Canadian hand dermatitis management guidelines

Prevalence and clinical impact of topical corticosteroid phobia among patients with chronic hand eczema-Findings from the Danish Skin Cohort

BACKGROUND

Topical corticosteroid phobia (TOPICOP) is associated with poor treatment adherence and is common among patients with skin disease. Knowledge about corticosteroid phobia and treatment adherence among patients with chronic hand eczema (CHE) is limited.

OBJECTIVES

To investigate patient-reported outcomes regarding topical corticosteroids (TCSs), and their impact on treatment adherence in patients with CHE.

METHODS

Patients with CHE from the Danish Skin Cohort answered a questionnaire including the TOPICOP scale and Medication Adherence Report Scale. Response rate was 69.2%.

RESULTS

Of 927 with CHE, 75.5% totally or almost agreed that TCS damage the skin, 48.9% totally or almost agreed that TCS would affect their future health and 36.3% reported some degree of fear of TCS although they were unaware of any TCS-associated risks. Most patients (77.9%) always or often stop treatment as soon as possible, whereas 54.8% always or often wait as long as possible before starting treatment. Overall, 38.8% reported that they had taken less medicine than prescribed and 54.0% had stopped treatment throughout a period. Treatment adherence decreased with increasing corticosteroid phobia (P = .004).

LIMITATIONS

TOPICOP has not been validated in patients with CHE.

CONCLUSIONS

Corticosteroid phobia is common among patients with CHE and negatively associated with treatment adherence.

Development and Validation of a Patient-Reported Outcome Measure of the Impact of Chronic Hand Eczema on Health-Related Quality of Life: the Hand Eczema Impact Scale (HEIS)

INTRODUCTION

Chronic Hand Eczema (CHE) is an inflammatory skin disease that causes significant impact on health-related quality of life (HRQoL). The Hand Eczema Impact Scale (HEIS) is a new patient-reported outcome (PRO) measure designed to assess the impact of CHE on key domains of HRQoL. This study aimed to develop and evaluate content and psychometric validity of the HEIS.

METHODS

The HEIS was initially developed on the basis of a literature review and concept elicitation interviews. Qualitative cognitive debriefing interviews (n = 20) were conducted with patients with CHE to assess relevance and understanding of items, response options, and recall period. Psychometric properties (item performance, dimensionality, reliability, validity, responsiveness, and estimation of meaningful change thresholds) were then assessed using data (n = 258) from a phase 2b trial (NCT03683719).

RESULTS

Cognitive debriefing confirmed all items were understood and relevant to patients. Inter-item correlations (all > 0.50) and confirmatory factor analysis (factor loadings ≥ 0.80) supported unidimensionality of the HEIS score, and mostly provided support for the HEIS Proximal Daily Activity Limitations (PDAL) score, with only one item loading below the prespecified threshold. Item properties and previous qualitative work supported retaining this item in the total score but removed from the HEIS PDAL domain. Internal consistency (Cronbach's alpha ≥ 0.89) and test-retest reliability (intra-class correlation coefficient ≥ 0.79) results were very strong. Strong correlations with concurrent measures (0.66-0.87) and significant differences between severity groups (p < 0.001) supported construct validity. Large effect sizes for mean change scores in participants that improved and significant differences between groups indicated ability to detect change. Anchor-based analyses supported within-individual responder definitions of ≥ 1.3 points for improvements in both HEIS score and HEIS PDAL score (covering three items) and of ≥ 1.5 points for HEIS embarrassment with the appearance of hands (Emb) score (covering two items).

CONCLUSIONS

The 9-item HEIS is the first CHE-specific PRO measure developed and validated according to regulatory guidance for assessment of the impact of CHE on key domains of HRQoL. This article provides evidence of strong content and psychometric validity and shows improvements of ≥ 1.3 points in HEIS score and HEIS PDAL score, and improvements of ≥ 1.5 points in HEIS Emb score represent clinically meaningful, important changes.

TRIAL REGISTRATION

NCT03683719.

Development and Psychometric Validation of a Patient-Reported Outcome Measure to Assess the Signs and Symptoms of Chronic Hand Eczema: The Hand Eczema Symptom Diary (HESD)

INTRODUCTION

Chronic Hand Eczema (CHE) is an inflammatory skin disease of the hands. The Hand Eczema Symptom Diary (HESD) is a new patient-reported outcome measure of worst severity of core CHE signs/symptoms. This study aimed to evaluate content and psychometric validity of the HESD.

METHODS

The HESD was developed based on the literature and concept elicitation interviews. Qualitative cognitive debriefing interviews were conducted with CHE patients to assess relevance and understanding of items, response options and recall period. Psychometric properties of the HESD (item performance, dimensionality, reliability, validity, responsiveness and estimation of meaningful change thresholds) were then assessed, first using data from a phase 2b trial (NCT03683719), and confirmed using data from the first 280 participants completing the 16-week treatment phase of a phase 3 trial (NCT04871711).

RESULTS

Cognitive debriefing supported item refinement and removal of items and confirmed all items were well understood and relevant to patients. Item properties and dimensionality analyses in the phase 2b data supported removal of additional items, resulting in the 6-item HESD included in the phase 3 trial. Unidimensionality was supported by inter-item correlations (all > 0.70) and Rasch analysis. Internal consistency (Cronbach's alpha = 0.96) and test-retest reliability (Intraclass Correlation Coefficient > 0.89) results were very strong. Construct validity was supported by moderate correlations with concurrent measures (0.53-0.64) and significant differences between severity groups (p < 0.001). Large effect sizes for mean change scores in participants that improved and significant differences between change groups indicated the ability to detect change. Anchor-based analyses supported within-individual responder definitions of ≥ 4-points for improvements in 7-day average HESD scores.

CONCLUSION

The HESD is the first CHE-specific, patient-reported outcome measure of CHE signs/symptoms developed and validated in line with regulatory guidance. This article provides evidence of strong content validity and psychometric validity and shows improvements of ≥ 4 points on 7-day average HESD scores represent clinically meaningful, important changes.

TRIAL REGISTRATION

NCT03683719, NCT04871711.

Treatment with delgocitinib cream improves itch, pain and other signs and symptoms of chronic hand eczema: Results from the Hand Eczema Symptom Diary in a phase IIb randomized clinical trial

BACKGROUND

Measuring patient-reported outcomes is crucial to fully capture the burden of chronic hand eczema (CHE).

OBJECTIVES

To assess the effect of delgocitinib cream on itch, pain and nine additional key signs and symptoms reported by patients with CHE using the Hand Eczema Symptom Diary (HESD).

METHODS

In a double-blind, phase IIb dose-ranging trial (NCT03683719), 258 adults with mild to severe CHE were randomized to delgocitinib cream 1, 3, 8 or 20 mg/g or cream vehicle twice daily for 16 weeks. Patients assessed 11 signs and symptoms of CHE daily through the HESD using an 11-point numeric rating scale; this was an exploratory endpoint.

RESULTS

Delgocitinib cream 20 mg/g was associated with an early and sustained reduction in itch and pain, along with clinically relevant reductions of ≥4 points from baseline to Week 16 in 48.4% and 63.6% of patients, respectively (17.9% and 5.9% with cream vehicle). There were improvements versus cream vehicle in all assessed CHE signs and symptoms (20 mg/g, p < 0.05).

CONCLUSIONS

Delgocitinib cream reduced itch, pain and other signs and symptoms in patients with CHE. This data correlated with clinician-reported outcomes, indicating that the HESD may be a useful assessment tool for CHE management.

The pan-JAK inhibitor delgocitinib in a cream formulation demonstrates dose-response in chronic hand eczema in a 16-week randomised phase 2b trial

BACKGROUND

Chronic hand eczema (CHE) is a burdensome disease, and new well-documented, safe, and efficacious treatments are warranted. In a recent CHE phase 2a trial, the pan-Janus kinase (JAK) inhibitor delgocitinib in an ointment formulation was found to be efficacious and well-tolerated.

OBJECTIVES

This trial assessed the dose-response, efficacy, and safety of delgocitinib cream in CHE.

METHODS

In this double-blind, phase 2b dose-ranging trial, adults with CHE and a recent history of inadequate response or contraindication to topical corticosteroids were randomised to delgocitinib cream 1, 3, 8, 20 mg/g or vehicle treatment twice daily for 16 weeks. Primary endpoint was Investigator's Global Assessment for CHE (IGA-CHE) treatment success (0 [clear] or 1 [almost clear] with a ≥2-point improvement from baseline to Week 16). Secondary endpoints were time to IGA-CHE treatment success and changes in Hand Eczema Severity Index (HECSI); other endpoints were itch and pain NRS scores, and Patient's Global Assessment (PaGA) at Week 16.

RESULTS

258 patients were randomised 1:1:1:1:1 to delgocitinib cream 1, 3, 8, 20 mg/g or vehicle. A significant dose-response relationship was established for IGA-CHE (p<0.025). IGA-CHE treatment success at Week 16 was achieved in 21.2% (1 mg/g), 7.8% (3 mg/g), 36.5% (8 mg/g), 37.7% (20 mg/g), and 8.0% (vehicle) of patients. Delgocitinib 8 and 20 mg/g showed a treatment effect against vehicle (p<0.001). Similarly, there were improvements in HECSI, itch and pain NRS scores, and PaGA. Delgocitinib cream was well-tolerated with majority of adverse events being mild or moderate and considered unrelated to treatment. Most frequently reported adverse events were nasopharyngitis (17.3%-29.4% in delgocitinib groups vs 40% in vehicle group), eczema (5.8%-11.3% in delgocitinib groups vs 16.0% in vehicle group) and headache (3.8%-11.5% in delgocitinib groups vs 4.0% in vehicle group).

CONCLUSIONS

In this trial, delgocitinib cream showed a dose-response relationship in terms of efficacy and was well-tolerated.

Low Dose Oral Alitretinoin With Narrowband Ultraviolet B Therapy for Chronic Hand Dermatitis

Background

Chronic hand dermatitis (CHD) is difficult to treat and has high individual and societal burdens. Phototherapy and oral alitretinoin are safe monotherapies for CHD, but their combination has not been assessed.

Objective

To assess the effectiveness and safety of low dose oral alitretinoin combined with phototherapy versus high dose oral alitretinoin for CHD refractory to topical corticosteroids.

Methods

This retrospective study of adult patients with CHD refractory to topical corticosteroid therapy compared low dose oral alitretinoin (10 mg three times weekly) combined with narrowband ultraviolet B therapy (three times weekly; LDA-UVB) to high dose oral alitretinoin (30 mg daily; HDA) for 16 weeks. Outcomes were improvement in disease severity measured by the Physician’s Global Assessment and quality of life measured with the Dermatology Life Quality Index.

Results

The mean age of the study population (n = 64) was 41.25 years and 57.8% were male. Both cohorts experienced improvements in disease severity and quality of life after 16 weeks, however, significantly more participants who received LDA-UVB (n = 21/33, 63.6%) achieved “clear” or “almost clear” assessments compared to those who received HDA (n = 12/31, 38.7%; P < .05). Adverse effects were significantly more prevalent in the HDA group (P < .0001) and included headache, elevated cholesterol, and dry lips.

Conclusions

The combination of low dose oral alitretinoin with narrowband-UVB therapy was more effective and had fewer adverse effects compared to high dose oral alitretinoin for participants with CHD refractory to topical corticosteroid therapy.

Prominent Role of Type 2 Immunity in Skin Diseases-Beyond Atopic Dermatitis

Type 2 immunity, illustrated by T helper 2 lymphocytes (Th2) and downstream cytokines (IL-4, IL-13, IL-31) as well as group 2 innate lymphoid cells (ILC2), is important in host defense and wound healing.¹ The hallmark of type 2 inflammation is eosinophilia and/or high IgE counts and is best recognized in atopic diathesis. Persistent eosinophilia, such as seen in hypereosinophilic syndromes, leads to fibrosis and hence therapeutic Type 2 inhibition in fibrotic diseases is of high interest. Furthermore, as demonstrated in cutaneous T cell lymphoma, advanced disease is characterized by Th1 to Th2 switch allowing cancer progression and immunosuppression. Development of targeted monoclonal antibodies against IL-4Rα (eg, dupilumab) led to a paradigm shift for the treatment of atopic dermatitis (AD) and stimulated research to better understand the role of Type 2 inflammation in other skin conditions. In this review, we summarize up to date knowledge on the role of Type 2 inflammation in skin diseases other than AD and highlight whether the use of Type 2 targeted therapies has been documented or is being investigated in clinical trials. This manuscript reviews the role of Type 2 inflammation in dermatitis, neurodermatitis, IgE-mediated dermatoses (eg, bullous pemphigoid, chronic spontaneous urticaria), sclerodermoid conditions and skin neoplasms.

DECISA Project (DErmatology Clinics in Italy: Survey on Alitretinoin): A real-life retrospective cohort multicenter study on 438 subjects with chronic hand eczema

Alitretinoin is the only systemic agent approved to treat moderate-severe chronic hand eczema (CHE) unresponsive to potent topical corticosteroids. No nationwide Italian data regarding real-life efficacy, safety, and tolerability of treatment are available. The DECISA project (DErmatology Clinics in Italy: Survey on Alitretinoin) retrospectively examined data from a registry including 15 Dermatology Clinics authorized to prescription of alitretinoin for CHE patients. Disease severity was assessed at baseline, and after 3 and 6 months of treatment, using the 5-point Physician Global Assessment (PGA) and the modified Total Lesion-Symptoms-Severity (mTLSS) scores. Between November 2010 and July 2018, data of 248 male and 190 female patients (mean age 49.71 ± 13.20 years) treated with alitretinoin were collected. Of them, 43.2% had irritant contact dermatitis, 22.2% allergic contact dermatitis, 18.0% atopic dermatitis, 16.7% mixed (irritant/allergic) type of eczema. At 3 months, the 420 re-evaluated patients showed significantly reduced mTLSS and PGA (P < .0000001 vs baseline for both); PGA was clear/almost clear in 35.6% of cases. At 6 months, the 341 re-evaluated patients showed significant (P < .0000001) improvement of mTLSS and PGA vs baseline and 3 months (PGA clear/almost clear: 41.4%). Relapses occurred in 125 patients; 58 underwent an additional course of alitretinoin, with similarly good results. No relevant safety issues were reported; 86 patients experienced adverse effects, which forced 40 to prematurely stop treatment. The DECISA project results confirm the real-life efficacy, safety and tolerability of alitretinoin in the treatment of moderate to severe CHE refractory to standard topical therapies.

Guidelines for the Diagnosis, Treatment, and Prevention of Hand Eczema

Hand eczema is a common condition associated with significantly impaired quality of life and high social and occupational costs. Managing hand eczema is particularly challenging for primary care and occupational health physicians as the condition has varying causes and both disease progression and response to treatment are difficult to predict. Early diagnosis and appropriate protective measures are essential to prevent progression to chronic eczema, which is much more difficult to treat. Appropriate referral to a specialist and opportune evaluation of the need for sick leave are crucial to the good management of these patients. These guidelines cover the diagnosis, prevention, and treatment of chronic hand eczema and highlight the role that primary care and occupational health physicians can play in the early management of this disease.

Red Grape Polyphenol Oral Administration Improves Immune Response in Women Affected by Nickel-Mediated Allergic Contact Dermatitis

BACKGROUND

Our previous findings demonstrated that in vitro supplementation of polyphenols, extracted from seeds of red grape (Nero di Troia cultivar), to peripheral lymphomonocytes from patients affected by allergic contact dermatitis (ACD) to nickel (Ni) could reduce the release of proinflammatory cytokines and nitric oxide (NO), while increasing the levels of interleukin (IL)-10, an anti-inflammatory cytokine.

OBJECTIVE

To assess whether an intervention with oral administration of polyphenols leads to a reduction of peripheral biomarkers in ACD patients.

METHODS

At T0, 25 patients affected by ACD to Ni were orally administered with 300 mg polyphenols prodie extracted from seeds of red grape (Nero di Troia cultivar) (NATUR-OX®) for 3 months (T1). The other 25 patients affected by ACD to Ni received placebo only for the same period of time. Serum biomarkers were analyzed at T0 and T1. In both groups, seven dropouts were recorded.

RESULTS

At T1 in comparison to T0, in treated patients, values of interferon-γ, IL-4, IL-17, pentraxin 3 and NO decreased, while IL-10 levels increased when compared with T0 values. Conversely, in placebo- treated patients, no modifications of biomarkers were evaluated at T1.

CONCLUSION

Present laboratory data rely on the anti-oxidant, anti-inflammatory and anti-allergic properties of polyphenols.

Interventions for hand eczema

BACKGROUND

Hand eczema is an inflammation of the skin of the hands that tends to run a chronic, relapsing course. This common condition is often associated with itch, social stigma, and impairment in employment. Many different interventions of unknown effectiveness are used to treat hand eczema.

OBJECTIVES

To assess the effects of topical and systemic interventions for hand eczema in adults and children.

SEARCH METHODS

We searched the following up to April 2018: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, AMED, LILACS, GREAT, and four trials registries. We checked the reference lists of included studies for further references to relevant trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared interventions for hand eczema, regardless of hand eczema type and other affected sites, versus no treatment, placebo, vehicle, or active treatments.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Primary outcomes were participant- and investigator-rated good/excellent control of symptoms, and adverse events.

MAIN RESULTS

We included 60 RCTs, conducted in secondary care (5469 participants with mild to severe chronic hand eczema). Most participants were over 18 years old. The duration of treatment was short, generally up to four months. Only 24 studies included a follow-up period. Clinical heterogeneity in treatments and outcome measures was evident. Few studies performed head-to-head comparisons of different interventions. Risk of bias varied considerably, with only five studies at low risk in all domains. Twenty-two studies were industry-funded.Eighteen trials studied topical corticosteroids or calcineurin inhibitors; 10 studies, phototherapy; three studies, systemic immunosuppressives; and five studies, oral retinoids. Most studies compared an active intervention against no treatment, variants of the same medication, or placebo (or vehicle). Below, we present results from the main comparisons.Corticosteroid creams/ointments: when assessed 15 days after the start of treatment, clobetasol propionate 0.05% foam probably improves participant-rated control of symptoms compared to vehicle (risk ratio (RR) 2.32, 95% confidence interval (CI) 1.38 to 3.91; number needed to treat for an additional beneficial outcome (NNTB) 3, 95% CI 2 to 8; 1 study, 125 participants); the effect of clobetasol compared to vehicle for investigator-rated improvement is less clear (RR 1.43, 95% CI 0.86 to 2.40). More participants had at least one adverse event with clobetasol (11/62 versus 5/63; RR 2.24, 95% CI 0.82 to 6.06), including application site burning/pruritus. This evidence was rated as moderate certainty.When assessed 36 weeks after the start of treatment, mometasone furoate cream used thrice weekly may slightly improve investigator-rated symptom control compared to twice weekly (RR 1.23, 95% CI 0.94 to 1.61; 1 study, 72 participants) after remission is reached. Participant-rated symptoms were not measured. Some mild atrophy was reported in both groups (RR 1.76, 95% CI 0.45 to 6.83; 5/35 versus 3/37). This evidence was rated as low certainty.Irradiation with ultraviolet (UV) light: local combination ultraviolet light therapy (PUVA) may lead to improvement in investigator-rated symptom control when compared to local narrow-band UVB after 12 weeks of treatment (RR 0.50, 95% CI 0.22 to 1.16; 1 study, 60 participants). However, the 95% CI indicates that PUVA might make little or no difference. Participant-rated symptoms were not measured. Adverse events (mainly erythema) were reported by 9/30 participants in the narrow-band UVB group versus none in the PUVA group. This evidence was rated as moderate certainty.Topical calcineurin inhibitors: tacrolimus 0.1% over two weeks probably improves investigator-rated symptom control measured after three weeks compared to vehicle (14/14 tacrolimus versus 0/14 vehicle; 1 study). Participant-rated symptoms were not measured. Four of 14 people in the tacrolimus group versus zero in the vehicle group had well-tolerated application site burning/itching.A within-participant study in 16 participants compared 0.1% tacrolimus to 0.1% mometasone furoate but did not measure investigator- or participant-rated symptoms. Both treatments were well tolerated when assessed at two weeks during four weeks of treatment.Evidence from these studies was rated as moderate certainty.Oral interventions: oral cyclosporin 3 mg/kg/d probably slightly improves investigator-rated (RR 1.88, 95% CI 0.88 to 3.99; 1 study, 34 participants) or participant-rated (RR 1.25, 95% CI 0.69 to 2.27) control of symptoms compared to topical betamethasone dipropionate 0.05% after six weeks of treatment. The risk of adverse events such as dizziness was similar between groups (up to 36 weeks; RR 1.22, 95% CI 0.80 to 1.86, n = 55; 15/27 betamethasone versus 19/28 cyclosporin). The evidence was rated as moderate certainty.Alitretinoin 10 mg improves investigator-rated symptom control compared with placebo (RR 1.58, 95% CI 1.20 to 2.07; NNTB 11, 95% CI 6.3 to 26.5; 2 studies, n = 781) and alitretinoin 30 mg also improves this outcome compared with placebo (RR 2.75, 95% CI 2.20 to 3.43; NNTB 4, 95% CI 3 to 5; 2 studies, n = 1210). Similar results were found for participant-rated symptom control: alitretinoin 10 mg RR 1.73 (95% CI 1.25 to 2.40) and 30 mg RR 2.75 (95% CI 2.18 to 3.48). Evidence was rated as high certainty. The number of adverse events (including headache) probably did not differ between alitretinoin 10 mg and placebo (RR 1.01, 95% CI 0.66 to 1.55; 1 study, n = 158; moderate-certainty evidence), but the risk of headache increased with alitretinoin 30 mg (RR 3.43, 95% CI 2.45 to 4.81; 2 studies, n = 1210; high-certainty evidence). Outcomes were assessed between 48 and 72 weeks.

AUTHORS' CONCLUSIONS

Most findings were from single studies with low precision, so they should be interpreted with caution. Topical corticosteroids and UV phototherapy were two of the major standard treatments, but evidence is insufficient to support one specific treatment over another. The effect of topical calcineurin inhibitors is not certain. Alitretinoin is more effective than placebo in controlling symptoms, but advantages over other treatments need evaluating.Well-designed and well-reported, long-term (more than three months), head-to-head studies comparing different treatments are needed. Consensus is required regarding the definition of hand eczema and its subtypes, and a standard severity scale should be established.The main limitation was heterogeneity between studies. Small sample size impacted our ability to detect differences between treatments.

Vesicular hand dermatitis

Vesicular hand dermatitis is a type of eczema involving the fingers, hands, and sometimes the feet. It is common in primary care, requiring prompt treatment to prevent chronicity. The cause is often unknown, making the condition challenging to treat. Management consists of avoiding irritants and using emollients and topical corticosteroids.

Investigating the therapeutic potential of a probiotic in a clinical population with chronic hand dermatitis

BACKGROUND

Hand dermatitis or hand eczema (HD) is one of the most common dermatologic conditions. Lesions, scaling, pruritus and pain are chronic and relapsing. Improved HD has been reported with the probiotic composed of Lactobacillus acidophilus CL1285, Lactobacillus casei LBC80R and Lactobacillus rhamnosus CLR2 (Bio-K+).

PURPOSE

Investigation of the therapeutic potential of this probiotic as the sole systemic treatment for adults with nonacute HD.

SUBJECTS AND METHODS

A single-center study documented clinical ratings and patient-reported outcomes in adults with chronic HD. The probiotic was taken orally for 12 weeks, adjunctive to standard topical treatments and preventative measures.

RESULTS

Most of the 30 subjects with mild to severe HD were compliant with the probiotic. Around 22 of the 30 subjects were able to complete the study, and of these subjects, an improvement was noted in 19. One required systemic therapy, and one subject was not able to tolerate the probiotic and therefore discontinued the study. 23% of the subjects achieved clear or almost clear hands by the end of 12 weeks. Pruritus, which was a common complaint at baseline, was improved with 59% of symptomatic patients within 2 weeks.

CONCLUSION

It is feasible and safe to administer Bio-K+ for HD. Clinicians saw an improvement in most subjects' hands, and cases of significant improvement in dermatitis were documented. Pruritus was the most rapidly relieved symptom, as reported by patients.

The Role of Moisturizers in Addressing Various Kinds of Dermatitis: A Review

Moisturizer is a major component of basic daily skin care, particularly in presence of epidermal barrier alteration and reduced epidermal water content. It is an important part of a dermatologist's strategy to maintain skin health as well as treating various dermatoses which co-exist with skin dryness and are linked to impaired skin barrier function, such as in atopic disorders as well as other types of dermatitis. Mastering the knowledge regarding mechanism of action, application, dosage, adverse effects as well as specific clinical usage of moisturizers is a must for a dermatologist in order to support their use, particularly for evidence-based, therapeutic purposes. This review discusses the use of moisturizer both for skin health maintenance as well as a definitive or adjuvant therapy for many kinds of dermatitis.

The Skin Microbiome in Atopic Dermatitis and Its Relationship to Emollients

BACKGROUND

Human-associated bacterial communities on the skin, skin microbiome, likely play a central role in development of immunity and protection from pathogens. In atopic patients, the skin bacterial diversity is smaller than in healthy subjects.

OBJECTIVE

To review treatment strategies for atopic dermatitis in Canada, taking the skin microbiome concept into account.

METHODS

An expert panel of 8 Canadian dermatologists explored the role of skin microbiome in clinical dermatology, specifically looking at atopic dermatitis.

RESULTS

The panel reached consensus on the following: (1) In atopic patients, the skin microbiome of lesional atopic skin is different from nonlesional skin in adjacent areas. (2) Worsening atopic dermatitis and smaller bacterial diversity are strongly associated. (3) Application of emollients containing antioxidant and antibacterial components may increase microbiome diversity in atopic skin.

CONCLUSION

The skin microbiome may be the next frontier in preventive health and may impact the approach to atopic dermatitis treatment.

Guidelines for diagnosis, prevention and treatment of hand eczema

The guidelines aim to provide advice on the management of hand eczema (HE), using an evidence- and consensus-based approach. The guidelines consider a systematic Cochrane review on interventions for HE, which is based on a systematic search of the published literature (including hand-searching). In addition to the evidence- and consensus-based recommendation on the treatment of HE, the guidelines cover mainly consensus-based diagnostic aspects and preventive measures (primary and secondary prevention). Treatment recommendations include non-pharmacological interventions, topical, physical and systemic treatments. Topical corticosteroids are recommended as first line treatment in the management of HE, however continuous long-term treatment beyond six weeks only when necessary and under careful me-dical supervision. Alitretinoin is recommended as a second line treatment (relative to topical corticosteroids) for patients with severe chronic HE. Randomized control trials (RCT) are missing for other used systemic treatments and comparison of systemic drugs in “head-to-head” RCTs are needed.The guidelines development group is a working group of the European Society of Contact Dermatitis (ESCD) and has carefully tried to reconcile opposite views, define current optimal practice and provide specific recommendations, and meetings have been chaired by a professional moderator of the AWMF (Arbeitsgemeinschaft der Wis-senschaftlichen Medizinischen Fachgesellschaften; Association of the Scientific Medi-cal Societies in Germany).No financial support was given by any medical company. The guidelines are expected to be valid until December 2017 at the latest.

Successful treatment of refractory chronic hand eczema with calcipotriol/betamethasone ointment: A report of three cases

Chronic hand eczema (CHE) is a common skin disorder with frequent relapses, and its treatment comprises a challenge due to its uncertain etiology. In particular, certain cases of CHE exhibiting severe keratinization have a very poor response to various treatments. The Daivobet ointment, a complex product comprising calcipotriol and betamethasone, has been successfully used for the treatment of patients with plaque-type psoriasis for ~10 years; however, there are few reports on the effect of the ointment on other skin disorders of abnormal keratinization, such as eczema. The present study reported 3 cases of refractory hyperkeratotic eczema of the hand that did not respond to several treatments, but responded well to topical Daivobet treatment.

Management of Chronic Hand Eczema

Management of hand eczema is complex because of the broad range of different pathogeneses, courses, and prognoses. Furthermore, the efficacy of most available treatments is not well established and the more severe forms can have a major impact on the patient's quality of life. Patient education, preventive measures, and the use of emollients are the mainstays in the management of hand eczema. High-potency topical corticosteroids are the treatment of choice, with calcineurin inhibitors used for maintenance. Phototherapy or systemic treatments are indicated in patients who do not respond to topical treatments. Switching from topical treatments should not be delayed to avoid sensitizations, time off work, and a negative impact on quality of life. Alitretinoin is the only oral treatment approved for use in chronic hand eczema.

Diagnosis and treatment of hand dermatitis

PURPOSE

To enhance the learner's competence with knowledge of hand dermatitis.

TARGET AUDIENCE

: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.

OBJECTIVES

After participating in this educational activity, the participant should be better able to: 1. Demonstrate knowledge of the pathophysiology and assessment of, and diagnostic testing for, hand dermatitis. 2. Apply knowledge of hand dermatitis to patient care scenarios for treatment recommendations and patient education. Hand dermatitis is a common disorder with different clinical presentations. Contact (irritant and allergic) dermatitis is the most common subtype with atopic dermatitis and dyshidrotic eczema as common differential diagnoses. The exact diagnosis and differential diagnoses (psoriasis, fungal infections) are important for specific investigations and treatment plans.

Hand eczema

Hand eczema is an inflammation of the skin; the cause is often multifactorial. Initial management includes avoiding causative irritants or allergens (e.g., by wearing impermeable gloves) and applying emollients and potent topical glucocorticoids.

Effective Treatment of Chronic Hand Dermatitis with 36 Continuous Months of Alitretinoin Administration: Report of Three Cases

Background:

Moderate to severe chronic hand dermatitis (CHD) is not well controlled by current medical strategies; however, recent studies have shown significant improvement in patients treated with up to 6 months of oral alitretinoin (9- cis-retinoic acid). The results of longer-term continuous treatment are lacking.

Objective:

To evaluate the long-term safety and efficacy of alitretinoin for the treatment of CHD.

Methods:

The Physician's Global Assessment (PGA) and Modified Total Lesion Symptom Score (MTLSS) were used to assess CHD improvement in three patients treated with alitretinoin (10–30 mg/d). Patients had routine bloodwork and were monitored for adverse events.

Results:

Significant improvement in MTLSS scores (≈ 76%) was seen at 2 months ( p < .002) and maintained for the 3-year treatment period with occasional dosage adjustments. No significant adverse events developed that necessitated treatment withdrawal.

Conclusion:

Alitretinoin was well tolerated in the treatment of these three CHD patients who were carefully monitored over this prolonged treatment period.