Antibacterial and antibiofilm effects of sodium hypochlorite against Staphylococcus aureus isolates derived from patients with atopic dermatitis

Fruit vinegar as a promising source of natural anti-inflammatory agents: an up-to-date review

OBJECTIVES

Fruit vinegar is one of the most famous fruit byproducts worldwide with several unique properties. There are two types of fruit vinegar, artisanal and industrial, for consumers to choose from. This review aims to assess for the first time the phytochemistry of fruit vinegar and its anti-inflammatory effects.

METHOD

The present work was conducted based on a literature search that selected the relevant papers from indexed databases such as Scopus, Science Direct, MDPI, PubMed, Hindawi, and Web of Science. We used numerous terms to assure a good search in different databases, including fruit vinegar, phytochemistry, bioavailability and bioaccessibility, and anti-inflammatory effect. All articles were selected based on their relevance, quality, and problematic treatment.

RESULTS

Literature data have shown that vinegar has a long medicinal history and has been widely used by different civilizations, due to its richness in bioactive molecules, vinegar plays an important role in the prevention and treatment of various inflammatory diseases, including atopic dermatitis, mastitis, asthma, arthritis, acute pancreatitis, and colitis. Fruit vinegar consumption benefit is highly dependent on its chemical composition, especially organic acids and antioxidants, which can act as nutraceuticals.

CONCLUSION

Fruit vinegar has a rich chemical composition, including organic acids that can be transformed in the digestive system into compounds that play an important role in health-promoting features such as anti-inflammatory effects throughout the control of intestinal microbiota and pro-inflammatory cytokine production.

Atopic Dermatitis in Children

Atopic dermatitis (AD) is extremely common in the pediatric population, and most children with AD will first present to their primary care provider (PCP). The PCP can recognize AD by its clinical features, including itch, a chronic relapsing course, and the characteristic eruption. The cornerstone of AD therapy is dry skin care, typically a short daily bath/shower followed by an emollient applied to all skin. Most children with AD will also require topical medications, such as topical corticosteroids and/or topical nonsteroidal therapies. For children with more severe disease, systemic agents, including several novel therapies, may be required. In managing AD, the clinician must monitor for side effects of medications as well as complications of the AD itself, the most common of which is secondary infection. An understanding of the pathogenesis, treatments, and complications of AD is essential for the PCP, as untreated (or undertreated) AD has a significant impact on the quality of life of affected children and their caregivers. [Pediatr Ann. 2024;53(4):e121-e128.].

Effect of Potassium Permanganate on Staphylococcal Isolates Derived from the Skin of Patients with Atopic Dermatitis

In atopic dermatitis (AD), Staphylococcus aureus frequently colonizes lesions, leading to superinfections that can then lead to exacerbations. The presence of biofilm-producing isolates has been associated with worsening of the disease. Potassium permanganate is used as a topical treatment of infected eczema, blistering conditions, and wounds. Little is known of its effects against microbes in AD skin. The aim of this study was to explore antibacterial and antibiofilm properties of potassium permanganate against staphylococcal isolates derived from AD skin. Viable count and radial diffusion assays were used to investigate antibacterial effects of potassium permanganate against planktonic staphylococcal isolates. The antibiofilm effects were assessed using biofilm assays and scanning electron microscopy. The Staphylococcus aureus isolates were completely killed when exposed to 0.05% of potassium permanganate. In concentrations of 0.01%, potassium permanganate inhibited bacterial biofilm formation. Eradication of established staphylococcal biofilm was observed in concentrations of 1%. Electron microscopy revealed dense formations of coccoidal structures in growth control and looser formations of deformed bacteria when exposed to potassium permanganate. This suggests antibacterial and antibiofilm effects of potassium permanganate against staphylococcal isolates derived from AD skin, when tested in vitro, and a potential role in the treatment of superinfected AD skin.

Bathing in Atopic Dermatitis in Pediatric Age: Why, How and When

Atopic dermatitis is a chronic inflammatory skin disease. The treatment plays an important role in influencing the patients' quality of life. The basic management consists of appropriate skin cleansing, including bathing and eventually using bathing additives. Recommendations regarding frequency and duration of bathing, water temperature and usefulness of bathing additives are widely different, often leading to confusion among patients. This review aims to give insights into the best bathing practices and the use of bathing additives in atopic dermatitis in children. Several bathing additives, including bleach baths, commercial baby cleansers, bath baby oils and bath salt, appear to be promising adjunctive therapies for atopic dermatitis due to their anti-inflammatory, anti-bacterial, anti-pruritus and skin barrier repair properties through different mechanisms of action. However, their efficacy and safety are not fully understood in some cases. The usefulness of other bath additives, such as acidic and more natural substances (green tea extracts, pine tar, sodium bicarbonate), is still under investigation. Further studies are needed to determine their optimal use to achieve clinical benefit safely.

Bleach baths enhance skin barrier, reduce itch but do not normalize skin dysbiosis in atopic dermatitis

Studies have demonstrated that bleach baths improve atopic dermatitis (AD) severity; however, the effects on itch, skin barrier, and cutaneous microbial composition are less clear. We examined whether bleach baths reduce itch, normalize skin barrier function, reduce S. aureus absolute abundance, and increase microbial diversity in adults with AD who were colonized with S. aureus on their non-lesional skin. This was an open label, non-randomized, controlled trial performed at a single academic center. Fifteen AD and five non-atopic healthy controls (NA) were instructed to take two bleach baths (0.005% NaClO; 5-10 min duration) per week for a total of 12 weeks as add-on therapy. Adults 18 to 65 years (inclusive) with mild to severe AD were recruited with EASI score > 6.0, S. aureus culture positivity, access to a bathtub, and ability and willingness to maintain current topical or systemic treatments. They were evaluated at baseline (before bleach baths), 6 weeks, and 12 weeks after the intervention of twice-weekly bleach baths. Efficacy measurements included EASI as well as 5-D Pruritus and ItchyQoL™. Transepidermal water loss (TEWL) and stratum corneum (SC) integrity assay were performed to assess the skin barrier. Skin dysbiosis was measured by S. aureus cultivation, S. aureus abundance (qPCR of thermonuclease gene), and V1-V3 16S rRNA gene sequencing on non-lesional and lesional AD skin. After 12 weeks of bleach baths, 8/15 (53.3%) AD subjects achieved an EASI50 and a significant reduction in itch as measured by 5-D pruritus and Itchy QoL. Eighty-seven percent reported improvements in sleep quality. At study entry, AD subjects had higher non-lesional TEWL values than NA subjects, and only AD subjects experienced a reduction with bleach baths (p = 0.006). Similarly, SC integrity improved as early as 6 weeks after bleach baths in AD subjects. Notably, bleach baths had no significant effect on S. aureus culture-positivity, qPCR absolute abundance, or microbial diversity. The addition of twice-weekly bleach baths improves investigator-assessed AD severity, patient-reported pruritus and sleep as well as physiological measures of skin barrier function in adult AD subjects while having no effect on qualitative and quantitative measures of cutaneous S. aureus. Trial Registration: ClinicalTrials.gov Identifier: NCT01996150, Date of registration: November 27th, 2013.

Skin Antiseptics for Atopic Dermatitis: Dissecting Facts From Fiction

Staphylococcus aureus is a known trigger and cause of infectious complications in atopic dermatitis (AD). Various antiseptics have been used in an attempt to decrease the burden of S. aureus in AD. In this Commentary, we present the evidence for and against some of the commonly used antiseptics in clinical and research settings. These agents remain attractive as an adjunct therapy for AD owing to their relative low cost and potential benefits of reducing S. aureus. Although a number of studies have evaluated the use of dilute bleach, its mechanisms remain controversial. A higher concentration of bleach than the commonly used 0.005% is likely needed for its anti-S. aureus effect. Silver-coated textiles have demonstrated anti-S. aureus effects in various studies; however, their efficacy and side effects in AD remain to be confirmed. Other antiseptics including chlorhexidine, triclosan, and triclocarban are also discussed. Variables that may affect the outcomes of these studies include length of use, concurrent application of moisturizers, and anti-inflammatory medications.

Innovations in Therapeutic Improvement of the Cutaneous Microbiome in Children with Atopic Dermatitis

Biofilm is the dominant form of skin microbiota organization that provides adhesion and preservation of microorganisms in the skin micro-environment. It is necessary to ensure epidermal barrier function and local immunomodulation. Staphylococcus aureus becomes the major colonizer of skin lesions in case of atopic dermatitis exacerbation, and it also can form the biofilms. S. aureus growth and biofilm formation due to other microbial commensals on the skin of patients with atopic dermatitis leads to chronic output of pro-inflammatory cytokines and later to abnormalities in healthy skin microbiome. The role of microbial biofilm in human’s health makes the skin microbiota an attractive target for therapeutic intervention in various skin diseases.

Narrative review on the management of moderate-severe atopic dermatitis in pediatric age of the Italian Society of Pediatric Allergology and Immunology (SIAIP), of the Italian Society of Pediatric Dermatology (SIDerP) and of the Italian Society of Pediatrics (SIP)

Currently, there are a few detailed guidelines on the overall management of children and adolescents with moderate-severe atopic dermatitis. AD ​​is a complex disease presenting with different clinical phenotypes, which require an individualized and multidisciplinary approach. Therefore, appropriate interaction between primary care pediatricians, pediatric allergists, and pediatric dermatologists is crucial to finding the best management strategy. In this manuscript, members of the Italian Society of Pediatric Allergology and Immunology (SIAIP), the Italian Society of Pediatric Dermatology (SIDerP), and the Italian Society of Pediatrics (SIP) with expertise in the management of moderate-severe atopic dermatitis have reviewed the latest scientific evidence in the field. This narrative review aims to define a pathway to appropriately managing children and adolescents with moderate-severe atopic dermatitis.

Optimizing topical management of atopic dermatitis

OBJECTIVE

Provide a review of atopic dermatitis management, focusing on optimizing topical therapy, creating a stepwise approach for treatment plans, and providing guidance on when to start systemic therapy.

DATA SOURCES

PubMed search of articles in the English language regarding atopic dermatitis in all ages.

STUDY SELECTION

Articles on the subject matter were selected and reviewed.

RESULTS

Topical corticosteroids are the first-line treatment for managing atopic dermatitis. Topical nonsteroidal agents, calcineurin inhibitors, crisaborole, and recently, ruxolitinib, which cause no cutaneous atrophy, are options for reducing the use of topical corticosteroids, including on sensitive sites. Emerging topical agents are in clinical trials. Proactive management, with continued application 2 to 3 times weekly of a midpotency topical corticosteroid or tacrolimus, may maintain control for clear (or almost clear) localized sites of dermatitis that rapidly recur when topical anti-inflammatory medication is stopped. If topical therapy alone cannot control disease and quality of life is impacted, reevaluation to confirm the diagnosis, manage comorbid conditions, address compliance and patient-specific concerns, and optimize topical therapy must be undertaken before deciding to advance to systemic medication. Dupilumab, an interleukin-4 receptor inhibitor, has become first-line systemic therapy given its efficacy and safety, allowing long-term treatment without laboratory monitoring. Other biologics and Janus kinase inhibitors are emerging as alternatives that could eliminate the need for immunosuppressants with their higher risks.

CONCLUSION

Several options are now available for topical treatment. A stepwise approach is needed to consider alternative therapies and diagnoses before advancing to systemic treatment, but the safety of newer immunomodulators will lower the threshold for more aggressive intervention.

Antimicrobial resistance in Staphylococcus pseudintermedius on the environmental surfaces of a recently constructed veterinary hospital in Southern Thailand

Background and Aim:

Staphylococcus pseudintermedius is a zoonotic bacterium commonly found in animals, especially dogs. These bacteria can survive on environmental surfaces for several months. The infection of S. pseudintermedius from the environment is possible, but properly cleaning surface objects can prevent it. This study aimed to investigate the prevalence of methicillin-resistant S. pseudintermedius (MRSP) in the environment of a recently constructed veterinary hospital in Southern Thailand, where we hypothesized that the prevalence of MRSP might be very low.

Materials and Methods:

At three different time points, 150 samples were collected from different environmental surfaces and wastewater across the veterinary hospital. The collection was done after the hospital’s cleaning. Bacteria were purified in the culture before being identified as species by biochemical tests and polymerase chain reaction (PCR). Next, the antimicrobial-resistant profile was performed using an automated system (Vitek 2). Finally, the antimicrobial resistance genes were identified using PCR.

Results:

Fifteen colonies of S. pseudintermedius were isolated from the surfaces of eight floors, four tables, two chairs, and one rebreathing tube. Fourteen colonies (93.3%) were multidrug-resistant (MDR) and carried the blaZ gene (93.3%). The majority of colonies were resistant to benzylpenicillin (93.3%), cefovecin (93.3%), ceftiofur (93.3%), kanamycin (93.3%), and neomycin (93.3%). Notably, only four colonies (26.7%) were methicillin-susceptible S. pseudintermedius, whereas 11 colonies (73.3%) were MRSP and carried both the mecA and blaZ genes. Five MRSP (45.5%) were resistant to at least 14 antimicrobial drugs, represented as extensively drug-resistant (XDR) bacteria. Ten of eleven MRSP (90.9%) were Staphylococcal chromosomal mec type V, while another displayed untypeable. Despite the routine and extensive cleaning with detergent and disinfectant, MRSP isolates were still detectable.

Conclusion:

Many isolates of MRSP were found in this veterinary hospital. Almost all of them were MDR, and nearly half were XDR, posing a threat to animals and humans. In addition, the current hospital cleaning procedure proved ineffective. Future research should be conducted to determine the bacterial biofilm properties and bacterial sensitivity to certain detergents and disinfectants.

The role of sodium hypochlorite in atopic dermatitis therapy: a narrative review

Atopic dermatitis (AD) is a common skin disorder, especially in the pediatric population. Genetic and immunological factors, epidermal barrier defect, as well as skin microbiota imbalance with increased colonization by Staphylococcus aureus (SA) are involved in the pathogenesis of the disease. One of the AD topical treatments is sodium hypochlorite (NaOCl) as a 0.005% water bath solution. This substance has been used for years as an antiseptic preparation. Studies show that NaOCl has an antimicrobial effect but probably at higher concentrations than those used in AD treatment. Nevertheless, many research studies confirm the anti-inflammatory and anti-itching effects of NaOCl, which contributes to clinical improvement in AD patients as well as reducing the need for local steroids and antibiotics. Bleach baths seem to be a well tolerated, cheap, and easily available therapy. However, research still should be continued to evaluate its antibacterial efficacy, anti-inflammatory effects, and safety.

A berberine hydrochloride-carboxymethyl chitosan hydrogel protects against Staphylococcus aureus infection in a rat mastitis model

Staphylococcus aureus (S. aureus) is the major pathogen responsible for mastitis in dairy cows, an important threat to their health, but prevention of S. aureus infection of the mammary gland remains challenging. Berberine hydrochloride (BH), a naturally occurring phytochemical, exhibits a wide range of activities, including antibacterial effects on S. aureus. In this study, we prepared a novel berberine hydrochloride-carboxymethyl chitosan hydrogel (BH-CMCH) with excellent thermosensitivity, injectability and in vitro antibacterial activity. In a rat model of mastitis induced by S. aureus, mammary duct injection of BH-CMCH reduced the bacterial load in infected mammary gland tissue and protected the tissue from damage from infection. In addition, proteomics analysis showed that mammary duct injection of BH-CMCH enhanced autolysosome degradation and promoted the innate immune response by activating the lysosomal pathway and up-regulating related significantly differentially expressed proteins (SDEPs). Taken together, the findings support the potential of BH-CMCH as an antibacterial agent against S. aureus-induced mastitis.

The Influence of Microbiome Dysbiosis and Bacterial Biofilms on Epidermal Barrier Function in Atopic Dermatitis-An Update

Atopic dermatitis (AD) is a common inflammatory dermatosis affecting up to 30% of children and 10% of adults worldwide. AD is primarily driven by an epidermal barrier defect which triggers immune dysregulation within the skin. According to recent research such phenomena are closely related to the microbial dysbiosis of the skin. There is growing evidence that cutaneous microbiota and bacterial biofilms negatively affect skin barrier function, contributing to the onset and exacerbation of AD. This review summarizes the latest data on the mechanisms leading to microbiome dysbiosis and biofilm formation in AD, and the influence of these phenomena on skin barrier function.

Updated understanding of Staphylococcus aureus in atopic dermatitis: From virulence factors to commensals and clonal complexes

Atopic dermatitis (AD) is a common inflammatory dermatosis that has multiple contributing factors including genetic, immunologic and environmental. Staphylococcus aureus (SA) has long been associated with exacerbation of AD. SA produces many virulence factors that interact with the human skin and immune system. These superantigens and toxins have been shown to contribute to adhesion, inflammation and skin barrier destruction. Recent advances in genome sequencing techniques have led to a broadened understanding of the multiple ways SA interacts with the cutaneous environment in AD hosts. For example, temporal shifts in the microbiome, specifically in clonal complexes of SA, have been identified during AD flares and remission. Herein, we review mechanisms of interaction between the cutaneous microbiome and SA and highlight known differences in SA clonal complexes that contribute to AD pathogenesis. Detailed knowledge of the genetic strains of SA and cutaneous dysbiosis is becoming increasingly relevant in paving the way for microbiome-modulating and precision therapies for AD.

Apple cider vinegar soaks do not alter the skin bacterial microbiome in atopic dermatitis

INTRODUCTION

Atopic dermatitis is a common skin disease characterized by altered cutaneous immunity in which patients often exhibit lower skin microbiota diversity compared to healthy skin and are prone to colonization by Staphylococcus aureus. Apple cider vinegar has been shown to have antibacterial effects; however, its effects on the skin microbiome have not previously been well-described.

OBJECTIVES

We aimed to examine the effects of topical dilute apple cider vinegar soaks on Staphylococcus aureus abundance, skin bacterial microbiome composition, and skin bacterial microbiome diversity in atopic dermatitis participants compared to healthy skin.

METHODS

Eleven subjects with atopic dermatitis and 11 healthy controls were enrolled in this randomized, non-blinded, single-institution, split-arm pilot study. Subjects soaked one forearm in dilute apple cider vinegar (0.5% acetic acid) and the other forearm in tap water for 10 minutes daily. Skin bacteria samples were collected from subjects' volar forearms before and after 14 days of treatment. 16S sequencing was used to analyze Staphylococcus aureus abundance and skin bacterial microbiome composition, and alpha diversity of microbiota were determined using Shannon diversity index.

RESULTS

There was no difference in skin bacterial microbiome in atopic dermatitis subjects after 2 weeks of daily water or apple cider vinegar treatments (p = 0.056 and p = 0.22, respectively), or in mean abundance of S. aureus on apple cider vinegar-treated forearms (p = 0.60). At 2 weeks, the skin bacterial microbiomes of healthy control subjects were not significantly different from the skin bacterial microbiome of atopic dermatitis subjects (p = 0.14, 0.21, 0.12, and 0.05).

CONCLUSIONS

Our results suggest that daily soaks in 0.5% apple cider vinegar are not an effective method of altering the skin bacterial microbiome in atopic dermatitis. Further studies are needed to explore the effects of different concentrations of apple cider vinegar on skin microflora and disease severity.

TRIAL NUMBER

UVA IRB-HSR #19906.

Sodium Hypochlorite 0.005% Versus Placebo in the Treatment of Mild to Moderate Acne: A Double-Blind Randomized Controlled Trial

Background

Acne vulgaris is a common inflammatory disease of the pilosebaceous follicle that affects many teenagers and young people. There is an obvious need for topical treatments with good tolerability and efficacy for the management of acne lesions.

Objective

This study determined the therapeutic efficacy of topical sodium hypochlorite solution (0.005%) in the treatment of mild to moderate acne lesions.

Methods

This placebo-controlled randomized controlled trial compared 0.005% sodium hypochlorite to placebo administered topically on each side of the patients' faces 3 times a day for 1 month. The numbers of papules and pustules were recorded at baseline, 1, 2 and 4 weeks after initiation.

Results

The total number of papules and pustules decreased after topical application of sodium hypochlorite 0.005% for 1 month.

Conclusions

Topical sodium hypochlorite solution (0.005%) can be effective in the treatment of mild to moderate acne, and its clinical efficacy was evaluated between the male and female groups and between the hormonal and non-hormonal ones.

Trial registration

Our study was registered in the Iranian Registry of Clinical Trials (IRCT) with the code number IRCT20200701047976N1.

Antimicrobial activity and biofilm inhibition of riparins I, II and III and ultrastructural changes in multidrug-resistant bacteria of medical importance

Natural products have been used to treat various infections; however, the development of antimicrobials has made natural products in disuse. Riparin I, II and III are natural alkamide isolated from Aniba riparia (Ness) Mez (Lauraceae), that exhibit economic importance and it is used in traditional medicine, and popularly known as "louro". This study investigated the cytotoxicity, antimicrobial and antibiofilm activity, and ultrastructural changes in vitro by riparins I, II and III in Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii and Pseudomonas aeruginosa. We analyzed the cytotoxicity by MTT assay in Vero cells and hemolytic action verified in human erythrocytes. The antimicrobial activity was determined by microdilution in broth against ATCC strains, identifying the susceptible species. Subsequently, only the MDR isolates of sensitive bacterial species were evaluated regarding its biofilm formation and ultrastructural changes. Riparin I presented low cytotoxicity and hemolytic percentage ranging from of 9.01%-12.97%. Only the riparin III that showed antimicrobial activity against MDR clinical isolates, and significant reduction in biofilm formation in S. aureus. Moreover, the riparin III promoted ultrastructural changes in bacterial cells, such as elongated cellular without bacterial septum, cells with a rugged appearance on the cell surface and cytoplasmic material extravasation. As has been noted riparin III has an inhibitory potential against biofilm formation in S. aureus, besides having antimicrobial activity and promoting ultrastructural changes in MDR clinical isolates. Thus, riparin III is an interesting alternative for further studies aiming to develop new therapeutic options.

Rosmarinus officinalis L. (Rosemary) Extracts Containing Carnosic Acid and Carnosol are Potent Quorum Sensing Inhibitors of Staphylococcus aureus Virulence

Staphylococcus aureus is an opportunistic pathogen and a common cause of skin infection. S. aureus also plays a role in the pathogenesis of the chronic inflammatory skin disease, atopic dermatitis. S. aureus virulence involves activation of the quorum sensing agr operon. In this paper, we show that the diterpene carnosic acid, present in R. officinalis L. (rosemary) leaves, is a specific inhibitor of S. aureus agr expression as low as 5 μM. Carnosol and rosmarinic acid are two other phytochemicals present in rosemary leaves. Carnosol, but not rosmarinic acid, is also a potent agr expression inhibitor. Natural rosemary extracts containing carnosic acid and carnosol inhibit S. aureus agr expression, both in luciferase reporter strains and in wild type strains isolated from patients with atopic dermatitis. Specific inhibition of S. aureus virulence using topical formulations of rosemary extract may offer a practical approach to preventing and treating flares of atopic dermatitis.

Staphylococcus aureus and the Cutaneous Microbiota Biofilms in the Pathogenesis of Atopic Dermatitis

Biofilm is the dominant mode of growth of the skin microbiota, which promotes adhesion and persistence in the cutaneous microenvironment, thus contributing to the epidermal barrier function and local immune modulation. In turn, the local immune microenvironment plays a part in shaping the skin microbiota composition. Atopic dermatitis (AD) is an immune disorder characterized by a marked dysbiosis, with a sharp decline of microbial diversity. During AD flares biofilm-growing Staphylococcus aureus emerges as the major colonizer in the skin lesions, in strict association with disease severity. The chronic production of inflammatory cytokines in the skin of AD individuals concurs at supporting S. aureus biofilm overgrowth at the expense of other microbial commensals, subverting the composition of the healthy skin microbiome. The close relationship between the host and microbial biofilm resident in the skin has profound implications on human health, making skin microbiota an attractive target for the therapeutic management of different skin disorders.

Sodium hypochlorite body wash in the management of Staphylococcus aureus-colonized moderate-to-severe atopic dermatitis in infants, children, and adolescents

OBJECTIVES

A cleansing body wash containing diluted sodium hypochlorite (0.006% NaOCl) was evaluated for management of moderate-to-severe Staphylococcus aureus-colonized, atopic dermatitis in children.

METHODS

A 6-week, prospective, open-label study was conducted with 50 evaluable participants (ages 6 months to 17 years) who had moderate-to-severe atopic dermatitis with S aureus skin colonization documented by culture. Participants were instructed to continue using their current medications while using the study product, 0.006% NaOCl body wash, once daily to affected areas for 6 weeks. Primary outcome measures were Investigator's Global Assessment, Eczema Area and Severity Index, and Body Surface Area scores. Secondary outcome measures were the Visual Analog Scale for pruritus, Family Dermatology Life Quality Index, and Patient Satisfaction Questionnaire for Problem Areas. A subject daily diary and a six-item subject questionnaire that provided information on preferences for bleach bath vs body wash were secondary outcome measures.

RESULTS

Daily use of the 0.006% NaOCl body wash led to improvement for all outcome measures comparing baseline to 2-week and to 6-week evaluations. Of the 50 skin S aureus-positive subjects, 32/50 (64%) were still positive at 2 weeks. A 36.5% decrease in subject's daily record of topical corticosteroid application at end of study compared to baseline was found. Participant surveys indicated preferences for the body wash over bleach baths.

CONCLUSIONS

Sodium hypochlorite (NaOCl) body wash improved all outcome measures for moderate-to-severe S aureus-colonized AD in infants, children, and adolescents. The limited reduction in S aureus further suggests that sodium hypochlorite has ameliorative effects other than antimicrobial actions.

Pathophysiology of atopic dermatitis: Clinical implications

Atopic dermatitis (AD) is the most common chronic inflammatory skin disease. Genetic predisposition, epidermal barrier disruption, and dysregulation of the immune system are some of the critical components of AD. An impaired skin barrier may be the initial step in the development of the atopic march as well as AD, which leads to further skin inflammation and allergic sensitization. Type 2 cytokines as well as interleukin 17 and interleukin 22 contribute to skin barrier dysfunction and the development of AD. New insights into the pathophysiology of AD have focused on epidermal lipid profiles, neuroimmune interactions, and microbial dysbiosis. Newer therapeutic strategies focus on improving skin barrier function and targeting polarized immune pathways found in AD. Further understanding of AD pathophysiology will allow us to achieve a more precision medicine approach to the prevention and the treatment of AD.

Topical, systemic and biologic therapies in hidradenitis suppurativa: pathogenic insights by examining therapeutic mechanisms

Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the skin, manifesting in chronic, recurrent painful pustules, nodules, boils and purulent draining abscesses. Our current understanding of the pathogenesis of the disease is incomplete. This review aims to identify available treatment options in HS and discuss the pharmacological mechanisms through which such agents function. Identifying common pathways may inform our understanding of the pathogenesis of HS as well as identify future therapeutic targets. The pharmacological mechanisms implicated in topical therapies, antibiotic, hormonal, systemic immunomodulatory and biologic therapies for HS are discussed. Significant differences exist between agents and implicated pathways in therapy for mild and severe disease. This is an expression of the possible dichotomy in inflammatory pathways (and treatment responses) in HS. Studies involving monoclonal antibodies provide the greatest insight into what these specific mechanisms may be. Their variable levels of clinical efficacy compared with placebo bolsters the suggestion that differential inflammatory pathways may be involved in different presentations and severity of disease. Nuclear factor kappa B (NF-κB), tumor necrosis factor (TNF)-α and other innate immune mechanisms are strongly represented in treatments which are effective in mild to moderate disease in the absence of scarring or draining fistulae, however complex feed-forward mechanisms in severe disease respond to interleukin (IL)-1 inhibition but are less likely to respond to innate immune inhibition (through NF-κB or TNF-α) alone. It is unclear whether IL-17 inhibition will parallel TNF-α or IL-1 inhibition in effect, however it is plausible that small molecule targets (Janus kinase1 and phosphodiesterase 4) may provide effective new strategies for treatment of HS.

Comparison of bleach, acetic acid, and other topical anti-infective treatments in pediatric atopic dermatitis: A retrospective cohort study on antibiotic exposure

BACKGROUND/OBJECTIVES

Skin infection is common in atopic dermatitis (AD), often necessitating treatment with systemic antibiotics. Topical adjunctive therapies such as dilute bleach baths are increasingly recommended, and topical dilute acetic acid (AA) has not been widely studied. The objective of this study was to evaluate whether various topical anti-infective bathing recommendations were associated with decreased systemic antibiotic exposure in pediatric AD, as well as evaluate topical anti-infective recommendations over time within our institution.

METHODS

Clinical data were extracted from charts of pediatric patients from 1/1/2000 to 12/31/2005 and 1/1/2009 to 12/31/2014 who visited outpatient dermatology clinics at Mayo Clinic, Rochester, a tertiary referral center. Recommendations for topical anti-infectives (dilute AA, dilute bleach, other, or none) at any time after patient had clinically proven or suspected AD superinfection were recorded as exposures to topical anti-infective. Primary outcome was the number of systemic antibiotic courses in a 1-year period.

RESULTS

Of 1111 patients with AD, 753 met inclusion criteria (303 in 2000-2005; 450 in 2009-2014). Of these, 351 (46.6%) had culture-proven or clinically suspected superinfection. Topical anti-infective recommendations increased between the time periods (23.3% to 79.2%; P < 0.001) and number of courses of systemic antibiotics decreased (1.9 per year vs 1.5 per year, P = 0.010). Number of systemic antibiotic courses did not differ between those who received bathing recommendations and those who did not, nor between different anti-infective groups (P = 0.398).

CONCLUSIONS

Practice behaviors have changed, and topical anti-infectives are now commonly recommended. Neither dilute AA nor bleach baths were associated with fewer subsequent exposures to systemic antibiotics in the treatment of pediatric AD.

Interactions Between Atopic Dermatitis and Staphylococcus aureus Infection: Clinical Implications

Staphylococcus aureus commonly colonizes the skin of atopic dermatitis (AD) patients and contributes to the development and exacerbation of AD. Multiple factors are associated with colonization of AD skin by S. aureus, including the strength of S. aureus-corneocyte adhesion, deficiency of antimicrobial peptides, decreased levels of filaggrin and filaggrin degradation products, overexpressed Th2/Th17 cytokines, microbial dysbiosis and altered lipid profiles. S. aureus colonization on AD skin causes skin barrier dysfunction through virulence factors such as superantigens (toxins), enzymes and other proteins. Furthermore, colonization of AD skin by S. aureus exacerbates AD and may contribute to microbial dysbiosis, allergen sensitization, Th2/Th17 polarization, development of atopic march and food allergy in AD patients. Skin colonization of S. aureus, particularly methicillin-resistant S. aureus (MRSA), is one of the major challenges commonly encountered in the management of AD. Bleach bath, and topical or systemic antibiotics could be used to control S. aureus infection on AD skin. However, careful use of antibiotics is required to control the occurence of MRSA. Recently, various strategies, including microbiome transplant, monoclonal antibodies against virulent toxins, vaccines and recombinant phage endolysin, have been studied to control S. aureus infection on AD skin. Further advances in our understanding of S. aureus could provide us with ways to manage S. aureus colonization more effectively in AD patients.

Dismissing the fallacies of childhood eczema management: case scenarios and an overview of best practices

BACKGROUND

Eczema or atopic dermatitis (AD) is a common relapsing childhood dermatologic illness. Treatment of AD is primarily topical with emollients and corticosteroid/calcineurin inhibitor, which is efficacious for the majority of patients. However, AD is often complicated and difficult to manage in many Asian cities. Effective therapy is impeded by fallacies in the following aspects: (1) mistrust and unrealistic expectations about Western medicine, (2) skin care and allergy treatment, (3) ambiguity about optimal bathing and moisturizing, (4) hesitation and phobias about the usage of adequate topical corticosteroid and immunomodulatory therapies, (5) food and aeroallergen avoidance and dietary supplementation, and (6) complementary and alternative therapies.

METHODS AND RESULTS

Eleven anonymized case scenarios are described to illustrate issues associated with these fallacies. A literature review is performed and possible solutions to handle or dismiss these fallacies are discussed.

CONCLUSIONS

The first step in patient care is to accurately assess the patient and the family to evaluate possible concerns, anxiety, and phobias that could impede therapeutic efficacy. Education about the disease should be individualized. Conflicting recommendations on the usage of topical steroid have a detrimental effect on management outcomes, which must be avoided.

Inflammatory cytokines and biofilm production sustain Staphylococcus aureus outgrowth and persistence: a pivotal interplay in the pathogenesis of Atopic Dermatitis

Individuals with Atopic dermatitis (AD) are highly susceptible to Staphylococcus aureus colonization. However, the mechanisms driving this process as well as the impact of S. aureus in AD pathogenesis are still incompletely understood. In this study, we analysed the role of biofilm in sustaining S. aureus chronic persistence and its impact on AD severity. Further we explored whether key inflammatory cytokines overexpressed in AD might provide a selective advantage to S. aureus. Results show that the strength of biofilm production by S. aureus correlated with the severity of the skin lesion, being significantly higher (P < 0.01) in patients with a more severe form of the disease as compared to those individuals with mild AD. Additionally, interleukin (IL)-β and interferon γ (IFN-γ), but not interleukin (IL)-6, induced a concentration-dependent increase of S. aureus growth. This effect was not observed with coagulase-negative staphylococci isolated from the skin of AD patients. These findings indicate that inflammatory cytokines such as IL1-β and IFN-γ, can selectively promote S. aureus outgrowth, thus subverting the composition of the healthy skin microbiome. Moreover, biofilm production by S. aureus plays a relevant role in further supporting chronic colonization and disease severity, while providing an increased tolerance to antimicrobials.

Sodium hypochlorite is more effective than 70% ethanol against biofilms of clinical isolates of Staphylococcus aureus

INTRODUCTION

Although disinfectants are used for eradication of bacteria from environmental surfaces, their antibiofilm efficacy is often not considered in determining the choice of disinfectant.

AIM

This study aimed to compare the effectiveness of 2 commonly used disinfectants, sodium hypochlorite and ethanol, against the planktonic and biofilm state of Staphylococcus aureus clinical isolates.

MATERIALS AND METHODS

Effect of 0.6% sodium hypochlorite and 70% ethanol was determined on the planktonic and biofilm states of 10 strong and weak biofilm formers through estimation of changes in colony forming unit counts and absorbance values. The morphologic changes were observed by scanning electron microscopy.

RESULTS

Significant difference in the efficacy of sodium hypochlorite and ethanol was observed against the biofilm (P = .004) as well as planktonic (P = .000) states of S aureus. However, no significant difference was observed in their activity against strong and weak biofilm formers. On electron microscopy, sodium hypochlorite was found to induce significant formation of craters and irregular depressions on the surface of strong biofilm formers.

CONCLUSIONS

Sodium hypochlorite demonstrated superior efficacy in controlling both planktonic and biofilm states of growth in S aureus. Furthermore, the characteristic morphologic changes observed in strong biofilm formers hint at its biofilm-specific activity.

Significance of Skin Barrier Dysfunction in Atopic Dermatitis

The epidermis contains epithelial cells, immune cells, and microbes which provides a physical and functional barrier to the protection of human skin. It plays critical roles in preventing environmental allergen penetration into the human body and responsing to microbial pathogens. Atopic dermatitis (AD) is the most common, complex chronic inflammatory skin disease. Skin barrier dysfunction is the initial step in the development of AD. Multiple factors, including immune dysregulation, filaggrin mutations, deficiency of antimicrobial peptides, and skin dysbiosis contribute to skin barrier defects. In the initial phase of AD, treatment with moisturizers improves skin barrier function and prevents the development of AD. With the progression of AD, effective topical and systemic therapies are needed to reduce immune pathway activation and general inflammation. Targeted microbiome therapy is also being developed to correct skin dysbiosis associated with AD. Improved identification and characterization of AD phenotypes and endotypes are required to optimize the precision medicine approach to AD.

Efficacy of bleach baths in reducing severity of atopic dermatitis: A systematic review and meta-analysis

BACKGROUND

Bleach baths have been proposed as a treatment for decreasing the severity of atopic dermatitis (AD). However, conflicting results have been found regarding their efficacy.

OBJECTIVE

To determine the efficacy of bleach vs water baths at decreasing AD severity.

METHODS

We performed a systematic review of all studies evaluating the efficacy of bleach baths for AD. Cochrane, EMBASE, GREAT, LILACS, MEDLINE, and Scopus were searched. Two authors independently performed study selection and data extraction.

RESULTS

Five studies were included in the review. Four studies reported significantly decreased AD severity in patients treated with bleach on at least 1 time point. However, of 4 studies comparing bleach with water baths, only 2 found significantly greater decreases in AD severity with bleach baths, 1 found greater decreases with water baths, and 1 found no significant differences. In pooled analyses, there were no significant differences observed between bleach vs water baths at 4 weeks vs baseline for the Eczema Area and Severity Index (I² = 98%; random effect regression model, P = .16) or body surface area (I² = 96%; P = .36).

CONCLUSION

Although bleach baths are effective in decreasing AD severity, they do not appear to be more effective than water baths alone. Future larger-scale, well-designed randomized controlled trials are needed.

Staphylococcal Biofilms in Atopic Dermatitis

PURPOSE OF REVIEW

Atopic dermatitis (AD) is a chronic, relapsing inflammatory skin disorder that is a major public health burden worldwide. AD lesions are often colonized by Staphylococcus aureus and Staphylococcus epidermidis. An important aspect of Staphylococcus spp. is their propensity to form biofilms, adhesive surface-attached colonies that become highly resistant to antibiotics and immune responses, and recent studies have found that clinical isolates colonizing AD skin are often biofilm-positive. Biofilm formation results in complex bacterial communities that have unique effects on keratinocytes and host immunity. This review will summarize recent studies exploring the role of staphyloccocal biofilms in atopic dermatitis and the implications for treatment.

RECENT FINDINGS

Recent studies suggest an important role for biofilms in the pathogenesis of numerous dermatologic diseases including AD. S. aureus biofilms have been found to colonize the eccrine ducts of AD skin, and these biofilms influence secretion of keratinocyte cytokines and trigger differentiation and apoptosis of keratinocytes. These activities may act to disrupt barrier function and promote disease pathogenesis as well as allergen sensitization. Formation of biofilm is a successful strategy that protects the bacteria from environmental danger, antibiotics, and phagocytosis, enabling chronic persistence in the host. An increasing number of S. aureus skin isolates are resistant to conventional antibiotics, and staphylococcal biofilm communities are prevalent on the skin of individuals with AD. Staphylococcal colonization of the skin impacts skin barrier function and plays multiple important roles in AD pathogenesis.

Identification of bacterial biofilm and the Staphylococcus aureus derived protease, staphopain, on the skin surface of patients with atopic dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disease characterized by an impaired epidermal barrier, dysregulation of innate and adaptive immunity, and a high susceptibility to bacterial colonization and infection. In the present study, bacterial biofilm was visualized by electron microscopy at the surface of AD skin. Correspondingly, Staphylococcus aureus (S. aureus) isolates from lesional skin of patients with AD, produced a substantial amount of biofilm in vitro. S. aureus biofilms showed less susceptibility to killing by the antimicrobial peptide LL-37 when compared with results obtained using planktonic cells. Confocal microscopy analysis showed that LL-37 binds to the S. aureus biofilms. Immuno-gold staining of S. aureus biofilm of AD skin detected the S. aureus derived protease staphopain adjacent to the bacteria. In vitro, staphopain B degraded LL-37 into shorter peptide fragments. Further, LL-37 significantly inhibited S. aureus biofilm formation, but no such effects were observed for the degradation products. The data presented here provide novel information on staphopains present in S. aureus biofilms in vivo, and illustrate the complex interplay between biofilm and LL-37 in skin of AD patients, possibly leading to a disturbed host defense, which facilitates bacterial persistence.