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de Oliveira CSF, Tavaria FK. Therapeutic textiles: A promising approach for human skin dysbiosis? Exp Dermatol 2024; 33:e15081. [PMID: 38628046 DOI: 10.1111/exd.15081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 03/12/2024] [Accepted: 04/07/2024] [Indexed: 04/19/2024]
Abstract
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.
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Affiliation(s)
- Cláudia Suellen Ferro de Oliveira
- CBQF - Centro de Biotecnologia e Química Fina - Laboratório Associado, Escola Superior de Biotecnologia, Universidade Católica Portuguesa, Porto, Portugal
| | - Freni Kekhasharú Tavaria
- CBQF - Centro de Biotecnologia e Química Fina - Laboratório Associado, Escola Superior de Biotecnologia, Universidade Católica Portuguesa, Porto, Portugal
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2
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Khosropanah MH, Vaghasloo MA, Shakibaei M, Mueller AL, Kajbafzadeh AM, Amani L, Haririan I, Azimzadeh A, Hassannejad Z, Zolbin MM. Biomedical applications of silkworm (Bombyx Mori) proteins in regenerative medicine (a narrative review). J Tissue Eng Regen Med 2021; 16:91-109. [PMID: 34808032 DOI: 10.1002/term.3267] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/12/2021] [Accepted: 10/19/2021] [Indexed: 12/19/2022]
Abstract
Silk worm (Bombyx Mori) protein, have been considered as potential materials for a variety of advanced engineering and biomedical applications for decades. Recently, silkworm silk has gained significant importance in research attention mainly because of its remarkable and exceptional mechanical properties. Silk has already been shown to have unique interactions with cells in tissues through bio-recognition units. The natural silk contains fibroin and sericin and has been used in various tissues of the human body (skin, bone, nerve, and so on). Besides, silk also still has anti-cancer, anti-tyrosinase, anti-coagulant, anti-oxidant, anti-bacterial, and anti-diabetic properties. This article is supposed to describe the diverse biomedical capabilities of B. Mori silk as the appropriate biomaterial among the assorted natural and artificial polymers that are presently accessible, and ideal for usage in regenerative medicine fields.
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Affiliation(s)
- Mohammad Hossein Khosropanah
- Department of Traditional Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Alizadeh Vaghasloo
- Department of Traditional Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Shakibaei
- Musculoskeletal Research Group and Tumor Biology, Chair of Vegetative Anatomy, Institute of Anatomy, Faculty of Medicine, Ludwig-Maximilian-University Munich, Munich, Germany
| | - Anna-Lena Mueller
- Musculoskeletal Research Group and Tumor Biology, Chair of Vegetative Anatomy, Institute of Anatomy, Faculty of Medicine, Ludwig-Maximilian-University Munich, Munich, Germany
| | - Abdol-Mohammad Kajbafzadeh
- Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Amani
- Department of Traditional Pharmacy, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ismaeil Haririan
- Department of Pharmaceutical Biomaterials and Medical Biomaterials Research Center, Faculty of Pharmacy and Department of Pharmaceutics, Tehran University of Medical Sciences, Tehran, Iran
| | - Ashkan Azimzadeh
- Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Hassannejad
- Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoumeh Majidi Zolbin
- Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
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3
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Huang D, Chen K, Zhang FR, Yang S, Guo Q, Xu JH, Li H, Tan GZ, Yang BQ, Lu QJ, Zheng J, Li LF, Gu H. Efficacy and safety of Run Zao Zhi Yang capsule on chronic eczema: a multiple-center, randomized, double-blind, placebo-controlled clinical study. J DERMATOL TREAT 2019; 30:677-684. [PMID: 31218889 DOI: 10.1080/09546634.2019.1571267] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background: Run Zao Zhi Yang capsule (RZZYC) has been widely applied for eczema treatment as a traditional Chinese medicine, while its efficacy has not been scientifically investigated. Objective: We conducted this multiple-centers, randomized, double-blind, placebo-controlled study to investigate the effectiveness and safety of RZZYC on the treatment of patients with mild to moderate chronic eczema. Methods: 240 patients were randomly assigned into the experimental group and the placebo group. The primary efficacy indicator was the Eczama Area and Severity Index (EASI) score at week 4. The patient with an EASI score that decreases more than 95% from baseline (EASI 95) was judged as cured. The cured patients were followed up for another 8 weeks. The differences on EASI, Visual Analogue Score (VAS), and Dermatology Life Quality Index (DLQI) score were compared. Results: The proportions of EASI 95 and EASI 60 in the experimental group were significantly higher than those of the control group at week4 (p = .002 and p < .001, respectively), the VAS score decreased more significantly in the experimental group at week 4. After 8 weeks follow-up, no difference on recurrence rate and adverse event rate between the two groups was observed. Conclusion: RZZYC provides a good effect on the treatment of mild-to-moderate chronic eczema with a low recurrence and tolerable adverse events, and is a potential treatment that may be implemented in clinical practice.
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Affiliation(s)
- Dan Huang
- a Hospital for Skin Disease (Institute of Dermatology), Chinese Academy of Medical Sciences , Nanjing , China
| | - Kun Chen
- a Hospital for Skin Disease (Institute of Dermatology), Chinese Academy of Medical Sciences , Nanjing , China
| | - Fu-Ren Zhang
- b Shandong Province Hospital for Skin Disease , Jinan , China
| | - Sen Yang
- c The First Affiliated Hospital of Anhui Medical University , Chongqing , China
| | - Qing Guo
- d Sun Yat-sen Memorial Hospital Affiliated with Sun Yat-sen University , Guangzhou , China
| | - Jin-Hua Xu
- e Huashan Hospital Affiliated with Fudan University , Shanghai , China
| | - Hui Li
- f The First Affiliated Hospital of Chongqing Medical University , Chongqing , China
| | - Guo-Zhen Tan
- d Sun Yat-sen Memorial Hospital Affiliated with Sun Yat-sen University , Guangzhou , China
| | - Bao-Qi Yang
- b Shandong Province Hospital for Skin Disease , Jinan , China
| | - Qian-Jin Lu
- g The Second Xiangya Hospital, Central South University , Changsha , China
| | - Jie Zheng
- h Ruijin Hospital Affiliated with Shanghai Jiaotong University Medical College , Shanghai , China
| | - Lin-Feng Li
- i Beijing Friendship Hospital, Capital Medical University , Beijing , China
| | - Heng Gu
- a Hospital for Skin Disease (Institute of Dermatology), Chinese Academy of Medical Sciences , Nanjing , China
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4
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Thomas KS. Response from the CLOTHES Trial Team. J Eur Acad Dermatol Venereol 2019; 33:e308-e309. [PMID: 30897239 DOI: 10.1111/jdv.15587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- K S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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5
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Langan SM, Stuart B, Bradshaw L, Schmitt J, Williams HC, Thomas KS. Measuring long-term disease control in patients with atopic dermatitis: A validation study of well-controlled weeks. J Allergy Clin Immunol 2017; 140:1580-1586. [PMID: 28456619 PMCID: PMC5716669 DOI: 10.1016/j.jaci.2017.02.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 01/24/2017] [Accepted: 02/09/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Because atopic dermatitis (AD) is a relapsing remitting disease, assessing long-term control is important. Well-controlled weeks (WCWs) have been used to assess asthma long-term control but have never been validated for AD. OBJECTIVES We sought to assess the feasibility, validity, and interpretability of WCWs in patients with AD. METHODS Three studies of patients with moderate-to-severe AD, including 4 to 6 months of daily/weekly symptom and treatment use data, were evaluated (study A, n = 336; study B, n = 60; and study C, n = 224). WCWs were defined by worsening symptoms and increased medication use. Feasibility, construct validity, and interpretability of WCWs were determined by assessing missing data, association with validated AD outcomes, and floor and ceiling effects. Analysis used linear and logistic regression. RESULTS WCWs were feasible to collect: 95.2% (study A) and 94.7% (study B) contributed data for at least half of the weekly data points, and 93.2% and 88.7% contributed to all data points up to 4 months. WCWs were significantly associated with validated AD severity instruments, including patient-orientated outcome measures and objective signs (Eczema Area and Severity Index, Three Item Severity Score, and Six Signs, Six Areas Atopic Dermatitis Scale). The odds of experiencing a WCW if AD severity was clear/mild was 5.8 (95% CI, 3.5-9.7), 1.9 (95% CI, 0.8-4.4), and 8.1 (95% CI, 4.5-14.6) in studies A, B, and C, respectively. WCWs were associated with ceiling effects: 31.6% (study A) and 37.5% (study B) of participants had no WCWs more than 90% of the time. CONCLUSIONS WCWs are valid and feasible for measuring long-term control in AD trials. However, ceiling effects and burden of data collection can limit use.
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Affiliation(s)
- Sinéad M Langan
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
| | - Beth Stuart
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Lucy Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Jochen Schmitt
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, United Kingdom; Centre for Evidence-based Healthcare, Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, United Kingdom
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6
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Thomas KS, Bradshaw LE, Sach TH, Cowdell F, Batchelor JM, Lawton S, Harrison EF, Haines RH, Ahmed A, Dean T, Burrows NP, Pollock I, Buckley HK, Williams HC, Llewellyn J, Crang C, Grundy JD, Guiness J, Gribbin A, Wake EV, Mitchell EJ, Brown SJ, Montgomery AA. Randomised controlled trial of silk therapeutic garments for the management of atopic eczema in children: the CLOTHES trial. Health Technol Assess 2017; 21:1-260. [PMID: 28409557 DOI: 10.3310/hta21160] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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 [DermaSilkTM (AlPreTec Srl, San Donà di Piave, Italy) or DreamSkinTM (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.
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Affiliation(s)
- Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Lucy E Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Tracey H Sach
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Fiona Cowdell
- Faculty of Health Education and Life Sciences, Birmingham City University, Birmingham, UK
| | | | - Sandra Lawton
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
| | - Eleanor F Harrison
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Rachel H Haines
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Amina Ahmed
- Patient and public involvement representative, Nottingham, UK
| | - Taraneh Dean
- Faculty of Science, University of Portsmouth, Portsmouth, UK.,Research and Enterprise, University of Brighton, Brighton, UK
| | - Nigel P Burrows
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Ian Pollock
- Royal Free London NHS Foundation Trust, Barnet Hospital, Barnet, UK
| | - Hannah K Buckley
- Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Cosham, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Joanne Llewellyn
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
| | - Clare Crang
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Jane D Grundy
- Isle of Wight NHS Trust, St Mary's Hospital, Newport, UK
| | - Juliet Guiness
- Royal Free London NHS Foundation Trust, Barnet Hospital, Barnet, UK
| | - Andrew Gribbin
- Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Cosham, UK
| | - Eileen V Wake
- Faculty of Health Education and Life Sciences, Birmingham City University, Birmingham, UK
| | - Eleanor J Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Sara J Brown
- Skin Research Group, University of Dundee, Dundee, UK.,Department of Dermatology, Ninewells Hospital and Medical School, Dundee, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
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7
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Sampogna F, Finlay A, Salek S, Chernyshov P, Dalgard F, Evers A, Linder D, Manolache L, Marron S, Poot F, Spillekom-van Koulil S, Svensson Å, Szepietowski J, Tomas-Aragones L, Abeni D. Measuring the impact of dermatological conditions on family and caregivers: a review of dermatology-specific instruments. J Eur Acad Dermatol Venereol 2017; 31:1429-1439. [DOI: 10.1111/jdv.14288] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 03/28/2017] [Indexed: 01/13/2023]
Affiliation(s)
- F. Sampogna
- Clinical Epidemiology Unit; Istituto Dermopatico dell'Immacolata (IDI)-IRCCS FLMM; Rome Italy
| | - A.Y. Finlay
- Division of Infection and Immunity; Department of Dermatology and Wound Healing; Cardiff University; Cardiff UK
| | - S.S. Salek
- Department of Pharmacy, Pharmacology and Postgraduate Medicine; School of Life & Medical Sciences; University of Hertfordshire; Hatfield UK
| | - P. Chernyshov
- Department of Dermatology and Venereology; National Medical University; Kiev Ukraine
| | - F.J. Dalgard
- Department of Dermatology and Venereology; Skåne University Hospital; Lund University; Malmö Sweden
| | - A.W.M. Evers
- Health, Medical, and Neuropsychology Unit; Leiden University; Leiden The Netherlands
| | - D. Linder
- Oslo Centre for Biostatistics and Epidemiology; University of Oslo; Oslo Norway
| | | | - S.E. Marron
- Department of Dermatology; Alcañiz Hospital; Aragon Health Sciences Institute; Zaragoza Spain
| | - F. Poot
- Department of Dermatology; ULB Erasme Hospital; Brussels Belgium
| | - S. Spillekom-van Koulil
- Department of Medical Psychology; Radboud University Medical Center; Nijmegen The Netherlands
| | - Å. Svensson
- Department of Dermatology and Venereology; Skåne University Hospital; Lund University; Malmö Sweden
| | - J.C. Szepietowski
- Department of Dermatology; Wroclaw Medical University; Wroclaw Poland
| | - L. Tomas-Aragones
- Department of Psychology; Aragon Health Sciences Institute; University of Zaragoza; Zaragoza Spain
| | - D. Abeni
- Clinical Epidemiology Unit; Istituto Dermopatico dell'Immacolata (IDI)-IRCCS FLMM; Rome Italy
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8
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Thomas KS, Bradshaw LE, Sach TH, Batchelor JM, Lawton S, Harrison EF, Haines RH, Ahmed A, Williams HC, Dean T, Burrows NP, Pollock I, Llewellyn J, Crang C, Grundy JD, Guiness J, Gribbin A, Mitchell EJ, Cowdell F, Brown SJ, Montgomery AA. Silk garments plus standard care compared with standard care for treating eczema in children: A randomised, controlled, observer-blind, pragmatic trial (CLOTHES Trial). PLoS Med 2017; 14:e1002280. [PMID: 28399154 PMCID: PMC5388469 DOI: 10.1371/journal.pmed.1002280] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 03/02/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The role of clothing in the management of eczema (also called atopic dermatitis or atopic eczema) is poorly understood. This trial evaluated the effectiveness and cost-effectiveness of silk garments (in addition to standard care) for the management of eczema in children with moderate to severe disease. METHODS AND FINDINGS This was a parallel-group, randomised, controlled, observer-blind trial. Children aged 1 to 15 y with moderate to severe eczema were recruited from secondary care and the community at five UK medical centres. Participants were allocated using online randomisation (1:1) to standard care or to standard care plus silk garments, stratified by age and recruiting centre. Silk garments were worn for 6 mo. Primary outcome (eczema severity) was assessed at baseline, 2, 4, and 6 mo, by nurses blinded to treatment allocation, using the Eczema Area and Severity Index (EASI), which was log-transformed for analysis (intention-to-treat analysis). A safety outcome was number of skin infections. Three hundred children were randomised (26 November 2013 to 5 May 2015): 42% girls, 79% white, mean age 5 y. Primary analysis included 282/300 (94%) children (n = 141 in each group). The garments were worn more often at night than in the day (median of 81% of nights [25th to 75th centile 57% to 96%] and 34% of days [25th to 75th centile 10% to 76%]). Geometric mean EASI scores at baseline, 2, 4, and 6 mo were, respectively, 9.2, 6.4, 5.8, and 5.4 for silk clothing and 8.4, 6.6, 6.0, and 5.4 for standard care. There was no evidence of any difference between the groups in EASI score averaged over all follow-up visits adjusted for baseline EASI score, age, and centre: adjusted ratio of geometric means 0.95, 95% CI 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 units, which is not clinically important. Skin infections occurred in 36/142 (25%) and 39/141 (28%) of children in the silk clothing and standard care groups, respectively. Even if the small observed treatment effect was genuine, the incremental cost per quality-adjusted life year was £56,811 in the base case analysis from a National Health Service perspective, suggesting that silk garments are unlikely to be cost-effective using currently accepted thresholds. The main limitation of the study is that use of an objective primary outcome, whilst minimising detection bias, may have underestimated treatment effects. CONCLUSIONS Silk clothing is unlikely to provide additional benefit over standard care in children with moderate to severe eczema. TRIAL REGISTRATION Current Controlled Trials ISRCTN77261365.
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Affiliation(s)
- Kim S. Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Lucy E. Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Tracey H. Sach
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Jonathan M. Batchelor
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Sandra Lawton
- Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, United Kingdom
| | - Eleanor F. Harrison
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Rachel H. Haines
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Amina Ahmed
- Patient and Public Involvement Representative, Nottingham, United Kingdom
| | - Hywel C. Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Taraneh Dean
- Faculty of Science, University of Portsmouth, Portsmouth, United Kingdom
- University of Brighton, Brighton, United Kingdom
| | - Nigel P. Burrows
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Ian Pollock
- Royal Free London NHS Foundation Trust, Barnet Hospital, Barnet, United Kingdom
| | - Joanne Llewellyn
- Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, United Kingdom
| | - Clare Crang
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Jane D. Grundy
- Isle of Wight NHS Trust, St. Mary’s Hospital, Newport, United Kingdom
| | - Juliet Guiness
- Royal Free London NHS Foundation Trust, Barnet Hospital, Barnet, United Kingdom
| | - Andrew Gribbin
- Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, United Kingdom
| | - Eleanor J. Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Fiona Cowdell
- Faculty of Health Education and Life Sciences, Birmingham City University, Birmingham, United Kingdom
| | - Sara J Brown
- Skin Research Group, University of Dundee, Dundee, United Kingdom
- Department of Dermatology, Ninewells Hospital and Medical School, Dundee, United Kingdom
| | - Alan A. Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom
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9
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Thomas KS, Batchelor JM, Bath-Hextall F, Chalmers JR, Clarke T, Crowe S, Delamere FM, Eleftheriadou V, Evans N, Firkins L, Greenlaw N, Lansbury L, Lawton S, Layfield C, Leonardi-Bee J, Mason J, Mitchell E, Nankervis H, Norrie J, Nunn A, Ormerod AD, Patel R, Perkins W, Ravenscroft JC, Schmitt J, Simpson E, Whitton ME, Williams HC. A programme of research to set priorities and reduce uncertainties for the prevention and treatment of skin disease. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04180] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BackgroundSkin diseases are very common and can have a large impact on the quality of life of patients and caregivers. This programme addressed four diseases: (1) eczema, (2) vitiligo, (3) squamous cell skin cancer (SCC) and (4) pyoderma gangrenosum (PG).ObjectiveTo set priorities and reduce uncertainties for the treatment and prevention of skin disease in our four chosen diseases.DesignMixed methods including eight systematic reviews, three prioritisation exercises, two pilot randomised controlled trials (RCTs), three feasibility studies, two core outcome initiatives, four funding proposals for national RCTs and one completed national RCT.SettingSecondary care, primary care and the general population.ParticipantsPatients (and their caregivers) with eczema, vitiligo, SCC and PG, plus health-care professionals with an interest in skin disease.InterventionsOur three intervention studies included (1) barrier enhancement using emollients from birth to prevent eczema (pilot RCT); (2) handheld narrowband ultraviolet light B therapy for treating vitiligo (pilot RCT); and (3) oral ciclosporin (Neoral®, Novartis Pharmaceuticals) compared with oral prednisolone for managing PG (pragmatic national RCT).ResultsSystematic reviews included two overarching systematic reviews of RCTs of treatments for eczema and vitiligo, an umbrella review of systematic reviews of interventions for the prevention of eczema, two reviews of treatments for SCC (one included RCTs and the second included observational studies), and three reviews of outcome measures and outcome reporting. Three prioritisation partnership exercises identified 26 priority areas for future research in eczema, vitiligo and SCC. Two international consensus initiatives identified four core domains for future eczema trials and seven core domains for vitiligo trials. Two pilot RCTs and three feasibility studies critically informed development of four trial proposals for external funding, three of which are now funded and one is pending consideration by funders. Our pragmatic RCT tested the two commonly used systemic treatments for PG (prednisolone vs. ciclosporin) and found no difference in their clinical effectiveness or cost-effectiveness. Both drugs showed limited benefit. Only half of the participants’ ulcers had healed by 6 months. For those with healed ulcers, recurrence was common (30%). Different side effect profiles were noted for each drug, which can inform clinical decisions on an individual patient basis. Three researchers were trained to PhD level and a dermatology patient panel was established to ensure patient involvement in all aspects of the programme.ConclusionsFindings from this programme of work have already informed clinical guidelines and patient information resources. Feasibility studies have ensured that large national pragmatic trials will now be conducted on important areas of treatment uncertainty that address the needs of patients and the NHS. There is scope for considerable improvement in terms of trial design, conduct and reporting for RCTs of skin disease, which can be improved through wider collaboration, registration of trial protocols and complete reporting and international consensus over core outcome sets. Three national trials have now been funded as a result of this work. Two international initiatives to establish how best to measure the core outcome domains for eczema and vitiligo are ongoing.Trial registrationCurrent Controlled Trials Barrier Enhancement for Eczema Prevention (BEEP) (ISRCTN84854178 and NCT01142999), Study of Treatments fOr Pyoderma GAngrenosum Patients (STOP GAP) (ISRCTN35898459) and Hand Held NB-UVB for Early or Focal Vitiligo at Home (HI-Light Pilot Trial) (NCT01478945).FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 18. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | | | | | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Tessa Clarke
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | | | - Finola M Delamere
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | | | - Nicholas Evans
- Trust Headquarters, West Hertfordshire Hospital NHS Trust, Hemel Hempstead, UK
| | - Lester Firkins
- Strategy and Development Group, James Lind Alliance, Oxford, UK
| | - Nicola Greenlaw
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Louise Lansbury
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Sandra Lawton
- Dermatology Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Carron Layfield
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Jo Leonardi-Bee
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - James Mason
- School of Medicine, Pharmacy and Health, Durham University, Durham, UK
| | - Eleanor Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Helen Nankervis
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - John Norrie
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Andrew Nunn
- Medical Research Council (MRC) Clinical Trials Unit, University College London, London, UK
| | | | - Ramesh Patel
- Radcliffe-on-Trent Health Centre, Nottingham, UK
| | - William Perkins
- Dermatology Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jane C Ravenscroft
- Dermatology Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jochen Schmitt
- Centre for Evidence-based Healthcare, Medical Faculty Carl Gustav Carus, Dresden, Germany
| | - Eric Simpson
- Oregon Health and Science University, Portland, OR, USA
| | - Maxine E Whitton
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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Nankervis H, Thomas KS, Delamere FM, Barbarot S, Rogers NK, Williams HC. Scoping systematic review of treatments for eczema. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04070] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BackgroundEczema is a very common chronic inflammatory skin condition.ObjectivesTo 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 sourcesElectronic 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 methodsStudies 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.ResultsOf 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.LimitationsThe 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.ConclusionsAlthough 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.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Helen Nankervis
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Finola M Delamere
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Sébastien Barbarot
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Natasha K Rogers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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Francis NA, Ridd MJ, Thomas-Jones E, Shepherd V, Butler CC, Hood K, Huang C, Addison K, Longo M, Marwick C, Wootton M, Howe R, Roberts A, Haq MIU, Madhok V, Sullivan F. 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. Health Technol Assess 2016; 20:i-xxiv, 1-84. [PMID: 26938214 PMCID: PMC4809466 DOI: 10.3310/hta20190] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Nick A Francis
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Matthew J Ridd
- Centre for Academic Primary Care, National Institute for Health Research School of Primary Care Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Emma Thomas-Jones
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Victoria Shepherd
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Christopher C Butler
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kerenza Hood
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Chao Huang
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Katy Addison
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Mirella Longo
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Charis Marwick
- Population Health Sciences, School of Medicine, University of Dundee, Dundee, UK
| | - Mandy Wootton
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, University Hospital Wales, Cardiff, UK
| | - Robin Howe
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, University Hospital Wales, Cardiff, UK
| | - Amanda Roberts
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | | | | | - Frank Sullivan
- Department of Family and Community Medicine and Dalla Lana School of Public Health, North York General Hospital University of Toronto, Toronto, ON, Canada
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