Atopic dermatitis: understanding the disease and its management

Comparison of lotions, creams, gels and ointments for the treatment of childhood eczema: the BEE RCT

Background

Emollients are recommended for children with eczema (atopic eczema/dermatitis). A lack of head-to-head comparisons of the effectiveness and acceptability of the different types of emollients has resulted in a 'trial and error' approach to prescribing.

Objective

To compare the effectiveness and acceptability of four commonly used types of emollients for the treatment of childhood eczema.

Design

Four group, parallel, individually randomised, superiority randomised clinical trials with a nested qualitative study, completed in 2021. A purposeful sample of parents/children was interviewed at ≈ 4 and ≈ 16 weeks.

Setting

Primary care (78 general practitioner surgeries) in England.

Participants

Children aged between 6 months and 12 years with eczema, of at least mild severity, and with no known sensitivity to the study emollients or their constituents.

Interventions

Study emollients sharing the same characteristics in the four types of lotion, cream, gel or ointment, alongside usual care, and allocated using a web-based randomisation system. Participants were unmasked and the researcher assessing the Eczema Area Severity Index scores was masked.

Main outcome measures

The primary outcome was Patient-Oriented Eczema Measure scores over 16 weeks. The secondary outcomes were Patient-Oriented Eczema Measure scores over 52 weeks, Eczema Area Severity Index score at 16 weeks, quality of life (Atopic Dermatitis Quality of Life, Child Health Utility-9 Dimensions and EuroQol-5 Dimensions, five-level version, scores), Dermatitis Family Impact and satisfaction levels at 16 weeks.

Results

A total of 550 children were randomised to receive lotion (analysed for primary outcome 131/allocated 137), cream (137/140), gel (130/135) or ointment (126/138). At baseline, 86.0% of participants were white and 46.4% were female. The median (interquartile range) age was 4 (2-8) years and the median Patient-Oriented Eczema Measure score was 9.3 (SD 5.5). There was no evidence of a difference in mean Patient-Oriented Eczema Measure scores over the first 16 weeks between emollient types (global p = 0.765): adjusted Patient-Oriented Eczema Measure pairwise differences - cream-lotion 0.42 (95% confidence interval -0.48 to 1.32), gel-lotion 0.17 (95% confidence interval -0.75 to 1.09), ointment-lotion -0.01 (95% confidence interval -0.93 to 0.91), gel-cream -0.25 (95% confidence interval -1.15 to 0.65), ointment-cream -0.43 (95% confidence interval -1.34 to 0.48) and ointment-gel -0.18 (95% confidence interval -1.11 to 0.75). There was no effect modification by parent expectation, age, disease severity or the application of UK diagnostic criteria, and no differences between groups in any of the secondary outcomes. Median weekly use of allocated emollient, non-allocated emollient and topical corticosteroids was similar across groups. Overall satisfaction was highest for lotions and gels. There was no difference in the number of adverse reactions and there were no significant adverse events. In the nested qualitative study (n = 44 parents, n = 25 children), opinions about the acceptability of creams and ointments varied most, yet problems with all types were reported. Effectiveness may be favoured over acceptability. Parents preferred pumps and bottles over tubs and reported improved knowledge about, and use of, emollients as a result of taking part in the trial.

Limitations

Parents and clinicians were unmasked to allocation. The findings may not apply to non-study emollients of the same type or to children from more ethnically diverse backgrounds.

Conclusions

The four emollient types were equally effective. Satisfaction with the same emollient types varies, with different parents/children favouring different ones. Users need to be able to choose from a range of emollient types to find one that suits them.

Future work

Future work could focus on how best to support shared decision-making of different emollient types and evaluations of other paraffin-based, non-paraffin and 'novel' emollients.

Trial registration

This trial is registered as ISRCTN84540529 and EudraCT 2017-000688-34.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (HTA 15/130/07) and will be published in full in Health Technology Assessment; Vol. 27, No. 19. See the NIHR Journals Library website for further project information.

Emerging nanotechnology backed formulations for the management of atopic dermatitis

Atopic dermatitis is a prevalent chronic skin inflammation affecting 2.1 to 4.1% of adults globally. The complexity of its pathogenesis and the relapsing nature make it challenging to treat. Current treatments follow European Academy of Dermatology and Venerology guidelines, but advanced cases with recurring lesions lack effective therapies. To address this gap, researchers are exploring nanotechnology for targeted drug delivery. Nanoparticles offer benefits such as improved drug retention, stability, controlled release and targeted delivery through the disrupted epidermal barrier. This integrated review evaluates the current state of AD treatment and highlights the potential of novel nano-formulations as a promising approach to address the disease.

How parents and children evaluate emollients for childhood eczema: a qualitative study

BACKGROUND

Eczema affects one in five children in the UK. Regular application of emollients is routinely recommended for children with eczema. There are four main emollient types, but no clear evidence of which is best. The current 'trial and error' approach to find suitable emollients can be frustrating for parents, children, and clinicians.

AIM

To identify how parents and children experience and evaluate emollients.

DESIGN AND SETTING

Qualitative interview study, nested within a primary care trial of emollients (Best Emollients for Eczema [BEE] trial).

METHOD

Semi-structured interviews with children with eczema and their parents were conducted. Participants were purposively sampled on emollient type (lotion, cream, gel, or ointment), age, and eczema severity.

RESULTS

Forty-four parents were interviewed, with children participating in 24 of those interviews. There was no clear preference for any one emollient type. The strongest theme was the variation of experience in each of the four types. Participants focused on thickness and absorbency, both positively and negatively, to frame their evaluations. Effectiveness and acceptability were both considered when evaluating an emollient but effectiveness was the primary driver for continued use. For some, participating in the trial had changed their knowledge and behaviour of emollients, resulting in use that was more regular and for a longer duration.

CONCLUSION

There is no one emollient that is suitable for everyone, and parents/children prioritise different aspects of emollients. Future research could evaluate decision aids and/or tester pots of different types, which could enable clinicians and parents/children to work collaboratively to identify the best emollient for them.

Topical agents for the treatment of atopic dermatitis

INTRODUCTION

Atopic dermatitis (AD) is perhaps the most common inflammatory skin disorder worldwide, with an increasing incidence in developed countries. The mainstay treatment for patients with AD is topical therapies, which are used not only by the mild patients but also by the moderate-to-severe patients, in conjunction with systemic treatment. While topical steroids and calcineurin antagonists are widely used, these are associated with long-term cutaneous adverse effects (AEs) or a black box warning, preventing their chronic use. Areas covered: The aim of this review is to provide a comprehensive overview of new and upcoming topical therapies currently in development and undergoing clinical trials, as well as their safety and efficacy profiles, and discuss current topicals used in the management of AD. Expert opinion: AD is a heterogeneous disease with complex pathophysiology. Treatments available to date for AD provide disease control; however, patients struggle to find an optimized therapeutic regimen they may use long term and without severe effects. Novel therapies are currently under investigation, with the hope of shifting the paradigm of AD management from symptom control to disease eradication.

Introduction

Atopic dermatitis (AD) is a chronic relapsing condition that is characterized by itching and redness of the skin. Our modern usage of atopic dermatitis dates back to 1933, when Wise and Sulzberger first coined the term to signify the disease's close association with other respiratory atopy, such as bronchial asthma and allergic rhinitis. A recent systematic review of 69 cross-sectional and cohort studies has confirmed that AD is now a worldwide phenomenon with lifetime AD prevalences of well over 20% in many affluent country settings. Although there is no obvious consistent overall global trend in the prevalence of AD, studies have shown that climate, urbanization, lifestyle, and socioeconomic class influence the prevalence of atopic dermatitis. Despite the pervasiveness of the disease, an understanding of atopic dermatitis has been hampered by a number of factors. Data suggests that extrinsic environmental factors work in concert with intrinsic immune mechanism and genetic factors to drive disease progression. With such a complex etiology, management of atopic dermatitis currently at best achieves symptomatic control rather than cure. This approach poses a significant burden on healthcare resources, as well as patients' quality of life. Current management methods of AD often involves a combination of non-pharmacologic modalities and prescription medications. Though they can be effective when employed, there are significant barriers to treatment for patients including time, costs, and medication side effects. Our aim, throughout this text, is to explore the complexities of AD, providing the healthcare provider with tips and tricks to improve patient care and satisfaction and the most current trends and treatment approaches on the horizon.

Advances in pharmacotherapeutic management of common skin diseases in neonates and infants

INTRODUCTION

neonatal and infantile skin diseases are frequently encountered in the clinical practice and represent worldwide a socioeconomic issue. They encompass a wide range of acquired or congenital conditions, including infections, vascular lesions and inflammatory diseases and can present with different degrees of severity, leading in some cases to dramatic complications. Areas covered: In this paper we report the most recent evidences on the management of some common skin diseases in neonates and infants. Hemangiomas, viral, fungal and bacterial infections, omphalitis, atopic and seborrhoeic dermatitis, napkin disease will be treated and discussed. Expert opinion: The majority of the dermatologic alterations in neonates are physiological, transient and do not require any treatment, thus the parents can be reassured about the good prognosis. However, in some cases, serious conditions must be excluded. In particular neonatal and infantile infections should be promptly recognized and properly managed, to avoid severe complications. The therapeutic options include traditional and, although few, innovative medical treatments, which will be carefully taken into consideration by the expert Dermatologists and Paediatricians.

Immunomodulatory effects of Pseudostellaria heterophylla (Miquel) Pax on regulation of Th1/Th2 levels in mice with atopic dermatitis

Pseudostellaria heterophylla (PH) has various pharmacological effects that include immunologic enhancement and anti-oxidation. However, it remains unclear whether PH exerts beneficial effects in dermatological diseases. The present study examined the effects of PH on a 2,4-dinitrochlorobenzene (DNCB)-induced atopic dermatitis (AD) mouse model and elucidated its underlying mechanism of action. PH extract (1 and 100 mg/ml) was applied topically to DNCB-treated dorsal skin of mice every day for 11 days. The immunomodulatory effects of PH were evaluated by measuring skin thickness, mast cell infiltration, serum levels of immunoglobulin E (IgE), and mRNA expression levels of T helper (h)1/Th2 and pro-inflammatory cytokines in dorsal skin. In addition, cluster of differentiation (CD)4⁺ T cells were detected in dorsal skin by immunohistochemistry. Topical application of PH significantly reduced the thickness of dermis, epidermis and serum IgE production compared with the DNCB group. PH treatment inhibited infiltration of inflammatory cells, including mast cells and CD4⁺ T cells, and suppressed the mRNA expression levels of cytokines (interferon-γ, interleukin-4, −6, −8 and −1β, and tumor necrosis factor-α) associated with the immune response. Furthermore, PH treatment significantly downregulated the protein expression levels of nuclear factor-κB, phosphorylated inhibitor of κBα and mitogen-activated protein kinases. The results suggested that PH may be a potential therapeutic strategy for the treatment of AD via the modulation of Th1 and Th2 levels.

Review of Atopic Dermatitis and Topical Therapies

Atopic dermatitis is one of the most common skin disorders in the developed world, affecting up to 20% of children and 1% to 3% of adults. This review concisely explains the pathophysiology and epidemiology of atopic dermatitis, as well as potential challenges facing its successful treatment. Furthermore, mainstay topical treatment modalities are evaluated, such as emollients, topical corticosteroids, and topical calcineurin inhibitors. The use of topical corticosteroids and topical calcineurin inhibitors in combination is discussed, as studies have indicated encouraging results. The proactive use of topical corticosteroids and topical calcineurin inhibitors is also investigated, in order to bring attention to a new possibility in long-term management of atopic dermatitis. Last, new and upcoming topical medications are described, including Janus kinase inhibitors, phosphodiesterase-4 inhibitors, and benvitimod. Although topical corticosteroids and topical calcineurin inhibitors can be very effective in the treatment of atopic dermatitis, it is important that practitioners are aware of mechanistically unique and new treatments for patients for whom more traditional topical therapies have failed. Overall, this review article hopes to serve as a comprehensive overview of currently available topical treatments for atopic dermatitis, while shedding light on new treatments coming in the future.

A randomised placebo-controlled trial of oral and topical antibiotics for children with clinically infected eczema in the community: the ChildRen with Eczema, Antibiotic Management (CREAM) study

BACKGROUND

Secondary skin infection is common during eczema exacerbations and many children are treated with antibiotics when this is suspected, although there is little high-quality evidence to justify this practice.

OBJECTIVE

To determine the clinical effectiveness of oral and topical antibiotics, in addition to standard treatment with emollients and topical corticosteroids, in children with clinically infected eczema.

DESIGN

Multicentre randomised, double-blind, placebo-controlled trial.

SETTING

General practices and dermatology clinics in England, Wales and Scotland.

PARTICIPANTS

Children (aged 3 months to < 8 years) with a diagnosis of eczema (according to U.K. Working Party definition) and clinical suspicion of infection.

INTERVENTIONS

(1) Oral flucloxacillin and topical placebo; (2) topical fusidic acid (Fucidin(®), Leo Laboratories Limited) and oral placebo; and (3) oral and topical placebos, all for 1 week.

MAIN OUTCOME MEASURES

Patient-Orientated Eczema Measure (POEM) at 2 weeks (assessing subjective severity in the week following treatment).

RESULTS

We randomised 113 children (36 to oral antibiotic, 37 to topical antibiotic and 40 to placebo), which was fewer than our revised target sample size of 282. A total of 103 (92.0%) children had one or more clinical features suggestive of infection and 78 (69.6%) children had Staphylococcus aureus cultured from a skin swab. Oral and topical antibiotics resulted in a 1.52 [95% confidence interval (CI) -1.35 to 4.40] and 1.49 (95% CI -1.55 to 4.53) increase (worse subjective severity) in POEM score at 2 weeks, relative to placebo and controlling for baseline POEM score. Eczema Area and Severity Index (objective severity) scores were also higher (worse) in the intervention groups, at 0.20 (95% CI -0.12 to 0.52) and 0.42 (95% CI 0.09 to 0.75) for oral and topical antibiotics, respectively, at 2 weeks. Analyses of impact on the family, quality of life, daily symptom scores, and longer-term outcomes were all consistent with the finding of no or limited difference and a trend towards worse outcomes in the intervention groups. Sensitivity analyses, including adjusting for compliance and imputation for missing data, were consistent with the main findings.

CONCLUSIONS

Our data suggest that oral and topical antibiotics have no effect, or a harmful effect, on subjective eczema severity in children with clinically infected eczema in the community. The CIs around our estimates exclude a meaningful beneficial effect (published minimal clinically important difference for POEM is 3.4). Although most patients in this trial had features suggestive of infection and S. aureus on their skin, participants primarily had mild-moderate eczema and those with signs of more severe infection were often excluded. Clinicians should consider avoiding oral and topical antibiotic use in children with suspected infected eczema in the community who do not have signs of 'severe infection'. Further research should seek to understand how best to encourage the use of topical steroids and limit use of antibiotics in those with eczema flares without signs of severe infection, as well as developing tools to better phenotype eczema flares, in order to better define a population that may benefit from antibiotic treatment.

TRIAL REGISTRATION

European Union Drug Regulating Authorities Clinical Trials (EudraCT) number 2011-003591-37 and Current Controlled Trials ISRCTN96705420.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Inhibition of inflammatory reactions in 2,4-Dinitrochlorobenzene induced Nc/Nga atopic dermatitis mice by non-thermal plasma

Non-thermal plasma (NTP) has recently been introduced and reported as a novel tool with a range of medicinal and biological roles. Although many studies using NTP have been performed, none has investigated the direct relationship between NTP and immune responses yet. Especially, the effects of NTP on atopic dermatitis (AD) were not been explored. Here, NTP was tested whether it controls immune reactions of AD. NTP treatment was administered to pro-inflammatory cytokine-stimulated keratinocytes and DNCB (2,4-Dinitrochlorobenzene)-induced atopic dermatitis mice, then the immune reactions of cells and skin tissues were monitored. Cells treated with NTP showed decreased expression levels of CCL11, CCL13, and CCL17 along with down-regulation of NF-κB activity. Repeated administration of NTP to AD-induced mice reduced the numbers of mast cells and eosinophils, IgE, CCL17, IFNγ levels, and inhibited NF-κB activity in the skin lesion. Furthermore, combined treatment with NTP and 1% hydrocortisone cream significantly decreased the immune responses of AD than that with either of these two treatments individually. Overall, this study revealed that NTP significantly inhibits several immune reactions of AD by regulating NF-κB activity. Therefore, NTP could be useful to suppress the exaggerated immune reactions in severe skin inflammatory diseases such as AD.

Management of atopic dermatitis: safety and efficacy of phototherapy

Atopic dermatitis (AD) is a common chronic inflammatory skin disease that can affect all age groups. It is characterized by a relapsing course and a dramatic impact on quality of life for patients. Environmental interventions together with topical devices represent the mainstay of treatment for AD, in particular emollients, corticosteroids, and calcineurin inhibitors. Systemic treatments are reserved for severe cases. Phototherapy represents a valid second-line intervention in those cases where non-pharmacological and topical measures have failed. Different forms of light therapy are available, and have showed varying degrees of beneficial effect against AD: natural sunlight, narrowband (NB)-UVB, broadband (BB)-UVB, UVA, UVA1, cold-light UVA1, UVA and UVB (UVAB), full-spectrum light (including UVA, infrared and visible light), saltwater bath plus UVB (balneophototherapy), Goeckerman therapy (coal tar plus UVB radiation), psoralen plus UVA (PUVA), and other forms of phototherapy. In particular, UVA1 and NB-UVB have gained importance in recent years. This review illustrates the main trials comparing the efficacy and safety of the different forms of phototherapy. No sufficiently large randomized controlled studies have been performed as yet, and no light modality has been defined as superior to all. Parameters and dosing protocols may vary, although clinicians mainly refer to the indications included in the American Academy of Dermatology psoriasis guidelines devised by Menter et al in 2010. The efficacy of phototherapy (considering all forms) in AD has been established in adults and children, as well as for acute (UVA1) and chronic (NB-UVB) cases. Its use is suggested with strength of recommendation B and level of evidence II. Home phototherapy can also be performed; this technique is recommended with strength C and level of evidence III. Phototherapy is generally considered to be safe and well tolerated, with a low but established percentage of short-term and long-term adverse effects, with the most common being photodamage, xerosis, erythema, actinic keratosis, sunburn, and tenderness. A carcinogenic risk related to UV radiation has not been excluded. Phototherapy also has some limitations related to costs, availability, and patient compliance. In conclusion, phototherapy is an optimal second-line treatment for AD. It can be used as monotherapy or in combination with systemic drugs, in particular corticosteroids. It must be performed conscientiously, especially in children, and must take into account the patient's features and overall condition.

Public health emergency planning for children in chemical, biological, radiological, and nuclear (CBRN) disasters

Children represent nearly a quarter of the US population, but their unique needs in chemical, biological, radiological, and nuclear (CBRN) emergencies may not be well understood by public health and emergency management personnel or even clinicians. Children are different from adults physically, developmentally, and socially. These characteristics have implications for providing care in CBRN disasters, making resulting illness in children challenging to prevent, identify, and treat. This article discusses these distinct physical, developmental, and social traits and characteristics of children in the context of the science behind exposure to, health effects from, and treatment for the threat agents potentially present in CBRN incidents.

Hizikia fusiformis fractions successfully improve atopic dermatitis indices in anti-CD3-stimulated splenocytes and 2,4-dinitrochlorobenzene-treated BALB/c mice

Objectives

In the present study, we aimed to examine whether fractions from an edible sea weed, Hizikia fusiformis, had immunomodulatory effects, particularly an anti-atopic effect, by attenuating the expression of T cell-dependent cytokines using in-vitro and in-vivo animal atopic dermatitis-like models.

Methods

The anti-atopic activities were examined in in vitro, and a 2,4-dinitrochlorobenzene (DNCB)-induced atopic dermatitis-like mouse model using quantitative real-time polymerase chain reaction, electrophoretic-mobility shift and histophathological analysis.

Key findings

Our results showed that the final fraction (F2′) of H. fusiformis contained a higher amount of butanoic acid which was not found in the other fractions, and effectively inhibited T cell activation by inhibiting dephosphorylation of nuclear factor of activated T cells in electrophoretic-mobility shift assay. As a consequence, helper T cell-dependent cytokines, such as interleukin-2, -4 and interferon-γ, were significantly inhibited while activated with an anti-CD3 antibody. We also showed that skin challenged with DNCB successfully recovered when treated with 2.5 mg/kg, comparable to that by 0.25% prednicarbate. These results indicate that F2′ may contribute to inhibit T cell activation by eliminating Th cell-dependent cytokines.

Conclusions

Taken together, we concluded that F2′ containing butanoic acid may be a new functional anti-atopic candidate, which probably acts through nuclear factor of activated T cell inactivation mechanisms.

Therapeutic effects of fermented soycrud on phenotypes of atopic dermatitis induced by phthalic anhydride

Atopic dermatitis (AD), which is known as the most common pruritic skin disease, is caused by epidermal barrier dysfunction, allergies, microwave radiation, histamine intolerance, and genetic defects. To investigate the therapeutic effects of fermented soycrud (FSC) on AD pathology, alteration of AD phenotypes induced by phthalic anhydride (PA) treatment was assessed by ear thickness analysis, measurement of immune-related organ weights, ELISA, and histological and pathological analyses of ICR mice after FSC treatment for 2 weeks. Except for water content, the concentrations of most major components were lower in FSC compared to common tofu (CMT). Thymus and lymph node weights were significantly reduced in ICR mice treated with PA+CMT or PA+FSC, whereas spleen and body weights were maintained. Elevation of ear thickness induced by PA treatment was rapidly diminished in the CMT- and FSC-treated groups, although there was no significant difference between the two groups. Furthermore, significant reduction of epidermal thickness was detected in both the PA+CMT- and PA+FSC-treated groups. However, IgE concentration and dermal thickness were reduced only by PA+FSC treatment, whereas PA+CMT treatment maintained levels comparable to PA+vehicle treatment. The number of infiltrated mast cells was higher in the PA+vehicle-treated group compared to the untreated control. Following CMT or FSC treatment, mast cell infiltration was slightly reduced, although the CMT-treated group showed greater cell numbers. These results indicate that FSC may significantly relieve the phenotypes of AD induced by PA treatment and should be considered as a potential candidate for AD therapy.

Reversal of atopic dermatitis with narrow-band UVB phototherapy and biomarkers for therapeutic response

BACKGROUND

Atopic dermatitis (AD) is a common inflammatory skin disease exhibiting a predominantly T(H)2/"T22" immune activation and a defective epidermal barrier. Narrow-band UVB (NB-UVB) is considered an efficient treatment for moderate-to-severe AD. In patients with psoriasis, NB-UVB has been found to suppress T(H)1/T(H)17 polarization, with subsequent reversal of epidermal hyperplasia. The immunomodulatory effects of this treatment are largely unknown in patients with AD.

OBJECTIVE

We sought to evaluate the effects of NB-UVB on immune and barrier abnormalities in patients with AD, aiming to establish reversibility of disease and biomarkers of therapeutic response.

METHODS

Twelve patients with moderate-to-severe chronic AD received NB-UVB phototherapy 3 times weekly for up to 12 weeks. Lesional and nonlesional skin biopsy specimens were obtained before and after treatment and evaluated by using gene expression and immunohistochemistry studies.

RESULTS

All patients had at least a 50% reduction in SCORAD index scores with NB-UVB phototherapy. The T(H)2, T22, and T(H)1 immune pathways were suppressed, and measures of epidermal hyperplasia and differentiation normalized. The reversal of disease activity was associated with elimination of inflammatory leukocytes and T(H)2/T22- associated cytokines and chemokines and normalized expression of barrier proteins.

CONCLUSIONS

Our study shows that resolution of clinical disease in patients with chronic AD is accompanied by reversal of both the epidermal defects and the underlying immune activation. We have defined a set of biomarkers of disease response that associate resolved T(H)2 and T22 inflammation in patients with chronic AD with reversal of barrier pathology. By showing reversal of the AD epidermal phenotype with a broad immune-targeted therapy, our data argue against a fixed genetic phenotype.

Topical pimecrolimus: a review of its use in the management of pediatric atopic dermatitis

Topical pimecrolimus 1% cream (Elidel) [hereafter referred to as topical pimecrolimus] is a nonsteroidal alternative in the treatment of pediatric atopic dermatitis. In vehicle-controlled, short-term, continuous-use trials in pediatric patients with mild to moderate atopic dermatitis, topical pimecrolimus was effective in treating disease symptoms. Topical pimecrolimus was effective in preventing disease flares and reducing the need for topical corticosteroids in longer term, intermittent-use trials. In addition, topical pimecrolimus was associated with improvements in the health-related quality of life (HR-QOL) of pediatric patients with atopic dermatitis and their parents. In vehicle-controlled trials, topical pimecrolimus was generally as well tolerated as vehicle. Topical pimecrolimus showed similar efficacy to topical tacrolimus 0.03% ointment (hereafter topical tacrolimus) in a short-term, continuous-use trial and the two agents had a generally similar tolerability profile. Although comparative data between topical pimecrolimus and topical corticosteroids are lacking in pediatric patients, and the long-term tolerability (beyond 1-2 years) of topical pimecrolimus is yet to be established, topical pimecrolimus is a useful agent in the management of pediatric patients with mild to moderate atopic dermatitis who do not achieve satisfactory treatment with other topical pharmacologic treatments, including topical corticosteroids.

The Asian dermatologic patient: review of common pigmentary disorders and cutaneous diseases

The Asian patient with Fitzpatrick skin types III-V is rarely highlighted in publications on cutaneous disorders or cutaneous laser surgery. However, with changing demographics, Asians will become an increasingly important group in this context. Although high melanin content confers better photoprotection, photodamage in the form of pigmentary disorders is common. Melasma, freckles, and lentigines are the epidermal disorders commonly seen, whilst nevus of Ota and acquired bilateral nevus of Ota-like macules are common dermal pigmentary disorders. Post-inflammatory hyperpigmentation (PIH) occurring after cutaneous injury remains a hallmark of skin of color. With increasing use of lasers and light sources in Asians, prevention and management of PIH is of great research interest. Bleaching agents, chemical peels, intense pulsed light (IPL) treatments, and fractional skin resurfacing have all been used with some success for the management of melasma. Q-switched (QS) lasers are effective for the management of epidermal pigmentation but are associated with a high risk of PIH. Long-pulsed neodymium-doped yttrium aluminum garnet (Nd:YAG) lasers and IPL sources pose less of a PIH risk but require a greater number of treatment sessions. Dermal pigmentary disorders are better targeted by QS ruby, QS alexandrite, and QS 1064-nm Nd:YAG lasers, but hyper- and hypopigmentation may occur. Non-ablative skin rejuvenation using a combination approach with different lasers and light sources in conjunction with cooling devices allows different skin chromophores to be targeted and optimal results to be achieved, even in skin of color. Deep-tissue heating using radiofrequency and infra-red light sources affects the deep dermis and achieves enhanced skin tightening, resulting in eyebrow elevation, rhytide reduction, and contouring of the lower face and jawline. For management of severe degrees of photoaging, fractional resurfacing is useful for wrinkle and pigment reduction, as well as acne scarring. Acne, which is common in Asians, can be treated with topical and oral antibacterials, hormonal treatments, and isotretinoin. Infra-red diode lasers used with a low-fluence, multiple-pass approach have also been shown to be effective with few complications. Fractional skin resurfacing is very useful for improving the appearance of acne scarring. Hypertrophic and keloid scarring, another common condition seen in Asians, can be treated with the combined used of intralesional triamcinolone and fluorouracil, followed by pulsed-dye laser. Esthetic enhancement procedures such as botulinum toxin type A and fillers are becoming increasingly popular. These are effective for rhytide improvement and facial or body contouring. We highlight the differences between Asian skin and other skin types and review conditions common in skin of color together with treatment strategies.