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Zhao Y, Zhu L, Yang L, Chen M, Sun P, Ma Y, Zhang D, Zhao Y, Jia H. In vitro and in vivo anti-eczema effect of Artemisia annua aqueous extract and its component profiling. JOURNAL OF ETHNOPHARMACOLOGY 2024; 318:117065. [PMID: 37604330 DOI: 10.1016/j.jep.2023.117065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/07/2023] [Accepted: 08/17/2023] [Indexed: 08/23/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Artemisia annua L. belongs to the Asteraceae family and has a long history of clinical application in China. It has been widely used for centuries to treat fever, malaria, jaundice and some skin diseases (such as scabies and sores). Modern pharmacological studies have shown that it has anti-inflammatory, immunomodulatory, antimalarial and antibacterial effects. AIM OF STUDY This study aimed to investigate the anti-eczema effect of A. annua aqueous extract (AAE), profile its potential bioactive components and try to explore its possible underlying mechanisms. MATERIALS AND METHODS The MTT assay was employed to assess the cytotoxicity of AAE. The anti-eczema effect of AAE was evaluated using both an in vitro 3D epidermal inflammation model and an in vivo guinea pig itching model. The bioactive components of AAE were characterized by ultra-performance liquid chromatography quadrupole time-of-flight mass spectrometry coupled with the UNIFI platform. RESULTS In this study, we found that AAE is safe for primary human skin keratinocytes at concentrations ranging from 31.3 μg/mL to 250 μg/mL. Further investigations indicate that AAE can increase the itching threshold, inhibit the expression of the inflammatory cytokine TSLP, and promote the expression of FLG mRNA. Additionally, the utilization of UPLC-QTOF/MS and UNIFI platform enabled us to identify 61 potential bioactive components of AAE, with sesquiterpenes and phenolic acids being the most abundant components. CONCLUSIONS In this study, the anti-inflammatory and anti-itch effects of the A. annua extract were revealed, along with sesquiterpenes and phenolic acids were identified as potential bioactive components according to literature. The AAE extract holds potential for utilization in the treatment of eczema.
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Affiliation(s)
- Yifan Zhao
- Artemisinin Research Center & Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Le Zhu
- Shanghai Jahwa United Co., Ltd., Shanghai, 200082, China
| | - Lan Yang
- Artemisinin Research Center & Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Mo Chen
- Shanghai Jahwa United Co., Ltd., Shanghai, 200082, China
| | - Peng Sun
- Artemisinin Research Center & Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Yue Ma
- Artemisinin Research Center & Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Dong Zhang
- Artemisinin Research Center & Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China.
| | - Ya Zhao
- Shanghai Jahwa United Co., Ltd., Shanghai, 200082, China.
| | - Haidong Jia
- Shanghai Jahwa United Co., Ltd., Shanghai, 200082, China
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Quan VL, Erickson T, Daftary K, Chovatiya R. Atopic Dermatitis Across Shades of Skin. Am J Clin Dermatol 2023; 24:731-751. [PMID: 37336869 DOI: 10.1007/s40257-023-00797-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 06/21/2023]
Abstract
Atopic dermatitis (AD) is a chronic, heterogeneous inflammatory skin disease that is associated with immense patient burden globally. There is increasing appreciation of disparities among patients identified as having skin of color (SOC), which often refers to patients of non-White race or non-European ancestry, but can broadly include individuals from a number of different racial, ethnic, ancestral, and skin pigmentation groups based on definition. In this narrative review, we discuss key terminology as it relates to AD across shades of skin, including modern definitions of 'race', 'ethnicity', and 'SOC'. We then synthesize the current literature describing disparities in AD prevalence, disease recognition, and burden alongside current data regarding genetic and immunologic findings across SOC populations. In the context of these findings, we highlight key concomitant social determinants of health, including environmental factors, socioeconomic status, and access to care, for which race often serves as a proxy for true biological and genetic differences. Finally, we discuss future efforts to shift to a more inclusive understanding of AD to encompass all shades of skin, to ensure equitable representation of diverse populations in high impact research, and intensify efforts to address the critical upstream factors driving observed disparities.
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Affiliation(s)
- Victor L Quan
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 N St Clair St, Suite 1600, Chicago, IL, 60611, USA
| | - Taylor Erickson
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 N St Clair St, Suite 1600, Chicago, IL, 60611, USA
| | - Karishma Daftary
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 N St Clair St, Suite 1600, Chicago, IL, 60611, USA
| | - Raj Chovatiya
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 N St Clair St, Suite 1600, Chicago, IL, 60611, USA.
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3
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Baker A, Mitchell EJ, Partlett C, Thomas KS. Evaluating the effect of weekly patient-reported symptom monitoring on trial outcomes: results of the Eczema Monitoring Online randomized controlled trial. Br J Dermatol 2023; 189:180-187. [PMID: 37194567 DOI: 10.1093/bjd/ljad163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/10/2023] [Accepted: 05/13/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Patient-reported outcome measures (PROMs) are commonly used in eczema clinical trials. Several trials have used PROMs weekly for symptom monitoring. However, the increased frequency of patient-reported symptom monitoring may prompt participants to enhance the self-management of eczema and increase standard topical treatment use that can lead to improvements in outcomes over time. This is concerning as weekly symptom monitoring may constitute an unplanned intervention, which may mask small treatment effects and make it difficult to identify changes in the eczema resulting from the treatment under investigation. OBJECTIVES To evaluate the effect of weekly patient-reported symptom monitoring on participants' outcomes and to inform the design of future eczema trials. METHODS This was an online parallel-group nonblinded randomized controlled trial. Parents/carers of children with eczema and young people and adults with eczema were recruited online, excluding people scoring < 3 points on the Patient Oriented Eczema Measure (POEM), to avoid floor effects. Electronic PROMs were used for data collection. Participants were allocated using online randomization (1 : 1) to weekly POEM for 7 weeks (intervention) or no POEM during this period (control). The primary outcome was change in eczema severity based on POEM scores, assessed at baseline and week 8. Secondary outcomes included change in standard topical treatment use and data completeness at follow-up. Analyses were conducted according to randomized groups in those with complete data at week 8. RESULTS A total of 296 participants were randomized from 14 September 2021 to 16 January 2022 (71% female, 77% white, mean age 26.7 years). The follow-up completion rate was 81.7% [n = 242; intervention group, n = 118/147 (80.3%); control group n = 124/149 (83.2%)]. After adjusting for baseline disease severity and age, eczema severity improved in the intervention group (mean difference in POEM score -1.64, 95% confidence interval -2.91 to -0.38; P = 0.01). No between-group differences were noted in the use of standard topical treatments and data completeness at follow-up. CONCLUSIONS Weekly patient-reported symptom monitoring led to a small perceived improvement in eczema severity.
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Affiliation(s)
- Arabella Baker
- Centre of Evidence Based Dermatology
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Eleanor J Mitchell
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Christopher Partlett
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
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Ezzamouri B, Palys TJ, Jackson BP, Coto SD, Madan JC, Flohr C, Karagas MR, Peacock JL. Water hardness and atopic dermatitis in the first year of life in the New Hampshire Birth Cohort Study. Clin Exp Allergy 2023; 53:362-366. [PMID: 36541020 PMCID: PMC10023435 DOI: 10.1111/cea.14272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 11/29/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Bouchra Ezzamouri
- Unit for Population-Based Dermatology Research, St John’s Institute of Dermatology, King’s College London and Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- School of Population Health and Environmental Sciences Research, King’s College London, London, UK
| | - Thomas J Palys
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Dartmouth College, NH, USA
| | - Brian P Jackson
- Trace element Analysis Core Laboratory, Department of Earth Sciences, Dartmouth College, Hanover, NH, USA
| | - Susana Diaz Coto
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Dartmouth College, NH, USA
| | - Juliette C Madan
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Dartmouth College, NH, USA
- Department of Pediatrics & Psychiatry, Children’s Hospital at Dartmouth, Dartmouth Hitchcock Medical Center, Lebanon NH 03756
| | - Carsten Flohr
- Unit for Population-Based Dermatology Research, St John’s Institute of Dermatology, King’s College London and Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Margaret R Karagas
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Dartmouth College, NH, USA
| | - Janet L Peacock
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Dartmouth College, NH, USA
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Flohr C. How we treat atopic dermatitis now and how that will change over the next 5 years. Br J Dermatol 2022; 188:718-725. [PMID: 36715500 DOI: 10.1093/bjd/ljac116] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/21/2022] [Accepted: 11/26/2022] [Indexed: 01/22/2023]
Abstract
We live in exciting times in atopic dermatitis therapeutics, with many novel treatments in the clinical trial pipeline. Frustratingly, most of these trials are vehicle- or placebo-controlled, rather than head-to-head comparisons. Network meta-analyses can rank treatments against each other, even for placebo-controlled studies, aiding evidence-based guideline formulation and clinical decision-making. Treatment registries are an important additional vehicle to collect 'real-world' data on the long-term (cost) effectiveness and safety of the new drugs, outside of the stringent and short-term settings of clinical trials. As further agents enter clinical practice, the need for biomarkers of treatment response and drug safety becomes more pressing to move us towards personalized medicine and to avoid wasting healthcare resources. This review takes stock of our current treatment armamentarium for atopic dermatitis, highlights important gaps in our knowledge - including the relatively low number of studies conducted in children - and maps out how our treatment approaches for atopic dermatitis can become more targeted and holistic in the future.
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Affiliation(s)
- Carsten Flohr
- St John's Institute of Dermatology, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK
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6
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Lopez DJ, Singh A, Waidyatillake NT, Su JC, Bui DS, Dharmage SC, Lodge CJ, Lowe AJ. The association between domestic hard water and eczema in adults from the UK Biobank cohort study. Br J Dermatol 2022; 187:704-712. [PMID: 35822417 PMCID: PMC9804584 DOI: 10.1111/bjd.21771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/05/2022] [Accepted: 07/09/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Eczema is a chronic inflammatory skin disease. Domestic water with high mineral content (hard water) is a risk factor for eczema in children, but this association has not been assessed in adults. OBJECTIVES To examine the association between domestic hard water supply and eczema prevalence and incidence in adults aged 40-69 years and the contextual effect in eczema outcomes by postcode in adults in the UK. METHODS We used data from the UK Biobank study collected in 2006-10 (baseline) and 2013-14 (follow-up). Eczema prevalence at baseline (2006-10) and at follow-up (2013-14) and incidence (new onset between baseline and follow-up) were determined from the touchscreen questionnaires and nurse-led interviews. Domestic hard water information was obtained in 2005 and 2013 from the local water supply companies in England, Wales and Scotland as CaCO3 concentrations. We fitted multilevel logistic regression models with random intercepts for postcode areas to examine the effect of domestic hard water on eczema outcomes, and we measured components of variance. RESULTS In total, 306 531 participants with a mean age of 57 years nested across 7642 postcodes were included in the baseline analysis, and 31 036 participants nested across 3695 postcodes were included in the follow-up analysis. We observed an increase in the odds of eczema at baseline [odds ratio (OR) 1·02, 95% confidence interval (CI) 1·01-1·04] per 50 mg L-1 of CaCO3 increase. Furthermore, exposure to domestic hard water (> 200 mg L-1 of CaCO3 ) was associated with increased odds of prevalent eczema at baseline (OR 1·12, 95% CI 1·04-1·22). Moreover, there was a significant linear trend (P < 0·001) in which increasing levels of hard water increased eczema prevalence risk. No association was observed with incident eczema or eczema at follow-up. The intraclass correlation coefficient for postcode was 1·6% (95% CI 0·7-3·4), which remained unexplained by area-level socioeconomic measures. CONCLUSIONS Increasing levels of domestic hard water, as measured by CaCO3 concentrations, were associated with an increased prevalence of eczema in adults but not increased incidence. Ongoing efforts to reduce hard water exposure may have a beneficial effect in reducing the burden of eczema in adults. Further research is needed to explore area-level factors that may lead to eczema. What is already known about this topic? Hard water is formed when minerals are dissolved in water from filtration through sedimentary rocks. Several studies have reported a higher prevalence of eczema in areas with hard water. However, all studies on this topic have assessed this in infants and school-aged children, while this association has not been explored in adults. What does this study add? Our findings suggest that exposure to higher concentrations of domestic hard water is associated with an increase in eczema prevalence in adults aged 40-69 years. Ongoing efforts to reduce hard water exposure may have a beneficial effect in reducing eczema prevalence in adults.
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Affiliation(s)
- Diego J. Lopez
- Allergy and Lung Health Unitthe University of MelbourneMelbourneVICAustralia
| | - Ankur Singh
- Teaching and Learning Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global HealthUniversity of MelbourneMelbourneVICAustralia
| | - Nilakshi T. Waidyatillake
- Allergy and Lung Health Unitthe University of MelbourneMelbourneVICAustralia
- Department of Medical Education, Faculty of Medicine, Dentistry and Health Sciencethe University of MelbourneMelbourneVICAustralia
| | - John C. Su
- Department of DermatologyMonash University, Eastern HealthMelbourneVICAustralia
- Murdoch Children's Research InstituteUniversity of MelbourneMelbourneVICAustralia
| | - Dinh S. Bui
- Allergy and Lung Health Unitthe University of MelbourneMelbourneVICAustralia
| | - Shyamali C. Dharmage
- Allergy and Lung Health Unitthe University of MelbourneMelbourneVICAustralia
- Murdoch Children's Research InstituteUniversity of MelbourneMelbourneVICAustralia
| | - Caroline J. Lodge
- Allergy and Lung Health Unitthe University of MelbourneMelbourneVICAustralia
- Murdoch Children's Research InstituteUniversity of MelbourneMelbourneVICAustralia
| | - Adrian J. Lowe
- Allergy and Lung Health Unitthe University of MelbourneMelbourneVICAustralia
- Murdoch Children's Research InstituteUniversity of MelbourneMelbourneVICAustralia
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7
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Hurault G, Pan K, Mokhtari R, Olabi B, Earp E, Steele L, Williams HC, Tanaka RJ. Detecting Eczema Areas in Digital Images: An Impossible Task? JID INNOVATIONS 2022; 2:100133. [PMID: 36090300 PMCID: PMC9460154 DOI: 10.1016/j.xjidi.2022.100133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 12/02/2022] Open
Abstract
Assessing the severity of atopic dermatitis (AD, or eczema) traditionally relies on a face-to-face assessment by healthcare professionals and may suffer from inter- and intra-rater variability. With the expanding role of telemedicine, several machine learning algorithms have been proposed to automatically assess AD severity from digital images. Those algorithms usually detect and then delineate (segment) AD lesions before assessing lesional severity and are trained using the data of AD areas detected by healthcare professionals. To evaluate the reliability of such data, we estimated the inter-rater reliability of AD segmentation in digital images. Four dermatologists independently segmented AD lesions in 80 digital images collected in a published clinical trial. We estimated the inter-rater reliability of the AD segmentation using the intraclass correlation coefficient at the pixel and the area levels for different resolutions of the images. The average intraclass correlation coefficient was 0.45 ( standard error = 0.04 ) corresponding to a poor agreement between raters, whereas the degree of agreement for AD segmentation varied from image to image. The AD segmentation in digital images is highly rater dependent even among dermatologists. Such limitations need to be taken into consideration when AD segmentation data are used to train machine learning algorithms that assess eczema severity.
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Affiliation(s)
- Guillem Hurault
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Kevin Pan
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Ricardo Mokhtari
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Bayanne Olabi
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, United Kingdom
| | - Eleanor Earp
- Department of Dermatology, Lauriston Building, Edinburgh, United Kingdom
| | - Lloyd Steele
- Department of Dermatology, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Hywel C. Williams
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, United Kingdom
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Reiko J. Tanaka
- Department of Bioengineering, Imperial College London, London, United Kingdom
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Okazaki K, Fujino Y, Morikawa Y. Effects of ultra-pure soft water on the hands of nurses in a neonatal intensive care unit: A randomized crossover study. Contact Dermatitis 2022; 87:521-527. [PMID: 35718935 DOI: 10.1111/cod.14177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Healthcare workers (HCWs) wash their hands with tap water (TW) and soap. However, hard TW causes dermatitis. OBJECTIVES The present study aimed to compare the effects of ultra-pure soft water (UPSW) with those of TW on the hands of HWCs. METHODS The present study was a prospective randomized trial with a crossover design. All the nurses in the neonatal intensive care unit (NICU) at the study centre were divided into Sequence 1 (UPSW to TW) or 2 (TW to UPSW) and washed their hands with TW or UPSW in alternating 4-week periods with a 4-week washout period. Trans-epidermal water loss (TEWL) and stratum corneum hydration (SCH) were evaluated. Skin condition was self-assessed. RESULTS Twenty-one and 22 nurses were assigned to Sequence 1 and Sequence 2, respectively. USPW increased SCH to a significantly greater degree than TW (mean: 26.3 μS ± 12.3 SD; 95% confidence interval: 1.12-51.54; p = 0.041) although it did not affect TEWL. UPSW use significantly improved the subjects' skin condition, as reflected in an overall increase in the assessment scores. CONCLUSIONS UPSW improved SCH and the condition of hand skin. Prolonged USPW use may increase nurses' comfort during work and hand hygiene compliance.
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Affiliation(s)
- Kaoru Okazaki
- Department of Neonatology, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
| | - Yuta Fujino
- Division of Neonatal Intensive Care Unit, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
| | - Yoshihiko Morikawa
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
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9
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Williams HC, McPhee M, Layfield C. Celebrating 20 years of the
UK
Dermatology Clinical Trials Network: Part 1 – developing and delivering high quality independent clinical trials. Clin Exp Dermatol 2022; 47:1048-1059. [PMID: 35199857 PMCID: PMC9322597 DOI: 10.1111/ced.15140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 02/13/2022] [Indexed: 11/29/2022]
Abstract
The UK Dermatology Clinical Trials Network (UK DCTN) was formed in 2002 with the aim of developing and supporting high‐quality independent national clinical trials that address prioritized research questions for people with skin disease. Its philosophy is to democratize UK dermatological clinical research and to tackle important clinical questions that industry has no incentive to answer. The network also plays a key role in training and capacity development. Its membership of over 1000 individuals includes dermatology consultants, trainees, dermatology nurses, general practitioners, methodologists and patients. Its organizational structures are lean and include a co‐ordinating team based at the Centre of Evidence‐Based Dermatology in Nottingham, and an executive with independent members to ensure probity and business progression. A prioritization panel and steering group enable a pipeline of projects to be prioritized and refined for external funding from independent sources. The UK DCTN has supported and completed 12 national clinical trials, attracting investment of over £15 million into UK clinical dermatology research. Trials have covered a range of interventions from drugs such as doxycycline (BLISTER), silk clothing for eczema (CLOTHES) and surgical interventions for hidradenitis suppurativa (THESEUS). Trial results are published in prestigious journals and have global impact. Genuine partnership with patients and carers has been a strong feature of the network since its inception. The UK DCTN is proud of its first 20 years of collaborative work, and aims to remain at the forefront of independent dermatological health technology assessment, as well as expanding into areas including diagnostics, artificial intelligence, efficient studies and innovative designs.
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Affiliation(s)
- Hywel C. Williams
- Centre of Evidence Based Dermatology, Population and Lifespan Sciences, School of Medicine University of Nottingham Nottingham UK
| | - Margaret McPhee
- Centre of Evidence Based Dermatology, Population and Lifespan Sciences, School of Medicine University of Nottingham Nottingham UK
| | - Carron Layfield
- Centre of Evidence Based Dermatology, Population and Lifespan Sciences, School of Medicine University of Nottingham Nottingham UK
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10
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Abstract
Water has numerous functions necessary for survival including cellular homeostasis, solvent properties for dissolving ions and solutes, thermoregulation, and transport of waste and nutrients. Despite the established beneficial role of water in skin physiology, the optimal methods for skin hydration and requirements for daily water consumption remain elusive. This review summarizes the cellular and molecular biology of skin hydration, the debate and current recommendations of daily water requirements, and the latest research on interventions to improve skin hydration by both internal and external means of water exposure. We also explore the chemical properties of water, such as the concept of water "hardness" and environmental pollutants, and their impact on skin physiology.
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Affiliation(s)
- Kathryn Bentivegna
- University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Reid A Waldman
- Department of Dermatology University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Jane M Grant-Kels
- Department of Dermatology University of Connecticut School of Medicine, Farmington, Connecticut, USA; Department of Dermatology University of Florida College of Medicine, USA.
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11
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Allan GM, Craig R, Korownyk CS. Atopic dermatitis and bathing. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2021; 67:758. [PMID: 34649901 PMCID: PMC8516174 DOI: 10.46747/cfp.6710758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- G Michael Allan
- Director of Programs and Practice Support at the College of Family Physicians of Canada
| | - Rodger Craig
- Medical student at the University of Alberta in Edmonton
| | - Christina S Korownyk
- Associate Professor in the Department of Family Medicine at the University of Alberta
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12
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Howells L, Gran S, Chalmers JR, Stuart B, Santer M, Bradshaw L, Gaunt DM, Ridd MJ, Gerbens LAA, Spuls PI, Huang C, Francis NA, Thomas KS. Do patient characteristics matter when calculating sample size for eczema clinical trials? SKIN HEALTH AND DISEASE 2021; 1:e42. [PMID: 35663143 PMCID: PMC9060078 DOI: 10.1002/ski2.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 11/11/2022]
Abstract
Background The Patient‐Oriented Eczema Measure (POEM) is the core outcome instrument recommended for measuring patient‐reported atopic eczema symptoms in clinical trials. To ensure that the statistical significance of clinical trial results is meaningful, trials are often designed by specifying the target difference in the primary outcome as part of the sample size calculation. One method used to specify the target difference is a score that corresponds to a standardized effect size. Objectives to assess how the standardized effect size of POEM scores vary across age, gender, ethnicity and disease severity. Methods This study combined data from five UK‐based randomized clinical trials of eczema treatments in order to assess differences in self‐reported eczema symptoms (POEM) corresponding to a standardized effect size (0.5 SD of baseline POEM scores) across age, gender, ethnicity and disease severity. Results POEM scores corresponding to 0.5 SD(baseline) were remarkably consistent across participants of varying ages, gender, ethnicity and disease severity from datasets of five UK trials in children (range 2.99–3.45). Conclusions This study provides information that can support those designing clinical trials to determine their sample size and can aid individuals interpreting trial results. Further exploration of differences in populations beyond the United Kingdom is needed.
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Affiliation(s)
- L. Howells
- Centre of Evidence Based Dermatology School of Medicine University of Nottingham King's Meadow Campus Nottingham UK
| | - S. Gran
- Centre of Evidence Based Dermatology School of Medicine University of Nottingham King's Meadow Campus Nottingham UK
| | - J. R. Chalmers
- Centre of Evidence Based Dermatology School of Medicine University of Nottingham King's Meadow Campus Nottingham UK
| | - B. Stuart
- Primary Care Research Centre School of Primary Care Population Sciences and Medical Education University of Southampton Southampton UK
| | - M. Santer
- Primary Care Research Centre School of Primary Care Population Sciences and Medical Education University of Southampton Southampton UK
| | - L. Bradshaw
- Nottingham Clinical Trials Unit University of Nottingham Nottingham UK
| | - D. M. Gaunt
- Bristol Medical School: Population Health Sciences University of Bristol Bristol UK
| | - M. J. Ridd
- Bristol Medical School: Population Health Sciences University of Bristol Bristol UK
| | - L. A. A. Gerbens
- Department of Dermatology Amsterdam Public Health Infection and Immunity Amsterdam UMC University of Amsterdam Amsterdam the Netherlands
| | - P. I. Spuls
- Department of Dermatology Amsterdam Public Health Infection and Immunity Amsterdam UMC University of Amsterdam Amsterdam the Netherlands
| | - C. Huang
- Hull York Medical School University of Hull Hull UK
| | - N. A. Francis
- Primary Care Research Centre School of Primary Care Population Sciences and Medical Education University of Southampton Southampton UK
- Division of Population Medicine Cardiff University School of Medicine Cardiff UK
| | - K. S. Thomas
- Centre of Evidence Based Dermatology School of Medicine University of Nottingham King's Meadow Campus Nottingham UK
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13
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Olabi B, Williams HC. Evidence-based management of eczema: five things that should be done more and five things that should be dropped. Curr Opin Allergy Clin Immunol 2021; 21:386-393. [PMID: 33993140 DOI: 10.1097/aci.0000000000000750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW We provide readers with an evidence-informed opinion on current treatments for eczema (atopic dermatitis) with the intention of improving patient care. We suggest five treatment aspects that should be promoted and five that should be demoted. Evidence sources include key randomized controlled trials and systematic reviews. RECENT FINDINGS Under-treatment of eczema can be countered by more aggressive use of topical therapies including the 'get control then keep control' regimen, and systemics for severe disease, supplemented with good patient education. Topical corticosteroids should be used once daily rather than twice daily. Topical calcineurin inhibitors are useful for sensitive sites. There is little evidence to support the continued use of oral antihistamines, oral or topical antistaphylococcal treatments for infected eczema or probiotics for treating eczema. Nonpharmacological treatments including silk clothing, ion-exchange water softeners and emollient bath additives have not been shown to benefit eczema patients. Despite promising pilot studies, large trials suggest that emollients from birth do not prevent eczema and may result in harms such as increased skin infections and food allergy. SUMMARY New evidence-based insights on existing and newer treatments allow clinicians the opportunity to change their practice in a way that enhances patients' quality of life.
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Affiliation(s)
- Bayanne Olabi
- Biosciences Institute, Newcastle University, Newcastle
| | - Hywel C Williams
- Centre of Evidence-Based Dermatology at the University of Nottingham, United Kingdom
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Henning MAS, Ibler KS, Ullum H, Erikstrup C, Bruun MT, Burgdorf KS, Dinh KM, Rigas A, Thørner LW, Pedersen OB, Jemec GB. The association between water hardness and xerosis-Results from the Danish Blood Donor Study. PLoS One 2021; 16:e0252462. [PMID: 34077478 PMCID: PMC8171951 DOI: 10.1371/journal.pone.0252462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 05/16/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The pathophysiology of xerosis depends on extrinsic and intrinsic exposures. Residential hard water may constitute such an exposure. OBJECTIVES To estimate the prevalence of xerosis and to compare water hardness exposure in blood donors with and without xerosis. METHODS In this retrospective cohort study in 2018-2019, blood donors with self-reported moderately or severely dry skin were compared to blood donors without dry skin. Blood donors with ichthyosis, lichen planus and psoriasis were excluded. Water hardness data was collected from the Geology Survey of Denmark and Greenland. RESULTS Overall, 4,748 of 30,721 (15.5%; 95% confidence interval 15.1-15.9%) blood donors had xerosis. After excluding blood donors with ichthyosis, lichen planus and psoriasis, 4,416 blood donors (2,559 females; median age 38.4 years [interquartile range 28.0-49.8]; 700 smokers) remained in this study. Water softer than 12-24 degrees Deutsche härte was associated with decreased probability of xerosis (odds ratio 0.83; 95% confidence interval 0.74-0.94) and water harder than 12-24 degrees Deutsche härte was associated with increased probability of xerosis (odds ratio 1.22; 95% confidence interval 1.03-1.45). The association between water hardness and xerosis remained significant after excluding blood donors with dermatitis. CONCLUSIONS Water hardness is associated with xerosis independent of other dermatoses.
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Affiliation(s)
- Mattias A S Henning
- Department of Dermatology, Faculty of Health and Medical Sciences, Zealand University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Kristina S Ibler
- Department of Dermatology, Faculty of Health and Medical Sciences, Zealand University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Ullum
- Department of Clinical Immunology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Erikstrup
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
| | - Mie T Bruun
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - Kristoffer S Burgdorf
- Department of Clinical Immunology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Khoa M Dinh
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
| | - Andreas Rigas
- Department of Clinical Immunology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lise W Thørner
- Department of Clinical Immunology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole B Pedersen
- Department of Clinical Immunology, Naestved Hospital, Naestved, Denmark
| | - Gregor B Jemec
- Department of Dermatology, Faculty of Health and Medical Sciences, Zealand University Hospital, University of Copenhagen, Copenhagen, Denmark
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Jabbar-Lopez ZK, Ung CY, Alexander H, Gurung N, Chalmers J, Danby S, Cork MJ, Peacock JL, Flohr C. The effect of water hardness on atopic eczema, skin barrier function: A systematic review, meta-analysis. Clin Exp Allergy 2020; 51:430-451. [PMID: 33259122 DOI: 10.1111/cea.13797] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 11/03/2020] [Accepted: 11/11/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hard domestic water has been reported to worsen atopic eczema (AE) and may contribute to its development in early life. OBJECTIVE To review the literature on the relationship between the effect of water hardness (high calcium carbonate; CaCO3 ) on (a) the risk of developing AE, (b) the treatment of existing AE and (c) skin barrier function in human and animal studies. DESIGN , DATA SOURCES AND ELIGIBILITY CRITERIA We systematically searched databases (MEDLINE, Embase, Cochrane CENTRAL, GREAT and Web of Science) from inception until 30/6/2020. Human and animal observational and experimental studies were included. The primary outcomes were risk of AE and skin barrier function. Studies were meta-analysed using a random effects model. Evidence certainty was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. RESULTS Sixteen studies were included. Pooled observational data from seven studies on 385,901 participants identified increased odds of AE in children exposed to harder versus softer water (odds ratio 1.28, 95% CI 1.09, 1.50; GRADE certainty: very low). Two mechanistic studies in humans reported higher deposition of the detergent sodium lauryl sulphate in those exposed to harder versus softer water. Two randomized controlled trials comparing water softeners with standard care did not show a significant difference in objective AE severity with softened water (standardized mean difference 0.06 standard deviations higher, 95% CI 0.16 lower to 0.27 higher; GRADE certainty: moderate). CONCLUSIONS & CLINICAL RELEVANCE There was a positive association between living in a hard water (range: 76 to > 350 mg/L CaCO3 ) area and AE in children. There is no evidence that domestic water softeners improve objective disease severity in established AE. There may be a role of water hardness in the initiation of skin inflammation in early life, but there is a need for further longitudinal and interventional studies.
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Affiliation(s)
- Zarif K Jabbar-Lopez
- Unit for Population-Based Dermatology, St John's Institute of Dermatology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Chuin Ying Ung
- Unit for Population-Based Dermatology, St John's Institute of Dermatology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Helen Alexander
- Unit for Population-Based Dermatology, St John's Institute of Dermatology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nikeeta Gurung
- Unit for Population-Based Dermatology, St John's Institute of Dermatology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Joanne Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Simon Danby
- Sheffield Dermatology Research, Department of Infection, Immunity & Cardiovascular Diseases, The University of Sheffield Medical School, Sheffield, UK
| | - Michael J Cork
- Sheffield Dermatology Research, Department of Infection, Immunity & Cardiovascular Diseases, The University of Sheffield Medical School, Sheffield, UK
| | - Janet L Peacock
- School of Population Health and Environmental Sciences, King's College London, London, UK.,Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Carsten Flohr
- Unit for Population-Based Dermatology, St John's Institute of Dermatology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
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Hurault G, Domínguez-Hüttinger E, Langan SM, Williams HC, Tanaka RJ. Personalized prediction of daily eczema severity scores using a mechanistic machine learning model. Clin Exp Allergy 2020; 50:1258-1266. [PMID: 32750186 DOI: 10.1111/cea.13717] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 06/10/2020] [Accepted: 07/06/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Atopic dermatitis (AD) is a chronic inflammatory skin disease with periods of flares and remission. Designing personalized treatment strategies for AD is challenging, given the apparent unpredictability and large variation in AD symptoms and treatment responses within and across individuals. Better prediction of AD severity over time for individual patients could help to select optimum timing and type of treatment for improving disease control. OBJECTIVE We aimed to develop a proof of principle mechanistic machine learning model that predicts the patient-specific evolution of AD severity scores on a daily basis. METHODS We designed a probabilistic predictive model and trained it using Bayesian inference with the longitudinal data from two published clinical studies. The data consisted of daily recordings of AD severity scores and treatments used by 59 and 334 AD children over 6 months and 16 weeks, respectively. Validation of the predictive model was conducted in a forward-chaining setting. RESULTS Our model was able to predict future severity scores at the individual level and improved chance-level forecast by 60%. Heterogeneous patterns in severity trajectories were captured with patient-specific parameters such as the short-term persistence of AD severity and responsiveness to topical steroids, calcineurin inhibitors and step-up treatment. CONCLUSIONS Our proof of principle model successfully predicted the daily evolution of AD severity scores at an individual level and could inform the design of personalized treatment strategies that can be tested in future studies. Our model-based approach can be applied to other diseases with apparent unpredictability and large variation in symptoms and treatment responses such as asthma.
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Affiliation(s)
- Guillem Hurault
- Department of Bioengineering, Imperial College London, London, UK
| | | | - Sinéad M Langan
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Reiko J Tanaka
- Department of Bioengineering, Imperial College London, London, UK
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The Role of Environmental Exposures in Atopic Dermatitis. Curr Allergy Asthma Rep 2020; 20:74. [PMID: 33047271 DOI: 10.1007/s11882-020-00971-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Although genetic factors clearly play a role in the development of atopic dermatitis (AD), the recent dramatic increase in the prevalence of AD in low- and middle-income countries is not consistent with only a role of genetic factors. These findings strongly suggest that environmental factors may play an important role in the pathogenesis of AD. RECENT FINDINGS We reviewed the role of gene-environment studies; in utero exposures including tobacco smoke, alcohol, maternal stress, various digestive supplements, and gestational diabetes; early-life exposures including diet, gut microbiota, antibiotics, and breastfeeding; climate including temperature, ultraviolet radiation exposure, and air pollution; and household products, indoor allergens, water hardness, pH, and skin microbiota and their effects on AD. Environmental factors definitely play a role in the pathogenesis of AD. However, identifying definitive factors continues to be difficult in the setting of conflicting evidence and the complex interactions between genotypes and the environment resulting in a multitude of AD phenotypes. All of the different environmental interactions discussed highlight the importance of intervening on multiple levels in a patient's environment to improve or even prevent AD symptoms. Further, the importance of modifying environmental factors early on in a person's life is demonstrated. When possible, all of these environmental factors should be considered in treating a patient with AD and the appropriate modifications should be made at population and individual levels.
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Logan K, Du Toit G, Giovannini M, Turcanu V, Lack G. Pediatric Allergic Diseases, Food Allergy, and Oral Tolerance. Annu Rev Cell Dev Biol 2020; 36:511-528. [PMID: 32634325 DOI: 10.1146/annurev-cellbio-100818-125346] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Pediatric allergic disease is a significant health concern worldwide, and the prevalence of childhood eczema, asthma, allergic rhinitis, and food allergy continues to increase. Evidence to support specific interventions for the prevention of eczema, asthma, and allergic rhinitis is limited, and no consensus on prevention strategies has been reached. Randomized controlled trials investigating the prevention of food allergy via oral tolerance induction and the early introduction of allergenic foods have been successful in reducing peanut and egg allergy prevalence. Infant weaning guidelines in the United Sates were recently amended to actively encourage the introduction of peanut for prevention of peanut allergy.
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Affiliation(s)
- Kirsty Logan
- Paediatric Allergy Research Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London SE1 7EH, United Kingdom;
| | - George Du Toit
- Paediatric Allergy Research Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London SE1 7EH, United Kingdom;
| | - Mattia Giovannini
- Paediatric Allergy Research Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London SE1 7EH, United Kingdom; .,Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, 50139 Florence, Italy
| | - Victor Turcanu
- School of Immunology and Microbial Sciences and School of Life Course Sciences, King's College London, London WC2R 2LS, United Kingdom
| | - Gideon Lack
- Paediatric Allergy Research Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London SE1 7EH, United Kingdom;
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TCM treatment of allergy induced by stainless steel implants for tibiofibular fracture: A case report. Allergol Select 2020; 3:15-21. [PMID: 32176224 PMCID: PMC7066679 DOI: 10.5414/alx02095e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 05/21/2019] [Indexed: 11/18/2022] Open
Abstract
Background: Metal allergy is frequently seen. Orthopedic metal implants, such as external fixators or other stainless implants, contain chromium, nickel, and molybdenum, which can cause type IV hypersensitivity. Case summary: A patient diagnosed with open comminuted tibiofibular fracture was treated with external fixation surgery, and she showed contact dermatitis and eczema-like symptoms 2 weeks postoperatively. She was then diagnosed as allergic to several metals by patch test and subsequently treated with traditional Chinese medicine (TCM), both orally and externally for 1 month. TCM treatment significantly alleviated the hypersensitive symptoms and made the patient bear the external fixator for 2 months until bone union. Conclusion:
TCM therapy may be an effective treatment for external fixation-induced metal allergy and contact dermatitis.
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20
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Arents BWM, Leonardi-Bee J. Eczema and water hardness: another piece of the puzzle found? Br J Dermatol 2020; 183:203-204. [PMID: 31994183 DOI: 10.1111/bjd.18864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- B W M Arents
- Dutch Association for People with Atopic Dermatitis, Nijkerk, the Netherlands
| | - J Leonardi-Bee
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham City Hospital, Nottingham, U.K
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21
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22
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Santer M, Rumsby K, Ridd MJ, Francis NA, Stuart B, Chorozoglou M, Roberts A, Liddiard L, Nollett C, Hooper J, Prude M, Wood W, Thomas-Jones E, Becque T, Thomas KS, Williams HC, Little P. Adding emollient bath additives to standard eczema management for children with eczema: the BATHE RCT. Health Technol Assess 2019; 22:1-116. [PMID: 30362939 DOI: 10.3310/hta22570] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Childhood eczema is very common. Treatment often includes emollient bath additives, despite there being little evidence of their effectiveness. OBJECTIVES To determine the clinical effectiveness and cost-effectiveness of emollient bath additives in the management of childhood eczema. DESIGN Pragmatic, randomised, open-label, multicentre superiority trial with two parallel groups. SETTING Ninety-six general practices in Wales, the west of England and southern England. Invitation by personal letter or opportunistically. PARTICIPANTS Children aged between 12 months and 12 years fulfilling the UK Diagnostic Criteria for Atopic Eczema. Children with inactive or very mild eczema (a score of ≤ 5 on the Nottingham Eczema Severity Scale) were excluded, as were children who bathed less than once per week or whose parents/carers were not prepared to accept randomisation. INTERVENTIONS The intervention group were prescribed bath additives by their usual clinical team and were asked to use them regularly for 12 months. The control group were asked to use no bath additives for 12 months. Both groups continued standard eczema management, including regular leave-on emollients and topical corticosteroids (TCSs) when required. MAIN OUTCOME MEASURES The primary outcome was eczema control measured by Patient Oriented Eczema Measure [POEM, 0 (clear) to 28 (severe)] weekly for 16 weeks. The secondary outcomes were eczema severity over 1 year (4-weekly POEM), number of eczema exacerbations, disease-specific quality of life (QoL) (Dermatitis Family Impact Questionnaire), generic QoL (Child Health Utility-9 Dimensions) and type and quantity of topical steroid/calcineurin inhibitors prescribed. Children were randomised (1 : 1) using online software to either bath additives plus standard eczema care or standard eczema care alone, stratified by recruiting centre, and there was open-label blinding. RESULTS From December 2014 to May 2016, 482 children were randomised: 51% were female, 84% were white and the mean age was 5 years (n = 264 in the intervention group, n = 218 in the control group). Reported adherence to randomised treatment allocation was > 92% in both groups, with 76.7% of participants completing at least 12 (80%) of the first 16 weekly questionnaires for the primary outcome. Baseline POEM score was 9.5 [standard deviation (SD) 5.7] in the bath additives group and 10.1 (SD 5.8) in the no bath additives group. Average POEM score over the first 16 weeks was 7.5 (SD 6.0) in the bath additives group and 8.4 (SD 6.0) in the no bath additives group, with no statistically significant difference between the groups. After controlling for baseline severity and confounders (ethnicity, TCS use, soap substitute use) and allowing for clustering of participants within centres and responses within participants over time, POEM scores in the no bath additive group were 0.41 points higher than in the bath additive group (95% confidence interval -0.27 to 1.10), which is well below the published minimal clinically important difference of 3 points. There was no difference between groups in secondary outcomes or in adverse effects such as redness, stinging or slipping. LIMITATIONS Simple randomisation resulted in an imbalance in baseline group size, although baseline characteristics were well balanced between groups. CONCLUSION This trial found no evidence of clinical benefit of including emollient bath additives in the standard management of childhood eczema. FUTURE WORK Further research is required on optimal regimens of leave-on emollients and the use of emollients as soap substitutes. TRIAL REGISTRATION Current Controlled Trials ISRCTN84102309. FUNDING This project was funded by the NIHR Health Technology Assessment Programme and will be published in full in Health Technology Assessment; Vol. 22, No. 57. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Miriam Santer
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Kate Rumsby
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Matthew J Ridd
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nick A Francis
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Beth Stuart
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Maria Chorozoglou
- Southampton Health Technology Assessments Centre, Wessex Institute, University of Southampton, Southampton, UK
| | - Amanda Roberts
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Lyn Liddiard
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Claire Nollett
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff, UK
| | - Julie Hooper
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Martina Prude
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Wendy Wood
- National Institute for Health Research Research Design Service South Central, Primary Care and Population Sciences, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Emma Thomas-Jones
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Taeko Becque
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Paul Little
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
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Stuart B, Rumsby K, Santer M, Ridd MJ, Francis NA, Chorozoglou M, Spreadbury C, Steele M, Nollett C, Liddiard L, Prude M, Hooper J, Thomas-Jones E, Roberts A, Thomas KS, Williams HC, Little P. Feasibility of weekly participant-reported data collection in a pragmatic randomised controlled trial in primary care: experiences from the BATHE trial (Bath Additives for the Treatment of cHildhood Eczema). Trials 2018; 19:582. [PMID: 30355360 PMCID: PMC6201535 DOI: 10.1186/s13063-018-2962-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 10/03/2018] [Indexed: 12/03/2022] Open
Abstract
Background Patient-reported outcomes measures in clinical trials ensure that evaluations of effectiveness focus on outcomes that are important to patients. In relapsing-remitting conditions, such as eczema, repeated measurements may allow a more accurate reflection of disease burden and treatment effect than less frequent measurements. We asked parents/carers of children with eczema taking part in a trial of bath emollients to complete weekly questionnaires for 16 weeks. Methods The objective of this study was to determine the acceptability and practicality of collecting weekly measures of eczema severity online for 16 weeks in children aged 1 to 11 years as part of the BATHE study. BATHE randomised patients to bath emollients plus standard eczema care or standard eczema care only. The primary outcome was eczema severity, measured by the seven-item Patient-Oriented Eczema Measure (POEM) repeated weekly for 16 weeks. Acceptability was explored through qualitative interviews with 10 participants. Interviews were audio-recorded, transcribed and analysed thematically. Practicality was assessed by exploring the completeness of the data and keeping a log of any problems. Results Four hundred and eighty-two participants were recruited to the trial and 429 opted to complete measures online (89.0%). Data were collected online for 83% of time points over the 16-week period and there was no association between socio-demographic characteristics and data completeness. Two hundred and six (48%) completed their weekly data every week for 16 weeks and 341 (79%) completed it at least 80% of the time. The mean number of weeks completed was 13.3 out of 16 (SD 4.2). Interviewees said that they understood the rationale behind weekly collection and some welcomed this as it helped them realise how their child’s eczema changed weekly. Whilst some interviewees spoke of weekly questionnaires as onerous, others said that they found them quick and easy. Reminders were welcomed. Parents/carers seemed happy to receive telephone reminders and it was sometimes useful for eliciting problems relating to obtaining trial medication or password problems for online data collection. Conclusions Amongst this population, high levels of data completeness suggests that weekly completion of the online questionnaire appears to be acceptable and feasible over a 16-week period. Trial registration ISRCTN84102309. Registered on 9 December 2013.
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Affiliation(s)
- Beth Stuart
- Department of Primary Care and Population Sciences, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK.
| | - Kate Rumsby
- Department of Primary Care and Population Sciences, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Miriam Santer
- Department of Primary Care and Population Sciences, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Matthew J Ridd
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Nick A Francis
- Wales School of Primary Care Research, Cardiff University, Cardiff, UK
| | - Maria Chorozoglou
- Southampton Health Technology Assessment Centre (SHTAC), University of Southampton, Southampton, UK
| | - Carla Spreadbury
- Department of Primary Care and Population Sciences, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Mary Steele
- Centre for Clinical and Community Applications of Health Psychology, Psychology, Faculty of Social and Human Sciences, University of Southampton, Southampton, UK
| | - Claire Nollett
- Wales School of Primary Care Research, Cardiff University, Cardiff, UK
| | - Lyn Liddiard
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Martina Prude
- Department of Primary Care and Population Sciences, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Julie Hooper
- Department of Primary Care and Population Sciences, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Emma Thomas-Jones
- Wales School of Primary Care Research, Cardiff University, Cardiff, UK
| | - Amanda Roberts
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, UK
| | - Hywel C Williams
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, UK
| | - Paul Little
- Department of Primary Care and Population Sciences, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
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Tsakok T, Woolf R, Smith CH, Weidinger S, Flohr C. Atopic dermatitis: the skin barrier and beyond. Br J Dermatol 2018; 180:464-474. [PMID: 29969827 DOI: 10.1111/bjd.16934] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Atopic dermatitis is the most common chronic inflammatory skin disorder, affecting up to 20% of children and 10% of adults in industrialized countries. This highly debilitating condition poses a considerable burden to both the individual and society at large. The pathophysiology of atopic dermatitis is complex, encompassing both genetic and environmental risk factors. METHODS This is a narrative review based on a systematic literature search. CONCLUSIONS Dysregulation of innate and adaptive immunity plays a key role; however, recent epidemiological, genetic and molecular research has focused interest on skin barrier dysfunction as a common precursor and pathological feature. Current understanding of the aetiology of atopic dermatitis highlights disruption of the epidermal barrier leading to increased permeability of the epidermis, pathological inflammation in the skin, and percutaneous sensitization to allergens. Thus, most novel treatment strategies seek to target specific aspects of the skin barrier or cutaneous inflammation. Several studies have also shown promise in preventing atopic dermatitis, such as the early use of emollients in high-risk infants. This may have broader implications in terms of halting the progression to atopic comorbidities including food allergy, hay fever and asthma.
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Affiliation(s)
- T Tsakok
- St John's Institute of Dermatology, King's College London, London, U.K
| | - R Woolf
- St John's Institute of Dermatology, King's College London, London, U.K
| | - C H Smith
- St John's Institute of Dermatology, King's College London, London, U.K
| | - S Weidinger
- Department of Dermatology and Allergy, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - C Flohr
- St John's Institute of Dermatology, King's College London, London, U.K
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Höger PH. Mythen in der Pädiatrie: Atopisches Ekzem. Monatsschr Kinderheilkd 2018. [DOI: 10.1007/s00112-018-0597-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Brown SJ. What progress have we made in the treatment of atopic eczema? Putting the new biological therapies into a wider context. Br J Dermatol 2018; 177:4-6. [PMID: 28731235 DOI: 10.1111/bjd.15646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- S J Brown
- Skin Research Group, School of Medicine, University of Dundee, Dundee, DD1 9SY, U.K.,Department of Dermatology, Ninewells Hospital, Dundee, DD1 9SY, U.K
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27
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Affiliation(s)
- Sandra Lawton
- Nurse Consultant, Dermatology, and Queen's Nurse, Rotherham NHS Foundation Trust
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28
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Santer M, Ridd MJ, Francis NA, Stuart B, Rumsby K, Chorozoglou M, Becque T, Roberts A, Liddiard L, Nollett C, Hooper J, Prude M, Wood W, Thomas KS, Thomas-Jones E, Williams HC, Little P. Emollient bath additives for the treatment of childhood eczema (BATHE): multicentre pragmatic parallel group randomised controlled trial of clinical and cost effectiveness. BMJ 2018; 361:k1332. [PMID: 29724749 PMCID: PMC5930266 DOI: 10.1136/bmj.k1332] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To determine the clinical effectiveness and cost effectiveness of including emollient bath additives in the management of eczema in children. DESIGN Pragmatic randomised open label superiority trial with two parallel groups. SETTING 96 general practices in Wales and western and southern England. PARTICIPANTS 483 children aged 1 to 11 years, fulfilling UK diagnostic criteria for atopic dermatitis. Children with very mild eczema and children who bathed less than once weekly were excluded. INTERVENTIONS Participants in the intervention group were prescribed emollient bath additives by their usual clinical team to be used regularly for 12 months. The control group were asked to use no bath additives for 12 months. Both groups continued with standard eczema management, including leave-on emollients, and caregivers were given standardised advice on how to wash participants. MAIN OUTCOME MEASURES The primary outcome was eczema control measured by the patient oriented eczema measure (POEM, scores 0-7 mild, 8-16 moderate, 17-28 severe) weekly for 16 weeks. Secondary outcomes were eczema severity over one year (monthly POEM score from baseline to 52 weeks), number of eczema exacerbations resulting in primary healthcare consultation, disease specific quality of life (dermatitis family impact), generic quality of life (child health utility-9D), utilisation of resources, and type and quantity of topical corticosteroid or topical calcineurin inhibitors prescribed. RESULTS 483 children were randomised and one child was withdrawn, leaving 482 children in the trial: 51% were girls (244/482), 84% were of white ethnicity (447/470), and the mean age was 5 years. 96% (461/482) of participants completed at least one post-baseline POEM, so were included in the analysis, and 77% (370/482) completed questionnaires for more than 80% of the time points for the primary outcome (12/16 weekly questionnaires to 16 weeks). The mean baseline POEM score was 9.5 (SD 5.7) in the bath additives group and 10.1 (SD 5.8) in the no bath additives group. The mean POEM score over the 16 week period was 7.5 (SD. 6.0) in the bath additives group and 8.4 (SD 6.0) in the no bath additives group. No statistically significant difference was found in weekly POEM scores between groups over 16 weeks. After controlling for baseline severity and confounders (ethnicity, topical corticosteroid use, soap substitute use) and allowing for clustering of participants within centres and responses within participants over time, POEM scores in the no bath additives group were 0.41 points higher than in the bath additives group (95% confidence interval -0.27 to 1.10), below the published minimal clinically important difference for POEM of 3 points. The groups did not differ in secondary outcomes, economic outcomes, or adverse effects. CONCLUSIONS This trial found no evidence of clinical benefit from including emollient bath additives in the standard management of eczema in children. Further research is needed into optimal regimens for leave-on emollient and soap substitutes. TRIAL REGISTRATION Current Controlled Trials ISRCTN84102309.
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Affiliation(s)
- Miriam Santer
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 5ST, UK
| | - Matthew J Ridd
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nick A Francis
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Beth Stuart
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 5ST, UK
| | - Kate Rumsby
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 5ST, UK
| | - Maria Chorozoglou
- Southampton Health Technology Assessments Centre, Wessex Institute, University of Southampton, Southampton, UK
| | - Taeko Becque
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 5ST, UK
| | - Amanda Roberts
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Lyn Liddiard
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Claire Nollett
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff, UK
| | - Julie Hooper
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 5ST, UK
| | - Martina Prude
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 5ST, UK
| | - Wendy Wood
- NIHR Research Design Service South Central, Primary Care and Population Sciences, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Emma Thomas-Jones
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Paul Little
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 5ST, UK
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Danby SG, Brown K, Wigley AM, Chittock J, Pyae PK, Flohr C, Cork MJ. The Effect of Water Hardness on Surfactant Deposition after Washing and Subsequent Skin Irritation in Atopic Dermatitis Patients and Healthy Control Subjects. J Invest Dermatol 2018; 138:68-77. [DOI: 10.1016/j.jid.2017.08.037] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 08/10/2017] [Accepted: 08/27/2017] [Indexed: 12/20/2022]
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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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31
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Howells LM, Chalmers JR, Cowdell F, Ratib S, Santer M, Thomas KS. 'When it goes back to my normal I suppose': a qualitative study using online focus groups to explore perceptions of 'control' among people with eczema and parents of children with eczema in the UK. BMJ Open 2017; 7:e017731. [PMID: 29146642 PMCID: PMC5695402 DOI: 10.1136/bmjopen-2017-017731] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To inform the development of a core outcome set for eczema by engaging with people with eczema and parents of children with eczema to understand their experiences and understanding of the concept 'eczema control'. DESIGN 37 participants took part in a total of six semi-structured online focus groups held in a typed chatroom with 5-7 participants per group. Three groups involved adults with eczema and three groups involved parents of children with eczema. Framework analysis was used for data analysis. SETTING A community-based sample was recruited from across the UK via social media and email. PARTICIPANTS 19 adults aged 17-61 years (15/19 female, 16/19 white) and 18 parents of children with eczema aged 9 months-17 years (9/18 female, 18/19 white). RESULTS Four main themes were identified:(1) 'Commonalities and differences in the experiences of control': a reduction in symptoms such as itch and sleep loss characterised eczema control, but what level was acceptable differed across participants;(2) 'Eczema control goes beyond the skin': psychological factors, social factors, the constant scratching and the impact on everyday activities are a variety of ways an individual can be impacted;(3) 'Stepping up and down of treatment': participants' stepped-up treatment in response to loss of control, but several factors complicated this behaviour. Control needed to be maintained after stepped-up treatment ended to be acceptable; and (4) 'How to measure control': self-report was generally preferred to allow frequent measurements and to capture unobservable features. Although most thought their eczema needed to be measured frequently, many also felt that this was not always realistic or desirable. CONCLUSIONS 'Eczema control' is a complex experience for people with eczema and parents of children with the condition. These experiences could have important implications on how long-term control should be measured in eczema clinical trials and clinical practice.
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Affiliation(s)
- Laura M Howells
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Fiona Cowdell
- Faculty of Health Education and Life Sciences, Birmingham City University, Birmingham, UK
| | - Sonia Ratib
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Miriam Santer
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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32
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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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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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Nankervis H, Thomas K, Delamere F, Barbarot S, Smith S, Rogers N, Williams H. What is the evidence base for atopic eczema treatments? A summary of published randomized controlled trials. Br J Dermatol 2017; 176:910-927. [DOI: 10.1111/bjd.14999] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2016] [Indexed: 12/23/2022]
Affiliation(s)
- H. Nankervis
- Centre of Evidence Based Dermatology; University of Nottingham; King's Meadow Campus, Lenton Lane Nottingham NG7 2NR U.K
| | - K.S. Thomas
- Centre of Evidence Based Dermatology; University of Nottingham; King's Meadow Campus, Lenton Lane Nottingham NG7 2NR U.K
| | - F.M. Delamere
- Centre of Evidence Based Dermatology; University of Nottingham; King's Meadow Campus, Lenton Lane Nottingham NG7 2NR U.K
| | - S. Barbarot
- Centre of Evidence Based Dermatology; University of Nottingham; King's Meadow Campus, Lenton Lane Nottingham NG7 2NR U.K
| | - S. Smith
- Centre of Evidence Based Dermatology; University of Nottingham; King's Meadow Campus, Lenton Lane Nottingham NG7 2NR U.K
| | - N.K. Rogers
- Centre of Evidence Based Dermatology; University of Nottingham; King's Meadow Campus, Lenton Lane Nottingham NG7 2NR U.K
| | - H.C. Williams
- Centre of Evidence Based Dermatology; University of Nottingham; King's Meadow Campus, Lenton Lane Nottingham NG7 2NR U.K
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Abstract
Atopic dermatitis is one of the most common complaints presenting to dermatologists, and patients typically inquire as to appropriate bathing recommendations. Although many dermatologists, allergists, and primary-care practitioners provide explicit bathing instructions, recommendations regarding frequency of bathing, duration of bathing, and timing related to emollient and medication application relative to bathing vary widely. Conflicting and vague guidelines stem from knowledge related to the disparate effects of water on skin, as well as a dearth of studies, especially randomized controlled trials, evaluating the effects of water and bathing on the skin of patients with atopic dermatitis. We critically review the literature related to bathing and associated atopic dermatitis treatments, such as wet wraps, bleach baths, bath additives, and balneotherapy. We aim to provide readers with a comprehensive understanding of the impact of water and related therapies on atopic dermatitis as well as recommendations based upon the published data.
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Affiliation(s)
- Julia K Gittler
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, 240 East 38th Street, 11th Floor, New York, NY, 10016, USA
| | - Jason F Wang
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, 240 East 38th Street, 11th Floor, New York, NY, 10016, USA
| | - Seth J Orlow
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, 240 East 38th Street, 11th Floor, New York, NY, 10016, USA.
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36
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Engebretsen KA, Bager P, Wohlfahrt J, Skov L, Zachariae C, Nybo Andersen AM, Melbye M, Thyssen JP. Prevalence of atopic dermatitis in infants by domestic water hardness and season of birth: Cohort study. J Allergy Clin Immunol 2016; 139:1568-1574.e1. [PMID: 28017882 DOI: 10.1016/j.jaci.2016.11.021] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 11/02/2016] [Accepted: 11/17/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Atopic dermatitis (AD) appears to be more common in regions with hard domestic water and in children with a fall/winter birth. However, it is unknown whether a synergistic effect exists. OBJECTIVE We sought to evaluate the association between domestic water hardness and season of birth, respectively, with onset of AD within the first 18 months of life in a large Danish birth cohort. METHODS Of children from the Danish National Birth Cohort, 52,950 were included. History of physician-diagnosed AD and population characteristics were obtained from interviews. Birth data were obtained from the Civil Registration System, and domestic water hardness data were obtained from the Geological Survey of Denmark and Greenland. The relative prevalence (RP) of AD was calculated by using log-linear binomial regression. RESULTS The prevalence of AD was 15.0% (7,942/52,950). The RP of AD was 5% (RPtrend, 1.05; 95% CI, 1.03-1.07) higher for each 5° increase in domestic water hardness (range, 6.60-35.90 German degrees of hardness [118-641 mg/L]). Although the RP of AD was higher in children with a fall (RP, 1.24; 95% CI, 1.17-1.31) or winter (RP, 1.18; 95% CI, 1.11-1.25) birth, no significant interaction was observed with domestic water hardness. The population attributable risk of hard domestic water on AD was 2%. CONCLUSION We observed that early exposure to hard domestic water and a fall/winter birth was associated with an increase in the relative prevalence of AD within the first 18 months of life. Although the 2 exposures did not interact synergistically, a dose-response relationship was observed between domestic water hardness and AD.
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Affiliation(s)
- Kristiane A Engebretsen
- National Allergy Research Centre, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark; Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Peter Bager
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Jan Wohlfahrt
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Lone Skov
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Claus Zachariae
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Anne-Marie Nybo Andersen
- Department of Public Health, Section of Social Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mads Melbye
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Jacob P Thyssen
- National Allergy Research Centre, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark; Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark.
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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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Hill MK, Kheirandish Pishkenari A, Braunberger TL, Armstrong AW, Dunnick CA. Recent trends in disease severity and quality of life instruments for patients with atopic dermatitis: A systematic review. J Am Acad Dermatol 2016; 75:906-917. [DOI: 10.1016/j.jaad.2016.07.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 06/28/2016] [Accepted: 07/05/2016] [Indexed: 11/28/2022]
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Gaunt DM, Metcalfe C, Ridd M. The Patient-Oriented Eczema Measure in young children: responsiveness and minimal clinically important difference. Allergy 2016; 71:1620-1625. [PMID: 27232584 PMCID: PMC5113674 DOI: 10.1111/all.12942] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2016] [Indexed: 11/27/2022]
Abstract
Background The Patient‐Oriented Eczema Measure (POEM) has been recommended as the core patient‐reported outcome measure for trials of eczema treatments. Using data from the Choice of Moisturiser for Eczema Treatment randomized feasibility study, we assess the responsiveness to change and determine the minimal clinically important difference (MCID) of the POEM in young children with eczema. Methods Responsiveness to change by repeated administrations of the POEM was investigated in relation to change recalled using the Parent Global Assessment (PGA) measure. Five methods of determining the MCID of the POEM were employed; three anchor‐based methods using PGA as the anchor: the within‐patient score change, between‐patient score change and sensitivity and specificity method, and two distribution‐based methods: effect size estimate and the one half standard deviation of the baseline distribution of POEM scores. Results Successive POEM scores were found to be responsive to change in eczema severity. The MCID of the POEM change score, in relation to a slight improvement in eczema severity as recalled by parents on the PGA, estimated by the within‐patient score change (4.27), the between‐patient score change (2.89) and the sensitivity and specificity method (3.00) was similar to the one half standard deviation of the POEM baseline scores (2.94) and the effect size estimate (2.50). Conclusions The Patient‐Oriented Eczema Measure as applied to young children is responsive to change, and the MCID is around 3. This study will encourage the use of POEM and aid in determining sample size for future randomized controlled trials of treatments for eczema in young children.
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Affiliation(s)
- D. M. Gaunt
- Bristol Randomised Trials Collaboration School of Social and Community Medicine University of BristolBristolUK
| | - C. Metcalfe
- Bristol Randomised Trials Collaboration School of Social and Community Medicine University of BristolBristolUK
| | - M. Ridd
- Centre for Academic Primary Care School of Social and Community Medicine University of Bristol Bristol UK
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Walters RM, Anim-Danso E, Amato SM, Capone KA, Mack MC, Telofski LS, Mays DA. Hard water softening effect of a baby cleanser. Clin Cosmet Investig Dermatol 2016; 9:339-345. [PMID: 27789967 PMCID: PMC5072514 DOI: 10.2147/ccid.s111729] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hard water is associated with atopic dermatitis (eczema). We wanted to determine if a baby cleanser and its individual components altered free ionized calcium (Ca2+) in a simulated hard water baby bath. For these studies, an in vitro determination of free Ca2+ in a simulated hard water baby bath, and an in vivo exploratory study of free Ca2+ absorption into skin from hard water were performed. METHODS Free Ca2+ was measured with an ion-sensitive electrode in vitro in hard water (100-500 ppm, Ca2+) before and after addition of the cleanser and/or its components. In an exploratory study, absorption of Ca2+ into skin from hard water was determined in three female participants (aged 21-29 years). RESULTS At an in-use dilution of 1%, the test cleanser reduced free Ca2+ from ~500 ppm to <200 ppm; a 10% in-use dilution bound virtually all free Ca2+. The anionic surfactant component contributed the most to this effect. In the exploratory in vivo study, we measured a reduction of ~15% in free Ca2+ from simulated hard water over 10 minutes. CONCLUSION Baby cleansers can bind free Ca2+ and reduce the effective water hardness of bath water. Reducing the amount of free Ca2+ in the water will reduce the availability of the ion for binding to the skin. Altering or reducing free Ca2+ concentrations in bath water may be an important parameter in creating the ideal baby bath.
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Affiliation(s)
- Russel M Walters
- Skin Care Research & Development, Johnson & Johnson Consumer Inc., Skillman, NJ, USA
| | - Emmanuel Anim-Danso
- Skin Care Research & Development, Johnson & Johnson Consumer Inc., Skillman, NJ, USA
| | - Stephanie M Amato
- Skin Care Research & Development, Johnson & Johnson Consumer Inc., Skillman, NJ, USA
| | - Kimberly A Capone
- Skin Care Research & Development, Johnson & Johnson Consumer Inc., Skillman, NJ, USA
| | - M Catherine Mack
- Skin Care Research & Development, Johnson & Johnson Consumer Inc., Skillman, NJ, USA
| | - Lorena S Telofski
- Skin Care Research & Development, Johnson & Johnson Consumer Inc., Skillman, NJ, USA
| | - David A Mays
- Skin Care Research & Development, Johnson & Johnson Consumer Inc., Skillman, NJ, USA
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Perkin MR, Craven J, Logan K, Strachan D, Marrs T, Radulovic S, Campbell LE, MacCallum SF, McLean WHI, Lack G, Flohr C. Association between domestic water hardness, chlorine, and atopic dermatitis risk in early life: A population-based cross-sectional study. J Allergy Clin Immunol 2016; 138:509-16. [PMID: 27241890 DOI: 10.1016/j.jaci.2016.03.031] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 03/08/2016] [Accepted: 03/16/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Domestic water hardness and chlorine have been suggested as important risk factors for atopic dermatitis (AD). OBJECTIVE We sought to examine the link between domestic water calcium carbonate (CaCO3) and chlorine concentrations, skin barrier dysfunction (increased transepidermal water loss), and AD in infancy. METHODS We recruited 1303 three-month-old infants from the general population and gathered data on domestic water CaCO3 (in milligrams per liter) and chlorine (Cl2; in milligrams per liter) concentrations from local water suppliers. At enrollment, infants were examined for AD and screened for filaggrin (FLG) skin barrier gene mutation status. Transepidermal water loss was measured on unaffected forearm skin. RESULTS CaCO3 and chlorine levels were strongly correlated. A hybrid variable of greater than and less than median levels of CaCO3 and total chlorine was constructed: a baseline group of low CaCO3/low total chlorine (CaL/ClL), high CaCO3/low total chlorine (CaH/ClL), low CaCO3/high total chlorine (CaL/ClH) and high CaCO3/high total chlorine (CaH/ClH). Visible AD was more common in all 3 groups versus the baseline group: adjusted odds ratio (AOR) of 1.87 (95% CI, 1.25-2.80; P = .002) for the CaH/ClL group, AOR of 1.46 (95% CI, 0.97-2.21; P = .07) for the CaL/ClH, and AOR of 1.61 (95% CI, 1.09-2.38; P = .02) for the CaH/ClH group. The effect estimates were greater in children carrying FLG mutations, but formal interaction testing between water quality groups and filaggrin status was not statistically significant. CONCLUSIONS High domestic water CaCO3 levels are associated with an increased risk of AD in infancy. The influence of increased total chlorine levels remains uncertain. An intervention trial is required to see whether installation of a domestic device to decrease CaCO3 levels around the time of birth can reduce this risk.
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Affiliation(s)
- Michael R Perkin
- Population Health Research Institute, St George's, University of London, London, United Kingdom
| | - Joanna Craven
- Children's Allergies Department, Division of Asthma, Allergy and Lung Biology, King's College London, London, United Kingdom
| | - Kirsty Logan
- Children's Allergies Department, Division of Asthma, Allergy and Lung Biology, King's College London, London, United Kingdom
| | - David Strachan
- Population Health Research Institute, St George's, University of London, London, United Kingdom
| | - Tom Marrs
- Children's Allergies Department, Division of Asthma, Allergy and Lung Biology, King's College London, London, United Kingdom
| | - Suzana Radulovic
- Children's Allergies Department, Division of Asthma, Allergy and Lung Biology, King's College London, London, United Kingdom
| | - Linda E Campbell
- Centre for Dermatology and Genetic Medicine, Division of Molecular Medicine, University of Dundee, Dundee, United Kingdom
| | - Stephanie F MacCallum
- Centre for Dermatology and Genetic Medicine, Division of Molecular Medicine, University of Dundee, Dundee, United Kingdom
| | - W H Irwin McLean
- Centre for Dermatology and Genetic Medicine, Division of Molecular Medicine, University of Dundee, Dundee, United Kingdom
| | - Gideon Lack
- Children's Allergies Department, Division of Asthma, Allergy and Lung Biology, King's College London, London, United Kingdom
| | - Carsten Flohr
- Children's Allergies Department, Division of Asthma, Allergy and Lung Biology, King's College London, London, United Kingdom; St John's Institute of Dermatology, Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom.
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Kantor R, Silverberg JI. Environmental risk factors and their role in the management of atopic dermatitis. Expert Rev Clin Immunol 2016; 13:15-26. [PMID: 27417220 DOI: 10.1080/1744666x.2016.1212660] [Citation(s) in RCA: 194] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The etiology of atopic dermatitis (AD) is multifactorial with interaction between genetics, immune and environmental factors. Areas covered: We review the role of prenatal exposures, irritants and pruritogens, pathogens, climate factors, including temperature, humidity, ultraviolet radiation, outdoor and indoor air pollutants, tobacco smoke exposure, water hardness, urban vs. rural living, diet, breastfeeding, probiotics and prebiotics on AD. Expert commentary: The increased global prevalence of AD cannot be attributed to genetics alone, suggesting that evolving environmental exposures may trigger and/or flare disease in predisposed individuals. There is a complex interplay between different environmental factors, including individual use of personal care products and exposure to climate, pollution, food and other exogenous factors. Understanding these complex risk factors is crucial to developing targeted interventions to prevent the disease in millions. Moreover, patients require counseling on optimal regimens for minimization of exposure to irritants and pruritogens and other harmful exposures.
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Affiliation(s)
- Robert Kantor
- a Department of Dermatology , Northwestern University , Chicago , IL , USA
| | - Jonathan I Silverberg
- b Departments of Dermatology, Preventive Medicine and Medical Social Sciences , Northwestern University , Chicago , IL , USA
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Guthrie S, Bienkowska-Gibbs T, Manville C, Pollitt A, Kirtley A, Wooding S. The impact of the National Institute for Health Research Health Technology Assessment programme, 2003-13: a multimethod evaluation. Health Technol Assess 2016; 19:1-291. [PMID: 26307643 DOI: 10.3310/hta19670] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme supports research tailored to the needs of NHS decision-makers, patients and clinicians. This study reviewed the impact of the programme, from 2003 to 2013, on health, clinical practice, health policy, the economy and academia. It also considered how HTA could maintain and increase its impact. METHODS Interviews (n = 20): senior stakeholders from academia, policy-making organisations and the HTA programme. Bibliometric analysis: citation analysis of publications arising from HTA programme-funded research. Researchfish survey: electronic survey of all HTA grant holders. Payback case studies (n = 12): in-depth case studies of HTA programme-funded research. RESULTS We make the following observations about the impact, and routes to impact, of the HTA programme: it has had an impact on patients, primarily through changes in guidelines, but also directly (e.g. changing clinical practice); it has had an impact on UK health policy, through providing high-quality scientific evidence - its close relationships with the National Institute for Health and Care Excellence (NICE) and the National Screening Committee (NSC) contributed to the observed impact on health policy, although in some instances other organisations may better facilitate impact; HTA research is used outside the UK by other HTA organisations and systematic reviewers - the programme has an impact on HTA practice internationally as a leader in HTA research methods and the funding of HTA research; the work of the programme is of high academic quality - the Health Technology Assessment journal ensures that the vast majority of HTA programme-funded research is published in full, while the HTA programme still encourages publication in other peer-reviewed journals; academics agree that the programme has played an important role in building and retaining HTA research capacity in the UK; the HTA programme has played a role in increasing the focus on effectiveness and cost-effectiveness in medicine - it has also contributed to increasingly positive attitudes towards HTA research both within the research community and the NHS; and the HTA focuses resources on research that is of value to patients and the UK NHS, which would not otherwise be funded (e.g. where there is no commercial incentive to undertake research). The programme should consider the following to maintain and increase its impact: providing targeted support for dissemination, focusing resources when important results are unlikely to be implemented by other stakeholders, particularly when findings challenge vested interests; maintaining close relationships with NICE and the NSC, but also considering other potential users of HTA research; maintaining flexibility and good relationships with researchers, giving particular consideration to the Technology Assessment Report (TAR) programme and the potential for learning between TAR centres; maintaining the academic quality of the work and the focus on NHS need; considering funding research on the short-term costs of the implementation of new health technologies; improving the monitoring and evaluation of whether or not patient and public involvement influences research; improve the transparency of the priority-setting process; and continuing to monitor the impact and value of the programme to inform its future scientific and administrative development.
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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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Abstract
There have been advances in our understanding of the complex pathogenesis of atopic eczema over the past few decades. This article examines the multiple factors which are implicated in this process.
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Affiliation(s)
- Tess McPherson
- Department of Dermatology, Oxford University Hospitals, Oxford, UK
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Santer M, Rumsby K, Ridd MJ, Francis NA, Stuart B, Chorozoglou M, Wood W, Roberts A, Thomas KS, Williams HC, Little P. Bath additives for the treatment of childhood eczema (BATHE): protocol for multicentre parallel group randomised trial. BMJ Open 2015; 5:e009575. [PMID: 26525422 PMCID: PMC4636671 DOI: 10.1136/bmjopen-2015-009575] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Bath emollients are widely prescribed for childhood eczema, yet evidence of their benefits over direct application of emollients is lacking. Objectives To determine the clinical and cost-effectiveness of adding bath emollient to the standard management of eczema in children DESIGN Pragmatic open 2-armed parallel group randomised controlled trial. SETTING General practitioner (GP) practices in England and Wales. PARTICIPANTS Children aged over 12 months and less than 12 years with eczema, excluding inactive or very mild eczema (5 or less on Nottingham Eczema Severity Scale). INTERVENTIONS Children will be randomised to either bath emollients plus standard eczema care or standard eczema care only. OUTCOME MEASURES Primary outcome is long-term eczema severity, measured by the Patient-Oriented Eczema Measure (POEM) repeated weekly for 16 weeks. Secondary outcomes include: number of eczema exacerbations resulting in healthcare consultations over 1 year; eczema severity over 1 year; disease-specific and generic quality of life; medication use and healthcare resource use; cost-effectiveness. Aiming to detect a mean difference between groups of 2.0 (SD 7.0) in weekly POEM scores over 16 weeks (significance 0.05, power 0.9), allowing for 20% loss to follow-up, gives a total sample size of 423 children. We will use repeated measures analysis of covariance, or a mixed model, to analyse weekly POEM scores. We will control for possible confounders, including baseline eczema severity and child's age. Cost-effectiveness analysis will be carried out from a National Health Service (NHS) perspective. ETHICS AND DISSEMINATION This protocol was approved by Newcastle and North Tyneside 1 NRES committee 14/NE/0098. Follow-up will be completed in 2017. Findings will be disseminated to participants and carers, the public, dermatology and primary care journals, guideline developers and decision-makers. TRIAL REGISTRATION NUMBER ISRCTN84102309.
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Affiliation(s)
- Miriam Santer
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Kate Rumsby
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Matthew J Ridd
- Department of School of Social & Community Medicine, University of Bristol, Bristol, UK
| | - Nick A Francis
- Wales School of Primary Care Research, Cardiff University, Cardiff, UK
| | - Beth Stuart
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Maria Chorozoglou
- Southampton Health Technology Assessment Centre (SHTAC), University of Southampton, Southampton, UK
| | - Wendy Wood
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Amanda Roberts
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, UK
| | - Hywel C Williams
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, UK
| | - Paul Little
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
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Font-Ribera L, Gracia-Lavedan E, Esplugues A, Ballester F, Jiménez Zabala A, Santa Marina L, Fernández-Somoano A, Sunyer J, Villanueva CM. Water hardness and eczema at 1 and 4 y of age in the INMA birth cohort. ENVIRONMENTAL RESEARCH 2015; 142:579-585. [PMID: 26298601 DOI: 10.1016/j.envres.2015.07.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 07/17/2015] [Accepted: 07/18/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND Exposure to hard water has been suggested as a risk factor for eczema in childhood, based on limited evidence from two ecologic and two cross-sectional studies. OBJECTIVES We evaluate this hypothesis for the first time in early infancy using prospective data from a mother-child cohort study. METHODS We used data from the INMA cohorts in Gipuzkoa, Sabadell and Valencia, Spain (N=1638). Current and ever eczema, bathing frequency and duration and covariables were collected by questionnaires at 14 months (14 m) and 4 years (4 y). Calcium carbonate (CaCO3) level in municipal water was assigned to home addresses at birth, 14 m and 4 y. We calculated Odds Ratio (OR) of eczema related to CaCO3 at home, bath exposure and a combination of both. RESULTS Prevalence of eczema ever was 18.4% at 14 m and 33.4% at 4 y. Mean CaCO3 ranged from 51.6 to 272.8 mg/L among areas. No association was detected between water hardness at home and current or ever eczema. Adjusted OR was 0.79 (95%CI=0.45, 1.39) at 14 m and 0.93 (0.56, 1.52) at 4 y among children in the highest vs. lowest tertiles of CaCO3. Bath exposure alone or in combination with water hardness did not increase the OR of eczema at 14 m or 4 y either. CONCLUSIONS We did not find an association between eczema and water hardness at home or bathing exposure during the first four years of life. This first cohort study in a critical age period with improved exposure assessment does not confirm the association suggested among children by previous studies.
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Affiliation(s)
- Laia Font-Ribera
- Centre for Research in Environmental Epidemiology (CREAL), Barcelona Biomedical Research Park, 88 Doctor Aiguader, Barcelona 08003, Spain; Universitat Pompeu Fabra (UPF), 80 Doctor Aiguader, Barcelona 08003, Spain; IMIM (Hospital del Mar Medical Research Institute), 88 Doctor Aiguader, Barcelona 08003, Spain; CIBER Epidemiologia y Salud Pública (CIBERESP), 3-5 Melchor Fernández Almagro, Madrid 28029, Spain.
| | - Esther Gracia-Lavedan
- Centre for Research in Environmental Epidemiology (CREAL), Barcelona Biomedical Research Park, 88 Doctor Aiguader, Barcelona 08003, Spain; Universitat Pompeu Fabra (UPF), 80 Doctor Aiguader, Barcelona 08003, Spain; IMIM (Hospital del Mar Medical Research Institute), 88 Doctor Aiguader, Barcelona 08003, Spain.
| | - Ana Esplugues
- CIBER Epidemiologia y Salud Pública (CIBERESP), 3-5 Melchor Fernández Almagro, Madrid 28029, Spain; FISABIO-UJI-Universitat de València Joint Research Unit, Av. Catalunya 21, Valencia 46020, Spain.
| | - Ferran Ballester
- CIBER Epidemiologia y Salud Pública (CIBERESP), 3-5 Melchor Fernández Almagro, Madrid 28029, Spain; FISABIO-UJI-Universitat de València Joint Research Unit, Av. Catalunya 21, Valencia 46020, Spain.
| | - Ana Jiménez Zabala
- Public Health Division of Gipuzkoa, Basque Government, 4 Av. de Navarra, San Sebastian 20013, Spain; BIODONOSTIA Health Research Institute, Paseo Dr. Beguiristain, San Sebastian 20014, Spain.
| | - Loreto Santa Marina
- CIBER Epidemiologia y Salud Pública (CIBERESP), 3-5 Melchor Fernández Almagro, Madrid 28029, Spain; Public Health Division of Gipuzkoa, Basque Government, 4 Av. de Navarra, San Sebastian 20013, Spain; BIODONOSTIA Health Research Institute, Paseo Dr. Beguiristain, San Sebastian 20014, Spain.
| | - Ana Fernández-Somoano
- CIBER Epidemiologia y Salud Pública (CIBERESP), 3-5 Melchor Fernández Almagro, Madrid 28029, Spain; Universidad de Oviedo, Campus del Cristo, Oviedo, Spain.
| | - Jordi Sunyer
- Centre for Research in Environmental Epidemiology (CREAL), Barcelona Biomedical Research Park, 88 Doctor Aiguader, Barcelona 08003, Spain; Universitat Pompeu Fabra (UPF), 80 Doctor Aiguader, Barcelona 08003, Spain; IMIM (Hospital del Mar Medical Research Institute), 88 Doctor Aiguader, Barcelona 08003, Spain; CIBER Epidemiologia y Salud Pública (CIBERESP), 3-5 Melchor Fernández Almagro, Madrid 28029, Spain.
| | - Cristina M Villanueva
- Centre for Research in Environmental Epidemiology (CREAL), Barcelona Biomedical Research Park, 88 Doctor Aiguader, Barcelona 08003, Spain; Universitat Pompeu Fabra (UPF), 80 Doctor Aiguader, Barcelona 08003, Spain; IMIM (Hospital del Mar Medical Research Institute), 88 Doctor Aiguader, Barcelona 08003, Spain; CIBER Epidemiologia y Salud Pública (CIBERESP), 3-5 Melchor Fernández Almagro, Madrid 28029, Spain.
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Alternative, Complementary, and Forgotten Remedies for Atopic Dermatitis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2015. [PMID: 26257817 DOI: 10.1155/2015/676897.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Atopic dermatitis, perhaps more than other dermatologic diseases, has garnered much attention in the realm of alternative medicine. This may be because its etiopathogenesis is incompletely understood, it is increasingly common, and it waxes and wanes often without clear precipitants, opening up many opportunities for misinterpretation. Herein we explore the evidence for a number of different alternative and complementary therapies, from textiles to vitamin supplements. By definition, none have enough data to be deemed "effective" in a conventional sense, but it is hopeful that some show promising evidence that may one day lead to mainstream acceptance with further research.
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49
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Alternative, Complementary, and Forgotten Remedies for Atopic Dermatitis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2015; 2015:676897. [PMID: 26257817 PMCID: PMC4518179 DOI: 10.1155/2015/676897] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 06/25/2015] [Indexed: 12/14/2022]
Abstract
Atopic dermatitis, perhaps more than other dermatologic diseases, has garnered much attention in the realm of alternative medicine. This may be because its etiopathogenesis is incompletely understood, it is increasingly common, and it waxes and wanes often without clear precipitants, opening up many opportunities for misinterpretation. Herein we explore the evidence for a number of different alternative and complementary therapies, from textiles to vitamin supplements. By definition, none have enough data to be deemed “effective” in a conventional sense, but it is hopeful that some show promising evidence that may one day lead to mainstream acceptance with further research.
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50
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Williams HC, Apfelbacher C, Chalmers JR, Schmitt J, Simpson EL, Spuls PI, Thomas KS. Clearing up misunderstandings around core outcomes for atopic dermatitis. Br J Dermatol 2015; 173:623-4; discussion 624-5. [PMID: 25819300 DOI: 10.1111/bjd.13787] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- H C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, U.K
| | - C Apfelbacher
- Department of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - J R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, U.K
| | - J Schmitt
- Centre for Evidence-Based Healthcare, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - E L Simpson
- Oregon Health & Science University, Department of Dermatology, Portland, OR, U.S.A
| | - P I Spuls
- Department of Dermatology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - K S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, U.K
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