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

Bleach suit for atopic dermatitis

Bleach baths are an important adjunct in the management of atopic dermatitis. However, many homes do not have bath tubs. We tried to overcome this by soaking a cotton pajama suit or Indian kurta pajama in dilute bleach solution and then having the child wear it for ten minutes. This is done two to three times a week, as in standard bleach tub baths. We have tried this technique in eleven patients with satisfactory outcomes and no adverse effects.

Tailoring plasmonic sensing strategies for the rapid and sensitive detection of hypochlorite in swimming water samples

A tunable plasmonic sensor has been developed by varying the dextran content in the initially synthesized dextran-gold nanoparticle (dAuNPs) solution. A colloidal nanogold solution (dAuNPs-Sol) was initially prepared using dextran and gold salt in alkaline media by a one-pot green synthetic route. The dAuNPs-Sol was combined with varying amounts of dextran (ranging from 0.01 to 30.01%) to create a tunable probe, along with different solid formats, including tablet (dAuNPs-Tab), powder (dAuNPs-Powder), and composite (dAuNPs-Comp). Both the liquid and solid phase plasmonic probes were characterized using UV-vis spectroscopy, transmission electron microscopy (TEM) dynamic light scattering (DLS), and zeta potential analysis. The impact of dextran content in the dAuNP solution is studied in terms of surface charge and hydrodynamic size. The influence of operational treatments used to achieve solid dAuNPs probes is also explored. All plasmonic probes were employed to detect a broad range of OCl¯ concentrations (ranging from µM to mM) in water through aggregation followed by calculating a lower and upper limit of detection (LLoD, ULoD) of the proposed colorimetric sensors. Results indicate that the most sensitive detection is achieved with a lower dextran content (0.01%), which exhibits an LLoD of 50 µM. The dAuNPs-Sol sensor is selective and demonstrates real-world applicability, as confirmed by interference analysis and successful testing with various water samples. Additionally, it is found that a 20 × concentration of dextran-coated gold nanoparticles could be attained without any changes in the particle morphology. This concentration is achieved through a straightforward process that does not require the use of a centrifuge machine. This finding highlights the practicality and simplicity of the method, indicating its potential for scalable and cost-effective production of concentrated dAuNPs without compromising their structural integrity.

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.

An improved human skin explant culture method for testing and assessing personal care products

BACKGROUND

Cultured human skin models have been widely used in the evaluation of dermato-cosmetic products as alternatives to animal testing and expensive clinical testing. The most common in vitro skin culture approach is to maintain skin biopsies in an airlifted condition at the interface of the supporting culture medium and the air phase. This type of ex vivo skin explant culture is not, however, adequate for the testing of cleansing products, such as shampoos and body washes. One major deficiency is that cleansing products would not remain confined on top of the epidermis and have a high chance of running off toward the dermal side, thus compromising the experimental procedure and data interpretation.

MATERIALS AND METHODS

Here, we describe an improved ex vivo method for culturing full-thickness human skin for the effective testing and evaluation of skin care products by topical application.

RESULTS

This newly developed ex vivo human skin culture method has the ability to maintain healthy skin tissues for up to 14 days in culture. Importantly, the model provides a quick and safe way to evaluate skin care products at different time points after single or repetitive topical applications using a combined regimen of leave-on and wash-off. We found that the results obtained using the new skin culture method are reproducible and consistent with the data collected from clinical testing.

CONCLUSION

Our new ex vivo skin explant method offers a highly efficient and cost-effective system for the evaluation and testing of a variety of personal care products and new formulations.

Management of atopic dermatitis: a narrative review

Atopic dermatitis (atopic eczema) is the most common inflammatory skin disease and has a significant burden on the quality of life of patients, families and caregivers. Its pathogenesis is a complex interplay between genetics and environment, involving impaired skin barrier function, immune dysregulation primarily involving the Th2 inflammatory pathway, itch, and skin microbiome. Restoration of skin barrier integrity with regular emollients and prompt topical anti-inflammatory therapies are mainstays of treatment. Systemic therapy is considered for moderate to severe disease. New understanding of inflammatory pathways and developments in targeted systemic immunotherapies have significantly advanced atopic dermatitis management. Dupilumab is a safe and effective treatment that is now available in Australia. Other promising agents for atopic dermatitis include Janus kinase, interleukin (IL)-13 and IL-31 inhibitors.

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.

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.

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.

Update on the Pathogenesis and Therapy of Atopic Dermatitis

Atopic dermatitis (AD) is a common inflammatory skin disorder characterized by recurrent eczematous lesions and intense itch. Although it most often starts in infancy and affects children, it is also highly prevalent in adults. In this article, the main aspects of AD have been updated, with a focus on the pathogenetic and therapeutic aspects. The pathogenesis of AD is complex, and it is evident that a strong genetic predisposition, epidermal dysfunction, skin microbiome abnormalities, immune dysregulation, and the neuroimmune system are critical in AD development. Mutations in the genes associated with disrupted epidermal barrier, exaggerated pathological inflammation and inadequate antimicrobial peptides can promote enhanced Th2 inflammation and mediate pruritus. Current understanding of etiology highlights gut microbial diversity, NK cell deficiency, and different immunological phenotype with age and race. For topical anti-inflammatory treatment for mild-to-severe AD, phosphodiesterase 4 inhibitors (PDE-4), JAK inhibitors, and microbiome transplantation with Roseomonas mucosa provided more management selections. The treatment of moderate-to-severe AD has been limited to merely symptomatic and relatively nonspecific immunosuppressive approaches. In-depth understanding of the pathogenesis of AD has led to the development of innovative and targeted therapies, such as biologic agents targeting interleukin (IL)-4, IL-13 and JAK/STAT inhibitors. Other potential therapeutic agents for AD include agents targeting the T helper (Th) 22 and Th17/IL23 pathway. Antipruritic therapy and complementary probiotics therapy have also been reviewed.

[Dysbalance between the immune system and skin microbiome in chronic inflammatory dermatoses]

BACKGROUND

The skin is an organ frequently affected by chronic diseases. Inflammatory, immune-mediated dermatoses such as atopic dermatitis and psoriasis show a high prevalence as well as a significant impact on the quality of life of those affected. In a large proportion of cases, atopic dermatitis is associated with a marked change in microbial colonization of both clinically healthy and affected skin. In psoriasis, changes to this effect have been described, but clinical relevance remains elusive.

AIM

In recent years, increasing knowledge has been gained in microbiome research with resulting clinical relevance. The present article deals with the disturbed balance of the immune system and the skin microbiome in chronic inflammatory dermatoses on the basis of atopic dermatitis and psoriasis vulgaris.

MATERIALS AND METHODS

A literature search was performed in PubMed and Medline databases (entries until 09 April 2021).

RESULTS

Staphylococcus aureus is known to play a central pathophysiological role in atopic dermatitis. This is revisited in light of new insights regarding biodiversity and immunoregulatory processes. In psoriasis, a more heterogeneous body of data emerges regarding the microbiome and its contribution to disease development.

DISCUSSION

While topical applications to directly influence the microbiome are already being tested in atopic dermatitis, further knowledge regarding the pathophysiological significance of the microbiota is still needed in psoriasis.

Colonization With Staphylococcus aureus in Atopic Dermatitis Patients: Attempts to Reveal the Unknown

Atopic dermatitis (AD) patients are massively colonized with Staphylococcus aureus (S. aureus) in lesional and non-lesional skin. A skin infection may become systemic if left untreated. Of interest, the incidence of multi-drug resistant S. aureus (MRSA) in AD patients is higher as compared to a healthy population, which makes treatment even more challenging. Information on the specific genetic background of S. aureus accompanying and/or causing AD flares would be of great importance in terms of possible treatment option development. In this review, we summarized the data on the prevalence of S. aureus in general in AD skin, and the prevalence of specific clones that might be associated with flares of eczema. We put our special interest in the presence and role of staphylococcal enterotoxins as important virulence factors in the epidemiology of AD-derived S. aureus. Also, we summarize the present and potentially useful future anti-staphylococcal treatment.

Treatments for Childhood Atopic Dermatitis: an Update on Emerging Therapies

Atopic dermatitis (AD) is generally considered a T helper type 2-dominated disease. Pediatric AD is usually less severe than adult AD, but it may present as moderate to severe lesions that are inadequately managed by current modalities including emollients/moisturizers, topical corticosteroids (TCSs), topical calcineurin inhibitors (TCIs), and even systemic immunosuppressants (such as cyclosporine, azathioprine, methotrexate, and mycophenolate mofetil). In addition, systemic immunosuppressants are often not recommended for childhood AD by the current guidelines due to their toxicities. Therefore, there is still an unmet need for a safe and effective long-term therapy for pediatric AD patients whose disease is inadequately controlled or who are intolerant to current treatments. The emerging therapeutics for AD focuses on intervening in the inflammatory pathway by targeting specific cytokines/chemokines or their receptors. Monoclonal antibodies against immunoglobulin E (IgE), interleukin (IL)-4 receptor subunit α, IL-5, IL-13, IL-31 receptor subunit α, IL-33, and thymic stromal lymphopoietin (TSLP) have been evaluated clinically for AD. Encouraging results have been reported for many of the biologics, of which the most exciting is dupilumab. Other emerging systemic therapies include small molecules such as baricitinib, abrocitinib, upadacitinib, and tradipitant. Several novel topical agents are under clinical investigation for the treatment of AD, including topical phosphodiesterase 4 (PDE4) inhibitors, Janus kinase (JAK) inhibitors, aryl hydrocarbon receptor (AhR) modulating agents, and transient receptor potential vanilloid subfamily member 1 (TRPV1) antagonists. Accompanied by thorough characterization of different phenotype and endotype subsets, the application of precision medicine could provide new prospects for the optimal treatment of AD.

Taiwanese Dermatological Association consensus for the management of atopic dermatitis: A 2020 update

BACKGROUND/PURPOSE

Atopic dermatitis (AD) is a chronic inflammatory disease commonly seen in children and increasingly recognized in adults. With recent advances in the therapeutic development for AD, the Taiwanese Dermatological Association (TDA) established a committee to update the consensus for AD management in Taiwan. This report describes the 2020 updated consensus for the management of AD.

METHODS

A panel of 11 core members was convened to review and discuss aspects of AD management and draft recommendation during the first two meetings. The 2015 TDA consensus and the 2017 European guideline, along with recent peer-reviewed articles, serve as the foundation for the update. In the third meeting, AD expert dermatologists selected on a national scale were invited to vote on the final statements. A total of 27 dermatologists attended the final meeting. The consensus was achieved when ratings of 7-9 (out of a total score of 9) accounted for ≥ 75% of the total votes.

RESULTS

Consensus was achieved on the therapeutic options for AD by lines of treatment. A treatment algorithm was presented to illustrate the place of each modality in terms of basic care, acute disease control, and maintenance therapy. Special considerations for the pediatric population, as well as for women during pregnancy and lactation, are discussed.

CONCLUSION

Topical corticosteroids with long-term emollient-based therapies remain the cornerstone of AD treatment. Systemic treatments are indicated when topical therapies and phototherapy fail to control the disease. The recent approval of dupilumab and emerging targeted therapies are expected to bring significant clinical benefit for patients whose disease is inadequately managed by existing options.

Atopic Dermatitis: Update on Pathogenesis and Therapy

Atopic dermatitis (AD) is the most common inflammatory skin condition in pediatric patients. AD has long been associated with comorbidities including food allergies, asthma, and allergic rhinitis, but recent literature has expanded this list to include attention-deficit/hyperactivity disorder and depression. AD has tremendous impact on quality of life for both affected children and their families. Improved understanding of AD pathogenesis, particularly regarding skin barrier dysfunction, the role of the cutaneous microbiome, and immune dysregulation, has spawned exciting new therapeutic directions. Although good skin care and appropriate use of topical corticosteroids remain first-line treatment, more precisely targeted treatments hold great promise. A recently approved topical phosphodiesterase inhibitor, crisaborole, and a subcutaneously administered interleukin-4/interleukin-13 blocker, dupilumab, are the first of what will likely be many new treatment options for patients with AD. [Pediatr Ann. 2020;49(3):e140-e146.].

Topical and Oral Therapies for Childhood Atopic Dermatitis and Plaque Psoriasis

BACKGROUND

Treatment of atopic dermatitis and psoriasis in children is difficult due to lack of standardized treatment guidelines and few FDA-approved treatment options. Treatments approved for adults may be used off-label in pediatric patients.

OBJECTIVE

This review evaluates the topical and oral treatment options available, including off-label uses, and provides a basic therapeutic guideline for pediatric atopic dermatitis and psoriasis.

METHODS

A PubMed review of topical and systemic treatments for pediatric psoriasis and atopic dermatitis with information regarding age, efficacy, dosing, contra-indications, adverse events, and off-label treatments.

RESULTS

The search identified seven topical and five systemic treatments that are routinely employed to treat pediatric atopic dermatitis and psoriasis.

LIMITATIONS

Standardized guidelines regarding treatment choice, dosing, and long-term safety are scarce. Reviews may be subject to ascertainment bias.

CONCLUSIONS

Current treatment guidelines are based on clinical experience and expert advice with few treatments officially approved for atopic dermatitis and psoriasis in children.

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.