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Matsui K, Kobayashi M, Nagano M, Matsuoka M. Effects of dual therapy with betamethasone and tetracycline in a NC/Nga mouse model of atopic dermatitis. JOURNAL OF PHARMACY & PHARMACEUTICAL SCIENCES : A PUBLICATION OF THE CANADIAN SOCIETY FOR PHARMACEUTICAL SCIENCES, SOCIETE CANADIENNE DES SCIENCES PHARMACEUTIQUES 2023; 26:11182. [PMID: 36942298 PMCID: PMC9990628 DOI: 10.3389/jpps.2023.11182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/10/2023] [Indexed: 01/21/2023]
Abstract
Purpose: Our previous study has demonstrated that tetracycline exerts excellent bactericidal activity against Staphylococcus aureus strains isolated from patients with atopic dermatitis (AD) while simultaneously inhibiting the development of T helper (Th) type 2 (Th2) cells. The present study was designed to evaluate the effectiveness of dual therapy with betamethasone and tetracycline for AD. Methods: Betametasone (0.1%) and tetracycline (3%) were topically administered to NC/Nga mice with AD-like skin lesions. Skin severity scores, histological changes to the lesioned skin, and serum IgE levels were assessed as indicators of therapeutic effectiveness. Results: Topical treatment with both drugs reduced the skin severity score more significantly than was the case with betamethasone alone or tetracycline alone. This was associated with a reduction in the degree of epidermal thickening, the density of cellular infiltration into the dermis, the mast cell count in the dermis and the serum IgE concentration. Furthermore, the degree of Th1/Th2 cell development in auricular lymph nodes and the S. aureus count on the lesioned skin were synergistically suppressed by simultaneous application of both drugs. Conclusion: The present results show that simultaneous topical application of betamethasone and tetracycline synergistically ameliorates AD-like skin lesions in NC/Nga mice. This suggests that dual therapy with betamethasone and tetracycline for AD lesions colonized by S. aureus might be one of the best options for inhibiting the development of both Th1 and Th2 cells and acting on superficially located S. aureus .
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Zhang MS, Huston J, Petrov A, Fajt ML. Peanut allergy in an adult following cardiac transplant from a non-atopic donor. Allergy Asthma Proc 2023; 44:81-84. [PMID: 36719692 DOI: 10.2500/aap.2023.44.220090] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We present a 62-year-old woman with severe heart failure and who required cardiac transplantation. On postoperative day 22, she experienced anaphylaxis to peanut, with an elevated peanut-specific immunoglobulin E level. This case highlights the differential diagnosis of posttransplantation anaphylaxis as well as the appropriate evaluation.
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Affiliation(s)
- Michael S Zhang
- From the Subsection of Allergy-Immunology, Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, and
| | - Jessica Huston
- Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrej Petrov
- From the Subsection of Allergy-Immunology, Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, and
| | - Merritt L Fajt
- From the Subsection of Allergy-Immunology, Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, and
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Jarquín-Yáñez K, Herrera-Enriquez MÁ, Lemini C, Melendez-Moreno E, Villena-López P, Ávila ME, Hernández-Téllez B, Piñón-Zárate G, Sampedro-Carrillo EA, Castell-Rodríguez AE. Epicutaneous Administration of 17β-Estradiol Induces Langerhans Cells Depletion. Immunol Invest 2021; 51:1561-1581. [PMID: 34569394 DOI: 10.1080/08820139.2021.1975738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Langerhans cells (LC) number and function in mouse vaginal mucosa are affected by 17β-estradiol (E2) application; nonetheless, its effect on epidermal LC has not been studied. The purpose of this study was to evaluate the effect of topical administration of E2 on the number, phenotype, and migratory ability of LC in mouse skin. METHODS Ears of adult CD1 male mice were topically treated once with several doses. Immunohistochemical staining for CD207 and TUNEL staining were performed. LC migration to lymph nodes and the effect on the expression of costimulatory molecules on cultured dendritic cells (DC) were also evaluated. RESULTS E2 decreased the number of CD207+ LC in a dose-dependent manner. One hour after treatment, 1 and 10 µg/mL E2 significantly reduced the LC number by 21% and 26%, respectively, after two hours, the reduction was 23% and 41%, respectively. After 48 hours, LC recovered, and after 96 hours of treatment, the CD207+/MHCII+ DC numbers were increased in regional lymph nodes. However, CD86 and CD40 molecules were expressed at lower levels than in positive control. The TUNEL assay did not show apoptotic cells. Furthermore, in cultured DC, E2 promoted a decrease in CD40 and CD86 expression and an increase in CD273, CD274, MHCII, and CCR7. CONCLUSIONS The topical administration of E2 induced a transitory local diminution of LC population and a tolerogenic phenotype. This decrease in epidermal LC suggests that E2 may affect skin immune responses, inducing an inhibitory response, which should be considered when prescribing topical E2 medications.
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Affiliation(s)
- Katia Jarquín-Yáñez
- Department of Cell and Tissue Biology, Universidad Nacional Autónoma de México, Ciudad de México, México
| | | | - Cristina Lemini
- Pharmacology, Medicine School, Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Edith Melendez-Moreno
- Department of Cell and Tissue Biology, Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Paulina Villena-López
- Department of Cell and Tissue Biology, Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Maria Estela Ávila
- Pharmacology, Medicine School, Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Beatriz Hernández-Téllez
- Department of Cell and Tissue Biology, Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Gabriela Piñón-Zárate
- Department of Cell and Tissue Biology, Universidad Nacional Autónoma de México, Ciudad de México, México
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Perna-Barrull D, Gieras A, Rodriguez-Fernandez S, Tolosa E, Vives-Pi M. Immune System Remodelling by Prenatal Betamethasone: Effects on β-Cells and Type 1 Diabetes. Front Endocrinol (Lausanne) 2020; 11:540. [PMID: 32849311 PMCID: PMC7431597 DOI: 10.3389/fendo.2020.00540] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/03/2020] [Indexed: 01/11/2023] Open
Abstract
Type 1 diabetes (T1D) is a multifactorial disease of unknown aetiology. Studies focusing on environment-related prenatal changes, which might have an influence on the development of T1D, are still missing. Drugs, such as betamethasone, are used during this critical period without exploring possible effects later in life. Betamethasone can interact with the development and function of the two main players in T1D, the immune system and the pancreatic β-cells. Short-term or persistent changes in any of these two players may influence the initiation of the autoimmune reaction against β-cells. In this review, we focus on the ability of betamethasone to induce alterations in the immune system, impairing the recognition of autoantigens. At the same time, betamethasone affects β-cell gene expression and apoptosis rate, reducing the danger signals that will attract unwanted attention from the immune system. These effects may synergise to hinder the autoimmune attack. In this review, we compile scattered evidence to provide a better understanding of the basic relationship between betamethasone and T1D, laying the foundation for future studies on human cohorts that will help to fully grasp the role of betamethasone in the development of T1D.
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Affiliation(s)
- David Perna-Barrull
- Immunology Section, Germans Trias i Pujol Research Institute, Autonomous University of Barcelona, Badalona, Spain
| | - Anna Gieras
- Department of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Silvia Rodriguez-Fernandez
- Immunology Section, Germans Trias i Pujol Research Institute, Autonomous University of Barcelona, Badalona, Spain
| | - Eva Tolosa
- Department of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marta Vives-Pi
- Immunology Section, Germans Trias i Pujol Research Institute, Autonomous University of Barcelona, Badalona, Spain
- *Correspondence: Marta Vives-Pi
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Strehl C, Ehlers L, Gaber T, Buttgereit F. Glucocorticoids-All-Rounders Tackling the Versatile Players of the Immune System. Front Immunol 2019; 10:1744. [PMID: 31396235 PMCID: PMC6667663 DOI: 10.3389/fimmu.2019.01744] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/10/2019] [Indexed: 12/13/2022] Open
Abstract
Glucocorticoids regulate fundamental processes of the human body and control cellular functions such as cell metabolism, growth, differentiation, and apoptosis. Moreover, endogenous glucocorticoids link the endocrine and immune system and ensure the correct function of inflammatory events during tissue repair, regeneration, and pathogen elimination via genomic and rapid non-genomic pathways. Due to their strong immunosuppressive, anti-inflammatory and anti-allergic effects on immune cells, tissues and organs, glucocorticoids significantly improve the quality of life of many patients suffering from diseases caused by a dysregulated immune system. Despite the multitude and seriousness of glucocorticoid-related adverse events including diabetes mellitus, osteoporosis and infections, these agents remain indispensable, representing the most powerful, and cost-effective drugs in the treatment of a wide range of rheumatic diseases. These include rheumatoid arthritis, vasculitis, and connective tissue diseases, as well as many other pathological conditions of the immune system. Depending on the therapeutically affected cell type, glucocorticoid actions strongly vary among different diseases. While immune responses always represent complex reactions involving different cells and cellular processes, specific immune cell populations with key responsibilities driving the pathological mechanisms can be identified for certain autoimmune diseases. In this review, we will focus on the mechanisms of action of glucocorticoids on various leukocyte populations, exemplarily portraying different autoimmune diseases as heterogeneous targets of glucocorticoid actions: (i) Abnormalities in the innate immune response play a crucial role in the initiation and perpetuation of giant cell arteritis (GCA). (ii) Specific types of CD4+ T helper (Th) lymphocytes, namely Th1 and Th17 cells, represent important players in the establishment and course of rheumatoid arthritis (RA), whereas (iii) B cells have emerged as central players in systemic lupus erythematosus (SLE). (iv) Allergic reactions are mainly triggered by several different cytokines released by activated Th2 lymphocytes. Using these examples, we aim to illustrate the versatile modulating effects of glucocorticoids on the immune system. In contrast, in the treatment of lymphoproliferative disorders the pro-apoptotic action of glucocorticoids prevails, but their mechanisms differ depending on the type of cancer. Therefore, we will also give a brief insight into the current knowledge of the mode of glucocorticoid action in oncological treatment focusing on leukemia.
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Affiliation(s)
- Cindy Strehl
- Department of Rheumatology and Clinical Immunology, Charité—Universitätsmedizin Berlin, Berlin, Germany
- German Rheumatism Research Centre (DRFZ) Berlin, Berlin, Germany
| | - Lisa Ehlers
- Department of Rheumatology and Clinical Immunology, Charité—Universitätsmedizin Berlin, Berlin, Germany
- German Rheumatism Research Centre (DRFZ) Berlin, Berlin, Germany
| | - Timo Gaber
- Department of Rheumatology and Clinical Immunology, Charité—Universitätsmedizin Berlin, Berlin, Germany
- German Rheumatism Research Centre (DRFZ) Berlin, Berlin, Germany
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité—Universitätsmedizin Berlin, Berlin, Germany
- German Rheumatism Research Centre (DRFZ) Berlin, Berlin, Germany
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Hur MS, Choe YB, Ahn KJ, Lee YW. Synergistic Effect of H1-Antihistamines on Topical Corticosteroids for Pruritus in Atopic Dermatitis: A Systematic Review and Meta-Analysis. Ann Dermatol 2019; 31:420-425. [PMID: 33911620 PMCID: PMC7992765 DOI: 10.5021/ad.2019.31.4.420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/15/2019] [Accepted: 02/27/2019] [Indexed: 12/12/2022] Open
Abstract
Background Although oral antihistamines (H1-histamine receptor antagonists) are the main treatment option for pruritus in general skin dermatosis, their effect in treating pruritus of atopic dermatitis (AD) has not yet been established. Objective We conducted a systematic review and meta-analysis to evaluate the effectiveness of combined therapy of H1-antihistamines and topical steroids. Methods We systematically searched MEDLINE, Embase, and CENTRAL databases for articles published from 1967 to 2015. We identified 1,206 studies and assessed their titles, abstract, and full-text. Random effects meta-analysis was used to calculate mean differences (MD) with 95% confidence intervals (CI). Results Two studies satisfying the inclusion criteria of antihistamine therapy with mandatory topical steroid use were selected. Comparing antihistamine monotherapy with combination therapy, patients treated with the addition of antihistamine to topical corticosteroids showed a statistically significant clinical improvement (standard MD, −0.24; 95% CI, −0.42 to −0.05; p=0.01). Conclusion H1-antihistamines may have a synergistic effect when combined with topical steroids by influencing various associative factors of chronic pruritus in AD.
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Affiliation(s)
- Min Seok Hur
- Department of Dermatology, Konkuk University School of Medicine, Seoul, Korea
| | - Yong Beom Choe
- Department of Dermatology, Konkuk University School of Medicine, Seoul, Korea
| | - Kyu Joong Ahn
- Department of Dermatology, Konkuk University School of Medicine, Seoul, Korea
| | - Yang Won Lee
- Department of Dermatology, Konkuk University School of Medicine, Seoul, Korea
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Perna-Barrull D, Rodriguez-Fernandez S, Pujol-Autonell I, Gieras A, Ampudia-Carrasco RM, Villalba A, Glau L, Tolosa E, Vives-Pi M. Prenatal Betamethasone interferes with immune system development and alters target cells in autoimmune diabetes. Sci Rep 2019; 9:1235. [PMID: 30718757 PMCID: PMC6362293 DOI: 10.1038/s41598-018-37878-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 12/17/2018] [Indexed: 01/03/2023] Open
Abstract
Non-genetic factors are crucial in the pathogenesis of type 1 diabetes (T1D), a disease caused by autoimmunity against insulin-producing β-cells. Exposure to medications in the prenatal period may influence the immune system maturation, thus altering self-tolerance. Prenatal administration of betamethasone –a synthetic glucocorticoid given to women at risk of preterm delivery– may affect the development of T1D. It has been previously demonstrated that prenatal betamethasone administration protects offspring from T1D development in nonobese diabetic (NOD) mice. The direct effect of betamethasone on the immature and mature immune system of NOD mice and on target β-cells is analysed in this paper. In vitro, betamethasone decreased lymphocyte viability and induced maturation-resistant dendritic cells, which in turn impaired γδ T cell proliferation and decreased IL-17 production. Prenatal betamethasone exposure caused thymus hypotrophy in newborn mice as well as alterations in immune cells subsets. Furthermore, betamethasone decreased β-cell growth, reduced C-peptide secretion and altered the expression of genes related to autoimmunity, metabolism and islet mass in T1D target tissue. These results support the protection against T1D in the betamethasone-treated offspring and demonstrate that this drug alters the developing immune system and β-cells. Understanding how betamethasone generates self-tolerance could have potential clinical relevance in T1D.
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Affiliation(s)
- David Perna-Barrull
- Immunology Section, Germans Trias i Pujol Research Institute, Autonomous University of Barcelona, Badalona, Spain
| | - Silvia Rodriguez-Fernandez
- Immunology Section, Germans Trias i Pujol Research Institute, Autonomous University of Barcelona, Badalona, Spain
| | - Irma Pujol-Autonell
- Immunology Section, Germans Trias i Pujol Research Institute, Autonomous University of Barcelona, Badalona, Spain
| | - Anna Gieras
- Department of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosa M Ampudia-Carrasco
- Immunology Section, Germans Trias i Pujol Research Institute, Autonomous University of Barcelona, Badalona, Spain
| | - Adrian Villalba
- Immunology Section, Germans Trias i Pujol Research Institute, Autonomous University of Barcelona, Badalona, Spain
| | - Laura Glau
- Department of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eva Tolosa
- Department of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marta Vives-Pi
- Immunology Section, Germans Trias i Pujol Research Institute, Autonomous University of Barcelona, Badalona, Spain. .,CIBERDEM, Barcelona, Spain.
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Ku JM, Hong SH, Kim SR, Choi HS, Kim HI, Kim DU, Oh SM, Seo HS, Kim TY, Shin YC, Cheon C, Ko SG. The prevention of 2,4-dinitrochlorobenzene-induced inflammation in atopic dermatitis-like skin lesions in BALB/c mice by Jawoongo. Altern Ther Health Med 2018; 18:215. [PMID: 30005655 PMCID: PMC6045835 DOI: 10.1186/s12906-018-2280-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 07/06/2018] [Indexed: 01/09/2023]
Abstract
Background Jawoongo is an herbal mixture used in traditional medicine to treat skin diseases. This study aimed to investigate whether Jawoongo ameliorates Atopic dermatitis (AD)-like pathology in mice and to understand its underlying cellular mechanisms. Methods AD was induced by 2, 4-Dinitrocholrlbenzene (DNCB) in BALB/c mice. Treatment with Jawoongo was assessed to study the effect of Jawoongo on AD in mice. Histological Analysis, blood analysis, RT-PCR, western blot analysis, ELISA assay and cell viability assay were performed to verify the inhibitory effect of Jawoongo on AD in mice. Results We found that application of Jawoongo in an ointment form on AD-like skin lesions on DNCB-exposed BALB/c mice reduced skin thickness and ameliorated skin infiltration with inflammatory cells, mast cells and CD4+ cells. The ointment also reduced the mRNA levels of IL-2, IL-4, IL-13 and TNF-α in the sensitized skin. Leukocyte counts and the levels of IgE, IL-6, IL-10 and IL-12 were decreased in the blood of the DNCB-treated mice. Furthermore, studies on cultured cells demonstrated that Jawoongo exhibits anti-inflammatory activities, including the suppression of proinflammatory cytokine expression, nitric oxide (NO) production, and inflammation-associated molecule levels in numerous types of agonist-stimulated innate immune cell, including human mast cells (HMC-1), murine macrophage RAW264.7 cells, and splenocytes isolated from mice. Conclusion These findings indicate that Jawoongo alleviates DNCB-induced AD-like symptoms via the modulation of several inflammatory responses, indicating that Jawoongo might be a useful drug for the treatment of AD. Electronic supplementary material The online version of this article (10.1186/s12906-018-2280-z) contains supplementary material, which is available to authorized users.
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Pecoraro L, Florile M, Piazza M, Comberiati P, Clemente M, Tadiotto E, Pietrobelli A, Piacentini G. Duration of topical therapy in the maintenance of atopic dermatitis remission in pediatric age. Minerva Pediatr (Torino) 2018; 73:294-300. [PMID: 29968448 DOI: 10.23736/s2724-5276.18.05064-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Topical corticosteroids (TCS) are the first-choice treatment for atopic dermatitis (AD) flares. In literature there are clear advice about the potency, dosage and frequency of application of TCS, but there are no shared indications about duration of the treatment during a flare. The aim of the study is to demonstrate if the use of a steroid cream for less than or 5 days, could be equal or more effective than the application for more than 5 days during a flare episode, in keeping a remission state of AD. METHODS The study population (N.=122) was selected according to the following inclusion criteria: at least one specialist allergological and dermatological examination in the period November 2015 to February 2017, age between 1 and 11 years; mild to moderate atopic dermatitis. All patients were given a standardized telephone questionnaire, which concerns on multiple aspects: parents' self-reported perceptions of the severity of their child's condition; actual use of emollients, moisturizers and steroid creams; number of consecutive days of using of topical steroid cream during an exacerbation of AD; average number of AD exacerbations per month in the last year; total number of AD exacerbations in the last year. RESULTS Data from 96 patients was examined. We classified three groups of patients from data collected: group 1 (N.=40): use of TCS for ≤5 consecutive days during an exacerbation event of AD; group 2 (N.=12): use of TCS for >5 consecutive days during an exacerbation event of AD; group 3 (N.=44): nonuse of TCS or use of TCS with a different posology. We found a further subgroup in group 3 (3a, N.=27) with patients using only emollient crème in AD management. In group 1, 27 patients (67.5%) did not show a good AD control; on the contrary, 13 patients (27.5%) reported a good AD control. In group 2, 4 patients (25%) did not show a good AD control; on the contrary, 8 patients (75%) reported a good AD control. By comparing the data obtained in the presence of good AD control, the difference between the percentages obtained was found to be statistically significant (P=0.034). CONCLUSIONS The results obtained show that a therapeutic pattern based on the use of TCS for a duration of more than 5 consecutive days during an episode of AD exacerbation is more efficient than the proposed alternative therapeutic scheme in the maintenance of AD remission.
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Affiliation(s)
- Luca Pecoraro
- Unit of Pediatrics, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy -
| | - Marta Florile
- Unit of Pediatrics, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Michele Piazza
- Unit of Pediatrics, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Pasquale Comberiati
- Unit of Pediatrics, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Maria Clemente
- Unit of Pediatrics, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Elisa Tadiotto
- Unit of Pediatrics, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Angelo Pietrobelli
- Unit of Pediatrics, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Giorgio Piacentini
- Unit of Pediatrics, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
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