Functional textiles for atopic dermatitis: a systematic review and meta-analysis

Advances in skin gene therapy: utilizing innovative dressing scaffolds for wound healing, a comprehensive review

The skin, serving as the body's outermost layer, boasts a vast area and intricate structure, functioning as the primary barrier against external threats. Disruptions in the composition and functionality of the skin can lead to a diverse array of skin conditions, such as wounds, burns, and diabetic ulcers, along with inflammatory disorders, infections, and various types of skin cancer. These disorders not only exacerbate concerns regarding skin health and beauty but also have a significant impact on mental well-being. Due to the complexity of these disorders, conventional treatments often prove insufficient, necessitating the exploration of new therapeutic approaches. Researchers develop new therapies by deciphering these intricacies and gaining a thorough understanding of the protein networks and molecular processes in skin. A new window of opportunity has opened up for improving wound healing processes because of recent advancements in skin gene therapy. To enhance skin regeneration and healing, this extensive review investigates the use of novel dressing scaffolds in conjunction with gene therapy approaches. Scaffolds that do double duty as wound protectors and vectors for therapeutic gene delivery are being developed using innovative biomaterials. To improve cellular responses and speed healing, these state-of-the-art scaffolds allow for the targeted delivery and sustained release of genetic material. The most recent developments in gene therapy techniques include RNA interference, CRISPR-based gene editing, and the utilization of viral and non-viral vectors in conjunction with scaffolds, which were reviewed here to overcome skin disorders and wound complications. In the future, there will be rare chances to develop custom methods for skin health care thanks to the combination of modern technology and collaboration among disciplines.

Therapeutic textiles: A promising approach for human skin dysbiosis?

The close interaction between skin and clothing has become an attractive cornerstone for the development of therapeutic textiles able to alleviate skin disorders, namely those correlated to microbiota dysregulation. Skin microbiota imbalance is known in several skin diseases, including atopic dermatitis (AD), psoriasis, seborrheic dermatitis, rosacea, acne and hidradenitis suppurative (HS). Such microbiota dysregulation is usually correlated with inflammation, discomfort and pruritus. Although conventional treatments, that is, the administration of steroids and antibiotics, have shown some efficacy in treating and alleviating these symptoms, there are still disadvantages that need to be overcome. These include their long-term usage with side effects negatively impacting resident microbiota members, antibiotic resistance and the elevated rate of recurrence. Remarkably, therapeutic textiles as a non-pharmacological measure have emerged as a promising strategy to treat, alleviate the symptoms and control the severity of many skin diseases. This systematic review showcases for the first time the effects of therapeutic textiles on patients with skin dysbiosis, focusing on efficacy, safety, adverse effects and antimicrobial, antioxidant and anti-inflammatory properties. The main inclusion criteria were clinical trials performed in patients with skin dysbiosis who received treatment involving the use of therapeutic textiles. Although there are promising outcomes regarding clinical parameters, safety and adverse effects, there is still a lack of information about the impact of therapeutic textiles on the skin microbiota of such patients. Intensive investigation and corroboration with clinical trials are needed to strengthen, define and drive the real benefit and the ideal biomedical application of therapeutic textiles.

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.

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.

Direct contact-mediated non-viral gene therapy using thermo-sensitive hydrogel-coated dressings

Nanotechnologies are being increasingly applied as systems for peptide and nucleic acid macromolecule drug delivery. However systemic targeting of these, or efficient topical and localized delivery remains an issue. A controlled release system that can be patterned and locally administered such as topically to accessible tissue (skin, eye, intestine) would therefore be transformative in realizing the potential of such strategies. We previously developed a technology termed GAG-binding enhanced transduction (GET) to efficiently deliver a variety of cargoes intracellularly, using GAG-binding peptides to mediate cell targeting, and cell penetrating peptides (CPPs) to promote uptake. Herein we demonstrate that the GET transfection system can be used with the moisturizing thermo-reversible hydrogel Pluronic-F127 (PF127) and methyl cellulose (MC) to mediate site specific and effective intracellular transduction and gene delivery through GET nanoparticles (NPs). We investigated hydrogel formulation and the temperature dependence of delivery, optimizing the delivery system. GET-NPs retain their activity to enhance gene transfer within our formulations, with uptake transferred to cells in direct contact with the therapy-laden hydrogel. By using Azowipe™ material in a bandage approach, we were able to show for the first-time localized gene transfer in vitro on cell monolayers. The ability to simply control localization of gene delivery on millimetre scales using contact-mediated transfer from moisture-providing thermo-reversible hydrogels will facilitate new drug delivery methods. Importantly our technology to site-specifically deliver the activity of novel nanotechnologies and gene therapeutics could be transformative for future regenerative medicine.

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.

The effectiveness of antibacterial therapeutic clothing based on silver or chitosan as compared with non-antibacterial therapeutic clothing in patients with moderate to severe atopic dermatitis (ABC trial): study protocol for a pragmatic randomized controlled trial

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease that affects 10 to 20% of children and between 2 and 15% of the adults in Western Europe. Since 2000, therapeutic clothing or functional textiles based on silver or chitosan as antibacterial agents were introduced for AD. These agents aim to reduce skin colonization with Staphylococcus (S.) aureus. Increased colonization with S. aureus is correlated with increased AD severity. The antimicrobial effects of silver and chitosan have been demonstrated before. At this point, there is insufficient evidence for the effectiveness of antibacterial therapeutic clothing in patients with AD.

METHODS

This is a pragmatic randomized controlled double-blind multi-center trial comparing the effectiveness of antibacterial therapeutic clothing based on silver or chitosan as compared with non-antibacterial therapeutic clothing in patients with moderate to severe AD. A total of 165 participants, aged 0 to 80, diagnosed with moderate to severe AD are included. The study is performed in the Erasmus MC University Medical Center, University Medical Center Groningen, University Medical Center Utrecht, Amsterdam University Medical Centers, and St. Antonius Hospital Nieuwegein. Patients will be randomized 1:1:1 into one of the three intervention groups: group A will receive therapeutic clothing without antimicrobial agents, group B will receive microbial growth reducing therapeutic clothing based on chitosan, and group C will receive antimicrobial clothing based on silver. All therapeutic clothing is to be worn at night during the 12-month intervention period. Usual care is continued. The primary objective is to assess the effectiveness of antibacterial clothing (silver and chitosan group) as compared to non-antibacterial clothing assessed with the Eczema Area and Severity Index at 12 months compared to baseline. Secondary outcomes include between-group differences in physician- and patient-reported outcome measures, topical therapy use, S. aureus skin colonization, and safety. Data will be collected at baseline and after 1 month, 3 months, 6 months, and 12 months. A cost-effectiveness analysis will be performed.

DISCUSSION

This trial will provide data on the effectiveness, cost-effectiveness, and safety of antibacterial therapeutic clothing for patients with AD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04297215. Registered on 5 March 2020.

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

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

Experimental Drugs with the Potential to Treat Atopic Eczema

INTRODUCTION

Eczema or atopic dermatitis (AD) is a chronically relapsing dermatosis characterized by pruritus and a significant impact on the quality of life.

METHODS

The authors undertook a structured search of peer-reviewed research articles from PubMed and Google Scholar. Recent and up-to-date studies relevant to the topic were included.

RESULTS

This report overviews current treatment and experimental drug for AD. Topical agents including topical phosphodiesterase E4 (PDE4) inhibitors such as crisaborole are efficacious in the treatment of AD with few side effects. Monoclonal antibodies such as dupilumab given subcutaneously are efficacious for more severe disease. Systemic treatment can ameliorate symptoms in severe and recalcitrant AD. New systemic treatment includes several traditional herbal formulations that have undergone clinical trials using modern research methodology to determine their efficacy and safety. AD is associated with many complicating psychosocial issues. Often suboptimal efficacy is due to unrealistic expectations and poor compliance making treatment difficult in spite of effective treatment and efforts in drug discovery. Randomized trials have shown that novel topical and subcutaneous medications are safe and efficacious. Regarding herbs, a methodology for the investigation of herbal medications is often flawed and scientific evidence is lacking. Experimental drugs include various biologics, PDE4 and JAK inhibitors in topical, oral, subcutaneous or intravenous forms are in various phases of trials.

CONCLUSION

Many novel medications demonstrate efficacy for AD. Experimental drugs include various biologics, PDE4 and JAK inhibitors are in various phases of trials.

The Effects of Fabric Containing Chamaecyparis obtusa Essential Oil on Atopic Dermatitis-Like Lesions: A Functional Clothing Possibility

BACKGROUND

Essential oil derived from Chamaecyparis obtusa (EOCO) has been used as an alternative treatment for allergy-related diseases due to its immune-modulating characteristics. Clothing has the longest and most intense contact with human skin, and functional fabrics with intrinsic properties have been increasingly implemented in medical applications. Specially designed fabrics may support atopic dermatitis (AD) treatment. In this study, the effects of fabric containing EOCO on AD were investigated using an NC/Nga mouse model.

METHODS

The fabric was applied for 6 h per day for 14 days. The therapeutic effects were evaluated according to measurements of skin lesion severity (modified SCORAD score), transepidermal water loss (TEWL), serum IgE and inflammatory cytokine levels, lesion thickness measured after hematoxylin and eosin staining, and immunohistochemical and Western blot analysis for skin epidermal differentiation protein.

RESULTS

The EOCO group exhibited significantly reduced modified SCORAD score, TEWL, and serum IgE levels. Among the inflammatory cytokines analyzed, only the mean values of regulated on activation, normal T cell expressed and secreted were observed to be decreased compared with other control groups. The histological analysis of the skin also revealed that the EOCO group expressed reduced epidermal hyperplasia and recovered filaggrin, involucrin, and loricrin expression.

CONCLUSIONS

It was confirmed that fabric containing EOCO has anti-atopic and anti-inflammatory properties. The study data show that fabric containing EOCO can be implemented as an alternative functional clothing for people suffering from AD.

An overview of drug discovery efforts for eczema: why is this itch so difficult to scratch?

Introduction: Atopic dermatitis (AD) is a type of allergic/inflammatory dermatitis characterized by itch and an impairment in quality of life.Areas covered: Herein, the authors review drug discovery efforts for AD, highlighting the clinical efficacy of novel drugs, with a particular focus on the relief of pruritus. Topical agents include emollients, topical antihistamines, corticosteroids, calcineurin inhibitors and herbs. Recently, topical phosphodiesterase E4 (PDE4) inhibitors like crisaborole have become available and are efficacious for mild to moderate AD with few side effects. For more severe AD, monoclonal antibodies like dupilumab are considered as efficacious subcutaneous treatment options. In severe and recalcitrant AD, systemic treatment can ameliorate AD symptoms.Expert opinion: Many topical and systemic medications have demonstrated therapeutic benefits for AD. Indeed, randomized trials have shown that topical PDE4 inhibitors and subcutaneous dupilumab are safe and efficacious. Objective tools to evaluate itch and gauge treatment efficacy is important, but current methodology relies primarily on clinical scores. AD is a systemic atopic disease with a lot of complicated psychosocial issues. Suboptimal efficacy is often due to poor compliance and unrealistic expectation of curative treatment, rendering treatment difficult despite the existence of effective medications.

Interventions to reduce Staphylococcus aureus in the management of eczema

BACKGROUND

Staphylococcus aureus (S. aureus) can cause secondary infection in eczema, and may promote inflammation in eczema that does not look infected. There is no standard intervention to reduce S. aureus burden in eczema. It is unclear whether antimicrobial treatments help eczema or promote bacterial resistance. This is an update of a 2008 Cochrane Review.

OBJECTIVES

To assess the effects of interventions to reduce S. aureus for treating eczema.

SEARCH METHODS

We updated our searches of the following databases to October 2018: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase and LILACS. We searched five trials registers and three sets of conference proceedings. We checked references of trials and reviews for further relevant studies. We contacted pharmaceutical companies regarding ongoing and unpublished trials.

SELECTION CRITERIA

Randomised controlled trials of products intended to reduce S. aureus on the skin in people diagnosed with atopic eczema by a medical practitioner. Eligible comparators were a similar treatment regimen without the anti-staphylococcal agent.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our key outcomes were participant- or assessor-rated global improvement in symptoms/signs, quality of life (QOL), severe adverse events requiring withdrawal, minor adverse events, and emergence of antibiotic-resistant micro-organisms.

MAIN RESULTS

We included 41 studies (1753 analysed participants) covering 10 treatment categories. Studies were conducted mainly in secondary care in Western Europe; North America; the Far East; and elsewhere. Twelve studies recruited children; four, adults; 19, both; and six, unclear. Fifty-nine per cent of the studies reported the mean age of participants (range: 1.1 to 34.6 years). Eczema severity ranged from mild to severe. Many studies did not report our primary outcomes. Treatment durations ranged from 10 minutes to 3 months; total study durations ranged from 15 weeks to 27 months. We considered 33 studies at high risk of bias in at least one domain. We present results for three key comparisons. All time point measurements were taken from baseline. We classed outcomes as short-term when treatment duration was less than four weeks, and long-term when treatment was given for more than four weeks. Fourteen studies evaluated topical steroid/antibiotic combinations compared to topical steroids alone (infective status: infected (two studies), not infected (four studies), unspecified (eight studies)). Topical steroid/antibiotic combinations may lead to slightly greater global improvement in good or excellent signs/symptoms than topical steroid alone at 6 to 28 days follow-up (risk ratio (RR) 1.10, 95% confidence interval (CI) 1.00 to 1.21; 224 participants; 3 studies, low-quality evidence). There is probably little or no difference between groups for QOL in children, at 14 days follow-up (mean difference (MD) -0.18, 95% CI -0.40 to 0.04; 42 participants; 1 study, moderate-quality evidence). The subsequent results for this comparison were based on very low-quality evidence, meaning we are uncertain of their validity: severe adverse events were rare (follow-up: between 6 to 28 days): both groups reported flare of dermatitis, worsening of the condition, and folliculitis (325 participants; 4 studies). There were fewer minor adverse events (e.g. flare, stinging, itch, folliculitis) in the combination group at 14 days follow-up (218 participants; 2 studies). One study reported antibiotic resistance in children at three months follow-up, with similar results between the groups (65 participants; 1 study). Four studies evaluated oral antibiotics compared to placebo (infective status: infected eczema (two studies), uninfected (one study), one study's participants had colonisation but no clinical infection). Oral antibiotics may make no difference in terms of good or excellent global improvement in infants and children at 14 to 28 days follow-up compared to placebo (RR 0.80; 95% CI 0.18 to 3.50; 75 participants; 2 studies, low-quality evidence). There is probably little or no difference between groups for QOL (in infants and children) at 14 days follow-up (MD 0.11, 95% CI -0.10 to 0.32, 45 participants, 1 study, moderate-quality evidence). The subsequent results for this comparison were based on very low-quality evidence, meaning we are uncertain of their validity: adverse events requiring treatment withdrawal between 14 to 28 days follow-up were very rare, but included eczema worsening (both groups), loose stools (antibiotic group), and Henoch-Schönlein purpura (placebo group) (4 studies, 199 participants). Minor adverse events, including nausea, vomiting, diarrhoea, and stomach and joint pains, at 28 days follow-up were also rare and generally low in both groups (1 study, 68 infants and children). Antibiotic resistance at 14 days was reported as similar in both groups (2 studies, 98 infants and children). Of five studies evaluating bleach baths compared to placebo (water) or bath emollient (infective status: uninfected (two studies), unspecified (three studies)), one reported global improvement and showed that bleach baths may make no difference when compared with placebo at one month follow-up (RR 0.78, 95% CI 0.37 to 1.63; 36 participants; low-quality evidence). One study showed there is probably little or no difference in QOL at 28 days follow-up when comparing bleach baths to placebo (MD 0.90, 95% CI -1.32 to 3.12) (80 infants and children; moderate-quality evidence). We are uncertain if the groups differ in the likelihood of treatment withdrawals due to adverse events at two months follow-up (only one dropout reported due to worsening itch (placebo group)) as the quality of evidence was very low (1 study, 42 participants). One study reported that five participants in each group experienced burning/stinging or dry skin at two months follow-up, so there may be no difference in minor adverse events between groups (RR 1.00, 95% CI 0.35 to 2.87, 36 participants, low-quality evidence). Very low-quality evidence means we are also uncertain if antibiotic resistance at four weeks follow-up is different between groups (1 study, 80 participants ≤ 18 years).

AUTHORS' CONCLUSIONS

We found insufficient evidence on the effects of anti-staphylococcal treatments for treating people with infected or uninfected eczema. Low-quality evidence, due to risk of bias, imprecise effect estimates and heterogeneity, made pooling of results difficult. Topical steroid/antibiotic combinations may be associated with possible small improvements in good or excellent signs/symptoms compared with topical steroid alone. High-quality trials evaluating efficacy, QOL, and antibiotic resistance are required.

A Real-Life Based Evaluation of the Effectiveness of Antibacterial Fabrics in Treating Atopic Dermatitis

BACKGROUND

Antibacterial clothes are classified as a complementary treatment in line with antisepsis, although meta-studies are unable to find significant improvements of eczemas.

METHODS

The antibacterial effectiveness of conventional AD clothes was compared across each other by (i) standard suspension tests for the appraisal of antibacterial products and (ii) a real-life setup of affected AD skin using S. aureus colonised artificial skin, to assess if functional clothes are effective under practical wear conditions. Additionally, the interaction of the fibre types with a moisturising cream was evaluated during a real wearing situation and after domestic laundry.

RESULTS

In the real-life setup simulating dry skin microenvironment, all samples failed to reduce S. aureus. Silver and zinc-fabrics showed a slight activity only under unrealistic moist conditions. When using standard suspension tests, samples differed considerably in their antibacterial effectiveness, where silver and zinc endowed fibres outperformed AEGIS endowed silk fabrics. Garments absorbed the cream dependent on the particular fibre types. Furthermore, domestic laundry was unable to completely remove the cream.

CONCLUSION

Considerable differences in the antibacterial effectiveness of conventional AD clothes were revealed. Under practical (dry) wear conditions, garments were unable to modify skin colonization with S. aureus, although effectiveness can be triggered by wetting the garments. Remnants of moisturising cream remain on the fibres after laundry.

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

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 second part of the guideline covers antimicrobial therapy, systemic treatment, allergen-specific immunotherapy, complementary medicine, psychosomatic counselling and educational interventions, whereas the first part covers methods, patient perspective, general measures and avoidance strategies, basic emollient treatment and bathing, dietary intervention, topical anti-inflammatory therapy, phototherapy and antipruritic therapy. Management of AE must consider the individual clinical variability of the disease. Systemic immunosuppressive treatment with cyclosporine, methotrexate, azathioprine and mycophenolic acid is established option for severe refractory cases, and widely available. Biologicals targeting the T helper 2 pathway such as dupilumab may be a safe and effective, disease-modifying alternative when available. Oral drugs such as JAK inhibitors and histamine 4 receptor antagonists are in development. Microbial colonization and superinfection may cause disease exacerbation and can require additional antimicrobial treatment. Allergen-specific immunotherapy with aeroallergens may be considered in selected cases. Psychosomatic counselling is recommended especially in stress-induced exacerbations. Therapeutic patient education ('Eczema school') is recommended for children and adult patients. General measures, basic emollient treatment, bathing, dietary intervention, topical anti-inflammatory therapy, phototherapy and antipruritic therapy have been addressed in the first part of the guideline.

Investigational drugs for atopic dermatitis

INTRODUCTION

Many novel medications and herbal medicines have claimed efficacy on atopic dermatitis (AD).

AREAS COVERED

This review covers evidence on efficacy of topical and oral forms of novel and investigational drugs. Topical agents include emollients, phosphodiesterase E4 (PDE4) inhibitors, and topical herbs. There is little evidence that ceramides or natural moisturizing factors provide relief in AD. PDE4 inhibitors have shown promise as an effective topical treatment for mild-to-moderate AD with minimal adverse events, and dupilumab as an effective subcutaneous agent for the treatment of moderate-to-severe AD in adult patients with little adverse effects. However, only preliminary data are available for dupilumab in children with AD. The long-term effects of dupilumab are also not known. Potential new systemic treatments include a number of herbal concoctions.

EXPERT OPINION

Randomized, double-blind placebo-controlled trials (RCTs) have demonstrated topical PDE4 inhibitors are effective and safe in the treatment of both children and adults with AD but further evaluations are needed. RCTs have also shown that subcutaneous dupilumab is an effective and safe agent for the treatment of AD in adults. Long-term effects of these topical and systemic investigational drugs are currently unavailable. Regarding herbal medications, scientific methods are often flawed and objective evidence is lacking.

Compression therapy in obese patients

Triggered by obesity, venous (obesity-associated dependency syndrome) and lymphatic drainage disorders (obesity-associated lymphoedema) can develop, which in themselves require compression therapy, or other comorbidities with indication for compression therapy may exist. In obese patients, some specific features have to be observed in compression therapy:

- An adequate initial decongestive phase with padding and bandage materials,

- Compression hosiery with a high degree of stiffness (high-strength materials, where appropriate, flat-knitted) and optimal fit (meticulous fitting),

- Garment types that are suitable for daily use, if necessary, multi-part garment,

- Need for aids or auxiliary persons to ensure correct use,

- Concomitant consistent, intensive, lipid-replenishing skin care and optimised hygiene to reduce complications and side effects

- Regular medical check-ups to ensure correct fit of the leg compression garment.

Sometimes, particularly at the initial provision and in patients with a complicated physical shape, the stockings have to be modified several times before an optimal fit is achieved.

Randomised controlled trial of silk therapeutic garments for the management of atopic eczema in children: the CLOTHES trial

BACKGROUND

Atopic eczema (AE) is a chronic, itchy, inflammatory skin condition that affects the quality of life of children and their families. The role of specialist clothing in the management of AE is poorly understood.

OBJECTIVES

To assess the effectiveness and cost-effectiveness of silk garments for the management of AE in children with moderate to severe disease.

DESIGN

Parallel-group, observer-blind, randomised controlled trial of 6 months' duration, followed by a 2-month observational period. A nested qualitative study evaluated the beliefs of trial participants, health-care professionals and health-care commissioners about the use of silk garments for AE.

SETTING

Secondary care and the community in five UK centres.

PARTICIPANTS

Children aged 1-15 years with moderate or severe AE.

INTERVENTIONS

Participants were randomised (1 : 1 using online randomisation) to standard care or standard care plus 100% silk garments made from antimicrobially protected knitted sericin-free silk [DermaSilk^TM (AlPreTec Srl, San Donà di Piave, Italy) or DreamSkin^TM (DreamSkin Health Ltd, Hatfield, UK)]. Three sets of garments were supplied per participant, to be worn for up to 6 months (day and night). At 6 months the standard care group received the garments to use for the remaining 2-month observational period.

MAIN OUTCOME MEASURES

Primary outcome - AE severity using the Eczema Area and Severity Index (EASI) assessed at 2, 4 and 6 months, by nurses blinded to treatment allocation. EASI scores were log-transformed for analysis. Secondary outcomes - patient-reported eczema symptoms (Patient Oriented Eczema Measure); global assessment of severity (Investigator Global Assessment); quality of life of the child (Atopic Dermatitis Quality of Life, Child Health Utility - 9 Dimensions), family (Dermatitis Family Impact Questionnaire) and main carer (EuroQoL-5 Dimensions-3 Levels); use of standard eczema treatments (e.g. emollients, topical corticosteroids); and cost-effectiveness. The acceptability and durability of the clothing, and adherence to wearing the garments, were assessed by parental/carer self-report. Safety outcomes - number of skin infections and hospitalisations for AE.

RESULTS

A total of 300 children were randomised (26 November 2013 to 5 May 2015): 42% female, 79% white, mean age 5 years. The primary analysis included 282 out of 300 (94%) children (n = 141 in each group). Garments were worn for at least 50% of the time by 82% of participants. Geometric mean EASI scores at baseline, 2, 4 and 6 months were 8.4, 6.6, 6.0, 5.4 for standard care and 9.2, 6.4, 5.8, 5.4 for silk clothing, respectively. There was no evidence of difference between the groups in EASI score averaged over all follow-up visits adjusted for baseline EASI score, age and centre (ratio of geometric means 0.95, 95% confidence interval 0.85 to 1.07; p = 0.43). This confidence interval is equivalent to a difference of -1.5 to 0.5 in the original EASI scale units. Skin infections occurred in 39 out of 141 (28%) and 36 out of 142 (25%) participants for standard care and silk clothing groups, respectively. The incremental cost per QALY of silk garments for children with moderate to severe eczema was £56,811 from a NHS perspective in the base case. Sensitivity analyses supported the finding that silk garments do not appear to be cost-effective within currently accepted thresholds.

LIMITATIONS

Knowledge of treatment allocation may have affected behaviour and outcome reporting for some of the patient-reported outcomes.

CONCLUSIONS

The addition of silk garments to standard AE care is unlikely to improve AE severity, or to be cost-effective compared with standard care alone, for children with moderate or severe AE. This trial adds to the evidence base to guide clinical decision-making.

FUTURE WORK

Non-pharmacological interventions for the management of AE remain a research priority among patients.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN77261365.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 16. See the NIHR Journals Library website for further project information.

Immobilization of bacteriophage in wound-dressing nanostructure

Opportunistic bacteria that cause life-threatening infections are still a central problem associated with a healthcare setting. Bacteriophage capsid immobilization on nanostructured polymers maximizes its tail exposure and looks promising in applications toward skin-infections as alternative to antibiotics standardly used. The main goal of this work was to investigate the covalent immobilization of vB_Pae_Kakheti25 bacteriophage capsid on polycaprolactone (PCL) nanofibers (non-woven textile), as a potential effective antimicrobial, laundry resistant and non-toxic dressing for biomedical use. Surface analyses showed that the immobilization of vB_Pae_Kakheti25 bacteriophage capsid on PCL nanofibres oriented bacteriophage tails to interact with bacteria. Furthermore, antimicrobial assays showed a very effective 6 log bacterial reduction, which was equivalent to 99.9999%, after immediate and 2 hours of contact, even following 25 washing cycles (due to covalent bond). The activity of PCL-vB_Pae_Kakheti25 against P. aeruginosa was immediate and its reduction was complete.

Microbiome in atopic dermatitis

Atopic dermatitis (AD) is a common chronic inflammatory skin disease affecting ~10–20% of the general population. AD is characterized by disturbances in epidermal barrier function and hyperactive immune response. Recently, changes in the skin and intestinal microbiome have been analyzed in more detail. The available data suggest a link between disturbed skin microbiome and course of the disease. Flares of the disease are associated with an expansion of Staphylococcus aureus on lesional skin and a substantial loss of biodiversity in skin microbiome. Staphylococci exoproteins and superantigens evoke inflammatory reactions in the host. Skin microbiome includes superficial stratum corneum that is affected by environmental factors such as exposure to germs and cleansing. Available evidence argues for a link between epidermal barrier impairment and disturbances in skin microbiome in AD. In contrast to skin microbiome, intestinal microbiome seems to become stabilized after infancy. There is also a significant heritable component for intestinal microbiome. The microbial taxa, relative percentages and quantities vary remarkably between the different parts of the intestinal tract. Early intestinal microbial colonization may be a critical step for prevention of further development of AD. Skin barrier-aimed topical treatments help to develop a neo-microbiome from deeper compartments. Probiotics, prebiotics and synbiotics have been investigated for the treatment of AD, but further investigations are needed. Targeted treatment options to normalize skin and intestinal microbiome in AD are under investigation.

Prevalence and odds of Staphylococcus aureus carriage in atopic dermatitis: a systematic review and meta-analysis

BACKGROUND

Staphylococcus aureus is increasingly implicated as a possible causal factor in the pathogenesis of atopic dermatitis (AD). However, the reported prevalence rates of skin and nasal colonization in the literature vary widely.

OBJECTIVES

This study evaluates the prevalence and odds of skin and nasal colonization with S. aureus in patients with AD.

METHODS

A systematic literature search was conducted. Odds ratios (ORs) for colonization in patients vs. controls and the prevalence of colonization in patients were pooled using the random-effects model.

RESULTS

Overall, 95 observational studies were included, of which 30 had a control group. The Newcastle-Ottawa Scale was used to assess study quality, with the majority of studies being of fair to poor quality. Patients with AD were more likely to be colonized with S. aureus than healthy controls [OR 19·74, 95% confidence interval (CI) 10·88-35·81]. Differences were smaller in nonlesional skin (OR 7·77, 95% CI 3·82-15·82) and in the nose (OR 4·50, 95% CI 3·00-6·75). The pooled prevalence of S. aureus colonization among patients was 70% for lesional skin, 39% for nonlesional skin and 62% for the nose. In lesional skin, meta-regression showed that the prevalence of colonization increased with disease severity. Study heterogeneity should be taken into consideration when interpreting the results.

CONCLUSIONS

These results demonstrate the importance of colonization with S. aureus in AD. Further evaluation of the mechanisms by which S. aureus influences inflammation is required in addition to the development of targeted strategies to decrease skin and nasal S. aureus load.

Dual-functional transdermal drug delivery system with controllable drug loading based on thermosensitive poloxamer hydrogel for atopic dermatitis treatment

The treatment of atopic dermatitis (AD) has long been viewed as a problematic issue by the medical profession. Although a wide variety of complementary therapies have been introduced, they fail to combine the skin moisturizing and drug supply for AD patients. This study reports the development of a thermo-sensitive Poloxamer 407/Carboxymethyl cellulose sodium (P407/CMCs) composite hydrogel formulation with twin functions of moisture and drug supply for AD treatment. It was found that the presence of CMCs can appreciably improve the physical properties of P407 hydrogel, which makes it more suitable for tailored drug loading. The fabricated P407/CMCs composite hydrogel was also characterized in terms of surface morphology by field emission scanning electron microscopy (FE-SEM), rheological properties by a rheometer, release profile in vitro by dialysis method and cytotoxicity test. More importantly, the findings from transdermal drug delivery behavior revealed that P407/CMCs showed desirable percutaneous performance. Additionally, analysis of cytotoxicity test suggested that P407/CMCs composite hydrogel is a high-security therapy for clinical trials and thus exhibits a promising way to treat AD with skin moisturizing and medication.

Atopic dermatitis

Atopic dermatitis (also known as atopic eczema) is a chronic inflammatory skin disease that is characterised by intense itching and recurrent eczematous lesions. Although it most often starts in infancy and affects two of ten children, it is also highly prevalent in adults. It is the leading non-fatal health burden attributable to skin diseases, inflicts a substantial psychosocial burden on patients and their relatives, and increases the risk of food allergy, asthma, allergic rhinitis, other immune-mediated inflammatory diseases, and mental health disorders. Originally regarded as a childhood disorder mediated by an imbalance towards a T-helper-2 response and exaggerated IgE responses to allergens, it is now recognised as a lifelong disposition with variable clinical manifestations and expressivity, in which defects of the epidermal barrier are central. Present prevention and treatment focus on restoration of epidermal barrier function, which is best achieved through the use of emollients. Topical corticosteroids are still the first-line therapy for acute flares, but they are also used proactively along with topical calcineurin inhibitors to maintain remission. Non-specific immunosuppressive drugs are used in severe refractory cases, but targeted disease-modifying drugs are being developed. We need to improve understanding of the heterogeneity of the disease and its subtypes, the role of atopy and autoimmunity, the mechanisms behind disease-associated itch, and the comparative effectiveness and safety of therapies.

Chitosan Coated Textiles May Improve Atopic Dermatitis Severity by Modulating Skin Staphylococcal Profile: A Randomized Controlled Trial

BACKGROUND

Atopic dermatitis (AD) patients may benefit from using textiles coated with skin microbiome-modulating compounds. Chitosan, a natural biopolymer with immunomodulatory and antimicrobial properties, has been considered potentially useful.

OBJECTIVE

This randomized controlled trial assessed the clinical utility of chitosan-coated garment use in AD.

METHODS

Of the 102 patients screened, 78 adult and adolescents were randomly allocated to overnight use of chitosan-coated or uncoated cotton long-sleeved pyjama tops and pants for 8 weeks. The primary outcome was change in disease severity assessed by Scoring Atopic dermatitis index (SCORAD). Other outcomes were changes in quality of life, pruritus and sleep loss, days with need for rescue medication, number of flares and controlled weeks, and adverse events. Changes in total staphylococci and Staphylococcus aureus skin counts were also assessed. Comparisons were made using analysis of variance supplemented by repeated measures analysis for the primary outcome. Interaction term between time and intervention was used to compare time trends between groups.

RESULTS

Chitosan group improved SCORAD from baseline in 43.8%, (95%CI: 30.9 to 55.9), P = 0.01, placebo group in 16.5% (-21.6 to 54.6); P = 0.02 with no significant differences between groups; Dermatology Quality of life Index Score significantly improved in chitosan group (P = 0.02) and a significant increase of skin Coagulase negative Staphylococci (P = 0.02) was seen.

CONCLUSIONS

Chitosan coated textiles may impact on disease severity by modulating skin staphylococcal profile. Moreover, a potential effect in quality of life may be considered.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01597817.

Consensus Guidelines for the Treatment of Atopic Dermatitis in Korea (Part I): General Management and Topical Treatment

Background

Since the treatment guidelines for atopic dermatitis (AD) were released by the Korean Atopic Dermatitis Association (KADA) work group in 2006, there have been several advances in AD management.

Objective

We aimed to establish updated evidence- and experience-based treatment guidelines for Korean AD.

Methods

We collected a database of references from relevant systematic AD reviews and guidelines regarding general AD management such as bathing and skin care, avoidance of exacerbating factors, education and psychosocial support, and the use of moisturizers and topical anti-inflammatory and antipruritic drugs. Evidence for each statement was graded and the strength of the recommendation for each statement classified. Thirty-nine KADA council members participated in three rounds of voting to establish an expert consensus of recommendations.

Results

Basic AD treatment includes proper bathing and skin care, avoidance of exacerbating factors, proper education and psychosocial support, and use of moisturizers. The regular use of moisturizer has a steroid-sparing effect and reduces relapse episodes. The short- and long-term use of topical corticosteroids and calcineurin inhibitors improves AD symptoms and should be encouraged to use in an active and proactive treatment. Wet-wrap therapy can be used for rapid recovery of acute exacerbation. Topical antipruritic drugs cannot be recommended for the treatment of AD.

Conclusion

This report provides up-to-date evidence- and experience-based treatment guidelines for AD regarding general management and topical treatment. In addition, the average agreement scores obtained by a panel of experts based on the Korean healthcare system and patient adherence are presented.

A multi-centre, parallel group superiority trial of silk therapeutic clothing compared to standard care for the management of eczema in children (CLOTHES Trial): study protocol for a randomised controlled trial

Background

Eczema is a chronic, itchy skin condition that can have a large impact on the quality of life of patients and their families. People with eczema are often keen to try out non-pharmacological therapies like silk therapeutic garments that could reduce itching or the damage caused by scratching. However, the effectiveness and cost-effectiveness of these garments in the management of eczema has yet to be proven. The CLOTHES Trial will test the hypothesis that ‘silk therapeutic garments plus standard eczema care’ is superior to ‘standard care alone’ for children with moderate to severe eczema.

Methods/Design

Parallel group, observer-blind, pragmatic, multi-centre randomised controlled trial of 6 months’ duration.

Three hundred children aged 1 to 15 years with moderate to severe eczema will be randomised (1:1) to receive silk therapeutic garments plus standard eczema care, or standard eczema care alone. Primary outcome is eczema severity, as assessed by trained and blinded investigators at 2, 4 and 6 months (using the Eczema Area and Severity Index (EASI)). Secondary outcomes include: patient-reported eczema symptoms (collected weekly for 6 months to capture long-term control); global assessment of severity; quality of life of the child, family and main carer; use of standard eczema treatments (emollients, corticosteroids applied topically, calcineurin inhibitors applied topically and wet wraps); frequency of infections; and cost-effectiveness. The acceptability and durability of the clothing will also be assessed, as will adherence to wearing the garments. A nested qualitative study will assess the views of a subset of children wearing the garments and their parents, and those of healthcare providers and commissioners.

Randomisation uses a computer-generated sequence of permuted blocks of randomly varying size, stratified by recruiting hospital and child’s age (< 2 years; 2 to 5 years; > 5 years), and concealed using a secure web-based system. The sequence of treatment allocations will remain concealed until randomisation and data collection are complete.

Recruitment is taking place from November 2013 to May 2015, and the trial will be completed in 2016. Full details of results will be published in the National Institute for Health Research Journal series.

Trial registration

Current Controlled Trials ISRCTN77261365 (registered 11 November 2013).

Alternative, Complementary, and Forgotten Remedies for Atopic Dermatitis

Atopic dermatitis, perhaps more than other dermatologic diseases, has garnered much attention in the realm of alternative medicine. This may be because its etiopathogenesis is incompletely understood, it is increasingly common, and it waxes and wanes often without clear precipitants, opening up many opportunities for misinterpretation. Herein we explore the evidence for a number of different alternative and complementary therapies, from textiles to vitamin supplements. By definition, none have enough data to be deemed "effective" in a conventional sense, but it is hopeful that some show promising evidence that may one day lead to mainstream acceptance with further research.

Alternative, Complementary, and Forgotten Remedies for Atopic Dermatitis

Atopic dermatitis, perhaps more than other dermatologic diseases, has garnered much attention in the realm of alternative medicine. This may be because its etiopathogenesis is incompletely understood, it is increasingly common, and it waxes and wanes often without clear precipitants, opening up many opportunities for misinterpretation. Herein we explore the evidence for a number of different alternative and complementary therapies, from textiles to vitamin supplements. By definition, none have enough data to be deemed “effective” in a conventional sense, but it is hopeful that some show promising evidence that may one day lead to mainstream acceptance with further research.

What's new in atopic eczema? An analysis of systematic reviews published in 2012 and 2013. Part 2. Treatment and prevention

This review provides a summary of key findings from 22 systematic reviews on atopic eczema (AE) published over the 2-year period from January 2012 to 31 December 2013, focusing on prevention and treatment of AE. For an update of systematic reviews on the epidemiology, mechanisms of disease and methodological issues, see Part 1 of this update. Based on current systematic review evidence, the most promising intervention for the prevention of AE is the use of probiotics (and possibly prebiotics) during the late stages of pregnancy and early life. Exposure to household pets, especially dogs, may also be protective, but exclusive breastfeeding for up to 7 months does not confer benefit. The role of vitamin D in preventing AE is currently unclear. Very few of the systematic reviews provided additional evidence for the use of specific treatments for AE. Further research is required to establish the role of desensitization, Chinese herbal medicines, homeopathy and specialist clothing. Nevertheless, there is now clear evidence that evening primrose oil and borage oil are not effective for the treatment of AE. There have been no randomized controlled trials on the use of H1 anti-histamines as monotherapy for the treatment of AE.

Recent advances in epidemiology and prevention of atopic eczema

Atopic dermatitis (AD), named also atopic eczema, is a chronic relapsing inflammatory skin disease with a considerable social and economic burden. The primum movens of AD is in most cases a genetic and/or immune-supported defect of the skin barrier, facilitating penetration and sensitization to food or airborne allergens, as well as infections by Staphylococcus aureus, herpes simplex virus, or other microbes. New pathogenetic concepts have generated new approaches to prevention and therapy of AD. In particular, the daily use of emollients in newborns at high risk of AD has shown interesting results, with a reduction in the cumulative incidence of AD ranging from 32% to 50% of the treated infants. On the other hand, the AD preventive efficacy of food and/or inhalant allergen avoidance has been questioned, and supplementation strategies (vitamin D, probiotics, or other compounds) need to be further investigated.