rate, and total effective rate after treatment were observed.Result: Through treatment, SCORAD score of the observation group (29.96 ± 2.88) was lower as against controls (36.04 ± 3.12), p < 0.05. Through treatment, the peripheral blood eosinophil count in the observation group was (311.26 ± 50.19) 106/L, which was lower than (582.71 ± 54.75) 106/L in controls; the serum lgE of the observation group was (712.44 ± 93.32) IU/mL, which was lower than the controls (890.12 ± 81.25) IU/mL, p < 0.05. The Observation group (56/60, 93.33%) demonstrated superior total effective rate to the controls (34/60, 56.67%); The recurrence rate of the observation group was 4/60 (6.67%), which was lower than the controls 16/60 (26.67%), p < 0.05.Conclusion: Self-made WenyangJianpi-qushi Decoction plus mometasone furoate cream to treat atopic dermatitis of spleen deficiency and dampness accumulation type has significant efficacy and good safety.

The causal relationship between immune cells and atopic dermatitis: A bidirectional Mendelian randomization study

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin condition whose origins remain unclear. Existing epidemiological evidence suggests that inflammation and immune factors play pivotal roles in the onset and progression of AD. However, previous research on the connection between immune inflammation and AD has yielded inconclusive results.

METHODS

To evaluate the causal relationship between immunological characteristics and AD, this study employed a bidirectional, two-sample Mendelian randomization (MR) approach. We utilized large-scale, publicly available genome-wide association studies to investigate the causal associations between 731 immunological feature cells and the risk of AD.

RESULTS

Significant associations were identified between six immune phenotypes and AD risk: increased Basophil %CD33dim HLA DR-CD66b-, CD25 on IgD+ CD24+, CD40 on monocytes, HLA DR on CD14+ CD16-monocytes, HLA DR on CD14+monocytes correlated with higher AD risk, while elevated CD3 on CD4 Treg was linked to lower risk. Reverse MR analysis revealed AD as a risk factor for IgD+ CD38br AC and IgD+ CD38br %B cell, but a protective factor against CD20 on IgD+ CD38- naive and CD8 on NKT.

CONCLUSION

Our findings elucidate the intricate interplay between immune cells and AD, informing future research into AD pathophysiology and therapeutics.

Topical anti-inflammatory treatments for eczema: network meta-analysis

BACKGROUND

Eczema (atopic dermatitis) is the most burdensome skin condition worldwide and cannot currently be prevented or cured. Topical anti-inflammatory treatments are used to control eczema symptoms, but there is uncertainty about the relative effectiveness and safety of different topical anti-inflammatory treatments.

OBJECTIVES

To compare and rank the efficacy and safety of topical anti-inflammatory treatments for people with eczema using a network meta-analysis.

SEARCH METHODS

We searched the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase and trial registries on 29 June 2023, and checked the reference lists of included studies.

SELECTION CRITERIA

We included within-participant or between-participant randomised controlled trials (RCTs) in people of any age with eczema of any severity, but excluded trials in clinically infected eczema, seborrhoeic eczema, contact eczema, or hand eczema. We included topical anti-inflammatory treatments used for at least one week, compared with another anti-inflammatory treatment, no treatment, or vehicle/placebo. Vehicle is a 'carrier system' for an active pharmaceutical substance, which may also be used on its own as an emollient for dry skin. We excluded trials of topical antibiotics used alone, complementary therapies, emollients used alone, phototherapy, wet wraps, and systemic treatments.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Primary outcomes were patient-reported eczema symptoms, clinician-reported eczema signs and investigator global assessment. Secondary outcomes were health-related quality of life, long-term control of eczema, withdrawal from treatment/study, and local adverse effects (application-site reactions, pigmentation changes and skin thinning/atrophy were identified as important concerns through patient and public involvement). We used CINeMA to quantify our confidence in the evidence for each outcome.

MAIN RESULTS

We included 291 studies involving 45,846 participants with the full spectrum of eczema severity, mainly conducted in high-income countries in secondary care settings. Most studies included adults, with only 31 studies limited to children aged < 12 years. Studies usually included male and female participants, multiple ethnic groups but predominantly white populations. Most studies were industry-funded (68%) or did not report their funding sources/details. Treatment duration and trial participation were a median of 21 and 28 days (ranging from 7 days to 5 years), respectively. Interventions used were topical corticosteroids (TCS) (172), topical calcineurin inhibitors (TCI) (134), phosphodiesterase-4 (PDE-4) inhibitors (55), janus kinase (JAK) inhibitors (30), aryl hydrocarbon receptor activators (10), or other topical agents (21). Comparators included vehicle (170) or other anti-inflammatory treatments. The risk of bias was high in 242 of the 272 (89.0%) trials contributing to data analyses, most commonly due to concerns about selective reporting. Network meta-analysis (NMA) was only possible for short-term outcomes. Patient-reported symptoms NMA of 40 trials (6482 participants) reporting patient-reported symptoms as a binary outcome ranked tacrolimus 0.1% (OR 6.27, 95% CI 1.19 to 32.98), potent TCS (OR 5.99, 95% CI 2.83 to 12.69), and ruxolitinib 1.5% (OR 5.64, 95% CI 1.26 to 25.25) as the most effective, all with low confidence. Mild TCS, roflumilast 0.15%, and crisaborole 2% were the least effective. Class-level sensitivity analysis found potent/very potent TCS had similar effectiveness to potent TCI and was more effective than mild TCI and PDE-4 inhibitors. NMA of 29 trials (3839 participants) reporting patient-reported symptoms as a continuous outcome ranked very potent TCS (SMD -1.99, 95% CI -3.25 to -0.73; low confidence) and tacrolimus 0.03% (SMD -1.57, 95% CI -2.42 to -0.72; moderate confidence) the highest. Direct information for tacrolimus 0.03% was based on one trial of 60 participants at high risk of bias. Roflumilast 0.15%, delgocitinib 0.25% or 0.5%, and tapinarof 1% were the least effective. Class-level sensitivity analysis found potent/very potent TCS had similar effectiveness to potent TCI and JAK inhibitors and mild/moderate TCS was less effective than mild TCI. A further 50 trials (9636 participants) reported patient-reported symptoms as a continuous outcome but could not be included in NMA. Clinician-reported signs NMA of 32 trials (4121 participants) reported clinician signs as a binary outcome and ranked potent TCS (OR 8.15, 95% CI 4.99, 13.57), tacrolimus 0.1% (OR 8.06, 95% CI 3.30, 19.67), ruxolitinib 1.5% (OR 7.72, 95% CI 4.92, 12.10), and delgocitinib 0.5% (OR 7.61, 95% CI 3.72, 15.58) as most effective, all with moderate confidence. Mild TCS, roflumilast 0.15%, crisaborole 2%, and tapinarof 1% were the least effective. Class-level sensitivity analysis found potent/very potent TCS more effective than potent TCI, mild TCI, JAK inhibitors, PDE-4 inhibitors; and mild TCS and PDE-4 inhibitors had similar effectiveness. NMA of 49 trials (5261 participants) reported clinician signs as a continuous outcome and ranked tacrolimus 0.03% (SMD -2.69, 95% CI -3.36, -2.02) and very potent TCS (SMD -1.87, 95% CI -2.69, -1.05) as most effective, both with moderate confidence; roflumilast 0.15%, difamilast 0.3% and tapinarof 1% were ranked as least effective. Direct information for tacrolimus 0.03% was based on one trial in 60 participants with a high risk of bias. For some sensitivity analyses, potent TCS, tacrolimus 0.1%, ruxolitinib 1.5%, delgocitinib 0.5% and delgocitinib 0.25% became some of the most effective treatments. Class-level analysis found potent/very potent TCS had similar effectiveness to potent TCI and JAK inhibitors, and moderate/mild TCS was more effective than mild TCI. A further 100 trials (22,814 participants) reported clinician signs as a continuous outcome but could not be included in NMA. Investigator Global Assessment NMA of 140 trials (23,383 participants) reported IGA as a binary outcome and ranked ruxolitinib 1.5% (OR 9.34, 95% CI 4.8, 18.18), delgocitinib 0.5% (OR 10.08, 95% CI 2.65, 38.37), delgocitinib 0.25% (OR 6.87, 95% CI 1.79, 26.33), very potent TCS (OR 8.34, 95% CI 4.73, 14.67), potent TCS (OR 5.00, 95% CI 3.80, 6.58), and tacrolimus 0.1% (OR 5.06, 95% CI 3.59, 7.13) as most effective, all with moderate confidence. Mild TCS, crisaborole 2%, pimecrolimus 1%, roflumilast 0.15%, difamilast 0.3% and 1%, and tacrolimus 0.03% were the least effective. In a sensitivity analysis of low risk of bias information (12 trials, 1639 participants), potent TCS, delgocitinib 0.5% and delgocitinib 0.25% were most effective, and pimecrolimus 1%, roflumilast 0.15%, difamilast 1% and difamilast 0.3% least effective. Class-level sensitivity analysis found potent/very potent TCS had similar effectiveness to potent TCI and JAK inhibitors and were more effective than PDE-4 inhibitors; mild/moderate TCS were less effective than potent TCI and had similar effectiveness to mild TCI. Longer-term outcomes over 6 to 12 months showed a possible increase in effectiveness for pimecrolimus 1% versus vehicle (4 trials, 2218 participants) in a pairwise meta-analysis, and greater treatment success with mild/moderate TCS than pimecrolimus 1% (based on 1 trial of 2045 participants). Local adverse effects NMA of 83 trials (18,992 participants, 2424 events) reporting application-site reactions ranked tacrolimus 0.1% (OR 2.2, 95% CI 1.53, 3.17; moderate confidence), crisaborole 2% (OR 2.12, 95% CI 1.18, 3.81; high confidence), tacrolimus 0.03% (OR 1.51, 95%CI 1.10, 2.09; low confidence), and pimecrolimus 1% (OR 1.44, 95% CI 1.01, 2.04; low confidence) as most likely to cause site reactions. Very potent, potent, moderate, and mild TCS were least likely to cause site reactions. NMA of eight trials (1786 participants, 3 events) reporting pigmentation changes found no evidence for increased pigmentation changes with TCS and crisaborole 2%, with low confidence for mild, moderate or potent TCS and moderate confidence for crisaborole 2%. NMA of 25 trials (3691 participants, 36 events) reporting skin thinning found no evidence for increased skin thinning with short-term (median 3 weeks, range 1-16 weeks) use of mild TCS (OR 0.72, 95% CI 0.12, 4.31), moderate TCS (OR 0.91, 95% CI 0.16, 5.33), potent TCS (OR 0.96, 95% CI 0.21, 4.43) or very potent TCS (OR 0.88, 95% CI 0.31, 2.49), all with low confidence. Longer-term outcomes over 6 to 60 months showed increased skin thinning with mild to potent TCS versus TCI (3 trials, 4069 participants, 6 events with TCS).

AUTHORS' CONCLUSIONS

Potent TCS, JAK inhibitors and tacrolimus 0.1% were consistently ranked as amongst the most effective topical anti-inflammatory treatments for eczema and PDE-4 inhibitors as amongst the least effective. Mild TCS and tapinarof 1% were ranked amongst the least effective treatments in three of five efficacy networks. TCI and crisaborole 2% were ranked most likely to cause local application-site reactions and TCS least likely. We found no evidence for increased skin thinning with short-term TCS but an increase with longer-term TCS.

A critical and comprehensive review of the current status of 17β-estradiol hormone remediation through adsorption technology

Even at low concentrations, steroid hormones pose a significant threat to ecosystem health and are classified as micropollutants. Among these, 17β-estradiol (molecular formula: C18H24O2; pKa = 10.46; Log Kow = 4.01; solubility in water = 3.90 mg L-1 at 27 °C; molecular weight: 272.4 g mol-1) is extensively studied as an endocrine disruptor due to its release through natural pathways and widespread use in conventional medicine. 17β-estradiol (E2) is emitted by various sources, such as animal and human excretions, hospital and veterinary clinic effluents, and treatment plants. In aquatic biota, it can cause issues ranging from the feminization of males to inhibiting plant growth. This review aims to identify technologies for remediating E2 in water, revealing that materials like graphene oxides, nanocomposites, and carbonaceous materials are commonly used for adsorption. The pH of the medium, especially in acidic to neutral conditions, affects efficiency, and ambient temperature (298 K) supports the process. The Langmuir and Freundlich models aptly describe isothermal studies, with interactions being of a low-energy, physical nature. Adsorption faces limitations when other ions coexist in the solution. Hybrid treatments exhibit high removal efficiency. To mitigate global E2 pollution, establishing national and international standards with detailed guidelines for advanced treatment systems is crucial. Despite significant advancements in optimizing technologies by the scientific community, there remains a considerable gap in their societal application, primarily due to economic and sustainable factors. Therefore, further studies are necessary, including conducting batch experiments with these adsorbents for large-scale treatment along with economic analyses of the production process.

Belgian atopic dermatitis guidelines

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.

Adherence in Atopic Dermatitis

Atopic dermatitis is a chronic dermatologic condition requiring extended treatment times with topical application of medications. While atopic dermatitis treatments can be highly effective when used as directed, oftentimes patients do not respond as expected, raising concern for nonadherence versus nonresponse. This chapter aims to describe what is currently known about adherence in atopic dermatitis and to discuss strategies to improve adherence in order to improve treatment outcomes. Whether intentional or unintentional, nonadherence to treatment can limit patient outcomes of this disease for a variety of reasons. These include frustration with medication efficacy, inconvenience, and fear of side effects. Other factors include forgetfulness, financial burden of treatment, lack of trust in the physician, dislike of prescribed medication, or lack of understanding of disease or treatment. Several interventions have been studied with the aim of improving adherence in atopic dermatitis-such as educational workshops for patients and caregivers, earlier follow-up visits, and text messages reminders-however, these are often limited by sample size and power. Further research is needed to study both specific patterns of nonadherence in atopic dermatitis, as well as methods to improve them.

Development and application of novel peptide-formulated nanoparticles for treatment of atopic dermatitis

Atopic dermatitis is a chronic inflammatory skin condition that is characterized by skin inflammation, itching, and redness. Although various treatments can alleviate symptoms, they often come with side effects, highlighting the need for new treatments. Here, we discovered a new peptide-based therapy using the intra-dermal delivery technology (IDDT) platform developed by Remedi Co., Ltd (REMEDI). The platform screens and identifies peptides derived from proteins in the human body that possess cell-penetrating peptide (CPP) properties. We screened over 1000-peptides and identified several derived from the Speckled protein (SP) family that have excellent CPP properties and have anti-inflammatory effects. We assessed these peptides for their potential as a treatment for atopic dermatitis. Among them, the RMSP1 peptide showed the most potent anti-inflammatory effects by inhibiting the nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) and signal transducer and activator of transcription 3 (STAT3) signaling pathways while possessing CPP properties. To further improve efficacy and stability, we developed a palmitoylated version called Pal-RMSP1. Formulation studies using liposomes (Pal-RMSP1 LP) and micelles (Pal-RMSP1 DP) demonstrated improved anti-inflammatory effects in vitro and enhanced therapeutic effects in vivo. Our study indicates that nano-formulated Pal-RMSP1 could have the potential to become a new treatment option for atopic dermatitis.

Corticophobia among Parents of Children with Atopic Dermatitis: Assessing Major and Minor Risk Factors for High TOPICOP Scores

Corticophobia, fear of applying topical corticosteroids (TCSs), is a rising issue in industrialized countries, despite the actual safety of TCSs for atopic dermatitis (AD). Patients attending the Pediatric Dermatology Unit for skin examination were screened for AD. AD patients were included, and data were collected. Parental corticophobia was evaluated through the Topical Corticosteroid Phobia (TOPICOP) questionnaire. The χ2 test and logistic regression were used to analyze statistical associations between parental corticophobia (mild/moderate vs. severe) and patients' and parents' characteristics. Overall, 100 patients were included (53 females; 47 males; mean age 5.9 years): 44 had mild/moderate AD (EASI ≤ 21), and 56 had severe AD (EASI > 21) (mean EASI 19.7). Of the patients, 33 never consulted healthcare providers for AD, and 67 did. Parental education was low/intermediate in 60 cases and high (gymnasium/university degree) in 40. Mean parental DLQI was 10.7. Mean parental TOPICOP was 39.1%: 51 had mild/moderate corticophobia (TOPICOP ≤ 50%), and 49 had severe corticophobia (TOPICOP > 50%). At the χ2 test, corticophobia was associated with mild/moderate AD (OR 20.9487; 95% CI 7.2489-60.5402; p < 0.001), older age of patients (OR 4.1176; 95% CI 1.7880 to 9.4828; p < 0.001), early disease onset (OR 9.8925; 95% CI 2.7064-36.1596; p < 0.001), and previous healthcare professional consultations (OR 4.9279; 95% CI 1.9335-12.5597; p < 0.001). Also, severe parental corticophobia was very significantly associated with severe parental involvement of life quality (OR 33.3333; 95% CI 10.9046-101.8937; p < 0.001) and with high education of parents (gymnasium or university degree) (29/49) (OR 5.2727; 95% CI 2.1927-12.6790; p < 0.001). At logistic regression, high parental DLQI (p < 0.0001), high parental education (p < 0.0338), older age of patients (p = 0.0015), and early disease onset (p < 0.0513) accounted for major risk factors influencing severe parental corticophobia. Assessing risk factors for corticophobia is essential for addressing groups of parents at higher risk for corticophobia using educational programs, to overcome unfounded fears and augment treatment adherence.

Practices and Perceptions of Community Pharmacists in the Management of Atopic Dermatitis: A Systematic Review and Thematic Synthesis

Understanding the contributions of community pharmacists as first-line health providers is important to the management of atopic dermatitis, though little is known about their contribution. A systematic review was carried out to examine practices and perceptions of the role of community pharmacists. A literature search was conducted in five different databases. Full-text primary research studies, which involved practices and perceptions of the role of community pharmacists in the management of atopic dermatitis, previously published in peer reviewed journals were used. Critical appraisal of included studies was performed using the Mixed Methods Appraisal Tool. Data were extracted and thematically synthesized to generate descriptive and analytical themes. The confidence of the findings of the included studies was assessed via either GRADE or CERQual. Twenty-three studies were included. Findings showed that community pharmacists lacked knowledge of the uses of topical corticosteroids. The recommendations of other treatments were limited. Pharmacists generally undertook dermatology training after graduation. Analytical themes indicated that the practices of community pharmacists were poor and misled patients. Inappropriate education in initial training was identified as a potential reason for their poor practices. This systematic review reveals a gap between patients' needs in practice and dermatological education provided to community pharmacists. Novel approaches regarding education and training should be explored to improve pharmacists' dermatological knowledge and skills.

Callicarpa dichotoma Leaf Extract Alleviates Atopic Dermatitis through the Suppression of T Cells and Keratinocytes Activation

Atopic dermatitis (AD) is a highly recurrent chronic inflammatory skin disease, characterized by severe itching, immune imbalance, and skin barrier dysfunction. Damage to the skin barrier function is known to be the main cause of Th1/Th2 immune imbalance, due to the Th2-mediated immune response, and pro-inflammatory cytokines, including IL-4, IL-5, IL-13 and IL-31 and it plays an important role in further eliciting the environment of AD through stimulation. Currently, the most widely used drugs for the treatment of AD are corticosteroids, antihistamines and immunosuppressants (used by more than 60% of patients), which are reported to exhibit various side effects when taken for a long time. Therefore, interest in the physiological activity of safer plant-derived natural extracts is increasing. Callicarpa dichotoma is traditionally used in oriental medicine for bruises, habitual pain, gastric and postpartum hemorrhage. Recent studies have reported that it exhibits antioxidant anti-inflammatory and anti-hepatotoxic activity, but the role and activity of C. dichotoma in AD have not yet been studied. Therefore, in this study, the new physiological activity of C. dichotoma in the AD environment was investigated, suggesting its potential as a natural therapeutic agent.

European guideline (EuroGuiDerm) on atopic eczema - part II: non-systemic treatments and treatment recommendations for special AE patient populations

The evidence- and consensus-based guideline on atopic eczema was developed in accordance with the EuroGuiDerm Guideline and Consensus Statement Development Manual. Four consensus conferences were held between December 2020 and July 2021. Twenty-nine experts (including clinicians and patient representatives) from 12 European countries participated. This second part of the guideline includes recommendations and detailed information on basic therapy with emollients and moisturizers, topical anti-inflammatory treatment, antimicrobial and antipruritic treatment and UV phototherapy. Furthermore, this part of the guideline covers techniques for avoiding provocation factors, as well as dietary interventions, immunotherapy, complementary medicine and educational interventions for patients with atopic eczema and deals with occupational and psychodermatological aspects of the disease. It also contains guidance on treatment for paediatric and adolescent patients and pregnant or breastfeeding women, as well as considerations for patients who want to have a child. A chapter on the patient perspective is also provided. The first part of the guideline, published separately, contains recommendations and guidance on systemic treatment with conventional immunosuppressive drugs, biologics and janus kinase (JAK) inhibitors, as well as information on the scope and purpose of the guideline, and a section on guideline methodology.

Dendrobium nobile Lindley Administration Attenuates Atopic Dermatitis-like Lesions by Modulating Immune Cells

Atopic dermatitis (AD) is a chronic inflammatory skin disease that can significantly affect daily life by causing sleep disturbance due to extreme itching. In addition, if the symptoms of AD are severe, it can cause mental disorders such as ADHD and suicidal ideation. Corticosteroid preparations used for general treatment have good effects, but their use is limited due to side effects. Therefore, it is essential to minimize the side effects and study effective treatment methods. Dendrobium nobile Lindley (DNL) has been widely used for various diseases, but to the best of our knowledge, its effect on AD has not yet been proven. In this study, the inhibitory effect of DNL on AD was confirmed in a DNCB-induced Balb/c mouse. In addition, the inhibitory efficacy of inflammatory cytokines in TNF-α/IFN-γ-induced HaCaT cells and PMACI-induced HMC-1 cells was confirmed. The results demonstrated that DNL decreased IgE, IL-6, IL-4, scratching behavior, SCORAD index, infiltration of mast cells and eosinophils and decreased the thickness of the skin. Additionally, DNL inhibited the expression of cytokines and inhibited the MAPK and NF-κB signaling pathways. This suggests that DNL inhibits cytokine expression, protein signaling pathway, and immune cells, thereby improving AD symptoms in mice.

Current treatments for atopic dermatitis in Japan

The goal of a treatment regimen for atopic dermatitis is to reach and maintain a state where the patient exhibits mild symptoms or an absence of symptoms, and the patient should not experience disturbance during daily activities. The basis of a treatment regimen for atopic dermatitis is topical therapy, and currently there exist topical corticosteroids, tacrolimus and delgocitinib. Using these, proactive therapy is performed as maintenance therapy after remission induction therapy. However, in cases of moderate to severe atopic dermatitis, topical drugs alone cannot induce remission and systemic therapies such as cyclosporin, ultraviolet therapy, and dupilumab should be used in combination. In particular, dupilumab has many advantages such as high efficacy, relatively few adverse reactions, and ease of use in elderly patients with severe atopic dermatitis. In this review, we present a treatment algorithm for atopic dermatitis that emphasizes the importance of maintaining remission after induction of remission, and summarizes the characteristics of current medication therapy for atopic dermatitis in Japan.

Community pharmacists' knowledge, perceptions, and practices about topical corticosteroid counseling: A real-world cross-sectional survey and focus group discussions in Korea

Topical corticosteroids (TCs) are widely used to treat dermatological conditions such as eczema and psoriasis. It can be a safe and effective treatment when used appropriately. However, misguided information and corticosteroid phobia appear to contribute to inadequate adherence to therapy, leading to unsatisfactory treatment outcomes. Therefore, community pharmacists (CPs) are in a prime position to inform patients about the appropriate use of medicine. The aim of this study was to examine how the knowledge and perceptions of CPs, as well as other factors, associate CPs’ patient counseling practice around the use of TCs. A structured, validated questionnaire was distributed to CPs in the Republic of Korea, and additional focus group discussions were implemented to obtain a deeper understanding of the survey findings. We analyzed the survey results by applying a modified knowledge-perception-practice model. In addition, we used path analysis to validate the model and assessed how knowledge level and perceptions of barriers affect CPs’ counseling behavior. We ran a multiple regression to identify factors that associate CPs’ practice levels. A total of 1018 surveys were analyzed. In general, respondents had sufficient knowledge to provide appropriate patient counseling on TC use. An increase in knowledge level positively associated the quality of practice, and more knowledge increased the perception of barriers that negatively associated patient counseling. Location in rural areas and pharmacists’ perception of counseling barriers negatively associated the quality of practice. A higher level of knowledge, training in ADEs, higher proportion of OTC TC sales, and increased time for counseling positively associated the quality of practice. Therefore, minimizing barriers such as negative perceptions is very important in facilitating CPs’ counseling practice around TC use.

Assessing the effect of clinical trial evidence and anecdote on caregivers' willingness to use corticosteroids: a randomized controlled trial: a critical appraisal

AIM

Johnson et al. aimed to assess caregivers' willingness to treat childhood atopic dermatitis (AD) with a corticosteroid when presented with clinical trial evidence, anecdote, or both.

SETTING AND DESIGN

This prospective parallel group (1: 1; eight groups) randomized control trial (RCT) was carried out with caregivers recruited from a tertiary care dermatology clinic in the USA and an online crowdsourcing platform using caregivers who may not have had a child with AD.

STUDY EXPOSURE

Caregivers were randomized to eight groups. The three main groups were given clinical trial evidence, anecdote, or a combination of both. Each of these three groups was further divided and presented with either the term 'medication' or 'topical steroid'. These were compared with the two remaining groups, which included a group told that they would not be informed of a medication's efficacy or safety profile, and a group informed that the medication was recommended by the doctor.

OUTCOME

Caregivers were asked about their willingness to treat based on the information they had received using a 10-point Likert scale where 1 was 'not willing' and 10 'completely willing'.

RESULTS

A total of 476 caregivers were recruited (80 clinic, 396 online), 48% of whom had a history of a child with AD. Caregivers' willingness to treat was higher in all information assignment groups compared with those not provided with safety information: clinical trial evidence of a 'medication' (P = 0·003; Cohen's d = 0·83) or 'topical steroid' (P = 0·030; d = 0·55), anecdote of a 'medication' (P < 0·0001; d = 1·37) or 'topical steroid' (P < 0·0001; d = 0·85), both clinical trial evidence and anecdote of a 'medication' (P < 0·0001; d = 1·00) or 'topical steroid' (P = 0·000; d = 0·89), and simply the doctor's recommendation (P < 0·0001; d = 0·92).

CONCLUSION

Johnson et al. conclude that the provision of anecdotal reassurance may be an effective strategy to improve caregivers' willingness to use topical steroids.

COMMENT

Exploring factors that affect caregivers' willingness to adhere to topical corticosteroids is an important area of research. This study was a potentially efficient way of conducting a rapid RCT to explore such factors. The study conclusions are significantly undermined by lack of a registered trial protocol, poor trial reporting, the use of caregivers who did not have experience of AD, the multiplicity and complexity of treatment arms, and the use of an unvalidated primary outcome.

Corticosteroid phobia: a questionnaire study using TOPICOP score

INTRODUCTION

Topical corticosteroids (TCS) are commonly used in dermatology for their anti-inflammatory action. The recent development of the TOPICOP© (Topical Corticosteroid Phobia) scale to assess steroid phobia has made the quantification and comparison of steroid phobia easier. The objective of this study was to assess the degree of steroid phobia at our institute and identify sources from which patients obtain information regarding TCS.

METHODS

A cross-sectional survey was performed of dermatology patients regardless of steroid use. TOPICOP scale was used for the survey. Sources from which patients obtained information were identified and their level of trust in these sources assessed.

RESULTS

186 surveys were analysed. The median domain TOPICOP subscores were 38.9% (interquartile range [IQR] 27.8%-50.0%, standard deviation [SD] 24.4%) for knowledge and beliefs, 44.4% (IQR 33.3%-66.7%, SD 24.4%) for fears and 55.6% (IQR 33.3%-66.7%, SD 27.2%) for behaviour. The median global TOPICOP score was 44.4% (IQR 33.3%-55.6%, SD 17.6%). Female gender was associated with higher behaviour, fear and global TOPICOP scores. There was no difference in the scores based on disease condition, steroid use, age or education. Dermatologists were the most common source of information on topical steroids and trust was highest in dermatologists.

CONCLUSION

The prevalence of steroid phobia in our dermatology outpatient setting was moderately high, with gender differences. Dermatologists were the most common source of information on TCS, and it was heartening to note that trust was also highest in dermatologists. Strategies to target steroid phobia should take into account these factors.

Assessing the Effect of Clinical Trial Evidence and Anecdote on Caregivers’ Willingness to Use Corticosteroids: A Randomized Controlled Trial

Background:

Treatment of childhood atopic dermatitis (AD) is hindered by nonadherence, but caregiver reassurance may help overcome this hurdle.

Objectives:

To assess caregivers’ willingness to treat childhood AD with a corticosteroid when presented with clinical trial evidence, anecdote, or both.

Methods:

A total of 476 caregivers were recruited through a dermatology clinic and online crowdsourcing platform. Subjects were randomized to receive clinical trial evidence, anecdote, or both, using either the term “medication” or “topical steroid.” Additional caregivers were queried about their willingness to treat with the doctor’s recommendation or without knowledge of its safety information. Responses were recorded on a 10-point Likert scale.

Results:

Caregivers’ willingness to treat was higher in all information assignment groups compared to those not provided with safety information: clinical trial evidence of a “medication” ( P = .003; Cohen’s d = 0.83) or “topical steroid” ( P = .030; d = 0.55), anecdote of a “medication” ( P < .0001; d = 1.37) or “topical steroid” ( P < .0001; d = 0.85), both clinical trial evidence and anecdote of a “medication” ( P < .0001; d = 1.00) or “topical steroid” ( P = .000; d = 0.89), and simply the doctor’s recommendation ( P < .0001; d = 0.92). Significance was corrected for multiple comparisons to 0.0018. There were no differences between caregivers of children with and without AD ( P = .36).

Conclusions:

Providing anecdotal reassurance, even in the setting of reported high willingness to treat with the doctor’s recommendation, may be an effective strategy to improve caregivers’ perceptions of starting new medications.

Atopic dermatitis disease registry in Japanese adult patients with moderate to severe atopic dermatitis (ADDRESS-J): Baseline characteristics, treatment history and disease burden

Moderate to severe atopic dermatitis (AD) has a high disease burden and a significant effect on quality of life. Observational studies are necessary to determine the patient disease burden and long-term disease control in the Japanese population. ADDRESS-J is a non-interventional, observational registry of adult Japanese patients with moderate to severe AD. Herein, we report baseline data from the ADDRESS-J study describing disease characteristics and current treatment practices. At baseline, 300 adult AD patients with Investigator's Global Assessment (IGA) scores (range, 0-4) of 3 (moderate) or 4 (severe) whose treatments for AD were intensified, were assessed for clinical and patient-reported outcomes and current AD treatments. The registry patients' median age was 34.0 years; 60.7% were male and 71.7% had had AD for more than 20 years. At baseline, 220 study patients had an IGA score of 3 and 80 had an IGA score of 4. The median Eczema Area and Severity Index score was 21.7 (range, 0-72), the median body surface area involvement was 46.25%, and the median pruritus numerical rating scale score was 7.0 (range, 0-10); for each of these measures, higher scores represent greater severity. Most registry patients (86.7%) had recently used topical corticosteroids or topical calcineurin inhibitors as treatment for AD. This registry cohort represents a population of Japanese patients with moderate to severe AD and provides an important resource for characterizing the disease burden and evaluating the safety and effectiveness of various AD treatments.

Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part I

This guideline was developed as a joint interdisciplinary European project, including physicians from all relevant disciplines as well as patients. It is a consensus-based guideline, taking available evidence from other guidelines, systematic reviews and published studies into account. This first part of the guideline covers methods, patient perspective, general measures and avoidance strategies, basic emollient treatment and bathing, dietary intervention, topical anti-inflammatory therapy, phototherapy and antipruritic therapy, whereas the second part covers antimicrobial therapy, systemic treatment, allergen-specific immunotherapy, complementary medicine, psychosomatic counselling and educational interventions. Management of AE must consider the individual clinical variability of the disease; highly standardized treatment rules are not recommended. Basic therapy is focused on treatment of disturbed barrier function by hydrating and lubricating topical treatment, besides further avoidance of specific and unspecific provocation factors. Topical anti-inflammatory treatment based on glucocorticosteroids and calcineurin inhibitors is used for flare management and for proactive therapy for long-term control. Topical corticosteroids remain the mainstay of therapy, whereas tacrolimus and pimecrolimus are preferred in sensitive skin areas and for long-term use. Topical phosphodiesterase inhibitors may be a treatment alternative when available. Adjuvant therapy includes UV irradiation, preferably with UVB 311 nm or UVA1. Pruritus is targeted with the majority of the recommended therapies, but some patients may need additional antipruritic therapy. Antimicrobial therapy, systemic anti-inflammatory treatment, immunotherapy, complementary medicine and educational intervention will be addressed in part II of the guideline.

Steroid phobia among general users of topical steroids: a cross-sectional nationwide survey

OBJECTIVE

The aim of this study was to assess steroid phobia among general users of topical corticosteroids and to analyze factors associated with steroid phobia.

METHODS

A cross-sectional nationwide survey was conducted using an online panel with participants stratified by age, sex, and region. Those aged 18-65 years with experience of topical steroid use within the past 1 year were included.

RESULTS

Of the 3000 respondents included, 929 (31%) had steroid phobia. Among those with steroid phobia, 322 (35%) reported that their fear developed after obtaining information from the media. Weight gain, asthma, skin thinning, growth stunting, and skin aging were the side effects cited as the main reasons behind development of steroid phobia. Female respondents and those with experience of the side effects of topical steroids were more likely to have steroid phobia, while those who obtained information on topical steroid use from a healthcare professional were less likely to have steroid phobia.

CONCLUSIONS

Steroid phobia among general users of topical steroids appears to be relatively high despite most of them being non-chronic topical steroid users. Healthcare professionals should not refrain from counseling patients, but instead actively address the issues leading to fears in patients.

Awareness of and phobias about topical corticosteroids in parents of infants with eczema in Hangzhou, China

BACKGROUND/OBJECTIVES

Knowledge of and phobias about topical corticosteroids in parents of infants with eczema affect efficacy of eczema treatment.

METHODS

We surveyed 300 parents of children with eczema using a questionnaire to investigate knowledge of and phobias about topical corticosteroids.

RESULTS

Overall, 85.7% (n = 257) of children had used topical corticosteroids, with 12.8% (n = 33) of children having steroids applied for only 1-3 days per episode; 79.4% (n = 204) of patients discontinued topical steroid therapy immediately after improvement. Twenty-five percent (n = 75) of parents refused a prescription of steroid ointment, and 32.3% (n = 97) did not use the steroid ointment on their children despite having received a prescription. During steroid treatment, 95.7% (246) of parents were very concerned about the side effects of topical steroids. One hundred eight parents (42%) did not use a topical steroid ointment for recurrence of eczema because of concerns about using topical corticosteroids.

CONCLUSION

Most parents of infants with eczema had excessive concerns about topical corticosteroids, leading to inadequate treatment of atopic dermatitis. In clinical practice, physicians should reinforce parents' understanding of steroid treatment for eczema and guide rational use of topical steroids for infantile eczema.

Topical Corticosteroid Concerns Among Parents of Children with Psoriasis versus Atopic Dermatitis: A French Multicenter Cross-Sectional Study

BACKGROUND

Atopic dermatitis (AD) and psoriasis are chronic inflammatory cutaneous disorders for which the gold standard treatment is topical corticosteroids. Although fears about topical corticosteroids are known to be a primary cause of poor therapeutic adherence in AD, this has not been evaluated in psoriasis. TOPICOP is a helpful and easy-to-use tool for the evaluation of topical corticosteroid concerns (TCC). It may help clinicians improve adherence to treatment and correct misconceptions.

OBJECTIVE

We aimed to compare the TCC of parents of children with psoriasis or AD using the TOPICOP scale and a visual analog scale (VAS).

METHODS

We performed a cross-sectional multicenter study in nine French hospitals from 1 October 2015 to 31 May 2016. The TOPICOP scale was developed for patients with AD and comprises 12 questions to assess patients' worries and beliefs about topical corticosteroids, with a maximum score of 36. We used a standardized questionnaire to collect epidemiologic and medical data, and the parents completed the TOPICOP scale and VAS (score 0-10).

RESULTS

A total of 122 children were enrolled (61 patients in each group). The mean Physician Global Assessment was 2.1 in the psoriasis group, and the mean SCORing AD index was 33.3 in the AD group. The TOPICOP score was 16.0 in the psoriasis group and 18.8 in the AD group (p = 0.10). The VAS score was 5.6 and 5.1 in the psoriasis and AD groups, respectively (p = 0.18). The mean TOPICOP score was higher if the mother answered (p < 0.0001; odds ratio 12.3; 95% confidence interval 9.2-15.5). In the AD group, the mean TOPICOP score was higher if follow-up for the child was as an outpatient (p = 0.018). In the psoriasis group, the mean TOPICOP score was higher if patients were seen for the first time (p = 0.047).

CONCLUSION

Using the TOPICOP questionnaire and a VAS, we found the level of TCC for the parents of pediatric patients with psoriasis to be similar to that for parents of pediatric patients with AD. As TCC is an issue in patients with psoriasis, future research is warranted to assess whether therapeutic education lessens TCC and improves treatment outcomes.

Non-corticosteroid adherence and itch severity influence perception of itch in atopic dermatitis

Topical corticosteroid phobia is an important problem in the treatment of atopic dermatitis as it can affect the ability to control disease severity and itch by reducing treatment adherence. Topical corticosteroid phobia often ends up even non-corticosteroid adherence. As such, non-corticosteroid adherence, disease severity and itch are likely to be associated with each other, but their relationship has yet to be thoroughly investigated. Thus, the purpose of this study is to investigate it in atopic dermatitis. Using data from 1190 participants in an Internet survey, we identified 255 non-corticosteroid users and 225 with moderate to severe itch who were defined as non-corticosteroid adherents. Corticosteroid users with the same itch categories (n = 878) served as controls. We also examined how itch severity affects the perception of itch in atopic dermatitis. Unexpectedly, non-corticosteroid adherents were less sensitive to the conditions to elicit itch such as perspiring, commuting homeward, drinking alcohol and wearing woolen clothes compared with the control. We also found that patients with severer itch were more sensitive to itch during/after bathing, when lying in bed, commuting homeward, studying/working, drinking alcohol, undressing, getting up in the morning, after a meal, ingesting piquant foods and when they were unoccupied, angry, busy, nervous, sad or enjoying themselves. In conclusion, we found that non-corticosteroid adherence and itch severity influence perception of itch in atopic dermatitis and discuss possible mechanisms underlying these results. The information obtained in this study may be useful for communication with and education of atopic dermatitis patients and their treatment in outpatient clinics.

Topical E6005/RVT-501, a novel phosphodiesterase 4 inhibitor, for the treatment of atopic dermatitis

INTRODUCTION

Local adverse effects of steroid use and the burning sensation of calcineurin inhibitors impair patients' adherence to treatment and decrease the treatment response in atopic dermatitis (AD). Steroid phobia appears to be a psychological problem in patients with AD. Topical non-steroidal remedies are in demand. Areas covered: This manuscript reviews the current literature on preclinical and clinical studies regarding topical E6005/RVT-501, a novel phosphodiesterase 4 inhibitor. We also discuss the mechanistic background of E6005/RVT-501 in the treatment of AD. Expert opinion: Topical E6005/RVT-501 improves skin eruption and pruritus of pediatric and adult AD patients without any serious side effects. It is useful for mild to moderate lesions of AD in pediatric and adult patients. Topical E6005/RVT-501 is non-steroidal agent but its potency is equal to that of mild rank topical steroid, therefore, it may fit the demand of patients with steroid phobia. Its steroid-sparing effects may also be investigated in future clinical trials and may minimize the dose and frequency of topical steroids.

Topical corticosteroid phobia in parents of pediatric patients with atopic dermatitis: a multicentre survey

Background

Families of children affected with atopic dermatitis (AD) often report fear and anxiety regarding treatment with topical corticosteroids (TCS), which may lead to reduced compliance. The objective of our study was to measure, through a standardized questionnaire, fear of TCS in families of pediatric patients with AD and to identify items associated with fear.

Methods

Families of pediatric patients with AD were enrolled in 9 Italian centers of pediatric dermatology. Enrolled parents were invited to fill in a questionnaire including questions on sociodemographic and clinical characteristics and 3 sets of questions on corticosteroid phobia (general fear, specific fears, behaviours regarding TCS). Determinants of the level of general fear were investigated through multivariable analysis.

Results

A total of 300 outpatients with AD were enrolled. Most parents (80%) had a high instruction level. Eighty-one percent reported to have a certain amount of fear of TCS. At the multivariable analysis, fear of TCS was associated with the following items: believing that TCS treatment advantages do not overweight disadvantages (P = 0.011); believing that TCS may be dangerous independently from the specific side effect (P < 0.001). Moreover, TCS fear was associated with fear of applying too much cream (P = 0.001).

Conclusion

TCS phobia is widespread among Italian families of children with AD. Fear of TCS is associated with fear of applying too much cream, thus increasing the risk of poor compliance and treatment failure. Therapeutic education of families on the use of TCS should be implemented.

Electronic supplementary material

The online version of this article (doi:10.1186/s13052-017-0330-7) contains supplementary material, which is available to authorized users.

Topical corticosteroid concerns from the clinicians' perspective

PURPOSE

Topical corticosteroids concerns (TCC) are common in dermatology patients, possibly leading to non-adherence to topical corticosteroids (TCS) and poor disease control. Clinicians play a key role in that context, as they can reduce or reinforce these concerns. It is unknown, if clinicians have accurate knowledge of TCC to appropriately address this issue and whether they have concerns themselves to use TCS. This questionnaire-based study aimed to assess these two aspects.

MATERIALS AND METHODS

Accuracy of knowledge was defined by how close the clinicians' estimates were to reference values of our previous study, in which we had examined TCC in dermatology outpatients. Moreover, clinicians indicated whether they have concerns themselves to use TCS.

RESULTS

Totally 202 clinicians participated. They underestimated both the prevalence of TCC and the resulting non-adherence. Whereas most clinicians correctly estimated characteristics of patients with TCC and the impact of patient information, only 31% of clinicians knew that skin atrophy was the leading concern, and only 30% correctly ranked the reasons for TCC. 74% of the clinicians had at least minor concerns themselves.

CONCLUSION

The majority of clinicians may have inaccurate knowledge of certain aspects of TCC and own concerns to use TCS.

Parents' and carers' views about emollients for childhood eczema: qualitative interview study

OBJECTIVE

Leave-on emollients form the mainstay of eczema treatment, but adherence is poor. We aimed to explore parents'/carers' views on effectiveness and acceptability of leave-on emollients for childhood eczema through secondary analysis of data from 2 qualitative data sets.

SETTING

Study 1 recruited through mail-out from 6 general practices in southern England. Study 2 recruited from a feasibility trial of an intervention to support eczema self-care in 31 practices in the same area.

PARTICIPANTS

Study 1 included 28 interviews with carers of children aged ≤5 years with eczema. Study 2 included 26 interviews with carers of children aged ≤5 years with eczema.

METHODS

Interviews followed semistructured guides: study 1 explored carers' understandings around eczema treatments in order to develop a web-based self-care support intervention; study 2 explored carers' understandings of eczema and eczema treatments after using the intervention. Interviews were carried out face to face or by telephone, audio-recorded and transcribed. Secondary analysis of data from both studies focused on views and experiences of emollient use. Data were analysed using an inductive thematic approach facilitated by NVivo V.10 software.

RESULTS

In study 1, most participants felt emollients improved eczema but held mixed views about long-term use to prevent flare-ups. In study 2, where carers had used the web-based intervention, all participants held positive views about long-term emollient use. In both studies, participants expressed a range of preferences about emollient 'thickness'; some felt that 'thick' emollients (ointments) were most effective, while others found these difficult to use. Carers described a process of 'trial and error', trying emollients suggested by professionals, friends and family, or bought over-the-counter. Carers expressed a need for understanding differences between products and their effective use.

CONCLUSIONS

Providing a rationale for long-term emollient use and choice of emollients could help improve adherence and help families gain more rapid control of eczema.

Crisaborole and its potential role in treating atopic dermatitis: overview of early clinical studies

Atopic dermatitis (AD), a chronic, relapsing, inflammatory skin disease that is characterized by intense pruritus and eczematous lesions with up to 90% of patients presenting with mild to moderate disease. Current topical treatments for AD have not changed in over 15 years and are associated with safety concerns. In AD, overactivity of phosphodiesterase 4 (PDE4), leads to inflammation and disease exacerbation. Crisaborole Topical Ointment, 2%, is a novel, nonsteroidal, topical anti-inflammatory PDE4 inhibitor currently being investigated for the treatment of mild to moderate AD. Preliminary studies in children and adults demonstrated favorable efficacy and safety profiles. Crisaborole may represent an anti-inflammatory option that safely minimizes the symptoms and severity of AD and that can be used for both acute and long-term management.

Topical Corticosteroid Concerns in Dermatological Outpatients: A Cross-Sectional and Interventional Study

BACKGROUND/AIMS

Topical corticosteroid concerns (TCC) are an important issue in patients with atopic dermatitis, leading to non-adherence with poor disease control and increased health care costs. However, neither the prevalence of TCC in a more comprehensible dermatological population nor the impact of patient information on topical corticosteroids given by clinicians is known. Therefore, we assessed the prevalence, characteristics, and sources of TCC in a dermatological population and the impact of written and oral patient information on TCC.

METHODS

A total of 643 outpatients with various skin diseases answered a 12-item questionnaire while waiting for the doctor's visit. Patients with TCC quantified their concerns on a discrete visual analogue scale before and after patient information, which consisted of written and oral information about topical corticosteroids (TCS) given by dermatologists.

RESULTS

The prevalence of TCC was 41.5%, and that of TCC-related non-adherence was 28.3%. TCC was positively associated with age <60 years, female gender, use of complementary and alternative medicine (CAM) and non-physician health care profession. The leading concerns were skin atrophy, systemic effects, and impairment of the immune system. The most frequent sources of TCC were negative reports by media, family, or friends. Both written and oral patient information significantly reduced TCC. The number needed to benefit from patient information was approximately 2. Non-responders were more often female, TCS-inexperienced, and users of CAM with an intermediate level of education.

CONCLUSIONS

TCC are highly prevalent in dermatological patients. Patient information may lower TCC in almost every second patient.

Systematic review of published trials: long-term safety of topical corticosteroids and topical calcineurin inhibitors in pediatric patients with atopic dermatitis

BACKGROUND

Many clinicians have concerns about the safety of atopic dermatitis (AD) treatments, particularly in children requiring long-term daily maintenance therapy. Topical corticosteroids (TCS) have been widely used for >5 decades. Long-term TCS monotherapy has been associated with adverse cutaneous effects including atrophy, rebound flares, and increased percutaneous absorption with potential for adverse systemic effects. Topical calcineurin inhibitors (TCIs), tacrolimus and pimecrolimus, available for 1-2 decades, are not associated with atrophy or increased percutaneous absorption after prolonged use and have much lower potential for systemic effects. However, since 2006 TCIs have carried a controversial Boxed Warning based on a theoretical risk of malignancy (eg, skin and lymphoma) that has limited TCI use for standard-of-care maintenance therapy.

METHODS

A comparative systematic search of PubMed was done for long-term (≥12 week) clinical trials of TCS or TCI treatment in patients <12 years with AD. Citations were reviewed for inclusion based on MeSH terms, abstracts, and relevant article text. Studies were excluded if they did not encompass subjects <12 years, or were <12 weeks' duration, retrospective, meta-analyses, or limited to anecdotal case reports.

RESULTS

Of 27 trials meeting criteria, 21 included 5825 pediatric patients treated with TCIs, and 6 included 1999 patients treated with TCS. TCS studies were limited to low- to mid-potency products, and all but one study lacked a vehicle control. Eight TCI studies were vehicle-controlled, and safety data were well reported, with ≤5 % of patients reporting discontinuation due to adverse effects (DAEs). Cutaneous and systemic adverse events (AEs) were similar in TCI and vehicle groups, with no reports of lymphoma. Safety data in TCS trials were less well reported. DAE incidence was addressed in just 2 trials, and systemic and cutaneous AEs were mostly unreported.

CONCLUSIONS

Data supporting long-term use of TCIs are robust, documenting safety and efficacy, while data supporting long-term TCS use are limited to low- to mid-potency products. Our review identifies a lack of information on the safety of commonly prescribed, long-term monotherapy with mid- to high-potency TCS in pediatric AD, and supports standard-of-care maintenance therapy with TCIs and intermittent use of low- to mid-potency TCS for flares.

The impact of the National Institute for Health Research Health Technology Assessment programme, 2003-13: a multimethod evaluation

BACKGROUND

The National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme supports research tailored to the needs of NHS decision-makers, patients and clinicians. This study reviewed the impact of the programme, from 2003 to 2013, on health, clinical practice, health policy, the economy and academia. It also considered how HTA could maintain and increase its impact.

METHODS

Interviews (n = 20): senior stakeholders from academia, policy-making organisations and the HTA programme. Bibliometric analysis: citation analysis of publications arising from HTA programme-funded research. Researchfish survey: electronic survey of all HTA grant holders. Payback case studies (n = 12): in-depth case studies of HTA programme-funded research.

RESULTS

We make the following observations about the impact, and routes to impact, of the HTA programme: it has had an impact on patients, primarily through changes in guidelines, but also directly (e.g. changing clinical practice); it has had an impact on UK health policy, through providing high-quality scientific evidence - its close relationships with the National Institute for Health and Care Excellence (NICE) and the National Screening Committee (NSC) contributed to the observed impact on health policy, although in some instances other organisations may better facilitate impact; HTA research is used outside the UK by other HTA organisations and systematic reviewers - the programme has an impact on HTA practice internationally as a leader in HTA research methods and the funding of HTA research; the work of the programme is of high academic quality - the Health Technology Assessment journal ensures that the vast majority of HTA programme-funded research is published in full, while the HTA programme still encourages publication in other peer-reviewed journals; academics agree that the programme has played an important role in building and retaining HTA research capacity in the UK; the HTA programme has played a role in increasing the focus on effectiveness and cost-effectiveness in medicine - it has also contributed to increasingly positive attitudes towards HTA research both within the research community and the NHS; and the HTA focuses resources on research that is of value to patients and the UK NHS, which would not otherwise be funded (e.g. where there is no commercial incentive to undertake research). The programme should consider the following to maintain and increase its impact: providing targeted support for dissemination, focusing resources when important results are unlikely to be implemented by other stakeholders, particularly when findings challenge vested interests; maintaining close relationships with NICE and the NSC, but also considering other potential users of HTA research; maintaining flexibility and good relationships with researchers, giving particular consideration to the Technology Assessment Report (TAR) programme and the potential for learning between TAR centres; maintaining the academic quality of the work and the focus on NHS need; considering funding research on the short-term costs of the implementation of new health technologies; improving the monitoring and evaluation of whether or not patient and public involvement influences research; improve the transparency of the priority-setting process; and continuing to monitor the impact and value of the programme to inform its future scientific and administrative development.

Topical steroid therapy in atopic dermatitis in theory and practice

INTRODUCTION

Topical glucocorticosteroids (GCSs) are commonly used in treatment of atopic dermatitis (AD).

AIM

To assess the patients' compliance with the recommended instructions of the therapy.

MATERIAL AND METHODS

The study involved 141 adult AD patients. The clinical course of AD and its treatment with GCSs during the last year were analysed.

RESULTS

In the periods of exacerbation the lesions involved 10-50% of the skin surface area. Outpatient treatment in specialised dermatological and/or allergology clinics was given to 93% of the study subjects. Sixty-five out of 141 patients regularly attended medical control examinations. Glucocorticosteroids, mostly very potent ones (70.2%), were applied to all the subjects. 66.7% of patients obtained no information about their medications' anti-inflammatory potential. The substances were applied more frequently than twice daily by 36.4% of the patients. Seventy-two of 141 subjects applied GCSs both temporarily and in the long-term treatment, for 8.3 weeks on average. In the long-term treatment, in which very potent GCSs predominated (70.7%), no one used intermittent therapy. One hundred and thirty patients introduced their own modifications to the instructions concerning GCSs use, among which 37.7% changed the site of application, 58.5% prolonged the duration of application and 49.5% shortened it or occasionally temporarily withdrew the prescribed drug. None of the patients knew the fingertip unit method of dose assessment. Apart from steroid therapy, 56.7% of the patients carried out regular care treatment.

CONCLUSIONS

The AD patients need to be thoroughly educated by the medical staff in the topical GCSs therapy in atopic dermatitis.

Advances in the diagnosis and therapeutic management of atopic dermatitis

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

Validation of treatment escalation as a definition of atopic eczema flares

BACKGROUND

Atopic eczema (AE) is a chronic disease with flares and remissions. Long-term control of AE flares has been identified as a core outcome domain for AE trials. However, it is unclear how flares should be defined and measured.

OBJECTIVE

To validate two concepts of AE flares based on daily reports of topical medication use: (i) escalation of treatment and (ii) days of topical anti-inflammatory medication use (topical corticosteroids and/or calcineurin inhibitors).

METHODS

Data from two published AE studies (studies A (n=336) and B (n=60)) were analysed separately. Validity and feasibility of flare definitions were assessed using daily global bother (scale 0 to 10) as the reference standard. Intra-class correlations were reported for continuous variables, and odds ratios and area under the receiver operator characteristic (ROC) curve for binary outcome measures.

RESULTS

Good agreement was found between both AE flare definitions and change in global bother: area under the ROC curve for treatment escalation of 0.70 and 0.73 in studies A and B respectively, and area under the ROC curve of 0.69 for topical anti-inflammatory medication use (Study A only). Significant positive relationships were found between validated severity scales (POEM, SASSAD, TIS) and the duration of AE flares occurring in the previous week - POEM and SASSAD rose by half a point for each unit increase in number of days in flare. Smaller increases were observed on the TIS scale. Completeness of daily diaries was 95% for Study A and 60% for Study B over 16 weeks).

CONCLUSION

Both definitions were good proxy indicators of AE flares. We found no evidence that 'escalation of treatment' was a better measure of AE flares than 'use of topical anti-inflammatory medications'. Capturing disease flares in AE trials through daily recording of medication use is feasible and appears to be a good indicator of long-term control.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN71423189 (Study A).

Atopic dermatitis

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

Detection of veterinary drug residues in surface waters collected nearby farming areas in Galicia, North of Spain

The occurrence of pharmaceuticals in the aquatic environment has become a matter of concern in the last decade due to potential risks posed to non-target organisms and the potential for unintended human exposure via food chain. This concern has been driven by a high detection frequency for drugs in environmental samples; these substances are produced in large quantities and are used in both veterinary and human medicine, leading to deposition and potential effects in the environment. However, few studies have focused on the presence of pharmaceuticals in rural areas associated with farming activities in comparison to urban areas. The aim of this study is to investigate the occurrence of pharmaceutically active compounds in surface waters collected from urban and rural areas in northwestern Spain. A monitoring study was conducted with 312 river water samples analysed by high-performance liquid chromatography coupled to tandem mass spectrometry. Positive detection of pharmaceuticals was made for 51 % of the samples. Decoquinate, sulfamethazine, sulfamethoxypyridazine and trimethoprim were the drugs most frequently detected, being present in more than 10 % of the samples. The sampling sites located downstream of the discharge points for wastewater treatment plants yielded the highest number of positive samples, 13 % of the positive samples were detected in these sites and 38 % of the samples collected near the collection point of a drinking water treatment plant were positive.

Oral administration of poly-γ-glutamate ameliorates atopic dermatitis in Nc/Nga mice by suppressing Th2-biased immune response and production of IL-17A

Atopic dermatitis (AD) is a chronic inflammatory skin disease that is closely related to dysregulation of the T helper type 1 and 2 (Th1)/Th2 balance. A previous study showed that high molecular mass poly-γ-glutamate (γ-PGA) isolated from Bacillus subtilis sp. Chungkookjang induces the production of IL-12 from dendritic cells (DCs). Here, we investigated the effect of γ-PGA on AD-like skin disease using an Nc/Nga mouse model. In vitro, γ-PGA activated DCs and induced IL-12 production in mice. In vivo, oral administration of γ-PGA markedly reduced the AD symptoms, similar to the response seen in the dexamethasone (Dex)-treated group. Treatment with γ-PGA also decreased the serum levels of IgG1, the skin levels of Th2 cytokines, the extent of skin inflammation, and the accumulation of mast cells. Furthermore, γ-PGA was effective against established AD, significantly decreasing serum IgE and Th2 cytokines in the inflamed tissue. Interestingly, the production of IL-17A in splenocytes was also suppressed by γ-PGA, indicating that it inhibits both Th2 and Th17 immune responses. Collectively, these results suggest that oral administration of γ-PGA could be a therapeutic strategy for treating AD via the modulation of Th2-biased immune responses in an Nc/Nga mouse model.