Efficacy and safety of silver textile in the treatment of atopic dermatitis (AD)

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.

Effectiveness of antibacterial therapeutic clothing vs. nonantibacterial therapeutic clothing in patients with moderate-to-severe atopic dermatitis: a randomized controlled observer-blind pragmatic trial (ABC trial)

BACKGROUND

Increased Staphylococcus aureus (SA) colonization is considered an important factor in the pathogenesis of atopic dermatitis (AD). Antibacterial therapeutic clothing aims to reduce SA colonization and AD inflammation; however, its role in the management of AD remains poorly understood.

OBJECTIVES

To investigate the effectiveness of antibacterial therapeutic clothing + standard topical treatment in patients with moderate-to-severe AD vs. standard therapeutic clothing + standard topical treatment; and, if effectiveness was demonstrated, to demonstrate its cost-effectiveness.

METHODS

A pragmatic double-blinded multicentre randomized controlled trial (NCT04297215) was conducted in patients of all ages with moderate-to-severe AD. Patients were centrally randomized 1 : 1 : 1 to receive standard therapeutic clothing or antibacterial clothing based on chitosan or silver. The primary outcome was the between-group difference in Eczema Area and Severity Index (EASI) measured over 52 weeks. Secondary outcomes included patient-reported outcomes (PROs), topical corticosteroid (TCS) use, SA colonization, safety and cost-effectiveness. Outcomes were assessed by means of (generalized) linear mixed-model analyses.

RESULTS

Between 16 March 2020 and 20 December 2021, 171 patients were enrolled. In total, 159 patients were included (54 in the standard therapeutic clothing group, 50 in the chitosan group and 55 in the silver group). Adherence was high [median 7 nights a week wear (interquartile range 3-7)]. Median EASI scores at baseline and at 4, 12, 26 and 52 weeks were 11.8, 4.3, 4.6, 4.2 and 3.6, respectively, in the standard therapeutic clothing group vs. 11.3, 5.0, 3.0, 3.0 and 4.4, respectively, in the chitosan group, and 11.6, 5.0, 5.4, 4.6 and 5.8, respectively, in the silver group. No differences in EASI over 52 weeks between the standard therapeutic clothing group, the chitosan group [-0.1, 95% confidence interval (CI) -0.3 to 0.2; P = 0.53] or the silver group (-0.1, 95% CI -0.3 to 0.2; P = 0.58) were found. However, a small significant group × time interaction effect between the standard and silver groups was found (P = 0.03), in which the silver group performed worse after 26 weeks. No differences between groups were found in PROs, TCS use, SA skin colonization and healthcare utilization. No severe adverse events or silver absorption were observed.

CONCLUSIONS

The results of this study suggest no additional benefits of antibacterial agents in therapeutic clothing in patients with moderate-to-severe AD.

Atopic Dermatitis: Managing the Itch

Atopic dermatitis has a substantial impact on sleep, appearance, psychological well-being, and other qualities of life. The visual appearance of lichenification, cheilitis, hyperpigmentation, ichthyosis, and erythema can be socially stigmatizing, and treatment of these symptoms is challenging. In managing pruritus in patients, practitioners should assess and document pruritus through questionnaires at each routine visit. Initially, practitioners should advise patients to employ nonpharmaceutical treatments such as emollients with wet wraps, elimination of triggers, changing scratching habits, and psychological interventions. If these methods of treatment are not successful or if the disease presentation is severe, pharmacological therapies should be employed. This chapter describes the therapeutic ladder for pruritus in atopic dermatitis and discusses each treatment modality in further detail for practitioners to advise their patients.First-line topical pharmaceutical agents include topical glucocorticoids and topical calcineurin inhibitors. Second-line topical agents include coal tar, menthol, capsaicin, or doxepin. After the use of topical agents has been exhausted, primary systemic agents can be applied. These include sedating antihistamines, nonsedating antihistamines, oral glucocorticoids, or cyclosporine A. Finally, neuromodulating or immunomodulating agents can be attempted, including SSRI/SNRIs, TCAs, immunosuppressants, neural modulators, and opioid receptor modulators. Outside of pharmacological treatments, phototherapy has been shown to provide a dramatic improvement of pruritus in atopic dermatitis and can be used at any stage of treatment including as a first-line agent.

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.

The "Maskne" microbiome - pathophysiology and therapeutics

"Maskne" is a new term coined during the 2020 COVID-19 pandemic. It refers to a subset of acne mechanica, deserving consideration in view of widespread reusable fabric mask-wearing to control the pandemic worldwide. Understanding of underlying pathophysiology directly relates to the novel skin microenvironment and textile-skin friction created by mask-wearing, distinct from nontextile-related acne mechanica previously linked to wearing of headgear. Specifically, the occlusive microenvironment leads to microbiome dysbiosis, which is linked to various dermatological conditions. Additional textile-skin interactions include factors such as breathability, stickiness sensations, moisture saturation, and hygiene maintenance. Increased skin temperatures can trigger sweat/heat-related dermatoses, and ear loops potentially trigger pressure-induced dermatoses. Important therapeutic considerations include increased skin irritation potential of conventional acne treatments under occlusion, exacerbation of chronic dermatoses, that is, perioral dermatitis, rosacea, and eczema, and susceptibility of these same patient groups to heightened discomfort with mask-wearing. Cotton, as the traditional fabric of choice for dermatology patients, has limited benefits in the context of face masks - increased subjective discomfort relates to increased moisture saturation and stickiness, inevitable because of high biofluid load of the nasal and oral orifices. Prolonged textile-skin contact time, directly proportional to the risk of maskne, can be an opportunity for the application of biofunctional textiles.

Fabric Selection in Atopic Dermatitis: An Evidence-Based Review

BACKGROUND

Clothing fabrics interact closely with the skin to shape our cutaneous microenvironment. Cotton and silk have been traditionally recommended for patients with atopic dermatitis because of reported patient comfort. New synthetic fabrics combine anti-microbial, anti-inflammatory, moisture-wicking, and soothing properties that may augment conventional management strategies in atopic patients.

OBJECTIVE

We review existing and emerging evidence for fabric selection in patients with atopic dermatitis including cotton, wool, lyocell, silk, anionic, cellulosic/cellulose based, zinc oxide coated, citric acid coated, chitosan coated, silver coated, borage seed oil coated, ethylene vinyl, and polyurethane and offer practical suggestions for clothing and bedding choices.

METHODS

A systematic search was conducted on PubMed and EMBASE electronic databases for articles from 1 January, 1994 to 1 January, 2020. Studies were included based on the following inclusion criteria: clinical trial, published in English, and fabric as the main agent being evaluated. Case reports, case series, conference abstracts, reviews, animal studies, and duplicates were excluded. Studies were then manually screened by title, abstract, and full-text articles and selected to specifically describe the effects of fabrics in patients with atopic dermatitis. Both adult and pediatric patient studies were included.

RESULTS

There appears to be an advantage to modern fabric manufacturing and processing techniques that have created smaller diameter, smoother fibers such as super- and ultrafine merino wool and anti-microbial finishes. Traditional cotton and silk fabrics have mixed evidence in improving atopic dermatitis symptoms and severity but have shown to be generally safe. Large-diameter wool has been shown to induce itching and irritation; ultra- or superfine merino wool is non-pruritic and may be recommended as an alternative. Emerging fabrics with potential efficacy in reducing atopic dermatitis severity and Staphylococcus aureus burden include silver-coated, chitosan-coated, and cellulose-based fabrics. Zinc oxide-coated, acid-coated, polyurethane-coated, borage seed oil-coated, anionic, lyocell, and ethylene vinyl fabrics have sparse evidence and require further study before conclusions can be made.

CONCLUSIONS

Appropriate fabric selection can reduce the symptom severity and exacerbations of atopic dermatitis.

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.

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.

Silver-coated textiles in hidradenitis suppurativa: A case report

Hidradenitis suppurativa is a chronic and debilitating skin disease of apocrine gland–bearing areas. The mainstay of treatment usually includes topical and systemic antibiotics. These agents can be used as monotherapy or combination therapy. The therapeutic role of functional textiles with antimicrobial activity has been recently emerging in the treatment of other skin diseases such as atopic dermatitis and epidermolysis bullosa. The pathologic processes involved in the development of atopic dermatitis and hidradenitis suppurativa are still incompletely understood, but these two diseases share some similarities including bacterial proliferation and chronic inflammation. We report the case of a 14-year-old boy with hidradenitis suppurativa that has been successfully treated with silver-coated textiles. To the best of our knowledge, this article is the first to report the benefits of silver-coated textiles in the treatment of hidradenitis suppurativa.

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.

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.

Scoping systematic review of treatments for eczema

Background

Eczema is a very common chronic inflammatory skin condition.

Objectives

To update the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) systematic review of treatments for atopic eczema, published in 2000, and to inform health-care professionals, commissioners and patients about key treatment developments and research gaps.

Data sources

Electronic databases including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Skin Group Specialised Register, Latin American and Caribbean Health Sciences Literature (LILACS), Allied and Complementary Medicine Database (AMED) and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched from the end of 2000 to 31 August 2013. Retrieved articles were used to identify further randomised controlled trials (RCTs).

Review methods

Studies were filtered according to inclusion criteria and agreed by consensus in cases of uncertainty. Abstracts were excluded and non-English-language papers were screened by international colleagues and data were extracted. Only RCTs of treatments for eczema were included, as other forms of evidence are associated with higher risks of bias. Inclusion criteria for studies included availability of data relevant to the therapeutic management of eczema; mention of randomisation; comparison of two or more treatments; and prospective data collection. Participants of all ages were included. Eczema diagnosis was determined by a clinician or according to published diagnostic criteria. The risk of bias was assessed using the Cochrane Collaboration risk-of-bias tool. We used a standardised approach to summarising the data and the assessment of risk of bias and we made a clear distinction between what the studies found and our own interpretation of study findings.

Results

Of 7198 references screened, 287 new trials were identified spanning 92 treatments. Trial reporting was generally poor (randomisation method: 2% high, 36% low, 62% unclear risk of bias; allocation concealment: 3% high, 15% low, 82% unclear risk of bias; blinding of the intervention: 15% high, 28% low, 57% unclear risk of bias). Only 22 (8%) trials were considered to be at low risk of bias for all three criteria. There was reasonable evidence of benefit for the topical medications tacrolimus, pimecrolimus and various corticosteroids (with tacrolimus superior to pimecrolimus and corticosteroids) for both treatment and flare prevention; oral ciclosporin; oral azathioprine; narrow band ultraviolet B (UVB) light; Atopiclair™ and education. There was reasonable evidence to suggest no clinically useful benefit for twice-daily compared with once-daily topical corticosteroids; corticosteroids containing antibiotics for non-infected eczema; probiotics; evening primrose and borage oil; ion-exchange water softeners; protease inhibitor SRD441 (Serentis Ltd); furfuryl palmitate in emollient; cipamfylline cream; andMycobacterium vaccaevaccine. Additional research evidence is needed for emollients, bath additives, antibacterials, specialist clothing and complementary and alternative therapies. There was no RCT evidence for topical corticosteroid dilution, impregnated bandages, soap avoidance, bathing frequency or allergy testing.

Limitations

The large scope of the review coupled with the heterogeneity of outcomes precluded formal meta-analyses. Our conclusions are still limited by a profusion of small, poorly reported studies.

Conclusions

Although the evidence base of RCTs has increased considerably since the last NIHR HTA systematic review, the field is still severely hampered by poor design and reporting problems including failure to register trials and declare primary outcomes, small sample size, short follow-up duration and poor reporting of risk of bias. Key areas for further research identified by the review include the optimum use of emollients, bathing frequency, wash products, allergy testing and antiseptic treatments. Perhaps the greatest benefit identified is the use of twice weekly anti-inflammatory treatment to maintain disease remission. More studies need to be conducted in a primary care setting where most people with eczema are seen in the UK. Future studies need to use the same core set of outcomes that capture patient symptoms, clinical signs, quality of life and the chronic nature of the disease.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Consensus Conference on Clinical Management of pediatric Atopic Dermatitis

The Italian Consensus Conference on clinical management of atopic dermatitis in children reflects the best and most recent scientific evidence, with the aim to provide specialists with a useful tool for managing this common, but complex clinical condition. Thanks to the contribution of experts in the field and members of the Italian Society of Pediatric Allergology and Immunology (SIAIP) and the Italian Society of Pediatric Dermatology (SIDerP), this Consensus statement integrates the basic principles of the most recent guidelines for the management of atopic dermatitis to facilitate a practical approach to the disease. The therapeutical approach should be adapted to the clinical severity and requires a tailored strategy to ensure good compliance by children and their parents. In this Consensus, levels and models of intervention are also enriched by the Italian experience to facilitate a practical approach to the disease.

The Role of Textiles in Dermatitis: An Update

Dermatitis has important implications for individuals who are affected. It can significantly impair function and quality of life. Dermatitis is multi-factorial and often includes elements of atopic dermatitis, allergic contact dermatitis, and irritant contact dermatitis in a co-existent manner. Textiles are in contact with the human skin for extended periods of time and as a result, they are an important part of the cutaneous environment. Thus, it is not surprising that textiles play a major role in both the etiology and the treatment of various types of dermatitis. This review discusses the role of textiles in dermatitis with an emphasis on interesting and recent advances, trends, perspectives, gaps, and conflicts in the field. In addition, we mention other disease processes to be aware of as they can often mimic textile pattern dermatitis. Lastly, we provide a diagnostic approach for patients presenting with textile pattern dermatitis.

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).

Non-pharmacologic therapies for atopic dermatitis

Atopic dermatitis (AD) continues to present significant therapeutic challenges, especially in severe cases. Navigating the line between risk and benefit can be difficult for more powerful medications such as immunosuppressants, but non-pharmacologic treatments are often overlooked and underutilized. Creative application of these more physical therapies can serve to minimize the pharmacologic treatments and their side effects, and possibly even create synergy between modalities, to maximize benefit to the patient.

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

Atopic dermatitis (AD) is a relapsing inflammatory skin disease with a considerable social and economic burden. Functional textiles may have antimicrobial and antipruritic properties and have been used as complementary treatment in AD. We aimed to assess their effectiveness and safety in this setting. We carried out a systematic review of three large biomedical databases. GRADE approach was used to rate the levels of evidence and grade of recommendation. Meta-analyses of comparable studies were carried out. Thirteen studies (eight randomized controlled trials and five observational studies) met the eligibility criteria. Interventions were limited to silk (six studies), silver-coated cotton (five studies), borage oil, and ethylene vinyl alcohol (EVOH) fiber (one study each). Silver textiles were associated with improvement in SCORAD (2 of 4), fewer symptoms, a lower need for rescue medication (1 of 2), no difference in quality of life, decreased Staphyloccosus aureus colonization (2 of 3), and improvement of trans-epidermal water loss (1 of 2), with no safety concerns. Silk textile use was associated with improvement in SCORAD and symptoms (2 of 4), with no differences in quality of life or need for rescue medication. With borage oil use only skin erythema showed improvement, and with EVOH fiber, an improvement in eczema severity was reported. Recommendation for the use of functional textiles in AD treatment is weak, supported by low quality of evidence regarding effectiveness in AD symptoms and severity, with no evidence of hazardous consequences with their use. More studies with better methodology and longer follow-up are needed.

Silver sulfadiazine–immobilized celluloses as biocompatible polymeric biocides

Sulfadiazine was immobilized onto cotton cellulose using ethylene glycol diglycidyl ether as a binder. Upon treatment with diluted silver nitrate aqueous solution, the sulfadiazine moieties in the immobilized celluloses were transformed into silver–sulfadiazine coordination complexes. The resulting silver sulfadiazine–immobilized celluloses provided a 6-log reduction of 108 CFU mL−1 of Staphylococcus aureus (Gram-positive bacteria), Escherichia coli (Gram-negative bacteria), methicillin-resistant Staphylococcus aureus (drug-resistant bacteria), vancomycin-resistant Enterococcus faecium (drug-resistant bacteria), and Candida albicans (fungi) in 30–60 minutes, and a 5-log reduction of 107 PFU mL−1 of MS2 virus in 120 minutes. The antibacterial, antifungal, and antiviral activities were both durable and rechargeable. Additionally, trypan blue assay suggested that the new silver sulfadiazine–immobilized celluloses sustained excellent mammal cell viability, pointing to great potentials of the new materials for a broad range of health care–related applications.

A proposal for the use of new silver-seaweed-cotton fibers in the treatment of atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is a disease with multifactorial etiology. Staphylococcus aureus is one of the predominant environmental factors acting on the course and intensity of the disease.

OBJECTIVES

The aims of the study were to evaluate the efficacy and safety of clothing made of cellulose fibers with seaweed enriched with silver ions in the treatment of children with AD.

METHODS

A prospective, randomized and double-blinded controlled selection was done to recruit 19 children with diagnosis of AD. This sample was divided in two groups with similar demographic and clinical characteristics (the "control" group of seven children who wore placebo clothing and the "trial textile" group of 12 children who wore clothing with the new textile). The severity of AD and clinical response were assessed by the SCORAD index, the intensity of pruritus and the changes in sleep characteristics, at the start of the study and after 7 and 90 d.

RESULTS

The SCORAD index improvement in the group with the fiber under study was statistically significant after the first 7 d of treatment (p < 0.001) and was reduced by about 45% after 90 d. There was also a statistically relevant reduction of the intensity of pruritus and an improvement in the sleep quality after the initial 7 d and at day 90.

CONCLUSION

The results showed that the textile clothing with seaweed enriched with silver ions brings a quicker improvement of the patients in the first days in opposition to the use of standard all-cotton clothes. The results also reinforce the importance of non-pharmacological measures, like clothing, in the management of patients with a diagnosis of AD.

The clinical efficacy, safety and functionality of anion textile in the treatment of atopic dermatitis

BACKGROUND

Several previous studies have suggested the improvement of atopic dermatitis (AD) in response to special fabrics. In particular, beneficial effects have been reported, following the use of anion textiles.

OBJECTIVE

The purpose of this study is to evaluate the effectiveness and safety of an anion textile in patients suffering from AD.

METHODS

We compared an anion textile with a pure cotton textile. Fifty-two atopic patients (n=52) were enrolled and divided into two groups. The patients in the test (n=25) and control (n=19) groups wore undergarments made of an anion textile or pure cotton over a period of 4 weeks. The overall severity of disease was evaluated using the SCORing atopic dermatitis (SCORAD) index, whereas, the treatment efficacy was measured using a Tewameter® (Courage & Khazaka, Cologne, Germany), Mexameter® (Courage & Khazaka) and Corneo meter® (Courage & Khazaka).

RESULTS

At the end of the study, a significant decrease in the SCORAD index was observed among the patients with AD in the test group (mean SCORAD decreased from 47.2 to 36.1). Similarly, improvements in the mean transepidermal water loss, skin erythema and stratum corneum hydration were significantly greater among the patients with AD in the test group than in the control group.

CONCLUSION

Anion textiles may be used to significantly improve the objective and subjective symptoms of AD, and are similar in terms of comfort to cotton textiles. The use of anion textiles may be beneficial in the management of patients with AD.

Silver-loaded seaweed-based cellulosic fiber improves epidermal skin physiology in atopic dermatitis: safety assessment, mode of action and controlled, randomized single-blinded exploratory in vivo study

BACKGROUND

The epidermal part of the skin is the major interface between the internal body and the external environment. The skin has a specific physiology and is to different degrees adapted for protection against multiple exogenous stress factors. Clothing is the material with the longest and most intensive contact to human skin. It plays a critical role especially in inflammatory dermatoses or skin conditions with an increased susceptibility of bacterial and fungal infections like atopic dermatitis. Previously, we have shown a dose-dependent antibacterial and antifungal activity of silver-loaded seaweed-based cellulosic fibres.

AIM OF THE STUDY

We studied the mode of action of silver-loaded seaweed-based cellulosic fiber and performed a broad safety assessment. The principal aim was to analyse the effects of wearing the textile on epidermal skin physiology in 37 patients with atopic dermatitis in a controlled, randomized single-blinded in vivo study. Furthermore, the sensitization potential was tested in a patch test in 111 panellists.

RESULTS

We could demonstrate in vitro a dose-dependent scavenging of induced reactive oxygen species by silver-loaded seaweed-based cellulosic fibers. Safety assessment of these fibres showed no detectable release of silver ions. Furthermore, ex vivo assessment after 24 h application both in healthy volunteers and patients with atopic dermatitis by sequential tape stripping and subsequently raster electron microscopy and energy dispersive microanalysis analysis revealed no detectable amounts of silver in any of stratum corneum layers. Serum analysis of silver showed no detectable levels. The in vivo patch testing of 111 volunteers revealed no sensitization against different SeaCell Active (SeaCell GmbH, Rudolstadt, Germany) containing fabrics. The in vivo study on 37 patients with known atopic dermatitis and mild-to-moderate eczema on their arms were randomly assigned to either silver-loaded seaweed fibre T-shirts or to cotton T-shirts for 8 weeks. A significant reduction in Staphylococcus aureus colonization was detectable for the silver T-shirts compared with cotton T-shirts without any changes in non-pathogenic surface bacteria colonization. Furthermore, a more pronounced improvement in barrier function (transepidermal water loss) was observed in mildly involved eczema areas during the first 4 weeks of the study. Stratum corneum hydration and surface pH improved in both treatment groups over time.

CONCLUSION

The tested silver-loaded seaweed fibre can be regarded as safe and seams to be suited for application in bio-active textiles in atopic dermatitis based on its positive in vivo activity.

The role of antibacterial therapy in atopic eczema

IMPORTANCE OF THE FIELD

Atopic eczema is highly colonized with Staphylococcus aureus in lesional as in non-lesional skin. Antimicrobial therapy as part of a comprehensive therapeutic concept in atopic eczema has been discussed for a long a time.

AREAS COVERED IN THIS REVIEW

A complete literature review of the accessible publications concerning antibacterial and antiseptic therapy has been undertaken.

WHAT THE READER WILL GAIN

This review covers the literature on antimicrobial therapy in atopic eczema and will try to weigh the different publications in the field.

TAKE-HOME MESSAGE

A beneficial role for antibacterial/antiseptic therapy on top of anti-inflammatory therapy in atopic eczema has to be questioned. However, a role in prevention of overt skin infection seems possible.

Atopic dermatitis

Atopic dermatitis (AD) is a chronic and relapsing disease affecting an increasing number of patients. Usually starting in early childhood, AD can be the initial step of the so-called atopic march, i.e. followed by allergic rhinitis and allergic asthma. AD is a paradigmatic genetically complex disease involving gene-gene and gene-environment interactions. Genetic linkage analysis as well as association studies have identified several candidate genes linked to either the epidermal barrier function or to the immune system. Stress, bacterial or viral infections, the exposure to aero- or food-allergens as well as hygienic factors are discussed to aggravate symptoms of AD. Athough generalized Th2-deviated immune response is closely linked to the condition of AD, the skin disease itself is a biphasic inflammation with an initial Th2 phase and while chronic lesions harbour Th0/Th1 cells. Regulatory T cells have been shown to be altered in AD as well as the innate immune system in the skin. The main treatment-goals include the elimination of inflammation and infection, preserving and restoring the barrier function and controlling exacerbating factors. The overall future strategy in AD will be aimed to control skin inflammation by a more proactive management in order to potentially prevent the emergence of sensitization as well as to design customized management based on genetic and pathophysiologic information.

Local antibiotics in dermatology

Although the vast majority of skin infection must be treated with systemic antibiotics, topical antibiotics are used overwhelmingly in the world, often as self-prescribed medications without taking into account the sensitivity of the presumed bacteria. Dermatologists are aware that different types of topical antibiotics kill different species of bacteria and tend to be more specific in their prescriptions. At present local antibiotics are advised to treat minor superficial uncomplicated skin infections (e.g., impetigo) and to prevent bacterial infections caused into minor cuts, scrapes, and burns. The role of topical antibiotics in the management of acne and atopic dermatitis is controversial. Retapamulin, a novel topical antibacterial agent, will probably replace the use of the old mupirocin and fusidic acid.

Interventions to reduce Staphylococcus aureus in the management of atopic eczema

BACKGROUND

Staphylococcus aureus can cause secondary infection in atopic eczema, and it may promote inflammation in eczema that does not look infected. Many antimicrobial products exist for eczema, but it is unclear if they work or if they promote bacterial resistance.

OBJECTIVES

To assess the effects of interventions to reduce Staphylococcus aureus for treating infected or uninfected atopic eczema.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (March 2008), the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 1, 2008), MEDLINE (OVID) (from 2002 to March 2008), EMBASE (OVID) (from 2002 to March 2008), Ongoing trials registers (March 2008). References from trials and reviews were searched, pharmaceutical companies were contacted for unpublished trials. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of people with atopic eczema who have been treated with a product intended to reduce S. aureus on the skin.

DATA COLLECTION AND ANALYSIS

Two people independently performed the study selection, data abstraction and quality assessment.

MAIN RESULTS

We included 21 studies (1018 participants) covering 7 treatment categories. Most studies were poorly reported and study differences limited pooling of results. Adverse effects were especially poorly reported, and only one study reported the emergence of resistant bacterial strains following oral antibiotics. Oral antibiotics were not associated with benefit in non-infected (2 trials, 66 participants) or infected eczema (1 trial, 33 participants). We did not find any benefit for antibacterial soaps (1 trial, 50 participants), or antibacterial bath additives (2 trials, 41 participants), or topical antibiotics/antiseptics (4 studies, 95 participants). Adding antibiotics to topical corticosteroids reduced numbers of Staphylococcus aureus in 4 trials (302 participants), but there was no evidence of any clinical benefit in 9 trials involving 677 participants: betamethasone plus neomycin vs clobetasol (MD 1.2; 95% CI 0.25, 2.15), prednicarbate plus antimicrobial vs prednicarbate (RR 0.64; 95% CI 0.25, 1.68), or betamethasone valerate plus gentamicin vs betamethasone (RR 0.31; 95% CI 0.07, 1.35). One trial (30 participants) showed no significant improvement in eczema for those using silver textiles (RR 2.67; 95% CI 0.98, 7.22), despite using 10 times the amount of topical steroids.

AUTHORS' CONCLUSIONS

We failed to find clear evidence of benefit for antimicrobial interventions for people with atopic eczema, despite their widespread use. This does not necessarily mean they do not work because the studies were small and poorly reported. Further large studies with long-term outcomes and clearly defined participants are urgently required.

Atopic dermatitis

Atopic dermatitis is an especially common and frustrating condition, and the prevalence is increasing. The disease can adversely affect the quality of life of patients and caregivers. Significant advances in our understanding of the pathogenesis have led to improvements in therapy. Patient and caregiver education, avoidance of potential triggering factors, optimal skin care, and pharmacotherapy offer the potential for good control for most patients.